Sunday, March 27, 2011

Ancillary Income

Economic times are tough all around and the practice of Surgery is no exception. Falling reimbursement and a large population of uninsured patients make it difficult to make ends meet. In the true American spirit of entrepreneurship I’ve decided to expand my business. Of course, saving lives and stamping out disease will remain the primary focus of my practice, but it’s time for me and for my partners, Coastal Surgical Group, to look for new revenue streams.

Let’s start with something obvious, but, nevertheless, important and in great demand. Recent years have seen an explosion in the area of Bariatric Surgery, that is, weight loss surgery. The most popular, because it’s a quick and safe operation, is the adjustable gastric band. This simple device is wrapped around the upper stomach and then inflated to constrict that part of the stomach and create small pouch with a narrow opening. The patient feels full after consuming a very small amount and, over time, loses weight. This surgery is unique because the band is adjustable. A small fluid filled reservoir that sits just beneath the skin allows the band to be inflated or deflated, thus allowing more or less food to pass.

Currently bands are adjusted in accordance with the patient’s ability to eat or symptoms that may develop if the band is too tight. However, I think there is a huge market to attend to those individuals that desire the band to be deflated for specific events. For instance, if portly Uncle Jack is going to his niece’s wedding, shouldn’t he be allowed to enjoy the large buffet, featuring all the lobster and prime rib he can eat? And, what about the open bar? What about poor Sadie, who has already lost 20 of her 400 lbs? Shouldn’t she be rewarded with a night out at the “Golden Corral”? Thousands of our largest citizens are suffering under the torture of these devices. At $200 a pop, a huge market exists for the canny individual that seizes this opportunity.

Another new source of income could come from office souvenir shops. If you go to Disney World or Universal Studios or even your local art museum, the last part of the visit features a mandatory walk through the “Gift Shop”. Shouldn’t a postoperative visit include a similar venue? After all, undergoing surgery can be quite a ride and a souvenir of the journey certainly should be offered. Coffee cups featuring the Coastal Surgical logo, pens with blood red ink or gallbladder shaped wine glasses are only a few of the items that could be offered for sale. Plush stuffed organs such as liver, pancreas or spleen would undoubtedly be hot sellers. Samples of actual organs, salvaged from real operations could be offered as collector’s items, much in the way sea shells or various geologic wonders are sold now. Who wouldn’t want the complete endocrine system, freeze dried and mounted for display on the living room or dining room wall.

Of course, post cards featuring images from actual surgeries would be available. And the usual coffee table tome, designed to impress the boss’s wife would be on sale. “Colons and Hemorrhoids I Have Known: a Pictorial History of Coastal Surgical Groupis already in pre-production.

Beyond such souvenirs, extra income could be proffered from selling advertising space on the backs of scrub suits and/or white coats. Currently, I wear embroidered scrubs that feature my name and Coastal Surgical Group above the shirt pocket. There is plenty of space on the right side of the shirt and on the back to add announcements or logos.

“Miranda’s Massage”, if tastefully designed could be worn on Mondays; “Joe’s Diner” Tuesday and so on. I envision seven separate sponsors, one for each day of the week. There would have to be some discernment, however. “Evan’s Slaughterhouse” would probably not be appropriate, unless the price was right.

Finally, the most lucrative untapped market is in the area of internal tattoos. Think about it; how many people do you know that have said “I always wanted a tattoo, but I really wouldn’t want to display it or it’s too painful or I’m afraid of needles. The obvious solution? Why, internal tattoos, inscribed on the stomach or liver or elsewhere. The bearer would have the quiet satisfaction of knowing he had a tattoo, just like his friends, without any embarrassment should he meet that special someone years later and her name happened to be Lucy, not Sheila. Sheila would be safely tucked away inside on his stomach, instead of prominently displayed on his shoulder and Lucy need not ever know.

A few cautions however. For the man who tattoos a naked image of his sweetheart on his stomach; that svelte 36-24-36 figure would take on new dimensions after a very large meal when the stomach is stretched to massive proportions. General anesthesia would be necessary, but the latest minimally invasive techniques would be employed with minimal discomfort and no down time. I daresay that these internal tattoos would be less painful than their traditional cutaneous cousins.

But, the wearer wouldn’t be able to see it, you object. No worry. Everyone that purchases an internal tattoo would receive a portfolio featuring his or her tattoo and, as a bonus, surrounding organs in 4x6, 5x7, 20 wallet sized and a 16x20 suitable for framing. Additional packages would be available.

Unprofessional you say, not dignified? These are difficult times for health care with no relief in sight. These few suggestions are fully in keeping with the American free market system. So, stop by Coastal Surgical Group, get your hemorrhoids checked and pick up a souvenir mug on your way out.

Saturday, March 19, 2011

Monsters and Heroes

In the practice of surgery it is common for individual surgeons to try to establish a niche, an expertise that sets the surgeon apart from his colleagues. Some General Surgeons become expert in bariatric surgery, which is weight loss procedures, while others may specialize in surgery of the head and neck. In the spirit of increasing specialization I’ve decided to concentrate my surgical practice in the area of tending to the powerful and famous.

I must clarify this, however, by stating that I don’t refer to such trite and mundane figures as Presidents, royalty, sports stars or movie stars. These media driven figures offer no special challenge to a surgeon’s quest for greater challenges; the search for endeavors that tax ingenuity and skill. The individuals I plan to offer my services are the truly powerful: superheroes such as Spiderman and Superman; along with the elite of horror: Vampires, werewolves, and Frankenstein’s Monster. Such powerful individuals present special challenges which my unique skills and innovative talents are particularly well suited.

For instance, let’s start with Superman. Here is an individual, a refugee from the now annihilated planet Krypton. On Earth he displays near invincible superpowers, extraordinary strength, invulnerability to all weapons, defiance of gravity and many other traits. But, is he immune from disease? Does his reported highly dense molecular structure eliminate the possibility of gallstones or an enlarged prostate? I doubt it.

But, surgery on such an entity poses problems never encountered in the typical residency program. After all, how can even the finest surgeon begin to operate on a being that is impervious to knives, bullets, nuclear weapons, fire, and everything else? This issue actually was addressed in one of the Superman stories. The obvious solution was to have Kryptonite in the OR to diminish the invulnerability of the Man of Steel. From my perspective, however, this method lacks the necessary refinement inherent to most operations. It would be far better to incorporate Kryptonite into the surgical instruments that would be utilized during any operation. The smaller amounts of Kryptonite would make for an operation that is more controlled and safer for the patient.

What about other superheroes? The Fantastic Four, composed of Reed Richards with his ability to stretch to amazing lengths, his wife Sue Storm, who can become invisible and generate force fields, Johnny Storm, capable of becoming a human torch on command, and Ben, aka “The Thing”, super strong and composed of solid rock, each would require special precautions and instrumentation should they need surgery. And, with the way they are out and about, fighting evil Dr. Doom and such, they are high risk to suffer serious trauma. I’ll bet they can’t get health insurance, even under the impending Obamacare. But, I digress.

Surgery on Reed Richards probably would require a very sharp scalpel to compensate for his extreme elasticity; a laser could be more appropriate to cut through the elastic tissue. However, once the injured or diseased organ was repaired/removed, reconstruction would be greatly simplified. The problem of excessive tension on a repair or anastamosis becomes moot in such a being.

Sue Storm’s special powers would require that she be maintained deeply under anesthesia throughout the procedure. Should she become “light” it’s possible that any level of consciousness could trigger a reflex activation of her powers and she could become invisible. I don’t know about other surgeons, but I would find it particularly daunting to try to operate on an invisible patient. Of course, during residency I did have the pleasure of operating with a surgeon who was nearly blind, but that is not germane to the current discussion.

Johnny Storm in the anesthetized state presents no particular difficulty. For my purposes, however, I would need to exercise caution if I were to use fluoroscopy during an operation on him. This is because I have a habit of yelling “Flame On” when I want to fluoroscope. It would be a pity if the OR crew was incinerated because of a lack of caution or slip of the tongue.

Finally, there’s “The Thing”; lovable creature whose skin is solid rock. Once the incision was made utilizing a jackhammer or, perhaps a diamond tip saw, I suspect the operation could proceed unhindered. If, however, his internal organs were also silicon based, surgery in the usual manner may not be possible. A mason or stonesmith may be better equipped to deal with such a situation.

There are a host of superheroes that developed their prowess after being infected, exposed or inoculated with some type of radioactivity, cosmic power, powerful serum or other transforming material. Spiderman, The Incredible Hulk, The Silver Surfer and Captain America fit into this category. They present the common problem of protecting the surgeon and OR crew from contamination originating from the patient during the surgery. Current gowns, masks and gloves are no match for gamma rays and other types of radiation that likely is percolating through the veins of these sometimes reluctant heroes. The obvious solution is lead lined garb. However, such OR dress could greatly encumber the surgeon and lead to suboptimal results. These patients seem to be perfect candidates for utilizing robotic surgery. The robot’s multiple arms would be safe from any noxious agents and the operation could be carried out with minimal fuss. Once again, however, adequate anesthesia would be absolutely essential as the robot bears a striking resemblance to some of the more dastardly super villains.

There are numerous other superheroes that present other potential surgical concerns, but I think I’ve covered some of the more important modern day heroes. It’s time to move on to the other end of the spectrum: Monsters.

Folklore, books and film are filled with tales of werewolves, vampires, zombies and such. Just as with the superheroes, monsters would require specific modifications of traditional surgical procedures should an operation become necessary.

Vampires are all the rage these days. Vampire novels, movies paraphernalia and clubs are encountered on a daily basis. Are these forlorn creatures monsters, heroes or both. I am not here to render judgment; vampires actually would pose few serious impediments to surgery.

They live on blood, so nutrition is not an issue. Apparently, the blood can be consumed enterally or parenterally. They are universally described as pale creatures suggesting they are chronically anemic and would well tolerate hemoglobin levels that are very low. Indeed, after being NPO for eight hours before surgery it’s likely that they would have very low circulating blood volume and low blood pressure, diminishing the likelihood of serious blood loss, even during the most complicated operation. Opinions on the effect of sunlight vary, but it would be prudent to operate in a room without windows to minimize the risk of the patient disintegrating into dust halfway through the procedure. Protection of the OR crew must also be considered. An accidental needle stick causing mingling of vampire blood with the surgeon’s could lead to transformation of the surgeon into a state of being undead, like the vampires. I don’t know about other surgeons, but my disability insurance doesn’t cover such an occupational hazard.

Werewolves present an entirely different set of challenges. Tradition has been that werewolves can only be killed with a silver bullet, although more recent research suggests that it is necessary to completely dismember the subject to completely eliminate their existence. Thus tradition suggests that silver instruments would be most effective for such creatures. Elective surgery should not be scheduled during a full moon, unless a qualified veterinarian is standing by.

Moving on, “The Blob” was a creature that came from outer space with a taste for the consumption of humans. Any attempt to undertake surgery on such an entity should entail caution. This beast would have no remorse at consuming the surgeon, nurse or scrub tech. Surgery could only be performed using hypothermic technique. Such lower temperatures render “The Blob” compliant and eliminate the danger of being consumed. The anesthesiologist would be vital in such a situation, as he would be charged with keeping the patient’s body temperature low enough to prevent untoward complications, but not so low as to kill the patient. IV access might be an issue, but I suspect a catheter placed anywhere into the patient would be adequate.

Zombies would not present any special challenge. They are dead already, their flesh is rotting and, in general, there are no operations that are actually indicated in this patient population.

Finally, no discussion of Monsters would be complete without Frankenstein’s Monster. A being born of dead body parts, knitted together and then instilled with life that originated with the powerful electrical charge of a lightning bolt. It has been stated, at least in film, that “The Monster” cannot be killed; that having been created from dead body parts, his life goes on indefinitely. Surgery becomes straightforward in this situation. Rubber gloves protect the surgeon and crew from any electrical surge, as they already protect us from the electrical charge of the cautery. Any injured parts can be replaced from the local morgue, although neurosurgery may require some delicacy to prevent radical alteration of “The Monster’s” sweet personality.

There are other heroes and monsters that live among us, in literature, film and politics (monsters only). Surgeon to such famous and powerful beings may not be financially lucrative (is any surgery financially lucrative these days?), but the experience, publicity and subsequent fame should be fodder for books and TV appearances for many years. And, when it becomes time to retire, a tell all book would sell millions, if not billions of copies. “Does Dracula really sleep with a nightlight?”

Saturday, March 5, 2011

Education and School

I just finished reading an eye opening book, “Weapons of Mass Instruction” by John Taylor Gatto, a retired school teacher. Mr. Gatto takes the reader into the world of schooling; examines the origins of our modern system of compulsory schooling and classrooms and blows the lid off the vast industry that is “school”. His principal point is that all this schools has absolutely nothing to do with education.

An education is the process whereby an individual learns. Information is processed, retained and then applied to life situations, to better the individual and, at some point, better society. School is the compulsory incarceration of individuals for the purpose of forced indoctrination into a curriculum established by a panel of individuals with varied motivations; the education of students being nowhere near the top of the list.

Mr. Gatto’s thesis is that the United States, by the nature of its origin and its political and economic system was a great cauldron of imagination and innovation that flourished until the post Civil War era brought compulsory, regimented schools, modeled after the existing Prussian system, which led to the stifling of this innovative nature that had allowed the United States to achieve remarkable growth. Such a system was promoted by the fabulously wealthy and influential industrial leaders of the day in an attempt to provide a steady stream of workers for their factories and consumers of their products.

The book looks at some of our present day leaders in business, industry and politics, pointing out that the success of these leaders had nothing to do with school. As a matter of fact, school does far more to quash original thinking than to motivate.

I thought about what I read in this book and examined my own education. At this point in my life I would be considered to be a very successful surgeon and a marginally successful author. Neither of these endeavors has anything to do with school. Was school important? Of course, but not for my education. School was important as a means to an end; a necessary process that allowed me to become a surgeon. The education of a surgeon currently requires 12 years of elementary and secondary school, 4 years of college, 4 years of medical school and 5-6 or more years of surgical residency. Certain high achieving individuals probably could find a pathway that would knock off 3-4 years, but the path still is very long.

But, when I examine all these years of school and try to remember what I learned, it becomes apparent that most of the time spent was completely wasted. I remember going to elementary school, but I can’t remember anything that I actually learned in the hallowed halls of Lincoln School. What I do remember is a stream of teachers who appeared to alternat between boredom, anger and rare enthusiasm; teachers that often seemed to wish they were somewhere else or doing something else; teachers that spent far too much time trying to fit round pegs into square holes, berating, ridiculing and humiliating those unfortunate students that couldn’t or wouldn’t conform to their arbitrary set of rules.

I remember poor Ken, a classmate with obvious emotional issues, who struggled with the simplest tasks, and was made to suffer under the tyranny of a series of unsympathetic “teachers”. Cal who was always in trouble for being disruptive; always on the brink of being relegated to the oblivion of “special class”, but who could also create amazing drawings that revealed a talent that shined through his behavioral issues. Round pegs both of them; but both stifled and possibly irreparably harmed by their forced incarceration in “school”.

Later years weren’t much better. Of course, I was “smart” and sailed through school with minimal effort. But did I learn anything? I’m sure I did, but as I think back to those years there are two things I learned; information I can recall even today, neither of which had anything to do with school.

Away from school, one of my greatest interests was horse racing. I made my first bet at age nine and, unfortunately, it was a winner and I was hooked. At the time I thought that betting on horses could be a bonanza; actually making money from being smart. Being the inquisitive young man that I was, I set about learning everything I could about the subject. Tom Ainslie was the authority on horse racing at that time and I read his books cover to cover, along with several others. I learned the origins of thoroughbred and standardbred racing and even wrote my tenth grade term paper on the history of thoroughbred horse racing. To this day I can name the winners of important races, the origins of the sport and still use the unique style of thinking that goes into evaluating a horse race almost every day in my practice of surgery.

Shortly after I discovered the joys and frustrations of the track I discovered something else that only brought me laughter and good cheer: the Marx Brothers. My older brothers and friends talked about the antics of Groucho, Harpo, Chico and sometimes Zeppo after attending the summer film festival held at Saratoga State Park. After a while I had to see what all the fuss was about. After seeing “Horse Feathers” I became an ardent fan.

Once the interest was kindled I was compelled to learn everything possible about the four boys. “The Marx Brothers Scrapbook”, “Groucho and Me” and, my favorite, Harpo Speaks” gave me a lesson in history, vaudeville, movies, the Roaring Twenties and the Great Depression, from a bit of a biased perspective. In particular Harpo had special appeal for me, probably because, like Harpo, I wasn’t much of a talker. The silent Marx Brother made his presence known, however, managing to join the highest echelons of New York literary circles, as a listener. While I can remember almost every detail of Harpo’s life; I can’t recall one iota of information specific to any high school social studies class.

In college I discovered English literature and Charles Dickens has always been my favorite. I love almost all his work, but maintain a great disdain for “Great Expectations”. I suspect my strong negative feelings for this book are the result of being forced to read it in the ninth grade. It’s not that the reading was torture; rather it’s the way I was required to examine the book, with every bit of soul, humor and irony removed, the product of a school curriculum that eliminated anything that could possibly spark interest in a young mind.

School for me was playing within the system to advance, while, all the time, pursuing my own agenda outside of the rigid structure of the school building and syllabus. Finally, after twenty years in “school” I graduated medical school and started training in surgery. All the years of education came into play, while all the years in school became irrelevant.

Years of playing the horses taught me how to think and approach medical dilemmas in a unique and effective way; Harpo Marx demonstrated the importance of being a good listener, while literature gave me an outlet away from the rigors of surgery. It is unfortunate that school does so little to educate and serves merely as a necessary gauntlet to traverse on a journey to a specific goal. Education is what prepares us for life; school prepares us for nothing.

I would recommend that everyone pick up a copy of “Weapons of Mass Instruction” by John Taylor Gatto. You won’t be disappointed and you will our schools in a way that will open your eyes and leave you more than a little angry.