We do NOT have a physician shortage.

There is a continual stream of commentary detailing the impending collapse of the health care industry (not all of it unfounded). One persistent recurring claim, which I do take major issue with, is that we have a vast shortage of physicians which will only be exacerbated by Obamacare. This is a powerful complaint, as it is easy to see the fear it might provoke in people who were led to believe that access to health care is a zero-sum game. Expanding coverage to 40 million Americans under Obamacare, so the thinking might go, and people currently with ready access to physicians could be stripped of that. The whole mindset here is broken, and it makes me think of the anecdote about Milton Friedman in India:

Our friend the late Milton Friedman once told us a story of being in India in the 1960s and watching thousands of workers build a canal with shovels. Milton asked the lead engineer, Why don’t you have tractors to help build this canal? The engineer replied: “You don’t understand, Mr. Friedman, this canal is a jobs program to provide work for as many men as possible.” Milton responded with his classic wit, “Oh, I see. I thought you were trying to build a canal. If you really want to create jobs, then by all means give these men spoons, not shovels.” 

Right now, physicians in America are working with spoons.

If the expectation is that American physicians will continue to order so many unnecessary tests and studies, perform unnecessary or unproven procedures, prescribe unnecessary medications, engage in futile or inappropriate attempts to sustain life or limb, fail to implement new technology that might otherwise allow us to practice more efficiently, and adamantly refuse to have an honest conversation with the nation where we explain that there are limits to what we can do, that people must die someday and it doesn't necessarily have to happen in the ICU during a full code, and that we must set reasonable expectations for margins of error instead of demanding the near absolute diagnostic certainty that we currently do...then sure, in that case we have a serious physician shortage.

The solution isn't to train more physicians and hand them spoons.

Using a phone while under water

If you put your smart phone in 2 or 3 Ziploc bags you can still use it but its well protected.

Just in case anyone is wondering:

1.  You can't place calls while under water.  The signal gets lost immediately once the phone is submerged.

2.  Its hard to use a touch screen under water because the screen thinks its being pressed everywhere at once.

3.  You can play good music underwater and hear it well from anywhere in the pool.

How many billions per year will the DSM-5 cost?

This was a really interesting article, because it gives a glimpse of the economic reality of the American medical system.  Among the parties involved - doctors, pharmaceutical companies, lawyers, and patients, there is but one incentive:  do more, prescribe more, treat more.  Whether patients are helped or hurt by these treatments seems to be of minimal concern, and certainly nobody is doing a cost-benefit analysis.  It is as if financial resources were infinite.

http://www.bloomberg.com/news/2012-12-20/how-many-billions-a-year-will-the-dsm-5-cost-.html

Read the comments at the bottom, too.

What does Adam Smith think about your medical degree?

This letter was written two years before "The Wealth of Nations", in 1774.

My favorite paragraph:

"A degree can pretend to give security for nothing but the science of the graduate; and even for that it can give but a very slender security. For his good sense and discretion, qualities not discoverable by an academical examination, it can give no security at all. But without these, the presumption which commonly attends science must render it, in the practice of physic, ten times more dangerous than the grossest ignorance, when accompanied, as it sometime is, with some degree of modesty and diffidence."

Vegan sandwich!

Who says you need meat and cheese to have a great sandwich?

Spinach, sauteed red peppers (if they are hard they don't fit into the sandwich well), red onion, hummus, avocado, tomato.  And here is the trick - use sprouts like a net to hold it all together.

Very satisfying and balanced..  Carbs from bread and tomato, protein from sprouts and hummus, fat from avocado.

Dumb, even by Fox News standards

I thought this was one of the dumbest columns about gender relations that I've ever read:  The "war on men".

Also worth mentioning, since I'm on the subject, is this video:  Fox News called out for Benghazi hype.  A lot of people on Fox News and in the Republican Party (listing those separately was redundant, I know) are pushing conspiracy theories about the Benghazi incident.  The problem is that nobody has a good explanation for why Obama would need to lie about it in the first place.  Why would a terrorist attack in Libya need to be covered up?  How does Obama gain if his ambassador is killed?  Call me crazy, but this omission seems non-trivial to me.  Apparently, motive isn't a necessary component of a conspiracy theory for paranoid people anymore.

Israel's missed opportunity

Two years ago I wrote a (sadly) prescient piece about what I believed was a historic missed opportunity on the part of Israel's leaders: 

"When it comes to Israel and war, there are two questions: one is whether Israel has the right to keep pounding its enemies, and the other is whether it should keep doing so. The first question: Israel certainly has the right to defend itself. No doubt, it feels good to see Israel teach a terrorist group like Hamas a lesson, especially after Hamas provoked the Israeli response. The second question is harder to answer. Israel beat Hamas, but hundreds of innocents died in the process. The international community almost universally condemned Israel. Relations with Turkey in particular melted down to almost nothing. The most important thing to remember is that pounding Hamas did not actually accomplish anything for Israel. Hamas is still in Gaza, it is as radical as ever, and it is still arming. Israel cannot continue to engage in these wars with non-state actors who don't care how many of their own people die so long as they hurt Israel; it's like playing chicken with someone who is suicidal. Weapons and war can only make Israel safe in the short term; the only thing that can make it safe in the long term is compromise, negotiation, and peace."

This has been so tragically predictable.  No nation would or should tolerate rockets being fired at a fifth of its citizens, no matter how poorly aimed.  I don't blame Netanyahu for the last four days; his hand is forced.  The last four years?  That's a different story.  Hamas may be unwilling to negotiate, but Abbas and the PA have been sitting in the West Bank doing nothing.  Imagine if significant progress had been made towards Palestinian statehood there?  The people of Gaza could then look to the West Bank - a peaceful land on the verge of statehood, and contrast that to their own homes - again under Israeli attack after relentless provocation by extremists.  If you want people to reject violence and terrorism, it will be easier if they have an alternative.

Medicine and ED docs: should you consult surgery for your demented patient?

As the surgery consult resident, I am frequently called by the emergency department or the medicine teams in the hospital to evaluate patients to see if they will need surgery.  I was recently called about an elderly patient (in his late 80's) with severe advanced dementia and other comorbidities who has no immediate family members.  The medicine physicians wanted to know if the patient would benefit from surgery.

Here is a statement from the Alzheimers Association website:

The research on the efficacy of aggressive treatments and the burden experienced by the person in the advanced stage of Alzheimer’s disease, the Association supports the elimination of hospitalization and aggressive treatments, including cardiopulmonary resuscitation, dialysis and all other invasive technologies, in favor of palliative and comfort care in the person’s residence, whether in the person’s home or in a nursing facility.

To assist individuals and families as they make decisions about end-of-life care, the Association recommends that physicians and other health care providers educate families regarding the choice of burdensome treatments in the advanced stages of dementia versus the choice to provide comfort through palliative and hospice services.

The Association asserts that open and honest communication between health care providers and families as to the person's prognosis as well as the implications for aggressive treatments will assist families in making compassionate choices.

As it turns out, the patient doesn't need surgery.  What if he did?  Should we operate?  Think the fact that I'm writing this right now suggests my own feelings about this particular consult.  The "default setting" in the American medical system is to constantly intervene and "treat" unless we can get someone from the patient's family to tell us not to.  Is it a sign of moral cowardice to fail to stand up to the system, to stand up for the patient? 

Why is it not the default option to restrain ourselves and let the individual's body follow its natural course?

The Economist on Mitt Romney: "nobody knows who this strange man really is."

The liberal media is at it again.  The left-wing Economist newspaper (/sarcasm) has not once, in the last three decades, endorsed an incumbent president for re-election.

2012 is sounding like it could be the first.

"All politicians flip-flop from time to time, but Mr Romney could win an Olympic medal in it."

"Competence is worthless without direction and, frankly, character."

"He has appeared as a fawning PR man, apparently willing to do or say just about anything to get elected."

"Behind all this sits the worrying idea of a man who does not really know his own mind."

"The Romney Programme for Economic Recovery, Growth, and Jobs" is like "Fifty Shades of Grey" without the sex."

"It is a little odd that the number two has a plan and his boss doesn't."

"A business man without a credible plan to fix a problem stops being a credible businessman.  So does a businessman who tells you one thing at breakfast and the opposite at supper."

How to lose the future

Taken as a percentage of GDP, investment in research by the United States is at the lowest level in decades.  Other nations such as Finland and Israel, known for their innovative and entrepreneurial economies, spend far more than the United States.  Cuts in research spending won't hurt us now - they will hurt us in a decade or two.  The time lag between benefit and cost makes such cuts a tempting political target. Enter the Ryan plan, which plans to cut "non-defense" research spending to trim our budget.

We're in a tough time economically, and our deficit is absolutely out of control.  If someone was making the case to me that we just can't afford to increase R&D spending until our fiscal future is secure, I don't think I would find that argument unreasonable, although I wouldn't agree with it. What I do find to be unreasonable is the Republican insistence that the military needs to be spared all forms of spending cuts.  It is the epitome of short sighted to cut general research spending in order to maintain our high current levels of military spending.

Mitt Romney plan will cut research spending, but he has promised to increase military spending (for what threat are our current forces insufficient, I wonder).  Barack Obama has stated he will not spare the military from a greater plan to fix our budgetary crisis, but has nevertheless urged increased spending on research and development.  Americans have been given a choice this election.  They can think about the present, or they can think about the future.  The central theme of pretty much every history book I've read ever, is that great national powers which maintain high levels of military spending to the detriment of other areas of the economy quickly cease to be great powers. 

A very good point re: Ryan medicare plan

Josh Barro on Bloomberg reminds us that the Ryan Plan would delay actual reforms to Medicare for 10 years. 

 

What are the chances that such reform will withstand a decade of partisan demagoguery by opportunist politicians?  Congress has proven time and time again that even when congress passes its own legislation that "forces" spending cuts down the road, the spending cuts don't happen.  Look at the medicare doc fix - every year, congress passes a 1-year funding bill to avoid the cut.  Listen to the howls of politicians about impending mandatory cuts from sequestration.  What are the chances those cuts actually go through?

 

A similarly lame attempt to "reform" medicare a decade down the road will similarly fail.  There is no shortcut to real reform, but that's what we need to curb health care spending in the long term.  Instead of gimmicks, real reform is going to require serious policy analysis, honest proposals, intelligent cost-benefit analysis, and good-faith compromise.

 

http://www.bloomberg.com/news/2012-08-17/mitt-romney-s-double-medicare-contradiction.html

Paul Ryan for VP

My biggest concern about a Mitt Romney presidency is that he would end up being a George W. Bush repeat:  expanding defense spending, cutting taxes, while leaving entitlements untouched if we're lucky or larger if not.  After all, if we are going to have big government, we need to pay for it.  The only thing worse than high taxes and big government is low taxes and big government.  In the former case, Americans living in the present are paying for services they receive; in the latter case, Americans in the present are living large while future generations are stuck paying the bills.

Up till now, Romney really wasn't very clear about where he stood on things.  We know for certain that he is a Keynesian, and has expressed that he would hesitate to cut federal spending if the economy was still weak.  He has promised to increase military spending, and to cut taxes.  Without massive cuts to entitlements, the math doesn't even begin to add up.  Paul Ryan as VP shows how Mitt Romney makes the equation work.  It is a relief that Americans will actually have a real choice to make this November.

If I knew that Ryan's strategy to cut spending would actually work, I might be willing to vote for the challengers.  I remain extremely skeptical that the Ryan plan will actually cut health spending rather than merely transfer it.  The problem isn't medicare per say, the problem is the health care system itself.  It is how we deliver care; it is about the incentives to do more that doctors, hospitals, and patients all have, and the consequences if they do less.  Our system only knows how to do more - there is no restraint.  Changing who pays for medicare doesn't change the system itself; in fact, it is more likely to exacerbate the worst tendencies of the system.  In a previous post, I explain why I don't think the Ryan plan will work.

This is what democracy is all about - real choices.  No matter who wins in November, I hope that administration will have some support from congress to enact their proposed agenda.

Enjoy your right to drive a car, part 3

Three hundred thousand miles...zero accidents.

Part 1:  why I think it will eventually be illegal for humans to pilot automobiles on public roads, and why we should embrace that future. 

Part 2:  intersections of the future.

I used to think the transition to computer-only driving was at least two decades out.  Now I'm not so sure - it could come much sooner because the technology is moving really quickly.  There are huge economic and safety gains to be had from banning error-prone humans from getting behind the wheel of cars.  Once those gains become apparent, there might be a massive push towards computer-only driven cars.
Considering how dependent on cars many Americans are for transit, the future could be pretty scary from a privacy standpoint.  If a citizen needs to tell the car's computer where to take them, then someone could potentially be tracking where that individual is going at all times.  Other than the government, there are of course other interested parties (spouses?  parents?) that might be keen to check on the car's recent travel history...

HCA "controversy" is the butt of a four+ year old internet parody video

There is a video on youtube which is now over four years old which many physicians-in-training find hilarious:

 

http://youtu.be/xskFo75Wdhs

 

The "news" that physicians in Florida are performing unindicated procedures because they have a financial incentive to do so is not news to anyone in the health care profession.

 

People respond to incentives.  There are incentives to perform procedures.  Physicians are people.  Follow me?

The China Study

Per recommendation from my mother, I've started to read "The China study".  She and I both have an interest in nutrition and disease so I am excited to read the book and gather new insights - and maybe find a new lifestyle ideal to work towards.  I have only started to read the book, but from what I gather, the author is going to build a case that animal products and specifically animal protein in the Western diet is responsible for many of the common diseases that afflict us, including heart disease, cancer, and obesity. 

As I was reading the first chapter, my mind wandered a bit and I remembered the time I spent in east Africa.  The Maasai people are nomads who live in the Great Rift Valley of Kenya and Tanzania and we had many encounters with them on our trip.  Their economy revolves around cattle - they are nomads because they must find new grazing lands for their herds.  Maasai diet is extremely high protein:  they drink milk from their cows and even harvest cow blood from a small cut in the jugular vein to drink raw.  They will consume meat from goats, sheep, and their cattle if they need to.

From the New England Journal of Medicine, on the Masai Diet, from 1971:

"The Masai of East Africa exhibit some unique biologic characteristics. Despite their customary diet composed of 66 per cent calories as fat, they have persistent low serum cholesterol and beta-lipoprotein levels. Post-mortem examinations provided direct proof of a paucity of atherosclerosis. Metabolic studies revealed that the Masai absorbed large amounts of dietary cholesterol, but also possessed a highly efficient negative feedback control of endogenous cholesterol biosynthesis to compensate for the influx of dietary cholesterol.  The high ratios of phospholipid to cholesterol and bile acid to cholesterol in their gallbladder bile explain the extreme rarity of cholesterol gallstones. All these characteristics may reflect a long-term biologic adaptation of the tribe."

I don't think this refutes anything, it is just food for thought.  For example, it seems plausible to me that relative dietary protein excess could be related to "Western" diseases but if such protein is immediately utilized that might be a different story.  The Maasai eat a lot of animal protein but they are also nomads and spend their days in different ways than your average American and probably make more use of the protein in their diets.  Also, I'm not aware of any good studies of cancer among the Maasai but I will keep looking.

Switching gears.  On page 80 off the book I made a self-serving observation:  there was not a statistically significant link between eggs and blood cholesterol found in the China study.  After some arguments with friends about the relative health risks/benefits of eating eggs, I had previously scoured pubmed for links between egg consumption and blood cholesterol.  After viewing multiple studies, I was able to find no such link - only transient increases in blood cholesterol were reported (immediately after consumption). 

From a scientific perspective I wouldn't be totally shocked if eggs were ultimately shown to be fairly benign dietary additions.  I am about to embark on a path of pure unadulterated, unsupported speculation (as I often do).  If there is something unique about animal protein and animal cholesterol as it relates to cancer, causing tumor progression, I wouldn't be surprised if it ultimately proved to be related to the consumption of signalling molecules & growth factors that feed malignancy.  Consuming "animal protein" essentially is an exercise in consuming the cells of various animal tissues.  Those cells all have membranes that are full of cholesterol molecules and transmembrane signalling proteins.  Those cells will also contain a cytoplasm full of hormones,intracellular signalling molecules, enzymes, signal amplifiers, and the like.

Eggs wouldn't necessarily have those things because eggs aren't tissue.  Its a protoplasm of undifferentiated nutrients that will ultimately be built into differentiating (specializing) cells and tissues.  Raw eggs just represent building blocks for later animal protein.  The animal protein in eggs would lack signalling molecules and hormones.

Anyway, I will be curious to see if there is stronger anti-egg evidence later in the book.

Have they learned nothing?

On domestic policy issues, I don't think that Obama and Romney will differ all that much.  Both men will work towards and almost certainly get a grand deficit-controlling bargain that will largely be limited in scope by constraints imposed by the legislative branch.  The Republicans in the house will limit the tax increases, although there will be some.  The Democrats will limit the cuts to entitlements, although they will be hefty in either case because they have to be.

 

The biggest difference between Romney and Obama, in my mind, is when it comes to foreign policy.  I don't believe that Romney is a war-monger but I do believe that he will be surrounded and supported by "intellectuals" who are.  The Republicans are ITCHING for another war.  They want a strike on Iran, they want intervention in Syria.  Its madness, but it is the truth. 

 

I don't believe that Romney will initiate these events, but I do believe that those who surround him or those in control of the party will push buttons and initiate events such that the gears of war start turning.  Once the machine starts moving, Romney will go along with it.  Read this for a sobering reminder of why this remains my single biggest concern for the prospects of a Romney presidency:

 

http://andrewsullivan.thedailybeast.com/2012/06/they-have-learned-nothing.html

 

John Bolton isn't just any foreign policy thinker in the Republican Party.  He is THE foreign policy thinker of the Republican Party. 

First, they came for your soft drinks

The hysteria surrounding Mayor Bloomberg's large soft drink ban is fairly ridiculous.  Really, my biggest problem is his approach; a ban on large drinks will be less effective than a hefty tax on soda by the ounce.  Not a ton of people agree with me on this:  Americans seem to think that what starts with a super-sized soft drink ban will logically and inevitably end with a nanny-police state.  This assumes that we have no capacity for restraint or rational governance, which is ridiculous.*

Most people already accept that the government has the right to intervene in some situations.  If a parent gave a child ice cream for dessert every night, we might think the child spoiled.  If a parent fed their obese child ice cream for breakfast, lunch, and dinner, we would be thinking about calling social services.  If a parent was giving their child alcohol or cigarettes, we would definitely call social services.  Many of the loudest voices criticizing mayor Bloomberg also firmly in the anti-drug legalization camp.  If a police state is scary, why are we incarcerating people who smoke marijuana?

Next, consider that while trying to regulate soda slightly infringes on the rights of people who drink soda, being obese and relying on government-provided health care greatly infringes on the economic rights of people who pay taxes.  If we lived in a nation where everyone had to sleep in the bed that they made for themselves, I would be more sympathetic to libertarian extremes.  As it stands, all Americans are guaranteed access to health care in emergent situations and all Americans are guaranteed health care at age 65.  Your right to drink soda and be unhealthy needs to be balanced with my right to be free from overwhelming tax burdens.

It is very important to remember that government is part of the reason we got here in the first place.  There are government subsidies for industrial agriculture, corn, meat, and processed food.  This artificially cheapens the price of the most unhealthy types of food; it is literally the case that the federal government pays Americans to eat at McDonald's (indirectly).  No wonder why we have an obesity crisis!  It is not libertarian or conservative to be a defender of a market so distorted by government influence.

The obesity crisis is getting worse, and health care costs are literally bankrupting the United States.  Are there more ideologically pure ways to fight the obesity crisis than to tax soda?  Possibly; but none are so simple to implement, likely to be effective, and politically realistic.  Smokers consume a lot of health resources, and we all agree that smoking is a bad habit.  Not a ton of people are upset about the fact that we tax cigarettes.  Soda should be similarly considered.

On an aside, from a purely speculative health standpoint, let me also say this:  if you forced me to either drink 3 cokes every day or smoke 10 cigarettes, I am inclined to think that I would be better off smoking the cigarettes.  It would be interesting to read a study that tried to compare the two to see which is worse for health.

* Unless Republicans are in charge

Will democracy survive in Europe?

Given the imminent collapse of the Euro, one blogger posed the question:  "Will democracy survive in Europe?"

I'm not so sure I buy the "locked-in" theory of modern democratic consolidation, which posits that once a nation state becomes democratic, and its culture molds around that political structure, it remains a democracy despite political or economic turmoil.  My personal belief is that historical trends are more a product of trans-national influences that exert changes in the same direction.  It is true that *generally* in the 20th century we've seen a trend towards democracy, but it is also true that the United States and Western Europe have been the wealthiest and most powerful nations in the world throughout that century.  The attraction and the influence of the Western democratic model has been strong for the last 150 years.

Look what happened to nations that were within the gravitational pull of powerful non-democratic states, though.  The eastern European states in the Soviet Union's orbit failed to become democratic until the Soviet Union collapsed.  Some of the Asian states around China (Vietnam, North Korea) have stubbornly failed to transition.  In the case of Hong Kong, we have an example of an economically free zone that has become less politically free with the decline of democratic political influence (Britain) and the rise of non-democratic ones (China).  The transnational influence doesn't rely on the presence of a regional power, either:  look at the brotherhood of thugs that have dominated Arab dictatorships for years.  If Jordan was surrounded by Arab democracies, I suspect King Hussein would not be the autocrat that he is.  Lebanon would not be so unstable.  Iraq's transition would certainly be easier if its neighbors were democracies.

In South America, the trend has been towards democracy over two decades when the only superpower in the world was a democracy, but those gains are tenuous.  What happens when the powerful Western democracies continue to wane in influence?  We're going to find out soon enough.  The author of the blog entry above puts the chance of a non-democracy emerging from a European political collapse into something else at 1 in 50.  Here is my prediction:  the chances are 1 in 3.  Greece is the most likely to go; it has a particularly toxic brew of factors that will make it ripe for dictatorship, something it has a fairly recent experience with anyways (as does Spain, coincidentally or maybe not).  Greece is facing a nearly unprecedented economic collapse.  It has an increasingly powerful historic foe (Turkey) on its doorstep, which will only increase feelings of nationalism and militarism.  I've also read reports of a new sense of animosity towards the Western democracies that it would otherwise be emulating.

The people of every age always think they're at the end of history.  Especially given the nearly unprecedented political instability that the United States has experienced over the last 12 years (as far as dysfunctional government is concerned), I think a little caution is warranted.

More end of life issues

Warning: this nymag article is depressing, but a worthwhile read. What I take away from the piece, as it pertains to health care for the elderly, is that oftentimes less is more.

Imagine how much worse the story gets when the decision makers lack the ability to differentiate between "alive" and "living", or have completely unrealistic beliefs in the ability of modern medicine to cure and reverse disease.

The American medico-legal-industrial complex knows only how to push in one direction: more, more, more. If the system is making the decisions, it will never stop. Patients and families need to always remember they can say no to the doctors.

Why America is going bankrupt: Barcelona vs Atlanta

If people are trying to figure out why middle class incomes are stagnant, here is one place to look: 

Would the free market - the driver of efficiency, ever have resulted in such a sprawling mess as Atlanta?  Of course not.  It got that way, like so many other American cities, thanks to government subsidies.  The government builds the roads, the utilities, the power grids.  It fights the wars to secure the oil.  Government regulates that businesses must have abundant parking spots (a subsidy for cars), offers cheap parking on the street for a few quarters; government zones land and centrally plans its use.

Imagine the wasted resources in infrastructure.  The wasted fuel costs.  Time wasted in transit.  What about the redundancy?  Atlanta must need 30 times the gas stations, 30 times the McDonalds.  Atlanta will need more airports, more parks.  I can only imagine the scale of the waste if we could somehow quantify it.  It must be on the order of trillions of dollars.  The US economy is more productive than Europe's, no doubt, but somehow the Europeans manage to maintain equal if not higher standards of living than Americans (maybe not for long thanks to the Euro crisis, but that is incidental).  I would argue that their superior organizational efficiency is a big part of it.

Some are quick to disagree; they point out that Europe is much older so their cities were already built up and became smaller by default.  That is only half true:  after all, most great American cities were well established by the year 1900.  The car didn't really come into its own until a decade or two later.  Make no mistake - America centrally planned this mode of development.  We could reverse this process by putting an end to the subsidies and the government works projects and let the markets or local citizens plan their transit.  Unfortunately, instead of free market solutions, we get 300 billion dollar highway bills for the next 5 years, calls to "drill baby, drill" or to "bomb, bomb Iran".  And that is just from the "pro-free market" political party.