The Profit Motive In Medicine

A vascular surgeon at Portsmouth Regional Hospital mentioned in his profile in the catalog of doctors that he had "trained with Dr. DeBakey," which caught the Phantom's attention. Everyone else listed their medical school, residency and fellowship training program but for this guy saying, "Baylor, Houston Methodist" would not do, as he may have thought that wouldn't mean much to New Englanders, but that DeBakey name would.  This particular surgeon became locally famous for never doing surgery. Mostly, he did not respond to consult requests, but on the rare occasions he did respond, he declined to operate. This can get the attention of the ICU staff when faced with a patient with a cold blue leg needing an arterial bypass. At his two year review, it was pointed out to this surgeon he had done only two surgeries and that did not justify the expense of his salary, and he disappeared.

That sort of extreme desultory behavior is unusual in medicine and, in particular, in surgery, but it is likely the sort of story administrators love to trot out to show how important it is to have administrators riding herd on doctors who would otherwise not show up to work.

In the Phantom's own department were two other doctors and one, a woman with two kids below the age of three, saw patients Monday through Thursday but on Friday she showed up in scrubs (rather than a white coat and dress) for her "surgical day," during which she did thyroid ultrasounds and, when necessary ultrasound guided needle biopsies of thyroid nodules. On those days, she saw only about four patients, rather than the usual 20-25 and she was home to her kids by noon. She missed days when her kids got sick and she was out for 3 months after the birth of one child. So, at her two year review it was pointed out that the number of dollars she generated compared to that of her two colleagues was substantially less and her salary would be cut.

She immediately resigned, in a huff, having stayed 3 years at this practice and she moved on. In that, she was in the mainstream of her cohort--many if not most young women physicians moved every three years when they learned they would not receive a raise in pay.

So, yes, the Phantom is aware that not every doctor is driven and a work horse. The idea that we are workers like any other sort of workers, and we move from job to job, from patient panel to patient panel based on the dollars is now accepted as a fact of life.

On the other hand, there are instances where the profit motive drives medical practice into dark places. 

The hospital in Portsmouth was run by a for profit corporation. It was set up as most systems were set up in those days: the hospital itself was flanked by two office buildings with doctors' offices which contained practices covering most medical specialties: including neurology,  rheumatology, oncology, endocrinology, and primary care. Unlike cardiology and gastroenterology which have lucrative procedures to bill, these "cognitive" practices broke even or even, some years, lost a little money in billings v overhead. 

The general concept is that the office practices "fed" the hospital, sending patients to the ER, to radiology, to the laboratories and all the other "in patient services." While doing so, the office practices provided care for the communities which surrounded the hospital.

But on day,  the administrators in Nashville looked at the corporate offices and they shut down the break even practices and saved a lot of overhead--office rent, staffing, phones, supplies. Primary care physicians were replaced with nurse practitioners and physicians' assistants, who cost less and could be booked for a patient every 10 to 15 minutes.

It turned out, the hospital could be "fed" by a few Urgent Care Centers placed in neighboring towns and the volume of hospital business pumped along just fine, with no drop in ER visits or radiology studies or lab studies ordered.

Mad Cow Disease

The administrators who did this were not bad people, certainly not monsters: they were simply doing their jobs, which was to increase profit, to increase the value of the corporation for the shareholders. They were, we heard later, "heroes" back in Nashville for having cut all that overhead.

Of course, all those patients with arthritis, diabetes, cancer, chronic lung disease back in Portsmouth, New Hampshire and in the surrounding communities were now bereft of care, but that was not the job, the mission of the administrators in Nashville, whose job was to increase profit. 

One day, a patient showed up at the Phantom's office with a letter from his insurance company informing him they would no longer cover the cost of his insulin pump and its supplies. His type 1 diabetes had been spectacularly well controlled for five years on his pump, with HbA1c levels, which measure overall blood sugar control in the normal range. But that did not please the insurance company. Somewhere, someone in the insurance company, reviewing the medical records we dutifully supplied the company, saw these normal numbers and said, "Oh, these numbers are all normal! We do not need to continue to pay for someone who is now normal, who no longer has disease!"

As if "tight glycemic control" is actually "cure."

The Phantom tried to telephone "the company," between patients but got nothing but the "your call is very important to us, please hold on," and he assigned a medical assistant who wound her way up the line of clerks and "patient care facilitators" and "community health advocates" and kept asking for a doctor for the Phantom to speak to--a "peer to peer," exercise where one doctor talks to another, the treating doctor and the insurance company doctor. It turned out the patient's insurance company had subdivisions and the part that insured the diabetes might have been different from the rest of his health insurance--it was never clear. In the end, by the time the Phantom's medical assistant went home at five p.m., having not been able to attend to any other patient that day, leaving the Phantom to call in prescriptions and do all the clerical stuff she usually did, and slowing down the machinery of the office that day so patients were kept waiting impatiently, there was no solution to the problem.

Delay, deny, desist. 

So, the health insurance company, like the company which ran the medical practices at Portsmouth, was profit driven. Private enterprise, devoted to reducing costs and keeping a tight rein on the budget. 

There may be other services which are not best run by private enterprise in search of keeping their organizations lean and mean: power companies, water companies, highway and bridge maintenance, meat and food inspections, fire fighting, police, coast guard, the Navy--things where cutting costs undermine the basic provision for the common good.

But somehow, all these other "public services" are accepted as better organized to service the public good rather than to serve profit. 

Alexandre Yersin, Conqueror of Plagu

In America, health care not for profit is communism, socialized medicine and a sign of impending doom.

And, oddly, the very people most likely to rail against socialized medicine benefit from their own socialized medical care:  military medicine, VA medicine and health insurance for US Congressmen and Senators (which is provided through an insurance so generous as to be basically government owned.)

So, we beat on, boats carried by the current, rudderless, drifting past riverbanks, headed toward the sea of oblivion.

The Imaginary University

 

Should you be fortunate enough to be admitted to the three year Phantom University,* and insane enough to matriculate, your course work will vary according to your major, which you may construct for yourself, or simply follow as outlined by the various academic departments, but  whether an engineering, pre med or philosophy major, you will be required to complete satisfactorily the three year course, "Introduction to Nothing In Particular," and the reading list is long, although entertaining. 

Phantom University

Woe be to any student who arrives in class having not read the book for discussion, because AI and Cliffs notes or Wikipedia will not save you. You will be called upon in class to comment on a particular remark, passage and you won't have time to Google it. Attendance is mandatory. Class participation is mandatory, may be excruciating, but that is the point. Education at Phantom University requires engagement, or "l'engagement" as the French would say, which means exactly the same thing but sounds so much cooler in French.

Humanities Quad

So here's the list, to be picked up, hopefully second hand, at the bookstore, or on Kindle, or signed out from your library online. How you come by the texts is of no concerned to Professor Phantom--did I mention Professor Phantom, the President of the University, teaches this course without teaching assistants?-- the only concern is that you have actually read the piece under discussion.

Library

Semester 1, Year 1: 6 weeks  (Female in a Man's World)

1. The Prime of Miss Jean Brodie, Muriel Spark.

(Extra credit: See the Maggie Smith movie, compare and contrast)

2. Play It As It Lays, Joan Didion

3. Memoirs of an Ex- Prom Queen, Alix Kates Shulman (Extra Credit: Living My Life, Emma Goldman)

4. Final Payments, Mary Gordon 

5. The New York Ride, Anne Bernays

6. The Last Picture Show, Larry McMurty

(Required: See the Movie directed by Peter Bogdanovitch)

Semester 2, year 1,  6 weeks (Origin Story)

7. The Adventures of Huckleberry Finn, Mark Twain

8. Silence At Appomattox, Bruce Catton

9. Animal Farm, George Orwell

10. The Guarded Gate, Daniel Okrent

11. Goodbye to Berlin, Christopher Isherwood

Extra Credit: Movie, "Cabaret"

12. Before the Deluge, Otto Friedrich

Semester 1, year 2, 6 weeks: (Quiet Desperation)

13. Looking for Mr. Goodbar, Judith Rosner

14. Little Big Man, Thomas Berger

(Alternate: The Movie--Dustin Hoffman)

15. The Pawnbroker, Edward Lewis Wallant

(Alternate: The Movie--Rod Steiger)

16. Miss Lonelyhearts & The Day of the Locust, Nathaniel West

17. The Bell Jar, Sylvia Plath

18. Slouching Toward Bethlehem, Joan Didion

Semester 2, year 2, 6 weeks (The Grand Sweep and those Swept Up)

19., 20. A People's History of the United States, Howard Zinn

21.West with the Night, Beryl Markham

22,23., Dark Continent, Mark Mazower

24. War Is A Force That Gives Us Meaning, Christopher Hedges

Semester 1, year 3, 6 weeks (Class, Society &  Self)

25. My War Gone By, I Miss It So, Anthony Lloyd

26, 27. Battle Cry of Freedom, James McPherson

28. White Trash, Nancy Isenberg

29. Lady Chatterly's Lover, D.H. Lawrence

Required movie: Laure de Clermont-Tonnerre director

30. The Wire, Season 1

Semester 2, Year 3 (Alienation by Fire)

31. The Wire Season 3

32. The Wire Season 4

33. The Paranoid Style in American Politics, Richard Hofstadter

34. If I Die In A Combat Zone, Tim O'Brien

35. The Stranger, Albert Camus

36. Parachute Infantry, David Kenyon Webb

* Phantom University offers BA, MD and JD degrees. The undergraduate program is 3 years, as are the graduate programs, following the British model, which seems to produce better educated individuals in 3/4 of the time it takes American universities. 

The campus is located above the 41st parallel, as the Phantom, its founder, believes no university located below this latitude can provide enough adversity to be a real university: To wit, the universities at Santa Barbara, New Orleans, anywhere in Florida are just too amenable to homo sapiens to foster any sort of honing of survival instincts. It's a variant of "I walked 5 miles through the snow to school." 

The buildings and architecture are neo-Hogwarts and the faculty is aged, sometimes decrepit and hand selected by the Phantom on the basis of actual, true, brain certified scholarship. 

For example, the Dean of Students, and head of the Department of What Matters is a graduate of the University of New Hampshire at Keene State and is the most thorough going scholar the Phantom has yet met--she never fails to read the footnotes, the references and the references within the references. She asks embarrassing questions whenever possible, and is simply the smartest person in the room on every occasion, and she has been in the room with Larry Summers, Bernie Sanders and Scott Brown. She denies knowing Jeffrey Epstein but cannot recall if she has ever met him.

Admission requirements are so exacting and discriminatory that no student has yet qualified for admission, but the Phantom remains hopeful. 

SAT's and ACT's are optional, but won't impress anyone. Starring roles in feature length films will be considered as part of the admission portfolio, but applicants are warned that the film criticism department has been known to make Pauline Kael look like a shill for People Magazine, and they will review your performance. 

Applicants who are certified in plumbing, HVAC, electrician services may be granted full scholarships on a work/study basis. (The buildings are old.) Auto mechanics, same deal.

Military veterans will be considered on a case by case basis, or on a war by war basis, whichever applies. 

Athletes are welcomed, but the university competes in no leagues and has no stadium.  

Swimming, baseball, wrestling, crew, tennis, rugby, football, golf are supported, in that order, but there are no coaches. 

State of the art gymnasium, weight rooms, swimming pool and fields are supported just as soon as we find rich patrons to write the checks.

Theatre arts, film making and film criticism are highly valued and may be your ticket into the school, just as soon as we get Spielberg, Geffen or Tom Hanks to write the checks. 

Music is a high priority, but the university has refused to support faculty until it can offer enough salary to make it worth their while. So far, Josh Redmond, Herbie Hancock and Susan Tedeschi have not been approached because we could never pay them what they would be worth.

Painting, sculpting and such like are allowed, but not supported. Rooms may not be heated, although northern light is provided.

 

A university infirmary is available just as soon as Elizabeth Warren gets the bill through Congress, with prevention of sexually transmitted diseases a priority. We know the demographic we are dealing with here. Also contraception.

The university does not embrace "diversity" although it's happy when it happens in our classes, but we are not talking about race here, to which we are indifferent, but class. "Inclusion" is a given. If you are admitted, you are in, or included or whatever you want to call it. "Equity" is discouraged, as people who decide to read all the assigned stuff will be treated way better than people who fail to engage the assignments, who will be expelled for non participation. 

Geographic distribution is not a priority. Race is not considered. If we find ourselves with a class of 400 Asians or Blacks or Blonde Caucasians, we will be happy if we think these are the best individuals we can find. 

 

 

Interviews on campus are required. Transportation to campus will be paid for by the university, just as soon as we can get Delta airlines to buy in. 

All rooms on campus are singles. 

Grades are recorded for each student for each course, but not shared with the student. 

Faculty are not required to write letters of recommendation for students, but if you are any good, they typically don't mind.

Students must vacate the campus the day after graduation and are never allowed back on campus and cannot contribute to the university thereafter.

The university will certify students have graduated but otherwise wants nothing to do with you once you are gone from campus.

The Sociopath On The Train

 

From Professor Google:

Sociopath: consistent disregard for the rights and feelings of others, lack of conscience, and manipulative behavior. Key traits include deceitfulness, aggression, impulsivity and an inability to distinguish right from wrong, often without remorse for their actions.

Distinction from "psychopath" may be artificial, although psychopaths said to more often be successful, owing to a consistent quality of deceptiveness which plays to other people's good will.

Apparently, the term "sociopath" has fallen out of favor but the Phantom saw one on a train ride out of New York just now, on a trip south and all his bells were ringing inside his skull: "SOCIOPATH!" And it was a little thrilling, however disturbing to observe.

So here's the story: The Phantom was riding in the business class of the Amtrak from Boston toward Washington, DC. He had spent the extra money because he wanted to ride next to his wife and she wanted to face forward so to be sure of assigned seats, you have to pay for business class, otherwise you're in coach, which is cheaper, but you may not be able to find two seats together, especially during the mayhem of train travel in the Northeast corridor three days before Thanksgiving. 

In New York, a thirty-something, maybe mid twenty something man takes the seat across the aisle from us, and he immediately spreads out over his aisle seat and the window seat, bringing the trays for both down and loading them up with three computers, not to mention at least one, maybe a second monster Apple phone.  He's also got some sort of technical journal spread out on the tray. 

The man is wearing a trim Navy blue hoodie with "New York Energy" emblazoned on it. Googling that, Phantom discovers these were very trendy after the NYC Marathon and were very hard to find or purchase. It's a sort of Kate Spade bag for men, or maybe a pair of Jimmy Choo shoes. He has a large diamond ear stud. He wears Diesel jeans or some sort of very pricey jeans and what are likely pricey sneakers, although the Phantom is insufficiently informed about sneakers. Jimmy Choo sneakers, maybe. He looks like young, conspicuous but very trendy money.

When the conductor makes his way down the aisle this man shows him his phone  and the conductor says, "Oh, this is a coach ticket," you'll have move. The next six cars are all coach. 

"Oh," the man says. "So sorry." The man is Asian and he sounds like he doesn't speak very much English, which might explain how he did not notice or was unable to read all the "Business Class" signs above his seat, suspended from the ceilings of the car, and on the doors at each end. 

The conductor continues on down the aisle but the man makes no move to leave. The Phantom's wife says, "He's not going to move." 

"Well, when whoever has bought that seat arrives, he'll have to move," the Phantom reassures her while she stares knives in his direction.

Sure enough, the man continues to work his computers and remains in place. 

Then he gets on the phone and, speaking very unaccented English he engages in several phone calls, the last one, makes him agitated.

"I don't care if your supervisor is busy. If you want to retain my company's business you'll fucking get your supervisor on the fucking phone! And I mean, like right now."

He continues to harangue whatever poor soul has the misfortune to be on the other end of the line.

His English, however profane, is very good. Like a native.

Around Philadelphia, a somewhat overweight, abused looking man arrives toting a suitcase, over the shoulder computer case and he looks at the seat numbers and finally concludes the Asian guy is sitting in the aisle seat but occupying with computer stuff the window seat this man has paid for. 

"You'll have move that stuff and let me in," the man says.

The Asian guy looks up from the phone and reverts to "I can barely speak English" saying, "Oh, so sorry. Just wait a moment. I'm on the phone." 

The train begins to leave the station and the man says, "No, I cannot wait until you've finished your phone call. I need to get to my seat so move your stuff and get up and let me by."

The Phantom's wife is enjoying this immensely--all  she needs is  a bag of popcorn.

The Asian guy collects his things and moves two seats down the aisle to an empty aisle seat. 

The conductor comes by to collect the tickets from the passengers who got on at Philadelphia and the Asian guy having no yellow paper slip over his head as a ticketed passenger who has been logged in by the conductor would have, and the conductor asks for his ticket and once again gets the phone ticket and tells the Asian guy he has to move to the coach car. It's the same conductor who had told him to move before but the conductor never returned to make sure he had moved. 

"Oh, so sorry," the Asian guy says. This time the conductor looks back at him as he continues collecting tickets from other passengers and the Asian guy gets up with all his stuff and walks back toward the coach car. But he ducks into the bathroom at the far end of the business class car, just before the coach car.

"You know," the Phantom tells the conductor. "You hear about 'If you see something, say something?' Well that guy never did leave business class when you told him to an hour ago."

"Yeah," the conductor says. "There's always one."

"And right now," the phantom says, "He's hiding in the bathroom."

"Yeah," the conductor says. "I'll hang around this time."

Another conductor comes by, a woman conductor and the two knock on the bathroom door and the Asian guy emerges and walks into the coach car.

The conductor looks at the Phantom. "There's always one," he says. "A sociopath. Rules don't apply to him."

"Happy Thanksgiving," the Phantom's wife tells the conductor.  "Mine already is."

Truth and Accuracy in the Blogosphere: Ad Hominen

 

Recently the Phantom was intrigued by a criticism of the Phantom's favorite blog-- which he considers almost as indispensable as the "Hitchens Resurrected" channel on youtube--a criticism which concerns accuracy and "fact" checking. 

The case arose over Trump's reaction to the statement by six Democratic Congressman--all veterans of the military or intelligence services--to the effect that soldiers must be aware of their obligation to disobey illegal orders, an obligation which emerged from the Nuremberg trials after World War II where the Nazis on trial invoked the defense, "I was only following orders" to defend themselves against charges they had herded Jewish women and children into a building and then burned them alive, or other such ghastly crimes, which, the American and Allies argued violated a basic sense of right and wrong common to all civilized people. 

Shot By National Guard: Kent State

In the context of modern day America, Trump quickly perceived that these Congressmen were warning National Guard soldiers that beating unarmed and defenseless men and women, and throwing them into vans for the crime of speaking Spanish near a construction site might come back to haunt those Guardsmen. 

National Guard Shooting Unarmed Students

Trump said he wanted those Congressmen arrested, tried and they should face execution.

These Guardsmen Were Never Arrested

Mad Dog had found that especially piquant because Trump, who evaded military service owing to his famous heel spurs has later (reportedly) echoed the mafioso's creed that you owe no loyalty to your country, and should serve only one group, your family. This was most famously and precisely depicted in the movie, "The Godfather," in the scene where the brothers are gathered around the dining room table on December 8, 1941, awaiting the arrival of the Godfather himself, and someone mentions that 30,000 men had enlisted in response to the attack on Pearl Harbor the day before. Sonny, the eldest of the brothers smirks, shaking his heads, saying those men, swept up in patriotic fervor to serve and defend their country are "saps." 

https://www.youtube.com/watch?v=435mkg6_eGQ

It is a perfect display of the conflict between the Old World values of clan, tribal and family loyalty colliding with the newer concept of loyalty to a nation state and it is one of the most important scenes across all of the Godfather saga, and provides the cultural subtext for this film series as noir literature, and it echoes through scenes of Michael walking through villages in Sicily emptied by blood feuds among families, which make the Hatfields and McCoys look like playground skirmishes. And it reveals the contempt these men hold for the American military. And it is perfectly reflected in Trump's (reported) derision of American military as being "losers" and "suckers," on a trip to Normandy, where he refused to get out of his limousine and walk in the military cemetery there, and his words (which he claimed were "fake news") were not captured on tape but were reported by the New York Times, the Atlantic and other sources.

(Of course, this report in the Atlantic magazine was a bombshell and Trump denied saying it, but it has had such durability because it fits Trump's cynical "the game is rigged" and all the poor people are being played by the big guys who pull the strings. Trump is Sonny incarnate. Or Michael, for that matter, as Trump was once asked  on camera about a murder ordered by some foreign leader and he said, "Oh? And you don't think American Presidents kill people?" That's a video the Phantom saw with his own eyes. It echoed precisely that scene when Michael says exactly the same thing to his girlfriend, defending his choice to enter the Mafia Corleone family as the Don.)

So, Mad Dog, referring to all this, said that Trump had no love or respect for the military but was only concerned about these Congressmen undermining his own authority, and Mad Dog said Trump viewed the military as saps and fools, rather than the Atlantic's reported, "losers" and "suckers."

The point being, Trump spoke derisively about people who enlist and serve in the military, echoing Sonny's contempt. Mad Dog had conflated one phrase of derision with another, his critic averred. 

Now, you may ask, why did Mad Dog not simply say Trump has spoken derisively or contemptuously about people who serve in the military and let it go at that?

The reason is that it is stronger writing to give an example of what you consider derisive rather than simply allege what was said was actually derisive--present the facts and let the reader see for himself the nature of the remarks and what underlying values they reflect. 

Not using the actual words allows Trump to wriggle off the hook, "I never disparaged the military!" Well, if you called them "losers" you disparaged them. That echoes the Bob Dylan song, "Join the army if you fail." Or if you call them suckers, then you are right back to Sonny Corleone, and all that is contained in quoting the words. 

But if you say Trump referred to patriots rallying to the flag as "fools" and "saps" then Trump's defenders can say, "He never said that!"

Of course, that is a distinction without a difference.

And, never mind the problem of what is a "fact." Without a video/audio tape nobody really knows whether Trump said, "saps and fools" or "losers and suckers." And even with a video/audio, Trump will claim it's all deep fake, fake news and never happened. He sat in that limousine and refused to walk in the cemetery in the rain because it was raining and his comb over would dissolve.

But we can believe Trump was saying anyone who joins up is a small person being manipulated by propaganda from the elitist, rich and powerful, because that's been his pitch from the get go. It really is of a piece with the old Communist jibe that a bayonet is a weapon with a worker on either end, meaning, of course, German workers who were conned into joining their army wound up fighting Russian workers who were conned into joining the Russian army, but they were both actually on the same side, that of exploited working class fools, who allowed themselves to be manipulated by rich capitalists who are fighting over profits.

In this case, fools, saps, suckers and even losers are pretty much identical, with only minor differences in connotations for the word "losers," but not really: They all refer to people who were conned, misled, not bright enough to see their own interests on each side of the bayonet. 

So the critic who upbraided Mad Dog for inaccurately saying Trump uttered the words "losers" and "suckers" rather than "fools" and "saps" was insisting on a distinction without a difference, was missing the forest for the trees, was blind to the abstract point of derision and focusing instead on what was not true about that statement rather than what clearly was true.

This is a sort of argument called "ad hominem."

And one thing you can say for AI and Google, it allows for simple, direct and clear explication, so here it is:

The technique of "seizing on an irrelevant inaccuracy to undermine an argument" is known as the ad hominem fallacy, or a personal attack that distracts from the actual point being made. While not exclusive to any one political group, it is a common tactic used to redirect an argument by attacking the person rather than their position, often to evoke an emotional response rather than addressing the logic of their argument. 

How it works

• Focus on the person: Instead of engaging with the substance of an argument, the attacker focuses on a perceived flaw, inaccuracy, or character trait of the person making the argument.
• Create a diversion: This is done to shift the focus away from the original topic and create a distraction.
• Ignore the facts: The inaccuracy may be true or false, but the key is that it is irrelevant to the validity of the original argument itself.
• Appeal to emotion: The tactic often relies on emotions and prejudices to make the opposition's case seem invalid, even if the underlying reasoning is flawed. 

Example

• Original argument: A person presents data on climate change and proposes a specific policy.
• Ad hominem response: "That person is a liberal elite who has never lived in the real world, so their opinion on climate change is worthless," or "They once got a statistic wrong in a different speech five years ago, so everything they say now must be a lie."
• The technique: This response avoids a factual debate about the climate data or the proposed policy and instead uses a character or past error to dismiss the entire argument.