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RESIGNED TO MY FATE

May 1, 2012

I just resigned from my column “Reality Check” in the medical society magazine, Sombrero, after nearly a decade of writing.

I wrote about 80 columns during my tenure, and it is sad that I will write no more.  The writing made me better, for one needs to practice to write well.  And that is the primary reason I left.  There is now a counterbalance column, so to speak, to my  column.  The primary issue is not that the writer has a far right wing perspective, but that he writes poorly.  The magazine deserves the best writing possible.

This individual had his first column published a few months ago, and I was not told, as an invited columnist, that he would be a regular.  That was unfortunate.  The first column  was about climate change being not true, using evidence from 3 cold days last winter and a cold winter in Iceland as examples.  This to me showed an inability to distinguish climate from weather.  At the same time he wrote, northern Scandinavia experienced temperatures nearly 13 degrees F. (7 C) above normal throughout the autumn, and while I won’t say the presence of Sandhill Cranes over winter in Nebraska is due to climate change, any more than 3/5s of the bird species in the Christmas Bird Count have the center of their range at least 160 km (100 miles) further north, it is suggestive. Nearly every climate scientist thinks manmade climate change is occurring, and most of those who don’t believe the Earth is warming.  Those who believe neither are truly on the fringe.  Of course, the fringe might be right, but everything we are seeing suggests under predicting of the effect.  It isn’t just warming, it is the rapidity at which it is occurring, that is an issue.

Conrad Anker, the world famous climber, who is going to take a group of physiologists up Mt. Everest, says the change in the high altitudes is incredible.  Routes that were snow covered 35 years ago no longer are.  I can speak to changes in the high latitudes.  As Mr. Anker put it, if one plays golf in Kansas, one doesn’t see climate change.  But if one is at high latitudes or elevations, or happens to live in the Seychelles or Bangladesh, where the oceanic rising is occurring, it is another story.

The writer was in favor of drilling in the Arctic National Wildlife Refuge (ANWR), calling it a “god-forsaken place” where only “Birkenstock clad hikers go.”  I have been to ANWR twice, I think it is one of the most beautiful places on Earth, and I fail to see what hikers wear (I don’t have any Birkenstock outfits) has to do with climate change.  How much oil is in ANWR is a controversial subject; what is clear is that we should use every conservation method possible before even beginning to consider drilling in what many call the “American Serengeti.”

The editor of the magazine is libertarian-right wing, and has consistently argued many times about what I have said, yet he did not check these climate statements out.  The heat island effect is the simplest proof of manmade climate change; the rapid acidification of the oceans (pH has fallen 0.1 unit, which is nearly a 30% increase in hydrogen ion concentration) is a quiet problem that is going to devastate world food supplies, should there be an interaction between acidity and oceanic warming, which many scientists feel there is.  An interaction means that the sum of two variables is greater than simple addition.

Today, the new writer’s fourth column appeared; 8 column inches longer than mine, rambling, and with false statements, such as he paid $500,000 into SSI, when the current rate is about 5% on $106,000.  He said it would take him until age 137 to get that money out, when in fact if he started at age 70, it would take him 17 years to obtain $500,000.  This shows a lack of attention to detail, unwillingness to check important numbers for validity.

Edmund Burke once said, “All that is necessary for the triumph of evil is that good men do nothing.”  I have done plenty, without much to show for it.  In any case, it is up to the medical society to decide whether they want a writer who writes 1200 words of vitriol and doesn’t check facts.  It is not up to me to respond.  I will continue to post on my blog, where I will fire salvos when I think necessary, but pay attention to detail as well.

Would I return?  It is difficult to say.  I would have several requirements, and I don’t see any of them being met.  I am leaving quietly, with no fanfare, no final column, no goodbys.  It is the same way I will be leaving Tucson, when the time comes, now getting sooner.  I will leave quietly with no fanfare and goodbys to perhaps five people.

There are few things worse than staying too long, be it as a guest, a writer, a worker, or a sports star.  The best stop sooner, rather than later.  I won’t say I am the best, but I think I made a few people think.

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MUST WE DEBATE EVERYTHING?

April 4, 2012

1983:  I am in court testifying that a woman post cardiac arrest is irreversibly brain damaged.  Her husband wants to discontinue support; her sisters sued to keep her on the ventilator.  Nothing I said in the hospital had changed the sisters’ mind.  I knew the science and the outcomes of persistent vegetative states after cardiac arrest, and I agreed with the husband.  Eventually, he prevailed.

February 1988:  I show a nurse the conjunction of Saturn and Uranus in the morning sky.  She said they were in Capricorn (the proper name is Capricornus), but the two planets were visibly in Sagittarius.  I argued with her for 5 minutes before realizing nothing I said would change her mind.  Their next conjunction is in 2032.

Later, a man got a great deal of publicity for supposedly having discovered a new planet near Neptune.  I got a call at home from the man, who told me the planet was moving rapidly.  I stated that at Neptune’s distance from the Sun, the planet would move about a finger breadth at arm’s length every year among the stars.  No matter.  The man was convinced.  Nothing I could say would change his mind.

A physical therapist took me to lunch and told me that manipulation of the bones in the skull got rid of headaches.  I told him that skull bones were fused in adults.  No matter.  “It works!” he said; nothing I could say would convince him otherwise.

1984-1994: I said that the science underlying asymptomatic carotid artery stenosis meant that operations should be done only if the surgeon had a complication rate of less than 0.5%.  No matter.  Many were done at the hospitals I practiced; the major complication rate was 14%.  I got screamed at and threatened a few times, for intimidation, repetition, and reputation often trump facts.  I did not prevail.

2005:  Terri Schiavo.  Senator Frist, a physician, said she had cognition, despite clear evidence she was vegetative (smiling is part of the vegetative state).  Congress intervened briefly, an example of government’s dictating medical care if ever there was one.  Fortunately, science (amicus curiae brief by the American Academy of Neurology) and the court prevailed; indeed, the 600 gm brain with large ex vacuo hydrocephalus at autopsy confirmed what we neurologists knew.

March 2012:  I am in Tower Blind at Nebraska’s Rowe Sanctuary, guiding people to a suitable place to see the Lesser Sandhill Crane migration, one of Jane Goodall’s top 10 sights in nature and one of my top three.  As we waited for the cranes to land, my co-guide, an elderly woman, told me how she saw an egg stand upright on the recent equinox.  I said that can happen any day of the year.  The equinox is an instantaneous point in time, like the tangent to a function, with no influence on egg behavior.  No matter.  She was convinced.  Nothing I could say would change her mind.

More people believe in astrology than know why we have seasons.  Many believe we didn’t land on the Moon, that strange lights in the sky are aliens, who may abduct us.  A woman doing the luge at the Olympics held her neck in a certain way to “increase vertebral artery blood flow to the brain”; holding her breath would have been better.  Each of us has heard some remarkably odd ideas from people, totally convinced, totally wrong, about how the body functions.  Laetrile and colonic cleansing come to mind.

Our Sun is at least a second generation star, for elements heavier than iron must form in supernovae.  I believe in evolution and that vaccines are several orders of magnitude more helpful than harmful. I wish in the above instances I asked a simple question:  “Is there anything that you could learn that would convince you that you are incorrect?”  If the answer is “nothing”, then I am wasting my time.

We should change our beliefs when sound science shows that our beliefs are wrong.  When I learned that anticoagulation did not help vertebrobasilar insufficiency, I stopped using it.  When physicians at the University of Western Ontario discovered EC-IC bypass didn’t improve outcomes, they discontinued the operation.  They discharged four patients that very day.  There are many issues in medicine that we should study, in order to do the best for our patients; after all, each of us will be a patient.   We should discuss, not debate, the way we need to change American medicine, because I believe few are happy with the current situation.  We need to listen to and understand other points of view.  We must be willing to try new approaches, in order to learn from and modify them.  We need leaders able to convince people they can do great things that they never thought possible.  We need to use the best science available, even if it shows that our beliefs are wrong.

Children are born curious; alas, too many have it drummed out of them.  Perhaps if more were curious, we would look for answers, discover what we thought was true wasn’t.  That to me is moving forward.  Could I be wrong on climate change?  Yes. I don’t think I am, but yes, sound science could change my mind.  But I would rather discuss how we are going to fix medicine, locally and nationally.  My error reporting system has languished, unused, for 11 years.

I hope I am wrong about human-caused climate change; if I am, I will admit it.  Promise.

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LOONS, WOLVES AND OTHER NATIONS

March 13, 2012

Years ago, loons were killed in Minnesota, because they had the gall to eat fish that fishermen wanted to catch.

Anybody who has traveled the boreal wilderness knows that without the sound of the loon, the scenery would still be there, but the experience would be lost.  I have awakened on hundreds of nights to hear the sound of loons calling.  They have four different calls, and I love each of them.  Those who have not heard a loon in the wild, and that would be most, have missed one of nature’s great sounds.  Gavia immer is a heavy bird, because its bones are solid, not porous, so it can dive and stay underwater for a significant time.  The bird needs a few hundred meters to get airborne, but flies at 60 knots.

The wonderful ability of the loon to do so much is not unique.  To me, animals are other nations, not something we should destroy.  Loons are superbly adapted to the boreal lakes.  What will happen to them as we continue to overpopulate the Earth and damage their habitat, may spell their doom.  It’s just a bird, some say.  Well, there are many Americans who dehumanize humans by calling them Kaffirs, ragheads, and words I will never dare say to myself, they are so ugly.  Femi-Nazis has been used by Rush Limbaugh, along with his other vile comments.  Dehumanizing your enemy is perhaps a great way to win arguments and wars; however, the cost is horrific, not just in war, but how it has polarized American society.  Another way, common in my experience, is to take their words out of context, and deliberately replace them with charged words.  A lawyer did that to me one time in court, and I called him out on it each time. He finally threw a book at me.  In court.  Literally.  But I have others who do the same, former colleagues, some of whom owe me a lot, for what I have done for them, and I call them out on their language, too.  Words are important.

Fortunately, in the case of the loon, a few wildlife biologists did some good science to show that fish eaten by loons really did not adversely affect overall fish population.  Nature regulates populations well, and nature will regulate us, too, should we fail to do so ourselves.  What did affect the fish population were those who caught and didn’t release large fish, the breeders, who kept the population alive.  I know some guides, if they have a client do this, quietly go to another area on a lake to ensure their client catches nothing more the rest of the day.

During the Great Leap Forward, the Chinese killed the sparrows, only to realize later that sparrows kept insects in check.  Before one disparages the Chinese, we kill coyotes, which keep rodents in check.  Most everything belongs, including wolves, since they are, after all part of the ecosystem.  What is remarkable is the number of people, who profess being religious and patriotic Americans, who believe removal of predators a good idea.  In Alaska, people killed the national bird, the Bald Eagle, which is remarkable for a group that prides itself on being “real Americans.”  How many of you have seen a Bald Eagle or a wolf in the wild?  Perhaps it doesn’t matter, any more than reading a great book or listening to great music.  But I am better for having seen eagles, reading books, and hearing music.  Seeing a wolf in the wild, both of us alone, 4 meters away, was one of the best experiences in my life.

We face tough choices.  We have too many invasive species, and we must decide how to handle them.  None of the answers is easy.  We can bring in species to kill species, but new species can become a problem.  We can poison lakes, kill the fish, and then restock, hoping to remove invasive species.  Tucson Arundo removal is trying to remove one invasive plant.  Alone, over 10 months I removed 20,000 buffelgrass plants, another invasive species, in 8 acres, battling snakes, and heaving heavy bags up a berm.  Buffelgrass was imported from the African savannah into Mexico for forage about 80 years ago.  It was a bad idea.

Three months after I finished my work, it was like I had never been there.  Nobody cared.

There are no easy answers.  Sadly, there are plenty of talk show radio hosts and others who act as if there were.  Most of their answers are less government, which frightens me, less taxes, and more freedom.  Having seen how people trash the wilderness, even when they know the rules, I am frightened when I think what would happen without regulation.  Without regulation, we would have lodges all over the Boundary Waters and have dammed Curtain Falls, ruining Crooked Lake.  How many of you have seen Curtain Falls?

We would have logged every bit of forest, and we would have cell towers everywhere in the wilderness.  As I write, PolyMet wants to put a molybdenum mine in the headwaters of much of the country I love.  The company lawyers and managers say it will be safe.  Everything is safe, until suddenly it isn’t.  There won’t be an accident with the pipeline from the Canada tar sands to Texas, either, until there is one, and the Ogallala Aquifer is destroyed.  The Alaska pipeline was safe, until 1989.  Three Mile Island was safe, until 1979.  Unregulated, we would trash the forests, pollute the wilderness lakes, cut down all the trees, mine, and get rid of every government regulation, because people will do the right thing.

Yeah.  Right.  Have somebody tell you what it is like on opening fishing day for salmon in Alaska.

Eventually, of course, like the forests world-wide, the salmon, and the cod, the biomass will disappear.  A few will become very rich, support those who lie their way into public office and keep the cycle going.

Glad I won’t be around when the bill comes due.  Also glad we don’t have children who would ask why I didn’t stop it.  “Because I couldn’t” seems pretty weak.

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GIVING BACK TO THE COUNTRY

January 7, 2012

In 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 is sacred ground for me. 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 went to Senator Jon Kyl’s office to push the idea.  I received a letter from him saying it was a bad idea.  Senator Kyl has never worn the uniform of his country.  The fact he doesn’t support it doesn’t mean I can’t.  There is nothing stopping me from getting a red, white and blue V pin with four stars on it, wearing it in the schools, where I teach 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 wear it at Rowe Sanctuary in Nebraska, where I have logged about 500 hours.  Maybe a few people might be curious and ask me what it is all about.

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TOUCHING OTHERS

November 13, 2011

I never knew Jamalee Fenimore or Stephne Staples.  Nobody who reads this knew them, either.  Both of them loved the Sandhill Cranes, as do I.  Both have a viewing blind named for them at Rowe Sanctuary in Gibbon, Nebraska, at the southern bend of the Platte River.

Every spring, the Sandhill and the Whooping Cranes, the most and least common of the 15 worldwide crane species, begin their 5000-7000 mile migration to the subarctic in North America and Siberia.  Their final staging area is on the Platte River.  They go to the Platte because there is food nearby–formerly small animals, but now mostly corn–and because of the safety that one of the largest braided rivers in North America affords.  They feed in the adjacent fields by day and roost in the river at night, where the shallow water allows them to hear predators approach.  Before the Platte was dammed and water used for irrigation, recreation and drinking, it was a mile wide and an inch deep, “too thick to drink, too thin to plow.”

Now, the Platte in many areas contains less water, has invasive species and many trees nearby, limiting the suitable habitat to 50 miles from the former 200.  Rowe Sanctuary manages 4 miles of river and owns 1900 adjacent acres, preserved as habitat.  Every night, for 6 weeks in March and April, up to 600,000 Sandhill cranes, 90% of the world’s population, roost in the river.  Every morning, they leave.  It is a spectacle that Jane Goodall has called one of the world’s best.  I’ve been fortunate to have seen many great sights in nature.  This one is in my top three; seeing a solar eclipse and a wolf in the wild are the other two.  I love the cranes so much that I volunteer at the Sanctuary, along with dozens of others, helping the full time staff of four–that’s right, four–show visitors the cranes from viewing blinds, for cranes are shy birds and will not let people near them.

Many talk about the cranes that migrate to Arizona.  I simply reply, “You don’t understand.”  And you can’t, until you witness the a flock of fifty thousand cranes, darkening the sky.

Stevie Staples mentored one of the Rowe Staff and lived 74 years, dying in 2006 from cancer.  She was a former canoe racer and a real character.  I once raced canoes, and I would have loved to have discussed racing with her.  She touched the staff at Rowe.  She knew it, for she did live to see a beautiful picture of a Sandhill Crane in flight with her volunteer tag with “9 years of service” on it.  The picture hangs on the wall in the hallway of Rowe.  A picture of Stevie’s receiving the picture from the Rowe staff hangs in Keanna Leonard’s office.  Keanna is the dynamic educational director at Rowe.

Jamalee Fenimore grew up in Nebraska and practiced veterinary surgery in Washington State.  She died of cancer far too young at 49, donating her estate to Rowe.  Nobody at Rowe knew or remembered her being there.  But obviously, she was touched by the river, the cranes and the sanctuary.  We volunteers learn that we may touch visitors in ways we never know at the time.

When I volunteer at Rowe, I work 17 hour days, sleeping on the floor in the sanctuary so I can hear the cranes on the river in the middle of the night.  I guide people to the viewing blinds, and I teach them everything I know about cranes.  Mostly, however, I let people look at the sight, staying silent, so they can hear the birds.  I clean toilets, paint, greet people, make a noonmark, build a sundial, do whatever needs to be done.

On one tour, I took a disabled person to Stevie’s blind in an electric golf cart.  Had he been able to walk, all of the group would have gone to Strawbale blind, which had better views at that time.  But we still saw many cranes, American white pelicans, and unusual crane behavior.  My rider loved the view and tried to tip me, which I of course refused, asking him to put the money in the container at the sanctuary.  I planned to talk to other clients, because as the lead guide, I hadn’t spent time with them.  But I spent time with this man.  He was originally from Singapore; when I told him I had been there twice, his first comment was “Thank you for saving my country.”  I’ve never heard that before, and it did me good.  I hope I and Rowe did him good.

We touch each other in ways we may never know.  Good people spread kindness throughout their world.  The lucky ones receive that kindness or are those who live long enough to discover that their kindness was deeply appreciated and honored.  But all who spread kindness are fortunate that they have the ability to do so.  Stevie knew in her final days that her kindness was appreciated.  I hope Jamalee Fenimore did, too.  But if not, I know she knew she was doing the right thing.  I deeply appreciate what she did.  And every time I guide people to either of the two blinds, I tell them the story. Both women deserve to be remembered.  To have a viewing blind named for you on a river where a half million cranes visit every March is a wonderful honor.  I really can’t imagine a better one, frankly.

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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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YOU ARE ON YOUR OWN…THIS IS THE NEW AMERICA

September 3, 2011

While waiting in a physician’s office, I heard a conversation between an elderly man and the receptionist about what Medicare covered.  It was obvious the man had difficulty understanding, and from his demeanor, I suspect he had difficulty understanding day-to-day matters, too.  The prevalence of dementia doubles every five years over 65.  An 85 year-old has an even money chance of dementia.  No, 90 is not the new 50; don’t plan on it.

That sad fact was emphasized by my later hearing a story from an acquaintance who helps an elderly woman with shopping.  She called the woman asking what she wanted.

“I won’t have money for food this week.  They are going to take away my Social Security.”

Of course, this has not yet happened, although many bullies, loud and unwilling to negotiate, want to kill the program.  Imagine being 85, a widow (a plurality of 85 year-olds are widowed women), no longer think clearly, have a failing body, and start hearing about Social Security being taken away.

We must couple spending for Irene’s damage with cuts–incredibly, both NOAA and the National Hurricane Center are on the chopping block.  I find that incredibly stupid and shortsighted.  Maybe we end Social Security and Medicare, too.  Suppose, given 32 C temperatures in the Gulf of Mexico, since the oceans are getting warmer, that a Cat 4 Hurricane enters, headed  northwesterly.  We can take Mr. Perry’s approach with Hurricane Rita in 2005, and pray that it stops and turns around, OR, we can be sensible and have scientific forecasts, which while imperfect, will save thousands of lives.  I am assuming, since Mr. Perry once considered secession, that he will not take federal money for the $30 billion that it would cost to rebuild Houston. Texans can pass the hat. We certainly won’t cut socialized defense or $2 trillion for wars that we could not afford and lied our way into.  No worries, however.  The climate is fine, since Congress passed a resolution saying there was no manmade problem. Maybe Congress will forbid hurricanes, too.  In the new America I see, you take care of yourself.  If you don’t have money, you don’t get medical care.  Vaccines are bad, public education is bad, and the private sector does everything right, from half finished jobs in Iraq that have wasted more than $60 billion to having the airlines regulate security through 10 September 2001, that indirectly cost more than a trillion in the past decade.  How many times do I have to say self-regulation does not work before I am believed?

My screening colonoscopy cost me $4000.  I have insurance.  Those over 50 without insurance will roll the dice.  When the current President finally put the money spent on the wars in the budget, I could hear the howling in Washington from Campbell and Skyline.  Mr. Bush did it, and not I did not hear one person outside my house who complained.

Many people barely make it.  In the new America, they will go bankrupt, medical costs the single biggest cause.  I wonder how much colon surgery for advanced cancer costs.  Oh well, that won’t be my problem, so why should I care?

But I do care.  Liberals care about those who aren’t as fortunate as they.  The current radicals were remarkably quiet when Mr. Cheney said “deficits don’t matter”  in 2005.   If Mr. Obama said that, he would be impeached.  If he kept emergency authorizations off budget, he would be impeached.  If he asked for a trillion to restore our infrastructure, providing jobs, I would need earplugs.  If he asked to raise the top marginal tax rate back to 39%, where we last ran a surplus (under Mr. Clinton), repealed the Bush tax cuts and put a 0.125% tax on stock transactions ($1.25 for every $1000, raising $600 billion by 2020 just on the NYSE alone), a progressive tax, we might get the deficit under control.  He could also put an 80% marginal tax rate on bonuses given to financiers, who have been shown by excellent research not to add value for what they are paid.

There is waste in medicine, too. But my neurosurgeon saved me from neck surgery, my dermatologist saved my face from disfigurement, my gastroenterologist saved me from colon cancer, and a Durango orthopedist’s quick actions on my right hip allow me to backpack today.  We should do better in medicine, but we add value.  I think the teachers who inspired me deserve better, too, and I fail to understand why if the free market is so good, teachers and others, who add clear value, are consistently undervalued.  Lack of oversight and self-regulation severely damaged the world’s economy.  Those who did it made billions.

The elderly lose their bodies, their minds or both.  The young need care, too. What do we do?  Do we remove their benefits and make them fend for themselves?  Do we decrease the surplus population?  Is this America? Where is the outcry demanding we will NOT allow our poor, elderly, disabled and those who did not get a break in life to live a better life?  This is one of the most religious countries in the world.  Where is organized religion?  Where are the voters to elect people who believe America tries to help those less fortunate?

I hear two sides of a story, as if both sides have equal validity.  They do not.  One side lied on Iraq, climate disruption, and vaccine safety, and dared say end of life discussion was “death panels”.  I will never forgive them that, any more than the physician who argued against evolution by saying “it debased man to the level of the animals,”  which is about as unscientific as it gets.  You are wrong, your data are flawed, you bully, and you pervert science.  Sadly, more believe you than I.

I’ve offered my solutions.  I’m ready for the usual attacks, the flawed reasoning, the rhetorical questions and lack of solid solutions from those in the majority. Maybe I need to live in Canada.  America has lost her way, and those of us who have been saying it for a decade are ignored.

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ON THE MEDICAL-SURGICAL FIRE LINES

August 14, 2011

In 1984, I had data about surgical outcomes by surgeon for carotid endarterectomy (CEA) in two Tucson hospitals.  There was a 14% major complication rate and a 23% overall complication rate, clearly worse than the results that we knew about medical management of the condition.  I referred my potential surgical cases to only one surgeon, whose outcomes were comparable to medical management; many patients, when told that the local outcomes, refused surgery altogether.  I took a great deal of heat from my colleagues for my stance.  So be it.  My patients mattered more.

I saw far too many complications post-operatively when I had not been involved pre-operatively.  In my view, many of these procedures, especially every asymptomatic CEA, were not indicated.  Some agreed with me.  Not many.  That of course, isn’t the only turf battle in medicine.  There are many. Patient care quality is often mentioned; I wonder today how much outcomes data is collected, how well it is collected, and whether decisions are made based upon it.  I would hope so.  However, as a physician with advanced training in statistics and quality, I never was called upon in this state to offer my opinion.

Before last summer’s fires, I wondered how many in Sierra Vista, a conservative city, had decried big government, only to realize that they needed the resources of the National Interagency Fire Center to save property, lives and indeed the city.

The National Interagency Fire Center was created by combining of three governmental agencies to cut duplication (waste)–the US Forest Service, the Bureau of Land Management and the National Weather Service.  Eight different federal agencies are now part of the NIFC, which has no single head. That isn’t to say that firefighting is done without an incident commander.  There is one.  But the organization itself has no CEO.

Aside from cutting waste, the NIFC did one other remarkable action: they coordinated nationwide firefighting.  Instead of each state having its own cadre of firefighters, on duty only for that state, the condition of the COUNTRY was looked at, so that wild land firefighters in Oregon might be called upon to fight a fire in Utah, because the latter was more severe than any fire burning in Oregon at that time.

This approach required that firefighting managers in a state give up local turf for the good of the country.  Incredibly, they did.  And we are better for it.  Congress would do well to follow that example.

That isn’t to say that the NIFC always gets it right.  The Fire of 1910 colored our wild land firefighting thinking for decades as sure as a missed diagnosis often colors a physician’s thinking for the rest of their practice.   Sometimes fire fighters, in spite of their training, do the wrong thing, as in Colorado’s Storm King fire in 1994 or the Thirty Mile Fire in Washington in 2001.  But there were no calls to dissolve the NIFC, to hand it over to the states, or worse, to local people, to handle matters themselves.  The fire deaths were investigated thoroughly, and the mistakes publicized, in hopes that they would not be repeated, although the Storm King fire deaths unfortunately paralleled those of the Mann Gulch fire in Montana in August 1949.

Without the NIFC, Sierra Vista, Alpine, Greer, Springerville, Pinetop/Show Low would not exist as we know them.   To me, that smacks as government doing something right, something that government should do, that individuals on their own, no matter how motivated, simply cannot do.   It is quite easy to set government up to fail.  I see that today.  It is far more difficult, but far more rewarding, to set government up to do good, to step in where individuals simply cannot deal with circumstances that are overwhelming, like severe poverty, catastrophic medical emergencies, education, or natural disasters.  Katrina was bad; the gutting of FEMA prior to that put the US on world-wide display as an incompetent country.  How many died because of that?

How much government we should have is a matter of opinion.  Frankly, I am willing to pay taxes, and a lot of them, to ensure we have a country that properly helps lead the world.

Like the NIFC, government won’t always get it right. But I am incapable of defending myself from wild land fires or knowing if my food, water or an aircraft are safe.  I depend upon somebody in government to have firefighters in place, mandatory food safety inspections, oversight of the financial system, and an aircraft control system, so that the results of unpreventable disasters are minimized and we prevent what can be prevented.

I want to know which physicians are best for me, should I need a bronchoscopy, colonoscopy, back surgery, or have a carotid event.  I hope my colleagues have sorted this problem out by now, but I don’t know, despite bringing a wealth of skills to the table.  Perhaps we need a National Interagency Medical Quality System, assuming we can find enough people to give up some turf and do what is right for the patient.  Like the NIFC, they wouldn’t get it right all the time, but it would be a step in the right direction.  Heck, I might come out of retirement to serve, should anybody ask.

 

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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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