Shout Outs

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. 

Doctor Fizzy is the host for this week’s Grand Rounds. You can read this week’s edition here (photo credit).

I attended my very first grand rounds as a third year med student. The talk was given by my former pathology professor to a large auditorium packed with students, residents, fellows, and attendings. I don't remember the topic of the lecture, but I do remember this:
Midway through the lecture, the professor called on me. In an hour-long lecture, he called on one person out of 200 in the audience, and somehow that person was me. I almost choked on my cinnamon-raisin bagel.   ……..

All in all, not my favorite grand rounds.

But this week's grand rounds are going to be awesome. I'm dedicating it to all the medical trainees that got humilated during lectures, pimped during rounds, or tried to answer three beeping pagers at once.  ……….

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H/T to @medrants who twitted  “Practicing Medicine Can Be Grimm Work - http://nyti.ms/kveFkD -  a beautiful op-ed from one of our med students”  

The NY Times Op-Ed piece is by Valerie Gribben:  Practicing Medicine Can Be Grimm Work

TODAY, after four arduous years of examinations, graduating medical doctors will report to their residency programs. Armed with stethoscopes and scalpels, they’re preparing to lead the charge against disease in its ravaging, chimerical forms. They carry with them the classic tomes: Harrison’s Principles of Internal Medicine and Gray’s Anatomy. But I have an unlikely addition for their mental rucksacks: “Grimm’s Fairy Tales.”………….

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Robin Young, Here and Now/NPR, interviewed Francesco Pia last Wednesday: What You Don’t Know About Drowning

……Lifeguarding consultant Francesco Pia has some advice for the summer about drowning. He worked as a lifeguard in New York’s Orchard Beach, and he made a documentary called “The Reasons People Drown,” that challenged a lot of misconceptions about drowning. He found that:

1.) Drowning is often silent: …..

2.) Drowning happens very quickly: ….

3.) Drowning often happens when people are around others: ….

Remember Drowning Doesn’t Look Like Drowning

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Check out this great advice from the Better Health post:  The Right And Wrong Ways To Strengthen Your Core Muscles

What do slouching, back pain, and a middling forehand or weak shot off the tee have in common? Often it’s a weak core—the girdle of muscles, bones, and joints that links your upper and lower body. Your core gives you stability and helps power the moves you make every day……..

Core Exercises: 6 workouts to tighten your abs, strengthen your back, and improve balance is available from Harvard Health Publications. You can read an excerpt here from the report with tips on checking and improving your posture. ……..

Core Exerise #1: Plank

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I’ve always been concerned about the number of drugs some patients have to take. The risk of side effects and bad interactions increases with each addition. H/T to Dr. Elaine Schattner (@medicallessons) to the link to this Scientic America article by Laura Newman: Overprescribing the Healthy Elderly: Why Funding Research and Drug Safety is Paramount

My frail, 92-year-old mother was prescribed 80 mgs of the cholesterol-lowering drug, or statin, simvastatin for years. She fell four times in the last four years of her life: the last fall was the least forgiving. Doctors diagnosed her with rhabdomyolysis, a life-threatening condition, and acute kidney failure; she was dead within 8 weeks. …..

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Dr. Sanjay Gupta speaks with Paul Stanley (KISS) about microtia and how he has dealt with it himself.

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Sarah McFarland, Threads Magazine, has a piece announcing: “Show Your Support" and Embellish a Bra (photo credit)

The 2011 American Sewing Expo is coming right up - September 23-25 at the Suburban Collection Showplace in Novi, Michigan…..

A staple exhibit at ASE is the annual entries in the "Show Your Support Bra Challenge." Sponsored by Coats & Clark and BurdaStyle, the contest showcases some amazing lingerie decorated by the skills of sewers across the country…..

You can find the Show Your Support Bra Challenge full rules and the entry form online at the ASE site. Good luck, and good for you if you enter!

Happy 4th of July

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. 

I made cheesecake for the family cookout.  On the healthier side, I am also roasting corn-on-the-cob to contribute.
 

I would encourage you all to remember your sunscreen as you get up out of your chairs and head outside.   Watch out for the heat.  Be safe as you enjoy the fireworks.

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I wish you all could read this wonderful essay in its entirety:  Sleepless by Joshua Alley, MD in the June 22 issue of JAMA (full reference below).  It is an essay that speaks of how we treat our enemies

I thought about our enemies tonight, and why and how we physicians care for them.  ….

…, but the reason I went nearly sleepless that night is so that I can sleep all the other nights. It's essentially the same reason I take extra care with each patient at home. A common phrase in my operating room is “I do it this way so I can sleep at night.” I can go to bed knowing I cut no corners, I gave each patient the best possible chance at a good outcome. There are still bad outcomes, and I agonize over those, replaying each decision in my head afterward. But I did the best I could by each one.  ….

One mark of a civilized people is our response to wounded enemies. …… Yes, caring for our enemies consumes resources: helicopter flight time, ICU days, operating room hours, sleepless nights, expensive medications and equipment. Because we ought to. Because I’ll have to live with my actions. “Do good to those who hate you,” we read in Matthew's gospel. And tonight, I can sleep, because last night I didn’t.

 Happy 4th of July!  Thanks to all our military (active and retired) and their families.

REFERENCE

Sleepless; Joshua B. Alley; JAMA, 2011;305(24):2501-2502.doi:10.1001/jama.2011.863

Shout Outs

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. 

Kim, Emergiblog, is the host for this week’s Angry Birds issue of Grand Rounds! You can read this week’s edition here (photo credit).

Welcome to the Angry Birds edition of that weekly compendium of medical blogosphere goodness, Grand Rounds! I’ve chosen my addiction du jour, Angry Birds, as the theme for my 7th turn as host.

For those who are not familiar, Angry Birds is a game in which Green Pigs steal Bird eggs, causing the Birds to become angry, start screeching and begin catapulting themselves from sling shots in an attempt to destroy the Pigs, who house themselves in various structures and giggle at the Birds.

Got it?
Okay then! Let’s get started!  ………..

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Last Tuesday @EvidenceMatters alerted me via twitter to a panel discussion regarding Vitamin D “Vigorous panel talk: Boosting Vit D - Not enough or too much? Liveblog: http://bit.ly/gL9JuX Video: http://bit.ly”

The webcast of the panel discussion can be viewed here.

The consensus report:  Dietary Reference Intakes for Calcium and Vitamin D

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I caught part of this great  @radiorounds episode (#509) this past Sunday afternoon.  The episode kicked off “Donate Life” month and  focused on the topics of organ donation and the organ shortage crisis.  It aired live on April 3 and will be available on April 5 on their iTunes page!   

The featured guests included:

• Dr. William K. Rundell, Director of Transplant Surgery at Miami Valley Hospital in Dayton, Ohio and Clinical Professor of Surgery at the Wright State Univ. Boonshoft School of Medicine

• Dr. John Donnelly, Asst. Professor of Family Medicine at the Wright State Univ. Boonshoft School of Medicine… and a pancreas transplant recipient

• Dr. Alex Tabarrok, Professor of Economics at George Mason University and co-author of the economics blog Marginal Revolution

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Victoria (@vpmedical), Beyond the Bedside, wrote her own post in response to mine:    Hand Transplant vs. Prosthesis

…. As a life care planning expert in amputation injury and limb loss, I find hand transplantation somewhat disturbing.  I can appreciate the technology and biological advances that have allowed transplantation to occur. …….

One need only to review the case of Mr. Jeff Kepner, a bilateral hand transplant patient, to understand the concerns of such a procedure.  One year after his transplant he still regretted his life changing decision. In his words……….

Be sure to read the comment from Wolf on my post.  It is very insightful.

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Engadget had an article by Christopher Trout yesterday:  Bionic eye closer to human trials with invention of implantable microchip

We've had our eye -- so to speak -- on Bionic Vision Australia (BVA) for sometime, and with the invention of a new implantable microchip it's coming ever closer to getting the bionic eye working on real-deal humans. The tiny chip measures five square millimeters and packs 98 electrodes that stimulate retinal cells to restore vision. ……...

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A lovely essay on the origin of how human hair wigs are sourced, created and distributed by Julia Sherman:  She Goes Covered

Following the global hair trade, from the braid-laden Peruvian highlands to the sheitel machers of Borough Park.

I.     In the fall of 2009, Helene Rosen, her husband, Yoni, and eight of their eleven children moved from Baltimore to Cusco, Peru, to harvest human hair.1 Helene is a forty-four-year-old Orthodox Jew and self-proclaimed “master sheitel designer” who began making wigs fifteen years ago, for ten dollars an hour; her custom hairpieces now sell for up to two thousand. “You can bring me any wig,” she said this past winter, sitting at the table in her spare dining room in Cusco, “and I can tell you how old it is, how much it has been worn, and if it has ever been repaired. I can tell you everything about it.”   ……….

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Arkansas Literary Festival begins this Thursday (April 7-13).  One of the authors this year is the son of a long time friend (from college days, a fellow physics grad who now works for Lockheed Martin in laser research). 

Benjamin Hale is a graduate of the Iowa Writers Workshop, where he received a Provost's Fellowship to complete his novel, which went on to win a Michener-Copernicus Award. He has been a night shift baker, security guard, trompe l'oeil painter, pizza deliverer, cartoonist, illustrator, and technical writer. He grew up in Colorado and now lives in New York. The Evolution of Bruno Littlemore is his first novel.

To visit Benjamin Hale's website, click here

Hands -- Guidance and Germs

Updated 3/2017-- all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

Some interesting items this week involving hands.  The one which has gotten much news coverage is the issue of hand washing.  Take a look at some of the headlines:

High five! Hand washing on rise (Chicago Sun-Times)

For Many, 'Washroom' Seems to Be Just a Name (New York Times)

93% of women wash their hands vs. 77% of men (USA Today)

All the above are reporting on the same study, but the difference in presentation is amazing to me.

The above study doesn’t involve hand washing in a hospital or doctor’s office setting.  The JAMA article (2nd reference below) does, but this article focuses on whether public reporting of hand washing compliance is helpful or not.  Do we inflate our numbers to make ourselves look better?

Public reporting creates an incentive to maximize performance but does not specify the manner in which this is achieved. Broadly speaking, 2 approaches are possible. Hospitals can adopt evidence-based strategies designed to improve patient outcomes that will also improve the publicly reportable indicator, or they can adopt indicator-based strategies designed to improve the reported indicator that may not improve outcomes and may even cause harm. Evidence-based improvement strategies would be favored in an environment in which organizations focus on improving patient outcomes—when such strategies exist and are easy to implement. Conversely, indicator-based improvement strategies would be favored in an environment in which the hospital focuses on protecting its reputation, when evidence-based improvement strategies are unproven or resource intensive, or when measurement of the indicator is easily manipulated to show improvement. …

I wish copyright laws would allow me to reproduce the entire essay from a recent issue of JAMA (first reference below).  The essay is written by Ariela Zenilman about her father’s hands. 

Between the scrapes from paper cuts, the finger on which a ring is worn, and the color of nail polish, the hands of the human body tell a story. They are the most mysterious reflection of character. The hands ….. Surgeons are blessed with steady hands for a reason: they reduce the trembling in the hands of worried family members, counteract pain and destruction, and alter creation for the better by fixing fault and disease within the body. A surgeon has the remarkable gift of a set of multifunctional and dexterous hands.

I have always admired my father's hands. From a very early age I could tell his grace and dedication to detail were apparent in how he moved and touched, felt and experienced the world around him. …... His hands seemed inexplicably and effortlessly linked to his every thought: as a young child I always dreamed of having hands like his.…….

When I see my father's hands ……. His hands are a mere reflection of his heart, an attribute I hope to see in my hands as I follow in his footsteps.

…. Hands reflect ability, accomplishment, and passion. …………., I have learned to trust my instincts, follow my heart, and, most of all, not to underestimate the power of my own hands.

I love hands.  I have been in love with the anatomy and mechanics of hands since medical school.  Before then I just loved to watch them work (my mother making biscuits, my teacher’s writing, basketball players shooting baskets, pianists, etc). 

For the general public, wash your hands – flu season is upon us.

For us involved in patient care, wash your hands before and after each patient.  This is one (if not the best) of the best lines of defense in preventing the spread of infection.

REFERENCE

The Hands That Guide Me; Ariela Zenilman; JAMA. 2010;304(10):1049. doi:10.1001/jama.2010.1291

Public Reporting of Hospital Hand Hygiene Compliance—Helpful or Harmful?; Matthew P. Muller; Allan S. Detsky; JAMA. 2010;304(10):1116-1117.

Finger and Wrist Exercises (April 19, 2010)

The Plastic Surgeon Knows Best?

Updated 3/2017 -- all links removed as many no longer active. and it was easier than checking each one.

I tend to agree with what Dr. Robert Goldwyn had to say in this essay from his book “The Operative Note: Collected Editorials” (published in August 1992). 

The Plastic Surgeon Knows Best: 

A Hazardous Assumption

Two incidents, within four hours, seemingly disparate, were instructive nevertheless.  The first was in the barber shop, where I paid a long overdue visit.  The hair stylist – there are no more barbers left in the world – was a woman, whom I had not seen before.  She was one-half my age and a hundred times as attractive.  She was sitting in her own chair, brushing Lady Godiva length hair muttering that her friend – another “stylist” – had “ruined” her.

“She cut too much off,”  she said.

My fantasy was that her hair previously must have trailed like a bridal train.

This is a good sign, I told myself.  She will not prune me excessively, something that is easier to do with each year.  To my request for a “light trim,” she replied, “Don’t worry.  I’ll take care of it.  You’ll like the result.”

That last statement triggered an iota of apprehension but I gave myself over to her obvious charm and flying fiingers.  I must have dozed and awoke to a World War II soldier staring back at me from the mirror.  I look like an old recruit, perhaps a General Schwarzkopf but without his girth or tanks.

Then a more primal fear seized me.  Maybe my modern hair stylist was really an incarnated Delilah.  That thought sent my strength ebbing as I went to my car and then to the office – for the second incident.

This was a new patient, a twenty-eight year old writer, who was displeased with the outcome of her rhinoplasty done elsewhere.

“I told him that I wanted surgery only on the tip,” she said.  “I even wrote him a note to that effect and also specified it on the operative permit.  I couldn’t believe what I looked like when he took off the splint.  He had given me a total nose job.  When I protested and asked him what he had done to me during the operation, he got very angry and practically yelled, ‘It’s none of your business.  I was the surgeon and I know what is best for you.’ ”

Her plastic surgeon and my barber have forgotten that my hair and her nose belonged to each of us respectively and not to anyone else.  They also shared the same deficiency:  not listening.  But there is more involved:  namely, arrogance.  After they have finished with their work, we are left holding the result.  Of course, I do not equate my Marine hair cut with her new nose.  With God’s grace, in a few weeks I will regain what I had but she will not.

I believe it was Osler who advised us to listen to the patient because he or she will tell us what is wrong and if we listen longer, the patient will tell us what to do.  I am afraid that each of us occasionally ignores or forgets that verity.  The patient becomes somehow incidental to our treatment which we impose without proper regard for that person’s sensibilities and desires.

This phenomenon of not taking into meaningful account what the patient wants I have observed more among older practitioners.  Perhaps they feel that they are beyond the restrictions that usually apply to other plastic surgeons.  This kind of megalomania is not without possible severe repercussions  -- the kind that take place in a court room.

In our specialty, more crimes are of commission than omission.  fewer problems result from doing less than from attempting more.  One would think that the older plastic surgeon would appreciate doing less in order to conserve his or her strength.  Maybe the issue is one of routine:  performing “the operation” instead of the right operation.  The patient who receives more than he or she requested is about as grateful as the diner who was served Beef Wellington when he wanted a green salad.

 

When breast augmentation and reduction patients ask me what size they should “go for.”  I tell them my opinion, but also tell them they should decide “what they want.” 

I have been known to use the example of me making them a dress in a lovely green silk.  The dress fits perfectly, the color suits their skin/hair/eye coloring, BUT I find out too late they hate the color green.

So while it is my duty to listen, my patients must tell me what they want.  Then we can have a discussion about whether it is possible, etc.

Goldwyn’s Laws of Plastic Surgery

Updated 3/2017 -- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.


Another thoughtful essay from Dr. Robert Goldwyn’s book “The Operative Note: Collected Editorials” (published in August 1992).  I left out the section between the third paragraph and the “plastic surgery laws”  as they were general day to day ones.

Laws of Plastic Surgery

We pitiful human beings, born not of our will, are thrust into this world, which throughout our lives we try to comprehend.  To make sense of our existence, we seek the verities; we try to formulate laws of earthly happenstance and human behavior – basic tenets akin to the laws of gravity and energy.  Take, for example, Benjamin Franklin’s fundamental:  “…in this world nothing is certain but death and taxes.”  And closer to our time is the observation of Professor Parkinson:  “Work expands so as to fill the time available for its completion.  Thus, an elderly lady of leisure can spend the entire day in writing and dispatching a postcard, another in hunting for spectacles, half an hour in search for the address….”

As valid as the law seems, it is not always true.  There are, I am sure, older retired women who would never devote more than a half hour to writing to their relatives.  So we have another law:  “Every rule has an exception (even this one).”  Whether the exception proves the rule, or the rule, the exception, I leave to that genre of professional deep thinkers, known as logicians.

The laws concerning how our world functions or malfunctions contain much wisdom in few words.  While we might add a qualifying “usually” to the statement, its soundness and acumen remain incontrovertible.  That the law does not hold for every circumstance should not disconcert us.  The impression of precision – "’a la Heisenberg – is a preoccupation of today’s mathematics and physics…….

Permit me a few “laws” of plastic surgery:

The preoperative photos that are lost are always of the patient with the best result.

The last stitch in a blepharoplasty always starts bleeding.

No insurance company ever makes a mistake in your favor.

No medical organization to which you belong ever reduces its dues.

The patient whose operation you do for visiting surgeons will have the hematoma.

VIPs are magnets for complications.

The patient with the best initial result never returns for follow-up.

The dissatisfied patient never moves away.

The older the surgeon, the less he or she perceives the need to retire.

The older plastic surgeon never thinks there is room for a younger one in town.

The initial sponge count is never correct when you are behind schedule.

The rhinoplasty patient with only a fair result is your most enthusiastic supporter.

The lengthy operative note (discharge summary) is the one that gets lost.

No surgeon ever has enough operating time.

No hospital ever has enough operating rooms or personnel.

Plastic surgeons resent a colleague in direct proportion to the aesthetic content of his appearance in the media.  Corollary:  The expert on hypospadias is never maligned.

Most surgeons lack the enzyme allowing them to praise the results of a colleague.

Most surgeons feel a twinge of pleasure at another’s complication.

Our readers doubtless have better rules of their own – and that, perhaps, is another law.

What People Think of Plastic Surgery

Updated 3/2017 -- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

Another thoughtful essay from Dr. Robert Goldwyn’s book “The Operative Note: Collected Editorials” (published in August 1992).

What People Think of Plastic Surgery

In conjunction with the publication of my book, Beyond Appearance: Reflections of a Plastic Surgeon, I recently was on a number of radio talk shows. Through the wonders of modern communication, I was fortunately able to participate in most of these sessions without having to go to the studio. To relax in bed and to have one’s voice perpetrated on the citizens of Alaska, for example gives one an inkling of how easily those in high political office can abuse their power. To what extent these talk shows influenced the sales of my book I really do not know. But what I did learn was what many people are thinking about in relation to plastic surgery specifically and medicine generally. Although I was ostensibly on these talk shows to discuss my book, it was not long before larger issues and personal surgical events took over. What follows is not intended to be a factual survey of public opinion, but simply a series of impressions.

First, the good news. Most of those who called in were very much aware of the worthwhile achievements of our specialty. Many mothers expressed their gratitude for what plastic surgery had done for their children deformed from birth or trauma. Several men reported how well our colleagues had reconstructed their faces after removal of a cancer. Some callers wanted to know what I thought would be important discoveries in our field. A few asked specifically how close we were to perfecting artificial skin and methods to forestall aging. In that regard, aesthetic aspects of our activities soon dominated the reconstructive. Not surprisingly, many women phoned in to inquire about face lift, eyelidplasty, abdominoplasty, and liposuction. Men also described their experiences with plastic surgery, with most calling about hair transplants and rhinoplasty. Those who complained about what they considered a poor outcome of their aesthetic surgery admitted that they had been warned of that possibility but still thought that they should have received a better result, especially since, in the words of one woman, “I had been charged an arm and a leg for my face.”

A common question from the talk masters and listeners was how to find a qualified plastic surgeon. Many said that advertising had confused them. Why would a good doctor advertise? If he is as talented as he claims, why shouldn’t he be busy enough? Another question was whether a plastic surgeon would admit that he or she did not do a certain procedure and refer the patient to someone qualified. A frequent query was whether we “operated on everybody.”

What I gleaned from more than 20 talk shows was that the public believes that all plastic surgeons do cosmetic surgery and that anybody who say that he or she is a cosmetic surgeon is most likely a plastic surgeon. Credentials and board certification, though they are important to us and should be to the patient, are poorly understood. Almost any diploma on the wall will do. Availability, kindness, and cost are the determinants for a large group of people. Many regard an aesthetic operation as a commodity, a luxury item to be shopped for and purchased. A sentiment of many callers was that it is not really surgery since it can be done in the office and is not covered by insurance. Several vented their resentment at having something go wrong and then being unable to get to the doctor. One caller remarked (I was keeping notes), “He was there to take my money but not my complaints. He sent the nurse out to do that. Is that what you learn in medical school?”

The longer the talk show, the more likely the surfacing of disappointment and hostility. While almost every caller treated me with respect, undiluted, high regard was not what many had for the medical profession. The public is no longer our ally, if they ever were. A crucial factor, not surprisingly, was money. If we charged nothing for our services, our patients would undoubtedly like us more, but only if the result were perfect and we were kind. In this real world, however, most of us are not saints, most of our work is not perfect, and yet we charge for it.

I did receive one unusual call: Someone championed “genetic honesty.” saying that he was against any reconstruction that changes nature’s workmanship, even the most faulty, as in the instance of a child born with a cleft lip or a craniofacial mishap. Within seconds, the phones became alive with callers who verbally murdered that nihilist. They did my work beautifully.

As an aside, let me offer another fact: Nobody wrote me to become my patient. Many people did send letters asking how they could find a plastic surgeon in their area for a specific problem. I referred them to the Executive Office of the American Society of Plastic and Reconstructive Surgeons.

I did get a call, however, from someone who insisted he speak to me immediately, even though I was busy with patients. Finally, my secretary capitulated and I took the call: “Doctor Goldwyn,” the voice boomed, “I read your book, and I think it is one of the best I have ever read. Congratulations on such an achievement [by then, I was purring]. Sir, it would be an honor for me to sell you life insurance.”

So much for books and talk shows.

Knowledge: What Kind and How Much?

Updated 3/2017 -- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.


Here is a second essay from Dr. Robert Goldwyn’s book “The Operative Note:  Collected Editorials” (published in August 1992).  

Knowledge:  What Kind and How Much?

A few years ago, when my daughter was a high school sophomore, she asked me to help her prepare for a biology quiz.  She was astounded that this paterfamilias, a certified physician, was ignorant of the precise base sequence of DNA-RNA.  In self-defense, I said that most of my colleagues would probably fail her test but were good doctors nevertheless.

“but how can they take care of patients properly if they don’t know all about these important nucleic acids?” she asked.

“Surprisingly,” I replied, “they do very well.”

This incident, aside from revealing my daughter’s knowledge and my lack of it, is relevant to the greater considerations of learning – What kind and how much?  Publilius Syrus, known for his maxims in the first centery B.C., said:  “Better be ignorant of a matter than half know it.”  Many centuries later, Alexander Pope expressed the same thought in his famous “a little learning is a dangerous thing.”  Huxley’s retort was “Where is the man who has so much as to be out of danger?”  In truth, most of us are in various stages of ignorance.

A medical student asked me, “How much basic science do I have to know to be a good doctor?”  The question, which may be unanswerable, is nevertheless perennial.  Because knowledge and wisdom are not synonymous, the central query is how much of each is necessary.  Any answer must take into account the individual’s needs at a particular time.  Students regularly complain about the irrelevance of the material they must digest, and teachers constantly chide them for their lack of perspective in not realizing that what may seem useless today may be helpful tomorrow.  What to teach and what to learn have stimulated curriculum committees to produce ponderous reports that rehash everything and resolve nothing.  Rare is the year without another “definitive” statement on the aims and strategies of education.

The human being functions astonishingly well knowing comparatively little.  Global enlightenment is unnecessary.  For most people, making a living in our complex society demands narrowness not breadth.  We are job-specific.  Major league pitchers would fail a high school physics test on mass, velocity, friction, and wind currents, yet they could easily strike out every professor at the Massachusetts Institute of Technology.  So also can a doctor do considerable good for a patient with more know-how than knowledge.  Deplorable, perhaps, but true.

Let us take the example of reconstructing the breast in a 45-year-old woman who has had a mastectomy.  How many plastic surgeons could discourse on the hormones at menopause?  Could we pass a thorough examination on the  various ways of treating breast cancer:  radiation, chemotherapy, surgery?  Are we well read in the history of each of these therapies?  Do we have a picture in our minds of the histology of the most common kinds of breast cancer?  Do we know the chemical structure of silicone and how the implant is made?  During the procedure are we familiar with the anesthetic agents and their pharmacology and physiologic effects?  Do we understand the manufacturing process of the surgical blade and suture material?  And what about wound healing, not only the names of the classic stages but the biochemical and biomechanical aspects?  Certainly, it would be better if we had this knowledge.  However, even if we possessed it, we still would have to know when to operate, on whom, and how.  And what about the not-so-small matter of being a compassionate physician with psychological understanding of this unfortunate person and a feeling of permanent responsibility toward her?

This editorial is not a plea or an apologia for ignorance, not is it a eulogy to it.  It is an attempt to recognize things as they are.  Often we are hypocritical in being hypercritical.  We usually demand more knowledge from others than from ourselves.  Furthermore, within the medical sphere, if we are honest, we would admit that many errors arise not from lack of knowledge but from absence of what moralist one called “character.”  In this situation, what motivates the doctor may imperial the patient to the detriment of both.

Unfortunately, I cannot offer a solution to the problem that prompted this editorial:  Knowledge: What Kind and How Much?  What is certain, however, is that knowledge without wisdom is like a ship without a rudder.  Correct timing and the proper application of  information hopefully come with experience.  Yet, as someone observed, there is a difference between a person who has 20 years of experience and someone with 20 years of 1 year’s experience.  Let us hope, at least, for the former.

Dr. Goldwyn’s “Surgeon”

Updated 3/2017 -- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

After learning about Dr. Robert Goldwyn’s death, I pulled out his book “The Operative Note:  Collected Editorials” to reread (published in August 1992).  I’d like to share a few with you over the next weeks/months.

The first is entitled “Surgeon”

On a recent trip to Hawaii, I learned that in the Polynesian dialect spoken there, the word for surgeon is kauka oki:  doctor (kauka) who cuts (oki).  While some of us surgeons might resent such a graphic, “cut and dry” definition, we cannot deny its verity.  No matter how we may slice it, a surgeon is a doctor who makes incisions.  In fact, the origin of the word surgery is Greek, from cheir, meaning “hand,” and ergon, meaning “work.”  That surgeons work with their hands did not always bring honor.  Centuries ago, one recalls that those who cut on others, with their permission, generally held a lower status than those who eschewed the knife.

At the bottom were the barbers, and slightly above them, the surgeons.  In England in 1462, the Guild of Barbers became the Company of Barbers, and under Henry VIII, the Barber Company was united with the smaller Guild of Surgeons to form the United Barber-Surgeon Company.  In commenting on Henry VIII’s role in this episode, Garrison cites the painting by the younger Holbein, the court painter:  “Henry VIII—huge, bluff, and disdainful—in the act of handing the statute to Vicary [Thomas Vicary, First Master of the United Barber-Surgeon Company], in company with fourteen other surgeons on their knees before the monarch, who does not condescend even to look at them.”1  Perhaps Henry was irate at having to leave his dinner table and his newest wife.

The metamorphosis from the lowly barber to the glamorized surgeon has been long.  I am sure that Henry VIII did not envision the consequences of his royal decree.  The seesaw of history is marvelous as long as you are on the upswing.  The rise of the surgeon did not erase the schism (in fact, it may have intensified it) between the so-called thinkers and the doers.  This enmity, although lamentable, is centuries old.  some, however, such as Lanfranchi of Milan (the first to describe concussion of the brain and to distinguish between cancer and hypertrophy of the female breast), did rise above the petty, professional fray.  In his Chirurgia Magna, completed in 1296, he wrote:

• Why, in God’s name, in our days, is there such a great difference between the physician and the surgeon?  The physicians have abandoned operative procedures to the laity, either, as some say, because they disdain to operate with their hands, or rather, as I think, because they do not know how to perform operations.  Indeed, this abuse is so inveterate that the common people look upon it as impossible for the same person to understand both surgery and medicine.  It ought, however, to be understood that no one can be a good physician who has no idea of surgical operations and that a surgeon is nothing if ignorant of medicine.  In a word, one must be familiar with both departments of Medicine. 2

We do accept the fact today that the best surgeon is one who knows not only how to operate, but when not to.  Harvey Cushing, about the time that he became the first Surgeon-In-Chief of the Peter Bent Brigham Hospital, Boston, said in his letter to his counterpart in medicine, Henry Christian:  “I would like to see the day when somebody would be appointed surgeon somewhere who had no hands, for the operative part is the least part of the work.” 3

Cushing, of course, did have hands, good ones, and more important, a superior brain, which he used prodigiously.  His remark was a hyperbole that reflected his correct view of surgery; it must grow from research and basic sciences and from its application to clinical problems.  Surgery, despite the awe it now has (for those who doubt this, see the afternoon “soaps”), represents a failure of nonoperative medicine.  Who would not want to take a pill rather than undergo an operation for cholecystitis, breast cancer, or benign prostatic hypertrophy if the results were the same?  Would not genetic engineering by medication to prevent facial clefts be preferable to repairing them, no matter how meticulous and innovative the surgeon?  The thought that a capsule could safely enlarge or reduce breasts or salve could eliminate Dupuytren’s contracture or a prominent dorsal hump may seem too fanciful even for the most imaginative, yet landing a man on the moon and retrieving him without mishap has long been a fait accompli.  However, since medical Shangri-La is many years hence, we heirs of Pare will be continuing our manual ministrations, our barbers’ burden.

References

1.  Garrison, F.H.  An Introduction into the History of Medicine with Medical Chronology.  Suggestions for Study and Bibliographic Data, 4th Ed.  Philadelphia: Saunders, 1929; reprinted in 1960. Pp. 238-240.

2.  Lanfranchi of Milan.  In M.B. Strauss (Ed.), Familiar Medical Quotations.  Boston: Little, Brown, 1968. P. 583.

3.  Fulton, J.F.  Harvey Cushing:  A Biography.  Springfield, Ill.:  Charles C. Thomas, 1946.  P. 352.