Archive for the ‘2011’ Category

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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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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MESSING WITH THE MIND

March 10, 2011

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

Twenty-three.

I’m sure there are those who disbelieve, saying “I know that can’t be right.”  What is disturbing is that even when a simple proof is delivered, many continue not to believe it.  That is stupid, but these days disbelief of reality by people in power is beginning to destroy this country.  The proof looks at the probability that two people don’t have the same birthday.   Here are the probabilities:

 

Number of People Prob (2 have same Bday) Probability (2 don’t)
2 0.003 0.997
5 0.027 0.973
10 0.117 0.883
15 0.253 0.747
20 0.411 0.589
22 0.476 0.524
23 0.507 0.493
25 0.569 0.431
30 0.706 0.294
35 0.814 0.196

 

A disease has a prevalence of 1 in 200 (0.5%), a sensitivity of 98% and specificity 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 percentages:

 

  Test Positive Test Negative 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.   We all know someone who died in a motor vehicle accident, but relative to the denominator, it is small, 1 in about 7000 Americans each year.  Mountaineering is a small community, and number of climbs is a small denominator.  Every serious mountaineer has lost several friends in the mountains.  Mountaineering is far more dangerous.

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.”

Too many Americans play “I’m sick do I see a doctor?” lottery:  I have abdominal pain, and I don’t have insurance. I hope it goes away.  But it doesn’t; instead, the pain worsens.  I call an ambulance, go to an ED and am admitted with a ruptured appendix.  The costs have increased and are well in five figures.  I’m bankrupted by the illness, nobody gets 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. 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 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 system makes it impossible for at least a sixth of Americans, not Zimbabweans, to get decent, timely care and not be bankrupted by it.  If you don’t want my solution, you fix it.   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, 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,  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.  The selfish say, “I got mine, and the hell with you.”  Liberals like me say, “I got mine, and I want to help you get yours.”

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 affected me and three family members and really tired of the bickering and the lies that stalled any meaningful reform.  It is disgusting and un-American.

The above birthday problem was solved by looking at what we didn’t want to find what we did want.  I don’t want a huge national debt.  Here are 2 thoughts:  end our wars, and enact a 90% marginal tax rate on those with incomes over $3 million.

I can live with 70%.

 

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WINNING THE JACKPOT AT AN AUCTION

November 26, 2010

I was recently auctioned off for a charitable event.  No, nobody was buying me, but they bought a dinner with me at a friend’s house with a star party to follow.  My job was to show up for the dinner then show the stars afterwards.

For 20 years, I wrote 750 astronomy columns for the local paper.  I don’t do much observing any more, other than chasing the next solar eclipse, which I’ve done 20 times, successful on 17.  I was once an avid observer of variable stars, sometimes getting up at 2 a.m. to make visual observations on one that the AAVSO (American Association of Variable Star Observers) needed.  I was so good, my eyes could detect a 0.1 change in magnitude.  I’ve seen about 400 galaxies, 2000 double/multiple stars, all the planets and once followed about 25 variable stars without using star charts.

The night sky is predictable enough to be reassuring but changeable enough to be interesting.  In 1999,  I saw 300 Leonids meteors in an hour.  I saw a red glow over the Catalinas in ’89, realized there was no fire but in fact an aurora.  I’ve seen one grazing occultation, where the Moon’s limb was tangent to a star, so that the star blinked in and out of view as the valleys and mountains of the lunar edge passed by.  That was really cool.  For many years, I did photoelectric photometry, then having to reduce the data by hand.  Other than a total solar eclipse or a total lunar eclipse, the occultation of 28 Sgr by Saturn in 1989 might have been the most striking thing I ever saw.  As Saturn covered the star, I could define every ring layer by the star’s passage.  I still have my notes for that one; the star disappeared from view 38 times in 45 minutes!  That was beyond cool.  I stayed out half the night looking, and I had an office full of patients to see the next day.  I’m sure more than a few of those patients noted the doctor was tired, but finally seeing the star in between the globe of Saturn and the inner ring was an image I will never forget.

I wrote an article for Sky and Telescope several years ago how astronomy and dark skies freed me from my shyness.  After I was auctioned, I didn’t know what would happen; the person who “bought me” was a minister, and I had some trepidation about the evening.  After all, some ministers believe the Earth is 4000 years old and don’t realize that we are made of star stuff; our Sun is at least a second generation star.  I am not religious, but I am intensely spiritual, the idea of the elements coming from stars strikes me to my core.  The iron in my hemoglobin, the calcium in my bones, and the carbon in the fat surrounding the myelin sheaths in the corticospinal tract leading from my brain to my lower spinal cord are just a few examples.

I wore my Argentinian eclipse T-shirt that two delightful women, brilliant German astrophysicists, gave me after the event.    I arrived at John’s house early, set up my ‘scope (20 cm reflector), then had a beer with John  and his wife.  John and I go back a decade as bike riders.  I quit the sport in 2006 after breaking my 6th, 7th, 8th and 9th bones, but we stay in touch.  Just as I finished my drink, the other guests arrived.

We went outside, as the brightest stars appeared.  This is navigational twilight, when the Sun is 6-12 degrees below the horizon, light enough to see both bright stars and the horizon.  I pointed out the Summer Triangle and Jupiter, and described star magic.  In Tucson, the mountains allow a rising star to suddenly pop into view, so if one can determine the exact time of its rising, she can go out 4 minutes earlier the next night and count down 4, 3, 2, 1 RISE!  And the star will rise.  It is like magic, except of course, it is entirely predictable.  I also spoke of “Earthmove” rather than “Moonrise,” for I have learned that if one changes perspective, it is possible to see the Earth rotate, which in fact is what Moonrise is.  I do it many times a year.  Seeing the Earth rotate is primal.

The minister thought all this fascinating.  His wife sat next to me at dinner and is, like me, is a teacher.  Before we finished dinner, she had invited me to her advanced junior high math class next February to talk to them about math in the outdoors, a subject I am particularly interested in.  American kids need to get out more, and this is one way.

After dinner, we went outside, and looked above us.  Even in the suburbs of Tucson, we can see the Milky Way.  I pointed out the beautiful curve of Andromeda, found the Galaxy, showed the star clusters around Mirfak in Perseus, the Pleiades and the Hyades.  I taught them how to use their fist to show that the elevation of Polaris was our latitude, and that Kochab, in Ursa Minor, is Arabic for “Pole Star.” which it was 3000 years ago.

As we turned to look at the southern sky, a minus 8 magnitude fireball, a meteor, shot across right in front of us.  Everybody saw it.  I’m not one into “signs”, but I had to be a bit impressed that we happened to turn at just the right time.  The minister and his wife were fascinated by the Moon.  I pointed out Alpenglow, where the tops of the mountains were lit up away from the terminator.  His wife loved seeing that.  I spoke of nuclear fusion in the center of stars, walking over to the sand nearby, pointing out that the silicon was made inside a star.  Heady stuff.  I showed them Albireo, a gorgeous blue and gold double star at the end of the Northern Cross, which seemed appropriate for a group of Christians.

I spoke so much that once again I forgot that I was a shy person.  I was bubbling over with knowledge about the sky.  I consider myself a profound introvert.  But it is all relative, for once I get talking about astronomy under a dark sky,  a solar eclipse, the wilderness I have seen, or the Sandhill Crane migration in March, I’m a different person.  For a long time, I thought it was the wilderness and the night sky that changed me.  But it’s more than that.  The next day I thoroughly enjoyed myself as a substitute math teacher.  What brings me out of my shell is teaching.  I am a natural teacher.  The minister and his wife learned a great deal about the sky that night, but I was luckier; I learned something about myself I had never realized before.  When I teach, I am a completely different person.  And I like that person a great deal.

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IF YOU WANT TO LEARN, TALK TO THOSE WHO SAY LITTLE

November 26, 2010

In November, I went to the Bosque del Apache National Wildlife Refuge for the Festival of the Cranes.  I got to see fellow volunteer crane guides and took a course in Sandhill Crane behavior, with on site examples.  I also visited the VLA, the Very Large Array of 27 large parabolic radio telescope dishes on movable tracks.

Lesser Sandhill Cranes are remarkable birds, some migrating as far as Siberia.  I now can identify juveniles, males and females by voice.  I can identify their unison calls, see the aggressive behavior they may display afterwards, and describe their dancing.  I was a decent guide last spring; I will be a far better one next year.

I stayed at a house in Socorro while the owners were temporarily living at the Refuge, volunteering.  Erv and Sandra are a remarkable couple; both well into their 60s, they are “professional volunteers,” known in the Fish and Wildlife Service as a couple who will go to a place for a few months, make a big impact, then move to another area.  In 2008, when I first met them, they “followed” the Sandhill Cranes north from their wintering spot in New Mexico, to the magnificent staging of 600,000 on the Platte, to Homer, Alaska, finally ending in Fairbanks.  While I was in New Mexico, they received an offer to go to Coldfoot, Alaska next summer.  They are either going there or to the Columbia River.  They are in demand.  Sandra can do it because she has two artificial joints.  Bravo for science, bravo for Medicare, bravo for Social Security.

My first evening, I went with both to watch the evening fly in of the cranes to a wetland.  Unfortunately, there weren’t many when I was there.  The cranes migrate south later every year, because the Arctic has warmed so much.  Indeed, the dates of the Festival will likely have to change.  One can argue about climate change, but cranes don’t argue; they sense warmth, not politics; 65% of bird species in the Christmas bird count, which I help out in, have moved significantly further north.  Erv and Sandra introduced me to several of their friends in a nearby RV park, and I was invited for dinner.  I was going to drive back to Socorro, grab a sandwich and sleep.  Fortunately, I didn’t.

That evening, I spent time with 6 other couples, all of whom older than I.  The food was good, the conversation better.  They were fascinated with my eclipse chasing and experiences.  Politics stayed out of the discussion, and mostly medical issues, too, a rarity among the elderly.   These people had worked for decades and were enjoying their retirement.  I wonder if they would be if it were not for the science so many disparage or the liberal programs of Social Security or Medicare.  I just wondered, but I kept my mouth shut.

I did open it later, however, to speak to the man who owned the RV and had been quiet most of the evening.  Quiet people often have a lot to say, if one can draw them out.  This man was no exception.  He was a physicist who worked at JPL and was surprised that I knew of it.  Are we so “educationally challenged” these days that we don’t know of the JPL, the place that allowed Americans get to the moon and do all sorts of other wonderful things?

The man was a pioneer in fiber optics.  He told me about silica (SiO2), the stretching and strength properties of the pure substance, which is the best spring we know of.  He told me that he thought it was better than satellite transmission, since it was faster and had fewer delays, so long as it was protected.  Satellites, as we all know, are far from safe, given solar radiation and space junk.  Bouncing signals off satellites leads to longer delays.  They are also more difficult to repair.  Fiber optics have revolutionized society, including medicine, although I learned fiber optics were most helpful was in transatlantic cables.

This man disparaged himself by saying that he was out of date.  But his explanation of fiber optics was by far the best I had ever heard.  Perhaps that is because he mentioned one of his teachers in quantum mechanics:  Richard Feynman, arguably the most brilliant physicist in the 20th century, and who single handedly figured out what happened to Challenger using simple science that even most Americans could understand.

I’ve come full circle.  In July, I met a young physicist from Germany, a woman who is working on an X-Ray telescope that will allow us to learn a great deal about X-Ray radiation sources in the universe.  She represents where we are going–brilliant, part of a large team, well educated, well traveled and articulate.

In November, I met an 80 year-old retired physicist who worked on fiber optic cables and studied under Feynman.  He represents the past and helped me understand how we got to where we are today.   Twice now, I’ve gone to see something and discovered far more.  In July, I went to see an eclipse; in November the Sandhill Cranes.  But my memories of both will be of two different people I met on each trip, young and old, German and American, woman and man, same field, different eras.  Both had a great deal to teach me.  All I had to do was draw them out.  For some reason I really don’t know, I did and was better for it.

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TIME TO MAKE TRAUMA PHYSICIANS AN ENDANGERED SPECIES

May 16, 2010

In early March, a young woman was thrown from her dressage horse during a routine schooling ride.  She was rendered comatose and two months later in a rehab facility with a mild hemiparesis but finally able to swallow.

The woman was a member of the US Equestrian Olympic Team, one of only two sports where men and women compete equally.  I say “was,” because we both know it is unlikely that she will ever be able to compete again at a high level in dressage, one of the most demanding partnerships between man and animal.  She has recovered remarkably well and hopes to teach riding; unfortunately, even her young age was not young enough for better recovery.  She is at higher risk for epilepsy, personality and emotional residuals as well.  In short, she suffered a catastrophe.  Fortunately, she didn’t end up vegetative, especially since the accident occurred in Florida, where adults with 600 gram brains are felt by cardiac surgeons to be conscious and doing well, because they smile even if they can’t comprehend 15 years after the insult.

Florida and the 109th Congress aside, what is finally occurring is a helmet debate in the equestrian community, similar to the helmet debate seven years ago in the cycling community, where 9 years earlier, almost to the day, Andrei Kivilev, a superb Kazakh rider, collided with two other riders on the Paris-Nice race.  The other two were fine; Kivilev, 29, hit his head and died the next day, leaving behind his widow and six month old daughter.  His death was a catalyst for mandatory helmets in major cycling races, which first did not mandate helmets for mountain top finishes, but now do.  Every cyclist in every major event wears a helmet.  Something good came out of Kivilev’s death; hopefully the equestrian community will do the same.  Already, several equestrian riders have stated publicly that they were saved by a helmet they began wearing.

But there is still no mandate.  Dressage riders must dress formally; indeed, proper riding attire is considered appropriate dress anywhere, something I often kid my wife about.  Helmets are not part of dressage riding.  Well, the judges need to get over it and deduct points should someone not be wearing a helmet.  Better yet, it should be cause for immediate disqualification if any rider on a horse at any time at a horse event is not wearing a helmet.

In 1976, Arizona allowed motorcyclists not to wear helmets.  I remember the demonstrations at the Capitol.  I wonder how many have since died or been permanently maimed as a result of not wearing a helmet.  It is time for a helmet debate in this country.  At what point do an individual’s rights conflict with the rights of his loved ones to have him (usually a him) around and whole, and society’s rights to pay for the extra care that going without a helmet and having an accident causes?  It’s a fair debate.  I know where I am on this issue.  I, like many of my former colleagues, bitterly remember coming into an ED at 2 a.m. to take care of another drunken biker who wasn’t wearing a helmet.  In my case, the lack of payment was a minor annoyance.  The sleep I lost was not so minor.  We live in a republic.  We have a government, and by definition, that government has some control over us, even in the hinterlands of Alaska.  We need an honest, factual debate on regulation, without Rush, Bill, Glenn, Sarah, Keith, Jon, Rachel or Steven.  In my view, failure to regulate almost took down the world’s economy and has given us wireless service that is worse than many third world countries.  There is an imperfect but better middle ground out there that we need to find; otherwise, Zappa’s Law about universality has a third part:   hypocrisy, in addition to hydrogen and stupidity.

Growing up, I didn’t know about seat belts; today, even in Arizona, 75% wear them.  I skied for 40 years without wearing a helmet; I didn’t know better.  Or didn’t want to know better.  I knew that ½mv2 =mgh, and a fall at 25 mph was like falling off the roof.  I would wear a helmet today if I skied.  In my three major bicycling accidents, my helmet was significantly damaged, damage my skull didn’t have.  I was not knocked out, even when I could hear the back of the helmet go WHACK! on Moore Road, the day I broke my clavicle.

Physicians need to frame the helmet issue and lead the debate.  And after we deal with helmets, we will have to deal with a hot, extremely difficult issue:  the long term side effects of playing football as the game is currently played, for the data show that the sport is far more dangerous than anybody ever realized.

For now, the equestrian community must recognize the dangers of being 10 feet off the ground on an unpredictable animal, and where a head might hit if the animal bucks.  It won’t be the only buck in the equation.

We will never drive trauma centers out of existence, but every physician should want to.  I hope most trauma physicians would be among the first to agree.

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Posted in 2011, MY WRITING, NEUROLOGY WRITING (NOT TECHNICAL!) | 2 Comments »

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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Posted in 2011, COLUMNS IN "REALITY CHECK", MY WRITING | Leave a Comment »