The Mind of a Surgeon

(and yup, that ones actually me - in my lead suit to protect me from x-rays! - can you tell I'm smiling?) 

today in the OR I was talking with the PA who was first assisting about the Whipple procedure we (really she and the attending) were working on.  A Whipple is a procedure most often done for pancreatic cancer, but because the pancreas is sort of hidden within all the folds of the intestines it's often hard to see on imaging and therefore hard to figure out if there is a tumor there.  This means that in the beginning-middle of the procedure, the surgeon takes biopsies of the pancreas and sends them to the lab to be quickly assessed by a pathologist.  This usually takes anywhere from 10-20 minutes and then the pathologist calls the OR and tells the surgeon: cancer or not cancer (and a few more details).  This pathology report along with the surgeon's own view of that patient's abdomen (to see how far the cancer has spread, if there is any) determine if the operation will continue.  

so anyways, while the surgeon was on the phone talking with the pathologist, I asked the PA what we would do differently if the biopsy came back negative for cancer. Our suspicion of cancer was high in this particular patient and I was really wondering if we would a) do more biopsies to see if we just missed the cancer, b) proceed with the operation anyways because we were pretty sure he had cancer and NOT treating pancreatic cancer has a <1year survival prognosis, or c) wait and not do the procedure because of the risks.  

she said she didn't know.  That even though she knew the technique of the procedure and had done it many times, she had no clue about the clinical decision-making involved and didn't seem very curious about it.  So I asked the surgeon who explained the intricacies of how we decide what to do - and how sometimes it's each of the decisions above, depending on the patient and the cancer.  Which is when I realized, that's why I went to medical school (and not PA or NP school, which I also considered) - because I want to know all the WHY we do things in medicine - not just the HOW.  To clarify, I'm not saying that all PAs do not care about the WHYs; actually there's a lot of the WHY involved in really knowing the HOW.  But it was affirming for me because when people ask me why I went to med school - and not PA or NP programs - I tell them that I wanted to be calling the shots.  Not all of them, and not always by myself, but I wanted to strive to be able to practice medicine in line with my own clinical knowledge and decision-making.  So it's cool to realize that this clinical decision making is what makes doctor training different and that I am being taught how to do it.

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"When it's over I want to say: all of my life I was a bride married to amazement, 
a bridgegroom taking the world into my arms"

- Mary Oliver (one of my most favorite poets)

Welcome to the Monkey House

Day 1 of Surgery 

I'm introduced to my first preceptor, a surgical oncologist who we'll call Ted.  Ted spent most of his life in Texas (and has a thick southern drawl to prove it) before he became a surgical chief and a Colonel in the Marine Corps for many years before going into private practice.  So the first thing I have to figure out is do I call him Doctor or Colonel or both.

Within minutes of meeting him we scrub into a breast cancer surgery.  My second day, we start with tumor board, which is a pretty awesome concept actually.  It's when the group of physicians and staff who treat cancer get together to talk about particularly difficult cases.  The surgical oncologists, the medical oncologists, the pathologists, the radiologists, and if appropriate, the residents and medical students are all in attendance.  We go through each case thoroughly, with the primary doctor presenting the case, then the radiologist showing what was found on imaging, and the pathologist showing what was found in the specimen, and then everyone chimes in with their two cents.  I think it's one of the fine times in medicine where there is true collaboration.  

After tumor boards, Doctor Colonel says to me:  "I'm gonna tell you the best piece of advice given to me by an attending.  He said, son, we could teach monkeys how to do surgery.  Hell, we could teach really smart monkeys to decide when to do surgery.  But why we're special is because we can decide when not to do surgery".  

(ps: as you've probably noticed, that's not really a photo of me, I've already asked and apparently I'm not allowed to take any photos in the OR)

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"I urge you to please notice when you are happy, and exclaim or murmur or think at some point, 'If this isn't nice, I don't know what is'"

-Kurt Vonnegut

10 Things I Learned in Ob-Gyn

1. body language matters.  for ob-gyn's, where you stand before, during, and after an exam makes a huge difference in the comfort of the patient. Pushing your naked butt forward while your feet are in stirrups towards someone you can't see who you know is about to use a speculum is so much more nerve-racking than someone standing beside you and saying, please scootch down until you feel like you're about to fall off the table - THEN going to the bottom of the table.

2. my body does strange things when it has to be awake for too many hours.

3. no one fully understands menopause.  It's one of the great frontiers of women's health that we have only barely begun to brush the surface of - but the good news is that there is a ton of interest in topics in  menopause because women are living at least 1/3 of their lives after menopause now.
4. women are not just like men.  for example, when women have heart attacks, they rarely get chest pain.  they are much more likely to get jaw pain.  science and medicine are just barely adjusting.
5. women are not so different from men.
6. say what you want, seeing a baby be born and especially helping a baby be born is one of the most incredible magical miraculous things in the entirety of existence.
7. if birth control access were truly universal - meaning that women would come in to get it, would be able to take it well (so we would be able to give them whatever kind they would actually use), and that women would follow-up regularly, there would be fewer unintended pregnancies, fewer women who have children when it's not a good time for them to have children or when they really can't handle having children, fewer abortions, and that would translate into everything being just a little bit better.
8. we have to talk about sex.  it's too much of a health issue to have your doctor not talk about it.
9. lots of cancer is preventable, yet people are either embarrassed or too busy to do the things.  Get pap smears. Get mammograms.  If you are a guy, encourage your mother/sister/friends/wife/girlfriend to get regular screening tests.
10. surgery is freaking cool.

"Hello babies.  Welcome to the Earth.  It's hot in the summer and cold in the winter.  It's round and wet and crowded.  At the outside, babies, you've got about a hundred years here.  There's only one rule that I know of, babies -- God damn it, you've got to be kind"

-Kurt Vonnegut, in Thanks You Mrs. Rosewater

Before I die I want to...

check out this incredible urban art by Candy Chang, an installation artist, urban planner, and TED Fellow who created this awesome piece in NOLA about all the things that people really think are important.  

The wall was filled in a single day.  (click on the photos to make them bigger)

What would you write?

(this last one lists two of my big hopes as a physician) 

Immortality

"it was the story of white selling black, of black cultures 'contaminating' white ones with a single cell in an era when a person with 'one drop' of black blood had only recently gained the legal right to marry a white person. It was also the story of cellls from an uncredited black woman becoming one of the most important tools in medicine.  
This was big news"

- The Immortal Life of Henrietta Lacks, page 197

I am overdue for my "10 things I learned in Ob-Gyn" and still working on it. But in the meantime I had to share with all of you this INCREDIBLE book that I'm reading right now because you need to go out and BUY IT and read it.  It's called "The Immortal Life of Henrietta Lacks" and is a mix between the Help (also amazing) and the The Double Helix by Watson (of Watson and Crick, who discovered the form of DNA).  We learn about some of this in medical school but not like this.  And for those of you not in medical school, I still think you won't be able to put it down, maybe even more so.

The story weaves between the life of the woman and the progression of the science behind the creation of the first cell line that is now ubiquitous in research of everything from the polio vaccine to in vitro fertilization.  Cells taken from Henrietta Lack's cervical cancer tumor in the 1950s, when she was only 30 years old and being treated in the "Black Only" section of Johns Hopkins, were used without permission or information to create a cell line that was immortal.

Without giving too much away about the book, I'll tell you why I think it's incredible and especially why I can't put it down.  It begins with a black woman growing up in the 1950s who feels "a knot" growing "inside her" and eventually goes to Johns Hopkins (the only hospital at the time in her area that even treated black people) and learns that she has cervical cancer.  In the midst of treating her (with radium and high intensity radiation that burnt the skin of her entire abdomen), the physicians took a sample of the tumor and sent it to a research lab at Hopkins that had been trying, unsuccessfully, to grow a line of cells.  The book covers everything from cervical cancer in the 1950s, the invention of pap smears (in the 1940s, but didn't gain popularity until the 1970s, and treatments for cervical cancer in the 1950s), to race relations in Maryland, to the Tuskegee experiment and the progression of laws protecting patients and/or medical research subjects, to the development of cell lines and what science thought it could do with them, Jewish doctors refusing to do research in the US on poor black people without their consent because WW2 wasn't that far in the past and they remembered, the trials and tribulations of trying to create immortality, and more.

Anyways, you should read it as soon as possible and tell me what you think.

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"We must not see any person as an abstraction.

Instead, we must see in every person a universe with its own secretes,

with its own treasures, with its own sources of anguish, 

and with some measure of triumph.

-Elie Wiesel

from The Nazi Doctors and the Nuremberg Code

(also on the cover page of the Immortal Life of Henrietta Lacks)

Two Towers

This is from the NYT special report on Sept. 11 - I always love portraits but these are especially amazing because they also have audio that you can click on to hear people's stories of the day.

It's a scary yet ultimately uplifting reminder of the slogan of my blog - everything (and everyone) is connected.  These stories may be different than yours or mine, but we all share the memory of the day - the horror, the disbelief, and the absolute need for one another.

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"There is no question what the roll of honor in America is. The roll of honor consists of the names of men 

[and women] who have squared their conduct by ideals of duty."

-President Woodrow T. Wilson