Tuesday, April 18, 2006

Big Mama's Waiting Room....
Without Martin Lawrence, thankfully. Grand Rounds Vol 2 No. 30 hosted by the Fat Doctor.

Sunday, April 16, 2006

Don't Steal this Book...
Buy it. If you are a surgeon, planning to become one, or are just close to one I highly recommend the surgical memoir of Dr. Sidney Schwab: Cutting Remarks : Insights and Recollections of a Surgeon Dr. Schwab describes his experiences as a surgical trainee at the University of California San Francisco in the early 1970's, as well as his tour of duty in Vietnam. I read this book over a day and a half, I just couldn't put it down. Dr. Schwab tells of training under such surgical greats such as Dr. William Blaisdell, Dr. Ted Schrock and Dr. Donald Trunkey. He brings home the lesson that all residents learn, that residency serves not only to teach you how to do things, but also how not to do things. While names are changed to "protect the innocent" Dr. Schwab pulls no punches in his criticisms of attendings that were incompetent or dangerous: "cursed to live in surgeons bodies, but unable to find the control panel". While this takes place at the same time as The House of God it does differ in many ways. While the House of God takes a dark view of residency training, wondering if the year was worth it, Dr. Schwab describes a grueling training experience but in the end he finds it all worthwhile. Also, not everyone is having sex with each other all the time (that is thankfully reserved for Gray's Anatomy). Surgical decision-making is succinctly examined:
Surgeons may have brass balls but not crystal ones.
Dr. Schwab provides an excellent description of the difference between a "great" surgeon and a "good" surgeon:
Being a great surgeon is not about having fast hands or making flashy moves. It's about knowing exactly what you want to accomplish And doing it without wasted motion. Knowing the right thing to do and doing it right the first time (rarely can a second attempt be executed without exacting a toll on the patient). Anticipating, adjusting. Understanding and being able to find the precise layers and planes between tissues and working within them. Many surgeons don't. I had a teacher in high school, the baseball coach, who liked to say that the best outfielder was the one making the easy catch. He knows the game situation, watches the catcher set up, sees the signs, figures where he needs to be. You can't avoid all circus catches, but they ought to be rare. Surgery is the same. You admire the surgeon who stops the bleeding, gets out of the tight spot, stays at the bedside in the ICU. I do, too. More, I admire the one who knows how to avoid all that stuff in the first place. A great surgeon makes it look easy. But because the body is resilient, because it will heal itself given half a chance, it mostly doesn't matter. Good enough is good enough, great is largely wasted. When the bandage goes on you likely won't be able to tell if your hernia was repaired or your colon resected in a beautiful way, displaying anatomy cleanly and apposing tissues artfully or just adequately. You'll be fine either way. But take several hundred patients, or a few very sick ones with no physiologic reserve, and over time you'll see a divergence.
I could not agree more. Go read it, and enjoy.

Friday, April 14, 2006

Overdue Summary....
Sorry for the long pause.
The 2006 edition of Trauma and Critical Care in Las Vegas was probably the best permeation of that meeting that I have attended. The lectures and panel discussions were excellent. One session was held on difficult surgical exposures (subclavian vessels, esophagus) and I will be able to apply the lessons learned to my patients. Another session dealt with disasters. Dr.Karim Brohi who moderates the trauma.org listserv discussed the responses to the London subway bombing from the unique perspective of someone who was there. Dr. Norman McSwain and Dr. Scott Norwood described the aftermath from Katrina from New Orleans and Baton Rouge. And as usual the case presentation discussion provided insight as to how the "big dogs" in the field handle things.
And occasionally the subject of the 80-hour workweek came up. My esteemed colleague to the west nonwithstanding, the limits, with one exception, were warmly received and were thought to be "overdue". Perhaps this is due to the "trauma/emergency surgery" or "surgical hospitalist" model that many of these physicians practice under at their facilities. The only objection came from Dr. Mattox himself, expressing concerns over the increasing "tradesman" mentality that was creeping in. With the commoditization of medical care that has occurred, I can't be surprised if the physicians begin to act like commodities.
Anyway, I am giving some serious consideration to an alteration of my career pathway. I am discussing with the various stakeholders about taking a year to go and do a trauma/critical care fellowship. My reasons include a desire to improve myself professionally and the desire to take my local program to the "next level", goals which would be easier to accomplish with the additional training and exposure. I also believe that I can get myself and my program taken more seriously if I go through with it. I am also unfortunately "falling out of love" with general surgery and would be happier limiting my practice. I would be a "non-traditional" fellow for the most part, but not too much. I'll keep you updated as the process continues, or doesn't, as the case may be.

Tuesday, April 04, 2006

Excellent Flow of Posts....
Grand Rounds Vol. II No. 28 today at Urostream.
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