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.

The new norm

I’ve known this mother for a long time. Far from wet behind the ears, she’s raised four other children, mostly on her own after her divorce several years ago. She’s never been one to run to the office for every sneeze and sniffle. If she brings one of her children in to be evaluated, it’s usually for a good reason. more»

Interested readers can peruse my latest JAAPA Musings blog post, newly published in the Journal of the American Academy of Physician Assistants.

Semper Paratus

In the United States we are faced with a shortage of primary care physicians, but fewer medical school graduates elect a career in primary care. Have the members of any Washington think tank seriously considered the role of generically trained physician assistants in this equation?  more»

Interested readers can examine my thoughts on this issue in my latest Musings blog post newly 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.”

In and out of medical practice

At the age of 46, disillusioned with modern medical practice, Dr. Margaret Kozel decided to end her 17-year-career in primary care pediatrics. She cites some of her reasons in her blog post, Confessions of a worn-out pediatrician.

“Our system of paying for health care and the stresses on today’s families were pitting my best medical judgment for the child against all the other worries and desires of the parents,” Dr. Kozel writes. “The economics of health care trickled down into my exam room, into the conversation between doctor and patient, distorting the relationship.”

High on her list of complaints are the inequalities inherent in our American healthcare system. Those who need pediatric care the most—poor and underinsured children—are the least likely to access it. And in those cases where health care is available, third-party payers dictate standard of care, sometimes with substandard results.

“Private insurance companies decide who gets paid for what, so pediatricians treat serious mental illness with little psychiatric training, use nebulous tools to diagnose attention deficit disorders, and valiantly tilt at the windmill of childhood obesity not because we can do this most effectively, but because we are the only professionals who can get paid to do so.”

“At the other end of the treatment spectrum, free market forces often urge us to over-intervene with minor illness, where less really would be more.”

“Clinical truth has only grown more obscure since my medical school days,” Dr. Kozel muses in a separate NYT Well blog post. “Today, as we take on the hard work of health care reform, doctors continue to work under an avalanche of pharmaceutical marketing, malpractice threats and shortsighted health insurance strategies.”

“In an age when public health issues like obesity are what pose the greatest threats to our children, pediatricians will need to move out of the confines of the fee-for-service exam room to advocate for effective healthcare policy in the wider community.”

Dr. Kozel has fleshed out her career in and out of medicine in her book, The Color of Atmosphere. Interested readers can glean much of her sentiments from an online video interview here.

Despite her misgivings, Dr. Kozel maintains a positive outlook for the role of pediatric healthcare in the future.

“I believe our society will eventually see the economic sense and moral imperative of universal health care coverage, paving the way for healthcare to be designed by health professionals, and to be viewed as a right and a responsibility, rather than a commodity to be purchased. I believe that pediatrics can evolve, too, in a way that will truly meet our society’s health needs.”

Follow Dr. Kozel’s opinions on these and related issues at Barkingdoc’s Blog.

What’s Wrong, What’s Right?

In a New York Times op-ed piece on the healthcare legislation, The Fight Is Over, the Myths Remain, Brendan Nyhan states:

Studies have shown that people tend to seek out information that is consistent with their views; think of liberal fans of MSNBC and conservative devotees of Fox News. Liberals and conservatives also tend to process the information that they receive with a bias toward their pre-existing opinions, accepting claims that are consistent with their point of view and rejecting those that are not. As a result, information that contradicts their prior attitudes or beliefs is often disregarded, especially if those beliefs are strongly held.

Nyhan addresses the curious tendency we humans have to regard opinion as factual information—in his example, popular myths about the content of the recently passed healthcare bill, now signed into law.  In short, it all comes down to preconceived personal perspective.  Here the old axiom about drawing your curve and then plotting your points is apropos.  We tend to view the world through tinted lenses, all the while assuming that we are the only ones who see objectively.

I was intrigued to read about the former medical student Michael Burry who turned his economic insights into a popular financial blog.  Impressed with his knowledge, Wall Street gurus began to take regular notice of his predictions.  Indeed, many of the financial companies he endorsed turned out to be winners in the market.  Everyone, it seemed, was on the same financial page, until Burry noticed a disturbing trend.  Solid institutions that went on to fail shared one thing in common:  all had invested heavily in subprime mortgage securities.  Eventually, Burry convinced Wall Street to issue credit default swaps through which he bet against the popular tide—and subsequently won big.

This scenario demonstrates Nyhan’s premise:  when faced with the same set of factual data, observers generate wildly different interpretations.  As a consequence of acting on the basis of these observations, the risks are enormous:  you could win big (like Burry), or you could lose big as well.

Which brings me to the role of science in contemporary society.  Just how objective a discipline is science?  When confronted with the same set of facts, how is it that scientists formulate theories with markedly different import?

Global warming:  true or false?

Health care reform:  good or bad?

Wall Street reform:  desirable or undesirable?

In his new book Wrong, science journalist David H. Freedman wonders why scientific pronouncements often turn out to be misleading, exaggerated or entirely off the mark.  Part of the problem, he opines, is that many times scientists are forced to rely upon surrogate measurements, because they cannot get at the things they need to measure directly.  Thus, they have to make inferences from suboptimal data.

Economists, for example, rely on economic indicators extracted from bits of data to identify trends and forecast the economic outlook. Unfortunately, most research papers published in economic journals don’t conclusively prove anything one way or the other.  Freedman wonders:  “If tests of the exact same idea routinely generate differing, even opposite, results, then what are we supposed to believe?”

Freedman highlights the work of Dr. John Ioannidis, an M.D. with an undergraduate degree in mathematics, originally published in JAMA (John P.A. Ioannidis, “Contradicted and Initially Stronger Effects in Highly Cited Clinical Research,” Journal of the American Medical Association Vol. 294, No. 2 (2005): 218-28).

According to Ioannidis, “most medical treatment simply isn’t backed up by good, quantitative evidence.”

The whole point of carrying out a study is to rigorously examine a question using tools and techniques that would yield solid data, allowing a careful and conclusive analysis that would replace the conjecture, assumptions, and sloppy assessments that had preceded it. The data are supposed to be the path to truth. And yet these studies, and most types of studies Ioannidis looked at, were far more often than not driving to wrong answers.

Ioannidis felt he was confronting a mystery that spoke to the very foundation of medical wisdom. How can the research community claim to know what it’s doing, and to be making significant progress, if it can’t bring out studies in its top journals that correctly prove anything, or lead to better patient care?

The largest source of wrongness in scientific studies is publication bias.  Prestigious medical journals eagerly publish studies that demonstrate novel or unanticipated results.  Witness Andrew Wakefield’s bogus study published in the Lancet that purported to link the administration of the MMR vaccine to autism.  This problem is compounded further by the mainstream media, which is only too quick to disseminate such conclusions to the public at large.  Such misperceptions have a tendency to persist for years.

In his classic treatise on The Structure of Scientific Revolutions, Thomas Kuhn argued that “professionalization” leads to “an immense restriction of the scientist’s vision and to a considerable resistance to paradigm change.” He opines that scientists become captives to a paradigm “like the typical character of Orwell’s 1984, the victim of a history rewritten by the powers that be.”

Perhaps scientists themselves possess their own set of preconceived notions, which in turn dictate how they interpret the data they measure.  I suppose that it all depends on which side of the emotional aisle you happen to take your seat.

As Mr. Nyhan writes: “People seem to argue so vehemently against the corrective information that they end up strengthening the misperception in their own minds.”

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?”

Humane Medicine — House calls, Homebodies

In my student days, I trained at an urban health clinic. Although we saw the gamut of general medical ailments, my most invaluable lessons came when the doctor and I ventured out into the local community to make house calls.

Interested readers can now access my latest Humane Medicine column, House calls, homebodies: Remembering that you came, recently published in the Journal of the American Academy of Physician Assistants.

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.

Living on the edge of being

In an article that appeared in the New York Times Magazine on Aug. 26, 1990—Doctor, Talk to Me—Anatole Broyard envisioned the ideal physician who would treat a patient’s body—and his soul:

”In learning to talk to his patients, the doctor may talk himself back into loving his work. He has little to lose and much to gain by letting the sick man into his heart. If he does, they can share, as few others can, the wonder, terror and exaltation of being on the edge of being, between the natural and the supernatural.”

Each one of us lives every moment of our lives on this edge of being, even though most of the time we pass our days totally unaware of it.  In part we are too busy, too caught up in the mundane affairs of everyday living, to glimpse it.  And I suspect that most of us would find living in a constant state of such awareness too intense to bear.  Wonder, terror and exaltation can fill our lives with awe—or burn us out.

As clinicians we are called to minister to our patients in many ways.  Sometimes we are called to talk, sometimes to listen.  In Broyard’s words, we have much to gain by letting our sick patients into our hearts.  The wise clinician learns that compassion helps to heal in ways that medication cannot—and that such healing can be reciprocal as well.

Anthony Martinez, a retired Navy eye surgeon, spends his days doing house calls on the homeless in Washington, D.C.  Each morning he slings a bag of medical supplies over his shoulder and tramps off on foot to visit those who live under bridges or in the street.  Martinez says that his work has given him a newfound purpose in life.  “It helps me deal with my own demons,” he observes.

In her poem “What I Learned from My Mother,” Julia Kasdorf writes:

Like a doctor, I learned to create
From another’s suffering my own usefulness, and once
You know how to do this, you can never refuse.
To every house you enter, you must offer
Healing: a chocolate cake you baked yourself,
The blessing of your voice, your chaste touch.