Myth # 1. Hawaii needs a “death with dignity” law to protect patient choice at the end of life.

            This is a complete untruth, peddled to a naïve society by a richly-funded marketing/lobbying group (Compassion and Choices, hereafter C&C) that has been trying for 20 years to sell the same story in every US state.

Everybody supports protecting patient choice. However, this bill is not about patient choice. C&C employs classic misdirection to gather support for a bill that seems to be about choice, and is actually about power – power allowing doctors to be involved in killing their patients with little investigation or followup.

Patients can already choose their end-of-life course without this law. When suffering is an issue, palliative care and specialized hospice care are widely available to everyone. A patient who wants to end his or her own life is free to do so. Suicide is completely legal in Hawaii and every other US state.

A doctor’s prescription is not necessary for suicide, and in fact represents a less-effective approach to suicide. Derek Humphry, founder of the Hemlock Society, C&C’s forerunner, tells how to arrange one’s death in his book “Final Exit,” still available on Amazon.

He favors inhalation of inert gas (helium, argon, or nitrogen – available over the counter everywhere) as the most effective and painless approach. He lists problems with the medical prescription approach.

SB1129 allows doctors to make decisions about who will die, to provide a Lethal Weapon in the form of a massive overdose of prescription medication, to cover up any details of the death that may seem unsavory, and to report as little as they choose to the state. Moreover, this bill will require that doctors lie about the cause of death on the official death certificate, even though these certificates become the basis for national medical planning and disease surveillance, in order to cover up an assisted suicide death.

 

Myth #2. Medication for suicide is easily available in the form of a pill that doctors can prescribe.

This is also completely untrue. No prescription medication produces death with a single pill, or even a few pills. No such medication would ever be allowed by the FDA to reach the market because of its risks. Death from prescription medications requires a massive overdose, up to 100 times the FDA-recommended therapeutic dose. At this point, the substance is no longer a medication but a Lethal Weapon.

There is no “best” Lethal Weapon drug. Manufacturers remove or restrict medications that are being used for killing, whether by legal lethal injection to serve a death penalty, or in a perversion of prescription use to commit suicide. Pentothal, for example, is no longer available anywhere because manufacturers did not want to support lethal injection. Darvon (propoxyphene) is no longer available as a pain medication because it was being used for suicide. Pentobarbital, once the recommended medication for C&C, has become unavailable because it is also used in lethal injection. Secobarbital is the only remaining sleep medication/barbiturate recommended by C&C. Death requires at least a 100-fold overdose (100 bitter capsules emptied into a bowl and mixed to become a slurry, taken quickly so the person intending to die does not fall asleep before a lethal dose is taken in.)

Barbiturates sometimes produce nausea or vomiting, raising the risk of breathing stomach contents into the windpipe and choking to death, or losing medication in the vomit so that death no longer occurs. Death from barbiturates overdose is not always swift. Patients in Oregon have lived as long as 4 days before dying; six patients have failed to die at all.

Doctors in Washington, and now in Colorado, are experimenting with other drugs. None have been used to produce death previously in this way, so every use is an experiment. Some patients have died very badly, some screaming in pain with burning throats or other misery. There is no FDA-approved Lethal Weapon dose of any medication. All use is untested, completely up to the prescribing doctors. The most frequent prescribers, those who work with C&C, do not publicly report their results.

 

Myth #3. Oregon has had an assisted suicide law for almost 20 years with neither fraud nor abuse. This proves it’s OK.

According to Neil Gorsuch in his book “The Future of Assisted Suicide and Euthanasia,” Oregon’s law was deliberately crafted in 1993 to appear to have safeguards and reporting requirements. C&C has done a skillful job of having people believe that safeguards and reporting are effective, and they have skillfully resisted any attempt to change or improve this law in the face of criticism. This applies to every state. C&C brings the law, sells it to legislators, appoints themselves guardians of the law, and finds that most of the patients seeking death come to physicians affiliated with the group, who are not required to share their information. States that adopt this law adopt a law with sham safeguards and reporting, and find it impossible to change thereafter.

Episodes of difficulty with the Oregon law have surfaced, but the lack of valid information at the state level prevents followup or effective statistical statements. Most deaths are unattended, so the events are unreported. Did the patient take the drug? Voluntarily? Struggling and fighting? Did somebody else “help out” by giving extra drug IV or rectally, or even by using a pillow or a plastic bag? Oregon has no such information, and no state conducts an anonymous survey as in Holland, depending instead entirely on individuals to self-report their own problems and face scrutiny.

Patients have no further protection after the prescription is issued. No further scrutiny or meaningful reports are required.

Lethal doses that are unused because the patient changes his or her mind, or dies too soon to use the medication, remain in the community, with no requirement for disposal or return.

Death certificates are falsified, with no way to track patients who have died of barbiturate overdose. Falsification of death certificates robs the CDC of accurate information about actual causes of death in the US, and prevents effective response to problems.

Before C&C’s lobbyists made false death certificates the law in cases of assisted suicide, false death certificates were used only by totalitarian regimes involved in actions that the regime did not want discovered. All “euthanasia” patients killed in Germany between 1939 and 1941 had false death certificates listing a plausible cause of death. All “final solution” victims who were killed during the holocaust also had false death certificates indicating plausible causes of death.

 

Myth #4. Hawaiians overwhelmingly want physician-assisted suicide. C&C’s surveys prove that as many as 80% support it.

It is true that Hawaiians overwhelmingly indicate an interest in retaining control at the end of life, in having freedom from suffering, and in dying with dignity. It is not true that Hawaiians want physician assisted suicide – this is a classical misdirection by C&C.

No survey has ever shown that Hawaiians want their physicians to be agents of death in order to meet those interests. There is no evidence that people answering these surveys have any idea at all what is actually involved in giving doctors the freedom to decide who will die.

C&C never discloses that its national agenda is to have doctors be agents of death in every state, and that it is prepared to move directly from “more palatable” assisted suicide to “more resisted” euthanasia, as is now happening in Oregon, where a “death by advance directive” bill is being considered. C&C equally does not disclose that it actually opposes any scrutiny of prescription requests or suicide deaths, and has attached the sham safeguards and reporting requirements only in order to reduce resistance to initial passage of a bill.

May 15, 2011

            Continuing the reposting of posts originally featured in “Playing Doctor.”

My sister and I have spent our adult lives getting fatter.  Neither of us wanted to do that, yet over the years we’ve accumulated enough extra fat between us to build a couple more people.

Now I’ve lost about 70 pounds on a healthy eating program, and I feel good.  She and her husband have been eating on this same program, and have each lost substantial weight, enough that people are noticing.

We talked about how easy this program has been, and how completely unaware we were that this is possible.  I once had the desperate feeling that I was doomed to continue inflating, since no matter what I did I continued to gain weight.

Since starting the program, I’ve thought repeatedly that it’s appalling how easy it has been for me to lose weight, bring down my glucose, and bring down my blood pressure.  Appalling because I didn’t know this was possible, didn’t know how to do it, didn’t know how to get direction from medical people anywhere.  Appalling because in my anesthesia practice every day I see people who are overweight, hypertensive, on oral hypoglycemics for early type II diabetes, and on cholesterol-lowering medications.  Appalling because I think that’s largely  unnecessary.  And appalling because almost nobody seems to know how to make a difference, yet.

The program that worked for me, lowering blood pressure and blood glucose in the bargain, was the Ultralite program (www.ultralite.us). The Ultralite people at Transformations.com have a program that works, but in my experience it’s marketed so casually that it’s very difficult to hook people up with it.

I’m now certified as a practitioner for that program. The program is certainly effective, and people who are doing it are pleased with the results.  People learn not only how to lose weight, but how to eat for the rest of their lives to keep the weight off. Why haven’t I recruited a gang of clients, if I think this is such a great program?

Two reasons. The program is expensive, and it’s hard to get patients started with other practitioners on the mainland. I think it’s too expensive for many of the folks for whom I’d like to make it available here on Kauai.  Why is it expensive? Mostly because it’s practitioner-supervised, and because it uses a proprietary snack between meals in addition to lots of “real” food.

When people who don’t live here ask about the program, I find it’s hard to get people started with practitioners in other locations, even though people on the mainland might be best served by someone in their own area.  Sure, I could be the practitioner for these people.  I can coach on the phone (the life coach training, you know), but there are a limited number of people for whom I can do that. I’m still practicing full time as an anesthesiologist, and I live in a time zone that’s as much as six hours dislocated from parts of the US.

Are there other approaches?  In truth, none that I’ve tried. But the ideas on which the Ultralite plan is based are not secret and not proprietary.  They are increasingly general knowledge.  Several people seem to be speaking to the same ideas as those used to create the Ultralite plan – people including Dr. Walter Willett from Harvard, Dr. Steven Gundry (www.drgundry.com), Isabel de los Rios (The Diet Solution, available on the internet), Gary Taubes of “Good Calories, Bad Calories,” and an increasing chorus of others.  All these people seem to be saying that the whole “low-fat” conversation has been a journey off the path, and that the biggest issue with our current way of eating is the preponderance of sugar and high-carb, high-glycemic processed food.  This deserves much more discussion in future articles.  For now it’s sufficient to say that many of my prior ideas about food and nutrition seem to have been all wet.

My sister and I also talked about the differences between the medical model and the coaching model.  In the medical model, something is wrong and we’re here to diagnose it and fix it.  Find a problem, prescribe a solution.  Pills work for high glucose, for high blood pressure, and for high cholesterol.  They don’t do much for excess weight, but there’s always weight loss surgery if you’re heavy enough to qualify.  I believe that weight loss surgery for most people, by the way, is one of the most inadvisable moves anyone ever can make.  It literally consists of making yourself sick for the rest of your life in order to lose fat.  That’s healthy?

Coaching (as in life coaching) takes a different approach to issues than does medicine. To coaches, people are whole and complete and have within them all the resources to create the lives they want.  People want help in discovering and developing these resources.  Coaches don’t fix, and don’t give advice.  But they do help people tap their own inner wisdom, learn new ways of being and doing, and create different lives.

So being fat isn’t something to fix, and it’s not a character flaw.  It is, for most of us, the predictable result of the choices we make and the way our bodies work.  Fat is simply the energy store that accumulates in a body skilled at gathering and storing energy in times of plenty in order to survive times of famine. In my own experience, even when I thought I was eating “healthy,” I was still making choices that directed my body to accumulate fat.  Increasingly, there’s information available that allows me (us) to make different choices.

Each of us has within us the ability to direct our actions, channel our instincts, and create the best lives of which we’re capable.

Over the next few months (years?) I’ll be looking at what we know about food, and what we think we know.  More than 30 popular diet books and a couple of internet programs are piled by my chair right now. I’ll look at places where people pretty much agree, and where they don’t.  I’d like to see a website with a simple eating plan to which I can refer people, one geared to empowering people for the rest of their lives instead of harvesting money, one with straightforward discussion of issues.

We will change the world’s conversation about food, and about fat.

 

May 6, 2011

Continuing the reposting of posts originally featured in “Playing Doctor.”

I used to think that only a fool could experience much confusion about food and nutrition.  When I went to medical school, back in the days of leeches and wooden needles, nutrition was briefly covered in the biochemistry course.  Beyond that, it was pretty much, “Mmm, food good.  Eat food.” And, of course, “Fat people have no impulse control.”  This came from my freshman roommate, himself a skinny guy who went on to become a skilled and apparently compassionate bariatric surgeon.

I’ve spent my life thinking that the equation was pretty simple.  If the number of calories taken in exceeded the caloric cost of running the body machinery, excess calories were stored as fat.  Weight loss occurred if we expended more calories than we had taken in, and weight gain occurred in the opposite circumstance.  Good nutrition meant taking in the right quantities of available “healthy food.”

Now I’m beginning to see that food isn’t an easy or straightforward issue at all.  Perhaps all calories are not equal.  Perhaps all food is not equally good for us.  Perhaps even the “healthy food” that’s available isn’t so healthy, at least for the people who eat it.  For the economy? Maybe so.

The movie Food, Inc. seems to say that we’re guided by advertising and availability to eat what we eat because that’s where the money is for food and agriculture interests.  The once-hallowed FDA Food Pyramid of my youth seems to have been the result of a political process involving lots of lobbying by folks who wanted to be sure we continued to eat what they were being paid to produce – thus the heavy focus on grains.  Apparently, neither nutritionists nor health authorities had much to do with its production, though it has a profound effect on health.

Individual voices stand out, sometimes out of proportion to the actual proven value of their message.  Gary Taubes’ article, “Is Sugar Toxic?” (NY Times, April 13, 2011) reiterates the story of nutritionist Ancel Keys from the University of Minnesota. Keys was such a strong proponent in the 1970s of his idea that dietary fat consumption was the best predictor of heart disease that he was able to discredit the equally-probably ideas of England’s John Yudkin, along with Yudkin himself.  Yudkin had argued that sugar consumption was linked directly to both the triglycerides of heart disease and the insulin levels of type II diabetes.  Keys’ powerful personality led to widespread acceptance of ideas about fat and heart disease that may have led us to adopt even more harmful high-carbohydrate diets to avoid fat.

I’m reminded of the Gary Larson cartoon in which a shark in the water near a beach cups his fins around his mouth to yell, “Bear, Bear!!” as panicked bathers stampede into the water to escape.

Casting caution to the winds, I have boldly asserted that I will wade into the morass of dietary information and sort out scientifically proven ideas from those that merely seem sensible.  In the process, I’ll identify those ideas without a shred of supportive evidence, and those that fly in the face of good sense.  When I’m done with that, it’ll be clear how we should all eat, and I’ll just jot it down and then we can get back to worrying about bigger things, like where Obama was born and whether autism causes global warming.

Or not.

Chris Mooney’s article on “Made-up Minds,” published originally in Mother Jones and excerpted in “The Week” (May 20, 2011), reminds us that reasoning is inseparable from emotion. We all tend to pull friendly information close and push threatening information away.  The fight-or-flight response, he says, applies not only to predators but also to information itself.

What’s that mean?  It means that emotion may not have much bearing on scientific conclusions, but it certainly colors those conclusions to which we give credence, and those we’re willing to talk up.  We accept evidence that supports our views, and reject evidence that doesn’t.  In fact, we often reject as experts those whose conclusions, however well researched, don’t fit our pre-existing views.

That’s a little awkward.  Does that mean that I can’t make an unbiased analysis of popular writing, looking for its scientific backing?  Will I filter out the stuff that doesn’t agree with my biases, even if it’s well-researched, and even if I think I’m being wonderfully even-handed?  Does that mean people shouldn’t trust me, either? Will my recommendations be just another set of biased ideas, based on that fraction of the literature that supports biases that I already have?

Yeah, maybe. I’ll be authoritative, but not a “final authority.” I’m a seeker, an inquirer, an asker of questions.  When I present an idea as true, I really think it is.  Remember, however, that my pronouncement and $4.00 will get you coffee at Starbucks.  In other words, my idea is just that — my idea, however well-spoken.  Even my objective judgments are difficult to separate from emotion, from my urge to affirm that the universe really does look the way I think it should look.

Trust and verify.

 

December 25, 2010

Continuing the series of posts previously published in “Playing Doctor”

Nine weeks ago I weighed forty-four pounds more than I do now.  I’m peeling off almost five pounds a week.  Without surgery.  Or drugs.  Or extreme exercise.  Or even any particular fortitude on my part.  And therein lies a story.

I had all but given up.  I seemed to be helplessly ballooning several pounds every year, and had been doing so for forty years.  Nothing worked, except for a brief period in my late 30s when I was running many miles a week. During that time my weight dropped as low as 180 pounds, almost as low as my college weight.

The rest of the time has been marked by slow and steady expansion of my girth.  Over and over I reached and passed a weight that I once thought unimaginable.  Clothes from a few years ago never fit.  I have jettisoned many wardrobes in my enlarging wake — suits, a tuxedo, wet suits, and any number of pants and shirts.  Finally, even clothing bought for the largest person I was ever going to tolerate no longer fit.

At age 66 I found myself approaching 265 pounds, 85 or 90 pounds more than my college weight – and none of that gain was muscle.  Pants with a 42 waist were snug.  I needed 2XL aloha shirts to fit my expanded abdomen and prodigious backside.  Rising from a chair was a chore.  Getting up out of a car required both elbows on the doorframe.  Tying shoes was increasingly difficult – I couldn’t breathe with my big belly mashed against my thigh, so I could tie only as long as I could hold my breath.

The progression to this stage hasn’t been a straight line, but it’s been inexorable.  Many times I’ve taken on some program or another and whittled away ten or fifteen pounds, only to watch the scale begin to rise again in a couple months.  For the past several years, however, I haven’t been able to do even that.  Even the most sensible calorie-counting and exercise seemed to have become ineffective in reducing more than a pound or two in a month.

I had begun to despair.  I was fat, I was increasingly out of shape, my blood glucose consistently ran above 100 fasting, and my blood pressure had begun to climb slightly, no longer returning to the old 120/70 when resting.

Then my college roommate and his wife talked about their experience at George Washington University in a practitioner-supervised program that involved a diet designed to spare muscle and use fat.  They’d both lost weight quickly, and they hadn’t been hungry.  No suffering was involved.  No drugs.  Real food, prepared at home from a list of acceptable foods.  And the objective of the program was to teach people how to eat for the rest of their lives in a way that maintained a healthy weight.

The Ultralite program, it was called.  Devised by a naturopath in Australia, apparently fairly popular there.  Strict diet, weighed portions, temporary withdrawal of the foods to which people commonly have reactions, and a supervising practitioner.

There were no practitioners on Kauai.  I talked to the people who run the program in Los Angeles, talked about becoming a practitioner myself in order to bring a program here if it was effective. They were willing to supervise me from a distance on the phone, and willing to have Jan do the diet with me.

And now it’s more than nine weeks later.  I’ve now lost more than 44 pounds, weighing in last Monday morning at 219. I feel good, I’m seldom hungry (no more than any other time), and I’m loving my new lightness.  Blood glucose has dropped to 70-80 fasting, and morning blood pressures run around 115-60.

Can it really be this easy?  I’m learning that it can, that all the sweat and struggle that I’ve gone through before has been unnecessary.  I’ll talk more about this diet later, but I’ll say at this point that I’m learning to eat a balance of protein and carbohydrates with virtually no hi-glycemic carbs – no wheat, no rice, and no potatoes, no sugar.  I thought I’d miss all that.  I don’t.  Will I want some later, once weight is lost?  Yes, and I will have learned to eat in a way that will have me maintain my new weight for life.  The new weight?  It’ll be around 180, about what I weighed 45 years ago before I began to demonstrate what an effective-energy storing ability my ancestors had evolved.

More on this later.  This is a big deal for me – I suddenly have easy access to making a difference where I’ve felt completely ineffective for most of my life.  And I see how easy it could be for others.

August 20, 2010

Continuing the series of posts previously published in “Playing Doctor”

In my hospital, one of the ways we measure quality of care is to look at patient perception of care.  A nationally known polling agency sends questionnaires to patients, and from them we learn something about whether patients are impressed by the care they receive.  We treat patient satisfaction scores with great reverence.  Our goal is to produce at least as many satisfied patients as comparable hospitals surveyed by this agency.

The larger health system of which my hospital is a part has for several years exhorted its employees to remember AIDET – perhaps the most awkward acronym every devised in service of a noble purpose.  AIDET stands for Acknowledge, Introduce, Duration, Explanation, and Thanks, or something close.  The acronym is meaningless, the construction isn’t parallel, and the actions are listed out of order to create the acronym.

Nevertheless, the fundamental idea is sound.  It fits with the customer service principles I learned in business school.  We want everybody to ensure they’re talking to the right patient about the right procedure. We want each patient to know exactly who we are and what our role in their care will be.  We want each patient to fully understand the procedures we’ll be doing.  We want patients to know how long their care will take, and we want them to know what to expect when delays arise.  And, finally, we want to thank patients for coming to us.

This week I accompanied a close friend to my hospital for an endoscopic procedure. I sat by her side as a series of people readied her for care and returned her to her room.  Overall, she says her experience was entirely pleasant.  People were friendly, reassuring, and competent.  Everything proceeded briskly, nothing went wrong, nothing hurt, and the outcome was perfect.  She left feeling that she’d had a good experience.

But not a great experience…  She didn’t come out singing the praises of the hospital and its employees.  We really didn’t surpass her expectations at any point.  We simply met them competently.

Did we remember AIDET? Not entirely. Everybody reviewed her full name, birth date, procedure, and allergies – so consistently that my friend began to question whether anybody believed her or was paying the slightest attention to the work of others.  It would have been useful to mention that everybody who is about to provide care would review this information.

On the other hand, few people did an adequate job of presenting their names and roles. She met one admitting clerk, two hospital assistants, one admitting nurse, two nurses from the endoscopy room, the anesthesiologist, and the endoscopist himself, whom she had met previously.  Few introduced themselves by name. Almost nobody except the anesthesiologist was introduced by role.  Even the anesthesiologist did not introduce himself by name.  Although he and I knew each other, he didn’t know my friend, and he didn’t carefully check her ID and procedure or introduce himself. None of this occurred as rude, exactly.  Neither did it say, “You’re an important person.  Before we touch you, we want to be sure you know who we are and what we’ll do.”

Almost everybody gave a good explanation of what would be happening, and how long it would take.  The endoscopist himself had her sign a consent without additional explanation in the procedure room right before she went to sleep.

Surprisingly, although everyone was polite and cheerful, nobody specifically thanked her for coming.  Even on a small island, she does have choices. It might have been impressive if one or more people had thanked her sincerely for choosing us for her care.  She was dismissed with a friendly wave and a warm smile, but not much thanks.  In fact, she points out that she wasn’t even actually formally welcomed.

A further observation: our hospital looks at hand-washing in a variety of ways in order to promulgate pervasive hand sanitation.  Patients are asked whether personnel caring for them cleansed their hands all the time, some of the time, or seldom (or something like that).  The only person I actually saw using the hand-cleaner dispenser in the room was one of the nursing assistants.  My friend saw two of the nurses and the anesthesiologist use the dispenser. Everybody may have had clean hands, but by the questionable measure of whether their cleanliness was witnessed, we didn’t surpass 50%.

What if everybody had done the good work they did AND paid attention to AIDET, with or without the silly acronym?  Would my friend have come away with the sense that all these people really cared about her experience with them, even more than she did?  Would she have come away with an experience that left her enthused and delighted, not just satisfied and relieved?  I think so. Almost certainly we could have improved an already-good patient-satisfaction score.

Would that have been better quality medical care? More health, less disease, more result for less money?

Everybody knows the story of the fellow who comes upon an inebriate crawling on the ground under a street light.   Asked what he’s doing, the inebriate replies that he’s looking for his car keys.  The newly arrived good Samaritan drops to his knees and begins searching too.

After several fruitless minutes, the Samaritan asks, “Are you sure you lost them here?”

“No,” replies the inebriate, “I lost them crossing that field.”

“Well, then,” says the Samaritan, “why are you looking here?”

“The light’s better here.”

Are we hoping that we can find medical quality by looking at customer satisfaction just because the light’s better here? If we really did improve customer satisfaction, would the quality of medical care be higher?

August 11, 2010

Continuing the posts previously published in “Playing Doctor.”

I saw part of an episode of the TV series “House” the other day.  In it, a young man required frequent lumbar puncture for daily injection of an anti-infective agent.  I don’t remember the story line, but I remember that the spinal tap was presented as an agonizing event during which the young man sweated, gritted his teeth, and bravely pulled through with the sympathetic help of the medical staff.

Here’s news, America!!  A spinal tap should not hurt.  A spinal anesthetic should not hurt.  An epidural should not hurt.  If it hurts, somebody is doing it wrong.

Under most circumstances, once skin is anesthesized (one big pinch or sting), there’s nothing else in the midline that hurts as a needle traverses bone-free space on its way to the epidural or intrathecal space.  I tell patients that I want to be in the midline where it doesn’t hurt.  If something bothers them, it means I’m not where I want to be.  Tell me it bothers you, and tell me which side, and I can easily correct to the midline. It did take me a while to learn that if I listen to my patients, they’ll tell me exactly where I am and guide me to a successful midline puncture.

Patients who have to endure great pain during a spinal procedure are, I believe, receiving incompetent medical care.  There’s no reason for it be painful, except operator carelessness and indifference.

Even a paramedian technique should not be painful, once the needle track is anesthetized (a little more painful than midline).

So why do patients so frequently think a spinal procedure will be miserable?  I suppose in part it’s the idea, but it’s also based on real experience.

I had a patient recently who was to have a total knee replacement, for which we usually do a spinal anesthetic with enough added sedation (propofol infusion) that patients sleep painlessly through the procedure.  He’d had a terrible experience with a myelogram 40 years ago, with painful repeated punctures, and for 40 years he’d refused to let anyone touch his back.

I told him why I’d prefer a spinal myself if I were having the procedure, and told him that I didn’t expect a spinal to be a painful ordeal.  He decided to go ahead with a spinal, which proved easy and uneventful.  I just received an e-mail detailing his parking-lot encounter with a hospital administrator in which he talked about what a good job I’d done with his spinal.

And that’s the sad part.  I did a very ordinary job, the sort of job every person having an anesthetic or a spinal tap has a right to expect every day.  That we continue to send the message that spinal procedures are by nature painful is a continued failing, I think.

And while I’m at it, I think starting an IV without local anesthesia is another unnecessarily barbaric procedure.  Digging around to find a vein without local is thoughtless and insensitive.  Tell ‘em I said so.

June 20, 2010

Continuing the old posts from “Playing Doctor”

Anger and I have a history. I have related to anger as a character defect, something wrong with me, for at least the last 20 years. But that’s not the truth.  That’s just a conversation, something people say.

What if we said something different? What if anger is not only normal for all of us as humans, but useful as a source of power?

“DON’T TOUCH ME!!” That’s the last phrase a large, intimidating male working in a mostly-female workplace wants to hear, especially out loud in front of witnesses. In my reality, I had touched the shoulder of a nurse anesthetist as she turned to leave a conversation about inadequate patient care before it was clear that she could fix her error.  In her story, I had struck her, severely injuring her shoulder and requiring that she be off work for months undergoing therapy.

The district attorney contemplated an assault charge.  The Board of Medical Quality Assurance contemplated lifting my license. (I learned that BMQA investigators carry badges and guns, as if the power to take a license were not intimidating enough.) The hospital board contemplated suspension of privileges.

None of these punishments came to pass.  Instead, I experienced my first anger management counseling in the upscale home of a woman who had previously run the hospital’s employee assistance program. Anger, she said, rises from fear – most commonly from fear of loss.

The workplace became less and less accepting of anger as I had experienced it. I was loud, I was foul-mouthed, and I looked intimidating.  I was no better at home on our ranch, where displays of temper were common and bad language frequent.  Though I never actually injured anyone, I broke my toe kicking a cow in anger during veterinary work, and I recall with shame brandishing a length of pipe at a teenager from the neighboring nudist colony when I caught him riding a dirt bike (fully clad) on our property.

I would have said that I was seldom directly angry at my first wife,  but I learned after our divorce that she had had a different experience.  I had been angry in her vicinity so frequently that she had felt virtually controlled by my anger.

I married again, this time a woman whose own anger was nearer the surface. She had little tolerance for any expression of anger from me.  Overt anger, a stern-sounding voice, an upset expression, cursing – all were unacceptable. There were no mitigating circumstances.  Anger around kids was even more reprehensible.

Over years, personal development courses and counseling have made a difference. I’m less and less volatile, less blaming, more aware that my world evolves from my own choices, more able to be with what’s so – and yet the goal of perpetual placidity and optimism continues to elude me.

Now in the midst of a second divorce, my men’s group said a few days ago that I seemed angry. I’d been denying that, generally saying that things are fine.

But they’re not fine.  I’ve lost my second marriage, my relationship with my stepchildren, my access to easy retirement, and some freedom of choice about how much I need to work.

The woman with whom I spent a dozen committed years decided last summer that she didn’t want to be married any more.  She said she’d like to end the marriage and be friends.  The friendly divorce that we first anticipated disappeared into failed negotiation, failed mediation, and wholly baseless suspicions that I must somehow have squandered or hidden our assets.

We do have much less than we once had, but our money isn’t hidden. It’s gone. We consensually spent it, lost it as our equity-based retirement account fell to half, or lost it in the real estate decline as our new mortgage went under water.  We’ll split what remains, with each of us a loser.

The children to whom I’d been stepfather for fifteen years seem to be pulling further and further away.

So I’m angry.  So what? What if anger isn’t wrong, isn’t a failing, isn’t a character defect?  What if anger is normal and natural, part of everyone’s emotional makeup?

What if we were able to treat anger as a form of power or energy?

If anger were volcanic energy, it might be instructive to look at the difference between Mount St. Helens and Hawaii’s Kilauea.  In one, energy is held in until it’s too powerful to contain.  Explosive release destroys the environment, rendering an area unlivable for years.  In the other, energy is constantly released, explosions are unthreatening, and the resulting lava flow creates an expanding island.

What if we could channel anger into constructive action rather than explosive displays?  What if we went running, or tore out a wall for reconstruction, or wrote a piece on anger, or focused on legal strategies that would end a stalemate?  What if we let anger power life-improving actions instead of destructive explosions? What would it take to keep anger constructive, positive, and unthreatening all the time?  Now that’s a worthwhile inquiry…

August 7, 2010

            I’m inserting older posts from a previous blog here for completeness. In 2010 I called myself a physician and life coach.  The original question for this blog was whether I could write as a professional about my own humanity.  Could I be open, vulnerable, in touch with fears and failings as well as strength and wisdom? When I began medicine four decades ago, it would have seemed un-professional to put personal thoughts in a place where they could be read by anybody who happened by.  Now it seems not only permissible, but valuable.  I learn daily from blogging physicians and coaches who speak without fear.

Not a single feature of my current life [in 2010] could have been predicted four years ago.

In 2006 I was working per diem as a clinical professor of anesthesiology at a major medical school in the Pacific Northwest, looking forward to creating a life coaching practice that would have me out of the operating room in a few more years.  I anticipated that we’d either stay in the Pacific Northwest or move back to central California to be near my middle son and his wife.  I planned to research and write a book on greatness, interviewing prominent people who seemed unafraid to let their light shine in the world.  I was happily married, eight years into a second marriage with children in their teens.

The first never-gonna-happen surprise is that I now live in Hawaii. Four years ago I had never spent a minute thinking I might live here.  I loved the Pacific Northwest.  Then in 2007 after a period of family inquiry, we chose to radically reshape our lives and move to the Big Island. I said I’d do whatever it took to make the Hawaiian adventure possible.  That turned my work life in an unexpected direction.

The second surprise is that instead of moving out of the operating room to be a life coach, I now practice anesthesiology full-time as chief of a high-quality rural practice on one of the outer islands. I thought I was burned out, done, tired of the whole thing.  I was increasingly afraid of the operating room.  I couldn’t have imagined practicing full-time and being responsible for a department, and I couldn’t have imagined loving this practice, its people, its challenges.

The third surprise is that my marriage has ended. I live by myself in a condominium on Kauai, not in the family home on the Big Island.  In the summer of 2009 my wife said that she no longer wanted to be married.  She wanted us to end the marriage and still be friends.  A year later, negotiations have failed to produce a simple or friendly agreement, and an appointment in divorce court seems likely.

Finally, and most surprisingly, I looked briefly on match.com last summer when it seemed that my marriage would soon be over.  I asked for a woman who was warm, loving, wise, kind, good-humored, sexy, and willing to love and be loved.  To my immense surprise that woman appeared, and we’ve been “together” for almost a year now despite my failure to finish a divorce as quickly as I’d predicted.  She’s exactly who I was asking for.  Once again, my experience could never have been predicted.

I’m guessing that the blog will be another unpredictable experience.  Stay tuned. Where once I thought I had many of the answers, I now have mostly questions.  This is where I’ll explore them.  I welcome comments.  Without dialogue, I’m simply in my own head…