Dr Bruce Berger shares a doctor’s view on Surgeon X, chapter 2. In case you’re wondering he’s Karen Berger’s brother.

Dr Bruce Berger

When Sara invited me to write a web piece for Chapter 2 of Surgeon X I was flattered. I am Karen Berger’s oldest Doctor brother. I am a nephrologist – an internist who is a sub-specialist in disorders of the kidneys. I have been a clinical academician, and worked in a university medical center, for close to half of my three decades in medicine. I must admit – I never quite got what my sister did -certainly not enough to ever read more than a page or two of her many creative endeavors. But all that has changed! Surgeon X and the themes being, and to be explored, through the creative and intellectual talent of Sara Kenney have already captivated me and resonate with my thoughts, reflections and beliefs of where medicine is now and where we are (hopefully not) heading.

Rosa Scott, the independently minded and patient-centric protagonist, is a character with whom I relate. When I went to medical school the ideals of training to be a doctor of medicine were more eclectic. There was a more prevalent spirit of social awareness and consciousness. Like so much of the mindset present nowadays in business, politics and society in general, the focus is on what’s best for me, myself and I. Although the desire to help and care for others still persists in young physicians, too often my observations and those of my contemporaries of this generation of physicians have reflected the absence of what had once been the ‘soul’ of medicine – we did what we did, even at the personal expense and sacrifice of time and family and life, to help our patients.

Over fifteen years ago, I chaired the intern selection committee in the Department of Medicine at a university hospital. Among my responsibilities was to interview fourth year medical students as they evaluated residency training programs. At that time the national governing body that accredits residency training programs began to limit work hours for house staff. I remember a few intern applicants (I suspect the Rosa Scott’s of their generation) discussing with me their objections to these absolute dictums placed on their time in the hospital – “I don’t want to have to sign out and leave the hospital when I have a critically ill patient” “I want to be able to follow up on pending labs or studies before I leave to see if anything else should be done” “I’m a doctor of medicine and I should be able to decide if I wish to stay longer”. Sounds like Rosa Scott, eh? Let’s fast forward a mere seven years to my last year as chair. The guidelines for work hours had became much more stringent and restricting. In that last year as chair, without hyperbole, probably 20% of intern applicants during their interview specifically asked of me what was I going to do to personally ensure they leave the hospital on time. So you can see why I relate to Rosa. Her commitment and her dedication come, if need be, at her own personal expense – physical, emotional, spiritual. She walks the walk. When the going gets tough she doesn’t go shopping, rather she doubles down based upon her principles and work ethics. Even if they be flawed she gives of herself. She does not lead a 9 to 5, banker’s hours, job as a surgeon.

Chapter two’s first exploration of Rosa’s relationship with her father is already upon us in the institutionalized health care environment. She defies her father’s wishes in order to help others – her patient on dialysis mattered more than the personal cost of opposing bureaucratic dictates. If you search the web you will find news reports of physician employees of institutions (more than half of all doctors in the US are salaried employees and the trend is only increasing) who were wrongfully terminated because they objected to administration dictates about what constitutes best (i.e. cost-effective -> least expensive, what we can get away with) patient care practice. Do you really want an administrator or policy wonk to tell an experienced physician how to practice their craft and art, and what tools are available to do so? I don’t. And guess what? This is not one of those – it only happens to the other guy events. After putting my concerns about aspects of ICU patient care in writing (more than once) to the senior administration of the academic institution I worked at, and despite having the support of colleagues and directors of the intensive care units, I was wrongfully terminated. It made no difference that I was the busiest and most productive member in my division or the multiple accolades in teaching and mentoring of medical students and house staff I received during my tenor. So all I can say to Rosa is, “you go girl!”

Some thoughts about dialysis. In the US chronic kidney disease (CKD) afflicts perhaps 20% of the population. When kidney (renal) function deteriorates to about 5-10% of normal (CKD Stage 5) renal replacement therapy, i.e. dialysis, is required to forestall death. In the US over 400,000 people are on dialysis. Unfortunately, children are not spared from CKD and end stage renal disease with the need for dialysis. As with any significant affliction that affects the young it is a heart-rending experience for the caring physician. We see this in Rosa’s rock solid determination to help her young patient emotionally and psychologically (and she’s a surgeon to boot!) while waiting for the regenerating kidney to mature. This reality is well underway – scaffolding, stem cells, all real. The complexities of the kidneys are such it will take time – but I dare say it will be upon us in the near future. As we await this day we will first see portable external dialysis machines that a patient will wear, most likely 24/7. This advancement in technology will allow individuals to no longer be hooked up to a dialysis machine four or so hours at a time, three times a week in a chair. No longer will they feel the fatigue or the cramping or the nausea and vomiting or the fluctuations in blood pressures that afflict a not insignificant number of people on hemodialysis. The main reason dialysis patients are hospitalized nowadays is because of blood infections through their dialysis lines. And when bacteria are resistant to antibiotics the outcome is fatal, fast and frequently not a nice way to die. It’s complicated and messy for the patient and distressing and traumatic for loved ones. When you couple the emerging global pattern of bacterial antibiotic resistance with the well-recognized impaired immune system response in patients with end stage renal disease (ESRD) the recipe for truly abysmal outcomes are all too real.

In the world of Rosa Scott, so aptly envisioned by Sara Kenney & John Watkiss, we find ourselves confronting “’realities” that I worry we lack the wisdom in leadership (across all spectrums) to effectively and efficiently address in the present. Certainly we see no legislative or political urgency amongst any of our leaders in addressing what can be done right now.

So, the next time you see a doctor for a cold or a sore throat do your part – don’t insist or automatically accept a prescription for an antibiotic. It’s okay to ask your doctor “why.” And quite frankly if you don’t get an explanation or you are brushed off you just may wish to consider changing doctors. You have your direct role, too in minimizing the risk of infections. Always wash your hands for 30 seconds with soap and water every time you go the loo (I think that’s how you Brits refer to it). And in public restrooms use paper towels to turn off the faucets (if they’re not automatic) and upon opening the door to exit.

May we all “live long and prosper” in good health.
From across the pond,
Bruce E. Berger, M.D.