I just finished a quick work for two percussionists playing several unpitched percussion instruments of their own choosing. I’m calling it two rhythmic spaces because in effect, each player resides in his or her own metric space. The first percussionist is playing 5:4 for most of the piece, while the second percussionist is playing 7:8 for the most part, so there is a 5:7 relationship between the two. I was going to leave it open as to whether the performers are strictly synchronized (in part because I suspect it’s really easy to get lost in the score), but the astute Dutch composer Samuel Vriezen convinced me on Facebook to take out my note in the score allowing asynchronous performance. He thinks it will work best that way, since the metric structure is so distinct anyway. Samuel also argues that good percussionists like challenges and will strive to do this with a high degree of accuracy, and he’s probably right. Percussionists generally are very receptive to new music and rhythmic challenges, and so I think they’ll be happy with this one.

I’m also in the early stages of writing a piece for a chamber ensemble and most of the music is already improvised, so it’s just a matter of notating and arranging it. But that’s laborious and sometimes even boring, so two rhythmic spaces was a nice diversion.

Score

mp3

I’m still ruminating over the murder of George Tiller yesterday.

As one of the diminishing number of physicians who performed second trimester abortions, I can state unequivocally that it is never a procedure that is approached in a cavalier fashion. Not every gynecologist can perform it, even if trained appropriately. The sad thing is that we’ve done a really bad job at training the next generation of providers. I taught many residents, but of those, many will not provide abortion services for a variety of reasons. Part of why this is is that abortion has been marginalized. People don’t want to talk about it. My colleagues for the most part didn’t want to deal with it. Some couldn’t say the “a-word,” substituting euphemisms like VIP (voluntary interruption of pregnancy). Abortion is a very common procedure. It is a necessary procedure. But it will be an extinct, forgotten procedure if clinicians are not trained to do it safely and compassionately. We need to get it back into the hospitals so that it is again part of routine gyn practice. Abortion training must be made more widely available within residency training programs. It’s idiotic that many ob/gyn residency programs do not offer in-house abortion services, but must send “interested” residents to outside clinics, often on their own time during weekends.

When I was in practice, I did a lot of procedures in ob/gyn. Including abortion. Some of my most grateful patients were those for whom I performed an abortion. I never performed any abortion without being absolutely certain that the patient desired it and that it was her own decision. That’s what “choice” is about, after all. My abortion patients didn’t wake up that morning and decide “What the hell, I think I’ll have an abortion.” This was a very, very difficult decision for any woman to make. People who have not walked in their shoes should not be making judgments or regulations about this most private and personal of medical decisions.

All of us who either performed or continue to perform abortions need to finally stand up, be counted, and say “enough.” Abortion providers have this terrible stereotype of being slimy, scumbags in the margins of the medical profession. We’re not. A lot of us are academics. We’re honorable. Most of us have delivered babies. All of us provide or provided services that are challenging and that many physicians either can’t or simply won’t provide. Rather than honor abortion providers, society (including many physicians) treats them like criminals. This must change. While I recognize the potential danger in coming out as an abortion provider, there is strength in numbers. And just as the Gay community came out and took steps to remove the stigma of being gay, abortion providers should stand up, be proud, and demonstrate that we’re here to stay. Only when abortion is de-marginalized can we start addressing the onerous restrictions on the provision of abortion services and also combat the insidious demonizing of abortion providers. Such demonizing was absolutely behind the assassination of Dr. Tiller yesterday.

I just read that someone assassinated Dr. George Tiller, an abortion provider in Kansas who was one of the few people who were skilled at and willing to perform abortions above 20 weeks’ gestation. Dr. Tiller was shot while attending church services near his home.

For those of us who perform or performed surgical abortion, Dr. Tiller, along with Dr. Warren Hearn in Colorado, epitomized the highest ideals of medical service. Regardless of one’s stand on abortion, Dr. Tiller was a true professional who performed abortion above 20 weeks despite many obstacles, including onerous regulations, overzealous protestors, death threats, a bombing and the shooting of both of his arms. He didn’t perform abortion for monetary reward; in general, there are far less dangerous ways to earn significantly more revenue as a physician. Rather, Dr. Tiller did what he did because it was necessary, and because midtrimester abortion is best provided by someone who has the patient’s best interests at heart.

This also demonstrates how critical it is that residents and other physicians get appropriate training in abortion services. While I provided second trimester abortion services while in practice here in Pennsylvania, I never performed one above 20 weeks to the best of my recollection, and as a resident would go to 24 weeks, but only using saline and prostaglandin amnioinfusion above 18 weeks. Dr. Tiller provided safe, legal surgical abortion up to, I believe, 28 weeks, which requires a great deal of art and skill to pull off without complications. Now that he is gone, there are far fewer people out there with that skill and experience. Only Warren Hearn comes to my mind, although I’m sure there might be a few others.

Dr. Tiller’s murder is another indication that we need to come together and find common ground. No one is more pro-choice than I am, period. I’ve performed many abortions, introduced medical abortion to my hospital in the days before mifepristone was available, lectured about abortion technique and taught many residents how to provide a safe surgical abortion in a compassionate fashion. I’ve never dissembled about my role as an abortion provider, and am very proud of what I did. Indeed, my patients for whom I provided abortion care were often among my most grateful patients. I’ve marched on DC twice in support of abortion rights, actively supported pro-choice candidates and have always been willing to donate money to the cause of reproductive rights. That said, I’ve also worked to find areas of agreement and cooperation with reasonable people on the pro-life side of the divide. I used to be a member of a local group called Common Ground, and it brought people together from both sides to have dialogue sessions on abortion-related issues. It was moderated with strict ground rules, so no one could interrupt or become disrespectful. In this fashion, people can talk with one another without coming to blows even when there is heartfelt disagreement. None of us were trying to convert one another, and indeed, conversion wasn’t possible. The pro-life participants were just as vehement about their side as those of us on the pro-choice side were about ours. But we got along and gradually had a better understanding and respect for the other viewpoint. It taught me that one can respect and even admire those with whom there is visceral disagreement.

We need more efforts like that. I remember the 90’s when several abortion providers were murdered along with volunteers and other staff. It seemed to be a reaction to having a pro-choice president in office, in that case, Bill Clinton. The murders can’t be justified, but I would suspect that they were born out of extreme frustration from not having a conservative administration in Washington, DC. Since January 20th, I suppose it was just a matter of time.

So I’m very saddened by the loss of Dr. Tiller. Unlike Warren Hearn, I’ve never personally known or communicated with George Tiller. But his work always meant a lot to me, and women who need a second trimester abortion are worse off due to his loss. However, the cause of reproductive freedom is very much alive, and will continue despite this terrible act of assassination. I hope that my colleagues, regardless of their personal stands on abortion, and medical organizations such as the AMA, come out and strongly condemn this murder. And even better if we can all learn from Dr. Tiller’s example and come together to try to find some common ground on a very divisive issue.

I’m planning a new piece for what probably will be an ensemble consisting of two women’s voices, violin, cello, marimba, bass clarinet, bass guitar and possibly piano. The work is tentatively going to be titled torture memos (a survivor from guantánamo). The music is already largely written, in that it will mostly be derived from several recent improvisations that were done as part of James Combs’ improvfriday sessions on various social media networks. Almost all of my works started off as improvisations, so this is pretty much standard operating procedure for me. I had thought of using the title Room 101 as that was the torture room in Orwell’s prophetic novel 1984 but I thought the significance might not be obvious to anyone who hasn’t recently read the book.

Why torture memos? Because I’m horrified by what this country has done, how it has taken a detour from its original ideals, and the fact that our last administration contained what amounts to war criminals who have yet to be brought to justice.

Another reason: I’m very much taken by the notion of music as a form of social action. The standard teaching has always been that “political music” tends to be very forgettable in the end (think some of the “Communist” works by Shostakovich or Prokofiev, or even Copland), so invoking political topics in music is a recipe for bad music. But I disagree; some of the best things out there have political or historic connotations, such as Reich’s Come Out, Rzewski’s Coming Together, Glass’ Satyagraha, etc. It’s not that political music is automatically bad. Rather, some political works that have been derided over the years just might happen to have been bad music. If you write decent music, the underlying social message doesn’t make the music bad. Similarly, a lofty social message doesn’t make bad music good. Two of my recent works already deal with social messages, such as darfur pogrommen and zichron

My original plan was to set actual words written by some of the torture survivors from Abu Ghraib, Bagram, Guantánamo, and possibly some of the rendition sites. But I haven’t been able to find such texts. Many of the victims remain incarcerated, some of whom undoubtedly are evil men, but many of whom are and remain innocent of wrongdoing. I’m sure at some point their words will be captured, but in some ways, the most meaningful takeaways remain the photos of prisoner abuse at Abu Ghraib, the full extent of which remain to be seen. Then there was the idea of setting the actual legal memos “justifying” torture by John Yoo and John Bybee, and indeed one of my friends recommended this approach as well. However, a fairly mundane list of approved torture techniques, however terrifying, cannot do as much justice to the abhorrence of the torture idea as can the actual words of the victims.

As of now, I’m thinking of letting the music speak for itself, to use a bad cliché. I might preface the score with some passages from the torture memos, but I have come to the belief that setting either the torture memos themselves or actual accounts from victims is not optimal, since both of these speak well for themselves.

The “a survivor from guantánamo” part of the title is an obvious reference to Schoenberg’s work A Survivor from Warsaw. I do not mean for this to suggest that the things that have gone on, and continue to go on, vis a vis torture are morally equivalent to the massive genocide of the Holocaust. However, I do want to imply that just as Schoenberg drew upon the words of a survivor to describe the unspeakable horrors he suffered through in the Warsaw Ghetto, I want to draw upon music to solicit thoughts about the multiple horrors committed in our name over the years since 9/11/01. That doesn’t mean the music is anything other than music, any more than darfur pogrommen depicts what goes on in Western Sudan. The music is just that; music. But if the subject matters stimulate more thought about their respective topics, then that’s all the better.

Not too long ago, a friend of mine in Philadelphia asked for a suggestion for a primary care provider (PCP). I referred him and his wife to our PCP, my wife and I having been that doctor’s patients for 18 years. We rarely see our doctor, truth be told, but he’s a Hopkins graduate, a good internist, and always returns calls personally and promptly.

My friend subsequently e-mailed me to ask for another suggestion, as our PCP has apparently switched to a “boutique” practice and there’s no way they could afford the annual membership fee. Such fees usually range from $1,000 – $3,000 each year. You’d think he was joining a country club or something Our doctor’s switch to a boutique practice was news to me, but as we rarely see our PCP, it’s not surprising we weren’t notified. Our strategy was going to be to hold out and hope our PCP would switch back to a non-exclusive practice, once he realized that this new approach was not popular and he was losing money.

Wishful thinking.

I had to call my PCP today for a referral and as usual, he returned my call personally and within a short period of time. I was asked by his answering service, however, if I was a “VIP” patient. I said we’ve been his patients for 18 years. I mean, that should count for something, right? So I spoke with our doctor about his new boutique practice. He told me that tons of people are signing up, and those who don’t can always see his partner as she still takes insurance. Boutique practices by definition are fee-for-service, cash-only. So in order to continue seeing our PCP of 18 years, we have to pony up a large annual membership fee. Thus, like my friend in Philadelphia, we’re looking for a new PCP.

I can’t blame our soon-to-be former PCP, really. Given that the average physician pays almost $70,000/year to argue with insurance companies it makes little sense any more to participate with third-party payors. This guy is a good doctor and he’s now able to continue doing what he had been doing all along and what he likes to do: practice good medicine in a personalized fashion.

Just like I understand why many of my gynecology colleagues have taken up cosmetic surgery, I understand the allure of boutique medicine. But both of these trends offend my sensabilities and epitomize a medical system gone astray. Boutique medicine establishes another tier in our multitiered health care system. If you have money, youre fine. If not, good luck.

And while I don’t expect all physicians to practice the way I used to practice, I do expect some basic tenets to hold. I returned patient calls. I saw them personally. I didn’t charge extra for what I viewed as quality standard medical practice. Who would have thought I should charge to see a patient in a timely fashion or return their calls myself or write a disability letter? I just stupidly thought this is what one does as a doctor.

So medicine has changed. And not really for the better. If you want to have personalized care like many of us used to provide as a matter of course, you have to pay extra for it. If you’re a surgical gynecologist, you might want to supplement your decreasing revenues from managed care by providing cosmetic services. And so on and so forth.

It’s crazy. Every time I get a hankering to go back to practicing gynecologic surgery, stuff like this gives me the kick in the ass reality check I need to contnue doing the fun stuff I’m doing. But it’s still a shame to see what’s happened to medicine.

The Inquirer just hired torture architect John Yoo for a monthly column. Another sign of the fall of a once great newspaper.

Here’s my letter to the Inquirer. Feel free to send them your thoughts here (you’re welcome to recycle my text below as your own).

I wish to protest the Inquirer’s hiring of John Yoo as a recurring columnist. As a chief architect of the Bush Administration’s misguided and illegal policy on torture, Yoo has no credibility and deserves condemnation by the Inquirer, not employment. I am urging all my friends and acquaintances to boycott the Inquirer until and unless the hiring of John Yoo is rescinded.

Sincerely,

David Toub

When I was a pelvic surgery fellow, I was doing a bowel resection with a general surgeon who was an older, distinguished Persian gentleman with an old world sensibility to him. When it came time to do the reanastomosis, I asked the scrub nurse for a surgical stapler and was stopped by the surgeon, who asked why I wanted to use a stapler to reconnect segments of bowel. I indicated that this is how I had always done it, and it was a faster method overall. The surgeon preferred that I do a hand-sewn anastomosis. When I asked him why, he said “Why do I drive a Mercedes rather than a Ford Taurus? Both will get me to my destination, right? But the Mercedes has craftsmanship.” His point: a technician can use a mechanical device to connect bowel back together. A craftsman takes the time to do it the long way, with artistry and precision.

So that’s how I came to learn how to do old-fashioned, hand-sewn bowel anastomoses. I still preferred staplers. But there’s something to be said for craftsmanship. In surgery, how you do something is often as important, or even more important, than the end result.

I was thinking back to that surgical experience during fellowship as I took stock of all the things in ob/gyn that are not representative of craftsmanship. Unlike any other surgical field I can think of, we as a profession have been oversimplifying and undoing years of craftsmanship. Sometimes perhaps for the better. But overall, for the worse. Examples:

• Replacing the more difficult art of forceps deliveries with a much simpler (yet often more dangerous) technique of vacuum extraction
• Replacing the art of hysteroscopic endometrial ablation with office-based nonresectoscopic endometrial ablation that does not permit visualization of the endometrial cavity
• Replacing advanced operative laparoscopy with robotics
• Replacing ureteral dissection with lighted stents
• Replacing laparoscopic hysterectomy with laparoscopic supracervical hysterectomy

Why am I lamenting all this? Because rather than become fluent in advanced surgical procedures, either through fellowship training or extensive preceptorships, my specialty has tended to ”dumb down“ surgical procedures in order to make them more accessible to the ”average gynecologist.“ Years ago, when endometrial ablation came out, it was looked upon as a way to make a significant dent in the ridiculously large number of hysterectomies performed annually in the US (~600,000/year for benign disease). However, only about 20,000 ablations were done every year, because most folks either never learned the hysteroscopic skills required to perform the procedure, or else just didn’t want to do it. So in its place came an office-based procedure, erroneously termed ”global endometrial ablation (GEA)“ that is a blind procedure but often as efficacious as the hysteroscopic version.

Now, I have nothing but praise for moving appropriate surgical procedures to an office setting. It’s easier for patients and better from a cost standpoint. But it’s one thing to move a procedure to an office setting thanks to innovative medical devices in an evolutionary fashion. It’s quite another to create a new device and technique in order to make a procedure accessible to more gynecologists due to their lack of surgical skills.

I hate to sound like an old curmudgeon complaining about the lack of skills of a younger generation. But just consider what’s happened to gynecology over the years. Can’t dissect the ureter worth a damn? No problem-just ask your friendly urologist to place some lighted stents into the ureters so that you can see them during surgery. Mind you, the stents only serve to make the ureters a better target for inadvertent injury, and the additional procedure adds minor risks and costs to the overall surgery. But it makes some gynecologists feel better. If only they didn’t fear the retroperitoneum and took less than five minutes to identify the ureter, dissect it, and mobilize it out of the way without the need for stenting.

Same with robotics. Again, I’m all for medical advances. But robotics had primarily been adopted by urologists in order to do laparoscopy simply because urologists traditionally have not been laparoscopic surgeons, unlike gynecologists. But what happened? Robotics became not just an expensive marketing tool by some hospitals, but a crutch for some general gynecologists to perform laparoscopic procedures that they couldn’t have done the ”old fashioned way“ (that is, without a $1.5-$2 million robot helping to facilitate the procedure). Robotics may yet be shown to have a rational place in gynecology; I know of at least one colleague who has similar objections to robotics but feels it makes it much more possible to close the uterus in an anatomic fashion during laparoscopic myomectomy. But when I hear about gynecologists using/needing robotics for laparoscopic operations that many of us routinely performed without any robotic systems, I wonder what the future is for my specialty. Same with laparoscopic supracervical hysterectomy. In the absence of any good data supporting an advantage over total hysterectomy, many of my colleagues perform laparoscopic supracervical hysterectomy as a way to make the procedure easier. It does reduce the risk of ureteral injury, to be sure. But do we really need to dumb down gynecology?

Surgery is all about craftsmanship. And skill. While I applaud attempts to make difficult surgical procedures more accessible to a larger number of physicians, it makes me wonder why such a large number of my colleagues don’t feel comfortable with, say, operative hysteroscopy or laparoscopic hysterectomy in the first place. So many things seem to require simplification, but I am not aware of that many general surgery or cardiothoracic surgery procedures that have been simplified in order to make them more performable by the average general surgeon or CT surgeon, respectfully. And just consider the average CT surgeon; would anyone dare imply that he/she isn’t capable of doing a valve replacement or some intricate vascular procedure, and thus would require a simplified operation to be able to treat his or her patient?

We need to do a better job at producing gynecologic surgeons who are capable of performing the more complex approaches to certain operations and procedures. If such procedures can evolve and become simpler and cheaper to perform, then great. But let’s do it for evolutionary reasons. Not in order to make something accessible to surgeons who really should be able to do the original procedure in the first place. If there is a real advantage to ”GEA“ then that’s wonderful. But is there an evidence-based advantage or is it really a case of ”dumbing down“ endometrial ablations?

• Prosecutions for US-sanctioned torture. I don’t care where it leads. A war crime is a war crime, period.
• Repeal of ”Don’t Ask, Don’t Tell.“ We’re supposed to have equal rights for all in this country. I’m not sure we can say that when we ask so much of people who are willing to sacrifice everything for this country, then essentially fire them for a biological reality, namely being gay or lesbian.
• A Twitter client that does everything I need in a simple way, and no more
• Time. I really need a 27-hour day.
• A Democratic primary victory by Joe Shestak over Arlen Specter, and a general election victory for Shestak. He gets it. Arlen doesn’t.
• Tolerance. We’re such a divided nation, and in a very personal, ugly way. I’m speaking about you, Rush, Sean, Glenn and all the other right-wing talking heads who just spew hatred against progressives and pull ”facts“ out of their asses. Guess I’m intolerant of intolerance.
• A moratorium on rain in the Northeast
• Real separation of church and state in this country. Get rid of the National Day of Prayer. We’re a pluralistic country, and just as clergy have no business telling people how to vote, the government shouldn’t be telling folks how to pray. Or whether to pray.
• No more funding of “abstinence-only education.” It doesn’t work. Or do facts not matter any more?
• Passage of the Freedom of Choice Act. Like the Equal Rights Amendment, it’s long overdue.
• A reduction in bigotry, including racism masked in “anti-immigration” hysteria. No one was pushing to close our borders with Canada during the SARS outbreak, were they?