Clueless

Someone named Ronen Avraham, a professor at the University of Texas School of Law, wrote an Op Ed piece in the NY Times (3/28/11) about the Obama administration's plan to invoke clinical guidelines as a solution to frivolous malpractice litigation. The good professor apparently had spoken with enough people to know that the problem with clinical guidelines is they are often written by the wrong people, and sometimes by people who have ulterior motives, e.g. to promote profit for the people the authors of those guidelines are working for. The other problem with the guidelines is they are too often written by people with the time to write them, faculty members at medical schools, who, perhaps surprisingly, are not the sharpest blades in the drawer.




I recently regaled a conference at my own hospital by simply reading from the clinical guidelines for the in patient management of diabetics which said, among other brilliant things, if the patient you are treating is terminal, i.e., if he is expected to die within a short time, then controlling his blood sugar, lowering it to normal ranges by the use of intravenous insulin may not be required, or at least it may not be as important as this practice would be for people who are expected to survive their hospitalization. Which is to say, if you are dying of widely met static lung cancer, if you have it growing in your brain, getting your blood sugar into normal range may not be your highest priority.



Ya think?



So who should be writing guidelines? And, more basic, is it really possible or wise to attempt to write guidelines at all? Is medical practice not in a constant state of flux, adjustment and re examination and is it not so complex that writing a single manual is impossible? Is this not what we go to medical school, residency training, specialty conferences to learn? It's like that old saw where the author is asked by the radio show host, "So what's your novel about, in a sentence?" and he replies, "If I could tell you that, I wouldn't have had to write the novel."





Some things are complex enough to defy simple dictums.





Then there is the case of "Medical Economics." The Obama people have their hearts in the right place: They want to provide health care for all, and they want to do all this at the lowest possible cost. But, understandably, they don't know where the hemorrhaging is. If you don't know the anatomy or the physiology, you are not going to find the bleeding point.





Not that the Republicans have any idea. What they have is fantasy. And fantasy is, at least, coherent--it makes a good story: Just let the market drive down costs. Get the malpractice lawyers out of the picture, driving up costs as they do. Stop all the regulation. Private enterprise will save all. Republicans love living in denial. They will cleave to these fantasies with ferocity, because they want to believe all this.





The Obama people, Peter Orszag in particular, have their own fantasies. They wanted to believe economists could tell them where the savings can come from. And they wanted to believe Atul Gawande had done a bone fide piece of medical economic analysis in Texas, showing the way as he described one Texas town where the billings to Medicare were very high versus another where they were close to the median as if these two towns held some sort of key. In the expensive town, it was all about greedy doctors, bilking the system by doing unnecessary tests.

So that's the answer! Search out those bogus, unnecessary tests!





Nice fantasy.





The real problems, of course, are much more pervasive and more difficult to fix because so many people are making so much money and they vote and they spend that money to hire elected officials.





A colonoscopy makes a local hospital $3400 and that's not even including the doctor's fee. This is a test which could be done by a technician for, reasonably, taking into account the overhead for equipment, cleaning equipment and staffing support, say $250 a pop and you could screen a lot more patients at far less cost. But colonoscopies are the cash cow of the gastroenterologist: he learns the procedure in a few months, masters it in a year and then supports his family and his boat payments doing this procedure which can be scheduled and is never an emergency, and he can be on his boat by 4 PM. You think the GI docs are going to give up that without a fight?





Similarly, you could replace 95% of dermatologists with technicians who could do excisions and biopsies at a small fraction of the cost people with MD's charge. This is another group which works 9 to 5 and profits are so enormous dermatology residency training programs are now the most competitive residencies out of medical school. Everyone wants that life and income.





Well, not everyone. Just the people who had really high SAT scores in high school, really great grades in college and who learned how to play the game to their own advantage. These are not people who dreamed of being heroes, saving lives in the middle of the night, leaving their warm beds in the middle of the night and driving into the hospital where a distraught family awaits, holding the hand of their stricken mother.





No, the dream of some medical students is a big house, nice cars and maybe a boat.





Truth be told, that hero dream is not much to be found in medicine anywhere. Just look at the TV programs now if you want to see the screen writers' fantasies about the possibilities of a medical career.





And with the advent of shift work in the hospital, with hospital doctors now just employees and with doctors in the community no longer self employed in private practice, medicine is becoming or has become not an ennobling profession, but just a job.





Medical practice has been deconstructed into its parts: Much of it is now being done by nurse practitioners, "procedurealists" , laceration technicians, physicians' assistants and other people who never went to medical school but took a short cut to the white coat and the stethoscope.





Not all of this is bad, but none of it saved money to the total system and the important part of medicine, which never paid well, is now often not done at all. That's the part where you listen to a patient's story, told in a fractured way by a person who does not have a clue what may be relevant and you tease out a coherent whole which tells you what test to order and to which specialist or for what procedure to send the patient.





One thing which looks pretty clear is the economists who do medical economics at Princeton, or MIT or Harvard or Chicago have no idea which rock to look under. Their approach, their tools are simply incapable of finding the truth, or any meaningful answers. They simply do not know how to do ward rounds and to gather the right information or to organize it into a meaningful analysis.

 

Survivor Resentment

A long article in the New York Times today about a psychiatrist who had to give up the practice of psychoanalyst and shift to the practice of pushing psychotropic medications. He went from seeing ten patients a day to forty and he feels unfulfilled, says he hardly knows his patients, can hardly remember their names now. Years ago, he knew them in some ways better than their own spouses and lovers. Now, he is "efficient."

Of course, no law required him to give up the aspect of his practice which he found most spiritually rewarding: It was financial forces. Talk therapy was devalued, in part because a psychiatric social worker with a masters degree two years out of college could do what he was doing with talk therapy, at least as far as the insurance companies are concerned. He could have studied with Sigmund Freud hisownself, undergone  ten years of psychotherapy himself, written his PhD thesis at Harvard, after two years as a Rhodes Scholar at Oxford and authored the standard textbook of psychotherapy--none of those indicators of quality would matter to the insurance companies, or, for that matter to the American Board of Psychiatry which makes its living "certifying" psychiatrists and psychoanalysts.

So that is one of the many effects of a commercial system of medical care: Quality is that thing which shines with a light not perceptible by computers, bean counters or  vice presidents of corporate America.  Price is the thing.

Not that I or many of those who traveled with me through medical school, internship, residency and fellowship training have much sympathy for those who opted out of what we considered real medicine for the pseudo science of psychiatry.  We considered those people, who went into psychiatry after medical school the worst mistakes the medical school had made. Gave away the glittering prize of a place in the medical school class to someone who realized, somewhere along the four years, that he (or she) had made a big mistake and he didn't want to do medicine after all. That place could have been given to an orthopedic surgeon, a heart surgeon, a neurosurgeon, a pediatrician, a cardiologist, endocrinologist, rheumatologist, to, in short, a real doctor.

And it was not a little galling to see psychiatrists earning tons of money so easily, while people who went into the aforementioned specialties struggled. The psychiatrist in private practice was burdened with almost no overhead. Typically, they could rent a one or two room office, and they may not even need the expense of a secretary--an answering machine could do. They often admitted no patients to hospitals, did not work weekends and took no real on call at night. They had it easy. So every dollar they charged the patient was virtually all profit. For the other specialists, overhead ate up at least half of the gross income.

Which is not say psychiatrists are unnecessary or that psychiatry is not an important part of medicine dealing with important diseases.

My medical school class confronted the department of psychiatry at our medical school and refused to do the psychiatry rotation. We had read a book by Thomas Szaz, The Myth Of Mental Illness. So we were very well informed and we knew mental illness was just a convenient way of putting away inconvenient or obstreperous people. 

Astonishing, the chairman of the department at our very conservative and very upper crust medical school on the chic Upper East Side of Manhattan, listened quietly to all these rants from the students and, once they had finished, he said, with a sly smile. "Okay, I'll make you a deal. You have an eight week rotation of psychiatry scheduled for your third year. Just go to the psychiatric wards and observe for two weeks. Then come back here and we'll all meet again. If you still think, after two weeks of observing the patients on these wards we have simply made up a disease, that mental illness is just a myth, then you can have the next six weeks off, with my blessing. Go to Aruba, wherever. You'll get full credit for having completed all we expect of you in the department of psychiatry."

Of course, after three days of watching people with real big time depression, of talking with patients who afflicted by what was then called "manic/depressive illness" (now bipolar) or interviewing patients with schizophrenia who were hearing voices, not one of the ninety students in our class took the Aruba option. 

We were all humbled. No second meeting was necessary. We simply went back to the wards and watched and learned and got even more humble, seeing what those diseases were like, what they did to people, and how difficult the job of those psychiatrists really was.

Not that we were ready to embrace psychiatrists unreservedly. When we were in housestaff training, psychiatrists typically were not stand up guys: We had a patient staring out a ninth floor window at the end of the ward hallway, looking longingly at the sidewalk below, with a nurse and a medical student right there with her to prevent her from leaping out, and the psychiatric residents refused to come to the ward and do a consult.

That, in fact, was the trouble with The House of God a widely read novel about a medical internship at the Beth Israel Hospital in Boston.  After describing in detail the dehumanizing aspects of medical internship, that process by which caring human beings are transformed into dispassionate human beings who are capable of standing fast and not flinching when people who they like are going rapidly down the tubes, each of the real, sensitive, human beings in The House of God, opts out for psychiatry, as if that were the only consconable option for a real, sensitive human being. It was as if every member of Easy Company in Band of Brothers had deserted or simply refused to fight any more and been shipped back to England. None of them would have then liberated a concentration camp. But I digress.

And there are psychiatrists and psychiatrists.

One of the best psychiatrists I ever saw was that woman who "treated" Tony Soprano. That fictional show illuminated for me something I never saw in medical school--the possibility of a really insightful human being helping another human being to take steps toward a more meaningful and livable life.

Among real psychiatrists, my prize goes to the psychiatrist who had the unfortunate duty of having to spend an hour with six medical residents after we had been up all night on call with desperately ill patients on the intensive care units, the cancer wards. We had to spend that hour because the American Board of Internal Medicine required we have a certain number of hours of "psychiatric training."  Like virtually everything else about the Board, we considered this a stupid politically correct thing with no real value to insuring quality of medical training.

Oddly, though, in this one case, it did not work out that way.

The psychiatrist came in a little late, wearing a splendid tweed jacket and a spotless silk tie, freshly pressed shirt and there we sat, blood spattered, urine stained, smears of feces, vomit and dirt of unknown origins despoiling our white tunics and uniform slacks. Some of us fiddled with reflex hammers, others snapped their rubber tourniquets idly, and all of us looked unhappy about having to spend an our with this rear eschelon shrink when what we were aching to do was to go home to shower, to bed, to crash for an hour before we had to be back on the wards.

He looked around and asked what rotations we were on and we told him, one by one: intensive care unit,  Emergency Room, cardiac care unit, oncology (cancer) ward.  And he asked, idly, innocently, "See anybody die last night?" Actually, we all had, each and every one of us.

"What," he asked calmly, "Would it mean to you to learn you were going to die today? I mean, once you got past the disbelief, the anger, the rest of all that. What would it mean to you?"

And that's when it got really interesting. That's when the three guys, guys I thought I knew, who had kids, each one said, "It would mean I'd never get to see my kids grow up."

I knew these guys had kids, of course, But I almost never saw the kids. Sometimes, in a playground near the housestaff housing building, I'd see kids but I never really connected any of these kids with my friends, these band of brothers who I knew at the hospital. They couldn't have seen much of their kids, given our hours. I suppose, when they got home they could look at their kids sleeping.

Those, who like me, were not even married and were more concerned with who the next young lovely to warm our beds might be, we all said something to the effect that life had not really yet begun. We had been in school and training for something our whole lives. If we died today, we'd have missed actually having really lived.

So we did get something out of that hour, no thanks to the Board. We just happened to have lucked into a psychiatrist who knew where we had been.

I often wonder what my buddies would say if we were reassembled, about all the nurse practitioners doing primary care medicine who never had to go through what we went through on those wards, about all the "Physicians' Assistants" who see primary care patients, assist in surgery who never had to suffer through organic chemistry, physics, calculus and comparative anatomy--all those ridiculous courses which helped not one iota in learning anything which really mattered in medical school, but we had to do well enough to survive the elimination derby just to get to medical school, just to have the chance to claim a place in medical school so we could then compete for a place in a residency and then a fellowship program where we could stay up all night for years.

What would it mean to you to be told, well now a days, you don't have to do that to practice medicine or surgery?

I've thought about that a lot.

For now at least, I've come to the place where I'm saying, I didn't need to go through all that. And it was pretty awful at times. But in the end, I was lucky to have had the experience. It really was an honor and a privilege, in an odd sort of way.  I mean, nobody would say he's grateful to have had the experience of an artillery bombardment. But once he has, well, it makes him appreciate life just that much more.

Pledge Alegiance and The Triumph of the Will

Just watched about an hour of ""The Triumph of The Will. It's the Leni Reifenstein documentary done at a Nuremberg rally about 1934. 

What a wonderful age we live in; I go on Netflix instant Q and can choose from 200 documentaries, and there I am, transported back to 1934. Germany.

Just about the time this film was made my father was getting out of college in New York City, sharing jobs with friends as theater ushers,  shoe salesmen, whatever they could get. The United States was still deep into the Depression, and on the other side of the world, well it was another world entirely. 

My father understood German. I don't know if he ever saw the movie. But I know what he would have thought about it.

I'm not sure what to think about it, or rather, how to think about it. 

It's not a movie made to be thought about.

You react to it.

The wierd thing is, it's sort of thrilling at first. 

It starts out in the clouds, seen from Hitler's airplane, flying into Nuremberg, which looks really magical, with it's steep pitched roofs and towers and church steeples. And then you notice the ranks of marching people in the streets, and then the banners which look so much like banners from castles lufting in the wind.  Banners in black and white, but you know they are red, black and gold because they are the German colors, and the banners which you know are the red of a Marchino cherry, bright red, because they have swastikas in white circles. 

And then the people. Very clean looking blondes, grinning, overjoyed, estatic, raising their arms in the salute. You see them from behind as they crane their necks and try to get a sight line through the crowds along the streets. And like a crowd at a baseball stadium doing a wave, they raise their arms along the line, and you know it's Hitler's car passing by, although all the bodies block your view. But you can see from the excitement, all the people going up on their toes, he's passing by. 

And you see children doing the stiff arm salute. And people all dressed up in some sort of German Black Forest peasant costume doing the stiff arm. 

And you listen to Hitler talk about wanting peace, but wanting the youth of Germany to be hard and courageous whether in peace or adversity. He never says the word, "War."

And there are speeches by all his friends: Goebels, Hess, Ley, Rosenberg, all of them. 

And Hilter speaks to young men who shoulder shovels. They are some sort of forestry or agriculture workers. And they build dams, too. And Hitler talks about how there will be no more classes, and physical labor will be revered and every citizen will do physical labor first, before he moves off in whatever other direction he may desire.  He is talking about respecting everyone in society, value to everyone. (He never mentions Jews, gypsies or other undesirables.)

And you feel yourself getting swept along. Everyone is so estatic.

All the flags and happy people.

And I thought of Ronald Reagan standing in front of the Statue of Liberty, with a hundred American flags waving behind him, with his hand over his heart as they played the Star Spangled Banner.

Very creepy.

I know we must be different. We are different. 

And I thought, there but for the Grace of God, go you and I.

Or maybe it's not only God, but the power to say no. To recognize when you are being swept along by emotion, by a crowd, and you say to yourself. No. Not me. 

Let others run like lemmings.

I will think where it all leads.

New Hampshire Winter

This is what I expected winter to be when I moved to New Hampshire. It has snowed almost every week since early December. Not always a lot of snow; sometimes just enough to freshen up the street side banks of snow which had been blackened by the cars and trucks.

The natives are complaining. They say it's been a tough winter. But they also say that's what native New Hampshire types do. They complain about the cold in the winter and the heat in the summer.

There are, the natives say, four distinct seasons in New Hampshire:  Almost Winter; Winter; Still Winter and Road Repair Season.

We are expecting more snow tonight, as February fades, and we may well have snow through the early part of April, but that is what I expected moving up here, and so I have no right to complain.

In fact, when Spring finally arrives, if I live that long, I will feel I have earned it.

Watching the Repbulicans engage their delusional state in Washington, DC, I am still happy to be in New Hampshire.

Remembering the lunatics I saw as a medical student, who saw the world as if through a keyhole, with tunnel vision, these Republicans seem eerily familiar. The answer to every problem is less government, invoking fear of the deficit, pronouncing disaster prophesies if we do not cut spending (except of course for the things they hold dear).

And the certitude!

I think it was Bertrand Russell who asked, "Why are the simple minded cocksure and the intelligent full of doubt?"

One might ask that question looking a Mitch McConnell, John Boehner, Micelle Bachman and the whole Republican House of Representatives.

The Desire to Instruct

I've been thinking lately about why people like Michele Bachmann and Glenn Beck and Rush Limbaugh gravitate to blackboards and presentations and pontification.

One thing they share is a lack of any sort of rigorous education. It's as if, never having had the blessing or curse of a rigorous academic experience, they crave that mantle of authority more than those who have.  


They want to pull on the cap and gown, as if magically, they can acquire by the accourments, the authentic power of knowledge.


Of course, there is a big difference between being formally educated and being intelligent.


And you need only come to New Hampshire to meet a lot of people with no more than a high school education, who are highly intelligent, highly competent but not very educated in the sense of academic ladders.


Lincoln, of course, had little formal education, but he was one of the finest writers and thinkers of his time. And his time included Thoreau, Emmerson and so we're talking about a pretty fast track. But, somehow, he used what he learned more effectively than anyone else, even those who had been educated at Harvard.


He had the power to see through and past convention to truth. When he was upbraided for not being religious he replied, "I feel bad when I do wrong. I feel good when I do right. That is my religion." Considering that religion was the basis for most formal education in the 19th century, and the learned were schooled in the languages in which the Bible was written so they could read it in the original--Greek and Latin, that was a pretty big statement.


When asked if he thought God was on the side of the Union Army and the forces of Union, he replied, "I simply hope the Union Army is on God's side."


In a sense, I have the feeling had he been sent through Phillips Exeter Academy (where he sent his son) and Harvard, Lincoln would have been better educated, but less brilliant.


There is a story about Anthony Fauci, who is the chief of the National Institute of Allergy and Infectious Disease and the head of the federal government  task force on AIDS. Having finished his year as a Chief Resident in the Department of Medicine at Cornell University Medical Center, New York Hospital, he was ushered into the sumptuous office of the Chief of Medicine, where various luminaries of the hospital staff had gathered around some bottles of good congnac and, as was the tradition, the Chief of Medicine shook his hand and intoned that Dr. Fauci would receive his appointment to the staff of Medicine at the New York Hospital and an appointment to the faculty of medicine of the medical college. This was something akin to being given the keys to heaven. A Park Avenue practice, keys to the Doctor's Coat Room, the doctor's lounge, the good life.


Fauci refused the prize.


The news raced through the hospital. Every intern on every ward, every nurse, evry medical student, every "Made Man" on the medical staff was talking about it.


Finally, when one of his friends could contain his curiosity no longer, he asked Tony how he could turn down this glittering opportunity.


"I told them, " Fauci is reputed to have said, "Someday, I will be either very rich or very famous. If I stay here at Cornell, I will be neither."


Fauci has never publicly confirmed this story, but everyone loves it.


So, for those who came up through elite academic institutions, the glow of academic respectability may not be as bright as it is for the Glenn Becks, and Michele Bachmann's and Rush Limbaugh's, who can only dream of what that experience would have meant for them.


But one thing most people get out of such training is a strong sense of what rigor in thinking means. How do you prove something?  How do you ask questions? What else? What are the possible deficiencies of this argument? 


All of which makes me wonder why people want to believe what they believe.


One of my co workers told me, quite appalled, that Barack Obama was not born in the United States, that he refused to say the Pledge of Alliegance and he refused to wear an American flag lapel pin. 


She listened to Rush Limbaugh and learned Obama was trying to detroy America.


I asked her why she wanted to believe these things.

She replied she did not want to believe these things. They were simply true. She had to face the truth.

And how do you know they are true?


Because she had heard them on the radio.


And do you think everything you hear on the radio is true?


That stumped her.

When the report on the causes of the financial crisis came out, there were over 400 pages of data, interviews, pretty straightforward accounting and about 100 pages of analysis.

The committee of four Democrats and three Republicans agreed on the "facts" in the 400 pages but the 100 pages of analysis split them along party lines.


Basically, you could understand where the analysis differences came from: They came from dearly held prior beliefs. The Democrats believe business and the free market pursue only one thing, profit, and ignore every moral, social and patriotic imperative which may impede the maximizing of profit.  The Repulicans believe the source of most, if not all, civic evil is the over reaching arm of the government.


So the Republicans  said the crisis was caused by government--Fannie Mae and Freddie Mac which made responsible, professional bankers give mortgage loans to undeserving, untrustworthy, dead beat low lifes who were probably Democrats. That caused the housing markets to crash and that caused the meltdown.


The Democrats said the bankers, CEO's and Wall Street tycoons dreamed up the idea of packaging mortgage loans and once they saw they could make money by selling these packages, they didn't care what was in them and so they sold damaged goods, bundles of mortgages which were loans made to people no self respecting banker should ever have approved. The whole idea of due diligence went out the window when the vision of huge profits flitted in front of these money movers.


Pundits of all stripes jumped in immediately, not having done the tedious, difficult work of reading the 400 pages of data and declaimed for one side or the other, because they wanted to believe their own dearly held darlings, the beliefs they had espoused for years, were supported by what is in those 400 pages. But few or none of them actually want to do the heavy lifting of reading through it all. 


I sure have not read through it all.


Don't know I ever will. 


I'll just believe, for now, the fault lay with the rapacious money guys, the Goldman Sacks crowd, and the government may not have done much to catch them or to prevent them from raping the system, but Fannie Mae and Freddie Mac are just whipping boys.


So I can understand why people cling to certain beliefs--mental laziness, fear of being shown to have been wrong in basic beliefs.


But why does that woman want to believe those things about Obama?


Why do people want to believe fluoridated water is a government plot?  Why do they want to believe the deficit is more important than spending money to create jobs and to improve infrastructure?  Why do they want to believe the new Healthcare law mandates death panels? Why do they want to believe Glenn Beck when he says the government is out to get your pancreas?


How does that work?


In What's the Matter With Kansas? The author spent hundreds of pages exploring the sources of resentment which caused people to believe crazy things which made them vote against their own economic self interest. 


There were class resentments, the resentment of the farmer whose son could not go to Harvard but that son could a rebuild a tractor engine and re wire a house, things few Harvard seniors could do--so why do the powers that be confer on the Harvard kid the respect and prizes and denigrate the farm kid from Kansas? 


There is the guy who never went to college, but worked at General Electric for thirty years as a welder, progressing up the ranks to the point he was doing the welds on airplane engines, which is so far beyond basic welding as to be the difference between shop class and astrophysics and ceramic chemistry, but when he came up for promotion to a managerial position, GE told him he didn't qualify because he didn't have a college degree.  And he said, "My brother went to college with a bunch of frat boys who were drunk in their fraternity for four years. Why are they more qualified than I am to manage the welding of airplane engines?"


So he wants to believe all regulations are ridiculous and the government makes regulations by the truckload.


But I still don't understand the woman who wants to beleve all those things about Obama.


Where does that come from?

Quintessential American: Supermarket

Many institutions have been said to be prototypical American—the drive in fast food joint, the baseball park, the shopping mall, the amusement park, but for me the quintessential American institution, the thing that has set the mold for what it is to grow up and live in America is the food supermarket.

When my mother-in-law returned to America after a dozen years abroad, what amazed her more than anything was the supermarket where we shopped  for groceries.

Now this is a woman who was born in Missouri, graduated from Berkeley, as white bread and heartland a growing up as you can get. But she had married an engineer who worked for Mobil Oil, so she had spent years living all around the world, wherever they drill for oil: Saudi Arabia, England (North Sea), New Foundland, and Norway.

Coming home, she was unfazed by the traffic, and she adjusted quickly to everything else, but the supermarket we took her to in Bethesda, Maryland stunned her.

The store Giant Food, was not too different from supermarkets you find in any American suburb. It was a typical supermarket, but a little more so. It occupied about a city block, and it had a bakery, butcher, produce, pharmaceuticals, hardware, lawn furniture, a gourmet section, a delicatessen, aisle after aisle of prepared food, barbecued chicken. You could go in and buy food for a month, as some people did, or you could buy a pre cooked dinner, ready to be taken home.

When it was first built around 1959, the locals were just as astonished by it as my mother-in-law was in 1990. It was called Super Giant then, but as other stores were built around the Washington metropolitan area, it became simply, “Giant.”

It was started and for decades own and run by a man named Israel Cohen, who visited each store, and wandered through talking to employees.

One of them told me about his first day on the job, in the produce section, and Israel Cohen ambles up and asks him how the peaches were that day. The stock boy said he didn’t know and Cohen said, “Well, I own this store and I want my employees to know all about the stuff they sell, so every day you come in, take a bite out of a peach, and take a bite out of the other stuff, so if someone asks, you can tell her whether the peaches are ripe or whatever.”

“Gee, Mr. Cohen,”  the stock boy said, “I thought if I were caught eating the food, they’d fire me.”

Cohen laughed and said, no, this was considered part of the job.  Cohen took a liking to the stock boy and eventually offered to pay his way through the University of Maryland, if the boy would promise to work a year at Giant  for every year he went to college.

The check out people, all the employees of the store,  knew Mr. Cohen and I never heard any of them say a bad word about him, and they smiled every time his name was mentioned.  He hired people with Down’s syndrome to help load the cars out front, when people came by for their grocery bags.

Ultimately, after Mr. Cohen died, Giant Food was sold to some international company, headquartered in The Netherlands, and the place became less friendly, less family, but it continued to offer a vast spectrum of food, and other products. 

I always thought of it as one of those big American enterprises which was essentially benign, a positive force in the world, one of those things that made you feel fortunate to be an American.

Later, traveling to Italy, I discovered grocery stores of a similar scale, and considerably higher tech—where you purchased your food simply by placing it in your shopping cart (and it was automatically charged to your credit card) so there was no check out line. And your cart was conveyed automatically down to the basement garage by a sort of cart escalator, so you didn’t have to drive around to have your bags loaded. But nothing anywhere I went ever quite matched the majesty, the efficiency and the sheer diversity of Giant.

And yet, having read Michael Pollin’s Omnivore’s Dilemma  and now being aware how little of what is offered in the American supermarket is actually unprocessed, unadulterated, and how the supermarket is just the final common pathway to the consumer, the final connection from a long line of industrial animal production, the whole institution seems less benign.

It’s the old story of the dazzling product, which seems so wonderful, but it has been gotten to you by a trail of tears, or at least by a pretty dubious process.

Those steaks, wrapped so appealingly in their plastic packages were once a cow imprisoned in a metal gated pen, standing knee deep in its own excrement, pumped full of industrial doses of antibiotics to ward off the bacteria festering in its wounds, and you have no idea when you buy it.

The stuff in the magnificently decorated  cardboard boxes with cereal in side—Gorgeous colorful Fruit Loop boxes—proclaiming their high fiber content as a health benefit of eating what is essentially close to pure sugar, it’s just so many lies, and a road to obesity, early coronary artery disease and dental decay.

Industry does not intend to harm us—it simply is not interested in the question of who may be harmed by its functions. It’s only concern is profit.

And that is, now at least, America.

Money rules.

For a while, in the 60’s, it was fashionable to speak out against commerce and profit and American industry, and the willingness to despoil the environment and to damage the public health, as long as profits increased.

But now that is all out of fashion.  We are back to being hard headed about the bottom line,

We are, after all, Americans.

The Phantom on Medical Education

From the day I got back my first college biology exam and realized I just might be able to be a medical doctor some day, I have had to think about that imperfect, dysfunctional, ridiculous, arduous and discouraging process called medical education, as it exists in this United States of America.

It's a story of sheer stupidity, cupidity, commercialism in the worse sense, but it has produced some pretty good doctors along the way. 

Recently, some New York medical schools and hospitals have expressed misgivings about foreign medical school graduates as they insinuate themselves into training programs at various city hospitals. This provoked a number of letters to the New York Times, mostly from paid spokesmen for various interest groups, but one from an American physician who had moved to Canada and found his American medical training was judged inadequate by the Canadians. He concluded for all our bragging, the American system of medical education was inferior to the Canadian system.


He may have had his own axe to grind, but I am prepared to believe we may not have the best system of medical education in the world.


We likely have among the most exclusive and competitive medical schools, by which I mean we make it difficult for applicants to gain acceptance, but it remains an open question whether we are excluding the right applicants and admitting the "best" ones.


And that just speaks to the process of undergraduate premedical education, by which we cull the applicants. What happens when students actually become medical students is another matter.


Beyond medical school, there is the real show, internship and residency, what is called "Post graduate training" by which newly minted MD's are turned into real, useful doctors. 


The problems with this phase of training have been widely presented, discussed and dissected, mostly by people who do not know what they are talking about, or by people who've been through it and want to tell you how tough it was and how it was the only way to forge physicians and surgeons of sufficient toughness, steel tempered by the hot flames of intensive training.


From the perspective of years and watching all the changes in the system, I'm more humble than I was when I was freshly minted.


For one thing, the landscape into which all these new doctors are dumped has changed.


When I entered private, solo practice years ago, most of the doctors who had trained me and most of the doctors I saw around me were self employed. Now fewer than 12% are. Eighty-eight percent of practicing physicians, I am told, are using W-2 forms, not 1099's. How many of these are actually self employed, but employed by a small doctors' group of 10 or less calling themselves a "practice," is unclear.

But now there are all sorts of "practitioners" out there. In a highly competitive market like Washington, DC, New York, Philadelphia, Boston, most of the doctors are MD's but beyond these concentrations of doctor rich cities, there are significant percentages of "DO's," doctorsof osteopathy, who deliver a lot of medical care in smaller cities and towns. 


Beyond the DO's are nurse practitioners who practice in offices without doctors, doing many of the things only doctors were allowed to do in the past--writing prescriptions, ordering expensive tests like MRI's, nuclear medicine studies, CAT scans.  And there are Advanced Practice Nurse Practioners, Physicians assistants, Nurse practictioners, specialized nurse practictioners in dermatology, urology, as well as general practioners nurse practictioners in family practice and internal medicine.

There are podiatrists doing complicated reconstructions of feet in the operating rooms.  


And in smaller towns you have homeopaths, chiropractors, optometrists, naturopaths, writing presciptions, advising patients.


There are any number of certified practitioners, all the way from certified nurse midwives (who have two to four years of college, two years of nursing school and two years of nurse midwifery training) to certified diabetes educators (who may be nurses or dietitians) and pharmacists, pharmacy techs, 


There are nurse anesthetists, putting patients to sleep in the operating rooms. There are surgical physicians assistants doing procedures we used to sweat bullets over when I was an intern trying to learn these things--thoracentesis, subclavian sticks, cut downs on peripheral veins, harvesting veins for bypass grafting 


Just about any procedure you can name has been "Certified" with some sort of exam and somebody who may have graduated high school can be trained to do it. 


Of course, this does not apply to colonoscopy or any procedure which is still a cash cow for some group of doctors--there the MD's only are allowed to do a procedure which takes six months to a year to master.


And the MD's have changed.  There are now as many or more women medical doctors emerging from medical schools as males, and these women are not at all reluctatn to say their children come first, before the needs of their patients. 


There are women doctors who have changed the whole dynamic the whole psychology of medical practice. One "Laser dermatologist" told me she did not want to cut out a pigmented lesion she noticed on a patient because if it came back as a melanoma, she'd feel uncomfortable having to give the patient the bad news. She wanted to do only cosmetic dermatology in her beautiful office, which she had spent six figures on creating with the help of architects and interior decorators, and where she sold her own line of dermatologic lotions and make up.  She took month long vacations in Europe because she had a European boyfriend. She could do this because she made more than $400,000 a year doing laser dermatology.


And she saw nothing about this to apologize about.


She was trained at  Duke and Harvard.  She was the best of the best, as far as she was  and she practiced in a glamor city among the rich and famous. 

In the same city, I knew a man who graduated from the American Medical School of the Caribbean and he trained at a non university hospital for his residency before gaining his fellowship at Georgetown. He has worked his way up, in status terms from a "fourth rate" medical school to a "third rate" residency to a university fellowship. 

And I never have had the privilege of practicing with a better physician in thirty years. He was up to date in the medical literature, an astute clinician, a wonderful observer, but mostly he always put the needs of his patients first, no matter how late it made him, how much it cost him personally or financially, and he never failed to take the time to remove the dressing to look at the wound, while all the graduates of the first tier medical schools and programs raced past their patients. 


Now, basing broad conclusions on exceptional cases, is an invitation to bad policy, I know, but it's tough to know how to do the best job when you can see the exceptional cases out shining the Ivy Leaguers. 


If I were the benign dictator of medical education, I could (as could many of my friends) do a much better job than is currently done. 


But we do not have a benign dictator.


We've got what the union army had during the civil war, a lot of generals with political connections, who fell along a spectrum of being simply inadquate to being truly disasterous. 

But we're only talking about medical training medical care here. 

It's not like having the wrong people at the head of General Motors and Chrysler. If you have the wrong people in those positions those industries crumble from pressure from foreign competitiors. 


With medicine in this country, you can keep telling everyone they've got the best system money can by and nobody will ever know the difference.