An inspiration.

Sometimes in life we have the opportunity to meet someone special. I met someone special this past weekend. Actually, I had met her about 5 months ago, but this time, it became quite clear how special she is. 

I’d like to introduce you to her. Meet Sadie Desjardins.

Sadie and her favorite pig

Sadie lives in northern Maine, in a town called Ft. Kent. And I mean northern. You can literally see Canada from her house (no you can’t see Russia from there!) Sadie is 13. She lives a pretty normal life of a young teenager. She goes to the local movie theater (1 screen) and enjoys sports and hanging out with friends and family.

But what is really special about Sadie is what she is doing with her summer. You see, one of her hobbies is sewing. She uses her grandma’s sewing machine. Earlier this summer, she decided to design her own stuffed animals. She designed them completely on her own, without a pattern. There was a pig, an elephant, a bear and a cat. Each animal is different. Some have tutu’s some have different colored eyes, and pigs have different colored buttons as noses.

As soon as she made these, her mom realized how amazing they were and asked her if she wanted to make them for other people. In a split second, Sadie knew what she wanted to do.

She decided to make 50 stuffed animals as a summer project and then personally take them to Boston Children’s Hospital (an 8 hour drive!) and give them to the children there.

That’s a big project! Fortunately, the word got out around her town and one of the locals donated stuffing and material. Even so, her grandmother tells me that she often hears the sewing machine running late into the night and in the early morning hours. Undaunted by the magnitude of the task, she had 30 completed as of last weekend. Then she gave one away to a child she met who had lost her mother to brain cancer.

What is really amazing to me is the spirit that she embodies. She is working her entire summer on a project for other kids that she doesn’t know, just so she can bring a little bit of happiness to their lives. She is such an inspiration to me and I hope, to you too. If we could all have that same spirit of giving, the spirit of caring for others, the empathy for others going through a tough situation, this world would be a much better place,

So, Sadie, thanks for being that inspiration and for sharing your talent and your thoughtfulness.

The Golden Rule

Treat others as you would like others to treat you.

That is a very simple rule. I know I remember learning it from my grandmother. I couldn’t have been very old, probably preschool age. And it was probably in response to fighting with my brother. I’m sure most have you have learned this early in your life too.

I was reminded of the Golden Rule recently when I was talking to my son about how he should be treating his friends at school. As I was giving him examples of how the Golden Rule plays out in everyday life, I was surprised at the number of examples I could give. Unknowingly, I realized that I commonly do things in my daily life based on it.

I hold the door for people. I try to stop for pedestrians trying to cross the street outside the crosswalk. I say hello with a smile to people I see in the hallway. The list could go on. But, I generally try to do these things because I know I would like it if someone did them for me.

The next example I gave my son, was that I treat patients like I would want to be treated. This one, I am conscious about. I will commonly try to put myself in a patient’s position before I go into the room. Doing this helps me to relate better to their particular issue. After interviewing a patient, I may also learn new things that completely change my understanding of their problem. I will then alter a bit the way that I interact based on how I would want my doctor to respond.

For instance*, I was once sent a patient for evaluation of gallbladder disease. The emergency physician had noted a rise in liver enzymes, and a gallbladder that had thickened bile, or sludge as it is called. The patient also had frequent bouts of vomiting. The scenario seemed to make sense on the paperwork that I was sent. So, I went into the room expecting to book the patient for surgery. But the tip off to me was that the patient smelled of alcohol. So, I researched old labs and found that his liver enzymes have been elevated for years. A little more research showed another recent ultrasound that was perfectly normal. So, I began to delve into the alcohol questions.

As it turns out, he only has episodes of vomiting after binge drinking. And he never really has pain in his abdomen, except after vomiting a lot. It was clear now that this wasn’t gallbladder disease.

But, probably more important than the medical facts of this patient are the social ones. He was actually glad that I asked him about his drinking, and what he was doing about it. He was happy for me to encourage calling his sponsor and getting back to an AA meeting. He really knew all along that it wasn’t his gallbladder. He told me that by the end of the conversation. He just wanted me to listen and support him.

That’s how I would want to be treated.

Leave it to George Bernard Shaw to have a problem with the Golden Rule. He famously contorted his own version of the Golden Rule, which honestly, I don’t understand. Suffice it to say that his argument was that not everyone wants to be treated the way that you would want to be treated. I can accept that. Sometimes, the way I would want to be treated isn’t exactly what my patient wants. And in that way, it is good to realize that Shaw wasn’t all wrong in pointing out that subtlety. 

I think the real key is to understand this and try your best to meet the patient’s needs. After all, we all want our needs met. 

Whether we are in the school yard or the doctor’s office, treating others as we would want to be treated really is a Golden Rule.


*As always, the details are changed so as not to indicate a specific patient.

What to ask your surgeon. A List.

Visiting your surgeon to discuss an upcoming operation can be quite stressful. Because of this, if you don't go prepared, you may forget to ask important questions. Also if you don't go with a piece of paper and pen, you might also forget the answers to important questions.

I was recently asked to come up with a list of questions that patients should keep with them when they make this important visit to their surgeon. In her blog about the importance of making lists for nearly everything in your daily life, The List Producer is managing to help simplify our lives by keeping us organized. Below is the list that I developed along with some extra information on each question. I hope you find this useful in your next trip to your surgeon.

1. What is my diagnosis?

            Surprisingly, this very simple question is not asked very often. In order to truly understand your operation you absolutely need to know your diagnosis. This will help you to explain your problem to your family, friends and any other physicians that you might have.

2. What is the operation you are recommending?

            Again, it is important to know the specific name of the operation. This will be on your consent form as well. Most hospitals will also ask you this question at least once during your interview process on the day of surgery to be sure that you are familiar with what is being planned.

3. How many of these operations have you done?

            If your surgeon has not done a large number of the operation that he or she is planning, it is important to specifically ask if he or she is comfortable with performing the operation. It is also not inappropriate to ask if the operation could be done better by someone more experienced in this particular operation.

4. How long is the in-hospital recovery?

            This is often difficult to predict, especially with bigger operations. Usually the answer will be a range of days to expect inpatient hospitalization. You're operation may also be outpatient which may be same-day surgery or an overnight stay that does not exceed 24 hours. Again, it is important to set your expectations for which of these options will be occurring.

5. How long is the out of hospital recovery?

            Recovery means different things to different people. For some people it means how long until you are pain-free. For others it is how long until you can get back to normal activity. Be specific with your questions and ask these specific things when talking about recovery period

6. Will I need a transitional period with rehab or home nursing?

            For bigger operations this is often necessary. Also for the elderly or for people who start the operation in a debilitated state, a rehabilitation hospital or skilled nursing facility may be an appropriate transitional facility.

7. How long do you expect me to need prescription pain medication?

            Commonly, surgeons will prescribe narcotic pain medication for a limited period after which you may be required to see your primary care physician for further narcotic prescriptions. It is also common to try to transition from narcotic pain medication to anti-inflammatory medication or acetaminophen as quickly as possible after the operation. This will minimize the side effects of narcotic use.

8. How long should I take off of work?

            Again, this can be difficult to predict and is largely dependent on your pain tolerance and your specific job. It is always better to try to anticipate this before the operation and your employer will thank you for an appropriate heads up rather than being surprised when you ask for 2 weeks of sick leave following your operation.

9. What are the risks?

            This is an absolute must-ask question. Most consent forms will indicate that your surgeon has discussed the risks of the surgery with you. Be sure that this has happened. It is often scary to learn the worst case scenario, but it is always best to be well-informed.

10. Are there alternatives to this operation?

            There are often alternatives to an operation. These can be medical alternatives, such as treatment with a specific medication, or there can be alternative operations to treat the same disease. Presumably, your surgeon is recommending a specific operation for a reason instead of the alternative therapies. Find out what they are and what their advantages or disadvantages are.

11. Is it worthwhile to seek a second opinion?

Any good surgeon will never discourage this. For simple operations or straightforward decision-making this may not be necessary. But for complicated issues, or if you just don’t feel comfortable with what you are hearing, a second opinion may be right for you. You can always come back and schedule surgery with your original surgeon after your second opinion.

12. Who will oversee my care while I’m in the hospital?

            Will the surgeon see you, you will you be seen by the Nurse Practitioner or Physician Assistant? Or, will there be residents and interns seeing you? All of these are reasonable options, but it’s nice to know up front what to expect in the hospital.

13. Will there be residents operating on me?

This is fine, but it is good to know beforehand rather than be surprised at the group of 20-somethings at your bedside.

14. What do I need to look for after the operation in terms of infection and wound healing and will I need sutures or staples removed?

            This may be covered at the time of your discharge, but ask just in case. If there will be a wound to take care of, it is good to buy supplies now. You won’t feel like shopping after the operation.

I hope this list helps with preparing for the stress of an upcoming operation. As Louis Pasteur once said, “chance favors the prepared mind.”

List Producer blogs at http://www.listproducer.com/ and is on Twitter @ListProducer

Overcoming impossible situations

Surgery, like life, can have complex problems. Not too long ago I was operating on a patient who we all believed had a ruptured colon cancer. He was quite sick and I was operating on him emergently*. As I explored the abdomen, it began to have the appearance of something different. I honestly had no idea what we were dealing with. 

It was clear that whatever this was, it was involving the colon, the spleen, the stomach and the tail of the pancreas. The entire left upper quadrant of the abdomen was completely cased in hard inflammatory crud. I have no better medical term for it. Every organ was plastered to the adjacent organ.

At this point in the operation, I remembered the words of a sage mentor of mine, Dr. Jeffrey Pelton. “Chris,” he said. “You will, at a few points in your surgical career get into a situation, which at the outset, will seem insurmountable. You will open the abdomen and find a tumor or other problem, which at first, will look like it is completely inoperable. My advise to you is this. Don’t look at the problem like it is one big problem. Take it one step at a time. Use the surgical principle of going from ‘known to unknown’ and start somewhere easy. Go and take down that easy part of the tumor. If you get to a place where you are stuck, go to another part and go until you get stuck. Eventually, this big problem will turn into a series of little problems, which, by the end, you will have solved. It’s like a jigsaw puzzle. Take it a piece at a time and eventually, you will have it solved.”

That is precisely what I did. Start at the colon. Move to the spleen, then the stomach. Finally, tackle the pancreas. Three hours later, it was all cleaned out. All the pieces that needed to be put back together were together. And the tumor, a nasty lymphoma as it turned out, was out. The big problem was taken care of one step at a time. The operation was a success, and the patient has seen me in followup, tumor-free.

As it turns out, Dr. Pelton was right. I have used his advise on many occasions. I have even taught residents the same thing. Take the big problems one step at a time and you will overcome situations that seem impossible.

*as always, details of this patient are changed so as not to indicate any specific patient

The Back Story

In the movie Love and Other Drugs, Jake Gyllenhaal plays a drug rep for Viagra. At one point, he is forced to go to the emergency room after having taken Viagra, because of a rare side effect called priapism, or persistent painful erection. No doubt, this was one of the funnier parts of the movie.

As a physician, the way I would approach this patient would be much different than the way I acted as I watched this movie from my couch. Sure, its tempting to act the same way, laughing about the awkward situation. But, the reality of being a physician is that patients rely on you to be above that. If I was in that position as a patient, I would want a doctor who could see that I was in trouble and treat me like any other patient with an urgent problem.

What helps me to get into that mindset is to figure out what the patient’s story is. I call it the back story. Sure, it may be as simple as the movie’s recreational Viagra use. But maybe not. 

An 80-year-old man presented to the emergency room with priapism. The back story of this man is that he underwent radical prostatectomy for prostate cancer 15 years ago, leaving him with erectile dysfunction. Years went by with only frustrating sexual experiences. Finally, after much discussion with his urologist, he decided to try Levitra. The result, an embarrassing emergency room visit. This is hardly a laughing matter. He is not Jake Gyllenhaal’s character. He is a real human, with a frustrating disease, now suffering an embarrassing complication of his treatment.

Much of being a physician is understanding not just the disease process of the patient but also the setting in which this disease occurs. For example, two patients recently presented with similar abdominal pains. One of the patients had a sister that had recently died of colon cancer. My approach to the work-up of these two patients was similar, but the way that I talked to them was much different. I had to be cognizant of the emotional distress in the patient whose sister had just died. In that patient’s mind, this abdominal pain was surely cancer. And there was nothing that I could say or do to convince her otherwise until I proved that it wasn’t.

Everyone's back story is different. 

As a physician, learning and understanding that back story is part of your job. It helps you to empathize and it helps you to treat the person, not just the disease. As a human, having an appreciation for the back story is imperative for acceptance.

Many times, I have discussed with my children the importance of acceptance because we simply don't know someone's history. For example, my daughter once told me that a girl in her class was weird because when she got frustrated she would hit people or nearby objects. I cautioned her not to label people as weird for the same reason that I cannot laugh at a patient with priapism. You have no idea what someone has been through or what has gotten them to this point. In the case of my daughter’s classmate, I knew that this girl lived in a household where her parents’ frustration would often lead to hitting and physical abuse. The child's behavior made sense. It is what she learned as the “normal” response to frustration. Seeing her back story suddenly made what seemed like weird outbursts understandable. 

This type of open-mindedness is critical to understanding people. Acceptance of people will not occur without it. The same is true with patients. If you approach the patient with the underlying knowledge that there is a back story which explains much of who they are, empathy and good judgment will follow.

Understanding the back story makes people real. Understanding the back story makes you a good physician, not just a person laughing at a movie character. And, with that knowledge, empathy and professionalism will go hand in hand.

Life is hard, Part 2

In my previous post, I discussed that by accepting that life is difficult, we have taken the first step to preparing ourselves for those difficult times. 

This is not a new concept. In fact, the first of the “Four Noble Truths” that Buddha taught is that “Life is Suffering.”

The Myth of Sisyphus is an essay by French philosopher Albert Camus. It analyzes the Greek myth of Sisyphus who was condemned to the underworld to roll a giant boulder up hill, only to have it roll back down and for him to start again. At the outset, all of us would think of this as the ultimate punishment. It would seem as if you could never reach a state of contentment. However, Camus argues that one could imagine Sisyphus happy. How could that be? He suggests that Sisyphus was able to find happiness only after he acknowledged the futility of his task. After that, he was freed to reach a state of contented acceptance.

Really? Happiness?

His task is not much different than the series of tasks that we all face in life.  We all have difficult tasks, whether it is in our jobs, our family, or simply our home life. We work hard to get these tasks done, and before long, there is a new task at hand. Just because our lives are taken up by a series of difficult tasks, is that a reason for despair? Are we to think of ourselves as condemned to the underworld? I think not.

Happiness is achieved by taking pride in the accomplishments of our individual achievements. Conversely, happiness is hard to find if all we do is focus on the fact that we have a lot of work ahead of us. In fact, it can be overwhelming to think of all the projects that need to be accomplished. There seems to be an infinite number of boulders to roll up the hill. In fact, there probably are. But, acceptance of that fact helps us to move on to something more important, which is doing a good job, and finding happiness at our current task. 

I like to think that Sisyphus focused on pushing the boulder up the hill each time like it was a new task. He could take pride in looking at the boulder sitting at the top of the hill. And by thinking this way, he was able to find happiness in a situation that seems awful.

Noted sculptor Donald Gialanella* was commissioned to sculpt an interpretation of the myth of Sisyphus, seen here. 

In it, Sisyphus is depicted holding a chain, in a never ending effort to hold up four solid granite slabs. Sisyphus must be proud to demonstrate that he is so strong that they never move. In the metaphorical sense, he is not really holding up the slabs. No, they are holding him up.


*http://www.donsculpture.com/

Life is hard

Surgery is hard. Of course there are always technical aspects which are difficult but I am speaking of something completely different. I think most surgeons will tell you that one of the hardest parts of their job is telling the patient and his or her family bad news. Certainly other specialties have this same issue. But somehow, taking a patient to surgery is usually viewed as a major, invasive step toward improving their lives. It is an aggressive intervention which at its heart, is designed to result in immediate gratification.

For instance, most patients with colon cancer go into the operating room with a tumor and leave the operating room an hour or two later without a tumor.  With or without the use of additional chemotherapy, they may be cured. However, if this scenario doesn't happen, it can be anxiety producing at best.

Not long ago I had a patient present with what appeared to be a “routine” colon tumor. At the time of exploration the patient was found to have tumor widely spread throughout the abdomen and was unfortunately completely incurable.* From a technical aspect, this operation was not hard. I removed the tumor in order to prevent intestinal blockage and sampled the tumor throughout her abdomen for microscopic diagnosis. Nothing there was technically difficult.

The difficult part of the operation came next. That was telling her friends and family the news. As it turned out, the patient had only recently gotten out of a 35-year abusive relationship, and the hope prior to this surgery was that she could live the rest of her life in peace. All that had changed now. The rest of her life would be spent with increased abdominal bloating as this tumor progressed, possibly toxic chemotherapy, and getting her affairs in order for her untimely death. The prognosis was months, not years, and months of pain, not happiness.

It's a terrible, sad situation. To somehow see hope or goodness in this is difficult. But, life is difficult and inherently, we all know that. It just sometimes takes situations such as this to make us remember that.

I find that as I get older, and hopefully wiser, I deal with these situations a little easier because I approach them with the underlying understanding that yes, life is hard. There are times in everyone's lives when we will experience pain, sorrow and sadness. Without that we would not be human. Without that, we would not know happiness. And, without that, we would not be real.

Life is hard. Approaching life with this attitude doesn't make sad times any less sad. But it does normalize it. And in some way, it helps me to put everything in perspective.

*some patient details are changed so as not to identify a specific patient

Pushing the Envelope, Part II. Life's Lessons

In my previous post, I commented about the need to push the envelope of surgical technique to continue advancement of the discipline of surgery. This is the argument against complacency. For complacency does not lead to advancement but to stagnation.


Life is not different. Like surgeons with careers of simply doing what they know, the rest of the world is equally full of people who keep the status quo. On the surface, these people may live very successful lives. But, where would we be if that is all we had? If we had no-one who pushed the envelope?


Examples of people who have pushed the envelope are easy. These are people who have gone beyond what might be expected in their respective careers. Take Bill Clinton. He could have stopped after leaving office. Certainly, after 8 years, he could have used a break. Instead, he started the Clinton Global Initiative. This organization convenes global leaders to devise and implement innovative solutions to some of the world's most pressing challenges. Impressive. Or how about Richard Saul Wurman, an author who founded TED (Technology/Entertainment/Design) conferences. TED now represents a global partnership of forward thinkers whose goal is to spread new ideas to change attitudes, lives and ultimately, the world. In short, they inspire people to push the envelope. Or, Lance Armstrong. Like him or not, doper or not, he has changed the face of surviving cancer.


My list could go on and on. There are surely millions who could be named. But we all know that the list of those of us who are complacent is a bigger one. Why?


One of my best classes in college was a philosophy class called "Man's quest for meaning." It included a diverse reading list, or seemingly so. But, as I delved into the underlying themes in each book, they all started to sound the same. The common theme was that people who are genuinely happy are those that dedicate themselves to a singular goal. And through that dedication to a higher goal, they find that they can in fact go beyond what would be expected.


Which brings us back to pushing the envelope. I believe that for us to progress as a society, we need to push the envelope, and encourage others to do the same. Whether it is in your job, in your hobby, or in being a good parent, spouse or friend, going beyond what might be expected will ultimately advance us to a higher purpose. And, happiness is sure to follow.

Pushing the Envelope

Complacency is extraordinarily common in every line of work. This is no different in surgery. Surgeons will commonly learn new techniques only after they have been widely published with prospective randomized placebo controlled trials. Less often, they will learn new techniques if there is a public demand. And even less commonly, surgeons will learn new techniques simply because they push the envelope of surgical technology.

A great example of this is SILS, or single incision laparoscopic surgery. This technique utilizes the same instrumentation and essentially the same operative technique as traditional laparoscopic surgery but it does so through one incision site which is hidden inside the belly button. As a result, patients get a virtually scar-less operation. This technique is being slowly adopted throughout the United States.

Surgeons are commonly reluctant to learn this new technique because it achieves only cosmetic improvement and makes fairly simple operations slightly more time-consuming and certainly more difficult. I learned this technique almost 3 years ago and immediately began to adopt this in my practice. Admittedly, it was a steep learning curve and no doubt added some extra time to my operations. However, as my technique improved, operative times decreased to roughly the same as traditional laparoscopic surgery.

Interestingly, I have noticed an added benefit. By pushing the envelope and forcing myself out of my comfort zone, I have become a markedly better technical surgeon. In all aspects of my laparoscopic surgical technique I have noticed better conservation of motion (a technical quality of no wasted movement; more efficient) and much improved surgical technique.

It is important to note that many surgeons will never learn this technique and will still have excellent outcomes and excellent patient satisfaction. So why would one want to do this? I propose two reasons.

First, I have come to realize that pushing the envelope and putting yourself outside of your comfort zone to learn new techniques is really an integral part of being a good surgeon. Without learning this technique, my skills would not have advanced as they have. I am convinced that my patients all benefit from this regardless of the operation they are getting.

Secondly, it contributes to the advancement of surgical care not only by improving one's general operative techniques but by pressuring technology to improve. Already, we have seen integration of single incision surgery and robotics and without the push towards the single incision movement this may not have been realized as quickly.

Currently, this technique is usually applied to the more routine operations, such as gallbladder and appendix removal. But, given the speed of technological innovation, it is reasonable to imagine most major abdominal operations being performed through one very small incision in the abdominal wall, and probably by robots with extremely small but versatile instrumentation. 

However, for this to happen, surgeons need to continue to push the envelope in not only their operative technique but also their forward thinking.

My opening remarks prior to a Cancer Benefit walk...

“Here’s looking at you.” We all know that great line from Humphrey Bogart to Ingrid Bergman in Casablanca. I tend to remember interesting lines from movies. How about “You can’t handle the truth.” That was Jack Nicholson yelling at Tom Cruise in A Few Good Men. Or how About this one. “Cancer.”

That's a bit more obscure. It was Judd Nelson talking to Alley Sheedy in an old favorite of mine called St Elmo’s Fire. In it, he said there are a few words that are just too awful to say out loud, so, you have to whisper them. Like, Mrs Smith has “cancer.” I thought that was pretty funny, and probably used that line a few times.

About ten years after that movie came out, I got that phone call that many of you here can relate to. It was my Dad. “Chris, I have cancer. Prostate cancer.” He didn’t whisper it.

Immediately the line “you can’t handle the truth” came to mind. How can my Dad have cancer? That can’t be right. But, it was.

After the initial shock, we talked frankly about it and planned our attack on it. And thanks to the great care of the doctors at Ohio State, he is still around to talk about it. That was 14 years ago.

Oddly, it was ten years after that phone call that got another call. This time it was my brother. “Chris," he said. "I have cancer. Prostate cancer." He didn’t whisper it either. Again, we talked, planned and called the docs at Ohio State. He too is cancer free to this day.

I don’t whisper the word cancer anymore. Because cancer is not about to go away if we shy away from it. It is a fact of life. A fact that all of you here are intimately familiar with.  We have all, in one way or another learned to handle the truth. The truth that cancer affects so many of us. The truth that cancer kills. The truth that cancer affects not only the lives of the people with cancer but the lives of all of their friends and family.

But, part of handling the truth is acceptance, and part of acceptance is learning that we can’t whisper the word cancer. We need to fight it. We have learned to fight by supporting programs that encourage early screening. We support research for better treatments. We support agencies that are there for the emotional and financial support of those families going through cancer. And, we simply provide our own personal support for those that we know that are going through it. It takes that sense of community to help us beat cancer and that is why we are all here today. We have learned to handle the truth. We don’t whisper the word cancer.

Here’s lookin at you.

POSTED AUGUST 2, 2010

• 0 responses
• Comment