Sunday, February 23, 2014

Paternalism: No, Rilly, It's a Bad Idea

Sandeep Jauhar is a cardiologist who has made a few recent contributions to the op-ed page of The New York Times of late, and he's been focused on lies lies lies. Earlier this week he wrote an essay titled "The Lies That Doctors and Patients Tell," which was a refreshingly, and ironically one supposes, honest take on the psychological motivations that can make both doc and patient dance around the truth. Yesterday's offering had the similarly provocative title "When Doctors Need to Lie," and is a meditation on the theoretically counterproductive consequences of what Jauhar calls "brutal honesty" when discussing diagnosis and prognosis with a patient.

I really liked the first essay; this most recent one I find deeply troubling. Jauhar's a good writer, and that talent obscures the fact that he appears to disregard the concept of patient autonomy in its entirety, even though he initially seems to lend credence to the concept. I get the impression that he's being too clever by half, starting out by saying, yes, well, we no longer live in the days where hard paternalism is acceptable, and this is a welcome development...and then he goes on to show an instance of what he thinks is justifiable hard paternalism, even though he never actually makes the argument head on that we should go back to the old ways. To do so would be to invite ridicule and derision; instead, he more or less flaunts his paternalism without calling it such. I don't know whether he's conscious that's what he's doing but it feels creepy, more on which in a moment.

Why do doctors need to lie? Well, some of this has to do with Jauhar's use of that very charged word. Needless to say, the use of that word, especially when attached to a discussion about the profession of medicine, is going to grab people's attention, so there is a bit of hucksterism going on here, especially as Jauhar doesn't really itemize instances of lying. First, he discusses a case in which he chooses merely to hold off on conveying the whole truth of a devastating and probably life-ending diagnosis to a young man at the father's request. Jauhar accedes to the plea, but dutifully notes that "over several days, I eased him into the knowledge of his true condition. Doctors sometimes have to know how to keep secrets."

I don't think this fits the definition of "lying" as understood by most people. Certainly I don't think that's a lie; choosing to "ease the patient into the truth" over a brief period is a common approach and raises issues about tactics more than ethics. But the second case he discusses, while also not really an instance of lying, goes straight to the heart of paternalism--when a doctor assumes the role of someone who knows what's best for his or her patient and makes medical decisions accordingly without consulting the patient. In textbook medicine today, paternalism is largely regarded as unethical, but Jauhar suggests that there are instances in which we should reconsider this:

Even so, there may be a place in medicine for hard paternalism, too. I am reminded of a patient I took care of some years ago. Fifty-something, he had received a stent to open up a blocked coronary artery. A few days after the procedure, while on blood thinners to keep the stent from clotting, he started bleeding into his lungs. He needed to be intubated with a breathing tube or he was going to die. However, I was informed that he had told doctors that he never wanted to be intubated.

Jauhar goes on to note that he was "sure" that the patient would do well after only a brief period of intubation, and lo, despite a rockier course in the ICU than he predicted, he was ultimately successfully extubated and has done well. The essay ends with a pat-oneself-on-the-back moment as Jauhar receives the deep thanks of the patient for having overridden his wishes.

This is post hoc reasoning of the worst sort, and is basically a frank admission that he doesn't seem to give a damn about patient autonomy. The entire point of being bound by professional ethical principles is that they have to be applied even when it goes against one's own preferences. So what that he might be reversed after a brief period of intubation? So what that his problem was transient and, if he could survive the event, there was no reason to believe he might not live for years or even decades afterwards? It's his decision to have a "do not intubate" status, and assuming he made that decision fully informed that there might be grave consequences because of that decision--that is, he might die because of it--it is not for us to think we as doctors know better than him. That's the entire fucking point of patient autonomy.

Jauhar mentions the Tuskeegee Experiment as an instance of ethics gone awry in medicine, and virtually all medical students in the US are acquainted with that dark chapter in the history of our profession. But there's another ethical dilemma that nearly all medical students are forced to grapple with as well before they receive their coveted initials of M and D: that of the Jehovah's Witness who refuses a blood transfusion. The classic case is of a young, otherwise healthy Jehovah's Witness who has experienced blood loss, usually from a trauma; since Jehovah's Witnesses believe that blood transfusions can lead to the intermingling of two bodies, which will cause grave problems on the Day of Judgment (massively oversimplified, with apologies to any Witness readers), they oppose the use of blood transfusions. As I said, nearly every medical student in the US is taught this scenario, and there's very much a right answer here. We are supposed to respect the patient's autonomy, even if it means that the Witness patient will die, even if it means that all they need is to survive through whatever physiologic bottleneck has been caused by the blood loss, and could live for decades afterward. The Jehovah's Witness scenario is not mere ivory tower conjecture, either; several times I've had to have this discussion with Witness patients of mine, and once I had a nail-biting 48 hours as I sat on a Witness in his fifties with severe anemia and moderate heart disease, waiting for a big MI to take him away, though he was placid in his refusal of my initial offer of blood.

Do I think that the theology leading to the Witnesses refusal of blood is misguided? Well, yes, I do. Would I defend my Witness' patients refusal of blood to the teeth? Yes, I would do that too. I do not maintain the corner on the market of wisdom. If my patients want to refuse whatever I have to offer them, and they understand the possible consequences of refusal, then I have done due diligence and it's not for me to judge them, nor is it for me to override their wishes because I'm a doctor. Unless I've badly missed something, I see no distinction here between that textbook Jehovah's Witness case and Jauhar's intubated patient. He just thought he could take matters into his own hands because he knew better than the patient. This is appalling.

In the feel-good happy ending to his essay, Jauhar fails to mention the very high likelihood that there could have been an alternate outcome. The patient could have become ventilator dependent: he mentions that he was intubated two weeks, an exceedingly long time for a person to be on the vent and have a full recovery. He could have had a stroke; he could have developed a pneumonia and become septic, requiring special medications that maintain his blood pressure but can also lead to gangrene of toes and fingers. Would his patient have thanked him so much had he lost the ability to brush his teeth or clean his body? Or has this already happened with one of his patients, and he has chosen to ignore that outcome in favor of the much cleaner scenario in which patients are grateful for the miracles bestowed upon them by angels in white coats, who always know best.


Monday, February 3, 2014


I don't watch very much television, and since my children were born I have gotten out of the habit of going to see movies, once a source of deep joy in my life. That said, I have found myself riveted by a new series on HBO called True Detective, largely on the basis of the performance by Matthew McConaughey. Woody Harrelson is no slouch, and the writing and directing are top notch, but McConaughey is the center of True Detective's dark and haunting geography. Coupled with his work on the small-budget movie Mud, as well as his starring role in Dallas Buyers Club, a role in which he lost 50 pounds to approximate the ravages of AIDS in the era before effective medications, I think we've watched McConaughey transform himself from a pretty boy who takes on safe projects (such as the aptly named Dirk Pitt in the movie Sahara) to--one hopes--one of the great actors of his generation. I haven't yet seen Dallas Buyers Club but it's playing down the street and is on my To Do list; what I have seen of True Detective has shown me that McConaughey is a top-notch craftsman who is interested in telling stories about real people, not the cardboard cutouts so often dumped on us by Hollywood.

It's not the kind of oeuvre equal to that of Philip Seymour Hoffman's but it is one hell of a promising start. Yet Hoffman was only a touch older than McConaughey--about a year separates them--and his range was jaw-dropping. So many great actors, even DeNiro and Pacino at their height, settled into similar kinds of roles. There's a similarity in the lead characters of Serpico and Dog Day Afternoon, as there is in Raging Bull and Taxi Driver. Hoffman, though, was all over the place, just as happy to have a small role as the lead as long as it was interesting.

His masterpiece will be, of course, Capote, but when I think of the kind of genius Hoffman brought to a role, the movie Boogie Nights comes to mind. In particular, there's this scene in which Hoffman's character, Scotty J, finally utters a ham-handed confession of love to Mark Wahlberg's character, Dirk Diggler:

It takes barely a minute to see longing, humiliation, self-loathing, and a desperate hope that we as viewers know has no chance of being fulfilled. It is pathetic in the deepest sense of the word, and Hoffman simply inhabited this character for the duration of the scene; to inhabit it any longer would be unbearable. As A.O. Scott said in his remembrance today, "He had a rare ability to illuminate the varieties of human ugliness. No one ever did it so beautifully."

That's what I think we lost with his passing.


Saturday, December 14, 2013

The Email I Want To Send, But Probably Won't

Dear Dr. [X],

Thank you for your note. I will let my patient know as soon as possible that you aren't interested in seeing him in your clinic so that he won't trouble you with his medical issues.

It is true that we did have him admitted to expedite a biopsy while you were the attending on service for the [Q] team. However, as he had not yet seen a specialist in [Q] and that Dr. [Y] had provided help to me in phone consultation, we both thought that you would have been the most logical choice to see him in follow-up. The misunderstanding is all mine, as I thought you were this person called a "doctor" and that doctors do this thing called "taking care of patients". You appear to be a "biopsy chaperone". Please forgive my confusion on this point.

Part of my need for assistance from a [Q] perspective is my concern that his labs are unchanged since late November. You note that "his [R] labs are essentially improving". On November 20, his [R] was 350; on discharge this week, nearly a month later, it was 410. Since I was a bottom-feeding medical student with no ambition and thus went into Infectious Disease, I must have been asleep at the lecture where they explained how an increase from 350 to 410 over a one month period constitutes essential improvement. Also, I must confess that I have factored in the notoriously unreliable, non-validatable, un-billable parameter of the patient's symptoms into my thinking: he is still in a great deal of pain, which is evident on this item known as the "physical exam". As I was not so driven to pursue as competitive a subspecialty as [Q], I have concluded that, one month into a serious complication in this man's treatment, he's not getting better, which is why I sought input from [Q] given the complications are in his [Q] organ.

Yes, it is true that all the notes &c. can be found in the electronic chart. However after I dutifully read all such notes, I still had no real idea what you as a [Q] specialist thought. Your email replying to my inquiries indicates you think this is drug toxicity, which is somewhat helpful because there is nothing in the chart that actually says that. Unfortunately, Dr. [Y] shared with me during our initial talks that drug toxicity has a characteristic appearance on biopsy, and the pathologists made no comment in their analysis to that effect. This is, of course, why I was seeking to do this thing called "talking with a colleague", as my experience is that it is a superior method to this other thing called "communicating through the chart". But perhaps you have had more success with the latter, or at least it minimizes how many discussions you must have with non-[Q] physicians, and that may indeed be how you define success.

Hereinafter I will do my best not to interrupt your wildly busy schedule, coming to bother you with such trivial matters as a patient with a potentially life-threatening illness. Thank you again for your careful attention to facilitating a biopsy and billing for an inpatient admission, and forgive me for assuming that also included caring for my patient by making a reasoned assessment of his [Q] problems.

Yours in disgust,

Friday, November 29, 2013

The "Hunger Games" Critique, Sequel Edition

It's not just me: about a year and a half ago the Billy Rubin Blog posted a cranky essay complaining that "The Hunger Games", whatever its cinematic merits, should not have been given a PG-13 rating. (We have since seen the movie during a very, very long flight to Mozambique, and our misgivings remain, unaltered.)

Now comes the sequel, "Catching Fire", and we've not much new to say. We do note, however, that ESPN's "Tuesday Morning Quarterback", Mr. Gregg Easterbook, offered up his own two cents in the midst of NFL Week #12 analysis, with which we entirely agree. It even includes a link to a medical journal!

Movie critics are noting the "Hunger Games" flicks soften the violence of the books. Viewers see Jennifer Lawrence launch arrows, but don't see the children-killing-children bloodbath that makes the books so disturbing. Any faithful cinematic rendering of the "Hunger Games" books would be R-rated, if not NC-17. There goes the shopping-mall tween-girl target audience.

Set aside what it says about contemporary culture that a franchise of bestselling books and box-office hits, about a fascist society that graphically slaughters children, is targeted to affluent shopping-mall girls and their moms. Books for the young-adult market have changed from dreamy happiness (the "Chronicles of Narnia") to horrific brutality ("Hunger Games," the "Golden Compass" trilogy, the thousands of interchangeable vampire books) during the very period in which crime and war have declined, living standards have improved, education has increased and lifespans extended. In "Hunger Games" flicks, Katniss is presented as a positive role model for girls, which seems like saying John Brown is a positive role model for boys. But at least, one might suppose, "Catching Fire" is an instance of Hollywood toning down rather than ramping up violence.

That's not the norm for shopping-mall flicks. This new study from the journal Pediatrics finds that depictions of gun violence are now as common in PG-13 movies as in R-rated fare. PG-13 is the shopping-mall audience: tweens and teens are being deluged with ever-more Hollywood depictions of gun use. Hollywood won't show characters smoking, because viewers might imitate that. But glamorous movie stars gunning down the helpless, Hollywood has no problem there.


Wednesday, November 27, 2013

GYN Update: Good Guys (Gals Mostly, Actually) Win!

Comes news from NYT that the American Board of Obstetrics and Gynecology have reversed their proscription against gynecologists who perform anal pap smears and anoscopies on men. We at the Billy Rubin Blog head into Thanksgiving, to say nothing of Hanukkah, yelping a small huzzah of delight.

It's worth noting that I'm not opposed to medical specialty boards taking hard lines against professional behavior for which there is a general consensus that said behavior is out-of-bounds. (More on specific examples another day, but you could make some assumptions about my views from the single word, "Lyme".) The anoscopies in HPV-positive men, however, did not by any reasonable measure constitute such bad behavior. So we salute the board for its reversal: bravo!


Saturday, November 23, 2013

OB/GYNs, Male Patients, & Anal Cancer

I am a touch wide-eyed at this news report in NYT detailing the hard line that the American Board of Obstetrics and Gynecology has taken with respect to treating men with anal cancer. The skinny: anal cancer is largely mediated by the same virus that causes most cases of cervical cancer (the human papilloma virus, or HPV). Gynecologists have extensive training in evaluating such cancers, and some GYNs have added men at risk for anal cancer to their patient panels by performing routine screening "anoscopies". The overall number of men cared for by such physicians appears to be very low, but these docs were just mandated by the OB/GYN Board, in no uncertain terms, to drop these patients or risk losing their board certifications. That is, putting it mildly, a pretty heavy sanction.

The logic of the Board is straightforward: OB/GYN is a specialty designed to treat women, period. Two Board members are quoted as emphasizing this, as well as noting that the anoscopy procedure is something that other specialists are capable of learning & performing as a matter of routine. (Side note: I have a colleague in my Infectious Disease division who does a lot of these procedures for our patients--a logical choice given our patient population with many HIV-infected gay men. She has no surgical training, so they have a point.) The article also notes that the Board has concerns about the unscrupulousness of certain OB/GYN doctors who have gone into lucrative business ventures treating men, such as prescribing testosterone treatments, burnishing their credentials with their Board certifications. The Board--understandably, from my perspective--wishes to put a stop to that. That said, I don't think the docs involved in male anoscopies are getting rich by enticing men to have a camera placed in their collective tuchus, so that issue doesn't apply here.

Regardless, the heavy handed no-anoscopies-in-men line is harder for me to comprehend, and though it is true that non-GYNs can perform them, the real issue is whether that's best for patients. "People with various types of medical training can learn the procedure," the article notes, "but experts say that gynecologists are the quickest to master it because of their experience in screening women." There's the rub. One of the docs featured in the article, Elizabeth Stier, is the only professional qualified to perform such procedures. And where does she work? Some Podunk hospital? Um, no: she's at Boston Medical Center, one of the two largest hospitals in New England, staffed by hundreds of doctors. So the loss to these male patients, while small in the grand scheme of things, is nonetheless very real.


Thursday, October 10, 2013

NPR Misses the Point of the Shutdown, Entirely

Mara Liasson is not a dumb reporter, but her piece today on NPR looking at the various political miscalculations that "led" to the government shutdown, called "How Political Miscalculations Led To The Shutdown Standoff", is a classic overthink about what has happened. As such, it's pretty dumb.

It's really not that hard to understand what led to the shutdown: a far-right faction of the political spectrum within the US citizenry has taken control of one of the two major parties, and by flirting with default, it is now playing politics in a very different way to what we've been accustomed for a very long time in this country. It's not because--as Liasson seems to believe--Boehner misread Obama's resolve, or the Democrats "assumed the Speaker had a plan for what he and his members needed to make a deal".

While these may be scenes in the play, they ain't what's driving the plot. The reason why we have a government shutdown is because the Tea Party caucus came up with this plan, and nobody in the Republican Party had the foresight, the desire, the willpower, or even the ability to derail their train of madness that has already adversely affected hundreds of thousands and just might possibly bring the whole economy crashing down on our heads. Any news story that purports to analyze the situation in Washington that does not start with this observation is misleading the public. Nothing Boehner or Obama or Harry Reid or Eric Cantor did over the past several months was going to change this outcome. It might have played out slightly differently, and it might have been portrayed differently, but what conservative columnist Charles Krauthammer has dubbed "the suicide caucus" wanted this fight since Obama was elected, and they've finally gotten it, and nothing--nothing--was going to prevent them from having this fight.

As for the part where Liasson suggests that Democrats assumed Boehner had a way out, she quotes nobody and provides no evidence that Dems would believe such a thing. She might be right, but I've been watching this thing from afar for months and I didn't think Boehner had a plan. Indeed, I assumed he had no plan precisely because he misread the President's resolve (and I wasn't convinced that the Speaker was wrong, either: if the Prez is going to cave in the 9th hour anyway, why have Plan B?) Moreover, Boehner has repeatedly moved his own goalposts throughout the past year in further acquiescence to his right flank; why on earth would anyone think he knew how to square the circle of the budget shutdown given how far he's been pushed?

At any rate, the fight is now upon us. It is a real political fight, with very high stakes, which is to say the stakes do not involve the careers or popularity of a small number of politicians from either party whose fortunes rise and fall with well- or poorly-played maneuvers, but rather affects all manner of hidden infrastructural details of our lives. What made the Tea Party what it is, is certainly a complicated topic worthy of all sorts of analysis, and we could fill up dozens of op-ed columns well into the future describing the demographic trends, social issues, splintering of the media and all manner of factors that has led to their rise in influence. And yes, we could even evaluate the misunderstandings from those on the left, right and center that allowed the Tea Party to achieve what it has thus far, if "achievement" is the apt description.

But why we have this fight right now is no real mystery. To treat it, as Liasson has done here, as a complex game of insider baseball, with important players trying and failing to read the situation, is to profoundly misrepresent what has happened in Washington. The reason why we have a shutdown is because we have the Tea Party--full stop. They do not share the same assumptions as most Americans about how to achieve their political aims in a representative democracy; they are playing by a new, very different, and I would argue, scary set of rules. Their kind has always been part of the American story, but with the sole exception of the Civil War, they have never been so organized nor wielded such political clout. They wanted this moment, and now we are here. Boehner could not have stopped it. Obama could not have stopped it. Harry Reid could not have stopped it. What happens next is anyone's guess.

Saturday, October 5, 2013

Being Mad As Hell At the Government Shutdown

I was just at a conference this week where I bumped into a former mentor of sorts. Always pleased to see him, I came over to chat about how things were going back at the mother ship, who was up to what, and so on. As part of the small talk, the government shutdown got mentioned. He just shook his head. "Those people are all crazy down there," he said, and just as I was about to ask which people he meant, he clarified it. "Democrat, Republican...I'd just vote 'no' for all of them if I could."

This is not a stupid man, although this is a decidedly stupid sentiment, and it almost certainly comes from automatically assuming that if there's a "problem in Washington", then the problem is shared equally, since there are radicals on both sides, and the extremes of the party hold the mainstream hostage, preventing the can't-we-just-fix-the-problem Good Guys & Gals from doing their job. Thus, as the shutdown drags on--and we careen toward what nearly everyone acknowledges is a much more consequential fight over the debt ceiling--people are having their "Mad As Hell" moments, both publicly and privately.

Witness, for instance, this CNN diatribe against the madness by Tom Foreman. In it, he blames everything on, well, everyone associated with the mess: "Democrats, Republicans, and the Insane Leap Into the Abyss" is its title, and it starts by stomping its feet in frustration over how the shutdown has just ruined the wedding plans of one happy couple who wanted to tie the knot at the Grand Canyon National Park, but now cannot due to its closure. (That there may be some people affected much more profoundly is indicative of the shallowness of the piece.) And who is at fault? "To be sure, there is enough blame out there to choke a horse," Foreman writes. "Polls show the Republicans taking the worst of it, but Democrats and President Obama are also being hammered for their part in the debacle."

In short, Foreman has absolutely no idea who is at fault because he is utterly ignorant of the details that led to the shutdown, and assumed that since there's an impasse, it must be everyone's fault--although those darned polls seem to think that the Republicans might just have a slightly bigger problem. A journalist who needs to resort to polling to help him figure out who deserves blame has major cognitive limitations.

Mercifully, elsewhere on the CNN website is a reasonably decent evaluation of the situation by Fareed Zakaria. Zakaria's followed the bouncing ball over the past two years, and he understands that the Democrats--especially through President Obama's previous ineptitude in handling the last budget fight--have basically already given every major policy demand to the Republicans despite having a Democrat in the White House and control of the Senate. "What cannot be allowed to stand is the notion that if a group of legislators cannot convince a majority in both houses and the president to agree with them, they will shut down the government or threaten to default until they can get their way," says Zakaria. "That is extortion, not democracy." Which is an accurate assessment of the situation. Just because it lays blame squarely at the feet of one group does not make it partisan. It makes it accurate.

Here's a detail that Tom Foreman may not have bothered to learn: the "clean CR" that the Republicans will not put up for a vote is the budget to keep the government running at "sequester levels", basically what Paul Ryan proposed when he ran with Mitt Romney. They lost, by the way, although an analysis of actual policies would lead disinterested observers to conclude otherwise. Every Democrat opposes these levels, so to ask the Republican House to simply agree to that is already having capitulated to an astonishing degree. Despite the Republican Party controlling only half of the legislative branch, and none of the executive branch, the fiscal policy of the federal government is somehow not only thoroughly Republican, it is, in effect, a dream budget for Tea Party politicians.

But even that wasn't enough for them to declare victory. What more is there to compromise, with the Dems with their backs to the wall, having blundered into the sequester, which appears as if it will be federal budget policy for the foreseeable future? There's only one thing that's left: the Affordable Care Act. For Obama, or the Senate Dems, to give this away would basically be to declare themselves to be Republicans. There would be no two-party governance in this country; it's already tilted heavily in favor of the Tea Party. The Tea Partiers don't believe this, of course. I can forgive them for this lack of appreciation for their own success because they are, as a movement, insane. I am far less patient with my friends and neighbors who don't follow politics enough to understand the dynamic of Washington since the Tea Party has been ascendant.

That is what worries me about the Foreman "everyone's at fault" piece. I think he's representative of a huge chunk of Americans who are, understandably, mad as hell, but who also are, somewhat less understandably, inchoate in their grasp of even the most basic details of how our government has been working, or rather, hasn't.

Wednesday, October 2, 2013

Government Shutdown and False Equivalence

There is an awful lot being said and written about the shutdown of the US Federal Government. I won't link to any of the news bits; I assume that if you're reading this, you've been reading at least something about the shutdown. I'm also not going to comment on the politics of the situation, which for me will require incredible self-control. We'll have to check back at the end of this entry and see if I made it successfully.

What I will comment on is the ongoing trope that this is a problem due to radicalization of both political parties. See, for instance, this common "they're all bums" title in an article running up to the shutdown: "Shutdown Crisis Shows Washington Breakdown", which dutifully lays blame at both parties for the troubles throughout the article, as if somehow President Obama is as wild-eyed in his zeal as Ted Cruz.

There has been some scholarly work devoted to this issue of ideological segregation, and the mantra seen in wonky articles on the matter is that both parties have become more pure and extreme. The link above throws in the caveat that the polarization of political parties is asymmetric--that is, it is more extreme on the right than on the left (see political commentary here)--but still sees the trend occurring in both parties.

This seems like utter nonsense to me--or at least is highly misleading--and I think it's based on how one measures "purity". If you have some members of Congress vote with their party 100 percent of the time and zero percent on bills floated by the opposing party, then those party members are 100 percent ideologically pure. If you have different members who vote, say, 75 percent with their caucus and 25 percent against, those people are less pure. The graph shown in the link compares "purity" from 1879 to 2011:

This gives the impression that the political issues between the parties have been more-or-less stable over that time. In reality, a graph of the Republican party from 1879 to 2011 would have shown itself to be a far left party, especially from 1850 through 1880, then a gradual move to the center for the next 80-90 years, then a lurch to the right starting in late 1960s and early 70s, and a much farther jump to the right from Gingrich's speakership on. Yet this isn't what you see on the graphic at all: Republicans occupy the top half of the figure, Dems the bottom.

What is missed, over and over again in these discussions about "party polarization" is that if the parties are becoming more divergent, it is only a phenomenon that can be described relative to each other and not at all about the underlying politics. Meaning: the left wing of the Democratic party may have less in common with virtually any member of the Republican party now than when I was growing up in the 1970s, but the left wing of the Democratic party (at least their representatives in Congress) has moved to the right politically over that time.

The proof can be found in the moronic howling over the very healthcare law that is the source of the shutdown. Despite the Tea Party claims that the ACA is socialism, it bears repeating that the key provision that makes the Affordable Care Act work, the "individual mandate", was essentially invented in the offices of The Heritage Foundation, the right-leaning think tank. (It also is worth noting that "Obamacare" is structurally the same as "Romneycare", and that the former Presidential candidate who campaigned on the repeal of Obamacare seemed pretty pleased with himself when his health care bill passed as Governor of Massachusetts. The fact that this needs to be noted is indicative of the ignorance of so many people who play key roles in forming policies for the Federal government.) Thus, by any sane definition, the ACA is a rightward bill that should have passed with tremendous Republican support, and would have a generation ago if Clinton had lost the Presidency to Bob Dole in 1996. The Republican party would then have claimed this as a legislative victory, and who knows what would have changed in domestic politics as a consequence.

A Tea Party-equivalent left wing approach to health care reform would have been truly nationalizing health care like Britain, where doctors are government employees and hospitals government buildings. Currently we have something similar in the US  in the form of the Veteran's Administration health care system, which is truly a federal government  operation from beginning to end. It's also reasonably popular. Despite this, there were only a few Dems open to this idea, and it was never realistically discussed.

A moderate left-wing solution to the healthcare problem was to push for "Single Payer", in which the government takes over the functions that the private insurance industry handles. This could be thought of as "Medicare For All", and to this day I don't understand why the Dems didn't embrace this sales pitch given Medicare's popularity. But Single Payer, even though there was a Tea Party-sized chunk of the Dem caucus that supported it, was deemed out of the question by party leaders, and never took center stage in policy discussions.

The centrist position was one in favor of the "Public Option", which would not force everyone into the Medicare pool but allow them to opt-in. It had a huge amount of support among rank and file Democrats; indeed, this was approved in the initial bill passed by the House, but was dead on arrival in the Senate for procedural reasons (it's unclear if it would have passed the Senate, but probably would have if it came to a vote). Even that approach, however, which was somewhere between mainstream and concessionary Democratic philosophy, couldn't survive the legislative process. So we got instead a law that would have warmed the cockles of Newt Gingrich's heart in the mid 1990s, yet you still hear reporters and talking heads let go unchallenged statements about the "problems of the radicals on both sides".

The two parties aren't getting more radical. Both parties have moved to the right. Repeat: both parties have moved to the right over the past two generations. Just because one of them has done so at an alarmingly accelerated rate doesn't mean the other has moved in the other direction. It's an optical illusion, and yet our media largely contributes to the underlying problems driving this crisis by their constant and tedious exercise in false equivalence. I would argue, to borrow a recent use of the phrase by Senator Rand Paul, that it's time to point out that the emperor has no clothes, although Paul might not approve of my meaning.


Sunday, August 11, 2013

Dissecting Two Damning Critiques of Medicine

I don't do a ton of op ed reading, but two pieces caught my eye in a span of a few days at the New York Times. Both are fairly savage critiques of medicine. Both should be taken very seriously, especially by those of us in the White Coat Tribe. But only one of them makes a compelling case.

One piece is called "When Doctors Discriminate" and is a meditation on the kinds of harm that non-psychiatrist MDs can inflict on patients with psychiatric conditions--in the author's case, a diagnosis of bipolar disorder. "You better get yourself together psychologically, or your stomach is never going to get better", the writer quotes a gastroenterologist as saying. This apparently was intended as a helpful piece of advice, and the article goes on to list the myriad ways in which physicians can negatively impact the health of these patients.

The second piece, called "Crazy Pills", notes the recent change in FDA policy toward the anti-malarial medication mefloquine, as it now includes a "black box warning" for the drug. The warning stems from mefloquine's neurologic and psychiatric side effects, which can persist well beyond the time period when it is taken (the drug is used to prevent malaria infection when people travel to areas with malaria). The author reports having had ongoing bouts of depression, panic attacks, and insomnia since his encounter with mefloquine as part of a stint in India for his Fulbright fellowship. The essay does not make for pretty reading, documenting murders and suicides, and lays them at the doorstep of the medication.

I heed the warnings explicit in both of these articles. Doctors should always be conscious about their biases, constantly on guard against anchoring their judgments based on one piece of data--in this case, a diagnosis of mental illness. Likewise, it's important for people to be aware of the potentially serious side effects of mefloquine, or any other medication for that matter. Nearly all doctors in Infectious Disease were keenly aware of mefloquine's psychiatric side effects even before the black box warning was issued. Nevertheless, making patients aware of the possible serious reactions to a medication, especially when a new warning is attached to it, is an important public service announcement.

But that being said, there is an enormous amount of innuendo and logical leaping in "Crazy Pills", while "When Doctors Discriminate" constructs its argument with a good deal more care. The author of "Crazy Pills" alleges that the drug was responsible for an Ohio man putting a shotgun to his head in 1999 after returning from a safari in Zimbabwe, as well as for the killing of a Somali prisoner by a Canadian soldier who took the drug. He also hints that Staff Sgt. Robert Bales, who went on a killing rampage in Afghanistan in 2012, was under mefloquine's influence. In the first example, we have no link to know any details beyond what is supplied to us by the author, and therefore no way to know anything else about this man. In the latter two examples, there appears to be no alternative hypotheses entertained for these most unfortunate horrors, but surely the fact that these men were under the duress of war might have played just as much a role, or indeed a more powerful one, than an antimalarial.

By contrast, "When Doctors Discriminate" relies not on a few carefully selected anecdotes that can't be considered in context, or even verified, but by noting broad research as reported by major public health organizations. It is a model of a well-constructed argument in the internet age, built not on hearsay, but on evidence, available for all readers to see should they choose to do so.

Lest I be misunderstood as being dismissive of mefloquine's side effects, I think that the inclusion of the black box warning was important for physicians and patients alike. But living in a malaria-endemic region with no prophylaxis is a very, very risky business: malaria kills. There are other drugs that protect against malaria--during my travels to Africa I took the drug Malarone without any problems at all, and it's a very well tolerated drug. But Malarone is expensive, and not all insurance companies will cover it. Should someone just avoid taking mefloquine if they can't have Malarone and take their chances?

That will very much depend on the numerical risks involved. The data presented in the op ed suggest that there's about a 6 percent chance of mefloquine causing a severe reaction for which it needs to be stopped. (The author ominously notes that "67 percent of people who took the drug experienced one or more adverse effects", which is, unintentionally or not, a scare tactic: "adverse effects" can include reactions as trivial as an upset stomach or a touch of insomnia.) Whether this number seems minor compared to the risk of full blown malaria is a proposition that patients and doctors must decide in a discussion, but I'm very concerned by the idea that everyone who needs malaria protection should just stop taking mefloquine if that's their drug. If his advice is heeded, we could soon be seeing NYT op eds about loved ones who went on safari and came home in a casket because they avoided protecting themselves against the great scourge of the tropics.