Saturday, December 14, 2013

The Email I Want To Send, But Probably Won't

Dear Dr. [X],

Thank you for your note. I will let my patient know as soon as possible that you aren't interested in seeing him in your clinic so that he won't trouble you with his medical issues.

It is true that we did have him admitted to expedite a biopsy while you were the attending on service for the [Q] team. However, as he had not yet seen a specialist in [Q] and that Dr. [Y] had provided help to me in phone consultation, we both thought that you would have been the most logical choice to see him in follow-up. The misunderstanding is all mine, as I thought you were this person called a "doctor" and that doctors do this thing called "taking care of patients". You appear to be a "biopsy chaperone". Please forgive my confusion on this point.

Part of my need for assistance from a [Q] perspective is my concern that his labs are unchanged since late November. You note that "his [R] labs are essentially improving". On November 20, his [R] was 350; on discharge this week, nearly a month later, it was 410. Since I was a bottom-feeding medical student with no ambition and thus went into Infectious Disease, I must have been asleep at the lecture where they explained how an increase from 350 to 410 over a one month period constitutes essential improvement. Also, I must confess that I have factored in the notoriously unreliable, non-validatable, un-billable parameter of the patient's symptoms into my thinking: he is still in a great deal of pain, which is evident on this item known as the "physical exam". As I was not so driven to pursue as competitive a subspecialty as [Q], I have concluded that, one month into a serious complication in this man's treatment, he's not getting better, which is why I sought input from [Q] given the complications are in his [Q] organ.

Yes, it is true that all the notes &c. can be found in the electronic chart. However after I dutifully read all such notes, I still had no real idea what you as a [Q] specialist thought. Your email replying to my inquiries indicates you think this is drug toxicity, which is somewhat helpful because there is nothing in the chart that actually says that. Unfortunately, Dr. [Y] shared with me during our initial talks that drug toxicity has a characteristic appearance on biopsy, and the pathologists made no comment in their analysis to that effect. This is, of course, why I was seeking to do this thing called "talking with a colleague", as my experience is that it is a superior method to this other thing called "communicating through the chart". But perhaps you have had more success with the latter, or at least it minimizes how many discussions you must have with non-[Q] physicians, and that may indeed be how you define success.

Hereinafter I will do my best not to interrupt your wildly busy schedule, coming to bother you with such trivial matters as a patient with a potentially life-threatening illness. Thank you again for your careful attention to facilitating a biopsy and billing for an inpatient admission, and forgive me for assuming that also included caring for my patient by making a reasoned assessment of his [Q] problems.

Yours in disgust,

Friday, November 29, 2013

The "Hunger Games" Critique, Sequel Edition







Wednesday, November 27, 2013

GYN Update: Good Guys (Gals Mostly, Actually) Win!

Comes news from NYT that the American Board of Obstetrics and Gynecology have reversed their proscription against gynecologists who perform anal pap smears and anoscopies on men. We at the Billy Rubin Blog head into Thanksgiving, to say nothing of Hanukkah, yelping a small huzzah of delight.

It's worth noting that I'm not opposed to medical specialty boards taking hard lines against professional behavior for which there is a general consensus that said behavior is out-of-bounds. (More on specific examples another day, but you could make some assumptions about my views from the single word, "Lyme".) The anoscopies in HPV-positive men, however, did not by any reasonable measure constitute such bad behavior. So we salute the board for its reversal: bravo!


Saturday, November 23, 2013

OB/GYNs, Male Patients, & Anal Cancer

I am a touch wide-eyed at this news report in NYT detailing the hard line that the American Board of Obstetrics and Gynecology has taken with respect to treating men with anal cancer. The skinny: anal cancer is largely mediated by the same virus that causes most cases of cervical cancer (the human papilloma virus, or HPV). Gynecologists have extensive training in evaluating such cancers, and some GYNs have added men at risk for anal cancer to their patient panels by performing routine screening "anoscopies". The overall number of men cared for by such physicians appears to be very low, but these docs were just mandated by the OB/GYN Board, in no uncertain terms, to drop these patients or risk losing their board certifications. That is, putting it mildly, a pretty heavy sanction.

The logic of the Board is straightforward: OB/GYN is a specialty designed to treat women, period. Two Board members are quoted as emphasizing this, as well as noting that the anoscopy procedure is something that other specialists are capable of learning & performing as a matter of routine. (Side note: I have a colleague in my Infectious Disease division who does a lot of these procedures for our patients--a logical choice given our patient population with many HIV-infected gay men. She has no surgical training, so they have a point.) The article also notes that the Board has concerns about the unscrupulousness of certain OB/GYN doctors who have gone into lucrative business ventures treating men, such as prescribing testosterone treatments, burnishing their credentials with their Board certifications. The Board--understandably, from my perspective--wishes to put a stop to that. That said, I don't think the docs involved in male anoscopies are getting rich by enticing men to have a camera placed in their collective tuchus, so that issue doesn't apply here.

Regardless, the heavy handed no-anoscopies-in-men line is harder for me to comprehend, and though it is true that non-GYNs can perform them, the real issue is whether that's best for patients. "People with various types of medical training can learn the procedure," the article notes, "but experts say that gynecologists are the quickest to master it because of their experience in screening women." There's the rub. One of the docs featured in the article, Elizabeth Stier, is the only professional qualified to perform such procedures. And where does she work? Some Podunk hospital? Um, no: she's at Boston Medical Center, one of the two largest hospitals in New England, staffed by hundreds of doctors. So the loss to these male patients, while small in the grand scheme of things, is nonetheless very real.


Thursday, October 10, 2013

NPR Misses the Point of the Shutdown, Entirely

Mara Liasson is not a dumb reporter, but her piece today on NPR looking at the various political miscalculations that "led" to the government shutdown, called "How Political Miscalculations Led To The Shutdown Standoff", is a classic overthink about what has happened. As such, it's pretty dumb.

It's really not that hard to understand what led to the shutdown: a far-right faction of the political spectrum within the US citizenry has taken control of one of the two major parties, and by flirting with default, it is now playing politics in a very different way to what we've been accustomed for a very long time in this country. It's not because--as Liasson seems to believe--Boehner misread Obama's resolve, or the Democrats "assumed the Speaker had a plan for what he and his members needed to make a deal".

While these may be scenes in the play, they ain't what's driving the plot. The reason why we have a government shutdown is because the Tea Party caucus came up with this plan, and nobody in the Republican Party had the foresight, the desire, the willpower, or even the ability to derail their train of madness that has already adversely affected hundreds of thousands and just might possibly bring the whole economy crashing down on our heads. Any news story that purports to analyze the situation in Washington that does not start with this observation is misleading the public. Nothing Boehner or Obama or Harry Reid or Eric Cantor did over the past several months was going to change this outcome. It might have played out slightly differently, and it might have been portrayed differently, but what conservative columnist Charles Krauthammer has dubbed "the suicide caucus" wanted this fight since Obama was elected, and they've finally gotten it, and nothing--nothing--was going to prevent them from having this fight.

As for the part where Liasson suggests that Democrats assumed Boehner had a way out, she quotes nobody and provides no evidence that Dems would believe such a thing. She might be right, but I've been watching this thing from afar for months and I didn't think Boehner had a plan. Indeed, I assumed he had no plan precisely because he misread the President's resolve (and I wasn't convinced that the Speaker was wrong, either: if the Prez is going to cave in the 9th hour anyway, why have Plan B?) Moreover, Boehner has repeatedly moved his own goalposts throughout the past year in further acquiescence to his right flank; why on earth would anyone think he knew how to square the circle of the budget shutdown given how far he's been pushed?

At any rate, the fight is now upon us. It is a real political fight, with very high stakes, which is to say the stakes do not involve the careers or popularity of a small number of politicians from either party whose fortunes rise and fall with well- or poorly-played maneuvers, but rather affects all manner of hidden infrastructural details of our lives. What made the Tea Party what it is, is certainly a complicated topic worthy of all sorts of analysis, and we could fill up dozens of op-ed columns well into the future describing the demographic trends, social issues, splintering of the media and all manner of factors that has led to their rise in influence. And yes, we could even evaluate the misunderstandings from those on the left, right and center that allowed the Tea Party to achieve what it has thus far, if "achievement" is the apt description.

But why we have this fight right now is no real mystery. To treat it, as Liasson has done here, as a complex game of insider baseball, with important players trying and failing to read the situation, is to profoundly misrepresent what has happened in Washington. The reason why we have a shutdown is because we have the Tea Party--full stop. They do not share the same assumptions as most Americans about how to achieve their political aims in a representative democracy; they are playing by a new, very different, and I would argue, scary set of rules. Their kind has always been part of the American story, but with the sole exception of the Civil War, they have never been so organized nor wielded such political clout. They wanted this moment, and now we are here. Boehner could not have stopped it. Obama could not have stopped it. Harry Reid could not have stopped it. What happens next is anyone's guess.

Saturday, October 5, 2013

Being Mad As Hell At the Government Shutdown

I was just at a conference this week where I bumped into a former mentor of sorts. Always pleased to see him, I came over to chat about how things were going back at the mother ship, who was up to what, and so on. As part of the small talk, the government shutdown got mentioned. He just shook his head. "Those people are all crazy down there," he said, and just as I was about to ask which people he meant, he clarified it. "Democrat, Republican...I'd just vote 'no' for all of them if I could."

This is not a stupid man, although this is a decidedly stupid sentiment, and it almost certainly comes from automatically assuming that if there's a "problem in Washington", then the problem is shared equally, since there are radicals on both sides, and the extremes of the party hold the mainstream hostage, preventing the can't-we-just-fix-the-problem Good Guys & Gals from doing their job. Thus, as the shutdown drags on--and we careen toward what nearly everyone acknowledges is a much more consequential fight over the debt ceiling--people are having their "Mad As Hell" moments, both publicly and privately.

Witness, for instance, this CNN diatribe against the madness by Tom Foreman. In it, he blames everything on, well, everyone associated with the mess: "Democrats, Republicans, and the Insane Leap Into the Abyss" is its title, and it starts by stomping its feet in frustration over how the shutdown has just ruined the wedding plans of one happy couple who wanted to tie the knot at the Grand Canyon National Park, but now cannot due to its closure. (That there may be some people affected much more profoundly is indicative of the shallowness of the piece.) And who is at fault? "To be sure, there is enough blame out there to choke a horse," Foreman writes. "Polls show the Republicans taking the worst of it, but Democrats and President Obama are also being hammered for their part in the debacle."

In short, Foreman has absolutely no idea who is at fault because he is utterly ignorant of the details that led to the shutdown, and assumed that since there's an impasse, it must be everyone's fault--although those darned polls seem to think that the Republicans might just have a slightly bigger problem. A journalist who needs to resort to polling to help him figure out who deserves blame has major cognitive limitations.

Mercifully, elsewhere on the CNN website is a reasonably decent evaluation of the situation by Fareed Zakaria. Zakaria's followed the bouncing ball over the past two years, and he understands that the Democrats--especially through President Obama's previous ineptitude in handling the last budget fight--have basically already given every major policy demand to the Republicans despite having a Democrat in the White House and control of the Senate. "What cannot be allowed to stand is the notion that if a group of legislators cannot convince a majority in both houses and the president to agree with them, they will shut down the government or threaten to default until they can get their way," says Zakaria. "That is extortion, not democracy." Which is an accurate assessment of the situation. Just because it lays blame squarely at the feet of one group does not make it partisan. It makes it accurate.

Here's a detail that Tom Foreman may not have bothered to learn: the "clean CR" that the Republicans will not put up for a vote is the budget to keep the government running at "sequester levels", basically what Paul Ryan proposed when he ran with Mitt Romney. They lost, by the way, although an analysis of actual policies would lead disinterested observers to conclude otherwise. Every Democrat opposes these levels, so to ask the Republican House to simply agree to that is already having capitulated to an astonishing degree. Despite the Republican Party controlling only half of the legislative branch, and none of the executive branch, the fiscal policy of the federal government is somehow not only thoroughly Republican, it is, in effect, a dream budget for Tea Party politicians.

But even that wasn't enough for them to declare victory. What more is there to compromise, with the Dems with their backs to the wall, having blundered into the sequester, which appears as if it will be federal budget policy for the foreseeable future? There's only one thing that's left: the Affordable Care Act. For Obama, or the Senate Dems, to give this away would basically be to declare themselves to be Republicans. There would be no two-party governance in this country; it's already tilted heavily in favor of the Tea Party. The Tea Partiers don't believe this, of course. I can forgive them for this lack of appreciation for their own success because they are, as a movement, insane. I am far less patient with my friends and neighbors who don't follow politics enough to understand the dynamic of Washington since the Tea Party has been ascendant.

That is what worries me about the Foreman "everyone's at fault" piece. I think he's representative of a huge chunk of Americans who are, understandably, mad as hell, but who also are, somewhat less understandably, inchoate in their grasp of even the most basic details of how our government has been working, or rather, hasn't.

Wednesday, October 2, 2013

Government Shutdown and False Equivalence

There is an awful lot being said and written about the shutdown of the US Federal Government. I won't link to any of the news bits; I assume that if you're reading this, you've been reading at least something about the shutdown. I'm also not going to comment on the politics of the situation, which for me will require incredible self-control. We'll have to check back at the end of this entry and see if I made it successfully.

What I will comment on is the ongoing trope that this is a problem due to radicalization of both political parties. See, for instance, this common "they're all bums" title in an article running up to the shutdown: "Shutdown Crisis Shows Washington Breakdown", which dutifully lays blame at both parties for the troubles throughout the article, as if somehow President Obama is as wild-eyed in his zeal as Ted Cruz.

There has been some scholarly work devoted to this issue of ideological segregation, and the mantra seen in wonky articles on the matter is that both parties have become more pure and extreme. The link above throws in the caveat that the polarization of political parties is asymmetric--that is, it is more extreme on the right than on the left (see political commentary here)--but still sees the trend occurring in both parties.

This seems like utter nonsense to me--or at least is highly misleading--and I think it's based on how one measures "purity". If you have some members of Congress vote with their party 100 percent of the time and zero percent on bills floated by the opposing party, then those party members are 100 percent ideologically pure. If you have different members who vote, say, 75 percent with their caucus and 25 percent against, those people are less pure. The graph shown in the link compares "purity" from 1879 to 2011:

This gives the impression that the political issues between the parties have been more-or-less stable over that time. In reality, a graph of the Republican party from 1879 to 2011 would have shown itself to be a far left party, especially from 1850 through 1880, then a gradual move to the center for the next 80-90 years, then a lurch to the right starting in late 1960s and early 70s, and a much farther jump to the right from Gingrich's speakership on. Yet this isn't what you see on the graphic at all: Republicans occupy the top half of the figure, Dems the bottom.

What is missed, over and over again in these discussions about "party polarization" is that if the parties are becoming more divergent, it is only a phenomenon that can be described relative to each other and not at all about the underlying politics. Meaning: the left wing of the Democratic party may have less in common with virtually any member of the Republican party now than when I was growing up in the 1970s, but the left wing of the Democratic party (at least their representatives in Congress) has moved to the right politically over that time.

The proof can be found in the moronic howling over the very healthcare law that is the source of the shutdown. Despite the Tea Party claims that the ACA is socialism, it bears repeating that the key provision that makes the Affordable Care Act work, the "individual mandate", was essentially invented in the offices of The Heritage Foundation, the right-leaning think tank. (It also is worth noting that "Obamacare" is structurally the same as "Romneycare", and that the former Presidential candidate who campaigned on the repeal of Obamacare seemed pretty pleased with himself when his health care bill passed as Governor of Massachusetts. The fact that this needs to be noted is indicative of the ignorance of so many people who play key roles in forming policies for the Federal government.) Thus, by any sane definition, the ACA is a rightward bill that should have passed with tremendous Republican support, and would have a generation ago if Clinton had lost the Presidency to Bob Dole in 1996. The Republican party would then have claimed this as a legislative victory, and who knows what would have changed in domestic politics as a consequence.

A Tea Party-equivalent left wing approach to health care reform would have been truly nationalizing health care like Britain, where doctors are government employees and hospitals government buildings. Currently we have something similar in the US  in the form of the Veteran's Administration health care system, which is truly a federal government  operation from beginning to end. It's also reasonably popular. Despite this, there were only a few Dems open to this idea, and it was never realistically discussed.

A moderate left-wing solution to the healthcare problem was to push for "Single Payer", in which the government takes over the functions that the private insurance industry handles. This could be thought of as "Medicare For All", and to this day I don't understand why the Dems didn't embrace this sales pitch given Medicare's popularity. But Single Payer, even though there was a Tea Party-sized chunk of the Dem caucus that supported it, was deemed out of the question by party leaders, and never took center stage in policy discussions.

The centrist position was one in favor of the "Public Option", which would not force everyone into the Medicare pool but allow them to opt-in. It had a huge amount of support among rank and file Democrats; indeed, this was approved in the initial bill passed by the House, but was dead on arrival in the Senate for procedural reasons (it's unclear if it would have passed the Senate, but probably would have if it came to a vote). Even that approach, however, which was somewhere between mainstream and concessionary Democratic philosophy, couldn't survive the legislative process. So we got instead a law that would have warmed the cockles of Newt Gingrich's heart in the mid 1990s, yet you still hear reporters and talking heads let go unchallenged statements about the "problems of the radicals on both sides".

The two parties aren't getting more radical. Both parties have moved to the right. Repeat: both parties have moved to the right over the past two generations. Just because one of them has done so at an alarmingly accelerated rate doesn't mean the other has moved in the other direction. It's an optical illusion, and yet our media largely contributes to the underlying problems driving this crisis by their constant and tedious exercise in false equivalence. I would argue, to borrow a recent use of the phrase by Senator Rand Paul, that it's time to point out that the emperor has no clothes, although Paul might not approve of my meaning.


Sunday, August 11, 2013

Dissecting Two Damning Critiques of Medicine

I don't do a ton of op ed reading, but two pieces caught my eye in a span of a few days at the New York Times. Both are fairly savage critiques of medicine. Both should be taken very seriously, especially by those of us in the White Coat Tribe. But only one of them makes a compelling case.

One piece is called "When Doctors Discriminate" and is a meditation on the kinds of harm that non-psychiatrist MDs can inflict on patients with psychiatric conditions--in the author's case, a diagnosis of bipolar disorder. "You better get yourself together psychologically, or your stomach is never going to get better", the writer quotes a gastroenterologist as saying. This apparently was intended as a helpful piece of advice, and the article goes on to list the myriad ways in which physicians can negatively impact the health of these patients.

The second piece, called "Crazy Pills", notes the recent change in FDA policy toward the anti-malarial medication mefloquine, as it now includes a "black box warning" for the drug. The warning stems from mefloquine's neurologic and psychiatric side effects, which can persist well beyond the time period when it is taken (the drug is used to prevent malaria infection when people travel to areas with malaria). The author reports having had ongoing bouts of depression, panic attacks, and insomnia since his encounter with mefloquine as part of a stint in India for his Fulbright fellowship. The essay does not make for pretty reading, documenting murders and suicides, and lays them at the doorstep of the medication.

I heed the warnings explicit in both of these articles. Doctors should always be conscious about their biases, constantly on guard against anchoring their judgments based on one piece of data--in this case, a diagnosis of mental illness. Likewise, it's important for people to be aware of the potentially serious side effects of mefloquine, or any other medication for that matter. Nearly all doctors in Infectious Disease were keenly aware of mefloquine's psychiatric side effects even before the black box warning was issued. Nevertheless, making patients aware of the possible serious reactions to a medication, especially when a new warning is attached to it, is an important public service announcement.

But that being said, there is an enormous amount of innuendo and logical leaping in "Crazy Pills", while "When Doctors Discriminate" constructs its argument with a good deal more care. The author of "Crazy Pills" alleges that the drug was responsible for an Ohio man putting a shotgun to his head in 1999 after returning from a safari in Zimbabwe, as well as for the killing of a Somali prisoner by a Canadian soldier who took the drug. He also hints that Staff Sgt. Robert Bales, who went on a killing rampage in Afghanistan in 2012, was under mefloquine's influence. In the first example, we have no link to know any details beyond what is supplied to us by the author, and therefore no way to know anything else about this man. In the latter two examples, there appears to be no alternative hypotheses entertained for these most unfortunate horrors, but surely the fact that these men were under the duress of war might have played just as much a role, or indeed a more powerful one, than an antimalarial.

By contrast, "When Doctors Discriminate" relies not on a few carefully selected anecdotes that can't be considered in context, or even verified, but by noting broad research as reported by major public health organizations. It is a model of a well-constructed argument in the internet age, built not on hearsay, but on evidence, available for all readers to see should they choose to do so.

Lest I be misunderstood as being dismissive of mefloquine's side effects, I think that the inclusion of the black box warning was important for physicians and patients alike. But living in a malaria-endemic region with no prophylaxis is a very, very risky business: malaria kills. There are other drugs that protect against malaria--during my travels to Africa I took the drug Malarone without any problems at all, and it's a very well tolerated drug. But Malarone is expensive, and not all insurance companies will cover it. Should someone just avoid taking mefloquine if they can't have Malarone and take their chances?

That will very much depend on the numerical risks involved. The data presented in the op ed suggest that there's about a 6 percent chance of mefloquine causing a severe reaction for which it needs to be stopped. (The author ominously notes that "67 percent of people who took the drug experienced one or more adverse effects", which is, unintentionally or not, a scare tactic: "adverse effects" can include reactions as trivial as an upset stomach or a touch of insomnia.) Whether this number seems minor compared to the risk of full blown malaria is a proposition that patients and doctors must decide in a discussion, but I'm very concerned by the idea that everyone who needs malaria protection should just stop taking mefloquine if that's their drug. If his advice is heeded, we could soon be seeing NYT op eds about loved ones who went on safari and came home in a casket because they avoided protecting themselves against the great scourge of the tropics.

Thursday, July 25, 2013

Stoopid Questions About Health: NYT Edition

Teachers insist that there is no such thing as a stupid question. I would beg to differ. Exhibit A is yesterday's New York Times article looking at rates of atrial fibrillation and other abnormal heart rhythms in the contestants of a cross-country ski marathon in Sweden. The article's title asks: "Can You Get Too Much Exercise?" as it goes on to discuss (possibly) slightly higher rates of abnormal heart rhythms in these über-fit marathoners compared to the general population.

So let's try here to respond in our own way to the Times, and ask again: can you get too much exercise?

The answer is no. The answer is NO. The answer is NO!

The key to unlocking the puzzle is the slippery use of the word "you" within the question. The percentage of people participating in marathon skiing events, or Iron Man triathlons, or various and sundry other "ultra" events is vanishingly small. You, by contrast, are much more likely to be significantly more sedentary than these human miracles of aerobic activity. You--as a matter of statistics--are probably not eating anywhere near the healthy diet of these people. And you are much more likely to die of a heart attack, or stroke, or possibly even a cancer, than a bunch of Swedes who think that a 60-mile jaunt on skis constitutes a rollicking good time. And for that version of you, I say this: you can't get too much exercise! Not right now, baby! Time to hit the treadmill!

I don't really quibble with the researchers' data, although as the article notes, interpreting this slightly increased rate of what are known in the biz as "arrhythmias" is not completely straightforward. But this is the kind of myopia that doesn't help people understand the extent of the problem of weight, exercise, and cardiovascular disease. It is an epidemic in every sense of the word. Indeed, it is a pandemic, no more or less than The Great Influenza of the early 20th century, as this Times article shows that the problem has spread to the other side of the world as well.

The bottom line: we need to be exercising more. We can't get too much exercise. If you get around to Swedish ski marathons, then call back. In the meantime, get moving! (And pat me on the back for my two 36-mile rides this past week while you're at it.)

Sunday, June 23, 2013

Vaccines Work: Gee, Whoda Thunk?

It was a banner week for the practice of vaccination, as the newest kid on the vaccine block, the Human Papilloma Vaccine whose brand name is Gardasil, was shown to have cut the rate of infection with the most dangerous HPV strains in half since its introduction in 2006. This will almost certainly mean that the number of women who will develop cervical cancer (to which HPV is causally linked) will decrease by a significant amount over the coming decades. This is great news, a true triumph of public health.

This shouldn't be a surprise.

What should be eye-opening is that only about one-third of young women in the US actually receive Gardisil so its benefits are limited. Why is there such a low vaccination rate? There is more than one specific reason, but all the grievances are based on confusion, ignorance, and, to a great extent, the politics of the far right. For instance, in September of 2011 in a prelude to the Republican presidential primaries when various and sundry politicians were jockeying for pole position, then front-runner Governor Rick Perry of Texas found himself on the defensive for his executive order mandating the Gardisil vaccine be distributed to all girls in his state. (Parents could opt out.) During primary debates, Perry had to defend this entirely reasonable and indeed laudable policy from the likes of Michele Bachmann, who darkly suggested--without any evidence, it turned out, though this didn't seem to faze the Congresswoman--that Gardisil caused mental retardation. Similar screeches of paranoia have been de rigueur in the insular environment of the Tea Party and its minions, and so a public health boon has not reached its potential, despite endorsements by such politically radical groups as the American Academy of Pediatrics (who, it should be noted, recommend the vaccine for boys as well).

Does the vaccine do better elsewhere? Why, yes, in fact it does. As the article notes, the vaccination rate is about 80--yes, eighty--percent in...Rwanda. Way to go, team USA.

Monday, April 15, 2013

Further Notes on Senseless Agony

I was born and raised in the great state of Ohio, and to my dying day I will always think of myself as a Buckeye. But my adopted home is Boston, Massachusetts, and I have lived here almost as many years as I have in Ohio. Unless I make a big move--say, to Africa, the mother of all homelands--in the years to come, Boston will remain my home, in part because there is much to love in this city.

Of all the great privileges of living in the Boston area, none is greater than an obscure little holiday known as Patriot's Day. Celebrated only here and in Maine, which was originally part of Massachusetts, Patriot's Day is nominally celebrated for the opening battle in the Revolutionary War (enthusiasts still gather in Concord and Lexington very, very early in the morning to watch reenactments). The entire state takes the day off just as spring is shaking off its hard frosts, almost as if to say to the rest of the nation, "hey, we deserve this day to ourselves for the brave deeds of our forebears...think of it as a gift in perpetuity for bringing this nation to life. See you Tuesday!"

While the reenactments are, I am told, a delight, the real celebration takes place at the running of the Boston Marathon and at Fenway Park, where the Red Sox often play their season's home opener just while the runners pass nearby on Beacon Street headed for the final stretch. Hundreds of thousands line the streets each year. They come to cheer for loved ones, support a cause, or just serve as spectators of one of the premier road races in the world.

It's hard to explain to people who haven't seen the marathon up close what a special event it is. Simply put, it is the greatest single sporting event in the world. To me, the marathon has always served as a metaphor for how we should behave in the world rather than how we do. First, Americans aren't even the reigning princes of the race: the owners of the day for the past few decades have been East African runners, earning thunderous roars from Bostonians who hardly know their names as they fly down Boylston Street en route to the finish. Unlike every other major "championship" in American sports, which involves the typically American shortsighted binary system of winners conquering losers, the marathon is--except for an incredibly tiny percentage of elite runners who really are out to win against other people--not an event where spectators must be forced to choose sides. Indeed, the ethos of the day is just the opposite, as the best and most spirited fans are the ones who cheer on all comers to the point of hoarseness, no matter the size, the shape, the age, the skin color, the flag worn by the runner.

It is a free event; there are no luxury boxes to be distributed as corporate baubles to ambitious executives who care little for the sport. It is a community event too: there are troops from the US National Guard who, in full dress and carrying heavy backpacks, march the entire length of the course, often to the loudest applause. And other than the staggered start, there is no segregation of any kind: the course is chock full of men and women; big-burly "Clydesdales" run alongside featherweight Olympians; the young run with the old; and some of the most fit athletes run with people who've trained for only six months trying to raise money for cystic fibrosis reseach. Yet they are all equal competitors, and their opponent is 26.2 miles of road rather than each other. The spectators want all of them to win.

In the marathon you can find what's best about our country. I'd say the ambiance of the Boston Marathon is the most apt illustration of the word nostalgia--nostalgia for an America as seen in Norman Rockwell paintings, Chevy commercials, and Bob Seeger songs--except unlike that nostalgia, which is a chimera, the behavior on display at the marathon is very real, even if it only happens one spring day every year. It still does, in fact, happen.

When I was younger and before I had kids, my wife and I would watch the runners at about Mile 23--toward the end of the race when most of the runners knew they had survived the worst the course had to offer. There was an Italian restaurant on Beacon Street in Brookline and we'd get there for an early lunch. (The marathon then had a traditional noon start, so we knew that the elite runners would get there around two; after a few 90-plus degree marathons when runners wilted in the heat and local hospitals dotting the course were overwhelmed with seizing runners, the organizers wisely moved to an earlier start, roughly staggered between 9 and 10 am.) I would start drinking beer at 11 am, even formally inventing my own rule for it--"Patriot's Day is the only day where it is acceptable to drink before noon!"--and usually be midway through my third when we could see some Kenyan duking it out with some Ethiopian on TV at the bar just as they passed Cleveland Circle. That was our cue, and out we ran to scream our lungs out for these human gazelles as they swept by us, running with a level of grace and energy that I would lose after about five steps...and then nothing, since they had so outpaced the other runners. So back in to finish off the third in preparation for screaming my head off for the next hour or two.

After heading back to Ohio for medical school I returned with children and a life in the near suburbs. It turned out that I had gotten Patriot's Day off in my intern year by accident. Mondays are not typically days that interns get to call their own, and I don't remember now what exactly were the circumstances that led to me having the day off. I considered myself insanely lucky; when I got off the following year, and the year after that, I couldn't believe my good fortune.

These years, and those that have passed since, I've watched the race in Newton, not far from where I live. Newton is really the proving ground of the marathon; you enter the city at about Mile 17, just when (so I am told, anyway) your legs are really starting to feel the distance. You take a slight hill over Interstate 95, come to a corner where one of the local firehouses sits (just "the firehouse" to experienced Boston runners), and round the corner to see what at first looks like another mild, innocuous hill. Only the hill never quite stops. Nearly a mile long, that is the first of three hills in Newton that causes runners to either drop out, or at least turn runners into walkers, by the thousands. The second is shorter but has a slightly greater incline, and the third one, the shortest, has a steeper incline still, and is so devastating to runners in their 21st mile that it is known even to runners who never come to Boston as "Heartbreak Hill". And after that there are some declines heading into Boston that my friends who have run the course assure me are very nearly as painful as the parts going up.

I simply love watching the runners in the Newton hills. I love shouting encouragement to them. I love watching my children caught up in the excitement. I love watching this one man, known to nearly everyone who follows the marathon as a spectator, running his paraplegic son  in a wheelchair for the entire course. His name is Dick Hoyt, and he and his son Rick have been doing this for 30 years. The Hoyts are the only runners I have ever seen get louder cheers than the marching soldiers, and they deserve it.

But I love one aspect of the race far beyond anything else. My favorite part of watching the race in Newton--my favorite moment of participating in the race--is watching those wheelchair racers face the nightmare of those hills head on. I bike a fair amount, and I take on those Newton hills fairly often as part of a regular route. Even on a bike, with four fully functional limbs, they aren't fun. These men and women in wheelchairs get up these three hills--toward the end of the race!--just with the strength of their arms, and the ability to persevere through hardship in pursuit of a goal. Nearly all of them demonstrably suffer. I jog by them and scream encouragement: "COME ON! YOU CAN DO IT!" And I keep screaming until the next crazy fan, another hundred feet down the road, takes up the gauntlet of supporting this athlete until he or she is at the top of the hill on Hammond Street and begins what for the wheelchairs is the perilous descent past Boston College and the train tracks at Cleveland Circle.

These people are my heroes. I have no idea how on earth they do it, but I am amazed each year at their determination.

That is what is on my mind tonight as I allow a little Scotch to numb the pain that comes when you see something this pure and beautiful be utterly violated by God knows what kind of person. Even as I write this I am certain the story is developing by the hour, and any thoughts on the specifics of what happened to whom will be out of date faster than one could flick 140 characters across a screen. So instead I figured I would let you know what it was that was defaced today. I have no idea what next year's marathon will be like, but I desperately hope that it hasn't been irrevocably changed.

Sunday, March 24, 2013

Belated Thoughts on Rob Portman (and Henrietta Lacks, Too)

It's been just about ten days since the announcement by Rob Portman that his previously-held opposition to gay marriage has melted away following the acceptance that his son is gay. There was a minor flurry of commentary and people have moved on to matters both weightier (Cyprus, Middle East) and less so (the aptly-named Shockers). So I'm a touch behind on weighing in on this; such is the life of an intermittent blogger. But so far I haven't seen anyone make the point I wanted to so here goes.

Matt Yglesias of Slate confesses to annoyance with the narcissism of Portman's stance that he had to arrive at gay marriage support only through direct experience. But there's more here than mere narcissism, and it's indicative of the general Republican approach to policy questions. The post-Nixonian Team Elephant doesn't employ reason as the primary tool to solve societal problems. It's the price of the Southern Strategy that shifted political power to the Republicans for nearly two generations. (An emblem: whatever one may think of her, there once was Jean Kirkpatrick addressing a Republican National Convention; now Sarah Palin stands and opines before them to yowling approval.)

Rather than providing a heartwarming tale about new found openness, Portman's reversal only serves to illustrate that very troubling underlying tendency. He didn't simply think about the issue and come to support gay rights. It's not like he hasn't had multiple opportunities to think this matter through. Instead it took something visceral to get him to budge from his bigotry. Although he should surely be commended for embracing a more progressive approach--he could have, in the manner of so many parents, simply cast his son away for either political expedience or genuine hatred or both, and did not--it's very unclear whether that process will be of any help where popular Republican sentiment still skews medieval, such as the understanding of evolution or the reality of climate change or the importance of evidence in public discourse.

As for Henrietta Lacks, today's New York Times brings word that a European research team last week had published Ms. Lacks's genome without anyone's consent. (If you don't know the story, Rebecca Skloot's The Immortal Life of Henrietta Lacks is a must-read; Skloot is also the author of today's Times piece.) There is a whiff of outrage in Skloot's prose that no consent was sought, although precisely how that could be accomplished is anyone's guess, as Lacks died over 60 years ago, long before current standards of consent even remotely began to address issues like this.

Skloot proposes that the family should have served as the surrogate for consent, but this seems at best to be an unwieldy solution. Who counts as family for a woman who passed away in 1951? What happens when there is a split decision? Based on my experiences with families of patients in end-of-life situations in ICUs, split decisions are the norm rather than the exception. And the publication of Lacks's genome has real--though difficult to quantify--scientific value, as her cells, the so-called "HeLa" cells, remain the workhorse cell line that forms the backbone of all biomedical research on the planet.

I have no idea how this is to be addressed. I am in agreement with Skloot that scientists need to be exquisitely sensitive to these issues. But I fear that our best intentions of outreach may not be sufficient to overcome objections to research--and HeLa cell research really is critical, and has the potential to improve or even save the lives of many people in the future.

Tuesday, February 5, 2013

Conflation Of "Education" With "Lecture" Is, At Best, Questionable Pedagogy

I do not often snoop about the blog pages of the Cato Institute owing to time constraints and a general sense that I won't find much enlightenment there. Hence, my acquaintance with Professor Alex Tabarrok's really interesting essay "Why Online Education Works"--which he wrote back in November 2012--came via a glance at Brad DeLong's blog today. But it's a provocative read, and at least in DeLong's blog, the commentary afterward was fascinating (and, I note with a certain delight, mostly free of the smack talk that so pervades online discussions that touch upon politics...mostly, anyway).

Tabarrok mainly argues that the reason why online education will largely displace university brick & mortar education as currently constituted is because it is wildly more efficient. In essence, he believes that one very, very, very large virtual lecture "taught" by one professor is a much less expensive model than lots and lots of smaller lectures taught by many professors. Since traditional universities, with their relatively-smaller-but-still-impersonal lecture-style format, are vastly more expensive than the online model, they will eventually be forced to adapt or face extinction since students will eventually realize that they don't have to bear the crushing debt associated with modern higher education. He uses his own TED talk as an example, as he writes, "the 15 minutes of teaching I did at TED dominates my entire teaching career: 700,000 views at 15 minutes each is equivalent to 175,000 student-hours of teaching, more than I have taught in my entire offline career."

What follows on DeLong's broadsheet is a discussion about how much Tabarrok's observations can be generalized--and thus how valid his basic point may be. For my part, I sit somewhere in the middle of the continuum: I think big universities had better listen up really quick or else find themselves losing students in the coming years to University of Phoenix in large numbers. Sooner or later there are going to be some enterprising "traditional" students who will decide to roll the dice at much cheaper online schools, and they will eventually find "traditional" employers in the workforce who are willing to roll the dice on students with online degrees. And if they discover that these students are just as prepared as ones from State U, the exodus from the traditional schools will accelerate.

That said, I also side with those in the discussion who point out that undergraduate education is much more commonly smaller classes with more individualized attention, and that Tabarrok is sounding the death-knell of a type of University that almost certainly doesn't exist at the smaller, lib-arts school. Moreover, he sidesteps the fact that the majority of an education of an intellectually curious undergraduate happens outside the classroom walls: a university's appeal--and value--lies in "the close, dense concentration of fellow students, and the close, dense concentration of adults interested in said students, and the dense array of programs tailored to students" in the words of one commenter. 

Mostly, though, I viewed Tabarrok's points as well as the replies through the lens of my work at a medical school. I am, at present, basically a 60 percent doctor and 40 percent teacher. You can dress it up in fancy titles but I'm a teacher, no different than a senior grad student lecturing to Chem 101 freshmen. That is, with one critical difference: my students are apprentices. The lecture hall is an inpatient hospital room, or an outpatient exam room. There is simply no legitimate way, thus far, to train a physician by anything other than working with them in a nearly one-on-one manner, right in front of the patient (or away from the patient's eyes listening to presentations and discussing medicine). It is an education where doing and theorizing cannot be separated. You can't solely watch TED talks to become a physician. You must learn at the feet of a master (typically, several masters) to develop your craft.

Which is why one terse little quip from a gentleman named Colin, whose twitter handle is mcgilcoli, caught my eye, and serves as a nice title for this post: conflation of "education" with "lecture" is, at best, questionable pedagogy. Whether Tabarrok would agree with that sentiment or not I do not know. However, I am certain that it highlights what we do at a medical school with our 3rd year students all the way through our interns, residents, and fellows. Education is an intensely personal experience in medicine.

I hadn't understood that at all when I got into this business, and it is certainly one of the most rewarding aspects of my career at this point. I don't think they're going to find an online me anytime soon that can replace the flesh-and-bones me in the medical school. Whether they can find a different flesh-and-bones person to replace the flesh-and-bones me is a separate matter. We promise to provide updates on that front to our intrepid readers.

Thursday, January 24, 2013

Letter to Momma, re David Brooks

Dear Mom,

Thanks for the link on David Brooks!

I cannot be precisely sure what you mean by your quick attached note: “I’m just sayin’.” I mean, I get the phrase in general—like “I’m just sayin’ that someone else out there agrees with me”—as a simple for instance. But both Jonathan Bernstein and Jonathan Chait operate from the assumption that pretty much everything that David Brooks writes is either stupid or crazy or disingenuous or all three; they only quibble over whether such nonsense defines his character (Chait’s point of view) or his job (Bernstein’s point of view). I happen to think that Chait is more correct on this point than Bernstein, although it is very nearly a distinction without a difference.

The problem, in a nutshell, with David Brooks and his ilk is that he puts on the appearance of reasonableness, but this is a very thin patina covering over the madness that is today’s Republican Party. Whether he knows that his chiding of Obama for not “coming to the center” (when in fact Obama is a deeply centrist—or even center-right!—President) is pure bullshit, or is just a clever ruse as part of the role of “House Conservative” at the Gray Lady, is immaterial. Pure and simple, he serves as a polite apologist for the ugliest elements of power, and neither the article you link nor the one on which it is based would disagree with that sentiment.

Now, I know that I’m decidedly un-DavidBrooksian, and I’m not simply referring to my political views. I know that I crew cut half my head when I was sixteen while leaving the other mop-top long, much to your general consternation (a view I would probably share if one of my eleven year-old children tried today; I have gotten a touch more conservative, at least in certain ways, as I've grown older). I know that I pepper my conversation with far too much foul language, writing such impolite disquisitions during college to garner the somehow less than subtle nickname “Billy ‘Pigfucker’ Rubin” in a nod to a moniker I once applied to a philosophical foil. I know that my rhetoric tends toward what one might call “destructive”—or what dad used to describe with glee as my “vitriolic prose”—although in my defense, I note that have worked and worked and worked toward keeping my verbal TNT reserved for only the most outrageous and cynical actions/statements/personalities and whatnot. Whether I have succeeded at that I leave you and others to judge, though I keep in mind Paul Fussell’s immortal words of advice, “contempt for the contemptible”. Words by which to live! (Plus, there's just so much crap out there for which utter contempt is the only reasonable response.
And note: in my blog incarnation, I’m incredibly well behaved.)

All of which is to say that, though I know David is the son you may have wished for, you are, now and forever more, stuck with your sometimes rude and nearly constantly foul-tongued son.

But know this as well: I care about those people whom power ignores—or worse (to hear the squawks of outrage from the Neanderthals who found Obama’s Second Inaugural references to Selma and Stonewall objectionable), actively vilifies. I will always be on their side. (Well, almost always. That’s a longer discussion.) David? Not so much. Never forget that key difference between the Nice Jewish Boy and the Boy Who’s Jewish And Nice Underneath It All.

Your loving son, (and seriously, I rilly do love you!),
With a wink,


Saturday, January 19, 2013

Flu: Yes, the Vaccine Works

If you have been stranded on a desert island the past month, you may not be aware that this year's flu season has been, to use not fully professional terms, a bitch. "Thirty states and New York City are reporting high ILI activity, an increase from 24 states last week," the CDC says in its typically restrained fashion ("ILI" stands for "influenza-like illness"--since a good percentage of these illnesses turn out on closer inspection to be due to other viruses such as metapneumovirus or parainfluenza). The city of Boston declared a state of emergency last week, and plenty of other places are buckling under the strain that the epidemic has placed on hospitals, nursing homes, doctors' offices, and pretty much everywhere else too.

I've been hearing various comments, sometimes from health professional colleagues, that the magnitude of the outbreak is the fault of a lousy vaccine--as many patients these docs and nurses have encountered with lab-confirmed flu did receive the vaccine. (I've seen about three such patients myself.) Hard not to conclude that we just had a dud of a vaccine, and if it weren't for that, we'd be in for smoother sailing this winter.

But it's worth noting that the influenza vaccine does, in fact, actually work. The data this year, while preliminary, indicate that the vaccine is about 60 percent effective--which means (roughly) that for every 10 people who would become sick from influenza infection as a matter of course, only four would become sick if those 10 people were vaccinated. That may not sound hugely effective but that's well within the range of a typical influenza vaccine, as this report demonstrates. And from a public health standpoint, a 60 percent effective vaccine translates to a tremendous preservation of resources.

That is, assuming people actually take the vaccine. Currently the vaccination rate appears to be hovering around 30 percent. Wouldn't it be fiendish if we charged higher copays for unvaccinated people who get hospitalized for influenza? Or made them pay full cost for oseltamivir (aka Tamiflu) once they develop symptoms? Now that might serve as a motivator to get people to offer their arms for the vaccine needle!

Also worth noting, since vaccines are so wildly misunderstood, that while the flu vaccine is only 60 percent effective, most other vaccines--especially the ones we offer children like the MMR--have effectiveness rates in excess of 95 percent. And there is no proof--none--that vaccines cause autism. For further reading, see here.