Half of the general surgery attendings at my hospital will do appendectomies laparoscopically. The other half routinely do them open, arguing that it’s faster and requires less equipment (and is thus less frustrating than trying to get techs trained mainly on ortho equipment to get right in the middle of the night), and that a 2cm open scar is no more painful or unsightly than three 0.5-1cm port sites.

My problem is that, after two and a half years, I still can’t remember which half is which. Thus, when I’m explaining to patients – you have appendicitis, you should have surgery tonight, I’ll call my boss and set it up – I usually give them the wrong spiel. Whether that laparoscopy is quick and easy, or that an open incision is quick and easy –  I always get it mismatched. Overall I’m getting better at telling patients ahead of time what the attending’s plan is going to be, which only makes it more painful to have to go back and correct. . . (You may wonder why I’m trying to predict the plan. It looks extremely unintelligent and unprofessional to take the history and physical, and then walk out of the room without explaining anything. If you can’t give the patient some kind of diagnosis, and an idea of whether they’ll be admitted, and whether or how soon they’ll need surgery, it looks as though you’re completely clueless, and not a doctor at all. Much more satisfying all around to immediately say, this is what’s most likely wrong, you’re undoubtedly being admitted, and I expect surgery tomorrow morning; let me check with the boss, and I’ll let you know the final plan. Of course, only satisfying if you get the diagnosis and plan right the first time.)

Tonight it was fun, though. One of the ER residents, feeling cocky, decided to try selling us a case of appendicitis based only on history and physical (how old-fashioned). I had to admire his idea (unlike some of his colleagues’ other attempts, he picked a patient with an appropriate history and physical, rather than say a 24-yr old woman with atypical symptoms). So I bought it, and then I managed to sell my attending on coming in to operate in the middle of the night without a CT scan. . . and we were both right, which was good for us and for the patient.

(And you thought the title referred to the Democrats’ scheme of taking the “public option” off the table to quiet public outrage, then slipping it back in and squeaking it through without adequate debate. . . don’t get me started. Here’s to obstruction and deadlock in the Senate.)

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