Behind the Head Mirror

A Reading and Reflection for Advent

2010-12-05T08:49:00.003-06:00

"They shall beat their swords into plowshares, and their spears into pruning hooks; nation shall not lift up sword against nation, neither shall they learn war any more. O house of Jacob, come, let us walk in the light of the Lord!"

-Isaiah 2:4b-5

As we bumped along the deeply-rutted Tanzanian road, we passed a man pushing a bicycle loaded with an enormous bale of corn stalks. I could not help but admire the seemingly impossible balancing act on his bike. I watched until he disappeared into the cloud of dust kicked up behind our truck.

Tanzanians "re-purpose" just about everything. Old tires turn into sandals. Containers become walls of homes. Five-gallon plastic chemical buckets haul water and food. Any object that is no longer needed for its original purpose is refashioned into something useful.

Isaiah tells of a time when weapons of war will become implements of agriculture. I always viewed this as idealistic, futuristic imagery of a world living in peace. Perhaps the man with the packhorse-bicycle would regard this passage differently. He might imagine himself choosing several shiny steel swords, pounding and shaping them into plow blades, and then fixing them tightly to a frame to be pulled behind an ox. Where I see romantic platitudes, he sees practical challenges.

Our Tanzanian friends certainly view the world differently than we do. Each of us, however, hopes that Advent will "re-purpose" our lives. Pray that we see this as a real, tangible opportunity and not just as a far-away dream.

God of the mountain and of the suburb: Prod us out of the hiding places to which we have retreated and force us to expand both our boundaries and our imaginations. Re-purpose our lives right now as we care for Your truly remarkable world, and inspire us to build relationships of peace and justice. In Your holy name, we pray: Amen.

Prepared for St. John's Lutheran Church, Brookfield WI

Milestones

2010-11-25T23:28:00.001-06:00

I am old enough (barely) to remember November 22, 1963. Back in those days, before working mothers, school lunchrooms, and buses, we all walked home long enough to have a sandwich and a bowl of soup before walking back to school for the afternoon. I was sitting in front of the black and white television and watching Bozo’s Circus when a serious (male) voice cut into the show.

“We interrupt this programing to bring you an important bulletin.”

I remember being afraid and confused. I recall pictures of adults crying. I stared at pictures in Life Magazine of the funeral procession with the riderless horse. I know that I was terrified for years every time a program was interrupted.

A whole generation of us knew exactly where we were and what we were doing the moment we heard of Mr. Kennedy’s assassination. It tied us together and started conversations. For better or worse, it gave us all a common moment in time – a touchstone – that could blend our experiences into one.

For decades, few other moments came close to a creating a moment which was so universally overwhelming. I was working on a project in a research laboratory at MD Anderson Cancer Center the morning the space shuttle Challenger exploded in 1986. Perhaps the experience was intensified because we were living in Houston at the time, and the television stations had many opportunities to explore local angles. Despite the passage of 23 years since that day in 1963, the sadness rolled over us as it had so long ago.

On September 11, 2001, I was performing surgery when one of the anesthesiologists popped into the room to tell us that the first tower had been hit by a plane. A few minutes later, he returned to tell us about the second plane and, not long after that, he brought news about the attack on the Pentagon. I begged him to stop. I needed to concentrate on my patient and his surgery. The sense of shared grief, which would certainly come, just had to wait.

Just wondering...

2009-05-29T10:50:00.001-05:00

So, if you are certain that God loves you more than God loves me, does that make you a gracist?

Palliative Grand Round is Up at Pallimed

2009-02-04T23:39:00.004-06:00

The inaugural edition of Palliative Care Grand Rounds is up at Pallimed. Christian Sinclair has compiled a remarkable assortment of posts by palliative care workers, patients, and family members. Rounds will be posted monthly.

For those of us who are from outside of the Palliative Care world, these posts provide a fascinating look behind the curtain.

Pass the word!

Writing but Not Posting

2009-01-14T22:20:00.003-06:00

Our electronic medical record is great! No, really, I mean it. I love the clarity it provides and I love having all of my colleagues' notes available. Since I am spending my evenings preparing my own progress notes, the turn-around time from appointment to outgoing letter is only a couple of days! That is what the system is supposed to do.

Still...

As the new system takes over my life, I find that I am writing less, journal-writing less, emailing less. I guess I get only so many keystrokes in my day before my fingers say, "Enough!" For example, one of my New Patient Consultation notes this week was 1100 words. That's enough for a couple of blog posts.

So, if blog volume is slowing down, maybe it is because my keyboarding duties are picking up. As the medical record transition settles down, I hope my writing returns to the more creative.

One-Trick Pony

2009-01-08T16:46:00.004-06:00

Every once in a while, I get interviewed. Yesterday, it happened once again.

About noon on Wednesday, just as I was finishing seeing patients in clinic, I received a call that a local TV station wanted a doctor to talk about the dangers of cancer patients continuing to smoke.

"Why are they interested in that right now?" I wanted to know.

"Patrick Swayze is being interviewed by Barbara Walters tonight on ABC. He is still smoking and has no intention of giving it up. Can you talk to them?"

"Sure," I said. We made arrangements. A couple of hours later, I spent 10 minutes talking about several aspects of the problem: How patients who quit have better survival statistics, how quitting decreases rates of second primary tumors, how quitting saves money, how quitting improves quality of life, how reassuring quitting can be to family and friends. It was a nice discussion. As ususal, only about 10 seconds of the conversation made it on the air.

I reflected on the experience. First of all, the process of giving an interview is fun. I enjoy the chance to appear on TV in the same way I enjoy the blog: it gives me the opportunity to reflect on what I see every day and distill my thoughts into a few words.

On the other hand, I realized that every time I have been on TV or get quoted in the paper, I become the dreary voice of authority: Smoking is Bad. Cancer is Bad. Research is Good. Snuff is Dangerous. Cigars are Not A Safe Alternative.

Not the stuff of comedy, irony, or light conversation.

I still got a kick out of seeing myself on TV last night and am amazed how many people spotted my brief moment on the air. Someday, though, it would be fun to talk about something a little less - say - predictable.

2008 Medical Weblog Award Finalists Announced

2009-01-07T11:18:00.005-06:00

My other blog (Reflections in a Head Mirror) is a finalist for the 2008 Medical Weblog Award in the "Best Literary Medical Weblog" category! Thanks so much to previous winner Ramona for the nomination. I have really enjoyed visiting the other sites on the list. There are some truly amazing stories and gifted writers represented.

If you are interested, voting will take place for the next couple of weeks at the links found here.

It's an honor to be included in a list like this! May the best blogs win!

Best Medical Weblog
Clinical Cases and Images
Clinical Correlations
The Health Care Blog
Kevin, M.D.
WSJ Health Blog

Best New Medical Weblog (established in 2008)
Laika's MedLibLog
Life in the Fast Lane
medtechinsider
The New Health Dialogue
Science-Based Medicine

Best Literary Medical Weblog
Notes of an Anesthesioboist
On The Clock
other things amanzi
Reflections by Dr. Bruce Campbell
Running for My Life: Fighting cancer one step at a time

Best Clinical Sciences Weblog
Clinical Cases and Images
Clinical Correlations
scan man's notes

Best Health Policies/Ethics Weblog
Better Health
The Last Psychiatrist
Stuart Laidlaw's Medical Ethics blog
Medical Futility
Respectful Insolence

Best Medical Technologies/Informatics Weblog
AppleQuack
Clinical Cases and Images
Life as a Healthcare CIO
medtechinsider
Ted Eytan, MD
TomographyBlog

Best Patient's Blog
Alin's Site
Beating Social Anxiety
Brass and Ivory: Life with Multiple Sclerosis
ButYouDontLookSick
Confessions Of A CF Husband
Duncan Cross
Furious Seasons
Look Me In The Eye
Running for My Life: Fighting cancer one step at a time
Six Until Me
Soulful Sepulcher
Survive the Journey

SurgeXperiences 214 is Up!

2009-01-05T16:57:00.005-06:00

I spent too much time on it, but it was fun!

SurgeXperiences is a collection of surgically-related blog posts and internet articles that is published every two weeks. I was given the opportunity to compile the "blog carnival" this week.

Blog compilations such as SurgeXperiences and Grand Rounds tend to have a theme. I had been thinking about Joyce Kilmer's poem, "Trees" for several days and decided to build off of that. Happily, the use of verse runs in the family. My mother always seemed to come up with a rhyme when the occasion called for it. I always thought the poems were silly, but, in keeping with the "tree" theme, I guess the apple did not fall far away, did it?

Stop by for a visit at this link.

The Christmas Poster

2009-01-02T21:32:00.008-06:00

We have one more task to complete now that the holidays are behind us.

Several years ago, we began a post-holiday tradition. As we look at the greeting cards for the final time, we gather all of the photos together. The pictures are trimmed and glued to a poster board. We focus on the faces of friends and family. Amazingly, each year the photos we receive just barely fill up the poster board. The board is hung on its own nail on a door in the kitchen where it will stay until the next Christmas.

Represented on the board are relatives from all around the country. There are several current and dearly missed former neighbors. There are friends and aquaintences from school and work. There are several people we haven't seen in years and pictures of many kids that we have never met. To be honest, there are some people pictured that we might not even stop and see if our travels took us through their towns. On the other hand, there are many people with whom we would love to see again and get lost in a long all-night conversation.

A couple of times each week throughout the year, I scan the photos on the board. Sometimes, a relative or friend will come up in conversation and we will look at their photo. Sometimes, I just like to remind myself of how fortunate I am to have known some terrific folks.

Each photo evokes a distinct memory or sentiment. I am so grateful for these people and enjoy having their images close at hand year round.

Llamas

2008-12-31T08:00:00.006-06:00

For many years, I cared for a gentle and generous man who lived most of the year in Peru. He served as a teacher in a school for indigenous people. On most of his visits back to the States, he would bring small souvenirs.

On one occasion, he presented me with a small bronze statue of a llama carrying hoppers full of copper. The little creature has lived in my office ever since, proudly standing among several other mementos from patients. I smile and remember my patient and his stories whenever I see the llama.

Recently, I was honored to be given a "Golden Llama Award" by Dr. Rob at Musings of a Distractable Mind. Golden Llamas are awarded because...well, um...just because. I was surprised and delighted to be recognized.

So, now I have two llamas, one bronze (pictured here) and one gold (on the sidebar). Both are fun and both are very much appreciated. Thanks to my patient and thanks to Dr. Rob.

Faked Memoirs

2008-12-30T10:51:00.009-06:00

Disappointing.

At the bottom of the sidebar to this blog is a list of books that I have enjoyed. One of them is "Left to Tell," an amazing story of survival and forgiveness in Rwanda during and after the 1994 genocide. I was moved by the story as I prepared to visit Tanzania in March.

A wonderful blogger and MCW graduate, Mary Rose Buckler, MD, brings some insight into the story...turns out much of the book is fabricated. Her post delicately hints at the details.

How sad! Just like the recent pulling of the faked memoir "Angel at the Fence," I would like to think that "Left to Tell" was written to make a point and to bring hope, rather than to cash in on an opportunity. It is hard to believe that there wasn't a story that would have moved people without fabricating any of the details.

Other recent fraudulent memoirs are listed here.

None of us is perfect, our cultural standards of "truth" differ, and our memories are subject to erosion. Still, as a person who writes a bit, I feel nothing but sadness for these discredited writers whose hard work went to waste.

Call for Submissions: SurgeXperiences 214

2008-12-23T09:46:00.003-06:00

I am honored to be the host of the next edition (214) of SurgeXperiences! This is a “Blog Carnival” of blog postings that are related, however tangentially, to surgery and the surgical experience. The post will go live on January 4, 2009.

Everyone is welcome to submit, whether you are a physician, nurse, technologist, videographer, quilter, llama lover, patient, or friend of any of the above.

I will host SurgeXperiences on Reflections in a Head Mirror.

I will try to be a clever host, but, given the holidays and the need to recover from all of the potential meals and celebration, we will just have to wait and see what happens. If you want to submit, click on this link to go to the submission page.

Submission deadline: Saturday, January 3, 2009

I will put this message on my main blog next week, but wanted to give my three readers a heads up.

Passwords and the Aging Process

2008-12-08T14:20:00.006-06:00

I am clearly aging. When I started working at my present job in 1987, our department had no computers at all, and, therefore, no password-protected security. Back in those days, I had no problem learning and recalling strings of numbers (credit card numbers, ID numbers, etc.) and adjusted quickly when a number changed. I chortled when the professors balked.

Security in those days depended much less on technology. When I started, the three keys I carried (office, clinic, outside door) provided all of the security the department needed. There were no electronic strips in name badges, no passwords, and none of the ubiquitous cameras. A few doors had punch-button codes that everyone knew. The most secure areas on campus could be accessed by calling a friend and being "buzzed" through a door.

Security has changed; many systems now require passwords. For example, to get to the first screen of our new medical record system, I sometimes need to log in three separate times using two different log in/password combinations. Every important website I visit requires a different password. And, of course, just when I finally get them all in sync, a screen pops up that requires me to change one of them. I currently carry a list of over 70 log in/password combinations. Too often, I forget to write down a new password and get locked out after making too many attempts to access a site.

Fortunately for me, one bit of security has never changed. When I walk into the operating room dressing area to prepare for surgery, the lock on my OR locker is the same one that I used in high school gym class from 1968 to 1972. The lock still works fine. And, best of all, I can remember the combination.

I know I am getting older. I can no longer remember new log in/password combinations when they crop up. I write them down and hope I can find my list when I need it.

But, the day I can not get into my OR locker because I can't remember the combination will be different. That event will be mark the day when I realize it is time to call it quits.

The Last Word

2008-11-29T07:55:00.003-06:00

All would live long, but none would be old.
-Benjamin Franklin

I have known him for more than thirty years. Back then, he was a clever, accomplished 60-year-old. He was self-aware, well-versed, well-read, and well-travelled. He was rigorously honest, selfless in his actions, and generous with his time. He was engaged with friends and colleagues around the world. His self-deprecating humor was well known by his family and friends. At the time, he was about to finish a career which had combined his gifts as a beloved teacher, a respected leader, and a deeply spiritual intellect.

Just one thing annoyed me, though: It seemed that whenever a conversation had reached a stopping point and I had taken a couple of steps toward the door, he would invariably call out one more question. It happened all the time. With each question, I would turn back, finish the conversation again, and retreat out the door. Sometimes, this happened two or three times before he would let me go.

Over the years, I got used to this propensity of his. Sometimes, I found ways to distract him as I snuck out. (“Look! A huge bird! Right behind you!”) I am certain that, too many times, I rudely just mumbled an answer or pretended that I had missed the final question. I did not like being rude. Sometimes, though, it was the easiest way out.

Over the past year, however, Alzheimer’s disease has tightened its grip on him. He is pleasant and attentive. He can still play some card games with help. He answers questions appropriately when they allow an automatic response. His eyes still sparkle. He smiles when he gets a hug.

But - sadly - he no longer calls anyone back to ask just one more question.

Who would have thought that the loss of his spontaneity would be manifest by the loss of his ability to call someone back into conversation? Who would have thought that he would still be able to process and answer simple questions but no longer be able to create his own?

I think about what he has lost whenever we end one of our simple conversations and he sits quietly, watching me walk away.

Engage with Grace

2008-11-21T23:14:00.008-06:00

Medical blog writers around the world will be including the message below for Thanksgiving this year. Please take a look and consider discussing these issues with your family. Happy Holidays!

-BHC

We make choices throughout our lives - where we want to live, what types of activities will fill our days, with whom we spend our time. These choices are often a balance between our desires and our means, but at the end of the day, they are decisions made with intent. But when it comes to how we want to be treated at the end our lives, often we don't express our intent or tell our loved ones about it.

This has real consequences. 73% of Americans would prefer to die at home, but up to 50% die in hospital. More than 80% of Californians say their loved ones “know exactly” or have a “good idea” of what their wishes would be if they were in a persistent coma, but only 50% say they've talked to them about their preferences.

But our end of life experiences are about a lot more than statistics. They’re about all of us. So the first thing we need to do is start talking.

Engage With Grace: The One Slide Project was designed with one simple goal: to help get the conversation about end of life experience started. The idea is simple: Create a tool to help get people talking. One Slide, with just five questions on it. Five questions designed to help get us talking with each other, with our loved ones, about our preferences. And we’re asking people to share this One Slide – wherever and whenever they can…at a presentation, at dinner, at their book club. Just One Slide, just five questions.

Lets start a global discussion that, until now, most of us haven’t had.

Here is what we are asking you: Download The One Slide and share it at any opportunity – with colleagues, family, friends. Think of the slide as currency and donate just two minutes whenever you can. Commit to being able to answer these five questions about end of life experience for yourself, and for your loved ones. Then commit to helping others do the same. Get this conversation started.

Let's start a viral movement driven by the change we as individuals can effect...and the incredibly positive impact we could have collectively. Help ensure that all of us - and the people we care for - can end our lives in the same purposeful way we live them.

Just One Slide, just one goal. Think of the enormous difference we can make together.

To learn more please go to http://www.facebook.com/l.php?u=http://www.engagewithgrace.org.

This post was written by Alexandra Drane and the Engage With Grace team.

The Gastrocnemius Muscle and the Cat

2008-11-19T21:58:00.008-06:00

All I do is eat and sleep. Eat and sleep. Eat and sleep. There must be more to a cat's life than that. But I hope not.
-Garfield

In early September, I walked into the bedroom just as the cat was leaving. I spotted a black item on the bedspread. This was upsetting to me. Our cat, who, by and large, is a well behaved, litter box-trained, somewhat autistic creature, has occasionally shown her displeasure with us by depositing evil things on the bed. It apparently had happened again.

I walked back to the family room looking for the perpetrator. There she was, looking innocent and resting (as always). "Bad kitty!" I announced. "Why do you do that?!" She regarded me coolly, refusing to make eye contact.

I bristled at her insubordination. I made a loud noise and moved toward her. She decided that I was a crazy person and took off toward the living room. I took a couple of quick steps after her in pursuit.

Suddenly, I felt a "pop" in the back of my right leg, as though something had hit me from behind. Then I felt the pain. Then I went to the floor.

I knew something was torn. I lay on the floor trying to self-diagnose the injury. One way or another, I knew I was going to be limping for a while. Kathi looked at me like the pitiable fool I can be and helped me into a chair. Ice, elevation, ibuprofen, rest. We knew the routine. This was not the first time I had done something stupid to my leg.

After I explained why I had been so upset with the cat, Kathi went to clean up the mess. She was back in a moment.

"Bruce?"

"Yes?"

"The mess on the bed?"

"Yes?"

"The thing on the bed was your pager. The cat didn't do anything."

"Really?"

Oh.

I eventually forgave the cat but she, of course, did not care. I did notice that during my period of immobility, especially in September and early October, I had more time to write posts for this blog because, especially during those first six weeks, walking was uncomfortable and running was impossible. Now, ten weeks after the injury, I am just now using the treadmill in the bedroom.

Sometimes, when I am running, the cat comes to watch. I occasionally catch her looking smugly at the bedspread. I am certain that she is gloating.

Blogging as a Way to Quench the Fire

2008-10-19T22:42:00.007-05:00

Write as if you were dying. At the same time, assume you write for an audience consisting solely of terminal patients. That is, after all, the case.
-Annie Dillard

There are days when I just cannot wait to pull out the laptop and begin working though a new topic for an essay or blog entry. The urge to write is unpredictable; I might hear a story, read an essay, or bump into an idea during a conversation. The urge forces me to confront and wrestle with the new concept until I have made it my own.

I always blamed this urge on my suspicion that I have at least a little Obsessive Compulsive Disorder within. A better (or, at least, alternate) explanation emerges from a recent interview with Poetry Magazine publisher, Christian Wiman. Mr. Wiman talks about how the writer (in his case, the poet) finds relief only when he or she completes the work:

“If you have that particular fire in your head (to paraphrase Yeats), it’s going to play practical havoc with your life. It’s going to require a lot of the emotional energy that you might be giving to other people, it’s going to afflict you at odd and unpredictable times, and it’s going to afford no compensation except for the sweet relief you feel when, as a poem finds its form, that fire goes out. What a relief that is, though, and how close to the very center of being itself you can feel at that moment.”

Despite my amateur status in the writing world, I have known the anxiety of an undeveloped thought. Now I also know that I am not alone.

"Please Hang Up and Dial 9-1-1"

2008-10-15T19:20:00.013-05:00

How we spend our days is, of course, how we spend our lives.

-Annie Dillard

I spend hours and hours each week waiting.

I wait for computers to boot up. I wait for computer screens to load. I wait for programs to ask for and accept my user name and password for the umpteenth time so I can view a CT scan and then re-enter a different user name and password to retrieve the patient's phone number. I stay near phones and wait for people to return pages.

I know, I know...not everything can be instantaneous. There are millions of electronic baby steps that need to be repeated each time I complete typing in my password and hit “Enter.” Maybe someday, my son, the computer engineer, will solve that one.

However, there are things that make me wait that seem completely unnecessary. Consider the phrases below that you each have heard (and waited through) thousands of times:

“Thank you for calling Dr. Bob’s office.”

(I suppose that phrase is okay. It’s nice to know that I reached the correct number. And that they are polite.)

"Our regular business hours are 8:00 to 4:30 Monday through Friday."

(I check my watch, knowing full well it is 10:00 a.m. on Thursday.)

"If you are hearing this message during business hours, it means we can’t get to the phone right now."

(Duh.)

“If this is a medical emergency, please hang up and dial 9-1-1."

(How stupid do they think I am? “I’m bleeding to death here!!! Any quick advice??? Can you squeeze me in today and sew my arm back on??? Gawd, I hope you are taking these calls in the order they were received!!!”)

“If you know your party’s extension, you can enter it at any time.”

(If I knew their extension, whether they are at a party or in their office, I wouldn’t still be listening to the recording.)

“If you don't know your party's extension or if you have a rotary phone, please stay on the line. We will be with you shortly.”

(Rotary phone??? Are they kidding? Who has a rotary phone? And what if it’s an emergency? Am I supposed to both hang up AND dial 9-1-1 on my rotary phone? While I'm bleeding to death??? I’m so confused…)

“Otherwise leave a message after the tone...”

I once had an administrative assistant who finished her message with, “... and I’ll get back to you at my earliest convenience.” At HER earliest convenience? I asked her to change that.

I wish I could live a whole week where I never had to wait for a computer to boot up, for a password to clear, for a page to load, for an operating room to turn over, for a person to answer a page, or for a recorded message to get to the beep.

Or else I wish I could learn to discover some form of regenerative and meditative peace in those endless delays where my life seems to slip away from me one wasted moment at a time.

Technology in the Wrong Place

2008-10-13T23:29:00.006-05:00

Listening is such a simple act. It requires us to be present, and that takes practice.
-Margaret J. Wheatley

A few years ago, I stood in the back of the medical school’s stadium-style lecture hall as a friend spoke to the room full of students. Of the 200 in the audience, maybe a couple of dozen had their laptops open and, from what I could see, few of the screens featured anything relevant to the topic being presented.

This seemed odd to me. These medical students were paying thousands of dollars each semester to be in that room. A world’s expert was in front of them, sharing her passion in a once-in-a-lifetime entertaining encounter covering a subject she knows well and for which she is a gifted instructor. Nevertheless, some of these students had chosen to spend the class time playing games, working on other projects, or checking their email.

A relevant essay appeared this week on the New York Times "Lesson Plans" website. In an essay entitled “Putting Technology in its Place,” high school teacher Matthew Kay writes about competing with his students' laptops in the classroom. The students “…struggle against the frequent distractions popping into their view. Not long ago, students would ball up scraps of notebook paper and pass them around the room. They now instant message three friends at once. Boys would tuck copies of Sports Illustrated under their textbooks — now they open another tab at SI.com.” He notes that “[t]he sternest words in my arsenal are ‘Screens Down.’”

Of course, distractions have always been available. I’m certain that the students gathered around the Greek sages of old drifted off by drawing lines in the dirt and finding patterns in the clouds. This seems different, somehow. Does the laptop, by its very nature a connection to “authority,” pose a new level of challenge to the teacher? I fear it does.

Next time I give a lecture, I think I will request “Screens Down” from the outset. And, you there, put your iPhone in your pocket, will ya?

SurgXperiences 208 is Up at Suture for a Living

2008-10-12T18:11:00.002-05:00

A great collection of surgery-related posts is cataloged in SurgXperiences at Suture for a Living. Once again, Dr. Bates does a terrific job of finding, compiling, and explaining.

A Chill in the Blogosphere

2008-10-09T21:57:00.002-05:00

My mother used to say, "He who angers you, conquers you!" But my mother was a saint.
-Elizabeth Kenny

Dr. Wes’s recent hassles with an anonymous blog comment writer gave me flashbacks of two very unfortunate incidents that happened to physicians I have known.

Several years ago, a woman died of cancer and her son blamed the physicians, one of whom happened to be a friend of mine. The son called and screamed at the doctor, threatening her and her family. He knew where the doctor lived and the names of her family members. The doctor and all of us who worked with her were shaken by the experience. One day, a package arrived. Inside, the physician found a body bag like the ones used by mortuaries. Fortunately, time passed and nothing happened. The memory, though, remains.

Another story had a more tragic outcome. Dr. John Kemink was a well-known and respected ear specialist at the University of Michigan. I met Dr. Kemink when I took an ear surgery course in Ann Arbor during my residency and found him to be a friendly person and a terrific teacher. In 1992, an unstable patient became convinced that Dr. Kemink and another physician were conspiring to perform an operation on the patient designed to kill him. The man brought a gun to the hospital and murdered Dr. Kemink in the clinic. It was an incredibly senseless act of violence that the patient apparently viewed as retaliation for a perceived wrong.

No one of us is perfect, of course, and conflicts will always occur. Still, you sure hate to see folks that you respect targeted by angry, unhappy people. It takes a long time for everyone to recover. We're all pulling for you, Dr. Wes.

Grand Rounds

2008-10-07T16:53:00.002-05:00

Grand Rounds is up at M.D.O.D.

Things That Wear Me Out

2008-10-03T21:20:00.006-05:00

In ascending order, here are the work-related things that have worn me out recently:

Sort of tiring, but exhilarating:

Spending the entire day in the operating room.

Sometimes difficult, but not too bad:

Spending two hours making patient-related phone calls.

Truly tiring:

Spending all day in clinic.

Tiring and also painful:

Spending two hours dictating the charts of the day in clinic.

Absolutely exhausting:

Spending all day teaching six periods of high school health class on the dangers of smoking.

I really respect teachers. How do they do it?

Learning to Drive

2008-09-30T22:58:00.006-05:00

I have helped teach four kids to drive a car. I have trained sixty otolaryngologists to operate. Both are daunting tasks that I have taken seriously.

In learning to drive, the kids were always straining at the bit. They wanted to go a bit faster, a bit more enthusiastically, and a bit more carelessly than I would have prefered. I would turn off the radio, confiscate the cell phones, forbid distractions, and talk about the finer points of driving a car as they drove.

As we moved through the kids, the state laws became more strict about mentored driving, night driving, and not having non-family members as passengers. I agreed with the changes.

The kids, of course, thought I was nuts. They were ready to drive well before I was ready to let them.

"C'mon, Dad! I have been driving for a whole month! Let me take the car!"

I would try to explain my anxiety by drawing on my experience teaching surgery:

When a new resident starts training, he or she spends a lot of time observing. This goes on for many months. He or she begins by performing simple portions of procedures under absolutely strict observation.

As they become competent, the residents are allowed more and more responsibility, still under the watchful eye. Even when they are almost ready to graduate and begin to practice on their own, they are scrutinized, evaluated, and corrected. It is a long process.

My point to the kids was always this:

Driving a car is a lot like learning to be a surgeon. No matter what you might believe, you begin by being completely incompetent; neither driving nor surgery is intuitive. You learn incrementally and develop skills. You find out how to get out of jams and tight spots. You learn to anticipate what might happen and make adjustments. You develop the ability to to plan three or four steps ahead.

The biggest difference? In surgery, the training takes five to seven years and you can only harm one person at a time. Why should driving a car, with so much potential to destroy so many more lives simultaneously, take any less time to learn?

The kids would just shake their heads.

Quilting

2008-09-28T21:44:00.011-05:00

Over at “Suture for a Living,” you will often find a quilt, because the author is both a plastic surgeon and a quilter. Today, I have a quilt on my blog, as well.

This is a quilt that includes all of the names of members of White Oak Presbyterian Church, the country church in southwestern Missouri to which my great-grandparents, and later my grandparents, belonged. The quilt is dated November 6, 1897.

Missouri was a border state during the Civil War and a major battle was fought in Carthage, Missouri, about twenty miles from the site of my great-grandfather’s homestead. The memories of the war were still fresh, as evidenced by the flag of the Confederacy in the center of the quilt.

The quilt contains the stitched names of the church members, including my great-grandfather, George, my grandfather, Harold, and his twin brother, Warren. My grandfather would have been nine years old at the time. My grandmother’s family, the Briggles, are also represented since theywere also members of the church.

The church membership dropped after World War II as farming and rural life changed. The congregation is no longer active and the building was recently sold. Running my hand over the carefully-placed hand-stitching reminds me, however, that the quilt remains intact and is as vibrant as the day it was completed.

Disparities

2008-09-24T08:53:00.004-05:00

It is impossible for a man to learn what he thinks he already knows.

-Epictetus

Every once in a while, you learn something about yourself you would rather not learn.

I consider myself to be an open, compassionate, and caring physician, not unlike most physicians. Oh, sure, there are times when I don't spend the time necessary for a complete understanding of a patient's problem, and, of course, there are other times when I don't know how to negotiate the barriers between a non-English speaking patient and myself. Still, my training and background equip me perfectly for working with patients from all backgrounds, right?

This week, while at the annual meeting of physicians in my specialty, I attended a session entitled, “Cultural Competency, Health Literacy, and Health Disparities.” The presentations opened my eyes.

There is no secret that people of color, the underinsured, and the disenfranchised in the US have higher rates of cancer, poorer survival, and delays in accessing the health care system. This was reinforced by the data presented.

What shook me was that we physicians are both knowingly and unknowingly complicit in this disparity. One study of California physicians indicated that, given the same indications for tonsillectomy in a child with commercial insurance and one with Medicaid, the physicians would be less likely to offer the procedure to the child with Medicaid. Despite this, a national survey found that we believe that we treat all patients equally, regardless of insurance status. Obviously, these findings are at odds with the other. It is possible that we are lying to ourselves.

A recent study in my specialty demonstrated that the vast majority of surveyed physicians were not familiar with the term, “Health Disparities.” As I listened to the discussion at the meeting, it seemed apparent to me that we need to not only make middle-aged white male physicians (like me) more effective, we must enlarge our ranks with physicians who come from the affected cultures.

Attracting people into a specialty, especially one that is encountered by only a fraction of medical students is a challenge. By being intentional, however, Otolaryngology has become a surgical “specialty of choice” for an increasing percentage of women over the past 20 years. Given the discussion after the presentation, I hope we will strive to make it a specialty of choice for people of color, as well.

Grand Rounds

2008-09-24T08:30:00.004-05:00

Grand Rounds 5.1 is hosted by Dr. Val, a recently URL-challenged PM&R physician of many talents. She is a blogger extraordinaire and shoulder-rubber of people in high places. You can find Grand Rounds here.

Uncertainty

2008-09-18T23:02:00.004-05:00

Medicine is a science of uncertainty and an art of probability.
-Osler

The cancer had been treated several years before. No recurrences and no new problems. Still, his wife remembers all of the details.

"I was really scared when we learned he had cancer," she reminds me. "It was a terrible time."

I remember, as well. There were many phone calls, anxious appointments, consultations, and questions. And there was one significant delay.

"Remember how long we had to wait for his surgery, Doctor? That was so horrible!"

Yes, I do remember. I had squeezed in his initial appointment on an off-clinic day just before I was going out of town for a much-anticipated family vacation. Before I left town, I had arranged his evaluation and had set everything up. There were plenty of instructions to provide and appointments to confirm. Still, my vacation had ended up delaying his surgery by several days. I could not deny that.

"Oh, Doctor, I was so certain that the cancer would have grown too large for surgery by the time you got back into town! I was certain that he would die!"

I had spent time reassuring her then, and I try to reassure her now. My usual discussion runs along these lines:

"By the time a cancer is big enough to be seen, it has usually been growing for several months. A delay of a few days should not matter." Still, I knew then and know now that tumor growth rates in a laboratory Petri dish might be different than in an individual.

She looks at me again. "Doctor, are you absolutely certain that he will be all right?"

Her question reminds me once again of that wonderful family vacation – and the few days’ delay in her husband’s surgery – that had occurred years ago. Not knowing with absolute certainty, I smile and assure her that he will continue to do just fine.

Grand Rounds

2008-09-16T10:15:00.003-05:00

Here is a link to this week's medical blogosphere Grand Rounds at Nurse Ratched's Place. Check it out for the great antique photos and devices. My post is the very last one on the list!

Best for last? or Listed by quality of writing? You decide...

PIN Night

2008-09-15T20:49:00.009-05:00

We went to PIN Night at the high school last week to follow our youngest child’s class schedule, meet her teachers, and hear about her upcoming year. (“PIN” stands for “Parent Information Night,” so I guess we went to Parent Information Night Night.) Because our oldest started grade school in 1988, this was our 20^th year of PIN Nights. These events are important venues for understand grading policies, classroom rules, and curriculum objectives; I applaud the school district employees for the time and effort it takes to mount these events each year.

However, as my lifetime of attending these events is drawing to a close, these are the things I will actually remember about PIN Nights:

- When I started attending PIN Nights, most of the other parents looked REALLY old. Now most of them look REALLY young.

- The teachers always looked young. Now a lot of them look even younger.

- At each PIN Night, I realized that many of the classes sound really interesting; This year, I wish I was the one taking Environmental Science, AP Biology, French, or World Literature.

- PIN Nights have reminded me that I remember next to nothing of the math I took in school. I don’t even understand the stuff posted on the walls in the math rooms. The calculators have too many buttons.

- PIN Night shows me how schools have changed – more technology, more expertise among the faculty, more services, truly outstanding music programs, and more awareness of individual differences

- PIN Night also reassures me that a lot hasn’t changed.

As we sat in one of the classrooms last week, I scanned the blackboard looking at all of the reminders, assignments, and information. Most of our kids have had this teacher in this classroom; I once spoke to students in this room about what I do for a living. The room reflects the educator who works within its walls – as I listened to the presentation, I sensed again that students passing through this place experience high expectations and stringent standards. I was able to sense how intimidating that could be for a kid, yet very rewarding.

But, of course, we are done with PIN Nights. Now, we are experiencing college parent orientation events. Unfortunately, college events just aren't quite the same as PIN Nights. Fortunately, the college parents still look REALLY old - at least for the time being.

“Healing the Doctor Patient Divide”

2008-09-13T09:19:00.001-05:00

The New York Times Health Blog “Well” edited by Tara Parker-Pope, published an article by Pauline W. Chen, MD this week. Dr. Chen, author of the best selling book, Final Exam: A Surgeon’s Reflections on Mortality, will write a new online column in the Times called “Doctor and Patient.”

The premise of Dr. Chen’s essay is that we “all want the same thing: the best care possible. But we have lost the ability to converse thoughtfully with one another. And because of that loss, we can no longer discuss the meaning of illness, care, health and policy in a way that is relevant to all of us.” She hopes that building an online community will bridge the gap.

If the readers’ initial reactions are any indication, she has struck a nerve. The first 300 comments range from patients ranting about bad personal experiences with physicians focused entirely on wealth accumulation to physicians ranting about a system that has screwed them. This is a target-rich environment: everyone from government to medical schools to HMO’s to insurance companies to lawyers to the economy to primary care reimbursement to societal breakdown is to blame. Solutions are rare.

I’m not certain that this forum will build community, but it makes interesting reading. I look forward to her columns.

Choosing a Specialty

2008-09-11T23:14:00.007-05:00

The most difficult thing is the decision to act.
-Amelia Earhart

When I was in medical school, I had to choose a specialty. Because I liked everything and because I worked in a hospital with a Family Medicine residency program and had gotten to know and respect all of the trainees, I was certain that I would go into Family Practice. I was even in the Family Practice Interest Club at my medical school. I was certain of my career path.

Then, I rotated through Obstetrics.

Suddenly, I was not so certain. I did not like delivering babies. When deliveries go well, they are great. But, occasionally, things go very wrong. Besides, babies can come any time of the day or night. They even had a faculty call room on the OB ward in the hospital. Ugh.

So – now I liked everything except OB.

What is Family Medicine minus Obstetrics? Right! Primary Care General Internal Medicine! This looked perfect. Continuity of care, lots of time to meet people (or so it seemed at the time), and no Obstetrics. Ideal.

Then I rotated as a Surgery sub-intern. I realized that this would be my final surgical rotation in school. I would never be in the operating room again! I had loved the OR – its energy and the excitement. Realizing that I would never again be in that environment made me both sad and ripe for suggestion.

A couple of days later, an ENT surgeon asked me what specialty I was pursuing. “Internal Medicine!” I responded proudly. “Do you like diabetes and hypertension?” he asked. “I dunno. I suppose,” I responded hopefully. He just stared at me. “You go into Internal Medicine and you will spend the next 35 years of your life just taking care of those two diagnoses!!!” He turned on his heel and walked away.

Needless to say, this was disconcerting. What if he was right? I paused, trying to figure out exactly why I had ruled out a surgical field in the first place. Then I remembered: At 6'2", I could not find scrub clothes that fit. I was not going to spend the rest of my career wearing scrub pants that were too short!

“I think I can get over that...” I thought to myself.

A few weeks later, I was in an Otolaryngology residency program and I have never looked back. Once in a while, though, I happen to look down, and sadly realize that my scrubs pants are still chronically too short. Maybe no one has noticed.

Bear in Mind…It’s Wednesday

2008-09-10T11:46:00.012-05:00

What you leave behind is not what is engraved in stone monuments, but what is woven into the lives of others.
-Pericles

I was rummaging through our rag bucket of old shirts, towels, and sheets a while ago. Out came a faded dish towel with a hard working needlework bear and the phrase, "Bear in mind...it's Wednesday." I looked at it for a minute.

I had seen this towel many times before. There used to be an entire set of them, one for each day of the week. The needlework was done by my father’s mother’s brother’s wife (get that? My great-aunt) many years ago. Given the fact that she was in her prime in the 1920’s, the piece of cloth in my hand was lovingly decorated at least 70 years ago.

Now it’s a rag. Should we regard it as a family heirloom? Should we find a way to display it and preserve it?

Perhaps.

Still, I am certain that touching the rag prompts me to stop and remember my Great-Aunt Helen much more frequently than I would if the towel had been lovingly folded and stored in a chest of drawers. Both the rag and our memories of a long-departed relative still have tasks to perform in our home.

Informality

2008-09-08T21:25:00.005-05:00

Saying thank you is more than good manners. It is good spirituality.
-Alfred Painter

This is an announcement of sorts. For the past several years, I have persisted in a routine. Here it is:

Wait staff: “Do you guys have any questions about the menu?” (Kids look at me and smirk)
Me: “No. I think we are ready to order.”
Wait staff: “What can I get you guys?” (Smirk.)
We order.
Me: “Can I have some iced tea, please?”
Wait staff: “No problem.” (Kids stifle grins and look at each other.) “Any of the rest of you guys want anything to drink?” (One kid pounds his thigh.)

After a couple more visits from the waiter or waitress, the check arrives.
Kids: “Dad, I counted six ‘no problems’ and five ‘you guys.’”
Me: “I think you’re right.”

You see, I have joked for years that my tip calculation would be adversely affected every time a wait person substituted a “you’re welcome" with a “no problem," and a personal greeting with a “you guys.” To be honest, the offense has never truly affected a tip, but it has been an unrelenting threat, one which the kids have perpetuated and enjoyed.

Nevertheless, as of today, I am retiring the threat. You think that is a good idea? You do? Well, no problem.

Reflections

2008-09-07T19:08:00.000-05:00

My blog "Reflections in a Head Mirror" was started in April 2007, and contains stories and reflections that have been generated by my medical practice as a head and neck cancer surgeon. That site is http://www.froedtert.com/reflections. I have enjoyed the blog for many reasons, but primarily since it has been a place for me to collect medical stories and reflect on how they have changed me. Sometimes, however, I have non-medical experiences or work-related events that deserve reflection but might not be appropriate for the "company" web site. Those observations will end up here.