Saturday, October 28, 2017

Simple Questions--or Not--At Harvard Medical School

The Billy Rubin Blog went mobile this week, as I gave a talk at the Harvard Medical School Academy's annual Medical Education Day. The theme of the day was medical uncertainty, which given my work in Snowball seemed to the organizers to be a perfect fit. Hopefully it was enough of a match that I didn't embarrass myself completely.

The talk is here: The talk proper starts at 30 seconds. Apologies for the stops and starts; it felt much more fluid in the moment than the slightly herky-jerky quality the address has on playback.

One exchange at the end is worth meditating on--and I include it here as a meditation, a sidenote, for I don't mean for it to indicate that this was anything approaching the most important moment of the hour. But it does allow a second for a departure on the philosophy of medicine.

When I was taking questions at the end, at about the 51:30 mark, a senior clinician wondered about the process of advice from doctors. Here's the exchange (in raw transcript form--the dead-ends make a little more sense as you hear it in the moment):

MD: There's a very specific prime question that I think is legitimate for patients to ask: "Well, what you you do if you were in my shoes?" And this is a very different question from an erudite but simple discussion of a problem, and they are asking for a very specific answer. And I wondered if you give this, believe in it, and if you do, what do you tell your students about answering such questions?

Me: When they [patients] ask, "What would you do if you were me?"

MD: Yes.

Me: So, I know we have one of my former students here who's a psychiatry resident; I would bounce the question right back and say, "Well, I'm not, um, I'm different. I come with certain, you know, fears, hopes...and then you open up a discussion about, really--because when they ask you that question, they're not asking you that question. They're trying to figure out how to prioritize things. That's my sense."

MD: I think they're asking, very specifically, that question. [Audience laughter.]

Me: I don't...I don't agree. I actually think that question is a good deal more complicated than it looks on the surface.

What's fascinating to me about this exchange, in a talk on uncertainty, was the unequivocal confidence this physician had that patients just want to know what their docs would do in the same situation, no further question asked.

My reply in the moment was not perhaps as quick-witted as I would have liked, but I'd add here that medical decisions aren't the same as car repair decisions. I trust what my mechanic tells me, because a car is an expensive but not priceless piece of machinery, important to my life, worth something but something finite. Thus, I can have a straightforward discussion about whether it makes sense to rebuild the engine for $3000 in a twelve-year old Toyota that has 180,000 miles on it and has a reasonable chance of breaking down in other ways, or just trade it in for a new model. Maybe it's more expensive in the short run to get another car, but that comes at the benefit of fewer headaches induced by repeated trips back to the garage.

A good mechanic can lay out the risks versus benefits in a clear way, and based on what they've seen over the years (the number of 12 year-old Toyotas that make it to 15 without constant servicing, for instance), they can say, "it's a good car, I'd hold on to it, but there's a risk," or alternately say, "I'd be rid of the headache." That kind of advice in that kind of situation is genuinely helpful, and more importantly, the terms being discussed are reasonably clear and equivalent to both parties.

But a doctor just casually dropping advice to a patient's family asking a similar question about a loved one struggling for life on the vent in the ICU, and whether the doctor would request to have all lifesaving measures stopped, presupposes any number of areas of understanding that may not be so. What value does the family place upon religion and ethical precepts about the value of life no matter the struggle? Have they had good or bad experiences with the medical system? Are there life events on the horizon that might make a patient or family try to subjugate themselves to the frequently tortuous procedures and treatments medicine can provide, in order to reach such moments? Does the patient or family have regrets about saying goodbye, of having fights years ago in which no reconciliation has ever been broached?

Don't these questions seem rather more important than, "Well, doctor, what would you do?" as if the subject could be so easily compressed to a singularity of physician wisdom?

And if those questions are explored between doctor and patient, or doctor and family, then what need of such an absurd and possibly dangerously oversimplified question?


Saturday, April 22, 2017

Why It's Not OK for Docs to Participate in Executions

Sandeep Jauhar's op-ed in the New York Times today poses precisely the opposite formulation, theoretically offering his musing on ethics as the State of Arkansas rushes to execute as many death-row inmates as possible prior to having their stockpiles of lethal injection drugs expire, for which there have been a flurry of legal challenges, although they have succeeded with one thus far. Given the topicality, Jauhar decided to wedge in some thoughts about how this policy interfaces with the practice of medicine, deciding in the end that it's copacetic.

It isn't, and from the moment the article appeared, a whole lotta people--including a whole lotta doctors--pointed this out, noting the intellectual contortions required to suppose that setting up the killing of an otherwise healthy human being doesn't violate the dictum, "do no harm." (Often dressed up in the fancier Latin phrase primum non nocere, the injunction against doing harm is taught to precisely every medical student, everywhere, on day #1 of school.) Jauhar's main argument revolves around the idea that only physicians have the required expertise to mix a batch of lethal drugs correctly, and therefore they are, in fact, relieving the patient's suffering. It is hard to write this with a straight face.

When I woke up at six and happened upon the article, there were perhaps a dozen replies; within an hour, there were two hundred. As of now, there are more than 500 comments. Most aren't impressed: the vast majority were outraged, and those that defended Jauhar often missed the point as they seemed to think the debate was about the death penalty itself, not the medical ethics of doctors participating in the process.

"As a correctional physician, it is chilling to wake to this. From his tone, it is doubtful to me that he has entered a correctional facility," wrote Matt from Boston in a comment. "The Times' decision to publish this comes as a shock. I entreat the author to refrain from more writing on the topic until he spends time in the correctional setting, meets our patients, and educates himself further on the ethical grounding of medical-correctional standards." Boom.

I had once thought myself a fan of Jauhar as I like to root for physicians who write for the public and help unravel medical complexities, but I'm less enthusiastic than I used to be, that's for sure. A few years ago, he had used similarly questionable logic while he advocated for the return of the old model of Doctor Knows Best, which led me to harrumph about it at the time. I haven't read his writing systematically or exhaustively, and now I'm beginning to worry what I might find if I do.


Monday, January 30, 2017

Quick Take on Trump Ban, MD Training Edition

I receive daily updates from a discussion board for faculty members involved in residency programs that train internal medicine physicians. Usually it's a sedate series of discussions about how best to achieve throughput from the ER to the floors, or how best to schedule swing shifts in the ICUs, and so on. There's usually two or three such posts each day, and mostly I flick through them just to see the kinds of technical matters that affect residency training.

Today, however, only 48 hours after Donald Trump's travel ban on people from Syria, Sudan, Libya, Somalia, Yemen, Iraq, and Iran, there is practically an explosion of posts about what this means for programs across the country and their International Medical Graduates (or "IMGs"). And there's a fair amount of hand-wringing about what comes next. "All of our alarm bells should be going off," wrote one physician--and it's worth noting that in physicianspeak this comment is the rhetorical equivalent of going bonkers, for while I may tend toward hyperbole in political analysis, my colleagues on the whole do not. Trump's order, along with a host of other actions he has taken in his first week in office, is changing this to a degree heretofore unprecedented for this generally nonpartisan, apolitical profession.

The cause of the alarm is that a lot of resident trainees are going to be affected by this--see here for what may be the first of many examples of much-beloved doctors in the middle of training being put on a plane and sent packing without any warning whatsoever. This not only affects the residents, but will probably include a fair number of licensed physicians currently in practice, as visa waivers are granted to physicians from abroad who are willing to work in underserved areas--including many areas of the rural Midwest, ie the kinds of places that have embraced Trump and may soon feel the impact of this policy. In my home of internal medicine, there are about 7000 positions filled each year, of which half are filled by visa-holding immigrant physicians. Of course, only a small portion come from these seven nations, although I have known many a Syrian and Iranian physician in my time.

But the ban's impact is going to affect much more than the physicians coming just from these countries for training. Any Muslim physician, particularly those from majority Muslim countries, would be wise to consider whether their country will soon be on this list as well. And this order comes just as residency programs across the United States sit down and decide whom to rank for offers of residency training--not just internal medicine programs, but all of them. There are about 28,000 first-year spots open, of which nearly a quarter are filled by IMGs. Again, the ban won't affect all IMG physicians, but a substantial majority of programs devoted to primary care--internal medicine, pediatrics, family medicine, as well as psychiatry--are going to have to decide whether they want to roll the dice on highly-qualified Muslim applicants they may ultimately never be able to train, or take less promising applicants from elsewhere, or simply not fill the positions--which increases the work burden for trainees and faculty alike.

Since we aren't by any means experts on the subject, physicians shouldn't be in the business of wading into policies about immigration, but the thoughtlessness that has thus far characterized the first eight days of the Trump administration has forced this on the profession. We not only have only the faintest notion of what consequences this single action will bring, and there is no reason to suspect that we aren't in store for more policies with even greater impacts. In one week, Trump has shown himself to be utterly incapable of governing in a way that does nothing but wreak havoc, and one doesn't need to be a policy expert to see this. Nevertheless, the vast majority of Republican politicians and Washington insiders, who are the only people who have any shot at restraining this man, have been feckless enablers even as they must surely know deep down that if he is not stopped, genuine ruin awaits.


Saturday, January 21, 2017

Inauguration Special: Flags & Hypocrisy

This weekend in Billy Rubinland we observe the passing of the torch from one president to another with the same level of dread that tens of millions are experiencing, and as such there isn't much to say, for certainly the words of the new President himself could not be a clearer elucidation of a philosophy of mendacity and unscrupulousness that Donald Trump has not in any way concealed since the very first moment he descended the escalator from his office tower to announce his intentions to supersize his medium-level business practice, which has always sordidly combined corruption and legal intimidation, into levels not previously witnessed in the American political landscape. His candidacy was a long shot, one that involved playing to the basest and most disgusting of the American--that is to say, the white American--id as part of a campaign to satiate an ego that can brook no criticism, and whose philosophy was really only that of self-adulation and worship of the little people because, well...him. He didn't adopt the Republican talking points of the past generation so much as exposed them for the galling hypocrisies that they were, channeling the white rage that Nixon kindled with his "Southern strategy" and Lee Atwater torched with Willie Horton and Rupert Murdoch poured gasoline on with Bill O'Reilly and Sean Hannity, dispensing with the code language that allowed so-called "conservative" politicians to maintain with a straight face that their unhinged hatred of a very mild-mannered, compromise-oriented centrist in Barack Obama was really all about ideology and had nothing, nothing whatsoever to do with race. After the 2016 presidential campaign, anyone who voted for such a scalawag was either an unapologetically virulent racist, a totally uninformed voter who did not bother to listen to his message, or was in absolute denial that somehow this man rejected the putative values of what heretofore had been the official ideology of the Republican party. To those who can't see the man for what he really is, there's not much point in having a discussion.

As I said, there isn't much to say. Basically, I would say this, if I could.

Instead, as we prepare for the Trump administration coming to power and the high likelihood that it will deliver justice on the national and international stage in a thoroughly arbitrary matter, I only wish to talk, ever so briefly, about one small piece of the vast edifice of hatred and hypocrisy that defines at least some of his supporters, and has been validated by the results of the election: the subject of free speech, treason, and the meaning of national flags.

Unsurprisingly, the US flag has become an object of scorn not only outside the United States, but from within as well. (Anyone from beyond the borders who didn't have a favorable opinion of the US prior to today's inaugural address just got a fresh & tasty justification that they were right to hold such views based on words issuing directly from the mouth of the new President himself.) Note here, for instance: US protesters engaged in the burning of the American flag in one of many demonstrations across the country. There were tens of thousands of people expressing their opinions in such marches without resorting to burning the flag, but the right-wing organs of media, along with Trump himself in the run up to the inauguration, immediately turned the actions of perhaps twelve justifiably angry people exercising their right to free speech into a matter of grave importance worthy of ignoring the unprecedented ethical conflicts of interest that--far from draining it--are about to make Washington DC a swamp that will be the envy of third-world tinpot dictators. After all, when uninformed billionaires who think poor people got that way because they are stupid and lazy are handed the keys to government power by a political movement that somehow thought it was--one tries in desperation to stifle a laugh--sticking it to elites....then it's of much, much greater importance to decide whether we should incarcerate some pissed-off millennial for years on the charge that he's somehow damaged the integrity of the country by setting flame to one US Flag.

It's one in a series of Three-card Monte games that will continue for the next four years--or, quite possibly as a result of some truly outrageous voter suppression shenanigans to which Jeff Sessions will minister, much longer. Today, marchers are marching as part of what is thus far not fully coordinated resistance to the Trump administration, and I am with them in spirit, but frankly I'm too depressed to head to the streets. If we live in a democracy that chooses a man such as Donald Trump to run our Government, then there's something very wrong with our democracy, and I'm not sure if marches or voting registration drives or legal filings by smart lawyers who actually fight for the small guys against the real elites will make any difference.

I know this is a hopeless and not especially helpful view of the matter. I would have been appalled by the presidency of a Ted Cruz or a Marco Rubio, and I would have at least have grumbled in disgust at the presidency of a Jeb Bush or a John Kasich or a Rick Perry, but I could at least feel like the combination of venality and shortsightedness was what I was used to. Trump, however, is in a class all by himself. He combines the bullying instincts of Chris Christie, the vengefulness of Rudy Giuliani, and the cluelessness of Ben Carson into one perfect package of American ignoramical anger. What makes him so unlike the other sixteen men who vied for the Republican nomination is that he never tried to hide it; even Christie, who at the start of 2016 I considered the most dangerous candidate, mouthed various pieties on the campaign trail about the value of democracy, and tried to distance himself from the most overtly racist rhetoric of the right-wing rallies. Trump by contrast brought the most deplorable elements--yes, Hillary Clinton was one hundred percent correct when she used the term--front and center into his traveling show of hate and resentment, shocking the Republican establishment which thought that you could only win if you used racism via the means of code words.

Now there's no more code words, and a monster sits in the White House, surrounding himself with people who on the whole are to the "establishment" what street thugs are to poor neighborhoods, with what seems to be only one well-informed and intelligent cabinet member not in possession of reams of conflicts of interest, and he happens to go by the nickname of "Mad Dog." Which is to say, not encouraging. If 60 million people can be presented this kind of a man and want to support him, we're no better off than Berlin was in 1933.

So I'm not going to try to engage in some sort of earnest appeal to anyone about which of the dozens of fubar elements of the Donald Trump presidency are worthy of shock and outrage, as there's not much point. The one quality I find so fresh and appealing about him is that one can't hide behind the veil of being uninformed when opting to support him. He doesn't trouble himself with the details of policy, and doesn't think you should bother, either. His brand, which he made exceedingly clear in his inaugural address, is hate, and you don't need a PhD in government studies or be familiar with the company Blackwater or understand the importance of the Iran-Contra affair or remember who Spiro Agnew was to know what Trump is about. Which is precisely why I see no point in any dialogue with any of his supporters.

But I am perfectly fine, on this first day of the new administration, to point out the standard asymmetric commentary--which is to say, frank hypocrisy--that's been part of the right-wing playbook for the last 40 years on one small matter. The flag-burning issue is, on the one hand, tedious: it forces centrists and liberals into legally defending an action that is, at the very least, aesthetically unpleasant, turning the dialogue into how to keep the mob quiet. (Not, of course, that the right-wing mob has a corner on the market: For left-wing hypocrisies, see "defending the good work that most cops do" or "supporting Israel's right to self-determination" during discussions about either systemic police violence against African-Americans or the Israeli-Palestinian conflict. But the left-wing mob isn't bankrolled by billions of dollars of organized Pravda-like media whipping them up into an ignorant frenzy on a daily basis.)

Anyway, it's a classic dumb issue intended to distract attention from the true outrages, but regardless it's still rank hypocrisy, for the free speech that Trump and his merry band of Republican lawmakers are prepared to punish in the most severe terms possible--treason is a crime that can carry the penalty of death, of course**--they're perfectly happy to endorse in the form of the waving of the Confederate flag. Since we have become so culturally inured to seeing the rebel flag, it's worth noting that this represents a political entity that was a mortal enemy of the United States of America. Our country has gone to war with many nations, demanding surrender of some of them, signing peace treaties with others. But the United States of America dissolved the Confederate States as an enemy nation, and while there has never been a federal law banning its display or use, it's clear that one who finds the burning of the US flag a crime should be moved in equal measure to criminalize the display of an enemy nation as part of political speech.

Personally I don't care about flag burning, but I'd be perfectly happy if we were willing to categorize traitors consistently across the board. Will our prisons be enough to hold so many? Of course, the penalty for treason includes death, so perhaps we can move things along at a quick clip.


(**Not long after the election, I had a long and unpleasant exchange with an acquaintance on Facebook, someone with whom I went to high school and an ardent Trump supporter, about the penalty for treason, since she had joined the chorus that Trump started by posting something vapid about punishing flag-burners. It became a painfully drawn-out conversation because I merely wished for her to acknowledge the simple fact that she was stating her belief that one of her fellow Americans should be shot to death because they burned a flag in a protest. Faced with the unassailable conclusion of her belief, she eventually agreed, at which point I was called an asshole.)