Random Thoughts from a Restless Mind

Dr. Darrell White's Personal Blog

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Archive for July, 2009

A Trip Straight to Madness

I missed church last Sunday. Again.

It seems that after most of a lifetime spent unable to find a reason not to go to church I am now unable to find a reason to go. I once found comfort in the fact that my time in church was “shared” with many millions of other churchgoers of the same stripe, comfort in the fact that the service I was attending would be mostly the same in any one of thousands of churches around the world. No matter where I might find myself I would always have one place where I felt at home.

This is no longer true. I almost wrote “sadly”, but I’m not really sure that would be truthful. To be honest I really have very little feeling about this development; I am neither happy nor sad. When I sit in church now I feel… well… nothing. I used to wonder when I was younger how my beloved Gama could stop going to church after decades of faithful attendance and I think I have a bit of an understanding now. You see, Gama never really lost her faith in God, never really lost her belief that there was something to come after this life that made the living worth the effort. She never stopped believing in that; she simply stopped believing in the Church. My friend fighting cancer is much the same–we agreed that he and I are not very faithful churchgoers but that we do, indeed, have Faith.

There was a certain pull to the Church of my youth. A certain “rightness”. There was also more than a little fear. What if the Church was right? What if it truly was the one and only truth, and believers of all other truths were doomed to a forevermore deprived of the ultimate afterlife? With time and more than a few miles under my belt I’ve given this considerable thought, and what I think is that Gama was more right than not. Could it truly be that all of the other churchgoers, attendees at slightly different types of churches, were wrong? And the millions of other people of faith, the Buddhists and Shintoists and Hindus, the Jews and the (peaceful) followers of Islam, all of the indigenous peoples of the world who worship the nature that surrounds them? Perhaps my Church is MORE right, but are they all wrong? Gama, I think, would have said no, that it is the faith in some greater good overseeing all that is right. My friend who is fighting cancer would agree.

It makes you wonder about atheists, doesn’t it? The existentialists are a little easier to fathom. For them there is one truth and therefore only one choice. Life is nothing but pain; one simply chooses to accept the pain or to end it. It seems as if Faith does not enter into the equation since the entire focus of the existentialist is the pain today, and the focus on that question makes all other lines of inquiry unnecessary. But what of the atheist? Is the atheist simply an existentialist without the insight or the courage to acknowledge the question? Or is an atheist someone who has looked for a reason to have faith and has simply stopped looking too soon?

I am a physician as is my friend above, and at our core all physicians are in some way scientists. We typically entered medicine via a science background or a science aptitude, and the best among us apply the very best of what science has to offer in the care and service of our patients. Science and Faith have certain fundamental conflicts, however, and these conflicts rise to the surface when Faith is reflected as Religion. The essential character of science is proof, or at least the attempt to secure the best approximation of proof. All Religion fails at the earliest application of science because all religions require a very early application of Faith. Is Faith the same? Is the very existence of Faith inconsistent with science? Is the atheist right?

I’ve been working my way through a very difficult book called “Quarks, Chaos, and Christianity” by John Polkinghorne. The author is the former Cambridge Professor or Mathematical Physics who is now an Anglican priest. The book is short on pages but long on words, if you know what I mean. In it Polinghorne attempts to reconcile particle physics with religion in order to answer the question of whether a scientist can believe, can have Faith. He attempts to prove that the end of every inquiry into the origin of life, and therefore every inquiry into the question of an afterlife, must always end in some measure of Faith. If you end your search in the Old Testament you conclude “Let there be light!”. If you find that evolution is the answer you must believe that some all-knowing Chef first stirred the primordial soup. And if you are a particle physicist there is really no answer behind the curtain of the infinitesimal dot that exploded in the Big Bang, is there?

No, in the end there is only and always Faith. Every inquiry ends in Faith. It must. The need to know and the need to prove are the essence of being human, but the existence of Faith is the essence of being alive. The absence of Faith is a type of intellectual laziness at best and an essential cowardice at worst. The existentialist acknowledges this by honestly attempting to answer one and only one question, whether or not to accept the pain for one more day. The atheist is essentially a coward, unable or unwilling to follow the inquiry to any conclusion. The essential questions of life, where did we come from and where will we go, can only end in some acceptance that there must be more. My friend the physician with cancer has always known this. At the end of every inquiry we must have Faith.

Without Faith every essential inquiry into the beginning and the end of life is nothing more than a trip straight to madness.

An (Im)Modest Healthcare Proposal

I have been pretty generous in sharing my thoughts about some of the ills of our American Healthcare system, especially with regard to the barriers erected between physicians and patients. I find the various proposals now before our legislative bodies in Washington to be rather curious, even offensive. Since when does the United States of America adopt wholesale an economic solution from another country? Especially another country that is in some way otherwise riding the considerable coattails of the U.S. economy?

The “baby with the bathwater” approach in the halls of our Capitol and the editorial offices of our leading media outlets (WSJ excepted) is about as wrong-headed as you can get.  What we need is an AMERICAN solution to the challenges that we presently face with the economics of healthcare in the U.S., using our present system as the foundation.

Not surprisingly, I have some thoughts!

1) Malpractice tort reform. See my thoughts in “Tort Reform = Healthcare Reform”. Effective reform will dramatically reduce the scourge of defensive medicine with its attendant costs and risks to patients. Defensive medicine represents 15-25% of all medical costs in the U.S. That’s 15-25% of $2 Trillion. Do the math.

2) Tax Reform #1: Remove the tax deduction for employer-offered health insurance. Provide a 100% TAX CREDIT to the lowest 60% of wage earners for the purchase of health insurance. Provide a progressive TAX DEDUCTION for the upper 40% of wage earners.

Tax Reform #2: Remove the tax deduction for advertising as a business expense for Hospitals. If we are concerned about unnecessary increased utilization of medical resources why are we allowing advertising by hospitals? For that matter, remove the tax-exempt status of any hospital or  provider that advertises. How is it appropriate to allow a hospital system to advertise to increase revenue, deduct that advertising as an expense, and still be not-for-profit? If it looks like a business, acts like a business, and sounds like a business, tax it like a business.

3) Insurance Reform #1: Reverse all of the for-profit conversions of previously not-for-profit health insurance companies. Who was the genius who thought THIS was a good idea? I don’t remember insurance premium increase that were quite so massive when all of the Blue Cross/Blue Shield plans were not-for-profit, do you? And while there were $Million execs in the non-profits I don’t recall any $10, $20, or $100 Million execs. Removing the need to answer to the stock market will create companies that will compete quite nicely with the for-profit companies without the horror of a government run system. Let the equivalent of NGO’s compete with the United Healthcares of the world.

Insurance Reform #2: Remove state-level coverage mandates and create a minimum federal set of mandates for comprehensive insurance policies. A REAL minimum. REAL medically necessary items. No Viagra or artificial  insemination coverage. Allow cross-state competition for the business. Real competition always drives prices lower.

Insurance Reform #3: Mandate high-deductible catastrophic health insurance for all. Real insurance, the kind that protects against a life-altering financial death sentence, not the pre-paid service plans that we now call health insurance. See Tax Reform #1 to see how it can be covered.

Insurance Reform #4: Allow insurance companies (Medicare and Medicaid included) to discriminate IN FAVOR OF people who make healthy lifestyle choices (eg. no nicotine, no DUI, etc.). We are all so afraid of the stick that we refuse to allow any use of the Carrot.

4) Freedom of Speech/Restraint of Trade Reform #1: Abolish, once again, direct-to-consumer pharmaceutical advertising. There was a quantum leap in the utilization of all sorts of medications immediately following the 1997 rulings that allowed DTC pharmaceutical marketing. If it is so obvious that our ever-increasing levels of spending on medical care is a threat to the very existence of our fair Union, then DTC drug marketing is a version of yelling “FIRE” in a crowded theater.

Freedom of Speech/Restraint of Trade Reform #2: Begin a return to the professionalism of yesterday by prohibiting all forms of advertising by, or for, physicians. The AMA gets a lot of criticism, most of it well-deserved in my opinion, but the court and FTC rulings that prohibited the AMA from censoring physicians who advertised was a seminal event in the de-professionalism of doctoring and medicine. Doctors and other medical advertising was, is, and always will be wrong. While we’re at it, do the same thing for lawyers and the practice of law.

5) Public Health. Finally, and most importantly, go to the true root of whatever “Crisis” we may have here in the United States, be it a “Healthcare Crisis” or a “Healthcare Finance Crisis” or what have you. We as a people are not healthy; certainly not as healthy as we ought to be. We are not healthy because of some wrong-headed previous Public Health decisions (simple-carbohydrate based diets, abolition of school phys-ed programs, tort-fearing closures of playgrounds, etc.). We are not healthy because our ability to treat the diseases that result  from poor lifestyle choices (cigarette smoking, alcohol abuse, preventable accidents, etc.) is SO GOOD that we are able to keep more and  more unhealthy people alive longer and longer, paying ever more to do so along the way.

This is where true leadership can make a difference. Remember JFK and the President’s Council on Fitness? I do. 8 pull-ups in the fifth grade for me. Sweden identified saturated fats from whole-milk products as a significant cause of heart diesease in the 70′s; a full court Public Health press for low-fat dairy brought about a dramatic decrease in cardiac deaths in the 80′s. Polio, measles, smallpox and whooping cough were once the leading killers of children in the U.S. but are now historical footnotes due to Public Health initiatives.

We lead the world in per capita alcohol related accidents and deaths, losing young lives by the thousands each year. We have ever more increasing numbers of truly obese citizens who go on to suffer the diseases caused by that obesity, and we pay ever more for their diabetes, hypertension, strokes and heart attacks. These lifestyle choices are root causes for our increased expenditures on Healthcare, much more so than all of the targets of Beltway demagoguery like insurance company expense ratios and pharmaceutical company profit margins. A solution to this issue, more than all of numbers 1 through 4 combined or any other proposal yet floated, is the true crux of the solution to any “Crisis” we may be facing. Everything else is only there to buy time. Time to get healthy.

There are no votes to be had in making Americans healthier. Nothing but hard work on every side of the equation. Who will stand up and do the hard work? Who will lead?

Who will have the guts to not only say that the Emperor is naked,  but also drunk and fat and puffing away our economy.

What Do You Do?

Have you ever been asked this question? Of course you have. Have you ever wondered what you were really being asked? Well, if you’re like me, probably not.

In Cleveland when you ask someone where they went to school they will invariably tell you where they went to HIGH SCHOOL; everywhere else in the country if someone has gone to college they will tell you what COLLEGE they attended.  It turns out that the question “what do you do?” has a similar geographic pattern. In most of the country “what do you do?” is shorthand for “what kind of work do you do?” or “what’s your job?”, but in California it means “what do you do when you are NOT at work?” You work every day to allow you to do what?

It’s a kind of proxy for “who ARE you?”

I’m an eye surgeon. That’s my day job. Like most doctors there’s a lot of “who am I?” wrapped up in my job, kind of an occupational hazard. We spend so much time in school and in our training, and we are so inwardly focused on attaining our eventual job, that it is natural for us to have a difficult time separating who we are from what we do for work. Indeed, many doctors of all shapes and sizes really don’t do anything other than doctor stuff; medicine is both their vocation and their hobby.

Think about it. Recall the last time you asked someone “what do you do?” or answered someone when they asked you. For most of us the knee-jerk response is to tell someone about our job. It’s kinda refreshing to ask that question in California, to eavesdrop in a restaurant or a bar or at a huge fitness competition/festival like I did last week. The answers were much more in tune with what people think of themselves, what they see when they look in the mirror and their true self looks back.

To be sure there was plenty of “I’m a firefighter” or “I’m a lawyer”, but there was also a ton of “I surf” or “I climb mountains.” I heard a lot of “I’m a full-time Mom”, which is both identity and occupation (during the earlier child-rearing days in my house my wife described herself as a “nurturer of human potential”!). Because I was attending the Crossfit Games, an international competition/festival for the “Sport of Fitness”, I also heard over and over again, “Dude, I’m a Crossfitter!” What we choose to do when we are not going about the business of food, shelter, and clothing says more about who we are than what job we have at the moment.

Imagine that you have won a lottery that removes all of the pressures of grocery shopping or paying the rent  or covering pretty much any of your needs  and most or your wants for the rest of your life, and NOW think of your answer to the question “what do you do?” Would you answer it the same way? It’s rather liberating, isn’t it? Almost thrilling. What do I DO? I play this game all the time as a way to emphasize to myself that being an eye surgeon is what allows me to have done all of the things that make up who I am to date. Husband and partner , and Dad, make up the foundation upon which everything else has been layered, but that leaves lots of room to think about what I do.

So here’s a little bit of homework! The next time you ask someone “what do you do?” and they tell you what their job is, say something like “no, no, no…what do you DO? What does going to work let you DO?” And be ready for the next time someone asks you the same question. Do my little thought experiment above; “win” a lottery and think about who you really are if you are allowed to be that person. What would your answer be then? And if you think about it, why can’t that be the same answer now? Or at least a part of the answer now. Isn’t the answer to the question “what do you do?” so important that you should be trying to do that now, even without winning a lottery?

For whatever it’s worth every time I play that little mind game I still end up working as an eye surgeon for some part of my time. I’m good at being an eye surgeon, and it feels good doing something you do well. But what do I DO?

Dude, I’m a Crossfitter!

An Epilogue

In “Residency Training and the Modern Physician” I wondered if I was as dedicated as my friend Bill, the general surgeon who left our dinner to attend to a youngster with appendicitis despite the fact that Bill was not on call. Bill was trained in such a way that he doesn’t see any alternative but to answer that call, day or night, on call or not.

I got my answer today.

Skyvision is closed today in observance of Independence Day. It’s a vacation day for both doctors and staff. Disease, however, respects neither the calendar nor the clock. I received two emergency consults in two separate hospitals, but I was reasonably certain that I could see both patients and still be able to join my wife and youngest for a planned late afternoon activity. Sure enough I was headed home at 3:30 or so, the afternoon shot but still in time to hop in the car at 4:15 with Beth and Randy. Severely under-caffeinated I decided to treat myself to a sweet iced coffee at the local mini-mart on the way home.

“Doc, doc…hey P___, there’s the doc I told you about. He’s the eye doctor who comes in all the time. Tell him what just happened.” Unbelievably an elderly gentleman had literally just lost his vision in one eye, not ten minutes before I walked in. This is roughly the eye-guy equivalent of a cardiologist seeing someone clutch their chest. P___ is a resident of a retirement home about 300 yards from the Mini-mart, on foot, with no family near. I bundled him into my car, stopped quickly at home to let my wife know where I was going and to wish her and Randy good luck on their adventure, and drove over to my closed office to try my best.

The diagnosis is bad; the treatment was as successful as it can be. I walked in to the Mini-mart for an iced coffee and a lottery ticket, hoping as always that THIS time there’d be some good karma in this particular visit. Time will tell if the good karma surrounding my new patient in his time of misfortune will make him one of the 5% of people who recover from this very bad problem.

I’ll be just as happy if the good Karma goes to him and not my lottery picks as I was to pick up the check when Bill had to leave dinner early.

Residency Training and the Modern Physician

The law of unintended consequences is alive and well in medicine.

One of my closest friends, my best friend in Cleveland, is a General Surgeon on the other side of town. We were medical school classmates a lifetime ago at the University of Vermont. Although we live in the same city we have done a terrible job of getting together over the years, consumed as we have been with the various duties of fatherhood, husbandhood, and doctorhood. We finally managed to get together for dinner at  what may be the best restaurant in Cleveland, Johnny’s Bar; it’s certainly the best “guys’” restaurant. It figured to be a perfect guy-getaway: my entire family was out of town, and Bill was NOT on call.

As fathers will do we spent the lion’s share of the time we were together talking about our kids. None of my progeny seem destined to follow their old man into medicine, but Bill’s two older kids are hell-bent to be doctors.  He wondered aloud whether they really knew what they were getting into, whether they really understood what it means to be a doctor and what they would go through to get there.  He also mused about the difference in both  the practice of medicine today in comparison with  medicine as it was practice when we decided to be doctors, as well as the apparent difference in the attitude and approach of recently trained doctors. Being old guys we naturally commenced whining and complaining about the newly minted doctors and how different they are from us and our generation. (Note to self: quit acting like an “old guy”)

How are new doctors different you ask? What is it that makes them different and how did that happen? Well, in order to answer that question it would probably be helpful to describe what it was like to be a doctor and to train to be a doctor “back in the day”. There was a time when only doctors possessed medical knowledge, when the canon of disease and disease treatment was the sole purview of those who had gone to medical school and trained to be doctors. Weird, huh? No internet around to google a disease or come up with a novel treatment in order to play “gotcha” at an office visit. Nothing but true quack remedies in the publications of the day, unless it was an article on some amazing cure discovered by a doctor.

Doctors served long apprenticeships in training, spendings years of their young lives as indentured servants, working brutal hours for what would be much less than minimum wage if such a thing existed. This rite of passage not only served to teach the newly minted doctor all that was known about his particular specialty (almost all doctors were men back in the day), but it also served to ingrain certain habits and skills that were characteristic of the profession. Among the most important of these was the ability to perform at a very high level when fatigued or just after being awakened, and the knee-jerk reflexive response to do just that whenever a patient was in need. Every time. The long, endless hours of patient care in training developed generations of doctors who simply didn’t know that there was any other choice but to go to the side of their patient whenever they were needed, day or night, every day and night. I think I’m like this, but my friend Bill most certainly is.

Patients responded by according enormous respect to doctors. A doctor, ANY doctor, was someone to look up to no matter who he was or what kind of doctor he might be. Answering the phone with “this is Doctor White” instantly set the tone for the conversation.

What kind of medicine, what kind of healthcare, and what kind of doctor did we get from this system. This was the day of the paternalistic doctor, the time when patients said things like “you’re the doctor” when asked their opinion about a treatment. Even though there was much less to know the gulf between what the patient knew and what the doctor knew was at least as immense as it is in today’s world of endless complexity. The relationship was not adversarial, though, but was rather very cordial and respectful in part because the doctor behaved as a professional, putting his patient before essentially everything including his own family. To be truthful this lead to some pretty dysfunctional physician families in the days before divorce, and a  pitifully high divorce rate among medical families once divorce became more common. But the primacy of the patient and the profession remained through all of the societal changes occurring around medicine in the 60′s, 70′s and 80′s.

What happened? Why do old guys like me and my friend Bill feel that new doctors are different? What is different about them and how did this happen? Somewhere in the 80′s there was a shift in how Americans viewed their doctors. No longer was the first instinct to trust, to respect a doctor simply because he (or she, now) had earned a degree. It became a little less OK to get up in the middle of the night, to leave the dinner table to take a call once the level of appreciation of the sacrifice involved declined. Add in a steady decline in income and a steady increase in bureaucratic headaches that took time away from doctoring and it was harder to feel good about putting your patient first. Yet doctors of a certain age continued to do just that because, frankly, it was what they had been trained to do and it was all that they knew.

If you talk to most doctors over the age of 40, and certainly any doctor over 50, you will hear them lament that younger doctors do not place enough emphasis on being a doctor. That newer doctors are selfish, too concerned about themselves and their lifestyles and their own comforts. Talk to a patient at 2:00 AM? No way–I’ll be too tired tomorrow. See a patient at 1:00 on a Saturday or on a holiday? Sorry. That’s family time. Is this all bad? Well, from the standpoint of the physician’s family it’s probably a very good thing, and who can blame the young physician if you think about it. Why should they put the patient first when in their minds they no longer get the respect and appreciation for doing so? When they are constantly second guessed by the Google-empowered, and paid less to boot. But if you are a patient and you call YOUR doctor it’s a little less of a good thing.

Why do doctors like Bill not adopt this attitude? I think it goes back to the traditional residency training that doctors of our generation endured. As a general surgical resident Bill routinely put in 100-120 hour weeks learning to function at a high level when tired and learning about how diseases progressed as you watched continually over time.Even more importantly the instinctive reflex to respond when called was indelibly ingrained. In residency training nowadays, not so much.

In the late 80′s I think it was, there was a very famous case in New York, the Libby Zion case. Young Ms. Zion was brought to an ER and was under the care of an intern heading into her second day of work without sleep. A medication error was made (Ms. Zion neglected to mention an illegal ingestation and the intern failed to consider the possibility) and Ms. Zion died. Now, Ms. Zion was the daughter of a rather famous publisher in New York and the case became a cause celebre. The intern was vilified, the hospital was sued, and calls rang out for reform of the medical training system that left a patient under the care an intern who had been awake and working for more than 24 hours. The well-known effect of fatigue on performance was judged to be the cause of the error and a sea-change in how doctors are trained resulted. Every state now has explicit laws that limit the number of hours a doctor-in-training, a resident or intern, is allowed to work in a day and in a week.

Was that it? Is that why Libby Zion died? Because an intern was awake for more than 24 hours and still at work? Did the system fail Libby Zion and rob the Zion family of their daughter? These are important questions because the work rules that have resulted from this case have contributed to the kind of doctoring we are now getting from our newest trained doctors. I believe the system did INDEED fail Libby Zion, but NOT because her intern was working more than 24 hours without rest. In my opinion the system failed because the other doctors who were supervising the young intern left her alone. Her resident, fellow, and attending failed to engage the case as they were obligated to do under the residency system, leaving an intern to fend for herself in a complex case. The senior doctors in the system failed their intern, a systemic failure that was, and would be, independent of the number of hours worked by the intern.

In came the “Do-Gooders” and “Know-Betters” to solve this problem and prevent any other Libby Zions from coming to harm at the hands of an overworked, under-rested intern. We are now training new generations of doctors who never learn what it is like to work under the pressure of fatigue. They never learn that reflex of going to your patient first, last, and every time because they never get called to do so–they have turned over the care of that patient to their relief. Our residency training programs are now turning out medical shift workers who punch a clock and put in their time. Patients don’t stop being patients and diseases don’t respect either the clock or the calendar, but in their zeal to correct the (wrong) problem with medical training that contributed to Libby Zion’s death the crusaders have removed one more cornerstone from the foundation of the practice of medicine: doctors don’t stop being doctors after office hours.

The law of unintended consequences is alive and well in medicine. Reform has come  although it is still quite an open question as to whether this has really made medicine in training programs any safer-the senior residents and attendings still need to show up to back an inexperienced, albeit well-rested  intern. A trend toward less respect for doctors and therefore less satisfaction while practicing medicine is now augmented by a training regimen that teaches our residents that they work on a clock. When they close the clinic door they leave not only the office but their patients behind. Not surprisingly this leads to a public with less respect for doctors and medicine. And on it goes.

So how did our dinner end? Although Bill was not on call the child of an OR nurse was in the ER with appendicitis and she insisted that Bill be called to do the surgery. Mid-way through the veal Bill left with a touch of sadness at the interruption but with no apology. We are, after all, the same age, doctors and surgeons of the same vintage, and Bill knew that I would understand.

I’ve never been happier to pick up a tab.

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