Boreal B[l]og

Remember Colton?  He was the young man who lost his girlfriend and job the same week and was likely to face foreclosure.  He now has another problem—a really painful tooth.  It hurt so badly he almost went to the ED, but he owed the hospital $2000, so instead he took aspirin and eventually got better.  But we know he’s headed for big problems and costs, with no insurance or medical friends who will cut him a break.

Yes, Colton’s life would have been easier had he been better educated.  I saw first hand how he and his sister lost ground when they were home schooled, which requires both special students and special parents.  As the son of a public school superintendent and a sociology teacher, I admit my bias favoring public education, because with 300 million people, it is the only viable approach – unless, of course, one believes that the poor and people of color shouldn’t be educated.  We need volunteers in the schools and the schools need to put them to work.  I’m now an on-call volunteer math teacher, math being the biggest need, but I’m only one guy trying to put his money where his mouth is.  Congress bickers about the cost of health care, but I’ve heard few discuss the cost of Iraq, for years deliberately hidden from the budget.  I don’t buy regime change, otherwise we’d clean out Zimbabwe, Burma, North Korea and Sudan just for starters.  Iraq has oil.  America has poor and sick people.  For 8 years, I heard deficits didn’t matter, when I thought they did.  Funny thing how the other side has now decided deficits do matter.

 But back to teeth.  Dentistry is the forgotten part of medical care and few have dental insurance.  I had braces for 8 years.  I was so sick of them, I didn’t go to a dentist for decades after, until my wife pointed out my bad breath; I’ve since had a root canal and a couple of cracked teeth needing capping.  I’m lucky; I can afford preventive dental care which makes my problems minor.

 Yes, Colton should have taken better care of his teeth when he was a teenager.  I ask:  when you were a teenager, did you brush twice a day, floss at least once and use a Water Pik?  I sure didn’t.  So, I’m not about to throw the first stone.

 There was an excellent article in Slate about the difference between British and American approaches to dental care.  In the UK, it is expected one gets dentures early.  Here, bad teeth labels one a hillbilly.  Don’t believe me?  Recall patients or others you’ve seen who had poor dentition.  Didn’t you think of them a little differently?  I label people differently if they misuse grammar.  They label me differently by how I look, dress or the odd things I like to do.  We all pre-judge.

 But it’s more than prejudice; it’s health, and we know it.  SBE and bad teeth.  Heart disease and bad teeth.  Facial abscesses and bad teeth.  Bad breath and bad teeth.  Caries give rise to what some call world stopping pain, and if you’ve ever had such pain you can’t function.  Poor people tend to eat the wrong food, don’t know much about dental care, can’t afford the time or money to fix their teeth, often lose work and can be miserable.  Having suffered from miserable conditions, I counted my blessings I didn’t have to work at the time.  How do these people put up with it?  Same way Colton did—aspirin, somebody’s codeine and a lot of hope.

 Let’s not forget dental care in our discussion of basic medical care, for prevention saves money.  A simple root canal is $1100.  Aren’t we supposed to help people relieve misery?  So why aren’t we doing it?  We’re talking teeth here, not Roux-en-y surgery.

 Colton needs to get on AHCCCS, but that won’t get his teeth fixed.  He’s 22 and headed for dentures before he’s half my age.  This was once the richest country in the world, and we could have dealt with these problems if we hadn’t decided upon socialized world policing and socialized nation building with our socialized military.  It’s time to admit we can’t afford our overseas commitments.  But even the Blue Dogs are silent on that one.

 Once again, here are 4 things we could afford that would help:

1. Cover all children’s medical and dental care until they are 18.
2. Limit the maximal debt people can have for medical/dental conditions.  I propose $50K but I’m flexible.
3. Put in an error reporting system, which I predict will decrease bad outcomes and malpractice case filing through learning.  Make it anonymous and non-discoverable.  And get it running in 6 months.  I know how to do it.
4. Tie any cuts in physician reimbursement to liability reform and a reporting system. 

I’ve been saying this for years.  Let’s try it.  If you disagree, then I recommend Oscar Rogers’ two step approach from Update Thursday.  It’s on my blog, under 2009 Reality Check, so you can click the link below:

http://www.hulu.com/watch/38477/saturday-night-live-update-thursday-fix-it

Step 1:  Identify the problem.  We’ve done that, so we’re half way there.

Step 2:  FIX IT!!

 It’s a bone chilling March morning in Korea, and the USS ST. LOUIS is off the southeastern coast, anchored at Pohang.  I’m finishing up in sick bay, having just seen my tenth case of gastroenteritis.  The last sailor told me word is spreading on board to stock up on absorbent paper products. 

Damn.  My goal was to get through the 8-month deployment without an epidemic.

I eventually learned we had distilled water from the harbor, violating Navy Regs, so we wouldn’t have to restrict water use or get underway to distill at sea.  I had questioned the Chief Engineer about our water supply and was assured we had plenty for the boilers and personal use.  I should have known better than to believe a snipe.

Several days and 300 cases later, an 80% attack rate, I was 10 pounds lighter, but the epidemic had finally “run” its course.  We were not fully mission prepared during that time.  To those who feel that funding military strength is more important than public health, I remind them that throughout history, disease has decimated military units and affected more troops than battle.

Many forget that Americans used to die from measles, cholera, typhus, rabies and tuberculosis.  Yellow fever devastated Memphis.  Malaria was as bad an enemy as the Japanese for the First Marine Division on Guadalcanal in 1942-43.  These diseases have not disappeared.  They are still out there, waiting,    waiting for us to let our guard down, to ignore the fact that the single biggest factor increasing our longevity has been improved public health.  We fortunately live in a society where many scourges are controlled – for now.

I remember how sick and photophobic I was with measles, which can kill one in a thousand.  A brother had polio; another mumps meningitis.  My father had tuberculosis; my mother scarlet fever and pertussis.  Americans used to fear crowds in summertime because of the risk of catching polio.  Today, these conditions make headlines; back then, they were “usual childhood diseases.”

Adjusted for inflation, Pima County has not increased public health funding in 15 years, despite a near doubling of population.  They are several employees under full staffing.  A bad economy not only decreases funding but increases demand, as un- and under employment increase.  Fees for immunizations, restaurant inspections, animal licensure, family planning, STD services and TB treatment will increase, because while such tests save money and misery, people now have short term,  more important concerns, like eating.  I predict more unwanted children, a food borne illness outbreak, increase in STDs, more unlicensed dogs and Arizona keeping its top ranking among the states for congenital syphilis.  I thought we were finished with that one. 

Immunization preventable diseases, HIV, MRSA, rabies and pandemic flu have no economic boundaries.  We take for granted no disease in the food we buy or in the restaurants we visit.  This is not a coincidence or the Eleventh Bill of Rights.  But we face a cut of $1.4 million from the local public health budget.  Cryptosporidium infected 400,000 in Milwaukee in 1993 and killed 100.  That bug is not restricted to Wisconsin; cholera is not restricted to Zimbabwe; bad lettuce not restricted to California; or bad peanuts to Georgia.  Lack of regulation kills people as well as making them unemployed and broke. 

Ten per cent of Pima County’s active TB cases are homeless, and we cannot afford to house them until they are non-infectious.  Nor can we afford to pay a radiologist to read their X-Rays.  Therefore, the number who complete therapy will decrease, fostering drug resistance and setting the stage for an outbreak, first in the homeless shelters, and from there, to the community — you and me.  Maybe people shouldn’t be homeless, but they are.  That’s reality.  Financial robber barons get bonuses for ruining the economy, TB and syphilis are making a comeback, and I feel I’m back in the 19^th century. 

We must make public health a priority.  There’s a lot of bad stuff outside the walls of our civilization, waiting for us to open the gates.  And that’s exactly what will happen if we inadequately fund public health.  Sure, I believe in the value of arts and sports.  But adequate public health allows people to live long enough to become artists or play sports.  It’s time that the public learns that vaccines save many orders of magnitude (10ⁿ, where n is order) more lives than they possibly hurt.  And it is time that the public learns that many diseases aren’t prevalent today because of scientific advances in general and public health in particular, not good fortune, vibrations, touch therapy or magical thinking.

A strong public health commitment here in Arizona and across America is an important part of national security.  Tell the Supervisors public health funding saves money and lives.  The department is already severely stretched to where further cuts will impact our safety.  Tell them if we ignore the benefits that come from good public health, we will reap the consequences that will surely develop.  Count on it.  Tell them the human and dollar cost of those problems will be incomprehensible and not amenable to sending good vibes or touching each other. 

Count on that, too.

Colton had a bad week: Tuesday, his girlfriend moved out.  Wednesday, the mines laid him off.

No question that Colton and his now ex-girlfriend, too young and unmarried, never should have bought a house together.  Colton was a high school dropout who eventually got his GED, but his money managing skills were poor.  He once bought a dirt bike because he read “monthly payment of $68” and didn’t read “for 5 years.”  He finally sold it for a large loss.

Colton’s mother told me how his buying a house would be good, since he wouldn’t “throw money away on rent,” would “build equity” and other platitudes pushed by the industry (beginning with “home,” instead of “house.”)  I knew that if everything worked perfectly, which it wouldn’t, Colton was headed for trouble.

I suspect he did not realize additional costs of ownership, like insurance, taxes, utilities and repairs.  I suspect that he didn’t appreciate that $4 a pound copper wouldn’t last, and when the price fell, his job would be in jeopardy.

We bought our house in 1977, after renting for six years in three different places.  Flexibility is a big advantage of renting.  Back then, down payments were 20%.  Our combined take home pay was four times the fixed monthly payment, a good rule of thumb, and we had job security.  Colton’s foreclosure will help keep Arizona among the nation’s leaders in that category, typical of places where the major industry is the unsustainable concept of permanent growth.  But when you live where individual rights trump common sense and education is an afterthought, foreclosure rates are among the nation’s highest and there is a payday lending problem.  Maybe that is why Arizona leads the nation in congenital syphilis cases.  I can’t prove it, but we probably have more than our share of animal hoarders and breeders, too.  The irony is how much these individual rights cost each of us, like the right to implant eight embryos in a woman with several young children or having another motorcycle accident victim in the ED who had no helmet and no insurance.

Colton had neither the education nor the judgment to buy a house.  One cannot understand finance without knowing how to manipulate numbers, but I’m repeating myself.  While he was childless, he moved back with his parents and will file bankruptcy.  I recently saw a bumper sticker on a giant Lexus SUV:  “Fight Socialism, show personal responsibility.”  Even as America under a Republican president embraced corporate welfare.  But the rich are different.  Just ask them.

Not all of us have personal connections, smarts, personality or luck to have scads of money to own such a vehicle.  While some of the poor are drunk and lazy, many are hard working folk whose only crime is not being young.  But most are women and children, ironic in a country that purportedly values the latter, ranking high in the developed world in birth rate and teen pregnancies, the last especially true in Arizona.  Individual rights and lack of education win again.

But let’s be clear:  Colton didn’t cause the financial catastrophe that in dollars is at least 400 9/11s.  Yes, 400.  I believe the financial community and politicians are guilty of treason for this largely preventable mess.  We had poorly understood financial instruments like credit default swaps, rampant speculation and gambling in what may have been a $60 trillion unregulated market.  Businesses like Enron, World Com and Tyco outright lied; loans were given to people to buy houses they couldn’t afford in a clearly overvalued unregulated “free” market.  Executives received obscene bonuses, perverting etymology, with tax dollars.  As a mathematician, I am ashamed at my colleagues who created models that failed to account for the possibility that housing prices could fall and incredulous that senior executives would believe them.  But that’s what happens when we base financial policy on ideology, rather than reality.  I hear the stock market “always goes up,” based on all of six decades’ experience applied to an America that today is a lot less productive of tangible goods than it was when I was Colton’s age.

My late mother, despite being a sociology teacher and an unabashed Adlai Stevenson liberal, often said “people are no damn good.”  If people did what they were supposed to, instead of being no damn good, we wouldn’t need regulation, for everybody would act appropriately, sometimes even against their economic self-interest.  If people were perfect, practically any system would succeed.

I find it hypocritical that many who decry the nanny state remain silent about financiers who put the world economy in free fall and now get free money and a free pass.  Those of us who are fortunate in life have some responsibility to those less fortunate.  The responsibility may not be financial but rather saying “no” at the proper time.  We used do that before the free market, free rides and free fall.  I believe in capitalism, but the idea that people will invariably behave properly without somebody occasionally reining them in is ludicrous, unrealistic and contrary to human behavioral science.  Heck, anybody who ever attended a MEC meeting should know that.

I just wish Colton had rented.

“Knowing that here on earth God’s work must truly be our own.                                                John F. Kennedy, 20 January 1961

From Sombrero, October 2009  

My mother once answered the front door and encountered two Jehovah Witnesses.  She was a Unitarian but remained polite, calmly stating she was not interested.  One of the Witnesses then said, “Don’t you want to live forever?”  My mother, not having a good day even before the doorbell rang, looked the Witness in the eye and retorted, “Certainly not.  I can’t imagine anything worse.”  She then witnessed speechlessness of two Witnesses. 

I am appalled at the lies stating the health care plan will have “Death Panels” deciding the fate of older Americans.  I’ve euthanized 12 companion animals; I allowed my parents to die naturally.  I know the difference far better than those who argue against the plan.  I was respected as a neurologist with the knowledge, skills and willingness to deal with families of patients with severe or irreversible brain injury, issues where a patient’s death was either likely or the best option.  It was tough, thankless work that wasn’t paid for, often unappreciated, but I took charge and did it well when it needed to be done right.  The elderly are far more worried they will be kept alive on machines too long than having the plug pulled too soon.  A family friend with severe neuropathy feared he would suffer the fate of Terri Schiavo and be kept alive against his wishes.  Government run medicine?  How about the Republicans trying to bypass the legal next of kin and dictate Ms. Schiavo’s care despite the American Academy of Neurology’s amicus curiae brief?  Where was the outrage?  I was an expert in dealing with coma and knew cold the probabilities of improvement.  Frist should have lost his license and been fined after his video diagnosis; he and those who voted with him should have been censured.  To those who still maintain this was a wrongful death, Schiavo’s brain weighed 615 grams at post.

 Many state “high quality care” as if repetition established validity, rather than definitions, measurements and improvement.  We need local outcome measures for central line insertion and care, ventilator and catheter-associated infections, pre-op antibiotic timeliness and post-op wound infections, hyperalimentation, carotid endarterctomy (CEA) and other high risk procedures.  Alone, in 1984, I discovered major CEA complication rates averaged 15% in 3 hospitals; knowing that, I dramatically decreased my surgical referrals and only to the surgeon with the best outcomes.

 The above procedures should be standardized, because cookbook medicine gives predictable quality.  Surgeons have their own op trays; each of us dictates a standard way.  Isn’t that cookbook?  Want liability reform?  Standardize, prove effectiveness with data, define outliers, learn from outcomes and errors and share the learning among the profession.  That means count, analyze and improve.

 I call upon all physicians to count something in their practice that bugs them.  Count it fairly, but count.  Send the counts to me (qssm@comcast.net) or Steve Nash.  For a defined period of time, count formulary hassles.  Count the minutes spent on hold or talking to insurance companies.  Count the dollar cost of tests you do that are defensive medicine.  Count the number of days of futile care in ICU or days’ hospice care is delayed.  Count the per cent of patients in the ED who should have been seen elsewhere.  Count the number of true life saves in the trauma unit.  Count the number of people sent to the trauma unit who could have been handled elsewhere.  Count the number of patients whose problems relate to their lifestyle.  Count the number of post-op infections.  Count the 15 day non-elective re-admission rate.  Count the per cent of your patients with no health insurance.  Count the dollars of your billings that aren’t paid.  Count the number of patients who admit to alternative medicine.  Count the number of times a day you say you are quitting.

 The way I see it, we can be “poor me” victims or we can take control with hard data that we collect.  The data won’t be perfect, but it beats complaining and doing nothing.  And I promise you this:  if Steve and I get enough decent data, we’ll go public.

 If we resent insurance companies or the feds getting into medical practice, then we must prove what we do and prescribe works.  If we disagree with a formulary or non-coverage, then we need clinical data, not polls, for proof.  Ineffective treatments must stop, even if it costs money or referrals.  Alternative medicine should be held to the same scientific standard that we should be abiding by.  We all know procedures and treatments that shouldn’t be done, but still are, because nobody wants to be the enforcer.  Count those, too.  I’m counting the percentage of obese middle schoolers and the number of teenagers who die in MVAs, about 12 annually in Pima County.

 I enjoy tutoring math (7 years), backpacking in Alaska (5 trips), chasing total solar eclipses (11 seen), canoeing the boreal lakes and rivers of North America (83 trips), hiking the AT (530 miles) and visiting the National Parks (41).  I would enjoy helping improve medicine using my unique skills.  But I have to do it now, while here on earth, because like my mother I don’t believe the Witnesses.

Appearing in Pima County Medical Society’s (PCMS) monthly magazine, Sombrero, September 2009. 

The elementary school teacher places a foot wide ball representing the Sun on a fence.  The Earth, 1/10^th the size of a drop of water, is 34 meters away; 1.3 million of everything we’ve ever created, walked or floated upon would fit inside the ball/Sun. 

At this scale, golf ball-size Saturn is off the property and Neptune 3/4 mile away.  Alpha-Centauri is in Amsterdam.  I am impressed by the vast distances in the universe.  Perhaps some of the kids are, too.  At a star party a few nights later, however, few are curious how to identify a planet.  That’s not surprising but unfortunate, for science is more than memorizing facts.  Science is a way of thinking, beginning with curiosity and willingness to change one’s beliefs – even long held ones – in the face of new evidence.  Unfortunately, we often drum curiosity out of kids and disparage those who change their beliefs as “flip-floppers.”  If not for curious physicians, MI patients would remain at bed rest for 6 weeks, we’d use Salversan and physicians wouldn’t learn from errors.  Well, as Meatloaf sang, two out of three ain’t bad. 

A recent controversial change in astronomy was the re-classification of Pluto.  Neil deGrasse Tyson, a leading astrophysicist and director of New York’s Hayden Planetarium, believes we should describe the solar system not by the number of planets, but classify bodies by atmosphere, core and shape.  Viewed this way, Pluto didn’t make the cut for planetary status. 

Tyson and others felt Pluto belonged to a category of small, non-spherical rocky minor planets and burned out comets.  The amount of hate mail he received was astounding, not only from disgruntled third graders, but from teachers and parents.  California drafted legislation to sue the astronomical community, which is unfortunately how Americans often deal with controversy; fostering confusion, mangling language (“socialized medicine”) and creating false uncertainty are others. 

One prominent astronomer I know was upset about Pluto’s demotion, because he knew Clyde Tombaugh, its 1930 discoverer.  I think he was biased.  Biases aren’t always bad.  The standard deviation is a biased estimator, but we still use it.  The mean, an unbiased estimator, can be misleading.  But our biases affect our rationality if we don’t recognize them, and I don’t think this astronomer did.  Because of his influence, his flawed analysis had power to convince others. 

When people with power and influence argue from biased premises, they shift public opinion in ways that may harm society.  That’s how we got involved in Iraq.  Influence and charisma often trump facts and sound ideas.  It may be why a majority of American adults don’t know what a year represents and believe humans coexisted with dinosaurs.  Yes, really.  The media, to be “fair and balanced,” presents two sides, even when one side confuses opinion with fact, ideology with truth, loudness, personal attacks, repetition and interrupting with validity, bullying to get one’s way. 

A regrettable number waste valuable time by still debating the existence of the Holocaust, the Grand Canyon’s age, Roswell, the Moon landings, Obama’s birth location and our government’s complicity in 9/11.  A plurality of Americans believe in astrology and some forms of alternative medicine that are plain bunk.  A plurality don’t believe in evolution, vaccine safety and climate change, which disturbs me deeply and bodes poorly for American competitiveness.  Science should deal with facts; if the facts are not known, there must be a quantitative expression of uncertainty using appropriate statistical terms.  There is no place in scientific writing for personal attacks, charged language, sarcasm or ideology.  These four coupled with no statement of uncertainty are issues I have with arguments of those who deny manmade global climate change. 

Science moves forward, not smoothly, but in fits and starts, often stopping.  Seldom does science retreat; over time, evidence for Newtonian mechanics, continental drift, evolution and climate change has become more compelling, not less, consistent of theories whose predictions have high confidence.  Even if these theories have flaws, and Newtonian mechanics fails to explain the precession of Mercury’s perihelion, does not render them worthless, something anti-evolution proponents still do not understand. 

I miss planet Pluto, but I understand its reclassification.  My 1929 astronomy book is accurate stating the outermost planet as Neptune but inaccurate in stating Saturn has 9 moons.  We know of 19.  Astronomy, every medical specialty and science in general moves forward, in fits and starts, occasionally stopping, rarely reversing a little before moving forward again. 

As we learn, we should change our view of the world.  A few visionaries take what we know and view it in a new way.  Relativity required thinking of time as changeable.  UV, Radio, X-Rays and Infrared radiation required vision beyond our vision.  Sometimes an idea is right but too far ahead of its time, like many of mine.  Turning the clock back is almost never proper; we need only look at desert societies which centuries ago knew the synodic lunar period within 2 minutes, named the stars, a major branch of mathematics and created beautiful sculptures.  The fundamentalists in those societies turned the clock back, blew up the sculptures, banned music and books, stopped teaching mathematics, stopped reaching to the stars, and even stopped kite flying. 

I’ve seen China; if American fundamentalism wins out, world leadership will move across the Pacific.