Master and Commander and The New Reality of Health Care Phantom Perspective

I had not been an intern more than three weeks when the ward nurse roused me at two A.M. because an eighty year old man was short of breath. He was more than that. He was bubbling over in pulmonary edema, literally. Froth of yellow, blood tinged stuff was spilling out of his mouth.

The nurse looked to me for orders and I told her to get the crash cart, and when she returned I ticked off each step I had been taught to do: I slapped in two large bore intravenous lines, one in each arm, gave him morphine through one and furosemide through the other. She inserted a catheter through his urethra into his bladder which she hooked up to a Foley catheter so we could see if he was responding to the furosemide by making urine. We hooked up an electrocardiogram and I ran off a twelve lead and could see the wildly elevated ST-T wave segments and knew he was well into a myocardial infarction.

We applied rotating tourniquets from the crash cart, one on each arm and leg.

All this took about fifteen minutes and he was still gasping for breath.

The nurse asked if I wanted to call the cardiac team, but to my mind the cardiac team was for cardiac arrests and he hadn’t arrested, yet. I didn’t want to sound a general alarm and wake an anesthesiologist (who would intubate him and hook him up to a respirator) a senior resident, a cardiology fellow until I had run through every step I had been taught.

I can’t say I had been drilled on any of this, but we had gone over this stuff in a session the first week of internship.

“He’s not looking so good,” the nurse said. “He’s not responding.”

I asked for the phlebotomy bottles. She wasn’t sure she knew what phlebotomy bottles were. I described them to her as they had been described to me and she remembered seeing them in a cabinet. She arrived and they were just as advertised and I plunged the business end of a large bore needle into the patient’s femoral artery and one liter of blood was sucked out of him and filled the glass bottle faster than  Jack pops out of a box.

The patient drew in a deep sigh and said, “Oh, that did it. Much better.”

We had broken his pulmonary edema.

I called the cardiac care unit and the resident, a year ahead of me in training came down and looked at the EKG and heard the story and said, “Good job.”

I was one proud intern.

The next day, on morning ward rounds the head nurse, who had been a head nurse about ten years and whose opinion mattered to me, looked at me when we arrived at the patient’s empty room—he had been trundled off to the cardiac care unit—and she said, “So I hear you do not flinch when the battle is joined.”

That made a lot of afternoons spent in malodorous organic chemistry laboratories on beautiful fall afternoons all worthwhile.

Last night I watched Master and Commander ,again. I love that movie for many reasons, but one of the most important is it is a wonderful coming of age story, and the scene where Captain Jack Aubrey continues his lesson on the use of the sextant to his midshipmen as the French cannon balls whiz around them, ignoring all that as an annoying distraction resonated with some of my own training on the wards.

But more than that, is the picture of what it is to be a man, a leader, a hero, to stand fast and not to falter and to grow and to do things which require training and heart and execution. It’s all there.

Jack Aubrey decides to pursue the dangerous foe, to take risks, to put his exhausted crew and himself through great travails because that is what it means to be a warrior, to defend his nation on the last battlefront before invasion of the homeland.

I mention all this because just this past week we had a discussion at our Clinical meeting and the new reality of medical practice became apparent.

We were talking about getting an electrocardiogram in the clinic. We are a subspecialty clinic. We take care of people with thyroid disease an diabetes. Until I arrived, I infer, none of the doctors listened to any patient’s heart with any regularity. They did “focused” physical exams, which is to say, they palpated the thyroid on thyroid patients or looked in the eyes at the retina on diabetics.

I listen to the heart on diabetics, on the grounds diabetes is a major risk factor for heart disease.

But if the patient has heart disease, my younger colleagues argued, that’s not our job. Send the patient to the cardiologist or to his primary care doctor or nurse.

But when I listen, about twice a week, I hear a rhythm disturbance called atrial fibrillation, or what might be atrial fibrillation (AF). AF causes strokes, so if the patient has new onset AF, then we should make that diagnosis and call his cardiologist and get him seen so he can be anticoagulated.

Just send him to the Emergency Room if you are worried, I was told.

But think how you’d feel, if you were the patient. You might not even need to go to the ER, if all I’m hearing is the more benign APCs or VPCs.

No, said the young woman doctor who is my colleague, she did not want to be responsible for interpreting the EKG.  She could get it wrong and get sued.

My younger male colleague, who is a very bright man and a very well trained subspecialist said, “You know the one time I did think I heard something and got you and we went over to the medical clinic and got the EKG, it put us both behind by almost an hour. And we’ve got to see fourteen patients a day. We just don’t have time to get involved like that.”

The nurse manager pointed out we had no method in place to bill for EKG’s and the extra time spent would not be credited to our “Productivity Assessment.”

Later she came by and said, “You are an old dinosaur. You were trained to put the patient first. It’s not about that any more.”

And I thought of a dermatologist I saw once for a mole I wanted excised. She was perfectly well trained to do this but she didn’t want to, because, she said, she had set up her beautiful office with its section of skin care products she sold by the front desk and she had an idea of what her practice would be like and it made her uncomfortable to think if this pigmented lesion did turn out to be a melanoma then she’d have to call me with the news, which would be unpleasant for her.

This is a woman who trained at Duke and Harvard.

And I thought back to a time decades earlier, when I was a fourth year medical student and I had just finished a six week rotation in dermatology, and I had loved the surgical aspect of it and the immediacy of the diagnoses and I had a form for the Chief of Medicine to fill out recommending me for a dermatology residency and he said, “You want to be a dermatologist?”  I gulped hard. “We’ve taught you how to save lives and you want to be a dermatologist?”

I withdrew the paper and slunk out of the room.

Now dermatology residencies are great prizes. Only the top of the class. No call. No nights. No weekends. But most of all, tons of money. Move through those exam rooms fast as you can and charge lots of money for small procedures. And no stress. No worry about losing a patient bubbling over in pulmonary edema.

Jack Aubrey would puke.

President Kumbaya

Paul Krugman says it. Letters to the editor of the New York Times from all over the country echo the sentiment. 

It's not that President Obama misled us, posed as something he wasn't and transmogrified once elected.

He did not--or as we now know--could not throw a punch during the campaign, when Sarah Palin used him like the bully uses the fat, soft kid on the playground.

I still like the guy.

But the country needs a leader.

Someone has to tell John Boehner and Mitch McConnell and all those Tea Party deep enders who travel with them,  "You want tax cuts? Fine. You got 'em. But none for the millionaires. That's the line in the sand. You want to hold all tax cuts hostage to your millionaire contributors, you got it. We've got the best Congress money can buy, it's been said. You want to prove that true, dig in your heels.  

The Republican leader of the Senate says publicly his top priority in the coming two years is to be sure I am not re elected. His top priority is not rescuing the economy. His top priority is not creating jobs. His top priority is not even protecting our citizens from the relentless attacks of all those deranged and determined terrorists out there. He wants to demonize me, to bring down all those complex problems to one problem, winning the next Presidential election.

Well, that is not my first priority. And it ought not be the priority of any senator or Congressman. Mr. McConnell wears the American flag as a lapel pin, but does a true patriot look past the problems of the nation he was elected to serve, and see only one hateful goal?  And in the House of Representatives, Mr. Boehner vows to undo healthcare  reform, which he determinedly calls, 'Obamacare.' 

Well, I take that as a compliment. 

For years Mr. Boehner and all those who travel with him ignored the plight of the mothers of children who were uninsured, ignored the kids who were between college and their first jobs, ignored the abuses of insurance companies who could not see past the bottom line to the health of their customers. And now they vow to undo what Congress finally accomplished. 

Are these men really serving the nation? Or are they serving a much smaller group? 

Much has been made of this country being a "Christian nation." Some right wing nuts have insisted I am neither a Christian nor born in America. But what is more Christian than the idea of sacrificing for your neighbor? How many of Christ's homilies were about helping and loving your neighbor. The idea terrifies Mr. Boehner and Mr. McConnell because that means they might have to give up some of their wealth, some of their power.

Well, the idea that we are all in this together does not terrify me. It did not terrify the visionaries who voted in Social Security and Medicare. 

And the very people who are now intent on destroying these successful are so blinded by their fear they cannot even see it was these very programs which saved the economy and the people on whose fortunes their own fortunes depend. I have tried to be reasonable, tried to listen, but the Republican party, the party which once was home to a revolutionary from my own state of Illinois, is no longer the home of the brave. It has become the temple of thieves."

Somehow, I don't expect the President to call up the Phantom and hire him on as a speech writer.  But we all can dream.

Idea Men: The Phantom Says A Good Idea is Often Wasted

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Bill Clinton remarked when he was President, he had to be very careful about everything he said, but once out of office he had the wonderful freedom to say anything he wished--the only problem was that none of what he said mattered any more.

What he was saying, of course, was that once out of power your ideas may be irrelevant  because they do not lead to action
.

When you are in power, people are hanging on your every word, reading meanings and gravitas into them which may or may not be there--the Being There syndrome. Alan Greenspan was the classic example of this.  Markets rose and fell on his every semi colon. But, of course, as is so often  true of economists, he had no idea what he was talking about. 

When he had to admit this later, it didn't matter. Nobody was really listening. He was out of power

Paul Krugman has been speaking good sense, if not real science, for at least the past two years, but of course, it doesn't matter because nobody is listening who can actually put his thoughts into practice.


So what good are idea men?  Or more to the point, what good are ideas if the man or woman expressing them is not in power?

Well, if you're lucky, I suppose, they could lead to a job which puts you in or near power.

But ideas are like sounds in the forest with no ear to hear.


What made me think about all this was reading two recent pieces from very different perspectives,  one by Hendrick Hertzberg of the New Yorker and the other by David Frum, in the New York Times.

Hertzberg noted the enormity of Mr. Obama's defeat with cogently assembled numbers: This is the first time in sixty years the Democrats will have fewer than 200 members in the House of Representatives (which has 435). This was the result of an election in which about half as many people voted than in 2008, when he was elected. 


And what were those voters, always referred to as "The American People" thinking? 


Herztberg's wonderful analogy is to arson and those who respond to it. The arsonists of the economy were pretty clearly those who sailed with the Republicans.  Republican senators may not have lit the match, but they opened the door and looked the other way when the arsonists crept in with their incendiaries.


Only the firemen (the Democrats who had found themselves in power) were left for The American People  to wreck their fury upon.  


So the American People put the very accomplices to the arsonists back in power--the party that 1/ opposed the stimulus, the party that  2/ blocked the extension of unemployment benefits, the party that  3/ turned surpluses into deficits, the party which   4/rages against deficits but refuses to fix the deficit with a tax on the super-rich and The American People rage against inaction but reward  5/ The party of No, whose sole purpose is to prevent the re-election of Obama, and if that means the country  and its economy must tank for two more years, this party thinks that's the price we all must pay to rid the country of this Democratic President. 


And the wisdom of the American People can only be judged by exit polls, and pre election polls--and who knows how trustworthy these are--but what they tell us is that 2/3 believed  1/ middle class taxes have gone up under Obama,  2/ that the economy has shrunk under the Democrats,  3/ the Troubled Asset Relief Program (TARP) money was lost, thrown down the toilet to the undeserving rich Wall Street men  4/ The healthcare law, Obamacare, will add to the deficit. 


None of these turn out to be true, but you can always trust that "Voters are not fools" and in the "Wisdom of the American People."


Some of the fault in the dementia afflicting The American People, is the explanations for why these things are wrong is not easy--1/ Without the bailout the Great Recession would have become the Great Depression--but try proving what didn't happen would have 2/ The health care law will only slowly gain effect and so its benefits are not yet clear 3/ The macroeconomy is different from your kitchen table checkbook--sometimes when the checkbooks of ordinary citizens are closed the government really does have to go into more debt and spend or nobody will and the economy shuts down.


Unfortunately, President Obama is no Harry Truman. He apparently thinks The American People are all as smart as he is and could see this without being told in forceful ways. Instead, The American People listened to Sean Hannity and Glenn Beck and Rush Limbaugh and that gaggle of ignorant self serving paranoid misfits.


David Frum reflects on how Republicans managed to dupe themselves into believing the Bush economy was working, that lowering taxes on the rich would pay for themselves, that even as corporate profits soar, corporate America is teetering on the brink of destruction by self righteous Democrats bent on controlling everything. 

Frum notes Republicans have confused the free market economy with "The Markets." The Markets are the financial system which is well paid people playing with other people's money and risking little or none of their own. So, little surprise, The Wall Street Journal  thinks trillions of dollars of derivatives, enough to wreck the entire economy should go unregulated.  

And, Frum adds,  the Republicans fail to understand the economy is more important than  the budget deficits. Lastly, the Republicans failed to comprehend that Social Security is better than no Social Security, even if Social Security is a socialist plot. It turns out, keeping people paying their rent, buying groceries is even good for Wall Street brokers, who would have no financial system to bilk if there were no economy.


Republicans like Sharron Angle say un employment insurance breeds laziness, removes all incentive for people to want to work ignoring there are five applications for every job. Are all those applicants really lacking incentive?


So, there you have it, idea men, with good ideas, with access to millions of readers. 


But does any of this make a difference?


Only if those in power are listening to ideas, are capable of analysis.


Lyndon Johnson, on his tapes, can be heard taking a phone call from an aide who is complaining about the farm lobby arguing over a difference of 3 cents a pound in a proposed bill. Three cents a pound, the aide complains, can you imagine digging in your heels over three cents?  Johnson, a rancher, of course understands and sets his callow aide straight. When you are talking about a 3000 pound heifer, and you've got 10,000 head on your farm, yes three cents a pound adds up to real money. No wonder they are fighting. 


But then Johnson takes a call from Richard Russell, his good friend, about Viet Nam. Johnson likes Russell. They are both good ol' boys from iway back, from the school of hard knocks. The thing is, Russell tells Johnson, the Viet Cong know we are going to go home some day. And they know we know they know it. It is clear Russell is telling Johnson this is an unwinable war. But Johnson gives up analysis in this area. He says he's not going to bend his mind about Viet Nam. He's just going to listen to the smart boys, McNamara, and all those boys who went to Groton, and Andover and Exeter and Harvard and Yale. They know about these things. 


So, like The American People, of today. Johnson decided not to try to analyze things for himself. He just put his faith in someone.  Thinking, ideas, numbers, analysis, asking hard questions, was too difficult. Faith. Having faith in someone was so much easier.


Ideas didn't matter then. Don't now. 

First Ammendment Follies: Phantom Rights

I know there's a first ammendment and freedom of speech, but why is it so many people who reach the public seem to speak complete, unadulterated garbage, when there is so much truth to be told?

I mean, given the choice between truth and phony, what is the appeal of phony?

Here's a little sampling from the Portsmouth (New Hampshire) Herald: 
"[Horowitz] said the negative effects [of fluoride] include reduced IQ, hyperactivity, increased risk of developing certain types of cancer and severe thyroid damage.
'Fluoridated water has been shown to have very serious health effects: quadrupled risk of bone cancer in teenage boys, damage to the thyroid and other organs, which could explain the explosion in hypothyroidism, which itself has been linked to heart disease, mental decline and other illnesses.'"

I read this, as someone who has studied the thyroid for years, with great interest and could only think, "Haven't I seen this movie before?"

Ah, yes.   "Do you realize that fluoridation is the most monstrously conceived and dangerous Communist plot we have ever had to face? I can no longer sit back and allow Communists infiltration, Communist indoctrination, Communist subversion and the international Communist conspiracy to slip impurities into all of our precious bodily fluids."

No, that is not Rush Limbaugh, although the rhythms sound a lot like him. It's none other than Dr. Strangelove.

Right there, a living breathing Dr. Strangelove, given a platform in the Portsmouth Herald.

Ask the Herald and what do you think they'll say in their own defense?

Likely the usual dodge, "We just report the news, we don't judge it."

Which is to say, "We want to sell papers, not pay someone to do fact checking."

To be fair, the bull detector meter is not flipping off scale in just the Portsmouth Herald. A look at Today's New York Times gets the meter jumping, although the Times has less responsibility because we are talking about the Letters to the Editor. But here's a good one, a letter from a pediatric cardiologist, no less, about how we can reign in costs of medical care:

"Permitting licensed and certified nonphysician medical personnel to form medical practices without physician oversight should significantly increase the number of medical providers and decrease medical costs by tempering the present physician monopoly of our health care."

Wow. What a great idea. It's easy to believe there would be more medical providers if we were not limited to the number of doctors medical schools can pump out yearly, but who has the studies which show all those extra providers would actually result in decreased medical costs.

In fact, the last time this was tried, increasing the number of doctors medical schools pumped out increased costs exponentially because they ordered more tests, admitted more patients to hospital and the policy makers had to admit, "Oops," and they beat a hasty retreat.

Now, you will argue, but if we have more nurse practitioners, they will be lower cost, charging less than doctors and costs will fall. But that's actually only a part of the costs of practitioners to the system--it's all the tests they order, all the admissions to hospitals. And, I would venture to guess, these practitioners tend to be less confident and, if what I have seen is any indication, they actually order more tests, and more expensive tests, than well trained doctors.

So where do these instant experts get their information?

Best I can see is it's the same phenomenon you see in the South, where people want to be "Preachers" and to "Speak in Tongues," and bring the Truth, i.e., the word of God to you and me. It gives them some sense of satisfaction, of self importance--just watch Rush Limbaugh if you want to see a study in the desperation of a personality in search of self importance--and our institutions of public address support all this, more or less indiscriminantly.

But then again, why am I writing a blog?

Libertarians and The Phantom

Having run what amounted to a small business ( a solo medical practice)  for years, I got a taste of the cold fear with which a mom and pop enterprise can regard the government. I had a  one employee and I needed to pay an accountant to do my taxes and I had to hire a sort of book keeper to help me bill Medicare without straying into the dreaded territory of "fraud and abuse," which was easy to do, even if you were trying not to. 

For example, I had to send out bills for $4.95 after Medicare and Blue Cross had paid, because if I simply wrote off that amount, I was committing fraud and abuse. The rationale was if I was willing to accept less, willing to forgo that $4.95 per patient, then my real fee was $4.95 less than I had originally billed Medicare. Stuff like that.

I could never keep up with all the new rules and regulations.

And I was always vulnerable. 

One year I got a post card telling me I had failed to file for my license to practice medicine in the state of Maryland. The license was renewed every two years and that was just enough to mean I could forget if I had renewed this year or last, but I always got that big brown envelop when the time came due. Until one year, when Maryland decided it was cheaper to make every one renew on line. Trouble was, they didn't bother to tell everyone about it.

So I wrote letters of protest to my local state legislators and the man who ran the Board of Medicine license renewal wrote me a letter telling me how hard everyone in his office worked and it was all my own fault. 

I got my license, but a month later, I got notified I was being audited to be sure I had actually got enough continuing medical education credits to maintain my license. It was a "random audit," which just happened to occur after I had created a stink for the Board of Medicine license renewal guy. A random audit, after two decades of never being audited.

It was a message from City Hall to let me know I could be sunk with a single wave of their hand, unable to practice medicine in the state if they decided to get nasty.

It was just one more reason to leave Maryland, a page right out of The Wire.  Baltimore slime in its purest form.

So I understand antipathy toward government from the perspective of the little guy, I really do.

On the other hand, when I hear these Tea Party characters carrying on about how they are going to reduce the deficit which our grandchildren will be paying for by cutting wasteful government spending, I always want to ask: but Senator elect, exactly which programs will you cut? 

And they always come up with cutting the entire Department of Education, which would make hardly a dent in the deficit or the national debt. 

Ronald Reagan, Jim DeMint, all the Tea Partiers,  want to believe there's waste out there. Undeserving Welfare Queens living high on the hog, on the backs of hard working, deserving people like you and me. Waste, fraud and abuse. Just waiting to be cut. Cut the pay of federal employees by 10%, all those overpaid government workers; sock it to them. Make them pay for their extravagant lifestyles the way we would never dream of making the Wall Street broker/banker pay. We'll balance the budget with all the savings, melt down the deficit by reduction in work force slips to government workers.

Ronald Reagan cut lots of federal government jobs and he tripled the deficit  and unbalanced our budget big time--I think those numbers are right, but being right about numbers never has seemed to matter in this discussion. 

Nobody really cares about the numbers in this numbers game. Rand Paul says by simply cutting spending, you can make everything all right. Keep those tax cuts in place for the billionaires--deficit hawks strangely never seem to see the income side of the ledger, only the outgo. The income to the government is always a moral outrage to the Rand Pauls and Jim DeMints of the world.  But nothing outrages them more than the outgo side. We should simply not spend, and then we would not need an income. Try that with the family budget.

For Rand Paul and all those who travel with him, it's not really about the money or the numbers. It's about belief which is really not founded in hard data, just bedrock faith in the idea we must be getting cheated by the government, because if the government is bad, well then, we're on our way to solving our problem.

Erection Day: What the Phantom Doesn't Know

Today the Republicans will, by every pundit's prediction, sweep back into control of Congress, on a promise of cutting taxes, getting the government off your back, reducing the deficit (while reducing taxes for billionaires) all by cutting spending, (although exactly where they will cut they are vague about--certainly not anywhere you care about) repealing Healthcare, or Obamacare as they call it, and repealing the estate tax, or the Death Tax, as they call it.

What joy. Wow, what those Republicans can do, or promise to do.

And that mythical beast, "The American People," are buying it. A neighbor told me about a friend, homosexual man she knows, who is voting Republican. How can a gay man vote Republican? Well, he hates the "Death Tax." He calls it the Death Tax, so you know who he's been listening to. He is outraged, outraged he will be taxed twice. When pressed about who he intends to leave his estate to, having no children or much in the way of family, he says, well, he really doesn't know, but he wants the government off his back, taking his hard earned estate away from him and giving it to the undeserving slackers who the Democrats always give money to.

The Democrats have been in power, (which in the case of the Democrats is a phrase to use advisedly,) for two years and apart from avoiding a Depression, passing a law to limit the power of health insurance companies, they haven't done much.

 In fact, to listen to the Democrats, you'd never know they'd done anything.

When the Democrats say they want to cut taxes for the middle class and keep the rates for the billoinaires, the Republicans huddle and come up with the phrase, "Class Warfare," and the Democrats go into a dead faint and when smelling salts revive them, they apologize for the whole idea.

If these are the Democrats, well then they do not deserve to rule. You've got to be able to come up with a phrase to parry whatever phrase the Republicans use.  Maybe something like, "It's not class warfare, it's called "Eat more, Pay more," or something like that. Think on it, maybe you'll come up with something better, but when you do get every Democrat using that phrase, just as the Republicans all use the same phrase until to becomes TRUTH, because, well, everyone's saying it and nobody's denying it, so it must be true.

The problem is, you can only feel sad. You see the Confederate States of America, fighting for slavery, economic oppression and moral smugness and winning, not because of the justness of their cause but because they have better generals, and you cannot feel anything but sad.

And so it is now--the might of the Republican Party, is not made right. They've got Carl Rove, Rush Limbaugh, John Boehner and Glenn Beck. They win because they are smarter. They are smarmier, and oh so sure. "Why is it the stupid are cocksure and the intelligent full of doubts?" I forget who said that. Some Englishman. But it sure holds true in our country.

Thus do once great nations decline.

Oh well, the English have declined for similar reasons and it's not so bad living in a second rate world power. You can still go to the pub, root for the local football team and find a mate. And in England, if you get sick, someone will take care of you.