Black Lives Matter, Blue Lives Matter

With the recent news of the shootings in Louisiana, Minnesota and Texas, I think about gun violence. I need to disclose that I am a middle aged white female. Yet gun violence and the fear of it have been part of my life.

At 15, I visited Prague. I went with a student group. We spent most of our summer in Germany, yet crossed to the East twice, once in Berlin, and then a few days in Prague. A beautiful city with so much history. Yet with fresh evidence of the suppression of the Prague Spring. Some of the leaders were still loose. And, the hard line authorities wanted to capture and punish them all.

As we were leaving Czechoslovakia, I was pulled off the bus, then queued up again, to have the same happen two more times. Then the officer began to question me. In Czech. I knew no Slavic languages except the bits of Polish I heard when we visited my grandparents. I asked him to repeat his questions in one of the languages that I knew. Yet this questioning was done with three young men with guns pointed at me. I dared not flinch, for fear that one of the soldiers might shoot. Meanwhile, I prayed that if they arrested me, for what I didn't know, they wouldn't send me to Soviet Union. I had heard bits of my grandmother's experience there working in a Siberian labor camp for the crime of being Polish. I knew I was too soft. Finally, I was allowed to board the bus, and leave the country. Then, the driver, who had understood the exchange told me that I looked like one of the student leaders. I never heard what happened to my twin. I hope she is well.

While in residency, I came to know my neighbor, who was a police officer. At first he was on medical leave. He had killed a man. His partner had also been killed in the shootout and my friend and neighbor injured.

My next experiences came when I worked in an inner city hospital. Gangs were active. There, I cared for hundreds of victims of all ages, from infancy up. But, usually, they respected those who cared for them. A colleague had his shoes stolen at gunpoint, but wasn't injured, because, "Doc, we might need you someday." A few times we were threatened that if a certain patient died, we would, too. And, once, we had a SWAT team in the hospital. We had to walk past them and their bullet proof shields to care for our patients, and worried that we might be caught in the crossfire.

Another threat was after I had been speaking out about gun violence after I cared for a young boy who had been shot on the freeway. He was one of about 20 shooting victims my hospital received on a typical Friday or Saturday in the mid-90s due to gang activity. This child was deemed different. He was middle class, from the suburbs, just driving home from a Dodger game with his cousins. So the press was interested. I spoke out, testified on the costs of gun violence to committees of city and state government. Thus, my photo was in the paper. And, a copy of my photo was sent to me with a target drawn over my face. Scary, but I knew that my activities were having an effect.

During this time, I also learned from colleagues the issues of "driving while Black," "running while Black," etc. It was something that had not been part of my experience until then. Instead, I had been told, even by Black and Hispanic colleagues, not to drive through certain neighborhoods.

Later, I had an alarm that triggered a "home invasion" alarm. I was home alone, by then middle aged, working on my computer, when the police came, with guns drawn, wanted proof that I was who I was. They looked through my home, following me, but finally left after I got my ID, showing this house as my address.

I realize that people are violent. But, guns increase the lethality of that impulse to violence. I don't have a solution, given the millions of guns in the hands of the American populace. I have worked in an area where gang violence was rampant. I have seen far too many lives destroyed by violence. I have worked to save and rebuild some of those lives.

I can understand that police may be afraid, but, I have seen reasonable control by well trained officers when we had the terrorist shooting in San Bernardino, not adding to the toll at the Inland Regional Center. I can understand that the people are afraid, especially Black men, but am impressed by the overall peaceful nature of the recent protests. I hope and pray that we can come together to end the violence. So that I don't have to try to patch up any more shattered victims.

Human experimentation

I recently saw an article on repair of vesicovaginal fistulae (http://www.npr.org/2016/02/16/466942135/remembering-anarcha-lucy-and-betsey-the-mothers-of-modern-gynecology). As a surgeon, I found this bit of history interesting. Surgery during the 19th century was difficult. Ether was first demonstrated in 1846. The surgeries on the slave women were between 1845 and 1849. It is also worth reading an article by LL Wall on the ethics of Dr. Sims work (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2563360/).

Since I'm not a gynecologist, I thought I needed to read up on the condition. Vesicovaginal fistulae, and rectovaginal fistulae, are a complication of childbirth and still a scourge in the third world (http://www.ics.org/publications/ici_3/v2.pdf/chap22.pdf). Most of the most dangerous countries for pregnant women are in sub-Saharan Africa, where poor women have limited access to obstetrical services, and so may suffer the consequences in terms of maternal death or fistula formation.

Anesthesia wasn't the norm for anyone in the first part of the 1800s, but became more common in the second half of the century. Only later did Dr. Sims use anesthesia, when it became standard. By that time, he had moved to New York and had a nearly all white clientele.

Throughout the south, slaves received varying levels of medical care, some reasonable for the time, some not. The owners gave consent. A friend visited one of these slave hospitals and she said that it reminded her of a veterinary hospital. But, at the time, alternatives were limited.

The standards for risk in clinical research have evolved over time, mostly since WWII, with the human experimentation on Jews, Poles, Gypsies and others by German physicians, and the Tuskegee experiment, and others, such as radiation experiments (see The Plutonium Files by Eileen Welsome). In all of these cases, the "research" had no intention of helping those subjects. I grew up knowing one of the survivors of the German experiments. She suffered from the sequelae for her entire life.

When I started my fellowship, in 1989, I remember the statement being made that an average of 1 person per year died as a result of experimental chemotherapy protocols that were being studied at my institution. Given the type of tumors we studied, without treatment, nearly all would have been dead within a year. Refining treatment has added months, or in some cases years to their average life expectancy.

I remember my patient. She was in her 20s and had a very aggressive type of tumor. She was white and middle class. But, her life was made shorter by the treatment she received. Do I feel responsible? Yes. Can I live with myself? Yes. I know she was on a protocol that was thought to possibly help her, as well as possibly helping more patients in the future. 

So, within limits, I think it reasonable to take some risk.

Certainly slavery is unacceptable. As is experimentation which has no chance to help the patient, yet has significant risk. But, there must always be a first patient or medicine can't advance. So, we try to help those for whom there is no other treatment. I would consent to a trial when I had no other option for treatment of myself or my children. It might offer us some benefit, and hopefully will help to create better treatment for future patients.

Did Dr. Sims put these slave women at risk? Yes. Might they have benefited from treatment? Maybe. There was no other option at the time, but to live with urine, and possibly feces, always dribbling out. Were these surgeries unacceptable? I don't know. Certainly, it is appropriate to acknowledge the patients.

San Bernardino

The recent shooting in San Bernardino called on not only law enforcement, but also health care to do their best. I am proud of how we handled the crisis. Here are interviews with some of my colleagues: http://www.cnn.com/videos/tv/2015/12/03/san-bernardino-er-doctor-swat-sanjay-gupta-lead.cnn/video/playlists/san-bernardino-shooting/
And, another: https://www.youtube.com/watch?v=-y-ZMEF_m3A

Kunduz

While this is not directly related to my journey, it is about medicine.

Many years ago, after my fellowship, I looked into volunteering for Doctors Without Borders. It was as the war in Bosnia was heating up. I had no dependents at the time, and knew that, as a surgeon, the greatest demand might be in a war zone. I mentioned that I knew two Slavic languages. As it worked out, I did not end up as a volunteer. But, I have followed the activities of both MSF (Doctors Without Borders) and EMERGENCY, a similar group. So, it greatly disturbed me that a US airstrike had repeatedly hit a MSF hospital in Kunduz, Afghanistan (http://edition.cnn.com/2015/10/07/asia/doctors-without-borders-afghanistan-airstrike/index.html?eref=edition).

As a physician, I take seriously the responsibility of caring for all, even at some risk to myself. I have worked in inner city hospitals where I have been threatened by some gangs, but, excused that due to the drug induced impairment of those who threatened me. And, I have known that many would not have wanted to harm me, knowing that they might later need my services.

International law protects hospitals, both military and civilian, from deliberate attack. Physicians should provide impartial care, and thus, might provide care to both civilians and combatants. Like my experiences in the inner city, those who wage war are at risk of injury, and so they want hospitals and physicians who will care for them. That is why the events of last week are so disturbing. Despite the coordinates of the MSF hospital being provided, there were several bombing runs targeting the hospital reported. Hence, MSF is asking for an investigation of a possible war crime (http://www.motherjones.com/politics/2015/10/us-bombing-afghan-hospital-war-crime).

The US has bombed hospitals before (http://thinkprogress.org/world/2015/10/08/3710486/hospitals-bombed/), and is not alone in this (http://www.theguardian.com/global-development/2015/oct/05/kunduz-hospital-bombing-latest-long-line-attacks-msf-staff; http://www.bbc.com/news/world-asia-34444053). Civilians have increasingly become the victims of war during the last century.

I hope the truth about this event will come out. And, that a hospital can be rebuilt for the people of the region.

The R Word

Recently, I saw my oncologist for a follow-up. Mostly good news. I am coming up to an anniversary. It is becoming less and less likely that my cancer will recur. Lab tests are looking better. And he ordered the annual follow-up imaging, something that would require preauthorization. Since it's to be done a few months down the road, I began to think about when I should start calling the insurance company to explain why I needed this test. Should I wait for the denial or be pre-emptive? Each year I have been denied, then after I called and demanded to speak to the oncology reviewer, who then approved the test.
I am a physician. I know the lingo. I can talk to the oncology reviewer and explain my case. But, what of my patients? It's clear why they might slip through the cracks. If the clinic nurse doesn't "bird-dog" every study for utilization approval, call when needed, and involve the doctor when needed, studies and procedures may not get approved. The denial may slip past. The patient may return to clinic, unable to get the study, and not know why. It's unlikely for a patient to know where to start. And, even if they did, many of my patients don't know English, or not speak it well enough to address the denial themselves. They must rely on their doctors and nurses to intercede for them. Yes, that is part of the job, but on the day to day basis, it often seems there are more urgent problems to deal with.
Today, a colleague was venting about how hard it was to get things done, to get referrals or studies. We discussed the process for a patient with a herniated disc. He talked about how hard it was to get a specialist referral. Sometimes it could be months, he said. Our nurse chimed in to say that we usually schedule the patient within 2-3 weeks of receiving the referral. But, we want imaging done first. So, the patient has already had to jump through the pre-approval hoop twice. Once for the MRI (or sometimes CT), and once for the specialist consult. Maybe a third time for physical therapy. Each of these may take 2-3 weeks with someone "bird-dogging" the referral, longer without. And, then, after seeing the surgeon, maybe more physical therapy and possibly a pain clinic referral, with more pre-authorizations. Sometimes, each of these steps has to go back through the primary care provider. And, after that, if the patient doesn't improve with conservative care, yet another pre-approval process for surgery. So, it can be a slow process at times. The American version of waiting lines for surgery. For some surgeries, this may not be a bad idea, since many patients may recover on their own from some problems. Often they do with disc problems.
But, what of other problems? The answer is that it varies. Emergencies don't go through the pre-approval process, but rather retrospective review. While I was off due to my illness, and some since, I have done some of these reviews. For all, the key to approval is documentation. The provider must clearly document the reason for the test or procedure. This is good medical practice. Sometimes, as a reviewer, I have been able to infer why something is being done, but the documentation must be there, and it must fit in the boxes defined as approved by the insurance company. Sometimes, there isn't enough documentation, so there is simply a denial. Sometimes, the reviewer may need something clarified. Mostly, once the information is made available, the request makes sense. Sometimes, it doesn't. These are the tests and procedures that probably should be denied.
This process may take some time. Some patients get lost in all of this, and come back angry that "nobody cares." Their problem didn't get better, and may have gotten worse as they stumble through the system.
To me, this seems like the American version of the waiting lines for treatment in other countries. We wait at each step of the way. Sometimes, patients get frustrated and feel there is no way to navigate the system. And, so, the insurance company saves the money they otherwise would have had to spend. The American version of the "R word," rationing. It is a system of rationing that affects those who are least able to speak eloquently for themselves more than those who can. So, the most vulnerable may not get the care they need. And, so we see income disparities in length and quality of life, since income may serve as a marker for education and status. This seems why so many candidates for office don't want to address the issue of rationing, because they would need to admit that we already have rationing, that America has financial rationing of health care. And, it affects nearly all of us. Since, even with private or employer sponsored insurance, most of us have HMOs or PPOs, so our insurances have forced this upon us.

Vaccinations

Today, I was just in employee health for my annual PPD (skin test for tuberculosis) and I was reminded about flu vaccines. While I am a believer in vaccines (when was the last case of polio you saw?), I do not take the flu vaccine. I am allergic. But, I encourage others to take appropriate vaccines on schedule. I have vaccinated my children. I have vaccinated my pets. I have only stopped certain vaccines for myself due to my allergy.

I asked rhetorically in the last paragraph, "When was the last case of polio you have seen?" Years ago there were rooms of patients in iron lungs at hospitals like Rancho Las Amigos in Los Angeles County. Now the hospital is a rehab hospital. Iron lungs are a thing of the past. There are pictures from this time: http://www.polioassociation.org/Faces_of_Polio.pdf. I remember getting polio vaccination as a child. I knew someone who wasn't so fortunate. She had polio as a child. Her disease did not get to her respiratory muscles. But, she wore long leg braces and used crutches.

I remember when I had measles. I felt deathly ill. But, I was luckier than some. I survived. Roald Dahl's daughter died, as did many others. He wrote an essay about her death:  http://www.people.com/article/roald-dahl-vaccine-measles-letter-daughter-olivia-death. About two weeks after my bout of measles, the vaccine was released. Even as a child, I understood that children wouldn't suffer as I had. I was jealous. I was unhappy that I had suffered. And those who have suffered measles, especially when very young, may suffer another complication SSPE--subacute sclerosis panencephalitis. They then may suffer a progressive decline and death. (https://en.wikipedia.org/wiki/Subacute_sclerosing_panencephalitis)

Last year, there was another measles epidemic. It was small, compared to those of the past, but, it reminded us that the disease is not gone. That avoiding vaccinations carries risk. But, fortunately, for most of the anti-vaxxers, herd immunity has protected them. While they risk not only their own children, but others who have medical reasons to not be vaccinated.

These diseases are still around. Some of us must rely on herd immunity. As I do for flu vaccines.

Physician to Patient (and Back Again)

Just had another short piece published about my experiences as a patient: http://aansneurosurgeon.org/features/from-physician-to-patient-and-back-again/

I found it difficult to change roles from physician to patient, and now back to physician, or should I now admit, both. My experiences as a patient have certainly changed me. I hope it has helped to make me a better doctor. I also should apologize in advance for a few typos, caught too late.