Forty Years of Progress in American Medicine

Alexandre Yersin

Nobody ever mentions Alexandre Yersin when candidates are asked during Presidential debates who their heroes are. Sometimes, a politico will dredge up "Jonas Salk," to show he is capable of appreciating something and someone who is not just about political or military power, but nobody ever mentions or every will mention Yersin.

Yersin would not play well because he was a German and French speaking Swiss, and very few Americans have ever heard of him. He was the guy who single handedly discovered the cause, the "etiologic agent," of the Black Death  (plague),  the bacteria which killed half of Europe in the 13th century or thereabouts, which terrifies mankind still. He was also the first human being to successfully treat plague, in an era before antibiotics, by raising an effective vaccine against it.

He never practiced ordinary clinical medicine, i.e., never did "private practice," because, as he explained, "To charge for my services, for treating an ill person would be like saying, 'Your money or your life.'"

Such words would not endear him to the American Medical Association, or to all those  idiotic savants, all those confident pundits, those economic sophisticates who insist the best model for delivering health care is free enterprise, market forces, unregulated business and no government involvement.

Recently, the Phantom was asked to comment on the major changes in medicine and medical practice on the anniversary of his graduation from medical school, 40 years ago.

There were some obvious things, like the advent of drugs (first the H2 blockers, then the proton pump inhibitors) which meant an end to that most harrowing of all medical admissions for the average medical intern: The GI bleeder.  No more nights pumping 15 units of packed Red Blood Cells into patients yorking up liters of blood from their bleeding ulcers.  That's what we did in the United States, but that's not what they did in the United Kingdom 40 years ago--but more on that later.
 
Of course, the advent of fiber optics meant endoscopy and laporoscopic surgery could revolutionized gastroenterology and general surgery, which became entirely different specialties, attracting entirely different sorts of people with different skills altogether from those who preceded them.

Radiology and imaging are so changed they hardly seem like the same specialty since the advent of MRI and CT scans. Advances here transformed other specialties: Neurology went from a painstaking specialty of "Where's Waldo?"  in which methodical bedside examination was used to localize lesions, to a specialty of imaging, and visual anatomy. Imaging has become so dominant that autopsies, once deemed essential, are now a rarity in general clinical practice. There are other forces driving this abandonment of the post mortem exams--they do not generate much money. They were done for the generation of understanding and knowledge but they could not be "monetized" so that avenue of learning has been largely abandoned.

 Ultrasonography has transformed endocrinology making thyroid nodule assessment more scientific and adding a surgical component to the endocrinologist's gig. It has also transformed obstetrics to the extent fetal activity can be seen at very early stages. 

One thing which has not changed much, sadly, has been the relentless toll taken by that family of malignancies we call breast cancer--but this will be a topic for another day. Some cancers have been stunningly conquered: Testicular cancer the notable poster child for success in cancer research.

And, of course, there has been the remarkable AIDS story.

But the really revolutionary changes have been in the sociology of medicine--with the entry of women into medicine, and the displacement of men by women in certain fields like obstetrics, with the advent of physicians assistants, nurse practitioners, nurse midwives, nurse anesthetists--all  sets of practitioners now functioning without direct supervision or with only minimal supervision by doctors, the idea that you can break down the tasks the doctor does into discrete parts and pay these practitioners only a fraction of what you'd have to pay a doctor. The application of the business model to medicine, thoroughly and down to the last detail.

With these changes came the idea that what the doctor used to do by himself can and should be divided among a team of shift workers, the assembly line idea, the Henry Ford model of streamlining the production, each worker responsible for only a part of the ultimate product--forget that cobbler who made the whole shoe-- so "hospitalists" now admit patients to hospital  and the patient does not see his own doctor from the community once he is admitted to the hospital. Soon there will be "laborists," who will deliver babies in the hospital rather than the obstetrician. 

And medical school classes are no longer made up of 22 year olds, having just graduated from college after four arduous years of organic chemistry, physics and biology, having survived the gauntlet, to hurtle forth into the next four year trial by fire. Medical school classes are not compromised of young, restless, energetic, stallions, straining at the bit. No, now men and women in their 30's, 40's and even 50's are admitted to medical school, after they have had other careers or pursued other interests.  Applicants are accepted to medical school and then defer matriculation while they spend a few years at Goldman Sacks.

"Dedication" is no longer a word heard much around doctors. In the 1970's doctors were afraid, at first, to complain about the structure of medicine. But with revolution in other aspects of American values, doctors began to revolt too. Why should we have to go to Grand Rounds at 10 AM Saturday and miss our kids' soccer games? Why could we not schedule these professional activities at times which allowed for more family life?  The answer from the powers that were used to be, "Your profession comes first. Medicine. Surgery come first. You are a parent second, a doctor first. What you are, is a doctor. Everything else comes after that. Your identity is now with the profession." No more. You can't tell that to the man who used to command a submarine and is now a first year medical student.  You can't even say that to the 26 year old Goldman Sacks alum, who is now beginning his first year in anatomy. He is going to use his MD to start a health care system, the next Kaiser or Oschner Clinic. He is a businessman first.

When women could say, "I'm just as committed to raising my children, to my role as a mother, as I am to being a good surgeon, cardiologist, obstetrician, pediatrician..." well, then things changed dramatically.

Which brings the Phantom back to his original observation: What's happened over the past 40 years in American medicine is we have finally arrived at where medical practice was in Great Britain in the 1970's--patients there did not expect their GP's to admit them to hospital. The hospital doctors took care of you and sent you back to your local GP later.  You got one unit of blood for your bleeding ulcer and you got put to bed and the house officers made rounds in the morning, to see how you had done, to see if you were still alive. And, actually, mostly, you did survive, because as recent studies have suggested, if you do not pump in that 15 units of blood, your blood pressure drops, and you stop bleeding. 

Back then, the Brits were using a technique for cardiac catheterization using an artery in the arm, rather than the groin; American invasive cardiologists have finally adopted this as safer and less fraught with complications.

The British doctors used to joke, "Well, they don't pay us anywhere close to what you Yanks get, but then again, we don't work too hard either."

Now, American medicine has come around to the British way of thinking--except, the American twist is--we do work pretty hard, just not doing the same complex things we used to do. We just grind through more billable procedures, make sure we get paid for every band aide.  Our computers allow us to track every suture, every gauze pad and every aspirin and to make sure the patient and his insurance company get the bill.

That, the Phantom reckons, is progress.


The shift has been from the practice of medicine as a calling to the practice of medicine and surgery as a business. Our commitment to the patient ends when the next shift begins, when the next consultant arrives. It's not two aspirin and call me in the morning; It's go to the Emergency Room and they'll charge you $300 for that two aspirin.

Predictable: Republicans Enlighten America about the Boston Bombing

Look, Ma! I'm on television! And people are listening!

Who let these foreigners in our white, Christian country?

One look at this guy and the FBI should have known he was a terrorist.

"Given the events of this week, it’s important for us to understand the gaps and loopholes in our immigration system," he said. "While we don’t yet know the immigration status of the people who have terrorized the communities in Massachusetts, when we find out, it will help shed light on the weaknesses of our system."

"How can individuals evade authorities and plan such attacks on our soil?" he continued. "How can we beef up security checks on people who wish to enter the U.S.? How do we ensure that people who wish to do us harm are not eligible for benefits under the immigration laws, including this new bill before us?"

Senator Grassley, Republican-Iowa

The shameless political opportunism award this week goes to...It's a toss up between the Republican Senator from South Carolina, Lindsey Graham, for trying to deny due process to the Boston bomber as an "enemy combatant" in the "War on Terrorism," which is a transparent attempt to create a war out of thin air using the most recent emotion stoking event in the news and....

 Senator Chuck Grassley, Republican of Iowa, who saw an opportunity to deny access to our shores to all those smart kids from Taiwan and Germany who want to take jobs in Silicon Valley by linking "immigrants" read "terrorists"  to the news that the two Boston bombers who had apparently assimilated into America turned on us and blew up bombs. 


Never mind Timothy McVeigh, whose bomb took an even more horrific toll was as American as Apple pie. Mr. Grassley did not suggest we outlaw nitrogen based fertilizer because whackos can use it to blow up federal buildings with day care centers.  (Mr. Grassley is from Iowa, where fertilizer is not easily demonized.) 

Mr. Lindsey never liked the Constitution none, and Mr. Grassely, well all those foreigners always stuck in his craw, speaking all those nasty languages and bringing all those new ideas into the country, just Euro trash is all. What ever got into us, allowing these dangerous people to settle in this country?  Why their names don't even sound American.

Let us now demonize whomever we please, based on last weeks headlines.

Let us consider a pack of jackasses. Now let us consider the United States Congress. But then, I repeat myself.

Accidental Rascist: What's In a Flag?

Brad Paisley is one of the few country singers the Phantom actually likes listening to; His "Mud on the Tires" album has some pretty solid tracks, although, like most country music, there is a strong streak of sentimentality.

Now he has a song, "Accidental Racist" which puts forth the proposition that just because a white guy wears a T shirt emblazoned with the Rebel flag, that doesn't make him a racist. Of course, what he is really addressing is the idea that a Southern white male who looks to the rest of the country like a Joe Sixpack racist does not necessarily harbor racist attitudes.

To the extent that Paisley is saying he does not endorse racism, this is fine. But to propose that a flag, which is after all a design meant to signify something, to be a symbol,  does not signify something, this is pretty weak.

21st century Southerners like to say flying the Rebel flag over the South Carolina state house, or running with it across a football field ahead of the Ol' Miss football squad is not an endorsement of Confederate racism, but simply an expression of pride in a past which had more to it than slavery.

The Southern male who says this is saying, often pugnaciously:  "So I'm supposed to reject my great grandfather who fought to defend South Carolina? Was Robert E. Lee a villain?"

Well, yes, actually. Lee and Jackson and Jefferson Davis may have been men who thought themselves moral and upright citizens, but they were in fact, by definition, indisputably, traitors. They took up arms against the United States of America and the war they fought took more American lives than the sum of  all the other wars fought by Americans since.

And what were they fighting for? States Rights?  The sovereignty of Virginia? The Southern Way of life?  Defending Southern womanhood and virtue from rapacious Yankee invaders? Yes, all of those things, but mostly, primarily, above all: Slavery. The idea that one man could and, in fact should, own another man and all his children,  his wife and that slave's nubile daughters, and that  master of the plantation could use any of these slaves as he saw fit,  is actually what the Confederate soldier fought for, ultimately. 

Oddly, most of the men who took up arms for the Confederacy were not rich enough to own slaves, but they fought to the death to defend the aristocrats right to do it.  Johnny Reb may have had as many reasons to join the Confederate army as there were Johnny Rebs, but, in the end, they fought to keep men, women and children enslaved. Lincoln would not admit it, for political reasons--he began his tenure by denying it, by saying the war was about Union, but by the time he gave his second inaugural address, he owned up to it. 

These may have been gallant, courageous, self righteous  men, but they served a truly horrific, despicable cause, the Southern Cause. The Cause of, "If I'm rich enough, and powerful enough to enslave people on my own plantation and in my own state, ain't nobody powerful enough to stop me."

And the Rebel flag, for better or for worse,  is the symbol of all that, for most people.

If you  walked around wearing swastikas, and claiming you  were only showing pride in your  German heritage, in the brave lads who fought for their country, we would say, well, but you could have chosen any part of that heritage and that history, but you chose the symbol of one specific part, the Nazi part which called for  "purification" of all lands occupied by German speaking people through mass murder. 

It does not matter whether or not Mussolini made the trains run on time, or whether Hitler built the Autobahn and the Volkswagen,  and was nice to his dog; the big thing we are reminded about when we see his red flag with the black twisted cross is genocide.  And it doesn't matter if Robert E. Lee loved his horse (who is buried next to him on the campus of Washington & Lee University) or if Stonewall Jackson was a Bible quoting man of great piety:  They fought for keeping other people in chains, for lashings and legalized rape (of slaves on plantations) for a system of aristocracy which turned out to be thoroughly un American and un democratic and utterly despicable. 

When McNulty runs across a typical Southern small time cop in southern Virginia, he assumes the cop is a racist, because the cop looks the part, sounds the part, when in fact the cop is married to a black woman and is offended by the racist line McNulty tries on him, in an effort to establish rapport. That is the sort of anti stereotype Paisley was hoping to present, but Paisley is not The Wire and the difference in the level of art  is painfully apparent.

The Rebel flag stands beside the Nazi flag as a symbol to most people of hate, racism and a Cause which we are fortunate was tossed on the trash heap of history. Whenever that symbol is waved, someone should stand up and say so.

 Qui Tacet Consentit. 

When Being Right Is Not Enough

Ignaz Semmelweiss

Joseph Lister

It is difficult, when faced with someone who knows more than you about something to decide when he is moving beyond what he knows to territory when he is just as ignorant as you are.

Your third grade teacher knew how to write cursive handwriting, do long division and locate Bolivia on a map; who were you to question,  if she says little Black boys should not be allowed to drink from Whites Only water fountains, because they will contaminate them and give white children diseases?

She was an authority and knew more and better than you did.

The surgeon who operates in a bloody apron, caked with the blood and pus from his ten prior surgeries, says rinsing his instruments in carbolic acid is unnecessary and even harmful, and rinsing a wound with carbolic acid will injure healing tissues, and he knows more than you about surgery. He knows the anatomy of the abdomen and can remove a gall bladder. But how much does he know about microbiology?

When Ignaz Semmelweiss noticed that women who delivered at home in Vienna, Austria in the middle 1800's rarely developed "child bed fever" a febrile illness which killed many hospitalized women post partum, his observations were ignored. When he noticed one of his colleagues died after being inadvertently stabbed with a scalpel during an autopsy, and the autopsy of the unfortunate colleague showed findings which looked like those of women who had died from  childbirth fever, Semmelweiss put two and two together and said, perhaps the disease seen in hospitalized women was somehow connected to the practice of physicians going from the autopsy room to the bedside of women who had just delivered babies, and examining those women with unwashed fingers.

Semmelweiss did not have an explanation for the mechanism by which infectious disease could be transmitted. He was working in the mid 19th century, as the Civil War was raging in America,  and the idea of unseen, invisible organisms causing disease was just emerging in the laboratories of Louis Pasteur in Paris.

When the British surgeon, Joseph Lister suggested cleaning instruments with carbolic acid, he had a better idea of how and why infectious can be transmitted from one human being to another. It was not "bad air" or miasma, it might be bugs. Lister could read French and German, and he had gone to Paris to see Pasteur. Students of Semmelweiss had published what this modest Hungarian physician had seen and concluded. The idea of a transmittable thing which could be conveyed from one wound to another was emerging, inchoate, but powerful.

Lister spoke at American surgical meetings, but his advice about sterile technique was largely ignored.  That ignorance cost thousands of lives during and after theCivil War.  As late as 1881, antisepsis was simply not considered proper in the practice of medicine or surgery.

Semmelweiss was caught up in the politics of revolution in the Austro/Hungarian empire and he found himself unemployed, stripped of his positions at Viennese hospitals, because he was Hungarian and Austrians were in charge and because he had offended too many colleagues by suggesting their own behavior might have contributed to the deaths of their patients.  He wound up in an insane asylum, and died within days of a beating there, administered by attendants.

He may have succumbed to the dementia of tertiary syphilis, acquired from examining patients or doing autopsies, before he had appreciated the possibilities for transmission of infectious particles. 

Aware of the mistakes of the past, American medicine maintains journals which serve not just to report the prevailing ideas of truth but to serve, even more importantly, as a forum for challenging the proffered nuggets of truth and wisdom. The correspondence sections of these journals contain the letters of criticism of each paper previously published and the reply from the author of the original article.

Would that we had the same mechanism for public consumption in American newspapers. We have letters to the editor, editorials but only rarely a really interactive forum, a point counter point, so the reader can see the questions which have been raised about ideas.  The Internet was supposed to provide this sort of interactivity, but the Internet is too vast and blogs too voluminous. There really is not enough give and take. Even the Sunday talk shows which may have a Krauthammer sitting opposite a liberal do not allow for much more than phrase making and shouting. Public Television's The News Hour once attempted spirited and civil interchange, but in an effort to ensure civility, the edge has been lost, and the people selected for appearance are selected because of government or academic titles, for their rings of authority rather than for the quality of their thinking.  Even the longstanding Shields and Brooks duo has degenerated into quips and winks, all real passion and clarity having been lost long ago.

What this country needs is not a good 5 cent cigar, but a good forum for vigorous exchange of ideas among engaged, knowledgeable people who can trade barbs and draw blood. 

The Brits were once good at this sort of discourse--their questions for the Prime Minister seen on American television Wednesday evenings was an enviable exercise. But for some time there has been more style than substance coming to us from across the pond.

Personally, I'd love to see Paul Krugman demolishing Paul Ryan, Mitch McConnell and Rush Limbaugh on TV regularly. I'd love to see Barney Frank square off against any right wing nut. And I'd like to see real, acerbic scientists dismantle the global warming deniers, the coal burner fanatics and the vaccine antagonists. Put up Michele Bachmann, Sarah Palin, Limbaugh, Beck, any of those South Carolina, Texas or Arizona Senators or Congressmen. What joy that would be.

Details: Denk, Sebok, Failure and The Meaning of Life

Gyorgy Sebok

Jeremy Denk

The Phantom has recently begun piano lessons and so he was drawn to Jeremy Denk's  New Yorker article "Every Good Boy Does Fine," in the April 8 issue. 

EGBDF is a device piano students learn to help them figure out the notes on a musical score.

Why the Phantom decided at a late stage in life to knock his head against the particular wall of piano is a mystery he is still trying to fathom. There are some things the Phantom has long known about himself, among them, he cannot dance and he has absolutely no aptitude for music, with all its mathematics and memory and pitch and rhythm and harmony and demand for precision. 

But the Phantom has reached that point of life where things can either become comfortable, where you say, okay I never had it in me to be a pro ball player, so what? I can live with that. Or you can revisit failure and ineptitude and try to enrich your life by struggle and failure.

Piano requires intense concentration and learning piano requires focus and faith. The faith is that doing all the exercises, the scales, hitting the right keys with the right fingers in time to a metronome is actually valuable and leads somewhere. But, at a later age in life you don't care if it leads anywhere. You are never going to play piano with any grace; it's just the challenge of hitting those keys. And you do get little peanuts of reward, hearing those notes sound right. 

The mysterious, bizarre thing is you can hear when notes sound wrong, even if you are as unmusical as the Phantom. So hearing the notes sound right is a little reward every time. 

And just when you are feeling a little happy about getting through the scales in one piece, you go on to your lesson about rhythm and eighth notes and you fail miserably again. And once you get things reasonably under control with your right hand, things come crashing down when you have to add in the left hand.

Music is like genetics.  There are hundreds of thousands of genes, all just combinations of basic notes (amino acids) and they spew out in overwhelming volume, but when they line up correctly, you get a whale or an osprey or a falcon or a tree frog, a functioning whole of stunning magnificence. When one of those base pairs gets inverted, you get some awful anomaly, some horrible disfigurement and even death.

Denk describes listening to Gyorgy Sebok play the Gigue from Bach's first Partita. He takes two long paragraphs to describe in broad strokes and minute detail what Sebok did, and concludes by saying hearing that brief passage determined the next five years of his life, as Denk left Oberlin to study with Sebok at Indiana University. (Who knew Indiana University was the epicenter of such a fine classical music department?)

With just a few anecdotes about Sebok, Denk provides an indelible and shimmering picture of the man. My favorite  is this:

"A new dean came to the school and asked for a mission statement from the piano department, so that our goals could be incorporated into the 'business model' of the school as a whole. Sebok smoked as various earnest options were presented. Finally, he offered: 'We want to teach excellent students, very well,' and looked wearily off into the distance."

The world of classic music, for that matter of jazz or any other form of music which is not popular and lucrative, is impractical. It is a passion, an addiction. Music is heroin for the soul, and heaven help those hooked by it, because nothing else can be as interesting, joyful, rewarding, challenging or frustrating.  

It cannot be done or even appreciated by everyone, and those who do it do not care much about whether or not it rewards them in the usual, earthly ways. 

In the Phantom's case, he is blessed with lack of talent and aptitude and so he can walk away from it. 

But he is haunted by a scene from the movie Pi, in which numbers just gush out, as the computer generates the number Pi carried out to millions of places, and you wonder why this is important to the universe. These numbers make no sense, have no meaning; they just gush forward. 

But the notes, the numbers which make music have meaning--afflicted individuals (real musicians) can hear the meaning.  

It's all very existential. 

Not a bad way to wake up atrophying neurons in a senescent brain, all in all. 

Machismo in The New Hampshire State House

Nick Anderson Houston Chronicle

It is legal for New Hampshire state legislators to carry guns into the statehouse at Concord. Kyle Tasker (R-Nottingham) who seems to have trouble keeping his two guns holstered, and periodically drops one or the other on the State House floor, says that 10% of legislators wear guns to the State House or to committee meetings, across the street. 

It is not clear to the Phantom whether or not they may wear swords or carry baseball bats, cudgels or other potentially lethal weapons. If not, the Phantom respectfully inquires: Why not?

The Knives Rights organization did succeed in getting all knives, switchblades, stilettos, any knife really, legalized, so maybe swords are included. They are, after all, merely long knives.

I would think it would be worth running for office in the state of New Hampshire simply to experience the thrill of walking into the State House decked out in a breast plate, a helmet and a nice saber, carrying a shield and a large club. 

Perhaps, if one person did this, another would at least strap on a cutlass and then another, and well then, you would have yourself a movement.

And if we could get this started at the State House, then perhaps we'd have men and women walking around the streets of Portsmouth with weapons strapped to their sides and eventually, if we had enough of these weapons bristling, people would get bored with the display and those little men who need big guns to feel powerful, might just look elsewhere for their sense of manhood.

Maybe they'd buy themselves vintage sports cars. Corvette sales might boom.

You never know what can happen, when you start a movement.

Preston Brooks Beats Charles Sumner on the Floor of the U.S. Senate
The Nation Survived. Senator Sumner did, just barely.