tag:blogger.com,1999:blog-68297112023400625802024-03-13T10:13:40.634-07:00Playing DoctorMike Plumerhttp://www.blogger.com/profile/00173416051400635467noreply@blogger.comBlogger15125tag:blogger.com,1999:blog-6829711202340062580.post-56764762596298412652013-03-18T12:35:00.000-07:002013-03-18T12:35:52.528-07:00If Treatment Is Expensive, Is It Therefore Effective?
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<br />
<div class="MsoNormal">
<span class="Apple-style-span" style="font-size: 13px;"><span style="mso-tab-count: 1;"> </span></span><span class="Apple-style-span" style="font-size: 13px;">Our
hospital CEO mentioned at an administrative meeting the other day that an
anesthesiologist who owns a pain clinic on the mainland is aggressively
pursuing an appointment with her.</span><span class="Apple-style-span" style="font-size: 13px;"><span style="mso-spacerun: yes;">
</span></span><span class="Apple-style-span" style="font-size: 13px;">He wants to talk, she thinks, about providing some service on our island.</span><span class="Apple-style-span" style="font-size: 13px;"><span style="mso-spacerun: yes;"> </span></span><span class="Apple-style-span" style="font-size: 13px;">She says that he has an impressive
website and 20 employees.</span><span class="Apple-style-span" style="font-size: 13px;"><span style="mso-spacerun: yes;"> </span></span><span class="Apple-style-span" style="font-size: 13px;">We
Googled the website at the meeting.</span><span class="Apple-style-span" style="font-size: 13px;"><span style="mso-spacerun: yes;">
</span></span><span class="Apple-style-span" style="font-size: 13px;">It is impressive.</span></div>
<div class="MsoNormal">
<span style="font-size: 10.0pt; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>She’s
been resisting the meeting on the grounds that he wouldn’t find enough work
here, but he’s insistent.<span style="mso-spacerun: yes;"> </span>She’ll
meet with him soon, I imagine. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-size: 10.0pt; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>What
can he offer?<span style="mso-spacerun: yes;"> </span>Treatment for pain, certainly.<span style="mso-spacerun: yes;"> </span>How?<span style="mso-spacerun: yes;"> </span>Simple things are already available here, so he will probably
want to offer complex and expensive options – injections (the website lists
more than 15 general types), implanted drug delivery systems, and implanted
spinal cord stimulators.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-size: 10.0pt; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>Though
he’ll probably want to do procedures, he will probably not propose a complete
coordinated multidisciplinary service.<span style="mso-spacerun: yes;">
</span>Still, wouldn’t that be great?<span style="mso-spacerun: yes;">
</span>Somebody could come help us stamp out pain through technology and drugs.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-size: 10.0pt; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>But
there’s a question.<span style="mso-spacerun: yes;"> </span>Do
interventional pain procedures really stamp out pain? I had dinner last week
with an old friend from the University of Washington, an anesthesiologist who
has been involved in chronic pain work for more than 40 years.<span style="mso-spacerun: yes;"> </span>In his view, there’s very little
objective evidence that any of the expensive, high-tech new therapies work well
in treating or eliminating chronic pain.<span style="mso-spacerun: yes;">
</span>In particular, few double-blind studies justify the procedural approach
to pain relief, despite its popularity and despite the fact that pain docs bill
bushels of money for performing these procedures.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-size: 10.0pt; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>Our
CEO is one of the smartest and most dedicated administrative people I’ve ever
known.<span style="mso-spacerun: yes;"> </span>But she’s in no position to
say, “Yeah, well prove that all this expensive stuff works, Bub.”<span style="mso-spacerun: yes;"> </span>Instead, she may feel obliged to make
space for a doc who wants to do procedures that produce substantial revenue for
the hospital.<span style="mso-spacerun: yes;"> </span>She’s obliged to
serve the hospital’s financial viability, not make judgments about the efficacy
of expensive treatments.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-size: 10.0pt; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>So
she may need to support procedure-based medicine that sounds good and is
reimbursed without question by all insurance companies, whether or not it’s
really of lasting value to patients.<span style="mso-spacerun: yes;">
</span>She can’t question the value of pain procedures, any more than she can
question the value of invasive cardiac procedures or cancer therapies.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-size: 10.0pt; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>But
there’s certainly room to question.<span style="mso-spacerun: yes;">
</span>Who should be doing that?<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-size: 10.0pt; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>Jeffrey
Parks questions.<span style="mso-spacerun: yes;"> </span>Dr. Parks is a
general surgeon who blogs courageously as Buckeyesurgeon.<span style="mso-spacerun: yes;"> </span>His most <a href="http://ohiosurgery.blogspot.com/2013/03/cardiac-outcomes.html">recent entry</a> refers to a review of </span><i style="mso-bidi-font-style: normal;"><span style="font-size: 10.0pt; mso-bidi-font-family: Arial; mso-bidi-font-size: 15.0pt;"><a href="http://www.amazon.com/Broken-Hearts-ebook/dp/B00BD2DVJ6">Broken Hearts: The Tangled History of Cardiac Care</a></span></i><span style="font-size: 10.0pt; mso-bidi-font-family: Arial; mso-bidi-font-size: 15.0pt;">, a new book by
Harvard medical historian David S. Jones.<span style="mso-spacerun: yes;">
</span>Jones’ book, he observes, “</span><span style="color: #343434; font-size: 10.0pt; mso-bidi-font-family: Arial; mso-bidi-font-size: 13.0pt;">explores
the rise of interventional cardiology and cardiac surgery since the 60's and
how much of the rationale for such a procedure-dominated treatment strategy is
undergirded by some surprisingly shoddy data.”<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="color: #343434; font-size: 10.0pt; mso-bidi-font-family: Arial; mso-bidi-font-size: 13.0pt;"><span style="mso-tab-count: 1;"> </span>Parks
says that Jones’ book cites the troubling lack of evidence from controlled
trials that either coronary artery bypass grafting or less-invasive coronary
stenting has any demonstrable effect on survival when compared to medical
management of coronary artery disease.<span style="mso-spacerun: yes;">
</span>Parks recalls no time during his surgical training when he heard cardiac
surgeons question whether CABG procedures were effective, though they lamented
the decline in such procedures, as it restricted new jobs available for
fellows.<span style="mso-spacerun: yes;"> </span>Cardiologists, too, he
says, have persisted in inserting coronary stents in spite of lack of evidence
clearly showing improved long-term survival.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="color: #343434; font-size: 10.0pt; mso-bidi-font-family: Arial; mso-bidi-font-size: 13.0pt;">“We may be
too far gone to change anything,” Parks says. “The coronary
intervention/surgery sector is a $100 billion industrial complex.” The idea
that the medical/pharmaceutical/industrial complex might be as troubling as the
military/industrial complex against which Dwight Eisenhower warned us is
increasingly part of conversation now.<span style="mso-spacerun: yes;">
</span>See Steven Brill’s lengthy Time Magazine piece entitled <a href="http://www.time.com/time/magazine/article/0,9171,2136864,00.html">“Bitter Pill: Why Medical Bills are Killing Us”</a> .
Brill covers a lot of ground, but he’s pretty clear that medical billing is out
of control.<span style="mso-spacerun: yes;"> </span>Hospitals charge
whatever they want, according to seldom shared price lists that he calls
“chargemasters.” People pay whatever their insurance companies have negotiated
– except for the uninsured, who are expected to pay the hugely inflated prices
of the chargemaster.<span style="mso-spacerun: yes;"> </span>It’s been
that way all the time I’ve been in medicine, but the gap between what’s charged
and what’s paid is much greater now.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="color: #343434; font-size: 10.0pt; mso-bidi-font-family: Arial; mso-bidi-font-size: 13.0pt;">When I was
diagnosed with prostate cancer in 2000, I didn’t care how much it cost to cure
it, if somebody else was paying.<span style="mso-spacerun: yes;">
</span>And I definitely didn’t want to wait for double-blind studies to
validate the treatments that sounded best to me. I found it difficult at that
time to compare one treatment with another, and very difficult to get an idea
of the side effect and survival profile of any particular treatment.<span style="mso-spacerun: yes;"> </span>At some point I realized that it was
virtually impossible to get any information on the difference between being
treated and not being treated.<span style="mso-spacerun: yes;"> </span>I
had some idea what might happen with different treatments, but almost no
information on what would happen if I took no treatment at all.<span style="mso-spacerun: yes;"> </span>I could clearly see that some people
were dying of prostate cancer, but I couldn’t see clearly that any of the
treatments I was looking at would have “saved” those people.<span style="mso-spacerun: yes;"> </span>Controlled trials were completely
unknown.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="color: #343434; font-size: 10.0pt; mso-bidi-font-family: Arial; mso-bidi-font-size: 13.0pt;">I asked the
physician who ultimately became my treating physician in Georgia why it was so
hard to get good comparative data, and why people seemed so reluctant to be
objective about the treatment they offered.<span style="mso-spacerun: yes;"> </span>“It’s big money,” he said.<span style="mso-spacerun: yes;"> </span>Each of the docs offered only a single treatment modality –
external beam radiation, seeds, prostatectomy, cryotherapy, and so on. And
everybody was so desperate to hang onto the big money in cancer treatment that
docs simply could not afford to have their business fall off substantially if
patients moved to a more appealing treatment, one which would be provided by
somebody else.<span style="mso-spacerun: yes;"> </span>Objectivity was an
expensive luxury for docs maintaining a state-of-the-art treatment center.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="color: #343434; font-size: 10.0pt; mso-bidi-font-family: Arial; mso-bidi-font-size: 13.0pt;">Treatment
was expensive even then, thirteen years ago -- $25,000 to $50,000 – and it was
paid for because the treating docs believed in it and convinced insurers of
their beliefs, not because they’d clearly shown effectiveness.<span style="mso-spacerun: yes;"> </span>They knew that they could make
prostates disappear, but they didn’t know whether that would make a long-term
difference in who survived the disease.<span style="mso-spacerun: yes;">
</span>And not one of us wanted to wait ten or fifteen years for results,
imagining all the time that the disease was crawling through our innards and destroying
our precious generative organs.<span style="mso-spacerun: yes;"> </span>We
patients were never, ever, going to argue for restraint in medical spending,
especially if somebody else was going to pony up the money for us.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="color: #343434; font-size: 10.0pt; mso-bidi-font-family: Arial; mso-bidi-font-size: 13.0pt;">On another
note, I’ve been interested in end-of-life care for a number of years.<span style="mso-spacerun: yes;"> </span>I’ll practice palliative medicine when
I leave the OR, and I’m training in the meantime to be a hospice
volunteer.<span style="mso-spacerun: yes;"> </span>In addition, Jan and I
have just been through the process of filling out extensive end-of-life
directives with each other.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="color: #343434; font-size: 10.0pt; mso-bidi-font-family: Arial; mso-bidi-font-size: 13.0pt;">I’m
reminded especially, now, that medicine at the end of life is more of the
same.<span style="mso-spacerun: yes;"> </span>We fear death, and we do whatever
we can to avoid it – we commit ourselves to operations, to chemotherapy, to
intensive care, to CPR, to intubation and artificial ventilation, to
tube-feeding. When we lose the ability to choose, those who love us may commit
us to these same options. <o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="color: #343434; font-size: 10.0pt; mso-bidi-font-family: Arial; mso-bidi-font-size: 13.0pt;">As a
society, we support that. Medicare will pay for any care a doctor orders,
including all futile efforts at preserving fleeting life at the end. On the
other hand, Medicare pays a severely limited amount of money for six months for
a patient who elects hospice care. <span style="mso-spacerun: yes;"> </span>How much of this limited care do people on Kauai actually use?<span style="mso-spacerun: yes;"> </span>We learned that on Kauai people who
come to hospice get an average of three weeks of care.<span style="mso-spacerun: yes;"> </span>We’re that afraid of giving up.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="color: #343434; font-size: 10.0pt; mso-bidi-font-family: Arial; mso-bidi-font-size: 13.0pt;">Here’s
where palliative care has a role, the search for what <a href="http://www.amazon.com/Best-Care-Possible-Physicians-Transform/dp/1583334599/ref=la_B001IGO01K_1_3?ie=UTF8&qid=1363634891&sr=1-3">Ira Byock</a> calls “the best care possible,” not simply the most interventions.<span style="mso-spacerun: yes;"> </span>Right now if we simply insist on the next possible
treatment, Medicare will pay for it all, no matter how futile.<span style="mso-spacerun: yes;"> </span>On the other hand, if we actively make
a selection in favor of pain relief, comfort, support, and gentle death we swim
against the tide of technology, and we find that money available for our care
is limited and carefully doled out.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="color: #343434; font-size: 10.0pt; mso-bidi-font-family: Arial; mso-bidi-font-size: 13.0pt;"><span style="mso-tab-count: 1;"> </span>We
have plenty of money to provide good medical care. Powerful forces distort the
distribution of this money.<span style="mso-spacerun: yes;"> </span>Our
medical/industrial/pharmaceutical complex has effective ways of attracting
money preferentially to the new and glamorous – not necessarily the effective.<span style="mso-spacerun: yes;"> </span>Not all that money improves patient
health.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="color: #343434; font-size: 10.0pt; mso-bidi-font-family: Arial; mso-bidi-font-size: 13.0pt;"><span style="mso-tab-count: 1;"> </span>On
a final note, a group of Canadian docs who were teaching in the <a href="http://www.theairwaysite.com/pages/page_content/Airway_Anesthesia_More.aspx">Difficult Airway Course</a> pointed out an interesting difference between their practice and
mine.<span style="mso-spacerun: yes;"> </span>In Canada, they said, the
money is all on the table at the start of the game.<span style="mso-spacerun: yes;"> </span>Surgeons and proceduralists do procedures that use up the
money, and are regarded as cost centers.<span style="mso-spacerun: yes;">
</span>In the US, on the other hand, hospital income comes from reimbursement
for medical procedures.<span style="mso-spacerun: yes;"> </span>Surgeons and
proceduralists do procedures that generate revenue for themselves and for hospitals.
<span style="mso-spacerun: yes;"> </span>They’re revenue generators.<span style="mso-spacerun: yes;"> </span>Cost center versus revenue center.<span style="mso-spacerun: yes;"> </span>Which has the most power?<span style="mso-spacerun: yes;"> </span>How can we expect hospital systems to
resist the temptation to support procedures that increase revenue, no matter
how poorly-studied they may be?<span style="mso-spacerun: yes;">
</span>Whose job is it to put a flag on the play when a medical procedure is
unstudied?<span style="mso-spacerun: yes;"> </span>Or worse, studied and
shown of little value?<span style="mso-spacerun: yes;"> </span>If we stop paying
for unproven procedures, will we have anything left we can offer?</span><span style="font-size: 10.0pt; mso-bidi-font-size: 12.0pt;"><o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<!--EndFragment-->Mike Plumerhttp://www.blogger.com/profile/00173416051400635467noreply@blogger.com2tag:blogger.com,1999:blog-6829711202340062580.post-29724104752146860882013-01-31T22:04:00.002-08:002013-01-31T22:04:51.671-08:00OH SAY, CAN YOU SEE...?
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<br />
<div class="MsoNormal">
<span style="mso-tab-count: 1;"> </span>Today
was the day for my cataract removal – technically, a phacoemulsification and
insertion of intraocular lens in my left eye.<span style="mso-spacerun: yes;"> </span>That’s my only working eye, about which more later.<span style="mso-spacerun: yes;"> </span>If you haven’t thought about how that’s
done, here’s a nice short video: <a href="http://www.youtube.com/watch?v=UIApXNXOnHs">http://www.youtube.com/watch?v=UIApXNXOnHs</a></div>
<div class="MsoNormal">
<span style="mso-tab-count: 1;"> </span>Basically,
the surgeon puts the eye to sleep, exposes the lens, inserts a device that
emulsifies the lens (sort of like putting a portable blender into a pot of
boiled potatoes and moving it around until you have a pot of mashed potatoes),
then sucking it out.<span style="mso-spacerun: yes;"> </span>The intraocular
lens is a piece of optical plastic slipped into the cavity created by the
absent natural lens, held in place by springy arms that extend out to the sides.</div>
<div class="MsoNormal">
<span style="mso-tab-count: 1;"> </span>It’s
highly skilled bit of surgery that has become very common.<span style="mso-spacerun: yes;"> </span>I’ve watched more than a hundred, and
thought it looked as though patients had a pretty easy time.<span style="mso-spacerun: yes;"> </span>However, I now know that their
experience is more complicated than I thought.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal" style="text-indent: .5in;">
For several days now I’ve been
dousing my eyes with eye drops to kill bacteria and reduce inflammation in
preparation, as well as washing with antibacterial soap and scrubbing eyebrows
and lashes vigorously to exfoliate bacteria-containing debris.<span style="mso-spacerun: yes;"> </span>I now have a really clean eye.</div>
<div class="MsoNormal">
<span style="mso-tab-count: 1;"> </span>Though
patients usually don’t get more than topical anesthesia and an oral valium
pill, they’re treated as though more anesthesia might be necessary.<span style="mso-spacerun: yes;"> </span>An anesthesiologist is at hand, an IV
is started, and the patient refrains from eating or drinking after midnight to
ensure an empty stomach.</div>
<div class="MsoNormal">
<span style="mso-tab-count: 1;"> </span>I
was to report at 0645 this morning, to be the second case.<span style="mso-spacerun: yes;"> </span>I arose at 0430 and made Jan’s
breakfast while she cleaned up.<span style="mso-spacerun: yes;"> </span>Thinking
that I might absent-mindedly take a bite of food or a drink, I plastered a
piece of packing tape over my mouth, good for a laugh when I brought Jan her
tea.<span style="mso-spacerun: yes;"> </span>As it turned out, the tape
was a good idea.<span style="mso-spacerun: yes;"> </span>I made a mess out
of peeling a hard-boiled egg, and only the tape prevented activation of the
reflex that causes me to dispose of food mistakes by eating them.<span style="mso-spacerun: yes;"> </span>I would have stuffed the whole mess into
my mouth to keep Jan from seeing it.</div>
<div class="MsoNormal">
<span style="mso-tab-count: 1;"> </span>At
the hospital, I thought I knew the drill for the procedure, so I thought I’d be
pretty relaxed. Check-in was easy, and soon I was perched on the gurney that I
would ride into the eye room.<span style="mso-spacerun: yes;"> </span>My
anesthesiologist chatted affably as he waited for his first case to be ready,
and in short order my nurse began my check-in procedure -- name, birthdate, name
of procedure, scan of name tag, scan of all medications, administration of eye
drops for numbing and dilation of the pupil. After the eye drops, the nurse
placed a tiny sponge in my lower lid and taped the operative eye closed. Finally,
it was time for the IV.<span style="mso-spacerun: yes;"> </span>My nurse
recruited a colleague with a reputation as the best IV starter, and even though
she had been up all night she inserted a truly painless IV.</div>
<div class="MsoNormal">
<span style="mso-tab-count: 1;"> </span>And
then I waited.<span style="mso-spacerun: yes;"> </span>Blood pressure had
been about 130 over 80, so I knew I was more uptight than I’d admitted.<span style="mso-spacerun: yes;"> </span>The valium helped, and simply closing
my eyes and relaxing helped.<span style="mso-spacerun: yes;"> </span>It
was hard to open my eyes without dislodging the tape holding the operative eye
closed. Jan held my hand and we talked as we waited.<span style="mso-spacerun: yes;"> </span>I thought I was being careful not to start mumbling so Jan
would believe she was witnessing my superior self-control, not merely the
effect of a potent drug.</div>
<div class="MsoNormal">
<span style="mso-tab-count: 1;"> </span>And
then it was time.<span style="mso-spacerun: yes;"> </span>Down the hall,
into the room, monitors on, head down, pillow down to my knees, head wedged into
position, oxygen under my nose, Velcro snuggie wrap around my torso, drapes
ready to pull up over my face.<span style="mso-spacerun: yes;">
</span>Betadine eye scrub, more local anesthetic drops, sticky drapes over the
eye after sheets are pulled up over my face.<span style="mso-spacerun: yes;"> </span>I had a moment of wondering whether I was going to turn out
claustrophobic.<span style="mso-spacerun: yes;"> </span>It passed.</div>
<div class="MsoNormal">
<span style="mso-tab-count: 1;"> </span>I
heard the surgeon’s voice, and in a minute the microscope swung into place over
me as he asked the anesthesiologist to lower the bed slightly.<span style="mso-spacerun: yes;"> </span>The springy eyelid retainer clicked
into place in my eye, and a blinding light gave me an overwhelming urge to
close a now wide-open eye.<span style="mso-spacerun: yes;"> </span>“Some
cool drops…” said the surgeon, an opening line I’ve heard over and over again
as he starts a case.</div>
<div class="MsoNormal">
<span style="mso-tab-count: 1;"> </span>And
he was at work. I could feel pressure and movement, but not at first any
discomfort.<span style="mso-spacerun: yes;"> </span>As we progressed I
realized several times that I was responding to minor discomfort in the same
way I do in the dentist’s office – by tensing up in anticipation of the big
pain that never comes.<span style="mso-spacerun: yes;"> </span>So I
relaxed, consciously, several times.<span style="mso-spacerun: yes;">
</span>Blood pressure stayed up a bit, and I could hear the occasional skipped
heart beat, testimony that the patient hadn’t quite gotten over being a little
uptight.</div>
<div class="MsoNormal">
<span style="mso-tab-count: 1;"> </span>The
surgeon was calm and directive – “look at the black bar between the lights,
look down an inch, look down again, thank you, you’re doing very well.” I heard
the phacoemulsification process begin, and had an impression of the light image
in my eye being fractured into a bunch of sparkly pieces.<span style="mso-spacerun: yes;"> </span>Maybe I made that up.<span style="mso-spacerun: yes;"> </span>In no time, the old lens was out and
the artificial lens had been inserted and I was done, aware of blurry vision in
the operated eye as drapes were untaped from my face (really the only
uncomfortable part of the procedure).<span style="mso-spacerun: yes;">
</span>I sat up, and the gurney was conveyed royally back to my starting point.</div>
<div class="MsoNormal">
<span style="mso-tab-count: 1;"> </span>Another
vital sign check proved I was still alive, so Jan was invited in and a
delicious cup of coffee appeared, along with the ophthalmologist’s special
healthy cookie and two kinds of less-healthy hospital crackers.<span style="mso-spacerun: yes;"> </span>As soon as the coffee was gone, I was
allowed to put on my shirt and retire briskly to the bathroom.<span style="mso-spacerun: yes;"> </span>Where does all that water come from
when you haven’t had a drink since the night before?</div>
<div class="MsoNormal">
<span style="mso-tab-count: 1;"> </span>I
was ready to leave.<span style="mso-spacerun: yes;"> </span>I could see
tolerably, partly through the perforated aluminum eye patch over the operated
eye, and partly through my other “bad” eye.<span style="mso-spacerun: yes;"> </span>My right eye is amblyopic, ostensibly because the brain
turned it off when I was a kid to resolve double vision.<span style="mso-spacerun: yes;"> </span>So forward vision in my right eye is
very limited.<span style="mso-spacerun: yes;"> </span>It looks like your
vision looks when you push your eye for a minute and then let go, sort of all
blackish (I was explaining this to a nurse the other day and she gave me an odd
look, saying “Who ever pushes in on their eye like that?”). Whatever I look at
directly is blacked out, and the blackness spreads the more I stare and try to
resolve the picture.<span style="mso-spacerun: yes;"> </span>The only
solution is to keep moving the eye around, so I look pretty shifty when I’m
trying to see with the bad eye.<span style="mso-spacerun: yes;">
</span>It’s useless for advanced life tasks – reading, driving, cutting up
food, repairing machinery, practicing medicine.<span style="mso-spacerun: yes;"> </span>But it works fine for avoiding walls and noticing when
somebody else is in the room.</div>
<div class="MsoNormal">
<span style="mso-tab-count: 1;"> </span>So
right now I’m using the vision through my perforated eye patch as I type this,
while my “bad” eye continues to supply the right-side peripheral vision that
it’s supplied so dependably all these years. My experience with the eye patch
makes it clear why perforated aluminum is so seldom used in the lenses of
spectacles, despite its obvious advantages in durability on the playground.</div>
<div class="MsoNormal">
<span style="mso-tab-count: 1;"> </span>I
see the ophthalmologist tomorrow morning.<span style="mso-spacerun: yes;">
</span>I hope he’s right when he says that vision will get better and
better.<span style="mso-spacerun: yes;"> </span>I’m ready.</div>
<div class="MsoNormal">
<span style="mso-tab-count: 1;"> </span>When
I was leaving the hospital to walk out to the car, I was laughing very readily,
finding humor in nearly everything.<span style="mso-spacerun: yes;">
</span>Jan asked if I was always this way at work.<span style="mso-spacerun: yes;"> </span>I said I thought so.<span style="mso-spacerun: yes;">
</span>I thought I was good-humored and easy to work with.</div>
<div class="MsoNormal">
<span style="mso-tab-count: 1;"> </span>Now
it’s afternoon, and I have better perspective.<span style="mso-spacerun: yes;"> </span>I’m afraid that was the valium talking this morning.<span style="mso-spacerun: yes;"> </span>I’m not actually jolly at work, and
perhaps often not even pleasant.<span style="mso-spacerun: yes;"> </span>I
can see that it might be fun to be that way, though…</div>
<div class="MsoNormal">
<span style="mso-tab-count: 1;"> </span>Amazingly,
my ophthalmologist called me personally this evening to see how I was
doing.<span style="mso-spacerun: yes;"> </span>I was moved by the gesture,
and my already high opinion of my ophthalmologist has moved even higher.</div>
<!--EndFragment-->Mike Plumerhttp://www.blogger.com/profile/00173416051400635467noreply@blogger.com0tag:blogger.com,1999:blog-6829711202340062580.post-78306364873320407442013-01-27T17:12:00.001-08:002013-01-27T17:15:22.844-08:00The Eye Man Cometh
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<br />
<div align="center" class="MsoNormal" style="text-align: center;">
“Better than a poke
in the eye with a sharp stick…”</div>
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
<div class="MsoNormal">
<span style="mso-tab-count: 1;"> </span>This
week I’ll pay a man to stick a sharp knife in my only functional eye.<span style="mso-spacerun: yes;"> </span>He’ll destroy the lens through which
I’ve watched my life for 68 years and leave an oddly-shaped bit of clear
plastic in its place.<span style="mso-spacerun: yes;"> </span>He’ll do all
this under topical anesthesia while I’m wide awake.<span style="mso-spacerun: yes;"> </span>He’ll make only a tiny incision, much smaller than the lens
that he’ll insert, which will start out as a tightly-rolled cylinder and unroll
once it’s in the eye. </div>
<div class="MsoNormal">
<span style="mso-tab-count: 1;"> </span>This
lens, I expect, will restore my once-dependable distance vision.<span style="mso-spacerun: yes;"> </span>I could once see so farsightedly, even
without glasses, that I was the go-to guy for visual ID questions.<span style="mso-spacerun: yes;"> </span>When we travelled, I could usually read
the road signs before anybody else in the car.<span style="mso-spacerun: yes;"> </span><span style="mso-tab-count: 1;"> </span></div>
<div class="MsoNormal">
<span style="mso-tab-count: 1;"> </span>Now,
especially in the past year, my ability to resolve detail at a distance has
deteriorated alarmingly.<span style="mso-spacerun: yes;"> </span>I can’t
see small boats on the horizon, I can’t see the whale spouts when Jan points
them out, and I can’t read many street signs until I’m abreast of them.</div>
<div class="MsoNormal">
<span style="mso-tab-count: 1;"> </span>When
we visited Sacramento in October, I drove downtown by myself early in the
morning to meet with my men’s group.<span style="mso-spacerun: yes;">
</span>Looking for “P” street, I found that I suddenly could not read any of the
single-letter signs against the sunrise-bright sky.<span style="mso-spacerun: yes;"> </span>I groped my way to the meeting, guessing at familiar sights,
feeling for the first time in my life visually impaired.</div>
<div class="MsoNormal">
<span style="mso-tab-count: 1;"> </span>In
Las Vegas in November, I had the same experience of being unable to read
freeway signs against a bright sky unless I already knew what they said.<span style="mso-spacerun: yes;"> </span>I found I was leaning heavily on Jan as
a sign-reader.</div>
<div class="MsoNormal">
<span style="mso-tab-count: 1;"> </span>Driving
at night has become incrementally more difficult, and I have difficulty seeing
the road in the glare of some oncoming headlights.<span style="mso-spacerun: yes;"> </span>When we go to dance lessons, even the brilliant green of the
multiple traffic lights at our turnoff from Kuhio Highway seems blinding,
forcing me to shade my eyes so I can see where to turn.</div>
<div class="MsoNormal">
<span style="mso-tab-count: 1;"> </span>Roadside
objects emerge surprisingly from the scenery.<span style="mso-spacerun: yes;"> </span>Walkers and cyclists appear on bright days where there was
only a shady berm seconds before.<span style="mso-spacerun: yes;">
</span>Dark cars with their lights off suddenly appear on empty pavement at
dusk and dawn.<span style="mso-spacerun: yes;"> </span>People who think
they can be seen just have no idea how invisible they are to somebody with even
a little visual difficulty.</div>
<div class="MsoNormal">
<span style="mso-tab-count: 1;"> </span>My
appointment with my ophthalmologist in December revealed that things were
actually as bad as they seemed.<span style="mso-spacerun: yes;"> </span>It
was not likely, his optometrist told me, that I’d be able to pass eye exam for
a Hawaii Driver’s License now.<span style="mso-spacerun: yes;">
</span>Lord, how the mighty have fallen…</div>
<div class="MsoNormal">
<span style="mso-tab-count: 1;"> </span>So
it’s time to have the cararact extracted.<span style="mso-spacerun: yes;">
</span>I’m on the edge of being significantly impaired, of being unable to read
well, of being unable to drive, and of being unable to practice medicine.
(“I’ll be putting a breathing tube in your windpipe, ma’am.<span style="mso-spacerun: yes;"> </span>I can’t actually see it that well any
more, but I’ve done it lots of times and could pretty much do it in my
sleep.<span style="mso-spacerun: yes;"> </span>Pretty much…”)</div>
<div class="MsoNormal">
<span style="mso-tab-count: 1;"> </span>I’ve
taken care of lots of patients having this operation, and have watched this
surgeon do dozens of these without a hitch.<span style="mso-spacerun: yes;"> </span>In fact, I’ve admired his technique from the first time I
sat in his room, everybody silent, all the details just so…<span style="mso-spacerun: yes;"> </span>And now it’ll be my details that will
be just so.</div>
<div class="MsoNormal">
<span style="mso-tab-count: 1;"> </span>For
a long time I feared having this procedure, back in the days when retrobulbar
block with a needle behind the eyeball was the standard method of regional
anesthesia for the procedure.<span style="mso-spacerun: yes;"> </span>I
knew the block usually went well, but with only one eye that works, I wasn’t
eager to risk any complication at all from such an injection.</div>
<div class="MsoNormal">
<span style="mso-tab-count: 1;"> </span>And
now, most surgeons do this operation with topical anesthesia.<span style="mso-spacerun: yes;"> </span>Even though we still make a big deal
out of it, which it is, surgically, the patient’s experience is more pleasant
by far than the average visit to the dentist. Jan reminds me that people don’t
even know about eye pain unless they’ve had lids and eyebrows tattooed, a
procedure that seems increasingly common here.</div>
<div class="MsoNormal">
<span style="mso-tab-count: 1;"> </span>So
I’m not nervous.<span style="mso-spacerun: yes;"> </span>I’m eager.<span style="mso-spacerun: yes;"> </span>Tomorrow I’ll undertake my three-day
regimen of eyelash cleaning and cleansing eyedrops, and Thursday I’ll have more
to tell.</div>
<!--EndFragment-->Mike Plumerhttp://www.blogger.com/profile/00173416051400635467noreply@blogger.com1tag:blogger.com,1999:blog-6829711202340062580.post-68523872873506626612012-11-26T22:36:00.000-08:002012-11-26T22:36:07.754-08:00What's So: Thanksgiving 2012
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<br />
<div class="MsoNormal" style="text-align: left;">
<span style="mso-tab-count: 1;"> </span>Creation
requires vision, but it also requires an accurate appraisal of what’s so in the
present. I’m powerless to create change without accepting the conditions from
which creation starts.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal" style="text-align: left; text-indent: 0.5in;">
For example, if I want to restore a
hurricane-damaged house, it’s important to have a vision of the restored result.<span style="mso-spacerun: yes;"> </span>But it’s even more important to
understand the house’s condition now – wiring corroded from salt water, drywall
and insulation wet two feet up from the floor, patio cover scattered half a
mile downwind, and roof shingles missing from the entire windward side. The
path to the house I want begins with the house I have. </div>
<div class="MsoNormal">
<span style="mso-tab-count: 1;"> </span>So,
too, in my life.<span style="mso-spacerun: yes;"> </span>I have clear
ideas about how I’d like things to be.<span style="mso-spacerun: yes;">
</span>Some areas are not like those ideas at all, and “should be”
different.<span style="mso-spacerun: yes;"> </span>Yet the path to the
life I want begins with the life I have.<span style="mso-spacerun: yes;">
</span>What do I have?</div>
<div class="MsoNormal">
<span style="mso-tab-count: 1;"> </span>I’ve
said that I want a life filled with love. <span style="mso-spacerun: yes;"> </span>I want a marriage with a woman I love, a woman who accepts my
loving her fully and who loves me.<span style="mso-spacerun: yes;">
</span>With Jan, I have that.<span style="mso-spacerun: yes;"> </span>In
that area, my life is working beyond my most inspired dreams.</div>
<div class="MsoNormal">
<span style="mso-tab-count: 1;"> </span>I’ve
also said that I want close, loving family relationships.<span style="mso-spacerun: yes;"> </span>What’s so is that I live in Hawaii while
my parents live in California and Oregon.<span style="mso-spacerun: yes;">
</span>My sibs live in California, Oregon, and Vermont.<span style="mso-spacerun: yes;"> </span>My children and stepchildren live in
England, Indonesia, New York, California, and Hawaii.<span style="mso-spacerun: yes;"> </span>My new family of in-laws lives primarily here on Kauai (we
had 34 people for Thanksgiving), though my new stepson lives in Iowa.<span style="mso-spacerun: yes;"> </span>I phone one parent and one sib weekly;
the other parent, episodically; the other sibs hardly ever.<span style="mso-spacerun: yes;"> </span>I talk to one son when he calls, my
stepdaughter when she calls, my daughter when she e-mails with a purpose, and my
other son and stepsons episodically, as the opportunity arises.<span style="mso-spacerun: yes;"> </span>Relationships with my many new inlaws
have just begun to move beyond cordial.</div>
<div class="MsoNormal">
<span style="mso-tab-count: 1;"> </span>I’ve
said I want a healthy body so that I can participate fully in life as long as
I’m here, and I’ve said I want to be here for a long time.<span style="mso-spacerun: yes;"> </span>I lost 70 pounds on an enlightened
eating program two years ago, and have coached several others to substantial
weight loss on that same program.<span style="mso-spacerun: yes;">
</span>I’m set to offer the program to employees of my hospital after the new
year, as part of creating a pilot program that might encourage an insurer to
pay people to stay healthy rather than fix problems after they occur.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal" style="text-indent: .5in;">
Right at this moment, I’ve regained
25 of those lost pounds.<span style="mso-spacerun: yes;"> </span>Left over
from the Thanksgiving meal, our house contains two kinds of pie, cupcakes, ice
cream desserts, and leftover Halloween candy.<span style="mso-spacerun: yes;"> </span>We have Hawaiian sweet potatoes and corn in the
refrigerator.<span style="mso-spacerun: yes;"> </span>We also have
turkey, ham, vegetables of all sorts, and fruit.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal" style="text-indent: .5in;">
We eat as though we believe it’s
more wasteful to throw food out than it is to convert extra food to fat, then
break it down and flush it out of our bodies.<span style="mso-spacerun: yes;"> </span>We dispose of extra food by eating it, and then we try to
lose the fat deposits that result.<span style="mso-spacerun: yes;">
</span></div>
<div class="MsoNormal" style="text-indent: .5in;">
My regular exercise program consists
of a walk once a week or so, and I find walking affected by pain in one knee
and one hip. </div>
<div class="MsoNormal" style="text-indent: .5in;">
My doctor has left practice, and I
haven’t yet made a move to find another.<span style="mso-spacerun: yes;">
</span>Twelve years after being diagnosed with prostate cancer, I don’t have a
doc and my insurance-approved supply of a valuable medication is running out.</div>
<div class="MsoNormal">
<span style="mso-tab-count: 1;"> </span>I
have said that I want a financially secure retirement.<span style="mso-spacerun: yes;"> </span>I’m still working at age 68, bringing
in much more income than I will ever have in retirement.<span style="mso-spacerun: yes;"> </span>I will be working less in 2013, but
will still be fully engaged in the practice of anesthesia on the rotating
schedule we have in our practice. </div>
<div class="MsoNormal" style="text-indent: .5in;">
My retirement funds halved their
value in 2000 and again in 2008 while managed by Merrill Lynch, so I created a
self-trusteed 401K to avoid the equity market.<span style="mso-spacerun: yes;"> </span>Though I have some clear ideas about investment goals and
mechanisms, almost all of the money sits in holding accounts, losing its value
to inflation, not invested.<span style="mso-spacerun: yes;">
</span>Several small details hamper turning intention into action.<span style="mso-spacerun: yes;"> </span>I am not significantly in action to
create a secure retirement.</div>
<div class="MsoNormal">
<span style="mso-tab-count: 1;"> </span>I
wrote a blog piece in April, 2011, celebrating agreement and moving on after a
divorce.<span style="mso-spacerun: yes;"> </span>As it happens, that
hasn’t entirely occurred yet.<span style="mso-spacerun: yes;"> </span>My
ex filed a suit nearly a year after the divorce asking the judge to set aside
our agreement, contending that I had fraudulently misrepresented the assets
available for division in a settlement. We’re now passing through a prolonged
discovery phase, with a hearing scheduled in January.<span style="mso-spacerun: yes;"> </span>Since there is neither fraud nor misrepresentation to
discover, I expect that the matter will be resolved early in the new year, but
it hangs over me now as a failure to reach closure.</div>
<div class="MsoNormal">
<span style="mso-tab-count: 1;"> </span>So
I do know what I want to create.<span style="mso-spacerun: yes;"> </span>Much
of it has been created.<span style="mso-spacerun: yes;"> </span>And I see
lots of places where I could be in action to create the results I want.<span style="mso-spacerun: yes;"> </span>That’s what’s so today.</div>
<!--EndFragment-->Mike Plumerhttp://www.blogger.com/profile/00173416051400635467noreply@blogger.com0tag:blogger.com,1999:blog-6829711202340062580.post-8363718221662568852011-07-24T16:11:00.000-07:002011-07-24T16:11:54.092-07:00DIETARY SCIENCE – OR RELIGION?<!--StartFragment--> <br />
<div align="center" class="MsoNormal" style="text-align: center;"><br />
</div><div class="MsoNormal"><span style="mso-tab-count: 1;"> </span>I haven’t written a useful word in the past two weeks.</div><div class="MsoNormal"><span style="mso-tab-count: 1;"> </span>Why is that significant?<span style="mso-spacerun: yes;"> </span>Because I took an entire income-free two-week period to write.<span style="mso-spacerun: yes;"> </span>I promised myself that by the end of that period I’d have a basic website in place, with the basics of an eating program that I’d distilled from the writings of others.</div><div class="MsoNormal"><span style="mso-tab-count: 1;"> </span>The period ends today. Today there’s no website, and no distillation.</div><div class="MsoNormal"><span style="mso-tab-count: 1;"> </span>Among other things I did instead of writing was to be Grandpa Mike for a few days in Sacramento.<span style="mso-spacerun: yes;"> </span>I spent three days with my wonderful granddaughter, and with my much-loved son and his amazing wife.<span style="mso-spacerun: yes;"> </span>Yes, I’m at the time in my life when it’s clear that at some future moment of reckoning, I’m more likely to wish I’d spent time with my granddaughter than to wish I’d spent time writing down my thoughts about an increasingly complex set of issues that seem to defy solution.</div><div class="MsoNormal"><span style="mso-tab-count: 1;"> </span>And I moved.<span style="mso-spacerun: yes;"> </span>I moved from my bachelor condominium near the hospital to a house 20 minutes away, in the Wailua Homesteads.<span style="mso-spacerun: yes;"> </span>I moved to begin sharing a house and creating a home with the woman I will marry.<span style="mso-spacerun: yes;"> </span>I moved with some trepidation to a house that’s been her family home for 38 years, a house she bought and built with her husband, who died in 2007.<span style="mso-spacerun: yes;"> </span>I moved despite plenty of advice from relatives and friends warning me that it would be difficult to create “our” home in a house that’s been “her” home or “their” home.<span style="mso-spacerun: yes;"> </span>Three weeks into the process of living in the same house, I have a rapidly-deepening appreciation of her strength, her adaptability, her willingness to embrace change, and her love -- and an even-greater ability to listen to well-meaning advice without incorporating it into my life.</div><div class="MsoNormal"><span style="mso-tab-count: 1;"> </span>Lest it appear that I frittered away my research time entirely, I hasten to point out that I devoted the entire return flight from Sacramento to Honolulu to reading and taking notes on Gary Taubes’ <i style="mso-bidi-font-style: normal;">Good Calories, Bad Calories</i>, a 2007 book from a science journalist who examines the [lack of] science behind the low-fat diet recommendations of the past 30 years, and the [overlooked] science suggesting that “carbohydrate-rich foods are inherently fattening, some more so than others, and that those of us predisposed to put on fat do so because of carbs in the diet.” (<a href="http://www.garytaubes.com/2011/03/dose-of-intervention-land-of-dr-oz/">Taubes' account of his appearance on Dr. Oz's show in March</a>) Moreover, he argues in his subsequent book <i style="mso-bidi-font-style: normal;">Why We Get Fat</i>, it’s almost certain that the same foods that make us fat are the foods that cause heart disease and diabetes and cancer – the diseases associated with obesity.</div><div class="MsoNormal"><span style="mso-tab-count: 1;"> </span>In short, Taubes says that much of what we think we know is wrong, or at least not proven, and the advice that we fatties should eat less and exercise more is at least inadequate and maybe completely misguided.<span style="mso-spacerun: yes;"> </span>He charges that organized medicine, the public health establishment, the food industry, and the government have succumbed to the urge to simplify a complex scientific situation so much that it’s no longer possible to meet the scientific obligation of presenting evidence with relentless honesty. We have created, he says, an enormous enterprise dedicated in theory to determining the relationship between obesity, diet, and disease. In practice, however, the enterprise is dedicated to convincing everyone involved, especially the lay public, that the answers are already known and always have been – “an enterprise, in other words, that purports to be a science and yet functions like a religion.”</div><div class="MsoNormal"><span style="mso-tab-count: 1;"> </span>Taubes took five years to write this first book.<span style="mso-spacerun: yes;"> </span>Perhaps it’s not surprising that in two superficial weeks I wasn’t yet ready to write, especially when I spent most of that two weeks allowing myself to be distracted by other aspects of my life.</div><div class="MsoNormal" style="text-indent: .5in;">I’ve said that I love to take complex ideas, churn up and digest all the underlying information, and make a distillation of my own ideas – that’s why I enjoyed medical teaching so much.<span style="mso-spacerun: yes;"> </span>And I’m beginning to see here that I’ve bitten off a much bigger chunk than I imagined. The more I learn, the more I see that I don’t know.</div><div class="MsoNormal" style="text-indent: .5in;">If I’m to make a difference in the food conversation, I’ll have to get busy churning and digesting.<span style="mso-spacerun: yes;"> </span>I hadn’t planned to be overtaken by such an irresistible inquiry while still working full time and in the midst of profound life change, and I don’t have in place a structure that accommodates that sort of intense work on top of everything else.<span style="mso-spacerun: yes;"> </span>This will be an interesting challenge…</div><!--EndFragment-->Mike Plumerhttp://www.blogger.com/profile/00173416051400635467noreply@blogger.com0tag:blogger.com,1999:blog-6829711202340062580.post-4623824046957058772011-05-16T20:37:00.000-07:002011-05-16T20:37:43.154-07:00Nutrition Science: An Oxymoron?<!--StartFragment--> <br />
<div class="MsoNormal"><span style="mso-tab-count: 1;"> </span>I used to think that only a fool could experience much confusion about food and nutrition.<span style="mso-spacerun: yes;"> </span>When I went to medical school, back in the days of leeches and wooden needles, nutrition was briefly covered in the biochemistry course.<span style="mso-spacerun: yes;"> </span>Beyond that, it was pretty much, “Mmm, food good.<span style="mso-spacerun: yes;"> </span>Eat food.” And, of course, “Fat people have no impulse control.”<span style="mso-spacerun: yes;"> </span>This came from my freshman roommate, himself a skinny guy who went on to become a skilled and apparently compassionate bariatric surgeon.</div><div class="MsoNormal"><span style="mso-tab-count: 1;"> </span>I’ve spent my life thinking that the equation was pretty simple.<span style="mso-spacerun: yes;"> </span>If the number of calories taken in exceeded the caloric cost of running the body machinery, excess calories were stored as fat.<span style="mso-spacerun: yes;"> </span>Weight loss occurred if we expended more calories than we had taken in, and weight gain occurred in the opposite circumstance.<span style="mso-spacerun: yes;"> </span>Good nutrition meant taking in the right quantities of available “healthy food.”</div><div class="MsoNormal"><span style="mso-tab-count: 1;"> </span>Now I’m beginning to see that food isn’t an easy or straightforward issue at all.<span style="mso-spacerun: yes;"> </span>Perhaps all calories are not equal.<span style="mso-spacerun: yes;"> </span>Perhaps all food is not equally good for us.<span style="mso-spacerun: yes;"> </span>Perhaps even the “healthy food” that’s available isn’t so healthy, at least for the people who eat it.<span style="mso-spacerun: yes;"> </span>For the economy? Maybe so.</div><div class="MsoNormal" style="text-indent: .5in;">The movie <i style="mso-bidi-font-style: normal;">Food, Inc. </i>seems to say that we’re guided by advertising and availability to eat what we eat because that’s where the money is for food and agriculture interests.<span style="mso-spacerun: yes;"> </span>The once-hallowed FDA Food Pyramid of my youth seems to have been the result of a political process involving lots of lobbying by folks who wanted to be sure we continued to eat what they were being paid to produce – thus the heavy focus on grains.<span style="mso-spacerun: yes;"> </span>Apparently, neither nutritionists nor health authorities had much to do with its production, though it has a profound effect on health.</div><div class="MsoNormal"><span style="mso-tab-count: 1;"> </span>Individual voices stand out, sometimes out of proportion to the actual proven value of their message.<span style="mso-spacerun: yes;"> </span>Gary Taubes’ article, “Is Sugar Toxic?” (NY Times, April 13, 2011) reiterates the story of nutritionist Ancel Keys from the University of Minnesota. Keys was such a strong proponent in the 1970s of his idea that dietary fat consumption was the best predictor of heart disease that he was able to discredit the equally-probably ideas of England’s John Yudkin, along with Yudkin himself.<span style="mso-spacerun: yes;"> </span>Yudkin had argued that sugar consumption was linked directly to both the triglycerides of heart disease and the insulin levels of type II diabetes.<span style="mso-spacerun: yes;"> </span>Keys’ powerful personality led to widespread acceptance of ideas about fat and heart disease that may have led us to adopt even more harmful high-carbohydrate diets to avoid fat.</div><div class="MsoNormal"><span style="mso-tab-count: 1;"> </span>I’m reminded of the Gary Larson cartoon in which a shark in the water near a beach cups his fins around his mouth to yell, “Bear, Bear!!” as panicked bathers stampede into the water to escape.</div><div class="MsoNormal"><span style="mso-tab-count: 1;"> </span>Casting caution to the winds, I have boldly asserted that I will wade into the morass of dietary information and sort out scientifically proven ideas from those that merely seem sensible.<span style="mso-spacerun: yes;"> </span>In the process, I’ll identify those ideas without a shred of supportive evidence, and those that fly in the face of good sense.<span style="mso-spacerun: yes;"> </span>When I’m done with that, it’ll be clear how we should all eat, and I’ll just jot it down and then we can get back to worrying about bigger things, like where Obama was born and whether autism causes global warming.</div><div class="MsoNormal"><span style="mso-tab-count: 1;"> </span>Or not.</div><div class="MsoNormal"><span style="mso-tab-count: 1;"> </span>Chris Mooney’s article on “Made-up Minds,” published originally in Mother Jones and excerpted in “The Week” (May 20, 2011), reminds us that reasoning is inseparable from emotion. We all tend to pull friendly information close and push threatening information away.<span style="mso-spacerun: yes;"> </span>The fight-or-flight response, he says, applies not only to predators but also to information itself.</div><div class="MsoNormal"><span style="mso-tab-count: 1;"> </span>What’s that mean?<span style="mso-spacerun: yes;"> </span>It means that emotion may not have much bearing on scientific conclusions, but it certainly colors those conclusions to which we give credence, and those we’re willing to talk up.<span style="mso-spacerun: yes;"> </span>We accept evidence that supports our views, and reject evidence that doesn’t.<span style="mso-spacerun: yes;"> </span>In fact, we often reject as experts those whose conclusions, however well researched, don’t fit our pre-existing views.</div><div class="MsoNormal"><span style="mso-tab-count: 1;"> </span>That’s a little awkward.<span style="mso-spacerun: yes;"> </span>Does that mean that I can’t make an unbiased analysis of popular writing, looking for its scientific backing?<span style="mso-spacerun: yes;"> </span>Will I filter out the stuff that doesn’t agree with my biases, even if it’s well-researched, and even if I think I’m being wonderfully even-handed?<span style="mso-spacerun: yes;"> </span>Does that mean people shouldn’t trust me, either? Will my recommendations be just another set of biased ideas, based on that fraction of the literature that supports biases that I already have?</div><div class="MsoNormal"><span style="mso-tab-count: 1;"> </span>Yeah, maybe. I’ll be authoritative, but not a “final authority.” I’m a seeker, an inquirer, an asker of questions.<span style="mso-spacerun: yes;"> </span>When I present an idea as true, I really think it is.<span style="mso-spacerun: yes;"> </span>Remember, however, that my pronouncement and $4.00 will get you coffee at Starbucks.<span style="mso-spacerun: yes;"> </span>In other words, my idea is just that -- my idea, however well-spoken.<span style="mso-spacerun: yes;"> </span>Even my objective judgments are difficult to separate from emotion, from my urge to affirm that the universe really does look the way I think it should look. </div><div class="MsoNormal"><span style="mso-tab-count: 1;"> </span>Trust and verify.</div><!--EndFragment-->Mike Plumerhttp://www.blogger.com/profile/00173416051400635467noreply@blogger.com0tag:blogger.com,1999:blog-6829711202340062580.post-36628539339398676842011-05-15T01:09:00.000-07:002011-05-15T13:37:08.619-07:00Fat is Not a Character Flaw<div align="center" class="MsoNormal" style="text-align: center;"><br />
</div><div class="MsoNormal" style="text-align: left;"><o:p> </o:p> My sister and I have spent our adult lives getting fatter. Neither of us wanted to do that, yet over the years we’ve accumulated enough extra fat between us to build a couple more people. </div><div class="MsoNormal" style="text-align: left; text-indent: 0.5in;">Now I’ve lost about 70 pounds on a healthy eating program, and I feel good. She and her husband have been eating on this same program, and have each lost substantial weight, enough that people are noticing.</div><div class="MsoNormal"> We talked about how easy this program has been, and how completely unaware we were that this is possible. I once had the desperate feeling that I was doomed to continue inflating, since no matter what I did I continued to gain weight.</div><div class="MsoNormal" style="text-indent: .5in;">Since starting the program, I’ve thought repeatedly that it’s appalling how easy it has been for me to lose weight, bring down my glucose, and bring down my blood pressure. Appalling because I didn’t know this was possible, didn’t know how to do it, didn’t know how to get direction from medical people anywhere. Appalling because in my anesthesia practice every day I see people who are overweight, hypertensive, on oral hypoglycemics for early type II diabetes, and on cholesterol-lowering medications. Appalling because I think that’s largely unnecessary. And appalling because almost nobody seems to know how to make a difference, yet.</div><div class="MsoNormal"> The program that worked for me, lowering blood pressure and blood glucose in the bargain, was the Ultralite program (<a href="http://www.ultralite.us/">www.ultralite.us</a>). The Ultralite people at Transformations.com have a program that works, but in my experience it’s marketed so casually that it’s very difficult to hook people up with it. </div><div class="MsoNormal" style="text-indent: .5in;">I’m now certified as a practitioner for that program. The program is certainly effective, and people who are doing it are pleased with the results. People learn not only how to lose weight, but how to eat for the rest of their lives to keep the weight off. Why haven’t I recruited a gang of clients, if I think this is such a great program? </div><div class="MsoNormal" style="text-indent: .5in;"> Two reasons. The program is expensive, and it’s hard to get patients started with other practitioners on the mainland. I think it’s too expensive for many of the folks for whom I’d like to make it available here on Kauai. Why is it expensive? Mostly because it’s practitioner-supervised, and because it uses a proprietary snack between meals in addition to lots of “real” food. </div><div class="MsoNormal" style="text-indent: .5in;">When people who don’t live here ask about the program, I find it’s hard to get people started with practitioners in other locations, even though people on the mainland might be best served by someone in their own area. Sure, I could be the practitioner for these people. I can coach on the phone (the life coach training, you know), but there are a limited number of people for whom I can do that. I’m still practicing full time as an anesthesiologist, and I live in a time zone that’s as much as six hours dislocated from parts of the US.</div><div class="MsoNormal"> Are there other approaches? In truth, none that I’ve tried. But the ideas on which the Ultralite plan is based are not secret and not proprietary. They are increasingly general knowledge. Several people seem to be speaking to the same ideas as those used to create the Ultralite plan – people including Dr. Walter Willett from Harvard, Dr. Steven Gundry (<a href="http://www.drgundry.com/">www.drgundry.com</a>), Isabel de los Rios (The Diet Solution, available on the internet), Gary Taubes of “Good Calories, Bad Calories,” and an increasing chorus of others. All these people seem to be saying that the whole “low-fat” conversation has been a journey off the path, and that the biggest issue with our current way of eating is the preponderance of sugar and high-carb, high-glycemic processed food. This deserves much more discussion in future articles. For now it’s sufficient to say that many of my prior ideas about food and nutrition seem to have been all wet.</div><div class="MsoNormal"> My sister and I also talked about the differences between the medical model and the coaching model. In the medical model, something is wrong and we’re here to diagnose it and fix it. Find a problem, prescribe a solution. Pills work for high glucose, for high blood pressure, and for high cholesterol. They don’t do much for excess weight, but there’s always weight loss surgery if you’re heavy enough to qualify. I believe that weight loss surgery for most people, by the way, is one of the most inadvisable moves anyone ever can make. It literally consists of making yourself sick for the rest of your life in order to lose fat. That’s healthy?</div><div class="MsoNormal"> Coaching (as in life coaching) takes a different approach to issues than does medicine. To coaches, people are whole and complete and have within them all the resources to create the lives they want. People want help in discovering and developing these resources. Coaches don’t fix, and don’t give advice. But they do help people tap their own inner wisdom, learn new ways of being and doing, and create different lives.</div><div class="MsoNormal"> So being fat isn’t something to fix, and it’s not a character flaw. It is, for most of us, the predictable result of the choices we make and the way our bodies work. Fat is simply the energy store that accumulates in a body skilled at gathering and storing energy in times of plenty in order to survive times of famine. In my own experience, even when I thought I was eating “healthy,” I was still making choices that directed my body to accumulate fat. Increasingly, there’s information available that allows me (us) to make different choices.</div><div class="MsoNormal"> Each of us has within us the ability to direct our actions, channel our instincts, and create the best lives of which we’re capable. </div><div class="MsoNormal"> Over the next few months (years?) I’ll be looking at what we know about food, and what we think we know. More than 30 popular diet books and a couple of internet programs are piled by my chair right now. I’ll look at places where people pretty much agree, and where they don’t. I’d like to see a website with a simple eating plan to which I can refer people, one geared to empowering people for the rest of their lives instead of harvesting money, one with straightforward discussion of issues. </div><div class="MsoNormal" style="text-indent: .5in;">We will change the world’s conversation about food, and about fat.</div>Mike Plumerhttp://www.blogger.com/profile/00173416051400635467noreply@blogger.com0tag:blogger.com,1999:blog-6829711202340062580.post-7566644947805549702011-03-05T11:18:00.000-08:002011-03-05T11:20:26.987-08:00Agreement and moving onYesterday my wife and I reached agreement on distribution of property, clearing the way for a divorce decree by the end of the month.<br />
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It's been almost two years since she first said that she wanted our marriage to be over. What once seemed a simple process became more and more complex and protracted as suspicion of withholding assets and anger about past issues was stirred into the mix. I began to think we'd never be free of each other, though clearly we each wanted to be.<br />
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Now that's about to be over. Neither of us ended up with all the assets we wanted. I'll give up a big chunk of the retirement savings for which I've worked, and I'll also put a great deal of cash into retiring a debt that I once dismissed as unimportant. In addition, I'll contribute half of the boatloads of cash necessary to refinance the house with its underwater mortgage and put it in her name. And a few other things.<br />
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We'll each have what we have, and we'll move on. Intact.<br />
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The irony here is that the mistakes and bad decisions that led me to a failed marriage have also been part of the path that's left me living in Hawaii, doing a job I really like, and living a life that I love. In the midst of sadness, I've never been happier. If I'd eliminated any of the mistakes, I might not be here. There's lots more to say about why life is good, and today isn't yet the day to say it.<br />
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By the way, as part of our agreement I have taken down all the divorce-related video cartoons. Letting go, moving on...<br />
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And by the way, I've lost almost 70 pounds as of this morning. And I feel great.Mike Plumerhttp://www.blogger.com/profile/00173416051400635467noreply@blogger.com0tag:blogger.com,1999:blog-6829711202340062580.post-52496130717096757202010-12-25T00:15:00.000-08:002010-12-25T00:15:47.358-08:00Nine weeks, 44 pounds<!--StartFragment--> <br />
<div class="MsoNormal"><!--StartFragment--> </div><div class="MsoNormal"><span style="mso-tab-count: 1;"> </span>Nine weeks ago I weighed forty-four pounds more than I do now.<span style="mso-spacerun: yes;"> </span>I’m peeling off almost five pounds a week.<span style="mso-spacerun: yes;"> </span>Without surgery.<span style="mso-spacerun: yes;"> </span>Or drugs.<span style="mso-spacerun: yes;"> </span>Or extreme exercise.<span style="mso-spacerun: yes;"> </span>Or even any particular fortitude on my part.<span style="mso-spacerun: yes;"> </span>And therein lies a story.</div><div class="MsoNormal" style="text-indent: .5in;">I had all but given up.<span style="mso-spacerun: yes;"> </span>I seemed to be helplessly ballooning several pounds every year, and had been doing so for forty years.<span style="mso-spacerun: yes;"> </span>Nothing worked, except for a brief period in my late 30s when I was running many miles a week. During that time my weight dropped as low as 180 pounds, almost as low as my college weight.</div><div class="MsoNormal"><span style="mso-tab-count: 1;"> </span>The rest of the time has been marked by slow and steady expansion of my girth.<span style="mso-spacerun: yes;"> </span>Over and over I reached and passed a weight that I once thought unimaginable.<span style="mso-spacerun: yes;"> </span>Clothes from a few years ago never fit.<span style="mso-spacerun: yes;"> </span>I have jettisoned many wardrobes in my enlarging wake -- suits, a tuxedo, wet suits, and any number of pants and shirts.<span style="mso-spacerun: yes;"> </span>Finally, even clothing bought for the largest person I was ever going to tolerate no longer fit.</div><div class="MsoNormal"><span style="mso-tab-count: 1;"> </span>At age 66 I found myself approaching 265 pounds, 85 or 90 pounds more than my college weight – and none of that gain was muscle.<span style="mso-spacerun: yes;"> </span>Pants with a 42 waist were snug.<span style="mso-spacerun: yes;"> </span>I needed 2XL aloha shirts to fit my expanded abdomen and prodigious backside.<span style="mso-spacerun: yes;"> </span>Rising from a chair was a chore.<span style="mso-spacerun: yes;"> </span>Getting up out of a car required both elbows on the doorframe.<span style="mso-spacerun: yes;"> </span>Tying shoes was increasingly difficult – I couldn’t breathe with my big belly mashed against my thigh, so I could tie only as long as I could hold my breath.</div><div class="MsoNormal"><span style="mso-tab-count: 1;"> </span>The progression to this stage hasn’t been a straight line, but it’s been inexorable.<span style="mso-spacerun: yes;"> </span>Many times I’ve taken on some program or another and whittled away ten or fifteen pounds, only to watch the scale begin to rise again in a couple months.<span style="mso-spacerun: yes;"> </span>For the past several years, however, I haven’t been able to do even that.<span style="mso-spacerun: yes;"> </span>Even the most sensible calorie-counting and exercise seemed to have become ineffective in reducing more than a pound or two in a month.</div><div class="MsoNormal"><span style="mso-tab-count: 1;"> </span>I had begun to despair.<span style="mso-spacerun: yes;"> </span>I was fat, I was increasingly out of shape, my blood glucose consistently ran above 100 fasting, and my blood pressure had begun to climb slightly, no longer returning to the old 120/70 when resting.</div><div class="MsoNormal"><span style="mso-tab-count: 1;"> </span>Then my college roommate and his wife talked about their experience at George Washington University in a practitioner-supervised program that involved a diet designed to spare muscle and use fat.<span style="mso-spacerun: yes;"> </span>They’d both lost weight quickly, and they hadn’t been hungry.<span style="mso-spacerun: yes;"> </span>No suffering was involved.<span style="mso-spacerun: yes;"> </span>No drugs.<span style="mso-spacerun: yes;"> </span>Real food, prepared at home from a list of acceptable foods.<span style="mso-spacerun: yes;"> </span>And the objective of the program was to teach people how to eat for the rest of their lives in a way that maintained a healthy weight.</div><div class="MsoNormal"><span style="mso-tab-count: 1;"> </span>The Ultralite program, it was called ( <a href="http://www.ultralite.us/">http://www.ultralite.us</a> ).<span style="mso-spacerun: yes;"> </span>Devised by a naturopath in Australia, apparently fairly popular there.<span style="mso-spacerun: yes;"> </span>Strict diet, weighed portions, temporary withdrawal of the foods to which people commonly have reactions, and a supervising practitioner.</div><div class="MsoNormal"><span style="mso-tab-count: 1;"> </span>There were no practitioners on Kauai.<span style="mso-spacerun: yes;"> </span>I talked to the people who run the program in Los Angeles, talked about becoming a practitioner myself in order to bring a program here if it was effective. They were willing to supervise me from a distance on the phone, and willing to have Jan do the diet with me.</div><div class="MsoNormal"><span style="mso-tab-count: 1;"> </span>And now it’s more than nine weeks later.<span style="mso-spacerun: yes;"> </span>I’ve now lost more than 44 pounds, weighing in last Monday morning at 219. I feel good, I’m seldom hungry (no more than any other time), and I’m loving my new lightness.<span style="mso-spacerun: yes;"> </span>Blood glucose has dropped to 70-80 fasting, and morning blood pressures run around 115-60.</div><div class="MsoNormal"><span style="mso-tab-count: 1;"> </span>Can it really be this easy?<span style="mso-spacerun: yes;"> </span>I’m learning that it can, that all the sweat and struggle that I’ve gone through before has been unnecessary.<span style="mso-spacerun: yes;"> </span>I’ll talk more about this diet later, but I’ll say at this point that I’m learning to eat a balance of protein and carbohydrates with virtually no hi-glycemic carbs – no wheat, no rice, and no potatoes, no sugar.<span style="mso-spacerun: yes;"> </span>I thought I’d miss all that.<span style="mso-spacerun: yes;"> </span>I don’t.<span style="mso-spacerun: yes;"> </span>Will I want some later, once weight is lost?<span style="mso-spacerun: yes;"> </span>Yes, and I will have learned to eat in a way that will have me maintain my new weight for life.<span style="mso-spacerun: yes;"> </span>The new weight?<span style="mso-spacerun: yes;"> </span>It’ll be around 180, about what I weighed 45 years ago before I began to demonstrate what an effective-energy storing ability my ancestors had evolved.</div><div class="MsoNormal"><span style="mso-tab-count: 1;"> </span>More on this later.<span style="mso-spacerun: yes;"> </span>This is a big deal for me – I suddenly have easy access to making a difference where I’ve felt completely ineffective for most of my life.<span style="mso-spacerun: yes;"> </span>And I see how easy it could be for others.</div><div class="MsoNormal"><br />
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<!--EndFragment-->Mike Plumerhttp://www.blogger.com/profile/00173416051400635467noreply@blogger.com3tag:blogger.com,1999:blog-6829711202340062580.post-83391011783695184982010-11-21T21:48:00.000-08:002011-03-05T10:48:09.568-08:00Another cartoon, more catharsis... Another adventure in creating a movie by typing text...<br />
The first movie has been posted, as an embedded film in my last post. The second is new, taken again almost entirely from real dialogue (85%) with the addition of some phony material designed to make me look better or add a little humor.<br />
In real life, a mediation conference November 8 was cancelled by the mediator, who felt settlement was impossible while one of the parties still felt the other was hiding money. A court-ordered settlement conference tomorrow was cancelled at the last moment because my lawyer is in the hospital.<br />
Meantime, the implication is that we'll soon find the money that I've hidden, and then I'll be sorry. I'm already sorry...<br />
This time I'm using the URL of the movie-creation website, since I've been unable to get the movie posted to YouTube.<br />
Friendly Divorce, Part 1<br />
<div class="MsoNormal" style="mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;"><a href="http://www.xtranormal.com/watch/7032309">http://www.xtranormal.com/watch/7032309</a><o:p></o:p><br />
Friendly Divorce, Part 2</div><div class="MsoNormal" style="mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;"><a href="http://www.xtranormal.com/watch/7607471">http://www.xtranormal.com/watch/7607471</a><o:p></o:p><br />
<br />
[<b><i>Note added 3/5/11: As a condition of our divorce agreement reached yesterday, I'm taking down the divorce cartoon videos. For both of us, it's part of letting the whole process go and moving on with our lives. I like the cartoon video process. I think I'll be using it in other places, for issues other than venting frustration.</i></b>]</div>Mike Plumerhttp://www.blogger.com/profile/00173416051400635467noreply@blogger.com0tag:blogger.com,1999:blog-6829711202340062580.post-88568415686800768192010-09-01T16:04:00.000-07:002011-03-05T10:46:36.536-08:00Cartoons and Catharsis Everybody in the operating room where I work has been having fun for the past several weeks with a short cartoon film depicting an interaction between an orthopedic resident and an anesthesia resident.<br />
<br />
<object height="385" width="480"><param name="movie" value="http://www.youtube.com/v/3rTsvb2ef5k?fs=1&hl=en_US"></param><param name="allowFullScreen" value="true"></param><param name="allowscriptaccess" value="always"></param><embed src="http://www.youtube.com/v/3rTsvb2ef5k?fs=1&hl=en_US" type="application/x-shockwave-flash" allowscriptaccess="always" allowfullscreen="true" width="480" height="385"></embed></object><br />
<br />
At the end of the movie, there's a short text notice that says something like "If you can type, you can make a movie." It took a while for this to sink in. I can type. I can make a movie.<br />
Are there any painful areas in my life that I might want to dramatize, lampoon, satirize, over-draw, and generally distort to make myself look good? Well, perhaps.<br />
So I took some early dialogue from my journals, distorted it appropriately, added some overblown fictional dialogue at the end, and voila:<br />
<br />
<object height="385" width="480"><param name="movie" value="http://www.youtube.com/v/zmRuPVeFOsw?fs=1&hl=en_US"></param><param name="allowFullScreen" value="true"></param><param name="allowscriptaccess" value="always"></param><embed src="http://www.youtube.com/v/zmRuPVeFOsw?fs=1&hl=en_US" type="application/x-shockwave-flash" allowscriptaccess="always" allowfullscreen="true" width="480" height="385"></embed></object><br />
<br />
Wow, was that fun!!! And cathartic, too. And fictional. This fictional story has its origin in an actual conversation (a series of them, actually) but has been subjected to the vicissitudes of scriptwriting and thus bears only a superficial resemblance to what really would have been recorded on, say, a security video.<br />
Posting this video acknowledges that turnabout is fair play, and that anyone else can submit a public video in which I'm lampooned. Let the play begin...<br />
<br />
[<i><b>Note added 3/5/11: As a condition of our divorce agreement reached yesterday, I'm taking down all the video cartoons related to divorce. It's part of letting the whole process go and moving on with our lives. Look for more videos later about different subjects. I enjoyed the process.</b></i>]Mike Plumerhttp://www.blogger.com/profile/00173416051400635467noreply@blogger.com0tag:blogger.com,1999:blog-6829711202340062580.post-13404606642291260532010-08-20T12:23:00.000-07:002010-08-20T12:27:49.747-07:00Customer delight equals medical quality. Right?<div style="text-align: justify;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-size: 13px;"><br />
</span></span></div><div class="MsoNormal"><span style="font-size: 10pt;"> In my hospital, one of the ways we measure quality of care is to look at patient perception of care. A nationally known polling agency sends questionnaires to patients, and from them we learn something about whether patients are impressed by the care they receive. We treat patient satisfaction scores with great reverence. Our goal is to produce at least as many satisfied patients as comparable hospitals surveyed by this agency.<o:p></o:p></span></div><div class="MsoNormal"><span style="font-size: 10pt;"> The larger health system of which my hospital is a part has for several years exhorted its employees to remember AIDET – perhaps the most awkward acronym every devised in service of a noble purpose. AIDET stands for Acknowledge, Introduce, Duration, Explanation, and Thanks, or something close. The acronym is meaningless, the construction isn’t parallel, and the actions are listed out of order to create the acronym.<o:p></o:p></span></div><div class="MsoNormal"><span style="font-size: 10pt;"> Nevertheless, the fundamental idea is sound. It fits with the customer service principles I learned in business school. We want everybody to ensure they’re talking to the right patient about the right procedure. We want each patient to know exactly who we are and what our role in their care will be. We want each patient to fully understand the procedures we’ll be doing. We want patients to know how long their care will take, and we want them to know what to expect when delays arise. And, finally, we want to thank patients for coming to us.<o:p></o:p></span></div><div class="MsoNormal"><span style="font-size: 10pt;"> This week I accompanied a close friend to my hospital for an endoscopic procedure. I sat by her side as a series of people readied her for care and returned her to her room. Overall, she says her experience was entirely pleasant. People were friendly, reassuring, and competent. Everything proceeded briskly, nothing went wrong, nothing hurt, and the outcome was perfect. She left feeling that she’d had a good experience.<o:p></o:p></span></div><div class="MsoNormal"><span style="font-size: 10pt;"> But not a great experience… She didn’t come out singing the praises of the hospital and its employees. We really didn’t surpass her expectations at any point. We simply met them competently.<o:p></o:p></span></div><div class="MsoNormal"><span style="font-size: 10pt;"> Did we remember AIDET? Not entirely. Everybody reviewed her full name, birth date, procedure, and allergies – so consistently that my friend began to question whether anybody believed her or was paying the slightest attention to the work of others. It would have been useful to mention that everybody who is about to provide care would review this information.</span><br />
<span style="font-size: 10pt;"></span><span class="Apple-style-span" style="font-size: 13px;"> On the other hand, few people did an adequate job of presenting their names and roles. She met one admitting clerk, two hospital assistants, one admitting nurse, two nurses from the endoscopy room, the anesthesiologist, and the endoscopist himself, whom she had met previously. Few introduced themselves by name. Almost nobody except the anesthesiologist was introduced by role. Even the anesthesiologist did not introduce himself by name. Although he and I knew each other, he didn’t know my friend, and he didn’t carefully check her ID and procedure or introduce himself. None of this occurred as rude, exactly. Neither did it say, “You’re an important person. Before we touch you, we want to be sure you know who we are and what we’ll do.”</span></div><div class="MsoNormal"><span style="font-size: 10pt;"> Almost everybody gave a good explanation of what would be happening, and how long it would take. The endoscopist himself had her sign a consent without additional explanation in the procedure room right before she went to sleep.<o:p></o:p></span></div><div class="MsoNormal"><span style="font-size: 10pt;"> Surprisingly, although everyone was polite and cheerful, nobody specifically thanked her for coming. Even on a small island, she does have choices. It might have been impressive if one or more people had thanked her sincerely for choosing us for her care. She was dismissed with a friendly wave and a warm smile, but not much thanks. In fact, she points out that she wasn’t even actually formally welcomed.<o:p></o:p></span></div><div class="MsoNormal"><span style="font-size: 10pt;"> A further observation: our hospital looks at hand-washing in a variety of ways in order to promulgate pervasive hand sanitation. Patients are asked whether personnel caring for them cleansed their hands all the time, some of the time, or seldom (or something like that). The only person I actually saw using the hand-cleaner dispenser in the room was one of the nursing assistants. My friend saw two of the nurses and the anesthesiologist use the dispenser. Everybody may have had clean hands, but by the questionable measure of whether their cleanliness was witnessed, we didn’t surpass 50%.<o:p></o:p></span></div><div class="MsoNormal"><span style="font-size: 10pt;"> What if everybody had done the good work they did AND paid attention to AIDET, with or without the silly acronym? Would my friend have come away with the sense that all these people really cared about her experience with them, even more than she did? Would she have come away with an experience that left her enthused and delighted, not just satisfied and relieved? I think so. Almost certainly we could have improved an already-good patient-satisfaction score.</span><br />
<span style="font-size: 10pt;"></span><span class="Apple-style-span" style="font-size: 13px;"> Would that have been better quality medical care? More health, less disease, more result for less money?</span></div><div class="MsoNormal"><span style="font-size: 10pt;"> Everybody knows the story of the fellow who comes upon an inebriate crawling on the ground under a street light. Asked what he’s doing, the inebriate replies that he’s looking for his car keys. The newly arrived good Samaritan drops to his knees and begins searching too.<o:p></o:p></span></div><div class="MsoNormal"><span style="font-size: 10pt;"> After several fruitless minutes, the new man asks, “Are you sure you lost them here?”<o:p></o:p></span></div><div class="MsoNormal"><span style="font-size: 10pt;"> “No,” replies the inebriate, “I lost them crossing that field.”<o:p></o:p></span></div><div class="MsoNormal"><span style="font-size: 10pt;"> “Well, then,” says the Samaritan, “why are you looking here?”<o:p></o:p></span></div><div class="MsoNormal"><span style="font-size: 10pt;"> “The light’s better here.”</span><br />
<span style="font-size: 10pt;"></span><span class="Apple-style-span" style="font-size: 13px;"> If we did improve customer satisfaction, would the quality of medical care be higher? Or are we hoping that we can find medical quality by looking at customer satisfaction just because the light’s better here? </span></div>Mike Plumerhttp://www.blogger.com/profile/00173416051400635467noreply@blogger.com0tag:blogger.com,1999:blog-6829711202340062580.post-74392758706590151412010-08-11T00:36:00.000-07:002010-08-11T00:36:18.926-07:00A Spinal Shouldn't Hurt<div align="center" class="MsoNormal" style="text-align: center;"><br />
</div><div class="MsoNormal"><span style="font-size: 10.0pt; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>I saw part of an episode of the TV series “House” the other day.<span style="mso-spacerun: yes;"> </span>In it, a young man required frequent lumbar puncture for daily injection of an anti-infective agent.<span style="mso-spacerun: yes;"> </span>I don’t remember the story line, but I remember that the spinal tap was presented as an agonizing event during which the young man sweated, gritted his teeth, and bravely pulled through with the sympathetic help of the medical staff.<o:p></o:p></span></div><div class="MsoNormal"><span style="font-size: 10.0pt; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>Here’s news, America!!<span style="mso-spacerun: yes;"> </span>A spinal tap should not hurt.<span style="mso-spacerun: yes;"> </span>A spinal anesthetic should not hurt.<span style="mso-spacerun: yes;"> </span>An epidural should not hurt.<span style="mso-spacerun: yes;"> </span>If it hurts, somebody is doing it wrong.<o:p></o:p></span></div><div class="MsoNormal"><span style="font-size: 10.0pt; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>Under most circumstances, once skin is anesthesized (one big pinch or sting), there’s nothing else in the midline that hurts as a needle traverses bone-free space on its way to the epidural or intrathecal space.<span style="mso-spacerun: yes;"> </span>I tell patients that I want to be in the midline where it doesn’t hurt.<span style="mso-spacerun: yes;"> </span>If something bothers them, it means I’m not where I want to be.<span style="mso-spacerun: yes;"> </span>Tell me it bothers you, and tell me which side, and I can easily correct to the midline. It did take me a while to learn that if I listen to my patients, they’ll tell me exactly where I am and guide me to a successful midline puncture.<o:p></o:p></span></div><div class="MsoNormal"><span style="font-size: 10.0pt; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>Patients who have to endure great pain during a spinal procedure are, I believe, receiving incompetent medical care.<span style="mso-spacerun: yes;"> </span>There’s no reason for it be painful, except operator carelessness and indifference.<o:p></o:p></span></div><div class="MsoNormal"><span style="font-size: 10.0pt; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>Even a paramedian technique should not be painful, once the needle track is anesthetized (a little more painful than midline).<o:p></o:p></span></div><div class="MsoNormal"><span style="font-size: 10.0pt; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>So why do patients so frequently think a spinal procedure will be miserable?<span style="mso-spacerun: yes;"> </span>I suppose in part it’s the idea, but it’s also based on real experience.<o:p></o:p></span></div><div class="MsoNormal"><span style="font-size: 10.0pt; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>I had a patient recently who was to have a total knee replacement, for which we usually do a spinal anesthetic with enough added sedation (propofol infusion) that patients sleep painlessly through the procedure.<span style="mso-spacerun: yes;"> </span>He’d had a terrible experience with a myelogram 40 years ago, with painful repeated punctures, and for 40 years he’d refused to let anyone touch his back.<o:p></o:p></span></div><div class="MsoNormal"><span style="font-size: 10.0pt; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>I told him why I’d prefer a spinal myself if I were having the procedure, and told him that I didn’t expect a spinal to be a painful ordeal.<span style="mso-spacerun: yes;"> </span>He decided to go ahead with a spinal, which proved easy and uneventful.<span style="mso-spacerun: yes;"> </span>I just received an e-mail detailing his parking-lot encounter with a hospital administrator in which he talked about what a good job I’d done with his spinal.<o:p></o:p></span></div><div class="MsoNormal"><span style="font-size: 10.0pt; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>And that’s the sad part.<span style="mso-spacerun: yes;"> </span>I did a very ordinary job, the sort of job every person having an anesthetic or a spinal tap has a right to expect every day.<span style="mso-spacerun: yes;"> </span>That we continue to send the message that spinal procedures are by nature painful is a continued failing, I think.<o:p></o:p></span></div><div class="MsoNormal"><span style="font-size: 10.0pt; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>And while I’m at it, I think starting an IV without local anesthesia is another unnecessarily barbaric procedure.<span style="mso-spacerun: yes;"> </span>Digging around to find a vein without local is thoughtless and insensitive.<span style="mso-spacerun: yes;"> </span>Tell ‘em I said so.<o:p></o:p></span></div><div class="MsoNormal"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-size: 13px;"><br />
</span></span></div><!--EndFragment-->Mike Plumerhttp://www.blogger.com/profile/00173416051400635467noreply@blogger.com0tag:blogger.com,1999:blog-6829711202340062580.post-72896491133390124902010-08-11T00:33:00.000-07:002010-08-15T03:42:22.326-07:00Anger and Volcanic Energy<div align="center" class="MsoNormal" style="text-align: center;"><br />
</div><div class="MsoNormal"> Anger and I have a history. I have related to anger as a character defect, something wrong with me, for at least the last 20 years. But that’s not the truth. That’s just a conversation, something people say. <o:p></o:p></div><div class="MsoNormal" style="text-indent: .5in;">What if we said something different? What if anger is not only normal for all of us as humans, but useful as a source of power?<o:p></o:p></div><div class="MsoNormal"> “DON’T TOUCH ME!!” That’s the last phrase a large, intimidating male working in a mostly-female workplace wants to hear, especially out loud in front of witnesses. In my reality, I had touched the shoulder of a nurse anesthetist as she turned to leave a conversation about inadequate patient care before it was clear that she could fix her error. In her story, I had struck her, severely injuring her shoulder and requiring that she be off work for months undergoing therapy.<o:p></o:p></div><div class="MsoNormal"> The district attorney contemplated an assault charge. The Board of Medical Quality Assurance contemplated lifting my license. (I learned that BMQA investigators carry badges and guns, as if the power to take a license were not intimidating enough.) The hospital board contemplated suspension of privileges.<o:p></o:p></div><div class="MsoNormal"> None of these punishments came to pass. Instead, I experienced my first anger management counseling in the upscale home of a woman who had previously run the hospital’s employee assistance program. Anger, she said, rises from fear – most commonly from fear of loss.<o:p></o:p></div><div class="MsoNormal"> The workplace became less and less accepting of anger as I had experienced it. I was loud, I was foul-mouthed, and I looked intimidating. I was no better at home on our ranch, where displays of temper were common and bad language frequent. Though I never actually injured anyone, I broke my toe kicking a cow in anger during veterinary work, and I recall with shame brandishing a length of pipe at a teenager from the neighboring nudist colony when I caught him riding a dirt bike (fully clad) on our property.<o:p></o:p></div><div class="MsoNormal"> I would have said that I was seldom directly angry at my first wife, but I learned after our divorce that she had had a different experience. I had been angry in her vicinity so frequently that she had felt virtually controlled by my anger. <o:p></o:p></div><div class="MsoNormal"> I married again, this time a woman whose own anger was nearer the surface. She had little tolerance for any expression of anger from me. Overt anger, a stern-sounding voice, an upset expression, cursing – all were unacceptable. There were no mitigating circumstances. Anger around kids was even more reprehensible.<o:p></o:p></div><div class="MsoNormal" style="text-indent: .5in;">Over years, personal development courses and counseling have made a difference. I’m less and less volatile, less blaming, more aware that my world evolves from my own choices, more able to be with what’s so – and yet the goal of perpetual placidity and optimism continues to elude me.<o:p></o:p></div><div class="MsoNormal"> Now in the midst of a second divorce, my men’s group said a few days ago that I seemed angry. I’d been denying that, generally saying that things are fine. <o:p></o:p></div><div class="MsoNormal" style="text-indent: .5in;">But they’re not fine. I’ve lost my second marriage, my relationship with my stepchildren, my access to easy retirement, and some freedom of choice about how much I need to work.<o:p></o:p></div><div class="MsoNormal" style="text-indent: .5in;">The woman with whom I spent a dozen committed years decided last summer that she didn’t want to be married any more. She said she’d like to end the marriage and be friends. The friendly divorce that we first anticipated disappeared into failed negotiation, failed mediation, and wholly baseless suspicions that I must somehow have squandered or hidden our assets. <o:p></o:p></div><div class="MsoNormal" style="text-indent: .5in;">We do have much less than we once had, but our money isn’t hidden. It’s gone. We consensually spent it, lost it as our equity-based retirement account fell to half, or lost it in the real estate decline as our new mortgage went under water. We’ll split what remains, with each of us a loser.<o:p></o:p></div><div class="MsoNormal" style="text-indent: .5in;">The children to whom I’d been stepfather for fifteen years seem to be pulling further and further away.<o:p></o:p></div><div class="MsoNormal"> So I’m angry. So what? What if anger isn’t wrong, isn’t a failing, isn’t a character defect? What if anger is normal and natural, part of everyone’s emotional makeup? <o:p></o:p></div><div class="MsoNormal" style="text-indent: .5in;">What if we were able to treat anger as a form of power or energy? <o:p></o:p></div><div class="MsoNormal" style="text-indent: .5in;">If anger were volcanic energy, it might be instructive to look at the difference between Mount St. Helens and Hawaii’s Kilauea. In one, energy is held in until it’s too powerful to contain. Explosive release destroys the environment, rendering an area unlivable for years. In the other, energy is constantly released, explosions are unthreatening, and the resulting lava flow creates an expanding island.<o:p></o:p></div><div class="MsoNormal"> What if we could channel anger into constructive action rather than explosive displays? What if we went running, or tore out a wall for reconstruction, or wrote a piece on anger, or focused on legal strategies that would end a stalemate? What if we let anger power life-improving actions instead of destructive explosions? What would it take to keep anger constructive, positive, and unthreatening all the time? Now that’s a worthwhile inquiry… <o:p></o:p></div>Mike Plumerhttp://www.blogger.com/profile/00173416051400635467noreply@blogger.com1tag:blogger.com,1999:blog-6829711202340062580.post-32435528299485280422010-08-07T21:02:00.000-07:002010-08-15T03:43:44.364-07:00The Keen Eye of the Retrospectoscope<span class="Apple-style-span" style="font-family: 'Lucida Grande'; font-size: small;"><span class="Apple-style-span" style="font-size: 11px;"> </span></span><br />
<span class="Apple-style-span" style="font-family: 'Lucida Grande'; font-size: small;"><span class="Apple-style-span" style="font-size: 11px;"></span></span><br />
<span class="Apple-style-span" style="font-family: 'Lucida Grande'; font-size: small;"><span class="Apple-style-span" style="font-size: 11px;"></span></span><br />
<span class="Apple-style-span" style="font-family: 'Lucida Grande'; font-size: small;"><span class="Apple-style-span" style="font-size: 11px;"><div class="MsoNormal"><span class="Apple-style-span" style="font-size: medium;"> </span><span class="Apple-style-span" style="font-family: inherit;"><span class="Apple-style-span" style="font-size: medium;"> A version of this blog appeared in 2009 on a coaching website I’d created with my wife. Then life happened. I took down the blog and let it marinate in a vat of good intention.</span></span></div><div class="MsoNormal" style="text-indent: .5in;"><span class="Apple-style-span" style="font-family: inherit;"><span class="Apple-style-span" style="font-size: medium;">I’m a physician and a life coach. The original question for this blog was whether I could write as a professional about my own humanity. Could I be open, vulnerable, in touch with fears and failings as well as strength and wisdom? When I began my life work four decades ago, it would have seemed unprofessional to put personal thoughts in a place where they could be read by anybody who happened by. Now it seems not only permissible, but valuable. I learn daily from blogging physicians and coaches who speak without fear.</span></span></div><div class="MsoNormal" style="text-indent: .5in;"><span class="Apple-style-span" style="font-family: inherit;"><span class="Apple-style-span" style="font-size: medium;">Not a single feature of my current life could have been predicted four years ago.</span></span></div><div class="MsoNormal" style="text-indent: .5in;"><span class="Apple-style-span" style="font-family: inherit;"><span class="Apple-style-span" style="font-size: medium;">In 2006 I was working per diem as a clinical professor of anesthesiology at a major medical school in the Pacific Northwest, looking forward to creating a life coaching practice that would have me out of the operating room in a few more years. I anticipated that we’d either stay in the Pacific Northwest or move back to central California to be near my middle son and his wife. I planned to research and write a book on greatness, interviewing prominent people who seemed unafraid to let their light shine in the world. I was happily married, eight years into a second marriage with children in their teens. </span></span></div><div class="MsoNormal" style="text-indent: .5in;"><span class="Apple-style-span" style="font-family: inherit;"><span class="Apple-style-span" style="font-size: medium;">The first never-gonna-happen surprise is that I now live in Hawaii. Four years ago I had never spent a minute thinking I might live here. I loved the Pacific Northwest. Then in 2007 after a period of family inquiry, we chose to radically reshape our lives and move to the Big Island. I said I’d do whatever it took to make the Hawaiian adventure possible. That turned my work life in an unexpected direction.</span></span></div><div class="MsoNormal" style="text-indent: .5in;"><span class="Apple-style-span" style="font-family: inherit;"><span class="Apple-style-span" style="font-size: medium;">The second surprise is that instead of moving out of the operating room to be a life coach, I now practice anesthesiology full-time as chief of a high-quality rural practice on one of the outer islands. I thought I was burned out, done, tired of the whole thing. I was increasingly afraid of the operating room. I couldn’t have imagined practicing full-time and being responsible for a department, and I couldn’t have imagined loving this practice, its people, its challenges. </span></span></div><div class="MsoNormal" style="text-indent: .5in;"><span class="Apple-style-span" style="font-family: inherit;"><span class="Apple-style-span" style="font-size: medium;">The third surprise is that my marriage has ended. I live by myself in a condominium on Kauai, not in the family home on the Big Island. In the summer of 2009 my wife said that she no longer wanted to be married. She wanted us to end the marriage and still be friends. A year later, negotiations have failed to produce a simple or friendly agreement, and an appointment in divorce court seems likely.</span></span></div><div class="MsoNormal" style="text-indent: .5in;"><span class="Apple-style-span" style="font-family: inherit;"><span class="Apple-style-span" style="font-size: medium;">Finally, and most surprisingly, I looked briefly on match.com last summer when it seemed that my marriage would soon be over. I asked for a woman who was warm, loving, wise, kind, good-humored, sexy, and willing to love and be loved. To my immense surprise that woman appeared, and we’ve been “together” for almost a year now despite my failure to finish a divorce as quickly as I’d predicted. She’s exactly who I was asking for. Once again, my experience could never have been predicted.</span></span></div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: inherit;"><span class="Apple-style-span" style="font-size: medium;"> I’m guessing that the blog will be another unpredictable experience. Stay tuned. Where once I thought I had many of the answers, I now have mostly questions. This is where I’ll explore them. I welcome comments. Without dialogue, I’m simply in my own head…</span></span></div></span></span>Mike Plumerhttp://www.blogger.com/profile/00173416051400635467noreply@blogger.com0