About ergeller57

Evan Geller is a surgeon and critical care specialist. He is happily married and the father of three extraordinarily pleasant children. He writes on the side. His blogging is inexplicable, unfocused, and not terribly prolific. Usually worth your time, however. Occasionally.

A Hard Place To Live–Part Two

The new Chairman of Surgery had only been in town for a few weeks when he asked me to accompany him for a drive to visit a friend in Westchester.  The new Chairman had just moved to New York after a distinguished, meteoric career at a famous medical center in the South.  Not the south side of New York.  I mean the South; where people are friendly and the pace is peaceful and life is grand.  He was, shall we say, new to New York.1-new-york-city-1270751697

The new Chairman had a research buddy in Westchester that he wanted to visit and it was a beautiful, sunny Sunday.  He thought we should drive his BMW the couple of hours it should take and I could help navigate and I’d surely be interested in the research project they were to discuss.  I had to explain that I had never been to Westchester and that my sense of direction is limited to up and down, and that only on a good day.  He was undaunted.

We started off confidently, driving down the Long Island Expressway at a good clip, discussing the new Chairman’s grand plans for the department.  As we began to navigate the sinuous and subtle exchanges of the various parkways and expressways of the city proper, our conversation lagged as we quickly realized that we didn’t know exactly where we were going.  This was confirmed when we passed under a large sign reading “New Jersey.”  Westchester, we were quite sure, was still in New York. Unfortunately, we were now on the rather intimidating approach to the George Washington Bridge and it appeared that our fate lay in crossing the Hudson River despite our reluctance.  As we paused at the toll booth, the new Chairman expressed to the toll worker that we really were going to Westchester.

“But you’re going the wrong way,” the toll booth attendant informed us.  We acknowledged this helpful bit of information and inquired how we could avoid crossing the bridge.  “You can’t,” she said.  “What you need to do is take the first exit after the bridge, get off the expressway, make a left and cross under to the other side, then get back on the expressway and come back over the bridge.  That’ll be sixteen dollars.”  The new Chairman thanked her for her helpful advice and got change for his twenty.  Now certain of our path, he did exactly as she recommended.  As he crossed under the bridge, however, a police officer standing just past the left turn waved him over and told he to stop the car.  The new Chairman pulled over and rolled down the window.

“Is there a problem, officer?” the new Chairman asked politely.

“License and registration,” the officer replied.

“I’m sorry?” the new Chairman asked.

“You will be if you don’t give me your license and registration in the next two seconds,” the officer replied.  The new Chairman looked at me.  I shrugged.  He gave the police officer his license and registration.  The officer disappeared to his cruiser.

“What’s going on?” the new Chairman asked.

“Haven’t a clue,” I answered.  “I’m sure we’ll find out, though.”  So we sat and waited to find out.  We sat for a half hour.  At last, the officer reappeared at the window.  He began throwing traffic tickets through the window at the new Chairman.

“Illegal left hand turn, obstructing traffic, expired license,” the cop rattled off, throwing the new Chairman’s license and registration back into the car. “Absent front license plate, failure to use turn signal,” the officer droned on as he continued to fling tickets into the car.

“Hold it, hold it,” the new Chairman spluttered, flabbergasted.  He reached down on the floor to retrieve his driver’s license.  “My license isn’t expired.  I just renewed it before I moved here three weeks ago.  Look,” he held up the license for the officer and indicated the back of the license where the renewal was documented.

The cop took the license and looked at the indicated sticker for a moment, then tossed it back in the car.  “They don’t pay me to look on the back.  Tell it to the judge.”

“Now hold it–” the new Chairman began.

The officer clamped his hand on the new Chairman’s forearm which was resting on the door sill, still holding the dollar bills he had gotten in change from the toll lady.  “And if you say one more word, asshole, I’m gonna arrest you for trying to bribe a police officer.”  He nodded at the four dollars in the new Chairman’s hand.

“You’r not serious,” the new Chairman said.  He turned to me.  “He’s not serious, is he?”

“I think he is,” I advised.  “I think you should stop talking now.”

The officer agreed.  Finally, we were allowed to resume our journey to Westchester.

“This place,” the new Chairman said as we drove on, “is a very hard place to live.”

I had to agree.

Are We Not Men?

While unavoidable personal circumstances have reduced the periodic percolation of new content on this blog to a mere unusual ooze, I will not insult you with any claim that I’m pursuing instead a plan to restore both Ukrainian unity and Wonder Woman’s starring role in the upcoming Avenger’s movie with a single email to Putin, cc’d to Joss Whedon (though this may well prove true with time). Just a bit busy, is all.20140423-141726.jpg

This is not a problem with my internal wiring. Though, lately–many people I know are having problems with their intellectual busses. Their bandwidth, it seems, is suddenly inadequate to allow them to respond to calls/texts/emails/hails from across the street in a timely fashion. I was recently astonished to read that this new bioelectronic cyborgian malady has even affected the august annals of The Economist (http://www.economist.com/blogs/babbage/2014/04/book-production). Didn’t know we were recently obsoleted. I await an upgrade. With greater bandwidth.

Killer

Quote

The young resident was flabbergasted to learn, in casual conversation, that the attending radiologist sitting next to him all morning had been in the Marines prior to going to medical school.

“Wow,” the student exclaimed in open admiration.  “Did you kill anyone?”

The radiologist shook his head.

“Not until I became a doctor.”

 

~CB, 2013

Automated Malpractice and Digital Dishonesty

Quite a few years ago, I was conducting morning teaching rounds on the surgical service of a university teaching hospital.  Teaching rounds are a combination of patient care and education, the educational aspects directed at the bevy of residents and medical students in attendance.  We stood outside the room of a postoperative patient who wasn’t doing well.  Either was the senior medical student struggling to explain just what was the reason that the patient’s health was failing.Minolta DSC

“What’s the white count this morning?” I asked the man.  He was an over-achieving rotator from another school, doing a senior elective on our service.  He suddenly blanched.

“I’m sorry?” he said.

“Don’t be.  Just tell us the white blood cell count of the patient this morning.”  I waited.  He looked at his junior resident.  The junior resident looked at the senior resident.  The senior resident looked at the chief resident.  The chief resident looked at me.  He shrugged sheepishly.  “No one knows the patient’s white count this morning?”  I asked.  Everyone looked at their shoes.  “Did you operate on this patient?” I asked the student.  He nodded.  “And though the patient trusted you enough to let you operate on him, you just don’t care if he lives or dies at this point?”

“I care,” the student replied, indignant.

“Just not enough to check his white blood cell count, is that it?” I asked.  The student wisely said nothing.  “It would be reasonable to suspect that your patient is suffering from an infectious complication from your operation.  If you do not make the diagnosis soon, he will die from your operation.  I suggest that you check his white blood count.”  Everyone nodded assent.  We moved on to the next patient.

Twenty-four hours later, we all stood once again in front of the same patient’s room.  The patient had spiked a high fever overnight.  “White count?” I asked the same student.

There was the briefest pause before the medical student said, “Twelve point two.”  Which was a lie.  He was a pretty good liar, looking me straight in the eyes as he said it.  I had checked the patient’s white blood cell count before rounds.

“Take this dime,” I said, handing a coin to the student, “and call your mother.  Tell her there is serious doubt about your ever becoming a doctor.”  All twenty members attending rounds looked at me with a blank, uncomprehending stare.  “Really?” I asked.  “Nobody’s ever seen The Paper Chase?”  They all shook their heads.  The student had gone beet red with embarrassment.  “Look,” I said.  “You screwed up.  I told you to check this patient’s white count.  You didn’t.  You have a responsibility to this patient.”  The student, his resident, and the chief resident started to explain about all the traumas cared for overnight, about how busy the service had been saving lives.  I held up my hand.  “I don’t care.  You screwed up. You all screwed up, by letting him screw up.  You are failing this patient.  But that’s not why I’m pissed.  We all make mistakes, every one of us.  Every day.  Can’t be helped. But you can’t lie about it.  You can’t stand here and pretend that you did something that you didn’t.  You can’t give me false information, information that may lead to my decision regarding the care of this patient, just because you’re too weak to admit that you didn’t do what you should’ve.  What this patient needed.  That’s not acceptable.  You can’t lie.  Not to me, not to this patient, not to your fellow residents or students.  Because if I can’t trust you, I can’t let you take care of my patients.  Worse, you are lying to yourself.  If you can’t trust that what you wrote in a chart last month was actually something you did–and not just something you made up because you didn’t have the time to actually check–you will hurt your patient.  Lawyers can lie.  Accountants can lie.  Stockbrokers can lie.  Surgeons can’t lie.  Surgeons who lie kill patients.  Go check the patient’s white count.  And while you’re at it,” I said, turning to the senior resident, “book the patient for reoperation this afternoon.  Because his white count this morning is 22,000 and I think your patient has an anastomotic leak.”

The embarrassed, hotshot medical student went on to be a very good orthopedic surgeon.  I like to think that he learned something that day about patient care and responsibility.  I don’t know for sure.  I am sure, however, that it no longer matters.  Every physician is now systematically dishonest on a daily basis.  Every one of us.

During the past two years, hospitals and medical practices across the country have been required to implement an electronic medical record system.  Every single health care practitioner has been falsifying patient records on a daily basis as a result.  Not by a desire to be dishonest, or any lack of effort on behalf of our patients.  It is now a systematic requirement.  Which is particularly ironic, because the intention of the electronic medical record mandate was to increase the quality and accuracy of medical record keeping.  The result has been the exact opposite.

“You can’t be a doctor without a pen,” the adage goes, because the foundation of all medical care is the medical record.  This was actually a major plot point in a book by Tom Clancy (may he rest in peace), where the ophthalmologist wife of our hero, Jack Ryan, points out that “if it wasn’t written down, it didn’t happen.” Patriot Games, I think.  I could be wrong.  Anyways, it’s true.  If it happened, you document it.  That way, everyone knows what was done, how, and why.  Want to know if I removed the appendix while I was inside that patient during surgery?  Read my operative report.  If I didn’t say I removed it, the appendix is still there. The corollary was also true: If it was written down, it must have happened.  If I wrote the lab test down, I checked it.  Simple.  Patient care depends on it.

Nothing’s so simple anymore.  In the era of the electronic medical record, everything is already written down, whether it’s true or not, whether I saw it or not.  Prepopulated rubrics, standardized physicals with normal findings documented by default, cut-and-paste patient histories with negative answers already filled in for all those questions the doctor may or may not have actually asked.  We can’t trust any of it any more, because we didn’t write it.  The computer did.  And nobody, no matter how professional or conscientious, can possibly undo all the stuff automatically done by the computer in the name of quality patient care.  Except most of it is bullshit.  Almost all of it.  Even the stuff I did myself, last month or last year.  When I look at a physical exam form, I can’t be sure that I really felt the patient’s pulse as it says on the record, or did the computer fill that in and I didn’t take the time to delete it?  Patient care decisions are now made on the basis of this flawed type of documentation every day.

It wasn’t supposed to be this way.  I was in Washington when the first discussions were being held about implementing an electronic medical record.  The advantages are obvious.  No more unintelligible doctor writing leading to patients getting the wrong drug.  Universal access to critical information on a real-time basis, eliminating repeated tests and procedures.  Less waste, greater safety.  It was all completely laudable.  Government and private industry allied to make health care better, cheaper, safer.  First step was to develop ground rules, a basis for all records to be standardized, to be developed by the US Bureau of Weights and Measures.  Never happened.  Too much money was at stake.  The government mandate, well intentioned but flawed in its implementation, was usurped by the greed of private industry.  Billions of dollars were at stake.  Lives were too, but nobody really stopped to notice.

Last year, I was called upon to be an expert witness in the defense of two emergency medicine physicians in New York.  The ER doc’s had heroically resuscitated a motorcycle rider who had suffered a traumatic amputation of his leg.  Sadly, the man had died from his injuries.  The family sued, alleging incompetence on the part of the treating doctors.  As far as I could tell from my review, the doctors had done everything they could possibly have done to save the man’s life.  I testified to this opinion in court.  With a dramatic flourish, the plaintiff’s attorney projected a ten foot high image of a page from the hospital record.  “Explain this, Dr. Geller!” the attorney demands, using his laser pointer to demonstrate where the medical record states that pulses were present and normal in both feet.  “These doctors didn’t even examine the patient, didn’t even realize that the patient’s leg was missing!” the attorney declaimed.

“No, not at all,” I had to explain to the jury.  “These doctors were so busy trying to save this man’s life, they didn’t have the time to uncheck the boxes on the computer form where it automatically fills in normal pulses for the feet of every single patient.”  It took me almost a half hour of explanation to the jury.  I thought I sounded like an idiot trying to explain this ridiculousness.  In the end the jury understood, and the physicians were acquitted.  It’s like something out of Joseph Heller’s novel, Catch 22.  Or MASH.  But with real dead people.

 

Publishers on Life Support: An Industry in Decline

There is no lack of opinion regarding the state of the publishing industry.  While I am not a professional insider, my status as a writer-publisher of two novels, as well as my previous experience as an author/editor of a traditionally (Big Six) published nonfiction work, gives me some credibility, I believe, in this discussion.  As much as many writing on the topic, at any rate.  It is my opinion that traditional publishing is exhibiting evidence of an industry that is deeply moribund.IMG_1115

As a surgeon practicing for over 27 years, I have had the deeply unpleasant experience of witnessing institutional decline and failure.  This past decade has been particularly challenging for hospitals.  On several occasions, I have witnessed the process of a hospital failing around me.  The signs are always the same.  The first evidence of a problem is the day that I’m told that some suture or medication that I’ve routinely used during an operation is “not in stock.”  While variously ascribed to “vendor problems” or “delayed shipment,” the real reason is that the hospital has stopped paying its bills in a timely fashion and the suppliers are waiting for a check before they send any more stuff.  Obviously, this is a problem.  It affects the care of my patient, but one finds a way to make do.  Next, the clerks start disappearing from the wards and nursing stations.  These individuals, while not licensed professionals, are the equivalent of the staff sergeants in the military–the people who know how to get things done.  They make everybody’s job easier.  But since they have no direct patient contact and are not regulated by the various accreditation agencies that the hospital must answer to, they are first to go as the hospital seeks to pare down its salary expenses (salaries are always the hospital’s highest expenditure).  The absence of the clerks doesn’t directly endanger the care of patients, but it makes the lives of the nurses, PA’s, and doctors much more difficult.  Suddenly, the care givers must spend time doing clerical duties to get things done for their patients, making everyone less efficient.  And it’s not like we have a lot of extra time to take on these tasks, so everybody feels the strain.  Hospitals depend on the fact that health care professionals, however, will pick up the slack for the good of the patient.  After all, everybody who works in the hospital has sworn an oath to that effect; everyone, that is, except the hospital administrators.  But this can only be stretched so far, and eventually, the best staff members leave to take positions at other, more solvent hospitals.  The remaining staff, too old or marginally competent to relocate, are left behind in a situation of downward spiraling care.  The final phase before the doors are ultimately locked is a deeply distressing period, though patients are often oblivious to the situation.

I see the same thing happening today in the publishing industry.  Obviously, traditional publishers are in a financially challenging environment.  Their current reaction, it seems to me, exactly mirrors what I describe above.  Experienced and talented professionals in the field, some of them my friends and associates, are being let go.  Divisions are being downsized or consolidated.  Jobs once done by these experienced pros are now done by interns, or not at all.  In-house expertise is sacrificed to subcontractors, always the lowest bidder.  My recent reading experience has given sad evidence to this trend.  Ebooks put out by major publishing houses on Kindle and Nook (I use both) exhibit extensive formatting issues, nonfunctional Tables of Contents, and copy editing errors pointing to a “scan but don’t proofread” approach to converting their manuscripts from print to the electronic format.  Even recent print editions, both hardcover and trade paperback books, show the kind of mistakes that shouldn’t be allowed by a professional publishing house that holds itself to a standard above the independent author-publisher.  Supposedly.

This is the crux of the matter at hand.  The traditional, professional publishing houses are in competition with independently published writers, as well as multiple small presses.  The response to this competition must be to turn out an even better product, to provide their contracted authors with a level of support and professional cache that will make for continued loyalty.  This has not been in evidence.  It seems, instead, that the response is to cut corners as they cut expenses.  It’s not going to work.  This short sighted approach, like the hospital trying to keep its doors open as it provides decreasing quality of care, leads to failure.

The response of a challenged industry giant must be to use their assets to explore new markets and areas of opportunity.  For example, many independents and small publishing houses are exploring the use of “bundles” to provide readers with greater value.  This is a natural technique for traditional publishing houses to employ, as they own the rights to huge libraries of previously published material, much of it desirable to readers.  It costs almost nothing for publishers to exploit this asset, but there is little or no effort being displayed in this regard.  It seems to me that every time I purchase a book written by an author published by RandomPenguinWhatever, I should receive the recommendation to buy a bundle of that author’s previous work, or some part thereof.  Not happening.

If traditional publishing houses continue to play defense rather than innovate, to pare down rather than promote those aspects of their industry in which they excel, the downward spiral to institutional failure is inevitable.  The best and brightest in the industry–authors, editors, marketing and legal professionals–will leave for the new opportunities which will  arise in their stead.  These folks haven’t sworn an oath to support their publishers.  And readers are not oblivious.

Give Your Sweetheart a Claddagh and Help the Homeless

Happy Valentine’s Day.  Just to prove that we are not simple dupes, reflexively buying chocolates and cards because the Hershey/Hallmark Intimacy Industrial Complex tells us to, do better for the one you love this year:

Just now available for your loved one:  The Problem With God, now in paperback.  The second (some say the best) book in The Claddagh Trilogy.  Available at Amazon at:

Buy the Book!

Pageflex Persona [document: PRS0000039_00025]

Isn’t (s)he worth it?  Of course he/she is, and proceeds go to charity.  What says “I love you” more than contributing to keeping homeless people warm this crazy cold and snowy holiday?

Enjoy your chocolates, too.

Professionals Perform

It should be obvious to anyone who reads this blog that I am not a professional author.  I have never made such a claim, despite the fact that I’ve written a bit.  I’ve traditionally published nonfiction with McGraw-Hill, I’ve edited quite a bit of nonfiction, and lately I’ve independently authored/published two novels.  And I write this blog which, I hope, occasionally doesn’t suck.  All of which does not make me a professional author.  I am a surgeon, and I write.  But I am a professional surgeon, and I am not, in any manner of speaking, a professional writer.IMG_1114

I make this point as a matter of introduction. I read a bit about writing, since it is my hobby.  Nobody who dabbles in this business can possibly miss the current controversy surrounding the seismic changes occurring in the publishing industry.  The recent changes have allowed anyone with a computer to publish a book.  I am, as I mentioned, a case in point.  This has led to a great deal of distress on the part of the established publication industry, exactly paralleling the cataclysm which struck the traditional music industry a little over a decade ago.  No surprise there.  What is unique to this authorship revolution, however, is the angst that this revolution has created amongst professional authors.  A case in point–

I recently read the blog post of Chuck Wendig at Terrible Minds.com entitled:

feb, 2014
SLUSHY GLUT SLOG: WHY THE SELF-PUBLISHING SHIT VOLCANO IS A PROBLEM

 At the risk of oversimplifying Mr. Wendig’s lengthy blog post, the gist of the problem as he sees it is that now that the barriers to publication have been dismantled, so many people are publishing so much bad literature that it is making it hard for readers to discover quality books and, in addition, that this lack of quality may lead to a backlash against independently published work.  This is a point that Mr. Wendig has made many times and is a point made by many concerned professionals in the field.

I don’t agree.

Oh, I wholeheartedly agree that we are currently experiencing an unprecedented wave of terrible, awful, self-published books.  Just like we’ve recently seen a surge of mega-best selling traditionally published dreck.  Nothing new there.  But I disagree with Mr. Wendig that this is a problem.  It sounds an awful lot like, “Those damn kids with their rock and roll are ruining all the good music for the rest of us.”  I don’t think Mr. Wendig has to worry so much.

You see, Mr. Wendig, you are a professional writer.  You dedicate all your professional energies to your craft, which is your job, which earns you a living so that you can put food on your family’s table.  That is not what I or these other yahoos spouting “the self-publishing shit volcano” do.  We dabble.  We emulate.  And very often, we suck.

You should be encouraged by this fact.  You should revel in the great discrepancy between your work and mine.  Trust me, if you decided to take up general surgery as a hobby and start taking out a few gallbladders on your kitchen table just for kicks, I’m not worried.  You are never going to approach my skill or professionalism in this endeavor.  If you can convince some folks that your hobby-level gallbladder removing skills are good enough to get a few people to lay down for a cut-rate cholecystectomy, I’m not feeling threatened.

Your job, Mr. Wendig, is to be so much better than the rabble that your professionalism makes you stand out above the crowd.  Your job, is to make sure that your work is valued and valuable, marketed in a manner that the audience/consumer finds desirable.  The music industry analogy is perfectly apt.  Believe me, Bruce Springsteen isn’t too worried that I can put out an album on iTunes using Garage Band.  However, quite a few million music lovers got a little ticked off when Springsteen’s albums were costing $18 a pop for a CD that cost thirty cents to make.  A lot of folks couldn’t afford $100 for a ticket to a concert in Madison Square Garden.  That’s when we all started to look around and realize that the bands playing at the local theater for $10 really were pretty damn talented.  So we went to see them perform, instead.  And then we bought their albums, instead.

So Mr. Wendig, don’t worry that most self-published books are terrible.  Just be professional. Worry when we start getting good at this stuff. 

Trust No One

I’m so proud of my  Mom.  She told me last night that she had gotten a call earlier in the evening (middle of dinner, of course) from a woman asking her to confirm her banking and credit card information.  Despite the woman insisting that it was perfectly fine to tell a complete stranger on a cold call your every vital identifying fact, my mother demurred.  At 87, she’s still too polite to just hang up on the pirate, but she knows a scam when she hears one.  Good for you, I told her.  But listen to this.  Here’s a new one.Minolta DSC

I’ve had my “identity” stolen at least four times over the past five years.   The first time, I was upset.  I got a call from my credit card company asking me if I was buying a lot of stuff in Tennessee.  Never been there.  The nice guy from the bank actually was able to tell me the name of the guy who was buying stuff on my account and the address that he was having all the stuff sent to.  “So, you’re going to have the police in Tennessee pick him up?” I asked naively.  “Naw, of course not,” the bank guy said.  “We’ll just cancel out the card and send you a new one.”  At the time, I was rather indignant that no one was going after the guy who had stolen my “identity.”  Having gone through this process a few more times now, I’ve come to be more blasé about the whole deal.  Happens every day, I know.

But this is different.

A close relative called up the other day, quite upset.  It seems that she had just received an email from her bank notifying her that the credit card that she had requested was in the mail to her home.  She hadn’t ordered any credit card.  She immediately called the bank and spoke to a representative.  “Oh,” he admonished her, “you probably filled out the application the last time you were in the branch and just forgot.”  “No way,” she said.  “I haven’t been inside a bank in years.”  She does all her banking online.  He agreed that something was amiss and cancelled the card.  He went on to recommend that she sign up for the bank’s credit monitoring service, in view of this near-miss identity theft. Only $14/month.  She was so upset by the incident that she agreed to the service, grateful that the whole mess had been caught before any real damage had been done.

“Hold it,” I said, interrupting her story at this point.  “The email said the card was in the mail  to you?”  “Yeah.”  “But that makes no sense,” I said.  Being old, I am an expert in all things.  Including having one’s “identity” stolen.  “Why would someone have the stolen card sent to you?  They steal a bunch of identities and have the cards sent to a post office box.  Then they use the cards for a day or two before they’re cancelled.  Makes no sense.”

She was quiet for a minute.  “I’ll call you right back,” she said.  She called the bank again, getting a different service representative.  She explained her previous exchange and asked, rather pointedly, what was going on.  There was a pregnant pause before the bank guy responded.  “It seems,” bank guy explained, “that one of our employees initiated the request for the new card.”  He went on to explain that it was not the bank’s policy to do such a thing, of course, but there were incentives to move more credit cards, you understand, and of course he would be certain that the card was indeed cancelled.  Oh, and he’d be reporting the entire sordid affair to his supervisor.

“Of course,” my close relative said.  “And what about the credit reporting service that you guys just sold me by scaring the shit out of me?”

“Oh, you sure you don’t want to go ahead with that?  Just in case?”