PROLOGUE: IDEAL HEALTH Experience is the oracle of truth . . . where its responses are unequivocal; they ought to be conclusive and sacred. James Madison, Federalist 18-20 Twenty-first century medicine offers better outcomes than at any other time in history, yet many, if not most people are unhappy with health care. The World Health Organization defines health as: "A state of complete physical, mental and social well-being and not merely the absence of disease or infirmity..." a statement suggesting an ideal state of complete well being that lies within society's grasp. This ideal might be achieved within the context of an altruistic society, inhabited by intelligent individuals possessing high moral and ethical values, abundant resources, access to advanced technology, and effective, equitable governance. The concept promises a paradise on earth, yet formidable challenges confound its realization-- this is one of several dilemmas confronting health care. People living in the third world, victimized by lack of education, unremitting poverty, and corrupt governments suffer widespread ill health due to readily correctible causes--undernutrition, lack of sanitation, contaminated food and water and ethnic violence. These unfortunate conditions relate to political, cultural issues and, some might say, moral issues. Inner city dwellers or those living in other deprived areas within the United States are also victimized, while more privileged inhabitants of 'advanced' societies sooner or later develop lethal diseases, many due to unknown or obscure causes. The treatment of these illnesses, to which the poor are not necessarily immune, requires specialized skills focusing upon individuals. This is also a part of the health care dilemma. Specialized approaches differ from world and public health centered views of 'Health Care.' Generalizations about health and prevention, in the minds of policy makers, have become conflated with treatment of advanced disease--a confusion that potentially threatens specialists who are the custodians of unique skills required to treat serious illnesses. Clearly, effective Health Care requires both preventive and advanced treatment services--part of the dilemma is that each needs more detailed definition. This book describes surgical care, some it involving general surgical problems and some of it within the specialty of vascular surgery. Each story or complaint highlights dilemmas facing doctors and patients alike. Surgical interventions are life saving, life enhancing processes that carry with them important societal implications. Surgical efforts are costly, time intensive, and come into play individually--one case at a time. Illnesses often present with a dominant symptom, a Chief Complaint. The patient's Chief Complaint is key to effective diagnosis and treatment. The words, manner, and circumstances of patient's complaints express specific truths. Complaints require action--sometimes immediate, sometimes measured and deliberate, and sometimes with judicious restraint. Deciding how, and at what rate, to react to complaints are also dilemmas facing patients, doctors and health care systems. Modern medicine, paradoxically, tends to overlook and marginalize individual concerns and cultural sensitivities in favor of 'cost-benefit' or public policy analyses, leading to rigid policy decisions that conflict with individual needs and sensitivities. Laboratory testing and imaging increasingly uncover the silent beginnings of serious disease before symptoms develop--this is usually a good thing--sometimes it is not--currently enhanced diagnostic prowess poses yet another dilemma facing doctors and health care policy makers. Abnormal test results, ideally, should be considered as Chief Complaints. Abnormal test results can become sources of anxiety prompting ill advised and premature actions, or conversely, may be ignored with disastrous results. Controversies about which tests, how many, and at what time intervals these should be performed contribute to a financial dilemma. Management of patients with positive test results, in the absence of specific complaints, requires expert knowledge about particular disease processes. Action decisions are best implemented in unique rather than in formulaic ways. Individual particulars often override aggregate dicta of branched chain logic and cost-benefit analyses--further compounding decision making. Process of care guidelines and cookbook approaches, while useful generally, will never provide unerring guidance for each and every person. This book describes people, individuals with complaints due to serious illnesses seen over five decades of evolving medical and surgical practice. The social and political contexts in which their complaints arose are instructive, not only for medical professionals and policy makers, but also for informed general readers. Where possible, insights for resolution of some of the dilemmas have been suggested. I have chosen old fashioned words: neither "providers" nor "healthcare workers" for doctors and nurses, nor "client" or "customer" for the sick and suffering. Anecdotes, stories, favorites of patients and doctors alike, convey detailed information about personal health care choices related to surgery, insights about how services are financed and how high quality care can be measured and assured. Specific anecdotes, grouped and analyzed intelligently, provide a theme stressing individual rather than aggregate 'Health Care' concerns. Each incident teaches lessons reinforcing the idea that treatment of sick people requires a focus that, in some degree, must distance itself from societal, financial or governmental constraints. While statistical discipline and randomized trials demand respectful attention--though some lately have been found to possess decidedly clay feet--analyses of individual illnesses and opinion reviews also generate important new information. Patterns of illness and specific interventions resulting in favorable or unfavorable outcomes have been and remain part of the science of medicine at well as its art. This knowledge base is in danger of being submerged by general aggregate approaches subservient to a vaguely defined concept of 'Health Care' . . . the lack of definition of what Health Care actually is comprises a dilemma in itself! Lessons learned by the medical profession in treating the sick originated from a rational, empiric discipline extending into past history, to the mid fourth century BCE, the era of Hippocrates. This approach to individuals and illnesses remains equally valid today. These stories, told from the viewpoint of a surgeon privileged to see, feel and smell disease pathology, show that medicine is neither completely scientific nor unerring. Surgeons appreciate abnormal anatomy and physiology of diseases as physical realities rather than as abstractions--a capability that provides critical insights into effective treatments. Modern surgery possesses an array of innovative interventions--powerfully combined with medical treatments that may cure or, at the least, ameliorate serious diseases. When surgical interventions go wrong, adverse effects usually appear promptly-- individual deaths or prolonged disabilities affect families, groups, and society. These adverse events have far reaching consequences that rise to the level of public health problems, for example, malpractice litigation awards that lead to overly defensive medical practices which ultimately inflates the cost of medical care delivery. Each story recounts how each patient complained, how missteps and mishaps sometimes occurred, and how each episode of care turned out. Each provides an account of progress over time along with suggestions about what might be done to improve future care. Each case history is accurate in context, with personal details, times, places, and identities altered to protect individual privacy. Chief complaints can be idiosyncratic, bizarre and even comical, were not the underlying issues of human suffering so serious. Most of the time chief complaints are highly specific. Occasionally people complain with deliberate intents to deceive, an accounting of this behavior is described in this book. Social, cultural and geographic factors influence how patients complain and how environmental conditions influence diseases and their treatment. The reader will not find algorithms, statistics, stick diagrams or 'provider' guidelines, though the last several chapters provide detailed technical insights about assessing quality. These stories mainly concern the sick. They seek to teach lessons about flexible, compassionate diagnosis and treatment for individuals.