Anniversaries - An excuse for reflection

I have been in Raleigh for six years.  And what a six years it’s been!

The time has seen a son born, friends made, colleagues arrived, and patients cured. Since anniversaries are an excuse for reflection…

The most incredible thing I have learned in this time is not to underestimate people.  I have seen so many people, in such dire circumstances, exude levels of poise and dignity I didn’t know people had and don’t think I am capable of.  To keep one’s sense of humor and humanity despite pain, nausea or a general lousy feeling is a truly magnificent feat. It shows one’s soul to the world, eases suffering and comforts family and friends. It is grace.

Technically, we as surgeons are much better now than when I came to Raleigh six years ago. Advances in minimally invasive surgery have revolutionized what we are able to do while decreasing pain and hospital stay. The future is bright! I work with many device manufacturers, and I can say from first-hand knowledge that new working materials and devices are soon arriving that will further expand our capabilities and deliver these advances to so many more people regardless of whether they are treated in small rural hospitals or large university settings. 

The spirit of innovation is not confined to the youngest. My adapting single site laparoscopic surgery, a very demanding technical skill, was prompted by my senior partner using it first. Rather than resting on his laurels, Dr. Jerry Stirman challenged all of us to continue to improve for the sake of our patients. He is a mentor to many of us in the surgical community and a treasure for those of us who know him.  Thank you, Dr. Stirman.

Despite what I thought six years ago when I moved here from Los Angeles, Raleigh is not a “small town.” We are blessed with a very educated population and an equally educated, savvy medical community that rivals Boston, Rochester, Minnesota or any other place in the world. We are innovators, from our medicine to our computers, biotech and other cutting edge industries the Triangle is known for.  With such progress in just six years, I can’t wait to see where we will be in another six years.

Tanning Booths - A Public Health Threat

Our society has an inconsistent history of establishing priorities that protect us.  We outlaw dangerous drugs such as marijuana and cocaine, but only limit other dangerous substances such as alcohol and cigarettes. Our health system, working hard to treat things we can’t help, is straining under the weight of things we can; diabetes, obesity, sedentary lifestyles, and tanning booths.

Tanning booths?

Yes, tanning booths.

Perhaps it seems silly at first glance. Tanning booths provide that lovely copper hue by bombarding the recipient with profound amounts of ultraviolet (UV) rays. UV rays are the part of the electromagnetic spectrum associated with cancers of the skin, most notably melanoma. And melanoma, a potentially lethal form of skin cancer, is becoming more common. Over 3.5 million people will be diagnosed with melanoma this year alone and mortality has risen nearly 700% in the past 3 decades. 

This important topic was discussed recently at the annual meeting of the Society of Surgical Oncology. As Surgical Oncologists, we see the impact that cancers, such as melanomas, have on patients and families. We decided to take action.

A special session was held with the intent of developing a position paper on this important topic. Our intent was to alert the public about the dangers of tanning booths and formalize and publicize our concern. Recent studies have found that the use of tanning beds during adolescence increases the risk of subsequent melanomas almost 200%.

With this known risk, other governments have begun to ban the use of tanning beds. Brazil and, as of 2014, New South Wales, Australia, have recognized the risk tanning beds pose and have outlawed them. In the US over 30 million people use tanning beds. Most are teenage girls, who, on average, use tanning beds over 20 times a year.

Is this really a public health problem? I think so. I appreciate the ability of consenting adults to engage in behaviors that are risky. But children? Do teenagers have the legal ability and responsibility to judge the risk of tanning?

I know what some of you will say. Should our exposure to the sun be regulated as well?  That would be like trying to outlaw carbon monoxide. But carbon monoxide, a significant by-product of cigarette smoke, is regulated by the federal government. Cigarettes, like alcohol, are regulated because of the well-established threat to our health. In my opinion, tanning beds fall into the same category.

In these troubled economic times, we should support small business. The tanning industry, mostly owned by small business owners, is a $2.6 billion dollar a year industry. But what cost, especially over the long term, does this have on health care expenditures as a nation?  Probably more than $2.6 billion a year in costs, loss of productivity, and quality of life.

I don’t know the answers, but I really want to know what people think.  Should the use of tanning beds be regulated?  Should it be restricted to people over 18?  21?  Not at all?

I appreciate the ability to talk to people in this digital form.  Please let me know what you think.

Visiting Surgeon in the Middle East: Part 17

I met Wissam at my hotel and we went to a different downtown area that was recently refurbished. It was a central area that was targeted by the Israelis in the last “troubles.” They left a few buildings in ruins to serve as a reminder of what happened. What struck me as the greatest juxtaposition, however, was the church that was adjacent to the Grand Mosque. How was that still standing, I wondered.

We ate another delicious meal (did I mention how good the food is in Lebanon?) and went to a local pub for a beer. With exposed brick, metal buttresses, and art nouveau films projected onto a white washed wall, I could have been in LA or NYC. Since my car was coming at 4:30 am to take me to the airport, we ended the night early (midnight in Beirut is very early). Wissam and I said our goodbyes. I was a little sad to see him go as I became very fond of him very quickly. We knew we’d see each other again.

I awoke very early the next morning, packed my things, and met my car outside the lobby. We drove through the deserted streets to the airport, and I realized that, somewhere on this trip several days ago, I stopped worrying so much about my safety. I think it happened in Kuwait at lunch with Wissam and the Egyptian pharmacists, as that is where I started seeing my hosts as well-spoken, thoughtful, intelligent friends very separate from extremists that claim to act on their behalf. I look forward to meeting my friends again.

Visiting Surgeon in the Middle East: Part 16

The next day, Friday, I ended up with nothing scheduled. I had hummus and Greek yoghurt for breakfast and decided to explore Beirut. Wissam was working and had to be at the office, so I was alone. I didn’t want to miss an opportunity to see Beirut. This was the first Friday (the Muslim holy day) since the death of Osama bin Laden and I was a little nervous about being alone on the streets of such a wonderful but notorious city. Having lived in New York City, Boston, and Los Angeles, I feel like I can blend in with city folk pretty easily (just look mad and don’t make eye contact). But I decided to avoid the area around Martyrs Square and the main mosques just in case there were any demonstrations or ill will toward lone American tourists.

I had a wonderful, uneventful day exploring the downtown area. I wandered over to the Corniche and walked along the sea. From a promontory I could see for miles north and south. I wondered how people that I could probably see to the south (where Hezbollah is dominant) would accept me being there on this day. I just strolled, stopping for a coffee or snack whenever it felt right. I took a lot of pictures and sent them to my 12-year-old nephew, Matthew. He, at such an early age, has the same travel bug I have and I knew he would get a kick out of seeing Beirut through my lens.

Visiting Surgeon in the Middle East: Part 15

We drove back to the hotel and I rested. The team told me I’d need it because they were going to take me out for a night on the town, and it could be late. Having watched decades of American TV news, I was a little worried what a late night on the town in Beirut would be like. Wissam picked me up and we went for a coffee at a French bistro in an open-air mall in a hilly district overlooking the city. The stores were all French chains but the atmosphere was nice in that one had the feeling of being on the street. We sat for 30 minutes chatting about our children and the funny things they do. It was time to meet the crew.

We went downtown near the central Martyrs Square. Many small, crowded streets emanated from it. One, anchored by a very crowded French brasserie, held their many bars and nightclubs. It was hopping. We settled into a nightclub and got a table. There were a variety of bands on the schedule, ranging from Arab tribal music to a disco cover band. Whatever the music, the crowd drank and danced with a fervor that took me by surprise. It reminded me of the Israeli nightclubs in Los Angeles. I couldn’t help but to think how similar everyone is. Why couldn’t they see it? Or did they. I didn’t want to ask since I was not sure of the answer I would get. The crowd was full of Lebanese, Europeans, and at least 1 American. No one cared. They just wanted to have fun. It was a good, albeit late, night.

Visiting Surgeon in the Middle East: Part 14

We settled into a small conference room, and I tried to get my Mac to work. For those who routinely talk in front of audiences, I don’t need to tell you that the scariest part of any lecture is the minute before you start while you are waiting for the computer to sync with the projector. Needless to say, it didn’t. Despite my technical difficulties, we managed to get the talk projected and had a very lively discussion. The group was small, so we all crowded around my 15-inch monitor and talked as colleagues about how to do various operations. Though I didn’t have the opportunity to operate with them (the case had been cancelled), I was thoroughly impressed by their obvious expertise (and ability to describe technical facets of surgery in English). These folks, obviously, were very well educated and qualified.

I learned a lot about health care delivery in Lebanon. or example, a night in the local hospital costs about $100 compared to over $1000 in the US. For that reason, length of stay as it relates to cost is not a very big determinant in Lebanon for making health care decisions. Trying to advocate for more technically difficult operations based on a lower length of stay was not impressive to Lebanese doctors. They were most interested in whatever made an operation faster, safer, and more efficient. No matter where you are, surgeons will always put the patient’s safety first.

Visiting Surgeon in the Middle East: Part 13

We picked up the area manager and the local sales rep and drove to Byblos. We headed north on what seemed to me to be their version of Pacific Coast Highway. The road hugged the rugged coast and overlooked beaches and resort areas. The sun was out and the water was sparkling. It felt a lot like California, especially the traffic. The 40 miles took about 2 hours. We arrived in Byblos a little early, and I was offered a tour.

Byblos is a 3000-year-old Phoenician city that, according to my tour guides, was the place of the first alphabet. There were ruins from that era, Roman, and Byzantine. We walked around the cobblestone streets lined with fossil and religious icon sellers. We settled in to a restaurant on the ancient harbor and ate a meal of fresh fish, hummus, and a variety of other incredibly delicious treats. I could really get used to this.

After a 2-hour lunch, we arrived at the private hospital in Byblos. It was small with a dirt parking lot that the local kids used as a soccer field and had a beautiful view of the sea. Unlike the other private hospitals I saw on this trip, there was neither marble on the walls or a foreign staff. Few women wore headscarves, and the men were dressed casually. As with everywhere I visited, everyone was entirely warm and gracious. The staff had even prepared a back table with local sweets made of nuts and honey.