The summer of 1974 stands out in my mind, mostly because of the days I spent in Saratoga at the famed racetrack. I was sixteen and the first part of the summer was spent at driver’s ed., where I did my best not to cause any angina among the various shop teachers who were earning extra money putting their lives on the line with a bunch of neophyte drivers.. A few odd jobs painting houses and such gave me a bit of money to waste at the track when it opened in August.
In those days the meet was only four weeks, but it had already started to take on the aura of prestige and celebrity it currently enjoys. Its legend as the graveyard of favorites had been reinforced the previous year as the great Secretariat, fresh from his smashing Triple Crown performance went down to ignominious defeat at the hands of the unheralded Onion, appropriately trained by the giant killer Allen Jerkens.
But, it was now a year later and the track beckoned again. Even though I had gone through driver’s ed I still didn’t have my license so transport to the track became problematical. When I couldn’t bum a ride from any local acquaintance I would walk over to Route 50, stick out my thumb and hope for the best. I usually started at a about 11:00 am, allowing myself plenty of time to make it by post time at 1:00.
Of course sometimes I was picked up very quickly and arrived very early, with an hour or more to kill before the first race. I took full advantage of these times to visit the local attractions or have lunch somewhere on Broadway. My favorite ways to pass the time, however, were either going to the National Museum of Racing or walking through the Rose Garden at the Yaddo.
The museum was almost always empty when I went. I would walk into a dark entry and as soon as the lone woman saw that she had a customer the lights would go on and I would wander through the rooms, perusing the paintings of famous horses, looking at famous silks and just enjoying the history that was recorded. The previous year I had written my term paper for Frank Palmer’s tenth grade Social Studies class on the history of thoroughbred horse racing, most of the details elegantly plucked from the pages of the Encyclopedia Britannica. The history I had actually learned seemed to come alive in the sculptures and paintings in that museum.
My other favorite attraction was the Yaddo. This is a mansion that had been built by financier Spencer Trask and, in 1900 was converted into an artist’s retreat. The very impressive mansion was off limits to visitors, but anyone could walk through the Rose Garden which was situated a short walk from the road and, besides providing a very peaceful way to kill time, also allowed me to speculate on what it was like inside the home and at times made me wish that I was a starving artist, just so I could go inside.
The main focus of those excursions to Saratoga was the racetrack. My interest in horse racing started at age nine when I won $4.20 on the first wager I’d ever made, hooking me with the delusion that I could actually generate some sort of profit from being smart, at least smart enough to pick a few winners. So, the money I earned from various odd jobs went straight to my pool of cash designated for the track.
The track that year had a few highlights. The first memorable occurrence was Maria Isabel. She was not a person; she was a filly running in the ninth race one day. She stands out for two reasons: she was the single best bet I’ve ever seen in any race, at any track, in any year since I started betting on horses and I made the largest wager on her I’d ever made up until that time. Anyone not familiar with the intricacies of handicapping the races may not appreciate what she was, but based on her past performances and conditioning she appeared to be at least five lengths faster than any of her competitors. Her times were about a second faster, she was running at her optimum distance, she had just run a credible race against better horses five days before and she was going off at 7/2, an excellent price for a horse that looked so outstanding on paper.
Seeing her in person did nothing to shake my confidence, so I bet $15 to win on her, a huge amount of money for me in those days. The race went exactly as expected, even though in midstretch she was briefly blocked. She found a hole to sneak through, however, and won going away by three lengths. I remember my hand shaking a bit as I cashed my tickets and I felt a bit of trepidation as I contemplated hitchhiking home with what seemed to me to be a lot of money in my pocket. One of the memorable things about that day was that I had a hard time finding a ride. As it turned out I did a lot more hiking than hitching and didn’t walk through our kitchen door until about ten pm. That single bet is so memorable that Maria Isabel is mentioned as a best bet of the week in my novel “Joshua and Aaron”.
The most memorable thing about the track that summer was Ruffian. Anyone that has read my books or visited my website knows of her significance. She was a two year old in 1974 and was the most impressive, overpowering filly the racing world had seen, perhaps ever. The tone for her career was set by her maiden victory by fifteen lengths, running 5 ½ furlongs in 1:03, equaling the track record at Belmont Park. She was coming to Saratoga undefeated and never headed (that is she had never been in second place at any point of any race).
She was running in the Spinaway Stakes against a local favorite, Laughing Bridge, who was owned by local businessman Neil Hellman. Laughing Bridge had been very imposing in stakes races earlier in the meet and their showdown received much hype in the local papers.
I convinced my mother to let me drive up to the track that day, with an older friend accompanying me to make it legal. The day was a bit showery, but the track was labeled as fast. When we saw Ruffian in the paddock my friend and I were both struck by her appearance. She was big for a two year old filly, but she also was a bit washy (sweaty), perhaps appropriate for the humid day, but it seemed to be more sweat than I would have expected.
Ruffian was the overwhelming favorite despite all the attempts by the local media to build up Laughing Bridge. In typical Ruffian fashion she jumped to the early lead, passing the quarter in a quick 22 1/5 seconds. She maintained her lead at the half in a quicker 44 4/5 and at the top of the stretch showed me something that impressed me more than any horse I’d ever seen. As if she were toying with her valiant competition up to that point and she decided it was time to put all the false media hype to rest and she proceeded to run away from her overmatched competition. She pulled away by almost thirteen lengths in the dazzling time of 1:08 3/5, which equaled a long standing track record; remarkable for a two year old filly.
Of course Ruffian’s racing career became legend and her end was tragic, as she broke down during her match race against the top 3 y-o colt Foolish Pleasure the following year and she had to be destroyed. Still, her brief racing career captured the imagination of millions and, for a short time, she became a symbol for women’s rights.
After that summer, I don’t think I ever hitchhiked again. My wife still thinks I was crazy for doing it, but those were different times; sometimes it seems like a different world. I don’t make it to upstate New York during racing season very often these days and the times I have gone to the track it’s not the same. There are no more free seats at the top of the stretch, the crowds are overwhelming and the quality of the racing seems to have diminished. Still, the summer of 1974 remains a fond memory; a reminder that summer days could be carefree and the only worry was how to get home from the track.
Thursday, July 22, 2010
Saturday, July 10, 2010
Talking to Patients
Years ago I read an article about what patients could or should expect from a visit to their doctor. There were four patients that recounted their experiences during recent doctor’s appointments. The length of time they had to wait, the details of their visit including actual time spent with the doctor were included. One of the patients complained that the doctor spent most of his time talking to her. I would bet that this particular doctor was the most thorough and conscientious of all the doctors that were presented in that article.
When a patient walks into a doctor’s office for the first time, the doctor faces a myriad of possibilities. In my practice, which is general surgery, I usually assume a new patient has or is suspected of having a surgical problem. Of course this differs from the primary care physician setting where the problem could be anything from headache to hemorrhoids. It is the primary care doctor’s task to sort out all the endless possibilities and determine the best medical approach for each. This is their great challenge, one that may be faced twenty times a day or more.
Fortunately, for me, the surgeon has a task that is a bit easier, at least initially. When I am asked to see a new patient, most of the time there is some information that comes with the request, usually something short and simple, ie: Gallbladder disease, abdominal pain, cold leg, etc. This very brief summary gives me a bit of direction, although occasionally it can lead in the wrong direction.
So, the first, and often the most useful, thing that I do is to sit and talk to the patient. Probably 98% of the time the patient will tell me what’s wrong and all that I need to do is confirm this presumptive diagnosis with the physical exam and appropriate testing. This is true for almost any condition, be it acute appendicitis or hemorrhoids.
But, how does simple talking do all this? The things that go through a doctor’s head, at least mine, when I take a history from a patient are myriad. First and foremost is, “Is this patient ‘sick’.” By this I mean does the patient seem to have a severe, possibly life threatening condition that warrants immediate hospitalization and possibly emergency surgery? Patients that cannot sit up, are afraid to move or are unable to give any history because they are too ill usually need to be in the hospital. It is one of my unwritten rules that patients that look sick usually are. Experience teaches doctors, particularly general surgeons, to be vigilant, assume the worst and do all that we can to achieve the best outcome.
But, I’ve strayed away from the point of this article. Talking to patients is the single most important part of patient visits. When I went to medical school the greatest amount of time was spent on learning the natural history of the many various diseases, all the possible presenting symptoms and signs and how to obtain this information from a sick patient. Unlike House I don’t believe that patients always lie. Most want to get better and most of the time the questions that I ask cannot be answered in misleading way. Starting with the simple question, “What brought you in here today?” and then paying attention to the patient’s answer will, in a few minutes, provide almost all the information necessary to begin that individual on the road to recovery.
Approaching a patient with abdominal pain provides an excellent example. In the days before routine CAT Scans the evaluation of patients presenting with abdominal pain required the skills of a detective; the history and physical exam, along with limited diagnostic testing, were the mainstays of diagnosis. The abdomen, in the days before CAT Scans and MRI’s, was a black box filled with vital organs and often inaccessible except through surgery.
The abdomen is usually divided into three segments, epigastrium, which is above the umbilicus (belly-button), mid-abdomen, the level of the umbilicus, or hypogastrium, which is below the umbilicus. The first thing I will usually ask is where did your pain start. Sometimes I get an answer like “In the bathroom”; some people are so literal. But, once properly directed, the starting point of the pain will go a long ways to narrowing the choices for the offending organ.
Epigastriium usually means stomach, duodenum, gallbladder, liver or pancreas. Mid-abdomen refers to the small bowel or the right side of the colon and hypogastrium usually refers to the left colon. These divisions are in no way arbitrary, rather they correspond to the nerves that supply the various organs and where the nerves will refer pain. For instance, the gallbladder sits in the right upper abdomen, but very often gallbladder pain is felt in the middle. This is because the visceral nerves refer the pain to the middle. Only after a gallbladder becomes more inflamed do the parietal nerves come into play and the pain then becomes localized over the offending organ.
Duration, quality and associated symptoms all direct me to a working diagnosis that only needs to be confirmed. Physical exam, blood/urine tests, imaging studies primarily are used to confirm the working diagnosis and to eliminate other possibilities. I’ve learned that relying solely on imaging studies is often misleading.
For instance, just recently I was called from the Emergency Room at one of the hospitals and informed of a patient that the admitting physician wanted me to consult. The ER physician said she had right sided abdominal pain and that an ultrasound had revealed gallstones. The white blood cell count was elevated, but she was otherwise stable. This patient, as presented to me, was properly admitted to the hospital, but a patient with these clinical findings generally is not a life and death emergency and can usually be seen later in the day. It is very rare for uncomplicated cholecystitis (gallbladder inflammation) to require immediate surgery.
I saw the patient a few hours later and the history that I received led me to very different diagnosis. Her pain was in the right lower abdomen, unusual for gallbladder disease, and she said it was very severe. She also had a history of severe cardiac disease. There was associated nausea and constipation. Physical examination revealed severe tenderness in the right lower abdomen and no tenderness in the right upper abdomen, where the gallbladder usually resides. I began to be concerned that she could have had appendicitis, which would require emergency surgery. The other possibility I considered was ischemic colitis (inflammation of the colon caused by poor blood supply), also a serious condition that could be a life threatening emergency.
When I checked the tests that had been done I saw that a CAT scan had also been done, which seems to be almost routine these days. The findings were thickening of the cecum, which is the first part of the colon, and a normal appearance of the appendix. With all this information I determined that the patient likely had ischemic colitis, but that surgery was not necessary at that time. The following day she had a colonoscopy which definitively confirmed the diagnosis and she is now recovering; responding to the non-operative therapeutic regimen that was started. She still has her gallbladder and her asymptomatic gallstones.
What is apparent is that properly talking with the patient, obtaining a clear history, points the physician in the right direction. Talking to patients is a skill that is easy to develop and actually saves time and money. It often takes no more than five minutes to gather the most pertinent history from a sick patient and, as I’ve shown, the rest of the workup flows out from this relatively short, but very informative interview.
So the next time you go to your doctor and he or she spends most of your appointment talking to you, be thankful; thankful that you have a doctor that cares enough to take the time find the right answer in the right way.
When a patient walks into a doctor’s office for the first time, the doctor faces a myriad of possibilities. In my practice, which is general surgery, I usually assume a new patient has or is suspected of having a surgical problem. Of course this differs from the primary care physician setting where the problem could be anything from headache to hemorrhoids. It is the primary care doctor’s task to sort out all the endless possibilities and determine the best medical approach for each. This is their great challenge, one that may be faced twenty times a day or more.
Fortunately, for me, the surgeon has a task that is a bit easier, at least initially. When I am asked to see a new patient, most of the time there is some information that comes with the request, usually something short and simple, ie: Gallbladder disease, abdominal pain, cold leg, etc. This very brief summary gives me a bit of direction, although occasionally it can lead in the wrong direction.
So, the first, and often the most useful, thing that I do is to sit and talk to the patient. Probably 98% of the time the patient will tell me what’s wrong and all that I need to do is confirm this presumptive diagnosis with the physical exam and appropriate testing. This is true for almost any condition, be it acute appendicitis or hemorrhoids.
But, how does simple talking do all this? The things that go through a doctor’s head, at least mine, when I take a history from a patient are myriad. First and foremost is, “Is this patient ‘sick’.” By this I mean does the patient seem to have a severe, possibly life threatening condition that warrants immediate hospitalization and possibly emergency surgery? Patients that cannot sit up, are afraid to move or are unable to give any history because they are too ill usually need to be in the hospital. It is one of my unwritten rules that patients that look sick usually are. Experience teaches doctors, particularly general surgeons, to be vigilant, assume the worst and do all that we can to achieve the best outcome.
But, I’ve strayed away from the point of this article. Talking to patients is the single most important part of patient visits. When I went to medical school the greatest amount of time was spent on learning the natural history of the many various diseases, all the possible presenting symptoms and signs and how to obtain this information from a sick patient. Unlike House I don’t believe that patients always lie. Most want to get better and most of the time the questions that I ask cannot be answered in misleading way. Starting with the simple question, “What brought you in here today?” and then paying attention to the patient’s answer will, in a few minutes, provide almost all the information necessary to begin that individual on the road to recovery.
Approaching a patient with abdominal pain provides an excellent example. In the days before routine CAT Scans the evaluation of patients presenting with abdominal pain required the skills of a detective; the history and physical exam, along with limited diagnostic testing, were the mainstays of diagnosis. The abdomen, in the days before CAT Scans and MRI’s, was a black box filled with vital organs and often inaccessible except through surgery.
The abdomen is usually divided into three segments, epigastrium, which is above the umbilicus (belly-button), mid-abdomen, the level of the umbilicus, or hypogastrium, which is below the umbilicus. The first thing I will usually ask is where did your pain start. Sometimes I get an answer like “In the bathroom”; some people are so literal. But, once properly directed, the starting point of the pain will go a long ways to narrowing the choices for the offending organ.
Epigastriium usually means stomach, duodenum, gallbladder, liver or pancreas. Mid-abdomen refers to the small bowel or the right side of the colon and hypogastrium usually refers to the left colon. These divisions are in no way arbitrary, rather they correspond to the nerves that supply the various organs and where the nerves will refer pain. For instance, the gallbladder sits in the right upper abdomen, but very often gallbladder pain is felt in the middle. This is because the visceral nerves refer the pain to the middle. Only after a gallbladder becomes more inflamed do the parietal nerves come into play and the pain then becomes localized over the offending organ.
Duration, quality and associated symptoms all direct me to a working diagnosis that only needs to be confirmed. Physical exam, blood/urine tests, imaging studies primarily are used to confirm the working diagnosis and to eliminate other possibilities. I’ve learned that relying solely on imaging studies is often misleading.
For instance, just recently I was called from the Emergency Room at one of the hospitals and informed of a patient that the admitting physician wanted me to consult. The ER physician said she had right sided abdominal pain and that an ultrasound had revealed gallstones. The white blood cell count was elevated, but she was otherwise stable. This patient, as presented to me, was properly admitted to the hospital, but a patient with these clinical findings generally is not a life and death emergency and can usually be seen later in the day. It is very rare for uncomplicated cholecystitis (gallbladder inflammation) to require immediate surgery.
I saw the patient a few hours later and the history that I received led me to very different diagnosis. Her pain was in the right lower abdomen, unusual for gallbladder disease, and she said it was very severe. She also had a history of severe cardiac disease. There was associated nausea and constipation. Physical examination revealed severe tenderness in the right lower abdomen and no tenderness in the right upper abdomen, where the gallbladder usually resides. I began to be concerned that she could have had appendicitis, which would require emergency surgery. The other possibility I considered was ischemic colitis (inflammation of the colon caused by poor blood supply), also a serious condition that could be a life threatening emergency.
When I checked the tests that had been done I saw that a CAT scan had also been done, which seems to be almost routine these days. The findings were thickening of the cecum, which is the first part of the colon, and a normal appearance of the appendix. With all this information I determined that the patient likely had ischemic colitis, but that surgery was not necessary at that time. The following day she had a colonoscopy which definitively confirmed the diagnosis and she is now recovering; responding to the non-operative therapeutic regimen that was started. She still has her gallbladder and her asymptomatic gallstones.
What is apparent is that properly talking with the patient, obtaining a clear history, points the physician in the right direction. Talking to patients is a skill that is easy to develop and actually saves time and money. It often takes no more than five minutes to gather the most pertinent history from a sick patient and, as I’ve shown, the rest of the workup flows out from this relatively short, but very informative interview.
So the next time you go to your doctor and he or she spends most of your appointment talking to you, be thankful; thankful that you have a doctor that cares enough to take the time find the right answer in the right way.
Wednesday, June 23, 2010
Improving the Game
A Few Modest Proposals
The World Cup Soccer games are in full swing and every morning I am privileged to watch whatever game is ongoing as I wait to start the day’s surgery. There are usually a number of physicians gathered around the large TV in the doctor’s lounge watching Nigeria or France battle it out. Personally, I have never been able to figure out what all the excitement is about.
There seems to be something wrong with a game where the most exciting moments seem to be when someone actually takes a shot at the goal and almost scores. I guess I can’t figure out the appeal of a game where twenty two men can run around a huge open field for ninety plus minutes and only manage to score one goal. It must be my ethnocentric upbringing that prevents me from seeing the grace and talent of the many international football stars.
So, I have put together a list; a number of suggestions that, if implemented could broaden the appeal of this sport and really make the game really exciting. Anyone of these would enhance the game by increasing the number of goals scored and elevate the obvious waning fan interest.
The first suggestion is to add some obstacles to the field. The field is huge and it is obvious that anyone, even the most inexperienced neophyte, has no trouble running over such a large, flat terrain. Adding some large boulders or some wooden sawhorses at varying points around the field would increase the necessary skills immeasurably. Fan interest would get a clear boost as they would be able to cheer, not only for shots and goals, but also that their favorite player not be maimed. Of course, the addition of such obstacles would mandate additional protective gear. Even if the number of goals did not increase the additional strategic elements that such a change would require would greatly heighten fan interest.
The second suggestion is to play the game on horseback. Now, I know what you’re thinking, this would merely convert football to polo. But, that wouldn’t be true. Polo players utilize a long mallet to strike a small ball. I propose that the soccer player still be required to kick or head the ball, just as before, only now it would be done on horseback. The new emphasis on riding skills in conjunction with the existing rules could only improve on the current game. Of course, the horse would also be allowed to kick or head the ball. The equine competitor would have some advantage, having four feet to kick the ball with instead of two.
The third suggestion would be to increase the size of the goal, perhaps to double its current size. Think about it. In basketball the player that can hit the three point shot with great consistently is highly coveted. Field goal kickers in American football are prized for their accuracy at greater and greater distances. If the soccer goal were twice as long and/or twice as tall players who could make an accurate shot on goal from midfield and not have to worry about any pesky goalkeeper swatting their shot away would be in the greatest demand. Undoubtedly the number of goals would increase and so would fan appeal.
The fourth suggestion, the converse of number three is to limit the size of the goalie. It seems unfair to have goalies that can easily reach the farthest corners of the goal. If a rule was adopted limiting the height of the goalie to no more than four foot ten inches tall, then the poor forward’s chance of scoring would be improved and scores of 12-10 or even higher could become the norm.
The fourth suggestion is that every ten minutes the game be briefly halted and the players allowed to quaff a beer or any other favorite alcoholic beverage. After the third or fourth such break I would expect that goals would be much easier to come by. Also, adding an additional drink if a goal is allowed would increase scoring even more. By the end of the game it is possible that nobody would care one way or the other if anyone scored a goal or not.
The fifth suggestion combines the best of both types of football. The game could start with the usual rules of soccer: no use of hands, minimal contact and such. However, at regular or even random intervals a horn could be blasted which would mark a time when the game would become more akin to American football. The players would be allowed to pick up the ball and run with it, block for their teammates, execute forward passes, etc. A premium would be placed on player versatility. During those periods when American football rules were in force, scoring would be worth six points instead of one. After all, kicking the ball through the goals is only worth three points at the most.
I’m sure that there are other changes that could be made that could drag soccer out of its current doldrums and elevate it to the level of its American cousin. The above proposals would require only modest modification of the current rules, but would definitely provide a tremendous boost to the current dwindling popularity of soccer. Feel free to make any other suggestions and forward them to FIFA.
Monday, June 14, 2010
More Things
A Parable for Our Times
George was a normal guy who set out to live a normal life after graduating from Mundane University. He moved to Regular City and went to work. He started with nothing, but he was very diligent and determined and gradually began to accumulate a few things.
At first it was only a few small things, but when he got these things he was very pleased and realized that if he worked harder he could get more things. So, he doubled his efforts and, in addition to the things that he already had, he started to get more and better things. Mary saw that George had some nice things, so she decided to take an interest in George and before long they were married.
They both worked even harder and really started to accumulate a lot of things. They decided that they needed more room to store all their things so they bought a house in Suburbs, kept working and soon had everything they needed and many extra things. Finally, George and Mary sat down together one day and looked at all their things and George said, “I’m so happy we have all these things; I don’t think there’s anything else that I could possibly want.”
Just as he said this he saw his neighbor, Mickey, go by with a new shiny thing and George realized that there were other things that he could get. The happiness he had felt a few minutes before disappeared when he realized his neighbor had more things than he had.
George and Mary worked even harder and soon he had more and better things than Mickey. Once again George was filled with contentment because of all the things that he had; until Andy walked by George’s house and stopped and said, “Look at the new thing that I just got.”
George was sad because Andy’s thing was truly special and George realized that he would probably never find any thing as nice as Andy’s. That night George couldn’t sleep, because he kept thinking about the thing that Andy had and that he wanted a thing just like it, only better. He resolved to ask Andy to share his thing with him. The next day, first thing in the morning, even before he’d had his morning coffee, George went to Andy’s house and asked him to share his wonderful thing. Andy refused. George became very angry and turned around and stormed home. Later that day, after Andy had left his home, George returned to Andy’s house, broke in through a window and stole Andy’s wonderful thing. That evening George showed Mary this wonderful thing, but he was careful not to take it out if other people could see, or else the foul truth would be discovered and he would lose this wonderful thing.
The people in the neighborhood soon became wary of each other and decided that they needed to be more careful or else someone would come and try to take their things. Everyone decided to protect themselves from having their things stolen; so each man went to work and built a strong, high wall around his house. This way they kept their things safe from their neighbors and from anyone else that might have wanted to take their things.
A short time later, Samuel moved into the neighborhood. Everyone watched from behind their walls as Samuel moved in to the small vacant house that was in the middle of the street. Everyone noticed that Samuel had only a few things, and they also noticed that he smiled all the time and seemed to whistle a lot as he walked up and down the street. He waved to all his neighbors as he passed by their houses where he could see them peering out at him from behind their walls. Every day Samuel walked down the street with his spry jaunty stride, always wearing the same white clothes, sandals on his feet and holding an elaborately carved walking stick.
One day as he walked by George’s house, George called out to him from behind his high wall. “Samuel, that’s a very fancy walking stick.”
Samuel stopped and smiled, looked down at his walking stick and said, “You have a very keen eye. This was carved by my father fifty years ago. It’s the only thing I have that was his.” Samuel saw the look of admiration on George’s face and went closer to the wall.
“I see that this walking stick impresses you. I’d like you to have it.” He held the ornately carved stick up high and George was just able to reach and pull it up and over the wall into his protected sanctuary. Samuel went on his way, smiling and whistling as he walked as George put the fancy object in a pile by the wall with some of his other things.
Everyday Samuel did the same thing, walked down the street smiling and whistling. All his neighbors began to feel uneasy and decide to get together and talk about Samuel; this troublemaker that had invaded their quiet neighborhood.
“He must have a truly great thing”, George said, “or else he wouldn’t be so happy.”
All the neighbors nodded in agreement. “We must have this great thing for ourselves” George said.
“Perhaps we should ask him to share this great thing”, Mickey said.
But George interrupted, “No, we must have this thing for ourselves.” Secretly, George decided that he would keep this great thing for only himself. All his neighbors had the exact same thought.
So they all went together, men and women and knocked on Samuel’s door. He answered it with a smile wearing the same clean white outfit he wore every day.
As soon as the door opened George said, “You seem to be happy all the time and we have all concluded that you must have a great thing that makes you feel that way.”
“Welcome to my home”, Samuel responded, “Please come inside. I have hoped for a long time that someone would come to visit. You are all correct; I do have a very great thing, perhaps the greatest thing anyone can imagine. I am happy to share it with you.”
They all went in, George in the lead with a big smile on his face. He and the others realized that they were finally going to get the thing they all had dreamed about. As soon as the door was closed and before Samuel could utter another sound the entire mob set upon Samuel and beat him mercilessly until he was dead, a bloody mass that was barely recognizable as human. Everyone went their own way, searching throughout the small home for the one great thing. All they found was a small mat and a thin blanket, one slice of bread and a bottle of wine with only a few drops left in the bottom. They searched high and low, but couldn’t find anything else.
“Perhaps he kept it with him”, somebody said and they all ran to the body and pulled off the bloody clothes. There were pockets in the thin, blood stained top which they turned inside out, but nothing was found. Same for the pants.
Truly perplexed they filed out of Samuel’s home shaking their heads. “He seemed so happy all the time”, Mickey said, “but, he didn’t have any things. I don’t think he ever had any truly great thing.”
“It was all an act”, George said. “He was trying to trick us. It’s a good thing we did this or else he would’ve come to steal our things. Yes, he definitely deserved all that he got.”
As they walked down the street, each man and woman went into their home, locking themselves behind their walls and felt the comfort that came with having so many things.
Afterwards
I really think the story ends at that point, but the idealist in me would like to believe that there is more. What follows is one scenario that I hope would be the final outcome of Samuel’s sacrifice and one that reveals the truly great thing he possessed.
Months passed after Samuel’s murder and George lived a happy, peaceful life; safe behind his wall, surrounded by his many things. One day, while admiring all his things he saw Samuel’s walking stick. He picked it up and studied the elaborate carvings; some sort of lettering that he didn’t understand. He wrote the symbols down and using his translator thing read the words:
“You will love the Lord your God with all your heart and with all your soul and with all your mind. And, love your neighbor as yourself.”
He decided to take a walk and carried the fancy walking stick with him. He passed from his protected fortress, down the street and walked past Andy’s house, the words that were carved into the sturdy stick resonated in his mind. As he went by, Andy called to him from behind his wall.
“Hello, George”, Andy called from the safety of his home. “It’s a lovely day for a stroll.”
George stopped, looked down at Samuel’s walking stick and remembered how Samuel used to walk down the street, past the many houses and smile and wave to all his neighbors. To honor his guilty memories of Samuel, George stopped, smiled and waved to Andy and walked up to Andy’s wall.
“It certainly is a lovely day, Andy; far too nice to stay hidden behind a wall”, George remarked. He looked again at the fancy walking stick and remembered how Samuel had treasured it, but also how he had freely given it away. He looked up at Andy and then said, “I’d like you to have this very elaborate walking stick. Perhaps it will give you some incentive to escape from behind your wall and take at least a short a walk.” He hoisted the stick up to Andy, who quickly grabbed it and put it with his other things.
Later that day, as George looked at all his things, he felt a warm feeling in his heart. He realized it wasn’t all his things that gave him this feeling, rather it was the act of giving, freely and without any expectation of something in return that gave him this feeling. He looked at all his things again and then he started to cry. He resolved at that time to give all that he possessed to Samuel’s family, to try to make some restitution for his terrible crime.
George soon learned that Samuel had no family. But, instead, he gave all that he had and more to any needy person he met. Very soon most of his things were gone, but he felt like he had more things than any person in the world and that he had found Samuel’s one great thing.
Tuesday, June 1, 2010
Surrogate Surgery
Surrogate Surgery
It was announced today that a pilot program is commencing in Baltimore under provisions covered on page 2438 of the new Health Care Reform Act. It is anticipated that there will be considerable shortage of general surgeons in the years to come. Incomplete filling of residency rosters coupled with the aging population will lead to a deficit of over ten thousand general surgeons over the next twenty years.
This deficit is expected to hit hardest in rural areas, but many urban areas are already experiencing many weeks without adequate emergency and, at times, even elective coverage for many specialties, but particularly in the very important area of general surgery.
This section of the Health Care Act provides for coverage by health care providers that act as surrogates for the traditional physician or surgeon. Nurse practitioners, physician assistants, nurse midwives and similar health care providers all are anticipated to play vital roles insuring that quality healthcare is delivered to many underserved areas.
The new program, called the Simian Surrogate Program or SSP, is undertaking the task of training apes to perform many of the operations now performed by general surgeons. Specifically, chimpanzees and orangutans are currently undergoing intense education in surgical technique and decision making at the Halsted Memorial Training Center at Johns Hopkins Hospital.
Program director Dr. William Roundtree’s comments, “The use of simian surrogates to perform many of the more common operations will fill a tremendous gap in the delivery of quality surgical care that was anticipated to arise over the next few years. The retirement of the huge baby boom generation threatens to put an untenable strain on the available resources. The use of chimpanzees and orangutans has, thus far, yielded outstanding results. The program is proving a point I’ve made for years. The many residents that have passed through these hallowed halls are no better than monkees.”
Dr. Roundtree went on to explain that originally the plan was to train baboons to provide surgical care, but it was soon discovered that all the available baboons were tied up in a sister pilot program where they were being trained to become Senators and Representatives.
The first simian surgeons are expected to complete their training in 2013, coinciding with the introduction of the first health care reforms. When asked if there was to be any role for gorillas, Dr. Roundtree remarked, “Gorillas haven’t shown much aptitude for general surgery, but we are looking into training them to do orthopedics.”
News of this new pilot program sent the value of Chiquita stock soaring in after hours trading today.
It was announced today that a pilot program is commencing in Baltimore under provisions covered on page 2438 of the new Health Care Reform Act. It is anticipated that there will be considerable shortage of general surgeons in the years to come. Incomplete filling of residency rosters coupled with the aging population will lead to a deficit of over ten thousand general surgeons over the next twenty years.
This deficit is expected to hit hardest in rural areas, but many urban areas are already experiencing many weeks without adequate emergency and, at times, even elective coverage for many specialties, but particularly in the very important area of general surgery.
This section of the Health Care Act provides for coverage by health care providers that act as surrogates for the traditional physician or surgeon. Nurse practitioners, physician assistants, nurse midwives and similar health care providers all are anticipated to play vital roles insuring that quality healthcare is delivered to many underserved areas.
The new program, called the Simian Surrogate Program or SSP, is undertaking the task of training apes to perform many of the operations now performed by general surgeons. Specifically, chimpanzees and orangutans are currently undergoing intense education in surgical technique and decision making at the Halsted Memorial Training Center at Johns Hopkins Hospital.
Program director Dr. William Roundtree’s comments, “The use of simian surrogates to perform many of the more common operations will fill a tremendous gap in the delivery of quality surgical care that was anticipated to arise over the next few years. The retirement of the huge baby boom generation threatens to put an untenable strain on the available resources. The use of chimpanzees and orangutans has, thus far, yielded outstanding results. The program is proving a point I’ve made for years. The many residents that have passed through these hallowed halls are no better than monkees.”
Dr. Roundtree went on to explain that originally the plan was to train baboons to provide surgical care, but it was soon discovered that all the available baboons were tied up in a sister pilot program where they were being trained to become Senators and Representatives.
The first simian surgeons are expected to complete their training in 2013, coinciding with the introduction of the first health care reforms. When asked if there was to be any role for gorillas, Dr. Roundtree remarked, “Gorillas haven’t shown much aptitude for general surgery, but we are looking into training them to do orthopedics.”
News of this new pilot program sent the value of Chiquita stock soaring in after hours trading today.
Sunday, May 23, 2010
Barriers
In the practice of surgery it is necessary to create barriers; obstacles that separate the surgeon from his patient. During any operation the surgeon and his assistants wear gowns, caps, masks and gloves which act as a barrier between the patient and the OR crew. These protective items help prevent contamination of the surgical field; keeping the bacteria that reside on our skin and in our mouths and noses from infecting the surgical wound. Indeed, certain orthopedic procedures, those in which any introduction of bacteria can be a life threatening disaster, take this barrier precaution to the extreme. The orthopedist has adopted an elaborate system of helmets and filters, strictly limits access to the room during the procedure and does everything humanly possible to banish the potentially deadly microorganism from the OR suite.
There is, however, much more to the barrier concept than protection of the patient. Unfortunately, it is a necessity of modern times that the OR crew also be protected; protected from contamination by the patient. It is one of the sad facts of our modern world that chronic infectious diseases exist. It is an almost daily occurrence that medical personnel will be called upon to care for patients with HIV, hepatitis B or C, MRSA and a host of other infectious agents that have the potential to be transmissible from the patient to OR personnel during the course of an operation. Proper barriers, proper technique and appropriate choice of operation protect us from our own patients and allow us the opportunity to live and serve another day.
At the end of most operations the final mechanical barrier is left with the patient, the surgical dressing. I have seen such dressings raised to the level of ritual, the surgeon mandating that only certain materials placed in a certain way be used, instructing the patient to leave the dressing in place for exactly 76 hours and 12 minutes and then remove it at precisely the proper time, unless there is a full moon, in which case it needs to be left until dawn the following day. A bit of an exaggeration, surely, but not as much as you might think. Personally, I think that a simple dressing is best; something that can be removed easily and painlessly in 48 hours.
The surgical dressing certainly is important, particularly for the first few hours. Most wounds, however are probably sealed from the outside world within twenty four hours. As a matter of fact, I instruct my hemorrhoidectomy patients to remove their dressings after only about six hours; for comfort and to begin proper care of the area. It is an extremely rare event for these patients to develop an infection, surprising really, given the location and environment of such surgery. There are reasons why infections in this area are rare which involve an entirely different sort of biological barrier, but that is a subject for another article.
There is another type of barrier that is necessarily built up between patient and physician. This is the psychological barrier; an invisible wall that prevents excessive bonding between a doctor and his patient, thus preserving an appropriate doctor-patient relationship, one that is intimate on a medically therapeutic level only. Medical School, at least my medical school, taught us to maintain an aloof concern for our patients, supposedly for the patient’s well being and to maintain our objectivity.
An excessively close relationship can make the patient too reliant on their doctor, while at the same time potentially cloud the physician’s judgment, leading to decisions based upon feelings, rather than proper objective findings. I carry this concept to its extreme in my upcoming novel Joshua and Aaron, as the doctors are prohibited from actually examining the patients in person. Such a scenario is unlikely, you are thinking, but the trend is already present.
Today, a patient visiting an emergency room is initially seen by a triage nurse, who makes the initial assessment of the severity of the condition and very often orders the indicated tests to help establish a diagnosis. After such tests are completed the emergency room physician will finally see the patient and confirm a diagnosis that has already been established. It won’t be long until the doctor becomes a superfluous intermediary and is completely eliminated from the equation, (Obamacare here we come).
It’s not just in emergency rooms such a scene plays out. The pressures of modern medicine force doctors to spend less and less time with the patient as regulations, paperwork and diminishing reimbursement force the doctor to do more and more in a limited period of time. However, don’t think that the quality of care suffers in such a system, because this definitely is not true. The amazing array of imaging systems and lab tests has made medical diagnosis far more accurate now than it was thirty years ago. What is lost is the personal aspect, the unique doctor-patient relationship.
In my surgical practice we have a physician’s assistant, whose job is to assist us in the operating room. When she first started with us our office manager asked me if I wanted her to help in the office. My answer was no. Surgery today requires much shorter hospital stays and the contact between surgeon and patient is greatly limited. Generally, I will see my patient once in the office; surgery will be scheduled, they’ll be seen again immediately before the operation and then once or twice more in the office afterwards. This is a far cry from years ago when the patient, for a similar operation, would go into the hospital the day before surgery and then stay for one or two weeks afterwards; certainly all this contact strengthened the physician patient relationship and lowered the barriers that existed, but in no way did it actually improve patient care or final outcome.
The current system is more economical and far better for the patient. But, it throws up a barrier of sorts. That is why I refused to have our PA see patients in the office. I am given one chance to create a relationship with my patient before surgery and I do not want anything or anyone to diminish this already limited opportunity.
There is one particular medical condition where I do everything possible to break down the barrier that exists between doctor and patient and that is with breast cancer patients. Of course all patients are important and most every type of cancer is serious, but of all the different diseases I encounter this one creates the greatest emotions and intense feelings for the patient and family and perhaps for the treating physician. I am often the physician called upon to inform a woman (99% of the time it’s a woman) of the diagnosis of breast cancer. Usually I’m the one that has performed the biopsy and often the first therapeutic intervention requires surgery. So, I have to break the news. Most of the time I’ve started to prepare my patient for such bad news even before the biopsy is done.
Probably 98% percent of the time when a woman comes to me with a lump in her breast or an abnormal mammogram or ultrasound it is immediately apparent whether or not the lump is cancerous. At this point I will tell her and her family that the findings are very worrisome for cancer, but that a biopsy is necessary. When I receive the confirmatory biopsy report I always tell her in person and make sure that I am not rushed for time while I explain all the implications and options. After the first explanation I usually explain everything a second and usually a third time, hoping that some of what I say will actually be retained. Even with all this many women hear nothing beyond the two words “breast cancer”. It is very common to get a call a few hours later or the next day asking about all the options again.
In situations like these I do my best to tear down the invisible barrier that exists between doctor and patient. The trust that is built in those moments contributes tremendously to healing for the patient and their family. It isn’t bad for the doctor, either.
There is, however, much more to the barrier concept than protection of the patient. Unfortunately, it is a necessity of modern times that the OR crew also be protected; protected from contamination by the patient. It is one of the sad facts of our modern world that chronic infectious diseases exist. It is an almost daily occurrence that medical personnel will be called upon to care for patients with HIV, hepatitis B or C, MRSA and a host of other infectious agents that have the potential to be transmissible from the patient to OR personnel during the course of an operation. Proper barriers, proper technique and appropriate choice of operation protect us from our own patients and allow us the opportunity to live and serve another day.
At the end of most operations the final mechanical barrier is left with the patient, the surgical dressing. I have seen such dressings raised to the level of ritual, the surgeon mandating that only certain materials placed in a certain way be used, instructing the patient to leave the dressing in place for exactly 76 hours and 12 minutes and then remove it at precisely the proper time, unless there is a full moon, in which case it needs to be left until dawn the following day. A bit of an exaggeration, surely, but not as much as you might think. Personally, I think that a simple dressing is best; something that can be removed easily and painlessly in 48 hours.
The surgical dressing certainly is important, particularly for the first few hours. Most wounds, however are probably sealed from the outside world within twenty four hours. As a matter of fact, I instruct my hemorrhoidectomy patients to remove their dressings after only about six hours; for comfort and to begin proper care of the area. It is an extremely rare event for these patients to develop an infection, surprising really, given the location and environment of such surgery. There are reasons why infections in this area are rare which involve an entirely different sort of biological barrier, but that is a subject for another article.
There is another type of barrier that is necessarily built up between patient and physician. This is the psychological barrier; an invisible wall that prevents excessive bonding between a doctor and his patient, thus preserving an appropriate doctor-patient relationship, one that is intimate on a medically therapeutic level only. Medical School, at least my medical school, taught us to maintain an aloof concern for our patients, supposedly for the patient’s well being and to maintain our objectivity.
An excessively close relationship can make the patient too reliant on their doctor, while at the same time potentially cloud the physician’s judgment, leading to decisions based upon feelings, rather than proper objective findings. I carry this concept to its extreme in my upcoming novel Joshua and Aaron, as the doctors are prohibited from actually examining the patients in person. Such a scenario is unlikely, you are thinking, but the trend is already present.
Today, a patient visiting an emergency room is initially seen by a triage nurse, who makes the initial assessment of the severity of the condition and very often orders the indicated tests to help establish a diagnosis. After such tests are completed the emergency room physician will finally see the patient and confirm a diagnosis that has already been established. It won’t be long until the doctor becomes a superfluous intermediary and is completely eliminated from the equation, (Obamacare here we come).
It’s not just in emergency rooms such a scene plays out. The pressures of modern medicine force doctors to spend less and less time with the patient as regulations, paperwork and diminishing reimbursement force the doctor to do more and more in a limited period of time. However, don’t think that the quality of care suffers in such a system, because this definitely is not true. The amazing array of imaging systems and lab tests has made medical diagnosis far more accurate now than it was thirty years ago. What is lost is the personal aspect, the unique doctor-patient relationship.
In my surgical practice we have a physician’s assistant, whose job is to assist us in the operating room. When she first started with us our office manager asked me if I wanted her to help in the office. My answer was no. Surgery today requires much shorter hospital stays and the contact between surgeon and patient is greatly limited. Generally, I will see my patient once in the office; surgery will be scheduled, they’ll be seen again immediately before the operation and then once or twice more in the office afterwards. This is a far cry from years ago when the patient, for a similar operation, would go into the hospital the day before surgery and then stay for one or two weeks afterwards; certainly all this contact strengthened the physician patient relationship and lowered the barriers that existed, but in no way did it actually improve patient care or final outcome.
The current system is more economical and far better for the patient. But, it throws up a barrier of sorts. That is why I refused to have our PA see patients in the office. I am given one chance to create a relationship with my patient before surgery and I do not want anything or anyone to diminish this already limited opportunity.
There is one particular medical condition where I do everything possible to break down the barrier that exists between doctor and patient and that is with breast cancer patients. Of course all patients are important and most every type of cancer is serious, but of all the different diseases I encounter this one creates the greatest emotions and intense feelings for the patient and family and perhaps for the treating physician. I am often the physician called upon to inform a woman (99% of the time it’s a woman) of the diagnosis of breast cancer. Usually I’m the one that has performed the biopsy and often the first therapeutic intervention requires surgery. So, I have to break the news. Most of the time I’ve started to prepare my patient for such bad news even before the biopsy is done.
Probably 98% percent of the time when a woman comes to me with a lump in her breast or an abnormal mammogram or ultrasound it is immediately apparent whether or not the lump is cancerous. At this point I will tell her and her family that the findings are very worrisome for cancer, but that a biopsy is necessary. When I receive the confirmatory biopsy report I always tell her in person and make sure that I am not rushed for time while I explain all the implications and options. After the first explanation I usually explain everything a second and usually a third time, hoping that some of what I say will actually be retained. Even with all this many women hear nothing beyond the two words “breast cancer”. It is very common to get a call a few hours later or the next day asking about all the options again.
In situations like these I do my best to tear down the invisible barrier that exists between doctor and patient. The trust that is built in those moments contributes tremendously to healing for the patient and their family. It isn’t bad for the doctor, either.
Tuesday, May 4, 2010
Amazing Weight Loss Program
VOODOOWEIGHTLOSS.COM
If you are overweight and want a quick and easy way to slim down then checkout Voodooweightloss.com. This remarkable diet plan is guaranteed to help you shed those unwanted pounds in a matter of weeks and all with a minimum of effort on your part. Too good to be true? Of course, it sounds like voodoo and, the amazing thing is, IT IS VOODOO.
That’s right. Madame Marie, Queen of the Voodoo curse, straight from Haiti, the voodoo capital of the world, guarantees that if you follow her plan you will be a size two in no time. Even better, Voodooweightloss.com weight loss program allows you to eat anything and everything. I know what you’re thinking; this is some kind of scam. But, the tried and true voodoo methods, perfected over thousands of years are now available for your dieting pleasure.
Madame Marie will use her skills to slowly slim your hips, tighten your thighs and arms, firm your chin, eliminate that unsightly cellulite and, for a small extra fee, enhance your breasts and buttocks. For you male customers, she can give you six pack abs, rock hard biceps, a tight shapely butt and a sharp, chiseled face. Other enhancements may also be available (extra fees may apply).
How does she do it? Is it magic? No, it’s voodoo. For a brief time we are offering Madame’s amazing service at the incredibly low introductory price of $69.95. For this initial low fee a miniature voodoo doll will be constructed in proper proportion to your current body habitus. Madame Marie, employing secret Voodoo techniques known to only a few Voodoo High Priestesses will over a period of several weeks gradually mold your likeness into a svelte image of the self you want to be. Want to be Barbie? She can do it. Rush jobs are available for an extra fee.
So, if you have a class reunion coming up and want to show that bully from high school what you’re really made of give Madame a buzz. She will turn those thunder thighs into tight, muscular limbs that will make you the envy of every man and woman that ever made fun of you.
Just send $69.95, plus $12.95 to cover the cost of the dead chicken along with any personal item (Fine jewelry preferred) to www.voodoooweightloss.com and start to see the pounds melt away.
Disclaimer: Not approved by the American Academy of Weight Loss Programs. Once the contract is signed all obligations must be fulfilled. The Voodoo Weight Loss program can also work in reverse. Individual results may vary.
American Express, Mastercard, Visa and Paypal accepted.
Obesity is a problem that pervades our society. In medicine and, particularly surgery, whenever there are a large number of techniques for a particular operation it is generally accepted that none of them is perfect and each has a drawback or flaw. The number of diet programs available suggests that there is no one program that works better than any other. The glycemic advantage, low carb high fiber, high carb low fat, high fat low carb, Adkins, South Beach, Jenny and all the others all seem like voodoo to me. Proper diet and exercise, although archaic and requiring some determination by the individual are the keys to safe and effective weight loss. But if you are looking for a safe, albeit unorthodox weight loss program check out Madame Marie and Voodooweightloss.com.
If you are overweight and want a quick and easy way to slim down then checkout Voodooweightloss.com. This remarkable diet plan is guaranteed to help you shed those unwanted pounds in a matter of weeks and all with a minimum of effort on your part. Too good to be true? Of course, it sounds like voodoo and, the amazing thing is, IT IS VOODOO.
That’s right. Madame Marie, Queen of the Voodoo curse, straight from Haiti, the voodoo capital of the world, guarantees that if you follow her plan you will be a size two in no time. Even better, Voodooweightloss.com weight loss program allows you to eat anything and everything. I know what you’re thinking; this is some kind of scam. But, the tried and true voodoo methods, perfected over thousands of years are now available for your dieting pleasure.
Madame Marie will use her skills to slowly slim your hips, tighten your thighs and arms, firm your chin, eliminate that unsightly cellulite and, for a small extra fee, enhance your breasts and buttocks. For you male customers, she can give you six pack abs, rock hard biceps, a tight shapely butt and a sharp, chiseled face. Other enhancements may also be available (extra fees may apply).
How does she do it? Is it magic? No, it’s voodoo. For a brief time we are offering Madame’s amazing service at the incredibly low introductory price of $69.95. For this initial low fee a miniature voodoo doll will be constructed in proper proportion to your current body habitus. Madame Marie, employing secret Voodoo techniques known to only a few Voodoo High Priestesses will over a period of several weeks gradually mold your likeness into a svelte image of the self you want to be. Want to be Barbie? She can do it. Rush jobs are available for an extra fee.
So, if you have a class reunion coming up and want to show that bully from high school what you’re really made of give Madame a buzz. She will turn those thunder thighs into tight, muscular limbs that will make you the envy of every man and woman that ever made fun of you.
Just send $69.95, plus $12.95 to cover the cost of the dead chicken along with any personal item (Fine jewelry preferred) to www.voodoooweightloss.com and start to see the pounds melt away.
Disclaimer: Not approved by the American Academy of Weight Loss Programs. Once the contract is signed all obligations must be fulfilled. The Voodoo Weight Loss program can also work in reverse. Individual results may vary.
American Express, Mastercard, Visa and Paypal accepted.
Obesity is a problem that pervades our society. In medicine and, particularly surgery, whenever there are a large number of techniques for a particular operation it is generally accepted that none of them is perfect and each has a drawback or flaw. The number of diet programs available suggests that there is no one program that works better than any other. The glycemic advantage, low carb high fiber, high carb low fat, high fat low carb, Adkins, South Beach, Jenny and all the others all seem like voodoo to me. Proper diet and exercise, although archaic and requiring some determination by the individual are the keys to safe and effective weight loss. But if you are looking for a safe, albeit unorthodox weight loss program check out Madame Marie and Voodooweightloss.com.
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