Gut Feelings

Wednesday, July 17, 2013

If I Only Had A Heart

Robert S. Rosson, M.D.

Former Vice President Dick Cheney Has Heart Transplant- -Hartford Courant: 3/24/2012

(To the tune of “Tin Man” from the Wizard of Oz)

When a man’s a former Veep,

Starting wars on the cheap

With the gun and sword;

If I’d catch a man of terror

To get info free of error,

I’d use the water board!

When hunting with a chum

I might shoot him in the bum,

And never give a damn.

While Bushy was the Chief

I could play him like a thief

And get Saddam on the lam.

It was fun and it was nice.

Although I was just the Vice,

A conflict I could start.

War was all consumin’

Pretending I was human,

If I only had a heart.

Silence

Robert S. Rosson, M.D.

It hangs over the house like a dense curtain,

Like a thick, impenetrable fog.

It is everywhere and nowhere;

Unbroken by the Brahms from the stereo

Or the nattering noise of the TV.

It is the silence of her absence.

There is the welcome ring of the phone.

They ask “How are you doing, Dad?”

I tell of the latest dinner with friends,

Or the movie attended alone.

Then the silence returns.

I long to tell her the latest gossip,

Or the good news about the choice

Of a new music director for the Symphony.

But there is only silence.

The lonely, numbing, deafening silence.

A Visit to the Doctor

The encounter described below was told to me by a physician friend. It illustrates many of the problems plaguing today’s medical care.

I enter the doctor’s waiting room 15 minutes before my appointment. I sign in and the receptionist copies my insurance cards for the ninth time. I fill out a lengthy questionnaire designed to be entered automatically into the electronic record. I then sign the privacy form without reading it.

I sit down and unfold my New York Times. I get through most of it before I realize that 45 minutes have passed. Finally a medical assistant appears and calls out “Doctor, you may come in now”.

“It’s about time” I say, irritably.

“Oh, I’m so sorry,” she says as she guides me into a tiny examining room that would be inadequate for a monk’s cell. The room is dominated by a large computer screen on a movable bracket attached to the wall. After she checks my weight and blood pressure she leaves, assuring me the doctor would be in soon. Another half hour goes by during which I wish I had brought something else to read.

Finally the doctor enters greeting me with “Hi Bill, how’s retirement treating you?”

“Great,” I say.

He disappears behind the monitor, eliminating any chance of eye contact. I tell him I’m there because of a cough that has persisted for six weeks after a common cold. He asks some questions, all the time typing away on the keyboard.

He then examines my chest, listening with his stethoscope through my shirt and sweater. I can’t resist asking him if he can hear anything this way. He assures me that with his electronic stethoscope he can hear quite well and that my lungs are clear.

He writes a prescription for an expensive cough medicine that isn’t covered by my insurance. I decide I’ll pick up a cheap over-the-counter preparation. I ask if a chest x-ray might be a good idea. As he goes out the door he says it’s not necessary because my “lungs are clear.” I glance at my watch. Total “face” time with the doctor is 11 minutes.

When the cough persists for another two weeks I order my own chest x-ray:

RADIOLOGY REPORT. “There is a five centimeter oval mass in the right upper lobe, adjacent to the mediastinum. The appearance is consistent with a primary neoplasm of the lung.”

Published originally in YJHM January 23, 2011

The UConn Health Center: Whither or Wither?

On November 21, 2009 it was announced that the University of Connecticut had rejected a proposal by Hartford Hospital to merge with the UConn Health Center to form a first rate medical school-hospital complex. Under this plan, supported by a state-sanctioned commission, the state would build a new hospital in Farmington to be owned and operated by Hartford Hospital. The result would be a new University Hospital with campuses both in Farmington and Hartford. The Hartford Healthcare Corporation would assume financial responsibility for the new hospital except for $13 million in labor costs to be born by the state. The other community hospitals in Greater Hartford would continue to participate in the teaching and research activities of the medical school.

Now the situation will revert to that of 18 months ago; the Dempsey Hospital will remain too small to be financially profitable, and the state will continue to be responsible for an annual deficit of about $20 million. Moreover, the 32 year-old hospital is said to be in need of major renovations. No alternative plan has been proposed by UConn or the Legislature. The question is where we go from here with this unsustainable situation.

In the Hartford Courant of Sunday, December 6, 2009, Connecticut State Representatives David Baram and Timothy Larson, suggest that the VA partner with UConn as a way to solve the problem. They make no mention of the Newington VA Hospital; which already has an affiliation with the Health Center. In recent years that hospital was reduced to an outpatient facility and its inpatients transferred to the West Haven VA, which is a major affiliate of Yale Medical School. At one time a suggestion was made that the VA build a hospital on the Farmington site, but nothing came of it. While the VA does provide salaries and space for residents and faculty at many medical schools, I do not know whether it can provide operating expenses for university hospitals or funds to build new non-VA hospitals.

I would suggest, as others have, that UConn revisit the idea of the “Harvard Model.” This system is one in which the university medical school has no hospital of its own, but rather utilizes the hospitals within its geographic area for teaching students, residents and fellows, and for care of patients and research by its faculty.

In this regard I suggest the following:

The Legislature and UConn should appoint a joint commission to study this possibility. Representatives should visit Harvard Medical School to learn in detail how the system works.
UConn should engage a consultant with intimate knowledge of the Harvard Model to determine the efficacy and implementation of such a system in Greater Hartford.
Under this proposal, the John Dempsey Hospital would close its inpatient services.
The hospital would be re-fitted to include research laboratories, outpatient clinics, outpatient surgical centers, a walk-in center, and a triage emergency center. Patients needing admission could be rapidly transferred to one of the cooperating community hospitals by helicopter or ambulance.
The participating hospitals, Central Connecticut, St. Francis, and Hartford Hospitals, and others, would provide laboratory and office space and designated hospital beds to the university physicians. Consultations between the university and community physicians would work to the benefit of both groups and their patients. Each group would contribute significantly to the education of medical students, residents and fellows, who would continue to rotate among the hospitals as they do now.

Obviously many financial and administrative problems would have to be worked out before such a plan could go into effect. With, however, strong, enlightened leadership and open-minded good will among the various players, the University of Connecticut-Greater Hartford Medical Center could become the first rate system of education and medical care the citizens of Connecticut deserve. If we can become first class in basketball and football, we ought to be able to do it in medical education, research and patient care.

Note: The writer is a graduate of Harvard Medical School and Clinical Professor of Medicine at the UConn School of Medicine. The views expressed herein are strictly his own and do not necessarily reflect those of either institution or YJHM.

Published originally in YJHM December 9, 2009

Remembrances of Internship Past

As I read the recent obituary of Dr. A. Stone Freedberg (NY Times, 8/24/09), memories of my internship at Boston’s Beth Israel Hospital came flooding back. Dr. Freedberg, who died at the age of 101, had a long and distinguished career in cardiology at that institution. I recall herein some of my experiences of some 50 years ago.

In the Beginning

I reported for duty at the BI as a medical intern on July 1, 1958. An eager, freshly-minted MD, I looked forward to working every other night and weekend, for $25 a month and all I could eat. I was outfitted in a white barber’s smock, white trousers and white bucks and sent off to the medical ward under the supervision of an all-knowing, experienced first year resident. Before I could catch my breath I was doing histories and physicals on admissions sent up from the emergency room. I quickly learned that the admitting residents were to be designated as “sieves” whereas when I was in the ER, I was to be a “steel door”.

My wife, Eileen, taught second grade in Norwood, Mass. She drove to work from our Boston apartment in our battered Chevy while I took the “T” to the hospital. The physical and mental stress of internship and our marginal financial status put a tremendous strain on our year-old marriage, but at the same time strengthened our relationship. The celebration of our 52nd anniversary this summer attests to that fact.

Emphasis on Cardiology

Dr. Herrman Blumgart was Chief of Medicine at the BI. This brilliant, gentle physician was the first doctor the entering freshmen at Harvard Medical School encountered. He had made outstanding contributions to the understanding of coronary artery disease, including the finding of plaques in the coronaries of young men killed in battle in WWII. His cardiology division included, in addition to Dr. Freedberg, Dr. Louis Wolff, Dr. George Kurland, Dr. Paul Zoll, and others. The most common disease admitted to our service was acute myocardial infarction. The treatment at that time was three weeks of strict bed rest and anticoagulation. Needless to say the mortality rate was quite high. We spent a lot of time using Dr. Zoll’s invention, the cardiac defibrillator, with limited success. Later Dr. Zoll’s machine would be supplanted by the one developed by Dr. Bernard Lown at the Brigham.

A Near Death Experience

Sometime in that first year I developed axiliary furunculosis. I had a resident drain the first boil uneventfully. When Dr. Jim Feeney, the physician to the house staff, found out about it, he insisted that the next one be drained by an attending surgeon. Two days after that was done I awoke with a temperature of 103 degrees, feeling worse than I had ever experienced. My wife was almost out the door heading for work when I called her back and suggested she take me to the hospital. I was admitted with septicemia due to the nasty strain of staphylococcus then running around our hospitals. The only drugs available at that time for treatment were oral Chloromycetin and intravenous erythromycin. Each day Dr. Blumgart listened to my heart and felt for my spleen while I pretended that I didn’t know he was looking for signs of endocarditis. I was also seen by the famous infectious disease expert, Dr. Louis Weinstein, which was at once a comfort and a source of anxiety. At one point Dr. Blumgart horrified Eileen by saying “We’re just as concerned about him as you are.” At any rate I recovered and a brilliant career was not aborted.

The Thyro-Cardiac Axis

The cardiology and endocrinology sections of the department of medicine collaborated on the relationship between thyroid function and coronary disease. Dr. Freedberg explored the treatment of severe angina by inducing hypothyroidism with radioactive iodine. Dr. Kurland investigated the role of hyperthyroidism in cardiac arrhythmias. For a time I worked in his laboratory, suspending an isolated rabbit’s heart in a lactate solution and recording its beat on a smoked drum kymograph (!). I tried to induce atrial fibrillation by adding thyroid hormone to the bath. I suspect the only fibrillation I induced was in my own heart.

Role Models

The physicians I was privileged to work with, and learn from, during that year, Drs. Blumgart, Freedberg, Kurland, Milton Hamolsky, Louis Zetzel, and Herb Saver, to name but a few were a source of inspiration that influenced my entire career. They taught me that no matter the specialty we are internists first and foremost, a lesson that I fear is lost to today’s crop of super sub-specialists.

Back to the Future

I stayed at the BI for two years, during which time my daughter Julie was born. I entered that institution a medical student and left as a physician. I then served two years in the Air Force, after which I went to Yale/New Haven for my GI Fellowship under Dr. Howard Spiro. But that’s the subject of another story.

Published originally in YJHM September 2, 2009

Your Online Ethics Quiz

Welcome to Your Online Ethics Quiz. Submit your answers to The Institute for Ethics Research, insethres@morality.org.

1. Rick Pitino, prominent and successful basketball coach, admits to a one time sexual “indiscretion” six years ago. The married father of five and pro-life advocate is also said to have paid $3,000 to the woman for an alleged abortion. The President of the University of Louisville, his current employer, should:

Fire him immediately, but with a golden parachute.
Give him a raise in pay.
Keep him on as coach if his team gets to the final four.
Force him to give 100 hours of community service to Planned Parenthood.

2. The former chief financial officer of Hadassah, Sheryl Weinstein, admits in her new book to have invested heavily for the organization and for her own account with convicted fraudulent investor, Bernard Madoff. Moreover she admits to an affair with the financial wizard. She should now be forced to:

Apply for food stamps.
See Bernie regularly for conjugal visits in prison.
Perform 500 hours of community service for Hadassah.
Accept a job at A.I. G.

3. Michael Vick, recently released from prison for running a dog-fighting ring, has been signed as back-up quarterback for the Philadelphia Eagles. The Commissioner of the NFL should now:

Commend the Eagles for combating unemployment.
Permit season ticket holders to bring their dogs to Eagles’ games.
Make Vick do 200 hours of community service for the American Kennel Club.
Permit the use of pit bulls in the backfield to protect Vick from opposing linemen.

4. Sarah Palin, the recently self-deposed governor of Alaska, accused the Obama administration’s health care plan of providing for “death panels” for seniors. She should now:

Promise never to run for elective office again.
Learn that “euthanasia” is not a young persons group in China.
Apply for membership in the Hemlock Society.
Perform 150 hours of community service for the Coalition for Teen Age Abstinence.

5. Governor Mark Sanford of South Carolina has confessed to an affair with a woman in Argentina, while allegedly hiking on the Appalachian Trail. He should now:

Divert attention by flying the Confederate flag over the state capitol.
Ask President Obama to appoint him Ambassador to Argentina.
Join the Appalachian Mountain Club.
Wear an ankle bracelet with a GPS device whenever he is away from his office.

Be sure to go online next week when our quiz topic will be: “Are there any ethical challenges on Wall Street?”

Published originally in YJHM August 18, 2009

XXY

More than seven years have elapsed since I retired from liberating common duct stones and electrocuting colon polyps. Recently I have discovered that I possess a new and rare talent. I am now able to diagnose obscure medical illnesses in celebrities based only on newspaper and TV reports.

My first, and only, case so far, ("Apple's Apudoma," YJHM, January 25, 2009) involved Steve Jobs, CEO of Apple Computer, in whom I successfully diagnosed an islet cell tumor of the pancreas, metastatic to liver, He recently underwent liver transplantation, a treatment for this type of tumor for which I was an early advocate.

I turn now to the case of recently deceased popular music star, Michael Jackson. I mean no disrespect to him or his memory. I am, however, unashamedly giving him the diagnosis of Klinefelter’s Syndrome. In this disorder males have an extra X chromosome, giving them a profile of XXY rather than the normal XY. This has a feminizing effect and is characterized by a scarcity of facial and body hair, small testes, low testosterone levels and absence of sperm.

Mr. Jackson had an androgynous appearance, a high pitched voice, lack of facial hair, and was apparently infertile. His two older children were allegedly conceived with the aid of a sperm donor according to TV reports. His personality and body habitus were compatible with those described for some cases of Klinefelter’s.

The ambiguity of his gender role was dramatically illustrated by his ex-wife, Debbie Rowe, who, when asked in an interview to explain her limited role in the lives of the children stated in effect that Michael did everything: “He was both mother and father to the kids”.

Whether this diagnosis is correct will probably be known only to his personal physician and the Los Angeles coroner. It does offer an explanation for some of his strange behaviors and characteristics, which have puzzled some of us pop music aficionados.

Published originally in YJHM July 12, 2009

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