A Doctor in the Trenches: A Guest Post on the Healthcare Mess [UPDATED]
My sister, a specialized internist at a major university medical center and a professor in its med school, has told me more than once that from her position on the front lines, as a physician seeing clinic patients, she would much prefer a government-run, single-payer healthcare system, or short of that a public option, to the chaotic mix we have now. I’ll post her thoughts, from several e-mails over time, without comment except for the questions that preceded some of her answers.
The conversation began when I wrote my sister about the predicament of an online friend in her city who had been unable to get needed joint-replacement surgery (surely not a waste of money in the case of someone my age, or even in that of our healthy 85-year-old mom who’s walking blissfully all over Chicago on her 3-year-old artificial knee) because she fell into that “too rich for Medicaid – too poor to buy insurance” gap.
So sad. And such a common story. It infuriates me that people have to spend so much energy/time trying to get the bus fixed (I just LOVE that metaphor) when this should be a given. I feel so strongly that health care is a basic human right. It’s hard enough having to deal with your body falling apart but to have to endure the indignities of having to apply for indigent care compounds the awfulness. She’s right…you have to be destitute to get Medicaid here. . . . I’m helpless in the face of the great bureaucracy. Plenty of people figure out ways to get around things—put property in a spouse’s name and then divorce on paper. What bullshit that people have to go through such things!! . . . [My institution] is usually good about setting up payment plans for people with huge bills—reasonable plans that don’t demand 50% of your monthly income.
A: Yeah . . . but would you like working in a govt. bureaucracy??
I work in a fucking bureaucracy now!! from my end it’s SO much easier to deal with Medicaid and Medicare than with private insurance. I’m RELIEVED when I have a patient with Federal or State insurance…actually less bullshit to negotiate in this day and age. I’m not just talking about HIV…I’m on the inpatient gen med service now dealing with everything (heart failure, liver failure, cardiac arrhythmias, pancreatitis, suicidal drug OD, obstructive uropathy from cancer, pneumonia with ARDS, pulmonary edema etc etc). You don’t understand what it’s like on the front line.
correction. you know what it’s like being on the front line as a patient in the system but not as a provider.
A: What is ARDS?
Adult (sometimes acute) respiratory distress syndrome. i hope i didn’t come on too strong…being on the inpatient service is kind of like being in the medical equivalent of combat.
A: How come you are there? Was it an assignment or a choice? Or is it a rotation everybody feels obligated to take, like being department chair?
It’s kind of depressing to me that everyone views the same chaos and comes to the conclusions they were brought up to come to. I bet you know conservative docs who believe the solution is MORE free enterprise, just ’cause that’s “where they’re coming from.” The conservatives say that government medicine offers more universal low-level coverage but expensive, high-level, high-quality procedures and treatments become scarce and harder to obtain if you need them.
I’m just in between . . . don’t know what to think. I too was raised to see government as tending to be “good,” big business as tending to be “bad,” and now I’m exposed to this barrage of the exact opposite. I suspect only people who ARE on the front lines as providers know enough to have this debate.
What a mess it is!! It must also be frustrating to have to clean up after people’s shitty life choices all the time.
we (all the attendings in medicine) have to do it [inpatient service] 1-2 times/yr. It’s actually “fun” in an insane, all encompassing way. But you’re so right SO many of the people we see are fat/smoke/drink too much/use bad drugs/don’t take their meds. pick from the choices. it’s extremely frustrating, especially when they expect us to fix it and get angry if we can’t. And there’s so much passivity and entitlement!!
We don’t need more access to expensive, high level high quality procedures. We need good patient centered primary care, less reliance on testing to rule out everything so we don’t get sued, less financial incentive for doing procedures (yes, including colonoscopy), more studies on the cost effectiveness of procedures on a population scale (are we REALLY saving $ by doing screening colons on everyone. Yes, you occasionally find cancers in young people and save them. but at what cost? or stenting every single stenotic coronary artery?) and some serious discussions about end of life care. we’re keeping [people] with miserable quality of life alive to torture some more! It makes me feel like a cat!
* * *
Today I had to make a decision about a therapy in a patient with a bad disease and the decision point was determined totally by economics instead of what was best for her. (She has very bad pyoderma gangrenosum that I could treat with infliximab (has worked well for her in the past) but this is considered an outpatient med so it wouldn’t be paid for by her insurance (and it’s $$$). So I could either discharge her and give it to her as an outpatient (she’s on a PCA (patient controlled analgesia) pump so I didn’t want to do that) or pick something else. So we’re trying IVIG…also $$$ but I can give it inpatient. What kind of bullshit way is that to have to practice medicine? This is only one of so many daily occurrences. We just incorporate it into our daily decision making like it’s normal.
* * *
[AMA came out against public option] A: Conservative friends on Twitter are ecstatic. One (Catholic, pro-life, mother of preemie twins) says “Go A.M.A! I would have two dead children if it weren’t for private insurance and the top-notch neonatologists in the U.S. circa 2003.” These people are fervently pro-capitalist. They decry making an idol of Obama, yesterday I told them I thought they were making an idol of capitalism. But I haven’t got a clue what to think.]
Totally predictable that the AMA would take this position…the potential is there for incomes to go down. It’s scary how many people we’re seeing who aren’t poor or disabled but don’t have health insurance. They don’t qualify for Medicare, Medicaid or our indigent care. One hospitalization could wipe out everything they own…it’s insane!!
I totally agree with your blog-friend about late in life care. Look what I’ve helped stave off for a patient in his 90s with arterial disease! More testing, more procedures, when he was functioning decently well…I’m thinking of the Podiatrist who was freaked out by his absent pulses and wanted dopplers then Vascular Surgery to do angioplasty when he didn’t have pain or obvious ischemia. The potential complications in him could be devastating. We (Dr’s) don’t think downstream–it’s all about fixing what’s broken (or looking for what might break) because that way we a) avoid lawsuits and b) are financially rewarded. And she’s so right about how there needs to be a shift in expectations on the patients’ side.
One thing I am worried about. There’s so much talk about outcome measurements–a good thing IF the measurements are good/accurate/meaningful. Based on one flawed study about giving antibiotics in a timely fashion to pts in the ED with pneumonia the big Joint Commission that does hospital accreditation now uses administration of abx [antibiotics] w/in 6 hrs of coming to the ED for any infection (or suspected infxn) as a quality measure. As a result some pts get abx before cultures are done (the waiting times in big public hospital ED’s can be incredible) which complicates and often prolongs hospitalization. Shitty quality measurement based on shitty science resulting in increased health care costs. This is only one of many such idiocies.
I quoted to her a comment by Ennui:
On the overall question of healthcare costs, if, as I suspect, the biggest factor input (especially for an aging population) is labor, and domestic labor costs cannot be simply reduced, the only way to reduce healthcare costs in a meaningful way is to reduce the quantity of healthcare delivered. The most effective way to do this, I think, is something like what Bruce B described. Here’s a concrete instance: when I was a TA I had a student who managed to slice the palm side of his fingers with his new knife (which he was proudly showing me – what can I say, it’s Texas). I took him to the emergency room where he was presented with 2 options.
- Option 1: Stitch up the skin and hope that the knicked (but not severed) tendons would heal (he was told that it would probably be fine). Price ~$750
- Option 2: Call in the specialist to stitch up the tendons as well. Price ~$5,000
He had no insurance. But he wasn’t broke. He mulled it over and chose option 1. As it happens, his hand was fine. This, harsh though it may seem, is cost cutting by means of market economics in the health care field. This is what I am for.
Agree that the reduction in quantity of healthcare is a critical component…ways to do this include tort reform (amazing how much testing is driven by lawsuit fears), decreasing payments for procedures (decreases incentive), also some way of regulating/eliminating physician ownership of testing services they get paid for. For example, many Heme-Onc practices have their own CT scanners and they do frequent CT’s…often more often than is recommended based on evidence based studies. It’s not pure evil greed (although that’s in the equation) since the patients love it because it gives them a (often false) sense of security. But if you’re the MD and you own the CT scanner and private insurance will pay you $800 for a scan of course you’re going to do a lot of them! And sometimes you’ll do them when watchful waiting or some blood work could give you similar info. [Her husband, a gastroenterologist]’s group owns their own endoscopy center so they get the facility fee instead of the hospital. They charge less than the hospital but it’s still (according to him) an amount disproportionate to the time/difficulty/expense to the practice. Do they do more endoscopies because they get paid directly? I’m guessing yes.
My admissions today so far…1) a homeless woman with horrible lice and a huge abscess on her butt. also 2 boyfriends who don’t know about each other converging on the hospital 2) a nice lady with an axillary abscess and a UTI with a kidney stone 3) a 24 y.o. Haitian woman who only speaks French with severe abdominal pain that started suddenly while she was on an airplane. The plane was diverted here. Her CT scan showed an abnormal spleen. When we finally found a French speaking med student we discovered she has sickle cell dz (she got splenic infarcts from the low O2 sats on the plane. leading to sickling). The sad thing was she was traveling with her 9 m.o. old baby. CPS had to take the baby (she can’t keep him in the hospital) and her sister is racing here from Connecticut to try to intercept. If she gets here before 5 they’ll give her the baby, if not then the baby goes into foster care for the weekend and she’ll have to go to court to get him back (WTF?????). 5 more (admissions) to go. just thought you might to know what my days are like. I honestly love it a lot of the time.
[On a cartoon I sent her about doctors’ callouw black humor] A: I’m not sure it’s something to deplore — it’s probably necessary for survival — but it can probably go too far, too.
it is kind of sad and inevitable at the same time. i see it happening and probably feed into it some myself…but you can’t help but generalize from your experiences. so when I feel/act all jaded about the 5th heroin/crack/meth/alcohol addict that’s being admitted to my team and the medical students see it i try to remember to tell them a story about the time i made assumptions about somebody and was wrong. it’s actually good for us to have students around because they make you behave. you have to at least fake being a role model.
in response to a 2008 Pajamas Media article I sent her, by the unpseudonymous Anchoress, “Socialized Medicine Looks Inevitable“:
not bad. maybe Obama’s such a great chess player that he saw all these moves in advance–the private sector will have to scramble to make huge changes to try to head this off and the need for a govt plan will be moot. I guess because I’m a visceral liberal (it was our [family] religion after all) i don’t get the terror that the specter of a government plan strikes in the hearts of conservatives. especially since we don’t even know what it would consist of!
* * *
I’m getting sick of all the squawking and the relentless posturing. How about you? From my in the trenches position I can tell you that the current private system is an inequitable mess that interferes with my ability to practice medicine on a daily basis. We have a large population of patients on Medicare and/or Medicaid and it’s a relief to deal with them! How ironic that there’s less red tape or obstructions to service with government-subsidized plans. We also have a substantial population of patients who aren’t impoverished enough or sick enough or old enough to get Medicare/caid. Some of them qualify for our indigent care funds and are responsible for some percentage of their costs. Many of these work but have no insurance or inadequate insurance. So they ration their own health care—if you have to pay for 40% of your screening colonoscopy, PAP smear, mammogram, routine blood work etc you wouldn’t be taking such great care of yourself either! Not to mention the folks with HIV who are working and earning more than $20K/yr so they don’t qualify for ADAP (AIDS Drug Assistance Program)—they’ll have to figure out how to pay for their HIV meds which cost 10-15K/yr! Or they can ration their care and wait until they get sick. I don’t see private insurance being an answer to these access problems–they’re in the health care business after all. I feel strongly that a public government-run option is part of the answer. Measures of quality of care are important but it’s critical that they be meaningful.
A: Why do you think it is that some doctors in the same trenches are adamantly opposed to the public option? Do they think they’ll make less money? Or is it just a question of how one is raised? Do we just see through the eyes we inherited? I saw a web page about how the hassles and time-wasting with Medicare were making some doctors refuse to take Medicare patients, so obviously some don’t find it refreshing, but maybe they’re going in with a bias against it? It seems there is no objective reality. You can go to Britain or Canada and find someone who thinks the world of their national health service and someone who hates it, based not even on their experience but on their demographics and preconceptions. It sometimes really does seem that believing is seeing.
I’m not sure why some docs hate medicare so much. maybe it’s older docs who remember the days of total carte blanche. or private practice types who are used to raking in the dough with no impdiments. The problem is that we’ve created a two-tier system that really impacts the uninsured—the folks with “good” insurance (i.e. no-holds-barred, OK to see your GI doc when you fart, your neurologist for your HA, have a CT because you’re worried you might have cancer etc) have absurd expectations about what care they’re entitled to and don’t want anything to change. The uninsured can’t even get the basics and “ration” themselves until they’re really sick, then have to declare bankruptcy to pay the hospital bill. How fucked up is that system??? And docs can be greedy pigs too. What about all these oncology practices that have their own CT scanners now, often with an in-house radiologist. They say the patients like it better–but they do an absurd number of scans and get paid fortunes by the insurance company. Oh I could rave on and on. Americans can be so selfish and shortsighted about their health care (“I’ve got mine so fuck you”). And as to the Canadian model–it’s done really well by [another of our sisters and her husband who had a detached retina], just for a personal example. When she had alarming symptoms last year she got bumped to the head of the line. and he got his eye fixed (or at least worked on) right away AND he doesn’t have to worry about how to pay for it. People get mad at docs because we ask what kind of insurance they have–for me at least it’s because i need to know how much shit i’m going to have to wade through to get done what needs to be done! And it’s not the government that’s providing the shit!
UPDATE: The author responds to the comments.
Cool! Love the comments. Realpc is a smart dude. So true that we do WAY too much in situations of futility (just put a demented 89 yo on dialysis ’cause his family wouldn’t hear of letting him go. How awful for him and how costly for us). When I say health care is a basic human right I absolutely am responding to the inequities of the current system. “Rich” people can get their diabetes and high BP
treated and “poor” people sometimes can’t. What’s up with that?? So I have to take care of the fat alcoholic and drug addicted smokers who drive too fast and when they’re impaired, don’t use condoms and sleep around? You bet. Since when is society allowed to pick and choose who gets services based on their lifestyle choices? There’s too much of the “I’ve got mine so too bad for you” in these conversations about health care. And re another comment…I can’t remember the last time anybody worshipped me as a doctor. where do people get these ideas?? Too much Grey’s Anatomy and “House”??
Ambiance 
amba12 said,
August 26, 2009 at 3:38 pm
A comment of my own: I can see one apparent inconsistency in my sister’s thinking (though from the trenches it’s probably a paradox rather than an inconsistency): seeing healthcare as “a basic human right” and at the same time being exasperated by people’s passive sense of entitlement to have it fix everything that ails them, without much if any input from them.
Which leads to another paradox: how do you encourage people to take responsibility for their own health maintenance without blaming them when they get sick? Because they are two rather separate issues. Good health habits can help to stave off some disease, but people will get sick nonetheless. I fear cost-cutters on both the left and right getting into a rather severe — and creepily New Age — mindset that if you get sick it’s your own fault. Except for statistically/demographically, we really don’t know for sure when it is and when it isn’t. So we need to separately encourage good health habits and treat illness, and try to avoid the slippery slope into a kind of blame-based rationing that the left will call “poor lifestyle choices” and the right will call “personal responsibility.” (We already have that to some extent, but mainly in the one case where cause and effect are unusually clear-cut: higher insurance rates for smokers and high taxes on tobacco. Smoke at your own risk.)
And finally: you don’t think early colonoscopies are a waste of money if you’re that one thirty-something out of hundreds of thousands whose life is saved by it. There could be a technological answer to this one: find better low-tech methods of early screening. (Apparently “fecal occult blood” for colon cancer turned out not to be very good.) For instance, absurd as it may sound, dogs can smell some kinds of cancer with a very high degree of accuracy. I don’t know how early, though.
Donna B. said,
August 26, 2009 at 6:18 pm
One of the things that I don’t see being discussed is the major economic disaster that putting private health insurance companies out of business would have. They employ somewhere around 500,000 people.
If we go with something like HR3200, it will not only cause the loss of a lot of private sector jobs, it will raise taxes on those still left employed. It will put more of a burden $ wise on employers to cover health care costs, thus slowing or stopping an economic recovery we need yesterday.
What your sister doesn’t mention is that people with Medicare, if they are also poor are still faced with selling the house or declaring bankruptcy to take care of the co-pays. The only real advantage to the patient is the low cost of Medicare coverage and the fact that it puts a legal limit on the co-pays. It also limits the number of days one can be hospitalized. Medicare for all, ie, single payer would not be the cure-all it’s being cracked up to be.
Medicaid is very limited in what it covers. In at least one state, it covers only two prescriptions per month. WalMart’s $4 prescriptions have done more to help Medicaid recipients and those without insurance at all than any recent government program I can think of.
HR 3200 also has a provision in it that greatly increases the power of the IRS that is totally unrelated to healthcare. One does not have to be against single payer or public option to be against that. It is badly written legislation.
I completely agree with you that prevention and treatment should be separated and that there’s little difference between “poor lifestyle choices” and “personal responsibility” other than choice of words. Under which of those falls my refusal to have another mammogram?
I’d get behind simple legislation that increased the scope and reach of Medicaid. But it would have to be accompanied with a massive influx of money to the states and Congress has squandered way too much bailing out other private enterprises and “stimulating” the economy to no avail.
One source of money could be freed up by ending the war on drugs, starting with legalizing marijuana.
Another step to be taken is to take on the AMA and various licensing rules. The cost of a medical degree has to come down to reasonable levels so that a doctor can be a doctor and enjoy a comfortable lifestyle.
realpc said,
August 26, 2009 at 7:57 pm
” seeing healthcare as “a basic human right” and at the same time being exasperated by people’s passive sense of entitlement to have it fix everything that ails them”
That is one of the problems being faced now. Is it really true that healthcare is a basic right, and does that mean we all have to pay for the results of the deadly American lifestyle, even if we don’t live that way ourselves?
First, healthcare isn’t technically a basic right. Until not very long ago, most patients either got well naturally or they suffered and died. Most things could not be fixed by doctors.
Now there is expensive medical technology that can fix some things. So when a patient could be fixed, it seems unfair to deprive them of a treatment a richer person could afford. I think that’s why some people have decided healthcare is a right — they don’t think it should be only for the rich.
But problems result because, for one thing, the expensive technology is used even when it doesn’t work or isn’t needed. They have it, so they use it, for some of the reasons your sister mentioned (avoiding law suits, more money for health care providers, etc.)
As usual, technology has created an immense problem for our society, and nothing in the past can guide us because this situation is new. We have extremely expensive medical technology combined with a deadly lifestyle that creates millions of chronic patients.
Our medical technology does sometimes save the lives or health of people who became sick or injured by accident, and who are otherwise healthy. But more often, I suspect, it is over-used on patients who are very sick and who get little or no benefits from the treatment.
I think every American should be given catastrophic health insurance that would provide treatments needed to restore them to health if injured in an accident. That kind of surgery can be extremely expensive, even if only a short hospital stay is required.
I don’t know what other health insurance the government should provide. I agree that the current system is a disaster, but I don’t share the progresives’ love of government. I don’t see anything lovable about the government. It might act lovable and loving, and it might have good intentions at first, but once it gets power and your money, it doesn’t need you anymore.
But socialized medicine seems to work in many other countries, and they are the progressives’ model. If it works for them, it will work for us. I have no idea if that’s true.
amba12 said,
August 26, 2009 at 8:34 pm
I was just reading about how new cancer drugs like Herceptin and Gleevec are overhyped; they must usually be taken along with chemo and/or radiation, not instead of them, and they prolong survival, but for almost meaninglessly short amounts of time — days, weeks, a couple of months. Actually Gleevec can put chronic myelogenous leukemia pretty completely into remission (as it has done for a friend of ours for several years now), but I gather it is much less effective on other cancers.
Donna B. said,
August 26, 2009 at 9:29 pm
Well… as the spouse of one who has been diagnosed with (so far) three primary cancers, I have to say that some treatments are well worth the money — for me personally.
I suspect that cancer will be what eventually causes the death of my husband. So far he’s been “cured” of colon cancer (the cancerous part removed surgically with no polyps for the last ten years) and “promised” a 20 year survival of his prostate cancer with radiation. It’s likely his bladder cancer will result in the removal of his bladder, making necessary an external bladder.
My completely non-scientific prediction is that he will be diagnosed with primary pancreatic or liver cancer next. Possibly kidney cancer, if his type II diabetes doesn’t cause kidney or heart failure first.
All of these diseases, in my husband’s case, are POSSIBLY due to lifestyle choices. He chose to be a Marine in the 60s. He was thus exposed to radiation from above ground nuclear bomb tests (Christmas Island) and to Agent Orange in Vietnam. There is no definitive cause, merely a presumptive one.
We are now arguing over whether we should apply for VA benefits for him. It would make no difference in his medical care — he is a military retiree and eligible for Medicare. We are medically covered (unless healthcare reform negates Tricare.)
And that is my dilemma. I, personally, will benefit from my husband’s VA benefits whereas I do not benefit from his military retirement. I married him after he retired from the military. BUT, if he is deemed worthy of VA benefits, I would also be, after his death. I am 13 years younger than he is and will probably (in the mathematical sense) outlive him.
Specifically responding to Amba’s comment on Gleevec and Herceptin:
Every cancer is different and essentially unique to the individual. Medications and treatments are intended to be more universal. It really is difficult to understand that each individual’s cancer is somewhat and somehow different from the person next to them with the same diagnosis.
We are playing with a law of averages vs. an individual incident. There will always be people who fall through the cracks. Unfortunately.
amba12 said,
August 26, 2009 at 9:38 pm
Donna, your irony is delicious. I love the idea of being a Marine as a “lifestyle choice,” up there with smoking and whole pints of Häagen-Dasz.
amba12 said,
August 26, 2009 at 9:41 pm
Every cancer is different and essentially unique to the individual. . . somewhat and somehow different from the person next to them with the same diagnosis.
That’s an excellent point and that seems to be what cancer vaccines are designed to address.
Donna B. said,
August 26, 2009 at 11:43 pm
Had the HPV vaccine been available when my daughters’ health care was under my control, you betcha they would have got it.
The huge problem I have with “lifestyle choices” being the cause of cancers is where childhood cancers are concerned. They just haven’t lived long enough to make that a viable cause. The same is true of autism, IMHO. Neither the children nor the parents are to blame… and vaccines don’t cause it either, else it would be an epidemic, which it is not.
Society as a whole expects far more from medicine than it can produce. This, I think is the ultimate cause of the health care “crisis”. Medicine cannot cure cancer, it cannot cure autism, it cannot cure a viral infection, it cannot always cure a bacterial infection.
We have much better diagnostic tools than we have curative tools.
Donna B. said,
August 26, 2009 at 11:44 pm
I should add that we cannot cure without first diagnosing. Good diagnostic tools are not a bad thing, they are just not equivalent to a cure.
amba12 said,
August 26, 2009 at 11:58 pm
I.e. they are necessary but not sufficient.
Donna B. said,
August 27, 2009 at 1:09 am
Exactly. And that is where I see your sister’s basic frustration coming from. There is no cure for heroin addiction. It’s easy to diagnose, almost impossible to cure. That is, of course, the extreme… but it is applicable to all other diseases.
Other than sanitation and antibiotics, has science been able to cure that many diseases? Do we not expect too much?
I do not think that medicine can cure addiction. I wish I were wrong, but there is no evidence otherwise. However, there is evidence that the expansion of the definition of addiction has led to the idea that it can be cured. For example, if the definition of addiction is extended to tobacco, those who quit smoking are evidence that addiction can be cured, and that it can be cured by social unacceptance.
Or disacceptance, or whatever neat term one might choose. The fact is that those who are addicted to the more malevolent drugs, such as meth and heroine do not give a rat’s ass whether it is accepted or not.
Let’s get to the nitty gritty here. How many commenters here have actually dealt with a binge alcoholic, a heroin addict, or a meth addict? How many of us have been personally persecuted for giving a heroin addict a cigarette? Or been the one to go to the ER when there’s an overdose?
Does the “commentariat” know what the hell it’s talking about?
eehhh… my comments are not limited to this post. It is just that I did not know how to respond to the post about depression being an adaptive good.
The main question I would ask is if any evolutionary “good” is actually socially good. I would say no. That “no” is why pure strength is not an evolutionary benefit. Pure strength, pure force has not been the conqueror of all, has it?
Strength /= good and Good /=strength is the dichotomy.
amba12 said,
August 27, 2009 at 1:26 am
You sound as if you know whereof you speak.
The closest I’ve been to an addict was my beloved alcoholic karate teacher. It was creepy and tragic to watch this sort of demon possession slowly destroy a very gifted man. There was also a far-gone neighborhood alcholic — a bar owner — whom I helped up the stairs a couple of times and once called an ambulance for when he thought he was dying. It didn’t stop him.
Ron said,
August 27, 2009 at 2:53 am
I’ve had occasion to deal with heroin addicts — once holding one off with a shotgun, and once taking one to the ER, which was tense, but he wanted to go, he didn’t fight me.
Alkys? Well, one last year, but outside that, not for many years now…
I pulled an alcoholic out of bin of sandblasting shot before he “drowned” in it. I held him by his bright red hair while someone pulled us both up…wacky!
Ron said,
August 27, 2009 at 2:58 am
Wait, I forgot…there was a girl who lived in my front upstairs apartment who was an alcoholic. She made me promise that I wouldn’t let her sleep outside if she came home wasted. (which was often) So, I’d find her hammering on my door before passing out and I’d try to drag her upstairs but she was like that proverbial ‘bag of wet cement’, so I’d just let her sleep on her stairwell.
But, hey, she’s now doing better than I am, so maybe I should have done more drinking back then!
wj said,
August 27, 2009 at 10:17 am
I wonder if the American approach to medicine overall (not just health care reform) is not substantially influenced by one cultural characteristic: We tend to assume that, if anything happens (especially something bad), someone/something must be “at fault.” Therefore, you can and should address whatever is the cause . . . and so the world will become perfect.
For medicine, that means that every condition must have a curable cause. And it is a moral imperative to find that cause and fix it. So what if it requires spending vast sums. So what if the “cure” (at least the one we have found so far) is actually just a marginal improvement over doing nothing. And if the cure doesn’t work optimally, it must be the “fault” of whoever was in charge of the treatment — who should obviously be sued for failing to perform a miracle on demand.
Other cultures, even extremely similar ones like in Europe, have a somewhat more realistic view of the limits of human control over the universe. And part (admittedly only part) of the differences in medical costs stem from just that — and that part won’t be changed by any legislation that anybody passes, now or in the future. Because we Americans will still feel like we are, or at least ought to be, in control.
P.S. I would be willing to bet that, should a big meteorite strike the United States and kill a bunch of people, there will be law suits against NASA for a) failing to spot it coming, and b) failing to intercept it and neutralize it (whether by deflecting it or reducing it to fragments which would not be damaging when they hit). I’d even be unsurprised if a jury was convinced. Any takers on that sucker bet?
realpc920 said,
August 27, 2009 at 11:39 am
“Society as a whole expects far more from medicine than it can produce. This, I think is the ultimate cause of the health care “crisis”. Medicine cannot cure cancer, it cannot cure autism, it cannot cure a viral infection, it cannot always cure a bacterial infection.
We have much better diagnostic tools than we have curative tools.”
That is true. The American public expects and demands miracles.
realpc920 said,
August 27, 2009 at 11:41 am
“Other than sanitation and antibiotics, has science been able to cure that many diseases? ”
Also very true. Surgical technology and anesthesia have also improved. But most of the cancer treatments, although expensive, are useless.
Ron said,
August 27, 2009 at 11:57 am
All right, so medicine can’t cure a variety of diseases, what of it? You want to go back to what…nothing? Haven’t we had a lot of improvement in heart attacks and strokes since the ’50’s? How’s about that whole polio thing? Maybe cancer is that difficult of a problem that we can’t just wave a magic wand and be done with it, but you want us to quit trying? I hope not.
realpc920 said,
August 27, 2009 at 11:57 am
“new cancer drugs like Herceptin and Gleevec are overhyped; they must usually be taken along with chemo and/or radiation, not instead of them, and they prolong survival, but for almost meaninglessly short amounts of time ”
I think it’s even worse than you realize — the older cancer drugs might not work either, for most types of adult cancer. As far as I understand it, cancer drugs generally work by being toxic, and by killing cells or slowing their reproduction. So everything in the body gets poisoned, and hopefully the cancer cells die off first. There are, I guess, certain types of childhood cancer that can be eradicated in this way. The child may have some permanent damage but at least they can survive.
But for most types of cancer, MDs only assume that this approach is effective, without actually having any good scientific evidence. They cannot do an experiment comparing patients who receive chemo to those who don’t, because it would be considered unethical, since chemo is assumed to work (because there some types of cancer it does seem to work for, I guess).
Even so, the medical industry claims it has a good cure rate for cancer that is diagnosed early, and has not spread. Believe it or not (and you probably won’t), this assumption is based on a statistical illusion. Actually, oncologists are aware of this but choose to ignore it I guess.
It is known that a person can be diagnosed with cancer, because there are cancer cells in their body, yet will never get sick from it. The immune system destroys or contains most cancer cells.
So if 10 people are diagnosed with early cancer and only 1 of them is destined to actually get sick from it, and all are given the standard treatments, then it will look like a 90% cure rate. This problem is called “over diagnosis.”
Another statistical problem is called ‘lead-time bias.” As cancer diagnostic technology improves, cancer cells are detected earlier. But “cure” is still defined in terms of 5-year survival. So if a type of cancer usually kills within 6 years and is diagnosed 2 years after it starts, the patient was obviously not cured. But if that same cancer is diagnosed only 6 months after it starts, the patient will be counted as cured, and that goes into the statistics.
So it looks like progress is being made in curing cancer, but there is little if any real progress. The new drugs Amba mentioned might prolong survival a little, but that might be because they are better at poisoning the body and preventing all cells from reproducing. The patient is not getting healthier, and is in fact being poisoned. The tumors might grow a little more slowly, so the cancer might be stalled a little.
But these new drugs do not provide any real hope, do not represent any real progress, and are costing us all a fortune.
The mentality of the medical industry needs to change.
realpc920 said,
August 27, 2009 at 12:03 pm
“Haven’t we had a lot of improvement in heart attacks and strokes since the ’50’s?”
Not as many Americans are smoking, so that might account for some improvement. But there is more type 2 diabetes now, so strokes and heart attacks may have increased. I would need to see the data.
“How’s about that whole polio thing?”
The polio vaccine is one of the small number of medical advances that helped people a lot. Also some of the other vaccines, and of course antibiotics. No one denies that there have been a small number of victories.
“Maybe cancer is that difficult of a problem that we can’t just wave a magic wand and be done with it, but you want us to quit trying?”
There is no need to quit trying to cure cancer. But trying to cure it the same old way, without having any reason to think you’re on the right track, is an expensive mistake. New ideas are needed, but the mainstream status quo likes the old ideas.
amba12 said,
August 27, 2009 at 12:24 pm
As far as I understand it, cancer drugs generally work by being toxic, and by killing cells or slowing their reproduction. So everything in the body gets poisoned, and hopefully the cancer cells die off first.
Not quite; apparently chemo targets cells that frequently divide and reproduce. Quiescent cells in the body won’t be poisoned, but those in hair follicles are (why hair/eyebrows fall out) and probably those in the gonads, too (why you’re supposed to bank your eggs/sperm before starting chemo).
amba12 said,
August 27, 2009 at 12:30 pm
Actually there have been HUGE victories over disease, brought about mainly by three advances: sanitation, antibiotics, and vaccines. 150 years ago, half of everybody’s children routinely died; young mothers died right and left in childbirth or soon after of childbed fever (now known to be a strep infection); and if you got a bad infection you were usually a goner.
Our ability to save lives in trauma situations is also quite astounding.
So — it’s always something — now we face cardiovascular disease and cancer, widely regarded as “diseases of affluence.” Heart disease is probably considerably easier in principle to prevent and treat. Also, heart disease is more impacted by lifestyle factors. Cancer, I suspect, has a lot to do with environmental pollution, which is unavoidable.
realpc920 said,
August 27, 2009 at 12:50 pm
Amba,
It’s all sanitation, antibiotics, and vaccine, surgical and diagnostic technology. Mostly an extreme decrease in infant and childhood mortality.
But most of our medical expenses are for other things, probably. Things that mostly do not work.
“chemo targets cells that frequently divide and reproduce”
Ok, fine, but does that sound good to you?
realpc920 said,
August 27, 2009 at 12:51 pm
“Also, heart disease is more impacted by lifestyle factors. Cancer, I suspect, has a lot to do with environmental pollution”
Maybe, but cancer probably often results from chronic inflammation, caused by lifestyle, similar to heart disease and diabetes 2.
Donna B. said,
August 27, 2009 at 1:31 pm
Cardiovascular disease and cancer are most often diseases of aging and genetics as well. I suspect genetics also plays a role in type II diabetes, as it is also linked to exposure to Agent Orange.
realpc920 said,
August 27, 2009 at 1:37 pm
Donna B.,
The major factor in diabetes 2, heart disease and cancer is lifestyle. They are called diseases of aging because it takes time for the American lifestyle to kill people. Genetics could be involved in almost anything, but it is not the major factor in the lifestyle diseases. People like to use genetics or age as any excuse, because then they don’t have to change their lifestyle.
Agent Orange is a different story and I don’t know anything about that. It’s possible your husband’s lifestyle had nothing to do with his getting sick, since he was exposed to a toxin. I don’t know. But if his lifestyle is similar to the majority of Americans, then it probably contributed.
amba12 said,
August 27, 2009 at 1:52 pm
Ok, fine, but does that sound good to you?
I didn’t say that!
amba12 said,
August 27, 2009 at 1:59 pm
Messed-up arteries run in my father’s family. Both his parents died at 67 and he was on track to do the same, except that almost by accident, it was discovered that he was on the verge of a massive heart attack, which he began to have on the bypass table, just as the cavalry arrived.
Now he’s 91! His carotid arteries and others, and probably his coronary grafts, are substantially occluded. He now has shortness of breath and chest pain on exertion, and can’t walk terribly far, partly because of spinal arthritis. He takes Plavix and other blood thinners and is always black and blue. But he must have developed corollary circulation because he’s mentally sharp, active and enthusiastic for life.
Genetically, he was dealt a lucky hand along with the unlucky one: naturally low-normal blood pressure (which I also have; so does J). That and modern medicine together have collaborated to give him a wonderful long run that’s still going.
realpc920 said,
August 27, 2009 at 2:12 pm
Amba,
I know people, including very close friends and relatives, whose lives were saved by surgery. We can all sing the praises of modern medicine all day long. My point is not that modern medicine is worthless — I am saying that there is a central hub of valuable chemicals and technologies, surrounded by a vast cloud that is doubtful and worthless, but extremely expensive.
We have to stop thinking of modern medicine as one big thing, and try to separate its different aspects. We just have to think more carefully about it. Because the cost threatens to destroy all of our futures.
amba12 said,
August 27, 2009 at 2:32 pm
I don’t think of it as one big thing.
I am always impressed by what it DOESN’T know.
And, I stay away from it as much as possible, by a combination of luck and healthy living.
I’m particularly suspicious of most drugs. I declined to give J Namenda for more than two years. Now it’s helping him some, so that looks stupid. But the effect tends to wear off; so maybe it was smart. Maybe we got more time out of it this way.
I’m very wary of antidepressants although quite a few people in my somewhat depression-prone family (mother’s side) have taken them, including, creepily, adolescents. If I had been an adolescent in these times I would surely have been put on them.
If I take after my father someone will try to put me on statins at some point. I will refuse.
I don’t have that hushed reverence for “Your doctor.” On the other hand, either there are a lot of quite wonderful doctors out there (along with the jerks), or J and I have been exceptionally lucky. He’s had lots of medical issues over the years, and he’s had several doctors who’ve become lifelong friends of ours.
Still, I only go to the doctor if there’s something wrong that I can’t ignore. Then I’m pretty good about it. So far, that’s worked for me. I’m always afraid it’s cancer. So far, it hasn’t been.
At some point, I’ll have a baseline cardiac checkup and go to the gyno again. The last time was in, let’s see, 2003. That was also when I had my first and only colonoscopy.
Recently I had a minor urinary tract infection and fought it off on my own with . . . cranberry juice.
I didn’t have a mammogram from 1993 to 2007. Then I got scared because I thought I might have a lump in my breast. I didn’t.
I am a cost cutter’s dream.
By the way, you know who else never goes to the doctor if she can help it? My sister the doctor.
Donna B. said,
August 27, 2009 at 3:00 pm
real… you’re projecting your biases onto me again.
realpc920 said,
August 27, 2009 at 3:01 pm
Amba, we are pretty much in agreement. I am not against MDs, I am just against worshiping MDs, and I’m against worshiping science and technology. Americans are generally too trusting of modernism, wanting to see only the advantages and not the disadvantages.
realpc920 said,
August 27, 2009 at 3:02 pm
“real… you’re projecting your biases onto me again.”
What do you mean Donna? I agreed with almost everything you said on this subject.
Donna B. said,
August 27, 2009 at 3:32 pm
Genealogists who include causes of death, not just dates, find a lot of evidence of genetic influence on health and longevity. Blended families highlight these differences in a unique way because the lifestyles are similar.
Twin studies are interesting too, especially the studies on twins not raised together. Some of these studies have suggested that even lifestyle choices may be genetically influenced.
Donna B. said,
August 27, 2009 at 3:34 pm
real… I’m probably still reeling from our last two discussions and may be overly suspect of the reasons for your disagreements. I just don’t know where you’re coming from.
realpc920 said,
August 27, 2009 at 3:37 pm
Yes I know that genetics is part of it. But lifestyle is really the overwhelming factor these days in certain disease. Type 2 diabetes, and the diseases it leads to, is mostly caused by lifestyle. Cancer is probably also more lifestyle than genetics, these days. Refined carbohydrates, processed junk food and inactivity lead to chronic inflammatory syndromes, which in turn cause type 2 diabetes.
I think it’s really important to avoid blaming too much on genetics. Yes some families are extremely vulnerable to unusual diseases. But the ordinary diseases that have become epidemics now are mostly not genetic.
realpc920 said,
August 27, 2009 at 3:40 pm
And yes one person can smoke and drink and never exercise and live to 90, while another does everything right and gets a heart attack at 50. But those are exceptions, and the rule is that the typical American lifestyle results in bad health over time.
amba12 said,
August 27, 2009 at 3:41 pm
Some of these studies have suggested that even lifestyle choices may be genetically influenced. Yeah!! That is weird and awesome stuff — separated twin sisters both wearing a lot of rings, brothers both married to women named Helen, naming their kids the same thing . . .
But much of that is actually better explained by Sheldrake’s theory of morphic resonance than by genetics!
Ron said,
August 27, 2009 at 4:31 pm
I am just against worshiping MDs,
Worship, no. Respect for doing a hard task, yes.
and I’m against worshiping science and technology.
Well, if I’m gonna worship something better this than what, ignorance? shamanism? folk wisdom? I don’t need to ‘worship’ science to have more respect for it than those things.
Americans are generally too trusting of modernism, wanting to see only the advantages and not the disadvantages. Geez make Danes out of us already! America is at its best when it places too much trust in the modern. The Old Fashioned has too much positive spin; we ain’t gonna be Euros no matter how you slice it, cause we believe there’s more future in…The Future rather than worship our drunken, ignorant ancestors. Hey, Atom Bombs or no, Ford promised me an Atomic Car and they wouldn’t lie to me, right? ;) Besides, nukes have been a greater guarenteeor (sp.) of , if not exactly “peace”, than at least civility between Major Nations than a thousand Metternichs! As Dr. Strangelove suggests learn to love The Bomb…and The Future.
Donna B. said,
August 27, 2009 at 4:55 pm
Wouldn’t that be Sheldrake’s hypothesis of morphic resonance?
I was actually thinking of the study I read about years ago that looked at similarities in careers chosen by twins raised apart, such as both being firemen or doctors, which is more revealing than quirks or coincidences. None of those studies proved any statistical significance. It merely suggests the possibility of a correlation which is what I meant.
While writing the above, I thought of instincts as being inherited, which led me a baby’s instinct to suck and the apparent (given the fast-growing field of lactation consulting) fact that mothers have to taught to breastfeed, which led me to wonder how Eve learned that skill.
realpc920 said,
August 27, 2009 at 5:38 pm
[ nukes have been a greater guarenteeor (sp.) of , if not exactly “peace”, than at least civility between Major Nations than a thousand Metternichs!]
Oh yes, I sleep well at night just knowing I am protected by mutually assured destruction.
Ron said,
August 27, 2009 at 7:29 pm
Oh yes, I sleep well at night just knowing I am protected by mutually assured destruction.
You should! Nukes are more honest than we are with each other most of the time!
Look at it this way: Ever want to commit suicide? Some people do, but most of the time it’s, let’s be generous and call it ‘a cry for help.’ With me so far? Good!
Now look at humanity in general. ( Yeah, I know, shudder!) Before nukes could we really have committed suicide as a species? Well…no, I doubt it. Even a Hitler or a Stalin could not really accomplish it I think. But Nukes? Oh, yeah. Especially since the ’70’s when the number climbs to around 50,000.
But get this! We haven’t done it! We cocked the gun and put it to the side of our head…and chose life instead! Such de facto optimism shatters my lack of faith in humanity! At least so far! We should dancing in the streets, cause, hell, it looks like we actually prefer living despite all of our gloomy gus BS.
Nukes — empowering AND life-affirming all at once.
realpc said,
August 27, 2009 at 8:25 pm
Ron,
Did anyone ever tell you you’re crazy?
Ron said,
August 28, 2009 at 4:13 am
Maybe I’m crazy…but I may not be wrong! :)
Randy said,
August 28, 2009 at 11:53 am
IMHO, you’re neither, Ron ;-)
realpc920 said,
August 28, 2009 at 12:28 pm
So there is more than one nuke-loving nut here? And how many more out in the world? Very scary.
Ron said,
August 28, 2009 at 1:22 pm
real, given the near-constant state of warfare that Europe shows me in the oh, say, 300 years before 1945 and the zero Great Power conflicts in the 60+ years since is this just a happy accident? Or did we suddenly see the error of our ways, like we did after the War to End All Wars? Could it possibly have anything to do with the idea that the next Big One would indeed bring the serious hammer down? Unhappy with that conclusion, or are we supposed to trust that good conversation will stop the next Auschwitz, the next Gulag, the next Great Leap Forward — all events in living memory — well, I’m just not that keen on placing that bet. To me, your naivete makes you look like a very scary nut yourself.
realpc920 said,
August 28, 2009 at 1:48 pm
“Could it possibly have anything to do with the idea that the next Big One would indeed bring the serious hammer down?”
I am not naive Ron. I know very well that we’ve had more peace since nuclear weapons. I do not expect to avoid war by talking or by hugging terrorists. I do not expect to end war. And I do not expect the nuclear weapons to prevent war for very much longer. Our peace is precarious and we are always on the verge of exploding. I realize that. The reason I called you crazy is not for pointing that out, but for being happy about it! That’s seriously psychotic.
One of the many drawbacks of our technology is that war becomes ever more destructive. For primitive tribes it was a great challenge and probably even fun, even though of course some died. The risk of dying made it more exciting, knowing you might be dying for your tribe made it heroic.
Weapons technology improved gradually, then more rapidly, and as it improved war stopped being so much fun. The idea that war is hell arose, and overshadowed the image of heroism and glory. Now even professional warriors claim to hate war. Now it’s ugly. Artists don’t paint dramatic pictures of battles anymore. War is out of style.
Well you claim that’s good. But I think our “peace” is an illusion. We don’t think about it because it’s unimaginably horrible to think that nuclear war can break out at any moment. It can, it will, eventually.
And you’re gleeful about it. I think you’re the one who is naive.
amba12 said,
August 28, 2009 at 1:57 pm
The reason I called you crazy is not for pointing that out, but for being happy about it! That’s seriously psychotic.
Oh, I don’t know . . . I think you have to take your happiness where you can get it! At least we’re still alive. As far as I can tell, that’s all Ron is gleeful about.
It certainly is sad that to stop fighting — what am I saying? even to partially pause fighting — we had to be confronted with the annihilation of everything. It doesn’t speak well for our species that that’s what it took. And in the long run, the short-term gain is likely to have a staggering cost. I agree that it’s almost certain not to stay that way, especially with the nukes in Pakistan and, next, Iran falling into the hands of extremist lunatics who believe death is greater than life.
Well, I’ll repeat my motto from Kafka: “There is infinite hope, but not for us.”
amba12 said,
August 28, 2009 at 2:05 pm
I seriously believe that the reason sports are so insanely important (and overpaid) in modern society is because that desire for simple, physical, hand-to-hand combat was so adaptive when weapons were simple. (However, theorists now believe that war didn’t become a real factor until agriculture led to settlement and territory and property, and population density greatly increased. Skeletons of pre-agricultural people show plenty of interpersonal violence, but not signs of organized war.) There hasn’t been time (nor would it be entirely advantageous even now) for that impulse to be selected out of human males. But it needs a safe outlet.
amba12 said,
August 28, 2009 at 2:05 pm
Obliquely related thought: if Kim Jong Il could make movies, he wouldn’t need nukes. If Hitler had had an art show . . .
realpc920 said,
August 28, 2009 at 4:24 pm
“war didn’t become a real factor until agriculture led to settlement and territory and property, and population density greatly increased. Skeletons of pre-agricultural people show plenty of interpersonal violence, but not signs of organized war.”
That is what a lot of historians and anthropologists say, and it makes sense to me. War was a normal territorial instinct, the same as in other species. That kind of war is a necessary part of nature — something has to keep animals spaced apart. Even plants have their own form of war. But massive organized war came along with agriculture — surplus food allowed the population to grow, which meant ever more land was needed. And there were groups who made their living by raiding agricultural societies.
Agriculture is an example of human technology, of our species findings ways to outsmart nature. And of course it backfires.
Again, I am not saying we should go back to the stone age. I am just pointing out that most of our current problems, especially including the threat of nuclear destruction, can be blamed on technology.
realpc920 said,
August 28, 2009 at 4:28 pm
And that is why I am not a progressive. I am not against progress, I just don’t see it as our salvation. Progress is inevitable for our species, because we are the creature that tries to outsmart nature. I can understand feeling joyful about the adventure and the process, but I can’t understand anyone who thinks we are actually going to solve the eternal problems of life.