Still nothing medical to write about. I spend my days doing social work and case management. I’ve gotten really good at sitting in patients’ rooms, taking the time to actually sit in a chair (which certainly does lend a more relaxed air to the conversation), and listening to all kinds of details about their lives which are not medically related. This makes me feel like a good person, and hopefully is giving me practice at establishing rapport with people. I haven’t done some of this stuff since medical school.

It makes me feel like a bad surgeon. Why do I not have anything else to do with my time? A surgery resident is doing something wrong if they are not busy. I keep going through my list looking for something to do, and except for the occasional consult (who now gets the complete history and physical, including review of systems, social, and spiritual history – some of which I have been in the habit of omitting when rushed), I have very little to do.

On the other hand, since it seems like every other surgery resident in the hospital loves Obama, there is no shortage of conversations opening with, “You actually like Palin? She’s an idiot. She’s never been outside this country. She likes to ban books. She likes guns. She believes in abstinence-only sex education. She is opposed to abortion at all times. Isn’t that horrible?” And I grin at them and say, “No, that sounds just perfect to me – except for the idiot part and the banning books part, which the media made up.” And we’re off. I think my political and religious convictions have a perverse fascination for my more liberal colleagues, and they can’t stop coming back to check if I still believe this stuff.

(And yes, I give up, all the rabid Obama supporters hating on Palin have convinced me: I’m voting Republican this year. Once I find the absentee ballot registry form. When does another chance like this show up: A Vietnam vet (from the Hanoi Hotel, no less; those guys are some of my biggest heroes), and a gun-toting pro-life soccer mom with five kids. Compared to an America-hating socialist with no clue about policy – and the only policy ideas he does have consist of taking more of my money to give to the unemployed, and nationalizing my job; after he surrenders to the terrorists, and invites Ahmadinejad to the White House.)


I thought WhiteCoat’s story about medical professionals not having heard about Medicare’s new strategy to avoid paying healthcare professionals for services rendered (otherwise known as the “never” events) had to be an exaggeration.

Then I mentioned their upcoming enforcement (next Wednesday, Oct. 1) to a senior resident, and he gave me a blank stare. He seemed to think this was another piece of raving insanity, along with my defense of Palin (what can I say? when all the men in the room start attacking her, I morph into a Republican) and my objections to abortion. It took me quite a lengthy explanation to get him to think I might be right – this despite signs all over the medical records department warning physicians of the events that are now not permitted to occur, as well as notices popping up all over the charts, and random walls in the hospital. I had no idea that my time in the medical blogosphere was so well spent.

(For further information on the concept developed by some genius in Medicare (who really deserves a million dollar bonus – this scheme is going to save the government so much money – except didn’t they take it all from us in the first place? – until all the hospitals go bankrupt; do you think the government will bail out hospitals who fail because they tried to take care of patients, the way they’re bailing out the financial institutions that made foolish choices?) – excuse me. Back on track: for further information, see Buckeye Surgeon’s analysis, and this piece by Dr. WhiteCoat (as well as a good deal more on his site). Basically, the idea is that Medicare (and the private insurance companies will inevitably follow suit) picks several events which everyone would prefer not to happen, and unilaterally mandates that they will now not pay for these occurences; the goal being to promote “quality” healthcare. Which is fine for the “never” events like wrong-site surgeries and mismatched blood transfusions; those are rare and truly preventable. But then you come to things like urinary tract infections, central-line associated bacteremia, C difficile infection, wound infections, and on and on – things which we all deplore, but which there is no scientific evidence to suggest the possibility of completely eliminating. All the studies show ways to decrease their incidence, but not to prevent them from ever happening at all. I can quote you the statistics; that’s stuff I get pimped on. Anyway, basically, Medicare is going to penalize hospitals for existing in the real world. They’ll all go bankrupt. Somebody please help me figure out some alternative career options? I need to get out of this circus before the whole thing falls apart.)

(And in case you were wondering, I know that the goal of all this is to decrease costs to Medicare, not to improve patient care. Because if patient care were the point, hospitals could be held to evidence-based standards for acceptable rates of infections and other complications. But this whole rigmarole is being arranged by some accountants and their secretaries, who know nothing about taking care of sick people. . . . I’m looking for the exit, and that’s only partially rhetorical. I do not want to spend my life explaining myself to bureaucrats, and begging for permission to take care of the patients that I am morally and legally responsible for.)

In the absence of any medical subjects of interest to write about, I’ll throw in my two cents worth about Sarah Palin: As someone who determined from the minute his name was mentioned that I would never vote for McCain – I’m impressed by his VP choice.

I don’t think it’s enough to make me vote for McCain (if you read this blog, you’ll know that I’m too far off the ultra-right wing/libertarian side to like his straight-down-the-middle politics), but Palin is certainly enough to make me think two and three times. She knows an easy solution to the rising gas prices (drill in ANWR; why do we have to give all our oil money to the Arabs?); she supports gun rights; she’s lived out the pro-life commitment to the value of all human lives (keeping a Down’s baby, as busy as she is, takes some commitment, no matter how much help she may have) (which balances out my biggest gripe with McCain, which is that he sprouted pro-life ideas overnight during this election season); she has some executive experience. We could stand to know more about her ideas on several other key issues (terrorism, immigration, taxes), but based on her record so far, I’m optimistic that once she has the chance to talk, small-government conservatives will at least be mollified by what she says.

McCain made a pretty smart choice: someone who has everything that he lacks to get the conservative Republican base excited about his candidacy – and a woman. I’m also not a feminist, but from plain schadenfreude, I’m tickled to see the Republicans as the ones running a serious female candidate on a national ticket. (I’m not sure Ferraro counted as serious. And Hillary didn’t make it onto a ticket.) It’s going to be fun watching the feminists go through their contortions for the next few months, trying to explain why they don’t want a woman as vice president (and a vice president who incidentally stands a good chance to inherit the presidency; a fact which could make me even happier about voting for them).

Caveat: There’s a catch, of course. In addition to distrusting McCain himself, who is still the lead name, I probably won’t vote Republican this year because it’s inappropriate/wrong for a married mother of five to hold a position of such authority, and one that will take her so much away from her family. It’s a little pointless to have five children, and then not raise them wholeheartedly. And as vice president, one step away from the presidency, her authority will far supercede her husband’s, which is not right. Fun as it maybe to have the Republicans running the female candidate, I still don’t want a woman in the White House.

We’re revisiting the subject of restricted duty hours. As Aggravated DocSurg comments in his humor-laced sarcasm, any sane person would be happy to be working less; so I must not be sane, to be a resident arguing for longer hours. But I think the “old fogies” have a point; and we ought to listen to them before it’s too late to turn this around.

This essay by a neurosurgeon (beyond being an extraordinary demonstration of how to claim to be superhuman, without being arrogant) has applications for all surgeons. Dr. Vates argues that neurosurgeons are unique because they deal with the only non-replaceable, non-repairable part of the human body, which is true; and that they are a breed apart, and that’s true as well. But he also suggests that if you think a surgeon’s ability to perform complex or delicate operations is impaired by fatigue, the solution ought to be to get really good at the procedure, so as to have room to work with when you’re tired. He repeats the line, which ought to be a self-evident truism, but apparently doesn’t compute for the folks at ACGME, that there are no hour restrictions in private practice, and that if we’re concerned about fatigue impairing judgment, that too should be practiced first under supervision.

Apparently some idiots are seriously proposing limiting the work week even farther, to 56 or 48 hours. I object. 80hrs is barely enough now; frequent readers of my blog will have recognized that I regard this as a rule made to be broken. If they cut it down to 56, they will have to extend the length of the residencies; right now, most people are 30 by the time they finish residency, let alone non-traditional students. Lifestyle may not be an issue under that regime, but paying back debts in time to have some money saved for retirement will be.

So I highly approve of Dr. Vates’ solution: The ACS needs to take its toys and leave, ie opt out of the ACGME, and set up its own standards for residency accreditation. Of course, since ACGME recognition is a prerequisite for Medicare to pay for anything, and for board eligibility, this is the kind of thing that would have to be orchestrated with 100% participation, essentially a boycott of the ACGME by the surgical specialties. I’m looking to see where I can sign a petition to that effect. . .

Pursuing the issue of work hours: suppose a patient dies right before change of shift. The family has been notified briefly on the phone (via a message, because no one is answering, or perhaps a conversation cut short by grief and shock), but won’t arrive for at least a couple of hours. If the day team goes home as planned, the only person there to talk to the family will be the night float junior resident, who, with all the good will in the world, is overworked. Even if he gets time to talk to the family, they’ve met him maybe once or twice before, and have discussed little of their loved one’s situation with him. The attending and chief who did most of the interaction with them will be gone. As residents, we’re not about to ask our attending his plans, but we doubt that he’ll come in from home, on a night he’s not on call, to discuss how one of his cases went bad.

Your initial response, and our instinct, would be for at least the chief to stay in the hospital (trying to use the time to study or do something else productive) or perhaps arrange to come in from home when the family arrives.

But the chief has been operating late into the night for the last several days, and was in the hospital almost the entire last weekend. Staying a few extra hours to wait for the family, or even coming back for an hour later on, will push him over the 80hr limit, and hinder him from fulfilling his responsibilities later in the week. He can either stick with the rules, and satisfy himself with having spoken on the phone, or ignore the rules, misreport his hours, and stay around to fulfill this last ultimate duty to a patient and family, to talk with them personally about the death.

This is an extreme but very plausible scenario which illustrates the basic problem with the 80hr rule: an outside agency (government, and the ACGME, which is not surgery-specific) imposes an iron-bound rule which sets our regard for the law and for honesty in our reporting at odds with all professional instincts and obligations, and leaves us feeling guilty no matter which we end up following.

A GOP insider reveals a conspiracy to prevent Ron Paul supporters from being heard at state and national conventions. It’s nice to have our suspicions confirmed (how come Paul was winning 10-15% in most primaries, a strong 3-4th place, and yet was almost never mentioned as a frontrunner, whereas Giuliani, who polled way behind him, was much more prominent? and how come someone who was winning 15-20% in the later polling states, with people deliberately coming out to register their objections to the McCain victory parade, is not getting any recognition from the national party?)

Anyway. It’s always special when a member of the conspiracy group (not that Doug Wead seems to approve of the general plan to silence Ron Paul and his supporters) admits that it exists.

My brother and I have been re-discovering one of Robert Heinlein’s less well-known masterpieces, The Moon Is A Harsh Mistress, about a Lunar colony which fights for independence from Earth. The revolution’s architects are a bunch of libertarian/anarchists, who speak a magnificent Russian-influenced English slang, participate in group marriages, and are assisted by a (secret) sentient computer. This is one of my favorite Heinlein books, right up with Starship Troopers. The way he manages to weave hard science and even harder political science into a novel set in a complete and believable future society with an action plot is amazing.

Clearly I can’t leave well enough alone. This is just a quick link to an MSNBC article about FLDS parents driving hundreds of miles to see their children, as the sibling groups have been scattered to all corners of the Lone Star state. The FLDS spokesman claims to see something fishy in this, and although I’m more disposed to suspect any spokesman than I am the individual parents, I have to agree. Forget about the parents. Does anyone honestly think it’s good for children from tightly-knit families to be separated from their siblings? We’re talking about elementary-age children here. And again, why the big emphasis on keeping the mothers, not accused of any crime, away from the children, unless the real point of all of this is to reprogram them into proper modern children?

Just basic constitutional principles here. No one should be deprived of life or liberty without due process of law. Both children and parents here are being deprived of liberty, and with only a farce of a legal hearing so far. What kind of a precedent is this setting? What if the Arkansas authorities decide that being forced to grow up in a family of 18 children constitutes abuse, or brainwashing? Can they just go and confiscate the Duggars’ children? What about Amish children, brought up in isolation from the world, without simple amenities like electricity and TV? Should we forcibly assimilate them, distribute them through foster homes? What about homeschooled children? Back in the ’70s and early ’80s, they were indeed kidnapped away from their families, and parents spent weeks, even months in jail, for the crime of not conforming to the government-run school system. Maybe we should reopen this. They get spanked, after all, and taught all kinds of weird things: creationism, obedience to their parents (rather than teenage rebellion), the biblical perspective on all subjects, and forbidden to date. Maybe we need to move towards imitating the German government’s approach, where they recently put a teenaged girl in a mental asylum because her parents were brainwashing her by teaching her at home. (in case you thought the Germans had gotten over the fascist approach to the state’s privileges)

Whatever happened to the old-fashioned idea of burden of proof? Doesn’t the Texas government need to prove its allegations in order to keep these children locked up away from their mothers, brothers, and sisters?

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