Podcast:

In his last post, DrRich demonstrated that our modern American healthcare system proposes to treat individual patients as if they were merely members of a herd of cattle or sheep.*

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*Doctors, on the other hand, will be treated like the border collies who – responding instantly to the various complex whistles, hand gestures, and occasional (less complex) kicks administered by their masters – will keep the herd nicely organized into manageable clusters.
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But we should take note that this systematic, official devaluation of individual worth was not produced out of whole cloth by the Obamacare legislation (nor would it be completely overturned by its repeal). Rather, it has been in the works for several decades, the natural, evolutionary result of a philosophy of healthcare that was all the rage until just a few years ago, but which – mysteriously – we seem to hear very little about these days. DrRich speaks, of course, of managed care.

Like many of the current travesties taking place within our healthcare system, managed care began with a pretty reasonable idea; namely, to apply certain management principles to the healthcare system that have been used successfully in other industries, thereby injecting logic, organization, and accountability to what had been a bastion of disorganization and inefficiency.

The unifying idea behind managed care boils down to one word: standardization. Standardization is virtually a synonym for industry. In industry, standardization is the primary means of optimizing the two essential factors in any industrial process: quality and cost.

This proposition can be stated formally as the Axiom of Industry:

The standardization of any industrial process will improve the outcome and reduce the cost of that process.

If you had a widget-making factory, you would break your manufacturing process down into discrete, reproducible, repeatable steps and then optimize the procedures and processes necessary to accomplish each step. To further improve the quality of your finished product (or to reduce the cost of producing it), you would reexamine the steps, one by one, seeking opportunities for improvement. You would need to understand the process thoroughly, and you would need to collect data about how well the process works. But with the right information, you could almost certainly identify a few minor changes to improve the manufacturing process. The beauty in such a system is that you have only to make one change — to the process itself — and every widget that comes off the line after you make that change will be improved.

So standardization is good. It leads to higher quality and lower cost. Conversely, variation is bad. It reduces quality and raises cost.

Proponents of managed care argued that standardization should be just as useful in healthcare as it is in other industries. As medical care has traditionally been individualized, highly variable, and without any semblance of standardization, there must be a huge opportunity to improve the processes of care and to make them both cheaper and more effective. There is obvious merit in such an idea.

Perhaps the most direct, and the most successful, application of managed care practices to modern medicine was the adoption of “critical pathways” in the 1990s.

Critical pathways are blueprints for delivering standardized care to patients with specific medical problems. Consider a critical pathway for hip replacement surgery. The critical pathway is a specific schedule of which services are to be provided for the patient and when, from the date of hospital admission until the date of discharge (which is, of course, predetermined). Checklists are created for which laboratory tests to order and when, which medications to administer at which times, and which specific complications to check for. Everyone involved in the patient’s care has their own relevant checklist. From the moment of the patient’s hospital admission, the critical pathway predetermines when to take vital signs, when to get the patient out of bed, when to begin physical therapy, and when to provide standardized instructions to the patient before discharge. Every vital service is included, and all extraneous services are omitted.

A “case manager” monitors the care each patient receives under the critical pathway. Every deviation from the prescribed procedure is tabulated as a “variance.” Variances are tracked not to decide who to punish, but to identify areas of the process that need improvement. If too many instances of a particular variance are seen in a critical pathway, then either medical personnel need to be retrained on following the pathway appropriately, or the pathway itself should be changed to reflect more realistic expectations.

Critical pathways, in fact, proved to be extremely helpful in many cases. But of course there were some drawbacks and limitations.

First, critical pathways are only useful for delivering medical services, like elective surgery, in which the process of care can be broken down into a predictable series of discrete, reproducible tasks that generate reproducible results. In other words, industrial management tools only work when the process of care is similar to the process of making widgets.

Critical pathways are almost worthless when you are dealing with medical illnesses in which neither the diagnostic procedures nor the treatments that may be employed can be predicted or, therefore, standardized. For instance, it has proven impossible to develop workable critical pathways to manage patients with congestive heart failure (CHF). Knowing only that a patient has been admitted to the hospital with CHF tells you nothing about whether that patient will require cardiac catheterization, a stent, bypass surgery, valve replacement, a pacemaker, an implantable defibrillator, a mechanical ventilator, a prolonged and complicated stay in the intensive care unit, or just a couple of diuretic tablets and overnight observation. No two patients with CHF are alike; and there is no such thing as a standard patient. Unfortunately, most non-surgical medical services fall into this category.

Second, it turns out that when you are taking care of patients, the Axiom of Industry simply does not hold true. Standardization does not always improve outcomes and reduce cost. The reason for this is: Patients are not widgets. And while in theory everyone seems to agree that patients are not widgets, the implications of this fact appear to escape many of our public health experts.

If you’re a widget maker, deciding between two manufacturing processes is a matter of economics. Nobody expects you to consider the widget itself. The outcome by which you are judged has nothing to do with how many individual widgets get discarded during the manufacturing process or even the quality of the widgets that pass final inspection. Instead, it’s the bottom line: how much profit you make in relation to whatever level of quality you put into the widget. So the quality of the widget is not necessarily maximized, instead it’s optimized, tuned to the optimal quality/cost ratio as determined by the market forces of the day. This is why, for a widget maker, the axiom holds: standardization, by rooting out variability, reduces the cost of making the widget (whatever quality level you choose). This automatically improves the outcome, because the outcome the manufacturer cares about is overall profit.

If instead of running a widget company you’re practicing medicine, the calculus is supposed to be different. You’re supposed to be more interested in how things turn out for individual patients than you are in the bottom line. So an expensive process that yields a better clinical outcome is one most people (patients, at least) would expect you to use, even though it only gets you a healthier patient and doesn’t help your bottom line. A process that increases patients’ mortality rate by five percent is one you should disregard, even if it is substantially cheaper than the alternative. The clinical outcomes experienced by patients — the measure of success you’re supposed to be concerned about — may move in the same direction as costs, or in the opposite direction. But because you’re dealing with patients instead of widgets, the Axiom of Industry doesn’t hold – and outcomes and costs do not always move in the same direction.

So the push to strictly apply managed care techniques to healthcare created a dilemma for doctors. Doctors – the widget-makers in this scheme – tried diligently to apply standardized procedures such as critical pathways to the care of their patients. But the more un-widget-like the medical services they were providing, the more often they were compelled to make “exceptions” to the prescribed standardized process, in order to best serve their individual patients.

Such exceptions are a legitimate and valued aspect of any industrial process. In the widget-making world, exceptions reveal that the process needs to be tweaked to make it more usable. Exceptions lead to further iterations and refinements of the process, and a steadily improving result. Exceptions are what allow these industrial processes to become self-correcting.

But in the messy world of patient care, the exceptions revealed instead that industry-like standardization only works for a minority of medical services. No amount of tweaking can standardize the management of complex patients with complex combinations of illnesses.

It did not take long for doctors to simply stop attempting to use critical pathways for non-widget-like medical services. They did this because they actually cared about what happened to the individual widgets in their charge.

Similarly, it did not take long for our public health experts to recognize the same problem. From their standpoint, however, the problem was not that patients are not widgets. The problem was that the doctors on the scene cared about the widgets. Further analysis revealed that the root of the problem was that classic managed care techniques were administered locally, and therefore the misguided loyalties of the doctors on the scene were allowed to rule the day.

The reason we don’t hear about managed care anymore is that such terminology refers back to those locally-administered, iterative, self-correcting, continuously improving industrial processes. And our public health experts have now realized that this model does not work, and must no longer be encouraged.

The solution to the widget-makers dilemma is to remove the dilemma. Since a dilemma requires one to choose between two bad options, any dilemma can be resolved by simply removing the choice. And this is what has now been accomplished.

There is no dilemma for physicians any more. Clinical decisions are now to be made centrally, through the “guidelines,” handed down by GOD panels (Government Operatives Deliberating), which will prescribe precisely who is to get what, when and how. Doctors are now enjoined, both by law and by the new medical ethics, to follow those “guidelines” to the letter, without exception.

Whoever thought that some day we would fondly recall managed care as the good old days?

Podcast:

On the same day that DrRich published his post about the American College of Physicians’ new Ethics Manual, Rob Stein of NPR’s Health Blog did the same thing. In his post, Mr. Stein took particular notice of the ACP’s admonition to physicians that, in order to practice medicine ethically, they must practice parsimoniously.

DrRich flatters himself to believe that he may be the one who called Mr. Stein’s attention to this remarkable terminology. Mr. Stein had contacted DrRich just prior to the New Year’s holiday for his reaction to the new Ethics Manual – and DrRich responded with a lengthy e-mail containing a substantial riff on the ACP’s usage of “parsimonious” (a riff that was not dissimilar to the one appearing here on the CRB a few days later).

In any case, whether DrRich had anything to do with his focus or not, Mr. Stein (being a reporter instead of a mere ranter) actually interviewed several persons of interest regarding this curious terminology. Dr. Scott Gottlieb of the American Enterprise Institute and Daniel Callahan of the Hastings Center appeared sympathetic to DrRich’s take on “parsimonious,” that is, that this word, at best, carries some very negative connotations under any circumstance, but particularly when it is used in the context of providing healthcare to people who need it. (DrRich himself was not mentioned in the NPR article. This undoubtedly shows good judgment on the part of Mr. Stein, who has his reputation to think of.)

The most interesting response to Mr. Stein’s questions on “parsimonious” was offered by Dr. Virginia Hood, current president of the ACP. She strongly defended the use of the word, saying, “Parsimonious is a good word in the sense that it means that you use only what’s necessary. I don’t see a particular problem with that. Maybe it has some connotations where people think frugality or being parsimonious is the same as being mean or inadequate. But I don’t think that is the real meaning of that word.”

So the mystery raised by DrRich in his last post is apparently resolved. When the ACP says “parsimonious” it turns out they are not referring at all to the “theory of parsimony” (or Occam’s Razor), the theory which states that when there is more than one explanation for a series of observations, one must always default to the simplest available explanation. It seems a shame that this is not what the ACP was referring to. While it would have been terribly misguided for the ACP to make an unqualified demand that doctors apply the theory of parsimony to all questions that arise in medical practice, at least they would have seemed somewhat sophisticated in doing so. For many academic papers have been written about the theory of parsimony, and some of them border on the esoteric.

But astoundingly, that’s apparently not what the ACP meant at all. It turns out that what they meant was, in fact, parsimonious. Dr. Hood purports to believe that “the real meaning of the word” is “efficient.” But she should know that it is not. According to Roget’s II New Thesaurus, parsimonious is “ungenerously or pettily reluctant to spend money.” Webster’s New World Dictionary gives “stinginess, extreme frugality.” Other sources DrRich has found list similar definitions, such as: excessively unwilling to spend, penny-pinching, miserly, sparing, grasping, tight, close, niggardly, illiberal, mean, avaricious, covetous, rapacious and tight-assed. Only one source even mentioned the word “efficient,” and it was the 15th or 16th meaning. The dictionaries make it clear that being “parsimonious” is not a thing to be admired.

Students of philosophy, religion, and psychology have known, at least since Dante, that a vice is a virtue carried to extremes. The vice of lust is a perversion of the virtue of love. Servility is a perversion of humility. Recklessness is a perversion of courage.

And parsimony (or miserliness, or stinginess, or any of the many synonyms that exist for this very common vice) is a perversion of thrift. We do not celebrate the addled stalker because his vice is rooted in a perverted form of love. We ought not celebrate parsimony because, despite its perversion into something awful, it is based on efficiency.

Notwithstanding Dr. Hood’s protests to the contrary, when the ACP admonishes physicians, as a matter of ethics, to provide healthcare parsimoniously, that is not a good thing.

While Dr. Hood may herself not be a lexicographer, DrRich thinks we can be fairly certain that, for a document like the ACP’s Ethics Manual, before final publication each and every word is carefully parsed, analyzed and considered by a number of astute and highly educated individuals. Indeed, one notes that the lead author of this document is an attorney, and attorneys are notorious for understanding every nuance of every word they allow into written documents. One would assume that this is especially true for a word which is so important to the message that it is being placed in a special call-out box, so nobody will miss it. It is simply not believable that “parsimonious” – which describes a well-known vice – managed to slip into this document inadvertently as a synonym for “efficient,” as Dr. Hood suggests. That explanation, of all the possible explanations, is simply not credible.

So perhaps Dr. Hood misspoke, and “parsimonious” really was referring to the theory of parsimony after all, and she either did not realize this (not being a lexicographer), or simply forgot. The only other credible explanation, which Dr. Hood indignantly denies, is that the ACP actually does mean for doctors to practice medicine parsimoniously – with all its negative connotations – and that her present dissembling is merely dissembling.

As it happens, DrRich has a brief history with Dr. Hood. Two years ago, the Covert Rationing Blog and the ACP Advocate Blog were both named as finalists for a Medical Weblog award in the category of Health Policy and Medical Ethics. So DrRich suddenly found himself in an ethics competition with the very organization that had published the notorious “New Physician Charter on Medical Professionalism,” and thus had destroyed the very foundation of medical ethics.  He could not resist the opportunity to publicly challenge the ACP, under the spotlight (and protection) of the Medical Weblog competition, to an open debate on medical ethics.

You can read all about the ensuing exchange here. What may be of some interest for our present purposes is that it was Dr. Hood herself – at the time the Chairperson of the ACP’s Committee on Ethics, Professionalism, and Human Rights – who finally drafted the ACP’s public response to DrRich. And interestingly, in her response (which was heavy on condescension but light on logic) Dr. Hood invoked the need for parsimonious care. So the ACP’s use of this word was not a momentary oversight; instead it has been rolling off their collective tongues for years, as a descriptor for what they consider to be the ideal approach to the practice of medicine.

Another aspect of that Medical Weblog competition between DrRich and the ACP is more to the point at hand, namely, the interesting manner in which the ACP finally beat DrRich out for the award. The way the competition works is that a short list of finalists is determined by a committee of judges, and then for two weeks anyone who is interested can vote for their blog of choice. The voting system allows only one vote per IP address (so if 20 people all vote from their computers tied into a company network, only one vote is counted). During the voting period, a running tally of results is shown to anyone who cares to see it.

Clearly, given the public spectacle DrRich had made regarding the righteousness (or lack of it) of the ACP’s stance on medical ethics, it would have been deeply embarrassing for the ACP to lose this medical ethics contest. So it was probably troubling to that organization when DrRich mounted a substantial lead early on, and held that lead for two weeks, right up until the last three hours before the voting ended, which, as it happened, occurred at midnight on Sunday, February 14. Then, late on Valentine’s night, when most normal people were with their loved ones doing, well, Valentiney things, apparently a large number of ACP members spontaneously rousted themselves from their activities, logged on to their computers, and voted for the ACP – just enough of them to overtake DrRich, and then to maintain a steady 10 – 20 vote lead for the remaining hour or two of the voting period.

DrRich is not relating this story because he is bitter, nor is he complaining. (This blog won the Medical Weblog award the following year, so there is nothing for DrRich to complain about.) Rather, he was and is deeply amused by these events, and he relates this story for a very pertinent reason – namely, for the purpose of illustrating the shortcomings of the “theory of parsimony.”

For what are the possible explanations for the ACP’s stunning last minute victory? One explanation is that, in the waning moments of Valentine’s Day, members of the ACP finally got around to voting. This is of course possible. These are internal medicine specialists, and many of them are the guys (and girls) you knew in college who looked forward to football Saturdays because the library would always be so much quieter. So it is indeed possible that the ACP membership had entered into their iPhones, weeks earlier, a reminder to vote for the ACP at 11:59 PM on Sunday, February 14. Perhaps they figured they would be logged on to their computers at that moment anyway, reading the latest research on the complement cascade.

Another possible explanation is that someone affiliated with the ACP, realizing how deeply embarrassing it would be to lose an ethics contest to a pain in the ass like DrRich, figured out a way to defeat the voting system’s firewall, and to enter the precise number of votes they needed at the last minute in order to gain a victory and save face. We have seen examples in electoral politics, over and over again and perhaps as recently as last Tuesday night in Iowa, that in close contests it is best to withhold a bolus of the votes you control until the last minute, when you know just how many votes you need.

DrRich is not accusing the ACP of anything, of course, as he has no direct proof that they behaved badly – just a series of observations that have more than one possible explanation. But he admits to finding it delicious that a straightforward application of the theory of parsimony – always choosing the simplest explanation for a series of observations – leads us to the conclusion that agents of the ACP apparently cheated in order to win an ETHICS contest.*

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*If they actually did this, of course, some would say it would indicate that the ACP has disqualified itself from ever establishing ethical rules for anyone.  But actually, it would simply be another illustration of utilitarian ethics, where important ends always justify whatever means are necessary to achieve it.

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Since we know beyond doubt that the ACP would never have done such a thing, and that the ACP won that competition fair and square, DrRich has therefore just demonstrated that applying the theory of parsimony, after all, will often enough lead to incorrect conclusions, and therefore the ACP ought not demand that doctors apply it as a matter of course in all questions of life and death.

So either way, whether the ACP’s use of the word “parsimonious” was supposed to indicate that doctors ought to be stingy and miserly in delivering medical care, or whether they were obligating doctors to always apply Occam’s Razor to medical decisionmaking, delivering parsimonious medical care is a very bad idea, and certainly ought not to be an ethical mandate for physicians.

The leadership of the ACP ought to know this. Indeed, Occam’s Razor suggests that they do know this, which would be the simplest explanation for why, when challenged on their choice of the word “parsimonious,” they insist that they mean the one thing that makes no sense whatsoever.

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In the tradition of “Yes, Virginia, &c.,” DrRich once again reprises his classic holiday message.

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‘Tis once again that time of year when we Americans gather together with our extended families and friends to celebrate the Season. It is a time for catching up – renewing acquaintances and making new ones, sharing in good news and commiserating in bad, welcoming our new arrivals and mourning our losses. It is a time for giving thanks, counting our blessings, and putting our sundry individual problems into perspective. Indeed, it is perhaps most importantly a time for each of us to remind ourselves that – despite the trials and tribulations that may cause us to become relatively self-absorbed in our daily lives – we are all part of something much greater than ourselves.

So, in a way, it’s a shame we must now cull out our obese relatives and friends, and disinvite them from these joyful and fortifying reunions.

It’s not something we should do lightly, as the obese are people, too. They enjoy the holiday gatherings as much as anyone else (more, some would say, given the abundance of sugary foodstuffs which are typically provided there). But alas, excluding the obese is now something we must do – for our own sake, of course, but more importantly, for the sake of our social networks, and indeed, for America itself. For, to allow the obese to continue participating in our traditional seasonal gatherings is something we now know (as DrRich will shortly explain) to be simply too dangerous and too counterproductive to our collective interests. We can no longer permit it.

Before demonstrating why, DrRich ought to digress for just a moment to address the burning question many of his kindly and generous readers must already be asking, namely, What about Diversity?

On the surface at least, it would seem that the exulted goals of Diversity – the uber virtue, from which all the other, more subsidiary virtues must necessarily spring – would be well-served by our including the entire panoply of body types in our holiday celebrations, from the very thin to the very fat. Must we really exclude from our table our obese family and friends, whom we know and may love, while at the same time, in the name of Diversity, welcome into our collective bosom, say, self-declared Islamist terrorists who openly aim to kill us?

In a word, yes.

For the terrorist, as much a danger to our persons as he or she may pose, is merely a fervent adherent to a minority (and therefore oppressed) religious sect, whose fundamental beliefs (though they center around the utter destruction of Western Civilization) we may not legitimately place ourselves in a position to judge, and therefore, whose tolerance by us, and proximity to us, greatly enriches our appreciation of the wondrous diversity of the human experience.

In contrast, obese people are just fat.

They have no redeeming qualities whatsoever which ought to merit their protection under the beneficent umbrella of Diversity. In this way, fat people resemble Sarah-Palin-lovers, global warming skeptics, tea party fanatics (at least 40% of whom, by the way, are overweight or obese, judging from photos of their rallies), and other groups of narrow-minded or otherwise inferior people the benign tolerance of whom would quite obviously do material harm to the true goals of Diversity. But the obese pose a greater threat to us than even these other unworthies do.

And unfortunately, as we approach that charitable season in which our natural inclination would be to temporarily overlook the sins of our obese friends and relatives, to allow ourselves to fraternize with these individuals – even if only for a few brief hours during this one time of year – is to place ourselves, our non-obese loved ones, and our nation itself, in immediate and immeasurable peril.

This sad fact came to light just a few years ago when a landmark study was published in the New England Journal of Medicine proving that obesity is contagious. Merely having fat friends (and not necessarily living with or near them, or even interacting with them regularly, but merely enumerating them among your friends at a distance) can make you fat as well.

The study came from the studios of the famous Drs. Christakis and Fowler, who have embraced a software package, comprehensible only to themselves, that churns out complex images of “social networks,” from which they can derive all manner of heretofore unimagined associations. These academic stars have turned their shop into a veritable factory of peer-reviewed publications, thereby solidifying their scholarly reputations and (doubtless, now that they have done so much good for the anti-obesity movement) their ability to secure NIH grants, and other favors from government agencies.

Using data from the venerable Framingham database, these pioneers combed through old records for information about the body weight, relatives, and social contacts of individuals who were enrolled in this famous study. They then used their esoteric computer modeling software to create various “animations” depicting the evolving social relationships of the subjects, and the development of obesity, over time.

To summarize their findings: A person is 57% more likely to be come obese if a friend becomes obese, even if that friend lives hundreds of miles away. (This finding is really quite remarkable, considering that the only other natural force that acts on bodies instantaneously and at a distance is gravity. This newly discovered force that produces obesity at a distance – shall we call it “obevity?” – will have to be incorporated, with great difficulty no doubt, into the Grand Unification Theory now being sought by physicists everywhere.) The same effect was not seen when close neighbors became obese, or even (to such a great extent) when family members became obese. Furthermore, if the friendship is mutual (that is, if the fat person considers you a friend in addition to you considering the fat person a friend), the odds of your becoming obese triples. And even worse, this study shows that, even if you wisely avoid the company of fat people yourself (in an attempt to remain acceptably svelte), fat people who are acquainted with your acquaintances may still have an impact on your BMI. That is, obesity is a contagion that tends to spread throughout the social network.

So clearly, if anyone within a given social network associates with fat people, then ultimately nobody in that network is safe.

(Here is an animation the authors have provided, to show a time-lapsed view of how obesity spreads. If this doesn’t convince you, nothing will.)

Now, to be sure, there have been critics of this study – individuals, DrRich thinks, who are nearly as dangerous as the obese themselves. Since this issue is so critically important, please allow DrRich a few brief paragraphs to debunk the debunkers.

Some have complained about this landmark study because the list of “friends” employed by the authors was determined decades after the fact, from administrative records that had been used in the Framingham study for follow-up purposes, in which subjects had been asked to list relatives and a “close friend” who would know their whereabouts at all times. Critics claim that somebody who can reliably provide your contact information may be a good friend; but perhaps not. Perhaps subjects were simply more inclined to give the name of a fat person as a round-the-clock contact. After all, it’s always easier to get ahold of an obese person who, being slothful, is likely to be parked in front of his TV, popping chocolates and munching chips, than it is to contact somebody who’s thin, and is likely to be out and about, probably jogging. The researchers, in other words, were not operating from a list of BFFs, but instead from a list of acquaintences judged by the subjects at the time to be most likely available by telephone. (The subjects, remember, had been enrolled long before the era of cell phones.) So, critics insist, the baseline assumption made in this study – that the researchers actually knew who the subjects’ close friends were – is highly suspect.

To which DrRich replies: These critics likely have fat friends, and are probably even fat themselves, and thus their complaints can be dismissed with a definitive, “Bunk!”

Moving on, critics have also complained because the kind of computer modeling used in this study is not for mere mortals to understand, and therefore amounts to a black box. And indeed, DrRich must admit that the authors’ description of their statistical maneuverings is enough to make your head spin – replete as they are with the running of numerous simulations, using differing assumptions along with a quite unembarrassed manipulation of all the variables (almost as if they were seeking the “right” combination of factors to yield the desired answer, reminiscent of the scientific techniques revealed in the emails of those global warming experts). Critics go on to complain that there are only a handful of humans who claim to understand this kind of complex computer modeling, the results of which, therefore, resemble “received knowledge,” akin to what the medieval clergy used to dole out to the unwashed masses, when most people were illiterate and there were no Bibles in the vernacular.

Bunk again, says DrRich. While the computer modeling used here is indeed unfamiliar to physicians, it is very familiar to a few theoretical economists, who have used similar modelings for years in the attempt to predict the behavior of markets within social networks. DrRich even found a formal critique of the Christakis/Fowler analysis, written by two such economists (Ethan Cohen-Cole from the Federal Reserve Bank of Boston, and Jason M. Fletcher of Yale University). And while this pair of economists, in fact, concluded that Christakis/Fowler bollixed-up their analysis of obesity to such a great extent that their conclusions are completely illegitimate, DrRich counters with this query to said economists: If you know so much about computer models, how’d your investments do during the big crash in ’08? Eh?

Finally, critics say, all the reports appearing in the popular media (which often have included provocative quotes provided by Christakis and/or Fowler themselves), seem to have exaggerated the conclusions of the study way beyond what the published study actually says. For instance, all media reports stress the general contagious nature of obesity. But when one reads the study itself, one finds that the highly-publicized ability of obesity to “spread” from friend to friend actually did not hold up for the following combinations of friends: man-woman, woman-man, and woman-woman. It only reached statistical significance when both friends were men. So while the results of this study have been mercilessly generalized, in fact only one real finding was actually suggested by this data. If either you are a woman or your friend is a woman, then your friend’s obesity is not contagious to you – even if you buy the results of this study.

To this criticism DrRich responds thusly: Having fat friends makes you fat, OK? So get over it. If you choose to believe only the details of the study, instead of its spirit (as clearly expressed by the media and by the public utterances of its authors), then go ahead and enjoy your obese female friends, and see where that gets you.

The real beauty of this study is that, since it comes from a completely unique database that will never be duplicated, the data we have is the only data we’re ever going to get. So, the quibbling of the critics aside, the very best study ever conducted or that ever will be conducted on this issue shows definitively – to the satisfaction of the people that matter – that obesity is contagious.

Since the obese are rapidly becoming the witches of the 21st century, we are obligated to do everything in our power to stop them while we can. (DrRich points out that burning witches is an evil act only if you don’t believe that witches are real. If you, supported by all the respected authorities of the day, believe that real witches are present in the community, and that they indeed are capable of producing extreme harm to innocent individuals, surreptitiously and at a great distance – kind of like the obese – then burning them is at least reasonable, if not the only responsible thing to do.)

DrRich of course is not advocating burning fat people at the stake. He is already on record as saying that committing such an act would be a crime against the environment, just based on the carbon emissions alone.

But, my goodness, why would you befriend a fat person – let alone invite one into your home for a holiday supper – when doing so will put you and your family, all the way down to the second-and-even-third-degree acquaintances in your social network, at grave risk? Until the day comes when our leaders develop the courage to do what needs to be done about the menace of obesity – perhaps gathering up all the fat people and concentrating them, say, in special camps – we must do our bit to keep them from contaminating our own social networks.

As our President says, our new healthcare reforms, to be successful, will rely utterly on the straightforward and unprejudiced application of the very best medical science available, rather than on emotions, on biased opinions, or on unsupported traditions.

Until our leaders grow the teabags to begin following their own advice, let us regular folks do what needs to be done in our own homes, especially during this very special holiday season.

May God bless you and keep you – thin.

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DrRich wishes his readers a Merry Christmas and Happy New Year – whatever their BMIs – and will return here to the CRB shortly after the holidays.

Podcast:

DrRich has written a lot on this blog about the intentional destruction of the classic doctor-patient relationship. That relationship, of course, was a fiduciary one, under which the patient was encouraged and expected to place full trust in the doctor’s sacred duty to put the patient’s own best interests above all other considerations.

Obviously, such a thing is incompatible with a healthcare system in which doctors are expected to covertly ration healthcare at the bedside. Indeed, it was the ethical tension between what the classic doctor-patient relationship required and the new duties of physicians in the real world, that led professional medical organizations to formally re-define medical ethics in 2002.

And today, of course, under these New Age medical ethics, doctors are no longer expected to place the needs of their individual patient first. Rather, they are required to make the needs of the collective – that is, social justice – their chief consideration.

When the needs of the individual and the needs of the collective coincide, of course, so much the better. But when they do not – and they frequently do not – the needs of the collective take precedence. And “the needs of the collective” are now being determined by panels of experts created under Obamacare, which are busily devising the “guidelines” for treatment that physicians must follow to the letter, or risk their careers, life savings, and freedom from incarceration.

Lest you think DrRich is making this up, allow him to remind his readers of this excerpt, from the ominously-titled book, “New Rules,” co-authored by none other than Donald Berwick MD, who has run CMS for the past 18 months:

“Today, this isolated relationship [between doctor and patient] is no longer tenable or possible. . . Traditional medical ethics, based on the doctor-patient dyad, must be reformulated to fit the new mold of the delivery of health care. . . The primary function of regulation in health care. . .is to constrain decentralized individualized decision making.”

Having thus terminated the classic doctor-patient relationship with extreme prejudice, the same political and medical leaders who conducted this assassination immediately realized they had to fill the void – for how can you have no such thing as the doctor-patient relationship? The solution to this problem, of course, was easy. Just as you can create a New Age medical ethics to fit modern exigencies, you can create a new doctor-patient relationship that will do the same thing.

So, what medical students are being taught today about the doctor-patient relationship has nothing to do with fiduciary responsibilities or ethical obligations. Rather, the New Age doctor-patient relationship is all about the interpersonal relationship between doctor and patient. Doctors are admonished: Be compassionate, be empathetic, be nice. And there’s nothing wrong with crying in front of your patients.

Not being an asshole, of course, has always been a useful trait for physicians. Doctors who can relate to their patients, displaying and actually feeling a certain amount of compassion and empathy, have always been more effective at communicating with their patients – and thus have been more effective physicians – than those who are arrogant, self-centered, aloof, or just plain mean*.

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*DrRich has already pointed out the following irony: many of the doctors who washed out of clinical medicine, possibly because they were too arrogant, self-centered, rigid, and/or aloof to be effective physicians, are now populating the expert panels which are writing the guidelines which will dictate the behavior of doctors who might otherwise be actually useful.
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The benefits of being a nice person are not exclusive to the medical profession. The same rules hold for anyone who makes his/her living by engaging in personal interactions with fellow humans. And so, until recent years, the medical profession categorized this fact (that doctors ought to have decent interpersonal skills) within the realm of common sense, common decency, and common knowledge – and the idea of the doctor-patient relationship meant something else entirely.

Every medical school now has formal training on the doctor-patient relationship, under which young physicians are taught to be compassionate, empathetic, and nice. To the extent that such traits can be taught – and DrRich has his doubts – there’s nothing inherently wrong with emphasizing interpersonal skills. There are, however, two problems that come to mind when emphasizing interpersonal skills becomes a substitute for emphasizing the real and true obligations of a professional.

First, teaching young doctors that a good doctor-patient relationship simply means being nice will result in newer generations of physicians having no concept of any fiduciary obligation to their individual patients. They will address the needs of the collective first, as a matter of course. (But as they withhold information on available treatments about which their patients are not to be informed, we can count on them to be extremely nice about it.)

Second, there is a growing school of thought, amongst those who are responsible for teaching this New Age doctor-patient relationship, that not only should doctors avoid stoicism at the bedside, but they also ought to openly display their emotions, so as to further reinforce their compassion, empathy, niceness, &c. By graphically displaying the deep empathy the physician has for his (or more likely, her) patients, he or she can really bond with them, and thus establish a really strong doctor-patient relationship.

And what better way to openly display one’s emotions than to cry?

Just as a general proposition, DrRich is against crying in front of patients. Certainly, there may be rare occasions when emotions rise up unexpectedly at the bedside – when a patient relates a particularly affecting personal story for instance. But in general, DrRich is convinced that doctors should not make a habit of expressing their emotions too frequently or too luxuriously to their patients.

Empathy and compassion are fine, but what sick patients really need is a doctor who can maintain some sense of composure even when things are the bleakest, some sense that, as bad as things are, this situation is not beyond the doctor’s experience. Even if the outcome is destined to be very bad, the patient deserves a doctor who acts like he or she has been there before, and who they can trust to remain at their side and help guide them through the ordeal that remains.

But DrRich is concerned that the faculty of our medical schools, who are busily training America’s Obamacare Doctors of Tomorrow, have reached the following epiphany: A particularly wonderful way to repair the failing doctor-patient relationship would be to indoctrinate young future physicians (most of whom these days, once again, are said to be women – not that there’s anything wrong with that) that crying at the bedside – indeed, openly displaying their every emotion at the bedside – is a marvelously therapeutic act. Such an open display of the doctor’s emotions conveys a powerful message to the patient, namely, “I care.”

Perhaps. But DrRich thinks crying at the bedside actually conveys two powerful messages to patients:

First Message: I empathize with you. I feel your pain.

Second Message: Your medical condition is so unbelievably dire that not even I can face it with any amount of composure. You, my friend, are well and truly screwed. I cannot imagine the agony you’re in for, without falling apart myself.  May God help you.

It is the conveyance of this latter message that, in the opinion of DrRich, ought to make most doctors on most occasions relatively circumspect about crying in front of their patients.

It is also this latter message that offers to make crying doctors a convenient tool for covert rationing.

When the doctor is reduced to tears (thus graphically demonstrating to the patient that the game’s about up; that there’s pretty much nothing, really, that’s going to change this bleak outcome; and how very sad it all is) – well! Talk about reducing your patient’s expectations!

A chief tenet of covert rationing is that patients who can be made to expect little will be satisfied with little. In most cases this is accomplished by simply coercing doctors to withhold from their patients all of their medical options. But if they can be encouraged to cry when delivering bad news, doctors can destroy patients’ expectations in a much more definitive fashion.

Furthermore, the traditional role of the doctor when a patient’s outlook is poor is to take charge of a very bad situation, and with great empathy, patience and fortitude attempt to guide the patient through that situation with as much skill and courage as possible, even if the final destination looks very bleak. If the doctor instead becomes just one more of the people who gather about the bedside crying about it, then the patient immediately perceives themselves to be abandoned and alone, placed into a position irremediably desolate, with no sense of direction, and no sense of control over their own destiny. Patients fighting illness from such a position do more than merely lose their expectations; they will also die much sooner and in greater despair than necessary.

So obviously, our modern healthcare system under Obamacare will see immediate advantages to encouraging emotional outbursts on the part of doctors. In the name of advancing empathetic physicians and fixing a broken doctor-patient relationship, we could, more easily and more often, get those folks who are in the infamous last six months of life to simply stop striving for a medical miracle – or even for non-miraculous but expensive therapies that actually exist, and that (alas!) might actually extend their survival – and thus effect the sick patient’s demise more quickly and more economically.

Certainly, now that medical schools are teaching forms of alternative medicine that in former years would have made real doctors blush, for courses on the doctor-patient relationship to encourage young doctors to let their emotions free is a good and natural fit.

Young doctors should not be taken in by such ploys. They should empathize with their patients, but remain strong, and lead their patients gently and resolutely through their medical ordeals. They should try to avoid allowing a free display of their emotions to break their patient’s spirit. Their job, instead, is to use their expertise to fortify their patient’s spirit, even in the worst of times. And above all they should not allow themselves to become the trained tools of an ultimately cynical healthcare system, that uses every ploy at its disposal to covertly ration medical care.

Podcast:

A key goal of the Central Authority, as it contemplates how best to run our healthcare system, is to do whatever it can to stifle medical progress. Medical progress usually means introducing new drugs or new medical devices, which are often very expensive in themselves, and worse, which often threaten to improve the survival of some category of patients with chronic disease. So typically, medical progress greatly multiplies the costs of healthcare, and all the Central Authority gets in return is more chronically ill people to contend with. For this reason, suppressing medical progress is a critical aspect of covert healthcare rationing.

It goes without saying that a major tactic in achieving this goal is to demonize the drug companies. If the pharmaceutical industry can be made out to be sufficiently evil, corrupt, greedy, and callous to the needs of the people, then it will become the duty of our leaders to constrain them, and in so doing, to limit their ability to develop and introduce new products. This is easily done by adding daunting new regulations, or by piling on oppressive new taxes, or by legislating “windfall profits” penalties, or by using the threat of the regulatory speed trap to threaten them with massive fines or imprisonment. It is indeed fortunate for the Central Authority that the drug companies are, in fact, not the most fastidious members of the corporate community, and that their actions and methods often suggest many fruitful avenues for demonization.

One such avenue that is particularly fruitful, since it recruits the public squarely into the camp of the prosecutorial horde, is to show how the corrupt pharmaceutical industry feeds at the trough of the American taxpayer.

A few years ago, to specifically document this sort of reprehensible behavior, the New York Times pointed us to the case of Dr. Laszlo Bito and the anti-glaucoma drug Xalatan.

In the early 1980s Dr. Bito, a researcher at Columbia University, made a key discovery about a new class of substances that could potentially treat glaucoma. His research was funded with American tax dollars through the National Institutes of Health.

Subsequently, the pharmaceutical giant Pharmacia purchased the rights to Bito’s discovery for a mere $150,000. Based on Bito’s tax-supported work, eventually Pharmacia released the anti-glaucoma eyedrop preparation Xalatan. Xalatan rapidly became a worldwide best-seller, yielding as much as $500 million in sales per year. For their part in this unalloyed success story, Columbia University has netted over $20 million in licensing fees and royalties, and Bito himself became a millionaire.

Meanwhile American glaucoma sufferers are forced to spend upwards of $50 every six weeks for a tiny vial of the drug, which costs the company only a small fraction of that amount to produce, and whose discovery the glaucoma sufferers paid for with their own tax dollars. And, as if to guild this already brazen injustice, Pharmacia makes Xalatan available in Canada, France, and most other countries around the world (where taxpayers decidedly did not support the discovery of the drug), for less than half what American patients pay for it.

It seems, the Times points out, that the American taxpayers are the only parties in this little scheme who reap no financial return on their investment. All they got were some expensive eyedrops.

And so, drug-company demonizers would have us conclude, this is a particularly egregious example of how the evil pharmaceutical industry is ripping us off. Not only are the drug companies mercilessly profiteering from sick Americans (which indeed is their openly-admitted business model), but they are also picking the pocket of every American by using our tax dollars to invent new drugs, then selling those drugs back to us at exorbitant prices. This, one could reasonably argue, is at least as sociopathic as anything the tobacco companies ever did. (The tobacco companies, in contrast, at least had the good graces to eventually stop claiming that their products were beneficial to one’s health.)

And (we in the great unwashed are all supposed to agree), if this reprehensible behavior doesn’t give our government the right to control the prices charged by drug companies, one would be hard pressed to say what does.

DrRich certainly doesn’t want to absolve the pharmaceutical industry of all responsibility for drug prices that seem obviously too high, or for the striking disparities we see in the prices they charge for their drugs between the U.S. and other countries. He has read the complex justifications, published by apologists for the pharmaceutical industry, as to why drugs in Canada cost so much less than in the U.S., and why a tablet whose actual manufacturing cost is five cents is sold to our elderly sick for five dollars. DrRich thinks that, despite all the pretty explanations the pharmaceutical industry gives for these “seeming disparities,” drug companies simply do what every other industry does – they charge the highest price the market will bear, for each market in which they participate. If they didn’t do this, they would be abrogating their fiduciary responsibilities to their shareholders.

There is much not to like about high drug prices, or the fact that people in other countries reap the benefits of American research for far lower prices than Americans do. And it is reasonable for us to seek to address these pricing issues. But as we address certain inequities in drug pricing, we should be careful that in doing so we don’t throw the baby out with the bath water. So if we’re going to alter the arrangement we have with the pharmaceutical industry, let’s be clear on how that arrangement works, and why we set it up in the first place to operate as it now does.

Consider once again the glaucoma drug Xalatan, and consider how Dr. Bito’s discovery was actually used by Pharmacia.

Bito did not discover a finished product. Instead he discovered a new concept for reducing intraocular pressure (that is, for treating glaucoma), and demonstrated that it could be effective – but the specific compound he discovered was not marketable. In fact, it was so highly irritating when applied to the eye that it was simply not suitable for human use. (DrRich does not understand why the drug companies are the evil players in this story, when Columbia University so obviously allowed research to proceed in their facilities in which irritating substances were intentionally placed into the eyes of bunnies or other cute animals.) Indeed, Bito’s new compound was so impressively unusable that, before Pharmacia bought the rights, his discovery had been offered to and rejected by a host of other drug companies as being completely infeasible.

So when Pharmacia finally agreed to pay for the rights to Bito’s patent, they took on an expensive risk that, some estimated, had less than a 5% chance of achieving success. Pharmacia assumed the difficult task of developing a brand new synthetic molecule that would have all the benefits described by Bito, but at the same time would not have the prohibitive side effects. There was no assurance at all that such a molecule could ever be developed, and the cost of searching for one would dwarf the cost of purchasing Dr. Bito’s compound in the first place.

If such a thing turned out to be feasible, then the company then would have to conduct painstaking and extraordinarily expensive human research trials, and if successful, would then have to shepherd their new compound through a time-consuming and costly regulatory gauntlet – which explains why the vast majority of promising new drugs fail to ever gain FDA approval. That their efforts were ultimately successful does not diminish the fact that, when Pharmacia agreed to invest the time, money and opportunity cost to develop Dr. Bito’s discovery, the company was committing itself to an expensive and extremely risky proposition, with no assurance of making a profit or even recouping their losses. It was, in fact, a very long shot.

The folks occupying Wall Street ought to remind themselves that the cool products they are using each day (such as the iPhones they use to organize their flash demonstrations) all came about because the profit motive – and only the profit motive – encouraged some entrepreneur to risk his/her time, treasure, and sacred honor on some new idea. And for each risk-taker who becomes a millionare or billionare, thousands of others achieve only modest success – or fail altogether. (That’s why it’s called “risk.”) But the lure of big profits drives the whole system, and accounts for American progress.

Bito’s (tax supported) idea was a promising one, but the challenge of developing that idea into a product that was useful to patients and that could be brought to market was very expensive and highly risky. Pharmacia took on that risk (all of which was borne by its shareholders, and not by taxpayers) only after difficult, internal corporate soul-searching. If not for the prospect of making enormous profits if this risk worked out, the company (like several other drug companies did in this particular instance) certainly would have walked away.

Before 1980, it is likely none of this would have happened. The Bayh-Dole Act of 1980 was passed expressly to encourage the further development of federally financed, university-based basic research. Until then, a large proportion of basic university research was never “translated” into useful medical products. Such translation of basic research was recognized by Congress to benefit society not only by advancing the practice of medicine, but also by stimulating the overall economy. So industry was actively encouraged to take on the risk of developing promising ideas that came out of federally-funded research. And the profit that greeted successful enterprises was designed to be the one thing that would lure industry into taking that risk.

So when the Times “discovers” a company “profiteering” from work done with tax dollars, it should not be a revelation, nor should it be an unmistakable sign that the company is inherently evil or dishonest. Nor does the company’s activity in this regard give us a justification to arbitrarily restrict its profits. Rather, that’s simply the deal we taxpayers (through our elected officials) have made with the drug industry. We made this deal because we felt it would benefit American society, the American economy, American patients, and quite probably, us as individuals. Of course, if we want to change that deal now, it is within our rights to do so.

Without Bayh-Dole, perhaps patients with glaucoma would still be getting surgical therapy and wearing those coke-bottle eyeglass lenses instead of just using eyedrops. And if we wish to allow the Central Authority to put the brakes on such medical advances (ostensibly to prevent unseemly profiteering, but actually to stifle medical progress), we certainly can. It’s how covert rationing works.

But we shouldn’t vilify the drug companies for taking us up on the deal we offered them, back when we were thinking more clearly.

Podcast:

DrRich does not like to pick on the New York Times.

No, really. DrRich does not like to pick on the New York Times, because he receives two paychecks each month from the New York Times*. This fact (which has been disclosed on this blog since its inception in 2007) constitutes a clear conflict of interest, at least when it comes to writing blog posts which might criticize or satirize or mock articles that appear in that venerable publication, from which he receives a not insubstantial proportion of his livelihood.

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*DrRich holds two positions at About.com, which is a New York Times Company. He has manged About.com’s Heart Health Center for 11 years, and also serves on About.com’s Medical Review Board.
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Yet, regular readers will know that the New York Times has served as a regular source of material for DrRich here at the CRB, and little of what he has written in response to that material has been supportive of it. Indeed, the opposite is true.

DrRich considers it his duty to respond to the New York Times whenever it publishes an article that advances the covert rationing of American healthcare, which (through no fault of his), it does frequently. The New York Times serves as a chief voice of Progressive America, and the Progressive takeover of the healthcare system has become, since this blog was first begun, the chief driver of covert rationing. So, conflicts of interest to the contrary notwithstanding, DrRich submits to his readers that he has acted responsibly and honorably despite his unfortunate financial conflicts.

But still, he does not like to pick on the New York Times.

It is unfortunate for DrRich, then, that for the second time this week he is compelled to do so. And this time, as it happens, the subject matter has to do with conflicts of interest (a subject about which, as he has just disclosed once again, DrRich knows something).

Today, the Times writes that experts are beginning to worry that the GOD Panels (Government Operatives Deliberating) now working to devise the clinical guidelines under which American doctors will be strictly compelled, under penalty of the law, to decide which patients will get what, when and how, are tainted by members who have had ties to (gasp!) industry.

When the GOD Panels were first set up, not very long ago, it was still considered acceptable for some members to have industry ties as long as they fully disclosed those ties, and recused themselves from voting on matters specifically related to their industry work. Having at least some members with industry ties was deemed essentially unavoidable, because it was thought that deep subject-matter expertise would be desirable on these panels. Since most clinical research in America is paid for by industry, it is difficult to have deep expertise without having had at least some contact with industry.

But as the Times indicates, modern medical ethics has now advanced well past this kind of primitive thinking. Nobody with any industry ties has any business being on a panel with such overwhelming authority over the practice of American medicine.

David J. Rothman, president of the Institute on Medicine as a Profession, tells the Times, “Consciously or not, they may well be making decisions that fit their funders, their payers and not the patient’s best interests. If you want the public to really believe in the guidelines, why not have a committee that is conflict-free?”

And the ubiquitous Dr. Steven Nissen of the Cleveland Clinic (a person DrRich numbers among those individuals who, by their public words and deeds, he speculates may be auditioning for the really important GOD Panels) says, “Recusing, disclosing — the reason it doesn’t work is the process involves give-and-take. Even if you don’t make a formal vote, you can still have a huge influence over what happens in the process.”

And so, while the Times does not come out and say so, it seems as if a purge of the GOD panelists may be already afoot. If not an actual purge, then at least the “conflicted” panel members are being sent a clear message, well before they take any final action. And at the very least, Ms. Sebelius is being given the cover she needs to select the people she really wants for the truly important GOD Panels which are being constructed for Obamacare.

All of this is pretty clear, and DrRich has great confidence that his readers can figure it out for themselves.

What DrRich really hopes to accomplish here is to note for posterity the great paradigm shift that has occurred in just the last two or three years, regarding the appropriate relationship between physicians and industry.

Until very recently, the American public, doctors, industry, and medical ethicists thought about that relationship in a certain way, which DrRich will call Theory A:

Theory A:

-  Medical progress is Good, and benefits mankind.
-  Industry is responsible for a high proportion of medical progress.
-  Industry-driven progress requires the active participation of physicians.
-  Therefore, a well-managed cooperation between industry and physicians is beneficial to mankind, and ought to be encouraged.

If you subscribe to Theory A you believe that, because well-managed physician-industry relationships benefit mankind, these relationships are good. So, fundamentally, it’s the management of these relationships which is at issue. These beneficial relationships produce unavoidable conflicts of interest, which we must manage by strictly limiting their extent, and fully disclosing the ones that are left.

So traditionally, the debate about conflicts of interest have been about where to draw the necessary limits.

What today’s New York Times article points out is that Theory A is no longer operative. The new thinking begins with the proposition that no amount of conflict of interest is acceptable, and ALL physician-industry ties should be prohibited. One of the most prominent advocates of this new thinking is Jerome Kassirer, former editor of the New England Journal of Medicine, who says, “The ideal handling of conflicts of interest is not to have them at all.” For these voices, Theory A simply does not apply. Rather, they subscribe to Theory B:

Theory B:

-    The greed of medical industry creates excessive costs, and produces far more harm to society than good.
-    Physician-industry alliances strengthen industry, and increase the harm.
-    Therefore, crippling these unholy alliances is critical to the interests of society.

Underlying Theory B, of course, is the largely unspoken and unacknowledged, but nonetheless fully-embraced, proposition that medical progress is not Good after all, but is the very thing that is driving up our healthcare costs, and so it must be stifled.

A corollary of Theory B is that not only is the Central Authority the only entity which is strong enough to cripple these unholy alliances between physicians and industry, but it is the duty of the Central Authority to do so.

Proponents of Theory B, noting, not incorrectly, that medical industry is chiefly concerned with profits rather than the public good, conclude (in a manner compatible with Progressive if not classical logic) that therefore industry will always behave in ways that are counter to the interests of society.  While many proponents of Theory B will agree that industry provides at least some benefits, they are convinced that these benefits are far outweighed by the harm they produce to the collective. Therefore, Theory B proposes to stifle, if not cripple, medical industry. And a very useful strategy for achieving this goal is to de-legitimize any practical relationships whatsoever between medical industry and physicians.

Proponents of Theory B rarely say what their real goal is. To come out and say that their goal is to cripple the companies responsible for producing medical progress would not be expedient. So most of them still give lip service to Theory A. One must discern their real motives from their behavior.

Much of that behavior, in practical terms, has to do with controlling the flow of information. Let industry develop whatever it wants (perhaps), but don’t let profit-drunk industry – or its greedy physician spokespersons – instruct doctors and patients on who ought to use industry’s products, or when and how. That kind of information can only be managed by unbiased sources.

This is the very thinking that produces the impetus for GOD Panels in the first place. Only experts who are free of industry ties and who answer only to our beneficent, unbiased, completely objective government can say which products of industry are good and bad, and can manage the flow of information about them. Information coming from anywhere else is to be regarded as being charged with bias and greed, and should be ignored, or even suppressed by whatever means are necessary.

To any reader who believes that our government is or can ever be an unbiased and honest broker, or that government officials (or GOD panelists) can cancel their own human natures when they put on a government name tag, DrRich can only wish upon you the grace of God (the old fashioned one). You’ll be needing it. To the rest of us, it is obvious that the government is desperately biased when it comes to medical progress in general, and in particular when it comes to establishing “guidelines” for the use of expensive drugs and medical devices.

For Theory B to have become the operative paradigm in America, as the New York Times today suggests it has, will assure the Central Authority that it is free to seed its GOD Panels only with members whose bias runs in their direction.

But under Theory B there is no government bias. There is only industry bias. And when we purge the GOD Panels of all industry bias, by definition we will have created perfect objectivity.

And this is why DrRich feels so comfortable continuing to write this blog despite his obvious financial conflict of interest in favor of the Times. For a conflict of interest in the direction of the Progressive agenda is no conflict at all.

Podcast:

In a recent post, DrRich described the Regulatory Speed Trap, and alleged that our leaders (long before the Obama administration came along) have learned to use it to intimidate and control selected citizens and institutions when it is to their advantage to do so.

The Regulatory Speed Trap, readers will recall, involves the sudden and arbitrary “reinterpretation” of various confusing, ambiguous, or impracticable regulations which have been on the books for some time, and for which affected citizens and institutions (out of sheer necessity) have established de facto interpretations so that they can continue to function. By their longstanding acquiescence with these de facto interpretations, the Central Authority has at least tacitly endorsed them, and thus commerce is permitted to continue. Until, that is, the time arrives when it behooves the Central Authority to suddenly reinterpret those tangled regulations, and convert selected law-abiding citizens into criminals. By the selective enforcement of ambiguous laws, of course, the goals of Social Justice can be advanced.

As a public service, as a warning to academic medical centers, and as a heads-up to the Central Authority (which DrRich has found in personal encounters to be very scary, and to which he would very much like to endear himself against any future encounters) he will now describe a very serviceable but potentially forgotten Regulatory Speed Trap which was laid more than 15 years ago, and which is ripe for springing.

During the decade of the 1990s, DrRich was chairman of the Institutional Review Board (IRB) in a major teaching hospital. The IRB is the committee that reviews all proposed human research projects in the institution, and assures that the research meets ethical and legal standards as set forth by the Office of Human Research Protections (OHRP) of the HHS, and that the rights and welfare of the human research subjects are protected. The IRB has the duty and the authority to prevent or shut down any research project which is not meeting expected standards. The IRB, unlike any other committee within a hospital, reports directly to the Feds, in order to limit any local influence that may be brought to bear over its decisions by hospital administration, well-endowed researchers, or any other local big wigs.

If the Feds decide that an institution’s IRB is not assuring compliance with all the rules, regulations, guidelines, &c., in all their particulars, then they can arbitrarily and indefinitely terminate all human research in that institution, until such time that sufficient corrections, and sufficient penance, can be made – a process that is typically measured in years. This kind of research “death penalty” – which can ruin an academic institution – has been dealt out more than once.  The prospect is a dreadful one to any academic medical center.

It was, in fact, in his capacity as IRB chair that DrRich first became reasonably adept at reading and interpreting the kinds of obtuse regulations and guidelines commonly promulgated by our government. The official documents under which an IRB must operate are many, lengthy, and often difficult to interpret with absolute surety. Yet, in order for the IRB to function, these regulations and guidelines must be resolved into concrete meanings, which, under scrutiny, would most likely prove acceptable to the Feds. (A difficult task to be sure, but still, not markedly different from the task faced by anyone who wishes to conduct an activity for which the government has devised regulations.)

In any case, readers will understand why it was with some dismay that, in 1994, DrRich received this letter from the OHRP, announcing a new policy regarding diversity in human research.

Now to be sure, such a new policy was needed, since up to that time medical research evaluating new therapies was overwhelmingly performed on adult white males. However, this distribution of the benefits (and risks) of research was not in place because of prejudice against (or in favor of) women or non-whites. Rather, it was there for good and practical reasons. Ever since the thalidomide fiasco, it was verboten to enroll women who might become pregnant (i.e., any woman of childbearing age) in most kinds of clinical research. And African-Americans were understandably and appropriately distrustful of medical researchers ever since the Tuskegee study, and as a group they assiduously avoided participating in clinical research. So the exclusion of these groups was made, for the most part, either out of the desire to protect certain classes of individuals (such as unborn babies), or out of the desire of certain groups of individuals to protect themselves.

Still, DrRich was very sympathetic to efforts to find ways of safely extending research on new products to excluded groups. Otherwise, how could we learn if new medical products were safe and effective in everybody? So he read the letter from the OHRP with interest.

And he was immediately dismayed. While the government’s new policy of diversity in clinical research was advanced for the best of intentions,  the substance of the policy was impracticable past the point of absurdity.

The new policy on diversity in clinical research, in its essentials, stipulated:

1) All minorities and all genders MUST be included in all clinical research studies.
2) Sufficient numbers of subjects MUST be enrolled to allow valid outcome statistics to be performed for each category of participant.
3) Cost is NOT allowed as an acceptable reason not to enroll the stipulated groups in sufficient numbers.

The letter and its supporting documents defined six racial and ethnic categories that must be included: Hispanic or Latino, American Indian or Alaska Native, Asian, Native Hawaiian or Other Pacific Islander, Black or African American, or White.

The letter and its supporting documents defined the three genders that must be included as: Male, Female, Indeterminate or Transgender.

Because each defined subgroup must be included in each study in sufficient numbers to allow for valid outcome statistics to be computed, the new directive seemed to require each research trial to expand its size by 18-fold (to account for six racial/ethic categories, and three genders). So a study which would normally require the randomization of 1,000 patients to achieve statistical surety would now need to enroll 18,000 patients. Notably, the recruiting effort that would be needed to comply with this new policy would be far more than merely 18 times more difficult. For it is one thing to find an “extra” 17,000 people who are willing to risk their health for the sake of medical science, but quite another to find these altruists in just the right distribution, including, for instance, 1,000 indeterminately-sexed Pacific Islanders.

But no matter. The new policy explicitly stipulated that the expense of such a recruiting effort was not a permissible excuse for failing to enroll the proper distribution of subjects.

After carefully examining the letterhead of this document to make sure it did not come from The Onion, DrRich made some well-placed, but gentle and appropriately circumspect, inquiries in an attempt to determine whether he was reading it correctly. How seriously must one take this astounding new federal policy on diversity in research? He quickly learned he needed to stop asking questions. His sources revealed to him that several of the authorities in question actually considered their new directive to be a bit mild – a little too watered-down.

For instance, limiting the number of racial and ethnic categories to only six had been a major concession to practicality. Some of the interest groups that had been instrumental in constructing this new policy apparently had argued, for instance, that each of the 337 federally-recognized American Indian tribes ought to be called out as distinct groups. And the authors had thoughtfully compressed the number of genders to only three (when clearly there are at least four). So the people responsible for this new policy had already carefully considered the issue of practicality, and had mercifully compromised in order to render this policy as reasonable as the principles of research diversity would allow.

So yes, the Central Authority was deadly serious.

As it happened, at this very time DrRich was lodged in the teeth of another Regulatory Speed Trap (which he has described elsewhere), so he took this new OHRP policy very seriously. He knew that while it could not be complied with in all its detail, it also could not be ignored. So he called a special meeting of the IRB to discuss how to respond to the new policy.

A long meeting was held in which this new policy was introduced to the membership, and the members’ reactions were permitted to move through the necessary stages of mirth, horror, disbelief, resignation, and finally, resolution. When sober discussion was finally possible, the members unanimously agreed that encouraging the enrollment of women and minorities in clinical research was an important and laudable goal. We also agreed that if researchers were made to comply with the letter of this new policy, all clinical research in the U.S. would come to an immediate halt. And for this reason, we concluded, it must be true that the policy actually desired by the OHRP must be different from what appeared to be the letter of this policy.

We therefore composed a formal response to this policy, which we placed into the minutes of the meeting, for posterity, and for the benefit of whichever future government agents might burst through the doors with automatic weapons, in order to conduct unspecified investigations. That response went something like this:

Medical research aimed at reducing mortality and limiting pain and suffering is a great boon to mankind, and as long as it is conducted ethically it should be encouraged in every way. Diversity in research is also an important good, and to the extent it is practicable, individuals from all races and genders should be offered an opportunity to participate in clinical research. In deciding which of these laudable goals takes precedence, we note that while research can continue despite imperfect diversity, it will not continue if perfect diversity is an absolute requirement – in which case, one ends up with no research, and no diversity. Such a result, we hold, cannot possibly be the aim of the OHRP.  It therefore seems apparent to the committee that the intent of the diversity policy recently handed down by the OHRP must necessarily be to optimize diversity to the fullest extent practicable, and not to stifle research altogether in service to impossible diversity goals. We therefore interpret this new policy to indicate that all practical efforts must be made to recruit research subjects from all racial and ethnic groups, and from whichever genders we can find, and we will hold researchers in this institution to that policy.

And that’s just what we did.

Our formal interpretation of the OHRP’s diversity policy, it must be admitted, did not follow what certainly appears to be the letter of the policy. But it does work toward the stated intent of the policy, and it has the not-inconsiderable advantages of: a) being actually feasible to implement, and b) allowing medical research to continue. In general, DrRich has found that regulators are somewhat more inclined to look upon your behavior as being relatively benign, if you are able to demonstrate that you have taken their regulations seriously (no matter how absurd they might be) instead of simply disregarding them. Accordingly, our IRB created a record demonstrating that we explicitly acknowledged the new policy, we made a good-faith effort to interpret it in light of universally-recognized truths, and then we acted in accordance with that reasonable interpretation.

DrRich does not know how all the other IRBs in the U.S. responded to this new diversity policy. However, since no institution has stopped doing research on its account, and since no institution has launched massive programs to seek out the tens of thousands of transgender Alaskan Natives that would be required in order to conduct medical research under such a policy, one can only conclude that all those other IRBs also decided not to follow the new diversity policy to the letter. DrRich does not know how many of them took the trouble to make a formal record of their interpretation of that policy, and of their rationale justifying their subsequent behavior. In any case, by the studied inaction of the Central Authority, those interpretations have been allowed to stand for well over a decade, and medical research has proceeded accordingly.

DrRich left the practice of medicine – and the wonderful world of IRBs – at the turn of the millennium. He has no idea how big a deal the issue of “diversity in research” is these days. But to the best of his knowledge the OHRP policy has never been rescinded. Indeed, DrRich finds it extremely unlikely that, at any time during that interval, it would have been politically feasible for any government agency, under any Administration, to soften this or any existing formal policy on diversity.

Most likely, after 17 years, this Regulatory Speed Trap is still set, and waiting to be sprung.

As it happens, the Central Authority today is desperately looking for ways to stifle medical progress, since medical advances are among the chief drivers of increased medical spending. The 1994 diversity policy, whose clear-cut plain-English language is being so universally ignored by medical researchers in every American institution, would seem to offer a fine opportunity for shutting down some of that research.

This Regulatory Speed Trap is not only set and baited, but is swarming with potential victims. Fair warning.

Podcast:

From all appearances, Republican voters are desperate for New Jersey Governor Chris Christie to throw his hat into the ring, and announce that he’s running for the Republican nomination for President. And, while the governor has made dozens of absolutely definitive statements utterly denying that he is going to run, he nonetheless seems quite happy to continue relentlessly teasing his supporters with the possibility. (Just the other night he gave a speech at the Reagan Library in which he discussed foreign policy and other topics not notably relevant to running his state. What’s up with that?)

There are several good reasons Governor Christie gives for not running. He promised the voters of New Jersey that he would stay in office and do everything he could to fix the fiscal disaster that his predecessors created there. He notes that he doesn’t have the fire in the belly which, apparently, one must have for this sort of contest. He does not have very much experience with governance, and has said repeatedly he does not feel ready to become the leader of the free world.

None of these reasons, of course, are dispositive, and all of them could be dispensed with very quickly. Governor Christie is pissing off so many people in New Jersey so quickly that it is not inconceivable that, if he asked them politely, the majority would soon give him a pass on all his promises, and bid him Godspeed in his new endeavors. Fires in the belly, it is said, come and go, and one might just show up at any time. And as for feeling ready to become the leader of the free world, well, the bar there has been lowered so much in the past couple of years that even DrRich – who balked at the responsibility of becoming secretary of his book club – would no longer be intimidated at the prospect. I mean, what the heck?

And so, despite all his denials and all the reasons he gives for staying out, it remains entirely possible that Governor Christie may still get in the race.

DrRich is alarmed by this possibility. And so should we all be, as Governor Christie’s potential candidacy poses a very great threat to us all.

You see, dear reader, the governor is just too damned fat.

Our leaders have just spent nearly three years demonizing the obese, and convincing we the people that fat people, by virtue of their unsightly and self-induced rotundity, are a grave threat to the well-being of each of us.

Here is what we have been taught: Aside from the obvious negative characteristics of fat people (their sloth, gluttony, laziness, selfishness, &c.), and the fact that they are unpleasant to behold and inconvenient to encounter (they are slow, they take up too much space in the grocery aisles and on buses, and they sweat more than you and me), and the fact that obesity is contagious so that fat people should be isolated and shunned, and the fact that the obese probably account for global warming, and thus will ultimately be responsible for untold death and destruction; aside from all these undeniable truths, the obese consume far more than their rightful allotment of healthcare resources, which, per force, leaves much less healthcare available to us holier persons. They are, in fact, trying to kill us.

Demonizing the obese is critically important to the program we have embarked upon in America. Obamacare may give the Central Authority the legal standing to control the personal behaviors and personal choices of individual Americans, but it does not give them the moral authority to do so, nor the ability to actually enforce that control. Americans, despite 50 years of indoctrination to the contrary, still value their individualism, and will still balk – or worse – when they perceive their personal freedoms are being taken away.

The obese are supplying our leaders the vehicle they need for breaking down this last barrier. For, if everyone can agree that obesity is evil, and so are the people who allow themselves to become fat (despite all the “help” they get from expensive public service announcements, calorie counts posted in restaurants, and lectures from First Ladies), then how can we object when our leaders are forced to take stronger measures to “encourage” better behavior, or, if necessary, to punish their behavior?

By virtue of their now-universally-accepted state of sinfulness, the obese are fair game for whatever actions the Central Authority deems necessary to cause them to either lose weight or pay for their sins. From appearances, such measures are likely to begin with taxing soft drinks and Twinkies and whatever other foodstuffs the experts (in their wisdom) deem to be illegitimate sources of calories. But really, the sky’s the limit. For instance, under the undeniable proposition that it costs more energy to move a fat person from point A to point B, whatever the mode of transportation, the obese could be subjected to a special carbon tax, based on their BMI. The periodic mandatory “weigh-ins” such a tax would require would serve the useful purpose of public humiliation, an important incentive to weight loss.

Further humiliations could be visited upon the fat by designating special isolated areas in the workplace (ideally, an area fully exposed to the elements) for fat people to consume their calories. This latter strategy, of course, is derived from the same restrictions placed on smokers, and can be legitimized by the same sort of logic. That is, the authorities can invoke the prospect of second-hand obesity* to induce fear and loathing of the fat, and cause them to become socially isolated.
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*The “scientific” conclusion that obesity is contagious, i.e., that those who associate with the obese are more likely to become obese themselves, has been proffered by academics employing the same kind of statistical legerdemain used to blame global warming on fat people. Clearly, obesity has now become so toxic to the survival of mankind that any paper submitted to a medical journal which offers some new reason to despise the fat – no matter how absurd – will be cheerfully accepted by the editors, and published with great fanfare.
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It goes almost without saying that the ultimate censure would simply be to withhold healthcare services from fat people. This is a strategy that is already being employed by the British healthcare system,  a system we are urged by many of our leaders, such as Dr. Berwick, to employ as a model.

The great benefit of taking the demonization of the obese to its logical conclusion, of course, is that by doing so, the Central Authority will have established the very important precedent of selectively enforcing certain rules, based on a person’s behavioral habits*, in order to achieve Social Justice.

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*While demonizing the obese is considered legitimate by many because fat people “choose” to become fat through their selfish behavior, it is nonetheless true that becoming truly obese (as opposed to becoming merely overweight) is almost always strongly mediated by genetic and metabolic factors. Blessed with the same genes and metabolisms, many of us svelter, more holy individuals would also have become fatties.
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This is a truly critical precedent to set. This precedent will ultimately allow our Central Authorities to restrict, control and tax virtually any human behavior they can claim may lead to an increased risk of healthcare expenditures. Such behaviors may include (in addition to obvious things like smoking and alcohol consumption), one’s choice of occupation, participation in sports, hobbies, hours spent or miles traveled on the highways, and how well you follow the lifestyle changes prescribed by your PCP in your annual, very-strongly-encouraged, “free” wellness checks. Indeed, it is difficult to conceive of any choice one makes in daily living that does not, in some manner, impact on one’s likelihood of requiring medical services, and which thus would not be subject to central control.

All this will become possible because Americans are willing to accede to the demonization of their obese neighbors.

So now we see why Governor Christie must not run. Think of the damage he could do!

The prospect of a fat man campaigning for President – an endeavor which everyone admits takes an incredible amount of initiative, intelligence, energy, and a robust constitution – would itself undermine important “truths” about fat people upon which we base much of our (hard won) hatred of them. Worse yet, if Governor Christie actually managed to secure the Republican nomination, there’s an excellent chance that a majority of voters would actually cast their ballots for him! And he might actually become President!

What would that say about the general acceptability of obese people in our society?

Governor Christie’s candidacy would do untold damage to the critically important obesity paradigm which our leaders have painstakingly established over the past few years, and thus, would seriously damage their entire program.

And it is for this reason that Governor Christie must not run.

Note: DrRich now realizes that he has made a major mistake by writing this post, and here offers an apology and a weak explanation for his error.

 

Podcast:

 

While Grand Rounds is normally the highlight of everybody’s week here in the medical blogosphere, this time it’s different. This week, we are all – each and every one of us  – completely distracted by the most wonderful sense of expectation and joy, to the exclusion of virtually every other human emotion. For DrRich, at least, the feeling puts him in mind of the giddy anticipation he experienced on, say, his 5th Christmas eve, when he was still young enough to consider Santa Claus a magical-but-real agent of earthly delights. (This was before DrRich realized that Santa, being obese, is actually a great menace to society.)

For this, dear reader, is the week when President Obama will turn his considerable powers of intellect, at long last, to the issue of jobs. The President indicated to us more than a month ago that he would, in his own good time, present to us his program for fixing the horrific and prolonged unemployment problem which now affects most American families in some way. And thus realizing that a solution is finally at hand, we in the great unwashed masses have waited, as patiently as we could, through earthquakes, hurricanes, Martha’s Vinyard vacations, and numerous pre-season football games, for the President to tell us the Answer. And, summoning together a Joint Session of Congress – a venue most often reserved for declarations of war and similar life-altering policy initiatives, thus confirming the momentous nature of his coming words – he will finally proclaim to us the Good News, a mere two days from now. One can cut the anticipation with a knife.

So, while it is indeed an honor to be hosting Grand Rounds during this historic week. DrRich must admit to finding it a little difficult to concentrate his efforts. No doubt readers will likewise find it a challenge to turn their attention away from the Big Event long enough to peruse the following posts – the best of the medical blogosphere this week.

But be assured that there is good stuff to follow. So, if you find yourself incapable of focusing your attention on Grand Rounds at the moment, simply bookmark this page, and return to it once your sense of soaring happiness returns (as it inevitably must) to a more normal state. Be assured that this week’s entries are timeless enough to outlive your ecstasy (an emotion which – alas! – to be effective, must always be transient).

So let us begin.

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DrRich – having been informed not long ago, by an actual U.S. Attorney who at that moment had him under a form of official duress, that the DOJ is well aware of this blog and the general tenor of its content – always likes to mention early in any long post (so that his minders do not have to read the whole thing) any items that might be helpful to the Administration. Accordingly, we open Grand Rounds this week with the announcement, posted in The Examining Room of Dr. Charles, of the 2011 Charles Prize for Poetry. Dr. Charles has been hosting this prestigious contest – which seeks and awards excellence in poetry touching on health, science or medicine – for some time now, and it has proven to be an exceedingly popular annual event.

In addition to the significant intrinsic merits that accompany the Charles Prize for Poetry, DrRich must note that Dr. Charles is also awarding a not-inconsiderable cash prize to the winners. That is, he is creating what, in our present economic environment, must be considered damned-near jobs. Encouraging employment in the career of poetry is something, DrRich thinks, the President should seriously consider before Thursday night, lest he be tempted to make the huge mistake of attempting to whip up enthusiasm yet again for Green Jobs. (In the wake of the collapse just last week of the heavily-government-subsidized and heavily-Obama-promoted Solyndra Company, and of at least two other companies that received large federal funds for Green Jobs, treading that dead ground again would merely reveal that he is entirely bereft of ideas.) The Administration ought to thank DrRich, and especially Dr. Charles, for this critically important advice. Encouraging poesy, instead of Green Jobs, would demonstrate the kind of new thinking we are all looking for from our President at this critical juncture.

At Dr. Malpani’s Blog, Dr. M. outlines his 3-step approach for helping his patients understand the intricate concepts of in-vitro fertilization. First, you describe how the thing is supposed to work when everything is functioning normally (the “thing” in this case being the human reproductive system). Then, you describe to the patient where the system is breaking down in his/her case. And finally, you describe the options available for mitigating the breakdown. Dr. Malpani’s system, which he points out is generalizable, is aimed at creating a consensus for action when faced with a complex problem.

DrRich will only remark that Dr. M’s system, which works well enough for problems based in human physiology, is proving pretty worthless for problems based in the more social sciences, such as economics. This is because of a fundamental disagreement, among the debaters, on how the economy is “supposed to work when everything is functioning normally.” Progressives and conservatives have very different ideas about this. So Dr. M’s approach, which requires both logic and a fundamental consensus on what constitutes “normal” behavior, is unsuitable to non-physiologic systems.

Dr. Val at Better Health posts a recent interview with Dr. Dori Carlson, president of the American Optometric Association, regarding the importance of screening children for subtle but significant vision problems. (Dr. Val and Dr. Dori are referring here to the kinds of vision problems that involve optics, and not the kind suffered by our political leaders.) The type of gross vision screening which is conducted by most schools misses the majority of these vision problems in children, and those undetected vision problems not infrequently lead to impaired learning. Also, they often lead to misdiagnoses and inappropriate treatment, likely including the misdiagnosis of ADHD. (Missed vision problems constitute only one of the causes for the explosion in ADHD diagnoses in recent years. A more common cause, in our overly-feminized schools, is being a boy. Indeed, as nearly as DrRich can tell, being a boy today is a disease; they have drugs for it and everything.) In any case, if you are a parent of a school-aged child, you should strongly consider having your child’s vision checked by an ophthalmologist or optometrist – especially if somebody wants to put him on Ritalin.

Henry Stern at InsureBlog tells us the good news and bad news about a new study related to heart attacks. He notes that heart attack victims are receiving definitive therapy in American hospitals much more quickly than they were just a few years ago. And when you are having a heart attack, minutes count – the longer that coronary artery is occluded, the more permanent damage is done to your heart, and the higher your odds of death or disability. So the diminished delay to treatment is good news. As usual, though, there is bad news attached. DrRich, always the sunny optimist, does not wish to repeat the bad news. You can go to the InsureBlog to read it for yourself.

The ACP Internist reports a study showing that 80% of today’s doctors look up on-line information in front of their patients. DrRich, who admits to being an Old Fart, does not find this surprising, since young physicians these days are, well, young. And young people are on-line all of the time, reporting their every trivial thought and mundane action instantaneously to the Cloud. (If Andy Warhol were alive today he’d be talking about our 15 minutes of anonymity.) But you don’t have to be a young doctor to take up these new habits. It appears from this new survey that doctors of all age groups have ritualistically placed an LCD screen between themselves and their patients. In so doing, they have awarded to those distant, expert panels – the ones spinning out all those guidelines, pay-for-performance checklists, marching orders, &c – their appropriate and rightful physical position, that is, directly interposed between doctor and patient. This is more than mere symbolism, but the symbolism is delicious.

But, dear reader, please do not be too critical of today’s doctors. If you yourself were a savvy modern physician, realizing that you could go to jail if you do what you think is medically appropriate before checking with the Authorities to find out if it is also allowable, you’d have a computer screen in front of your face too, and you’d be looking stuff up in front of your patients the entire time they were blathering on about their symptoms or whatever. DrRich worries for the 20% of doctors (likely, his fellow Old Farts) who haven’t “gotten it” yet.

Beth Gainer at Calling the Shots makes an important observation about the two classic narratives to which all victims of breast cancer are assigned – the narrative of the triumphant hero, and the narrative of the courageous and noble victim. Ms. Gainer’s observation is that most women with breast cancer do not fit either of these prescribed narratives. Many women are thus left feeling guilty or diminished when they find that their experience is not meeting with society’s expectations. Ms. Gainer is absolutely correct, and indeed, her observation is generalizable. The same thing occurs whenever society’s designated narrative-makers assign a range of permissible attitudes, thoughts and behaviors to any defined group. Mercy on any member of the group who falls outside those designated norms.

David E. Williams at the venerable Health Business Blog addresses the question of how we – society – will cope with the next big trend in the drug industry – the development of “niche” drugs, drugs that are suitable for only a relatively small number of patients and which, therefore, are exceedingly expensive to develop and market. David goes directly to the real question – the problem of niche drugs makes the issue of healthcare rationing unavoidable.

So far, of course, we are doing our healthcare rationing covertly, and in the case of niche drugs that usually means interpreting clinical results in such a way as to minimize their potential benefits. We do this by saying that Drug X “only increases survival by 4 months,” and ignoring the fact that “4 months” is an average value, and that while many patients have no benefit at all, a non-negligible minority may live a lot longer. The question, “Is it worth $50,000 for only four more months of life?” is different from the question, “Is it worth $50,000 to have a realistic shot at living several extra years?” Covert rationing causes us to frame the question in such a way that the answer to any question beginning with “Is it worth. . .” is always, “no.”

At the Road to Hellth, Douglas Perednia, one of the best analysts of health policy writing today, looks at the rationale for the onerous penalties which are required under Obamacare for hospitals whose patients are readmitted at higher than the average readmission rates. Perednia describes the bogus math which the Feds are apparently using to determine what appropriate readmission rates ought to be – and points out the irony of requiring doctors to behave in an “evidence-based” fashion, while the Feds themselves are using frivolous statistics to dole out the equivalent of the NCAA Death Penalty to our hospitals.

Steven Seay, PhD discusses what ought to be second nature to any clinician – applying the principles of the scientific method to clinical practice. That is: gather the necessary data to formulate an hypothesis; institute therapy based on that hypothesis; measure the results of that therapy; revise the hypothesis to reflect this new data; repeat as necessary. This is the way clinical practice should be done. DrRich is happy to learn that it is still apparently OK for clinical psychologists to function in this manner. For physicians, especially PCPs, the scientific method has become forcibly compressed to: make a diagnosis; treat according to the guidelines. While the patient might not do so well with this new method, the physician will be OK, since “quality” will be measured according to one’s compliance with the guidelines. Measuring the actual results of the treatment, of course, would only lead to trouble, and in most cases will be avoided.

James Gault, MD, of the blog Retired Doc’s Thoughts, is a long-time champion of classical medical ethics (as opposed to the New Age medical ethics now formally espoused by all the major professional organizations).  As such, Dr. Gault often deconstructs arguments being published by modern medical ethicists supporting these New Age ethics, which require doctors to act for the benefit of the collective rather than for the benefit of their individual patients. In this post, Dr. Gault gives a very effective what-for to Professor Fuchs of Stanford, who, once again, has published a paper advancing the bankrupt argument that what’s good for the collective is necessarily good for the individual. These kinds of vapid arguments may fool the Whippersnappers, but they’re not fooling us Old Farts.

The ACP Hospitalist notes that, according to the Institute for Safe Medication Practices, a “grey market” is developing for life-saving medications that have been in severe short supply for the past few years. A grey market, DrRich thinks, is like a black market, but less illegal – though it is possible they are referring to Old Farts who are merchants. In any case, the ISMP says the grey market is price-gouging hospitals that need those important drugs, and have nowhere else to buy them. The solution, according to the ISMP, is (among other things) to empower the FDA to manage drug shortages and tighten regulations for drug distribution.

The growing, widespread shortage of important medications is indeed a bad problem. We should look for a solution to this problem. Shortages of any product occur when it costs companies more to make the product than they can get for it in the marketplace. Onerous regulatory policies by the FDA which, in the name of product safety, have greatly increased the cost of doing business for pharmaceutical companies, along with recent de facto price controls on generic drugs, have combined to make it economically unfeasible for drug companies to expend large resources to manufacture these drugs. It seems doubtful that piling on even more regulations will improve the situation. And attacking the grey markets will simply drive them further into the dark (since black markets are nature’s way of providing a product when governments act to limit it). Given the expected 500,000 pages of new regulations being conjured up out of the Obamacare legislation, drug shortages are merely the first of many critical medical shortages we will be seeing in the coming years. So it will be instructive to watch how our leaders handle this problem.

In any case, from the job-creation standpoint, DrRich believes there will be many employment opportunities in coming years in sundry black markets related to healthcare. Many skills will be needed, some of which should be quite exciting!

At the Prepared Patient Forum, Trudy Lieberman writes a post entitled “Health Insurance, Meet the Jolly Green Giant,” in which she discusses the new, patient-friendly labels that are supposed to accompany health insurance policies under Obamacare beginning no later than 2014. The labels sound like a good idea, but as Ms. Lieberman points out, there will be problems. For instance, for the Feds to mandate transparency in labeling is unlikely to be all that helpful when, at the same time, they often mandate utter secrecy on the part of providers (for instance, in creating severe anti-trust penalties for doctors who reveal the fees they have negotiated with insurance carriers). But as always, results are far less important than simply meaning well.

Sharp Incisions, a blog written by a self-described “fledgling” medical student, has sent in an affecting post about scrubbing in on a unique surgical case – the harvesting of six vital organs for transplantation from a patient who has been declared brain dead. DrRich prays that Dr. Incisions will maintain for a long time the same sense of wonder and gratitude, expressed in this post, for the gift of life.

A medical student who blogs anonymously at the D.O.ctor Blog, describes her first experience participating in cardiopulmonary resuscitation when it actually counted. DrRich, who in his days as a cardiac electrophysiologist ran hundreds of these things, and who became convinced over the years that three people was the optimal number to run a “code,” admits to being a little taken aback by this student’s description of the event, which sounds like it must have been as complex to coordinate as a Busby Berkeley production number. No wonder she was a little astonished by her experience. DrRich supposes that this must be the new-style CPR mandated by some new guideline or other, and would not be surprised to learn later this week that CPR procedures requiring 15 participants is part of the President’s new Jobs Plan.

Speaking of sudden death, one of DrRich’s recurrent themes here on the CRB is that sudden death is a great boon to our healthcare system (since not only is sudden death itself very cheap, but also it tends to remove individuals who would otherwise continue collecting Social Security, and who tend to have expensive chronic heart disease), and that therefore the government will tend to stifle the prevention of sudden death any time it can. Accordingly, Dr. Wes tells us that the Feds are about to further limit the use of the Zoll wearable defibrillator. Doctors have taken to using this device in high-risk patients during the first month or so after a heart attack, since guidelines specify that ICDs (implantable defibrillators) must not be implanted during this interval. Since sudden death is particularly likely during that first month, the Zoll device is being used as a “bridge to ICD.” Obviously, sudden death being the healthcare system’s friend, this must not be permitted. And so, Dr. Wes points out, soon it will not be.

At the HealthAGEnda Blog of the John A. Hartford Foundation, Marcus Escobedo describes how his father is coping with the decisions that need to be made as he deals with recurrent prostate cancer. Helping elderly patients deal with health issues is the thrust of Mr. Escobedo’s work at Hartford, and his new personal experience, he tells us, drives home the point. Specifically, Escobedo works to assure that elderly patients are considered to be more than just the sum of their disease and their age. DrRich is sorry to have to point out that no less an expert on American healthcare than President Obama has explicitly disagreed with this approach, and on national television to boot. Perhaps when he said this the President was suffering under the influence of teleprompterpenia, and perhaps if he had an opportunity to meet with Mr. Escobedo over a beer in the Rose Garden, he would possibly begin to revise his position to one that is more compatible with the mission of the Harford Foundation. On behalf of America’s Old Farts, DrRich would certainly hope so.

Dr. Thomas Pane writes in the Business, Surgery & Medicine Blog about tantrums, specifically, the kind occasionally thrown by surgeons in the operating suite. His post carries an important Labor Day lesson for anyone who hopes to make a career in the medical field in the coming years, so pay attention:

Everyone can agree that throwing tantrums in the operating room is never a good thing, and that quite often, it is a very bad thing. But Dr. Pane points out that, counterproductive as tantrums often are, they are nonetheless not the worst possible way in which a surgeon can express his/her utter frustration at a bureaucracy that blithely conspires to disrupt surgical procedures at critical moments. He reminds us, once again, that the biggest handicap one can ever have when working in an environment in which bureaucratic mud has fouled every gear is: giving a sh*t. So, while Dr. Pane may or may not agree, here’s the lesson: If surgeons would simply adopt the apathetic, indifferent attitude that classically characterizes long-term survivors in work environments mired by bureaucracy, all would be well.

Jaqueline writes Laika’s MedLiblog, a blog dedicated to medical information science. She submits a post entitled, “PubMed’s Higher Sensitivity than OVID MEDLINE… & other Published Clichés,” in which she shows how medical researchers doing literature searches for, among other things, meta-analyses, will stumble upon various “anomalies” in their searches of the PubMed and OVID databases, and then write additional, CV-padding papers about those anomalies. Jaqueline points out that these so-called “anomalies” are actually well-documented “clichés,” which are well-known to information specialists and anyone else who is competent in doing comprehensive literature searches. In other words, Jaqueline has documented that these meta-analysis researchers are rank amateurs at doing the most critical step in conducting meta-analyses – searching the literature for all the appropriate published studies. DrRich has always mistrusted meta-analyses, and Jaqueline has helpfully identified yet another reason to justify such mistrust. He thanks Jaqueline, and whoever planted those database anomalies which allow us to identify potentially incompetent meta-analysis researchers.

Nicholas Fogelson of Academic OB/GYN writes about taking care of the dying Jehovah’s Witness patient, or rather, taking care of the Jehovah’s Witness patient whose illness is potentially curable but who is dying because he or she refuses to accept blood products. DrRich can attest to how very difficult it is for a doctor to respect a patient’s religion when doing so results in their death. Dr. Fogelson’s description of his evolving attitude regarding this dilemma is compelling.

Need to be uplifted after reading the above post? Read Jordan Grumet’s submission from his blog, In My Humble Opinion. It’s brief and beautifully written, and it reminds us that sometimes our efforts as doctors – which all too often seem futile – can pay off in unimagined ways.

Pranab at the Scepticemia blog points to a news story about a medical school in Mumbai selling seats (that is, entry to medical school) to the highest bidder. He strongly objects to this practice, even though he postulates that his objection will make some of his readers call him “a leftist commie” (which DrRich finds to be the most common kind). DrRich does not agree with Pranab’s (tongue-in-cheek) conclusion that it is America’s fault that Mumbai medical schools are selling seats. (It is actually only George Bush’s fault.) But DrRich does agree entirely that the practice itself is an abomination. Indeed, we can all agree that entry to any career which requires a high degree of skill, talent, and/or intelligence ought to depend on merit, and nothing but merit. Can we not? Good.

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DrRich will end by noting that he is finishing this Jobs! Jobs! Jobs! Edition of Grand Rounds during the waning moments of Labor Day, which causes him to fondly recall those long-ago days of yesteryear, when the U.S. still had plenty of steel mills and DrRich was a card-carrying member of the United Steelworkers of America, and the thought of attending medical school had not yet penetrated his still-empty head. And he recalls how, while he was working one day as a lowly laborer, a union boss came over to him to explain (after DrRich had complained about it) the utility of his spending three painful days moving a large pile of slag, employing only shovel-and-wheelbarrow technology, from one location to another – AND THEN BACK AGAIN.  Now, those were the days when we knew how to make jobs!

Say, whatever happened to those steel mills, anyway?

Podcast:

While all the Republicans and Democrats in Washington are spending all these fine summer weekends fighting over the debt ceiling, and so far have absolutely nothing to show for it, the smart people at the New York Times have gone ahead and solved the whole debt problem for us.

Blaring at us from the front page of today’s Sunday Review, in huge, bright red print, we see the following chain of logic: A 20% tax on soft drinks will produce a 20% reduction in consumption, which will prevent 1.5 million people from becoming obese, which will prevent 400,000 cases of diabetes – yielding $30 billion in health savings.

This revelation leaves DrRich slapping his forehead and wondering, “Why didn’t I think of that?” Simply use the tax code and the regulatory muscle of the Central Authority to change human behavior in the proper manner, and everything will fall into place.

It takes a special kind of person to believe that human behavior is so predictable, and so controllable, that one can actually titrate in such a manner the amount of obesity that exists in a society, and therefore, titrate the cost of healthcare. It takes a special kind of person to believe that, simply by tweaking a specific tax here, or adding a specific regulation there, one’s actions will yield precisely the response predicted by the “experts,” and that this response will translate precisely down a complex chain of assumptions (based on selective analysis, conjecture and wishful thinking) to yield cost savings anything similar to those predicted, and that the cascade of results (not being subject to any vagaries of human nature) will not have all manner of unintended consequences. That special kind of person is called a Progressive.

Let’s say that some really smart operative in the Obama administration, reading today’s Times, takes it into his head to solve the obesity crisis, the healthcare crisis, and the debt crisis all in one brilliant stroke, and accordingly, gets the President to appoint the entire New York Times Editorial Staff as the country’s new Czar of Food. These fine folks, sensing a once in a lifetime opportunity and not wanting to squander it on such small potatoes as a softdrink tax, decide to go all out. They institute large, prohibitive taxes on ALL the foods consumed by our society that contribute to our obesity. As a result, the only foodstuffs that remain untaxed are fresh fruits, vegetables, and fish. (And, considering the possibility that one or more of the NYT editorial staffers may very well be vegans, DrRich is not sure about the fish.)

According to the Times’ variety of calculus, this action will have remarkably positive consequences.  The consumption of unhealthy, obesity-producing foods will drop by some very large amount – probably 90% if the taxes are high enough – and American obesity will nearly disappear. Diabetes will go the way of tuberculosis and leprosy, all the other medical disorders made worse by obesity will greatly diminish, and we will save trillions of dollars in healthcare expenditures.

What would actually happen, of course, is quite different.

If all sugary foods and fatty foods and processed foods were heavily taxed, the demand on the untaxed foods (the fruits, vegetables and fish) would skyrocket, and prices would go through the roof. Only the very wealthy could get all the healthy food they wanted. The merely wealthy would get some of the healthy food, and would supplement their diets with the unhealthy stuff, grudgingly paying the excessive taxes to do so. DrRich does not know what the poor would do for food, but he bets they would be pissed.

A lot of other unpleasant things would happen as well. The companies that process foods and soft drinks – and most American restaurants – would suffer badly, and would probably go out of business. Robust black markets would establish themselves, trafficking in inexpensive, calorie-dense (and possibly even tasty) foodstuffs, which would now be produced in Mexico, Canada and China instead of in the US. Junk food cartels would murder each other along our borders. Americans would find themselves envying, rather than pitying, that occasional old fart who is discovered dining on a can of Fancy Feast Cat Food.

And furthermore, Americans will learn something about one’s ideal body weight that we don’t hear too much about today, because it does not fit into the “overweight is bad” narrative. Namely, while severe obesity is very bad for your health, being a little overweight is probably not so bad. Statistically speaking, it is more threatening to one’s longevity to be too thin than to be a little overweight.

DrRich does not have the solution to the obesity problem we have in America. If there is a solution, DrRich thinks it is likely to be some combination of science (since there is a large genetic component to true obesity), encouraging a sense of personal responsibility for living one’s own life, and yes, even public policy. But he finds the kind of linear thinking displayed in today’s Times – relying on assumption piled upon assumption, ignoring the obvious human and economic reactions that will knock those assumptions off their straight-line path – to be silly. And if they actually encourage public policy experts to behave in such a manner, they can be dangerous.