Steven's Journal

So, it\'s been over a year since my valve surgery. Generally speaking, things have been going quite well. But the last few months I was starting to have some shortness of breath that I couldn\'t blame on being out of shape. So off to the cardiologist we went. After an EKG and an echocardiogram, they decided I was back in atrial flutter. I had a MAZE procedure and I\'ve been cardioverted twice since my surgery. But apparently it just isn\'t sticking. So next week I\'m scheduled for a transesophageal echo (TEE) to make sure there\'s no clots, then off to the cath lab for an ablation. This seems like the best option, and hopefully one that will result in a sustainable outcome.

A quick update, it\'s been four months now since my surgery and I think I\'ve progressed very nicely. I\'ve been diligent about the treadmill work and I\'ve become a disciple of the low-salt diet. My energy level has been good. Confirmation medically of my progress was given to me last week after I saw my cardiologist and after my first echocardiogram post-surgery. I got the results yesterday and my ejection fraction was 55%! That\'s fantastic, since in January it was 25% and right before surgery is was about 35%. So definitely progress is being made. Next I see an electrophysiologist since I\'m still in an irregular heart rhythm. Hopefully that will resolve itself somehow. Next week I\'m off to Ecuador for my daughter\'s wedding. A long flight, but I should be good to go now.

Something that I was certainly concerned about was the fact that we went out-of-network for my surgical care. Like most of us that have gone through this, I was one of those that thought \"I\'m going to find the best possible surgeon and facility that suits my particular situation\". Well, my research told me that Dr. Bolling and the University of Michigan was the right ticket. But my insurance company didn\'t seem to agree. Here\'s a chronology of events relative to my insurance issues. Two months before my surgery, after consulting with my cardiologist, I had a letter sent to my insurance company requesting in-network benefits for a distant referral to an out-of-network provider. Of course, they denied in-network benefits immediately, but to their credit they approved out-of-network benefits. But in reality this wasn\'t much a stretch since they were required per my contract (through my work) to allow me to go out-of-network at my discretion). But we were rather determined that this surgery should be covered with in-network benefits, so we appealed their decision. I received their denial of appeal the day I traveled to Michigan to have surgery. During my recovery time at home I filed for a second appeal (required by law by my insurer) which afforded me the opportunity to either provide the appeal in writing or appear before their Appeals Committee to make my case. Because I\'m rather stubborn, I chose the latter. I formulated my arguments during the time I was recuperating since I had lots of computer time on my hands. On June 1st, my wife and I went face-to-face with a committee of three who were to decide the merits of my arguments which were based on clinical need, the inappropriateness of the in-network providers suggested, and ultimately reduced costs to the insurer outside of their network. I fully expected another \"no\" from them and was prepared to file another appeal to our state\'s Department of Commerce (another right, by law). In fact I had already filed the appeal simultaneously with the appeal I filed with the insurance company. I didn\'t need the third, external review since my insurer found my arguments persuasive and they reversed their decision. The take home message in all of this is \"don\'t give up\" if you believe there is a strong case to be made. I think the insurers assume that most people won\'t go through the trouble of the appeals process. I can guarantee you it was well worth the effort in my case. (The total list price for my surgery, including very little pre-op diagnosis, the surgeon, anesthesia, radiology, labs, 3 of 7 in-patient days in the ICU, and one follow-up visit was nearly $120K not including the travel expenses). Lots of people were praying on my behalf not only for a positive outcome from the surgery, but also that our insurance company would come to its senses. Positive responses on both! I love it when a plan comes together.

Tomorrow marks six weeks since my mitral/tricuspid valve repair surgery. My wife and I flew back to the University of Michigan for a post-op visit with Dr Bolling. My EKG showed a reasonable rhythm (not perfect, but ok). My chest x-Ray showed all is well with my lungs and the sternum\'s healed nicely. He started to back down on a few of the Meds. I\'ve been steadily increasing my walking program and today went for two 30 minute stints on the treadmill. So all in all, everything looks good. Dr Bolling \"released\" me from his care with no restrictions. So I\'m back to driving, lifting, and back to full time work on Monday! I\'d say my outcome is the best possible considering the poor condition of my heart at the onset. I truly believe that was God\'s work as well as the gifted surgical expertise of Dr Bolling. If there\'s one thing I can\'t stress enough, choosing the right surgeon is the most important thing to consider before you go through this. Thanks everyone for their support during this journey.

Many of you have been curious about how things are going, so I thought I\'d give everyone a little update. I wish I could say everything is fantastic, but honestly I\'ve had some pretty low energy days the last couple of weeks. The good news is that I\'m having more good days than \"bad\" ones. So I guess that is progress. Today was a pretty low energy day, but Rose and I ventured out to church tonight nonetheless. I also forced myself to get on the treadmill and walked for twenty minutes. That\'s about my daily limit. My chest is still healing and the worst is when I sneeze or cough...ouch! I\'m definitely not ready for any wrestling or boxing. I\'ve been able to wean myself off the narcotic pain meds and I\'m only using Tylenol to manage the residual pain. So I guess that\'s progress too. The hardest part for me is dealing with the things I\'m not supposed to be doing, like using my arms to lift myself out of bed or chairs or driving or lifting more than 10 lbs. Rose is being very gracious and shuffling me all around town. I still am going to my cardiologist office at least once a week to get my INR checked.

In two days it will be two weeks post-surgery. God has certainly been good to Rose and I. We returned home to Minnesota yesterday (Saturday) after an uneventful flight. Delta airlines was very accomodating when the put us in the bulkhead seats. It was as comfortable as could be expected, even though I\'m used to flying in first class with upgrades (I travel a lot for work). But since we used frequent flyer miles for these tickets, Delta usually doesn\'t upgrade. I think I\'ve been doing remarkably well. I had a follow-up visit with Dr. Bolling on Friday before departing. The EKG showed a normal sinus rhythm and all my numbers looked great. Rose has been trying to get me out and about at least once a day. While we were in Ann Arbor, we did a little grocery shopping at Whole Foods and sat in Starbucks with some friends for about an hour. I\'m sure the other people in the hotel were curious about why we were strolling up and down the hallways a few times a day, but I\'ve been trying to do \"what the Dr. ordered\" which is walking, walking, and more walking. It was really nice to sleep in our own bed last night for the first time in 2 weeks. A home health care nurse visited this afternoon to assess the situation. She was a little confused as to why she was there (not our suggestion, btw) since it was pretty clear that I\'m not really \"home-bound\". I don\'t think we\'ll be using these services. Rose and I just returned from grocery shopping so we could restock the kitchen after being gone for a couple of weeks. I think tomorrow I\'m going to work for a one hour meeting. It\'s all good and only going to get better. I\'m trying to take the approach that the next day will certainly be better than the previous day, both with the pain and the ability to walk further and more strongly. I\'m determined to continue to make this bump in the road just that, a bump in the road. \"The Lord is my strength and my shield; my heart trusts in him, and I am helped. My heart leaps for joy and I will give thanks to Him in song.\" Psalms 28:7

I was discharged yesterday (Tuesday), exactly one week after the surgery. Rose and I are back in the hotel for a few days of recuperation and then a visit with Dr. Bolling on Friday before flying home on Saturday. We spent the morning making looking at some of the \"data\" involved in my surgery. For those of you who know Rose and I well, this makes perfect sense since it\'s pretty much what we do day in and day out in our medical device research jobs. Here are the numbers as best as we can recollect: Surgery (March 30): - 8:30am- preop preparations begin - 12 noon- surgery starts - 4:30pm- surgery done - 7:30pm- family visit in ICU - 2 valves repaired (mitral and tricuspid) - 2 chordae tendinae repaired with autologous transfer - 1 MAZE procedure - March 31- by 8am, ET tube was out - 6 days in ICU - 1 day in step-down - 7 days total in the hospital (not counting the pre-op work-up) - 14 total days away from Minnesota Post surgery (in hospital): - 9 tubes and/or wires coming out of my body; gradual removal during hospital stay; 2 IV restarts - 6 IV bags at a time (maximum) - 5 chest x-rays (including preop & intraop) - 10 incentive spirometry blows per hour - 1000 ml on day one - 3000 ml on day seven - 5 days until first post-op bowel movement - 4 minimum walks per day (at least suggeste4d) - 13 different meds prescribed (and TED stockings) at discharge - 80 mg of oxycodon (pain med) per day allowed...and yes, I\'m using it, but not the maximum dose. Thanks for all the support in prayer, emails, etc.

Yipee! They just moved me out of the ICU into a nice room on the fifth floor (right above ICU). Rose is a lot more comfortable on the nice couch and it doesn\'t seem like they\'re going to bother us as much here. All my numbers are average to good. My heart rhythm floats in and out od sinus rhythm and atrial/flutter; even had a little bradycardia with a HR of 48, but that didn\'t last too long. So, no worries. Next step discharge!

Still in ICU. I think it\'s because of bed availability in the Step Down unit. They\'re still adjusting my meds and I\'m down to two IVs. All other tubes, cables and wires have been removed. I did have a bowel movement last evening...very exciting :-) My biggest complaints now are the headaches and a little bit of boredom. Hiccups are a little better with less frequency. I\'m still being compliant with ROM exercises and spirometry. I know it\'s probably normal, but I just wonder why I\'m not feeling better than I am. I had a special visitor today...a therapy dog named Ivy. That can brighten your day. Rose snapped a photo, when we\'re at a place to upload we certainly will. Regards, Steve

I\'m thankful that we\'re able to celebrate Christ\'s resurrection today! But I\'m dissapointed that I still reside in the ICU. Still haven\'t had a bowel movement yet and I guess they\'re still concerned about a few other things. I have been walking without support and not connected to any tubes (they finally pulled the Foley catheter this morning). My nights have been punctuated by headaches and hiccups. As silly as it sounds, the hiccups areally annoying (ie uncomfortable). I\'m hopeful both will subside once they get my electrolytes better balanced. Looks like another night here....maybe two.

Good Morning and Happy Easter:   Praise God!  He is an incredible healer, provider, life restorer and peace giver (plus so much more!).      Lots to report on these past 2 days…Steven remains in ICU.  It sounds like they will transfer him to the Step Down Unit today – providing a room is available.  Friday they removed his chest tubes.  Saturday afternoon they discontinued the continuous Lasix IV and instead placed him on IV Lasix 40mg bid.  Saturday evening they removed his pacemaker wires.  He continues to sit up in the chair most of the day and has reduced his walks to 2 to 3 times daily – but they are longer walks.  He’s transferring from chair to bed like a champ.  Activity really wears him out which is understandable.  He has been back in atrial fibrillation since Friday and it seems more pronounced following activity.   Friday they pulled off a negative 3 liters of fluid (that’s what? about 6 ½ lbs?) and when I left last night his output was 3800 with a couple hours left to go so I’ll find out today what his negative total was.  Needless to say, they are managing to pull off a lot of fluid which certainly helps him feel somewhat better.  A chest x-ray was obtained last night but we haven’t heard the results yet; his lungs are sounding clearer though.  Steven’s pain level range remains 4 to 7 although yesterday after a good neck and shoulder massage he rated it only a 2!  Oh, if it could only stay there.  The nursing staff are such blessings and extremely capable as well as compassionate.   Well, that’s probably enough for now.  If there are substantial changes, I’ll write an update tonight, otherwise, it will be Monday night.  Again, thank you all for being such phenomenal prayer warriors and great friends.  We remain humbled and overwhelmed by your love and support.  Thank you for the gift of your friendship and prayers, they mean so much more than we could ever hope to express.  As I started this communication so shall I conclude it, God is so very good all the time!     Wishing you a wonderful Easter,   Steven and Rose

Hello All:   Steven had multiple good workouts today.  He was up and walking (4 times throughout the day for fairly lengthy strolls).  It exhausts him but walking is crucial.  Most of his time today was spent sitting up in the recliner-type chair rather than in bed – again very necessary.  He has a lot of extra fluid in his lungs, abdomen and various other sites so they are working diligently to diurese him with a continuous IV Lasix drip.  Because of the excess fluid, they may keep him in the ICU/CCU for 2-3 more days before moving him to the Step Down Unit.  He’s being a good patient (mostly), doing his exercises and spirometry and trying to not complain too much.  Tomorrow will be more of the same so unless something changes, I will wait till Saturday to write another update.   Thank you all for the many responses we have received and for the Happy Birthday wishes for Steven.  They, and you, are much appreciated.   Good night and may God bless you one and all,   Steven and Rose

Greetings and Salutations:   Thank you all for your sweet and supportive responses and for sharing in this miracle.  We are overwhelmed by the outpouring and tender notes.  Post-op day 1 for Steven was a big one.  They extubated him (he was so very happy to have the tube removed!), started range of motion exercises, sat up in the chair several times for about 1.5 hours each (to help with pneumonia prevention) and believe it or not – began a walking program already (strolled about 20 feet out and back twice during the day).  Needless to say he was feeling a bit tired after each therapy session and is still sleeping a lot – which is to be expected.  His pain level when he’s awake is ranging from 4 to 7 on a scale of 1-10 but that will get better, and he’s not eating much for he’s still on a clear liquid diet and really doesn’t have much of an appetite – again nothing unexpected.  Throughout it all, he maintains a gentle demeanor.  God is so good!   Wishing each of you a perfect peace,   Steven and Rose

Rose and I made it to Ann Arbor yesterday evening without any problem. After a good night\'s rest, we headed over to the University Medical Center. We were very impressed with the efficiency of this place. In the span of a few hours, I had blood drawn, a urinalysis, an EKG, a chest x-ray, a complete history and physical, and multiple visits with healthcare providers (including Dr. Bolling) where all our questions were answered. I was a little anxious coming into the facility since it was the first time I\'d ever been there. The decision to come here was made without a \"site visit\". So I was concerned that my confidence in this facility might be put into question. That couldn\'t be further from the truth. The entire experience just instilled more confidence than before that I\'m in the right place. Everyone was very professional, friendly, helpful, and very efficient...from the parking valet to Dr. Bolling. Dr. Bolling re-reviewed my chart and records and explained his surgical approach. He\'ll definitely be doing the mitral valve with an annuloplasty ring. He\'ll repair the broken chordae with either Gortex suture or with an autologous transfer. The tricuspid repair will be a \'game time decision\' intraoperatively depending on what he finds. And they will be doing a MAZE procedure; the EKG showed that I was still in atrial fibrillation. Both Rose and I are very pleased with how things are going so far. Tomorrow starts at 8:30am with check-in the surgery is scheduled for 11:30.

This time next week I\'ll be heading to the hospital for admission. Yikes! My son asked me last weekend if I was getting excited. I told him \'excited\' really wasn\'t the word I\'d use. I guess I\'m more anxious, not because I\'m worried, but because I\'m anxious for it all just to be over or more realistically for the recuperation to begin. Nothing like a serious surgery to make you stop and reflect a little on life and death. I\'ve read the journal articles about mitral valve surgery and the odds are really pretty good for a positive outcome. But there still remains a small mortality percentage intraoperatively. And still further down the road after surgery, there\'s a certain percentage that have morbidity and mortality rates that can be scary when you stop and think about it. And it\'s those small percentages that can cause loss of sleep, inability to focus, and melodrama in my head. Quite frankly I don\'t know how anyone without a Christian faith has the fortitude to undergo these types of surgeries or circumstances. In an ever attempt at being overly prepared, Rose and I discussed (and I executed...really a poor choice of words when you think about it) an advanced medical directive. This document describes what my desires are for my medical care if I\'m unable to make those decisions for myself in a critical situation. Although this document is important, I\'m grateful that my God has already established His own \'advanced directive\' when it comes to what happens if and when I leave this earth. I found it interesting that our pastor last Sunday spoke about trust from John 14, \"Do not let your hearts be troubled. Trust in God; trust also in me...Peace I leave with you; my peace I give you. I do not give to you as the world gives. Do not let your hearts be troubled and do not be afraid.\" I mentioned to Rose on the way home that verses that describe \'the heart\' have taken on a whole new meaning for me lately. I\'m grateful that I have the assurance of God\'s peace in this circumstance even though admittedly it\'s sometimes hard to grasp.

A good friend of mine continues to remind that although this heart valve thing causes some obvious anxiety, one of things that remains in my control is my choice of surgeons. I\'ve heard and read other heart surgery patients say that when faced with the decision of who is going to actually cut into your chest and hold your beating heart in his or her hands...everyone has an opinion or suggestion. My experience was really no different with the exception that I actively sought out the opinions of some other med device industry colleagues and doctors. Those of us in the device industry have some insights into the workings of hospitals and the skill sets of many surgeons; sometimes we think we know the secret handshake, if you will. As we all know, some surgeons are better than others and more importantly, some surgeons are better than others in very specific circumstances. The obvious fact that every patient uniquely presents with his or her own set of medical issues suggests that finding the \"right\" surgeon is certainly a very personal decision. I can give you my personal perspective. The wealth of medical information on the internet and in libraries can be pretty overwhelming. And I have to admit I\'m partly to blame since I\'ve contributed many peer-reviewed papers and actually edited a couple of medical technology books. I dove into the medical literature and began to research topics that I\'ve long forgotten about. As a slight digression, my PhD in physiology and biophysics from Indiana University Medical Center had a high level of cardiopulmonary medicine involved. My dissertation research involved describing the changes in the pulmonary artery smooth muscle in response to altitude-induced pulmonary hypertension. Needless to say, what I supposedly learned then has not necessarily been totally assimilated or kept up to date since I moved on to spinal surgery research topics after graduation. But at least I can hold my own when discussing these issues with my cardiologist, surgeons, and other medical professionals. I soon came to the realization that mitral valve repair or replacement was certainly fairly common and most cardiothoracic surgeons are adequately adept at performing these surgeries. My situation seemed to cause a few surgeons pause because of the mitral regurgitation compounded by the effects of severely low ejection fraction, dilated ventricles (i.e., Stage IV heart failure), non-ischemic cardiomyopathy, ruptured chordae tendinae, and atrial fibrillation. It is difficult to figure out what is the chicken and what is the egg when trying to understand the root cause and effect of why my heart was so sick. All of this played into my decision making exercise. Everybody I talked to said that surgery was indeed necessary, but there were differing opinions about the eventual prognosis of surgery (which by the way, has yet to be determined). I talked to doctors and surgeons about minimally-invasive approaches (vs a sternotomy) and quickly realized that this was probably not an option for me. One particular surgeon from Johns Hopkins University in Baltimore who is one of the innovators in this area told me that although he could do that type of procedure, he wouldn\'t recommend it in my case. His opinion was that he needed to get in and get out as fast as safely possible and since the minimally-invasive or robotic approaches take longer than an open case, this probably wasn\'t the best idea. Since I\'m keenly aware that surgeons like to do what they do best (trust me, they have options), the fact that this thoughtful gentleman said he wouldn\'t do the approach that he\'s on the cutting edge of spoke volumes to me. So, open sternotomy it\'s going to be. I considered going to Baltimore to have this surgeon do the procedure, particularly since I also spoke with the MD in charge of the ICU there and he mentioned that if it was him, he\'d have this guy do it since he sees his patients afterward and for whatever reason it seems like his patients do better. I spoke with another surgeon at the University of Minnesota (right in my back yard). A very competent surgeon, I\'m sure, and he instilled confidence in his skills. But when asked how many cases he\'d done with similar medical history and recommended surgery he said he\'d done a couple of dozen. And when asked further about how many ended up with an LVAD, he thought about 50%. I didn\'t particularly like these odds. Remember I mentioned that I have the sense that many surgeons do what they like to do best. In other words, \"if he\'s a hammer, everything looks like a nail\". University of Minnesota is one of the top five LVAD-implanting centers in the country, you draw your own conclusions. Still with the possibility of needing an LVAD, I started focusing on large centers that had that option available, just in case. As I continued to scour the medical literature and continued to talk with friends and colleagues, it became apparent that five medical centers and specifically five surgeons began to surface as leading contenders. The five centers that were now on my radar screen were Mt Sinai in NY (Dr. David Adams), Northwestern University in Chicago (Dr. Pat McCarthy), Cleveland Clinic (Dr. Marc Gillinov), Mayo Clinic here in MN (Dr. Hartzell Schaff), and the University of Michigan in Ann Arbor (Dr. Steven Bolling). Without ever talking to any of these five, I was fairly comfortable choosing any one of them because of the vast amount of research and personal communications I had with others that knew them personally. By the way, none of these medical centers are in-network when it comes down to insurance coverage, but that\'s a topic for another journal entry. The reason I\'m heading to the University of Michigan to have Dr. Bolling do my surgery is mainly because of his experience, my colleagues recommendations (he\'s done hundreds of these repairs), and the fact that he has extensively published in the area of MV repair specifically in patients with cardiomyopathy and congestive heart failure. He\'s documented his outcomes in a way that\'s easy for me to understand and has, as one of my colleagues suggested, \"was one of those surgeons that saved mitral valve repair as a viable surgery\" because of his innovations and forward thinking. For anyone interested, he has an interesting hour long video on the internet at OR-Live that discusses his research, his technique, and his thoughts on how and why things work the way they do (http://www.orlive.com/edwards/videos/a-valvular-solution-to-a-ventricular-problem). This certainly appeals to my need to know as much as I can about what he\'s going to do and what I can expect; be warned though it might not be for you if you have a sensitive stomach since he has video from one of his cases. Both my wife Rose and I found this extremely helpful. Ultimately I was looking for a surgeon who had done many, many of these surgeries since I\'m a firm believer in experience over arrogant confidence. The best outcomes are achieved when the right patient is operated on by the right surgeon at the right time. So at the end of the day, one of the only things I can really control in this situation is my choice of surgeon. I\'m at peace with my decision and I\'m holding onto the fact that God has promised that, \"...the manifestation of the Spirit is given for the common good. To one there is given through the Spirit the message of wisdom, to another the message of knowledge by means of the same Spirit, to another faith by the same Spirit, to another gifts of healing by that one Spirit...\" (I Corinthians 12:7-9)

I\'m turning 50 on April 1st and I feel like someone\'s playing a really bad April Fool\'s joke on me. Until January of this year (2010), I had no idea that I had problems with my heart. It started with a business trip to San Francisco. I had gone to my internist a week before because I had a really bad cough that just wouldn\'t go away. He gave me a strong cough medicine and a steroid dose pack. While I was in San Francisco, walking around the downtown area was causing me shortness of breath that was more than just being out of shape (which I am). After returning home, my wife made an appointment again with my internist who quickly realized that more was going on than just a bad cough or cold. My heart was racing at 150 bpm (ventricular tachycardia) and things were not good. He immediately admitted me the hospital and after a week of tests, they determined that I need to have my mitral valve repaired. While in the hospital I had an angiogram, an echocardiogram, multiple blood tests, and other routine stuff like EKG\'s, etc. The first echocardiogram I had suggested an ejection fraction of about 20-25% and an enlarged heart indicative of cardiomyopathy. The angiogram showed that my coronary arteries were clear with 10% or less blockage, so an ischemic problem was/is not an issue; it also suggested a lower ejection fraction (10-15%). Things were apparently not looking good. My EKG showed that along with the tachycardia, I was in Atrial Fibrillation so a transesophageal echocardiogram (TEE) was ordered. And after it was evident that there were no clots, they cardioverted me into normal sinus rhythm. I was beginning to feel better and after a long week in the hospital, I was sent home to contemplate the reality that I still needed to have open heart surgery. The first night home was still uncomfortable and I was having difficulty sleeping. Since it was a weekend, a phone call to my cardiologist landed me back in the emergency room for evaluation and eventual readjustment of the multiple meds they had put me on. After about a week, I wasn\'t improving and continued to have trouble sleeping. Another cardiologist consult and they suggested another attempt at cardioversion since I was now in atrial flutter (another version of an irregular heart beat). The regular heart beat lasted about a week. Based on some conversations with my cardiology office, it seems that there is some concern about performing mitral valve surgery in patients with advanced heart failure (I was labeled as Class III/IV failure), so they suggested I discuss surgical options with someone that could have left ventricular assist devices (LVAD) as a back-up, in case after repairing the mitral valve the heart was too weak to sustain function. An LVAD is typically put in as a bridge to transplant and some patients are living with the device for longer periods of time (so-called \"destination therapy\"). The prospect of an LVAD wasn\'t encouraging, so I began discussions with surgeons in hopes of avoiding one of these. My cardiologist has been very good about maintaining my physical condition through medications. I\'m on warfarin (a blood thinner, ie., coumadin), an ACE inhibitor (lisinopril), a Beta blocker (metoprolol), an antiarrhthmic durg (amiodarone), and a diuretic (fuorsemide, i.e., lasix). I feel like a polypharmacology experiment. I had a second echocardiogram a few weeks after my hospitalization. When they compared the second to the first, they suggested that my ejection fraction had improved some but not much. The last echocardiogram that I had was three weeks ago and this one showed an ejection fraction of 36%. So, the lifestyle changes (low sodium diet) and the meds have apparently done some good. And this probably improves my prognosis a bit. Next entry will describe my process of choosing my surgeon.