I have trained in three fairly respectable academic institutions and worked in several civilian and military hospitals. I have witnessed disruptive behavior in all these settings, by a variety of people, from professors down to interns. My sense has always been that despite their prestige, rank, and technical ability, these people were almost always insecure and lacked resourcefulness in resolving issues they felt adversely impacted the care of their patients. They became verbally abusive, offensive, and even violent in attempting to make everything conform to their standard of perfection. The surgical world is not perfect, and this includes nurses, administrators, laboratory personnel, and surgeons. The art of the surgeon should encompass dealing with less-than-ideal situations without humiliating and abusing other people (however you choose to define that). Pare said, "He who would be a surgeon should find an army and follow it." I recommend that, as penance, any surgeon found to be consistently disruptive should join the army, where he or she will practice surgery in an austere environment in which everything is always less than perfect and less than desirable. Then, these surgeons can return to the general hospitals in the United States and realize just how good they—and their patients—have it, even when it is discovered that the nurse who was supposed to have the stapler ready in the operating room has gone on break.
J. Norris Childs, MD
The insurance industry giant Lloyd's of London was born in a coffee shop that operated on the docks of London, where ship owners gathered and often lamented the loss of a ship. Several owners united and devised a system whereby an individual loss would be dispersed among the lot of them rather than becoming one owner's catastrophe. Insurance has journeyed a long way from the idea of sharing losses and now exists to profit the insurance company. Protecting the insured is low on the list of priorities. Examining the language insurance companies have developed to hide their activities (consider "whole life" versus "term") is enough to prove what a dishonest school of piranha they constitute. A vascular surgeon since 1977, I have been fighting them for more than 30 years to get what I am due.
My very first interaction with the insurance industry was in 1965, when I elected to drive my 1959 Ford over a dead deer in my lane rather than swerve into traffic. The deer ripped off the exhaust manifold, and although my insurance policy covered damages caused by acts of nature, the company refused to pay for my repairs. The agent explained that while hitting a live animal was covered, hitting a dead deer was more like hitting a tree and was therefore not covered.
Not long ago I received two letters from Blue Cross on the same day. The first notified me that my employees' health insurance premiums were increasing due to increased costs; the other explained that payment for my professional services would be decreasing due to increased costs. It brought to mind an article in the
San Francisco Chronicle 15 years earlier, which stated that Blue Cross had listed its overhead as 7% of costs when it was a not-for-profit company, but as a for-profit HMO, it claimed overhead expenses of 35%. Perhaps these overhead costs explain why my wife and I were paying around $1,400 monthly for our Blue Cross health insurance.
I recently used our Blue Cross insurance to cover minor foot surgery at a San Francisco hospital. The hospital bill exceeded $30,000, but for this outpatient procedure, Blue Cross allowed only $2,000. My benefit from the insurance company, therefore, was the $2,000 it paid and not the $30,000 billed originally. If the hospital offered private patients the same fees it gives insurance companies, it would make financial sense for many people to forego insurance or at least purchase only catastrophic coverage.
There are so many problems with the insurance industry, including the workers compensation and disability insurance fiascos, malpractice insurance, and the way the legal system and the insurance industry feed each other. I could write for a year on this subject and never finish detailing the great injustice I feel Americans have been dealt by the insurance industry.
Ray Hanson, MD
I wish to call your attention to an error in the Superficial Palmar Arch anatomical chart. In the palmar (ventral) view, the "cut" tendon was labeled "plantaris tendon (cut)," when it should have been labeled "palmaris (longus) tendon (cut)."
Andrew A. Slemp, Jr., MD
Editors' response: We regret the typo. The corrected chart is now online at Superficial Palmar Arch.
I look forward to receiving Surgical Rounds for a number of reasons, including the extremely well done anatomical charts. I have a binder where I keep the charts, and they have been invaluable over the years to illustrate surgical sites to my patients. You can imagine my disappointment when I found the chart in the November 2007 issue was just on plain paper and not really conducive to saving. Hope you go back to the previous format.
Ray Hanson, MD
Editors' response: We regret that we had to make this change, but the charts are now accessible on our Website as PDFs and can be printed on any paper stock desired. You can even print copies for your patients.