Archive for the ‘FUTURE COLUMNS STILL BEING WORKED’ Category

LILLIPUTIAN LESSONS

February 7, 2010

Foregoing the elevator, I went to the stairwell at the Nairobi Intercontinental, ascending to my third floor room.  When I reached the spacious second floor, there were a dozen hotel workers taking a break.  When I appeared, an old white western guy, the scene got–shall we say–awkward.  Their conversation stopped.

I smiled and said, “Jambo,”  an all purpose Kenyan greeting, one from the heart, my guide, Danson, told me several days later.  I heard several “Jambo’s” in return, and tension left the stairwell like air from a popped balloon.  I continued up the stairs, and they continued their conversation.  Trying to speak the language in another country is a sign of respect.  “Jambo,” told the men that I was cool with the situation, I knew a little KiSwahili and was a guy who respected Kenyans as people, not former colony inhabitants.

One of my big regrets in life is never having learned any foreign language well.  Still, within 12 hours of arriving in Nairobi, I could count, say please and thank you, and “Jambo,” which I used a great deal, along with “Hakuna Matata,” the Kenyan version of “Don’t sweat it.”  My French in France was not appreciated.  But my Spanish worked in Spain (and not badly in Italy, either), and the Filipinos absolutely loved it when I spoke Tagalog, 35 years ago.   I blew one vendor away with my “Hindi ako kumakain nang barbeque dito,” essentially stating I wasn’t interested.

At Lake Nakuru, I showed several lodge staff the annular solar eclipse through solar filtered binoculars, the eclipse being the reason I traveled to Kenya.  I love eclipses, and I love showing them to people and explaining the phenomenon.  Many were flat out amazed a guest would take an interest in making sure they could see something that almost certainly they will never see again (the November 2013 eclipse will be partial in Kenya).  In the short time I was there, many called me “Mr. Mike,” an appellation I particularly like, since it simultaneously shows respect and liking.  I told one waiter my age was sitini na moja, (look it up!)  It took him a few seconds, but he got it, and later (in English) talked to me at length about the lodge.  Danson later told me that I had made a big impression on the staff, one of the nicest compliments I received.

People are people.  Just like me.  The Kenyans have a life, a far more difficult one than I can imagine, but they are still people.  Unlike us, they have a beautiful memorial site for their disaster of 7 August 1998. Also unlike us their cellphones work everywhere.  I texted the eclipse phenomenon in real time back home. My text immediately went through from Jomo Kenyatta airport; it didn’t from Houston’s Intercontinental.  Not infrequently, I get “No Service” from Campbell and Skyline.  So who is Third World?

When I left practice in 1992 to take a leave of absence, I received many notes, cards and letters.  The one I remember the most was from a dietitian, who was also leaving to go to pharmacy school.  She said, “You respected the little people.”  I tried to.  I was taught at a very young age not to beat up on those who can’t defend themselves (nurses, custodians, aides), which I have done and for which I have been ashamed.  I’ve seen too many physicians and others in power who beat up on people, and I remember taking the brunt of it when I was an intern scrubbing on a bypass case.  It was difficult to hold the retractor properly when my eyes were filled with tears.  I was thanked only 5 of the 12 times I scrubbed with those two surgeons.  I was the little people, and I never forgot that treatment.  It was so bad, I got blisters on my hand from learning how to take a hemostat off a piece of wet kleenex with one hand without tearing the kleenex, so I wouldn’t get yelled at in the OR.  And I mean yelled.

I finally got some revenge.  On a later case, with the pair, I had my thumb too far through a hemostat.  “Don’t hold your instruments like that, Smitty,” one yelled (a term I detest), “you don’t hold your silverware like that, do you?”

“I don’t use silverware,” I retorted.  “I use my fingers.”  That was the end of that conversation.  When they quizzed me on anatomy, which I happened to know cold, I spat the correct answer back at them.  After three correct answers in a row, they left me alone.  One later had a nervous breakdown; both must have been incredibly unhappy people.

I always thanked nurses for helping, I tried to clean up after myself, and if you read Code Team on my blog, you will discover what other things I cleaned up in the hospital.  But occasionally I lost my cool.  We all do.  I just tried to remember to apologize when I did.  And if one is polite most of the time, he or she can easily be forgiven for a lapse.  There just can’t be too many of them, and an apology,must be coupled with a change in behavior.

When you’ve been at the bottom as many times as I have–undergraduate, medical school, internship, residency, graduate school and now teaching, you understand a lot better what it’s like being the little people.  That gives you two choices:  to haze those below you or to break the cycle.  I’ve tried to choose the latter.

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AFTER ALL, THESE THINGS HAPPEN

January 3, 2010

A 52 year-old woman lies in extremis in ICU following a gastric perforation discovered after contrast is put through an NG tube. So what?  These things happen.  Yep, they sure do.  Here’s how this particular one happened.

The woman had an Upper GI four months earlier showing a paraesophageal hernia, where the esophagus went through.  The report mentioned the hernia, it didn’t mention its prediposition to gastric volvulus.  While one can’t mention every possibility in a report, it might have been useful to mention this particular fact.

Four months later, the woman presented with abdominal pain.  Her initial CT of the abdomen and pelvis mentioned the hernia and an ovarian cyst, but no comment was made about gastric distention or the type of hiatal hernia.  Unfortunately, the prior study wasn’t re-evaluated during the reading.  That was unfortunate, but many studies today contain a thousand images; indeed, a radiologist may encounter 100,000 images a day.  An NG tube was passed, and a second scan, with contrast, showed the perforation – really well.  Fatigue, the volume of images, hospital and referring physician demand for quick reads, compensation for number of studies (not images) viewed, make errors more possible.  Reviewing past studies is not compensated, so there is less of a  tendency to do so.  What do clinicians do if they receive a huge chart when a new patient arrives, inconveniently booked into a follow up slot?  Compensation is based on a numbers game; what game is played dictates what gets done well, what gets done, and what doesn’t.  Having been on both sides of the medical fence, I can easily spot a distracted, harried and hurried physician.  All three of these are a setup for cognitive errors, the single biggest type of mistake a physician can make.

The patient developed peritonitis.  Perhaps if fewer CT scans were ordered, it would be easier to routinely evaluate prior studies as part of the reading process.  Once having practiced neurology, I believe, and the literature supports, a person with intact cortical function, no neck pain, no tenderness to palpation and no neurological deficit doesn’t need a cervical spine CT after an injury.  Whole body scans are often done when clinical judgment would suffice.  Besides being a radiation issue, it is a time issue affecting emergency department throughput (we patients call it waiting), a money issue, because these studies are expensive, and a quality of care issue.  After my bicycle accident, I had several studies, but nobody took off my shirt to look at the road rash on my back.  Nobody palpated my entire body, since severe pain in one place may mask a significant injury elsewhere.  Those additions take perhaps thirty seconds.

Worse, if little clinical history is provided, it affects the type of study and the radiologist’s approach.  Differentiating PE from dissection makes a big difference in timing of the scan after contrast.  “Chest Pain” is not helpful to the radiologist.  Yes, you are in a hurry.  I was too.  But I always put clinical information on my neuroimaging requests.  The radiologists appreciated it.  I got better reports.  It helped my patients.

This woman survived.  The medical community ought to learn from this, rather than copping out and saying “these things happen,” “nobody’s perfect,” or “who made you the quality expert?”  “Nobody’s perfect” doesn’t cut it if a person dies from something preventable, either in or out of medicine.  You don’t hear the civilian or military aviation community say that.  They learn from the mistakes, and they publicize them.  Read a few sometime, and you would be surprised how much we could take away from their field, rather than the mantra, “We’re doctors.  We’re different.”

Rheumatic fever, polio and gas gangrene used to happen; 30 years ago auto accidents killed twice as many people per capita, anesthesia deaths were once far more common.  Sean Elliott and Alonzo Mourning would have died from uremia the way actress Jean Harlow did.

Excessive workload increases the likelihood of a radiologist’s not reviewing past studies and not dictating, “Paraesophageal hernias can lead to gastric volvulus.”  What does workload do to you in your field?  There ought to be a way that physicians can do a decent job, make decent money, learn from their mistakes and those of others, have a life and not fear lawsuits.  Here are a few thoughts:

It’s time we had community standards for common, high risk procedures that lend themselves to standardization: hyperalimentation, ventilator management, pre-op antibiotic delivery and central lines.  We can standardize and still respect individual differences.  It’s time disciplines who function together, like emergency medicine and radiology, work together.  It’s time to have legislation mandating a free from discovery error reporting system which I proposed in 2001 and which failed the legislature in 2004 and 2005; the hospital association worked to  kill it.  It’s time to have liability reform so physicians aren’t treated like criminals when they err.  Maybe if we did the first two and supported the third, we could get the fourth.  Along the way, we might additionally work towards complete medical coverage for childhood up to at least age 18 – with real-time data on outcomes and costs.  We might start having a better system.  Maybe we could expand age 18 to all.

And perhaps see fewer cases of preventable peritonitis.

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“I NEVER KNEW HOW IMPORTANT THAT WAS TO YOU”

December 18, 2009

I had a depressing holiday season.  Too much death.  Not in my family but in the families of two people that I know.  The three of us were once riding buddies, but after my bad accident in 2006, I gave up the sport, and while we stayed in touch, calls became less and less frequent.  I basically let the friendship go.

Shame on me.  I kept the friendship alive with Mike Manlove from my days in the Forest Service by stopping by every time I was in Minnesota.  Mike died at 52; I had visited him two weeks prior to his sudden death and he expressed his gratitude for my coming by.  It was important to him that night.  And to me.  But at the time I didn’t realize how very important it was.

The first death was Don’s son, in an accident.  I’ve known Darrell for 8 years.  When my mother was dying, in 2002, I had to bring her and my father back from Oregon.  I had to fly up to Portland, get their car and bring it back.  On his own, Don told me he would pay for his flight up and help me drive back.  I was astounded that anybody would do that.  But that’s the kind of friend Don is.  So, when I read about his son’s death in the paper and called Don, I didn’t know what to say, except that my wife and I never forgot what he did for us, and we were going to be there in any way we could for him.  I reminded him of our 1500 mile old guy road trip, and got him to laugh, even briefly.  Don has many friends, so there wasn’t much I could do to help except attend the funeral, where I saw several other people I knew.

One of them was Rick, the oldest of the three of us,  fifteen years my senior, and a nationally ranked cyclist in his age group who could outride me on flat road any day of the week.  Rick and Don are really tight.  They and their wives had dinner together every week.  But a month earlier, Don told me that Rick’s wife was dying from cancer.  I didn’t know Rick as well as I had Don, but I still should have called him.  I didn’t.  At the funeral, I had to not only express my sadness at his wife’s illness but apologize for my behavior.

Right in the pew, I gave Rick a hug and in tears told him how sorry I was about his wife and how much I appreciated his support for me back in late 2005, when my father was dying.  Back then, I was running ragged with visits to the hospital and then to his care facility.  One Sunday, Rick called me and said, “Hey Mike,” in his great booming voice, “you need a break.  We’ve got a bike ride with your name on it.  Come out with us.”  I don’t remember much of the ride, except that once again Rick whupped me.  But I never forgot the fact he had called me.  Such a little thing.  But in relationships, the little things are the big things.  I owed Rick big time.  But good friends never keep score, they just find a way to help each other when it matters.

Four days after the funeral for Don’s son, Rick’s wife died.  Don was the one to call me.  One can only imagine how he was feeling, given how close he and Rick were.  I asked when it would be appropriate to call Rick.  “He’s sleeping, now, Mike,” Don said, “but he really wants you to call him tomorrow.”  I suddenly felt like a friend again.  Somebody needed me, and I needed to step up.

I called Rick the next day expressing my condolences.  Yes, it was a blessing his wife died quickly, but she was still dead.  He then asked, “Do you have a few minutes?”  I had all day if he wanted it.  For a half hour he went through the last few weeks of his wife’s illness, the support he received from his children and his closest friends.  I just listened, because I knew enough that all he needed was somebody just to listen.  But he then blew me away:  “I never knew that day when I asked you to do that ride how much it meant to you.”

“Rick,” I said, “it meant the world to me.  I was so grateful to you.”  We had a good conversation and agreed to meet later in the holiday season.  Out of this hell will come a rekindling of a friendship that I let go.  I really bumbled, but one of the things I’m good at is not ignoring people after a death.  I also try to say something specific about the person who died.  I’ve long known how much those small details mean to the bereaved.  You see, small to you may not be small to somebody else.  What appears to be a few insignificant trite-sounding words to you may make somebody else’s day.  Sometimes, you never find out how important those words mean.  Other times, it may take four years to discover that what you said really mattered to somebody, as it did with Rick.  Don’t ever forget that.

I have every thank you note a patient ever wrote me.  When I left Ely, Minnesota, after my leave of absence from practice in 1992, I didn’t get to say goodby to my boss, because he was helping in Florida after Hurricane Andrew.  But I later got a post-it note from him, along with a framed picture of a two man handsaw, a hardhat,  Pulaski, pack, radio gloves and a broom leaning up against a tree.  They symbolized what I did as a trail crew volunteer in the Boundary Waters for six months, and I still view the picture fondly.  But what I never have thrown away after 17 years was that single yellow, small square post-it note:

All it said was, “Thanks a lot for your help, Mike!”

Such a little thing.  Such a big thing.

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HORSE SENSE, MEDICAL SENSE. BET ON THE ONE WITH THE MOST LEGS

December 10, 2009

A friend of my wife, who still rides horses at age 79, recently had a breast biopsy that showed cancer, estrogen receptor positive, nodes negative.  She had breast cancer 28 years ago, but no recurrence, so this is almost certainly a second cancer.  She was placed on Tamoxifen, appropriate for this condition.

A week back, she was told she needed to be seen immediately by her oncologist.  I’ve not had cancer, but every time I see a physician, I fear the worst.  My vision changed recently, and I started thinking of cataracts and macular degeneration, even though I saw perfectly through a pinhole, a classic manifestation of astigmatism.  I’m starting a cataract in my right eye; my maculae are fine, so I have garden variety astigmatism.  This woman and my wife were thinking bad scenarios and wondering why nobody told her what was going on a lot sooner.  Wouldn’t you worry and wonder why nobody said anything sooner?

So, my wife brought a bunch of papers back from the barn, all dealing with genetic markers in the tumor and risk of recurrence.  I’m amazed at how far medicine has progressed since I practiced.  I’m less impressed by how well medical personnel deal with statistics.  The woman was told she needed to start chemotherapy immediately.  That’s obviously bad.  It is worse, however, because she is absolutely phobic about chemotherapy.  Don’t laugh.  Any neurologist who has given intrathecal cisternal Amphotericin B to a patient with cocci meningitis knows that when the physician (conditioned stimulus) arrives for the injection, there is a conditioned response of vomiting by the patient.

This woman had a recurrence score of 35.  That is based on 21 genetic markers, and the score goes from 0 to 100.  It is not a ratio scale, so 35 isn’t 7 times worse than 5.  If you want the details, go to:http://www.oncotypedx.com/ and look under Healthcare Professionals.

Several studies were quoted, and while the science was good, the writing was less so, which made ferreting out facts difficult.  One study said that she had a 24% risk of recurrence in 10 years on Tamoxifen alone.  In 10 years, this woman will be 90; her current life expectancy is 9 years.  Another study quoted a 14% risk on the new chemotherapy and 42% risk without it, differences clearly statistically significant:

After looking at the paper more carefully, two further graphs suddenly put everything into clear focus, even given my astigmatism.  A bar graph showed the absolute percentage of increased risk with and without chemotherapy.

Because this woman had a RS of 35, she was told she needed immediate chemotherapy.  This bar covers RS from 31 to 100, not stated in the article, and this woman is at the low end of that range.  So, I wondered, is she not being grouped with a lot sicker patients?  I then went to the line graph, specifically looking at node negative cancers (black line at the bottom):

While difficult to read, a RS of 35 means a 15% of distant recurrence (bad), with 95% confidence intervals of (11%, 19%).  That means we don’t know her exact risk, but we are highly confident it lies between those values.  Note, however, where the y-intercept is:  where RS is 0, her risk is 5%.  Therefore, I think her increased risk is 10%, not 15%.  Note that if she had a RS of 25, she would have a 10% risk.  I think the Web page should have commented on this.

Finally, go back to the first graph.  The curves don’t diverge until at least 2 years, and because the sample size is small for RS >30 (47), I suspect statistical significance wasn’t reached for at least four years.  This woman is nearly 80.  Summarizing, she has a 15% chance of distant recurrence in 9 years and a life expectancy of 9 years.  The increased risk of distant recurrence doesn’t kick in until 3-4 of those years.  Her increased absolute risk is under 10%, not 28%.

Should she get chemotherapy?  That is her decision, not the oncologist’s, the insurance company’s, or mine.  But what she needs is a clear statement of the potential risks and benefits.  The risks are chemotherapy in an elderly lady who is likely more sensitive to the side effects, including difficulty using her fingers and walking and fatigue, making it impossible to ride her horse for 6-12 months.  We are now getting into the “art” of medicine, which is important, but must follow giving the patient the information she needs to make an informed decision.

I believe she needed an appointment, but the “come in immediately,” approach was unfortunate (my wife used “appalling”).  Testimonials should also be removed from the science portion of company Web pages.  Busy physicians need better summaries of data, and if studies are mixed, there needs to be unusually clear writing.  Summaries are good, but the information that significance kicked in after 4 years in this lady’s group was important in this instance and found only after a lot of work.  A scatter plot of RS and outcome would have been helpful, since grouping data throws away information.  What we need is somebody who understands statistics, medicine, and knows how to write clearly.  I know an individual who can do that.

We should treat patients as unique individuals who are anatomically and physiologically similar and respond in similar ways pathologically.  Each of us has emotional, occasionally irrational approaches to life.  In medicine, these responses may be detrimental but must be validated.  When I practiced, data were my friend.  I told patients the risks and benefits of procedures, like carotid surgery.  I told them the two ways I could be wrong (recommend a bad thing, not recommend a good thing), tell them what the literature showed, give them my opinion, and then allow them to make what I felt was an informed decision, based on my use of the history, physical, lab, knowledge of the individual and known risks and benefits.

It is a shame that in the face of good data, that this woman was put through a death scare.  I have long felt medicine needs clinical statisticians who know how to communicate, which is why I took time, effort and money to get my statistics degree in addition to my medical degree.  This instance tells me that despite the disinterest I encountered, there is still a need.  I worry what may be happening in other instances.

Over the years, most of my statistical consulting was for free.  This was, too.  But never have I felt as useful to a patient as I have here.  She was not going to go through chemotherapy and worried it was the wrong decision.  I helped her realize that for her, the decision made a great deal of sense.  And that’s what informed consent is all about.

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CONTINUING ON IN THE FACE OF SOME REALLY BAD S—

December 10, 2009

Well before the Cessna Grand Caravan cleared the mountains near Fairbanks, Nancy, a vivacious fortyish woman next to me, started talking.  We were traveling to Arctic Village, 235 miles northeast; from there I would fly over the Brooks Range in a smaller plane, landing along the Aichilik River on Alaska’s North Slope, near the Arctic Ocean.

Nancy told me that she and her husband, Jim (both names changed), who was dozing in the single seat on the other side of the aircraft, were going to a different river on the North Slope for their trip.  As she talked, I realized they were as familiar with this country as I was with the Boundary Waters, except “their country” was 20 times bigger and vastly more remote; the last road we would see for two weeks was behind us.

I noted that her husband looked not just older, but his hair was patchy and almost ravaged.  I didn’t say anything, and Nancy soon elicited from me that I had once practiced neurology.  Jim was an exceedingly smart geologist who several years earlier had been diagnosed with a left hemispheric astrocytoma and forced to retire.  These tumors are malignant, and at a young age grow slowly.  But they eventually get nastier and will kill in 5-10 years.  Jim was treated at Duke, which is about as far from Fairbanks as London is from New York.  She was remarkably upbeat for somebody who had gone through a hell I hope I never will, and they were doing the trip while they still could.  I was sitting next to a saint.

“He has some trouble word-finding,” she said, but with a smile that would light up an Arctic winter, added, “he just loves this country, and I do, too.  We’re going as long as we can.”

We talked about Alaska, the time passed quickly, and we soon landed on the dirt strip at Arctic Village.  The weather over the Brooks Range was poor, and many of us to be shuttled in.  Jim and Nancy would go in the mid-afternoon; I was in the last group and wouldn’t depart for 8 hours.  We put all our gear by a small building, new from the previous year, unstaffed and christened “Arctic Village Visitor Center.”  One hour took care of seeing the village; when I returned Jim and Nancy were inside, looking at a large map of the Refuge and nearby Yukon.  Jim was pointing out, with minimal but noticeable dysphasia, some of the areas where he had traveled.   I looked with awe and envy at his travels.  I was never going to see that incredible country and he had.  On the other hand, I’ve seen sixty, and he would likely not see fifty.

Later that afternoon, Nancy suggested Jim and I walk across the airport to a nearby lake.  Jim had a quick pace, was able to identify a lot of plants and birds, and soon, like his wife, asked me what I had done.  When he heard I was a neurologist, he said, “I have this s— growing in my brain.”

This was one of those difficult moments where one has to quickly decide whether to lie, tell the truth, change the subject, or just run away.  I knew what Jim had, but he didn’t know I knew.  I didn’t want to act curious; I just wanted to be somewhere else.  God, I thought.  What do I do?  Just then a couple of loons called in the distance, so I took option number 3:  I quickly changed the subject to loons.  I felt like a coward.  Whether Jim noticed, I’ll never know, but during the rest of the walk, we didn’t discuss his medical condition.  We birded, spending about a half hour sitting beside one of the many lakes that surround Arctic Village.  Jim pointed out the plants to me, and I just worked like mad keeping the subject off astrocytomas.  I’ll never know what he thought of me, but I sure learned much about the local flora.

We eventually returned to the airport, and later, Jim and Nancy left for their trip.  At 7 p.m., the guide, Aaron; I; and pilot Kirk Sweetsir, a Rhodes Scholar (in another life, as he puts it), finally departed.  When we saw the wall of black ahead over the Continental Divide, Kirk turned around and set us down in ANWR, along the Sheenjek River, half way to our destination.  We had the stove, dinners, breakfasts, and a dry place to camp.  The other group that did get to the North Slope that day had none of those four things.

But all of us had functioning brains and bodies that would get us through eleven tough days in ANWR and hopefully for many, many years after.  But there are no guarantees.  Jim is one of the reasons why I go when I can.  Bad stuff – s—, if you will – happens, and it can happen to anybody, good or bad, young or old.  I’ve had some nasty medical problems, but compared to Jim, I’ve had nothing.  He’s still going while he can, able to carry gear, navigate and love his wife, who copes with a grace I wish to emulate.  Both of them have and will continue to see country that few will ever see.  They are special people, truly living fully while they can, as we all should.

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A DAY IN A TEACHER’S SHOES

December 3, 2009

After 7 years as a volunteer math tutor at a local high school, I was allowed to be an on-call volunteer math teacher, meaning I teach with a certified substitute present.  I address the occasional problem when a teacher is absent and a fully qualified math substitute is unavailable.  On my first day, I was given a lesson plan for algebraic inequalities and prepared one for geometry.  While I don’t find these subjects difficult, understanding a subject is far different from teaching it. 

I arrived at 7 a.m. with water bottle, lunch and objects needed to explain the material, for good teachers don’t parrot the textbook.  The official substitute took attendance, introduced me and I began teaching.  Fortunately, I had no problems with student behavior, because the teacher for whom I substituted is an exceedingly good disciplinarian, knowing when and how to act with words, inflection and body language.  My experience could easily have been worse. 

What’s it like to teach for a day?  I was on my feet nearly continuously for 7 hours.  I needed a bathroom break at 10:30, but preparing for the class before lunch took priority, and I nearly sprinted to the men’s room an hour later.  Other than a few swallows of water, I ate nothing until I finished at 2:20.  I left at 3:45 and wasn’t the last teacher leaving.  That evening, I relaxed, not having to grade homework or prepare the next day’s lesson. 

My parents were both hard-working teachers, and I frequently heard, “You can’t eat dedication.”  I’ve taught exactly one day and didn’t deal with problem students, parental e-mails, after school tutoring, worth $40/hr, but freely offered by many teachers or faculty meetings.  I’m 61 and want to teach math.  I can afford to; many of our best and brightest teachers, with whom I’ve had the honor and pleasure to be associated, struggle to pay their student loans.  Summers off?  Many teach summer school out of necessity. 

A properly educated populace won’t solve all our problems.  But it is a necessary condition if we ever hope to address them sensibly.  Arizona ranks last in per capita spending for what is arguably the highest yield and lowest risk investment of all – education.  Nationally, we invest far more in low yield/high risk unwinnable wars and impossible nation building.  Those whose high risk complex financial instruments devastated our economy receive annual bonuses greater than a teacher’s lifetime earnings.  Important, difficult jobs requiring significant training and long hours deserve appropriate compensation, which is how we attract and keep good people.  As a former neurologist, I was paid well for my training, work and hours.  Teachers are not paid commensurate with their extensive training, hours and immense responsibility preparing the next generation.  Teaching math, or any other subject, to 35 teenagers who’d rather be elsewhere is difficult:  doubters should try it – assuming they have the skills to do so.  Increased funding for teachers and education is one of the best investments Arizona and America can make.  Our future depends upon it. 

Michael Smith, retired physician and statistician, has been a grader for the AP Statistics examination.

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MIND TRICKS

November 26, 2009

How many people do you need in a room before any two are more likely than not to have the same birthday? 

Twenty-three. 

I’m sure there are those who disbelieve, saying “I know that can’t be right.”  What is disturbing is that even when a simple proof is delivered, many continue not to believe it.  That is stupid.  The proof, by the way, looks at the probability that two people don’t have the same birthday.  Sometimes, looking at what you don’t want makes it easier to find what you do want.  Here’s the proof:

# of people Probability 2 w/ same birthday Prob. Not having same   birthday
1 0.000   1.000
2 0.003   0.997
3 0.008   0.992
4 0.016   0.984
5 0.027   0.973
6 0.040   0.960
7 0.056   0.944
8 0.074   0.926
9 0.095   0.905
10 0.117   0.883
11 0.141   0.859
12 0.167   0.833
13 0.194   0.806
14 0.223   0.777
15 0.253   0.747
16 0.284   0.716
17 0.315   0.685
18 0.347   0.653
19 0.379   0.621
20 0.411   0.589
21 0.444   0.556
22 0.476   0.524
23 0.507   0.493
24 0.538   0.462
25 0.569   0.431
26 0.598   0.402
27 0.627   0.373
28 0.654   0.346
29 0.681   0.319
30 0.706   0.294
31 0.730   0.270
32 0.753   0.247
33 0.775   0.225
34 0.795   0.205
35 0.814   0.186

 A disease has a prevalence of 1 in 200 (0.5%), a sensitivity and specificity each of 99%, meaning if you have the disease you test positive 98% of the time and if you don’t you test negative 99% of the time.  Not knowing if you have the disease, you test positive.  What is the probability you will have the disease? 

  Test Positive Test Negative Total
Disease Positive 49 1 50
Disease Negative 99 9851 9950
Total 148 9852 10000

 The answer is about a third (49/148).  That’s why we don’t do routine HIV blood tests for couples who are going to get married.  In a randomly selected individual (that is important), a positive test for something rare has a significant likelihood of being a false positive. 

Many mountaineers defend the safety of their sport by saying one can get killed in a car accident.  That’s true.  But nearly all of us drive and a lot.  We all know someone who died in a motor vehicle accident, but relative to the denominator, it is small, 1 in about 5000 to 6000 this year.  Mountaineering is a small community, and number of climbs is a small fraction of number of auto trips.  Every serious mountaineer has lost several friends to the mountains.  Mountaineering is much more dangerous.  I love reading about it, and I admire those who do it, but it is high risk. 

The lottery is a tax on those who don’t understand probability.  The chances of winning the Powerball jackpot are approximately those of randomly picking a minute chosen since the Declaration of Independence was signed.  Yet people continue to tax themselves because “if you don’t play, you can’t win.”

Too many Americans play another lottery:  I have abdominal pain, and I don’t have insurance.  I can’t afford to see a doctor, so I will bet it goes away.  Instead of going away, the pain worsens, and I now can’t walk.  I have to call an ambulance, go to an emergency department and am admitted with a ruptured appendix.  The costs have increased and are well in five figures.  I’m bankrupted by the illness, few who are involved in the care get paid, and my productivity is zero for a long time.  I’ll probably never get out of debt.  If I get sick again, I’ll bet again it goes away.  I have no other choice. 

Well, you say, that is just a bad example.  Here’s another:  I have abdominal pain and go to urgent care, because I don’t have a family doctor or it takes weeks to get in.  The workup costs, say, $2000.  I can’t pay it except in $20 increments.  That was my Literacy Volunteer student’s experience.   How many Americans say some morning “I  have a toothache, I can’t afford to take off work.”  They are miserable, and their productivity isn’t very good.  Maybe it will go away, or maybe they will need a root canal, which hurts like hell, because there is already a problem.  That’s about $1200, so they are more in debt.  Sure, they say. if I had the money for dental care, I might have been able to avoid this.  Instead,  I’m betting that my body’s natural healing ability will bail me out.  Maybe it will.  Or maybe it won’t. 

We were once the richest country in the world.  Our annual medical costs are more than a trillion dollars.  How many of them could have been avoided by timely prevention?  How many could have been avoided by universal coverage?  I don’t know.  But I do know that our poor system makes it impossible for at least a sixth of the population to get decent, timely care and not get bankrupted by it.  If you don’t want my solution, you fix it.  And not by going back to the 20th or 19th century, since going backwards never works.  Here are my metrics:  your fix has to show an increase in productivity, a decrease in emergency department overcrowding, a decrease in bankruptcies that are primarily due to medical reasons and a decrease in late diagnosis of disorders like appendicitis.

 If that requires I pay more taxes, I’ll pay them.  I’d rather pay taxes for education and health care than for Iraq and Afghanistan, foreign aid to countries who despise us and bailouts to car makers who built monstrous SUVs, when it was obvious decades ago we needed to retool.

Do I like government as a single payer?  No.  But again, if you disagree, you fix it.  I don’t want reading assignments.  I’m a patient, and I’m tired of waiting weeks to see a physician (I thought only Canadians waited), worrying about medical errors that have affected three family members and really tired of the bickering that has stalled any kind of reform.  It is disgusting – and is un-American. 

In these pages, I’ve offered many solutions, all of which have been ignored.  Your turn.  And please be quick about it.  I hate waiting.

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BODY BETRAYAL

November 26, 2009

I remember a time when I “owned” the ICU.  I had eight patients – eight – who were severely brain damaged, irreversibly brain damaged, or brain dead.  I don’t remember all the diagnoses, but they included aneurysms, intracerebral hemorrhages, ischemic strokes, hypoxic encephalopathies and a bad surgical outcome. 

During my ownership stage, the MICU staff were absolutely great in using my time, as they shepherded me from one family group to another.  It is easy to get jaded when one faces bad, irreversible or total brain damage in eight patients that one needs to see a few times a day.  I tried not to be, but I don’t know how successful I was.  Taking time to talk to families is often a real pain, but it is necessary, deeply appreciated and what physicians get paid for.  Do it.

If I returned to medical practice, which I won’t, I would be a far more compassionate physician than I was during the twenty years I did practice.  Mind you, I think I did a good job.  I allowed patients to die at the right time with dignity and less stress on the families.  When it came time for my parents to die, I did everything I promised them, and neither lived more than eight weeks from the time they started to die. Ensuring the quiet, painless dignified deaths of my parents was one of the best things I’ve ever done in my life. 

If you want to read about how I dealt with the change in my relationship with my father, after he was widowed, read A Wise Owl.    That is probably the best thing I will ever write. 

But having lived through their deaths and several personal infirmities, I look at life a good deal differently.  I could now tell families how it is normal to feel guilty when it is time to stop life support.  I could tell them how one will miss having that loved one to talk to, all the conversations that one would want to have in the coming years.  I could tell them how the relationship between children and surviving parent would change.  I would really be compassionate, because I have been there.

 I’ve had two major infirmities of my own in the past decade.  The first was getting buggered when a Buick turned in front of my bicycle up in Durango.  I went down and hit my fortunately helmeted head on the bumper.  Remarkably optimistic (some would say stupid), I got back on the bike, not realizing I had broken my right femoral head, the coronoid process of my left elbow, my fifth right metacarpal, and had a comminuted fracture of my right index finger.  I actually rode the bike six miles with these injuries, hobbling 100 yards into the school where the group was staying to take a shower.  While I was drying myself, the bench on which I was sitting collapsed.  It was a totally crappy day. 

Denial wore off when the adrenaline did, and I was operated on that night.  I had one functioning limb for about three weeks, and I was pretty damn miserable.  But I healed.  Still, I know what it is like to need a handicapped parking spot, have kids say “Mommy, what’s wrong with him?” have people hold doors and yet not wanting to be treated like a invalid.  I was a full-time graduate student then and teaching basic stats to college students. 

More recently, I had a nasty non-life threatening miserable infection for several months.  Without getting into details, I really didn’t want to live with it, which put me into counseling and from there into self-hypnosis.  Once, I might have been skeptical of self-hypnosis, but desperation changes one’s mind set, and it is amazing what hope and practice can do.  I can now get myself into a deep altered state and become pretty comfortable. 

During this infirmity, I went on the Internet and learned a good deal about the condition.  As much of a scientist as I want to be, there was simply no way I was going to try one thing at a time for a few weeks and see what happened.  I was too uncomfortable.  Rather, I tried a few things, had hope, lost hope, wondered what else I could do, figured out something new and kept going. 

My advice?  Do your research.  Hope your doctor is willing to work with you.  Write down questions, which is something I always hated patients doing.  Hope your doctor calls you back when you have an occasional question.  Try things.  Try other things. 

I took sleeping pills every night for a month, because getting sleep was one thing that really helped.  My condition didn’t affect my ability to exercise; indeed, exercise seemed to alleviate it.  So I tried to stay in shape.  I canceled a volunteer trip to Nebraska to help out with the Cranes.  It broke my heart, but it was the right decision.  Two other trips on the chopping block were at the moment salvaged by great people who knew me and gave me a bit more time on paying the final deposit. 

I’d be so much more understanding of patients with chronic conditions today.  I’d be a wonderful doctor.  Too bad it took me so long to figure it out.  Don’t you make the same mistake.

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A CURIOUS CAT PERSON

November 21, 2009

It’s our third night out on Lake Insula, 40 miles from civilization, completely quiet, the weather mild for late September.  The barometer is falling and I notice a slight south wind, so change is coming, but for now, we savor Indian summer in Minnesota.  We camped on a point with views on three sides and up into Museum Bay, haven’t seen another soul for two days and won’t for three more.  On the north shore, a half mile away, is a fine beach that few ever see.  We walked it yesterday.  After dinner, I head out to ledge rock 20 feet above the water and start scanning with binoculars.  I do that when I’m in the woods.  I usually see conifers and rocks, but sometimes I strike gold. 

This was one of those nights.  Within 15 seconds, my hands stop.  I see a large bull moose – his antlers catch the last bit of light – in water by the beach, and as I watch, he starts walking the shoreline toward us with alternating clops and splashes.  I’ve seen more than sixty moose in the wild, been within 12 feet of several, far too close.  One even followed me.  But to see one sauntering through the water, unaware of our presence, was one of my more memorable sightings.  We watched him 15 minutes in the growing dusk before he disappeared into the woods with the crashing of branches only a moose can produce. 

Curiosity is one of the greatest gifts I’ve been given.  A while back, I worked with a church group removing buffelgrass in Oro Valley.  I’m not willing to cede our part of the Sonoran Desert to an invader.  Nor is “Dave,” who manipulates his wheelchair into deep sand of washes to bag it.  He is amazing. 

Usually, I listen to music or podcasts while hacking, but this group was friendly, not trying to convert me and were living their faith, good stewards of a portion of the Earth.  That impressed me.  When we finished, a boy started asking questions about invasive species — why it was a problem, how it got there and burned so hot.  That impressed me, too.  I answered the first two questions, couldn’t answer the third, telling his mother that her son asked great questions.  She said he attended a science charter school.  Science and religion need not be mutually exclusive, but the anti-science drift and rise of American fundamentalism is disturbing.  Fortunately, I’m probably not going to be around when the bill comes due.  Perhaps this boy will help keep America competitive in science. 

Later, his brother asked why clouds were white and how they formed.  They were also great questions, along with why the sky is blue and sunsets red or yellow.  More than half of Americans don’t know the astronomical definition of a year.  Bet these boys did. 

I wish I had told the mother how good she was not quieting her boys.  Too many adults think it impolite for children to ask searching questions and drum curiosity out of children.  That’s wrong.  Perhaps it is a misguided sense of politeness.  Or perhaps the adult is embarrassed they don’t know the answer.  We need better questions asked, and we need more “I don’t knows.”  Maybe then we would be smarter.  I have a few questions:

  • When you awaken at night, why aren’t you fully dark adapted, but within a minute are?
  • What causes us to have annoying, persistent songs in our head?
  • What is the neuroscience behind dreaming?
  • Why do people with right hemispheric infarcts keep their eyes closed during the acute phase?
  • What causes shadow bands just prior to a total solar eclipse? 

Instead, we are fed a fare of stupid tweets and non-balloon boys.  Another question:  What is happening to Tucson’s climate?  Colton hunts and sees first hand the desert’s dying.  He knows it is changing.  The Sonoran desert suffers from 26 consecutive years with above normal temperatures (and “normal” has been raised twice in the interval), 14 of the last 16 years with below normal rainfall, 2 ½ years’ deficit in the last 10; 7 of the 10 warmest years this decade and 1 in 5 days “unseasonable,” more than 10 degrees above normal.  Except 20% is no longer unseasonable.  It occurs two-thirds as frequently as below normal temperatures. 

A snowfall in Baghdad is anecdotal.  Tucson’s changes are over decades and worsening.  For 20 years I’ve called it climate change, to be more precise, for world-wide rainfall patterns are changing, too.  This year, Tucson will be a “minor” 3 degrees above normal.  “Minor” is 7 of the first 11 months in the top 10 for warmest, even during the strongest solar minimum in a century, which ought to enhance cooling. 

Half the bird species in the annual Christmas bird count have significantly moved north.  They don’t think climate change is a hoax.  Kutek Lake in Gates of the Arctic NP is disappearing as the permafrost melts.  My wife and I will eventually follow the birds, for we see the meteorological and political climate in Arizona both worsening.  I still have not heard a counterargument containing a margin of error, no pejorative attacks and no charged language.  We may be in an Anasazi drought.  I never dreamed I would become a climate refugee.

We can still deal with buffelgrass.  Go to www.buffelgrass.org and help out.

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FOR THIS I SERVED AMERICA?

November 21, 2009

I visited two elementary schools in the Sunnyside District to speak to the nurses about obtaining obesity data on their children.  Sunnyside is the only district in Arizona to mandate a nurse in every school.  Because of the nurses, fewer children are sent home with medical problems, and the nurses are able to immunize some of the children who haven’t completed their immunizations.  I know these days many Americans on both sides of the political spectrum think vaccines are dangerous; the diseases they prevent, like rabies, are still out there in the wild just waiting for us to let our guard down.  I find myself wishing they would get a case of measles.  Not complicated measles, which is not rare.  Just measles.  Maybe that would change their perspective. 

All districts must check hearing in the 6th grade.  But Sunnyside additionally weighs, measures and checks vision of their students pre-K, 2nd, 6th and 9th grade.  Nobody else in the Tucson valley is doing this.  They don’t have extra money; they just decided it was important. 

Because of their work, we have the first step to obtaining obesity data on middle school kids in Tucson.  From there, we hope to get the other districts involved and have county-wide data on public school 6th graders, which likely would be some of the best data in the state, if not nationally.  I’m pretty excited about the prospect. 

It was eye-opening to watch the kids leaving the school going home.  There weren’t a line of large SUVs and vans picking the kids up.  Many actually walked home.  Imagine that.  The houses down there aren’t six to seven figure ones up in the Foothills.  Their parents aren’t movers and shakers.  They can’t home school their kids.  They are too busy trying to scrape by.  If they don’t have public education, how will these kids get educated?  Or is it just too bad and they should just stay in entry level jobs and be house or yard cleaners because they can’t do anything else? 

America has given three things to the world — liberty, the national park system, and public education to support a vibrant middle class.  None of these has occurred as quickly or as effectively anywhere else.  In 1966, I learned what LIONS Club stands for “Liberty, Intelligence.  Our Nation’s Safety.”  Exactly how are we going to educate millions of children without public education?  Who is going to pay for it?  Or will volunteers step forward?  Why not have volunteers step forward to save public education?

Will this be an America where people don’t vaccinate, and visitors will need vaccinations the way I needed a yellow fever shot to go to Africa?  Already, immunocompromised children can’t go to day care centers, because there are too many unvaccinated children.  Will this be an America where we end public education, because it is a government program, and all government programs (except defense, of course) are bad?  Should people should be free to do whatever they want, including logging the rest of the redwoods and old growth forest, mining the national parks, taking oil out of ANWR, because somebody rich has bought the land and can do whatever they want?  Is this why I, among only 7% of Americans, served America in uniform? 

If we end education, health care, food stamps, social security and Medicare, we will have people on the streets the way we have stray animals, lots of people, because the fundamentalists would have banned birth control, too.  We’d have people dying horrible deaths from treatable conditions, the way stray animals do.  Isn’t that a death panel?  And I don’t consider a stray animal an “only,” having taken in many.  Indeed, I rank companion animals above the Norquists and the Newts of the world.  Reread that. 

Those who espouse smaller government have not been in these schools, learned nothing from Katrina and have not been down to the county public health department. 

I don’t know how big our government should be.  But I do know that leaving people unregulated is akin to a fraternity house on a Sunday morning, the economy a year ago, the 60 to 37,000% fold difference in frequency of medical procedures depending upon where you live and worse driving than we already see.  How much do we regulate?  As much as we need without doing too much.  And what would that be?  I don’t know, but we better start figuring it out as a country and soon.

In these pages, I have stated that I am not religious.  But I think we have a duty as human beings to help make our society better.  Sometimes by saying no, we make things better and by saying yes, we make them worse.  Sometimes we should leave people alone; other times, we should step in.  Those who argue solely from one side are as wrong as they are loud and nasty, and I have never heard an ideologue naturally laugh, not once, nor make fun of themselves, which healthy people do. 

Those who read my columns are in general well off in life, probably wealthy.  One of my mottos is “Those to whom much is given, much is expected.”  Give of your time, your knowledge and your resources to make this country better.

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