Dr. Lana Nelson shares a few random and not so random thoughts and insights from a general surgeon practicing in the Heartland

Friday, May 22, 2009

Top 10 best things about being a surgeon

This is a little tidbit of personal information and insight for anyone who may be considering a career in general surgery or for anyone who may be interested in why I love what I do. This is certainly not an all inclusive list, but just a glimpse into the highlights of my career at this point in my life.
They are loosely arranged David Letterman style, leading up to the best...

10) Collaboration: I have the opportunity to collaborate with other physicians and health care providers to improve and optimize the outcomes in patient care. This comes in many different forms. I may provide a referring physician with information that will help them care for their patient. I may obtain expert advice from others outside of my specialty area assist with care. I may confer with a colleague regarding a complex case. I serve on various hospital committees that work to provide access to current information, streamline patient care, and standardize care to follow well established standards.

9) Autonomy: I have the chance to be my own boss. Although we all have to work within the confines of certain regulation bodies, from the local to the national level, I still get to make my own choices. I get to choose what I will do, who I will offer it to, where I will do it, and when I will do it. This can be the most difficult part of my job as well, as I have to juggle clinical care, administrative tasks, and running a business (because even though I am not a businesswoman, I have to pay the rent, pay my employees, pay the government, etc).

8) Innovations: The field of medicine is one of constant change. Although some change is slow, there is constant research to explore and confirm current practices, to explore alternatives, or to discover unknowns, adding another layer to what we understand about the incredible human body. This means that I have the opportunity to never get bored with what I am doing, because there is always an alternative way, and sometimes we even find out there is a better way. Although I would like a certain level of proof prior to accepting new discoveries or adapting new techniques, I never want to be that surgeon who does that way because we have always done it that way and it works just fine!

7) Variety: No two human beings are exactly alike (yes, including identical twins). This means that even if I choose to never change (which I won't), I will still never get bored with what I do. Yes, of course anatomy follows patterns, as do diseases. But there are always varieties in presentation and response to treatments. This can also be a frustrating part of my job, as you might imagine.

6) Technology: I have to admit, we have the best tools in surgery! Many of you would be amazed at the instrumentation that we have. Some of the stuff is really technologically advanced, and the medical device companies funnel countless time and resources into making even better tools. Who can imagine a stapler which lays down multiple rows of tiny filamentous wires to form staples perfectly spaced with the option to cut in between the rows- and it is not just in a straight line, but also in a curve or perfect circle?!

5) People: I have the opportunity to meet lots of different and interesting people from all walks of life. I don't have an age limit on my practice (although I do not operate on infants and toddlers), so from a precious 4 year old who needs their appendix out to the 94 year old with a twisted colon who need emergency surgery, I meet a wide variety of people. There are people from different cultures, different careers, different religions, different lifestyle preferences, different dietary restrictions, different parts of the country (and sometimes world). Sometimes they provide me with a glimpse into a world which is unfamiliar or unknown to me. Sometimes they affect our decisions and directions in care. Frequently, they enhance my daily life (and sometimes challenge it).

4) Exceed: I have the opportunity to exceed peoples' expectations. I take great pleasure in providing quality and friendly care to the grumbling middle aged man who has a bad gallbladder he just can't ignore anymore and gets dragged to my office by his wife against his will to get help after he's been whining about pain for the last year and just can't stand anymore. I love to see that transition from a cross-armed, stiff-faced quiet man before surgery to an open, smiling man after surgery because he found out it wasn't all that bad after all, and he's feeling so much better now, he wonders why he waited so long.

3) Impact:
Frequently, I have the opportunity to have a positive impact on someone's health. Whether is something little that they will probably forget my name in a year or two- like taking out their gallbladder, removing their appendix, or fixing a small hernia- or something that they will likely never forget- like removing a cancer or helping them lose a few hundred pounds with gastric bypass- I get to provide a service which frequently may be health improving, life altering, or life saving.

2) Technology Part II: With those really cool tools, I get to do really cool procedures. There is such a sense of satisfaction and accomplishment with being able to make tiny holes in the abdomen, remove, re-route, or otherwise re-arrange things to accomplish #3. I remember the first time I got to do a laparoscopic gastric bypass start to finish (years ago when I was still a resident)- it was an amazing sense of accomplishment. And not to long ago- when I completed my first single incision laparoscopic cholecystectomy (SILS lap chole)- at the completion of the surgery when the belly button was returned to its original location, and even a few weeks later when I saw my patient in follow-up- there was no appaprent visible evidence that anything had been done! This one ranks really high on the warm fuzzy list!

1) Appreciation: Many times patients will take a minute to mutter those words that mean so much, "thank you." It may come from friends or family members. It may come in the form of a hug, a gift at the holidays, a souvenier from a recent trip, or a note in the mail. No matter what form it comes in, I always recieve great joy in knowing that my job has been done well, my efforts appreciated, my care acknowleged. This is definately the best part of my job, because it allows me to know that all I do and seek to do for an individual is well recieved, and maybe, no matter how small or how big, I have managed to make a difference in someone's life.

Saturday, February 14, 2009

No scar surgery?

When I first heard about single incision laparoscopic surgery (SILS) for gallbladder removal, I was quite skeptical. I really had a difficult time understanding what the benefit is over traditional laparoscopic cholecystectomy. I have always been an advocate of smaller scars whenever possible. From the medical standpoint, anytime we have smaller incisions, we reduce the incidence of hernia formation following abdominal access. From the human/vanity/cosmesis side of things, who would want a big, ugly scar if the same surgery could be completed equally without any visible scars?

Let's consider the progression of cholecystectomy. Tradionally, the gallbladder was removed via a large incision (5-10 inches) below the ribcage on the right side. Currently, the standard approach is to remove the gallbladder via laparoscopic cholecystectomy. This involves 4 small incisions from 1/4 to 1/2 inch each. Open cholecystectomy is reserved for cases in which the gallbladder cannot be removed via the laparoscopic approach and accounts for less than 5% of gallbladder surgery today. Few surgeons have adopted the "mini lap chole" which is accomplished by 3 small incisions- 2 which are 1/4 inch and one which is 1/8 inch. I am one such surgeon, and whenever it is technically safe and feasible, I use the mini lap chole approach. Ultimately, when the incisions are healed, they are tiny yet still visible.

Over the last 2 years, surgeons have improvised a way to remove the gallbladder through a single incision made right through the middle of the umbilicus. Ultimately, when the belly button is closed and the incision heals, there is no visible scar. I was definitely a skeptic at first. In order for me to consider this approach, the surgery had to be equally safe as traditional laparoscopic cholecystectomy. This was the number one priority. Next, it had to be similar in cost to traditional lap chole- no additional instrumentation special tools should be required. Finally, the length of time to complete the surgery has to be similar as well. So when I saw someone complete a single incision laparoscopic cholecystectomy that met all of these criteria, I was sold. If you would like to see for yourself, check out the video on YouTube by Alberto Iglesias, MD, surgeon at the University of Miami.

So now any patient who has not had any abdominal surgery and wants to have the possibility of no scars after gallbladder removal is given this opportunity. So far, the results have been amazing. My patients- mostly young female- are so happy to have a relatively painless surgery and no scars to show for it. It sure beats the alternative of going to the surgeon across town who makes four big holes for the traditional lap chole then staples them all shut at the end (doubling the visible scarring)! I would personally opt for the no scar approach.

Thursday, January 29, 2009

Choosing a weight loss surgery procedure is like hanging a picture

Ask the next 5 people you see "how would you hang a picture?" It seems like a simple enough question. Of course all you need is a hammer and a nail to get the job done, right? Maybe you would like to use one of those little hooks that nails into the wall. Perhaps you would rather use a screw, which would require the help of a screwdriver or drill. You may even chose to use an anchor, which requires something to bore your hole, the anchor itself, the right sized screw, a screwdriver, and a drill. Seems a little more cumbersome, but it provides a stronger hold. It is also a little more invasive- if you decide you don't like the picture where you made your hole, then you are left with a sizable hole in the wall. You can even consider adhesive- there are some really strong double sided tapes on the market. I guess before you make the decision as to how to hang the picture, we have to consider where- not only the location on the wall, but the type of wall that we are hanging it on. Is the wall made of plaster, of wood, of sheet wood, of concrete? How about the location- do we have to worry about where the stud is? Is it to be centered on the wall? How far down from the ceiling should it be? At eye level? Or is the wall really tall so we want to place it higher to draw the eyes up? Lets consider the picture to be hung. Is it a really heavy piece of artwork that needs extra support or multiple nails/screws/anchors/picture hangers? Or is it an 8X10 light weight frame with the grand kid's picture? What kind of hanger is on the back of the picture? Do you have a wire? A ledge? A grooved plaque? Nothing at all?

I'm sure I haven't exhausted all of the possibilities, but I hope I have shown that what seems like a simple question is usually not a simple question. Take for example weight loss surgery. Certainly there are many options to choose from. Today, in the US alone, you can opt for a laparoscopic adjustable gastric band (Lap-Band or Realize), open or laparoscopic gastric bypass (with at least 10 different variations on each), vertical sleeve gastrectomy, "mini" gastric bypass, biliopancreatic diversion with or without duodenal switch, and vertical banded gastroplasty. The choices today are different than they were last year and certainly next year as this is a changing field with new procedures and options moving in and out of favor and popularity. You may even opt to leave the US, which further expands the possibilities of surgical options (and risks, complications, etc, etc which deserves its own discussion).

Determining the right choice is influenced by our experience, knowledge, and perceptions. When it comes to weight loss surgery, many factors affect an individual's procedure of choice. Although ultimately the decision to have surgery and what type of surgery ultimately rests in the hands of the patient, many things will influence the decision along the way. Advertising, media, and internet definitely shapes the way individuals view different types of surgery. Friends, family members, and acquaintances also provide their own opinion. The family doctor may add her/his perspective. All of this occurs even before the patient has the opportunity to meet with the surgeon, who is perceived to give the expert opinion in the decision process.

Unfortunately, the decision may or may not become any easier after meeting with the surgeon. Perhaps the decision you made prior to your visit has to be reconsidered after the surgeon has advised a different perspective. Ideally, she/he will take into consideration all of the known factors which influence your outcome (both potential success and potential risks) with a particular procedure. There are certainly things which you may not know about your own individual case which can influence your success with different procedures. Admittedly, there are even things surgeons/physicians don't know about that influence your success. This is evidenced by the growing amount of research into intestinal hormones, endocrine hormones, among others which may affect weight loss and response to different avenues of weight loss. As if this is not enough to consider, we have to remember that what we discover about human physiology follows pathways and patterns, but we are all genetically unique from one another so what works for one certainly won't work for all.

Some individuals will try to oversimplify the decision on weight loss surgery. For example, I have many patients who want the band because they saw a commercial for it on TV and the model looked successful. After I have had the opportunity to consider that patient as an individual, I may be left with the task of explaining that this may not be an option, or may not be the best option. It is my responsibility, and the responsibility of any surgeon, to inform, educate, evaluate, and assist you in the decision. But be forewarned: I admit that my own personal bias, knowledge, and experience may impact that advise as well. Any surgeon who tells you otherwise is either stubborn, arrogant, or indifferent to the wealth of varying information available.

What may seem like a simple proposal to some becomes quite complex when we consider all of the possibilities. If you ask your surgeon "how would you hang a picture," beware of the surgeon who answers "a hammer and a nail" before you have told her/him what kind of picture you would like to hang, what your walls are made of, and where you would like to hang it. You may end up with a bunch of holes in your wall and no picture to show for it!

Tuesday, January 27, 2009

Baby Blogger

Okay, so I have to admit I am way behind on the whole blogging thing. From a physician and surgeon who embraces change when it comes to my professional career, I have been reluctant to embrace certain technologies of the web. Sure, I have used "e-mail" faithfully since 1995, just shortly after it became widely available, but I have been admittedly slow progressing past that point. Yes, I know how to use such applications as Powerpoint, Picassa and Google calendar, but beyond that, I am a computer, software, and web novice.

My first memories of the concept of blogging are relatively new. My sister, who is my scrapbooking partner in crime, has talked about blogs for quite some time. Her use of blogs spans from paper crafting and stamping techniques to sports to "freebies." Although she has never ventured into the world of blogging as a host, she is an avid and regular visitor to various sites. I am amazed by not only the wealth and breadth of information that she is able to retrieve, but by the simple fact that blogging allows any average Jane (or Joe) who wants to share thoughts, insights, information, or simply journaling with a world of people who are willing to read.


So as I begin this blogging journey, I have a few questions that remain to be answered:

1. Will anyone be interested in what I have to say?
2. Who will be interested in what I have to say? Will it be friends and family who just wants to keep up? Or will it be past and future patients curious about who I am? Or will it be the information seeker who believes I have something worthwhile to share? Or will it be other health care professionals seeking knowledge? Or worse yet, will it be no one?
3. Will I be able to find enough topics to talk/write about?
4. What are the rules of blogging? Do I have to post every day? Every week? Every month?
5. Will I have the ability to share and ultimately educate, inform, or entertain?
6. Will I be able to maintain regular postings in the midst of what seems like an already full schedule?

So my goal-stated to you and as a proclamation of the intent of this blog- is to focus discussions on topics related to surgery and health with likely recurring themes of nutritional issues, obesity related issues, and minimally invasive surgery. I reserve the right to present the occasional personal insight into family, hobbies, entertainment, local and world news, etc.

I have to give credit to this idea for a blog to Buckeye Surgeon. I ran across his blog while doing a web search a while back, and was interested in the idea of sharing thoughts and experiences with the public at large. I have been considering the idea for a few months now, so here it goes.....If you have any suggestions along the way, comments, encouragements, or snide remarks, I would be happy to have your input.