Balls and Walnuts
more than you ever wanted to know
Category Archives: The Barbarous Craft
Hands-off medicine
Bend over, I need to check your doody.
My Sis was bemoaning the fact that all her new internist did was listen to her heart, look in her ears, and check her throat. Frankly, I’m surprised she did that much. My last three docs (always changing docs because we’re always MOVING, go figure) reviewed my meds, checked my BP, and asked what drugs I needed refilled. End of story. Do you think my wife, who actually has some trouble, gets a closer look? Not really. They like to tap out her reflexes.
Notwithstanding the countless texts written in the 19th and 20th centuries predicated on the value of physical diagnosis (Zachary Cope’s Early Diagnosis of the Acute Abdomen comes to mind, for one), one could make an argument that an internist’s job nowadays breaks down to algorithms crunching raw data: patient’s age? sex? family history? smoker y/n? drinker y/n? list of medications? and so forth. Turned fifty, let me send you for a colonoscopy. Eighteen months since your last mammogram, ooh, you’re overdue for another. Same goes for that pap smear. Not taking baby aspirin, well, take a baby aspirin.
I’m not an internist. I’m a surgeon. I practice physical examination and physical diagnosis with each and every patient I see. I’d be lost without my hands and eyes. Since I’m not an internist, you could argue I have no business criticizing them. And I don’t, and I’m not. What I want is to draw attention to the perception that internists are data crunchers who no longer practice the laying on of hands.
If we notice it, others will, too. Health care administrators, health insurance executives, health care policy wonks and politicians will notice. And what happens when these folks decide that the internist’s job can be replaced by a fairly unsophisticated computer program?
I do think that internists, most of them, bring a lot more to the exam table than would a computer program. I suspect they could argue very well for the necessity of their existence. But one thing I’ve learned in medicine these past 25 years: we doctors have little control over our own destinies. Bureaucrats have done a tidy job altering our professional lives to suit their fancies.
So doesn’t it seem logical that internists should strive to win the perception war before someone without an MD or DO after his name tries to debate them out of existence?
D.
Working on becoming the world’s youngest laryngectomy patient?
Toddler down to 15 cigarettes per day.
That links to a video of a rather chunky three-year-old (by my guess) puffing like a veteran. As docs, we regularly take a smoking history from our patients. Do you use tobacco? Smoke, chew . . . which? How much? When did you start?
This all translates into a metric, the “pack-years” logged by the patient. The earlier you start and the more you smoke, the higher your pack-years. All of us remember our record-holder. Mine was 120. How does a sixty-something guy log 120 pack-years? By starting at age five and averaging two to three packs per day.
How does this happen? Uncles, grandparents, sometimes even parents give the kid a cigarette — you know, because it’s cute. And we’re talking about nicotine, one of the most (if not THE most) addictive substance known to humankind, more addictive than heroin or cocaine. Doesn’t make much work to turn the kid into a coffin nail junkie.
These kids, they’d probably be doing themselves less damage swigging 40-ounce bottles of malt liquor. And they’d look much cuter doing it, too.
The things we do to our kids . . .
D.
This must be some kind of mitzvah. How do you say cockroach in Hebrew?
I got my patient in ASAP. You’d want to get in ASAP too if you had something crawling in your ear. I expected to find the usual cockroach, and indeed, my patient did not disappoint. But it was more than a cockroach.
It was Cockroach Plus.
Uh oh theca.
Cockroach plus ootheca, to be exact — an egg case. This was a female caught embarazada. Knocked up. Up the duff. On stork watch. Wearing the apron high. In the pudding club. Eating for 48.
And she was desperately trying to fulfill her Darwinian destiny in her last moments on Earth.
By the way, the egg case pictured above belongs to a Madagascar hissing cockroach, a beastie we used to breed in days of yore. And if you had one of them in your ears, you’d really have something to worry about.
Don’t know why Cockroach Plus should be so much more disturbing than Just Plain Roach, but it was. But hey, I’m a professional. I squirted some lidocaine down the ear canal (paralyzing and more or less killing the critter) and removed it piecemeal with suction and alligator forceps. End result, one happy patient who took the roach-bits home wrapped in gauze. So who knows, perhaps that egg case will find a happy home after all.
I told Karen all about it. She wanted to know, why didn’t it just back out?
“They can’t back out. Didn’t you know that? Don’t you remember the earwig episode on Night Gallery? They have to eat their way through to the other side.”
“Oh. Night Gallery. That’s your authority on this, huh?”
Yup, that’s my story, and I’m sticking to it. If it weren’t for me, the she-roach would have eaten it’s way through, laying eggs en route to the other side. Hey! I just remembered, there is a phrase for this in Hebrew — pikuach nefesh.
To save a life.
D.
You Don’t Know Jack
Believe it or not, in med school we did receive instruction in medical ethics. Our teacher was a minister, if I remember correctly, but he usually did not have much of a judaeochristian bias — at least, none that I could detect at the time. One day, he talked to us about euthanasia, and while sympathetic to the cause of euthanasia’s proponents, he felt certain that doctors had no business practicing euthanasia. “We need another professional specialty altogether,” he said. “Call them thanatologists.”
The two things I remember from that moment: the uncannily bright grin of one of my classmates, a fellow we’d nicknamed Mickie Mouse for his uncannily bright grins, and who would eventually go into psychiatry; it was as if the clouds had parted and he had looked upon the face of God. Like he had found his home. Sometimes I wonder what he’s up to*.
The other thing I recall: a loud and persistent thought. Why isn’t this our domain? It’s all a matter of how you view doctors. If our role is to keep people alive, then yes, euthanasia is a clear conflict of interest. But if our role is to relieve pain and suffering, then euthanasia should be part of the job.
About this time, the late 1980s, Jack Kevorkian was just getting started in his role as “death counselor,” soon to be death facilitator, eventually to be known to the media as Dr. Death. The media loved to portray the man as a ghoul. Sometimes I suspect that he reveled in this caricature; his artwork, which could best be described as “fitting for the Night Gallery,” would do nothing to destroy this image.
Knowing Time Magazine, I wouldn't be surprised if they had picked murderer.
While Kevorkian initially acted as a facilitator, he ceaselessly pushed the envelope. As long as he served as facilitator and not prime actor, he was judicially unscathed, thanks to the craft of lawyer Geoffrey Fieger and the sympathies of the juries. (When people are forced to confront the prospect of their own deaths, few would not want the option of a painless passing.) But when he himself administered the euthanasia drug to an ALS patient and then arranged for the videotape to be broadcast on 60 Minutes, the D.A. went after him. Kevorkian unfortunately represented himself in this case, and was ultimately convicted of second degree murder. He was ultimately paroled in 2007 after a little over 8 years in prison.
You Don’t Know Jack (HBO) is a wonderful bit of docudrama, not to be missed. Susan Sarandon stars as Hemlock Society member Janet Good, John Goodman as Kevorkian’s friend and assistant Neal Nicol, and Al Pacino plays Kevorkian himself. And while I like Pacino in just about anything he does, I have to admit that lately, Pacino plays Pacino and it’s rare to see him play anyone else. But in You Don’t Know Jack, Pacino lives and breathes Kevorkian. If you’ve ever watched Kevorkian on TV (and if you haven’t, I’d be surprised if he isn’t well represented on YouTube), you’ll find the resemblance striking. Also remarkable casting: Danny Huston as lawyer Geoffrey Fieger. I had to google “Geoffrey Fieger” to make sure he wasn’t playing himself.
I can’t praise this one enough, people. It’s a thoughtful, albeit biased analysis of the issue of doctor-assisted suicide. If you’re looking for a character in this film who can provide a cogent argument against euthanasia, keep looking**. Much like its subject, the movie has an agenda. But it was entertaining, too — funny, poignant, and above all a showcase of terrific acting.
D.
*Ach, what a disappointment. Just googled the man. He’s a successful molecular biologist at U of Chicago . . . not a thanatologist.
**Really, the only argument that comes close to being persuasive is the possibility for abuse by next of kin; but abuse to the point of death can occur in many and varied ways, from neglect to outright physical harm, and the law is there, ready to punish the offender. Euthanasia, since it is such a public act — it must ultimately pass muster with a coroner, I would think — could be easily regulated to greatly reduce the possibility of such misuse.