Inadequate Coverage

The End of Print Media?

To the Editor,
I am writing to you to register a complaint regarding your newspaper, The Houston Chronicle. I’ve noticed that recently the coverage provided by your publication has been inadequate. The exposure in recent months has been unacceptable and has left glaring gaps that are intolerable. Actually, I’ve noticed this deficiency since the fall of 2008.
During the most recent Presidential Campaign I have to say that your newspaper met my needs in a most efficient manner. I rarely found any significant areas left uncovered and nothing of importance ever was missed by your pages. However, starting around the time of the 2008 election I began to notice glaring deficiencies. At first I tried to ignore the obvious lack of coverage, but after a while I found it impossible to overlook.
So, I decided to change. After looking at all the possible substitutes I settled upon The Wall Street Journal. Admittedly, this paper also may be lacking in some departments compared to the Chronicle, but no other paper surpasses the quality of its coverage. Since I’ve made the change there are no more gaps and my time utilization efficiency is greatly improved.
Now, every Saturday, when I change the paper at the bottom of Isaac and Rebecca’s cage I am thankful for The Journal. The paper overlaps perfectly, so that when one layer is removed the layer underneath is pristine and ready to receive whatever may fall its way. I am also using fifty percent less paper each week and, thus, am helping to preserve one of our most precious natural resources.
As an added benefit Isaac and Rebecca, two Eclectus parrots native to the Solomon Islands, are speaking in much clearer tones and their words seem to make more sense. Of course they have been clamoring for more luxurious accommodations ever since I left the “Homefront” page staring up at them.
And so, dear Editor, it is with a heavy heart that I am cancelling my subscription to the Chronicle. The reduction in the size of your pages was the final straw. I may miss “Dear Abby” and “Blondie”, but I believe that the benefits to our planet and to the aching in my back far outweigh any potential negative effects.
I thank you for your consideration.

Sincerely,

David Gelber MD

Christmas Carols

Christmas Carols
A Message for the Season

This Christmas season brings memories of growing up in the quiet village of Scotia New York. The winter holiday season was always highlighted by the Lincoln Elementary School carol sing. This was a mandatory school event which featured all the students of the school assembling in bone chilling cold to offer heartfelt renditions of a variety of Christmas classics.
The songs were always Christmas songs, some with religious themes and some with wintertime and seasonal themes. There was never any apology made to non-believers and there was no such thing as political correctness and, as far as I know, no student was ever excused because “we don’t believe in that.” So, we took turns lining up in front of our freezing parents, singing our little hearts out and, afterwards, we were treated to Christmas cookies and other delights.
Thoughts of this annual event came to me the other day as I posed the question to the operating room crew: “What is your favorite Christmas carol?”
My assistant across the table offered up “O Christmas Tree”, a wonderful song that speaks of the steadfast, faithful and unchanging nature of God. The others in the room were stumped and did not give an immediate response. Years ago while I was reading the autobiography of Harpo Marx there was one anecdote recounted where he and some of the very literate people of his day asked a very similar question; only their question was “name the best song of all time”. Their collective answer was “Silent Night”.
I really believe that “Silent Night” is a beautiful song that captures the holy nature of the newly born Jesus, but it really does not do justice to the events surrounding that wonderful Christmas Eve.
Christmas Eve started as thousands of other nights had begun, quiet, cold, mundane. But, all of a sudden, for no obvious reason, the shepherds in the field have this quiet solitude rudely interrupted. An angel comes to announce a birth, the birth of a Savior. Then, the night sky suddenly becomes bright and is filled with all the Heavenly host announcing the birth of a new King, but not just any old earthly king. This is the King of the universe, a baby, God’s own Son, sent to save the world. This is an event that was anything but silent. It was and is, rather, a reason for shouting; shouting with joy as the angels announce a new order for our world, one that promises Peace and Goodwill.
The shepherds leave their flocks and investigate and what do they find? The baby, lying in a manger. Perhaps at this moment there is silence as they, along with Mary and Joseph, ponder the cosmic implications of this singular event. The silence is brief, however, as the shepherds leave and spread the news to everyone that can hear, all the while singing praises to God. Definitely, the Christmas story is not one of silence.
My response to the question, “What is your favorite Christmas carol?” results in a tie. My first favorite is “Hark the Herald Angels Sing”. This song brings all the joy and exaltation of Christmas, while also summarizing all the hopes for mankind that Jesus brings. It is best sung with all the power and force one can muster; a true celebration of the true meaning of Christmas.
My other favorite carol is “The Little Drummer Boy”. It is a relatively modern song, written in 1958, but it carries a message that I think we all should heed. Christmas is about giving. God gave this world the greatest gift imaginable, his only Son. But he didn’t just send his son to live among us. Jesus came for one purpose: to reconcile a wayward, sinful people to their Holy God. It is this great spirit of giving all that you have that “The Little Drummer Boy” presents. This spirit of giving and hope is the true message of Christmas, a message for the Christmas season and all the year.

Hark! The Herald Angels Sing

Hark! the herald angels sing
Glory to the new-born King!
Peace on earth and mercy mild,
God and sinners reconciled!
Joyful, all ye nations, rise,
Join the triumph of the skies;
With th' angelic host proclaim
Christ is born in Bethlehem!
Hark! the herald angels sing
Glory to the new-born King!

Christ, by highest heaven adored;
Christ, the everlasting Lord;
Late in time behold Him come,
Offspring of the Virgin's womb.
Veiled in flesh the Godhead see;
Hail, the incarnate Deity,
Pleased as man with man to dwell;
Jesus, our Emmanuel!
Hark! the herald angels sing
Glory to the new-born King!

Mild He lays His glory by,
Born that man no more may die,
Born to raise the sons of earth,
Born to give them second birth.
Risen with healing in His wings,
Light and life to all He brings,
Hail, the Son of Righteousness!
Hail, the heaven-born Prince of Peace!
Hark! the herald angels sing
Glory to the new-born King!

Come, Desire of nations come,
Fix in us Thy humble home;
Rise, the Woman's conquering Seed,
Bruise in us the Serpent's head.
Adam's likeness now efface:
Stamp Thine image in its place;
Second Adam, from above,
Reinstate us in Thy love.
Hark! the herald angels sing
Glory to the new-born King!



Little Drummer Boy
Come they told me, pa rum pum pum pum
A new born King to see, pa rum pum pum pum
Our finest gifts we bring, pa rum pum pum pum
To lay before the King, pa rum pum pum pum,
rum pum pum pum, rum pum pum pum,

So to honor Him, pa rum pum pum pum,
When we come.

Little Baby, pa rum pum pum pum
I am a poor boy too, pa rum pum pum pum
I have no gift to bring, pa rum pum pum pum
That's fit to give the King, pa rum pum pum pum,
rum pum pum pum, rum pum pum pum,

Shall I play for you, pa rum pum pum pum,
On my drum?

Mary nodded, pa rum pum pum pum
The ox and lamb kept time, pa rum pum pum pum
I played my drum for Him, pa rum pum pum pum
I played my best for Him, pa rum pum pum pum,
rum pum pum pum, rum pum pum pum,

Then He smiled at me, pa rum pum pum pum
Me and my drum.

On Surgery

One Surgeon's perspective


This blog is called Heard in the OR, a place I spend many hours most days, rummaging around inside people’s bodies. I hope that you will get a glimpse into what can be the bizarre thoughts of one surgeon and I hope you enjoy what I have to say. I welcome any and all comments.
For more than twenty years I have made my living as a general surgeon. This is more than a job, perhaps even more than a profession; it is best described as a passion. The surgeon is called to be passionate about what some would call the unthinkable, the extraordinary, the epitome of arrogance. “Arrogance”, one may say, “how can that be?”
What a surgeon does can only be called arrogant. The surgeon takes an incredibly sharp instrument, slices through living human tissue, and in the course of the operation decides what organ is offensive and is to be removed and what is innocuous or important and is to remain. Or, the surgeon may rearrange our tissues, taking what was once God’s perfect creation and altering it for a, presumably, nobler purposes. Man nobler than God? “Impossible”. Such is the arrogance of the surgeon.
Of course, I don’t in any way imagine any man, surgeon, priest, baker or used car salesman to be nobler than God. It is one of the consequences of living in this fallen world that we need surgeons. Diseases and the specter of Death having been released with the first taste of the forbidden fruit create a need for physicians and surgeons to help keep these evils at bay.
What is it that makes anyone do such a thing? How is it that out of a typical class of one hundred medical students some will choose to pursue a career in surgery. And, after years of rigorous training, of getting out of bed at three in the morning to attend to an anonymous individual who had the misfortune to be hit by a bus, shot, stabbed, suffered a perforated intestine or any number of maladies that can’t tell time, this endeavor remains a passion, something done for the reward of seeing the sick and injured walk out of the hospital alive and whole.
I’ve often considered that what surgeons do for a living would be reason for incarceration if it was done away from the operating theater. In general, cutting people open with sharp objects is considered socially inappropriate and frowned upon by legal authorities. To avoid this hazard the operating theater was developed and we surgeons try to limit such endeavors to that location. Theater is an appropriate description; surgery used to be performed in just such a way. Students and professors would observe the operation from seats in an amphitheater; sterility not a prime concern in those days. Even after the research of Joseph Lister introduced the concept of asepsis to surgery, thus eliminating the open spectacle, the operating room still had observation decks, frequently seen in old movies, but rare today.
So, we surgeons, haughty actors of the medical world, ply our trade before a smaller, but captive audience: anesthesiologist, circulating nurse, surgical technician, surgical assistant and the occasional student. But, the star and center of any operation is not the surgeon; rather it is the patient. Above all, the patient is given the most attention, loving care with every detail of the procedure geared towards carrying this individual to a successful outcome.
Before any operation time is spent evaluating, examining and explaining the operation to the patient. A very common question I hear is something like this: “This is routine isn’t it?” Most of the time the answer is that a particular operation is common, hopefully straightforward, but I never consider it routine. Every operation requires proper planning, attention to detail and the utmost care. And, with every procedure surgeons have a single goal; to perform the right operation, at the right time, with proper technique so that our patient returns to their normal life as expeditiously as possible.
A general surgeon spends 5-6 years in residency after medical school studying and practicing every aspect of the profession so that at the end of his time he believes he is fully and properly trained. This residency provides the necessary basics; how to evaluate a patient, plan surgery, carry out the operation and provide post-operative care. All those years certainly seems to be enough time to learn all that needs to be learned. But, in reality, the practice of surgery is a lifetime of learning. Every day brings the potential for something new, an unexpected anomaly, a new presentation of an old disease, a situation never previously encountered; one that may only echo a vague memory of an article read in an old journal.
So, in our arrogance, we are humbled. It is this humility that separates the good and very good surgeons from the great surgeons. Because, every person that picks up a scalpel has to have the arrogance, the confidence that says I can do this better than anyone. If this belief is missing and the surgeon believes that another surgeon can do the job better, then it is in that patient’s best interest to be referred to that other surgeon. If humility is lacking, the patient may suffer.
What about humility? Physicians quickly learn that, despite our best therapeutic efforts, the human body can be a frustrating and unforgiving subject. Invasion by micro-organisms, tumors, external forces and foreign objects or even by the body attacking itself can rapidly overcome all our good intentions. We do all we can to give our patients the greatest chance for complete recovery and, happily, we are successful in the vast majority of cases. But, every individual is unique and every individual demands our unflagging attention. It is something I am reminded of everyday. The truly great surgeon is never so arrogant as to believe that something can’t be wrong. It is an unfortunate truth that patients sometimes become sick after surgery; that our best efforts may not have been good enough. When this happens we start to look for a reason; all our searching usually leads back to the original operation; something bleeding or not healing as expected, an infection or a wide variety of other potential complications. And so, it is the surgeon’s humility that allows him or her to say, “something’s not right, I need to figure this out and solve this dilemma.” It is this attribute that comes with experience and is the single, most difficult thing for the young surgeon to learn.
Arrogance and humility, truly an oxymoron, but no two words give a better description of what we surgeons are made of. It takes a truly unusual, dedicated person to follow the trail that at the ends bestows the title “Surgeon”. I have followed this path for twenty years and have always enjoyed the challenge. I hope you are informed and entertained by my words as I record them in the months and, hopefully, years to come.

It's Alimentary

Praise to our Intestines

My recent work has taken me to weaving my way in and around people’s bowels, something that is a common task for any general surgeon. However, I’ve had more than my usual share over the last few weeks. While making my way around a particularly difficult colon today those of us in the operating room discussed the relative merits of what has been named the alimentary tract, our intestines, the gastrointestinal tract, bowel , guts or “chitlins”.
If one considers all our various organs one would have to agree that our GI tract is, by far, the most intelligent. Think about it; our brain stands isolated within its protective cage, so snobby and aloof, only allowing certain special materials to enter its domain, always giving orders, but out of touch with its co-organs. The heart is a tireless worker, but mindlessly does the same thing over and over, day in and day out, blood comes in, blood goes out. Ditto for the lungs, a monotonous pastime of breath in, breath out, inhale, exhale, occasionally fending off noxious fumes and fighting invaders.
Kidneys are efficient cleaners and bones are glorified coat racks. Muscle is a little smarter, only working when called upon, but always the same thing, relax, then contract, hold this up, push that down. No wonder they get stiff and sore.
But our bowels do remarkable things. When not needed they rest, blood flow is shut down and our guts essentially go to sleep. Yet, when called upon, they spring into action, sorting out a variety of nutrients, directing them to the liver through the bloodstream or bypassing the liver sending fats through our lymphatic system.
This long tunnel through the middle of our body is constantly fending off invaders, be they micro-organisms, noxious chemicals or a variety of foreign bodies. The GI tract lives in symbiosis with huge numbers of bacteria, using these microscopic invaders for its (and our) own purpose. Yet if one of these foreigners behaves badly they are expelled, one way or another, causing us a brief period of discomfort, but also keeping us well. No other organ has to deal with such insults on so massive a scale, yet our bowels handle them with aplomb. Perhaps, our skin, the body’s largest organ, comes close, but on a much smaller scale.
So, I say, let us praise our bowels. When they are working properly they keep us happy, healthy and whole. But, when they go bad; when they are blocked or punctured or dying nothing can make us so incredibly ill. I say there should be a take your bowel to lunch day. But, come to think of it, everyday is take your bowel to lunch day.

The Obesity Problem

The Obesity Problem

Today I read an article that tried to shed light on a medical condition endemic to modern society. Obesity plagues our post modern world, particularly in the United States and more particularly in Houston, Texas; my hometown. Houston carries the dubious distinction of having been named the least physically fit, most obese city in the US several years ago. In my general surgery practice I face this reality every day.
There is no question that obesity contributes to the rising costs of health care. Overweight patients can turn straightforward surgical conditions into complex operations that may require significant adjustment or compromise to have a successful outcome.
There is a huge industry catering to the desire of the obese individual to go from size 20 to size 8 or 48 waist to 36. Fad diets, diet pills, lap bands and gastric bypass surgery ads fill our airways, magazines and internet pages promising a svelte and youthful body in thirty (or sixty or ninety) days or your money back.
Today in surgery, while creating a colostomy (always a mind stimulating endeavor), we proposed a powerful solution to this pervasive problem. As background let me say that human beings originally were foragers, searching for their food. Later they became hunters and eventually farmers. The scarcity of food was the driving force in ancient society and wealth was measured in sheep and cattle, rather than dollars.
Of course, times have changed and scarcity of food has become a thing of the past in our developed nations. A casual stroll down the aisle of the neighborhood megasupermarket will result in a cart laden with all the necessities of life. As a matter of fact one need not even make the short drive to the grocery. With a few clicks of your trusty mouse it is possible to select and have delivered to your front door everything you need to keep your pantry and your stomach full.
So, today those of us in surgery decided it is time to return to our ancestral roots. The supermarket should become a place to hunt and forage for food. No longer should the shopper be allowed a leisurely stroll down capacious aisles. No, it is time to work for our food. And, to battle obesity, food that is high in fat and calories should require the greatest work. Fresh fruits and vegetables could require only a short stroll through the “Produce Patch.” However, high fat steaks would need to be hunted, perhaps in a way akin to laser tag, requiring shooting a moving freezer to claim the elusive porterhouse. A craving for donuts would necessitate rock climbing a forty foot wall and Twinkies would oblige the shopper to face a fire breathing mechanical dragon armed only with a sword and a shield.
This very modest plan would fight obesity in several ways. The effort expended to successfully reach the desired food would burn off a considerable number of calories. Those individuals that are unable to put forth the necessary effort would have to forego their fried pork rinds or Ben and Jerry’s and be forced to diet or eat healthy, easily obtainable food.
This plan could solve not only the problem of obesity, but also food shortages in some countries as extra food would probably become available and could be shipped to those in need. A major healthcare issue also would be addressed and in the long term health care costs would go down. Such a modest change could reap benefits for decades.

Global Warming

New Data on Global Warming

An announcement issued today from the Environmental Protection Agency warned of a sudden spike in global warming. This phenomenon has been followed since January of this year. Intense research by the EPA in conjunction with the environmental studies dept at Wassa Matta U. has traced the source of this CO2 spike to Washington DC.
Apparently, increased emissions of carbon dioxide have been measured in the areas around the District of Columbia, southern Maryland and northern Virginia. The economic crisis, coupled with the US Congress’ attempts to reform health care along with cap and trade have led to unprecedented CO2 release from members of Congress and the Executive Branch. The excessive CO2 emissions have also coincided with a three hundred percent increase in hot air emanating from this region of the country.
An executive order was immediately issued from the Obama administration aimed at attacking this environmental hazard at its source. Starting November 1, 2009 there will be strict controls instituted to curb this CO2 release. The order states that Democrats will only be allowed to exhale on Mondays, Wednesdays and Fridays. Republicans will have exhalation rights on Tuesdays, Thursdays and Saturdays. Sundays have been deemed a day of rest and no exhalation will be allowed by members of congress from either party on this day.
An unnamed White House spokesman issued this statement, “The President realizes that this is a drastic step to take. However, the EPA has declared a state of emergency. There estimates are that these new regulations will not only slow the growth of global warming, but actually may allow the planet to cool by several degrees.” When questioned about the Executive Branch reducing its own release of greenhouse gasses the spokesman replied that steps had already been taken in this area. He reported “Although the President firmly believes that CO2 emissions from the Executive Branch have been within appropriate limits he still wants to show that he is doing all that he can. Consequently, he has taken steps to eliminate all carbon dioxide and hot air emissions from the Vice President.”
The newly released order was met with cheers from Wall Street where the Dow Jones immediately rose over 350 points. There was also loud applause heard in northern Alaska where large numbers of polar bears had gathered.
Reaction from Congress was swift. Both Democrats and Republicans condemned the order, calling it an end run around the constitution. A few thoughtful senators, however, stated that it was a wise decision and that they would make every effort to comply. They even went farther, stating that if the newly imposed regulations were effective they would consider drafting legislation that would apply to the many cable news and talk radio sources of excessive CO2 release. FOX News reacted by calling it a violation of the First Amendment. Stay tuned.

The Health Care Debate Part 2

The Healthcare Debate
The View from the Trenches, part 2

The last article I posted cast light upon the virtues of a single payer system for the delivery of health care to the people of our country. In the time since I wrote that article I’ve had the opportunity to discuss the matter further with many of my colleagues. Responses ranged from enthusiastic agreement to belligerent argument, with several variations in between.

The most commonly voiced objection to a single payer system is that “the government can’t manage anything.” I think there is evidence to the contrary, but the objection raises a very valid point. Reports out of Washington are daily reminders of the incredibly dysfunctional apparatus that is our federal government. An article written by a medical doctor who has been serving in our nation’s capital for the past year casts a bright light on this fact. Our representatives are bogged down in a quagmire of lobbyists, special interests, bloated staffs and insulation from their true employers, namely us.

Politics and perception overshadow careful analysis, scientific study and simple truth. It seems that few congressmen have the time or desire to study this issue from a truly objective vantage point. They glean their information from a bevy of special interests bent on preserving their own slice of the $2.4 trillion healthcare pie and ignore most of the facts that would allow a truly educated decision. In my last article many of these facts were presented.

But, assume for the moment that it is true that the government is not capable of properly administering a Medicare for all system. What is the answer? It seems to me that policy could start at the federal level and then be administered by private insurers. Certain minimum requirements would be mandated, including what and what is not covered, establish appropriate reimbursement for providers and set insurance premiums at a reasonable level. That sounds like a step towards rationing you might say; correctly. But it is no different than what occurs now everyday.

For example, a teenage boy comes to see me with a condition called gynecomastia. This means enlarged breasts in a male. The abnormality may be minor, barely noticeable or it may be a gross abnormality. Either way the unfortunate boy suffers terrible ridicule from his peers. The condition is easily remedied by a surgical procedure, subcutaneous mastectomy. Despite the potential psychological damage the boy may have to endure if the condition remains uncorrected, this procedure is almost never approved by insurance companies; they consider it cosmetic. The patient, his parents and I are left with a dilemma, how do we provide appropriate treatment for this teenager? If the family has resources they can pay out of pocket, probably $4-5000 for the outpatient surgery. I could lie to the insurance company and give them a diagnosis that they will cover, but I really don’t want to commit fraud. What I almost always do is take photos and send them to the insurance company, argue with the medical director at the insurance company, have the parents call the insurance company and after all this, once in a while, the surgery will be approved. In many instances I can find a way to take care of this patient, but sometimes the patient remains untreated.

Denials by health insurers are a daily occurrence and are the current form of rationing health care. It seems to me that any health care reform will have to draw the line somewhere. There certainly is no argument from anyone that a facelift or breast implants (except for reconstruction after cancer surgery) are cosmetic and should not be covered by insurance, just as no one would argue that removal of a cancerous portion of colon should not be covered. There are, however, numerous conditions like the one cited above that are in a gray zone. How they will be dealt with is one of the central issues to any reform proposal.

Having raised these points, what, then, is the answer? The answer lies in spending the healthcare dollar on healthcare. The previous article cited the very high administrative costs for private insurance under the current system. These costs would need to be eliminated and the savings redirected to actually providing care. A government sponsored health plan, one that people could purchase at true cost, should be developed. Health savings accounts coupled with high deductible insurance should be offered. These entities put the power of choice directly in the hands of the consumer and direct the healthcare dollar to patient care, not to administration. A plan such as this is what I have for myself and my family. I have a deductible of $5200, a heath savings account which can be accessed for smaller or uncovered incidents, but catastrophic insurance that pays 100% of costs after the deductible. This allows me to save money each year, but protects me at the same time.
A few other points need to be made. I see the health insurance industry licking their collective chops at the prospect of health care reform as it is currently being proposed. A mandate that 50 million individuals who currently do not have health insurance all of a sudden be covered presents an unexpected bonanza to all the Aetnas and United Healthcares out there in insurance land. Many of the uninsured are that way by choice, foregoing health insurance and playing Russian roulette with their health; many are healthy and rarely use the health care system. Adding these people to the rolls of the insured will put a large amount of money into the insurer’s pockets. I think policy should be that this money be used for health care and not for insurer’s profit. In particular, this windfall should be earmarked to help defray the costs of providing health care to the indigent and those for whom requiring health care coverage would be a great burden.

Health care reform should include relief for providers from frivolous malpractice claims. I am lucky to live in Texas where recently passed reforms have made our state one of the more attractive places to practice medicine. The reforms do not prevent meritorious suits from being filed, but have drastically reduced frivolous claims.

Finally, any reform should be a change in health insurance, not health care. Doctors, nurses, therapists and technicians all receive very thorough training and the overwhelming majority wants only the opportunity to take proper care of our patients and to return them to good health. We all work together towards this goal. Those doctors whose only motivation is earning money soon find themselves in trouble and out of work. There is talk of legislating “clinical, best practice guidelines” with the suggestion that providers that do not adhere to such guidelines face some penalties. However, good medical care cannot be legislated. It is taught in our medical and nursing schools, during internships and residencies and through years of hard work and experience. Every patient is a unique individual and most do not fit into the classic illustrations presented in our textbooks. Despite what one may read, doctors and all allied health professional do a pretty good job of policing themselves and this should be allowed to continue.

In conclusion, I think that any reform of health care insurance should allow the providers to continue to provide high quality care. Money earmarked for healthcare should be spent on the delivery of such care, not on administrative costs or profits. A properly and efficiently administered single payer plan is the most cost effective and efficient system, but any private company that can provide health care coverage within legislated guidelines should be allowed.

Let’s hope that our representatives in Congress can suddenly find the wisdom and fortitude to give us such a system.