[HSF] (OT?) Medicine as practice: what every surgeon should know

Sun Aug 19 22:12:51 EDT 2007

Thank you Don and Bill for your responses.

I think that I mentioned the story behind my resultant situation was quite interesting, but not particularly germane to the HSF (assuming that anything I say is germane to the HSF audience.) I do have an information filter. It is just exceedingly weak.

As it turns out one of the rules for finding fruitful observations is to look for things that don't seem to fit like my loose string on the coat or the rough edges of a theory like Ben's humble opinon that all ventricular changes are molecular. One of the children that I saw had the odd complaint of chest pain and SOB with while playing, which I watched her do after I saw her. I had my stethoscope by then and was expecting perhaps a wheeze, but instead I heard a loud, harsh holostolic murmur, which I took to be a VSD. I left some money with my host to try to get her a further work up with instructions that I would like to review the studies myself thinking of possible solutions and you, Bill, but we will see whether this comes to pass. She is a darling little girl about 5 or 7 with amber green eyes...

I think it would be very interesting also to go with you on a working trip. If I could spend a day or two at the beach so much the better, but I get bored just setting on a beach in the sun after a couple of days. Brushing up on pediatric surgery would likely make me and you, too, reconsider the advantages of nihilism, however.

It is interesting to see how people take to a story that one tells. There is a lot of ambiguity in life as one passes by some doors of understanding and enter others. I don't in the final analysis believe that my trip was a failure. The nihilism is rather in our ability to ever know enough to understand  what we really need to do to match the enlightened empiricist world view. Quite frankly in most respects that world of medical science does not exist at all "out there". Diseases or pathologies exist without (despite?) our recognition, but therapies require us and our patients together. I think that in describing the medical therapeutic world as empirically out there awaiting our "discovery" is a great disservice to ourselves and our patients. We can all look at our own hands and recognize that somethings are there and some are not no matter how much we "know" about the subject. We will not stop looking at results, our or others, or "testing" them
 mathematically, but they will never be able to tell us what is best to do, nor will guidelines, nor government funding, or even a course on ethics or the next decree from JCAHO. It is a dance between the patient and the doctor, which is for our patients and us surgeons quite a personal one. Our world, particularly our surgical world, exists only in our dance. Our epistemology is anemic. This is what makes Ani and myself look jaundiced...well at least me, I am supposed to be whitish pink.

tea

----- Original Message ----
From: "ichfno at aol.com" <ichfno at aol.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Sunday, August 19, 2007 5:44:26 PM
Subject: Re: [HSF] (OT?) Medicine as practice: what every surgeon should know

Tea,

I am a little surprised you set yourself up for such an experience, one that would be doomed to failure in your eyes. You are a cardiac surgeon, why in the name of Peete did you go to Nicaragua to run a rural primary medicine clinic, should have been looking for cardiac patients. Next time you get the urge to join the ranks of Schwietzer let me know and we will send you to a place where your skills can be put to use, not to the land of Nihilism. 

Bill

William M Novick MD
Paul Nemir Professor
International Child Health
University of Tennessee Health Sciences Center
Founder/Medical Director
International Children's Heart Foundation
www.babyheart.org

-----Original Message-----
From: Donald Ross <donross at bigpond.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Sun, 19 Aug 2007 5:32 pm
Subject: Re: [HSF] (OT?) Medicine as practice: what every surgeon should know

>?
Nihilism: "The belief that all endeavors are ultimately futile and devoid of meaning."?
Don't despair Tea, on the nihilism scale Ani scores a perfect 10 and you only manage 8.?
If you had smuggled a million bucks of parasite treatment into the steamy jungles, you wouldn't have even scored.?
Don?
On 20/08/2007, at 12:42 AM, Tea Acuff wrote:?
?
> This post is a sequelae to thoughts on my brief attempt to provide > care in rural Nicaragua. I have included the description of that > effect for reference for any that missed or wish to refer to the > details.?
>?
> My first impression of the task to provide medical care in > Nicaragua was that of an incapacitating nihilism. Not unlike the > description of the residents today (and probably yesterday) that > seem unwilling to prepare for an operation, I minimized my need to > study for what seemed a daunting lack of knowledge and resources > for my "mission". Surely we all remember that feeling from many of > our firsts: first H and P as a medical student, first pelvic exam, > first day as an intern, first "real" operation, first month in > practice, etc. As mentioned I even "forgot" my only personal tool, > my stethoscope, the first day. Sound familiar??
>?
> As I reflected on the why of this, being a practitioner of more > than 20 years having set up both new pediatric and adult heart > programs, why did I assume a nihilistic attitude at a rural > medicine clinic where no doctors of any kind are readily available??
>?
> I think it comes from our standard or orthodox view of medical > practice, which I would better call the naive view, similar to > descriptive accounts of religious belief. It is a residual of the > Lockean enlightened "tabula rasa" or blank slate. (Not unrelated to > this discussion, John Locke is philosophically known as an > empiricist.) It is a similar view for education or any "learned" > field. In this presumed, if not officially espoused view, the > doctor is one who accumulates a large amount of information and/or > skill about the "real" and scientific world which makes his service > as a benevolence to those in need for either reasons of incapacity > or ignorance. This may further explain the doctor's proclivity to > not see the need for his own care despite the fact that, he/she > will also succumb to life's entropy.?
>?
> This nihilism in the face of daunting need for information and > responsibility makes clear sense to all neophytes of medicine > either by virtue of time or situation. What is not so obvious is > the other pole of this view. It is the certainty or at least > colonial-like conceptualization that the "knows better" and > conceived "benevolent" action confers on its adherents. I use > colonial not to suggest malfeasance, but to convey the sense of > correctness supported by the guidelines and mores of those that > import their principles on others.?
>?
> That I completely failed to fulfill virtually any component of my > side of this orthodox but naive view, yet patients waited hours for > a week worth of analgesics or H2 blockers, caused a profound and > solitary realization of the mission of a physician independent his > wealth of resources (as a cardiac surgeon in the USA) or lack of > the same (as my situation in Nicaragua). Heroics are nice for us > adrenalin addicts, but the true role of physician is to provide > comfort and reduce to that extent possible the discomfort in which > we find our patients and their loved ones. Period. Sometimes we are > wildly successful, but most often we are able to obtain only more > modest gains. In the scope of all that is life, modest or temporary > relief seems a better description of our work than that of the life > givers we seem so wont to assume.?
>?
> A few of the patient situations that I encountered may better > specify my more formal thinking about the practice of medicine. One > 60ish year old woman had among a variety of complaints a swelling > in her neck. By physical exam of this area she had a mat of nodes > in her right supraclavicular fossa. By history she had a year or so > ago an abdominal or pelvic operation in Guatemala (despite the > admonition that no other care was available per my hosts) which was > likely a malignancy. Although there was a small chance that I could > be mistaken, I decided that she was "dead man walking". I could do > little except share my "suspicion" that she may have her cancer > back and she might wish to reevaluate that if she could. I wondered > whether she was worse off in Nicaragua or my home town. I was > betting that in the USA we had a better chance of making her time > left worse or at least "invaliding" her than we had of making it > better. She
 likely faced a more purpose
ful?
> existence in Nicaragua. Why should this be so? Have we as doctors > fairly squared our limitations with our successes? Is our treatment > of our "end stage" disease in the US more humane than that in > Nicaragua? Or is it less, either outcome merely by default and not > thoughtful design??
>?
> As I was giving out a dollar's worth of analgesics for headaches or > to those sore from carrying burdens daily, I wondered whether the > pitiful value I was offering was a better value than the LVADs we > offer to the pitiful patients that we discuss on HSF. If we look at > it through the prism of personal economics (patient pays for the > full value), I imagined both would have been less available than we > currently observe, but likely the LVADs would be even less funded. > Ben has already commented that social LVAD funding makes little > sense from a developed country down under. I doubt he would say the > same for the lack of generic drugs like ASA or ibuprofen.?
>?
> LVADs are just a convenient extreme example, but not different in > kind for an understanding of how to understand our practice of > medicine. Societies, or the regulators and their complementary > physicians, have already noticed that the naive view of medicine > has its flaws. But I do not think the addition of economic (or my > dismissive, Marxist) perspective alone adds much to the over > arching understanding of medical practice. Rather it tends to re-> enforce a bi-dimensional (eg, cost versus care or recommendation > versus incentive) aspect of medical care, and its largely > ineffective corrections such as "financial disclosures" and > regulation of "conflicts" of (economic) interest.?
>?
> This related "economic" or barter pattern I also noticed during my > patient interactions. After a while I noticed a stylized pattern > between the patients complaints and their expectations of which > drug I would/ should give. It seemed as over time the complaints > became more "focused" toward particular "stories". It was like > there was a verbal barter for that which I had to offer the "right" > drug. I imagined in retrospect that the "patients" debriefed their > fellow patients and correlated their stories to match that which > they wanted. For myself I "naively" tried to "practice" what I knew > which was little. It may have been that they all had much of the > same complaints, and that this style came from us. Part of this > surely was. However, I never had much idea what would be the > symptoms for parasites, and the complaints did not match much of > what I did read about parasites. While it is possible (does anyone > reading know) that
 "children grinding their te
eth"?
> became a symptom for "parasites", it seems more likely that this > was an acceptable and imaginative synonym created by the patient > culture for "I need parasite medicine". Toward the end of the > clinic some patients returned and/or flatly asked for parasite > medicine, if I failed to make the connection for which I could make > no medical sense. This is not what we typically mean by the > economic influence of medicine, but defining it as economic informs > our predictable and insipid solutions. This barter was more of a > dance than an economic contract.?
>?
> So I moved from the more naive (orthodox) view, that is I know (or > should know) and would give to the tabla rasa of misunderstood > needs of the patient, to the likely hood that what really was > occurring was a barter between different cultures of doctor and > patient. That I was not privy to most of their culture and even > language made it somewhat more clear to me that this might be the > case. In different words in the phrase we appeal to over and over, > I could not imagine what I would want for "my mother or loved one" > in terms of their culture. I am sure that we all have had glimpses > of the same divide and this barter in our own practices. The > question then becomes how often do we cross the line naively or by > design in our own practices? Does everyone (populations) or anyone > (individuals) really "want" in the language from the patient > culture or "need" from language from the doctor culture LVADs, > chemo, or bypass with or without
 three valves? Whom ar
e we?
> serving and why? If they (our patients) had to pay would that > separate the cultures of care more realistically? Do we entice by > advertisement, anecdotal success, guidelines and technology, or > subsidized care? Who does not want something for nothing? Who can > actually have it? Any answer or direction to seek to answer these > questions is dependent on our presuppositions on the nature of > evidence or knowing and the model of interaction between doctor and > patient in the practice of medicine.?
>?
> Enough for today. For anyone interested next time: Is there a > better formal model for exploring medicine as practice? I think a > different model leads to some interesting questions.?
>?
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