“Some roads you shouldn’t go down. . . . 

‘There be dragons there”.

              Lorne Malvo (2014)

Give me a little space to ruminate and philosophize on some controversial stuff. I’ll start at the top of the pyramid and work down through the expanding bases. All of this is just my idle observation. The mileage of others will surely vary.

First, the impending SCOTUS erasure of Roe v. Wade, a black letter law since 1973. There is no controversy about how the SCOTUS will rule. The now “Conservative” majority of the SCOTUS knew how they would vote to upend Roe as soon as they were seated. It was amusing to watch them double talk to Democrats during their Senate confirmation. You would notice none of them ever said they would preserve Roe, they said they might think about it (with their fingers crossed).  They had already thought about it through their entire judicial history and they always let on they would trash Roe if they ever got a chance. They will trash Roe and the minute they do that, a number of states already have pending laws making abortion illegal, the rest will brutally enforce the Texas law, following which the following will occur quickly:

         1.  The decision to abort is a binary one. It’s either support a full-grown woman’s needs or the needs of a tiny mass of dividing cells. There is no other option; it’s one of the two choices. In a perfect world, there would be neither of these choices, but in our world we get to choose unless some political party that normally supports “small government” and “choices of the individual” blazes out of those platforms to stick their noses into choices of grown women. A “conservative” party that’s conservative only as their policies toward the poor and working citizens. Not so much big corporations and the rich. 

There is and will always a demand for the cessation of a pregnancy. Justice Barrett opines that adoption is a desirable alternative for women who become unexpectedly pregnant, an alternative that can be more difficult, expensive, dangerous and traumatic than terminating a pregnancy in its early stages. Rape, incest, young girls accidentally with a pregnancy that would ruin their lives, poor women that can’t afford a child, affluent woman that simply don’t desire a child. These women will do and will go whatever or wherever it takes to stop something that’s undesired or unaffordable. The “legality” of this decision is not a consideration as long as it’s available, which it will be as a quickly emerging cottage industry as it all was before Roe. 

         2. The SCOTUS is probably not stupid enough to believe trashing Roe will stop abortions. It’s just a dry interpretation of the law. Those carrying picket signs are certainly that naïve, but the reality is that well heeled women desiring abortion will travel to states allowing it or other nearby countries that figure out they can make a lot of money in this new cottage industry. Poor women will get their abortions in back alleys in dirty, unsafe conditions. They will end up in emergency rooms with PID and septic death. Trashing Roe will not stop one abortion, only the logistics of availability will change for the infinitely worse. 

         3. What making abortion illegal will do simply give Republicans their traditional chance to blame victims. The Trump administration previewed it in their comments about those crossing into the country illegally. If they hadn’t showed up and crossed illegally, they wouldn’t have had to put up with the atrocities visited on them. The victims are at fault, not the policy. This is exactly where trashing Roe is headed, especially if Trump is re-elected. As a practical matter, I don’t think conservative Republican leaders are stupid. They know all of my predictions will come to pass in spades. It’s all acceptable collateral damage to be rooted out and placed where it belongs, the criminal justice system.

This new “conservative” force poised to visit this stellar disaster on women is part of a much bigger change in society that my confounds my generation. I was brought up as a 60s flower child believing in the evolution of society to a better place than the insipid 50s. Demonstrations of “minorities” were pretty much limited to the interest of minorities. We didn’t understand the significance of the Black Panthers or Dr. King. We wished them well but from afar. They were a “minority”. Our demonstrations were focused on seemingly larger issues to us, Vietnam, education and Nixon. 

As a practical matter, black persons in the new millennium are no longer a minority. Two events brought them to the forefront of political muscle. 

         1.  Chris Rock trashing the 2016 Academy Awards, bringing “diversity” to the forefront. This occurred because not a single picture featuring a black actor was nominated. Will Smith had starred in a very unremarkable film, “Concussion” and boycotted the awards opining that he should have had a shot at best actor or best picture. I was deeply involved in concussions in my medical career and I saw the film. It was OK but not anywhere in the league of “Fury Road” or “The Revenant”. There were simply better pictures that won, but Chris Rock galvanized the industry and to avoid further bad publicity, the Academy insured some films featuring black actors were nominated, none winning but an emerging powerful and forceful caucus that didn’t exist in the 60s or 70s had made the mark.  

Today, the black population is no longer a “minority” and promoters of almost everything have figured out that “diversity” doesn’t mean acceptance of “all” minorities, it means more of everything for the black population because the accusation of “racism” carries virtually unlimited liability. Any criticism of any black faction for any reason is automatically “racist” and the accusation is quickly carried back to the accuser, or anyone that limits the participation of the black population into anything. 

Persons of color have infiltrated everywhere because they are no longer a minority. They’re a very powerful functional majority that’s learned how to use the cabal of “racism” very effectively; giving them extremely potent political power by the use of one word fits all. That one word renders them without any natural enemies other than a relatively few cops shooting at them. And I know several black guys that don’t refer to themselves as “African-Americans”. Aligning ones-self with a country like sub-Saharan Africa, a place full of injustice, corruption, abuse and an origin of slavery seems disingenuous. Most have never been there.

If you’re a TV watcher, make a mental note next time you sit through the rapidly increasing number of TV commercials. See if you can find one that doesn’t have one or more black person in them. Emus don’t count. Cops and lawyers on any CNN feature are mostly Black. And very interestingly, if you watch TV commercials long enough, you’ll notice that skin tones of “persons of color” are getting lighter and lighter as they become progressive bi-racial iterations, ultimately to look like Meghan Markle or Kamala Harris, neither of whom have any appearance of “color” but both of whom refer to themselves as persons of color when it suits them. 

         2. Then came the George Floyd murder in May of 2020. This sentinel event prompted violent outbursts in virtually every city in the country, and even a few abroad. It was widely thought that this event would radically change the way police and many others assessed the black population, presumably for the better. However, the extensive history of how the “majority” (white) population assessed the “minority” (black) population was temporarily placed on the back burner, but to emerge pretty quickly. The white population (Caucasian?), as a political force has ever and always discriminated against blacks all the way back to Reconstruction. That population is also very potent. It exists mostly underground to camouflage its reality but It’s never altered no matter what the incentive and is unlikely to with the “black lives matter” demonstrations. Cops continue to shoot those black guys, sometimes in cold blood after George Floyd. The “protests” have slowly drained away.

Jason Riley wrote in the Wall Street Journal on Nov 30:  

“The protests that followed Floyd’s death 

rested on two Assumptions. The first is that 

Floyd, a career criminal and drug addict, 

was somehow representative of black 

America, which is not only false but deeply 

insulting. The second is that police acted 

out of racial animus, which has never been 

proven. This is what happens when racial 

identity becomes the centerpiece of politics 

and public life in a multiracial society”.

Now we come to the next platform supporting all this, the Donald J. Trump voter base, a group so incredibly alien to my generation or any generation before me that they may as well have landed from Venus. I have two friends that passionately supported Trump and still do, despite his malignant narcissism and lifelong untruthfulness pathology. Interestingly, as I mentioned before about the SCOTUS and Republican leaders, they aren’t stupid. They completely understand Trump’s pathology and accept all of it to promote the longer game- a movement of the new millennium social orders more toward “conservatism” and less what they term “liberalism”. 

Two issues prompts this seemingly new order capable of electing presidents of the United States. 

         1.  The incredibly stupid Democratic fathers allowing Hillary Clinton, with her trainload of dishonorable baggage to enter the quest for US presidency. They had no idea how much Hillary was despised among a very large but quiet set of voters who would vote for Charley Manson before they’d support Hillary. They were lulled into a false sense of security by polls that didn’t represent those who chose not to participate.

         2.  The fact that a large number of voters that consider the entire congress from A to Z to be a bunch of monkeys cavorting in big, expensive playpens, expending senseless energy, getting nothing of consequence done.  Trumps antics were exactly what this emergent voting faction desired. Someone capable of “stirring the pot”, creating a comical playground for congressional monkeyshines. 

These new quota of voters savor their TV sets in their wife-beaters with a can of beer laughing loudly at Trump’s comedy routine. Trump couldn’t do any more harm than what’s normally transpiring and he’s more fun to watch, better than Saturday Night Live. But the Republican fathers know exactly the value of Trump, namely the long game. They’re happy to appear as scatterbrained airheads pumping out Trumps false value to American society, quietly ignoring Trump’s disasters. Supporting Trump puts them in touch with the “new quota” of powerful voters, the supply of which elected this monster in 2020 and is likely to do it again in 2024 so they can continue to pack courts with conservative judges and gerrymander voting states, limiting anyone likely to vote Democratic.

We now live in a society my generation never dreamed of. Protests of the tangible ills of the 60s and 70s replaced by “Black Lives Matter”; an indulgent surrogate for “All Lives Matter”.  

* “Demonstrations” focused only one of societies ills that has never been addressed or repaired since 1864 and are unlikely to in 2022. 

* Massive hordes of would-be immigrants shifting around the globe, first inspiring fear among countries liable to be trampled, then used as politically threatening pawns giving some countries leverage over others by directing the herds.

* Stone cold criminals driving cars into demonstrations with the intent of killing or injuring as many as possible. The Waukesha rampage suspect released from jail on inappropriately low bail, suggesting such activity doesn’t have the same weight as it used to in better days. Incompetent minors shooting up “protesters” during “demonstrations” and getting a clean bill, suggesting to others the ease of getting with that program. 

* A hue & cry arising to delete funds for police, replacing them with social workers that would presumably show criminals the error of their ways. A terrifying bit of nonsense. 

* An underage kid living in an adjoining state arriving at a volatile “black lives matter” rally in Wisconsin ostensibly to render medical help he had no training or aptitude for and armed with a very visible rapid-fire assault rifle with a 30+ round magazine for his “self protection”. This immediately prompted violence leaving two dead and another severely injured.  But it was all OK, the jury finding that there was reasonable doubt as to this kid’s intentions. Maybe he was just defending himself from unarmed assailants.

*Random shootings virtually everywhere, the newest of which occurring in schools by persons who should never have been allowed to come near weapons firing bullets and who just shrug when captured. The NRA advocating more arms for law-abiding citizens viewing firefights at the sites of fender bender car incidents as acceptable collateral damage. 

*Incompetent observers decrying life saving vaccinations on the basis of their “choice” to be dangerous to themselves and others.

“Oh, wonder! How many goodly creatures 

are there here! How beauteous mankind is! 

O brave new world that has such people in it!”

                      From The Tempest.

But again, these are just my idle observations you may take for what you think they’re worth, if anything.

“I cried when I wrote this song……

Sue me if I play too long….

              Steely Dan (1977)

David Crippen, MD

Antivax- An argument sort of like the war cry of the Appalachian Wing Nut: “Ain’t no gov’ment gonna tell me what to do”, but in fact, it’s an empty argument since the Gov’ment tells all of us what to do all the time and if we don’t do it, there are unpleasant consequences. We must prove we have liability insurance for our cars. We must wear seat belts. We must have “approved” child seats for kids ion our vehicles.  We have speed limits. States with a half a grain of sense have mandatory DOT approved helmets for motorcyclists. We must pay income tax. There are rules pertaining to possession and use of firearms. If there are minor children involved, you must pay child support in the advent of divorce. The list goes on and on, 

And by the way, by law your child must have several vaccinations before they can enter public school. All these vaccinations are considered extremely safe and the very few adverse reactions that might occur are inconsequential compared to the disaster if any kid gets the childhood diseases they would be protected from. So-called “anti-vaxxers” are a blight on the planet. When they get away with avoiding vaccines for childhood diseases, those diseases (measles) explode in those areas.

The number of vaccinations in the USA have stalled now at under 50% for all the population last I looked, not enough for “herd immunity”, which means that the resistant forms of COVID in the un-vaccinated now have fresh meat. As a result the number of hospital admissions for COVID related issues are exploding. CDC reports that from one year (August 01, 2020 – July 30, 2021) there were two and a half million hospital admissions for COVID and over six hundred thousand deaths. All increasing now since the advent of the delta variation.

The number of vaccinations are stalled because we’ve reached the population that understand the importance of the shots and go out of their way to get them. We’re now looking at the population that actively reject the shots for whatever reason. Some distrustful of them, some political, some rabid anti-vaxxers, some lazy and don’t care. Some states have tried to generate interest by offering money and other incentives. If you watch Fareed Zakeria’s show this Sunday morning, one of his guests went into detail on why that won’t work. His book “Nudges” is quite interesting, 

Nobel winner Richard Thaler suggests that the way to get all those recalcitrants in gear is to create the same kinds of irritating adverse consequences we all suffer if we get crosswise with all the irritating laws currently in place (by the gov’ment). Sorry- no mask, no service. Sorry, no vaccination card, no seat on an aircraft. Sorry, no vaccination card, go eat or work somewhere else. Your kid didn’t get his vaccinations?  Home school. Those are the incentives that get people to comply with things like vaccinations.

If there are no adverse consequences to that population who for whatever reason don’t get the shots (and that’s where we’re stalled), then that population will inevitably land in hospitals and many will die from the virus. The personal and economic consequences of this mandate the same kind of laws that exist to protect the population.  It isn’t a personal choice issue. It’s my personal choice if I choose to drive my Ferrari at 120 miles per hour on Rt 28 near my home. But if I choose to do so, there are unpleasant consequences if I get caught, which is likely as a yellow Ferrari passing other cars like they’re standing still sort of stands out. 

There is no convincing data that there are any untoward reactions to any of the vaccinations more than would be expected by luck of the draw. There is convincing evidence that the vaccinations are at least as safe and effective as childhood disease vaccinations. The consequences of COVID are positively scary and are getting worse by the month. If we don’t achieve something like “herd immunity” (the virus is stamped out for want of a susceptible population), this scourge has the potential to keep killing people indefinitely. If there are no consequences for those refusing the immunization, the won’t do it, and that action will have it’s own consequences.

Unclear to me exactly what your argument against demonstrably effective vaccinations for viral illness is. The Government tells all of us what to do all the time and if we don’t do it, there are unpleasant consequences. We must prove we have liability insurance for our cars. We must wear seat belts. We must have “approved” child seats for kids in our vehicles.  We have speed limits. States with a half a grain of sense have mandatory DOT approved helmets for motorcyclists. We must pay income tax. There are rules pertaining to possession and use of firearms. If there are minor children involved, you must pay child support in the advent of divorce. The list goes on and on,

And as it pertains to children, by law, a school age child must have several vaccinations before they can enter public school. All these vaccinations are considered extremely safe and the very few adverse reactions that might occur are inconsequential compared to the disaster if any kid gets the childhood diseases they would be protected from. Polio and Smallpox were wiped out by vaccinations. So-called “anti-vaxxers” are blight on the planet. When they get away with avoiding vaccines for childhood diseases, those diseases (measles) explode in those areas. Nut cases like Jenny McCarthy know nothing about the science and are using completely obsolete evidence.

The number of vaccinations in the USA have stalled now at around 60% for all the population last I looked, not enough for “herd immunity”, which means that the resistant forms of COVID in the un-vaccinated now have fresh meat. As a result the number of hospital admissions for COVID related issues are exploding. Current numbers from the New York Times show to date in Pennsylvania there are 2.62 million COVID cases and 40,257 deaths. 

Way back when dinosaurs roamed the earth, I was a medical microbiology major in college. At some point, I had a virology course, taught by a full professor. The question of whether viruses were alive inevitably came up. Best of my recollection, the professor said there were two basic criteria that defined “life”:

1. The ability to replicate.
2. The ability to adapt to (survive) injurious environments.

If such an entity could not replicate or couldn’t adapt, the line would also stop right there.  The question of whether “personality” was necessary for life was undefined. Probably not, but then do we know whether viruses have personality?

Viruses most likely originated from early RNA-containing cells that for unknown reasons made an evolutionary leap away from the cellular form, casting off weighty metabolic shackles to opt for a more streamlined existence. While a virion is biologically inert in and of itself, once it enters a hospitable environment, it most assuredly can replicate and adapt. It is therefore “alive” (and smart) in a satisfactory sense.

The nature of a virus is to change its form to survive any environment. When one environment gets hostile, maybe from a creation of antibodies, it morphs to become resistant to those threats. Started with the original virus, then morphed to Delta and now Omicron. Pretty good chance it will continue to do so, maybe indefinitely, but each iteration becomes less virulent. There doesn’t seem to be much evidence that this virus will die off any time soon, even if we reach huge levels of vaccinated humans. We don’t seem to be on a rapid course for that. We’ll probably end up with yearly shots for it just like the usual Flu.

The numbers of vaccinations are stalled because we’ve reached the population that understand the importance of the shots and go out of their way to get them. We’re now looking at the population that actively reject the shots for whatever reason. Some distrustful of them, some political, some rabid anti-vaxxers, some lazy and don’t care. Some states have tried to generate interest by offering money and other incentives. If you watch Fareed Zakeria’s show a few Sundays ago, one of his guests went into detail on why that won’t work. 

Nobel winner Richard Thaler suggests that the way to get all those recalcitrants in gear is to create the same kinds of irritating adverse consequences we all suffer if we get crosswise with all the irritating laws currently in place (by the government). Sorry- no mask, no service. Sorry, no vaccination card, no seat on an aircraft. Sorry, no vaccination card, go eat or work somewhere else. Your kid didn’t get his vaccinations?  Home school. Those are the incentives that get people to comply with things like vaccinations. 

If there are no adverse consequences to that population who for whatever reason don’t get the shots (and that’s where we’re stalled), then that population will inevitably land in hospitals and many will die from the virus. The personal and economic consequences of this mandate the same kind of laws that exist to protect the population.  It isn’t a personal choice issue. It’s my personal choice if I choose to drive my Ferrari at 120 miles per hour on Rt 28 near my home. But if I choose to do so, there are unpleasant consequences if I get caught, which is likely as a yellow Ferrari passing other cars like they’re standing still sort of stands out. 

There is no convincing data that there are any untoward reactions to any of the vaccinations more than would be expected by luck of the draw. There is convincing evidence that the vaccinations are at least as safe and effective as childhood disease vaccinations. The consequences of COVID are positively scary and are getting worse by the month. If we don’t achieve something like “herd immunity” (the virus is stamped out for want of a susceptible population), this scourge has the potential to keep killing people indefinitely. If there are no consequences for those refusing the immunization, they won’t do it, and that action will have it’s own consequences.

I and everyone I know got the booster because it’s the lesser evil and the numbers are definitely on our side. The statistics clearly show that over 90% of those hospitalized and dying didn’t get the shots. Those that did had very mild courses if they got the bug. Two of my clinical colleagues that took a stand against the shots BOTH ended up in an ICU, one almost died. Don’t get fired over this. Your career is worth infinitely more than making a stand for a lost cause.

Recall several months ago I wrote some editorial opinions on where I thought critical care was headed, some of them not too kind. I foresaw a critical care world full of Physicians Assistants (PA) and Nurse Practitioners (CRNP) doing patient care and critical care physicians as their handlers in executive roles. The actual experience and training of the critical care fellows to do that more and more attenuated as they eschew night call and direct patient care the PAs and CRNPs are more than happy to provide.

I see it already in the surgical specialties. I saw the guy that fixed my ruptured Achilles Tendon once, the day of surgery. Everything thereafter was handled by his PA. No way to contact him even if I wanted to. I saw the guy that fixed my femur fracture once, the day of surgery. The followup visit three weeks later was handled by his PA.

I was told a while back by the head of our Department who happens to be a long time personal friend that my weakness was that I wasn’t into teaching the fellows the algorithms and protocols that are ruling critical care, and that direct patient care is becoming overrated as it really won’t be done by physicians much anymore. It will be “directed”. the critical care physicians job will be to know every possible parcel of literature and to be involved in some form of research, because that’s where the institutional prestige (and probably money) is.

My response to that was that the directorial critical care physician will be more of a figurehead as he or she gets less and less hands-on experience, especially at night when all disasters happen. That’s, of course, not to say that these people won’t do an outstanding job. It is to say that either you’re a physician and trained as such or you’re not. That distinction is becoming more and more blurred.

So, as I go down the road, predictably this Paradigm is bearing very visible fruit in my case. First time ever, my “faculty reviews” broke the bottom end of 4 (5 being the highest possible). 3.8 for this partial year (this year has been tough for me). That means bottom end of “Very Good” because of a number of “satisfactory” marks given me (3.0).

Now, you have to understand that this is a lot like “Officer Efficiency Reports” in the Army. If a guy gets a completely fair report, his career is over. The only acceptable report is hugely inflated, and mostly bullshit. Pretty much the same here. The report detailing the statistics for all clinical attending here glows for anything over 4.25 and anything under 4.0 is mentioned only as an anchor dragging the Department down.

So, if you examine my strength and weakness numbers, you see that my highest numbers are involved with the issues of (quotes) “Faculty should promote patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health”. “Faculty should promote knowledge of established and evolving biomedical, clinical, epidemiological, and social behavioral sciences, as well as the application of this knowledge to patient care”. Faculty should demonstrates respect, compassion, integrity, and altruism in the maintenance of professional relationships with patients, families, and colleagues. Meets all professional responsibilities with regard to patient care. Highest score: Faculty explains the ethical, economic, and legal aspects of Critical Care Medicine as well as the psychosocial and emotional effects of critical illness on patients and family”. Creates an appropriately relaxed, cordial, positive, and stimulating learning environment. Briefly reviews expectations of the fellow at the beginning of the rotation or at the start of time on service.

Lowest scores: “Faculty should promote the ability of trainees to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence.” These scores were low enough to bring my average down below 4, first time ever. A fairly dramatic change from years past.

I’ve cherry picked here as much of this is much more complex but I give you the skinny. What’s happening is that the CCM Fellows are being told what is important. What is important is less hands on direct medical care and more ability to honcho others to do it based on current literature cites and research data. If they don’t feel they are getting what’s important, they downgrade those they don’t think are giving it to them.

So, I think it is happening and it’s happening fast. My fear is we are graduating more intelligent, intuitive doctors that have less and less experience in dealing with direct patient care and more experience bringing forth the latest cite on any subject. Direct patient care will more and more be done by non-physicians. . Unclear where it ends and what the sudden, unexpected aftermath will be. Maybe it will work out fine. If so, the curricula of medical college will begin to approximate that of PhD programs.

Comment:  Much of what has happened is a result of supply, demand and market forces here in the south. Few intensivists, fewer who will choose to be up all night, and relatively plentiful NP/PA who value training and practice in critical care.

This has been a steady process of deterioration here for the past few years and fighting it is impossible since prospective fellows can choose to enter a “Pulmonary, Allergy and Critical Care” fellowship that has NO night call and get jobs identical to those coming out of multi-disciplinary fellowships that demand night call as a learning experience. We actually started seeing a deterioration in qualifications in our applicants until we cut back on night call. I think currently they have to do one night a week and at the rate we are adding PAs/CRNPs, most of that is just hanging out watching other people work.

Comment:  Our challenge becomes finding an effective and efficient strategy to train up those physicians who are willing to work hard to an ever higher standard. My bias–and this is a personal, not corporate bias–is that we need to get to progressively more realistic simulations that expose trainees to more problems and issues in 4 hours than we ever encountered in a fortnight.

I think the pool of those would-be physician trainees is dwindling and dwindling fast. In fact, physician trainees willing to deal with the hassles of direct patient care is dwindling. Why should they. Nuclear medicine and radiology specialists are well paid and they all go home at five. Physical Medicine and Rehabilitation. Rheumatology. Sleep medicine. Hematology. Physician trainees are choosing specialties that come with a built in barrier to being bothered after hours.

So we are building a full compliment of clinical intellectuals who know everything there is to know about subjects that fully insulate them from after hour disasters. Who’s there in the middle of the night when the dying happens. Emergency Physicians, but they are normally not credentialed for in-house care. Hospitalists? Jury out. It will be PAs and CRNPS because it seems they are more affordable. The legacy of affordability has yet to be confirmed but I see the hazy vision as it forms.

Comment:  One view is that the technology to achieve this is “too expensive”. Another view is that whoever pulls it off could create a national sim center that operates around the clock for primary and recurrent training.

This is another factor I’m seeing come to fruit here. My medical students all look at their watches mid-morning during or after rounds and decry they are late to the “sim-center” where presumably they spend the rest of their day. I am on record that if the day ever comes and it might, that students get most if not all their time dealing with clinical emergencies via simulators, we are all in deep, deep trouble indeed. The worst possible place to end up would be a hospital where providers translate virtual reality to real reality.

I landed in a hospital in the middle of the night with a femur cracked from stem to stern, a hematocrit dropped to 26 and hypotensive. Even as a long term attending physician at this institution I took pot luck when it came to a provider that knew how to deal with this issue. When Dr. X cruised into my room, had a look at me and the films and told me he’d take care of this I could have kissed him. By the time I got to the operating room it was something like 4 am and he’d been operating all day. The conversation in pre-op went like this : “Him (Putting his initials on the skin of my leg): “you up for this?”. Me: “better question- YOU up for this?” Him: “(stretching)…..You bet. Lets get this done”. Four hour procedure started at 0400 hrs, masterfully done.

Young guy seven years out of his fellowship in trauma and orthopedics. Literally putting my life and my future ability to ambulate in the hands of someone I don’t know. Trusting him with my life and livelihood? How long do you think we’re going to have these spirited guys willing to beat themselves to death for the benefit of people they never saw before. I genuinely fear we are not headed for more of them.

Comment:  I do not think there’s much point in bemoaning the new division of labor. We need to consider how to concentrate training and broaden experience at the same time. At risk of sounding like a “broken record ” (for the younger list members, please Google this archaic expression), aviation figured out the importance of high-fidelity simulators a while ago.

Dealing with the infinite clinical nightmares all conspiring at the same time is NOT like high resolution avionic training. I genuinely fear for sick people in ten years. Hospitals may or may not have the ability to care for them. I am not optimistic, Tim. Making the best of an inherently bad situation for the worst possible of reasons (diminishing funds) isn’t the same as streamlining provision logically and intuitively.

Here’s what I see happening to critical care in the next ten years.

1. Insurers will become more and more tight with funds as they discover the multitude of patients transferred to ICUs simply to die after a massive wallet biopsy to chronicle their impending demise. But politically, it’s impossible to “say no” to it so they will find other ways co cut funds for “critical care” that can’t be traced back to bean counters. As a result, the time and energy needed to prove admissions are deserving of “critical care” will become progressively ponderous and difficult. Critical Care physicians will become experts in reimbursement policy and will spend most of their time doing it.

2. Most if not all of the clinical catering will be accomplished by mid-level providers, PAs and CRNPs, and they will all do a great job because if for no other reason most of the day-to-day patient care isn’t all that intuitive. Busy work looking after numbers, cultures, vitals and so on. Acute decompensation in the middle of the night will be addressed mainly to keep the patient alive until morning when higher levels of expertise will come to bear.

3. I have always said that the day will come when I can tap into a huge global multi-million patient data base, punch in my patient’s particulars and show the family what the real mortality will be and when it will occur no matter what treatment is afforded. I think that day is close. Similarly, that same data base could be used to create algorithms and protocols showing the best possible outcome according to how those millions in the data base did with any treatment scheme.

4. Accordingly, morning rounds will consist of input from executive levels of critical care physicians who will select the proper clinical protocol for the patient to be on. Protocols based on “evidence based medicine” (consensus of journal articles on the subject), and there will be one for every possible disorder. Respiratory, cardiac, gastrointestinal, neuro and do on. Of course there will be a trailer at the end of each suggesting that they may be modified by “clinical judgment”, but since the critical care attending has long since lost any experience in clinical judgment, that won’t matter. Variations of response to protocols will be met by more protocols, and if the patient dies, it will be because he had no ability to respond to good, standardized care.

As medicine becomes more complex and the information base has increased beyond the ability of individuals to contain it, we go more to the tender mercies of collective clinical judgement (from the literature). Individual clinical judgment is not amenable to control or standardization which is a situation that can’t be condoned.

When I walk into a patients room, the entire ambiance of illness and infirmity flows into my own personal database. I see and feel things that only someone who has spent 35 years at the bedside sees & feels and I intuitively know a lot of things that I don’t need to test against a computer database of the literature to see if it’s valid for THAT patient.

However, I might be wrong because I also have human frailties. And if I am wrong, then my wrongness will be measured by the database of “evidence based” literature which will always be right, especially since it didn’t need to be consulted for THAT patient.

So, current thought is that in the end, everything will be measured by “evidence based” data. The BEST chance for success is to plug everything into a protocol that reflects “evidence”. Although sometimes brilliant, individual care plans suffer from poor quality assurance. Sometimes they can be lousy and there isn’t sufficient ability to separate the two.

So, the whole point of a protocol is that’s it’s uniformly followed to the letter. Deviations result in uncertainty which cannot be condoned. It’s like letters from the Internal Revenue Service. A half page informing you that money is owed and you have been identified as the person owing it, then five pages of what they’re going to do if you don’t pay up.

Protocols are not for thinking processes of whether they should be followed. Protocols are to be followed or those refusing will die the death of 1000 meetings to explain why to stern faced administrators.

Are protocols a good thing that will improve patient care. Unknown. Will be eventually seen. My personal brand of clinical intuition is clearly dead and if I last the next couple of years before forced retirement, I’ll be lucky.

I am the last of my kind.

5. There will be no place for medical education as we understand it in this scheme. There will be no point in medical students dealing with these patients because they are cut out of the protocol loop. Medical students will spend 90% of their time on simulators watching the numbers fly by and the robot twitch. Any direct patient care performed by resident staff or medical students will be for routine hospital care. Anything resembling an emergency for a hospital patient will be dealt with by mobile emergency response teams who will arrive at the bedside to usurp the continuity of the previous trainees who will observe the goings-on from the back of the pack.

That this will occur (and is occurring now) is a lead pipe cinch guarantee unless……………..

The big joker in this deck is now political. (FL now suspends previous prohibition against political diatribe temporarily because it is integral to this discussion).

As the cost of health care continues to escalate and the reimbursers continue to find novel and bulletproof ways to cut funding for it, the “real” predictions of how this will all go are just that. The scenario I presented above is what’s happening right now and what will progress all other factors remaining equal, but other factors will not remain equal. Everything is now changed as of the mid-term elections where we now have a radically different power structure and a VERY unclear picture of what the Presidential situation will be in 2016.

The Affordable Health Care Act of 2008 was created to do several important things including to make health care portable and affordable by spreading the cost over all those involved. This became a political football and as of today survived those who would destroy it. However, the barbarians previously at the gate are now in charge and so it is now very unclear whether the AHCA will survive. If it doesn’t, and it may not, then we will drop back to our previous system of “private” insurance for those not eligible for Government health insurance. That insurance has been in the process of escalating the cost of indemnification yearly to as much as 50% a year and will continue to do so as long as demand exceeds supply until it collapses under it’s own weight. When it does, there is nothing else in sight for non-Medicare and Medicaid patients other than “self pay” which guarantees instant lifetime financial insolvency for a routine illness requiring hospitalization or surgery.

I also believe then that if the AHCA fails, the next step is European style National Health Service, which is the ultimate affordable system. It gets X amount of $$ and that’s it. Use it wisely. If and when that occurs, my previous predictions above are dashed on the rocks and we will be sailing through completely uncharted waters.

 

This missive is an abstract of two letters to a friend asking me to sign a petition urging current Pennsylvania Governor to “do the right thing” and expand Medicaid benefits in our State. Sadly, I think the fate of that issue is not amenable to public or provider opinion, for the reasons outlined below.

———————————————

In order for this petition to have any impact, two variables must be expressed positively.

1. Tom Corbett must care about the welfare of those that will lack meaningful health care if Medicaid expansion doesn’t occur. There is little evidence that he does. Mr. Corbett is a Republican, which means by political inclination he has little interest in the financial woes of those impacted by Medicaid and has continued to support other Republicans efforts to cut even more of their resources.

2. Tom Corbett must be amenable to changing his lifelong political inclination on the basis of rational pleas from providers. This would be a lot like pleading with God to cure your brain tumor. If the tumor spontaneously regresses, it’s the work of God. If it doesn’t, it’s still the work of God but we just don’t understand the celestial logic.

Mr. Corbett is also very likely to be elected out of office soon, to be replaced by an increasingly popular Democratic candidate. You can be sure that Mr. Corbett will do everything in his power to hobble or incapacitate that person who will follow him. Not only is Mr. Corbett insulated from rational persuasion, you can be sure that this decision has already been made and the only issue left is how to present it to the public to minimize the political damage to Mr. Corbett and blame subsequent problems on his successor.

As a Republican Governor, Mr. Corbett’s only interest in Medicaid is cutting it, and since his money connection is the same as all of them, extreme right wing factions, he’s very unlikely to do anything not in the best interest of his political future.

So, unfortunately, we will have to live with the Medicaid issue, or hope an incoming Democratic Governor can cobble together something from the ashes.

————————-

Sure. Be happy to sign the petition, but you must keep in mind that this is a political issue not amenable to coercion from special interests (health care providers) for  lot of reasons.  This decision and many others like it were made long ago. The only residual is how to assure political opponents get the blame for unpopularity with those affected after they’re implemented.

Again, Corbett is a more or less as it suits him “conservative” Republican which means among other thing (1) he’s committed to insure the rich get richer on the backs of the disadvantaged and (2) he lays awake every night praying and dreaming of how to get rid of the Affordable Care Act of 2008 (see #1).  So, Corbett has already decided that the only way he will approve any help for the poor is if he can make them pay more or work for their pittance. Yes….sickly single mothers of three and chronically ill old people up every morning to report to a WPA-like assignment.  Why not whips and chains.

The only public coercion that would move Corbett is if he figured some of it might hurt him politically. Unlikely for at least two reasons:

1. Corbett is a lead pipe cinch to be dumped in 2016 and replaced by a popular Democrat (Wolf), so the opinions of those affected by his decisions always quickly transfer their ire to the most proximal victim, not the one that made the decisions (Obama in 2010).

2. Paradoxically, although Republicans are quick to defend richer citizens (doctors), they (we) have managed to get bad enough press that it puts us into a different category- need to cut expenses to show fiscal responsibility. So as the media portray us as greedy abusers of Medicare (millions made ramming patients through “clinics” illegally, we become ripe targets to cut fat from a system with little fat to be cut elsewhere. Besides, Doctors complain a lot but they don’t strike so they’re paper tigers and can be effectively ignored, unlike Teamsters.

This is why since 1997, there has been no permanent fix of Medicare reimbursement policies, instead trying to find a way to tie cuts to the desired demise of the ACA of 2008.  And by the way, all of it is said to be financed by cuts to providers.  By rejecting joint/federal Medicaid expansion under the ACA, Corbett becomes the 11th Republican governor to stiff poor recipients of these funds in a hope of somehow dismantling the ACA.

 

Corbett would cheerfully toss two-bits at a homeless guy and snarl: “get a job”.  His path to do similarly to Medicaid recipients is pretty clear as well. He’s happy to humbly accept petitions for anything and might even actually have one of his flunkies read and summarize them before they’re trashed. Like Nixon’s response to 200,000 Vietnam vets demonstrating under his window on April 24, 1971 (I was there).