On Being Heard

Every year there is a convention of American Booksellers. When I published my first book, years ago, my publisher ushered me in, and I was stunned. The Washington Convention Center covered a full city block, and the floor I was surveying covered that entire expanse with 50,000 books, all published that year. 

And I thought, how is my book ever going to get anyone's attention in all this?

The answer was, it wasn't. Mine was a voice, unamplified, lost in that ocean of voices all straining  to be heard.

I understood that old story about a child who grew up in a family with ten children. He never spoke a word and nobody noticed because everyone was always talking, at him, over him, for him.

And there is the questioin asked by Samuel Johnson, "Why is it there is so much writing in the world, and so little listening?"

Somewhere, in most human beings, is a desire to be heard, to express one's outrage or observation.  In Treme John Goodman plays a character in post Katrina New Orleans, a professor of English at Tulane, who records a UTube rant about how he and everyone in New Orleans is being ignored, not being heard, and he is outraged by what has happened to the city he loves.  Oddly, he has writer's block and cannot get going on his novel about New Orleans, even though he's got the advance in the bank, or maybe because he's got the advance in the bank.

Beneath all this is an idea somewhere, that talking, writing a blog, is a wasted effort.

If a tree falls in the wood and there is no ear to hear it, does it make a sound?

I would have to say, yes, but it doesn't matter.

The same may not be true of writing a blog. If nobody reads it, it is still a message sent, like those probes sent into outer space for intelligent beings who may never hear it. At least there is a reaching out, just in case, some day, someone will hear.

Or, even if nobody ever hears, you have had a conversation with yourself, and that, in the end, may be the most important audience.

 

The Days of the Giants

NB: I first published this as The Road Taken, in a hospital newsletter, some years ago, but I've had occasion to remember these events recently.

When I was fourteen, my good friend suggested the worst thing about being a doctor would be that all my friends would be doctors, or at the very least, I’d have to spend a lot of time hanging out with doctors.

Actually, in retrospect, that has proved to be one of the best things about medicine—not that all my friends are doctors, but the doctors I met along the way turned out to be one of the best things about medicine.


Take the neurologist, Kathleen F. , for example. When I was a third year medical student, I was lucky enough to draw Dr. Kathleen  as my resident for the six week neurology rotation. She had been one of the four women in her medical school class of one hundred and she was the only woman I ever heard of who landed a neurology residency in a department headed by a very famous chief of Neurology who thought women would always be mothers first and doctors second, and never as committed to the profession as men, and so he refused to appoint a woman to his faculty.

But even he had to give Kathleen a spot in his residency program--not because there was any political force in those days which would have motivated him, but he gave her a residency spot because she was a stellar medical student. He was the co-author of the classic textbook, Stupor and Coma, the Chief of Neurology, but if he believed in the idea of meritocracy, he had to give Kathleen a residency, even if he would ultimately refuse her a faculty position.

The first thing which struck me about her was how fragile she looked: Five feet five, no more than one hundred pounds, very blonde hair and skin and eyes so light blue they were almost white. I could well imagine her in her plaid Catholic school skirt and patent leather shoes, but she wore a white skirt and short white jacket, pockets stuffed with reflux hammer, tuning fork, ophthalmoscope, packets of coffee for testing the olfactory nerve--Kathleen tested each and every cranial nerve in every patient—stethoscope, and the notebook in which she kept the names and numbers of patients she would call in for admission to the neurology ward.

She was all business, but she was a hummingbird among the bears on that ward.


Life on the neurology ward was rigidly punctual: The four medical students arrived at six a.m. to draw bloods on the forty patients; Kathleen  arrived at six-fifteen and did teaching rounds from six-thirty until seven fifteen; then the students fanned out on the ward to do patient chores until ten a.m. when the Chief arrived to do his harrowing, teach-by-humiliation rounds. The rest of the day went downhill from there.


On the days she was on call, I shadowed her doing consults on the wards, in the emergency room, wherever her beeper took us. One night, well after midnight, we were called to the ER to see a seventy year old man who had become demented over the prior three weeks, started falling a lot and taken to bed.


It was a pro forma consult: Nobody expected Kathleen  to do more than take a quick look and reject him for the neurology ward, which was for neurologically interesting cases, not for garden variety cases of dementia, which went to the general medical wards. But Kathleen kept jerking his foot with her hand and kept looking at his tongue, wriggling in his mouth. I was leaning with my back against the wall, nodding off, when I heard her say, “Do you know what this is?”

I had to admit I did not and she informed me it was myoclonus and I should go home and read up on it for morning rounds, which were now only about five hours away. She admitted the patient to the neurology ward with Jacob-Creutzfield disease, which she had diagnosed at one a.m., in a dark ER stall, by physical exam and history alone, picked him out of all the other demented old “gomers,” filling the ER.


The next morning, the Chief of Neurology examined the patient on rounds and had to agree the patient had Jacob-Creutzfield and he moved on to the next patient, as if there were nothing remarkable about this. Of course, medical students came from all over the hospital to see the patient,--interns and residents, too. Her dark hours diagnosis added to Kathleen's  local renown, but she never showed any sign of special pride about it. She treated her coup as casually as the Chief had.


Later that week I had to present a case to the Chief, a patient with a parietal lobe tumor. Kathleen  prepared me rigorously, so I could point out all the findings and she warned me the one thing which was not explained by the tumor was the patient’s significant memory deficit and we went over how to handle that part of the case in the presentation. The Chief listened intently with the expression he reserved for student presentations, which made him look as if he was smelling something nasty, but he did not interrupt me, nor did he castigate me as being unworthy of taking up space in the highly select medical school, nor did he grunt or snort. I kept pausing, waiting for his slings and arrows, which never came.

Finally, he asked about the memory deficit, just as Kathleen had warned me he would and I answered exactly as she had prepared me to answer and the Chief turned to Kathleen  and the other residents and said, “This presentation is just a little too perfect. Did any of you tell this student what to say? Did any of you prepare him for this?” He was looking directly at Kathleen.


She met his glare and said, simply and directly, “No, sir, we did not.”


Later I pulled her aside and said, “How many Hail Mary’s are you going to have to say this Sunday? I presume bearing false witness is still a sin.”


She said, “The Chief is not a normal person. The best thing to do is to do your work and stay away from him.”


Our next on call night, we got called down to the pediatric ward to see a fourteen month old in the pediatric ICU.

We were met by the Chief Resident in Pediatrics, the junior resident and two medical students and they all had a stricken look I hadn’t often seen among housestaff at that hospital. I understood, when they told the story: A twenty year old single mother had her child by one hand and a bag of groceries in the other, and she walked up the three flights of stairs to her apartment, holding the kid with one hand the groceries with the other. She lived in one of those apartment buildings with an Alfred Hitchcock type stairwell, where you could look down over the banisters four flights, right down to the cement landing in the basement. The mother had eggs in the grocery bag and rather than setting down that bag, she let go of her child’s hand, reached in her pocketbook for her keys, turned to unlock the door and in the time it took to get the key in the lock, her child managed to squirm through the banister rails and plunge four flights down, head first, to the cement landing.


We were being called to say if there was any brain activity or to pronounce him brain dead.


I watched over Kathleen's shoulder as she examined the rag doll child, as she went through all the tests with which I was now familiar, Babinski’s and so forth, but what I found myself looking at was not the child, but Kathleen's  ears, which had gone quite crimson. She had her hair up that night, and you could see her ears. Kathleen was the mother of a child about this kid’s age. She went over him methodically, as she always did, but after about five minutes, she reached in her pocket and got out a tissue and wiped her eyes and blew her nose. Then she finished examining the baby.


I followed her out to meet the residents in the ICU and she told them she would see the mother in the conference room, alone. She dismissed the residents and the students and headed into the conference room and sensing I was still with her, she turned around and said, “I’ll do this alone. Hold my beeper. Answer any pages. Wait for me.”

This was the first and only time she did not allow me to stay with her. I was just a happy, but I also knew she was sparing me something nobody had much stomach for. And she was thinking of the mother. She was in there a long time. Then she came out, totally composed, and we got in an elevator and I handed her back her beeper and reported there were no more consults to see, for which I was grateful, because it was now approaching two a.m. So we stood in the elevator together staring at the overhead numbers and I said, “You okay?”


“Yes,” she said. “Don’t be late for rounds.”


I suppose I could have gone into some other sort of work, and there would have been rewards, and talented, intelligent people. But if I had, I never would have been instructed by Kathleen, never seen her grace under fire and tried to emulate it.

And I would not have met all those whom I met later, who sailed with her, guided by the same stars she followed, those people who combined toughness, rigor and kindness who call themselves doctor.

Marketing Mayhem

Reading Howard Zinn last night about the numbers of English males who volunteered for duty and were promptly slaughtered during World War I, I was struck by the idea that we tend to repeat the past, but, if there is any consolation, as bad as Viet Nam and Iraq and Afghanistan have been, they have been only pale reflections of what others have suffered through the marketing of the idea of "Patriotism" or the mass indoctrination of what you owe God and Country.

World War I was fought for the flimsiest of reasons--people are still trying to figure out how that one started, who drove it, and who benefited, but clearly, whatever got that one going, it was not to make the world safe, or to make it safe for democracy or for whatever other reasons were given by the English government, the German government or the French or the American governments.

As Slim Charles tells Avon Barksdale in The Wire,  "Don't matter who did what to who now. Fact is, we went to war. If it's a lie, then we fight on that lie, But we got to fight. That's what war is, you know."

Slim Charles is a street hood in Baltimore, He hasn't gone to school. He's been schooled on the streets. And, as if in testimony to Paul Simon's line, "When I think back on what I learned in high school, it's a wonder I can think at all."  Which is to say, if you are living your life outside the mainstream, your mind is not distorted by all the marketing and indoctrination. 

So it is the little child who can see clearly that the emperor has no clothes. He hasn't been schooled not to see the truth.

Zinn takes us through a month by month slog through WWI with the English general making some idiotic decision to send waves of soldiers across fields as Wellington once did, only to have them mowed down by modern machine guns. So 600,000 are lost in a month. Then another 500,000. Whole armies of Englishmen are mowed down. And on the home front people are told to not think they know as much as the general who is issuing these orders.

Know your place. Don't disrespect your betters.

And here we are listening to secretaries of defense, four star generals talking about "The Mission" in Iraq and "The Mission" in Afghanistan, as if there were a real mission in either place.

What is The Mission?

To deny Al Qaeda a "Safe Haven?"  What idiot would believe you can deny a group of 19 men a safe haven? Groups so small they can live in an apartment in Germany or a hotel room in Florida, and you think you can destroy them by invading a country as big as Texas, where the people don't speak your language and they can hide in mountain caves?

So, if it's a lie, then we fight on that lie.

One of my favorite series is Band of Brothers. If The Wire is a dystopia about dysfunctional institutions, then Band of Brothers is a story about an institution which actually did work, or at least an institution which bumbled into success. Certainly, you see the American army making stupid mistakes--giving parachute troops a bag to carry their equipment which they were supposed to strap to their ankles and jump out of the plane--and popping this on them after two years of training, giving them this untested bag the night before their jump into Normandy. And the bags, containing weapons and ammo simply blew away, leaving troops landing without weapons. And the night jump leaving troops miles from their targets. But, somehow, the officers and men were trained well enough to overcome obstacles and they succeeded.

As is typical of a Stephen Spielberg production, there is a heavy lard of sentimentality which nearly destroys the story.  In the episode titled, "Why we fight," the 101st airborne stumbles onto a concentration camp. This happens just after a scene where one of the soldiers has told his comrade he doesn't fight to win a war, but to simply survive and, at least, to be able to use toilet paper again and to sleep on a bed with real sheets rather than in a foxhole. This same soldier is stunned by what they find in the concentration camp. And the moral of the story, is that's what we were fighting for, to defeat a hugely evil entity--the Third Reich.

The problem is, how can you say the why you are fighting is for something you never knew existed until after you had defeated it.

You took on faith, you believed the marketing that you were fighting on the side of God. But the other side was told and believed they were fighting you because they were on the side of God. (The Germans wore belt buckles, Gott Mitt Uns.)

So it's not why you fought. You can't invent a motivation retrospectively. You fought because you wanted to for other reasons. Because you bought into the idea of heroism, of God and Country or for the adventure, or to escape boredom and a sense of meaninglessness. But you did not fight to free the victims of Nazi Germany who were buried in concentration camps you knew nothing about.

We were hoping to find weapons of mass destruction, mass graves, something in Iraq to justify our crusade, but we did not. So why did we fight there? Because we believed the line Saddam Hussein was evil. He probably was, but no more evil than a dozen other despots. Why him?

We fight on that lie.

As for Osama Bin Laden, well, I'll accept on faith he was a murderous man--or on the possibly tampered evidence of his Internet videos in which he spewed hatred toward America. He may or may not have had much to do with 9/11, but he was apparently a cheerleader, so I'm happy he's dead.

But what lies have we been sold about him?

You have to believe there are haters when you watch the evening news and see the random bombings of trains, subways, markets. There are haters out there for us to hate, hunt down and fight. But, how can we trust the people who say they know who the villains are and how to get at them?

I haven't figure out that part yet.

Karen Sibert, MD and Don't Quit This Day Job

--Bring All Your Medications in a Bag to Your Next Office Visit


Dr. Karen Sullivan Sibert wrote a lovely, politically incorrect, thoughtful, incendiary op ed in the Sunday New York Times about the effect of women in medicine who believe their first job is being a mother and their second is being a medical doctor.

Dr. Sibert writes in the long tradition of the older physician looking disapprovingly at the younger doctors who follow, who seem less committed, who seem soft, coddled and insufficiently tough and dedicated to be worthy of the world's most demanding and ennobling profession.

From Googling her, it appears Dr. Sibert is about 58 years old, graduated from Princeton in 1974 and from Baylor Medical School ten years later in 1984--so there was a gap between her college and her beginning medical school of about 6 years, during which she may have got married, had a couple of kids and got a start on raising them.

She practices in a specialty which is demanding in the sense of requiring a physical presence with the patient, after hours on call and long stretches of uninterrupted attention to a single patient.  On the other hand, Anesthesiology is one of those four specialties  of the ROAD to happiness, being high paying, relatively less demanding in time and on call--the others being Radiology, Dermatology and Ophthalmology.

Residency training programs are the most competitive for these spots, presumably because medical students now look to these coveted spots as the doorway to a happy life of prosperity without much pain.  The dermatologist does not get called in on weekends or nights, and really does not need hospital privileges and his patients do not get very sick and when they do, he hands them off to the oncologist or to someone else.  Radiologists often do not see the patient at all, dealing only with images of the patient, and so never has to give bad news or answer vexing, emotionally draining questions. He simply speaks to the referring physician and sends the patient the bill. Ophthalmologists do have to meet the patient face to face and they have some pretty delicate and sometimes nerve wracking surgeries to perform, but for some golden years, ophthalmologists gave up all those more taxing parts of their specialty and opted out of vitrectomies and cataract surgery for LASIK surgery, which was low pressure and highly compensated.

I was reminded of the National Public Radio show which reported a confrontation between the Dean of Medicine at Mount Sinai Medical School in New York city and a fourth year medical student who had been top of his class, but who chose a training program in Florida of minimal academic standing. He could have done his gastroenterology training at the finest Harvard programs and the Dean was disappointed his name was followed by a community hospital program and it made her list of graduating seniors look bad.  The student said, "If I trained at Harvard, I'd be slaving away doing research for some faculty twelve hours a day, trying to learn endoscopy and colonoscopy during the remaining six hours. In Florida, I can do my colonoscopies from 9 in the morning to three PM and be on the boat with my family by 4 PM."

Such were his values. He knew why he went to medical school and what he wanted from medicine.  He was honest enough to say so to his Dean's face.

It reminded me of my encounter with the Chief of Medicine when I was a fourth year medical student. I had just finished a fourth year elective down at New York University in the department of dermatology. I loved it. It had just enough surgery, lots of patient interaction, a wide variety of diseases and instant diagnoses.  I brought in the form for a recommendation from the Chief of Medicine for the derm program at NYU.  Cornell, my school, did not even have a department of dermatology. The Chief held up the form between finger and thumb as if it were a soiled piece of toilet paper.

"We have trained you to save lives. You did a nice job during your subinternship in Medicine. You learned how to bail out patients in sepsis, how to get a deathly ill patient through the night, alone, with confidence. And now you want to leave medicine? For this? We were going to rank you highly for a spot in our internship class. But we want to train people at this institution who are going to go out and save lives."

I slinked out of that office with my tail dragging along the floor.

Those were the days when you were either a doctor or you were ashamed of not being a doctor once you got the chance.

There was no mention of time on boats or of time with family.

But eventually, the younger doctors refused to go to Saturday morning Grand Rounds because they could not go to their kids' soccer games and they argued Grand Rounds could be held during the week. They put forth the argument that family time was a reasonable thing for doctors to demand, that the medical profession could be arranged to accommodate family life. Male doctors said this, not just female doctors.

It is true female doctors take more time off, work part time more often, but male doctors do not put in the hours or sacrifice home to profession the way they once did.

And when you make the argument about precious and limited places in medical school, well that is true if you are talking about Baylor or Columbia P&S or Duke. It is no so true of Florida State and who knows how true it is  of any of the hundred plus chiropractic schools which grant DO degrees?

And, the fact is, from my viewpoint in New Hampshire, many if not most patients get their primary care from nurse practitioners or physicians' assistants who are practicing independently of physician supervision.

What Dr. Sibert is really complaining about is the devaluation of what it means to be a physician. You work really hard to get into a school like Baylor. You take ridiculous courses (of doubtful value) like organic chemistry, calculus, physics, which are designed to cull the herd, not to select the best physicians and surgeons. And when you get that degree, you feel proud.

But then you see others, who are also called "Doctor" who do not seem to place the same value on being the best physician, the most dedicated physician they can be. They seem to look at the profession as if it were, at best a trade, something to generate profit, and not the focal point of their lives.

But then again, when I was a medical student the old dinosaurs used to disparage the interns and residents who were training me because they worked only every third night on, rather than every other. In the Days of the Giants when men were men (and their were few or no women doctors) you worked every other night, which meant you worked all the time. Your night "off" was just a recovery night to sleep and when you awoke, you were back on the ward.

Trouble with the Days of the Giants, the patients were not as sick; there was not nearly as much you could actually do for the patients and there was only a 50/50 chance of helping any patient. Now the odds are much improved; the technology has transformed medical practice--thyroid sonogram has supplanted thyroid physical exam; endoscopy has replaced hourly hematocrits;CT and PET and MRI have made autopsy confirmation of diagnosis less critical.

Things have changed.

Money has driven most of these changes;  technology has driven other changes.

But mostly, we have a dysfunctional system of selecting tomorrow's doctors and a dysfunctional system for training them. We have Deans and Chiefs who do not embody toughness and dedication. 

At a forum for parents of medical students a graduating fourth year student told his story of having been accepted to Columbia P&S and going into the Dean of Admissions saying he wanted to defer his acceptance so he could work at Goldman Sacks for a year, to get the finance bug out of his system. (And to earn some money for medical school.) The Dean agreed.

In my day, the Dean would have said, "If you are so insufficiency dedicated, we withdraw our acceptance." Medical school admission was a glittering prize. You had to prove yourself worthy of it.

That's not true at too many medical schools any more.

Patriotism on Memorial Day

The flags are out today, all along Exeter Road and High Street in Hampton, New Hampshire.
It's Memorial Day and the American Legion, which has a building right across the street from the bank, with a gun from the USS Wilimington out front and a stack of cannonballs has men wearing those American Legion hats standing around the front door.

On days like this I get a rush of images blowing by my eyes: The local Democrats beginning their meeting with the Pledge of Allegiance, the look on my high school teacher's face when we started discussing Henry David Thoreau's On Civil Disobedience, the face of a man I met who had his eye, hand and part of his foot blown off in  Viet Nam, who had nothing but dismissive contempt from the "Professional Veterans" he saw down at the Viet Nam Memorial the first and last time he went down there, the picture from Butterfield's wonderful pictorial history of the United States, showing American soldiers standing on top of piles of Filipino bodies from the Spanish American war, a war American school children never heard about when I was in school, and the photo in an article in the New York Times Book Review, of the former head of Fannie Mae, some guy name Johnson, who pocketed 100 million dollars for his part in the financial collapse which greeted President Obama upon assuming office, and the photo of Sanford Weill, who was responsible for getting a Depression era law repealed which was meant to prevent the occurrence of another Depression, but the law had stood in the way of Weill's making a profit, so he threw enough money around Congress to get it done. He made untold millions, and just to show he was a good guy, he donate $150 million to Cornell University Medical College and got the school renamed, after himself. 
    
      So all that streams by. 


      And I think about the fact this country is the only country I'm aware of which ever fought a war, and a the most costly war of all our wars, to free an underclass, to free our own slaves.  So you have to give us some credit. 


      But, as anyone who has not been in the military but who has seen The Band of Brothers or Full Metal Jacket can appreciate, the reasons men join the armed forces to go to war are seldom love of country. Each joins for his own reasons. Very few do what that professional football player did, drop a million dollar career and join the Army to go fight (and die) probably pretty much in vain, in Afghanistan.


      Thoreau said the real patriotic serves his country best not as a "wooden solider" but with his mind. The real patriot asks himself and his government why going to war is necessary and in the interests of his fellow citizens, and analyzes the answers he gets with ruthless dispassion. I did not understand what he meant by "wooden solider" in high school, but I know now. And, having lived through the Viet Nam years, I agree with him.


     As for the Pledge of Allegiance, well, all I can say is any "patriotism" which is easy is not patriotism at all. It's just all "Zeig, Heil," feel good, group hug and worse than useless.


    And as for America being the best country in the world, well, it may have become that, although the competition is not stiff. But we have a very sorry past to consider, to be informed by.  We had white American boys of the most murderous persuasion giving vent to their unwholesome passions from the Phillipines at the turn of the 20th century, to Viet Nam in the middle to Abu Gharib in Iraq, so there is very little to be proud of there.


    On the other hand, we fought a war which helped defeat Hitler, and we did fight that great war to free the slaves. And don't get miss led by later revisionism. Just read Lincoln's second inaugural address--he clearly says everyone knew, at some level, the slaves were the cause of the conflict. More succinctly, when he met Harriet Beecher Stowe, who wrote Uncle Tom's Cabin
he leaned over and shook her hand (she was just about five five tall) and he said, "So this is the little lady, who wrote the book, that started the great big war."


     

Atul Gawande: Knowing What Good Is

Atul Gawande delivered the commencement address at Harvard Medical School this year, and it was published in The New Yorker.

The Phantom would like you to know, right from the start, he is a big fan of Dr. Gawande, of Harvard Medical School and of The New Yorker (not necessarily in that order.)

But there is something disturbing about Dr. Gawande's remarks, and I'm having trouble distilling just what it is that bothers me.  The word "facile" keeps percolating up, and that's not a word I'm fond of.  But it sort of gets stuck in place, somewhere in the higher cortices, blocking synapses and I'm stuck with it.

Here's how it breaks down: First, there is the history of medical practice as depicted by Dr. Gawande, which does not fit the history I have lived through over the past decades. I think I can speak for almost the past 50 years of medical practice even though I haven't been in medicine quite that long--I have my sources.  Second, there are the claims about what ails us now (an unwillingness to work in groups and big organizations). Third, there is the solution, or set of solutions (checklists, identifying best practices, insisting on these clearly identifiable best practices and using this approach to solve the financial problems of American healthcare) and Lastly, there's the endorsement of where our new young doctors are heading, the skills they seek and the values they embrace.

History as He Sees It:
"We are at a cusp in medical generations."
                 I heard that at my own graduation nearly forty years ago and have heard it every year since. It seems medicine is forever on the cusp of something.

"When doctors could hold all the key information patients needed in their heads and manage everything required themselves."
                 He alludes to 1937, and maybe doctors could know it all then, but clearly, I did not think I had a chance to know it all, forty years ago. Even when doctors were mixing up their own medicines, I doubt they thought they knew it all. There was never a use-to-was like this, the good old days when things were simply and a doctor could know everything.  Good doctors have always been humble enough to know how little they knew.

"One needed only an ethic of hard work, a prescription pad, a secretary and a hospital willing to serve as one's workshop."
                  Dream on. Never was such a time.

What Ails Us Now:
"Two million patients pick up infections in American hospitals."
"Forty per cent of coronary disease patients and sixty percent of asthma patients receive incomplete or inappropriate care."
         I'm sure he's referring to some study or another, but ask yourself,  how would you design a study to actually figure out exactly where patients picked up their infections and whether or not patients were appropriately treated? First you'd have to know exactly when and where those infections were acquired and you'd need to be able to know really adequate coronary and pulmonary care when you saw it and you'd need really nifty metrics to figure out how often this care was delivered. 
         Just a for instance: When beta blockers were new, back in the 1970's, the worst thing you could do with them was to give them to a patient in congestive heart failure. Giving spironolactone to a patient with congestive heart failure was thought to be pissing in the wind--more potent diuretics meant good care. Aspirin was thought to be irrelevant. Today, quality of care people track beta blockers, spironolactone and aspirin as indices of good care.  So what was bad to ineffective care then is good care now. Do you really think these things will still be good care ten years from now? So how do we get so high and mighty about knowing what the right thing to do for Americans hearts really is?

"It's like no one's in charge--because one is."
            Again, teamwork and working as part of a big system is nothing new. As a medical student and an intern, forty years ago I worried I could never survive in private practice because all I knew was my part as part of the big wheel of the hospital. I realized there were dozens of people who were behind me every time I treated a GI bleeder, from the lab techs to the blood bank techs to the nurses to the guy in the ER who screened the patient.  Cooperation is nothing new in American Medicine.

"Medical performance follows a bell curve, with a wide gap between the best and worst results."
          Interesting if you could actually identify metrics for what makes for good medical performance. This reminds me (you knew this was coming) of The Wire that wonderful scene where Howard "Bunny" Colvin tells his young detective sergeant, Carver, about the destructive effects statistics have had on police work. When all you care about is how many arrests you've made, or how many pounds of heroin you've seized, you stop talking to the woman on her stoop, who might tell you who raped the girl down the block, or who shot the kid in the street. You're too busy buffing your statistics; you don't care about getting to know the woman on the stoop.


The Solutions:
"You must acquire an ability to recognize when you've succeeded and when you've failed for patients."
              He's right about that. What is more interesting is how.
"People in effective systems become interested in data. They put effort into collecting them, refining them, understanding what they say about their performance."
              Actually, I couldn't agree more. This is really Moneyball , which every doctor should read. When you just care about batting averages, you miss better metrics, like on base percentage.

"The simplest checklist...[can allow us to] eliminate many hospital infections, to cut deaths in surgery by as much as half globally, and to slash costs, as well."
             He's written a whole book about checklists. He is a true believer. But the first sign of aging is when you find you are repeating yourself.  I really like checklists. Use them all the time. If they are good enough for airline pilots, they are good enough for me.

"The recognition that others can save you from failure no matter who they are in the hierarchy."
             This is really a cool idea. Not new, but very cool. When I was a third year medical student, I was astonished when the circulating nurse in the OR told the surgeon, who everyone was afraid of, to reglove because he had "Broken scrub." The system was in place then, as I'm sure it still is. The nurses watched the surgeons and no surgeon could pull rank when it came to breaking sterile field.

The New Young Doctors Will Save Us
"I see this in the burst of students obtaining extra degrees in fields like public health, business administration, public policy...Of some two hundred students graduating today, more than thirty five are getting such degrees, intuiting that ordinary medical training wouldn't prepare you for the world to come."

        I'd love to believe this. But another way to see it is this new crop of physicians and surgeons are not committed to medicine; they have seen the future and they realize they need a way out of medicine.  Or as one fourth year student told his Dean, "I do not want to do research. I do not want to teach in a medical school. I want to do my colonoscopies from nine in the morning to three PM and be on the boat with my family by 4 PM." 
       And this is the generation of medical students who call the ROAD to happiness Radiology, Opthalmology, Anesthesia and Dermatology--specialities which have the following characteristics :1/ High income  2/ Minimal interaction with patients 3/ Good, predictable hours.

      So Atul, I love your enthusiasm and your drive to improve medical care in America.
      But as my mother, who taught high school, once told me, when I asked her what the job of a high school  principal is,  she replied, very simply:  "He has to know what good is. And that's no small task."

Certain

"Why is it the stupid are cocksure and the Intelligent full of doubts?"


Every day, I listen to people who cleave to beliefs which fall into all sorts of disparate categories: There are beliefs which sound as if they are correct: Like the idea that the federal government is  spending more than it brings in and this means we are headed for certain disaster; there are beliefs which sound right, initially but then you said, "Wait, what?": Like the Republican/Tea party/Rush Limbaugh mantra that deficits are the fault of the Democrats and if only the Republicans controlled the Senate and the White House, we would proceed forthright to the promised land.

But then I ask, how does that heckler I heard on the radio know with such certainty that government spending, such as we are currently doing, is sending us down that slick tube to perdition and destruction? When you listen to other people who just might have some grasp of the numbers, as I did last Sunday when Paul Krugman, an economist,  said actually we are not spending at historically high levels and we might actually be better off, in the long run, spending more, creating jobs and infrastructure which are in fact an investment in the future, it makes me wonder how that heckler (who had gotten herself to a town meeting with some unfortunate Congressman) how did she know about government spending and its dire consequences?

As for the deficit, which John Boehner assures us is the fiery abyss, then why is he unwilling to tax the rich, tax the oil companies, in short, take steps to increase the government's income?

The Republicans are always comparing the economy to our household budget, always put us at the kitchen table with the bills and the pay stubs--they make it all so simple.

But when times have been tough at home, I went out and sought ways to increase my income. There was a certain amount of spending we either could not reduce or which did not seem prudent to reduce, so I earned more.

And that's what the Republicans seem to so blithely not be willing to see: Need more money? Raise taxes.  Add new taxes. Get us out of the recession, and people will have jobs, pay more taxes and then we can cut back on those individual taxes because the tax base will have expanded.

But somehow, this does not seem a possibility to John Boehner and Mitch McConnell. It does not fit into their belief system.

So there we have it:  Unshakable beliefs are the immovable object. But what do the Democrats have in the way of Irresistible force?