Liberating Us From Crap (And Other Totally Random Stuff)

Techno-Savvy

I am no Luddite. Like most of the younger physicians today, I grew up with computers. My father had one of those suitcase-nuke Osbornes and I am old enough to remember how cool we thought the Commodore 64 was, what with its sweet cassette tape drive and way cool BASIC instruction set that let you GOTO all kinds of programming bliss. In the now-distant 1980s I was a Computer Science major and did pretty well in those classes even if I failed everything else and ended up being kicked out of the University of Vermont for bad grades. I have written a FORTRAN 77 program on punch cards and even wrote an assembler (a program that converts assembly language into the CPU’s binary instruction set) for the ancient PDP-11. I remember well the DEC VAX, the first version of windows (I preferred DOS until Windows 3.1 which finally closed the gap with Apple for a graphical user interface), and my first real computer was an IBM PS-2 with a giant 5 MB hard drive. I’ve used all the major software; WORD, Excel, and Powerpoint as well as sophisticated structural analysis programs like RISA and STRUDL, not to mention at one time being something of an expert at AutoCAD. My medical school was completely wired and all of the lectures and notes were on line. In fact, mine was the first class were the administration realized that there was no need to have a “This is a Computer, This is an Icon” orientation as everybody in the class had also been raised with computers. On top of that, we use tablets with the T-system at one of our hospitals and I have adjusted to it effortlessly as have most of my colleagues.

I therefore take umbrage to the conventional wisdom that doctors are not technologically adept. I was thinking about this the other day as I manipulated the ultrasound probe to get a better look at my patient’s aorta. It’s not that we’re not adept, it’s that we like to see a return for investment and are well beyond the reflexive, “Golly Gee Whiz” reaction when confronted with something new. We just want the motherfucker to work and by work we mean to simplify our day, not make it more complex. Take for example the typical hospital computer system which is usually an ancient relic from the 1970s, still running on some baroque IBM mainframe and to which has been grafted a modern-looking “front end” to give the illusion that we are, in fact, cooking with future gas. It can’t communicate with any other system, it’s slow, and it can only retrieve a limited amount of information, usually lab values and some dictated notes. Forgive our lack of enthusiasm but there is nothing to get excited about here.

In other words, we are in the doctor business, not the computer business. I don’t really want to learn anything about the equipment except how to get what I need out of it. I don’t trouble-shoot faulty hardware or kludgey software. If the problem can’t be solved by re-booting then I’m done. It’s time to call technical support and let them handle it as that is their business.

Or consider writing notes. Leaving aside issues of legibility and access to your notes by some nebulous doctor in the unforeseeable future, until very recently it was just much easier to open the paper chart and write a note or dictate than it was to find a computer, log in, locate the patient, check this box, click that one, and type the same note, especially on the hospital’s chimera of a system. This is all changing, of course. Windows-based and internet accessible Electronic Medical Records are much easier to use now and very fast but, as the requirement to document for billing and not for medical decision making is driving the EMR business, most of the notes you produce are automatic boilerplate and, except that we must kill what we eat, if it wasn’t for the billing requirement it would still be easier to hand write a quick note on most patients, the important information about which can usually fit on one side of an index card.

I use email and I of course have a blog. I am accessible but for the record I do not routinely carry my cell phone (I have it perpetually charging in my car for the once or twice a week when I use it) and have only a vague idea what a “ringtone” is and if it’s what I think it is, cannot believe that anybody pays money for them. I do not “text message” either and I will ignore anything on my phone written in “Cutesy.” I have a pager and believe me, that’s enough. More than enough. If someone needs to get a hold of me they can and other than that, I guess I just don’t have a lot to say.

On the other hand in our new twenty-acre Emergency Department they have us carry “in house” cell phones and I love these…but only because I can page an admitting physician, for example, and pick up the call anywhere. See? Technology making our job easier and more efficient. (Now that the charts are on the tablets I can also talk intelligently about any patient on the phone from anywhere in the department.)

My point? Nothing, really, except that I am Best Buy’s worst nightmare. I don’t own much in the way of personal electronics, I don’t really listen to that much music, and despite my cell phone having hundreds of features, all I really need is to dial a number every now and then and do not need to be in constant communication with everyone I know all the time. I know how to use all the stuff, I just don’t want to.

Except…I just bought my wife an MP3 player, thirty bucks, one GB of memory, and I’m hooked. I remember when the Sony Walkman first came out and while I eventually bought one, this thing is nothing like that. Keep in mind that most popular music is crap. Utter crap. Filler, compost really, for the one or two good songs on an album (do you kids still call them albums?). Even with the Walkman which I assure you was revolutionary for its time, you still had to buy tapes that were mostly crap to get to the one or two songs that were worth listening to. Come on now. Admit it. Very few artists and bands are consistently good. Maybe the Rolling Stones and the Talking Heads but U2? Madonna? Get real.

Now, on an intellectual level I have known for a long time that you can pick whatever tracks you want to download onto your MP3 player. I just didn’t realize the power of this until I started downloading the songs my wife wanted. She’s into the Latin sound, J-Lo, Enrique Inglesias, Santana’s “Smooth” and the like. I was skipping around her playlist, just sort of checking to make sure everything was there and I realized that every single song, while maybe not exactly my thing, is good. A winner. Worth listening to. (Say what you like about Ricky Martin, that vato can jam.)

Finally, we have been liberated from crap.

Complementary and Alternative Medicine

Maybe I haven’t been clear about the subject of Complementary and Alternative Medicine. Or maybe my articles, as has been suggested by some of my critics, are too long and the reader’s lips and brains are tired by the time they get done with them. Let me summarize:

1. CAM is mostly an expensive, carefully constructed placebo. The major academic centers that sell it to the gullible admit as much but flog it anyways using “well-being” and other nebulous concepts as an alibi (do you really think anybody at the Duke Center for Integrative Medicine with a medical degree, for example, really believes that some yahoo can shoot spiritual fire out of his appendages?). While I rise in support of having a good attitude and a positive outlook, the real medical effects of placebos are terrifically over-rated. You can feel as good as you want about your pancreatic cancer, for example, but it’s going to kill you or not pretty much on its own schedule. The microscopic advantage you may glean by believing that spiritual fire is flowing into your body is nice to have, certainly harmless if not your sole treatment, but not worth the ridiculous expense of having a shaman on the payroll.

2. In other words, even in the real world of medicine, a lot of our therapies and interventions are marginally effective at best and there has to be some consideration of cost versus effect. The effect of most CAM is not even close to being worth the cost as it is mostly entertainment and not medicine. Just because the patients want it doesn’t mean we have to give it them, except of course as part of a customer-satisfaction driven business model which is great…but not on my dime.

3. The CAM that is not pure bunk, some aspects of naturopathy, for example, that use medicinal properties of botanicals and other substances as therapies are unnecessarily complicated, unsafe, and based on a shoddy philosophical basis that makes no sense. “The Healing Power of Nature” is an insipid marketing phrase. “The Vicious Automatic Killing Default Position of Nature” is more apropos as it realistically describes what anybody who has ever watched even a few minutes of the Discovery Channel could tell you. Naturopathy and many of the other bambicentric CAM modalities are political statements, not medicine, and while they may accurately reflect the world-view of their purveyors, are less than optimal therapies in a world that is indifferent to your nature fantasies.

4. In other words, there is no “Mother Nature” or “Planet Earth” who cares about the difference between a quality-controlled dose of digoxin produced by an evil pharmaceutical company or a cup of oleander tea steeped in the hand-made clay urn of a nature-loving hippy. Now, in our Godless and tradition-rejecting society, I can understand the panic that many feel when they look into the void and see nothing. But if you’re going to reject religion, then reject it and grow some gonads. It makes no sense to eschew the irrelevant religious beliefs of your parents but then, without a pause, to eagerly latch on to some hodge-podge of Earth Worship and Eastern Mysticism except that these things don’t require the self-discipline of traditional religions and therefore give you a purpose for life on the cheap.

5. Which is to say that except as it can inform moral decisions, religion has no place in medicine. My priest offers the last rites to our parishioners but he wouldn’t think of recommending ventilator settings. It’s not his job and I wouldn’t dream of asking him. Complementary and Alternative Medicine is a shoddy, cut-rate religion preoccupied with individual ego and, as it doesn’t even offer any moral guidance (except the commandment to recycle) it has even less of a place in medicine than traditional religion. A priest from my old parish often joked that his vestments make him look like Mandrake the Magician. If Reiki healers, homeopaths, acupuncturists, and the like just dressed the part and billed themselves as chaplains I’d be a lot more accepting. I respect everyone’s right to worship or not worship how they please.

6. While it’s true that “Science Doesn’t Know Everything” and even that many things that were once considered preposterous are now generally accepted as true, if you bothered to notice the movement in science is away from mysticism. Science is moving away, not towards, the grand unifying theory that will prove acupuncture, homeopathy, and any other CAM modality devised at a time when science was in its infancy. For most of human history there really was no science as we know it today but only the venerated received wisdom of the ancients, itself based on a faulty view of the natural world. A lot of what was believed to be preposterous was only considered to be because it flew in the face of this received wisdom.

7. A person who believes in homeopathy, Reiki, and the like…I mean really believes and not just keeps his mouth shut because he’s too afraid that his ignorant peers will accuse him of being close-minded….really has no business in the medical profession and should voluntarily surrender their license. Obviously all that medical school was a waste and didn’t really take.

8. On that note, it is possible to be so open-minded that you enter a sort of Twilight Zone, a strange place where the ordinary laws of physics and reason don’t apply and you must contort your mind into impossible positions to accept many strange and often contradictory beliefs. Being open-minded to that extent is no virtue but merely a glorification of chicken-hearted indecisiveness.

Liberating Us From Crap (And Other Totally Random Stuff)

Defending the Pie

(The pie is a metaphor. I’m only mentioning this because the last time I mentioned pie, I received several irate emails, the gist of which were that pie is not to blame for the collapse of society. -PB)

Primary Snake Oil

The silliest thing about the practitioners of Complementary and alternative medicine is that they don’t know when to leave well enough alone. Currently, with the exception of the occasional over-enthusiastic chiropractor who breaks somebody’s neck or tears an important artery that he has never even heard of, Complementary and Alternative Medicine is a low-risk enterprise, the business model of which is to take a panel of essentially healthy patients with predominantly psychosomatic complaints, stroke their egos a little, mumble either some pseudo-scientific rigmarole or some whacky Eastern nonsense, and send them on their way totally cured and none the wiser. The worst that could happen is the patient still feels bad but, since lawyers have yet to work out a way to demonstrate in court that your qi was irreparably damaged by your acupuncturist, as long as the needles are reasonably sterile and there is really nothing in your homeopathic pills but sugar and a one-in-one-billion chance of one molecule of sheep spleen, you are as a CAM practitioner (if you will pardon the expression) shitting in high cotton.

It is with great interest therefore that I read about naturopaths and chiropractors, among others, trying to pass themselves off as primary care physicians. I see the usual billboards in my town from the chiropractors advertising themselves as the complete medical solution for the entire family and there is even a small subset of back-crackers billing themselves as pediatricians. Naturopaths, for their part, are even recognized as Primary Care Physicians in some states (particulary in the Northeast) and are attempting the usual inroads elsewhere. Leaving aside the obvious, that chiropractors and naturopaths are physicians in the same way that I am a Starfleet Admiral, it is puzzling that, with such a good racket going, the witchdoctors would be trying to sneak into a job for which their training is inadequate and which opens them up to all of the hassles of real medicine like deadly earnest malpractice suits (not to mention suffocating government control, and declining reimbursements).

Suppose you used a chiropractor or a homeopath as your primary care provider. In the best of circumstances, and loosely following the mid-level model for delivering primary care, the CAM practitioner would be a low-level gatekeeper, assuming they knew their limitations which is not usually the case. The typical education model for a CAM practitioner with an advanced degree in his modality, also known as lipstick on a pig, leans heavily on their own particular flavor of snake oil and throws in just enough of the traditional medical curriculum to say, “See, nobody here but us scientifically trained doctors,” but not enough where anybody should feel confident that they would even know when to refer to a real physician.

Even if you came across the rare naturopath or chiropractor who knows that he is selling hokum and is therefore keenly aware of his limitations, if he wanted to be a primary care physician he would do nothing but add another layer of expensive and completely useless medical care to an already overdoctored society. Except for the rare public service of calling 911 like any good Samaritan would if somebody showed up at his clinic with chest pain, he is contributing nothing, and the only difference between he and his more adventurous and less self-aware colleagues in that he will quickly refer to real primary care physicians for real medical problems while they might sit on the truly sick patient for a long time before getting spooked, scratching their heads and wondering why the Ginkgo friggin’ Biloba isn’t doing the trick.

Benefit to society: Zero. My neighbor can call an ambulance and most people know when to go to the doctor. Hell, the real trick is getting them not to go. There is, you see, more to primary care than referring to a real doctor or a specialist. Certainly knowing when to call a real doctor shouldn’t be all the credentials you need to label yourself as as primary care provider. You do actually have to treat something and adjusting qi to improve the subjective well-being of your bored patients isn’t it.

For their part, the chiropractors and naturopaths will point to the existing mid-level providers, many with only a couple of years of formal medical training who are also making inroads into the primary care field, and invoke the doctrine of “me too,” reasoning that since they have a fancy four-year degree they are more than qualified to work as primary care physicians. Whatever the qualification of Physician Assistants and Nurse Practitioners however, their training at least follows the rational model of medicine and is not encumbered by snake oil. A Physician Assistant may only have only two years of formal training but all of it is good which cannot be said for CAM practitioners. Chiropractic school may be four years long, for example, but as most of it involves instruction in a completely debunked treatment philosophy as well as desultory clinical years where all the student sees are mostly well patients with the aforementioned psychosomatic complaints, it is not exactly medically rigorous and in no way prepares the practitioner to understand, let alone treat, even the simplest of presentations. Not only is their first instinct is to throw useless woo at medical problems, under the theory that if you have a hammer you nail, but they don’t even know enough to know their limitations which is perhaps the most dangerous character flaw in the medical world.

Sure, anybody can see somebody with a cold or some other minor complaint and the odds are good that nothing they do, provided they don’t get too jiggy with it, will do much harm. But let’s suppose that you have never rotated on a medical service or done your share of critical care. Suppose you have never worked in an emergency department or spent a few sloppy months on the labor and delivery floor. Imagine, if you can, seeing a provider for your family’s medical care who is treating your kids but has never had a lick of formal pediatric training or so little that she has never seen the really bad pediatric diseases that look like a little bit of nothing when they first present. Does your chiropractor, for example, know the odds that a fever in a neonate is some flavor of bacteremia that needs aggressive treatment?. Let us further suppose that while your chiropractor has spent hundreds of hours learning how a little normal misallignment in the spine can cause “dis-ease,” he has never had to recognize appendicitis, pancreatitis, or the first subtle hints of colon cancer. In short, while a lot of primary care is routine stuff, little potatoes that the school nurse would have to work at to screw up, not all of it is and if all you’re barely qualified for is to pass sick patients to somebody else as some kind of completely redundant middleman, maybe you should stick to the entertainment business and leave medicine to those with training.

Seriously now, there are whole groups of trained physicians, radiologists and orthopedic surgeons for example, who have not only legitimate training in general medicine but the legal license to practice any kind of medicine in which they feel comfortable who wouldn’t dream of doing pap smears or treating some kid with an ear infection because they are a little rusty in that kind of thing. Internists do not moonlight as obstetricians even if they have delivered a few babies in medical school and for my part, although I have done six months of surgery rotations in my training as an Emergency Physician, I’m not taking out anyone’s gallbladder anytime soon. I’m not adequately trained and I could not look the patient in the eye and ask for their trust.

Remember, also, that your primary care physician has a minimum of seven years of formal medical training. Your family physician has, in fact, done a lot of inpatient pediatrics, internal medicine, and a few months in the Pediatric and Adult Intensive Care Unit. The only legitimate question is whether a residency-trained primary care physician is over-qualified for many of the patients they see. The purveyor of snake oil doesn’t even rise to the threshold of qualification.

Mid-level providers and physicians practice in the real world of medicine and when confronted as we all are from time to time by the limits of our knowledge or abilities refer to a higher level of care. The Complementary and Alternative Practitioner, in a tacit acknowledgment that his therapies are ridiculous, will always defer to real medicine when he at last realizes that he is an ineffectual bufoon but only after exhausting his repertoire of snake oil. The danger is that there is no higher level of care in complementary and alternative medicine, just a hodge podge of smooth-talking clowns to whom the customer may be sent, and unless the chiropractor or naturopath honestly assesses his abilities (which would preclude him from even wanting to be in primary care) we’ll have a subset of sick patients who need real medical attention but are not getting it. Now, while this may be good from a strictly Darwinian point of view, allowing the oldest and sickest to die before they can become to much of a burden on society, this is not exactly a ringing endorsement of Complementary and Alternative Medicine.

Currently, the only benefit at all from CAM is that it keeps otherwise healthy people with no real medical complaints from clogging a medical system that is already overloaded, in part because of patients for whom nothing really needs or can be done. And it’s fine. I have long passed the stage in my life where I view it as a personal mission in life to cure others of their stupidity. It’s a free country and if you think you have it all figured out, then knock yourself out. The only money you are wasting is yours and you obviously have more of it than you know what to do with. The problem comes when public money and “quasi-public” money from private insurance pools is used to pay for this kind of things which is, I suppose, the Holy Grail of the Complementary and Alternative Medicine practitioner. That is, to get their claws into the the trillion dollar pie, which, unlike most economic pies, is indeed finite and not big enough to feed everybody all they want. For my part, I don’t think we even need to eat the whole pie but should instead save some for later.

The trouble is that when you leave a pie out and turn off the lights, the rats will edge towards it for their share. I’d like to protect the pie from the rats, both in real medicine and most especially from the exotic rats in the world of Complementary and Alternative Medicine.

Defending the Pie

Evidence Based Medicine? We Don’t Need No Stinking Evidence Based Medicine

The Free Netter’s Ain’t Worth It

I am an educated man. I have an extensive liberal education, a degree in Civil Engineering, a Medical Degree, and am almost done with residency training in Emergency Medicine. Just for fun, I read the kinds of books they forced you to read in your long-forgotten English literature course (not that you actually read them but instead passed the course with the help of CliffsNotes and the professor’s fear of damaging your ego). While not an expert in much, I have a good working knowledge of physics, biology, chemistry and enough of the medical sciences where I at least know enough to understand new concepts as they present themselves and when smoke is being blown up my ass.

On the other hand I am also an ordinary guy and have done my share of regular jobs from fast food to landscaping and a lot of things in between. As I may have mentioned once or twice, I was also a United States Marine Infantryman and consequently know which is the dangerous end of a gun and, while I am today just a stocky suburban dad, at one time could and did endure physical hardships that would make the typical malignant Attending Physician, cock-of-the-walk in the hospital chicken house, weep like a little girl.

I have by no means seen and done it all but I have a pretty good idea how things work. I confess, however, that about one of the major underpinnings of the great structure that supports my beliefs, I have been wrong. Completely and utterly mistaken, so much so that if I could, I would find everyone upon whom I inflicted my totally incorrect theory and humbly abase myself in abject and total apology.

You see, for my whole life I have believed, and defended vigorously, the notion that being educated does not preclude one from having common sense. The conventional wisdom is the contrary of course, and I have heard this wisdom expressed often, especially when I was a Marine. “Yeah, he’s book smart,” went the typical conversation, “But that guy can’t find his ass with two hands and a flashlight…couldn’t pour water from his boot if the instructions were on the heel.”

I’m not saying that educated people are immune from stupidity, just that education does not cause stupidity and I have been a champion, a lion, in the defense of education as a complement and even an enabler of common sense. After all, many of the cool kids at my high school who eschewed the Chess Club are currently living in single wide trailers with women who, despite weighing 400 pounds (181 kg), are still trying to cram themselves into the same revealing clothes they wore in their brief flowering of trailer park beauty, those precious couple of years as fleeting as the tundra blossoms, between their first tattoo and their first illegitimate baby.

And then I read, via Orac at Respectful Insolence, about something called the Complementary and Alternative Medicine Leadership Program, sponsored not by some third rate chiropratic mill but by the American Medical Student Association, a splinter group of the august American Medical Association, who have bribed hundreds of thousands of medical students to join their ridiculous organization by giving them a free anatomy atlas (Netter’s).

I wept.

Suddenly, what I once thought to be the stable soil underneath the foundations of my weltanschauung heaved as if nothing more substantial than wet gumbo clay. Maybe smart people are prone to be booger-eating morons after all. I mean, seriously, here’s a group of American medical students who they tell me are drawn from the very top percentiles for intelligence spending their summer sitting at the feet of homeopaths, acupuncturists, and Reiki healers, soaking up the woo like so many lumps of dry cornbread. And they are buying it. Completely and wholeheartedly. The natural skepticism which is the true birthright of an educated man seems to have skipped a generation.

Take something like Reiki, one of the latest and trendiest of the new age Complementary and Alternative Medicine therapies. The Reiki practitioner claims to produce medically significant effects on a patient by shooting sacred fire out of his appendages. That’s it. That’s all there is to it. Once you strip away the Eastern mysticism and flamboyant Asian ambience it’s just a guy shooting spiritual energy into a patient. I told my Heating and Air Conditioning Guy about Reiki and he laughed.

“Hey, maybe you can get a a Reiki healer to shoot some mystical fire out of his ass to fix your furnace,” he said, “But in the meantime I’m still going to have to charge you a hundred and twenty bucks for the new igniter.”

The Good Lord knows that I embrace the concept of Evidence Based Medicine. A lot of what we do in medicine is marginally effective (if at all) and it is sometimes only tradition and a general sense that something should work (even if it doesn’t) that keeps us doing it. Evidenced Based Medicine is a world-view, a system of thought, that allows us to test everything we possibly can and eliminate these therapies that are ineffective or even harmful. But Reiki? With respect to my colleagues investigating every aspect of medicine, I don’t need a double-blinded placebo controlled study, a meta-analysis, or any other proof except the obvious one that some smarmy guy with a mail-order degree in Eastern mysticism cannot shoot spiritual fire out of his hands. First because there is no such thing as spiritual fire and second because, well, he’s some smarmy little fraud with a mail order degree. As I mentioned in another post, res ipsa loquitor; some things just speak for themselves and while I appreciate the zeal of many in the scientific community to test even things that are obviously ridiculous on a fourth grade biology level, I don’t necessarily need a lot of evidence to suggest that magic fairies and pixie dust are not legitimate treatment modalities.

Which is kind of the point of research into things like Reiki and Homeopathy. What on Earth do you expect to find? Even those who are inclined to believe in this kind of nonsense, when pressed, will admit that for any given Complementary and Alternative Medicine therapy the research is generally incredibly shoddy and, even allowing for a generous confidence interval, a blind eye turned towards the biases of the researchers, charitable peer review, publication in journals that are only one step above the supermarket checkout line variety, a favorable wind, planetary alignment, and an early showing by the groundhog, the positive results are slim, barely detectable, and easily ascribed to a placebo effect; something that is controlled for in real medical research and, if detected taints the entire study. In the world of real medical research, you understand, discovering that your prized medication is no better than a placebo is not greeted with war whoops and fists clenched in triumph.

No high fives, in other words. Back to the old drawing board. Things work the other way in the mystical world of Complementary and Alternative Medicine. The discovery of some insignificant statistical anomaly in a poorly designed and non-reproducible study is greeted with the same enthusiasm by the true believers as the discovery of the structure of DNA and we must now run, not walk, to legitimize their particular brand of fairy dust and use it on everybody. Pulling the same trick in real medicine leads to eventual exposure, embarrassment, ridicule, and even criminal charges. While every medical therapy involves some combination of cost and effectiveness, for Complementary and Alternative Medicine the cost (because Reiki healers do not dispense spiritual energy for free) is not even remotely worth whatever miniscule and highly subjective clinical results can be delivered by what is essentially an entertainment modality and not a medical one. You could, for example probably get the same results watching old Kung Fu reruns as you could with acupuncture. Or, to put it another way, acupuncture won’t work if it’s some bored acupuncture tech named Frank doing it, even if he puts the needles in the right spots. Unless he dazzles you with his mystical dog-and-pony show it’s just some paunchy guy smelling of cheap cologne sticking needles in you.

You know, I cannot help but sympathize with the young AMSA scholars. Medical students are not generally the popular kids in high school or college. The demands of making good grades and navigating the poodle-circus of medical school admissions preclude a normal social life. For my part, I was something of a nerd in high school. I was on the Debate Team, for Mohammed’s sake. Can’t get more uncool than that so I understand full well the appeal to you, oh young AMSA scholar, of going to some retreat with a group of your geeky friends lead by a bunch of people who, as you are the future leaders of medicine, will coddle, stroke, and reaffirm how special you are. It probably gives you the same rush you got from representing Cuba in the Model United Nations. But that’s the thing, isn’t it? Complementary and Alternative Medicine at the medical student level is not about the patient but about the medical student who use it as a positive affirmation of their own values; their open-mindedness and their unshakable belief that some Native American Medicine Man chanting around a sacred fire has something legitimate to teach the medical profession. It’s a way to resist the brutal self-discipline required to put away the fantasies of childhood and deal with the World-As-It-Is rather than how you would like it to be.

It also affords you the opportunity to get close to that awkward but reasonably pretty girl who otherwise won’t give you the time of day but who sent shivers up your spine that time she accidentally brushed by you. Dude, that’s why they have Spring Break. Not that I don’t applaud your motivation, especially if you are into earnest chicks who want to save the world but just admit it and stop with the magic fairies.

Housekeeping Stuff:

1. Congratulations to Graham over at Over!My!Med!Body! for matching into Emergency Medicine. Welcome to the club and no matter what they say, all the other specialists secretly wish that they were the combination of poker player, cowboy, daredevil, scholar, and circus clown that it takes to be an Emergency Physician. I can’t imagine doing any other specialty (even though anesthesiology looked mighty good, details in a later post, when I recently did a two week rotation) and once you get through all of the intern year crap you will enjoy yourself immensely.

2. Your comments are appreciated. Please, limit your links to two (2) as my spam filter is on a hair-trigger. No matter what your comment-the cardioselectivity of various drugs, your groundbreaking economic theories-if you use the words Brittney or Spears anywhere in the comment I think it is automatically shredded.

Evidence Based Medicine? We Don’t Need No Stinking Evidence Based Medicine

The Best-Laid Schemes O’ Mice an’ Men Gang Aft Agley (And Other Things)

(With apologies to Robert Burns. -PB)

Less is Better

I imagine that some day Graham, the author of the superlative medical blog Over!My!Med!Body, who is just now emerging Siddhartha-like from the palace of his father to see the world-as-it-really-is rather than how he wants it to be, is going slam his imported microbrew down on the bar of his favorite San Francisco bistro and announce to his friends that the problem with medical care is “All them goddamn free-loaders mooching off the system,” after which he will stagger to the registrar of voters, change his registration to “Libertarian,” and have his designated driver scrape the Obama bumper sticker off his Prius. He’s certainly headed in that direction, especially on perusing one of his latest articles on futile care where he correctly identifies the disassociation between cost and effectiveness of much of what we inflict on patients in their twilight years. He’s also slowly gaining awareness that many of our patients, far from being poor-but-noble victims of the brutal society in which we live are, in fact, shameless opportunists who will take and take all of the government freebies social justice that they can get their hands on.

In other words, he is slowly, oh so slowly, seeing the obvious: That the problem is one of demand and cost, not some nebulous failure of social justice or systematic oppression. Sure, we can blame insurance executives with their multi-million dollar severance packages and greedy physicians opening specialty centers and concierge practices but the fundamental problem is that everybody wants all the medical care they can eat but nobody wants to pay for it themselves. Hey, it’s a right after all. We don’t have to pay for our freedom of speech and since burning an American flag only costs a few bucks, why should we pay a dime for medical care?

I mention this because it’s an excellent series of articles, by themselves justification for including him on my blogroll, full of bang-on insights to some of the problems of American medical care, many of which I agree with wholeheartedly. You all know my views on futile care for example but Graham and I also share a disdain for Direct To Consumer drug advertising, a practice which I think is ridiculous on so many levels that I hardly know where to begin. Now, as a rapacious, right-wing, pro-industry capitalist who will kill a million caribou without a qualm to drill for Alaskan crude, like Nixon going to China, I probably have a little more…I don’t know…maybe we’ll call it “authenticity” than Graham when it comes to attacking a cherished part of our capitalistic system but Graham still knows of what he speaks.

My only qualm with Graham is the general impression one gets that every solution to every problem is going to involve a whole lot more government involvement. In other words, to decrease the amount of fraud and abuse in whatever socialized or quasi-socialized (or we-swear-it-isn’t-socialized) system the TPGA-axis eventually forces on us Graham would likely turn to the gubbmint’ to implement some byzantine regulatory solution in whose labyrinth will vanish whatever efficiency, flexibility, and innovation is left in our system. It cannot be otherwise. Governments do not give money to anyone willingly, despite the promises of politicians, and money is scarce and getting scarcer. The fundamental problem, in fact, and almost the exclusive preoccupation of every Western Democracy is how to buy off their citizens, to whom were promised lavish social welfare benefits, with treasuries that are becoming rapidly depleted. Covertly or not, medical care and other freebies need to be rationed and governments, to avoid admitting that they’ll be putting down yer’ granny, disguise rationing behind impenetrable bureaucratic obstacles. In Greece, for example, my ancestral homeland and the poster-child for Socialism Gone Wild, while everybody gets free medical care, unless you can fork over a bribe or belong to one of the 149-or-so trade associations with good insurance plans (kind of like co-ops, many of which have failed to the extent that they are all going to be nationalized shortly into about a dozen broad associations), your wait-time for a major operation that even our winos can get in less than a day can be months or years.

That maybe what we need to do is decrease the amount of government involvement in medical care is never seriously considered by anybody, at least not anybody who has a decent chance of doing anything about it. The conventional wisdom upon which every major politician from both parties operates is that government has to do something, the exact something although it may vary is still usually just a question of how much more, not whether it needs to be done at all. For my part, while I think that both Graham and I agree that few can really afford a major hospitalization or the high cost of getting old and multiply comorbid, I have never understood the lust of the wonketariat to provide comprehensive medical insurance for free to everybody whether they need it or not. Surely we will always have some unavoidable costs in our system that the tax-payers will have to suck up. There are many people in our country who are not only poor but completely helpless, conditioned by years of mammary government to be incapable of solving a single problem in their lives without guidance and support from a bureaucrat. The elderly at the other end of the spectrum, many of whom have not contributed nearly as much into Medicare, both from payroll deductions and premiums, as they will eventually use need to be supported as do those who are struck, from out of the blue, by a debilitating illness that leaves them incapable of productive work. To let people die because they can’t afford life-saving treatment, while not exactly a mortal sin against the capitalist ethos, would nonetheless be demoralizing to our nation and only the most Borg-like of Ayn Rand followers would think otherwise. But why compound the problem, why run up the tab on obligations that we cannot possibly meet, by giving away medical care to those who can pay for it themselves? In other words, why bankrupt the nation to ensure that nobody ever has to decide between cable television and taking their kid to the pediatrician?

Which is kind of the choice many of our citizens make, the mantra of the middle class in particular being “Thousands for Personal Watercraft but not a Dime For My Doctor.” Primary care on an individual basis is not that expensive and we are not a nation of paupers. In a country where even the poor can drop a couple of hundred a month for luxuries, things like ringtones for their cell phones and designer clothes, why Graham or anyone agonizes over the best way to make sure that nobody has to pay a dime for medical care if they don’t want to is inexplicable. They’re just not giving people enough credit, displaying the suffocating paternalism that is the hallmark of those with a religious faith in the power of government to solve problems and whose fear is that most of the sturdy and not-so-sturdy yokels, if allowed to make their own decisions about medical care with their own money, will let their children suffer and their own health deteriorate before they’ll spend a dime of their beer money.

Can’t have that of course. People making rational decisions about how they’ll spend their own money. Pandemonium would ensue! The Apocalypse! Panic in the streets! Human Sacrifice! Dogs and cats living together! But, if primary care is relatively cheap and getting cheaper with the advent of four-dollar generics at the shopping Mecca of your choice, where is written that people need expensive comprehensive medical insurance or that the taxpayers, through the sausage-nozzle of government, have to pay for it? If you give a crap about your health, by definition you will pay a hundred bucks every now and then to see your doctor and twenty bucks a month for the (hopefully) minimum amount of medications she deems necessary to control your potentially dangerous medical conditions. If you don’t give a crap you won’t pay which is a personal problem, nothing more. People don’t want to pay because they have been conditioned, first by fifty years of comprehensive medical insurance as a de facto condition of employment and lately by the munificent hand of government that lets them present to the Emergency Department with a complaint of “My ass is sweating” without being arrested for embezzlement of public funds, to expect medical care to flow as effortlessly and cheaply as water from a tap. There is, you understand, a certain transparency to public utilities. Water comes out of the faucet and is carried away to Candyland by the toilet and people don’t really think about it. These things just exist which is how many in the public would like to view medical care, an endeavor which requires several orders of magnitude more money and effort than providing water.

For both mice and men, the best-laid plans often go astray. Unintended consequences flourish, particularly when government which is largely staffed by people who are not qualified for any other job but public service gets involved and tries to control behavior with complicated schemes. We have a nation of unmarried teenage mothers and ruinously expensive government health care grown to a hundred times its most pessimistic projected cost to remind us that socialism is a moth-eaten, half-starved, unpredictable tiger that once let out of the cage is almost impossible to put back in. It’s an economic theory entirely built on the mistaken idea that people will cheerfully and willingly work long and hard to support people they have never met and who don’t do anything for them in return. It is, finally, a philosophy which is turning the West into a nothing more than a crappy nursing home, full of people without the foggiest notion how to be productive and look after themselves, and paid for by money borrowed from the Sheiks of Araby and the Mandarins of China who will eventually decide that paying for the cradle-to-grave benefits of a French poet or the inhabitants of a trailer park in the vast, empty wastes of Massachusetts is not such a good investment. Unfortunately, Western socialism is financed with borrowed money and is therefore unsustainable, especially as economic growth cannot keep up with the growth of entitlements.

It would be a simpler, cheaper, and, as our country is terrifically overdoctored and overmedicated, probably not even detrimental to the aggregate health of our nation if the government withdrew from as much of the medical industry as possible and instead, if they can’t resist the temptation to tinker, enacted policies that encouraged people to pay for as much of their own medical care as possible. Nobody, for example, except the very poorest (to be determined by Graham’s compassion Gestapo) should have a dime of their primary care paid for by the the government on any level. If you need to go the doctor for a cold or to check your blood pressure, you need to pony up. If the government has to be involved, and as most of us agree that a major illness or two will wipe out most people, it can guarantee the solvency of high deductible, major medical policies that citizens would be expected to buy for themselves and their families. Maybe even make it mandatory, call it a tax, and be done with it. We can always take it out of the Earned Income Tax credit for the majority of Americans who, in fact, pay no income tax whatsoever.

On the carrot side, we can encourage health savings accounts from which primary care and other medical expenses can be payed without involving the complicated dance of the bureaucracy, the idea being to encourage the health care market to be a little more transparent and rational. If you’re spending your own money, maybe you don’t want all of those marginally useful treatments and studies.

Of course, medical care is still going to be horrifically expensive. Things cost what they cost and it is impossible that the elderly and their lobbying groups will accept the kind of rationing that is needed to really control spending. Maybe when I get to be seventy I’ll also want my share of heart caths and joint replacements so all of us have a terrific self-interest in supporting our current high-tech and highly expensive medical system. But if a few simple reforms (simple conceptually but almost impossible politically, I mean) to include tort reform could shave twenty or thirty percent off of our current two trillion dollar per year spending spree, that would be enough to keep things solvent.

Other Blogs You Should Read

The best blog on my blogroll, the Macho Response, is not even a medical blog but rather the observations and reflections of a guy living deep in one of the many strongholds of the lunatic fringe and who is slapping them around as they deserve and to the best of his abilities. I’m sure we don’t agree on everything. The Crack Emcee, as he styles himself, is an artist, a musician, and an atheist while I am tone deaf, art-insensate, and a devout Orthodox Christian…but I ain’t a fascist and there is plenty of room in my mind at least for some reasoned differences of opinion. The Emcee is nothing if not reasonable which is not to say that he doesn’t, in a commendable macho fashion, disembowel the usual sensitivity fascists, self-help gurus, and the obnoxious cult-like behavior that is the norm among many of our elites. Sometimes even reasonable men must run up the Jolly Roger, spit on their hands, and commence to cutting throats (If I can paraphrase H.L. Mencken).

You also need to read, regularly, the Happy Hospitalist. I used to think I could write a good article or two but now I must cower in shame in the long shadow of a guy who can really break things down to their most basic level and demonstrate not only what’s wrong with them but what would be required to fix them. My non-medical readers need to go over there because most people who are not involved in medicine have no idea of the obstacles put in the path of a typical private practice physician by the same people who wonder why there aren’t enough doctors to go around.

I have to plug Kevin, MD of course because he is the Don Vito Corleone of the medical blogosphere and he promised to send some of his capos over to break my kneecaps if I didn’t.

Do It for the Children

I’m still looking for more advertisers. I like writing my blog and I hope you folks enjoy reading it but it can be something of chore, not to mention that my wife wonders why I spend so much time doing it instead of surfing for internet porn like normal husbands. At least if I make some money it won’t seem so weird.

Advertising inquiries can be directed to [email protected] I am getting about 30,000 unique visits a month (according to Sitemeter) so while I am not in the Kevin, MD league maybe we can talk.

The Best-Laid Schemes O’ Mice an’ Men Gang Aft Agley (And Other Things)

The Great Lawsuit Rush of 2049

The Future, or Something Very Similar
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“No, I don’t have a spleen, Jimmy. Hardly anybody from my generation does. Or a second kidney, a gall bladder or any other of those useless organs that nobody knows the purpose of. In fact, the Nurse Practitioner Assistant over at Bowel, Bile, and Beyond said that he probably only sees three or four gallbladders a year. He’s not even sure what the gallbladder is for although he thinks it’s part of the immune system or something. He’s the manager, you understand. They send them to a pretty intensive six-week course so he knows what he’s talking about. “

“But anyway, most of us had all those things removed. Why? Well, let me backtrack a little. Now don’t roll your eye at me. It’s an interesting story and I know they don’t teach you much about these things in holoschool. Even in my day sensitivity training, sexual awareness, and learning our recycling catechisms took up most of the day so we didn’t learn too much history. Oh sure, we learned about Martin Luther King signing the Declaration of Independence and about how the United States lured the Japanese to their destruction at the Little Big Horn but, you know, learning to put condoms on bananas is serious business and important things like that took up a lot of our time.”
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“So you kids know that your old grandpa was a lawyer, right? I went to law school and everything, oh, must have been nearly forty years ago, right after the Burger Wars. Man, those were the days! Not much business for lawyers nowadays of course but things were booming back then. Most of it was in medical malpractice, suing doctors I mean. It’s hard to believe but at that time vast herds of doctors, the law profession’s natural prey, still roamed the country raising huge clouds of paperwork wherever they passed.”
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“They’re all gone now…the doctors I mean…you remember me telling you about doctors, right? Like I said, I know they don’t teach you much about them now in school but at one time doctors, or ‘Physicians’ as they were also called, were completely responsible for everybody’s medical treatment. That’s right Jimmy, back then there were no Cath-in-the Boxes or Tumor Marts. If you got sick you had to go see some pompous, over-educated doctor who asked you a lot of embarrassing questions and then threw a bunch of big words at you before trying to force you to do things you didn’t want to do. It was pretty insulting. I mean, seriously, if I have a history of rectal bleeding, what business was that of my doctor’s, especially if all I was seeing him for was some tummy pain? But that’s what you get when you give somebody from seven to twelve years of training…they get a little big-headed and think they know better. Arrogant bastards. Believe me, nobody shed any tears when the last one was hunted down. Give me a guy with a few weeks of superficial training any day of the week. At least we can talk on the same level and if he doesn’t know something, he can just shrug his shoulders and say, ‘I dunno’ Man,’ not call in even more doctors to ask even more embarrassing questions.”

“So I was a lawyer and business was good at first. I was doing all the usual things. I got my start as a court-appointed malpractice attorney and, after the fire department decided that we were tailgating the ambulances a little too closely for safety, even spent a few years riding shotgun with the paramedics (It’s a lot easier handing the patients and family your card if you’re the first one on the scene, let me tell you).”

The big money, however, was in the hospitals so after a few years of little stuff; you know, the usual ‘If-we-settle-for-a-couple-of-grand-will-your-patient-let-us-exam-him’ things, I started taking on big cases. You gotta’ understand that it was a no-lose situation for us. After the passage of the 58th amendment which emancipated citizens from personal responsibility, what had previously only been assumed became law and doctors had prima facie responsibility for all bad outcomes, non-compliance, and bad habits of their patients. Heart attack from smoking hover-crack? It was the doctor’s fault for not motivating you to quit. Contract a case of HyperAIDS? Hey, the doctor should have warned you about contaminated gerbils and got you into to a clean gerbil exchange program. Eat too many Big Macs…well yeah, I know they’re illegal now but this was before the war and everybody was eating them (before we knew what those sinister clown-faced Mickies were putting in them)…blame the doctor for your high cholesterol. And win in court…big time. The money just kept rolling in, that is, until the doctors got smart and started fighting back.”

“I mean, nobody said they weren’t intelligent. I know your cousin Billy who runs the Colectomatron down at Spleens n’ Things isn’t the shiniest nickel in the kitty but things were different back then. A GED might be all you need for an exciting career in the medical profession today but back then medical professionals were in the top percentile for intelligence in the country. Now, don’t laugh Ricky, it’s true. Billy might not be able to think his way out of paper bag but at one time medical schools only took the cream of the crop, kind of like the interior design schools do today.”

“Apparently a bunch of doctors got together and decided that, since they were taking a beating on missed diagnosis (that’s where the super-genius doctors fail to spot a diagnosis even though, as it has a one in a million chance of occurring, it is fairly common) the only solution was to start working-up and treating everybody for everything all the time. The logistics of this seemed daunting but as a lot of pioneering work had already been done by a group of doctors in a specialty that they used to call ‘Emergency Medicine’ (yes, Jimmy, kind of like Quickie Med but actually a lot slower), the solution presented itself fairly quickly. To start, the doctors installed big CT scanners at all of the entrances to the hospital, usually hidden behind fake plants or Joint Commission decrees, and scanned everybody who came in the door. They were still missing a lot of things so, initially with modified airport baggage handling equipment, every patient who came to the hospital was sedated, placed on a conveyor belt and routed to the appropriate diagnosis and treatment area depending on the chief complaint. At first there was some differentiation. If you had a cold, for example, all you got was a chest xray and intravenous antibiotics before being deposited at the exit three days later. Eventually, however, as liability increased the lines merged and everybody got the works.”

“It was probably horrifically expensive but nobody could say the doctors weren’t being thorough and they didn’t miss too much. I went in one day with a sprained ankle and, after being sedated and passed through the intubation and foley station, I was routed to the Prophylactic Surgery Unit where I had my spleen and all of those other potentially dangerous organs removed before being placed in a full-body cast at the orthopedic pre-processing section. They had immigrant surgeons from Canada and other Third-World countries working on this part of the line and each one did one little part of the procedures as the patient moved by him. After the PSU and the OPS the belt wound around the Antibiotic Holding Area for a fourteen day intravenous course of one of every major class of antibiotics. The doctors eventually added a chemotherapy station ‘just in case’ and everybody got fourteen days of chemotherapy concurrently as well as a (barely) sub-lethal dose of radiation therapy. Upon completion of my infectious disease and cancer prophylaxis I was moved to the imaging section where in rapid succession I was passed through a CT, an MRI, and a PET scanner to make sure nothing had been missed. Finally, I had all my coronary arteries stented and after a quick pass through the lab station for the 3000 or so required tests was topped off with fluids, had my electrolytes replenished, was given a haircut, a shave, a coupon for a day at the spa, weaned from sedation, extubated, and dropped off at my apartment kind of dazed but absolutely as disease free as possible.”

“Eventually they added comprehensive major joint replacement and that was it for the legal profession…or so it seemed. I mean, they checked for everything and did everything you could possible imagine, effectively throwing a brick wall in the path of almost every once-lucrative case. Oh, we tried of course but all the defense had to show was that, while it was regrettable that yer’ stinkin’ granny died, the doctors did everything they could…which was true. No way to argue otherwise. Eventually we tried to get them on the paperwork, you know on the the basis that if it wasn’t documented it didn’t happen, but that’s where those clever bastards really ate our lunch.”

“You see, by that time every doctor was using electronic medical records and their documentation was air-tight. At every processing station of the hospital conveyor the operator pressed a few keys and produced wonderfully complete documentation. I have sneaking suspicion that it was mostly boilerplate but there was no way to tell as the patients were sedated for their whole stay and couldn’t tell you either way what the doctors had done. Sure, the Review of Systems was usually, “Unable to Obtain, Patient Intubated and Sedated” but those mercenary defense attorneys made it sound as if every patient was heroically saved by a dedicated team of doctors even if it was actually mostly cheap Canadian migrant workers doing most of the work.”

“Times were lean, let me tell you. Nobody in the legal profession could find any work. When you get right down to it a lawyer is not really qualified to do much of anything. Eventually roving bands of unemployed lawyers roamed the countryside, terrorizing small towns with nuisance lawsuits against little league teams or shoddy Girl Scout cookies but none of this paid very well and things were starting to look mighty grim, so grim that most of us were thinking of turning to prostitution or other respectable work, that is until an unemployed lawyer named John Sutter made an amazing discovery.”
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“Like most lawyers at that time, Sutter had turned to day labor to keep his BMW from being repossessed and his kids fed. He had been hired to do some demolition on an old, abandoned hospital in Rochester, Minnesota when, on January 24th, 2049, his hammer broke through a basement wall and there, before his eyes, lay acres upon acres of abandoned patient records. Paper charts, I mean, not electronic. Manilla Gold. The good stuff. Thinking quickly, he realized that every single chart represented a patient who was either dead, old, or sick and that, as they predated the assembly line hospital, not only had everything not been done for them but their charts were cornucopias of shoddy documentation, errors of omission, and poorly explained medical decision making. He dug around for a few days before hitting a rich vein of legal gold, the Motherload, in the Oncology section. All he had to do was pull a chart at random, find out if the patient had died, and then sue the doctor for missing something…anything…it didn’t really matter. It didn’t even matter if the doctor was still alive because he could always sue the widow and children out of the doctor’s estate.”

“Of course Sutter tried to keep news of his find secret but soon his fellow attorneys noticed his new suits and fancy dinners at expensive restaurants and it didn’t take long for the news to leak out. Word of the find spread quickly and the great lawsuit rush of 2049 was on! All over the country unemployed lawyers flooded into places like Boston and San Francisco feverishly racing to stake a claim in musty medical records departments and turning what had once been sleepy, decrepit backwaters into overnight boomtowns. The population of Philadelphia, for example, tripled in three months as twenty-thousand lawyers descended like starved locusts.”

“There was tort in them thar’ hills! Pandemonium! Litigation fever swept the nation and all over the country, clerks and bakers abandoned their professions, spent their life savings for mail-order law degrees, and headed to the great litigation fields. Maybe you have seen the holo-pictures of them, standing stiffly by their claims, briefcases held grimly in their hands, ties loosened, and cellphones pressed firmly to one ear. Most of them didn’t strike it rich of course, because although the charts were free for the taking, most lacked the resources to try cases. They usually sold good charts to the big law firms for pennies on the potential dollar who brought them to trial and made the big money. Some of the ‘Forty-niners worked on commission but you had to have a claim to a rich vein of legal ore, say the records of a plastic surgeon, to make it work. Mostly, the ‘Forty-niners returned to their homes after the medical records were played-out, older and wiser but flat busted. If you really wanted to make money the thing to do was to open up an office supply store or trendy coffee shop for the prospectors. Can you believe that some places were charging up to five dollars for a cup of coffee! Insanity!”

“You should have seen it. Creaky little towns like Baltimore took on a wild-west appearance overnight with gambling, illegal Asian fusion restaurants, and latte grandes flowing like water. Every vice known to man could be found except prostitution of course. Apparently the hookers had a little too much self-respect to be associated with lawyers. The fever only lasted a few years. Like I said, even at that time doctors had been hunted almost to extinction and what once seemed like a vast and endless supply of money slowly petered out. The bottom dropped out of the litigation market in the summer of 2052 and that was that. The rush was over leaving nothing but empty designer water bottles strewn over the now-empty streets of medical ghost towns.”

“So that’s kind of why we don’t have spleens. Can’t say that I miss it.”

The Great Lawsuit Rush of 2049

Rambling Around the Medical Blogosphere

(A roundup of some of the non-seismic events that have been troubling medical bloggers -PB)

Whaddya’ Mean it Doesn’t Work?

I rise in support of the makers of Airborne, an all-natural cold remedy, who are the unfair victims of a class action lawsuit that alleges, among other things, that the product neither works as advertised nor has any legitimate research behind it to back its claims. Developed by a couple of school teachers in the late nineties, this nostrum was promised to do nothing less than cure the common cold and in the process fulfilling the second part of the impossibility trifecta; the first of which was putting a man on the moon and the third, the remote possibility that Whoopi Goldberg will ever make a funny movie. Having been involved in a couple of business ventures myself, I understand the difficulty of marketing a new product in an economy packed to the gills with hundreds of variations of every product you can think of. The spatula section alone at a typical Target, for example, offers a bewildering array of spatulas (spatulae?) each with some carefully researched but ultimately ineffectual angle to attract the consumer. It’s not easy marketing some crap in bottle as the market is currently saturated with the stuff.

Claiming to cure the common cold was a good start because that takes some chutzpah even if it did require a careful strategy to keep the FDA at bay. The teacher angle was pretty good, too. I mean they’re school teachers fer’ Muhammed’s sake. School teachers! Everybody knows they’re smart and that they can do no wrong. They’re, like, untouchable, man! Accusing them of chicanery would be like bludgeoning the Pope with a baby seal. It should have been enough except that the makers of Airborne forgot one important lesson: In this day and age, lawyers are everywhere and if you’re going to sell useless crap to a gullible public, at the bare minimum you’ve got to have some big academic medical center providing cover. They know this in Durham, North Carolina where Duke Integrative Medicine flogs the usual candy-ass Complementary and Alternative Medicine with complete impunity, secure in the knowledge that every brand of snake oil they peddle, from Reiki to Guided Imagery and every breed of utter stupidity in between, bears the august imprimatur of Duke University.

You’re Doing it Wrong

I also rise in support of the New Scotland International School of Medicine, which, as its home page breathlessly informs us, is the Number One Leader in US Medical education. Not bad for a school that just opened its alleged doors a little more than a year ago. Ostensibly a churlish little enterprise taking advantage of some little-known (and perhaps imaginary) World Health Organization loophole conceived by French bureaucrats to legitimaze medical schools in countries ruled by oleaginous fat guys in military uniforms, Stewart University (as it is also known) promises to provide affordable and easily accessible medical training to people who, by virtue of bad grades, poor test scores, lack of a high school education, and other injustices are incapable of gaining admission to more traditional American medical schools.

Is it a scam? What do you think? At the risk of sounding shallow, one look at the nepotic rogues gallery comprising its administration, including the Provost Emeritus whose photograph lools like the last known picture of a Nazi war criminal before he fled to Argentina and the Chief Operations Officer who is a dead ringer for the Girl in the Back of the Bus who smoked cigarettes and let the boys look at her hooters, should be all anybody needs to know. The provost himself is a 32nd Degree Mason and a Member of the Ancient Arabic Order of the Nobles of the Mystic Shrine so, you know, he’s gotta’ be qualified as is the Facilities Director who couldn’t get a date for the prom and decided to get a job with Stewart instead.

Clinical rotations, you ask? Hah! “Clinical rotations,” the eponymous Chancellor informs us, “Are the least concern of a new applicant to medical school.” So apparently yer’ not going to do any. MCAT? College degree? Not required, allegedly, in Burundi or Southern California. A GED will do. That troublesome extra fourth year? Not necessary. The United Nations has decreed it, we believe it, and nothing more need be said. All you gotta’ do is get one of their cut-rate degrees, pass the USMLE Step tests, and finagle your way into the American residency training system with a generic international medical degree and no clinical experience whatsoever.

Oh the seductive allure to those whose dreams of a medical career are otherwise impossible to attain. This school has it all. No admission requirements to speak of. Easy courses taught by a lackluster faculty. Three-year curriculum. Southern California location. One last chance to redeem frustrated dreams, an in-your-face to those who said that your child pornography conviction would forever keep the prize out of your reach. With this in mind I must ask Graham to stop busting down on this little enterprise, this last best hope for those who could be great physicians if they could only get a handle on that, what do you call it, heart-thingy. The fact that this beacon of mediocrity might have to close its alleged doors (if it already hasn’t) would be a great blow to American health care and could be avoided if the school just tried a different marketing approach.

First of all, if you’re going to make a virtue of a weak curriculum, broken-down faculty, and shoddy instruction, you have to protect yourself from your potential critics. The military angle had got to go. The academic left will forgive a lot and tolerate all sorts of assaults on their academic standards but as every single member of Stewart’s executive body is a uniformed, blood-thirsty, baby-killing, My Lai torching, brainwashed, current or former military officer, they are nothing if not a big old fat target. Might as well put a big sign on the alleged doors begging to be shut down. If they’re going to do it right the Chancellor et al need to grow beards, learn how to tell jokes, and give their medical school some whimsical name like the Gesundheit Institute or the Center for Caring. Can’t shut you down if you’re wearing clown suits, home boy, or don’t you watch movies?

Not to mention the school needs to drop the legitimate medical education angle. Nobody’s buying it and it is too hard to fake. Instead, they need to invent some useless crapola and market it to the leftover hippies. I suggest they go au natural and offer degrees in Naturopathic medicine or similar horseshit. It’s not as if there are any standards. You can pretty much make it up as you go along, gleaning whatever you need from head shop catalogues, Wiccan literature, and whatever you can rustle up in the Alternative lifestyles section of your local Barnes and Nobles. Then they need to move to Seattle where they’re into that sort of thing. Give Bastyr University a run for their money.

Rambling Around the Medical Blogosphere

From Excessive Knowledge, Good Lord Deliver Us

(Writing this blog can be difficult. While I am interested in many subjects, developing coherent ideas and putting them down in a logical and entertaining manner does not always come easy. In other words, most of my articles do not just fall effortlessly from my brain. On the other hand, there are some subjects about which I am so interested and have such well-developed ideas that I almost want to avoid writing about them because it feels too much like “phoning it in.” Some run home to their mommies at the first sign of trouble. When I have trouble coming up with anything new I, too, metaphorically run home to the comforting bosom of my mother, revisiting subjects like futile care and the abuse of residents. Precisely because these things are easy to write about and I take great pleasure in doing it, sometimes I feel like a fraud, one who is just repeating himself with only slight variation, and throwing to you, my loyal readers, easy-to-obtain red meat instead of coming up with something original.

With this in mind, please accept the following article as more red meat. I hadn’t planned on writing it but I received so many private emails about what was really just a throwaway line in my last article that I felt compelled to fire up the old easy-writing machine to shoot ducks in a barrel and pluck the low-hanging fruit. You get my drift. I’m not proud of it but there it is. -PB)

Cry Me a Friggin’ River, Why Dontcha’?

It seems that I can’t mention mid-level providers, even in an offhand way as I did in my previous article where I compared Physician Assistants to brand-new interns, without the usual scolding from assorted mid-levels who are quick to rehash the usual half-truths and agitprop about their profession vis-a-vis physicians. It is not enough, apparently, for me to be generally highly complementary to mid-levels in many of my articles but I must instead roll over and submissively urinate, crying Uncle and admitting that the only difference between a physician and mid-level is some inconsequential and medically irrelevant minutia that we had forced on us in medical school and residency but from whose wasteful tyranny the mid-levels have been spared.

This is not the case however and the credence one gives to the theory that Less is Better depends on how much knowledge, the currency of medicine, one has in their possession. Since it is, barring some warping of space-time, impossible to cram the same amount of teaching into a typical two-year-and-change Physician Assistant or Nurse Practitioner curriculum as is crammed into a four-year medical degree, a graduating medical student on his first day of intern year starts out with an advantage in medical knowledge and it’s not an inconsequential one either despite the usual protestation from mid-levels that their shortened curriculum is just as rigorous as the medical school curriculum (but it’s not ’cause they don’t learn any of the useless stuff…see?). Is this extra knowledge important? Of course it is. I am not exactly medical training’s biggest fan but there is not a single thing I learned in medical school, from the structure of cardiac ion channels to neurolation in the embryo that does not, in some way, make me a better physician strictly by virtue of being a more knowledgeable one. It’s easy to stand on the low ground and insist that all of this knowledge is useless but, and maybe I’m missing something, we have not yet arrived at a time where we admire and seek to emulate those physicians who make an effort to limit their knowledge, judiciously deciding that they can do without this or that, and adopting the attitude of one of my fellow students in a now-distant pre-med anatomy class who, exasperated by the depth of the subject matter, said, “This would be a much better class if their weren’t so many word.”

It also should be noted that upon graduation, a mid-level’s mandatory education is at an end while an intern’s is just beginning. Strictly speaking, medical school is a minimum of seven years for all physicians as residency training, although not legally necessary, is a de facto requirement to practice medicine. I will have had eight years of medical training before I feel barely comfortable to practice on my own which is typical. Residency training lasts anywhere from three to seven years (and even more if we count fellowships) which is something that many mid-levels forget or ignore when they assert the equivalence of their training. Additionally, training is not the same thing as punching the clock. In other words, a mid-level can graduate from his program, secure a position, say as an extender for a busy cardiology group, and after a little on-the-job training get into his groove as a paid professional, keeping up with his continuing education requirements of course, but essentially having arrived at a point in his career where he can decide to sit around watching American Idol after he punches out. This is not the case with residency training. Every rotation is training and every day is an exploration of the dark continent of our ignorance, a vast territory whose boundaries no man can see and in which no sooner is one hill crested than we are presented with the prospect of still more hills in the distance. So it goes for eight years and it is the background acquired in medical school and residency, the useless minutia, that provides the foundation for understanding and the ability to synthesize original thinking on medical problems and not to just regurgitate contextless facts.

Now, as to the assertion that because most of medicine is fairly routine a mid-level can handle 90 percent or some arbitrarily high percentage of a physician’s job, the first thing you have to realize is that for those of us in the generalist specialties, even Emergency Medicine, it should surprise no one that fifty percent of what we see is absolute bullshit (if I may be allowed to create statistics from whole cloth, I mean). Far from requiring the skill of an expensive mid-level, most of these presentations could be easily sorted and sent home by a reasonably competent school nurse who has learned even less of that bothersome and useless knowledge. We don’t even need a well-trained registered nurse either because although their focus is patient care and not diagnosis and treatment, registered nurses particularly Emergency Department and ICU nurses, are extremely sharp cookies and they are probably over-trained to assess and send home many of the patients we see.

In other words, in their zeal to devalue medical knowledge, mid-levels are, perhaps unwittingly, bringing into the question not only the justification for having physicians but also for spending money training so many mid-levels to the extent they are trained today. Far better to just allow reasonably motivated high school graduates to take a year or two of basic coursework at their local junior college, give them a white coat and a stethoscope, and let ‘em at all of those routine patients. Why not? My undergraduate degree is in Civil Engineering, for example, and any sharp witted, smooth-talking village idiot could make a good case that this contributes nothing to my ability to diagnose and treat disease. The same fellow could also make the case that eight years of medical school and residency training is not necessary to recognize the flu, treat garden-variety diabetes, or write a couple of prescriptions for blood pressure medications. Hell, as long everything goes smoothly and all we expects is low-level primary care then everything is going to be fine. Unfortunately, as we push the boundaries of medicine and reap a bumper crop of increasingly elderly and multiply comorbid patients, most of whom expect to survive their visit to the doctor, the trend nowadays is towards more complex patients, albeit mixed in with some undetermined proportion of sublimely ridiculous chief complaints or cookie-cutter cases that can be handled by our intrepid Junior college graduate.

Mid-levels are quick to note however that the trend even in their professions is towards more, not less education. Obviously some of that useless minutia is of value.

Let me relate a parable. As many of you know I was once an engineer and after graduating with my engineering degree found myself in an engineering firm where I was in charge of a stable of young design-draftsmen, the “mid-level” providers of the engineering world. Most of these design-draftsmen had Associate degrees in Engineering Technology from reputable junior colleges where their curriculum was heavy on drafting with a smattering of low-level engineering design courses. Good guys, for the most part, and I picked their brains for tips on computer-aided design and drafting as many of them had been using AutoCAD for years and were fairly good at it. (Junior engineers nowadays are expected to do a lot of their own drafting, probably because it is easier to do it yourself than prepare a sketch for a draftsman to translate into a finished drawing). The useful thing about well-trained design-draftstmen is that you can send them, for example, the design drawing for a piece of process equipment (a roll cage, conveyor, etc.) and they have the knowledge to produce detail drawings and parts lists without having to bug you all day about it. Same with detail drawings for structural or foundation work. Very few structural engineers, for example, produce detailed drawings of structural steel connections but instead pass the design drawings to a “mid-level” steel detailer who produces cut lists and all of the drawings need to fabricate and assemble the structure. The details are based on the engineers specifications and if, for example, I were to specify a shear-only connection to resist a certain load the detailer would produce the drawings from which the actual pieces could be fabricated. It’s not rocket science and, as a structural engineer, I am quite capable of designing and drawing my own connections but didn’t, habitually, except for the difficult ones that did not fit the cookie-cutter examples in the two major steel design manuals (that would be the AISC ASD and LRFD manuals for those of you who are interested and still following along).

Naturally, when I finished my five years as an “Engineer in Training” (interestingly enough also called an “intern” in the Civil Engineering world) and passed the licensing exam to become a Registered Professional Engineer I was completely responsible for all aspects of the design, drafting, and detailing of everything that passed through my hands including the detail drawing produced by the detailer, himself usually an independent contractor. Did I check every single connection on a large structure, burning the proverbial midnight oil for weeks at a time with a red pen in hand? Of course not. My detailer had been in the business since before I was born and knew a thing or two about steel fabrication. But that was his thing, you see. My thing was design and management and I don’t recall ever taking a detailer or a design-draftsman aside and asking their help for a particularly thorny foundation design problem. That was my thing.

One day, one of the more crusty design-draftsmen let on to me that he didn’t think it was fair that engineers made more money, especially as he believed he could do ninety percent of what an engineer did.

“Well,” I replied, “seeing as ninety percent of my job involves standing around drinking coffee making sure that you’re doing your job I don’t doubt it.”

But you see, the devil is in that left-over ten percent (or fifteen or twenty or whatever percentage makes you comfortable with your career choice). Most of every career is routine, repetitive, and can be handled on autopilot. The difference between medicine and other careers is that one never knows what patient is suddenly going to become one of the ten percent. Consequently we want to avoid the autopilot as much as possible. Emergency Medicine in particular is all about not just treating the ten percent but accurately determining who is part of this dangerous minority and until such a time as we can determine which of the ninety percent only need the school nurse and which need an attending physician, prudence dictates that we have the physician standing by even if many of his cases turn out to be nothing…keeping in mind of course that your definition of “nothing” depends on your training. Many of what I once thought were incredibly complicated patients are now just another boring case of sepsis or meningitis.

In reality the practice of medicine is a team effort, not unlike a symphony orchestra where everyone has a part and an instrument they are expected to play. If any individual from the conductor to the third flute doesn’t do his job well the entire ensemble is going to sound like a high school marching band. While it is true that a good symphony can produce ethereal musical magic from the great composers, they also spend a lot of their time sawing out The Nutcracker to keep the proles interested.
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On another note, many of the critical emails I receive about the difference between mid-level providers and residents start out with some variation of, “I have been a PA for twenty years,” and then proceed to expound on the uselessness of an intern. Well, God bless you. I’m willing to allow that a new Emergency Medicine intern on his first day in the department can probably have circles run around him by a Physician Assistant who has been practicing for twenty years. But we’re comparing apples to oranges here. There is a steep learning curve for a resident and I would not presume to say I am even near to cresting it. That’s why we call it it “training.” On the other hand, a typical Emergency Medicine attending with twenty years of experience can run circles around a twenty-year mid-level and their little dog too. They didn’t get that way by stopping their ears against useless medical knowledge.

From Excessive Knowledge, Good Lord Deliver Us

Some Simple Math and other Random Thoughts from a Harmless Asian Bear-Mammal

I’m Better, Thanks

Like I said, it’s only in residency training where one could be happy to be sick while on vacation. I am just getting over a bout of what was probably the flu and as there is no practical way to take any time off as a resident, about the only time we can lay in bed or otherwise rest is either on vacation or when our day’s off correspond to our illness. They make a big deal about cautioning us not to work when we are sick for the sake of patient safety, of course. That’s all some of our patients need, to be exposed to their doctor’s gastroenteritis or other noxious infections but realistically, what are we supposed to do? In a pinch we can usually take one or two days off but as this involves screwing over the person assigned to back-up call, there is a tremendous reluctance to do this among residents. In other words, most of us would have to be spitting up blood or passing large chunks of our large intestine in our stool before we’ll call in sick. Still, there is nothing worse than having to work three fourteen-hour shifts in a row while running to the crapper every hour. Far better to be at home on vacation where you can at least relax between bouts and get some rest. Not to mention that my empathy for the typical 3AM vague-abdominal-pain-and-oh-by-the-way-can-I-have-a-sandwich patient, never very strong, is non-existent which is probably unfair to the patient (but if the shoe fits…).

Some residency programs are so small that they really have no backup for their residents at all and calling in sick in that situation will cause a major panic as well as instantly refuting the assertion made by shifty hospital bureaucrats that residents don’t contribute to the running of the hospital and are a burden to the put-upon institution. If this were really the case then the hospital would be delighted if we took a generous helping of sick days as this could only improve their bottom line. As is, however, when a resident unit goes down the service into which it had been installed goes into a major panic mode complete with sobbing and pleas for help. The sad thing is that a lot of residents buy into the notion that they are a liability to their program and act accordingly. Yes, I will grant you that a brand-new intern may appear to be good for nothing but he is actually many times more savvy than, for example, a brand-new PA who is actually paid real money, not to mention that the intern can make medical decisions limited only by his self-awareness of his limitations and his own personal comfort level. And by the time he gets a little experience the intern is a definite asset, many times for all practical purposes running the service at night. Good residents are completely trusted to handle routine admissions as well as routine emergencies and while I have never had an attending physician give me any grief whatsoever for calling him in the middle of the night for advice or to run a difficult patient by him, the expectation is that we should be able to handle most things and maybe the call for a patient admitted at 2AM can wait until 0730.

But most of us, like in any other non-government job, work when we are sick.  What choice do we have?

Some Simple Math To Illustrate Where the Money Goes

“But Panda,” many of my regular readers write, “Surely you are exaggerating the cost of futile care. Is this not a red herring, merely a symptom of your dislike of dealing with living cadavers more than a real problem?”

Let me address this question by making three points. First of all, I am not against providing expensive, high tech medical care to the elderly. How could I be? Not only are the elderly the majority of my patients but most of them are completely lucid, healthy enough to enjoy whatever it is the elderly do for fun in their secret recreational vehicle conclaves, and benefit mightily from the installation of the occasional artificial joint or the correction of a once lethal medical condition or two. While it is true that from a purely economic point of view, it would be better if we all died the day after we retire or from the first major medical problem that blindsides us (whichever came first), we are not pure economic creatures and that two-trillion bucks we’re spending should at least do some good.

Second, while there are gray areas in determining when care is futile, I know real futile care when I see it. The patients I often describe, the ones who are older than dirt, not nearly as responsive, and collections of every major pathology you can imagine but who yet manage to cling to some strict constructionist version of life are distressingly common, so common that I probably see and admit at least one or two of them a week to the ICU. (This is not even considering the patients that are post-arrest or on the losing side of a major cerebral vascular accident accident and who are, in fact, dead except for the polite fiction of ongoing organ perfusion.) Suppose that each of these breathing cadavers is admitted to the ICU and stays for a week before either subverting our best efforts and dying or pulling through and being sent back to their pre-death warehouse until the next time. Suppose also that I work fifty weeks a year and see a hundred of these patients in that time. A week in the ICU probably costs close to twenty thousand dollars, maybe more, maybe less, but probably around that if we add the cost of their passage through the Emergency Department.

Folks, that means that about two million dollars of futile, almost entirely wasted medical spending passes through my humble resident hands every year. There are about 5000 Emergency Medicine residents working at any given time in the United States and through our combined hands, assuming that they all see the same patient mix, must thus pass around 10 billion dollars. And that’s only hospitals with residency programs and not even counting direct admissions to the ICU. Assuming that a year of comprehensive medical insurance (not that I’m into that sort of thing, you understand) costs $12,000-or-so a year for a typical family; that’s about 80,000 families worth of medical insurance. Consider also that only one-fifth of the major hospitals in the United States have residency programs of any kind but most still have the usual ICU facilities and it is not hard to see that the bill for futile, end-of-life care siphons off enough money to pay for all of the medical care for about half a million families (again, not that I think we should do this kind of thing). And that’s just direct hospital costs. We probably spend twice as much in non-critical and non-emergent care in the last long, slow, tango with the reaper.

My third point is that there is no incentive at any level of the medical industry to use a little common sense. At the high end, physicians risk severe legal consequences for not doing exactly what the family wants no matter how unrealistic. So dangerous is the legal terrain in this area of medicine that most hospitals have an ethics committee part of whose purpose is to spread legal responsibility. In many cases, however, there is no financial incentive to withdraw care as Medicare makes no distinction between the living and the living dead. At the patient end, the families have no financial stake in any of the decisions they make. If we but charged the families a small fraction of the cost for futile care or, more diabolically, had payment garnished from the patient’s estate upon their death, the families would be looking for the plug, especially in the cases where the ICU serves as an expensive funeral home where families can meet to see the body. If the family ever says, “We want to keep Uncle Joe on the ventilator until the rest of the family can fly in from Seattle,” they should be responsible for the full cost of the additional stay.

Some Simple Math and other Random Thoughts from a Harmless Asian Bear-Mammal