California Medicine Man

Interesting Case of "Co-rumination"

2008-06-10T10:53:00.000-07:00

I haven't written much about actual medical cases I see here at my hospital but this one intrigued me. Some details have been altered of course.

A 30ish female showed up in our emergency department complaining of a sharp, stabbing pain in her left neck (10 out of 10 in intensity) for several days along with a palpable mass over the area. The pain had been present for two to three months but not nearly this intense nor had the mass been as large. She also complained of fatigue, shortness of breath, tactile fevers (felt hot but hadn't actually checked her temperature), and a range of other symptoms. The intern who presented this case to me found absolutely nothing on physical exam: normal vital signs, no mass, lungs clear, etc.

My impression just from the presentation was that this was unadulterated BS (medicalese for "move along, nothing to see here"). How wrong I was.

When I walked into the exam room there were two healthy-appearing women sitting, both with the same look of overwhelming dread. Usually I'm fairly insightful but in this case, it took several seconds to determine which one was the patient. Seeing an "older" attending, the patient's friend whom I'll call "Patient #2" immediately unloaded Patient #1's symptoms upon me.

Patient #2 related in great detail every ache, every sensation, every pain, every bowel movement, indeed every agonized breath of her friends over the past three months. Certainly, it is not unusual for a patient's friend or family to function as an advocate and relate observations about the patient that may be helpful to clinicians.

It's rare however for such advocates to give detailed subjective descriptions of how the patient is actually feeling (at least when the patient herself is articulate, not shy or embarrassed, and for whom English is her native language). Between Patient #1 and Patient #2, I was barraged with with a torrent of imagined symptoms.

In examining Patient #1, I agreed with my intern that there was no mass, nor any other physical findings of note. In my most professorial and reassuring manner and despite the fact that my skin was crawling in much the same way as when I walk into a room with a patient believed to have scabies, I told her her symptoms were nothing to worry about, that medical science can't always explain what patients are feeling, that her problems would undoubtedly resolve shortly, and that we were always here in case she didn't get better...

Our patients were greatly reassured and they both thanked me profusely. I walked out of the room feeling I'd done some good.

The diagnosis? This woman (and her friend) turned out to have a severe case of co-rumination, a topic I've written about before. The problem was that, like many females, they tend to "share" far too much. By doing so, their anxieties spiral upwards out of control as happened here. Men seem much less likely to engage in this maladaptive behavior. Certainly, we'll see more of this with men as society continues to encourage us to explore our "feminine side".

Perhaps if I had been more upfront with my convictions, I would have also recommended they stop co-ruminating regarding each other's maladies.

But that might not have been cool.

Google Commemorates Memorial Day

2008-05-26T04:06:00.000-07:00

Google generally makes special holiday modifications to their homepage logo. Here's Google's celebratory logo for Memorial Day:

What kind of statement are they making here? It seems that I'm far from the only one who's noticed the extent to which they honor the deaths of our nation's fallen warriors; the same dead who gave Google the ability to freely gather and disseminate information in a free society.

Google may be ignoring this day but at 10:30AM, my 5-year-old daughter, my wife, and I will be at the Los Angeles National Cemetery where we go every year...to remember.

Update:
In case anyone wants to send a message to Google telling them how they feel about this, here's how. My message to them:

"One of the ways I'll be celebrating Memorial Day is by not accessing your website for a week.

"Maybe next year you'll consider the pernicious effect of your decision to pointedly ignore one the United States' most solemn days."

A Practical Suggestion for President Bush and Congress

2008-05-20T21:27:00.000-07:00

I rarely write about non-medical issues but I have an important policy recommendation that I think will help the country.

Several days ago, the media lampooned President Bush for being "snubbed" by the Saudi's for refusing his request to significantly increase oil production. Bush's request was part of his plan to to ameliorate the problem of seriously rising oil prices. I wasn't there but I imagine that his plea was met with an admonition to "go pound sand".

Today, it was announced that the House of Representatives passed a bill allowing the U.S. to sue OPEC for their antitrust activity in arbitrarily limiting oil production. I may be wrong on this but I kind of doubt that the idea of being sued in an American federal court has the OPEC nations shaking in their boots right now.

So to these two Solomonesque solutions, I've decided to add one of my own: Let's have a bipartisan committee from Congress travel, along with the president, to India and China and ask them to stop buying so much oil. Most economists believe that their dramatically increased consumption (due to rising industrialization) is a principle reason for our current high prices at the pump.

Who could doubt that these two countries would willingly curtail their own drive for progress so that we Yanks can shave off a buck or two a gallon here in the states?

See? This policy stuff isn't so hard.

Those Crazy Politicians and University Endowments

2008-05-10T10:03:00.000-07:00

The Wall Street Journal is reporting that Massachusetts is contemplating a 2.5% state tax on university endowments in excess of $1 billion per university (via Greg Mankiw's Blog). Now personally, I could care less about Harvard's financial concerns. It's hard to worry about a school with a $34 billion endowment. I'd be happy if my net worth was half that amount.

Here's an idea that would take some of the wind out of these legislative proponents' sails. Harvard could take 2% of their endowment each year and give it to their 19,000 undergraduates and graduate students. This is surely a fraction of the annual interest Harvard makes on its investments each year.

This would amount to over $35,000 per year per student and would essentially give them free tuition. Of course the B-school students would still have to cough up about $7,000 more per year but well...they're B-school students. They'll be able to pay that off after their first few weeks of gainful employment.

Massachusetts would have an awfully hard time taxing such "good" citizens as the Harvard administrators for providing a world class education for free.

I don't know. 2.5% going to taxes vs. 2.0% going to their own students? Seems like a no brainer to me. Maybe the legislature is threatening the universities with this tax just to achieve this end. Either way, it seems like an abuse of their authority to me.

More on my thinking about government meddling in the affairs of private universities (non profit organizations) here.

The EMTALA and Inintended Consequences

2008-05-09T14:54:00.000-07:00

Edwin Leap wrote a revealing post about one of my personal pet peeves: the EMTALA laws (h/t KevinMD). Read the whole thing.

The EMTALA (Emergency Medical and Active Labor Act) mandates that essentially all patients must be seen regardless of ability to pay. Admittedly, this federal law states that people can be sent away without treatment after they've been properly evaluated. However, the penalties for being wrong are so severe that few hospitals are willing to take the chance. In effect, hospitals see and treat almost all E.R. patients even if they know that they won't be payed for doing so.

People will of course argue that some patients might die after having been mistriaged to home. Unfortunately, it is the nature of things that this is so. Triage nurses will always make mistakes on occasion and as sure as the sun rises in the east, some patients or their families will pay a tragic price.

Inevitably, such cases will become front page headlines, but rare as they may be, the victims will be "named" and therefore worthy of our sympathy and compassion. Consider though, that in California alone, at least 65 E.D.'s have closed in the last decade. Unreimbursed care is at the root of most or all of these closures.

How many more patients will die, however, because of a lack of nearby or conveniently located E.D.'s? Moreover, these patients will not be named but will instead be mere statistics in some as-yet-unperformed observational study.

Again, read Leap's article for more reasons why the EMTALA is a bad idea (as it's currently written).

From Dr. Jill Bolte Taylor: The Most Electrifying Lecture You'll Ever Hear

2008-03-29T23:55:00.000-07:00

I've heard a lot of lectures in my life but never one like this. This is neuroanatomist Dr. Jill Bolte Taylor giving a talk on the functional differences between the right and left hemispheres of the brain. She's passionate about her subject as she actually suffered a massive intracranial hemorrhage that trashed her left brain. Dr. Taylor brilliantly describes the experience and sensations both as a stroke victim and as a scientist.

Not that I want to replicate her experience but man do I wish I could teach like her! Check it out and prepare to be riveted by the most amazing 20 minute talk you've ever heard.

It makes me never want to step up to a podium again.

Universities' Endowment Funds and the Federal Government

2008-02-07T10:29:00.000-08:00

Here's an idea I hate (via the instapundit). Congress is considering regulating the amount of university endowments that schools may keep for themselves and how much they have to pass on to students (in the form of tuition cuts, financial aid, or scholarships). Do these guys really have this much time on their hands?

Laws such as those being proposed give our legislature the bad name that it has. Why a private, non-profit organization such as a university endowment "needs" to be controlled by the federal government eludes me. Don't get me wrong. When I read that elite schools such as Harvard could pay the tuition of their entire student body on just the interest that their endowments earn, I find that reprehensible and a poor reflection of their governance. But that's their problem, not the fed's.

Surely people will make the argument that as tax-exempt organizations, some limitations on their behavior is appropriate. Really? Is the federal government really so much the paragon of efficiency and insight that they should decide where the Red Cross or Harvard should allocate the contributions they collect? Is that what we want?

Likewise, some will point out that many (most?) students receive some federal aid in the form of grants or federally insured student loans and as such, the government has an overriding interest. To me, this just strengthens the position that the fed should get out of higher education completely.

My guess is that such legislation will probably go nowhere (although some provision for more transparent reporting of where endowment money actually goes may pass). I think though, that the real intent of such debate is to put a chill in the minds of fund managers' minds. The mere threat of such laws may well be enough to "influence" behavior. In my opinion such saber rattling is an immoral use of federal power.

Bad law. It's contagious.

Gonzo Medical Blogging

2008-02-02T10:22:00.000-08:00

Periodically, I will add a new blog to my "blogroll". Unlike many bloggers that maintain such lists, I try to post only the ones I like to read frequently. Some bloggers maintain huge alphabetized lists of blogs, a practice I've never really understood. Perhaps these lists grow because of quid pro quo (you link to me and I'll link to you, a practice I hate) or perhaps some people just like the look of really unwieldy, completely unfiltered lists.

Personally, when I look at someone else's blog, I enjoy looking through their blogrolls to see just what they like to read. Being an avid reader, I'm always curious about such things. When my patients or their families have books with them in the hospital or exam room, I invariably ask what they're reading. Huge blogrolls don't really give me that kind of insight into the compiler's tastes.

At any rate, this post is to announce an addition to my blogroll. That we are judged by the company we keep concerns me as I add a link to Panda Bear MD but what can I say? The guy is hysterically funny and says things that many of us think but are unwilling to express in polite company. Panda is a resident in emergency medicine. I'm sure he is a bit older than his fellow residents as he's described a wide variety of prior life experiences.

This added age undoubtedly gives his writing a level of sophistication extremely unusual in someone the age of a typical resident. If I had to pigeonhole him, I guess I'd call him the Hunter S. Thompson of medical writing, an appellation I'm sure he'd understand as a compliment.

I enjoy his observations, his insights, and his style very much and have pointed colleagues, nurses, and residents towards selected posts to much hilarity.

Truthfully, I sometimes worry about Panda. My hope is that his posts are put-ons and that the darkness, even bitterness, imbued in his writing is more for shock value than anything else, sort of like Ann Coulter's subtle style. But I have my doubts. His writing is too authentic and fluid.

I think that while most of us will occasionally laugh at the peccadilloes of our patients and their families, most of us don't define such people by them. I hope he is happy in what he does and that if so, medicine continues to sustain him. Unfortunately, my suspicion is that his cynicism has been acquired at far too early a stage in his career. He has all the markings of someone headed for premature burn-out. Hopefully by turning others' attention to his writing, I'm not reaffirming his world view and somehow facilitating such burn-out.

One last point Panda, if you're reading this. You should give some serious thought to posting your name and your institution. Not because I want to know who you are but instead, to protect yourself. While I don't recall reading anything you've written that's frankly libelous or in violation of HIPAA or terribly likely to get you into trouble, some of your posts definitely push the envelope. I think that writing without the imagined security of anonymity helps ensure just enough caution to prevent saying things that can have tremendous legal or professional repercussions. Internet anonymity is fleeting. Just ask the Flea.

My two cents.

Service in Medicine, Has it become a quaint anachronism from a bygone era?

2008-01-31T03:13:00.000-08:00

Bob Wachter has posted some great points regarding the "service" of radiology.

The last paragraphs are priceless:

In my NEJM article on dis-location, I described the growing teleradiology trend, driven by the fact that the same technology that allows me to read my films without going to the radiology department also allows a radiologist in Banglaore to read a film as easily as a radiologist in Bangor. The Indian radiologist earns one-tenth of what the U.S. radiologist earns. If my experience in visiting Radiology World tends to be of the positive, collegial sort, I’ll fight like hell to keep the radiologists in the hospital. If it feels like I’m distracting them from their “real work,” then (assuming comparable technical competency) there’s no reason for me to care whether they are in the building.

Or the country.

I feel the same way about so many aspects of modern medicine. If primary care physicians want better reimbursement, they need to "add value" to their interactions with patients. Otherwise, why not have a nurse practitioner or physician assistant grab their business at a discount (e.g. at CVS Pharmacies)? If emergency medicine docs want more respect from their colleagues and to not render themselves useless, then they have to do much more than act as glorified triage nurses. In the same way, if radiologists want to avoid having their jobs outsourced, let them raise their standards of service.

The list of examples could go on and on. Read Arnold Kling's recent article in tcsdaily to see one reason why quality has declined so frequently. Hint: imagine what happens to a service when the recipient pays for it rather than someone else like a third party payer.

Who says big government is inefficient?

2008-01-22T08:35:00.000-08:00

Courtesy of the InsureBlog: A little USA article on your government at work. So it seems that the NIH can't keep track of the potential conflicts of interest between grant recipients and the companies they ~~shill~~ consult for.

I was going to ask myself how the General Accounting Office (GAO) could allow this to happen and then I realized...

Of Mice and Men

2008-01-17T21:42:00.000-08:00

This caught my eye. It's an article in Yahoo News entitled Humans Crave Violence Just Like Sex. I'm thinking, this has to be noteworthy. Imagine my disappointment in reading the first few lines:

New research on mice shows the brain processes aggressive behavior as it does other rewards. Mice sought violence, in fact, picking fights for no apparent reason other than the rewarding feeling.

The mouse brain is thought to be analogous to the human brain in this study...(my italics)

Pardon me my skepticism.

From the Field to Angiogram.

2008-01-17T21:24:00.000-08:00

Here's an interesting study in the New England Journal of Medicine.

There have been several studies that fairly conclusively demonstrated that reducing the time from the symptoms of a particularly dangerous type of heart attack (the so-called ST-segment elevation myocardial infarct or STEMI) to the time of balloon angioplasty saves lives. Getting this symptom-to-balloon time down is of course partly a function of physician skill. But the biggest determinant has to do with the nature of the system that's in place to move the patient from initial transportation to assessment to cath lab team mobilization.

Getting this time down involves tremendous planning, resources, and careful thinking. This study looked at door-to-balloon time (the time the patient hits the hospital to the time the angioplasty balloon is inflated (thus opening a clogged artery). It seems to show that if paramedics in the field are taught and allowed to diagnose STEMI's, then patients can be transported directly from the street to the cath lab thus bypassing the emergency room.

Using this strategy, the door-to-balloon time was shaved from 123 to 69 minutes. Judging from morbidity/mortality results of previous studies, this is no small amount and probably has important clinical significance. In fact, inpatient mortality went from 5.7% down to 3.0% using direct transport.

This study was not randomized nor blinded and numerous confounders can be assumed and postulated. It is noteworthy however that the baseline characteristics between the direct transport and emergency room transport groups are surprisingly similar which suggests that these clinical benefits may be real and not explainable by such confounding variables.

These results are preliminary but definitely tantalizing. It seems unlikely to me however, that a randomized trial testing this approach will ever be done and this data may be the best that we get.

Might it be enough?

Physicians and Their Role in Executions

2008-01-11T08:01:00.000-08:00

The New England Journal of Medicine has published a provocative editorial on capital punishment and the physician's role in carrying it out.

Read my thoughts on this important editorial here.The New England Journal of Medicine has published a provocative editorial on capital punishment and the physician's role in carrying it out. In truth, the position taken, that no physician should agree to facilitate an execution is old and has been endorsed by many medical societies. However, in over 1,000 words, the closest thing to an argument in support of this are these words: "A professiondedicated to healing the sick has no place in the process ofexecution."

Yet even this statement is offered without proof or justification and is merely a recapitulation of the authors' opinion. Cannot the exact opposite position also be offered, that in a nation that condones the death penalty through its laws and courts (and incidentally in public opinion), medical science should be brought to bear to insure that all executions are administered with compassion and decency?

If that is the case, who better to supervise an execution than a physician; preferably one expert in pain management, anesthesiology, or critical care medicine? After all, the article cites several instances of botched executions that almost certainly increased the pain and suffering of the criminal.

The position that this editorial takes, that the medical community's canon of ethics forbids it from participating in executions may well be heartfelt. Yet consider revealing words such as these:

Injected drugs, now used in all but 1 ofthe 37 states in which capital punishment is legal, have beenpart of the increasing medicalization of executions and the enlistment of medical personnel to lend them apparent morallegitimacy" (my emphasis).

I can't help but think that something else is going on here. Could it be that these authors are simply opposed to capital punishment and that by promoting a policy forbidding physicians from facilitating it, they in effect render it an impossibility?

If that is truly their agenda then that should have been their thesis and they should be forthright about it. Pardon me for finding it intellectually dishonest however, to hide behind some vague, poorly established interpretation of the Hippocratic Oath (which they also cited). The Oath was never understood to forbid the palliating of pain and suffering when death was imminent due to disease. Why should it be any different here?

By the way, unless you know me well, don't presume to know where I stand on the death penalty. This post is more about being upfront than about capital punishment.

medGadget Posts a Cool One

2008-01-10T08:38:00.000-08:00

This is one cool post by medGadget!

Outsourcing the Day to Day Stressors of Life

2008-01-10T08:06:00.000-08:00

Here's some insight regarding life on the other side of those monuments to outsourcing, Indian call centers. It seems that operators in India are succumbing to the stress of dealing with European and American ire:

Miss Aggarwal, an English graduate, said she planned to quit, tired of wishing customers a good morning only to hear: "Oh, I'm through to India am I? Put me through to someone who can understand English, you f****** cow."

Yikes. These people are apparently suffering from various medical problems real and imagined from this sort of work.

I'm reminded of a patient I saw in my office many years ago, a young woman with a "positive review of systems" which is medicalese for having every complaint under the sun. After getting a detailed medical history and examining her thoroughly finding nothing wrong, I asked her if anything in her personal life was bothering her.

"Well gee doc, I hate my job. It's kind of...you know, stressful."

I asked her what she did (which I should have done in the first place). Her answer convinced me that she did in fact have one of the worst, most stressful jobs in the history of mankind.

She worked as a cashier at an impound garage. She had to take rather large payments from less than cheerful "clients" to retrieve their cars which had been towed. My advice: find another line of work.

Who says medicine has to be complex and arcane?

Disaster Preparedness and Emergency Out-Of-State Physician Licensing

2008-01-09T08:14:00.000-08:00

During Hurricane Katrina, I called our local Red Cross chapter to offer my services in Louisiana. I attended their training course to do just that but was then told that I wouldn't be able to volunteer as a physician. Louisiana was unwilling to temporarily grant licensing reciprocity to out-of-state doctors even though it had experienced a massive disaster.

Any such physician assisting there would be practicing without a license and I surely don't need to review the medicolegal implications of that. Their state legislature is obviously filled with a group of rocket scientists!

I instead opted to be placed on a list of physicians willing to respond to in-state disasters (California in case you missed the title of this blog).

An interesting letter was published in the latest issue of JAMA. Lori A. Boyajian-O'Neill et. al. surveyed each state in the U.S. to find out what their policies were regarding the licensing of physicians in the event of a disaster. The chart they compiled lists three possibilities: an "expedited" licensing procedure, waiver of licensing altogether in the event the physician has a license in another state (reciprocity), or my favorite -- none.

Louisiana belongs to the expedited procedure group. During Katrina, their governor wrote an executive order suspending the usual licensing procedures. Apparently this wasn't in place at the time I considered going with the Red Cross (who would only send docs with a valid Louisiana license).

I was surprised to see that 18 states opted for no emergency licensing at all. Talk about protecting your turf!

Maybe every states' lawmakers should be reviewing their own laws. To me, emergency reciprocity seems like the way to go. For most state medical boards, a physician's licensing status can be checked reliably and instantly on the internet. Why wouldn't a state want a physician in good standing in his home state to volunteer in the event of an emergency?

Are Medical Device Manufacturers About to Get a Truly Free Ride?

2008-01-08T01:17:00.000-08:00

If my reading of an article in the latest New England Journal of Medicine is accurate, then the Supreme Court is about to rule on a case of momentous implications.

The case is Riegel v. Medtronic and it's a big one. Charles Riegel is suing Medtronic over a balloon angioplasty device that malfunctioned necessitating emergency care and ultimately coronary bypass surgery. Medronic is arguing that because their product received premarketing approval by the FDA, it has effectively been "immunized" against lawsuits in any state court arising from the failure of that product and that the suit should be thrown out.

Read more about this extremely important case here.I'm not a attorney and I don't play one on TV. But unless I'm facing the wrong end of a lawsuit (which has happened more than once), I do find the law fascinating and engaging. Every once in a while though, I encounter a legal case that truly cuts at the heart of our day-to-day lives. One such case was Kelo v. City of New London. This case ruled in 2005 by the U.S. Supreme Court gave local municipalities incredibly broad power in exercising eminent domain over private property owners.

Kelo sent shockwaves through society when a previously assumed fundamental right to be secure in one's property suddenly vaporized. A town could now take your home and give it to a real estate developer who could then commercialize it in such a way as to increase tax revenues to that town. People across the country (even people who were not owners but hoped one day to be) instantly felt less secure about their homes and their lives.

If my reading of this article in the latest New England Journal of Medicine is accurate, then the Supreme Court is about to rule on a case with similarly momentous implications.

The case is Riegel v. Medtronic and it's a big one. Charles Riegel is suing Medtronic over a balloon angioplasty device that malfunctioned necessitating emergency care and ultimately coronary bypass surgery. Medronic is arguing that because their product received premarketing approval by the FDA, it has effectively been "immunized" against lawsuits in any state court arising from the failure of that product and that the suit should be thrown out.

Their argument is based on an amendment to the FDA charter voted by Congress in 1976. This amendment granted authority to the FDA to certify the safety of medical devices, a power that had not previously been extended to them. In order to ensure that this new FDA mandate wasn't usurped by laws that individual states might create, a clause (360k(a)) was inserted in the amendment guaranteeing that FDA guidelines would supersede any such state laws.

It is this clause that Medtronic is attempting to exploit in this case. They are arguing that 360k(a) gives the FDA priority over state laws and that this includes state provisions allowing lawsuits against device manufacturers if the FDA certified a product before it went to market. Medtronic's argument then, is that Riegel's lawsuit against them should be completely thrown out.

If the Supreme Court rules for Medtronic, this would open the door to immunizing all medical device manufacturers from lawsuits. The article in the NEJM does an excellent job of describing the implications of such a ruling.

I hate lawsuits as much as the next guy but I'm not so militant that I don't recognize the important social good that they can serve. While lawsuits are a blunt, often misused weapon, they clearly help promote better medical product reliability and safety. To simply eliminate the public's right to sue a company making a faulty device would be extremely damaging to society.

I love medical device companies. I think the products they develop help incredible numbers of people. It is naive to think however, that getting FDA premarket approval is all that's necessary to insure product safety. It is the sword of Damocles in the form of a lawsuit that truly stimulates device manufacturers to "do the right thing".

I differ with the authors in one respect. They claim that the most compelling argument the Supreme Court should be guided by is whether a ruling for Medronic will truly benefit or hurt society. My understanding is that the role of the Supreme Court is simply to adjudicate the law and determine whether or not it conforms with the U.S. Constitution. It is not the Court's job to decide whether a law is stupid or not or whether it does or doesn't achieve a particular objective

In this case, I think that the Court needs to determine whether Congress ever intended clause 360k(a) to prevent product liability lawsuits against device manufacturers. For me, it's inconceivable that that was the case.

I can only hope that for my patients and for society as a whole, nine justices think long and hard about this one.

Any lawyers have an opinion on this?

Project Steve and Its Detractors

2008-01-07T14:08:00.000-08:00

A few days ago, I blogged about Project Steve. Predictably, I ruffled some pro-creationist feathers, particularly those of M. Mitchell who commented.

So M., I'm sorry if I've offended you but this is not a "petty squabble". The reason for Project Steve is to show that a larger and much more prestigious group of scientists can be compiled that discount rather than support creationism--even while limiting themselves to those named Steve. It's a whimsical idea but as a rhetorical tool, it also sheds light on exactly what's happening here.

Creationists compile lists of scientists to cause the illusion that there is scientific merit to their positions when in fact, the opposite is true. One of the most important features of a scientific theory is that it has to be testable, i.e. it has to lead to conclusions that can be disproven. Creationism does not meet that standard as attributing the known world to God (or some other "intelligent" designer) can NEVER be tested nor proven wrong.

People have looked at the fossil record and carbon dating evidence for evolution and simply said 'God created that these findings thus giving the "illusion" that evolution is a viable conclusion.' How can a scientist possibly respond to this? Such an idea is impervious to refutation.

For this reason, the vast majority of scientists refuse to endorse creationism as science. I have no problem with including such theories in classes on religion...just not in science class.

Even one like myself who unashamedly believes in God can recognize the difference. This is no petty squabble.

John Edwards Disgraces Himself With Regards to Nataline Sarkisyan

2008-01-07T01:57:00.000-08:00

The Wall Street Journal just published an article on the Nataline Sarkisyan case and how it has been exploited by presidential candidate John Edwards. I have never endorsed nor rejected a political candidate in this blog. Today, I'm making an exception. I think that Edwards' actions regarding this case are despicable. It is clear that by giving Sarkisyan's family voice at his political rallies, he has accepted the preposterous notion that CIGNA systematically killed their daughter for profit (which they claim).

It's bad enough when this family's lawyer makes such statements to the press. Malpractice attorneys have a rich and colorful history of trying their cases in the media. In law, this is thought of as mounting a "vigorous" advocacy for one's client. Edwards however wishes to be President of the United States.

In my eye, his actions have firmly established his status as a lightweight. Policy differences aside, I for one would never wish for a president with such a simplified world view.

By the way, I was quoted in this article but my title was mangled a bit. I'm sure that UCLA, my employer was quite surprised to find that I was promoted from assistant to associate professor.

Does the Drive for Equality Trump Absolute Benefit?

2008-01-06T08:55:00.000-08:00

I'm going to point to two, shall we say...divergent viewpoints as linked by KevinMD. Read them both.

My sense is that most people would choose Graham's perspective over Panda's. One survey of college students revealed that they would prefer two nations to experience the same growth in their standards of living over having both achieve improvement but one having significantly greater gains than the other. Equality seemed to trump absolute gains for both nations.

I believe the same finding would hold were the question to concern a wealthy and a poor group within the same country. The notion of equality has been imbued with biblical preeminence, even if its quest might exclude policies that improve the lot of the poorest but improve that of the wealthy even more.

I'd love to know what people think about this. Please comment or email me.

Political Correctness and the Elderly

2008-01-04T18:04:00.000-08:00

I REALLY want to be on the road at the same time as this guy: 85 years old and driving 100 MPH in snow and ice. Apparently they're pretty lax about such things in Canada. He only lost his license and the use of his car for one week.

My feeling is that while this may have been an appropriate punishment for a younger person, in this case, doesn't it suggest a blindness to the physical realities of getting old? Is it political correctness not to ask if the combination of this driver's age and actions alone betrayed a lack judgment and a decline in cognitive function?

Are such questions not to be asked even the face of an overriding public health interest? To me, this individual's "right" to drive should be terminated before someone else's life is.

Project Steve and Evolution

2008-01-04T08:19:00.000-08:00

This post assumes that the reader believes in evolution. It's not funny otherwise and is likely insulting. There. You've been warned so I cannot be held responsible for the indignation you may experience.

The National Center for Science Education (NCSE) has embarked on Project Steve to convince evolution deniers that their list of scientists endorsing such beliefs is shall we say...deficient. To counter their list, the NCSE has attempted to compile a similar list of evolution adherents.

To be a signatory, one must have a doctorate (can be an M.D.) and be willing to sign the following statement endorsing evolution:Evolution is a vital, well-supported, unifying principle of the biological sciences, and the scientific evidence is overwhelmingly in favor of the idea that all living things share a common ancestry. Although there are legitimate debates about the patterns and processes of evolution, there is no serious scientific doubt that evolution occurred or that natural selection is a major mechanism in its occurrence. It is scientifically inappropriate and pedagogically irresponsible for creationist pseudoscience, including but not limited to "intelligent design," to be introduced into the science curricula of our nation's public schools.
Oh, and you have to be named Steve or some variant thereof (Stephen, Stephanie, Esteban, etc.)

So far, Project Steve has 860 signatories the most recent of whom is Steve Vance. Within the U.S., this would correspond to almost 54,000 scientists (1.6% Steve variants according to census figures). Two thirds of them are biologists. This is a far higher proportion than is on any list of deniers. It is also a far more prestigious group. The majority are working scientists. Many on the denier lists are not.

The NCSE hopes that when anyone shows you a list of evolution deniers, your response should be "but how many Steves are on your list!?"

CIGNA Responds in More Detail to the Nataline Sarkisyan Case

2008-01-02T12:41:00.000-08:00

Today, I received an email from Wendell Potter of Corporate Communications, CIGNA Corporation. He directed me to an open letter from CIGNA's chief medical officer Jeffrey Kang, MD, MPH that expands on his previous public communication regarding Nataline Sarkisyan.

I think it's rather illuminating and adds credence to the notion that there's more than one side to this story. Of course for those who have made up their minds, this won't matter at all.

I've posted my feelings on this case here and here.

Words to Remember (When You're Not Forgetting)

2008-01-02T12:22:00.000-08:00

Here's one approach to eliminating fear (via the Instapundit). Just induce forgetfulness. Personally, I don't know if this is the ideal approach. It may sound crazy but sometimes our fears are justifiable and based on concerns better not forgotten.

It did remind me of some words of wisdom from my father:

"If you can keep your head when all about you are losing theirs...perhaps you don't have a clear understanding of the situation."

Apologies to Rudyard Kipling.

More Sexy Ways to Spend Your Health Care Dollars

2008-01-02T08:02:00.000-08:00

Dr. Wes, an electrophysiology cardiologist has posted on two remarkable implantable devices. They continually monitor the heart's pulmonary arterial and left atrial pressures. Normally, continuous monitoring of these parameters requires the insertion of a pulmonary artery catheter in the ICU. The patient doesn't get to take this invasive equipment home with them (fortunately).

These new devices however, are permanently implanted and may yield an early warning when a patient with congestive heart failure begins to "decompensate".

Read my thoughts on this here.Dr. Wes, an electrophysiology cardiologist has posted on two remarkable implantable devices. They continually monitor the heart's pulmonary arterial and left atrial pressures. Normally, continuous monitoring of these parameters requires the insertion of a pulmonary artery catheter in the ICU. The patient doesn't get to take this invasive equipment home with them (fortunately).

These new devices however, are permanently implanted and may yield an early warning when a patient with congestive heart failure begins to "decompensate". Such a warning may allow the patient's doctor to adjust his medications to reflect these alterations in cardiac function. This is analogous to asthmatics measuring their lung function with portable peak flow meters and adjusting their inhaler frequencies accordingly.

Of course the difference is that peak flow meters cost hardly anything. They're disposables that we give away in the E.D. all the time. The devices mentioned by Dr. Wes will undoubtedly cost a zillion dollars each and will certainly be associated with nasty complications.

It may seem quaint but there was once a time when we used to assess patients' cardiac function by listening to their hearts and lungs and looking at their feet. We even trusted patients to adjust their own meds by actually weighing themselves each morning!

Now we'll have these gadgets. Of course as Dr Wes points out, there won't be a market for them unless they can be shown to add significant benefit to these more arcane methods of assessment. Randomized clinical trials are no doubt on the way to see if they improve cardiac outcomes (MI, death, cardiovascular hospitalization).

Here's a little prediction: these upcoming studies will compare the use of the devices with "usual care" (physician assessments). They will NOT be going head-to-head against "that other" early warning system: serial monitoring of serum brain natriuretic peptide (BNP). BNP is a relatively cheap blood test that also appears to provide clinical information that augments that of the physical exam. Serial monitoring reduced heart failure-related death or hospitalization compared to usual care in some small studies and at least one big study (see here).

Why would the device manufacturers go looking for trouble by comparing themselves to another technology that also works and that is almost certainly cheaper?

I don't think I'll be pulling out my Vanguard S&P 500 cash for the these particular investment opportunities.