Talking About the Book with Surgeons (and Others)

I have been grateful to talk to groups about my life, surgery, ambiguity, narrative medicine, and A Fullness of Uncertain Significance: Stories of Surgery, Clarity, & Grace. Recent talks and reflections:

February 18, 2022 - Albert Einstein College of Medicine Department of Otorhinolaryngology

This was a virtual presentation. The residency program director, John Bent, MD, read about the book in ENToday, a national newsletter for the Triological Society (the only national print coverage the book has garnered, by the way). He emailed and asked if I would talk to the department.

It was a wonderful experience! I did some reading and conversation. A surprise was the presence of Marvin Fried, MD, chair emeritus of the department and an early role model of mine from residency.

I had some great email interactions with a couple of the Einstein residents and faculty after the talk.

March 14, 2022 - Johns Hopkins Department of Otolaryngology Head & Neck Surgery

I have known and admired many of the Hopkins faculty over the years and, in preparation for this presenation, discovered that I also had connections with two of the residents, as well. One of the current fellows was an MCW resident. Nick Rowan, MD helped coordiante the session.

The residents had a Book Club the week before my presentation. They found three of the essays most compelling, including "Harbinger," an essay about the excitement of a first medical experience and how it impacted an early moment in a personal relationship. I also read "Ending Your Career with Grace Means Letting Go of the Knife," whic is an essay about retirement. Great conversation.

Thanks to Chris Gourin, MD for being such a wonderful advocate for my book!

March 16, 2022 - Rush University Department of Surgery

I graduated from Rush Medical College in 1980, so this virtual visit was a bit of a homecoming. I found some old pictures and told some stories, warning people to nice to medical students because, you never know who might come back in thirty-five years and talk about you."

I called out the influence of Steven Economou, MD, a general surgeon who was also an accomplished artist. I also mentioned that I had won second place in an essay contest on, "Why the Medical Humanities are Important to Medical Education," my first foray into the topic back in 1977.

Here's a Rush photo of me standing over the shoulder of Ronald Weinstein, MD, the chair of Pathology and later pioneer in telepathology. Preparing the talk was a great opportunity to remember how influential many of the surgeons and other medical school teachers were in shaping my career.

March 22, 2022 - Medical College of Wisconsin Department of Otolaryngology and Communication Sciences

A presentation to the home team crowd. This was a tag-team talk with fellow MCW book author, K. Jane Lee, MD. She talked about the process of writing her amazing book, Catastrophic Rupture: A Memoir of Healing. We had read sections of each other's work as we were moving toward publication, and it was a delight to share a reading, compare notes, and discuss what we had learned along thw way. We talked to our residents and faculty about the process of writing and how helpful it can be to read and reflect.

March 30, 2022 - Medical College of Wisconsin Department of Surgery

I have been fortunate to work with the general surgeons and surgical specialists at MCW for four decades. My session shared some of that admiration both for their work and for many of them, both current and past. The photo shows a Surgical Grand Rounds presentation, likely from the early 1990s with one of the residents being quizzed by Robert Condon, MD the department chair.

My talk focused on the benefit of including the humanities and reflection for students and residents rotating through surgical rotations. One study showed that 90% of third-year medical students on surgical services were "stressed" or "very stressed," and they found that reflective sessions were very helpful.

April 5, 2022 - Theological Ethics in Helathcare - Mount Mary University - Milwaukee

I was invited to spend time in Professor Shawnee Daniels-Sykes' class at Mount Mary University, speaking in conversation with Sister Shawnee and

her undergraduate students about the book. The students had each been assigned one of the essays in the book to read and be able to summarize. They each had to come up with a question to ask me. The questions were wonderful, ranging from wondering about my own faith to what medical school is like to dealing with dying patients.

Also attending the class was Mary Fran Otterson, MD, an MCW colleague, colorectal surgeon, Mount Mary alumna, and friend of Professor Daniels-Sykes. Having her in the class to provide perspective as a woman, an alumna, and a surgeon was wonderful.

Friday, February 8, 2022 - Creighton University Department of Surgery - Omaha, NE

My long-time head & neck colleague and friend, William Lydiatt, MD, invited me to come to Omaha to speak to his colleagues where I was honored to be the Albano Distinguished Visiting Professor. I gave a book reading and talked about Narrative Medicine. In addition, we had a writing workshop with about forty residents, faculty, and medical students, doing close readings of "Girl," by Jamaica Kinkaid and "Midsummer Rain," by Ted Kooser.

The group was very welcoming and the writing experience excellent. The residents appeared to really work at the opportunity to reflect. I was impressed by what they shared.

The afternoon session, the Dan Lydiatt, MD Symposium on Cost-Effective Care in Head and Neck Cancer, was headlined by Chris Holsinger, MD from Stanford University. Below are some photos from the day.

Thanks to all of the groups who have invited me to share my book, my experiences, and my thoughs about the value of reflection and narrative in a surgical life.

Here's looking forward to more conversations.

#AFullnessOfUncertainSignificance #AFoUSBook #NarrativeMedicine #NarrativeSurgery

Our Hands

One day during my residency many years ago, an older man arrived in clinic with a large neck mass that had been growing for months. The mass, which by then was the size of half a baseball, wasn’t bothering him much, so he hadn’t rushed in. He finally made an appointment to see if anything should be done. “I only came because my family has been bugging me,” he said.

One of my fellow residents evaluated him. Standing behind the man as he sat in the examination chair, the resident cupped his hand over the mass and moved it side-to-side and up-and-down. It wasn’t painful and did not seem to be extending deeply into the tissues—those were good things. As the resident continued the examination, I am certain he was asking his fingers to tell him more. Maybe he was wondering, What does this mass represent? What scans and biopsies will I need to order? What’s going on here?

Suddenly, the resident and the patient yelped simultaneously. I heard the commotion and rushed to the room. The resident and patient were both wide-eyed. “It came off!” the resident exclaimed. “As I was palpating the mass, it just fell off!” He stood still, holding the mass tightly against the man’s neck in case he had torn any underlying blood vessels. The man looked surprised but, otherwise, seemed fine. There was no blood accumulating. I reached for supplies.

“Quick!” he said. “Grab some gauze!”

I opened a couple of gauze pads and got ready. The resident gently pulled the mass away from the man’s neck. Nothing happened. The circular area where the mass had been attached was red and a bit angry looking. The surface oozed, but only a little. Within a couple of minutes, we had cleaned the neck skin, stopped the small amount of bleeding, and taped on a dressing.

The man looked in a mirror and grinned.

“You’ve got magic hands, Doc!” he said. “Now, my family will leave me alone.”

The neck was, basically, back to normal. I picked up the mass and pressed against its surface with my hand before dropping it into a specimen container. It was firm, and the size and shape of an old-style paperweight. No harm, no foul, I thought.

There was more to the story but, given the decades that have passed since then, I don’t remember either the pathology or what treatment was needed. I do know that I never again saw a large, worrisome neck mass simply come off in the physician’s hand during a physical exam.

Using our hands for work

Our hands are central to what we do. When I have had to offer virtual visits over the past couple of years, I missed the “hands-on” of clinical medicine. With a patient in front of me, I can fill in the gaps in their story while performing the examination. I check for pulses, areas of numbness, muscle strength, and joint function. I palpate tissues and press my fingertips into tender areas. I hope that my patients will trust me to use my hands wisely as I search for masses, perform procedures, and remove cancers. In return, my hands offer a moment of connection with the patient and allow me to feel my own sense of purpose more intently.

Our hands, variously, bring healing, inflict pain, and provide comfort. If all is well, our hands might signal that everything is fine. If all is not well, they might offer solace.

Our hands are integral to our identities

Too often of late, we have been forced to trade our hands-on moments for virtual visits, Zoom conferences, and social distancing. In clinic, we bump fists or wave to patients and family members when, once, we would have shaken hands or, even, hugged. I miss the personal contact. Maybe that will change again soon. Our hands are not idle, of course, since our fingers must still complete the day’s medical record notes.

Philosopher Immanuel Kant noted, “the hand is the visible part of the brain.” This makes sense to me, confirming that our hands extend into the world to fulfill our missions and gather information from everything with which we come in contact. That might be why I remember that day in clinic when a big neck mass simply came off of a patient, and I held it in my wondering hand.

_____________

A slightly different version of this essay entitled, "Using our Hands for Medicine and Wellness," appeared in the January 28, 2022 issue of the Transformational Times, a newsletter of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.

#AFoUSBook #KernInstitute

The VA - A Book Reading in the Operating Room and a Few Memories

I was honored to read stories and share writing insights with my friends and colleagues in the OR at the Zablocki VA Medical Center today. Thanks for the warm reception!

I did my first rotation at the VA in July 1980 as a brand new PGY1. Many of the people I spoke to today had not yet been born then, of course. The VA has changed quite a bit but not nearly as much as our other campuses. Here are a few things that I remember from 1980 that no longer hold true:

• We routinely had thirty patients on the ENT Service, many of whom stayed in the hosptial for months. It was common to admit someone in the fall when the weather turned cold and discharge them in the spring. Some would be hospitalized for their entire course of radiation therapy. I remember one veteran who was on our service for at least two years, hoping to heal his wounds after a laryngectomy.

• There was a sixteen-bed open ward on our floor (5A South). Making rounds was simple and we moved from one bed to the next. The vets would rat each other out if someone had refused medications, was still smoking when they assured us that they had quit, or wasn't complying with physical therapy.

• There was no such thing as outpatient surgery. Everyone was admitted the night before and stayed at least one night after. No one could be admitted for an elective procedure over the weekend, so patients undergoing surgery on Monday had to be admitted on Friday, then sent out on a pass until Sunday evening.

• Our section chief insisted that the pathology report be back before a patient was discharged (apparently in response to a missed report at some point in the past), so a patient undergoing a direct laryngoscopy (now an in-and-out procedure) would be admitted on Friday, have the procedure on Monday, and go home after the pathology report came back on Thursday.

• Patients who were at risk for alcohol withdrawl could have beer from the refrigerator in the nursing station. As I recall, it was not very good beer.

• The cafeteria closed at 2:30 for the day, so if I was on call wanted to eat anything between 2:30 pm and 7:00 am, I had to bring an entire meal from home. Or have nothing to eat.

• Smoking was permitted anywhere in the building. The VA had the cheapest cigarettes in town because there was no state tax. It was common to see patients pushing wheelchairs full of cigarette cartons to their cars after clinic visits. Ironically, the VA was the first Milwaukee-area hosptial to ban all smoking in the building, although there was pushback from the VFW and the American Legion. The VA built heavily utilized smoking shelters and initially put them right outside the front door. Not a good look.

• The operating room was on the second floor but the ICU was on the seventh floor. Waiting for elevators and navigating long corridors while moving very sick patients to the ICU from the OR was sometimes terrifying.

• As surgical trainees, we had frighteningly little supervision in the operating room and none at all in clinic. There was a coding system for faculty involvement in surgery ranging from 1 ("faculty surgeon scrubbed in and performing the case") to 5 ("faculty surgeon in town and available by telephone"). We did a lot of surgery as residents that would have been 3s and 4s. That never happens these days; the staff won't bring a patient into the OR unless the faculty member is present, in scrubs, and ready to go. Somehow, the lack of having faculty present seemed "normal" back then. It was wrong.

• The hosptial was built on the grounds of the Milwaukee Soldiers Home, an institution created in 1867. The current building was erected in 1966. When I was in training, it was the Wood VA Hospital. It was renamed the Clement J Zablocki VA Medical Center in 1984 after the powerful US Congressman in whose district the medical center sat. For years, there was a full-size recreation of Zablocki's office preserved as a museum piece near one of the entrances.

• Two of the most important employees at the VA were the men who worked in the radiology department file room. Back in the days when all xrays were on film and needed to be sorted and filed, they had an uncanny ability to find any film at any time.

• There were always a few employees that inexplicably kept their jobs despite assidiously accomplishing nothing while at work. As residents, we quickly learned who would help us and who would passively agressively make our lives harder. Maybe that is still true.

• Early on, I was always struck that the VA was a small town that just happened to have some incidental healthcare functions. There was a post office, a barber shop, a nursing home, a police department that could make traffic stops and write tickets, a store and cafe ("the canteen"), a bowling alley, a house on the grounds for the center director, its own zip code, a cemetery, a motor pool, libraries, and plenty of signs telling you that this-or-that was prohibited. There was a row of bars across National Avenue that were patronized by hospital patients, some in VA pajamas and pushing IV poles.

Here is what hasn't changed, though. I began working there caring for a few WWI vets and mostly WWII vets. I actually met a hundred-year-old veteran of the Spanish American War (the era of which ended in 1902!). Now, most of the people I see with head and neck cancer are from the Vietnam War or Gulf War eras. No matter when they served, it has been an honor to be part of their care.

#AFoUSBook #AFullnessOfUncertainSignificance