I always enjoy Apollo MD’s posts (who happens to be a classmate and friend of mine).  I would therefore like to share with you all a recent post he published.

Please, Sir, Can I Have Some More

He shares a lot of my thoughts.  I especially want to emphasize that rationing is happening already in a major way.  Therefore the question is not should we ration, but how can we improve the current rationing system.  In addition I want to stress his point that we already have a mult-tiered system of healthcare.  Although I agree that it would be ideal to live in a Utopian society where all is equal – I would much prefer have a two-tiered system where everyone got at least some access to healthcare.

Dr. Rudolph Matas - pioneer of vascular surgery - in Charity Hospital's "Bullpen"

One of the most common questions I receive (especially now) is, “what kind of doctor do you want to be?”

Well I have finally narrowed this choice down.  General Surgery or Urology.  I grew up in a Urologist’s household and thus was exposed to the surgical lifestyle from a young age.  I then began medical school with the much anticipated Gross Anatomy course.  I absolutely loved learning about the physical makeup of the body.  I enjoyed dissecting with my hands and exploring this amazing and miraculous machine that comprises our physical being.  I then went through my 3rd year working in the hospitals and clinics in various parts of medicine with an open mind hoping to learn what I could from every specialty and considering that specialty as a career.  I enjoyed most of them and had thoughts at times that, “I could see myself doing this.”  However when I began work on my surgery rotation I truly fell in love.  I enjoyed almost every aspect of what we did.  Many days I worked from 4am – 7pm or even later and yet I came home excited and wanting to read more about the surgeries we saw or what we would do the next day.  I loved being able to know there was an anatomic problem with a patient, perform the surgery and cure the problem.  I enjoyed working with the operating team comprised of people from all different training levels and backgrounds to ensure a successful operation.

It also seems to me that there are few other fields than surgery that cause patients as much emotional distress.  I consider it a great honor and privilege to be there for them from beginning to end to comfort them and their loved ones through that time no matter what the outcome.  I think the time that I enjoyed the most on surgery was talking to a patient right before they would be taken to the operating room, laying a hand on them and ensuring them that we were going to take care of them.

Here’s a quick breakdown of general surgery vs. urology:

A general surgeon, as the name implies, is a surgeon who is trained and qualified to operate in many areas throughout the body.  As a rule general surgeons perform: thyroidectomies, parathyroidectomies, breast surgery and abdominal surgeries (gallbladder, stomach, spleen, small intestine, large intestine, liver, appendix, as well as hernias).  Many also do skin cancer excisions and some will do basic chest surgeries (heart, lung, etc.).  Some rural general surgeons even find themselves performing basic Urologic and Gynecologic surgeries as well.  It all sounds very romantic to be able to operate on virtually any part of the body and to be the one-stop-shop for all of your surgical needs.  However, this field has been hit hard in every which way.  Surgeons have very high malpractice insurance rates.  Since a general surgeon receives virtually all of his income from operating this leaves lots of opportunity for things to go wrong and law suits to be filed.  And just like car insurance, even if you did nothing wrong, the rates still go up.  They often work grueling hours because they are called for any surgical emergency and it is not uncommon to have to operate at any hour of the day or night.  They have also been particularly affected by decreasing reimbursements to the point where many communities are left without surgeons at all.  In addition, in practice many general surgeons do not get the luxury of practicing the large litany of surgeries they were trained to do because of extreme sub-specialization as well as a host of political, economical and legal reasons.  Why would a hospital want a general surgeon to manage the ventilator settings in the ICU when they hired a Pulmonary Critical Care person to do that?  Why should they want the general surgeon to do breast cancer surgeries when they just hired a dedicated breast surgeon to do that?

The present paints a difficult picture for general surgeons on all fronts – long hours, minimal pay, huge liability and a physically demanding job.

A urologist focuses his attention on issues such as: the urinary system (kidneys, ureters and bladder) as well as the male reproductive system.  The main difference for me here is that urologists balance their operative time with an office practice where they see patients with issues such as: kidney cancer, prostate cancer, bladder cancer, erectile dysfunction, urinary tract infections, male infertility, kidney stones.  The office practice is extremely attractive to me.  I really enjoy building a relationship with my patients and being able to see them for years and then take care of their family members.  (In contrast, general surgeons generally see you once or twice before they operate and a few times afterwards.  It’s uncommon to have long term relationships with patients.)  Urologists also get to perform a number of in-office procedures and do not spend all of their procedure time in the operating room.  This creates a nice balance of work.  They have much fewer emergencies and thus have more control of their personal time. The main drawback to me is that I worry that focusing on such a more narrow field of medicine may bring me out of touch with other aspects of medicine.

I’ll keep you guys updated on which path I choose.  Both are great fields and I would enjoy working in either.  It’s more the quality of life issues that I’m deciding on.  Both fields lend themselves to surgical volunteerism both local and abroad.  However, a general surgeon is able to offer more diverse services.

Until then, I leave you with a quote from one of my professors, “There are worse decisions to make in life than deciding between two equally fulfilling and challenging fields of medicine” – Dr. Jeffrey Wiese

For those unfamiliar with this facade it is the (in)famous Charity Hospital in New Orleans which has been closed since hurricane Katrine in August of 2005.  I find it quite curious that our tax dollars our spending money on K9 patrols of this structure when the state claims they do not have the funds or desire to repair the building for clinical duties.

I also see many floors of lights on at all hours of the day and night and I am told the air conditioning is running as well (although I can’t confirm that myself).

Louisiana is a strange place indeed to spend all the money on utilities and guard dogs but not try to repair the facility when only 2 floors were damaged.

There has been much talk about reforming healthcare in the last several months.  I wanted to take a few moments to share some thoughts on the subject.

Physician Reimbursements:

People often claim that physician make way too much money and they are a major reason for our healthcare debt.  There is some truth to this, some physicians make quite a bit of money and certainly in recent history physicians could make huge sums of money.  So, I’m not in complete disagreement.  However, I would like to offer some food for thought.  I invite you to listen to this brief interview of two young doctors from NPR and I encourage you to read the comments following the interview.  Many medical students graduate with $200,000 or more in school loan debt just from medical school (obviously more if they have loans from undergraduate as well).  This is a huge sum of money to owe and interest quickly takes this sum higher.  In addition, primary care physicians on average earn around $130,000 per year.  Now while that sounds like plenty (and I’m not minimized the income) it must be understood that there is tremendous overhead in being a private practice or even a group practice physician.  Because of increasing amounts of paper work and insurance drama physicians often need the help of several office employees.  Then there is malpractice insurance which for procedural based specialties (surgery, intervential cardiology, etc.) can be as high as $250,000 per year!  Procedural specialties also are much more likely to be involved in litigation and have to spend more of their time defending their outcomes.  This overheard must be paid upfront before the physician ever makes any money.  Combine that with an average of 60 day delays in collecting insurance reimbursements and physicians are cutting it tight in the beginning many times.  General Surgery has been particularly hard hit.  They often make the same or less than non-surgical primary care physicians and have higher malpractice insurance and often longer work hours.

CMS (Centers for Medicare and Medicaid Services) has announced that they want to raise primary care physician’s salaries by 6-8% by cutting reimbursements of certain higher paid specialties such as interventional cardiology and radiology.  While this looks appealing on the surface it does seem to place an element of blame on those greedy cardiologists and radiologists.  However, as Buckeye Surgeon comments, these are not primary care specialties.  This means that they only do those procedures and read those scans because a primary care physician ordered a consult or ordered a scan.  The primary care physicians orders those consults and scans readily because they want to be sure they don’t miss anything lest they become involved in litigation.  Therefore it is more of a system problem than individual doctor’s salaries.  Again, I’m not saying salaries don’t play a role, but it’s just not the only problem.  And while some physicians make perhaps more than they should, a greater number are underpaid and many have resorted to earning income by other means and no longer practicing medicine.  Defensive medicine is a huge problem in my opinion and much more of a player than salaries.  Read another opinion by Buckeye Surgeon here.

Healthcare reform is desperately needed, but I’m afraid the solutions are not simple.  More to come later on other topics of this nature.

In a beautiful blend of medicine/disco irony, researchers at the University of Illinois announced that the Bee Gees song, Stayin’ Alive is a great rhythm to perform CPR.  Debra Bader apparently got the memo and saved her husband’s life by performing CPR while singing this in her head.  She heard about this via a public service announce thus once more demonstrating the power of advertising.  So to all my friends in public health – keep up the good work!

I just heard a story on the radio tonight about family’s plan to help others for Valentine’s day.  They live in a rural town and have to drive into the city periodically.  When they do, they notice the beggars on the street.  The teenage son came up with an idea to spend his own money, buy food and snacks for these folks.  

How awesome!  What an encouragement to those folks.  I love how teenagers look at a situation like that and think, why not?  Adults figure out a million reasons why it wouldn’t work or why it wouldn’t by fair or why they need to regulate the distribution so that bureaucracy drowns goodwill.  

What awesome stories have you all heard?  Any plans of your own to help others?

While doing some studying tonight, I ran across a couple videos about Huntington’s Disease.  I’ll leave it to Wikipedia and the videos to explain more for those who don’t know what this is.  I encourage you to watch them.  It was a reminder to me to not gripe and complain when I think things unfairly affect me.  Huntington’s is a genetic disease that does not manifest itself until people are around 40 (so they usually reproduce before they know they have the disease).  Obviously this is not something anyone asks for, and there is currently no cure or even effective management of the disease.  People decline rather quickly with physical, cognitive and psychological effects.  This causes not only extreme distress for those affected, but for everyone involved in their life.  

A couple of points the videos don’t discuss very much:

-There is a genetic test available for the disease.  However, this is very difficult decision to make since there is no cure and employers and insurance companies might use this information against people.

-Afflicted individuals often forget loved ones and even become hostile towards them, making it even more difficult for loved ones to help.

-If someone finds out they will develop the disease, at what point should they tell someone they are dating this information?  Should they even get married knowing their spouse will have to watch them go through this?  Should they have children, knowing there is a high likelihood the children will also have the disease?

The first video shows more of the human emotion to the disease, the second is a clip from a CBS special.  

May we each take some time this week to recognize the humanity in people regardless of how they act or treat us.  May we step out side of our own woes and gripes about life to help others around us with theirs.  May we understand that “fairness” is not a quality of this fallen world and that Justice is God’s to handle in a way which all too often exceeds our comprehension.  And finally, let’s hope Deanna posts soon so you’ll have a break from my serious and controversial posts.  :)

I just received an email about ACOG (American College of Gynecology) ethical opinion 385.  In summary it urges OB/GYNs to either provide services (including abortions) or provide a referral.  On the surface I understand the argument against this.  I also realize that what I’m about to say is very unpopular with most Christians.  So, I invite comments for and against my opinion.  I will also approach this from a Christian point of view since that is often where many of the staunch opposition comes from.  

Christianity (contrary to much of the popular practice) is about relationships-even at the expense of religious rules.  Jesus says the greatest commandment is to “Love the Lord your God with all your passion and prayer and intelligence…and to others as you love yourself” (Matthew 22:34-40, Mark 12:28-34).  What I take away from that is that if any rule inhibits me from loving God or loving others, then I am holding too tightly to that rule.  Jesus realized this and this is why he had no qualms with “breaking the sabbath” by healing people or feeding his disciples.  

Therefore, as a Christian and as a physician I have a responsibility and a spiritual call to love my patients even if I don’t agree with their choices and even when these choices violate my beliefs.  I will say that I would not feel morally comfortable performing abortions and I would counsel mothers against this decision in a polite and loving way.  However, I have two choices once the mother has decided on her course of action.  I can essentially sever the relationship by throwing rules and morality in her face and become one more christian who shoved rules in their face over relationship.  Alternatively I can say, “I respectfully disagree with your decision, but I value you as a person and recognize that we all have a right to make our own decisions.  I do not perform that procedure because of my spiritual beliefs, but I will agree to help you find another provider who will.  In addition, I encourage you to continue to ask my any questions you might have and to feel free to come to me with any other health issue.”  

I think that if most of us were honest we have all done things we knew were in opposition to someone else’s beliefs (whether it be breaking a law – no matter how small, or disobeying a parent or a teacher).  In addition our decisions always have an impact on others.  As Americans we are particularly guilty of choosing our own comfort and finances over others in our community who desperately need help.  When people have been aggressive and inflexible it often hinders the relationship with that person.  When people have been accepting that we made a choice they didn’t agree with, but continued to love us and have a relationship with us, it causes a deeper bond and a greater respect.  In the end, I think we are much more likely to agree with people who gently walk with us in our tough times than we are to agree with the drill sergeant types.  

Again, I see Jesus as having this perspective.  In the story of the Prodigal Son (Luke 15:11-32) Jesus paints a very radical picture.  The son in the story demands his inheritance and insults his father.  His father no only allows his son to leave, he actually finances his debauchery!  Furthermore, he is not angry or bitter with his son, but rather desperately waiting for him to return home safely.  What a tremendous challenge for us.

Therefore, although I do not agree with the practice of abortions, I do not feel the need to be so hard-nosed about the issue.  Every life is precious and the mother’s just as much as the unborn child.  I would prefer that neither one would be sacrificed.  But what kind of spiritual life is the mother likely to have when everyone treats her like dung and refuses to walk with her through a very difficult time.

Deanna and I were talking with some folks tonight about some examples of people who have gone out of their way to serve others.  It reminded me of several of the doctors and students at Tulane.  I am proud to attend a school where so many of the people there make a priority of serving others.  I wanted to take a minute to share a couple examples.

One of the family physicians who used to be on staff at Tulane Medical School volunteers his Tuesday nights at Bridge House.  Bridge House is a substance abuse rehabilitation center.  Dr. Theis sees the men who are undergoing treatment for no charge.  In addition, he provides medicines and tries to connect them with other free clinics and resources in the city so that they can have better follow up care and obtain diagnostic imaging.  

Fleur de Vie Clinic (https://tmedweb.tulane.edu/fdv/) is a clinic that was started by Tulane medical students and run by a multitude of volunteers.  Twice a month residents and attendings (physicians on staff with Tulane) volunteer their Saturdays to help see patients who have no means of paying.  The clinic is an extension of Tulane’s Community Clinic at Covenant House (http://www.tucovenanthealthcenter.org/).  This clinic was started after hurricane Katrina to help serve the needs of the people of New Orleans who have no ability to pay for healthcare.  

Tulane also has other clinics that serve low income areas.  They recently opened a community clinic in a Vietnamese community which has very few other healthcare options in the area.  Tulane faculty and students are also very active in volunteering their time, money and expertise in several other countries.  

Time is something that very few people have in abundance, especially physicians and arguably medical students.  To see so many of my classmates and teachers take such a proactive and giving role  is very encouraging.  It helps fuel my fire to do the same with my time now and especially in the future.

Roll wave roll!

Deanna and I wanted to wish everyone a Merry Christmas.  This year has been filled with many joys and challenges. We got another dog – Shadow.  We found her online from a couple who could not keep her.  She is a black lab mix and she and Jack get along great together.  

Deanna was accepted into an LPN (licensed practical nurse) program.  She is so excited about it as it took a lot of work to get accepted.  Furthermore, she is doing very well in her classes and was elected President of NFLPN (National Federation of Licensed Practical Nurses) for her class.  She is also currently on the honors list. She will graduate in July.

I have been working in the clinics and hospitals doing my rotations since July.  I still haven’t decided exactly what field of medicine I want to go into, but I’m narrowing down the choices.  I’ll have to start putting in my applications for residency in late summer, so I’ll have to decide by then.  It’s been an amazing opportunity to be working directly with patients everyday.  

It has been challenging having both of us working and studying so much.  God has been gracious in helping us through this time.  But we are both looking forward to having a little more time together next year.  

We hope everyone has a wonderful Christmas.  May grace and peace be with you all.

John Roger, Deanna, Jack, and Shadow Bell 2008