Tuesday, July 20. 2010
 Medicine has always abounded with quackery, and placebo effect is real. Hope springs eternal...
However, when tax dollars are expected to pay for it, it's another matter: Europeans Cast Critical Eye on Homeopathy.
In a free country, folks are welcome to buy their own quackery if they want, on their own nickel. Most docs privately think of Chiropractic as quackery, but the Chiropractors have a lobby in DC, and I believe there is a legal injunction against MDs terming chiropractors "quacks" in public. They sometimes do help people with sore backs. I am just imagining the debates about whether federal guidelines will include crystal therapy and massage therapy.
American medicine itself has little intentional quackery, but many treatments which are of dubious value. For examples, futile treatments for terminal cancer, or those $15,000 treatments for "Chronic Lyme". Thus far, in America you can pretty much get whatever medical treatment you want regardless of its usefulness for you. Problem is, others are usually paying for it.
My prediction is that government-controlled medical care will be determined by politics and, to some extent, politically- or bureaucratically-oriented docs. That is not good medicine.
Good medicine is individualized, not based on statistics.
Friday, January 29. 2010
Cardiocerebral resuscitation (CCR) is a new approach to patients with out-of-hospital cardiac arrest that has been shown to improve rates of neurologically intact survival by 250%--300% over the approach advocated by the 2000 American Heart Association guidelines. And EMS systems can realize these improvements without having to buy a single new gadget or device.
People try to die all the time, in church, in parking lots, in supermarkets. Here's the new method to try to save them from the Grim Reaper:
Friday, September 4. 2009
Medical technology has confused the simplicity of death. One quote from the piece at New Atlantis:
...as long as the ventilator remains, that body does not look like a corpse. It remains warm, like the living, and the organs continue to do the work they have always done, albeit with the assistance of chemical interventions. Most significant and most challenging, from the point of view of common sense, is the fact that the heart still beats. The injury to the brain has destroyed the centers in the brainstem that regulate breathing—thus the perpetual need for the ventilator. But the heart of an animal—even one profoundly injured—has its own “inherent rhythmicity,” its own originative source of motion. This means that heartbeat and circulation have no absolute dependence on the brain in the way that respiration has. The heart, without any input from the brain, can continue to beat as long as its own tissue is intact.
The characteristic puzzle of the total brain failure condition, then, is this: the body remains warm and pink as blood courses through the vessels; the vital organs continue performing their work; but the human being as a whole, permanently unconscious and permanently and profoundly disengaged from his surroundings—eyes closed, making no response to pain, making no effort to breathe—seems something short of alive.
Thursday, September 3. 2009
Regular readers know how much I love Stats. Peter Donnelly is wonderfully fun here: How Stats fool Juries. I don't think the lawyers understand the stats either, but you can in a few minutes. (H/t Bird Dog via the Right Wing Prof)
Monday, August 31. 2009
 People hate it when I burst their bubbles about eating habits, but facts are facts. Everybody likes to imagine that they can control their health by what they eat, but there is no real evidence for that unless you are starving to death or fat as a pig. (Ordinary American fatness has minimal health effects, but major aesthetic effects).
Here are some real facts for readers who fuss about their food. In my view, unless you are on a serious diet, anybody who fusses overly much about what and when they eat has an eating symptom. Harmless enough, but a symptom.
(Everybody has his share of neurotic symptoms. It's human.)
I will say it again: the only reason to fuss with your food is to make it taste good - and to stay skinny and fit so you look good, have endurance, and do not offend others with your unpleasant appearance.
Hey, honey. Get that beer man over here. I need a cold one or two to go with my Sabrett's.
Friday, August 28. 2009
The women of the world owe a giant debt of gratitude to Hungarian physician Dr. Ignaz Semmelweiss.
Mocked and ridiculed by the experts, he was correct that puerperal fever, which killed many mothers, was somehow spread by doctors and nurses who did not disinfect their hands.
The germ theory of infectious disease had yet to be explained in the 1840s, but he was a practical doc, not a theorist.
Wednesday, August 26. 2009
- Should you take an aspirin, or a baby aspirin, daily or every other day to reduce your risk for nasty cardiovascular events (heart attack, stroke)? Check it out. As I once mentioned here in the past, all male docs I know over 40 take a baby aspirin daily.
- Middle-aged women get Frozen Shoulder. Know what it is? It's not an excuse to avoid vacuuming, doing the dishes, or sex. It's a nasty thing.
- Also, I recently heard a talk about ADHD. There is a strong association between ADHD and Social Phobia, which I thought was interesting. However, it's confusing because ADHD is such a confusing pattern of symptoms since it is so commonly combined with other diagnosable problems: bipolar disorder, anxiety disorders, depression, conduct disorder, antisocial personality, etc. It's a mess of a diagnosis.
Friday, August 21. 2009
Obesity is probably decreasing in the USA. What changed (in 1998) was to change the definition of obesity down to 30 lbs. overweight, thus adding millions to the "obese" column.
There's no way somebody 30 lbs overweight (by whatever standard is used) is what people consider obese. 30 lbs overweight is "plump," pudgy," or, as they used to say, "sleek" or "prosperous-looking." In women, "matronly."
In fact, being 30 lbs overweight has no ill medical effects at all. The aesthetics of it are, of course, highly subjective.
Tuesday, August 18. 2009
 Bremelanotide. It's a nasal spray, works quickly. Looks like it can be bought online.
Is it a party drug, or a medical drug? I do not know. Haven't tried it yet, personally, but I probably would if only for my educational purposes...
All of the late middle-aged docs I know are "scientifically" curious about it. It is said to be the only true aphrodisiac. If it has no serious side effects, I can see this drug leave Oxycontin in the dust on the black market.
Not everybody, for sure, is fully satisfied with his or her sex life, unless young and in love.
All doctors know this: The "Preventive Care" Myth from Krauthammer.
Preventive care is expensive, and has a very low yield. Things like mammograms do not exist because they are cost-effective: they exist because people want them.
Friday, August 7. 2009
When somebody collapses and stops breathing, make sure you remember how to do CPR. Just make sure you don't do it to some person who simply fainted, because you can be sued if you break a rib. Legal protection for Good Samaritans in the US is fading fast. Still, every citizen ought to know how to do this.
I have had to do it twice, once in a parking lot and once in church. One lived, one died.
Saturday, August 1. 2009
Hanson at Overcoming Bias posts the graph below from the British Medical Journal. It says they looked at 2500 treatments, so I suspect this isn't just medicines. I'd like to see the list to determine whether it only included standard treatments like antibiotics for pneumonia or stents for coronary artery blockages, or whether it includes things like homeopathy and massage therapy.
I don't know what to make of the Terra Incognita of the 46% of "unknown effectiveness." I want to see the details.
Saturday, July 25. 2009
Michelle:
Health and Human Services Secretary Kathleen Sebelius tried to reassure citizens in New Orleans this week that Obamacare bureaucrats will make sound medical decisions for all Americans. She failed. Under the government-run plan, she promised, a team of health care experts will recommend what should be covered: “I think it would be wise to let science guide what the best health care package is.”
I guess it didn't occur to her that doctors know some science - and they also know something else: they know their patient. No two patients are alike. People do not want an "approved treatment protocol" - they want to work it out with a doc who is working for them, and is not a de facto civil servant. I think what Sebelius means is not "science": she means a board of cost-containing medical efficiency experts.
However, I do not think anybody wants a government to have that sort of power. Governments create omnipotent monopolies.
It's one thing for a private medical insuror to tell you they don't cover in vitro fertilization, and another for the government to tell you that you cannot have it because "science says" that it's not cost-effective. In the former case, it's a freely-entered association, as Milton Friedman would say, and if you want the in vitro badly enough, you can save your pennies and get one. Furthermore, I'd much rather make an appeal to a private biz than to the government.
We suspect that the government wants two things: 1. To get more folks on the Government Plantation and, 2. To control Medicare costs. Re the latter, the O might be right that it may have been unwise for his Grandma to have a hip or knee replacement when she was dying from cancer - but he is correct that 80% of medical costs occur in the final year of life. However, unless somebody has terminal cancer or something comparable, how do you know it's somebody's final year of life in advance?
Another related issue is the equating of "health care" (a dumb term) with medical insurance. I suppose with the high costs of medical technology and hospital treatments, those costs are out of reach for the average person (which is why we buy cheap catastrophic, ie high-deductible medical insurance) but, for most purposes in life, a regular office visit for a bad sore throat or a camp physical doesn't cost very much at all, while an ER visit for your bad sore throat can set you back $750.
We agree that it is foolhardy for anybody who is not wealthy - especially for a family - to carry no catastrophic major medical insurance, because bankruptcy sucks. We also think it is foolish for people to expect insurance to cover every office visit: the whole point of insurance is supposed to be that you hope you never need it.
However, years of Medicaid (for the poor), Medicare (which pays for everything, at low rates), union-driven medical benefits and work-related medical benefits have produced a sense of entitlement and, we would argue, have driven up the cost - and the quality - of medical treatment in the US.
What is the right role for government in medical care? We don't know, and we don't trust anybody who says they know. Fact is, government already controls much of it via Medicare, Medicaid, and now SCHIP. It has been incrementalism at work, with the long socialist view. One thing we do know is that fewer and fewer Docs want to accept Medicare, and few ever accepted Medicaid except for charity clinics and inner city Medicaid mills staffed by foreign medical graduates.
Why do so many Docs opt out of Medicare? Because of the paperwork requirements and the unsustainable rates of reimbursement. When people get a doctor's bill, they often forget that it's not a bill for his time: it's a bill for his rent, his machines, his two nurses, his insurance coder, his bookkeeper, his receptionist, his staff's benefits, his malpractice insurance, etc. Your local Internist and Pediatrician is not getting rich on $65 office visits these days. In fact, they are struggling.
No, the big costs are tests, some medicines, hospitalizations, cancer treatments, dialysis, the ICU, etc. The big ticket items - and those costs are not compressible. They can only be rationed if costs are to be cut. We do not think those costs should be cut, because we believe that such decisions are a matter of personal choice and freedom and, as they always say, "All you have is your health." Or your disease, as the case may be.
We wish we knew the right answers to all of these issues but, despite the problems, we will say one thing: With the best, most innovative and most available medical care in the world, one must be extremely careful about messing with it. Freedom is always messy. We re-link Cardinal at Tigerhawk's defence of American medicine.
From another point of view, a quote from an annoyed Vanderleun's Who, Whom?, which reiterates our Roger's thoughts about The Plunder Economy:
Who—whom?" Who shall be forced to give up the health care that they like (most Americans), and whom shall receive health care they (supposedly) ain't got -- for free -- at a cost to everyone else of trillions in dollars and immeasurable quantities of freedom and privacy and security.
Who (shall give)? You and hundreds of millions of others. Anyone who has a job, or makes things, or owns things that can be taxed. And then have a fee for this or that levied (for the common good). And then taxed again.
Whom (shall receive)? The poor shall be marched to the front of the line; their ragamuffin children with protruding bellies on their shoulders for the photo-op. But right behind them will come.... the slackers, the lazy, the whacked-out, the grifters, the hustlers, the useless, the career recipients of endless government hand-jobs, the hard-core unemployable, the 17% of crack whores that do not work for the government, and a few million others that form the hard, adamantine core of Obama's and the Democrats' aptly named "base."
"From each according to his ability, to each according to his needs," is what's going on here. Except this time the add-on is "Even if you don't need it or want it, because little Susie the crack whore does. P.S. We're gonna slip in some language to pay for her abortion too, just because it will piss you off."
That is a bit cold, Mr. V.
Written by The B and BD together.
Monday, July 20. 2009
Dr. Bob has penned a definitive essay on the topic of preventive medicine. It's all true, and all docs know it. One quote:
One big-picture aspect of this huge transformation in American health care which seems to be receiving little or no attention is its heavy emphasis on preventive medicine. We have been hearing for some time about how preventive medicine will save substantial sums of money and thereby make the overall health care system far less costly. Of course, such rhetoric has an enormous appeal at a surface level — after all, if you can prevent diseases, you certainly don’t need to spend money to cure them.
Who could argue with this?
But this innocent-sounding, simplistic Trojan horse will prove deadly for American health care, and end up empowering the bureaucrats and politicians who will, in fact, gain the most from this change in direction.
Read the whole thing.
Saturday, July 18. 2009
 It looks like we are on the subject of health freedom today. What I have observed over the past ten years is that people increasingly equate insurance coverage with medical care. That's sad.
In my view, it's a pathologically infantile sense of entitlement when people expect others to take care of them. Sad, indeed when Americans can afford their cars and car insurance and computers and iPods and cell phones etc. but expect somebody else to pay their bills if they get sick.
My view is that every responsible adult needs cheap catastrophic medical coverage - what used to be called Major Medical, with the deductible of your choice. Budget into your life the costs of your kid's broken arm and annual $120 camp physical - or don't have kids. If there's a big problem, the Major Medical will cover you. Like if you have a heart attack, break your back falling off a ladder, or if your kid gets shot in the eye with a BB gun.
I want to know what the Dems want to cover with their grand plan to "reduce" medical costs:
Will they cover Reike, massage therapy, homeopathy, acupuncture, chiropractic, crystal therapy, therapeutic touch, late-term abortion, breast enhancement, plastic and cosmetic surgery, hopeless chemotherapy and radiation therapy, eye movement therapy, light therapy, Chinese herbal medicine, hypnosis, social workers, bunion removal, in vitro fertilization, elective Psychoanalysis, alcohol rehab, penile implants, heart transplants, high colonic cleansings, liposuction, ingrown toenails and toenail fungus, Native Indian Soul Renewal, and liver transplants?
And do you want politicians making these decisions for you?
Me? I want the government 100% out of medical care and medical choices, because they have no idea what they are doing. No more of a clue than they know how to run GM - or the corner candy shop. I know what my private family policy covers. I chose it, I pay for it, and it's cheaper than the family's car insurance.
What the heck does the government have to do with these decisions, anyway?
Friday, July 10. 2009
 There is no convincing evidence that "healthy eating" - whatever that is (eating "organic" vegetables?) - or a "healthy lifestyle," eg exercising daily or whatever - has any beneficial effect on your long-term medical future.
Those things might - or will - make you feel better, happier, and more functional, and nobody likes to carry 30 lbs. of unecessary lard around with them, looking like a muffin-top or worse. Nothing to do with health, though. And that is why "Lifestyle Medicine" is quackery which has been foisted on a credulous public.
One quote:
...it’s little wonder, then, that the results of every major randomized, controlled clinical trial of healthy eating and lifestyles to date have been ignored, downplayed, or explained away... or their benefits greatly overstated. As incredible as it seems, they have failed to demonstrate significant benefit in preventing chronic diseases of old age, like the big three diabetes, heart disease or cancers, or in living longer. Nor has any healthy eating intervention been credibly shown to give everyone a government-approved BMI.
Other than avoiding smoking and substance abuse, and taking our medicines, our fates are sadly not in our hands.
Carpe diem: every day could be your last.
Tuesday, June 23. 2009
The main reason Americans spend more on medical care is not about life expectancy - it's about two simple things: quality of life, and the trial lawyers.
(American life expectancy stats are also pulled down by the numbers of premies and babies with terrible abnormalities we attempt to save.)
First, in how many countries can you get a shoulder repair or a new knee or hip in a week? Annual screening colonoscopies and mammographies? Guys with advanced ALS on home ventilators? And how many countries generate the new treatments that the US does? (We do 90% of them. For a recent dramatic example, see this via Insty.) We all wear out and die, but there aren't many countries where my 83 year-old Mom would be playing tennis with her new shoulder, hips and knee, her synthetic mitral heart valve, her pacemaker, her cataract surgeries and her hormone replacement. She calls herself The Bionic Mom. She is willing to die, but while she is alive she wants to live: play tennis, work in her gardens, go to the ballet, sit on her volunteer boards, cook for my Dad, and go to Europe every August. What is that worth in $ terms? Of course they are on Medicare, but they would gladly buy private insurance instead.
Re the trial lawyers, where else in the world do you get a $7000 work-up if you walk into the ER with a migraine headache? Where else in the world do obstetricians pay $350,000/year in malpractice insurance because the law permits suits for bad results, not just practice errors (like amputating the wrong leg)?
If something needs fixing, it's the latter, not the former.
George Will put it this way:
The president characteristically denies that he is doing what he is doing — putting the nation on a path to an outcome he considers desirable — just as he denies any intention of running General Motors. Nevertheless, the unifying constant of his domestic policies — their connecting thread — is that they advance the Democrats’ dependency agenda. The party of government aims to make Americans more equal by making them equally dependent on government for more and more things.
That, plus power, is what it's all about. As the Cube puts it:
The main question of the day is, can Americans afford NOT to adopt socialized healthcare? Everyone knows that the individual will never take the necessary steps; it is up to the State to do it for us. In a vital decision like this, do we really need to depend on the vote of emotionally underdeveloped conservative segments? Those incapable or unwilling to acknowledge the moral superiority and the ethical progress of the more socially advanced Europeans, do not deserve a right to vote. Voting rights shall be taken away from them, as well as their medicine. One cannot expect a society to prolong the lives of its useless, degraded elements at its own peril.
I need to squeeze in here somewhere the fact that members of Congress and the government would keep their own generous private medical plans, and not be subject to government control.
Monday, June 22. 2009
I majored in Statistics in college (with a minor in English Lit), but my stats sophistication is a bit rusty now. But it's not so rusty that I do not raise my brow at any latest stats reported in medicine, or especially in Psychiatry - and especially genetic studies.
As Gene Expressions points out, it's partly because a p-value of 0.05, commonly used in such studies, is unrealistic for these things. It's straight out of How to Lie with Statistics, which is essential reading for all high school students.
As the man says, if there is a genetic serotonin link with trauma and depression, it has yet to be proven.
In his second post on the topic, Why are most genetic associations found through candidate gene studies wrong? he makes the key point:
For nearly all diseases, reproducible associations have small effect size and are only detectable when one has sample sizes in the thousands or tens of thousands (for many psychiatric phenotypes, even studies with these sample sizes don't seem to find much). The vast majority of candidate gene association studies had sample sizes in the low hundreds, and thus had essentially zero power to detect the true associations. By the argument above, in this situation the probability that a "significant" association is real approaches zero. The problem with candidate gene association studies is not that they were only targeting candidate genes, per se, but rather that they tended to have small sample sizes and were woefully underpowered to detect true associations.
While I find the field of behavioral genetics to be as fascinating as anything else in this world, I always read the latest gene-behavior studies with the highest skepticism. (Do I think real Bipolar Disorder has some provable genetic underpinning? Yes, I do, even though I do not think it has been adequately proven yet. But not much else genetic in Psychiatry has been adequately proven in my view. Schizophrenia maybe, IQ almost certainly, but possibly not homosexuality, or depression, or alcoholism.
The trick to getting papers published is to run your numbers so they show something. It's not rocket science if you know how to do it: just look at the climate studies. (Even Einstein fudged his math. He happened to turn out to be right, though, as far as we know today.) Science is about hypotheses, not Truth.
Wednesday, June 17. 2009
No good deed goes unpunished.
Well, that is surely not always true, but with the economic downturn, the charity medical clinic at which I volunteer one day per week has seen a sharp upturn in lawsuits against us Docs and the clinic this year.
The medical defence lawyer we have now engaged (we have had no complaints or suits for 10 years until January 2009) tells us that we should now regard each patient as a potential enemy. (Our clinic's founding Christian philosophy is to regard every patient as a friend and neighbor.)
He tells us that our notes must be guided by the principle of CYA (your notes are legal documents, not medical reminders as we had thought) and that every decision a doc makes contains some basis for a suit in the hands of a hungry lawyer because all medical decisions are judgement calls and every situation is unique.
He also told us that recessions tend to see more suits against doctors because more folks are looking for cash, and much more so in charity settings. Plus the tort lawyers are hungry too - but they always are. He also advised us to refuse to treat any patients with substance abuse histories for our protection - other than alcohol.
He actually said "Do not be kind. They will screw you whenever they decide to." He has been around the block a few times.
I do not like this at all. A Psychiatrist/Psychoanalyst cannot do the job under such conditions. Furthermore, I can not and will not endure any relationship in my life without mutual trust. I am considering resigning (even though I was one of the founders of the place) and finding some other outlet for my charity. Maybe prison work, where you can safely begin with the assumption that everybody is a liar and cheater and working the system - and take it from there.
My position on the Board, plus my volunteer time (all unpaid) doubles my legal liability. I just want to do my best, tithe and double-tithe my time, and avoid hassles that do not fit into my life - and legal fees that I cannot comfortably afford.
And no, I would never work for ObamaCare. Never. I did not go into medicine to be a government employee. I went into medicine to work for my patients, doing my best, with no intention of looking out for lawyers.
Tuesday, June 9. 2009
It's tough for doctors because we are often held responsible for people who either do not want, or do not accept, our help and advice. But, as long as their name remains on our rolls and as long as we persist in trying to be constructive, the lawyers can get us.
I have been burned several times by keeping them on the rolls in the charity clinic, only to be sued by them eventually for not doing a better job "taking care of them." What? I am not a professional mother and I do not "take care of" anybody. I am a doctor, not a caretaker and, despite the modern lingo, not a "care-giver" either.
Like all doctors, I try to work with my patients - and do not take care of them, or I to try to bring them around to where I can work with them.
If I were more self-protective, I would not even try and would just say "I cannot help you. Good bye," but that is not my medical tradition. My medical tradition is that you are a friend to your patients, whoever they are.
Novalis presents such a case. More practical docs than I am would just throw them out of the office. However, after being punished and hassled legally several times by going the extra mile, my heart grows harder.
Indeed, good deeds often are punished and yes, it does lead to some bitterness especially when it is performed on a charity basis. I have never been sued or hassled by a private, self-paying patient.
Wednesday, May 27. 2009
Via Tiger at Althouse, Mary Roach (author of Stiff) with video on orgasms from fetus to death.
Friday, May 8. 2009
Another reminiscence from our shrink friend Nathan about his days in the Indian Health Service -
 A limp and a death among the Lakota Sioux marked my first day at Eagle Butte, devoid of eagles and buttes. Two days’ drive from Chicago, I am greeted from afar by John Running Horse, he dipping and rising like a Venetian gondolier, waving aloft what from afar seemed to be the plaster sculpture of a leg. Up close, it is.
Before I could stop completely, John Running Horse lay one hand on the open window of my red Fiat 128, bowed in head and cast, asked, “You the new doc?” I was. “Put this thing on again”; hands me the cast, then points to his gondoliering leg. I park and head in.
The Indian Health Service had told me that there were two docs; arrive Sunday.
But, by Sunday, Dr. K. had been flown out with her atrial flutter to be cardioverted eighty miles up the road to Mobridge; Dr. L. was riding shotgun with a mother in active labor also to Mobridge. No docs in Eagle Butte.
I wrapped a new cast on John Running Horse’s right leg and asked as I did so -- dipping plaster rolls in warm water, smoothing them first around, then smoothing downward along the fracture to make it seamless -- how his old cast got cut off. Itched, he said; cut it off himself, as he unsheathe his James Black/Musso pattern S-guard bowie knife. White plaster still dusted its curved Stainless steel back tip and brass quillion; hadn’t even wiped it clean.
I told John Running Horse that his skin would itch again after a few days; dried skin flakes. I found a metal coat hanger, bent it straight and showed him how he could insert it within the cast to scratch itches. He found this marvelous; made a special leather sheath for it to hang from his belt. Later, he returned; brought a water color gift; painted himself on his horse; he wearing Sioux gear. In his right hand, born aloft like some victorious banner is not a leg cast, but his Winchester Model 1894 lever-repeating rifle -- the gun that won the West, the weapon of choice for the Rifleman of TV.
Continue reading "A Limp and a Death"
You used to just plain peter out at 68 or 79 or 93 but, after 1951, the law changed and some Doc had to make up a cause to put on the death certificate. A proximate cause, plus additional lines to fill in for contributing causes/underlying causes of death. (Imagine what that change did to disease stats!) More many more little-known facts about death.
Old time Docs knew that people died when they got old and rickety or had a bum ticker or some nasty growths. You plumb wear out eventually, and it is just a matter of which internal doohickey crapped out first. It was considered sort-of natural, and not a medical issue.
And, when folks died, they either said "They died" or "They ascended to their Maker" or "Went to their eternal reward." They did not say "They passed" (what a strange expression - passed what? New Agey-sounding, isn't it? Took a pass on more life, or what? Passed into the Spirit World?) or "passed away," as the relentlessly euphemistic funeral home people used to say. Like they aren't dead: they just sort of floated away past the 7-11 and the Pontiac dealership and the Pizza Hut to somewhere else.
Maybe to the lovely Mall in the Sky.
Tuesday, April 28. 2009
 The news mills are ginning up yet another medical crisis storm these days in an effort to pave the way for gummint medical care by the same good folks who run the DMV and the post office. They seem to imagine a problem with cost, access, and insurance. Maybe we are a nation of crybabies, because we have the best medical care in the world with which to pamper our so-called precious selves.
It's time we got beyond that self-love, and cared about the Greater Good. I have a few simple, rational, Utilitarian solutions.
Cost: Cost is driven by technology and modern pharmacology, cancer treatment, crocks (people obsessed with their health), gomers ("gomers go to ground"), and futile, guilt-driven end-of-life treatment for annoying old or sick relatives. The cost of American medical care can be dramatically reduced by forbidding all cancer treatment other than Oxycontin and at-home 10-gallon morphine pumps, all medical treatment for those over 57 (the children are our future!), all CT and MRI scans, all blood tests, and all medicines other than friendly, holistic, herbal organic ones. No more vaccinations - they cause Autism. No more antibiotics - everybody knows that they make people sick. Eliminate Dermatology (just stay out of the sun, people). Eliminate Opthalmology (bad eyesight is from masturbation - it's your own fault). Eliminate Psychiatry (mental illness is socio-political mind control). Eliminate Urology (do you want a #3 gauge tube stuck up your urethra?). Eliminate Surgery - it is physical assault on comatose victims. Eliminate Neurology - it's just nerves.
Access: Doctors are like waterfront trade unions: they limit their numbers to keep their payments high enough to join country clubs, to buy boats, and to take vacations. My idea: anybody who gets a C or better in Organic Chem is automatically admitted to a government medical school. Lots of good, caring people are weak in math and chem and bio and stuff, but that's who we need more of. My medical school flunk-out rate was 18%: what a waste of talent. Plus there are too many Jews and Asians in medicine anyway, and too few people of color or of gender identity diversity. So, with this increase in the numbers of docs, fees could go down to $5 per office visit and the docs who don't like it can open dry cleaning shops, cigar shops and wine shops like they do in Canada.
Insurance: Medical insurance is a dumb idea. Why expect your neighbor to pay your medical bills when they will be so low under my plan anyway? They will be cheaper than your garbage pick-up, your newspaper subscription, your cigarette costs, your car payment or your monthly payment for your big screen TV. (Did you ever notice how nobody complains about the cost of their TVs, computers, or Life Insurance?) Or just save your money if you want and die quietly without complaint, dude, and make space for the next generation. Too many people on the planet and, let's face it, life isn't all it's cracked up to be anyway. A vale of tears and toil, a tale told by an idiot, full of sound and fury, signifying nothing. What's the big deal about death? Didn't your parents teach you that life is a bitch?
Friday, April 24. 2009
Our shrink friend Nathan, who has completed Aliyah in Israel, sends this reminiscence of his days working for the Indian Health Service, doing general practice including surgery and obstetrics - and anything else that was needed. Old-timey medicine.
Before replacing the sloughed skin on Mrs. R's arm, I had to find out why her forearm was raw to the muscle. New here among the Sioux, I am surprised to learn that my colleagues (and one ancient Roman Catholic always fiddling with her rosary) hadn't checked this elderly, chunky widow's blood sugar: diabetic, sure enough, never diagnosed. So, first things first: stabilize her blood sugars, treat the diabetes, and give proper antibiotics (for anaerobes and aerobes -- they missed this too), then when you see the shiny, glimmer of healthy tissue margins, go for a skin flap transplant.
The pharmacist was my surgical assistant; he was the brightest of the bunch, from N'orlins, La before the Flood, he couldn't get into med school, he said, but he was smart, hard-working and pleased to assist. He also ordered special hickory chips from N'orlins, La. to barbecue and made his own roux. It was then that I learned I loathed ochra, that slimy matrix it exudes.
Then how to unskin a lady was not to be straightforward as it was at the University hospital where I studied. The surgical suite -- well-endowed -- had not been used for years; surgery was sent eighty-miles up-road to Mobridge to the White hospital; none done here, except deliveries (which too often evolved into C-sections who had to be sent, ambulance screaming, up to Mobridge. One trip, the eternally-soused obstetrician kept his fist in the mother's vagina to keep the baby from popping out.
To unskin a forearm means to find a donor site from the inner thigh. Anesthesia needed for this and there was no anestheiologist, no nurse-anesthetist, even in the 1970's. I do double duty. First, a lumbar block to numb the donor site; second, a brachial plexus block -- in the armpit -- to numb the recipient, the naked forearm. Lumbars I had done many of: babies with possible meningitis; Southside Chicago girls in active labor, with no prenatal care and needing an urgent C-section. But, brachial plexus block was a never-done for me; remembered the anatomy, the complex twistings and routings within that armpit, like some noodling of telephone wires beneath the city streets, but never stuck a needle there. The night before surgery, I bone-up on my Netter's anatomy and hit the spot square-on the next day in the O.R.
Before hitting the OR, I had done several days debriding of the sloughed wound: fresh it must be to transplant the sod of skin. In the OR, flipped on her side, I slid into the vertebral space between L4 and 5; a bit lordotic pull by the nurses and I had a clear tunnel in. Then, flapped on her back, Mrs R. was ready. The thigh well scrubbed, Betadined, aproned, an oval hole isolating the site. Instruments we had. The strange loopy-scalpel to slice just-thick-enough epidermis and a touch if dermis to both "take" to the new site, yet leaving some dermis to heal-over the thigh; something like a large cheese knife the instrument looked. Forearm next. Her arm flung up like some lop-sided angel wing, I probed left-handed with two gloved fingers, then slid the massively long needle --- like from the cartoons -- in between the stretch of skin. Wait. Wait. Numbness without paralysis in the arm. First, a touch on the skin (for sensitive fibers); then a pinch with a forceps (for the pain C-fibers) and success.
 Laying the layers onto the site is much like laying sod; carefully, side by side, the edges trimmed to the wound shape. The "root" growing will take on its own, a pressure bandage holding the skin sod in place. A fine lawn it will hopefully be; like sodding around a putting hole -- it should look good and cover the ground. And after five or six days of brief peeks, it looks darn good.
But, Mrs. R. wants a pass to leave early. There will be a Sundance ceremony with several initiants, including, I learn later, Russel Means, wanted by the FBI for shooting three men on Rosebed reservation, down south. I explain, I plead in fact, that she can't rotate the arm; she must stay in hospital a week or so until we know healing has happened. Mrs. R. has donated two buffalo for eats at the ceremony and insists, politely, quietly, firmly, that she is going. Wakantanka, the Sioux god whose voice one hears shushing through the Black Hills, will protect her. She invites me.
Being invited was one thing; getting in another. I and Debby were the only washichus, white men, attending. While this was a Lakota Sioux ceremony, it had become politicized; other tribes, mostly the more militant ones, as far away as the Navajo, had sent "guards": thick-armed toughs with long, greasy black hair and their image of mean on their faces. The fellow who greeted us -- we had the red Fiat 128 in South Dakota -- commanded us out. A face like a slab of steak with two eyes embedded, he frisked me; looking for drugs and guns, he said. His compatriots searched the tiny Fiat's baggage, checked under the carriage, beneath the seats, glove compartment. When he turned to frisk Debby, I told him firmly, no way: I would turn around and he could explain to Mrs. R. why I was not admitted. Her name was a key to the lock that was his harshness. We were passed through.
I did not expect to be the only Washichu; thought other docs would be invited; learned later that my do-gooder colleagues who come to save the Indians are not so welcome. Already, I had dispensed with making morning rounds with them, as I tired and was irritated at the "religion" they spouted at bedside; told them I needed to round earlier.
We formed a large circle. Formed is not quite right. A circle was somehow formed by the few hundred there, centered by the cottonwood from which leather strops hung. Each strop was anchored with a bone hook -- from what animal I don't recall, perhaps antelope. The six piercees entered; I'm told by Mrs. R. that they had purified themselves in the wild for several days with fasting and water. The hooks are pierced into the pectoral muscle, not the skin, to hold more firmly; one on each side. as the men leaned back against the leather thongs, faces skyward, Cubist, uptilting tits were formed: this manly ceremony giving rise to a touch of woman. A moaning or humming was emitted by them by these men; also those in the circle, as the men stomped sidewise about, a dance they called it, in a hypnotic slowness. A timeless quality it felt.
Near the end, several men appear with massive shallow wooden bowls, face us in the circle and pass around the dried buffalo donated by Mrs. R.
She is called to near the center. A peace pipe is to be given to her for her generosity. As some chiefly type raises the pipe, his arms extended, palms upward, I realize, a touch shocked, that she will now rotate her arms upward to receive the peace pipe with both hands. I feel a belly clutch: will she tear the stitches?
Mrs. R. looks back at me afterwards; tosses a smile of reassurance. Thanks to Wakantanka the skin is fine, she explains.
One weekend, we go to the Black Hills, find a cabin, rest outside beneath a sky filled with more stars than I have ever imagined. I feel a sense of annoyance as I hear the rush of what sounds like highway traffic just beyond the ridge. Ridge top I look: no highway; it is Wakantanka speaking through the black pine.
It was the only time He has ever spoken around me.
Top photo: Sioux war party, 1870s?
Middle photo: Sioux warrior
Lower photo: Sioux village
Friday, April 17. 2009
I opted out of Medicare years ago. I felt morally torn about doing so, but finally my bookkeeper refused to do any more of their paperwork. That settled it.
My compromise was to institute a generous sliding fee scale for Medicare-aged folks. (My general policy is to never decline a referred patient because of money.) From a young Doc, in the WSJ:
Here's something that has gotten lost in the drive to institute universal health insurance: Health insurance doesn't automatically lead to health care. And with more and more doctors dropping out of one insurance plan or another, especially government plans, there is no guarantee that you will be able to see a physician no matter what coverage you have.
Consider that the Medicare Payment Advisory Commission reported in 2008 that 28% of Medicare beneficiaries looking for a primary care physician had trouble finding one, up from 24% the year before. The reasons are clear: A 2008 survey by the Texas Medical Association, for example, found that only 38% of primary-care doctors in Texas took new Medicare patients. The statistics are similar in New York state, where I practice medicine.
More and more of my fellow doctors are turning away Medicare patients because of the diminished reimbursements and the growing delay in payments.
Monday, April 13. 2009
 Here's the real story about who is and isn't covered by medical insurance.
Not that the facts matter all that much in politics - and everybody wants a free Easter buffet.
Related: How the government plans to create its own medical insurance monopoly. (Just like public schools.) And once they have done that, they will drive through their rationing, rules, and controls. - and freedom in medical care will disappear. At that point, Doctor, your proud and noble profession will be transformed into involuntary servitude to the State rather than voluntary servitude to your patient and, at that point, patient, your treatment choices will disappear.
Then watch "doc-assisted" suicide for those over 60 become all the rage in government circles.
It's one more government power and money grab.
Thursday, April 9. 2009
Yesterday morning's NJ post on "Quality Care" from the WSJ was enlightening, and just gives me one more reason to stay away from Medicare (besides the fact that they pay me peanuts, and that their paperwork requirements are over my head and take more time than my patients take).
I see how government "Quality Care" works: the academic medical experts take a vote, and that becomes "Quality Care." That's not medical care: that's government policy. Forget the individual patient and his or her unique situation, forget the Doc's experience and skills and insight, forget the Doc's judgement, forget the fact that academic Docs aren't always practical, forget that next week's new data will completely alter the information at hand. Just Follow The Rules and stay out of trouble.
I have seen plenty of cases go bad in the hands of young Docs who strictly follow the rules. It's not a good example of that, but when I was a resident one of "the rules" of the time included strict limits on the use of pain-killers, even for terminal cancer patients. Didn't want them to become addicts, you know. They forgot that pain relief remains one of a handful of the greatest blessings medicine has bestowed on humanity (along with anesthesia, antibiotics - and Lexapro).
One of the best things about seasoned physicians is that they are a cranky bunch who do not take orders, who think for themselves, who feel that rules are made to be broken, and who do not like to take crap from anybody - especially anybody in "authority". Your patient comes first, or you are nothing. There is a "House" inside every Doc. In most lines of work, you can't get away with that sort of attitude.
When government gets involved in things, they tend to screw them up. The article's example of high blood sugars in the ICU was a perfect example. Even I, who have not cared for ICU patients for more than a decade, know that tight sugar control for critical patients is insane and dangerous. Not only that, but it doesn't matter: if the patient survives and gets healthy, a few days of higher sugars with a good margin of error will not have hurt them one darn bit. But I am a Doc with a practical mind.
Expertise always has to be taken with a grain of salt, and government-emitted expertise with a tablespoon-full. I am not disparaging expertise, which I respect enormously. I just distrust the combination of expertise with power over others: anointed experts who want power instead of simply to educate give me the willies.
Non-"experts" often have loads of common sense. We take an ancient oath, too.
Ed. note: Somewhat related: Socialized medicine: A warning from across the pond
Wednesday, April 8. 2009
Mrs. BD had increasing pain in her right shoulder, then running down her biceps, for two weeks, finally keeping her awake at night. Gets an appointment with the #1 shoulder guy in the world at the Hospital for Special Surgery in three days (last Monday). He is a kind, caring fellow who takes time with her. She gets a shoulder MRI two days later. Gets the diagnosis of early frozen shoulder one day later. Begins physical therapy and anti-inflammatory meds one day later.
Feeling better already. Even Fidel Castro couldn't get that kind of care and help, nor could Obama get better. Do I want my neighbor to pay for this for me? No - but thanks so much for offering to pay her bill. I believe in taking care of my own.
The bad news for her: no tennis for at least 2 months. The bad news for me: I gotta do all the cleaning and scrubbing, right when it's time to begin enjoying yard and garden work.
Well, we have snow flurries today, thanks to global warming climate change, so I guess the gardens can wait a while.
Saturday, March 28. 2009
That's the latest cardiovascular recommendation for brisk aerobic exercise. (It used to be 20 minutes three times a week, but new data has changed that recommendation.)
I have not asked whether 30 minutes of vigorous sex five times/week counts, but we hope it does.
Tuesday, March 24. 2009
For some today, and for just about everybody in the past, medical insurance was something everybody bought, just like life insurance or disability insurance, to cover extraordinary expenses. It is called Major Medical, and it is still readily available.
Over the past 20-30 years, governments, businesses, and union contracts began expanding their coverage by reducing deductibles and covering more routine things. Medicare, of course, was the model for that. During the same time, costly medical technology and new drugs were developed in a near-miraculous way, mostly in the US.
With those changes, folks began wanting "insurance" to cover their routine maintenance medical expenses instead of the things that would financially overwhelm them. When that shift was combined with the CYA style of medicine which results in $5000 work-ups for dizzy spells (fed by the ambulance-chasers), everybody expected everything.
That isn't sustainable, and will never happen. Medical technology has grown to an amazing extent, but those machines are expensive.
I have no idea what the folks in power are trying to plan for us, but I know it will be an entitlement disaster, filled with unintended consequences, that people would not be happy with. It will end up with politically-determined rationing.
Our family bought Major Medical insurance many years ago. It cannot be cancelled. It's more important than a cool car. Why everybody does not do that when they are young and healthy is beyond me, because it would seem like the logical and prudent thing to do. Over the years, we have increased the deductible so that it is quite affordable, and we keep a money market savings account specifically for medical bills to the amount of the deductible. As I recall, we began with a $2000 annual deductible, and now we finally have a dirt-cheap $20,000 2-year deductible on the original policy. It does not cover any routine or preventive medical care, which is as I think it should be. Nobody owes me medical care, in my view, any more than anybody owes me auto insurance.
We have kept this policy whether or not I or my husband had some form of insurance through work, because you never know how long you will want to keep a position - or when you will be let go.
Off-topic: Around 30% of Medicare expenditures occur in the last year of life. In other words, on failing and terminal people. Interestingly and unsurprisingly, when docs hold end-of-life conversations with these patients (as we should), the costs go way down.
Wednesday, March 18. 2009
You can die of hypothermia when the temperature is well above freezing, and you will die of hypothermia after a while in 77 degree water. Many interesting facts at Freezing Persons Recollect (h/t, Cons Grapevine). All outdoorsmen should know this stuff. One example:
...many hypothermia victims die each year in the process of being rescued. In "rewarming shock," the constricted capillaries reopen almost all at once, causing a sudden drop in blood pressure. The slightest movement can send a victim's heart muscle into wild spasms of ventricular fibrillation. In 1980, 16 shipwrecked Danish fishermen were hauled to safety after an hour and a half in the frigid North Sea. They then walked across the deck of the rescue ship, stepped below for a hot drink, and dropped dead, all 16 of them.
Tuesday, March 10. 2009
George Bernard Shaw warned “Beware of false knowledge; it is more dangerous than ignorance.” The major overhaul of American health care pursued by President Obama and his supporters is based on many false premises and is excessive and likely to do more harm than good. Tuning up and improvements already always dynamically occurs. Instead, ObamaCare is aimed at dramatically changing one-sixth of the US economy in ways that are untested or tested and found wanting, primarily involving huge increases in government direction of health care.
The details of ObamaCare are largely being left to Congress, the same body that stuffs the federal budget with earmarks, waste, and other programs that are not requested. ObamaCare is premised on claims for drastic changes in health care and major increases in government programs being necessary. Those claims are largely specious.
Below the fold, the top ten specious premises for ObamaCare are discussed:
1. Comparing US Health Care To Other Developed Countries
2. US Health Care Spending Is More Than We Can Afford
3. Reform Overhaul Will Yield Major Savings
4. Increased Evidence-Based Medicine And Health Information Technology Will Significantly Improve Care and Reduce Costs
5. Present Administrative Costs And Insurer Profits Are Too High
6. US Consumer Dissatisfaction Requires Drastic Health Care Changes
7. Health Care Costs Are So High They Are A Major Cause Of Personal Bankruptcy
8. The Number Of Uninsured Is So Large That Drastic Health Care Changes Are Necessary
9. More Preventive Care Will Better Serve Consumers And Save Costs
10. Health Care Consumers Are Being Served By Drastic Health Care Changes
(More could be added, such as that government restraints on prescription drug prices will not impede incentives for innovations, but they are so transparently false that the list below dwells on other ObamaCare premises more misleading.)
Continue reading "Top Ten Reasons For ObamaCare Are Based On False Information"
Tuesday, February 10. 2009
Docs have been poo-pooing routine vitamin-taking for many years. We tend to think of it as a rip-off (although I do take a daily Vit D). Studies continue to indicate their uselessness in adulthood, but the placebo effect cannot be underestimated.
We linked the Bloomberg piece this morning describing what the "stimulus" will do to ration care under Medicare. Also in the stimulus will be a federal monitoring of your medical history and treatment - this from our Canadian friend at Small Dead Ducklings:
The bill’s health rules will affect “every individual in the United States” (445, 454, 479). Your medical treatments will be tracked electronically by a federal system. Having electronic medical records at your fingertips, easily transferred to a hospital, is beneficial. It will help avoid duplicate tests and errors.
But the bill goes further. One new bureaucracy, the National Coordinator of Health Information Technology, will monitor treatments to make sure your doctor is doing what the federal government deems appropriate and cost effective. The goal is to reduce costs and “guide” your doctor’s decisions (442, 446). These provisions in the stimulus bill are virtually identical to what Daschle prescribed in his 2008 book, “Critical: What We Can Do About the Health-Care Crisis.” According to Daschle, doctors have to give up autonomy and “learn to operate less like solo practitioners.”
[...]
Hospitals and doctors that are not “meaningful users” of the new system will face penalties.
If Obama screws up the American health care system, where the Hell are Canadians supposed to go?
If they want docs to give up their autonomy, they had better find a new, lesser breed of docs in this country. And I'd rather fight with an insurance company about my medical choices than fight with a federal bureaucrat. If the insurance company doesn't want to pay, I can at least pay for it myself.
Tuesday, January 6. 2009
General hospitals are increasingly relying on "hospitalists" to care for inpatients, freeing up office practitioner's time for their (steadily less lucrative) outpatient practices.
I have yet to be a hospital inpatient except for childbirth, but I think that, if and when I am, I'd like to see the face of my own Doc daily.
This is a new model for medical practice. More time-efficient? Probably. Less comforting? Probably. Overall, better or not? I cannot say.
Internists, and what few GPs still exist, are having a tough go of it these days: Medicare, which is the bulk of their work, compensates them now at a rate lower than a plumber or electrician in Boston.
Friday, December 5. 2008
Your doctor may be so concerned about protecting you from alcoholism that he or she might not tell you that current research indicates that 1-2 drinks per day appears to reduce the risk of heart and arterial disease by 18-30%. More is not better, however. Details at Medscape.
Monday, November 17. 2008
 We have posted on statins in the past.
Here's further evidence that statins are helpful, regardless of your triglyceride levels. Maybe all guys should take them (per your Doc's advice, of course.)
Saturday, November 15. 2008
Re-posted from November, 2005 
As a native Cape Codder and cranberry fan, it's a delight to report that they may have a powerful anti-atheroscletotic effect. Maybe this news might have a beneficial effect on a specialized family farming that has been bedeviled by low prices. The big producers are Wisconsin, Massachusetts, New Jersey, Washington, Oregon and Michigan. The sentence in Science Daily I don't understand is the following: "The researchers said that the next step is to determine which compounds in cranberries contribute to the benefits and then figure out how to incorporate them into the diet in a form palatable to humans." How about in cranberry juice, cranberry muffins, cranberry pancakes, 25 kinds of cranberry sauce, cranberry cobbler, and dried cranberry "raisins,"....for starters? You can buy unsweetened, undiluted cranberry juice now in most supermarkets. We keep bags of them in the freezer, and they seem to last a year. Cranberry sauce: it's not just for Thanksgiving turkey. It's good for chicken and almost any kind of game meat. Never use the junk from the can, though. Even if you think you like it, you will find you like the home-made far better. More on this native North American wetland plant here.
Saturday, October 11. 2008
David Thompson led us to a report about the evolution of the anus. How did critters get from one opening to two? One theory presented is that it entailed a connection between the GI tract and the reproductive system. Many animals, like birds and reptiles, have a cloaca (or "vent" - hence the word "venting"), which combines urinary, defecatory and sexual functions. (Most birds copulate via a "cloacal kiss," but a few lucky birds, notably ducks, swans and ostriches, have penises.) This reminds me of the Yeats: Vl: Crazy Jane Talks with the Bishop I met the Bishop on the road
And much said he and I.
'Those breasts are flat and fallen now,
Those veins must soon be dry;
Live in a heavenly mansion,
Not in some foul sty.' 'Fair and foul are near of kin,
And fair needs foul,' I cried.
'My friends are gone, but that's a truth
Nor grave nor bed denied,
Learned in bodily lowliness
And in the heart's pride. 'A woman can be proud and stiff
When on love intent;
But Love has pitched his mansion in
The place of excrement;
For nothing can be sole or whole
That has not been rent.'
Wednesday, October 8. 2008
A piece on the subject in the NYT notes: The myth is that like magic, preventive medicine will simultaneously reduce costs and improve health.
Read the whole thing. Sadly, except at the margins, there is little we can to to prevent disease. The wishful thought that we can control fate and the gods never quits, though.
Tuesday, October 7. 2008
From guest author Bruce Kesler:  Health care could be the next Fannie Mae type disaster. Similar forces are at work, and despite the lessons that should be drawn instead may be accelerated by the current financial meltdown. These forces are exaggeration of need and rights among the poor, greed by many of the rest of us, and many politicians seeking votes or contributions.
The forces in the credit crisis were the appeal to provide opportunities for home ownership to the poor and the consequent inflation of housing values that provided paper gains to the middle class and wealthy. Underlying these forces was a pyramid scheme profiting the political and financial elites that was dependent on trust in repayment of subprime loans by many without the means or stake in doing so. Thus, ultimately the taxpayer and more careful consumers and investors are required to pay off, also making other worthy goals unaffordable.
Continue reading "The Fannie-ization of Health Care"
Thursday, September 25. 2008
 What's up with Beauty Studies (ie Neuroaesthetics) these days?
A quote from Beauty and the Brain (by the proprietor of Neurophilosophy) in Seed (h/t, Dr. X): ...recent work by several researchers at University College London — including the establishment of the first major grant-driven research program for the neurobiological investigation of aesthetics, or neuroaesthetics — has made the first steps toward a unified biocultural theory of art. An object's beauty may not be universal, but the neural basis for appreciating beauty probably is. The researchers' initial discoveries and the increasing formalization of the field promise to open the way for the first time to an understanding of beauty based on something other than speculation.
Can things of the soul and spirit be understood in terms of neurotransmitters and neural wiring? Count me a skeptic. Different levels of organization have different rules and patterns which do not transfer one to the other. For example, you could know everything about atoms but never predict a living cell, and you could understand everything about a cortical network without predicting Moby Dick. (And, for me, on a good day I see beauty everywhere but on a bad day I see it nowhere.) Still, they may as well give it a try. I get skeptical when they call it a bio-cultural model, however. It makes it too clear that they seek to detour around the psychology part.
Monday, September 22. 2008
 How are your teeth?
Teeth are a sensitive subject. When you lose one as an adult, you feel a bit emasculated. Lose a handful, and you can develop a clinical depression. And root canals are a torture which even the CIA would never inflict on Osama. My first one was without Novocaine at age 14. The elderly dentist didn't "believe in" Novocaine. I have had plenty since then. Plus it costs big bucks to keep good teeth after 45, unless you are one of the lucky ones with genetically strong enamel. My teeth are mediocre-to-poor. I have one implant so far, many crowns, and a number of failing crowns. My wisdom teeth were pulled years ago. I have some extractions and two more implants on the way, plus a bridge. Most of my teeth have fillings and miscellaneous repairs. My dentist blames it on cigars and bad tooth genes, and says I need a serious big-time periodontistry before he can do any more repairs and reconstruction. I also lost a few front ones playing hockey in prep school. The brother of my then-girl friend stuck the end of his stick in my face, entirely by accident no doubt. Whenever I am sent to a new person, eg a periodontist or an implantologist or an oral surgeon, before I open my mouth I always say "Promise you won't say 'Oh my God what a mess.'" This stuff gets expensive. But even worse is that it is a depressing reminder of ones' aging and deterioration, a memento mori. Entropy always wins. We pay and struggle, but we always lose the battle.
Thursday, September 18. 2008
People talk about the Canadian system (horrible for Docs and patients) and the NHS (which 56% of Brits want eliminated). Few discuss the way the French do it, but it's worth thinking about. Part 1 of Health Care Reform discusses the history French system, noting "They emphasize private, fee-for-service practice even more than we do." If you are interested in the topic, Synthstuff links all 4 parts of this essay, written by a Doc who likes the system.
Monday, September 15. 2008
Robert Samuelson, in Getting Real about Health Care: It's not about coverage. It's about cost, begins: Whoever wins should put health care at the top of his agenda. But the central problem is not improving coverage. It's controlling costs. In 1960, health care accounted for $1 of every $20 spent in the U.S. economy; now that's $1 of every $6, and the Congressional Budget Office projects that it could be $1 of every $4 by 2025. Ponder that: a quarter of the U.S. economy devoted to health care. Would we be better off? Probably not. Countless studies have shown that many diagnostic tests, surgeries and medical devices are either ineffective or unneeded. "More expensive care," notes CBO director Peter Orszag, "does not always mean better care."
Read the whole thing. Of course, the only way to control costs is to limit services. HMOs do that, and people rebel. Besides freedom, what do American people value more than their health (well, plus their guns and Bibles)?
Sunday, August 24. 2008
 Just as professional journals and newspapers are more interested in printing pieces that support hypotheses rather than papers with negative findings, so we all tend to spend more time discussing the risks of action rather than the risks of inaction.
That seems to be human nature, but it ain't rational and, fortunately, people vary across a spectrum of activity/passivity. Passive people worry about the risks of action. Active people worry about the risks of inaction. I am more-or-less in the middle. To discuss that half-intelligently, though, I first need to review the notion of Type 1 and Type 2 errors, now that we have taken a look at the null hypothesis a couple of days ago. A Type 1 error, also known as False Positive, is the error of erroneously rejecting the null hypothesis. In other words, it supports a connection which does not really exist. A Type 2 error, or False Negative, is the error of wrongly accepting the null hypothesis. In other words, it says nothing is there, when it is, in fact, there. For example, a blood test which has a 10% False Positive rate will wrongly tell you that there is an abnormality 10% of the time. A blood test with a 10% False Negative rate will miss an abnormality 10% of the time. For another example, convicting an innocent person is a Type 1 error; letting a guilty person go free is a Type 2. Depending on the matter at hand, either sort of error could have worse consequences. A Type 1 error in a death penalty case is a grievous error. But sometimes you need Type 1 errors. My favorite example of a good Type 1 error is in the emergency treatment of appendicitis. Since medical diagnosis contains both art and luck as well as science, some error rate is inevitable unless you have the diseased organ in hand. But since a False Negative diagnosis would have dire consequences (ruptured appendix), it is necessary to do some unnecessary appendectomies on patients who might have appendicitis, but do not turn out to. In the case of emergency appendectomies: one study indicates that the Type 1 error rate is around 10%, with 18% False negatives. I would have guessed that the False Positives would be higher, and you could argue that there is room for them to go higher. The point is that, with appendicitis, you want to minimize your False Negatives by having more False Positive diagnoses - by being deliberately biased against the Null Hypothesis that there is nothing there, but without cutting open everyone with a bad stomach ache. Thus that is the opposite of what you want in a justice system, where the null hypothesis of innocence is presumed in order to minimize False Positives.
Saturday, August 23. 2008
Diagnostic errors remain the  leading reason - or excuse - for medical malpractice lawsuits by the swarms of hungry sharks which parasitize American's fine physicians - the best physicians in the world. Kevin, MD. All the more reason for docs to be irrational - or rationally irrational - in spending your money (either yours directly, or the insurance company's money - which was your money). If you have a headache, I am going to order an MRI of your head which will cost you between $700-1100 in my area. I know darn well that you don't have a tumor, but I could be wrong 0.3% of the time. So I'll order the MRI, because you will want me to, and my law suit defensiveness will want me to. Still, I will know that it is poor medicine. Indeed, I know that your particular pattern of headache, and your exam shows it to be a Common Migraine, and not a tumor, not an aneurysm, not a stroke or subdural, etc. And I know that all sorts of guidelines have been constructed, such as these. Well, you can toss the guidelines for all I care. The Barrister's recent series on error (Part 1 - Fun with the Null Hypothesis,
Part 2 - False Positives and False Negatives,
Part 3 - Risk of Inaction and Opportunity Cost) applies beautifully to modern medicine. There is almost no end to the amount of your money we can spend to try to reduce our False Negative rates - our Type 2 errors. And they will occur, regardless. It is very unpleasant to be sued. It damages a doctor's enjoyment of his art, it absorbs huge amounts of time and energy, and it damages his relationships with all of his patients. And, finally, it has nothing to do with his competence and everything to do with the greed and litigiousness of his patient. I pay 42,000/year for malpractice insurance as a GP, and I have never been sued. I know guys who pay 160,000. You are paying those bills.
Thursday, August 14. 2008
There are tests of your social situational sensitivity. I know, and like, people from across the spectrum. And severely autistic people are still people. Nobody's wiring is perfect. How could it be?
 Yet one more manufactured, over-hyped crisis is being debunked.
Nowadays you can define anything you want as pathological. And this whole new fashionable category of "at risk" silliness expands things to include everybody. For example, at middle-age I am "at risk" for obesity. Not wanting to be fat, I decided not eat carbs and I do a tough daily workout. It's not too complicated. Prosperous nations have lots of fat people. More of them than poor nations, although poor nations have plenty of them too. The reason is that humans have a weakness for carbs. Thus being trim and fit is a sign of self-control, but being heavy is a time-honored sign of prosperity. If you want to see fat people, go to Disneyworld and get grossed out. There are Americans there so fat that they have to ride around in motorized chairs, like King Kamehameha. God bless 'em. The world needs more fatties, in my opinion. It means people have plenty to eat, but I don't like to have to look at them. To be evenhanded, however, I find anorectics even more disturbing. I happen to feel that excess fat in women is unattractive, slovenly, and unsexy. Somewhat less so in men: some stout men are cool, like Teddy Roosevelt was. Anyway, we have been subject to much brouhaha about obesity in recent years. Big health crisis, etc. You have surely read the news that being overweight is not such a big deal, from a medical standpoint. Even the WSJ covered the story, amusingly. Obesity - and that means much more than ordinary fatness and pudginess - is often quite benign. And being overweight is fine, from a health standpoint. Just like the the AGW fad and all such fads that governments are suckered into, there is fat money to be made from the obesity silliness. Follow the money: you know that somebody always wants some of yours. Careers. Respect. Pensions. Fat City. Fact is, when I was an intern in NYC, I saw plenty of skinny, athletic guys in their 40s come into the ER and crap out with massive heart attacks. Also, skinny guys with insulin resistance. The reasons to be relatively thin are to be fully functional - and aesthetic. If an American lady wishes a decent sex life, it behooves her to be trim. Not so in some countries, however, where they prefer us gals Biggie-Sized. Here's a good food story, from the Englishman: His typical breakfast order from Pete's Grille in Baltimore, Maryland: Start with three [white bread] sandwiches of fried eggs, cheese, lettuce, tomato, fried onions, and mayonnaise; add one omelet, a bowl of grits, and three slices of French toast with powdered sugar; then wash down with three chocolate chip pancakes. According to his autobiography, growing up, lunch also consisted of 1 pound of pasta, 2 large ham and cheese sandwiches with mayo and 1,000 calories of energy drinks. Dinner’s another pound of pasta and a whole pizza and 1,000 calories more in energy drinks. No food hang-ups with him. He gets it. Food is fuel, not endowed with magical or evil effects.
What a fat slob he must be, bet he can barely get up from the sofa to get to the fridge, something ought to be done to prevent our youths ending up like him...
Let's all be relaxed and tolerant: being fat is a "life-style" choice. Let them eat cake. Addendum: At Pajamas, Fast food restrictions fatten government
|
