Boreal B[l]og

“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.