John R Taylor

You can publish an editorial.

I seldom read editorials in medical journals, especially the ones from “Mount Olympus”. I do read the light breezy ones with an original or irreverent point of view. The late Robert Goldwyn was a master at making a point with humour. We miss him. Editorial writing is a good way to express what you think. Here are a few suggestions for writing your own editorials. The first job of the writer is to be read. Be bold and catch the reader’s attention. Think of your favourite writers and emulate them. Ask yourself, “How does PJ O’Rourke, Joel Stein or Malcolm Gladwell do it?” Start with a burning idea and write it in 800 words. This fits nicely on one page. Have a beginning, a middle and an end. Think of an opening line and the ending first. Make the reader want to read the whole article and want more. Make your point once. Use humour if you can. This is important to being read, but can be difficult to write. Be lighthearted, but never use sarcasm, which is too powerful. Use irony if you can, but use it gently. How did Stephen Leacock and Mark Twain do it? They told stories and liked the people they wrote about. Making fun of yourself works. Do not pontificate. Spend a lot of time choosing your subject. Sit down and write quickly. There will be problems, but when you rewrite, it will be a lot better. Do not spend a lot of time on grammar; just write clearly, and never use a big word when a little word will do. Eliminate ‘than’s, and’s and then’s’ following The Elements of Style by William Strunk Jr and EB White. The journal editor’s job is to be objective. An editor can comment on wording to make your ideas clearer, but it is your job to submit it in finished form. Do not expect the editor to rewrite opaque writing. If you have a particular grievance or a physician’s hobby-horse you like to ride, an editorial is a great way to express yourself. It helps you hone your point of view as you learn the weakness of your argument by writing it. You need to choose a style and a voice. It can be a debate, with you taking both sides. It can be a story with a meaning. It can be a personal experience. Whatever it is, it is a style you have chosen for that editorial. If it works, use it. If it doesn’t, start again. A personal question about scientific papers. Why can’t they be briefer and more entertaining? How did physicians learn to write obscurely? It is time to forget jargon and write simply. Just state the problem you wanted to solve and how you solved it. Show, don’t tell. Tell if you must, but clearly. If we used metaphor and visual imagery in journal articles, we might read more of them. A novelist completed his masterpiece, a 400-page tome and asked a reader how he liked it. The reader considered what he really thought, and said, ‘next time, write shorter’. Be surgical and debride it! Love words and play with them. Remove the debris and leave the gold. Discussing a problem is fine, but it is better to propose a solution. Entertain, be short and use imagery. Get in, make a point and get out. Bring the fog into focus.

How to drive your surgeon crazy

Why would anyone want to drive their surgeon crazy? Do patients intentionally do this? Probably not, I mean, why would you? The surgeon is supposed to be the soul of patience. He is supposed to treat you and make your problems go away. But first, he has to diagnose you. Suppose you wanted to drive your surgeon crazy for some reason best known only to you. This is how you could do it. Remember, this is secret information so be careful how you use it, and don’t quote me. The first and best way: Never answer a question. If the surgeon asks, “How long have you had this”, always reply, “A long time”. It drives them crazy, and it’s none of their business anyway. After all, they are just going to ask you why you didn’t come sooner. You don’t really want to be there anyway; it’s only because the ointment and beetroot didn’t work. Even better, answer a different question. Question: “How long have you had this”; answer: “It really hurts”. Make a big point about the difference between your advice and your family doctor’s advice. “So how come you are telling me something different than my doctor said?” This is a real winner. The surgeon has to explain that he is a surgeon, so the advice is different. This is guaranteed to get his attention because he has to explain his qualifications and even explain why you were referred. You can say, “I think I like my doctor’s advice better”. Also, before you come for the visit, look in the mirror and practise a suspicious look meaning, “Of course you are going to recommend surgery, that’s how you get rich”. Don’t say it, just practise the look. You’ve won when the surgeon starts to reassure you. Once you’ve gotten the confused look perfected, try this: “I don’t know why my doctor sent me”. The surgeon has no way out of this. If he says, “I don’t know either”, or if he says, “Your doctor is worried you have a ganglion”, you can say, “I already knew that”, so you’ve won again. Try saying, “It went away, but I thought I would come anyway”. You can mispronounce simple words, so see if he will correct you. Try saying “gangrion”. Then when he corrects you, you can say smugly, “I’ve always called it gangrion”. But be careful, the goal is to assert the upper hand, not to look like an idiot. Get upset when the surgeon says you have to wait four months for surgery. Practice a pout, but don’t throw a tantrum; that is going too far and is counterproductive. Just conjure up sympathy. Do your homework before the visit. This is a lot like, “My dog ate my homework”, but being older and wiser, you can come up with a better reason as to why you should have surgery right away and why the doctor should cancel someone else so you can get in. Do not say, “I’m going to Florida”. Even if you stay in a trailer in Florida, this excuse will not work. Ask to get in right away because it is only a little operation. A pine sliver in a finger needing urgent removal is a good one. After all, it will only take 15 min, right? Dress funny. The surgeon likes to think he is a minor Sherlock Holmes who is able to diagnose by mannerisms and little things he sees. So wear your strangest clothing. Dressing like a Morris dancer is good, or a character from a Monty Python sketch. Be careful. Saying, “Not much of a hospital, is it”, might bring the response, “Best one in Dibble County, sir”. Act as if you expected surgery on the first visit, and are disappointed you have to come back for the actual operation. This shows the surgeon how trivial you think the operation is, and how valuable your time is. Keep at it, you are gaining the upper hand. Always come to the visit with all your relatives, but for special effect, bring your strangest ones. Uncle Alfred with the strabismus and 1946 dental work is a nice touch, especially if he is deaf. Prepare him to ask, “What did he say?” when he sees the surgeon speaking. Having to shout is a good way to keep the surgeon off balance. You know you’ve succeeded in driving your surgeon crazy when he gives you anything you want just to get you out of the office. This is the time to use your advantage. Wait until the visit is over, then pull out your insurance form. He’ll sign anything now. Another way to tell: Look for two things. The telltale twitch in your surgeon’s face, and how he gets up and slumps toward the door. Now the visit is over. But look on the bright side. You can always come back!

Rules for practice in 2008.

In 2008 I resolve: To answer every phone call the same day the call was made. The call may be trivial to me, but it may be important to someone else. To slow down. I will remember that the patient and his or her relatives are anxious. Because they are anxious, I will not rush. I will ask what they want to say, and listen to the answer. I will not interrupt, even to clarify something. I will remember that many people are not verbal. They cannot describe what is wrong, but, instead, expect me to somehow know. John R Taylor I will not scare people with informed consents. I will be reasonable in discussing the risks of surgery. I will say, “in this operation I will be worried about...”. I will recommend surgery only if I am convinced there is a very high chance of helping the patient. I will surgically change the patient’s appearance only if the problem is immediately apparent. I will decline all minor changes that are seen by the patient only. I will do only one consultation for one problem at one visit. No more triple consults ‘while we are at it’. I will communicate more by my demeanor and smile, and less with words. I will make fewer notes while the patient is in the consulting room, and leave my notes for later. I will look at the patient’s face when I explain what is wrong. I will use clear, nonmedical language, and repeat it slowly. I will suggest the safest anesthetic that will allow me to perform the operation properly. I will assume nothing about what the patient understands. I will remember the word ‘patient’ means sufferer, and put myself in the patient’s position imagining myself in the other chair looking at me. I will remove all abruptness and criticism from my tone. I will make haste slowly. I will try to be on time. I will refer to colleagues with more expertise than I for a second opinion. I will write honest referral letters that include my diagnosis. I will avoid all unnecessary tests, instead relying on my clinical experience in making a diagnosis. I will tell patients the diagnosis I think is correct and avoid long lists of possibilities. I will tell patients the one best treatment, the one I recommend, clearly and with confidence. I will explain the second-best treatment and why my first treatment is the best, but I will not confuse by recommending more than two possible treatments. Even if surrounded by troubled people I resolve to be kind, courteous and patient to all. I will remember aequanimitas. I resolve not to talk about myself but rather listen to other people. I will remember that the world does not revolve around me. I resolve not to play the ‘can you top this’ game. No one wants to know I have had more troubles than they have. I will not take second-hand gossip or interpreted stories as fact. I will avoid people who sincerely generalize on the basis of one experience. I will remember that not all questions are questions. When asked what I think of vitamin E on scars, I will wait until the patient tells me what they already believe. I will not try to change a believer’s mind. I will not ask rhetorical questions in the consulting room. Socrates does not live here anymore. I will never discuss politics in the consulting room. I will encourage and give the patient hope. I will wash my hands before every patient visit and not wear a long tie. I will rely on my charts, not my memory, in the operating room I will encourage relatives to attend the consultation, particularly mothers and daughters, and watch their relationship. I will not overbook. I will learn how to say “no” graciously. I will telephone referring doctors regarding difficult cases, explaining my advice. I will be positive every day. I will enjoy my practice and thank my lucky stars for being able to do this fascinating work.

The 6th Annual Toronto Breast Surgery Symposium, March 30, 2006, and the 36th Annual Symposium on Aesthetic Plastic Surgery, March 31–April 1, 2006

The University of Toronto’s Annual Breast Surgery Symposium, chaired by Dr M Brown and Dr J Semple, was followed by the Annual Symposium on Aesthetic Plastic Surgery, chaired by Dr W Peters. The meeting was small enough to meet friends and share surgical experiences. Every meeting has pearls, and our invited guests were outstanding speakers and teachers. Rather than listing all the speakers, I will mention a few of the ideas discussed at the meeting. Some breast reconstruction is being done with submuscular expanders and implants with very slow expansion. Nipple reconstruction is done alone and the areola is added later. If a breast cancer is in situ or low-grade, immediate breast reconstruction is more likely than if there are multiple positive axillary lymph nodes and radiation is used. The breast reconstruction rate is 10% and those who have reconstruction live longer. This fascinating finding could be related to immunity, well-being and surgeon selection. Chest wall recurrence can have a good outcome. With wide excision, there are many flaps available for coverage: vertical rectus abdominis myocutaneous flaps, free flaps, large abdominal flaps and latissimus dorsi flaps. A dermis homograft can be used to add cover to an expander in immediate reconstructions sutured from the chest wall to the lower border of the pectoralis muscle. Breast implants can be safely irradiated and the skin below the inframammary crease can be dissected to recruit skin into the breast reconstruction. Immediate reconstructions are on the rise, partly because there is a considerable wait for delayed reconstructions, and because a transverse rectus abdominis myocutaneous flap surgery now requires only about three days in hospital after surgery, aided by printed patient information. The breast implant debate goes on. Some surgeons prefer gel implants above muscle if one can pinch more than 2 cm in the upper pole for better implant cover, if there is slight ptosis and if the pectoralis is thick. Saline-filled implants, partially sub-muscular, are advised if there is less than a 2 cm pinch, if there is no ptosis and if the pectoralis is thin. The breast may look better with the transaxillary approach because the inferior pectoralis is intact. Many of the tenets of breast augmentation were debated, such as ‘bigger is better’, achieving the patient’s desired cup size, a specific implant making a specific breast cup size, further inflation for rippling, implants to treat ptosis, implants to produce cleavage, anatomic implants are superior and different implants can produce symmetry; all are commonly believed but can be challenged. Reconciling ‘wishes with tissues’ underlies the best decisions. We discussed what ‘cohesive’ means. Essentially all gel-filled implants are cohesive; the difference is how cross-linked and how thick the gel is. We were reminded that breast implants can change the breast. Very big implants can cause breast tissue atrophy over time, and those who want very large implants should be advised against surgery; certainly the implications would need to be discussed in detail. Intensive preselection is the best predictor of patient happiness, and reoperation for size change should be discouraged. If a secondary size change operation is performed, an additional 50 mL to 100 mL will not be seen – a 200 mL difference will be needed. Accurate surgery and minimizing drugs can make augmentation recovery rapid. In the face, the best view to assess facial youth is the three-quarter view, which should show a gentle ‘S’ curve. This can be achieved by doing a superficial musculoaponeurotic system elevation above the jowl. A hollow upper eyelid looks old, so upper lid fat grafts below the eyebrow can rejuvenate. Fat grafting the nasojugal groove in the cheek is good, and a hollow temple can be augmented. Fat grafts can be used on each side of the centre of the lower lip to create areas of fullness, at the base of the nose and at the red-white margins of the lip and the chin. The lateral tarsal support suture is a useful addition to lower lid blepharoplasty. Fat grafts should not over-correct, and fat at four months is permanent. Constant motion and multiple passes while injecting small amounts of fat are key details. Facial rejuvenation is not the application of one operation to all faces; rather, it is the application of multiple operations to achieve a subtle result and recovery in a reasonable time period. In abdominoplasty, some surgeons advise against abdominal wall liposuction at the same time, but it is safe to perform as long as the lateral abdominal wall blood supply is intact. Lateral sutures can aid in narrowing the waist. Paralytic ileus can occur as a complication of abdominoplasty even without perforation. Informed discharge is an accepted concept in clinical practice, particularly knowing what to look for postoperatively. Risk management is showing benefits in a decreasing number of claims. It is this writer’s view that the symposium owes its effectiveness to all those who participated and shared the practical aspects of breast and aesthetic surgery surgery.

Dr taylor and the transylvanian peel.

Having been inspired by the great sleuth, I learned many things; the most important was the ability to observe. I knew that fortune favours the prepared mind and I determined to pursue the course I thought would favour my destiny. John R Taylor I was attending in my consulting rooms one afternoon, when a woman entered my office. She had come about her hand, but it was a minor problem and I dealt with it quickly. What fascinated me, however, was her face. It was an ordinary face – weather-beaten and marked by hardship, although she was young. On both cheeks were large, vivid, red marks. I wondered if this was a form of rosacea or if she had the Wolf syndrome; a syndrome characterized by muscle and joint pains and a skin rash of both cheeks. She was offended and made to leave, but I was able to persuade her to stay, showing my extreme seriousness in pursuing the cause of her unusual condition. I decided this could not be lupus or rosacea because her skin was too smooth, the edges of the rubrous-violaceous marks too defined. After much hesitation, she told me that she had been applying a substance to her cheeks to smooth them, a substance which was secret and about which she could tell me no more. I did, however, have the opportunity to examine her cheeks from every aspect and angle of light, and used my senses (as was my wont) to determine what she had been applying, for indeed I saw a remarkable smoothness. Where the red colour was, the skin was new, with a soft reflective surface not unlike the surface of undisturbed water. I determined she had arrived in London some three years previously from a village near the Black Sea after a long and arduous voyage. She had been working as a cook and occasional fortune teller. I bid her farewell and thanked her for her indulgence. Being excited that I had perhaps stumbled upon some new treatment with widespread application, and being at the time one step above professional destitution, I was determined to investigate further. I proceeded to make a lotion containing what I suspected the ingredients to contain. Within two weeks I had made a lotion containing various soothing agents including lanolin and perfumes, honey and, most important, the substance which I felt to be the active agent. Unfortunately, this material exuded a noxious and foreign aroma which I thought had to be disguised to be acceptable to a London clientele. I was able to purchase it from my patient who had her own sources which she would not disclose. With great trepidation I applied the unguent to a society matron who had consulted me, her own physician being indisposed. Within a month, my waiting room was full and I was dispensing each container for the sum of 10 guineas. Because this was considerably more than my consultation and complete treatment for a difficult case, I was astounded. I was besieged on all sides by demands to reveal my formula, but I saw no reason to divulge my secret until one day, when the cook returned to my office. She told me she knew that she had been the foundation of my success and suggested a partnership which I could not very well refuse. She said that if we worked together it would be to our mutual advantage. She was a much different person than at our first meeting. Confident and well dressed, she showed every sign of being a woman of means. She told me she wanted to keep our arrangement between the two of us but left no doubt regarding my fate if word became bruited about relating to the origins of my success. We married the following month and now I am pleased to say, have five healthy and active children who work in the family business when they are not pursing their studies and avocations. We grow the plant which supplies the secret ingredient at home in our back garden and my wife also uses it in the very popular restaurant she manages. After many years, I determined that many agents can be used to improve the skin as long as the skin turns red after application and the agent is not so strong as to damage or thin it. I am determined to try Dr Lister’s carbolic acid solution soon and think it might have possibilities. My botanical studies have also uncovered a tree leaf from Florida, a desolate marsh in America which according to the natives might have possibilities. I am planning to try galvanism, which might be useful combined with a small roller made of alternating magnetic metals to roll the skin smooth. With the permission of my wife, and for the betterment of humankind, I can now reveal the active agent and the foundation of our success. The plant is rather small, about the size of a small lemon and its name is Allium sativum, but you might know it as garlic.

The luckiest generation.

It was the end of the sixties, the start of the seventies. The flower power generation was aging and trading in their vans for family cars, Nixon was in the White House, and we were plastic surgery residents. Our road to that place had been long though we were barely aware of it. Born before or during World War Two we represented the hope of the end of the great Depression –our parents hope – and if our parents were the best generation, we were the luckiest generation. Lucky to be born and grow up in a time of prosperity and expansion, when careers were expanding and when it was easy to get into medical school with average marks. We all could have done better academically but we didn’t see the point as we were having too much fun (there’s no such thing as too much fun). We were shaped by music, cars and television. We transitioned from Glen Miller to Bill Haley and the Comets, Chubby Checker and the Twist, the great Satchmo, the Beatles and Elvis. Our cars were prewar art deco monsters, Volkswagens and rocket ships with fins. Hugh Heffner and John F Kennedy were our gurus. We were idealists, and if not exactly libertines, much more liberated than our parents. In October, 1962 at the time of the Cuban Missile Crisis, we were certain we would be at war within the week. I cannot describe the relief we all felt when the crisis was defused. That event alone made us peacemakers. We were interested in the world, as we knew we could not sit in isolated smugness believing that events would pass us by; we had grown up with the cold war and the arms race – to us, Dr Strangelove was real and we needed ironic comedy as a way of looking at the lunacy of fanaticism. The great Peter Sellers spoke for us and we imitated his accents as we slipped from one character to another. We developed a great distrust of very serious people for we knew that those with a mission, especially those who believed there was only one way of doing things, were inherently dangerous. A lot has been written about the drug culture, most of it hype. I can assure you that those of us who were medically trained only experimented with alcohol and caffeine, and usually one binge was enough. Our pharmacology training prohibited us from experimenting with anything else. There was no way we were going to let psychotropic drugs affect our brains, not after we learned how potent pure drugs were, not to mention drugs brewed in somebody’s garage. We might have talked freely, but we were not foolish; after all, we were much like our parents’ generation. Medical school was where we grew up. We were enthralled by the idea of becoming physicians. It was egocentric and idealistic. In six years, a raw high school graduate could become a white-coated doctor with a pipe and stethoscope and, we hoped, a chick magnet. (In those days we carried our stethoscopes in our pockets, not around our necks.) My problem was that I found the lectures repetitive, narrow and stultifying. It was more than that; driven by a need to find heros, I found only my anatomy professor (for his Scottish humour) and my surgery professor (for his encyclopedic knowledge and war record) objects of my admiration. There was too much drudgery and not enough passion. I was starting to understand it was the teachers job to show the student how easy everything was and assume the student had the mental equipment to understand; but it was the repetition that finally got me; I was starting to have a glimmer of a great truth; just give me the concepts, the details come later and to understand by doing. John R Taylor As Jack Webb said on Dragnet, “just the facts, Ma’am.” Even as medical students, we could see the difference between the medical and the surgical life, and the surgeons in embryo were being drawn toward surgery as much for it’s action and decisiveness as anything else. We wanted to live large and this was how we were going to do it. I think we chose our specialties by image more than anything else – what we wanted to become; how we saw ourselves in the future. We were lucky because we could do anything we wanted. The future was open to us. Unlike today, we could try family practice for a while then specialize later if we wanted. Once we started training, we were junior assistants to the great surgeons. We had to know our stuff, work hard and keep our heads down. Now in our late twenties, we were almost all married by this time and many of us had young families. We worked and stayed in the hospital every second night and every second weekend. Our spouses were the real heros of our training and the adjustment and loneliness was difficult for all of us, and a source of not a few divorces. The system made us work hard to get training over with so we could get on with life. And how we studied. On our nights off, instead of playing with the kids, we went to the basement and studied. We were young and could do it, but it was tough. We had great seminars. One evening every two weeks and every Saturday morning we covered our work in the form of topics or fellowship exam questions. It wasn’t like medical school at all, it was way better. In the operating room, we were asked what we thought. We were seldom told what to think, and our surgeon teachers were generally kind. We were taught the Socratic method before problem-based learning became trendy. We learned early never to make up answers. If we did, the response would be a loud “HA!” or a kinder, “most people wouldn’t have said that, actually.” We made great life long friends for there is nothing like mutual hardship to cement a bond. We learned to joke and mimic as a way to change roles and release tension, but always after the boss had scrubbed out. We learned to do difficult things and give bad news in a human way. When it was time to wake the patient up we’d look at the anesthetist, a doctor we’d gained great admiration for and say, “run for the helicopters” (after the African Show in which the TV personality gave the elephant the antidote and ran to avoid getting trampled as the giant beast staggered to its feet). “He lives, Igor” was another favorite. We were correct without being political. We didn’t know if we had what it took to become surgeons when we started and nobody ever told us, we just did our best and tried to survive. There must have been a day when we knew we were going to make it, but I was never aware of it, we were too busy to think that way. It was as if we started as them and us, and imperceptibly we became us. I remember one day when I must have been daydreaming, sighing or looking out the window and the Great One told me, “Taylor, always remember, if you don’t want to do this there are eleven others eager to take your place.” That woke me up. And the minds we were exposed to! They were great, and many were intuitive and lateral thinkers. They were disciplined, optimistic, punctual and they always cut to the chase. They accepted us as the next generation and when they knew we were serious students they would let us into their worlds as equals. Many became life long friends. They had many dimensions, but we were too young to be aware of more than a few. We learned a lot of manual dexterity tricks and how to use various instruments, but it was more thinking based than manual dexterity. One did not need the talent of a great piano player; more the thinking of a chess player and the ability to shift ideas around. Later, when internal medicine was called intellectually based and surgery procedurally based, we just laughed. We knew where the intellects were and didn’t bother explaining it to anyone. Years later a close surgical friend said to me, “you know, we had a military training.” This had not occurred to me but I knew immediately it was true. Many of our teachers served in the military, achieving high ranks. When they chose us for training they were choosing junior officers who could take command some day. Our training was military to see how tough we were, and whether we could tolerate battlefield conditions, or crack under the strain. They wanted to know if we could focus, achieve, and understand the concepts, and we did because they taught us to do this. We also did it because we admired and respected them for who they were. They were decisive and confident and had solid achievements they didn’t talk about much. They had a quiet pride. We were worried about the fellowship exams because we did not want the humiliation of failing, and we needed to move to the next stage as soon as we could. Our families needed us. Our training was an indulgence allowed us, but we could not allow it to go on forever. We need not have worried. Every day and every seminar was preparation for our examinations. Every question in the operating room was getting us ready, and when the exam time came, the questions were fair and aimed mainly to assure we were fit for independent practice. We were very proud of our achievement – the FRCS(C); I have never been as proud of anything before or since, except my family. That is how I feel to this day. I never had to go to war due to the sacrifices of others. I didn’t choose my generation –none of us ever do. I was fortunate to be born when I was, and have others encourage me. We are members of the luckiest generation. That’s why we try to give some of that luck to others along the way.

Money and quality in health care: Muttered medical musings from the back of the class.

Time is money, as the saying goes. You get what you pay for is another. This is often used to justify buying something expensive when something cheaper would do quite nicely. Sometimes paying a lot for a service is another way of assuring that the service is of high quality. It seems much easier for the customer to decide whether a purchase is ‘worth it’ if something concrete is bought. It seems much more difficult to decide when what is bought is an opinion or advice. Perhaps this explains the rise of patients being self informed and discounting their physician’s opinion. What about buying a medical service? Is the quality of the service related to the time spent? The beauty and difficulty of asking a question like this is that the answer seems often to be, ‘it depends’. Which leads to the next question, as every progression like this always does: “How does one decide what quality is?” Right away let us agree what quality isn’t. It isn’t democratic. You don’t determine a quality opinion by having three consultations and taking the best two out of three. Maybe the minority opinion is best (not right or wrong). How do you tell; that is the question. Also, you don’t decide by finding the opinion you already agree with; then what would be the point of getting any opinions? So let me get it off my chest and have it done with. Our present system, though accessible, seems to place accessibility ahead of quality, because it promotes open access but not the time spent for complexity. The system leaves quality up to the doctor and patient. There are two assumptions here: the doctor will not supply low quality and the patient will not accept low quality. I am also making another assumption: that time spent is related to quality. Quality is such a morass that it is seldom discussed, but some quality issues are easy. The well-selected surgical patient who is happy with their result is not a quality issue, the unhappy patient might be purely on the issue of selection, not on the basis of surgical performance. The viable flap flush with good circulation speaks for itself because it succeeded. The struggling flap might be an issue but equally might have been wonderfully selected and performed in heroic circumstances, but still fail. Then there is quality from the surgeon’s point of view. The surgeon looks at quality from the view of being able to decide how best to achieve quality. This might need operating room accessibility, well-trained interested operating room staff and preoperative investigation. It means excellent surgical assistants, instruments and anesthesia with finesse. The Physician Charter published in the Annals RCPSC, Vol 35, number 7, October 2002 page 400 states: medical professionalism demands that the objective of all health care systems be the availability of a uniform and adequate standard of care. What is adequate anyway? Is it fair, good, good enough, very good or excellent? In who’s opinion is it adequate? If it is not adequate, who do you tell? How do you make your case and to whom? What do they do then? What if you think more money would make it better since you don’t like the quality? What if you think quality is in fact related to money? What if you are the only one who thinks money and quality are linked? I’d like to give a simpler answer. The committee that wrote the statement about adequate care was writing a sermon proposing a high ideal. Sermons derive their suasion from the pulpit, the obviousness of the statement, the sheer impudence of debate and the high mindedness of the issue. Sermons (at least the ones I’ve attended) seldom give practical advice on how to achieve the goals and virtually never invite debate from the back rows, which is my favorite seat. I admit I have always sat in the back row since here I could make editorial comments about the teacher or sermonizer with minimal chance of being overheard and read exciting books under the desk during the boring bits. (I once read Peyton Place during grade 10 physics – exciting stuff in the fifties). But I digress. John R Taylor Forget the charter, it’s not real. Patients will tell us when they think their care is less than adequate. On the other hand it has to be obvious to them, not so with us, since we tell patients what they should be getting in investigation and when surgery needs to be performed. When surgical delay could result in an inferior result we have a particularly difficult dilemma; the dilemma of telling someone they need something immediately when we know it is not available right now. It is so easy to compromise and seek the middle ground, ie, treatment that is adequate. There is that word again. I’ll take a chance and say that no surgeon ever wanted to be adequate – merely adequate. We want to be something better than adequate: good, excellent, better, more skilled – but we avoid adequate like the plague. So whoever wrote that sentence, it could not have been a surgeon. We strive, evolve and change, and therefore are never merely adequate. We sit in the back row and comment. We never let the adequate go unchallenged. So this question is unanswered because there is no answer. Those who pay will cut until people complain. It will be like a thermostat. The temperature will be lowered until we get tired of wearing sweaters. Then we might have some answer to the question of whether money and quality are related.