Tuesday, September 29, 2009

Medicare for All = Healthcare for None

Doctors Are Opting Out of Medicare


EARLY this year, Barbara Plumb, a freelance editor and writer in New York who is on Medicare, received a disturbing letter. Her gynecologist informed her that she was opting out of Medicare. When Ms. Plumb asked her primary-care doctor to recommend another gynecologist who took Medicare, the doctor responded that she didn’t know any — and that if Ms. Plumb found one she liked, could she call and tell her the name?
Many people, just as they become eligible for Medicare, discover that the insurance rug has been pulled out from under them. Some doctors — often internists but also gastroenterologists, gynecologists, psychiatrists and other specialists — are no longer accepting Medicare, either because they have opted out of the insurance system or they are not accepting new patients with Medicare coverage. The doctors’ reasons: reimbursement rates are too low and paperwork too much of a hassle.
Of the 93 internists affiliated with New York-Presbyterian Hospital, for example, only 37 accept Medicare, according to the hospital’s Web site.

Two trends are converging: there is a shortage of internists nationally — the American College of Physicians, the organization for internists, estimates that by 2025 there will be 35,000 to 45,000 fewer than the population needs — and internists are increasingly unwilling to accept new Medicare patients.

In a June 2008 report, the Medicare Payment Advisory Commission, an independent federal panel that advises Congress on Medicare, said that 29 percent of the Medicare beneficiaries it surveyed who were looking for a primary care doctor had a problem finding one to treat them, up from 24 percent the year before. And a 2008 survey by the Texas Medical Association found that while 58 percent of the state’s doctors took new Medicare patients, only 38 percent of primary care doctors did.

29 percent of Medicare recipients can't find a physician who is willing to take them as patients. That's huge. How high would that number go if most of the country became Medicare or Medicare-like recipients? How high will this number go if the federal government's scheduled 21% cut in Medicare payments to physicans comes real (on January 1st, 2010)?

Yeah, give everyone free coverage, but don't be surprised when you can't find anyone willing to accept it.

Sunday, September 06, 2009

Just Brilliant: "A Doctor's Plan for Legal Industry Reform"


Since we are moving toward socialism with ObamaCare, the time has come to do the same with other professions—especially lawyers. Physician committees can decide whether lawyers are necessary in any given situation.

At a town-hall meeting in Portsmouth, N.H., last month, our uninformed lawyer in chief suggested that we physicians would rather chop off a foot than manage diabetes since we would make more money doing surgery. Then President Obama compounded his attack by claiming a doctor's reimbursement is between "$30,000" and "$50,000" for such amputations! (Actually, such surgery costs only about $1,500.)

Physicians have never been so insulted. Because of these affronts, I will gladly volunteer for the important duty of controlling and regulating lawyers. Since most of what lawyers do is repetitive boilerplate or pushing paper, physicians would have no problem dictating what is appropriate for attorneys. We physicians know much more about legal practice than lawyers do about medicine.
Following are highlights of a proposed bill authorizing the dismantling of the current framework of law practice and instituting socialized legal care:

• Contingency fees will be discouraged, and eventually outlawed, over a five-year period. This will put legal rewards back into the pockets of the deserving—the public and the aggrieved parties. Slick lawyers taking their "cut" smacks of a bookie operation. Attorneys will be permitted to keep up to 3% in contingency cases, the remainder going into a pool for poor people.

• Legal "DRGs." Each potential legal situation will be assigned a relative value, and charges limited to this amount. Program participation and acceptance of this amount is mandatory, regardless of the number of hours spent on the matter. Government schedules of flat fees for each service, analogous to medicine's Diagnosis Related Groups (DRGs), will be issued. For example, any divorce will have a set fee of, say, $1,000, regardless of its simplicity or complexity. This will eliminate shady hourly billing. Niggling fees such as $2 per page photocopied or faxed would disappear. Who else nickels-and-dimes you while at the same time charging hundreds of dollars per hour? I'm surprised lawyers don't tack shipping and handling onto their bills.

• Legal "death panels." Over 75? You will not be entitled to legal care for any matter. Why waste money on those who are only going to die soon? We can decrease utilization, save money and unclog the courts simultaneously. Grandma, you're on your own.

• Ration legal care. One may need to wait months to consult an attorney. Despite a perceived legal need, physician review panels or government bureaucrats may deem advice unnecessary. Possibly one may not get representation before court dates or deadlines. But that' s tough: What do you want for "free"?

• Physician controlled legal review. This is potentially the most exciting reform, with doctors leading committees for determining the necessity of all legal procedures and the fairness of attorney fees. What a wonderful way for doctors to get even with the sharks attempting to eviscerate the practice of medicine.

• Discourage/eliminate specialization. Legal specialists with extra training and experience charge more money, contributing to increased costs of legal care, making it unaffordable for many. This reform will guarantee a selection of mediocre, unmotivated attorneys but should help slow rising legal costs. Big shot under indictment? Classified National Archives documents down your pants? Sitting president defending against impeachment? Have FBI agents found $90,000 in your freezer? Too bad. Under reform you too may have to go to the government legal shop for advice.

• Electronic legal records. We should enter the digital age and computerize and centralize legal records nationwide. All files must be in a standard, preferably inconvenient, format and must be available to government agencies. A single database of judgments, court records, client files, etc. will decrease legal expenses. Anyone with Internet access will be able to search the database, eliminating unjustifiable fees charged by law firms for supposedly proprietary information, while fostering transparency. It will enable consumers to dump their clunker attorneys and transfer records easily.

• Ban legal advertisements. Catchy phone numbers such as 1-800-LAWYERS would be seized by the government and repurposed for reporting unscrupulous attorneys.

• New government oversight. Government overhead to manage the legal system will include a cabinet secretary, commissioners, ombudsmen, auditors, assistants, czars and departments.

• Collect data about the supply of and demand for attorneys.Create a commission to study the diversity and geographic distribution of attorneys, with power to stipulate and enforce corrective actions to right imbalances. The more bureaucracy the better. One can never have too many eyes watching these sleazy sneaks.

• Lawyer Reduction Act (H.R. -3200). A self-explanatory bill that not only decreases the number of law students, but also arbitrarily removes 3,200 attorneys from practice each year. Textbook addition by subtraction.

Enthusiastically embracing the above legal changes can serve as a "teachable moment" and will go a long way toward giving the lawyers who run Congress a taste of their own medicine.

Dr. Rafal is a radiologist in New York City.

Wednesday, September 02, 2009

Moral Objectivity, Revisited

Excellent post found here that mirrors much of my thinking on ethical objectivity, but written much more clearly and comprehensively than anything I've ever written on the subject.

Common human prosperity and wellbeing are the goals of ethics and true, objective ethical rules are those that lead to their apex. We can analyze which ethical rules we use are closer or further away from the "true objective rules" by comparing their effects on societies on Earth, historical comparisons, logical critiques for internal consistency and the like, and reasoned discourse.

The only assumptions here are that human prosperity and wellbeing ought to be universally valued and that we have common understanding of these terms to build a consensus of action. These are not really much of leaps, especially as compared to the deontological set of rules assumed wholesale to be objectively correct by various moral Absolutists. And this way of thinking escapes the sinkhole of moral relativism where moral rules are proposed and defended by nothing more than emotion and whim.

Tuesday, August 25, 2009

Yet Another Reason Why Nuclear Power is Good

Medical Isotope Shortage

Joan Stephenson, PhD
JAMA. 2009;302(7):732.

A worldwide "critical shortage" of medical isotopes is expected due to the shutdown until late 2009 of a nuclear reactor in Ontario, Canada, according to Canadian authorities. The reactor, which stopped operations because of a heavy water leak, produces as much as 40% of the global supply of molybdenum 99 (99Mo), which decays to form technetium 99m (99mTc). 99mTc is currently used in approximately 80% of nuclear medicine scans.

According to Natural Resources Canada, the world's current supply of 99Mo is produced by 5 aging reactors in Belgium, Canada, France, the Netherlands, and South Africa. The shortage was expected to be exacerbated by the temporary closing of the Netherlands reactor for a month-long maintenance inspection from July 18 to August 18. Because the isotopes have a relatively short half life, they cannot be stockpiled.

Canadian authorities said they were working with medical isotope distributors and others to maximize the use of existing isotope supplies and with other international producers to increase isotope production and to coordinate shutdowns and other operations.

That's right, we use nuclear power to make medically-important isotopes. Well, not "we," as in local US plants but we rely on foreign plants to irradiate our 'topes for us. I'm not sure why we don't have our own plants churning out isotopes ourselves, but that could be related to the fact that we haven't built a new nuclear plant in America in 30+ years. There's a brain drain of nuclear expertise from this country and we'd probably have to import some European-made design if we ever started being smart with nuclear and joined the proper energy source of the 21st century.

That's right, I think nuclear power is great. Think about it: nuclear power produces virtually no greenhouse gases and can make us virtually energy independent. Two big birds down with one stone. Oh, and if you want to create jobs - how about building new plants and building a smart nuclear engineer workforce in America? Nuclear energy has a proven safety record in America - and this is with using clunking designs from 50 years ago. How much better would we be with if we built new, more efficient and safer designs that we find in places like France? This is one area where France got it right: most of the electrical energy of France is supplied by French nuclear power plants.

Worried about nuclear waste? Read up about Yucca Mountain - a location long-studied in geology as an ideal place to store radioactive waste and practically ready for operation if the politicians would only let it. Worried about transportation of radioactive waste? The US has a track record of shipping waste thousands of times and there has never been an incident or accidental release of waste. Worried about terrorists? Seriously? You can't hold back our nation's progress based on the fear of a might-happen. All nuclear facilities in America are very well guarded.

That all said, I don't think nuclear fission will be the only power source of the future. I think solar energy is an excellent source as well. Solar energy bathes America with tons of free energy on a daily basis and if we could harness even a bit of that (particularly from our little populated, but very illuminated Southwest deserts) the Sun could easily supply more energy for us than this country uses many times over. Hydroelectric power has its niche uses but it's poor for general energy supply. Wind energy seems like a goofy idea to me and likely to always be marginal since it's such an eyesore. Other ideas like geothermal are unlikely to become much since their technical maturity would come at around the same time as nuclear fusion power and fusion could be the real powerhouse for the end of the 21st century.

Nuclear power is power of the future - whether it's made right here on Earth or has to travel 93 million miles from Sol.

Thursday, August 06, 2009

The Essential Orthoprax

Every now and again Jewish skeptics of various stripes respond with some surprise when I tell them that I am observant of Jewish rituals, traditions and the like. Sure, they can understand wearing a yarmulkah for social reasons, playing along while in public and eating Thursday night chulent, but observance in private for its own sake seems like a bewildering concept. So I'd like to go over here my reasons for observance in no particular order.

First off there's the basic essential of Jewish identity. Of course many Jews are not observant and especially not of all the minutiae of Halacha and yet still consider their self-identification as Jews to be very strong, but I find that if I'm not cognizant of the likes of Shabbos and our annual pageant of holidays then I'm missing a big part of the Jewish experience. I'm set apart from core Jewry if I don't know where the local synagogue is or what time candles are supposed to be lit. I'd feel out of sync and adrift if I'm not fasting on Tisha B'av or attending a seder for Pesach or even keeping kosher in inconvenient places. There's nothing immoral about eating meat during the nine days, but you're breaking with a shared Jewish experience if you do so. To be Jewish is to DO Jewish and identity absent these core activities may be fragile.

And this leads into the related reason of demographics. I care about the Jewish people and our fate as a group - but demographically we are suffering deeply from the likes of assimilation and intermarriage. And who are most likely to marry out or otherwise be lost from Jewry? These are the people who are least observant. Reform Jews have an astounding intermarriage rate and low retention over generations. If Reform Judaism was the only brand of Judaism available today I would have grave doubts about the survival of Jews as an identifiable group for even just a few generations down the line. Observance is correlated with significant knowledge of Jewish texts and general heritage and is correlated with intramarriage and strong Jewish identities over generations. Commitment to an observant life is a vote of confidence in the livelihood of the Jewish people.

Another important reason is that doing frank religious acts is a way of bringing the sacred into everyday life. Modern man is overly concerned about what he can get out of an activity. Shaking a bush and a lemon seems like a silly (and costly) thing to do without any benefit to anyone - and materially that's true. But what it does, through our history of investing in the act a sense of the divine, it brings the divine into what is otherwise a very secular existence. Now, as is well known by most who read my blog (I think), my conceptions of God are rather different from the popular views and even from what much of tradition suggests, but nevertheless, raising our minds to the transcendent of existence by using Jewish rituals as vehicles is something I consider a worthwhile effort.

This is also related to another criticism I've heard from a friend of mind who stated that he didn't particularly believe in God because once it was understood that God wasn't a doorway for on high reward or punishment and that intercessionary prayer is ineffective then he didn't really care about the metaphysics of the matter as it doesn't really effect him either way. The philosophical abstractions I tend to conceive of don't interest him, even while he may recognize them as plausible. This is a fair criticism if you are seeking religiosity as a means to an end in the way modern man approaches virtually everything - What's in it for me? But if the goal is simply truth-seeking then it is simply that life choices follow convictions. The point is not to choose convictions for the mere sake of making your life easier. So it is from my conviction of basic philosophical positions that observant life follows.

Now, here's a bunch of potluck ideas that are not full justifications on their own but do string through my mind: There's the sense of continuity and history with thousands year old practices. Pride in being a Jew and in being a Jew and a man in the street and at home. A sense of irony that Jews should give up their cultural and religious vocation at a unique time in history when Jews can choose whether to be Jewish or not. A sense of duty to past generations that have suffered and sacrificed on behalf of being Jewish and doing Jewish. Ethical improvement that can be accomplished through correctly applying various traditional experiences and measures. And of course for various acts there is the simple fact that I enjoy performing them.

So is it still so surprising why I remain Orthoprax?

Monday, August 03, 2009

In Usufruct to the Living

The question Whether one generation of men has a right to bind another, seems never to have been started either on this or our side of the water...and that no such obligation can be so transmitted I think very capable of proof.--I set out on this ground, which I suppose to be self evident, "that the earth belongs in usufruct to the living": that the dead have neither powers nor rights over it. - Thomas Jefferson, 1789 [From here]

This is an interesting quote which means that one generation cannot obligate a later generation in any way. This is relevant in terms of great public debts where, by right, the time to pay it off ought to be within the same generation's lifetime which benefited from the loan. The Earth belongs to each generation fully in each's turn and a past generation cannot rightly rule over those presently living.

As Jefferson goes on (my bolding):

To keep our ideas clear when applying them to a multitude, let us suppose a whole generation of men to be born on the same day, to attain mature age on the same day, and to die on the same day, leaving a succeeding generation in the moment of attaining their mature age all together. Let the ripe age be supposed of 21. years, and their period of life 34. years more, that being the average term given by the bills of mortality to persons who have already attained 21. years of age. Each successive generation would, in this way, come on, and go off the stage at a fixed moment, as individuals do now. Then I say the earth belongs to each of these generations, during it's course, fully, and in their own right. The 2d. generation receives it clear of the debts and incumberances of the 1st. the 3d of the 2d. and so on. For if the 1st. could charge it with a debt, then the earth would belong to the dead and not the living generation. Then no generation can contract debts greater than may be paid during the course of it's own existence.

Jefferson went even further and calculated with the given life expectancy of his time and actuarial numbers that at 21 years of age, half of the people of that generation would be dead in 18 or 19 years and therefore, "19 years is the term beyond which neither the representatives of a nation, nor even the whole nation itself assembled, can validly extend a debt." As a half-life, extending a repayment of a debt any longer than that would impinge on a following generation which never agreed to accept the debt in the first place.

In an egregious example: "Suppose Louis XV. and his contemporary generation had said to the money-lenders of Genoa, give us money that we may eat, drink, and be merry in our day; and on condition you will demand no interest till the end of 19. years you shall then for ever after receive an annual interest of 125/8 per cent. The money is lent on these conditions, is divided among the living, eaten, drank, and squandered. Would the present generation be obliged to apply the produce of the earth and of their labour to replace their dissipations? Not at all."

I suppose that the recieved opinion, that the public debts of one generation devolve on the next, has been suggested by our seeing habitually in private life that he who succeeds to lands is required to pay the debts of his ancestor or testator: without considering that this requisition is municipal only, not moral; flowing from the will of the society...but that between society and society, or generation and generation, there is no municipal obligation, no umpire but the law of nature. We seem not to have percieved that, by the law of nature, one generation is to another as one independant nation to another.

Consider this idea as our nation's federal government's uncontrolled spending of recent years has left us with a huge $11 trillion deficit with annual interest payments that amount to nearly 10% of our whole federal budget. Is it our generation alone who will be paying this debt?

Are we doing right by our children?

Wednesday, July 29, 2009

Insensible Losses

I weigh about 190 pounds. That's equal to about 85 kilograms.

To figure out the appropriate hourly fluid replenishment for a (basically) healthy 85 kg patient just lounging around in the hospital we follow the 4-2-1 rule, which is that for the first 10 kg we supply 4 cc per kg per hour, the next 10 is 2 cc per kg per hour and then 1 cc per kg per hour for the rest of the weight. So 40 + 20 + 65 = 125 cc per hour.

This means that a basically healthy 85 kg guy (like me) loses around 125 mL of fluid from urine and insensible losses (think sweating, respiration, etc) per hour.

Over a 25 hour period that amounts to a nice figure of 3,125 mL or 3.125 Liters. Think about it - that's a huge water debt. A big bottle of soda is only 2 Liters of fluid.

People don't drink enough before a fast and it's dehydration far more than hunger that makes them feel like crap.

So drink well and have a meaningful fast.

Tuesday, July 28, 2009

Healthcare, Oh Boy

So I was asked recently to publish my views on the ongoing healthcare debate facing this country. I’m not sure why my views are so sought out given that I have some obvious vested interests in the issue, but regardless it is a topic of interest to me and I haven’t blogged in awhile so this is a good topic to rebreak the ice on.

To be clear, the issue at hand is the concept of a broad-covering government sponsored ‘insurance’ plan essentially modeled after similar programs like Medicaid for the poor and Medicare for the elderly to include anyone else who doesn’t fit into either of those titles. And apparently there are a whole bunch of Americans who are set in just that fix – 47 million is the number which gets thrown around, but just who are these 47 million Americans?

From the US Census Bureau:

Did you know that nearly 18 million of them are people from households that make more than $50,000 a year, i.e. people who could afford insurance but opt otherwise? And 8 million or so are between the ages of 18 and 24?
Did you know that around 10 million of these uninsured are not citizens of the United States, i.e. those who would not be covered by any of the public options being bandied around Congress anyway (and even should they be covered)?
Did you know that about 25% of these uninsured are estimated to already be eligible for existing public programs?

Now these figures likely overlap a bit, but you can pretty easily see that 47 million problems have been cut in at least half, if not more. Do ~20+ million truly uninsurable American citizens require an entire reformation of the system or are there some obvious and simple tweaks we could make that would absorb them into what already exists? Could we do that without costing (likely far more than) a trillion dollars over ten years? Hmm...

It has also been suggested by ‘objective’ assessments of medical care provided by different countries that the United States offers healthcare at about as good quality as Iran, or something to that effect. By counting things like average life expectancy and infant mortality and comparing them to some European nations, it appears that the US comes far inferior. But what these same comparisons fail to realize is that it’s isn’t just healthcare that determines those figures. Americans tend to also be generally more unhealthy in their simple daily diets and activities than those other countries – this alone could leave the statistics showing a reduced life expectancy in America. And unlike in Europe, Americans are far less likely to abort imperfect fetuses and far more willing to try and save premature babies – thereby leading to higher reports of infant mortality.

Additionally, US News and World Reports writes “[I]t's shaky ground to compare U.S. infant mortality with reports from other countries. The United States counts all births as live if they show any sign of life, regardless of prematurity or size. This includes what many other countries report as stillbirths. In Austria and Germany, fetal weight must be at least 500 grams (1 pound) to count as a live birth; in other parts of Europe, such as Switzerland, the fetus must be at least 30 centimeters (12 inches) long. In Belgium and France, births at less than 26 weeks of pregnancy are registered as lifeless. And some countries don't reliably register babies who die within the first 24 hours of birth. Thus, the United States is sure to report higher infant mortality rates.”

Now, putting that all aside for now, I’d like to discuss a couple of philosophical problems I have with the idea of these semi-socializing welfare programs in general. The key thing to always keep in mind with welfare programs is that they sound nice and kind, but there ain’t no such thing as a free lunch. See, it’s a great political ploy that works again and again and again whenever it’s tried since not only do politicians get to play the moral high ground by offering the people free healthcare, for example, (as they oppose the opposition which clearly prefers that people die without treatment) – they also get to offer them free stuff! And what electorate can resist the idea of free stuff with the moral superiority package? But it ain’t free – somebody has to foot the bill.

Historically, those who were mandated to pay for the peoples’ insurance were the general taxpayers as they funded Medicaid, Medicare, SCHIP and so on – all unrestrained entitlements that are bankrupting this country. But also corporations and small businesses had to supply their workers with expensive health benefits which was a cost passed simply onto the consumers (ie the American people) and made American products completely uncompetitive on the international markets (which is also part of the reason why the United States is no longer an industrialized nation). And who has recently been suggested to pay for this newest gift to the American people? The middle class, of course. But how smart do you think it is to continue taxing the most productive segments of society – in a recession no less! - to sink money into the least productive? At a certain point, those smart people are going to realize that their hard work and ability is no longer working for them, but against them as they sooner and sooner hit marginal returns on their EARNED rewards. Better for them to work 30 hours a week and keep $150,000 than to work 60 hours a week and take home $200,000, eh? From where then are any of these programs going to be funded? Thus you should be not shocked at all to find that European per capita GDPs tend to be 25% less than America’s.

And despite what people clamor on and on about, healthcare is NOT a right. You cannot have a right to a service that someone else provides. Rights are natural things that surround the idea of personal freedom which others ought not interfere with. You have the right to life, liberty and the pursuit if happiness, but you don’t have the right to impose your will on a medical professional to treat you since that would enslave him and take away his rights. Free people trade value for value and you have the right to pursue professional care of your health through peaceful interactions. Doctors are not serfs and will not put up for long being government property.

Now, with even all of that said, the key thing to recognize is that financially the US healthcare system sucks. The U.S. healthcare system costs double what other countries cost with largely comparable end results. Even though nations with socialized medicine have a degree of rationing – so do we, TODAY. Sure, it’s not the government largely doing the rationing (though it obviously is in part as any Medicare recipient is well aware) but is it better when private insurance companies do not cover everything or have restrictively high premiums? In America we don’t ration by first come first serve, we ration by ability to pay. Better? And even though we don’t have a well organized socialized system, we still mandate that anyone coming in to an ER will be seen and treated – which is essentially the way the government eventually picks up the tab for the uninsured. The uninsured have no provisions for regular visits and simple meds to keep them in health so they show up to the Emergency Room when disaster eventually strikes, costing the system way more than regular upkeep would. So we effectively already have socialized medicine in America, we’re just paying for it ass-backwards.

The solution? I favor the gradual removal of all of these government-sponsored entitlement programs and a return to individual payment for medical care. Way better than any fraud-infested bloated bureaucracy or even any profit-driven corporation, the best person to take care of your own expenses is you. If you’re paying, little doubt you’d pay attention to the reasons for every proposed test, little doubt you’d seek the generic drug when you’re told it works as well as the more expensive new one, little doubt you’d not want to overload the system with minor complaints, little doubt you’d take a measure of responsibility for your own care and know your own history so that your doctor at the new hospital doesn’t need to redo a whole slew of the same tests you got at the hospital in your old town. This reality plus a healthy charity mentality in medicine is the way to go. Healthcare should be recognized as a charity of high regard – millionaires should endow hospitals and individuals can help others in their community. Doctors too should be willing to take a certain number of pro bono cases, since after all, they can afford it now that they are actually receiving the money they billed from their regular patients.

But since this is never going to happen, is a broad covering government insurance option the worst idea? Perhaps not. If creating it removes our other non-afforded entitlement programs then it may be well worth it. But will it end up being the same kind of bloated bureaucracy, with waste and fraud being hallmarks of government involvement - most probably. My prediction: it will happen eventually - it will cost a ton of money, be moderately effective and significantly rationed which will lead to the existence of a two-tiered medical coverage system. People who have private coverage will want to stay private while everyone else will be grouped in the new program. It won’t change medical care all that much but will possibly lead to simpler medical billing for many Americans. Economically we'll get by but with people far less willing to share their earnings charitably (like it is in Europe, charity is a rare gift) and our grandchildren will be the ones still paying the interest on our out of control spending today.


Monday, May 25, 2009

Memorial Day

On report about the land of America:

"Jews, there, are treated just like human beings, instead of dogs. They can work at any business they please; they can sell brand new goods if they want to; they can keep drug-stores; they can practice medicine among Christians; they can even shake hands with Christians if they choose; they can associate with them, just the same as one human being does with another human being; they don't have to stay shut up in one corner of the towns; they can live in any part of a town they like best; it is said they even have the privilege of buying land and houses, and owning them themselves, though I doubt that, myself; they never have had to run races naked through the public streets, against jackasses, to please the people in carnival time; there they never have been driven by the soldiers into a church every Sunday for hundreds of years to hear themselves and their religion especially and particularly cursed; at this very day, in that curious country, a Jew is allowed to vote, hold office, yea, get up on a rostrum in the public street and express his opinion of the government if the government don't suit him! Ah, it is wonderful."

-Twain, Mark. "The Innocents Abroad," 1869.

It bothers me to no end how too often do people nowadays completely take for granted the amazing country we live in. It's so cliche already, but the real freedoms we have here as well as the opportunities which permit us to reach as high as we are able are gifts unprecedented in all of human history. Sure, America is not perfect and there's plenty to criticize in its history and recent events, but the ideals it stands for, as embodied in the Constitution and the Bill of Rights, are among the best and highest ever set in text.

So it's quite proper now to take a moment and acknowledge the great sacrifices (some with the ultimate sacrifice) given by American servicemen to protect us and our way of life. May we soon see the day when no further American soldier need give so much.

Absurd Adventism

I'm not sure why but it seems that people I meet often feel comfortable to share their nutty beliefs with me. It started when I went into see this one patient who from the very beginning upon my entrance into the exam room was eyeing my yarmulkah. This happens from time to time and nothing usually comes of it. Sometimes things do, obviously, but generally the patients don't seem to care much. Anyway, that was the way this interaction seemed to be heading since nothing came of it throughout the standard history and physical that I do for every patient. But as things were wrapping up, he gave me a strange little look and asks, "You Jewish?"

"That I am." I respond, entirely unsuspicious. For some people it's rare for them to have extended interaction with a Jew of any stripe and so they'll often ask me an innocuous question or two.

"Ah," he says, "I thought so."

So I answer dry as a bone, "Oh, what gave it away?"

He laughs, tells me I'm a funny guy - and then the conversation turns weird.

After confirming that I observe the Sabbath on Saturdays he reveals that he's a Seventh Day Adventist and asks me if I'm worried about that. Worried about observing Shabbos? Not really, I answer. He goes on to tell me that I should be because the Pope is planning on enforcing a one-day Sabbath observance and that it'll be on Sunday. Now I'm not exactly an expert on Papal policy, nor do I closely follow Vatican movements, but that didn't sound like something high on the Pope's agenda - and in any event, I didn't care much about the Pope's efforts on that issue. I tell him that the Saturday/Sunday divide has been an issue between Christians and Jews for some time now and I wasn't expecting the Pope to start religious coercion over the Sabbath in modern day.

Not so, he responds, the day is coming soon for when we'll all have to *run to the mountains* to escape this coming religious persecution or otherwise suffer martyrdom! He directs me to read Revelations and the Book of Daniel, where he insists that this whole course of events is clearly written.


That's some wacky stuff. Eschatological beliefs in general tend to approximate different forms of nuttiness, but as the beliefs become more specific and the timeline more acute it becomes only more obvious. I was willing to chalk this one up to one man's weird understanding of religion or Papal conspiracy paranoia since I had some affinity to Seventh-day Adventists, but it turns out that this is basic ideology of the original Adventist Church!

So sayeth Wiki, "The pioneers of the church taught that the Seventh-day Sabbath will be a test, leading to the sealing of God's people during the end times. Ellen G. White interpreted Daniel 7:25, Revelation 13:15, Revelation 7, Ezekiel 20: 12, 20 and Exodus 31:13 this way. Where the subject of persecution appeared in prophecy, it was thought to be about the Sabbath commandment. Some early Adventists were jailed for working on Sunday, in violation of various local "Sunday laws" or blue laws which legislated Sundays as a day of rest. It was expected that a universal Sunday law would soon be enforced, as a sign of the end times."

An interesting aside is that the Adventists were early critics of the Blue Laws, which were designed in the early part of the last century to protect the so-believed Christian heritage of the nation by enforcing certain aspects of Sunday. Some of the Blue Laws still persist today throughout the country, including limitations on liquor stores to not operate on Sunday mornings and the fact that the United States Postal Service does not deliver on Sunday. In this manner, the Adventists have been suspicious of government intrusion into religious life - an orientation that benefited all minority faiths in this country.

See, it's strange how rational-appearing people can have truly way-out-there understandings of the world laying right below the surface. Though, on retrospect, that should not have been so shocking from the Adventists, given that it is a religion founded on the *thrice-failed* predictions of William Miller and Samuel Snow regarding Jesus' immanent return in 1843/1844. As a religion focused on eschatology (hence the "advent" part of Adventist), I wonder whether there is anything to be concerned about over this rapidly expanding religion.

Monday, May 18, 2009

Dammit Jim!

Just saw Star Trek over the weekend. With honor, I present:

Saturday, May 16, 2009

Where's that from?

If anyone who has borrowed a sum of money from Jews dies before the debt has been repaid, his heir shall pay no interest on the debt for so long as he remains under age, irrespective of whom he holds his lands. If such a debt falls into the hands of the Crown, it will take nothing except the principal sum specified in the bond.

If a man dies owing money to Jews, his wife may have her dower and pay nothing towards the debt from it. If he leaves children that are under age, their needs may also be provided for on a scale appropriate to the size of his holding of lands. The debt is to be paid out of the residue, reserving the service due to his feudal lords.

Debts owed to persons other than Jews are to be dealt with similarly.

Nice. Guess the source.

Thursday, May 14, 2009

Who Said it?

Alexander of Aphrodisius said that there are three causes which prevent men from discovering the exact truth: first, arrogance and vainglory; secondly, the subtlety, depth, and difficulty of any subject which is being examined; thirdly, ignorance and want of capacity to comprehend what might be comprehended. These causes are enumerated by Alexander.

At the present time there is a fourth cause not mentioned by him, because it did not then prevail, namely, habit and training. We naturally like what we have been accustomed to, and are attracted towards it. This may be observed amongst villagers; though they rarely enjoy the benefit of a douche or bath, and have few enjoyments, and pass a life of privation, they dislike town life and do not desire its pleasures, preferring the inferior things to which they are accustomed, to the better things to which they are strangers; it would give them no satisfaction to live in palaces, to be clothed in silk, and to indulge in baths, ointments, and perfumes.

The same is the case with those opinions of man to which he has been accustomed from his youth; he likes them, defends them, and shuns the opposite views. This is likewise one of the causes which prevent men from finding truth, and which make them cling to their habitual opinions.

Quote from whom? (No cheating!)

Monday, May 11, 2009

The Physicians’ Perspective: Medical Practice in 2008

"Through responses provided by approximately 12,000 physicians nationwide that included more than 800,000 data points – as well as through written comments by more than 4,000 physicians – the survey offers a unique and valuable insight into the practices and mindsets of today’s doctors."

Some key findings:

Only 6% described the professional morale of their colleagues as “positive”
78% said medicine is either “no longer rewarding” or “less rewarding”
60% said they would not recommend medicine as a career to young people

Only 17% rated the financial position of their practices as “healthy and profitable”
82% said their practices would be “unsustainable” if proposed cuts to Medicare reimbursement are made
65% said Medicaid reimbursement is less than their cost of providing care
36% said Medicare reimbursement is less than their cost of providing care
33% have closed their practices to Medicaid patients
12% have closed their practices to Medicare patients

49% of physicians indicated they will take one or more steps in the next one to three years that will reduce or eliminate patient access to their practices:
11% said they plan to retire
13% said they will pursue a job in a non-patient care setting
20% said they will cut back on patients seen
10% said they will work part time
7.5% said they will work locum tenens
7% said they will switch to concierge practices

So folks, for those of you who're steaming forward trying to establish a Medicare-type plan for everyone in the country - where do you expect to find doctors who will be willing to accept them? More and more doctors are finding that public health "insurance" programs reimburse them less than they're laying out, thereby making such practices frankly unsustainable. In response, more and more practices are simply not accepting such insurance programs.

Consider: these programs which are designed to help the poor gain access to care are actually making it more difficult.

How can the state respond?

Oh, we get fun stories like this from Illinois where the attorney general sued clinics who were simply trying to stay in business. They refused to accept more Medicaid patients because they just could not afford to continue operating at the reimbursement rates they were receiving. Yes, apparently the state thinks it has the right not only to dictate prices but also the right to force doctors to accept them. Isn't it nice to see doctors becoming government serfs? Does anyone think actions like these will encourage people to enter the healthcare arena, much less primary care?

My solutions: return free market medicine to primary care. Don't pretend that government reimbursement is full compensation for the doctor's time and effort. Care given to those who cannot pay should be understood as charity care and should be able to be deducted come tax day.

Sunday, May 10, 2009


Academic medicine is supposed to be different. It is supposed to exist for the purpose of applying scientific principles to medicine and thereby making new discoveries to use to treat disease, testing them in clinical trials to find out if they are effective, and then applying them systematically. Uncritically introducing therapies that are by their very nature unscientific, therapies like homeopathy, reiki, reflexology, and “energy medicine” taints the entire scientific enterprise at these institutions. Worse, offering such therapies outside the context of a clinical trial in academic medical centers gives the patina of scientific credibility to therapies that have not earned it, promoting the impression that science supports their efficacy....Medicine has finally, after over a hundred years, evolved to the point where it can actually become truly science- and evidence-based. From my perspective, the growing uncritical acceptance of CAM in academic medicine is a major threat to the continuation of that evolution. There should be no such thing as “alternative” medicine, anyway. There is medicine that is effective, as determined by science and clinical trials, and there is medicine that is not or is as yet unproven. We should not be “integrating” the latter with the former, and especially not in academia.

-Dr. David Gorsky; "The infiltration of complementary and alternative medicine (CAM) and 'integrative medicine' into academia."

Excellent article. Do read: http://www.sciencebasedmedicine.org/?p=28

Saturday, May 09, 2009

Overheard in Conversation

"I think vampires are real. How do you know vampires don't exist? It says in the Torah that witches are real, so why not vampires?"


Can't argue with that...

Thursday, April 30, 2009

Pet Peeve

It really annoys me when I'm walking down the street and some random guy (always non-Jewish) walking the other way will say "Shalom!" to me and then continue on their way. They don't mean it maliciously as far as I can tell, but it's offensive in the same way as walking up to a Native American and saying "How!" would be.

Wearing a yarmulkah doesn't make me an effing mascot, jerks.

Monday, April 27, 2009

Picture God?

In response to Daas Hedyot's recent post, where he asks "What persona was your god?," he gave me pause to recall how I conceived of God as a child, and this is what I pictured:

I can't remember a time when I ever considered God to be any kind of person. Even as a child if I tried to picture God, I thought of a black misty cloud against a dark backdrop or of my standing before a focused yet endless expanse of white presence. God was the moral imperative that without words communicated approval or disappointment for my behavior.

In retrospect, I guess I had a different kind of picture than most people. This may be instructive.

Sunday, April 19, 2009

Nihil and Void

Sigh. Alright, we're here again pondering the meaning of life. I halfway hate myself when I think about these issues because I sound irritatingly like some angsty teenager, but in reality people don't typically figure it out to any real satisfaction, they just ignore it by embracing one distraction after another. Perhaps that's easier to do as an adult when there are more practical concerns (whether necessary or artificial) which can serve as distractions. But in any event this issue should bother people right down to their very being, whether they go to highschool or can drink alcohol legally.

Of course nobody really knows the answer but there are a two basic approaches: one, that there is no point and the only "goal" is to make yourself as fulfilling a life experience as you can - however you define that for yourself. Or two, there is a point and the ideal is to match your goals to be in proper accordance with that point - however you understand the point to be.

Obviously you can see the basic self-centered vs externally centered foci between the approaches. There's a value judgement there that makes (at least) me feel that selfish concerns should not be the ends of one's existence, but that hardly serves as a point of fact to base a conclusion on. I go back and forth on this issue - often several times a day. That is, when I'm not distracted. When I'm feeling idealistic and moralistic I find myself leaning towards there being a reason for existence - where what we do matters, where our choices and the effects of our choices matter beyond how they make us feel. In those times I feel encouraged to pursue an active course of bettering the world, fighting for causes, conscientiously intervening in things gone wrong.

But then there are other times when I think that everything I know and everyone who knows me will be gone and lost and long forgotten by some not-too-distant future time. So I feel fatalistic and disinclined to make an effort to change anything at all. Kohelet. Humanity is filled with the wretched, the poor, the liars, the hypocrites; persecuters and the persecuted - all destined to die after a few short years, why work yourself up about it? This has been the staus quo for virtually all of human history and there is little sign of it changing. I'm constantly amazed at how far we've gone and how we've survived so long when there is so many WRONGS in how people do things. Our public institutions reek of intrigue and scandals. Our private lives fill the newspapers with crime and senselessness. Civilization itself may just be a bubble waiting to burst. Is anything worth fighting for?

In the end I make the conscious decision to live as though there is a point. But in my heart the battle wages and I fear that the other side - the void of fatalism and selfish nihilism - may take the field.

Sunday, April 05, 2009

A Haiku: Palliative Care

Palliative Care
Not meant to cure what ails you
Hope you feel better

Friday, April 03, 2009


So I'm in the middle of a two-week stint of Geriatrics right now. The topics of the day invariably surround the most depressing parts of medical practice. We have the incurable chronic conditions, the terminally ill, the demented, the depressed, the disabled and the debilitated. How many times have I heard the term "health care proxy" this week? I can't even guess. Palliative care; "sedation therapy."

Which is more depressing - nursing homes or hospices? At nursing homes the residents are generally demented and seem to exist in a sad world of juice boxes, patronizing nursing staff and the pervasive smell of urine. A second childhood? Perhaps. More akin to a gentle warehouse where they wait for...y'know. At the hospice the patients are generally making the good faith effort to gradually complete their wretched existence which at the end revolves around their particular personal horror. Yet their families want them to die "with dignity." Ha. Dying with dignity is among the most mythic of all ideas. There is no dignity in death, folks. None at all.

Are these the successes or the failures of modern medicine? Thanks to modern medicine we've destroyed the previous strongholds of the Angel of Death. Infectious disease, once the major killer of humanity, has now largely fallen thanks to germ theory and antibiotics. Women dying in childbirth is today only a remnant of the merciless killer of a bygone era. What we are left with are the chronic conditions like heart disease, COPD, and cancer. We are so good at keeping people alive longer that more of them successfully make it to a state of debilitation and dementia. On the one hand, of course it is better that people live longer (and presumably better) lives today - but on the other hand, they weren't storehousing people in nursing homes and hospices in the past. Of course we are glad when a person survives an ordeal that would have easily taken them in a previous century, but we then all too likely send them on their way to a possibly worse ordeal before they take their final leave. Better? Depressing. The Angel of Death is less brazen today, but he makes up for it by being more sinister.

There is no mystery for why this is so. Evolution via natural selection is a great problem solver but it applies its solutions jealously only towards the primary goals of survival and procreation. The human body is incredibly complex and works amazingly well - but only for the first few decades of life. Y'know, the decades where the procreation and raising of young takes place. After the children are grown the elder generation no longer serves a much adaptive role. They are expendable. Natural selection stops working its problem solving magic on the likes of grandparents and soon enough the human body breaks apart on predictable fault lines. If the human body is like an automobile - modern medicine has largely cured the likes of a head-on collision, but after driving hundreds of thousands of miles even the best designed car will be totaled by an accumulation of wear and tear.

Ideally the purpose of medicine is to cure disease - not to let disease win. Yet palliative care is about letting the disease takes its natural course while treating the symptoms. Perhaps we need to recognize our limits since medicine today is still remarkably primitive in many ways, but palliation is still the real booby prize of medicine. The patients suffer less but they still die. There are no victories, only slightly less bitter defeats.

Sunday, March 15, 2009

Eye Opening...

'What was practicing general surgery like?'

"Horrible!! Absolutely horrible. The ER would call with "this old lady has non-specific belly pain...I'd like you to come lay hands on her?" As if my hands are magical. As if I can really tell what the hell's going on. The ER doc is just trying to cover his ass (which is necessary in a society where patients see a 'normal, expected complication' as an opportunity to get rich), so it makes my workload that much heavier. So, I got lots of these CYA calls. Also, I was oncall every 4th night. And sometimes that would increase if a member of our group was ill, or otherwise absent. The money was pathetic, especially for the amount of time you're available...I couldn't even have a glass of wine with dinner, for fear I may be called in. I wouldn't make promises to attend events, or meet other obligations (that may be more meaningful to my life and well-being), just in case I got called in...or happened to run late on a case. This is a big imposition on your life..

Basically, your life is unbalanced. You miss tons of things that are important to you. You go thru life sleepy and tired...chronically. Your health isn't optimal...and it's all for what? To be called 'a surgeon.' That will get old as your children begin acting out in school....or choose grandpa over you for comfort and snuggles. When they seem to not like you very much...and you feel excluded from their lives. When you have a mild, dull headache from lack of sleep (or some other vital ingredient to a healthy body), on that 1 day off you may have in 10. And, low and behold, if you get 2 consecutive days off....you try to make-up for lost time. Guess what? You *cannot* make up for lost time. So, do you really want to spend your life doing this? And if not, why torture yourself for a decade, give up your 20s/30s, when you could be building something more sustainable....mentally, and physically?

'Any advise for those who may be trying to decide on a specialty?'

Shouldn't students pursue something they'll enjoy rather than a choose based on lifestyle? I agree that you should do a medical specialty that you (think you'll) enjoy. But, how long will you enjoy a miserable lifestyle? Is the practice of 'that specialty which brings you joy' going to be *enough joy* to off-set the absence of life outside of work? Like seeing your kids play little league. Being there at your daughter's dance recital. Taking your kids to a puppet show in the middle of the week at the local library. Sleeping in late on Sunday morning, then going out to brunch, spur-of-the-moment with your wonderful family. Drinking until you're tipsy, and then having great sex with your spouse. Just having time for creative flow of energy, and silence to obtain inner peace!! These things may not be possible if you only get one day off a week...and you have a ton of basic life stuff to attend to. For the rest of your life...imagine 'not having enough time.'

Who runs your household? Grandma or mother-in-law? That may be better than a nanny, but it's still not ideal. A mom who's in her 30s - 40s is a lot more attentive, active, and better able to deal with toddlers/tweens than a grandma. Besides, Grandma has raised her kids...and now it's time for her to be a *Grandma.* It's one thing for Grandparents to be intricately involved, and to hire a nanny for supplemental support as needed. But, if they're raising your kids instead of you...you'll have to consider the consequences of that (for both you, your family, and your children).

Would you rather pay someone to be the Mommy while you're the doctor...or would you rather be home doing the mommy (or daddy) thing yourself? Would you rather have other kid's fathers who have time to coach flag-football on Saturday mornings teach your son how to throw a football, or otherwise be present as the male figure in your son's life....while you're at work being the 'greatest surgeon ever?' It's no wonder that so many old men end up saying "Rosebud" as they lay dying, alone, on their deathbed.

You'll need to nurture your marriage, or it won't last. People (including spouses) will only tolerate so much. Even if you think your wife is "happy staying at home"...no one gets married to be alone.

You need to be present while your kids are kids. In 12-15 years, they won't need so much of your time...and a large part of your influence over them (your parental guidance) is over.
Are surgeons so cool? Yes and no. The work is like no other. It's exhilarating when you can cut someone open, and fix the problem. It's easy to get an ego...which is almost a requirement if you want to survive the process of training. If you're to compete, and not become an emotional wreck....you shield yourself from criticism with an enormous ego. This translates to the rest of your life....and your personal relationships will become antagonistic. At times, the only thing in your life going as planned is...surgery. So you hold on to that. Surgeons are as diverse as the population. I'm sure there are some who get off on being a surgeon because everyone says "ooohhhh." But, most people are just as impressed when you say "I'm a doctor." Nothing special (or even distinctive) about being a surgeon to much of the population. So, who are you really trying to impress? Other doctors? Your partner? Yourself? And that ego, that desire for respect and accolades, keeps 'em coming to surgery....even if it's not the right career choice for them. That thought of 'surgeons are so cool.'

Criteria used to decide:I say, decide *overall* what's important to you...and find a way to make those things fit together. This may mean choosing "your second favorite medical/surgical specialty" instead of your dream specialty...if you want a *dream life* overall!!

Thursday, March 12, 2009

The Other Side of the Curtain

So I'm now three quarters through my surgery third-year clerkship [and what, 15 months until my MD? Yikes!] and I'm thinking maybe it isn't the field for me. Not that I don't think the surgeries aren't cool, they really are for the most part, but there's a lot of baggage that comes with a surgery practice that I'm less keen on. There's the time spent in clinic, the time rounding on patients, the notes, the forms, the dictation on the phone, the frequent (and frequently busy) nights on call, the fact that my days run easily 14, 15, 16.....27 hours long, blah blah blah. And this isn't just residency, it's pretty typical of what an attending needs to do in general surgery too. I'm not letting all that cloud the coolness of doing surgery itself, but is it worth it? The money would be decent, but the lifestyle sucks and the practice is only a shining prize under a pile of detritus. I really don't know if that prize is worth the substantial cost.

I sense in myself the perspective that I wouldn't want to live this way my whole life and I would easily end up in a sub-specialty like colon/rectal (which sounds bad, but is actually cool because I have a fondness for the digestive system - don't know why), but once there I'd have to still do plenty of clinic/office time just so I could perform my half-dozen specialty procedures which I fear would eventually bore me. How awful.

So now I'm peeking over the curtain and considering another field: Anesthesiology. It's chock full of procedures (which are my favorite), they get to play with some of the most powerful drugs known to man, virtually no clinic, call is generally more limited and when called it isn't to consult but to do a procedure (intubate/epidural/general anesthesia/what have you). Anesthesiologists can also have a much more varied practice where they can be in the OR, on the labor floor, and in the ER or ICU securing a difficult airway all in one day. People tend to not realize this, but anesthesiologists are critical care specialists (as would make sense since they put people into a state of respiratory arrest multiple times daily) and often run the codes at the bedside. Plus, an anesthesiologist's day is defined by shift parameters so that when a case in the OR is running late, the anesthesiologist is relieved by the night shift at six or seven pm and goes home to eat dinner with his/her family while the surgeons go on working late into the night. And to top it all off, the compensation for anesthesiology is great - typically even better than a general surgeon.

In addition, there's virtually no overhead for an anesthesiologist's practice (which equates into significant freedom of where to live and where to work), they also get to wear pajamas (scrubs) to work all day, and they get to potentially participate in the full range of surgical procedures - pediatrics, plastics, brains, hearts, trauma, etc. - without being pigeonholed in a given specialty. The residency is also shorter, the people tend to be more personable, and the training is far less malignant.

Sounds pretty good, eh?

Some concerns: Would I get bored sitting in the 'cockpit' watching vital signs during those long cases? Will I be jealous of the surgeons and down the line regret my decision? (I have the same worry mirrored that if I'm a surgeon would I regret not choosing anesthesia? Though general surgery residencies have a 20% attrition rate, with most residents leaving for anesthesia. Comparatively, leaving anesthesia for another field is rare.)

Do CRNAs pose a real threat to the practice of anesthesia as we know it? (I doubt it.) Will socialized medicine reign in America to the point that I'd have to fill out more red tape and work longer hours for less compensation? (Same concern I have for most of medicine.)

Sunday, February 22, 2009

Do You Know What You're Signing Up For?

As apparently due to the ever increasing demand for organ donations and the limited supply of poor saps with brain death and viable organs, the Organ Procurement and Transplantation Network and the United Network for Organ Sharing (known as OPTN/UNOS collectively, the non-profit group which determines national policy for organ donations) has lowered the bar on death as of July 2007. No longer is brain death the only standard by which organ harvesting may begin.

According to the new rules a suitable candidate for organ donation can consist of:

"1. A patient ... who has a nonrecoverable and irreversible neurological injury resulting in ventilator dependency but not fulfilling brain death criteria may be a suitable candidate for DCD [Donation after Cardiac Death].
2. Other conditions that may lead to consideration of DCD eligibility include end stage musculoskeletal disease, pulmonary disease, and high spinal cord injury."

The idea here being that once a patient is determined to be a good organ donating candidate (i.e. ventilator dependent and without likely hope of recovery), his or her doctor can (with agreement from the next of kin) switch off the ventilator, wait five minutes or so until the heart stops beating and then declare death. After which the body is taken to the OR by the organ retrieval team. But the key thing to understand is that the patient is not yet dead when the decision for organ donation is being determined!

As Dr. Keamy notes:

"For some of the pathophysiological states enumerated, this amounts to plucking the fruit off the vine shortly before it would fall anyway. But this list also includes people with advanced ALS like Stephen Hawking, who has lived in that "donation qualifying" state for two decades or so; there is no mention of brain function whatsoever in this formulation; lack of awareness is specifically not a necessary component for inclusion."

Additionally, one must recognize that this system sets an all too likely scenario where the doctor has a conflict of interest between his patient and the organs which will go to the patients' of others. He's flipping that switch on a schedule that may have nothing at all to do with the state of his patient's health status. The drugs doctors give at the end of life can be palliative but they can also double-edgedly be used euthanizing-ly. Plus, there are drugs that can be given for the sake of organs health which do nothing for the individual's length of life. For a person to become an organ donator while still alive is extremely dangerous territory. Because while we hope each physician will keep himself minding his patient's needs and only his patient's needs, organ donation can require massive coordination and it's doubtful he'd be operating in an "ethically pure" environment. Indeed, if he starts to care about the sake of those organs (as would be difficult for him not to), might he be operating at cross-purposes?

And last but not least, the Halachic implications are obvious. The person is not brain dead and is therefore NOT DEAD when the ventilator is turned off. At least according to US law, R' Moshe Tendler and HODS, that is. This method for organ donation would therefore be totally improper by those Halachic authorities which permit donation. It would in fact be murder. Though ironically, the Israeli Chief Rabbinate Council's test of "respiratory failure coupled with profound nonresponsiveness," which rejects the need to check for brain death may fit what OPTN/UNOS has decided.

Now, practically speaking, patients are pulled off of ventilators all the time even when brain death is not determined since that may have been the expressed will of the patient or the health care proxy. The secular legal precedent is already there many times over and if that's already accepted why shouldn't they schedule an organ harvest ahead of time to act upon death? Maybe this is a good call after all that will lead to more organs being available for those who need them. Maybe. For now though, adjusting the definition of death for the sake of organ donations gives me the willies.

Sunday, February 01, 2009

Yesterday's Parsha

Exodus 13 (KJV):

6Seven days thou shalt eat unleavened bread, and in the seventh day shall be a feast to the LORD.
7Unleavened bread shall be eaten seven days; and there shall no leavened bread be seen with thee, neither shall there be leaven seen with thee in all thy quarters.
8And thou shalt shew thy son in that day, saying, This is done because of that which the LORD did unto me when I came forth out of Egypt.
9And it shall be for a sign unto thee upon thine hand, and for a memorial between thine eyes, that the LORD's law may be in thy mouth: for with a strong hand hath the LORD brought thee out of Egypt.

10Thou shalt therefore keep this ordinance in his season from year to year.

11And it shall be when the LORD shall bring thee into the land of the Canaanites, as he sware unto thee and to thy fathers, and shall give it thee,
12That thou shalt set apart unto the LORD all that openeth the matrix, and every firstling that cometh of a beast which thou hast; the males shall be the LORD's.
13And every firstling of an ass thou shalt redeem with a lamb; and if thou wilt not redeem it, then thou shalt break his neck: and all the firstborn of man among thy children shalt thou redeem.
14And it shall be when thy son asketh thee in time to come, saying, What is this? that thou shalt say unto him, By strength of hand the LORD brought us out from Egypt, from the house of bondage:
15And it came to pass, when Pharaoh would hardly let us go, that the LORD slew all the firstborn in the land of Egypt, both the firstborn of man, and the firstborn of beast: therefore I sacrifice to the LORD all that openeth the matrix, being males; but all the firstborn of my children I redeem.
16And it shall be for a token upon thine hand, and for frontlets between thine eyes: for by strength of hand the LORD brought us forth out of Egypt.

So we have eating matzah for seven days in order for it to be "a sign unto thee upon thine hand, and for a memorial between thine eyes" in order for when your son asks you what it's all about you can explain. And then we have redemption of the firstborn which is also given as "a token upon thine hand, and for frontlets between thine eyes" for the same co-generational exposure and explanation.

C'mon now, how do these verses imply leather boxes instead of simply figurative phrases describing a mnemonic device?

Wednesday, January 21, 2009

The Dying of General Surgery

Chief surgical resident Aaron Kendrick, who wanted to be a surgeon since middle school, has spent almost six years in a grueling general surgery training program at Erlanger hospital.
But this summer he’s switching gears to begin a three-year residency in anesthesiology, a field with better pay and a more relaxed schedule that will allow Dr. Kendrick to spend time with his wife and new baby, due in December.

“Mainly for me it’s the predictability of schedule,” he said. “General anesthesiologists work shift work, and when your shift is done, you go home.”

The number of general surgery residents here who practice as general surgeons is falling, said Dr. Phillip Burns, chairman of the department of surgery at the University of Tennessee College of Medicine’s campus in Chattanooga.

“Whereas 15 years ago 75 percent of our (general surgery residency) graduates here would be going into general surgery practice, it’s now down to about 25 percent,” Dr. Burns said.


“We have a shortage of surgeons, and physicians in general, that is coming on like a freight train in this country,” Dr. Burns said. “If we don’t do something to increase the numbers of surgeons that are graduating and available to go into spots, we’re going to have huge problems. In 10 years we’re going to have catastrophic problems.”


It’s a field in which pay is declining, with falling reimbursements from private insurers and government programs such as Medicare. Doctors also point to increasing medical liability insurance costs as a deterrent to entering the field.

For many young doctors entering practice with sometimes $150,000 in debt, general surgery may not make sense as a career choice, said Dr. Charles Portera, a surgical oncologist, a subspecialty that still incorporates general surgery.

“It’s kind of a sad state of affairs,” he said. “You’ve got to work harder to make the same amount of money that you did a few years ago. ... Why should these young kids go into it when there’s easier ways to make a living out there and still have a family and quality free time?”

[Full Article]

As a guy who's been interested in surgery since early childhood, it was quite the smack in the face to find that I have yet to encounter even one person involved in the medical field who would recommend going into general surgery. And I've spoken to plenty. The training is long, you work like a dog, and the compensation is small (and shrinking - thanks Medicare!) compared to the time put in and opportunity costs - and especially compared to the careers of other specialties.

General Surgery is a dying field in America through the shrinking compensations of government programs, endless hassles of hospital administrative red tape, which make for an unpleasant working environment and which exist only secondary to the perverse litigiousness of American society. This artificially intense liability of a surgeon simply working his trade also manages to add insult to injury by requiring ever larger chunks of one's salary be handed directly to malpractice insurance. As surgeons need to take on larger and larger loads just to stay afloat it saps them of leisure time, basic family interaction and those periodic iconic personal events that make up a person's private life.

Why would anyone want to be a general surgeon?

Heck, in twenty years where are you even going to find a general surgeon when your kid has emergent appendicitis at 3am? Is America ever going to wake up?

Tuesday, January 20, 2009

Little Details

Right in the third sentence of his inaugural address Pres. Obama says:

"Forty-four Americans have now taken the presidential oath."

Eh, not so much. Grover Cleveland swore himself in twice in nonconsecutive terms as number 22 and 24 Presidents of the United States.

Oh well.

In any case Obama made a decent speech, but I still think the best presidential speech I ever heard was this one:

Still brings tears to my eyes...

Monday, January 19, 2009

How I'm feelin'...

Greatly Relieved - that a cease fire has finally been established in Gaza. Though...

Endlessly Frustrated - that a true peace seems further away than ever.

Growingly Anxious - about big career decisions that I'll need to make this year as I realize med school is nearing its final few stretches and most of my information comes in second hand form.

Downright Concerned - about the fate of medical practice in America where managed care, government regulations and CYA practice secondary to litigiousness is progressively grinding enthusiasm out of the field.

Abashedly Hopeful - as I see the strength of American democracy in the upcoming inauguration of Obama, through whom I also feel a...

Frank Solidarity - with the Black people of America who are seeing what was unthinkable just a few decades earlier.

Awed Delight - for Sully Sullenberger who with aplomb saved 150+ lives with an amazing landing in the Hudson.

Defeatedly Blase - about studying all this week for the coming exam that caps off my latest hospital rotation. Though I've also got..

High Hopes - for my irregular week off after that exam when maybe I'll go skiing and have a superbowl party or something.

There you go. The latest review of what's on OP's mind lately.

Thursday, January 01, 2009

Conubium aka Kiddushin

"According to [early] Roman law, a child is the legal heir of his father and is in his father's custody (potestas) only if his father and mother were joined in a legal marriage (justum matrimonium). The capacity to contract a legal marriage was called conubium (or ius conubii), and was possessed almost exclusively by Roman citizens. Marriage between a person with conubium and a person without conubium was valid, but it was not a justum matrimonium; and without a justum matrimonium, the status of the child follows that of the mother." - Shaye J. D. Cohen, "The Beginnings of Jewishness," page 294.

Compare with:

According to Jewish law, a child follows the tribal status of his father if both his father and mother possessed the capacity to join in a legal marriage. This capacity is called kiddushin and is possessed exclusively by Jews. Relations between a person capable of kiddushin and a person incapable of kiddushin, say a Jew and a Gentile, results in the status of the child following that of the mother.

An echo of Roman law in Halachic matrilineal descent?