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GIVING BACK TO THE COUNTRY

January 7, 2012

n the visitor’s center in Waldport, Oregon, mid-way down the Oregon Coast, is a sign that reads:  Federal Emergency Administration of Public Works, 1936, Project #982.

This project was a bridge over Alsea; the river flows into the Pacific about 0.5 nm after the bridge crossing.  The original bridge no longer stands, having been replaced by a new span in 1993.  Outside the visitor’s center is a wall covered with plaques of names of people, who wrote their names, all volunteers in helping with traffic, explanations of the need for a new bridge, and other jobs.  At the top, on the right side, are the names of my parents.  My father showed that to me in 2003, his last summer up there, and the only one of the 30 summers he spent there alone.  I will not visit Waldport without looking at their plaque.  This time, I viewed it with sadness, happiness, but no tears.

I don’t believe in turning back the clock to the “golden days,” which weren’t so golden (cars broke down a lot, more people died in transportation accidents, Jim Crow, the Poll Tax, and the KKK were all alive and well), but I do believe in learning from history.  I had hoped we would have learned from Vietnam, before our “misadventures” in the middle east.  We didn’t, other than to support the troops, so long as most of us didn’t have to change our lives one iota.

I also believe that maybe we can learn from the ideas engendered by the Great Depression, where we put people to work–honest, hard work–rebuilding this country’s infrastructure.  It used to take several weeks and ferry crossings to traverse Oregon from north to south.  Now it can be done in a few hours, although the coast itself should require a few days.

A few kilometers south of Waldport is Cape Perpetua, about 300 meters above the Pacific with a trail, a tunnel through rock, and a park that was built by the CCC, whose abbreviation everybody should know.  We need a new version of the CCC, a need for volunteerism, a need for giving back to this country.  I had hoped in 2009 we would see this, but I was wrong.  We need it, and I know I am right.  I am often right, and I wish I weren’t.  I wrote a column on that a while back.  I make mistakes, but I admit mine, and in the need for mandatory national service and volunteerism, I am about as right as I can be.

We need those who have to give freely to those who do not. Interestingly, this is one of the five tenets of Islam.  That statement, I’m sure doesn’t go over well, but fundamentalists of all sorts are dangerous.  American fundamentalists blamed Katrina on homosexuality, rather than on a rather normal way for the Earth to remain in heat balance.  That is, of course, why we have tropical and extra-tropical cyclones.

We need those who have to give freely to their country, by giving of time to a variety of secular organizations in this country.  I have no problems with people who give to religious organizations, but to me giving to the country as a whole, in some other way than to a specific religion, is required.  I can name several possible places, besides rebuilding our infrastructure, so that Interstate bridges in Oklahoma and Minnesota don’t fall into rivers, trains don’t derail near Kingman, because water washed out part of the rail bed.

I think we need volunteers in the public schools.  We need people to tutor, before, during, after school and on weekends.  We need people to help kids of all sorts get outside and exercise more, as well as to teach good eating habits.  That might help with obesity.  We need people to actually measure some of these outcomes appropriately, the way I did for free, so we know what works and what doesn’t.  Things that don’t work are still good, if we learn from the mistakes.

I think we need volunteers in animal shelters and to teach the next generation about care of animals, which correlates highly with care of people.  Animal cruelty in the young is a red flag for real trouble as an adult.  Did I mention that leg hold traps and cock fighting used to be legal?  How about two other words:  Michael Vick.

We need people who are fluent in other languages to help out in public places, be it airports, hospitals, or national parks.  One of my dreams, that probably won’t become reality, is that I will be able to do that adequately in German some day.  We need volunteers to teach people how to read, since a frighteningly high percentage of Americans cannot.

I see volunteers who wear large V pins, red, white and blue if they are a veteran, blue (for justice, since that is what the blue in our flag stands for).  They can have stars for 1000 hours, and they would pay for the pin, a nominal cost, whose funds would be used for something special in this country.

I think citizen science should count as volunteerism:  the annual Christmas Bird Count is one example, where we have learned a great deal about birds, including the fact that nearly two-thirds have moved significantly further north in the past 112 years.

We need volunteerism.  Oh, there would be mistakes, but it would help.  I’d love to wear a V pin in a school, teaching children math, physics, chemistry, or English.  I’d love to wear one in the canoe country of Minnesota, where I’ve logged over 1000 hours.  I’d look on others wearing these pins as my colleagues.

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JUST CUBANS

October 27, 2011

In 1900, Cuban meteorologists knew a big hurricane was going to strike the US.  We had our own US Weather Bureau (as it was called at the time), and since we were Americans, and Cubans were–well, Cubans–we did not believe them, even though Cubans had a great deal of real world experience with hurricanes.

The 1900 hurricane that destroyed Galveston is to date the single biggest weather disaster to strike the US.  The destruction of the city was not preventable; the massive loss of life was.  Unfortunately, arrogance trumped science and listening to people who might know what they were talking about.  It is a recurrent theme.  Congress passed a resolution stating that man-made climate change is not occurring.  I wonder when they can tell me when Tucson’s average temperature for a year will again be normal.  It has been above normal every year since 1984, and the normals have been raised 3 times.

While they are at it, perhaps these same people can tell me when Tucson will again have normal rainfall.  It isn’t just warming, it is ocean acidification, changes in rainfall patterns with floods and droughts longer lasting, and earlier springs, affecting animal life.  Two-thirds of the birds in the Christmas bird count have moved significantly northward.  Dust from Chinese pollution is falling on snow in the Rockies, leading to earlier snow melts and changes in water level.

A while back, a person challenged me to “prove” global climate change without using models.  As a scientist, and especially as a statistician, I use models as a way to depict the world.  A model is a map, and I would no sooner work without models than I would go into the wilderness without a map.

Perhaps this particular individual, who sold real estate in Phoenix, had no use for models.  After all, the mathematicians who created models for the housing market assumed that housing prices would never fall, which is a remarkably dumb assumption.  Worse, purportedly smart people believed these mathematicians.

I work with models in statistics; I use and am familiar with at least nine different weather models for predictions.  Would we do away with models for predicting a hurricane’s path?  Maybe we will, in the new America.  After all, models are an attempt to use science, and many presidential candidates are already anti-science, even as they use aircraft, electronic devices, and the media, all of which were developed by science.  Many are alive today, like me, because of science.  To deny science is to turn back the clock, and  that deeply disturbs me.

I hope everybody noted the science used with Hurricane Irene.  The models originally had Irene hitting Florida, then progressively changed as new data came in.  This is science at its best, changing predictions in the face of new data, not being afraid to admit that the Hurricane might miss the East Coast altogether, but that it would be unlikely to do so.  Should we just hope?  Is that the new America?

Why should I have my hands tied when I am asked to prove something?  We do guess what natural phenomena will occur.  But why should we do uneducated guessing?  Are the models right?  No, they aren’t.  If anything, they are under predicting the severity of climate change.  And they might be wrong, although they have confidence intervals, which is a measure of uncertainty.  If you don’t understand confidence intervals, that is fine.  You just shouldn’t be arguing against climate change.  True scientists admit where there is uncertainty, try to define it, and draw conclusions, just as clearly as physicians tell their patients what they can expect, knowing that there is a certain degree of uncertainty.  Unfortunately, many physicians, being human, are often shocked when they learn how their brain can play tricks upon them in dealing with uncertainty.  (How many people do you need in a room before it is more likely than not that 2 have the same birthday?  Answer:  23)

If I lived on the east coast, I certainly would not be using my spiritual beliefs to predict whether a given hurricane would strike near my house.  I would be tuned into the National Weather Service and looking at what the models show–the cone of uncertainty and the probability of a hurricane’s striking me.  To do anything else would be stupid.

Since I live in this world, I am using what scientific models I can find to determine what the world will be like in the next 30 years, hopefully my lifetime.  I know these models aren’t accurate, but I believe in facts such as ice core analysis, oceanic warming, oceanic acidification, and what appear to me to be major changes in rainfall patterns, with three 500 year floods in North Dakota in the last 15 years, a prolonged drought here, and in Africa.  Perhaps I am just over worried and not scientific, but again, maybe this is all normal.  If it is, perhaps somebody could tell me when we will return to the temperatures and the rainfall that we used to have.

I just want an answer with a number, the word “years,” and a confidence interval. I don’t need any reading material.  How long?

 

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HARRY TRUMAN WOULD HAVE KNOWN WHAT TO DO

October 26, 2011

I had a a screening colonoscopy recently, which went very well.  The process for check in, the procedure, and the departure went smoothly.  It ought to.  This center does thousands a year.

The bill for everything was about $4000.  We know that screening colonoscopies catch early cancers and can be treated at the same time.  It is a great test.  It helped me 10 years ago.  Early colon cancer, as far as we know, is completely treatable, and this is one of the common cancers.  We cannot say that for sure about breast cancer, because it is entirely possible that many of the early cancers might stay that way.  But certainly screening mammography has some value.

Here we are, with an expensive test that clearly can save lives.  You can think of many others.  I had insurance.  If I didn’t, well…. I guess I take my chances and hope.  Many Americans do.

How do we as a country provide better medical care to our citizens?  It is clear that our care is suboptimal.  Nobody counts errors in care, which I tried to know more than a decade ago.  Nobody knows what percentage of people who need screening colonoscopies–those over 50 and those with a family history–get them.  And I am not even mentioning the other cancers and the other biochemical screening that we should do.

Of course, I don’t have time here to mention how we provide after illness care without bankrupting the country.  I just think we should do better than we do.  My detractors will probably say we have the best care in the world.  Perhaps, at some places, we do.  I would like to see good data.  But nobody can convince me we have the optimal care for people given costs and illness burden.  We do not.

And we will continue not to.  I saw what happened during the insurance reform debate.  It was called health care reform by the media, and it had nothing to do with care.  I bet my career on improving care and lost.  This was about insurance reform and little else.  We polarized the country, and those who have not treated as many dying patients as I have (including family members) had the gall and the audacity to call end of life planning, something only 30% of us have, “death panels”.  We polarized the country, in large part because those who had theirs cared not a whit for those who did not have care.  Many decried government’s role in health care, even as they were receiving Medicare or were in the military.  This is a fact.

What is the best answer?  I have my thoughts.  I want my detractors to come up with an answer, and I want it now.  I want it to be put to the House of Representatives and the Senate, and I want it enacted now.  If America can afford a trillion dollars for one war that was not necessary and another that is no longer necessary and cannot be won, then America can afford a trillion dollars for improving what we have now.  We can call it an “emergency authorization,” as Mr. Bush did, and keep it off the budget, so our finances don’t look so bad.  It worked for Mr. Bush, so it should work now.

I’ve offered my solutions to deal with waste and to improve the care we give.  I have been slammed for it.  So to my detractors, I ask, time to stop slamming me.  I have offered my solutions.  You offer yours.  No rhetorical questions, please.  Just tell me, how do we screen people for colon cancer in this country?  How do we screen for other issues?  How do we care for those who do not have 7 or 8 figure net worths and do not have the good fortune to have medical insurance?  How do we prevent things better, and how do we have efficient treatment for the most common medical conditions?  How do we allow people to die when it is time, and how do we deliver good care to those who bodies are failing but whose brains are fine?  How do we deliver good care to those whose brains have failed but whose bodies are fine?  How do we quit when we should, and how do we know we have done this appropriately?

I have offered my solutions to these problems for the past quarter century, without success.  I am now dealing with my own medical issues.  I want solutions, I want them clearly defined, I do not want personal attacks, which are cowardly, I just simply want the country to run better.  That to me is patriotism.  If the Republicans do it and take credit, good.  They should deserve it.  If the Democrats do, then also good.

We would do well to heed the comment by one who cut waste in government, and was called by one of the leading House Republicans as a patriot–Harry S Truman. Mr. Truman once said, “There is no limit to what a man can accomplish if he doesn’t care who gets the credit.”

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SWIMMING WITH THE ORCAS

July 17, 2011

“In nature, there is no right or wrong, only consequences.”

An Alaskan cruise ship happened upon several deer swimming across an inlet.  Suddenly, several Orcas appeared, attacking the deer, killing the whole group.  The passengers screamed, begging the captain to “do something.”  There was, of course, nothing the captain could do.  Or should have done.  This is how nature works, predator and prey, survival of the fittest.  It is terrible to see it, but deer feed other animals as well as to breed and make more deer.  It is the way of the world.

Unfortunately, I didn’t like the way of the world when lightning caused Minnesota’s Pagami Creek Fire,  It was monitored, because wilderness fires are beneficial phenomena to the ecosystem. Jack pine seeds can only open after a fire, and I’ve seen large forests of young jack pines 10 years after a major burn. Unfortunately, one day the fire exploded, running 12 miles, ultimately burning 92,000 acres.  Regrowth has already begun, but I will never again travel my favorite route to Lake Insula.  It is the way of the world.

Large fires have burned huge swaths of Minnesota, the last big one in 1918.  That fact has not stopped many on the Iron Range from blaming the fire on the Forest Service or “radical environmentalists” like me. Scientists know fire belongs; if there is anything “radical”, it is the idea that forests, like life itself, are immutable.

Often, those who decry big government are first to ask where government is when there is a disaster.  FEMA was decimated in the name of smaller government, until Katrina, proving the adage to some that government can’t do anything right. I might counter with “Lehman Brothers.”  Wildland firefighters, who save so much property and risk their lives, are part of “big government”.  A PCMS member once made a pejorative remark to me about “government doctors.”  I think those of us who were medical officers, including the VA physicians who trained all of us, might feel differently. The previous Vice-President, who never wore a uniform, referred to those 16% of us against the Iraq invasion as traitors.  I want every president to succeed, because if they fail, we are in big trouble. If being against a war is treason, wishing a president to fail is the same, unless there is a double standard.

Big government cleaned the air (under Nixon) and the rivers, because corporations would not do it voluntarily. Accountants do not factor environmental costs in the bottom line.  When free markets fail because of greed or poor planning, big government must step in. If government is bad, then it must not interfere in the bedroom, marriage, and how I should decide to die. Drowning government in a bathtub would appear, in my world, to drown national defense. I don’t want that.

We did canoe in Minnesota, just not where we had hoped. While the fire was beneficial, we are likely to see more of these as boreal rainfall patterns are changing to a savannah-like ones with floods and droughts, rather than even, a phenomenon ascribed to climate change.  The oceans are more acid, the Ksp (solubility product) of calcium and phosphate will now, with 30% more hydrogen ions, cause deterioration in shell formation.  This is a major concern, since the oceans are acidifying at a rate 100 times faster than ever recorded during the past 20 million years.  Carbon dioxide + water=carbonic acid.  Nearly every glacier is retreating, and the volume of cubic kilometers of fresh water entering the ocean will further change the climate.  This isn’t bad, it just is, unless you are human, live on a coast, eat seafood, or get your water from a glacier, as do Peruvians and Indians, in which case it is a huge concern.

Every prediction of the future must quantify uncertainty; to do otherwise is unscientific. Not one argument I have heard against climate change has stated a p-value, confidence interval or margin of error. The late Sen. Moynihan said “you can choose your opinions but not your facts.” The IPCC is 95% confident, which we statisticians consider high. Using a cold week or a record low as a counterexample shows an inability to distinguish between local weather and global climate, which is basic to understanding climate change. For the record, in Tucson there have been 6.5 times as many record highs than lows since 2001 (142/22). This is a fact.

Not one argument I have heard against climate change has been free of personal attacks.  These attacks, having nothing to do with science, obscure the issue, ironically diluting and degrading the writer’s thesis. The subject is climate change, not what hikers wear.  I have discussed the science using statistics, which may be confirmed.  To clarify, I have been to ANWR twice, hiked 120 miles in three of its major river valleys, including 1002, and I find it and Antarctica among the most beautiful places on Earth.  I strongly disagree with those who disparage ANWR or climate change without having ever seen or understanding each respectively, and I have considerable knowledge of both topics.

Of course, some scientists, ever fewer, do not agree, but the vast majority of reputable scientists believe manmade climate change has occurred. Per cent occupancy of the globe is statistical misuse: 70% of the planet is water, and vast stretches are desert.  Fukushima is 0.0003% of Japan’s area, but radioactive Cesium contaminated 10% of the country. It is the way of the world that as a statistician, I frequently see statistics misused (99.999996% of aircraft flights in the US were not hijacked in 2001).  Mankind has never encountered CO2 levels this high.  We are running an uncontrolled experiment; worse, models are under-predicting the consequences. The average temperature has risen, overall weather patterns have changed and the higher sea level has already caused problems. These are facts.  It is the current way of this world.

When I was a neurologist, I often delivered bad news.  I do so again as a scientist and writer.  As a physician, I changed my patient management in the face of convincing evidence.  I believe I have convincing evidence about the world’s climate. I believe if nobody speaks out against those who disagree, and I continue to be polite with my word choice, misinformation will continue. I am calling them out; I will not be silent.  It is the way of my world.

The voters who elected this Congress believe that they will benefit from smaller government.  Ironically, many of these voters will need SSI and Medicare, which may be cut.  They are deer, and they actually want to swim with the Orcas.  It is, sadly, the way of their world.

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TRYING TO BE CIVIL DURING A CIVIL WAR

March 10, 2011

Twenty-five years ago, I went to trial for alleged malpractice.  During the trial, the plaintiff’s lawyer kept quoting a neurology book, trying to make it appear that I practiced below the standard.  Each time, I asked to see the passage, and each time, I read the paragraph before and after the lawyer’s quotation.  He was quoting out of context.  He was lying, to make a point.  The third time I asked for the book, he literally threw it at me, on the stand.  Several jurors actually gasped.  For the first time, I thought I might not lose.  I didn’t, but of course in a malpractice trial, a physician never wins: it is lose or not lose.

I question whether the U of A’s new to promote civility will be successful.  I will try to be civil in my comments.

I find it difficult to be civil to those who did not serve this country in uniform, but are quick to support our military in our many misadventures that have cost hundreds of thousands of lives and trillions of dollars.  I was among the 16% of Americans in 2003 who thought invading Iraq was a bad idea.  I was right.  I am often right on the big issues, not that it matters much.  The bullies and the jerks usually win.

I find it difficult to be civil to bullies who use ideology, rather than facts, to call those who disagree with them unpatriotic, and sold a war that has been so costly.  These bullies polarized the country.  Worse, the media supported them in the name of “balance.”  We allowed the debate on health care to be uncivil, allowing words like “death panels” into the national discourse.  My opinion piece was entirely civil, factual, and appropriate, since I have dealt with death and dying many times when my colleagues were quite happy that I, and not they, would.

During the last total lunar eclipse, CNN interviewed two astrologers, no astronomers, because the eclipse happened to occur near the solstice.  Is this what America has come to?  I will ask:  what does a total lunar eclipse require, and why does it occur?  Can you tell me why we have seasons?  Can you tell me how you would determine the number of square feet in an acre and how many square kilometers equal a square mile?  Can you tell me what case follows the word “between”?  Do you know where Guadalcanal is, why it was important and what Marine Division has it on their emblem?

I find myself difficult to be civil to those who disparage science, want to take us back several centuries, at the same time enjoying their cell phones, cars, food and water so safe we don’t think about it.  I find it difficult to be civil when I am in a minority of Americans who believe global climate disruption is occurring and man caused.  And I will not argue this with anybody, unless they (1) avoid all use of pejorative language, (2) use statistical terminology and (3) state the consequences if they should be wrong.  I have yet to find anybody who can do this. I find it difficult to disagree so without being disagreeable, for I see these people and others destroying a country that I served as an officer in uniform, and at least 98% of Americans have not.

I find it difficult to be civil, when 10 years ago I proposed a reporting and counting system for medical errors, which failed.   And do we know the scope of the problem in 2011, and have we improved our care?

I find it difficult to be civil to those who received complete data on 6th grader obesity–from 5 middle schools–promised to help, and didn’t.  Tucson has a grant to deal with this problem, when with a few volunteers from PCMS and the school of nursing, we could have obtained data from every middle school in the county–free, since I would not have charged for my data analysis.

Do we have any data this year?  None that I know.  The principal at one of those middle schools yelled at me, uncivil, although we were helping him meet his mandate.  What is happening in his school?  Is the median BMI still at the 89th percentile, rather than the 50th?  Are 14% of his students still above the 95th percentile and 7% above the 99th percentile, 3 and 7 times the expected values, respectively?  Is his school representative of the county?  Does anybody care?

What we need in America are volunteers, service, ideas, hard data, willingness to say “I was wrong,” and polite, respectful discussions with willingness to listen.   It is time we say “no more” to those who deliberately lie to push an agenda.  It is time that we and the media gasp, like the jurors did in January 1986, call these bullies out on their lies, because equal time requires equal facts.  Bullies must be stopped, whether high school students, lawyers or fat old non-veterans who deliberately lie on the public airwaves.

I took my skills out of medicine to other fields.  I now wonder whether I take myself and my skills out of this country, which I see as in major decline, because of lack of MY “family values”:  education, politeness, population control, caring for the Earth and all its living beings.

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YES, I WAS RIGHT, BUT I WISH I HADN’T BEEN

June 17, 2010

When I saw a familiar ship steam into Subic Bay and moor, I decided I ought to visit to check out their sick bay.  It would be the only time in our 8 month WESTPAC deployment my ship and theirs would simultaneously be in the same port.

It was a wise decision.

The other ship had a corpsman, and it had been one of my ancillary duties to ensure their medical readiness for deployment to the Western Pacific.  Before boarding, I had received a list of their deficiencies:  instruments still wrapped in cosmoline, poor record keeping and outdated supplies were the worst.  On my first visit, I additionally discovered their Executive Officer (XO) was a Type I diabetic, who apparently varied his insulin depending upon how he felt (this was before blood glucose monitoring). The ship was a floating medical mess, and I told my shore-based medical boss my concerns about the XO.  He ordered me to ignore the diabetic and do whatever else it took to get them ready.

My adoptee vessel would spend time training at sea when my own was in port, giving me opportunity to ride her and fix deficiencies.  So, the following week, I boarded for three days of steaming 50-100 miles off southern California.  After morning sick call, where the corpsman was thrilled to have me, we got to work cleaning instruments, removing outdated supplies, ordering new ones, re-organizing the department.  We had a lot to do; unfortunately, their ship rode a lot worse at sea than mine.

Later that morning, I took a break to the bridge wing, watching California recede, when the Captain came up beside me.  I saluted, he returned it, promptly ripping me a new one:  “I don’t appreciate your trying to torpedo the career of my XO.”

Stunned, I replied,  “Captain, what are you talking about?”

“Your concerns about his diabetes went to the Commodore, and I had to answer to him.  My XO sees a full Captain at Balboa (the Naval Regional Medical Center), who knows far more about diabetes than you do.  So stay out of this, doctor.”

He walked away, not returning my salute.

The Captain at Balboa did know more about diabetes; I was 3 months out of internship.  But I was a shipboard doctor, and he almost certainly never was.  We had shore based physicians who sent sailors back to the ship with instructions not to climb, when we dealt with ladders dozens of times a day.  Another said a sailor couldn’t return to a ship because of exposure to salt spray, as if we were a catamaran, not a 14,000 ton vessel where I stayed drier on a Pacific crossing than a 5 year-old at the beach.

I felt relaxed that December day in the Philippines when I went to the other ship.  I had made their medical department ready for deployment.  I taught the corpsman everything I knew about diabetes and on a routine physical of a crewman discovered an abdominal mass that was lymphoma.

I asked permission to come aboard, saluting the colors and Officer of the Deck (OOD), saying I could find my way to sick bay.  As I walked down the passageway on the 1 deck, the corpsman practically ran me down.  “Quick,” he said, “The XO.”

Surprise, surprise.

We rocketed up 3 ladders topside to the XO’s stateroom, where I found him sweaty, uncoordinated with slurred speech, a vial of insulin and a glass of orange juice on his desk.  Fortunately, I had ensured the emergency kit had an amp of D50, 50% sugar.  I told the XO to lie down, found a vein, and injected.  Within seconds, he was normal.

We had the OOD call the local Naval Hospital and the Chief Staff Officer, (CSO), the squadron’s troubleshooter.  The CSO was superb; he and I took the XO to the hospital for admission, his sea career finished after 14 years.  He would never command a ship.  Worse, the ship needed a new XO immediately, difficult in mid-deployment.

I had been proven right but felt like hell.  I wish I had been wrong, the XO having no further problems, eventually wearing the 5 pointed star in a circle signifying command at sea.  But I knew he never should have been aboard.  I occasionally wonder why I went over to their ship that day.  Like the lady and the tiger, I wondered had I not been there whether he would have taken/given insulin or orange juice. Not surprisingly, I never heard from the Captain; the CSO, however, thanked me profusely.

We all like being right, dreaming about revenge upon our detractors.  I was right, not because of brilliance, but because common sense, my medical training and probability dictated a brittle diabetic had no business being second in command of a deployed warship.  I’ve been right on many other issues for decades:  climate change, too many carotid endarterctomies, diagnosing depression in patients who thought I was saying they were crazy, chronic pain being highly correlated with not at fault injury, the need for a medical error reporting system.  I wasn’t brilliant; all I did was to observe nature and people, be realistic, use science, probability and tried to avoid magical, irrational, ideological behavior I and all of us are prone to. I often wish my conclusions were different or I was wrong, but I try to follow the facts.

Whenever I want to say “I told you so!” I remember that time in Subic Bay.  Being right often brings no joy; it only means that one’s observations and conclusions are correct.

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MIND TRICKS

June 10, 2010

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.  Our minds can play tricks on us.  That’s normal.  But in the face of a compelling proof, failure to accept the premise borders on 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:

Number of People              Probability 2 have same birthday           Probability 2 don’t

1                                                   0.000                                                          1.000

2                                                   0.003                                                          0.997

3                                                   0.008                                                          0.992

5                                                   0.027                                                          0.973

10                                                 0.117                                                           0.883

15                                                 0.253                                                           0.747

20                                                0.411                                                             0.589

21                                                 0.444                                                           0.556

22                                                 0.476                                                           0.524

23                                                 0.507                                                           0.493

25                                                 0.569                                                            0.431

30                                                 0.706                                                           0.294

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?   The issue here is that having the disease and testing positive is very different from testing positive and wondering if one has the disease.  If the disease is rare, the likelihood of a positive test’s being a false positive is significant.  Here’s why, using 10,000 people and the above percentates:

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

If you test positive (148), a third of the time (49) you will have the disease.  The others are false positives.  That’s why we don’t do routine HIV blood tests for marriage.  In a randomly selected individual, and 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 Americans this year.  Mountaineering is a small community, and number of climbs is an incredibly 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, 1 to 110 million.  Yet people continue to tax themselves because “if you don’t play, you can’t win.”  You have far more likelihood of being struck by lightning or dying in a motor vehicle accident than you do winning the lottery.

Too many Americans play another lottery, the I’m sick do I see a doctor? 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.  But it doesn’t; instead, 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 will 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 $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 far more than a trillion dollars.  A trillion, by the way, is roughly the number of days since the Earth formed.  How many these costs 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 Americans to get decent, timely care and not get bankrupted by it.  This is America, not Zimbabwe, India or Tajikistan.  If you don’t like 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, that should all be picked up early–in America, again, not Tajikistan.

If that requires I pay more taxes, I’ll pay them.  I’d rather pay taxes for education and health care than for fighting, and not building schools in Iraq and Afghanistan, which is the fundamental solution to terrorism, not nuking Muslims and letting Allah sort it out.  We stop 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 me and three family members and really tired of the bickering that has stalled any kind of reform.  It is disgusting – and is un-American.

The America I served used to have innovative solutions to tough problems.  Where is that country?

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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-five.

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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