The Tebowing Neurosurgeon

So, after successfully matching and a relatively awesome weekend, things are starting to calm down a bit and I’m hoping to blog a bit more. (I have said this before …)

The Atlantic recently ran a piece about a neurosurgeon who “2-Corinthianed” an atheistic patient before taking him to the OR, dropping a lot of “jesus-this” and “christ-that”. The post concludes “It was wrong for that neurosurgeon to preach at his patient’s bedside without first inquiring about his patient’s spirituality.” To me this seems like much ado about nothing.

I have several very religious (non-physician) friends who have explicitly told me that they will pray for me (for instance, during the match week) or for my family. Frankly, even though we don’t share common religious beliefs, I don’t mind. They are going to pray anyway, and for them, prayer is one expression of love and friendship, so hey – I send flowers, they talk to JC. I’m grateful to them for that expression of friendship. For what it’s worth, apparently the professor had a similarly bemused reaction.

I have only been on the receiving end of requests for prayer, which I accepted even though the patients often said things that I don’t theologically agree with. While I tell the patients that I’m happy for any help that I can get, the truth is that I agree to these requests solely out of respect for the patient and because their spiritual and mental strength may have some positive effect on their outcome. Lastly, (given that the patient and I have made the decision to have an operation) anything that will steady their nerves on the day is a win-win.

I do think that in a perfect world of rainbows and unicorns, the neurosurgeon could have developed a better routine for this situation. One might imagine a perfect surgeon saying something like “Faith is an important part of my life and I pray several times each day. I am going to pray now and you are welcome to join me.” followed by a short pause to allow objections, followed by the prayer du jour.

Although I think that there could be some grossly overbearing theists out there, for the most part I find these gestures to be benign. It is not my personal style to Tebow at the bedside, but I think we have bigger things to worry about in healthcare than these well-intentioned gestures of faith. Maybe an aspiring Christopher Hitchens out there can comment and disagree, but given that our life and time is finite, I would rather invest in better communication in counseling patients regarding indications for surgery, risks, benefits and alternatives, rather than prayer styles.

If I’m ever on the other side and a physician wants to “2-Corinthians” me, I would nod, smile, and be grateful for their well wishes.

YES!

More to follow …

8 Days

(Not So Brief) Book Review: Catastrophic Care

One of the most fascinating books I have read, “Catastrophic Care: American Healthcare Killed My Father” (http://www.amazon.com/Catastrophic-Care-American-Health-Father/dp/0307961540) offers no answer to its central question of how to save the lives of hundreds of thousands of Americans who die each year of “iatrogenic” causes. Instead, in a long, repetitive and begrudingly persuasive diatribe, it offers a sensible economic solution to our health care crisis while steadily losing sight of its ostensible raisôn d’ètre.

For me, Goldhill’s persuasive hook was that health insurance is not insurance in the traditional sense of the term insurance. It does not seek to spread risk of rare events across a large population. In a world which has medicalized human existence from cradle to grave, it is not a rarity but a certainty that we will rack up huge hospital bills somewhere along the way. The only question is when – not whether – six figure bills will be thrown our way. Health insurance purports to protect us from those oscillations. .

Lost in the shuffle, somehow, is any evidence that market-based reforms can improve quality and outcomes. Ironically, for a book motivated by the death of his father due to medical error, Goldhill offers slim evidence that increased marketplace competition will reduce medical errors. One need only to read the newspaper for a few days (or go to a store or restaurant) to note the alarming rate of errors made even in the most competitive marketplace segments. Now, one might argue that the marketplaces disciplines those actors over time, and that might be true, but I would like to see some evidence before believing that claim.

Also lost in the shuffle is the evidence that many physicians are motivated by pecuniary gain. In the training and practice environments that I am familiar with, financial considerations are minimized. Granted, I don’t work at a private institution and have never trained at one (few training programs are based at for-profit hospitals, for obvious reasons). And while “efficiency” and profit concerns are always present in the background, I have not yet seen a treatment performed or not for financial reasons.

And what would a more blatant capitalist system look like? As a model, I propose the only market-based physician I am aware of, Dr. Mehmet Oz. A recent fantastic article by one of my favorite nonfiction authors, Michael Specter, in the New Yorker showed a fascinatingly terrifying glimpse into this world (
http://www.newyorker.com/reporting/2013/02/04/130204fa_fact_specter
).

For instance, in neurosurgery, one of the core competitive areas is the treatment of intracranial aneurysms. Thanks to a few clinical trials in the early 2000’s, most people believe that endovascular therapy (treating aneurysms using wires threaded through the blood vessels) is superior to open brain surgery if endovascular therapy is deemed possible, except in a few specific conditions. Having spent a good bit of time around cerebrovascular surgeons, I can say that the biggest determinant is the opinion of the open surgeon vs. the interventionalist – and while financial considerations don’t exactly get into play openly, I am sure that job security is always present in the back of the surgeon and interventionalist’s minds when they compete/bargain for cases. I’m not sure that the open competition, though, is really best for patients since both sides push the limits of their technology and skills.

Anyhow, this post is now 300 words longer than “brief” – so I’ll wrap up by saying that the book is well written and a worthy read for anyone who will participate in health care as a physician or patient, and I strongly recommend it.

Wow, it’s January.

Interview season has finished. Look for more posts in the days and weeks to come.

At this point, all I can say is that I’ve interviewed broadly, at almost everywhere I wanted to interview, and the rest is up to the robots who run the match (and human politics).

Congratulations to all of those who will be training in Urology and Ophthalmology (YES! I SPELLED IT RIGHT THE FIRST TIME!) – and best of luck to those who are taking a longer path to those fields.

Rank lists for the regular NRMP match are due 2/20 and the fateful days are 3/11 (when we find out if we matched) and 3/15 (when we find out where). Thoughts & prayers appreciated.

Monthly Interview Trail Update and Musings

Interview Status:

63 Applications Sent

37 Invitations (2 complete, 28 scheduled, 7 unable to schedule)

6 Pending (programs who have not yet sent any invites)

2 Waitlists

4 Rejections

14 Pending (invites sent to others but I have received no response)

Mostly, I’ve managed to schedule my interviews on three two-week swings, one each in November, December and January, with breaks interspersed.

Overall I think the system is shockingly inefficient. Programs often choose one or two dates, which commonly conflict with each other, forcing candidates to choose between several similarly desired programs. This is bad both for programs (because applicants cancel at the last minute and because programs don’t get as many desirable applicants due to scheduling) and for applicants (since they cannot interview at all the programs where they have been invited).

The system could be improved by strongly suggesting that programs to coordinate their dates (e.g. via a central SNS calendar). There are ~100 programs: if each program wants 3 dates, then there could be 300 possible dates. Ideally a central schedule ensure that the same tiers/locations of programs don’t conflict at every opportunity, and that programs in a single location had contiguous interview dates to minimize airplane travel costs (in terms of time, money and fatigue on applicants).

Additionally, interview days are often too long and involve many faculty asking similar questions. I’m not sure what the programs gain from having the program director, multiple senior faculty, and multiple junior faculty speaking with candidates in a (seemingly) uncoordinated fashion. At smaller programs, admittedly, I understand the desire to have every faculty member interview every resident. Applicants *could* gain a lot from speaking with all of these faculty, but the reality is that at most an applicant might get to ask a single question or two since the interviewer (rightly) controls most of the conversation. I often try very gently and tactfully to tie the end of my interview answers with questions for the interviewer, but this works more often in theory than practice. It’s also very difficult to ask most of the questions you really want to ask during a structured interview.

I actually liked the UK system where (as I understand it from speaking with one of the consultants/attendings) there is a more centralized and more practical interview attended by all of the departments (think NFL combine), followed by interviews with each program.

There are some logistical difficulties in translating that system into the larger world of US Neurosurgery with 100 programs and 200-300 applicants, but if the NFL can do it with their pre-draft Combine then so can we. I’m envisioning a one week process with 2 days of knowledge and skills testing, followed by invitations for a further 5 days of interviews with faculty from the program at a centralized location. If the individual school interviews were 2 hours each, one could easily accommodate up to 20 program interviews per applicant in addition to the “combine” testing.

Applicants would then be able to travel to programs of their choice for visits that are more akin to current “second look” visits where they get a better behind-the-scenes glimpse of the programs. Of course, if a program or an applicant wanted to have more than the 20 interview slots available, they could schedule those during their visit.

You are all invited to comment on how terrible this system would be and why my idea sucks.

 

In the event that you haven’t seen …

And, here’s a little JDS for you, easily translatable to surgery (one of my favorite blog posts of all time, particularly when I start to feel a bit lost):

You won’t be asked if you were working on a wonderful, moving piece when you die. You won’t be asked if it was long or short, sad or funny, published or unpublished. You won’t be asked if you were in good or bad form while you were working on it. You won’t even be asked if it was the one piece of writing you would have been working on if you had known your time would be up when it was finished—I’m so sure you only get asked two questions. Where all of your stars out? Where you busy writing your heart out?

If you only knew how easy it would be for you to say yes to both of those questions. if only you’d remember before you ever sit down to write that you’ve been a reader long before you were ever a writer. you simply fix that fact in your mind, then sit very still and ask yourself, as a reader, what piece of writing in all the world Buddy Glass would most want to read if he had his heart’s choice. The next step is terrible but so simple I can hardly believe it as I write it. You just sit down shamelessly and write the thing yourself. I won’t even underline that. It’s too important to be underlined.