Government and Medicine: Legislative and Judicial Follies

I try--I repeat, I try--to construct eloquent blog posts as often as I write them, taking care to choose my words as I tiptoe through the minefields of cyberspastic hyperbole and vitriol. That said, I could do little more than utter "blech" at this news piece that the Massachusetts State House has voted overwhelmingly, as part of an "economic development" bill, to repeal a ban on gift-giving from pharmaceutical companies to physicians that had passed in 2008. For those who have been trapped in solid ice since, say, the mid-1930s and the heyday of the Henry Cabot Lodges and William Morgan Butlers, in Massachusetts, the House belongs to the Democratic party. So how does such a law that seems to once again encourage the wink-wink nudge-nudge relationship between docs and the pill-pushers--particularly when the same legislative body clamps down on labor's bargaining rights in an effort to rein in spending costs--get passed?

Amazingly, the answer appears to lie in...the dining & entertainment lobby. According to Garrett Bradley (D) of Hingham, the sponsor of the measure, the ban stifles business, hurting convention centers and "restaurants where companies typically hosted physician events and dinners." (NB--the quote is from the article, not a direct of Mr. Bradley, though I doubt he'd quibble if the line were attributed to him.) Never mind the fact that this sector of the Massachusetts economy appears to be doing reasonably well, with an increase in overall revenue compared to last year, the measure's backers appear to be saying that it's perfectly fine if a payola-style arrangement is in place, as long as the palms continue to be greased and the filet mignon gets served with the Cabernet.

Blogger-doc Dan Carlat has already staked out the Swiftian rhetorical territory with a delightful skewering of the follies, leaving me and others to play the straight guy. So here goes my best effort: no self-respecting physician compromises the health of his or her patients by allowing themselves to be manipulated by claptrap. There is ample evidence that gift-giving induces an attitude of reciprocation, lucidly-but-luridly described in such books as The Truth About Drug Companies and White Coat, Black Hat, regardless of the actual quality of the product, and that drug reps know this and seize on the vanity of physicians to play them for dupes. Drug companies, however beneficial their societal effects may (or may not always) be, have a responsibility to shareholders, whose primary or sole interest is in the generation of wealth. To anyone in any state of mind other than that of abject denial, this is a primary objective that is in direct conflict with the caring of patients. Thus, doctors cannot accept gifts of any kind from those whose job it is to sell drugs.

A related theme is being played out in the judicial branch of government, as the US Supreme Court is hearing arguments on a Vermont law that bars the commercial use of physician prescription patterns. Based on the early returns, and noting previous Court decisions that take a fairly broad view of "free-speech" rights (at least if you are a corporation), it appears that the law is destined for being overturned. I can't claim to be a legal expert and thus won't even begin to take a crack at the wrangling over the First Amendment, other than to note a certain puzzlement at what passes for "free speech" these days among the Court's "strict constructionist" wing. Did the Founding Fathers really have the selling of a doctor's prescription habits in mind when crafting the First Amendment? I'm thinking not, but I await the peals of derision from my philosophico-legal foils (and loyal readers!) such as Ted Frank, a conservative maverick (I'm not sure if "conservative" is the right word for him; I'm certain that "maverick" is) and who ranks as the second smartest person I have ever had the pleasure of knowing in my life. (And in case anyone might misunderstand, I'm not implying that I occupy the top spot; I doubt I crack even the top 75, and I don't have that many friends.)

Regardless of the legal principles at stake, Chief Justice John Roberts made his contribution to the follies by appearing to frame this as an argument of "restricting the flow of information to doctors," as silly a line that can be uttered in such an august house as SCOTUS. How would withholding prescription info from drug companies prevent them from making their pitch for their drug? How does this even remotely "restrict the flow of information"? The naivete exhibited by the Chief Justice is pretty remarkable (and shared, without surprise, by Justices Scalia and Kennedy). The "it's all data, it's all protected by the First Amendment" argument seems to only work when big business benefits, but not the other way around. The recipe to Coke is just data, too; somehow I don't think the Coca-Cola Corporation considers that to be something that your local Joe can just barge on in and demand. Pray tell, what's the difference?

A hat-tip to Carey Goldberg at WBUR's Common Health Blog, especially for her humoring me in my response of "blech"!
--br

Fukushima Daiichi, and the Perception of Radiation Risk

Evolutionarily speaking, we are as a species hardwired to analyze risk based off of information that's directly in front of us--immediately accessible to our five senses. We're designed not to trust food that smells funny, can instantly calculate how far away we should stay from large cats capable of having us for a snack, and do a host of other things that were very useful for us to eke out a living in Olduvai Gorge.

But we live in the 21st century, and nowadays our ability to perceive and estimate risk is hampered by the fact that many of today's risks are abstract, and require a resonably sophisticated understanding of statistics. Take, for example, a recent discussion found in the Paper Of Record about income distribution in the United States. True--it's not really a round table about "risk" per se, unless you consider radically unequal wealth distribution to be a risk to democracy, as Supreme Court Justice Louis Brandeis did when he said that "we can have democracy in this country, or we can have great wealth concentrated in the hands of a few, but we can't have both." Still, the NY Times roundtable was remarkable in that all of the contributors, whether approaching the issue from a left or right viewpoint, agreed that most Americans had vastly underestimated how much wealth is held by relatively few. In particular, a study by Michael Norton and Dan Ariely found that not only do Americans think that wealth distribution to be significantly more equitable than it actually is, but that they would prefer it to be even more equitable than what they (wrongly) perceive.

If this isn't a classic example of what George W. Bush would call "misunderestimation" then it's not clear what is, and moreover, it highlights the difficulties people have in making accurate estimates about things like the distribution of wealth in a hugely complex society: the information simply cannot be found by opening your eyes and looking around. In medicine, we see this all the time: people are often terrified of exotic diseases that pose little threat to them, while being utterly blithe to the daily assaults on their bodies--frequently self-inflicted--that are much more likely to send them six feet under. To wit: drinking, smoking, eating poorly and not exercising.

The recent events at the Fukushima Daiichi nuclear power plant have been a case study in this process of risk assessment, and not altogether surprisingly, we haven't done well collectively in harmonizing our level of panic to the actual threat that the reactors pose. Despite a good number of depressing news stories, some cataloging evasive action by non-Japanese governments, it is far from clear how huge an impact the nuclear accident  is going to have. While it is already comparable to the Three Mile Island accident in 1979, and is not (yet) as catastrophic as the Chernobyl accident of 1986, the question still remains: just how dangerous is it? Though the story is far from over there with events taking dramatic swings in short periods, the short answer is something like dangerous, but not as dangerous as you think. Not nearly as dangerous as you think.

That point is neatly illustrated, both in sound and visual format, in this news story from Adam Ragusea of WBUR (Boston), and is described as the "Dread-to-Risk ratio" by Andrew Revkin of the Dot Earth blog at NYT. Both pieces have the same useful graphic to give you some sense of the relative levels of radiation that we're talking about. Live within 50 miles of a nuclear power plant for one full year? That will give you about 0.1 microSieverts (uSv) of radiation. (What a Sievert is, is a longer discussion, but we'll just shorthand it here and say that it's some relative value of radiation, and that the higher the number, the more dangerous it gets.) One flight from New York to LA buys you about 400 times that amount (40 uSv). That's not even the round trip! A standard chest x-ray, meanwhile, is worth about 20 uSv. But a mammogram is a whopper, clocking in at 3 milliSieverts--thus about 150 "standard" x-rays and just under forty roundtrip flights from NY to LA. A CT scan can be worth almost twice the amount of the mammogram (5.8 mSv).

(In case I've lost some people on this micro/milli distinction, you need 1000 "micros" to make 1 "milli." I'm going to flip back and forth but will point it out when I do.)

So how do these numbers stack up to the nuclear disasters? If you lived within 10 miles of the Three Mile Island plant during the accident and didn't make a run for it, the total dose of radiation you received was 80 microSieverts--far less than one mammogram. By contrast, one area near the Fukushima plant recorded a total dose in one day of 3.6 milliSieverts: less than a CT but more than a mammogram, though of course we're only talking about one day's worth of radiation. With Chernobyl, the radiation levels fluctuated wildly both in time and place so making a general statement about the radiation is essentially impossible, but had you been moved by some weird spirit to take a stroll on the grounds just last year, about 25 years after the accident, you would have gotten two mammograms' worth of radiation for your troubles: 6 milliSieverts. I won't reproduce the pic here out of respect for copyright but highly recommend it to anyone with the time; Ragusea of WBUR translates this into a tone equivalent, and the radiation from TMI is a blip, while the sound for "mammogram" is substantially longer.

I draw two conclusions from all of this. First, while the troubles at Fukushima are by no means trivial, and for that matter aren't yet finished, I think it's a bit premature to write the obituary for nuclear power. In terms of accidents, it's not nearly as dangerous as most people suppose. The problem with nukes, in the TMI and Chernobyl age as well as today, is what to do with the radioactive waste generated by the plants rather than the risks they pose viz. accidents. Second is that we should try to minimize mammograms! Do only the amount that will help save lives, and not one more after that. This was the logic behind the recently revised US Preventative Services Task Force, which recommended no mammograms to women under 50, and biannual ones to those over. Despite this entirely sensible approach--based on good research with a careful eye toward the risk/benefit ratio of the radiation, it should be noted--there were howls of indignation from people purportedly speaking for women, accusing the very bureaucrats who issued the new recs to be female-hostile, or something like that.
--br

(NB--the first draft of this version, which snuck out prematurely, posted some incorrect calculations with respect to x-rays, mammograms, and NY-LA flights. The corrected version is now present.)

The "Back-Door CD4" and Its Ethics, or Lack Thereof

Every year, virtually every first-year medical student gets introduced to medical ethics by learning about the quirky religious beliefs of a small Christian sect: Jehovah’s Witnesses. Based on their interpretation of a passage from Leviticus, Jehovah’s Witnesses consider blood transfusion to be against God’s word, and will thus not accept them, even if their life depends on it. Medical students are introduced to this situation as the classic example of how an American physician is supposed to behave: it don’t matter what your personal beliefs are with respect to the Witnesses, only that you accept their right to their beliefs and, if need be, protect them, defend them, and do whatever else is necessary to let them decide what to do with their bodies. We call that concept informed consent, and it’s the basis of most serious discussions about life-saving medical care in this country. (Of course, I'm talking about adults here; with kids, the situation gets stickier, and with adolescents, stickier still.)

In theory, informed consent is the process by which patients take the reins and make all the genuinely important medical decisions for themselves, while docs serve as something like advisors. Needless to say I’m not talking about the minutiae of medical decision making, like whether to switch a patient from amlodipine to atenolol, but rather the stuff that most patients worry about when they (or their loved ones) walk through the hospital doors: do I want to be resuscitated? do I want to have “everything” done for me? can I refuse some procedures the doctor recommends? These are precisely the kinds of questions where we, as physicians, have an obligation to help patients and their families figure out what they want—that is, not impose on them what we want—and guide them as best we can, even if, indeed, especially if they make decisions that we find shortsighted or wrongheaded or both.

That’s the theory. Fortunately, in terms of practice, most of the time I think we physicians do a pretty admirable job of supporting our patients. You would be hard pressed to find a doctor who thinks it’s acceptable to override the beliefs of a Jehovah’s Witness and force-feed them blood to save their lives. That said, while the core of that philosophy is wholly adopted by the profession, precisely where the boundaries lay can be contentious. And last week I was again reminded that we don’t all agree on what constitutes honoring our patients’ wishes.

It happened when I was hearing about a case of a patient in the Intensive Care Unit fit for an episode of House, M.D. The patient was older without being elderly, and had a respiratory illness that had defied diagnosis despite the best intentions of cardiologists, pulmonologists, infectious disease specialists, and a few other medical professionals to boot. The ID docs, though unsure of what was going on, thought that this was most likely some infection seen in the setting of underlying AIDS, and I, being an ID guy, shared their point of view while hearing the details. Like my colleagues, the question to which I wanted to know the answer was: what was the result of the HIV test? But the patient had adamantly refused HIV testing. And that’s within his right: a doctor can order most blood tests without having to discuss them with a patient, but an HIV test—just like a blood transfusion—is special, and requires a signed form saying that the patient agrees to it. In this case, where a diagnosis of HIV infection might be helpful (more on this later), such a refusal can be maddening. But that is how the rules are set up right now, and once the patient says no, then that’s all she wrote.

However, in this case, that wasn’t all she wrote. HIV is a virus that infects, and destroys, a special kind of white blood cell called a CD4 cell. In general, the further your CD4 cell count drops, the more you are at risk of being infected by the weird organisms that are the sine qua non of AIDS, things like toxoplasmosis, cryptococcosis, penicillium marneffei and a host of other parasites, bacteria and fungi that people with healthy immune systems never develop. A person with a healthy immune system typically has a CD4 count that runs from 500 to 1500, give or take; the definition of AIDS is someone with HIV infection and a CD4 count less than 200.

One of the loopholes of informed consent for HIV testing is that it does not cover CD4 counts.

You can see where this is going. Some doc tried to do an end run around the refusal and checked the patient’s CD4 count. Surprise! It was low, less than 200, although the pattern of the CD4 cells didn’t really look like AIDS (skipping some technical detail here). So then what do you do? You have gotten no closer to the diagnosis, and you have put yourself into the uncomfortable situation where you may be tempted to take action. Sometimes the treatment for some of those weird “opportunistic infections” in AIDS is to just give a person medications for HIV, but you wouldn’t give those meds to a patient without a diagnosis of HIV. In this situation, that wasn’t the case, but what if it were? Would you throw antiretrovirals at the person because his CD4 count was suggestive of HIV—even though the patient unambiguously refused the test? To me, this smells exactly like giving blood to a Jehovah’s Witness: doing what I call a “Back-Door CD4” might seem clever, but it pretty obviously violates the spirit of the patient’s wishes, if not the letter.

Some would argue that the very need to consent people for HIV is outdated. HIV consent was established at a time when the diagnosis was severely stigmatizing, and “positives” could lose jobs, insurance premiums and in general face ostracism from their communities; it also happened at a time when treatment wasn’t exactly effective. Today, the latter is definitely not true, and as I tell my HIV patients all the time, there is no reason to suppose that, should they take their meds every day faithfully, they should live as long as anyone else. Whether the former is true I am a touch skeptical, but I acknowledge that the level of stigma nowhere near approaches where it was twenty years ago. Thus, proponents of the Back-Door CD4 would say that the time for HIV consent has come and gone. Way back in 2004 a doc named LA Jansen wrote in the Journal of Medical Ethics and supposed that the Back-Door CD4 was a form of “conscientious subversion,” something akin to conscientious objection, where a physician acknowledged the existing legal landscape but did his or her own thing based on their personal ethics.

Jansen dresses the term up in calling it “conscientious subversion”; I prefer using simpler language and think of it as a bad idea. By my compass, patients have rights to refuse tests, medications, procedures, and any attempt at thwarting those desires defeats not only the entire point of informed consent, it belies the idea that we are advocates for our patients. Don’t get cute, is what I’d say: we are better than most professions at standing by those we serve. Let’s not mess things up by thinking we know better than they do.

—br

PS—the Jehovah’s Witness example has, for me, not been entirely academic. Twice I have cared for Witnesses who were in situations where transfusion was definitely worth considering, and in one of the cases it was pretty clearly indicated. Like most of my profession, it never entered my mind to try to push the idea on them once I learned of their religious beliefs. For more on Jehovah’s Witnesses and their philosophy behind their refusal of blood transfusions, see here, here and/or here.

Profile in Courage, Writ Small, But Still

Today was Grand Rounds at my academic medical center. The subject was diabetes and how we--"we" being the medical system as opposed to "we" the individual doctors--can improve outcomes in this disease, which is a killer, and which we (pick whichever "we" you like) stink at treating successfully. The view of the speakers, with which I'm sympathetic, is that we require less gee-whiz bioscience breakthroughs than we do a comprehensive, systematic plan for identifying, following, and ensuring affected patients stay on their meds. None of their suggestions were particularly sexy and didn't involve lots of fancy technology except for using a personal computer. I was persuaded by their assertion that sometimes it's simple but labor-intensive solutions in medicine that are the ones with the best chance of success.

Grand Rounds at my hospital always begins with a physician "presenting a case." Typically this involves a resident summarizing a bare-bones medical history of some patient who has some affliction related to the topic being discussed: gout, Wegener's granulomatosis, multiple myeloma, sepsis, a heart attack, you name it. Often the speaker will make some remark about the case in relation to his or her talk, and then it's on with the show. This kind of case presentation is de rigueur among physicians, and after one has lived & breathed medicine for long enough (i.e. survived the third year of medical school), one becomes so acclimated to the rhetorical form that one can get fairly desensitized to the reality that it's actual human beings that are being spoken of.

I don't mean to imply that physicians speak about patients in a de-humanizing way when a case is presented--that's never acceptable--only that the process of summary and discussion of history, physical exam, and laboratory findings in the dry, sterile, & detached form of the "case presentation" is second-nature to physicians, and must be creepy as hell to patients if they had to listen to themselves being discussed. Sometimes I try to teach residents and students at the bedside in the old-fashioned manner, but I always make sure to alert patients that such feelings might overtake them as I "do some doctor-talk with my colleagues." I do everything I can think of to make that moment as comfortable as possible for patients, but ultimately my suspicion is that all my efforts, at best, help blunt the sense of creepiness rather than remove it altogether.

So you can imagine what it must have felt like for the gal today to have her case of diabetes discussed in the amphitheater filled with well over 100 physicians in attendance, watching the medical facts of her life, neatly summarized into three Power Point slides, as she sat in the fifth row. I've been part of this community for more than ten years now and I still get nervous when facing the White Coat Army en banc; I can only imagine how intimidating that must have felt for her. Then, at the end of the presentation, the presenter noted to the crowd that the patient was in attendance, and asked her if she had any thoughts to add. Again, with what I would describe as remarkable poise, she eloquently explained some of the life circumstances that made her choose treatment options that, without that critical context, would puzzle and frustrate physicians.

She not only did this, but managed to deliver an observation with a small barb attached to the end of it: "I see that many of you here are eating really nice lunches here today, really healthy food. Well, my family has to live month-to-month because of our income, and I can tell you that a pound of pasta and some tomato sauce goes a lot further than some other food." It was a complex observation, but the sheer nerve & determination it took to march into what could very well have felt like a Lion's Den, and deliver that speech with such clarity, was quite a thing to watch. (Disclosure: lunches are not sponsored by anyone at our medical center. Mostly this woman was referring to tasty-but-modestly-sized deli sandwiches using fresh ingredients and a fruit salad.)

It's very unusual to invite patients to hear their own cases discussed in this kind of format, weirder still to give them a platform for a few minutes to speak about their challenges. Certainly in this setting it was a brilliant idea to include such a patient in the dialogue: my school gets an "A" not merely for effort but execution as well! Though at the end of the day, when the speaker concluded the lecture and the audience gave its polite applause per the cultural conventions of Grand Rounds, no one thought to give a special thanks for this woman. On that count, I think the organizers earned a D-minus.

BRB Link Dump

My spiritual and theological leanings are probably just enough to drive everyone concerned totally nuts: I am intellectually atheist, though functionally Jewish, plus I'm fond of various other religions (or at least certain aspects of them). We have a new Rabbi at our Synagogue and while he appears to be a very charismatic man, my own religious leanings are such that I do not look to him for spiritual leadership in any capacity, and I remain a member partly because I like going to synagogue, but mostly because I really like peace between me and my wife.

The point of this rambling being that although I long ago decided to follow my own path and look toward no other man or woman as my spiritual leader, if I had to choose a person, I quite possibly could have chosen Peter Gomes, whose life ended just a little too soon for my tastes earlier this week. Gomes was about the most polar opposite person you could pick for me to follow: he was African-American; I was white. He was Christian; I, an agnostic Jew. He was gay; I, not so much, thanks, though as Jerry Seinfeld noted, not that there's anything wrong with that. He was, for most of his life, a Republican, and I have mostly not been a Democrat because I regarded them as too far to the right. He was something of a dandy with something of a pompous manner of speaking at the most Establishment university in the United States; I am a well-educated though frequently unspeakably crude dude who went to Abbie Hoffman's school and often sneers at The Establishment. On the surface, thus, not my kind of guy.

But once you peel away his formal and sometimes antiquated mannerisms and really listen to Peter Gomes, there is aught but beauty, truth, and light. Here is a brief comment on gay marriage, while here a longer talk with Charlie Rose. He opens the conversation with Rose with a line that elegantly encapsulates why I find him so admirable: "I like the notion that there is much yet to be revealed about the Christian faith; it's not all over yet. It's not a complete story, and we're moving into it. There is much yet to be revealed, and I think our best theological days are ahead of us." If that ain't a bare-bones summary of the philosophy of the great Talmudic masters (that is, the part of the Talmudic masters that I find worthy of attention), then I don't know what is. I have not read any of his books, and my acquaintance with him is largely through talks & other coverage he's received in that peculiar Harvardo-centric fishbowl of Boston media (you could catch his sermons on Sunday morning on WHRB, the Harvard radio station). It may be a tough pill for me to swallow to read a book about Jesus, but in the coming months I may peruse one of his books to stay connected with this eminently decent and astonishingly eloquent man.

More immediate concerns that nobody else in the vicinity of Harvard Yard prematurely join the Reverend Gomes are very much on the minds of Massachusetts public health officials as they scramble to contain a measles outbreak inflicted on the city by an unvaccinated French woman working for the French consulate downtown. What a mess: the super-contagious virus may have spread to a professor at UMass Boston, and thus his students are bearing the brunt of some public health measures, but fortunately seem not to be too bothered by the whole fuss. Though make no mistake, a fuss this is: measles spreads like wildfire and--while not overwhelmingly lethal by Andromeda-strain standards--kills simply by the fact that so many can become infected so quickly. Even a low mortality rate of, say, three percent can be a lot of bodies if tens of thousands become infected. And while the vaccine for measles (the "MMR") is good, it's not perfect, so even vaccinated people are at risk of infection, especially if they haven't been vaccinated in decades. As I noted in a previous entry: this virus is a killer. How this gal got into the US and was allowed to work without having a documented MMR is not fully clear to me, but many are paying the price for her folly.
--br

Doctors in Wisconsin Sign Fake Sick Notes for Protesters; Civilization to Collapse Shortly

Whenever I begin to think that I have Sold Out in life and have embraced respectable living and taken an establishment career track, something will happen to remind me that, whatever desires I might nurture in the bosom of my soul to be acceptable and thus accepted, I am in fact a person with a fringe philosophy that most in my profession would consider dangerously radical.

A long sentence, that, but a good summary of my reactions to recent blog posts by my medical blog siblings. Their scorn was directed at physicians (several, apparently, from the Department of Family Medicine at the University of Wisconsin School of Medicine) writing fake sick notes for the protesters hunkered down for the political fight in Madison, Wisconsin, in which Governor Scott Walker is attempting to rewrite, and effectively strip, the collective bargaining power of public-sector workers. Health Care Renewal led the charge, calling it "the face of postmodern medicine: lying," while Happy Hospitalist danced a little jig after having 10,000 hits after Instapundit's shout-out on his post calling these docs "an embarrassment to their profession." db's Medical Rants piled on, saying much of the same.

I'd be so much more impressed by these sermons if they weren't so over-the-top in both their collective tone and in their historical comparisons. Based on their posts, you'd think that because of this little stunt, which is equal parts civil disobedience and wink-wink chicanery, the world was coming to an end or thereabouts. Happy uses the event to scream with a certain incoherence at Democratic pols involved in the fight, and HCR compares the sick-note signing to doctors who enabled the legal claims of minor car accident victims by medically legitimizing their fake symptoms. (Is this really the same thing? If so, do tell me what is in it for the docs this time around; accident-injury fakery yields a financial benefit for the doc, which is, to my moral compass, considerably more troubling.) db uses lots of words heard at White Coat Ceremonies and the like, intoning about the "sacred trust [between physician and] society."

Curiously, back in 2003, db (of whom I am normally a fan) not only chose not to utter so much as a peep about the potential dissolution of that sacred trust when doctors in New Jersey refused to see patients as a protest about malpractice insurance rates, he wrote several entries that were sympathetic toward them (such as here and here--the latter entry explicitly entreating us to understand the motivations of the physicians, while never wondering if it's maybe unbecoming for a physician--as well as a violation of that supposedly precious "sacred trust"--to tell a patient to go Shove It). Last year, when urologist Jack Cassell thought it a good idea to notify patients that, had any of them voted for Obama, they should seek care elsewhere, db did not see fit to call this man to account for what I would define as deeply unethical behavior (from what I could find on db's archives, at any rate), though perhaps he was unaware.

To be clear: I'm not so sure I'm supportive of these docs, and I do think they've gotten themselves into swift waters without, it appears, thinking carefully about the consequences of their actions (at the very least, they didn't take into account the political consequences, if not the moral ones). But this isn't the beginning of some fake sick-note movement, and none of these people are doing it for personal gain. I don't have qualms with raising doubts about the ethical wisdom of their actions, but the smell of sulfur coming from these heavy-handed judgements is a bit much for me.
--br

UPDATE: So far I appear to stand alone among doc blogs in not jumping up and down in blistering condemnation of the sick note scandal: GruntDoc's quick take is here and Retired Doc shakes his head here. RW Donnell, who against all expectations manages to once again defend the status quo, airs his thoughts here among various entries.

Michele Bachmann, the First Lady, Breast Milk, and Much Ado About Nothing

It makes for a very intriguing headline: could some political spat somehow realign self-identified liberals with Michele Bachmann, and conservatives with Michelle Obama?

At first, while glancing at the NYT headline, "A Breast Feeding Plan Mixes Partisan Reactions," I thought that perhaps the moon was indeed in the Seventh House, and Jupiter had aligned with Mars.

But as much as NYT and some other outlets would like to have you believe that we've reached the Age Of Aquarius, I'm thinking more that we've reached the Age of Same-Old, Same-Old, with a page from the Mountains Out Of Molehills playbook.

To recount the mini-saga, last week Representative Bachmann fired a broadside at the First Lady during an interview with radio host Laura Ingraham for "the government's role in breastfeeding," as Ingraham's website proudly chirps. Ms. Obama has been promoting breastfeeding for almost a year now, from what I can find on the WhiteHouse.gov website, but Bachmann was reacting to the latest news that the IRS had announced that breast pumps, which can cost up to several hundred dollars, would be available for a tax break. Bachmann first complained about the tax break--something very un-Republican like--by complaining that "government is the answer to everything." She then added, "to think that government has to go out and buy my breast pump—you want to talk about nanny state, I think we just got a new definition,” in classically Bachmannian rhetoric which is either exasperatingly stupid or chillingly cynical, since a tax break in no way implies that the government is going to purchase breast pumps for the mothers of America.

[That's my emphasis, by the way. Also, I have been unable to find the link to the actual IRS announcement, though many outlets report on it, as TIME does here, or ABC News does here--the ABC News link is dead.Typing in "breast pumps" into the IRS search engine turns up nothing, and searching IRS.gov on "breasts" does turn up a lengthy document released in August, though I could find no breast pump references while perusing it. Nor could I find a press release on tax breaks for devices designed for the liberation of boob juice. Needless to say, I am having an enormous amount of fun tonight.]

Anyway, the story received attention from media outlets in search of culture-war fodder or some such, and lots of outlets, even including ones across the Pond, ran with it. Which, no doubt, is precisely what Representative Bachmann had hoped for, even if the attack made no real sense: she's in the headlines. Maybe this is part of a coordinated effort to put her name in the mix for the 2012 Republican Presidential primaries, and chip into the Republican/conservative gal-appeal of Sarah Palin, who, perhaps sensing a missed opportunity, got in a shot in at the First Lady in a speech in Long Island.

Who knows? Who cares? But the Times article tried a new slant: the reactions from party loyalists were flipped. "On blogs and in interviews, some liberal Democrats found themselves agreeing with Representative Bachmann...some conservatives, meanwhile, stood up for Mrs. Obama for promoting what they said was a healthier choice," the Times reporter, Kate Zernike, observed.

Which is technically correct, as the article goes on to quote some self-described liberals siding with the utter nonsense of Ms. Bachmann, and conservatives siding with Ms. Obama. But as numbers go--and after a not-exhaustive and not-scientific but well-intentioned reading of comments at the soft-left Times, the soft-right WaPo, the harder-left Salon and a few other places to boot--I found no evidence of massive political realignment.  I found a small number of comments from self-described conservatives supporting the First Lady, a good many more criticizing her, and more than half of those totally missing the point...but no comments from liberals defending Bachmann.

(As a side note, I read the Salon comments with a certain horror--the comments section has become a den of lefty sleaze. On many topics I am of one mind with Salon's editorial staff, and I share in their righteous fury at the various injustices of the world, but reading the comments section of pretty much any Salon political article these days is chilling. Civility is considered quaint as commenters attempt to outvulgarize each other, and the menacing allusions to violence would make you think you had just walked into a Tea Party rally. It's disturbing.)

I was feeling quite proud of this analysis until I discovered this article from HuffPo that explains how Zernike used one anonymous commenter, and a second equally anonymous "progressive mother in Brooklynite" as a source to gin up what amounts to a fake article. NYT should be a bit embarrassed; if it isn't Billy is on their behalf.
--br

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Will Doctors Be Relevant in the World of Watson?

Like so many other people, I watched Jeopardy this week with rapt attention as I saw IBM's uber-computer Watson clean the clocks of Jeopardy's two greatest champions, Ken Jennings and Brad Rutter. My reaction--that of fascination bordering on the point of awe simultaneously mixed with a not insignificant amount of apprehension--was probably also shared by a good number of viewers. Did we witness the creation of something worthy of comparison to the Brandenburg Concertos, or Frankenstein? No way to know at the moment. Check back with the Billy Rubin Blog in about four or five decades. I promise to do a follow-up entry at that time.

While watching the informational clips during the Jeopardy show in the first round, where various Big Bluers explained the mission and the challenges of developing Watson, I was struck by how Watson could be used in medicine. Give it a patient who explains their symptoms, then feed Watson with basic lab or other clinical data, and you could easily produce a computer doc that would rival the best in the biz. IBM seems to have had the same thought, as Carey Goldberg of the CommonHealth blog notes, as they have partnered with Nuance Communications of Burlington, MA to set up computer systems built on the advances gained from the making of Watson.

Leave aside the rather terrifying fact that this could deprive me of a job in the decades to come, it's not hard to see the ways in which a Doc Watson could outperform a flesh-and-blood physician. Take, for instance, the news story this week about the neurologic event of TV anchor Serene Branson, which earned speculation from ER physicians as well as a Happy Hospitalist as to the diagnosis (for a prescient discussion of the media portrayal, see Gary Schweitzer's HealthNewsReview entry here). Leave aside the dramatic videotape of Ms. Branson for a moment. What's the diagnosis?

The immediate speculation was that Branson suffered a Transient Ischemic Attack or "mini-stroke." To me, this never quite made sense for the simple fact that Branson is young, and TIAs are typically a disease of people in their 6th decade and beyond. Of course, there are outliers, as demonstrated by the sad story of professional baseball pitcher Darryl Kile, who died in his sleep in midseason at age 33 and was found at autopsy to have obstruction of two major coronary arteries, which is extremely unusual for one so young. So although a TIA seemed possible, I thought that the list of possible diagnoses included things like Multiple Sclerosis, and since I'm an ID doc I immediately thought of neurologic diseases associated with HIV. Other docs weighed in on the blogs and several proposed the possibility that this was a complex migraine headache This is now the official diagnosis of the authorities who have cared for her at the UCLA medical center (though, as Happy notes, this pronouncement came from a neurosurgeon, which from a medical standpoint is very odd and not entirely appropriate).

The diagnosis might be spot-on but it's a tough one to make. What could a Doc Watson do that we couldn't? Watson would be able to take the patient's age, take the information from all the data generated by her care (vital signs, physical exam findings, the history of garbled speech, any pertinent information from her family and social history, labs and radiologic tests) and arrive at a mathematically precise risk assessment for each of these various diagnoses, just as it did in trying to answer Alex Trebek's questions. (Yes, I know, it's the other way around in Jeopardy. Let's just move on.)

That is, I can note in a vague way based on my learning in medicine that TIAs are less likely to occur in younger people, but I have no idea the precise numbers; for Watson, I would assume that it would be a small matter to incorporate hundreds of epidemiologic studies allowing it to calculate multiple probabilities for all sorts of diseases. It's not that Watson would be doing anything different than what we do every day when we form differential diagnoses on patients, it's just that Watson would have three huge advantages: it could access considerably more information than we can (we are limited by how much we can read, and then remember, while for Watson that's just a download), it can then take that information and process it orders of magnitude more quickly, and it can describe the likelihood of an uncertain diagnosis with a precision that is virtually impossible for a lone human physician to do in live time while seeing a patient.

I'm not a computer specialist and don't know the inner workings of Watson, but I don't think this is wild speculation on my part. I suspect that we're not far away from being able to feed information into Watson-like programs that will help our diagnostic accuracy increase tremendously in the years to come. I also suspect that there will come a point where Watson-like programs will obviate the need for physicians. Hope I'm retired by that point!

Hat tips to Grunt Doc, Gary Schweitzer, Happy Hospitalist, CommonHealth.
--br

Another Milestone

Among various items for which it is tedious to be Jewish, the adherence to the lunar calendar must rank relatively high. We're talking about a people who have won Nobel prizes in every field, far out of proportion to their actual numbers on this earth, leading the world in physicists, mathematicians, and astronomers. And they can't use a modern calendar? Leap months every few years? Please.

Its tediousness bothers me at this hour because tonight marks the end of my first year on earth without my father. That is, by the Christian, or Solar, calendar, call it what you will. And herein lies the problem: the official mourning period ended for me some several weeks back. But even then that wasn't the completion of a Jewish, lunar year, because for reasons which I am not especially curious, the mourning period ends at 11 months in Jewish tradition. Then there was the Jewish year marking...yet another date. And I am ignoring the two or three other periods of Jewish mourning, which include shiva (the seven days following the burial) or shloshim (the thirty days), each of which has its own particular rites & obligations. Fortunately, as I am just a hair shy of atheist, the specifics didn't trouble me a great deal, with the sole exception of the prohibition against shaving during the shloshim, to which I adhered, in what is perhaps a term not used in jest, religiously.

But in my spiritual clock, as it were, I always measured Dad's death by the date of February 15th. To hell with this lunar nonsense, I thought--I don't pay attention to the Jewish calendar in any other part of my life except to show up for High Holidays or Passover when I'm told. The truth is that I have not taken Jewish chronology into my bones, and the 11 months came and went without any reflection, without making a point to go to the synagogue to say kaddish (Pops could have cared less, which helps assuage my guilt in this respect), without any reckoning of any sort. But in my quiet moments over the past few weeks, I see his face in my mind's eye, I think about how much of my father's son I have become--against even my own expectations and understanding--and how this past year would have been had he been part of it.

Paradoxically (or, for those who know me, likely not paradoxically at all) I have found myself in these moments taking comfort in about the least respectful of ways, saying to myself things like it's almost been a year since Dad bit it or yep, he sure bought the farm when he went to get the mail. I have giggled with a certain childish giddiness of the magnificent tribute paid to Graham Chapman by his Monty Python alum and longtime collaborator, John Cleese: "he's kicked the bucket, hopped the twig, bit the dust, snuffed it, breathed his last, and gone to meet the great Head of Light Entertainment in the sky." On New Year's Eve, a friend asked a truly loving and caring question about how my mother has fared since father's death, and perhaps a bit too mischievously I immediately flipped back, "actually she's been doing really well. She's really risen to the occasion. Dad should have died more often."

I'm glad I said it as I not only think the line is funny, but I think Dad would have laughed at it. And I'm glad to have a laugh when I think about him even in death, as I loved to tease him in life, especially after I overcame my fears of this man whose quiet thoughtfulness intimidated the oft-loquacious-and-not-nearly-as-thoughtful-me for many years. But the mirth is short-lived, and the truth undeniable: my heart is broken. I do miss him, and doubly so as I tried to make up for lost time once I figured out exactly how to be his son, as well as the fact that I am as much my father's son as I am my mother's--something much easier to spot, for me as well as everyone else. For nearly four decades our similarities had escaped my notice; now I ruminate upon them often.

I write this tonight not to excessively hash over these details (though readers will kindly forgive for the little bit of hashing I have done above), but rather to write about the toughest reckoning of all surrounding his death. To wit: I experienced his death both as a son and as a doctor, and I remain undecided as to whether I've screwed the pooch. But let me explain a little.

My father had reasonably clear instructions in his "living will" that he did not want what we in the biz would call "heroic measures." That is, if, say, his heart stopped beating, he would not want anyone to start CPR or shock him or do much anything else. For an in-hospital strategy, that works fine, but Dad's heart chose to stop beating out by the mailbox for the condo association. A neighbor, who of course knew nothing of that living will, called 911. The EMTs arrived and were able to resuscitate him. I can't and don't blame anybody for "saving" Dad's life at that point. But after that things get murky.

The blow-by-blow of the next ten days is unnecessary to recount, but the gist is that he underwent a series of maneuvers designed to give him the best chance of not only surviving "the event," as we call it (it was almost certainly something known as Sudden Cardiac Death, though even that's a loose term), but surviving it "neurologically intact." My sense from the start was that we needed to get the tube out of my father and let him die. It wasn't that I didn't want him to pull through. It wasn't--or at least I think it wasn't--that I had seen enough cases of patients like this to know the steep odds he faced in having anything approaching a "meaningful" recovery. Rather, it was the knowledge that a ventilator isn't what he wanted! Yet despite this we had doctor after doctor, from the ICU attending to the PCP, continue to tell us to stay the course.

Several days of back-and-forth passed until I finally said that he would be extubated or I would leave, and my mother agreed. We approached the hospital and explained our position, said that we understood the recommendations of the doctors, but were no longer in agreement with them. The following morning my father's primary care internist relented and acquiesced to our demands--though not without a subtle parting shot where he said, after acknowledging our position, that "it's not something I would do for one of my family members." Dad was extubated that morning, and died a few days later.

And there's the rub for me. I spent a week trying to be such a good doctor and seeing the reasonableness of their point of view, as well as their medical management, that I may have forgotten how to be a good son in the process and fight for what my father wanted, which was to be left alone. (For what it is worth, I have no qualms with their medical management; as far as I am aware all of the doctors involved in his case made fine medical judgements.) In particular, I have spent much of the past year unclear if I have been furious with the loose ethics of Dad's PCP, who imposed his own ethics onto the situation without regard for Dad's wishes (which might be shorthanded as live at all costs), or if I am just disappointed with him and understand that he made a tough call with which I might disagree but hardly one that deserves scorn. And, since my identity is split between son and doc, I have vacillated on even whether I am angry, flinging myself into meta-analysis upon meta-analysis, or am just trying to manufacture anger on my father's behalf, since I see the quandary of the PCP, who pushed, pushed, pushed for us to keep him, and hope, alive. Not how I'd play it but totally justifiable from a medical standpoint. So am I a furious son, or a distant doc? Search me.

What fills me with dread is that I may be bringing that shit into a room when I admit patients on Friday nights. I am not Sir William Osler--while I think I am a very competent doc I have never quite been able to make medicine sing like a few of my fellow residents--but I do pride myself on my ability to communicate with patients and their families. If I have a strength, it is in helping families through the kinds of moments that my family went through one (solar) year ago. But I can't tell at the moment whether I bring that damned baggage into those rooms, and I don't know when I'll be able to sleep soundly knowing that I haven't let my own experiences get in the way of what I do very well, at least in my own opinion. Thus I am being tested but have no way of knowing the grade.

Until I can find some internal method of ascertaining my own emotional and intellectual response, a one-year anniversary can't serve as a marker for some kind of closure for me. Pops may rest in peace, but his son the doc continues to cope in the aftermath, wondering how he did as a son, wondering what it has done to him as a doctor.
--br

Industrialization Comes to a Small Hospital

If the relationship I have with the University Medical Center where I work is like a spousal relationship (substantial, committed, long-term, serious), then the hospital where I moonlight is more like a friends-with-privileges arrangement. I 've been moonlighting at this small hospital (about 200 beds) for the past five years now, and my feelings for the place are unquestionably fond, but my emotional and spiritual investment in it is minor. I use her for a little extra sustenance, not merely financial, as I like the people there and they--shockingly and inscrutably--appear to like me back in turn. In short, I like her but I do not love her. I want her to thrive but my heart will not be broken if she doesn't.

That said, my heart did a little breaking this weekend when I strolled in for an evening shift, ready to enjoy the give and take with patients and staff alike, and emerged 10 hours later having bade farewell to five employees (four docs and one secretary) that I had come to respect. They are all headed out the door, and while each has some particular reasons for departing, they all share one common motivation: the hospital is "industrializing" its hospitalist work force (using it for lack of a better word, I am definitely open to suggestions), and about 40 percent of the current hospitalist group has decided nearly en banc to look for greener pastures. Amazingly, after these departures are complete and the new crop of docs comes in, I am going to end up being one of the graybeards of the group, either the second or third most senior of the hospitalists...perhaps apropos since my actual beard has been sprouting grays & whites more insistently these past few months. What I find somewhat sad and slightly disconcerting about this is that I am, among the medicine physicians at least, becoming the one with the longest institutional memory.

But let's backup a moment and explain how we got here.

This hospital used to operate on the old model: if a patient was admitted to the hospital under the medicine service (i.e. not for a surgical procedure), the patient was usually under the care of that patient's primary care physician. I'm oversimplifying things here, but since internal medicine had begun to get significantly more complicated in the '80s and '90s, that old model, where the outpatient doc doing rounds and writing orders at 7 a.m. on the way into office hours, became increasingly impractical. The "hospitalist" movement sprang up as a consequence, and a new specialty was created: full-time inpatient internal medicine doctors whose sole job was to take care of internal medicine patients during a hospitalization.

At my hospital, about 10 or so years ago a few physicians began hospitalist work, and they would contract with particular medical groups to take care of that group's patients when they were admitted. When I first came to moonlight there that first hospitalist group was small, covering perhaps a third of all the patients admitted to the hospital. If a patient was admitted, the ER doc would call us, and we were supposed to check to see whether the patient belonged to our contracting medical group, and if they didn't we were supposed to inform the ER that such a patient was the "responsibility" of some other group. Since I found spending 15-20 minutes figuring out who "owned" such-and-such a patient rather tedious, and since I was moonlighting at least in part to maintain my hard-earned internal medicine skills, I just admitted everyone they told me to without concern for the primary physician, and accepted the frequent lectures from some of the full-time hospitalists the following morning when I found out that 5 of the 8 patients I admitted didn't "belong" to the group. (Their group still made money off those admissions since they could bill for them, while then as now I was paid to work by the hour, so I don't feel so bad about the whole thing.)

Anyway, once the primary care physicians saw how much contracting with hospitalists relieved their work burdens, a clamor arose to expand the hospitalist group, and the hospital started placing direct pressure to achieve this, because if the PCPs could find hospitalists at the other nearby small community hospital, then my hospital's revenue stream would start to dry up. The problem was (and I say this from the perspective of an outsider who watched from afar, so take my observations both with a grain of salt and at your own risk) the group couldn't expand fast enough to keep up with the demand. This led directly to a major problem, which was that the hospitalists who had been recruited had to shoulder larger and larger amounts of work, and see more and more patients, in order to keep up with the demand. The hospital, feeling perilously close to losing its patient base, mandated that within 6-9 months the hospitalist group be prepared take on all of the patients previously seen by the PCPs. But there weren't enough boots on the ground: each individual hospitalist was seeing more than 20 patients a day, which is far too many to do good medicine on a daily basis, and so morale sank. A few people departed, making matters worse, since larger amounts of work had to be shouldered by even fewer hospitalists.

Long story short, the hospital became concerned enough to take the program over and administer it directly. They promised to recruit more physicians and resolve the morale problem by lowering the patient census for each doc. I was skeptical and on the verge of hanging up my spurs, wondering in particular how the hospital thought it was better situated to recruit nearly a dozen physicians where the private group had failed, but over the next several months I was pleasantly surprised to see the administration deliver on pretty much all of its promises. I stayed on and met several new colleagues with whom I was proud to work. I thought that this little community hospital had solved the riddle of creating a stable hospitalist group, with at least some of the docs serving for years to come, becoming part of the fabric of not only the hospital, but of the community as well. And what better way for a community hospital to achieve its mission than by effecting this change?

Alas--that happy arrangement lasted about 18 months. While the hospital managed to succeed in a stellar manner in creating and sustaining a decent group of physicians devoted solely to the hospital and its patients, it came at a high cost. Literally. I have no idea of the numbers involved but by the summer of last year the administration began discussions with various companies who would take over the hospitalist group and administer them. The one they chose to take to the prom is a for-profit company, listed on the NYSE I am told, who must have promised huge savings for the hospital. Whence my term "industrialization": I remain uncertain as to whether this is the optimal word. Either way, the affairs of a major chunk of how this hospital runs was going to be dictated by a company run from far away, with its primary concern for the economic welfare of its shareholders rather than the health of the community who live and sometimes die within the hospital walls.

The administration found the pitch so irresistible that within the span of a few months, they went from trying to "explore options" with the hospitalist group, to submitting a take-it-or-leave-it offer to each individual physician that they become employees of this "hospitalist corporation" or submit their resignations. (To digress briefly, from my own narrow standpoint their offer seemed quite handsome, as the corporation would cover my malpractice insurance, which costs me nearly $10 thousand per year--that covers several nice bottles of zinfandel, I can assure you--and I was not required to work a minimum number of shifts for coverage.)

So over the past 3-4 months I watched with dismay the hospital re-create the exact situation it was trying to solve when it first took over the group, and this weekend I saw off some colleagues that not only will I miss, but much more importantly my "girlfriend" the hospital will as well. And this was just a quirky night where my schedules intersected with theirs: there are several other physicians who also chose to call it quits whom I haven't seen.

What kind of financial alchemy does this company perform to both make a profit for itself and save money at this not-for-profit hospital? After all, they can't increase the revenue stream unless they have a plan to make everyone in Small New England Town sicker, or unless they plan to blow up Other Local Community Hospital. Cutting costs may be part of it but I haven't read anything in the documents I signed that rewarded physicians by limiting test utilization, an approach that's totally reasonable in concept and very difficult to execute in reality.

Again, because of my very part-time status, my answer is far from definitive, but my suspicion is that they're not giving us a new wheel so much as repackaging the old one. Which is to say that the way they will generate more revenue by increasing the individual doc's workload. Overhead for hospitalists is relatively small (depending on how a hospital would charge a practice for things like office space and computer access), but salary is huge. Cut the size of the group by a third and you've found a lot of previously missing money--I'm thinking something approaching $2 million based on my back-of-the-napkin calculation for this particular hospital. I have no experience with hospital budgets, but for a hospital of that size, I'm guessing that's a serious amount of cash. Some of that, of course, will go directly to the pockets of the shareholders of Hospitalist Corporation, but the hospital stands to benefit from this arrangement.

As to whether the whole venture will succeed, I have no idea. My nature is to be suspicious of anything tied to the term "for-profit," and doubly so when it applies to entities involved in healthcare. But that is--to appropriate a term from RW Donnell--a bias, and it may well prove to be a faulty one in this instance. At this particular moment in the life of this particular hospital, its influence cannot be described as anything other than destructive, but I remain open to the idea that this new, industrialized relationship might benefit everyone by the time we next sing Auld Lang Syne. To say that I am optimistic, however, may be saying too much. We will see, and barring an unforeseen event, I'll be around at least long enough to see the immediate effects of the transition, which takes place in less than a month.
--br