From Funny T-shirts to Thoughtful Reflections

Nicholas Genes, MD, PhD


April 08, 2008

You might not expect a successful cardiologist to start fundraising by selling witty, irreverent medical T-shirts online. And even Dr. Westby Fisher, creator of the site, was surprised when traffic, sales, and spin-off ideas started pouring in. Then one of his early creations, a shirt that said "Death: Been There, Done That, Got the T-Shirt," wound up on the back of a prominent blogger, and soon "Dr. Wes" was blogging himself.

Dr. Wes is also unusual in his diverse writing style, covering topics that vary from EKG interpretation to healthcare reform to introspective posts on his family life. Through it all, he maintains a clarity and thoughtfulness that is rare in an online world where hyperbole and shock get people's attention:

My head is still reeling after the reports of doctors hacking into the wireless transmissions of an automatic defibrillator. Oh, it's not so much the fact that it was done. Really, that was something. It certainly took our best and brightest a remarkable amount of scientific expertise to reverse-engineer the protocol for communication with Medtronic's defibrillator device...

Doctors must continually strive for equipoise in medicine. While it is a noble cause to want to always cure disease, strive for perfect patient safety in all arenas, and help mankind progress to the ultimate prize of immortality, we realize that each of these goals, taken to their extreme, is an impossibility. We have to balance the inevitability and cruelty of disease, the social and political climates in which we work, and even the sometimes atrocious things that one human being does to another, to help the unfortunate patient, victims and family members cope with the reality of their medical predicaments.

To me, it seems that since the Institute of Medicine's report on medical errors was published admonishing the safety record of medicine as a whole, we've begun tipping to one side of the scale of medical reality. We strive for perfect safety records and implement protocols analogous to airline checklists to become robotic and perfect in our actions. Mountains of paperwork and regulation requirements are completed by teams of well-meaning individuals each day. Countless hours are devoted to record-keeping to prove that we've been keeping our records. Electronic medical records spew forth past medical histories, medication lists, family histories, social histories time and time again not because it helps the patient, but because we don't want to "miss anything" that might be perceived as "inadequate" documentation for the patient. (In reality, we just have to do that stupid requirement just to get paid adequately -- but that's a discussion for another essay.)

Now I have nothing against improving our health care delivery system, and Lord knows there are areas where the Institute of Medicine's wakeup call has helped patients. But politically, we've already seen how neat and tidy the patient safety argument becomes. I mean, what compassionate physician in their right mind could ever not argue for patient safety? It would be professional suicide.

But exactly how safe is safe enough?

Should all surgeons, in their quest to minimize infection, scrub for 3 minutes, 5 minutes, 10 minutes, 30 minutes, or become obsessive hand washers in the interest of minimizing the possible spread of that last remaining bacterium from their hand before entering the operating room? When do we stop?

Or maybe, since defibrillator wireless transmissions can be tapped now, we should encrypt other wireless transmission devices, like entire telemetry units or hospital administrators' cell phone conversations?

...We have so many incredibly difficult challenges ahead in medicine: funding of healthcare, the loss of primary care doctors, the social problems in our inner cities, the overcrowding of our emergency rooms - the list goes on and on. Be it cardiology, medicine, obstetrics, or neurology, or general surgery, etc. -- each branch of our profession has a million more important clinical and non-clinical problems to tackle right now. But when we start looking for problems in areas that do not represent active problems, thereby creating a new problem where none existed previously, we begin to tip the balance of equipoise in medicine to the penurious. And when this scale is tipped too far toward one side, we completely miss the boat as a profession as what it will take to maintain our clear perspective in our upcoming challenges.

Our resources are finite. When we spend so much money on safety trivialities in our most esteemed medical education establishments relative to the Big Picture of healthcare today, all of us who proclaim to be purveyors of our patients' best interests have completely dropped the ball.

Dr. Westby Fisher hosts Grand Rounds
April 8, 2008

Or consider this charming look at how a cardiologist would like to die:

He was the most respected man in our training program. The oldest cardiologist at our institution, gruff, never afraid to shy away from a four-letter word to make his point, and with the uncanny ability to diagnose critical aortic stenosis (pulsus tardus et parvus) or insufficiency (bisferiens pulse) by placing his hands on his patient's pulse. No echocardiogram was necessary. His incredible knack for inductive reasoning of associated diagnoses was unparalleled. His breadth of clinical experience and expertise unequalled. I had always held him in my highest esteem -- a real model to follow.

So after returning to that institution of higher learning after fellowship training and getting settled in my new routine as a young staff physician, I headed to lunch with an entourage of medical students and residents. It was then that I saw him, my medical idol, in line with a burger and fries, and a tall Coke.

"Hello, Dr. B., how have you been?"

"Hell, just fine, Wes." It was then I noticed his tray.

Smiling, I quipped, "Dr. B., aren't those things bad for you?"

"Well, shit, Wes," he smiled with a twinkle in his eye, "... I look at this way. I have a 50-50 chance of dying of cancer or heart disease... and I'd much rather die of something I understand!"

Brilliant, as always.

I had the chance to correspond with this blogger recently.

Dr. Genes: Your first blog post describes the origin of MedTees. Over the years, has blogging come to serve another purpose in your life?

Dr. Fisher: Blogging has opened a unique and creative outlet for me to express my personal thoughts on a myriad of issues relating to my life, personal experiences, and the healthcare market in general.

My medical background hails from a diverse set of experiences -- first as a medical student in a large academic medical center, then as a government physician within the US Navy for 13.5 years (and an additional 9 or so years in the US Naval Reserves), then in a private-practice setting for a little under 4 years, then back to a hybrid practice that marries private practice clinical work with an opportunity to help train incredibly bright Northwestern University cardiology fellows in my area of expertise, cardiac electrophysiology.

I presently work in a 3-hospital system (Evanston Northwestern Healthcare in Evanston, Illinois) that is affiliated with the Northwestern University Feinberg School of Medicine through its academic teaching and research affiliations, but is financially a separate entity from Northwestern University Medical Center in downtown Chicago. Throughout my medical career, I have been involved in clinical trials and basic research due to my biomedical engineering background and have worked with many of the medical device manufacturers.

Along the way, life throws curve balls at you. My father's terminal illness and eventual death was a sentinel moment in my life, since he was instrumental in my decision to enter medicine as a career. I took comfort in writing about his struggles and realized that this diary of experiences was a valuable means of reflection as this difficult time faded in my memory. Also, I hoped others might somehow find comfort that they were not alone in similar struggles. I know my mother still cherishes re-reading many of those posts.

After his death, I have continued to post on many of the changes I have witnessed in my short tenure as a physician. Clearly, while I stand in awe of the miraculous and incredible advances in our field, I am equally concerned about the changes that have occurred in healthcare as it relates to the problems of burdensome bureaucracy and erosion of the doctor-patient relationship. I have found blogging to be a unique way to voice those concerns and to learn from others about ideas to preserve some modicum of sanity in the ever-changing healthcare arena.

Through my short tenure as a physician blogger, my motivations for blogging have evolved over time, but still relate to experiences I encounter on a day-to-day basis as a physician. I guess I focus a bit more on the device industry and policy issues now than I had, but there's still the humorous post on needle sizes that breaks the monotony.

Finally, I have also enjoyed the art of teaching, and because of this, I have begun posting interesting cases or EKGs that I have encountered over the years. These have been well received as the back-and-forth commentary on the posts can attest. The blogosphere provides a unique opportunity to interact with brilliant (and sometimes not-so-brilliant) people throughout the world in a unique and powerful way that enriches our understanding of the myriad of issues that come our way. Hopefully, with my blog, I can add another perspective to these discussions.

Dr. Genes: Dr. Westby Fisher will inject his perspective into online medical discourse again this week, when Grand Rounds comes to his blog. Join him as he highlights the week's best writing from medical bloggers -- doctors, nurses, patients, students, researchers, and healthcare personnel.


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