A Socratic dialog on health care reform (VIII)

While on his way to barter for health insurance through the Athenian health care exchange in the Agora, the philosopher Socrates has a chance encounter with Hippocrates, the father of medicine.

Hippocrates: Socrates, my dear fellow! Good day to you. But to what business are you hastening at such an early hour? And, I might add, with such a limp?

Socrates: Good morning, Hippocrates. Were it not for your timely greeting, I might have passed you by. I make haste to join the line of my fellow citizens who stand outside the newly formed healthcare exchange in the Agora. Finally, after years of waiting, we can sign up for affordable health insurance! I can hardly wait to compare the options, for alas! — as of late I have been plagued by this painful hip and fear the need of an artificial replacement.

Hippo: Ah, good Socrates, how sorry I am to hear of your woes! And yet, I fear that your painful hip may be the least of your worries in this healthcare debacle.

Soc: Whatever do you mean, Hippocrates? Are there not enough willing surgeons to go around?

Hippo: Of surgeons there are plenty, Socrates.

Soc: What then? Do you refer to the lack of affordable plans in the healthcare exchange?

Hippo: No, Socrates. A review shows that there are plenty of plans from which to choose. Moreover, with the increased competition, the premiums have dropped appreciably.

Soc: This is good news indeed! But tell me, Hippocrates, what are these concerns which you harbor in your heart?

Hippo: Have you not heard the latest news from the Senate floor, Hippocrates? There are those in the Congress who have plotted to derail the Affordable Care Act. If they have their way, the entire enterprise could come undone.

Soc: But what is this? Tell me more, Hippocrates!

Hippo: A small select group of representatives from the more conservative quarters have vowed to postpone the implementation of the Affordable Care Act for at least another year.

Soc: How can they orchestrate such a thing? Is the ACA not now the law of the land?

Hippo: To be sure, good Socrates, it is. But this select group has tied the postponement of the ACA to the budget bill now before the Senate. Because of their ridiculous amendment the Senate has refused to pass the legislation required to fund the government, the result of which being that all non-essential governmental employees are to be furloughed without pay indefinitely.

Soc: What? To jettison the funding of the Athenian government merely to undercut the implementation of a law on the books! But that is an outrage!

Hippo: (sadly nodding his head) To be sure, to be sure, good Socrates. But I am told that there is little which can be done to remedy the situation. The conservative party has closed ranks, despite the fact that there are many among its members who lament this action.

Soc: Such behavior is outrageous and unbecoming of statesmen!

Hippo: Alas, Socrates, there are few statesmen left in our time. Plato has informed me that this plot has been years in the making, for no other reason than to discredit the president and his program.

Soc: It would appear that politics is alive and well in our Athenian economy.

Hippo: Indeed, the Athenian Times reports that the current budget brinkmanship is just the latest development in a well-financed, broad-based assault on the health law. It gives one pause to wonder at the extent to which our politicians will go to rescind it, even if that means not funding the government and refusing to raise the debt ceiling, which would all but ensure a global Athenian default.

Soc: How small the problem of pain in my hip appears in comparison! Perhaps the mad hatters in the party of tea should consider hemlock.

Humane Medicine — When difficult decisions must be made

Moral distress: when clinicians feel they cannot do the ethically appropriate thing. Midnight medicine: when difficult decisions must be made with no time for consultation and critique. more»

Interested readers can now access my latest Humane Medicine column — Midnight Medicine: A time when difficult decisions must be made — recently published in the Journal of the American Academy of Physician Assistants.

A Socratic dialog on health care reform (VII)

Socrates pays Hippocrates another visit to discuss the latest political rumblings concerning the health care reform legislation.

Hippocrates: Good day, Socrates. I see that you walk with the step of a healthy man these days. I trust the former injury to your foot is now well healed.

Socrates: To be sure, my good friend and physician. Once again I find myself healed well, if not well-heeled. (chuckles to himself) But tell me, Hippocrates, what do you make of the recent resurgence of heated political debate in the Senate concerning our newly passed health care law?

Hippo: Ah, my good Socrates, know you not that the opposition has sworn to dismantle the law even before it is enacted? For they have sworn an oath to have it annulled before the legislative session is brought to a close.

Soc: By whose authority?

Hippo: By the mandate of the voters in the mid-term elections of last fall. The opposition is claiming victory on the basis of the mandate for change.

Soc: But I was of the understanding that the law contained many desirable provisions to enhance the coverage of health care for the citizens of Athens—forbidding third-party payers to deny coverage for preexisting conditions, guaranteeing the portability of coverage, removing the provision for lifetime caps on payments for care, and so on.

Hippo: What you say is true, my friend. But those of the opposition argue that the law is unconstitutional because it mandates coverage for all citizens—

Soc: (breaking in) Excuse me, Hippocrates, but is that not a good and desirable thing, to have coverage for all our citizens?

Hippo: To be sure, it is—but in this instance the law mandates that coverage be purchased by individual citizens if they have no provision for coverage from their employer.

Soc: I was under the impression that universal coverage was to be enacted as a right of every Athenian citizen.

Hippo: Alas, the single payer option was defeated in the preliminary debate. The lobbyists for the health insurance industry made certain of that through the influence of much silver coin in the pockets of the politicians. Likewise, the sorcerers bought their influence to insure that the price of pharmaceuticals could not be negotiated in the Agora.

Soc: It seems as though that which began as a good and noble idea has been degraded through bribes, trickery and quiet whisperings behind the scenes.

Hippo: Legislation is crafted much in the same way as sausage, good Socrates. In each instance the process is best left undisclosed to prevent a sudden surge of nausea and queasiness of the stomach.

Soc: Tell me, Hippocrates; is there no way to retain the noble points of the law while discarding the undesirable tenets?

Hippo: Undesirable to whom, Socrates? To those with influence and power? They will see the entire piece of legislation rescinded before compromising on these points. In the end we live in an era where the winner takes all in politics.

Soc: But our Athenian government is based on the premise of democratic rule. Ultimately, the people decide their common weal.

Hippo: Have you not heard that our supreme court has ruled that the multimillion drachmae corporations must be considered as bona fide entities having a political voice? A fist full of drachmae speaks louder than the jingle of pennies in a purse.

Soc: Then our democracy—

Hippo: Is but an oligarchy, my dear Socrates. Or better stated, a plutocracy in which the great wealth of the few controls the destiny of the many.

Soc: And what of the middle class, those of the artesian guilds and such?

Hippo: Alas, Socrates, they continue to disappear from the Athenian social strata. The gap has widened between those who have and those who have not.

Soc: What! Is there no political solution to this dilemma, Hippocrates?

Hippo: Perhaps, Socrates. You should pose that question to your old student and politico, Plato. He might be able to offer a feasible plan. I’m told he spends his days engaged in drafting a treatise that deals with such issues. He calls it The Republic.

Soc: Indeed, he has written “the price of apathy towards public affairs is to be ruled by evil men.”

Holistic Solutions

“Wow, they’ve certainly been busy!”

My neighbor and I stood side by side with our necks careened back, staring up at the south face of my house.  Scattered throughout the cedar shakes along the periphery there appeared a string of holes expertly drilled into the wood—the work of a woodpecker, most certainly.

“You said you heard him drumming on the side of the house?”

I nodded my head.  “Sometimes it’s so loud I have to stop working in the upstairs office—I can’t concentrate.  Do you have any idea why a woodpecker would attack a house?”

“Could be searching for bugs,” my neighbor mumbled, as he scraped away the sandy soil at the foundation.  “Don’t see any evidence of that here.  Then too, woodpeckers are territorial—they mark their territory by drilling holes, the same way that dogs urinate.”

“What can I do about it?”

My neighbor, formerly a pest control specialist, shrugged his shoulders.  “You could hang up a few aluminum pie pans with some string.  They make a racket when the wind blows and keep the birds away.  Trouble is, that doesn’t always work.

“You could shoot them with a pellet gun.  Technically, that’s illegal—you’d have to get a federal permit to do that.  One big headache, let me tell you.

“You could also go up to the hardware store and buy a spring-loaded rat trap.  Bait it with suet and nail it to the side of the house.  When the bird comes to peck at the suet—bingo!  Adios, problem.”

“Wouldn’t I need a permit to do that as well?”

“There’s no law against setting out rat traps,” my neighbor said with a wink.

My neighbor had stopped by to borrow my Have-A-Heart trap so he could capture a stray cat.  I handed it down to him from the shelf in my garage before retiring to my rocking chair to consider my options.

That afternoon from my front porch perch I watched the season change. The fire bushes along the driveway had begun to blush.  Tall maples on our street were turning orange and gold.  Blackbirds gathered in the tops of the old ash trees.  Overhead, hawks sailed high on the air currents along the eastern flyway.

I went to bed uneasy that night, wrestling with a decision.

I remembered when my third grade teacher used to read us from a chapter book entitled Rabbit Hill, by Robert Lawson.  The narrative was told from the perspective of the animals that inhabited the grounds of an abandoned Connecticut country estate.  At some point new folks move into the house on the hill.  Animal lovers at heart, they put out food for the birds, squirrels and rabbits.  When the moles tunnel beneath the expanse of lawn, the owner instructs his hired man to roll the mounds flat instead of killing the tiny creatures.  But none of these animals did damage to the old foursquare house.

The next day I wandered out into the yard and looked up at the damaged shakes.  I knew what I had to do.

The following Wednesday afternoon I drove to the hardware store and browsed the aisles, looking for the paraphernalia I would need.  I paid cash at the checkout counter and threw the brown paper bag into the back of my station wagon.

Back home, I pulled up the garage door and found the aluminum extension ladder buried beneath the workbench.  I manhandled it across the yard and leaned it up against the south side of the house.  I ratcheted up the extension, gathered my tools and ascended the ladder to the top of the second story to begin my work.

It didn’t take as long as I had imagined.  Satisfied, I dropped the ladder down and stowed it back in the garage.  I returned the tools to their place above the workbench in the basement and strode into the kitchen to wash up.

“So, you made your decision?” my wife asked.

I nodded my head.

“What now?”

“There will be plenty of time to prime and paint the putty,” I said.  “If that doesn’t fix things, I suppose I can always hang out some aluminum pie pans.”

Humane Medicine: Love’s Labors Lost

When a 17-year-old boy makes inquiries about erectile dysfunction, I’m puzzled.  I ask him a few questions to ascertain that there is no evidence of physiologic sexual dysfunction. The boy has no history of a medical condition that would compromise his sexual response. Now is the time, I decide, to launch into the small spiel that I have been rehearsing in my mind.

Interested readers can now access my latest Humane Medicine column, Love’s Labors Lost, recently published in the Journal of the American Academy of Physician Assistants.

Web and Flow

On the morning of the day prior to departing for Atlanta, where I was scheduled to give a formal presentation about a pig and a spider, I rolled out of bed early—it was my Saturday to cover the office.

While toweling off after my shower, I noticed a grey spider descending from the light above the bathroom sink. Her spinnerets formed a nearly invisible silken thread as she dropped down to hang motionless before the mirror. Shortly, she retreated up to the light and selected another point from which to begin a new descent. This time she dropped down to the shelf below the mirror and crawled behind my toothbrush. Gingerly, I nudged it to the side to reveal the spider resting by a tiny puddle of water.

She measured a centimeter in length, double that if you included her front legs. I could see the array of her black eyes and mouth-parts moving as she drank from the miniature pool.

I exited the bathroom to dress, and when I returned I found that the spider had struck out in a new direction, cantering across the wall to the shower stall, where she tucked herself in behind the aluminum molding.

Here is E.B. White’s description of Charlotte in Charlotte’s Web: “Stretched across the upper part of the doorway was a big spiderweb, and hanging from the top of the web, head down, was a large grey spider. She was about the size of a gumdrop.”

I’ve seen plenty of spiders around our place, but never a solid grey one like this one in the bathroom. Uncanny!

With the exception of a minor glitch in the sound system (thankfully, there was a savvy tech in the room to remedy the situation), the presentation at the Georgia World Conference Center in Atlanta, What Charlotte’s Web Can Teach Us about Caring for Critically Ill Children, came off well.

When I arrived at the lecture room 10 minutes before we were scheduled to start, I counted 8 tables with 10 chairs at each table, and no one to fill them. I needn’t have worried—within minutes the hall was packed to standing room only. One group actually huddled on foot at the back for small group discussion over the entire two hours. (I found out afterwards that we hosted 125 attendees.)

I told a story as part of the introduction, then proceeded to show the video clips from Charlotte’s Web, pausing intermittently for discussion and feedback.

Several folks gave us two thumbs up afterwards. One fellow who works in interventional cardiology asked me if I might be able to give the same presentation at the institution where he works—Children’s Hospital in Dallas.

I also met a fellow who, after he learned who I was, told me that he’s read every column I’ve written for the past two years. Now what are the odds of that happening?

When I returned home, after I unpacked my bag and stowed my paraphernalia in the proper places, I retired to the bathroom. As I stood outside the shower, reaching in to test the water temperature with one hand, once again I glimpsed the grey spider. She descended from the storage shelf by a single silken thread, hanging motionless for a moment in the air, before continuing down to light upon a purple plastic box lying on the floor.

I bent down to have a closer look and studied her carefully. I was certain she was the same spider that I had seen that day before departing for Atlanta. The color and body size were identical, right down to her tiny facial features. Then there was the fact that she inhabited the same small room as before.

But what clinched it for me was when she said, “So tell me: how did the presentation go?”

The Hands of a Surgeon

A young Vietnamese immigrant wandered into the inner city clinic where I trained as a student and subsequently worked for several years. Although he spoke little English, his chief complaint was obvious:  an unsightly mass protruded from the right side of his face along the jaw line.  He had been to a number of medical facilities for treatment, but no one wanted to excise the cluster of bumps just beneath the skin.  In retrospect, the reason was obvious—he had no medical insurance.

I asked my supervising physician to have a look. He agreed with my assessment: a cluster of subcutaneous cysts. “You could do it,” he said. “Incise directly over the blebs. It should be fairly straightforward. You won’t be able to get them out without breaking them, but no matter. It should pull together nicely.”

In those days we performed minor surgery in the clinic. I scrubbed and prepped the area, positioned the drape, infiltrated the region with anesthetic and with a scalpel made the incision. Our nurse stood by, ready to assist, as I began the dissection.

When I was an adolescent over the course of three summers I worked on the staff of a local camp. One year I taught camp craft and pioneering. Under my supervision my young charges felled a number of tall tulip trees, lopped off the branches and laid them out according to plan. We spent several weeks that summer constructing a signal tower, using only braided rope for the lashings that bound the spars together.

As we labored one afternoon in the hot sun, the camp director wandered into the meadow to observe the progress. He stood with his hands on his hips, watching me demonstrate a standard lashing to the boys. Afterwards, he paid me a compliment: “You’ve got the hands of a surgeon,” he said. Carefully chosen or not, his words stuck in my head.

Several years later I learned how to close simple lacerations when I worked as a hospital corpsman aboard a high-endurance cutter. One night during a layover in Lisbon I was called to attend a sailor who had been stabbed during a fight that broke out in a bar. The man was drunk. They hauled him into sickbay and stretched him out on the table. I explored the shoulder wound (not as deep as it first appeared), irrigated and surgically closed it. The next day we put out to sea. Ten days later I extracted the sutures. The wound never suppurated; I counted both him and myself lucky.

Several of my classmates in PA school elected to pursue careers in general surgery. I opted for a track in general medicine instead. Even so, I found myself standing over this young Vietnamese man that afternoon, excising a mass that other clinicians more experienced than I had refused to touch.

I dissected the mass in toto and closed the wound, using vertical mattress sutures. The following week the young man returned to have the sutures removed. Only a hairline scar remained. I showed him the result in a hand mirror. I remember his smile—the only thing he had to offer in payment.

I still close minor lacerations on occasion in the office. These days I use Dermabond for the most part. It’s quick, easy and painless. They say that the results are every bit as good as surgical closure.

That may be the case. But I take some satisfaction in knowing that somewhere out there today, an older Vietnamese man remains grateful for the gift I was given in my youth: the hands of a surgeon.

Memes and the evolution of medical practice

A meme is “a postulated unit of cultural ideas, symbols or practices, which can be transmitted from one mind to another through writing, speech, gestures, rituals or other imitable phenomena.” The British evolutionary biologist Richard Dawkins postulated this concept in his 1976 book The Selfish Gene to explain the spread of ideas and cultural phenomena in evolutionary terms. Susan Blackmore, the British psycho-theorist, further developed Dawkins’ theory and believes that we are moving toward a new form of meme, the teme, which is spread by the technology we’ve created.

If we consider for the moment that memes do indeed exist (and their existence is far from certain), we could postulate that medical memes propagate through the medical community via medical journals, lectures and mentors. Published research eventually generates new approaches to the diagnosis and treatment of disease. Much contemporary medical research in the U.S.A. is underwritten by the pharmaceutical industry.

Nowadays, children routinely take medication for chronic conditions such as allergic disease, asthma, ADHD, depression, diabetes, gastroesophageal reflux and hypercholesterolemia. A spate of recent articles documents that 1 in 4 children covered by health insurance took some form of prescription medication in 2009. Annual spending for prescription drugs in children increased by 10.8 percent the same year, and the price of branded prescription drugs increased by 9.2 percent. Clearly, someone besides the patient is benefiting enormously from these trends in medical practice.

As a clinician who has worked on the front lines in ambulatory pediatrics for 30 years, I can vouch that these statistics seem to be supported by what I have observed over the past decade. The sheer number of children who take daily prescription medication for chronic conditions is astounding; and in my opinion these numbers will only escalate exponentially.

What drives these trends? Are clinicians becoming more astute at recognizing and diagnosing these conditions in children? Are the conditions themselves growing at an alarming rate secondary to cultural influences such as high fat diets, readily accessible food, over consumption of calories, unlimited access to TV and video games? Are parents themselves at fault, seemingly unable or unavailable to rear children with their best interests in mind?

Although any or all of these factors could potentially contribute to these disturbing trends, might medical memes—those ideas which seem to infiltrate medical practice and become acceptable norms—also play a role here? Are we clinicians too quick to reach for the prescription pad at the expense of taking time to offer wise counsel to our patients?

Some memes may replicate effectively even when they prove detrimental to the welfare of their hosts. According to Dawkins, “systems of self-replicating ideas can quickly accumulate their own agenda and behaviors,” which ultimately might prove to be good or ill for society, culture and the population at large.

Perhaps the medical profession needs to examine itself and take a closer look at what drives contemporary medical practice. In the meme, that might be a good thing.

“Ruminating on GERD” published in YJHM

Something happened to change the approach to treatment of infant spittyness over the past decade:  H2 blockers and PPIs were introduced into the pharmacological armamentarium of pediatric primary care.

I was chagrined to learn recently that 5% of infants are prescribed medication for GERD—gastroesophageal reflux disease, the latest diagnosis du jour in primary care pediatrics. >>more

Readers can now access my latest essay, Ruminating on GERD, newly published in the Yale Journal for Humanities in Medicine.

A Life or Death Decision

Her father is sick, again—but this time she’s asked to choose.

The will of the father; the wishes of the daughter.

His body is spent; and intuitively, he knows it. Still he clings to life by one thin thread of hope.

She’s become the designated caregiver.  Emotionally exhausted, she has no energy left for family and friends.  Her career has suffered, and she wants her life back.

Suddenly, she has been charged with making a decision on his behalf:  to intervene or not to intervene, knowing full well that intervention will ultimately only prolong her father’s suffering.

It would be so easy to say: “No, don’t intubate; let’s end this folie a deux right now and get on with our lives.”

Yet for him, that is not the right thing to do.

As his daughter, she respects his will to live.

In this case, technology is a curse. If we didn’t have ET tubes and ventilators, life would take its natural course. We have created our own demons, and they constantly come back to taunt us: in this case, six additional months of ventilator dependence, dialysis and a feeding tube before death from heart failure.

What a pity this whole scenario could not have been discussed with the father during one of his more lucid moments! Perhaps then he could have made a more rational decision.

But then, death is never rational, is it?