Category Archives: Medical Stuff

Things having to do with the practice of medicine as I live it

Editorial comment by me 5/14/2020

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What I’m seeing here in Pittsburgh is similar to what’s happening elsewhere in the mid-west, lots of people believing that rituals will save them from doom and gloom. That wiping down things with alcohol, wearing essentially ineffective surgical masks and bandanas that demonstrate they’re “doing something” and playing out the opera as dictated by experts who have never seen anything like this before and are all guessing.

Sunday, on Fareed Zakaria’s show, expressed the idea that the virus most probably did start from a wet market in China where a large number of previously “wild” animals were herded together (as food stuffs) in proximity to lots of humans, some probably sick or with immune deficiency for whatever reason. It’s easy for any virus to follow these pathways from sick animals to sick humans. And as more and more of the natural habitat of these animals is destroyed to build Hiltons and parking lots or simply to slash and burn, the pathway from animal to human becomes smoother. I think that’s a very viable theory and what it means as a practical matter is that this virus made a very smooth transition to the globe and for all those reasons we can expect more of the same.

In Pittsburgh, we are now in the “Yellow Zone” of social activity, which means “some” businesses are now open in a limited sense, with nods to social distancing and crowd control, lots of wiping things down and some kind of mask for all. But Americans always find creative ways around anything that inconveniences them. Two businesses that are STILL shut down in the Yellow Zone are gyms and hair salons. I have no idea why, but I have an appointment at a local Gym tomorrow to start building my functional ability back again. I also have an appointment next week for a haircut after two months. If I look around, I can find a place to go out to eat. So, I would hazard a guess that all over the country, most of these admonitions for the viral infestation are simply ignored or things like surgical masks are being touted as “real” prevention. What that means is that the virus will persist for a LONG time and lots of things will become the “new normal”.

What will be the new Normal? Last night on the news, they explored the probability that we will become a “Virtual” nation. That means computer visualization of meetings, education and everything else formerly requiring face-to-face discourse. It’s already happening. Schools and universities have already served notice that they are most assuredly transitioning to computer classes, students participating by laptops from home. Harvard School of Medicine has served notice that they are rapidly gearing up for visualized classes from home. The dehumanizing effect of this kind of faux social interaction is truly scary.

Everyone accesses their daily items and desires from Amazon, Craig’s List and eBay, with more added every month.  It’s simply more convenient and those on-line businesses have EVERYTHING for sale, cheaper than the increased cost of the necessary middle-man in structural stores. Brick & Mortar businesses are closing right and left. The last one yesterday was GNC food supplements, a huge office building and shops all over the country. They’re going to go the way of Radio Shack, with thousands of jobs going with them.

The concerts that normally fill stadiums have all been cancelled with no hint of when, if ever, they will return. That means the Kenny Chesney concert scheduled for next week is out and all the football games that normally number over 50,000+ rabid fans that come from all over the country to see the Steelers in Heinz Field are cancelled till further notice. Similar actions for hockey and baseball. What they didn’t mention is what’s happening right now. All those 50,000 rabid fans eat food, drink beer and park their cars in Pittsburgh, bringing in a ton of money and literally supporting industries. All gone, and with it those industries and jobs.

The major grocery in Pittsburgh is the Giant Eagle and going for food is a very interesting trip. The entrance to the store is about 30 or so yards along the side of the store from the entrance and the only way out is the designated exit. No entry without a mask of some variety. 6 feet spacing on the sidewalk and store personnel walking around to enforce social distancing. Large chunks of foodstuffs missing off the shelves due to panic buying, including water bottles. Prices of everything are up at least 30% so far. As there is more and more unemployment and providers of meat slow down production, this will continue and get worse. As demand from kids school meals vanishes, Farmers are dumping milk into their fields as the cows need milking whether the product is sold or not. The income from milk is now less than the cost of producing it. This has the potential to destroy farming.

The CEO of Boeing Aircraft was interviewed yesterday and he opined that at least one, possibly two airlines were poised to enter Chapter 11 due to decreased number of passengers and increasing cost of fuel and airport costs. Delta is burning through fifty million dollars a day. There are several photos of passenger planes lined up, filling the entire runway at Pittsburgh International. The planes that are still flying are doing so with only a few passengers. They won’t do that for long at the current cost of fuel. So, not only are people not traveling anymore, the potential for carriers is progressively crashing. I was thinking I might want to go one more interesting place before I died. Delta told me to forget it unless I was prepared to pay an astronomical price for a seat 6 feet from the next guy.

The Washington Post detailed American workers filing 3 million new unemployment claims last week, bringing the eight-week total of coronavirus-induced layoffs to 36.5 million. This number will progressively increase as more and more businesses go under. The money men in government are sending out trillions of dollars here and there. No one knows where it’s coming from or exactly where it goes. The effective long range planning by central government officials can best be described as loose cannons rolling around the deck firing the odd shot here and there. The unemployed will start protesting their plight in larger and larger numbers resulting in ????  This is said to return when “things get better”.  I think there is some evidence that once many of these industries die, the cost of resurrecting them would be prohibitive and they’ll stay dead. Society will then learn to live without them and that will be a very interesting life, indeed.

I’ve made it to nearly 77 years of age and I now count myself as exceptionally lucky to have lived in an era where I could do pretty much anything I wanted, go where I wanted and work in a career that worked very well for helping sick persons. I’m very glad I won’t have to live in the world being created right now as I sit here. I feel very sorry for those much younger than me that will have to figure out how to survive in it.

 

“The Edge… There is no honest way to explain it because

the only people who really know where it is are the ones

who have gone over it.”

 

―Hunter S. Thompson, “Hell’s Angels: A Strange and Terrible Saga”

 

Some history that might affect us in 2020

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Some history that might affect us in 2020

David Crippen

The great famine in Ireland, 1845 -1849.  During the worst of it, 1847, one million Irish died and another one million were put on ships bound for America. A microorganism, the “potato blight” was actually found first in Philadelphia and New York City. Winds spread the spores to the rest of America and it crossed the Atlantic into most of Europe but settled most in Ireland because of its dependency of a single susceptible variety of potato, the “Irish Lumper” The blight also affected Germany, leading to the deaths of 700,000.

In 1846, three-quarters of the Irish harvest was lost to blight. By December, a third of a million destitute people were forced on the dole or straining meager public works. Since over three million Irish people were totally dependent on potatoes for food, hunger and famine were inevitable. By February 1847, there were huge snowdrifts and the poor had no warm clothes to work outdoors in cold and wet weather. When the father of a family became sick or died after working on the public works, the women or children in the family tried to take over the work but it was very hard and involved carrying heavy loads or digging. This type of work was not useful in helping the people who were starving.

English landowners quickly figured out it was cheaper to purchase tickets to the new world for their Irish tenants than support them through a blight no one knew the potential length of. New York, three times the size of Boston, was better able to absorb its incoming Irish. Throughout the Famine years, 75 percent of the Irish coming to America landed in New York. In 1847, about 52,000 Irish arrived in the city with a total population of 372,000. The Irish were not the only big group of immigrants arriving. A substantial German population totaling over 53,000 also arrived in 1847.

Unlike many other nationalities arriving in America, the Irish chose to huddle in the cities partly because they were the poorest of all the immigrants arriving and partly out of a desire to recreate the close-knit communities they had back in Ireland. The Irish loved each other’s company, but the daily pressures of living in America at the bottom rung of society also brought out the worst in them. Back home, the Irish were known for their honesty, law-abiding manners, and chastity. In America, old social norms disintegrated and many of the Irish, both men and women, behaved wildly. In the hopeless slums of New York, prostitution flourished and drunkenness occurred even among children.

So many Irish drifted into the five points of New York City, a repository of the poorest, most disadvantaged and exploited of all the immigrants, including the Irish and the Blacks. Since virtually all Irish were Catholic, the burgeoning supply of them fostered fear of the Papacy, which became fear and hatred of the Irish.

The original Five Point in New York City are no longer there as they were in the mid-1800s. They existed off Centre Street to the west, Bowery to the east, Canal to the north, and Park Row to the south. The Civic Center and Chinatown also bound this area now. The Martin Scorsese film“Gangs of New York (2002) , accurately depicted a long running catholic/protestant feud erupted into violence fueled by Irish immigrants rebelling against low wages and social repression and an influx of freed slaves with similar repression. This mix of low wages, lack of jobs, racism and social repression generated frustration and anger finally brought to a head by the onset of conscription into the Union Army (in New York) in at the time of “Draft Week”(Mid July, 1863).

The actual riot boiled over July 13-16, 1963.  Working class discontent and smoldering anger were a function of white working-class men, mostly of Irish descent, who feared free black people competing for work and resented that wealthier men, who could afford to pay a $300 fee to hire a substitute, sparing them from the draft. Initially focused on frustration and anger at the draft, the protests evolved into a race riot. The death toll was thought to be around 120 individuals. Herbert Asbury, the author of the 1928 book “Gangs of New York” upon which the 2002 filmwas based, puts the figure much higher, at 2,000 killed and 8,000 wounded.

The military swinging up from the residual of Gettysburg did not reach the city to create martial law until late in the second day of rioting, by which time the mobs had ransacked or destroyed numerous public buildings, two Protestant churches, the homes of various abolitionists or sympathizers, many black homes.  The “Colored Orphan Asylum”  at 44th Street and Fifth Avenue was burned to the ground. Eleven black men were hanged over five days.  The area’s demographics changed as a result of the riot. Many black residents left Manhattan permanently with many moving to Brooklyn. By 1865, the black population had fallen below 11,000 for the first time since 1820.

Reading through the narrative of the New York City situation in the mid-1800s, reveals several things that stand out. A populous stranded by low or nonexistent wages into squalor and miserable living areas full of crime and death. A populace unable to get reasonable paying jobs. Rampant disease and no real protection from it. Psychologists suggest that these conditions have the facility to alter the normal adaptive human brain to a “Mob Mentality”. Humans tend to imitate each other’s behavior in certain situations.  Crowds can easily become uncontrolled and frenzied once a critical mass of numbers is reached, exerting a hypnotic impact resulting in otherwise unreasonable and emotionally charged behavior the individuals would ordinarily indulge in. When angry and frustrated individuals congeal into a large group, they “deindividualize”, absorbing the power and authority of the anonymous mob, then they become capable of striking out violently at issues not original to their complaint. The violence becomes the remedy for their complaint, which usually broadens quickly.

A study of riots in the 60s and 70s show that original complaints of poor, crowded living conditions, few jobs, police hassle of a poor black population and no viable hope of any improvement eventually boiled over into massive riots that did millions of dollars of property damage, and death, most of it doing more damage to the original complaints of the rioting population. Seemingly minor issues sparked many of these riots. The Watts riot started when a Los Angeles police officer tried to arrest a Watts resident for drunk driving. The Watts riot lasted for six days, resulting in 34 deaths, 1,032 injuries and 4,000 arrests, involving 34,000 people and ending in the destruction of 1,000 buildings, totaling $40 million in damages. Rioting to make a social point vanishes when rioters destroy and loot business establishments they would ordinarily protect.

But all that was then. This is now but we have some of the same pressures building and we should be aware of them because we’ve been there before. What we have now for the first time in 100 years is a massive social and physical disaster that threatens to bring back some of the factors that created mob violence in the past.

  1. Coronavirus has the capability to relentlessly incapacitate virtually human on the planet. It’s like the “Terminator” (1984) “Listen, and understand! That Terminatoris out there! It can’t be bargained with. It can’t be reasoned with. It doesn’t feel pity, or remorse, or fear. And it absolutely will not stop…”. We canmore or less “flatten the curve” of its longevity and potential to kill humans, but not obliterate it. It moves and shakes in its own schedule.

 

2.  In “flattening the curve”, we perpetrate on ourselves a style of living that doesn’t work well for our longstanding social order. “Social Distancing”, voluntary or involuntary quarantining, involuntary closing of all but (seemingly) necessary businesses, creating virtual ghost towns.

 

  1. Large masses of citizens forced to be out of work with no consistent end in sight, none of their usual funds to pay for rent, transportation, food. Promises of Federal money to offset this, none seen as of yet. Panic within the population that their homes, cars and especially their jobs are at risk.

 

  1. Previously healthy persons not predicted to succumb to this strain of flue, unexpectedly dying, sometimes very quickly. The realization that first line defenders of the population, doctors, nurses and other medical providers seen to be wrapped up like modern day mummies, many lined up to (legitimately complain bitterly about their lot on Cable News Network (CNN).

 

  1. Federal Administrators promising to insure all the needed materials to buttress the viral Pandemic, face masks, gowns, gloves, goggles/face shields, ICU equipment, mechanical ventilators. These promises are inconsistent and the identified individuals in charge, mostly politicians have not come through as yet, leaving the population with the impression there is no protection from the virus.

 

The point of this long diatribe is to point out how some of the above factors have led to violent riots in the past.

 

  1. A seemingly inalterable scourge will continue seemingly unabated, picking out innocents to infect everywhere and anywhere. Open-ended fear and anxiety that death looms unpredictably.

 

  1. Loss of normal social interaction (distancing and quarantining) creating lonliness, antisocial ideation, open ended anger at a threat that cannot be seen or felt. Looking for something to rage at.

 

  1. Loss of the extremely important social interactions inherent in meaningful performance of work that generates a paycheck that an individual can maintain social visibility by paying his bills. No convincing evidence this situation will resolve before the job is lost.

 

My point is that if all this comes to a substantial head, a critical mass of angry, frustrated citizens ready to find something to rail at, riots are possible. History shows that some of the factors that created riots like the Draft Day riot of 1863 can be superimposed over some of the factors involved in the Pandemic of 2020. A hated but otherwise indistinct metaphysical object (the Draft), uncomfortable living conditions, loss of jobs, social breakdown, inconsistent political assistance (Boss Tweed) and fear of unpredictable death from the environment. That we haven’t seen any yet, only means the requisite critical mass has not been reached, but it could happen if some of these factors don’t start resolving fairly quickly.

A critical mass can be a very dangerous thing. Camp of the Saints (Jean Raspall- 1975)  a dystopian fiction novel depiction the destruction of western civilization by the mass migration of the “third world” (the poor and disadvantaged) to France and the West, like locusts in the western United States. The critical mass of humanity was reached to enable them to move as one force, absorbing everything in their way.

Copyright DWC, 2020

 

 

 

A treatise on aging and dementia

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I read with great interest Mike Darwin’s essay on aging and potential dementia. I decided to add some to that, including a perspective of my own experience- how it applies to me as I age. (76 years of age this month).

The issue of dementia has become more prevalent for a very interesting reason. In my research for my 60s music appreciation class at Pitt I ran across a very interesting statistic. Because of the huge birth rate during and following WW II, all those kids landed in the same place at the same time.  Do the math.  Born 1945, in 1965 half the population of the USA was under 21 years old. This formed the platform for the 60s cultural and musical era that never would have happened otherwise. Then all the 21 year-olds continued along the line until now ~2015, add 50 years and they’re all in their early 70s.  50% of the 2015 population is over 65 years of age.

That age group is responsible for at least two discrete population dynamics: a much larger population getting sick and a much larger population living longer and suffering from various degrees of dementia.  In the early 1960s, the average life expectancy in the United States was 70.2 years. In 2013, the average life expectancy was 78.8 years. However, the quality of life of aging Americans has not increased commensurately. In the 1960s, the incidence of dementia among people approaching death was less than 1%. Currently, the incidence of dementia in Americans is between 5% and 7% for adults’ age 60 or older. Starting at age 65, the risk of developing some form of dementia doubles every 5 years. By age 85 years, between 25% and 50% of people will exhibit signs of Alzheimer’s disease or some degree of nonspecific dementia.

The issue of subtle, age-related deterioration of brain function is difficult to sort out. The “heart too good to die” concept as espoused by Peter Safar does not apply to the brain. The heart is usually amenable to restart by traditional resuscitation. The brain has proven to be dramatically less so. The brain is a rather frail organ, rapidly damaged during hemodynamic or metabolic disasters and difficult to resuscitate.

Cerebral atrophy occurs naturally in aging and is accelerated between the ages of 70 and 90. But the process actually begins sub-clinically in gray matter of the cerebral cortex at a much earlier age. It’s unclear whether “normal” cerebral atrophy during aging affects each brain the same way or how each cognitive area is affected. Cognitive abilities such as verbal fluency increase until the mid-50s but start to deteriorate in the sixth decade, after which most of the neo-cortex continues to degenerate until death. Many people in their fifth and sixth decades experience “word searching” and a transient inability to recall previously known names. This variety of cognitive deterioration is associated with hippocampal inadequacy.

Interestingly, aging people have a propensity to trade cognitive decline for enhanced judgment. As processing speed slows in late life, logic, reasoning, and spatial abilities remain generally well preserved. Older individuals’ life experience, their long accumulation of knowledge, and their maturity and wisdom offset some of the losses during processing decline. For instance, an adult tells a child to play in their safe yard and not in traffic. The child has the knowledge and enhanced ability to play with great vigor but lacks the wisdom to refrain from dangerous behavior.  This, of course, proceeds into the teen years.

Now, I’m 76 years of age and much like Linda Ronstadt, I can feel the onset of something wrong before it actually happens. Poor Linda. In her time, one of the most beautiful voices in the universe. In the movie of her life she said one day she instantly knew something was wrong because she could feel the prodrome no one else could hear. She went on to get Parkinson’s so severe she was too frail to travel to Cleveland to get her award at the Rock & Roll Museum.

If I could name one deficit that started about age 65 and continues to encroach on my life much like Darwin’s slope of deterioration, it would be the extremely irritating and debilitating issue of “word-searching”. It’s reached the point where holding a conversation with friends is punctuated by instant inability to remember the formal name of persons, places or things. “Yeah, I went to the ……….(blank) concert and it was great! I knew what I wanted to say. It was safely ensconced in my memory bank, but I couldn’t recall it in the time available. I meant to say “I went to the Electric Light Orchestra with Jeff Lynn concert…..”, but when asked to recall it instantly, I just look blank and offered “I’m blocking”. I watch “Jeopardy” on TV and I actually know the names of many of the questions but I can’t produce them in time to hit the button before any of the contestants.

My general physical condition began to deteriorate at about age 70 and unrelentingly progresses yearly, as does my word-searching. When writing something, I frequently use Google to pull up the name I’m trying to remember. I’m a victim of a phenomenon of the 1940s (baby boom) that silently followed me for two generations until we’re all the majority of the population now, collectively consuming huge amounts of medical care to keep us alive longer, but our quality of life has not necessarily followed increased with our viability. Not what we anticipated in the 60s.

So I’ll leave you with the masterful philosophy-of-life according to Pete Townshend of “The Who” (currently age 75):

“People try to put us d-down

Just because we get around

Things they do look awful c-c-cold

I hope I die before I get old”

                 

                          The Who, “My Generation,” 1965

 

 

 

 

 

 

 

A political/medical care observation for the New Year

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donald-trumpIt is after all Sunday and this is a bit more of a time for a “Village Green” observation by your FL, for what it might be worth. What I’m about to say involves an obligatory observation on National politics because it impacts what’s happening in medicine today and in the near future. My observations are NOT so much for public debate here as they are simply pointing out facts, as they are readily apparent. Please just reflect on this, not start arguments. Med-Events does that very nicely. If you want to argue about politics, join Events.

A paper came across my desk (enclosed) suggesting that the potential for health care providers’ autonomy is under assault and eventually will all but disappear. I think there are clear reasons for this. The demand for medical care continues to increase but the supply remains relatively static. All kinds of schemes have been developed though the years do decrease the demand (cutting the price). Denying service for pre-existing conditions, “managed care”, “rationing by inconvenience” and yet the cost of health care continues to increase yearly.

The “Affordable Care Act of 2008” (Obamacare) hoped to put a dent in that by spreading the cost out over a very large population, some sick, some well, and of course, “opt-outs” wouldn’t be allowed, as they would eventually turn up in emergency rooms demanding care even though they hadn’t paid the premium. Part of this plan would have been the “public option” to take care of outliers.

There isn’t really much argument that this plan would have worked pretty well, allowing for adjustments, had it been implemented as formulated. Not perfect but a very good start to get people covered for their health care affordably. What happened was a bit unexpected. We didn’t realize at the time that opponents of the President became the “party of no” vociferously obstructing, delaying and destroying everything and anything that came out of that White House. The ACA then became a political issue and was widely advertised by the Party of No as something it wasn’t. Then the Public Option was killed, removing much of the efficiency of the entire program, followed by allowing healthy people to opt out of the program leaving a large population of sick ones.

Of course, as a natural consequence of supply and demand, the price per individual rose, as it would have (and did) for any kind of health care indemnification. Blamed on the program, of course. I had lunch with a very intelligent, perceptive friend (not the only one I have that supports repeal of the ACA) who solemnly advised me that she couldn’t wait to see the ACA repealed because middle class people couldn’t afford it and it was literally bringing the economy down. Never mind that any- and every health care indemnification program in the country was similarly raising their rates, including mine.

Enter the stimulus for all this, the current President-Elect of the USA, Mr. Trump, and his new best friends, ultra-conservative Republicans now in control of congress and soon to be also in control of the Judiciary. Mr. Trump, a very talented and experienced huckster knows nothing about any of it, but his new friends do and they’re now after many years of trying, in place to do damage to health care and a great many other things in our lives.

As is widely observed, the election of Mr. Trump caught virtually every observer by surprise, but not me. They that Pennsylvania is a state with two cities on either end (Pittsburgh & Philadelphia) with Alabama between, and that turned out to be true last Nov 8). I saw it coming as I rode bikes around the rural center of Pennsylvania, spotting Trump signs on virtually every home or business in small towns and country areas. I knew all these people would vote and they intended to “shake up” the establishment that no longer worked for them (not suspecting they had the potential to destroy it).

So now, before the new President-Elect actually takes power, we’re already getting a view of how it’s going to be.

  1. The institution of a Presidential Cabinet full of officers dedicated to untried and unlikely theoretical political ideals, not necessarily the benefit of the population.
  1. The dissolution of a health care system that currently serves about (said to be) twenty million should to one degree of another with the promise of something to replace it someday.
  1. A President-Elect that has publically disputed the opinion of every single individual in every single intelligence and law enforcement office regarding the illegal and intrusive activities of Russia in our political-social system. “The difference between skepticism and disparagement”
  1. As of Friday, the funding of a wall separating the USA from Mexico asked to be funded by congress with a bill to be sent to the other side with no mechanism to collect it. Estimated cost ~ 25 billion $ and estimated by most experts to be worthless.
  1. Active plans to decrease any and all funding for the poor and disadvantaged, active plans to decrease taxes for the well-off, active plans to get more guns on the street and eliminate “Planned Parenthood”, a service that benefits many women.

All this even before January 20.

Now, again, I ask not for argument. The above remarks are above argument, they simply exist and can be substantiated anywhere. It’s just my humble personal observation and it all matters in our health care future, which is why I bring them up.

Our current health care situation is quickly falling apart for at least two reasons (I’ll omit my scathing remarks on what’s going on in medical education).

1. I honestly believe that there is about a 50-50% chance that Mr. Trump’s coalition will collapse completely within 30 days of Jan 20. He has no clue about the delicate realities of global politics and his Cabinet members have no real experience in any other than “business” and that isn’t the way any of it works. Any number of other countries in the world could hurt us more than we could hurt them if they took a mind. Mr. Trump’s coalition fully intends to create a society built on unlikely or untried theoretical political conditions as a practical matter. It is absolutely not out of the question that the fabric of our society could be ripped apart into chaos and very quickly.

It’s already started. An increasing number of Republicans, his own party, have figured out he has no firm foundation for any of his Tweeted opinions, all capricious ramblings of what he happens to think at the moment. They’re making it known they’re re-thinking their support for him. This brings up another potential reality, that Mr. Trump et al will become very quickly bogged down in a system of government meant for- and created for bipartisan cooperation to get things done. If Mr. Trump’s coalition descends into the same kind of stubborn non-participation that has marked the past eight years, then nothing (again) will go forward and our system of government will descend into vicious and bitter fighting, wasting time and money in a very dangerous world. So much for “fixing” broken government. I do NOT see Mr. Trump actually achieving many if any of the advertised platform (such as it was) that elected him.

2. If any of that hat happens, our currently fragile health care provision system will collapse, if for no other reason than our current strategy to cope with administrative rationing will fail with it. Insurance and government strategy is to make reimbursement increasingly complicated so that those unwilling or unable to comply don’t get paid. What we’re doing now is allowing “middle management” and “financial specialists” to deal with the increasing complexities of reimbursement.  There are now an entire hall full of administrators and financial people where a lot of doctors used to be (including me). These guys peck at computers all day long all getting excellent salaries and benefits.

Now, at this point, everyone on this List should download and read every word of the following Time Magazine site (let me know if it doesn’t open for some reason).

http://content.time.com/time/subscriber/article/0,33009,2136864-1,00.html

Pay particular attention to the justifications given for incredibly outrageous charges by an automated service “Chargemaster” for patient caught in the middle- too young for Medicare and too many resources for Medicaid. Both Medicare and Medicaid pay providers only a small fraction of “Chargemaster” bills and they’re accepted. Also pay attention to the salaries for middle managers, CEOs, COOs and the like. You’ll note somewhere in the middle that the CEO of the University of Pittsburgh Medical Center’s salary (before bonuses) was close to 6 million $ per year. The same guy that mandates draconian budget cuts for the clinical departments, including mine every year.

W
e as providers are losing the battle of self-determination. We are losing that battle because we’re handing middle managers and financial officers the authority to order health care in an administrative system that considers us irrelevant. It considers us providers that create demand and they want to limit demand. They formulate policy and let us know how we fit into it, which is why the majority of us are not “hospital employees”. We can be controlled.

This is the state-of-the-art now for providing medical care for our population and I can assure you that if the administration, such as it is, of Mr. Trump collapses, this will all collapse with it. If Mr. Trump’s administration becomes embroiled in an endless fight with everyone creating chaos and stasis, this system will follow suit. If Mr. Trump is successful in killing the ACA, there will be a lot of people left wondering what and when their promises will be kept, even if it could be financed which is unlikely if he spends 25 billion on a useless wall. It took Obama two years to formulate the ACA and it wasn’t perfect. We’ll see what Republicans dedicated to “conservative principles” can come up with and when they can come up with it.

To end this diatribe as I sit here “retired” with a cup of coffee and my trusty iMac, I am very, very fearful for the future of the country, the health care system or the world for that matter and I’m not by nature a terribly pessimistic person. I am now an observer. We’ll all observe in time.

 

 

Some comments on where critical care medicine is headed in the next ten years

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Recall several months ago I wrote some editorial opinions on where IIF 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.
  1. 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.
  1. 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.
  1. 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.

  1. 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.

 

Some acerbic notes on the new generation of physicians

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“My impression is that the older ones found work-life integration while the younger ones are focused on work-life balance. There’s not a lot of balance when up at 3 am with a sick patient or 5. And the a common refrain is “I don’t want to work weekends “

Crippen: When I was a medical student on clinical rotations in the early 70s, I was expected to be the first to arrive and the last to leave. I “took” patients and was responsible to the resident for reporting on morning rounds everything going on. I did procedures under guidance and I got chewed out or my ass kicked when I didn’t perform up to expectations. I was expected to have no other obligations during that rotation and it NEVER crossed my mind to complain that I was overworked. Had I done so, that revelation would have been greeted with dropped jaw astonishment and an admonition to get with the program or take my mangy ass elsewhere.

When I was a resident at Bellevue, there were about 100 patients on the general surgery service and ten in the surgical ICU. There were two first year residents on the service and every-other-night call. Do the math. Similarly, there was no excuse for not getting the work load done. One learned to prioritize to get the important stuff done and suck up the hassles on the rest. Complaints of overwork were nonexistent. Not conceived of.

And yes, I did walk to work 20 miles one way on crutches in waist deep snow fighting off alligators and snakes along the entire course.

Then in the new millennium, Libby Zion came along and the path of least resistance led to the proposition that residents were overworked and too sleepy to function so they had to be given a break. That evolved to a situation where medical students and residents became entitled. No more of this “service” stuff, it has to be all book learning education. Complaints of “I’m overworked” are forwarded to the RRC (Residency something Committee) a body that immediately investigates all such complaints and the burden is on the teaching program that they’re not overburdening the poor babies with a work load that they can’t handle. As a result, that work load gets smaller every year.

This is an honest to God true anecdote told to me by the Chair of one of our clinical departments here. He was teaching a session for medical students on some subject he felt was important and after a while one of the students raised her hand. She told him maybe he had spent enough time on this subject and maybe he should move on. Astonished, he told her he wasn’t finished yet, whereupon she picked up her books and walked out.

Medical Emergency Teams (MET) appear in at least some, not all, data to be doing a good job in interdicting acute deterioration episodes for hospital inpatients. As they evolve, however, the propensity for nurses to call for the MET instead of the responsible resident evolves with it, for a number of complex reasons. Then the responsible resident stands at the back of a crowd of people watching as their patient is taken care of by someone else. The issue as far as the hospital is concerned is that patient safety trumps medical education, and that may be. But in the immortal words of Bill Gates:

“We always overestimate the change that will occur in the next two years and underestimate the change that will occur in the next ten”

And that’s exactly what’s happening with medical education. We’ve entered a realm where the “education” portion has exceeded the “experience” portion. We’re teaching them all the contents of the Textbook of Medicine and then sending them out into a world where the translation of education into experience is required to survive, and it isn’t there. They were standing in the back of the crowd that day, and every day they survive the mix is a day that their minuscule experience base fails them. To be exceeded only by the next wave of graduates.

Similarly, critical care fellows have complained about night and weekends now for the 28 years I have been involved with the UPMC system and they are following the lead of the rest of them. When I was a fellow in 1986, I was on call every third night and every other night when someone one went on vacation or got sick. Now the fellows are on call one night a week and the night calls are progressively being taken over by Certified Nurse Practitioners and Physicians Assistants. The fellows want to think of themselves as executives now, in a teaching and mentoring mode for the night and weekend crews. How they are getting that knowledge base now is with books and simulators.

I hasten to add that there is nothing intrinsically wrong with the CRNP and PA mode of direct patient call after hours. I have some in the NICU and they are REALLY great in every respect. They do EXCELLENT patient care and they know when to call for the executive modulators, which consist of the Resource Intensivists covering the house at night.

The problem with this model is that since every critical care fellow has the same training as most other residents in their specialty, they are at risk for the same dumbing-down (not always). As the syndrome as Med Student/resident Entitlement continues, will the fellows not bear fruit from the poisoned tree? Unclear at this point. We shall see.

There has been a lot of hand wringing about the poor overworked physician trainees that I am not particularly impressed with. I went through all that and not only did I survive, it made me a provider that is never surprised at ANY clinical situation because I’ve seen them all, and there aren’t many physicians that have had a fuller personal life than me (trust me on this).

Hand wringers lament that overwork and overstress creates drop outs, landing in psychiatrists office, going through ten divorces or killing themselves from what amounts to PTSD related disorders. Sorry, I can’t fix those that sink into PTSD. I wish there was a better way to sort those with a tendency for PTSD out before they get into medical school (unlikely as long as grades move all). I went through all that in Vietnam and I just worked it out and went on. I know Viet vets that thrived on it and wish they could go back and do more of it. PTSD is just luck of the draw.

I don’t know what the fix is for PTSD. I think arbitrarily decreasing work loads may solve some of it but invokes the Great Principle of Unintended Consequences (GPUC), we’re seeing it now and we will continue to see it in the future. Well rested physicians aren’t necessarily the ones you want to look up and see during a disaster in the middle of the night. But then at the rate things are going, no one may ever see one after 5 pm anyway.

I am the last of my kind.

A few notes on State of Pennsylvania health care politics

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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.

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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.
  1. 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.

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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).
  1. 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).

 

Stress, physicians and age

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Physician “burnout” is defined as loss of enthusiasm for work, feelings of cynicism, low sense of personal accomplishment.

I think the factors involved are infinitely complex. I will also hazard a guess that the issue of burnout builds on two fronts:  Stress and Age, and the nomenclature for each is radically different.

Front 1– The peak “burnout” in the age group of 36-45 comes on two groups:

Group 1.  Doctors that emerge from the long training grind to find out they’ve bitten off more than they can chew and are having trouble digesting it. Too many responsibilities, too much work load combined with the era of mortgages, spouses, kids and mounting expenses acquiring the creature comforts lacking in the austere training days.

Group 2.  Doctors that emerge from the grind to find out that their reward was a false promise and they really don’t like living with the end product. The difference between training for a career and the nuts/bolts of the career don’t match and they’re miserable locked into the saddle with no escape.

The salvation of group 1 is usually that the personality type that thrives in this environment is selected out during the gauntlet. Those that can’t hack it fall by the wayside during training, like Navy Seals in boot camp that ring the bell when they’ve had enough. I think this is an unusual burnout group.

I think group 2 is much more common and not necessarily amenable to filtering by the gauntlet. By and large, there is a big qualitative difference between trainees and attendings, and the realities of that difference are not necessarily apparent before the fact. Some seemingly high quality trainees go bust quickly in the clinch and vice versa, and as far as I can tell, it’s very difficult to discern which is which before the saddle is cinched.

I’d hazard a guess that this group is at highest risk for becoming functionally incapacitated, call it what you will, and also I might add a risk for suicide if there is no escape valve.

All complain about the following factors, but most realistic physicians understand these factors are identical to working for any major corporation in any career position.

Bureaucratic tasks, Too many hours, Compassion fatigue, Difficult employer, Difficult colleagues, The Affordable Care Act of 20008

I don’t think I have ever met a doctor that burst into tears at the thought of onerous paperwork. I do know some however that started drinking heavily at the thought of the Affordable Health Care Act of 2008. The stark reality is that all these things are the price of admission to medicine highly unlikely to cause significant lack of professional fulfillment for no other reason than they are ubiquitous to nature.

Front 2-  aging physicians are a much more convoluted and textured phenomenon- physicians who have successfully run the gauntlets to arrive at a place of relative safety only to discover seniority is a new liability. Inevitable physical limitations and the duty and obligation to make way for others climbing up the same ladder behind them. A different and much more subtle order of “burnout” from the rest.

The limitations and hassles of old age are not linear. They escalate rapidly after a variable certain age”. At 65 I was doing four night calls a month and bounced back easily. I was racing motorcycles and doing high-speed track days at 66. I thought of myself as limitless.

Then I slowly discovered my concentration on the track at 120 mph was fading and I started crashing, once twice in the same corner. I quit at age 66+ before I hurt myself or someone else. Night call quickly became difficult to maintain concentration and the day-after became more difficult to bounce back. I still had the same knowledge base but not as much concentration ability to apply it under stress.

At age 70, I have the exact same drive and passion to be the best I can as when I was at the top of my game at 36.  The only limiting factor is my physical ability to bring it all to bear as effectively and efficiently in a world of emerging young people with the same fire in their bellies. Thereby burns the age related “burnout” flame- the fear of becoming irrelevant. An absolutely terrifying, life threatening burden.

That will be the burnout issue that I think will require some creative thought on how to rectify, if it’s even possible.

Epitaph on my headstone:

“This is my generation…..

Hope I die before I get old”

Pete Townshend, 1965. (BTW, Pete is 71 this year)

 

 

The “new brain death” in 2014

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<http://usnews.nbcnews.com/_news/2013/12/30/22114290-brain-dead-teen-to-remain-on-life-support-pending-appeal-by-family#comments>

We now have a completely different complexion on the brain death = death issue.

Back in antiquity (1968) brain death was defined objectively as death so we could get dead people off ventilators. Organ issues came later.  But 1968 was a different world of “life support” than it is now and many of the fine points were unknown then. We can now maintain “lifelike” cadavers indefinitely.

Brain death = death has never rested on structurally firm ethical ground. Brain death persons maintain some bodily integration and have been maintained for months so they could deliver healthy babies. We just drew a line in the sand and made objective criteria for brain dysfunction as a practical matter. Not every cell in the brain stone dead. Brain dead persons were simply “dead enough”.

We also now live in the age of surrogates that don’t want their relatives to die and we accommodate them by maintaining warm cadavers in a lifelike appearance on “life support”. Increasingly they’re demanding their relatives stay that way because if they give the appearance of life, there is always a possibility of unexpected reanimation.

Getting surrogates to accept the concept of brain death = death has never been easy in the best of worlds. A cadaver in the morgue looks decidedly dead. A brain dead cadaver on a ventilator looks decidedly comfortable, even animated. The only reason we’ve gotten away with selling brain death so far is the preponderance of multidisciplinary certitude to families.

The number of surrogates who demand futile care for near-dead persons is increasing anyway. Because of “life support”, they simply don’t believe our prognostications of doom and gloom. Their eyes and emotions tell them differently. With this case, it’s now escalated to brain dead persons, and this has the potential to change the complexion of organ donation.

Surrogates have figured out that they don’t have to accept medical prognostication they never fully believed anyway, and now enforce it legally. The groundswell for maintaining this warm cadaver is astounding.  An Internet site to raise money for her “life support” maintenance containing at last count US$28,000, all from the grass roots. Pastors of local churches imploring the court to “save this poor innocent’s life”, 60’s style marches chanting “Don’t kill Jahi!”. The child’s uncle declaring on NBC Nightly News that the child’s mother is certain she responds to her.

This is not a fluctuation in the ether. This is a gift that will keep on giving and will grow like a sunflower seed in the noon day sun. An increasing number of surrogates have now figured out they can get their way, any way they want, simply by calling a lawyer. Once it gets into court, the justice system always errs on the side of “life” as the court understands it. Sustenance of vital signs.

This is now a totally new paradigm in organ donation. It’s been a long time coming and it’s now here.

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CCM-L Member Response: An element that you don’t discuss below is the question of reimbursement. According to news reports, her family’s insurance continues to cover her care while hospitalized. If this becomes more of a trend, I suspect that the carriers will quickly stop that sort of “flexibility” around reimbursement.

I say;  Health care insurers understand the reality that hospitals must continue to care for patients whether they get paid or not. So they routinely get away with rationing and conserving at the provider level, not at the level of their insured. They cut payments to providers retrospectively on the basis of paperwork while assuring their clients they are fully insured. This is a political reality.

The truly significant part of this travesty is the groundswell at the grass roots level. People contributing to the on-line fund. The 60’s, Berkeley style marchers carrying placards, just like “End the Vietnam War”. The public media revelation that the mother “feels like the child responds to her”.

All that means that the groundswell here is NOT limited to this particular family as outliers. It’s broken into the mainstream now, and you can bet your sweet bippy it will “go viral” like a youtube video of Britney Spears naked.

As of now, the “law” pertaining to death by neurologic criteria is moot. Anyone that simply doesn’t believe in death by neurologic criteria can trump it quickly and efficiently by getting a lawyer and petitioning the court. Hungry lawyers looking for work will fall all over this. The precedent is set and a significant portion of the public seems to support it. Do you see marchers today with “This is ridiculous” placards?

This has MASSIVE implications for organ donorship.

CCM-L Member Response: Not intending to make a political statement, but I suspect even more strongly that someone covered by Obamacare will find that reimbursement stop even more quickly.

I say: There is no currently convincing evidence that the Affordable Care Act of 2008 will act any differently than any other “private” company, equally as reluctant to face the political firestorm of “saying no” to their insured. Tradition has it that “saying no” to providers is the path of least resistance.

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Update:  (1/1/2014)

The family’s court filings said New Beginnings Community Center in Medford N.Y., is willing to take Jahi and provide 24-hour medical care. The center was founded by a former hair stylist whose father suffered traumatic brain injury after a 2007 motorcycle crash. New Beginnings founder and owner Allyson Scerri shared a statement on her Facebook page Tuesday explaining how her facility “is about preserving life and treating brain-injured patients with care and dignity.” “We do encourage every citizen to take the time to educate themselves more clearly on the issues of what brain death is and what it is not,” the New Beginnings statement read. “This child has been defined as a deceased person, yet she has all the functional attributes of a living person despite her brain injury.”

(Did I mention radical right-to-lifers…….)

On Tuesday, the Terri Schiavo Foundation, named for the Florida woman who provoked a national debate about end-of-life-issues when she was diagnosed as being in a persistent vegetative state, said it had been helping Jahi’s family find a facility that would take the girl.

Some thoughts on mandatory influenza prophylaxis

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This month marks a year since I got a demyelinating spinal cord disorder a week after getting the same flu shot I had received every year for at least 20 years. This one happened to be the one that liked me spinal cord better than the virus. It is very slowly improving but definitely still there.

Both of my lower legs are on fire 24 hours a day. Just like both legs immersed in a bath of hot water. Both hands are the same. It appears to be completely sensory in nature but now maybe not. My personal gym trainer noticed that all my muscle groups are consistently tight, then nagged me for months to have a massage therapist check it out. So I finally relented and had one bend my bones for an hour, She said every muscle group was tighter than a turkey’s ass, especially the muscles of my feet and lower legs and that was unusual. So there may be some long-term motor stuff as well.

Neurologist says it might go as long as two years but if it goes longer; I’m probably stuck with it. I’ve learned to live with it and it rarely interferes with my daily life.

I DO believe in immunizations, especially as it pertains to children. I fervently believe Jenny McCarthy, who made a career as a dumb blond really is one as it pertains to children’s immunization and she has all the credibility of Sarah Palin.

And that said, I hope the efficacy of flu immunizations are at least better than chance for adults. If so,then complications such as mine for a few are collateral damage that must be accepted to gain the benefit of many. But there are some problems as it pertains to mandatory injections for all health care workers.

First, I would like to see more convincing evidence that the flu shot actually works. People get the shot every year and are relived that they didn’t get the flu. I have elephant repellant in my back yard and I’ve never seen an elephant back there. Does that mean the repellant works? What if they do get the flu after accepting the shot? Is it the old Christian paradox, if you have good luck, its God’s working in your life. If you have bad luck, it’s still good, you just don’t understand the big picture of God’s will. If I am to accept the bad luck component for me, I’d like a little more evidence that the flu shot has a better than chance potential for mass benefit.

Second is the consent issue. I can assure you after going through this that there is NO informed consent involving potential complications of the flu shot. Anyone who asks is told that the occasional complication may occur but it’s minuscule compared to the benefit for all so don’t worry abut it. If asked specifically about the potential for Guillian-Barre, they are told this possibility is shown in the literature to be about the same as chance. BTW, this year I had a woman with Guillian-Barre that developed a week after her flu shot in my ICU. That’s two cases in this hospital this year.

So, everyone lining up for the shots are overwhelmed by good news and any potential for bad news buried. Fine. But we are a society that runs on informed consent, so much so that it frequently gets ridiculous. So should everyone in line be told that there have been two potentially serious complications of the flu shot this year in this hospital (that we know of).

But that implies they have the option to decline the shot, an option that is rapidly disappearing. The crushing wave of optimism for an injection containing various iterations of virus has now reached the point where the issue of informed consent is crushed with it. The prevailing opinion that darts thrown at a list of a thousand potential damaging viruses will hit the right ones has obliterated the issue of options.

In New York, a law is being considered, and will probably pass, that will create incentive for getting the flu shot by punitive measures. If anyone opts out, they must wear a “surgical mask” everywhere in the hospital. Now the wave of optimism for flu shots turns into a gun to the head.

This is straight up coercion with an empty gesture. There is NO evidence in any world literature that suggests ANY efficacy for surgical masks preventing spread of virus or anything else. When the ‘bird flu” came along a few years ago, I attended a mandatory lecture and fitting of a “real” effective mask we would be wearing. It was bulky, heavy and incredibly uncomfortable. The audience was told in no uncertain terms that surgical masks were worthless and no one would be wearing one.

So the mandatory wearing of a surgical mask to prevent spread of virus is not to prevent spread of virus. It’s to provide an incentive to avoid having to wear a mask everywhere. We’ve now entered theater of the bizarre.

I continue to be conflicted. On one end, I do believe in immunizations and I support them, even accepting the occasional complication. On the other end, I’m not so sure about FORCING health care workers to line up and get with the program in the face of weak evidence and known life threatening complications, however rare.

Patients, prospective or otherwise, are said to have a right to determine medical treatment on the basis of informed consent. Every other hospitalized patient can, and frequently does refuse treatment even when informed the benefit greatly exceeds the marginal risk. And they do so with total impunity. Are we now suspending that societal maxim for the flu shots because our optimism exceeds theirs?

So, I will be watching all this unfold from the sofa of fraternity rejects of “Animal House”.