Despite the best attempts of the New York Times Wellness Blog to get me fired, I’m still here and doing fine. Somehow a post about how impressed I was with surgery, the professionals that practice it, and how many of my preconceptions about surgeons were incorrect, got all turned around into some “peak behind the curtain” into the secrets of the medical profession. This is terribly absurd and the article made a hash out of what I was trying to say. I was trying to relate some of the shock one experiences going from an academic setting into a clinical one for the first time, as a reminder to those who have done this before, and maybe preparation for those who have yet to make the jump. None of these things are secrets, and all could be culled from watching about 15 minutes of the Discovery channel or Scrubs.

But the confusion of some individuals over what I was trying to communicate is still my problem, even if I was quoted all out of context. Clearly the biggest issue is the change in audience, my sb audience includes a lot of scientists and doctors, and the way I write is somewhat geared to this group. Thus you’ll notice in my comments mostly positive responses – especially from medical professionals like Orac, PalMD and various others. When the NYT expands my audience to a group of people who don’t know my writing, my assumptions or my more egregious stylistic shortcuts, it is not surprising there was some confusion and hurt feelings, not to mention some people with absolutely no sense of humor.

This does not mean that there is no problem however, ultimately this is a sign that I need to remember that I am writing in a public arena and need to be more careful with the assumptions I make about my audience on any given day. Rather than clamming up for the next couple of decades until I’m tenured, instead I’m going to use this as an opportunity to broaden the appeal of the blog and help explain to a wider audience what evidence based medicine is, the process of learning it, and why I think medicine the best career in the world. Writing this way will help educate people about medicine and how its practiced, and at the same time improve my knowledge of medicine with the goal of making me a better doctor one day. So, back to basics.

First, an explanation of the role of a medical student in the arena of patient care. Medical students are being introduced into the profession of medicine. To accomplish this they take two years of some of the most arduous training imaginable, intensively learning about anatomy, physiology, pharmacology, biochemistry, genetics, pathology, microbiology, physical exam, history taking, and all the other knowledge that makes up the foundation of clinical knowledge. By the third year, which is what I am currently in, you have accumulated more knowledge in two years than you probably have in your entire life. You are tested, retested, observed, corrected, and tested again and after all this work you get the incredible privilege of participating in patient care in your second two years of med school. This does not mean your first week of patient care is any less of a shock to the system – it is very much different from the purely academic pursuit of medicine – it is more of an apprenticeship in which you learn by doing and is certainly the most important part of learning to be a clinician. At this point you are participating in patient care, usually at an academic setting, and you see patients, take histories and physicals, learn how medical decisions are made in the care of individual patients, and in the case of surgery, observe how operations are performed. While you are an important part of the patient care team, you are not responsible for clinical decisions at this point and are at the bottom of the proverbial totem pole. You work with interns, residents and attendings who are ultimately responsible for medical decisions. For the most part, you observe, participate, tell them what you would do, and then wait patiently as these more experienced clinicians explain why you are right or wrong and what is the correct course of action. It is training to develop clinical judgement and competence in patient care. Further, when I say that I “scrub in” to a surgery, it means that I am allowed into the sterile field (after scrubbing, gowning, gloving etc.) and am given the privilege of watching surgery up close. If you’re lucky you may get to participate, but in a very limited capacity, never beyond your abilities (usually just holding instruments, aiming a camera, applying traction, suction etc), always under the supervision of someone with between 5 and 40 years more experience than you, and in a very controlled environment. Always paramount is the patient’s well-being, and if it is ever in question you quickly find yourself shuffled back behind the doctors who are doing the very difficult and demanding work. Before you even step into the room one must remember the student has years of training to understand the pathology and anatomy of the case, the student has read up on the patients’ specific case, and has reviewed the surgical procedure, relevant pathology, anatomy etc. Before you work with patient on a medicine rotation you’ve done similar prep, and throughout the case are studying the patient’s case, lab results, textbooks of medicine, the scientific literature, etc., as part of your training. When you graduate from medical school and become an intern and then a resident you are still training for about 3-5 more years, you become directly responsible for patient care, and are under the supervision of an attending physician. This structure is ultimately very successful and academic medical centers provide the best medical treatment in the country, attract bright people, take all kinds of cases (the ones many other hospitals simply can’t handle), and constantly push the boundaries of medicine.

Now, onto the fun part. A clinical case. This is how we learn medicine, as being social animals, it’s almost always easier to remember medicine in the context of a person. You’ll always remember medical facts and treatments better if they are associated with an actual human being. And this is, of course, an artificial teaching case having nothing to do with an actual individual. I had a post all prepared describing a complicated procedure, but since we’re starting from basics, let’s begin with wounds.

The patient is a 52 year old construction worker who suffered from an open fracture (bones sticking out of the skin) of his left radius and ulna (bones of the forearm) from on-the-job accident. He was taken to the ER, his arm was evaluated with a plain X-ray film, and the break was cleaned, reduced, and set in the OR. He received prophylactic cephalosporin antibiotics before the surgery. 24 hours later he is on your floor, admitted to your service, and he complains of chills, and severe burning pain at the site of his incision. The patient is alert and oriented to time, place, and person, but is diaphoretic (sweating), pale and in some distress. He has a fever of 39.2, BP 140/90, and his heart rate 110 beats per minute. An examination of the arm reveals a brown, weeping wound at site of the repair, the arm is warm to the touch, and acutely painful. Physical exam and review of systems is otherwise unremarkable. Labs show an elevated white count. He has a history of type II diabetes and hypertension.

What do you do?
A) Treat empirically with a broad spectrum IV antibiotic like Cipro and culture the bacteria for a definitive diagnosis and sensitivity testing.
B) Clean and debride the wound.
C) Change the dressing and wait for the wound to heal naturally.
D) Send the patient back to surgery to debride (clean) the wound and start therapy with penicillin and clindamycin.

I think most of you will guess the right answer is D since I presented this as a surgical case. This is a classic infection with a bacterium named Clostridium perfringens (gas gangrene) and represents a surgical emergency. Typically when we’re learning in a classroom setting to get the students attention and interest one begins with a simple case presentation and some questions to get the students thinking about possible treatments. Then the presenter provides information on the differential diagnosis (aka other possible diagnoses) consistent with these symptoms, information from the current literature about the efficacy of various treatments, and a plan for the individual patient.

The two most common infections within a day or so of an injury or incision are group A streptococcal bacterial or clostridium perfringens which is associated with serious injuries and possibly contaminated wounds (like an open fracture or burn). One does not wait to diagnose these infections as they require immediate treatment. Group A strep would be treated with antibiotics without debridement.

Most post-operative infections occur between 5 and 7 days after the injury or surgery and for clean surgical wounds or slightly contaminated wounds the rate are about 1% and 3% respectively. The most common causes are Staph aureus, E. Coli and Enterococcus, but several other microbes may be responsible. The rate of post-operative infection has not changed significantly for decades, and is a common complication of surgery.

This case is an example of what I was referring to when I said surgeons don’t waste time with excessive diagnostics. This was not an insult, or a statement that they are not excellent diagnosticians. But the secret to being a good surgeon is being fast and decisive. Often with medicine you have the luxury of time to think, weigh options, do tests, try empirical therapies and deliberate extensively before acting (although regular docs are trained to recognize medical mysteries and act in a flash too). However with surgery the range of possible maladies is limited by the fact your recent procedure is likely to be the major source of morbidity in your patients. You don’t stop to consider a huge medical differential diagnosis. You are trained to know the complications of your procedures, how they present, the complications of surgery in general, and to act fast because time is often critical. This is the essence of good medical practice and not a statement about some aberrant behavior specific to surgeons. This is how they should behave.

Now remember, I am a student, and if you think I’m wrong feel free to correct or amplify my answers in the comments. I’m here to learn too. I think as part of my slow introduction to surgery next I might cover the very most common operations – hernia repair, appendectomy, and cholecystectomy – to introduce you guys to some less complicated surgeries, aseptic technique, how an OR functions, and some of the simple surgical instruments. Also, I’ll continue to emphasize that surgery is a big deal. It’s serious, it is necessarily hard on the body, should not be taken lightly, and surgeons will be the first to tell you this. The net benefit is often huge, but there are always risks to surgical procedures and surgeons weigh these risks against the benefit of the surgery every time, for each individual patient. This will be another focus in each procedure I present.


  1. I just checked out the NYT blog… I couldn’t get over how off-base some of those comments were. Even if they only read the selected quotes it seems they were stretching to react in such a bitchy way. Sheesh.

  2. I’ve very much enjoyed your observations — in general, but especially the last few days, when the passion and wonder surface. I hope you can continue to write “from the gut” without having to second guess your words.

  3. One wonders if this jaundiced read has anything to do with their Opinions page being labled a “denialist” source.

    It seems odd that they would even comment on this entry at all, much less give it such a strange slant.

  4. I am afraid you aren’t going to “broaden the appeal of the blog” by writing such lengthy posts however 🙂

  5. The Clostridia are also exquisitely sensitive to nitric oxide (which is one of the reasons meat is cured with nitrite). This may be the explanation for the folk remedy of putting manure on the umbilical cord of newborns to prevent tetanus. Nitrifying bacteria in the manure might generate enough NO to suppress them. Before the days of sterile techniques, antiseptics and antibiotics, getting the “right” bacteria there first may have been the only line of defense.

  6. lukkystarr

    “This does not mean that there is no problem however, ultimately this is a sign that I need to remember that I am writing in a public arena and need to be more careful with the assumptions I make about my audience on any given day.”

    This is nonsense. Why, if you are writing for a specific audience, do you need to pander to some that cannot, or refuse to understand. THEY don’t understand, so YOU have to work harder? Complete BS. How about expecting just a little effort from individuals to consider they might not have the background necessary to comprehend everything written? I don’t think that is too much to ask.

  7. lukkystarr,

    ” Why, if you are writing for a specific audience, do you need to pander to some that cannot, or refuse to understand. THEY don’t understand, so YOU have to work harder? Complete BS. How about expecting just a little effort from individuals to consider they might not have the background necessary to comprehend everything written? I don’t think that is too much to ask.”

    I understand your perspective on this, but then again, since Mark is representing a profession sometimes when he writes, I don’t think it’s out-of-line for him to make an effort to represent it in the best light possible to the widest audience possible.

    A good-faith effort to improve communication on Mark’s part is not out-of-line.

    Then again, your point about not knocking yourself out to accomidate/pander to the lowest common denominator, or people determined to take offence/misunderstand is also very valid.

    It would completely ruin my enjoyment of this blog.

  8. lukkystarr

    Teresa, I appreciate your thoughts and candor. Believe me when I say I’m not trying to be contrary or militant for its own sake, but I think the blog itself is a good faith effort. I find it extraordinary that he puts up with everything they throw at him, and he still has the inclination to post anything at all. On top of that, it is still as concise and coherent as it is. Furthermore, I don’t think he said anything that people couldn’t figure out for themselves if they really wanted to know.

    But then again, I’m of the mindset that you can’t please everyone all the time, so most of the time there is no point wasting time trying. Another point is that his candid observations are rare and rather refreshing, it would be a waste to compromise that simply to please a reporter.

  9. Wow. The comments section at the Times is *incredible*. Lots of interesting if completely out-from-left-field takes on your post. Cheers to Dr. Gorski though. Mark, your post was perfectly fine. I checked and rechecked and still couldn’t figure out what half the people were talking about.

  10. “Why, if you are writing for a specific audience, do you need to pander to some that cannot, or refuse to understand. THEY don’t understand, so YOU have to work harder? Complete BS. How about expecting just a little effort from individuals to consider they might not have the background necessary to comprehend everything written? I don’t think that is too much to ask.”

    Because it’s a writer’s job to make themselves understood, as best they can, to the audience they know they’re writing for.

    And I’m speaking as a professional writer. If a few people misunderstand me, that’s just life. But if a large portion of my intended audience misunderstands me, that’s my responsibility.

  11. lukkystarr

    Granted, the whole point of the communication is to be understood, this goes without saying. But should the Dr assume a large portion of the audience misunderstands? Referring to the comments to his posts in general, I would say not. This is my whole point, he expresses himself well, and to make concessions to the few that don’t see this, he does himself and the intended audience a disservice.

  12. The troubling thing about the comments on the NYT blog was how many comments were clearly from medical professionals who went off half-cocked at Mark on the basis of the NYT blog article, quite obviously without bothering to check the original reference. I wouldn’t be particularly worried about having surgery at Mark’s institution, but the thought that I might be diagnosed with the same degree of intellectual sloppiness and reliance on unfounded assumptions as exhibited by some of Mark’s critics is profoundly disturbing.

  13. “Often with medicine you have the luxury of time to think, weigh options, do tests, try empirical therapies and deliberate extensively before acting”.

    I appreciate your opinion, but how about having had this rotation before making comments about how it works? There are medical emergencies, just as there are surgical emergencies.

  14. Fair point Tree, I don’t want the medicine people made at me next. I will, of course, write about medicine when I get there and will, of course, have to change all my preceptions again I’m sure. It’s my next big rotation in the spring.

  15. Ooops, sorry I’m late to the party. Mark, I’ve read the blog for a while and just wanted to encourage you to keep on keepin’ on. Beware of dummy-ing down too much, although putting information in context is always OK. It’s very cool to get a sense of your awe and wonder at the stuff you’re getting to learn.

  16. Wow, what a ridiculous firestorm. It certainly makes me hesitant to speak about what I’ve heard and seen in the medical profession.

    I think the reality is that there is a lot that’s messed up, quirky, and weird in medicine in general, and anyone that comes to it (like many patients) with the idea that it is all clinical and robotic and perfect is going to seem shocked by it. Likewise, many doctors are extremely sensitive to what they feel is the profession being taken out of context: fearing that patients won’t understand the world that lies behind a doctor’s smiling face is pretty complicated, full of clashing personalities, and everything else one might expect from dealing with applied science on one of the most complex and dynamic things ever: the human body.

    It IS amazing how physically violent some surgical procedures are. But on the other hand, often those things are the best we can do: if you don’t use a lot of force sometimes, what you need to get done won’t get done, and the patient is sitting there in more and more danger while you wait. Too many people hear about the things done in medicine without knowing the reasons and logic behind it, or that while not everything is perfect, sometimes all the alternatives are worse.

  17. How about going ahead and posting the Whipple procedure piece? You don’t want to lose your medical audience by writing only for a lay audience. Maybe you could include an introduction for the lay audience.

  18. interesting article

  19. As a lay person, I found this article/post fascinating. It takes great skill to reach average people and still be interesting and informative to other specialists in the field.
    I would take to task other medicos to be more accommodating by acknowledging your greater purpose, bringing understanding of medicine and the intense training, and the passion and personal involvement – the dedication – to a wide audience.
    I think when reading stuff like you just wrote, people will only gain much respect for the integrity of medicine and be less likely to get wooed by quackery. You make medicine human.
    I like the way you write.


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