In contrast to the term "reportage," the word "essay" usually connotes a more personal message from writer to reader. "An essay is when I write what I think about something," students will often say to me. Which is true, to a certain extent - and also the source of the meaning of the second "R" for "reflection." A writer's feelings and responses about a subject are permitted and encouraged, as long as what they think is written to embrace the reader in a variety of ways. As editor of Creative Nonfiction, I receive approximately 150 unsolicited essays, book excerpts and profiles a month for possible publication. Of the many reasons the vast majority of these submissions are rejected, two are most prevalent, the first being an overwhelming egocentrism; in other words, writers write too much about themselves without seeking a universal focus or umbrella so that readers are properly and firmly engaged. Essays that are so personal that they omit the reader are essays that will never see the light of print. The overall objective of the personal essayist is to make the reader tune in - not out.
The first "R" has already been explained and discussed: the "immersion" or "real life" aspect of the writing experience. As a writing teacher, I design assignments that have a real-life aspect: I force my students out into their communities for an hour, a day, or even a week so that they see and understand that the foundation of good writing emerges from personal experience. Some writers (and students) may utilize their own personal experience rather than immersing themselves in the experiences of others. In a recent introductory class I taught, one young man working his way through school as a sales person wrote about selling shoes, while another student, who served as a volunteer in a hospice, captured a dramatic moment of death, grief and family relief. I've sent my students to police stations, bagel shops, golf courses; together, my classes have gone on excursions and participated in public service projects - all in an attempt to experience or re-create from personal experience real life.
This is why it will never be easy to submit to coaching, especially for those who are well along in their career. I’m ostensibly an expert. I’d finished long ago with the days of being tested and observed. I am supposed to be past needing such things. Why should I expose myself to scrutiny and fault-finding?
The patient was a woman with a large tumor in the adrenal gland atop her right kidney, and I had decided to remove it using a laparoscope. Some surgeons might have questioned this decision. When adrenal tumors get to be a certain size, they can’t be removed laparoscopically—you have to do a traditional, open operation and get your hands inside. I persisted, though, and soon had cause for regret. Working my way around this tumor with a ten-millimetre camera on the end of a foot-and-a-half-long wand was like trying to find my way around a mountain with a penlight. I continued with my folly too long, and caused bleeding in a blind spot. The team had to give her a blood transfusion while I opened her belly wide and did the traditional operation.
One afternoon in McAllen, I rode down McColl Road with Lester Dyke, the cardiac surgeon, and we passed a series of office plazas that seemed to be nothing but home-health agencies, imaging centers, and medical-equipment stores.
This last point is vital. Activists and policymakers spend an inordinate amount of time arguing about whether the solution to high medical costs is to have government or private insurance companies write the checks. Here’s how this whole debate goes. Advocates of a public option say government financing would save the most money by having leaner administrative costs and forcing doctors and hospitals to take lower payments than they get from private insurance. Opponents say doctors would skimp, quit, or game the system, and make us wait in line for our care; they maintain that private insurers are better at policing doctors. No, the skeptics say: all insurance companies do is reject applicants who need health care and stall on paying their bills. Then we have the economists who say that the people who should pay the doctors are the ones who use them. Have consumers pay with their own dollars, make sure that they have some “skin in the game,” and then they’ll get the care they deserve. These arguments miss the main issue. When it comes to making care better and cheaper, changing who pays the doctor will make no more difference than changing who pays the electrician. The lesson of the high-quality, low-cost communities is that someone has to be accountable for the totality of care. Otherwise, you get a system that has no brakes. You get McAllen.
There was a moment in sports when employing a coach was unimaginable—and then came a time when not doing so was unimaginable. We care about results in sports, and if we care half as much about results in schools and in hospitals we may reach the same conclusion. Local health systems may need to go the way of the Albemarle school district. We could create coaching programs not only for surgeons but for other doctors, too—internists aiming to sharpen their diagnostic skills, cardiologists aiming to improve their heart-attack outcomes, and all of us who have to figure out ways to use our resources more efficiently. In the past year, I’ve thought nothing of asking my hospital to spend some hundred thousand dollars to upgrade the surgical equipment I use, in the vague hope of giving me finer precision and reducing complications. Avoiding just one major complication saves, on average, fourteen thousand dollars in medical costs—not to mention harm to a human being. So it seems worth it. But the three or four hours I’ve spent with Osteen each month have almost certainly added more to my capabilities than any of this.
Since I have taken on a coach, my complication rate has gone down. It’s too soon to know for sure whether that’s not random, but it seems real. I know that I’m learning again. I can’t say that every surgeon needs a coach to do his or her best work, but I’ve discovered that I do.
A former colleague at my hospital, the cancer surgeon Caprice Greenberg, has become a pioneer in using video in the operating room. She had the idea that routine, high-quality video recordings of operations could enable us to figure out why some patients fare better than others. If we learned what techniques made the difference, we could even try to coach for them. The work is still in its early stages. So far, a handful of surgeons have had their operations taped, and begun reviewing them with a colleague.
Osteen has continued to coach me in the months since that experiment. I take his observations, work on them for a few weeks, and then get together with him again. The mechanics of the interaction are still evolving. Surgical performance begins well before the operating room, with the choice made in the clinic of whether to operate in the first place. Osteen and I have spent time examining the way I plan before surgery. I’ve also begun taking time to do something I’d rarely done before—watch other colleagues operate in order to gather ideas about what I could do.
Talk about medical progress, and people think about technology. We await every new cancer drug as if it will be our salvation. We dream of personalized genomics, vaccines against heart disease, and the unfathomed efficiencies from information technology. I would never deny the potential value of such breakthroughs. My teen-age son was spared high-risk aortic surgery a couple of years ago by a brief stent procedure that didn’t exist when he was born. But the capabilities of doctors matter every bit as much as the technology. This is true of all professions. What ultimately makes the difference is how well people use technology. We have devoted disastrously little attention to fostering those abilities.
The whole interaction was astonishing to me. Just having the cardiologist pop down to see the patient with the surgeon would be unimaginable at my hospital. The time required wouldn’t pay. The time required just to organize the system wouldn’t pay.