Sunday, June 25, 2017

This is America

In America, we have millions uninsured (even after the ACA), high deductible plans and ten thousand dollar per month chemotherapy treatments for desperate patients with stage IV disease.  In America, alone among western democracies, medical bills represent the leading cause of personal bankruptcy.  In America, we choose to commodify the health care sector, transform it into a vast, complex money generating machine.  This is the American way: free markets, personal responsibility, distrust of government interference.

And so it ought to surprise no one that some private companies (from Bloomberg) see opportunity in the misery of others.  Crowdfunding websites like GoFundMe are seeing remarkable growth in the category of medical expense fund raising.  And why wouldn't they?  What else are people to do when you get a bill from a hospital for 12 grand or your company's "insurance plan" carries a $6000 deductible?  It's the 21st century: you go on line and ask for money from strangers.

Of the $2 billion in money raised on GoFundMe last year, nearly half was for medical expense campaigns.  This is both commendable and abhorrent.  Commendable in the sense that it suggests a widespread philanthropic spirit running through our nation.  But is this really the best we can do?  A 21st century version of a spare change jar at the check-out counter of your local diner, proceeds of which to be used for "Jenny Miller's cancer pills"?  It's utterly absurd.  And most of these crowd funded endeavors don't raise nearly enough to cover the outstanding remittances. One study suggested that over 90% of medical expense campaigns on GoFundMe came up short of the requested goals.  In fact, the average fundraiser for medical bills got only 40% of what was needed.  So an American citizen, drowning in debt, gets the double ignominy of having broadcast his financial troubles for all to see, only to come up short anyway.    

But at least GoFundMe makes out all right.  Shed no tears for them.  For every donation, they take 5%.  That's a nice round number when you're talking about billions.

Sunday, June 18, 2017

Surgery Residency: Drop-Out Nation?

In the first decade of the 20th century, William Halsted---using principles he had learned from watching German surgeons---- implemented a new model of training general surgeons in America.  Replacing the old journeyman/apprenticeship paradigm was an intensive, arduous, all-encompassing program that integrated basic science with bedside patient care, emphasized repetition and volume under the tutelage of master surgeons, and introduced responsibilities and skills in a gradual step wise manner.  Resident surgeons basically spent 5 years of their lives living at hospitals, immersing themselves completely in the acquisition of essential skills and knowledge.  The Halstedian paradigm quickly became the standard across the nation as its tenets were adopted by the newly formed American College of Surgeons in 1913.

For most of the next 90 years, he basic training model remained constant.  Of course it was brutal and inhumane.  Young men (almost all men, during these years) literally never saw their families.  Pyramidal structured programs meant that most interns would never make it through the training.  Something had to give. Pyramid programs are no longer acceptable.  Work hour reform has allowed most residents to maintain at least a tenuous grip on sanity.  But there are no panaceas when you are talking about training future general surgeons.  If anything, the demands on a surgical trainee are much greater than even what I faced 15 years ago.  New technology, rapidly changing treatments algorithms, hyper-advances in basic science make it very difficult to acquire a firm knowledge base and technical proficiency in a feld with constantly shifting, expanding foundations.  And despite all the changes with work hour reform, general surgery residents have continued to drop out of training at much higher rates than residents in other specialties, even today.

Heather Yeo and her group at Cornell has a somewhat discouraging paper coming out soon in Annals of Surgery  that attempts to delve into this phenomenon  Theirs is a national longitudinal cohort study designed to identify factors associated with resident attrition.  One important finding, much discussed in a era where women make up slightly more than half of incoming general surgery residency classes, is that the female gender is the most important factor in predicting withdrawal from a residency program.  Further, minority women represent the highest risk cohort for dropping out from surgery training (35% will drop out before graduating).

The thing that jumped out at me was the overall withdrawal numbers, regardless of sex or race.  From an article Christina Frangou of General Surgery News wrote about this paper:
"For the past 25 years, attrition rates have remained steady in general surgery, with about one in four residents not completing training. That is much higher than other specialties, including surgical specialties. Orthopedic surgery has a dropout rate of less than 1%, OB-GYN is about 4.5%, and medicine is about 5%.
“It was thought that changes in work hours and the kinds of things might lower the attrition rate, but they have not. So we need to look at other solutions,” Dr. Yeo said."

Shit man.  You mean 20-25% of highly educated, extremely motivated young adults who have chosen to embark on a career in surgery end up bailing after a couple of years?  That's outrageous.  We're not talking about young buckos who quit McDonald's after a couple weeks because they can't handle the heat of the fryer in the summertime.   These are elite, highly prepared individuals who have busted ass for 15 years, excelled in college and medical school, done internships and sub-internships, sometimes even research in surgical sciences.  And they are quitting left and right.

I don't feel strongly at all that this persistent attrition rate over the decades has anything to do with race or gender or generational dispositions.  It's just that general surgery is fucking hard, man.  And you don't really see it until you start learning it, doing it, seeing older surgeons living the kind of life it requires.  It's a hard ass life.  Emergency and unanticipated cases will always represent 30-35% of a busy general surgeon's practice.  Doesn't matter who you are.  You will always have to take ER call.  You will always have to smile and say "no problem!" when a Primary doc calls you at 4:30 pm on Friday with a "painful hemorrhoid, can you see him in the office right now".

It's a hard, exhausting, brutal life at times.  Rewarding sure.  I can't imagine doing anything different (that's the brainwashing speaking).  But it will chew you up and spit you out.  The years will pass faster than the cards flying by you at a blackjack table in Vegas.

And this essential FACT resonates with residents.  They see what a community general surgeon has to do.  They see these older surgeons working harder than interns.  And I suppose it just gets a little demoralizing after a while.  Who wants to be a grunt for the next 45 years?  As they say in the military, only the nut jobs, eccentrics, cranks and psychopaths actually volunteer for the infantry.  General surgery, man, you're on the front lines.

Even the ones who make it through seem do do so with a jaded eye.  At many top programs, we see reports of 75-80% of 5th year residents going on to do additional training and fellowships.  No one wants to be this thing called a "general surgeon".

I think that's too bad.  We may be on the precipice of another paradigm shift in how surgeons define themselves.  Maybe there's just too much to know, too much to stay up on, too many advanced skills for one surgeon to acquire. Time will tell.  Maybe the pendulum will swing back in the other direction as wider and wider swaths of geographical America finds itself without enough broadly trained, competent surgeons to meet the needs of its population.....

Sunday, June 11, 2017

Sunday Poem

Goodbye, My Ocean

We went to say goodbye to the ocean.
Our week elapsed, time a despot.
The morning was cold and ashen---
Weather more for a funeral than a summer respite---
And waves crashed in to shore in periodic roars.

I had brought her here as a baby years ago
---she doesn’t remember the picture of me holding her on a patio.
But she didn’t want to say goodbye today.
She was tired of the ocean, the rain and gray.
Instead she danced on a dune, a slow adagio
Her eyes closed, arms outstretched, around and around.
She didn’t hear when I called
(The waves crashing and roaring)
She was way up there and I was down here,
Foreign lands separated by a strip of sand.
She performed alone for lumbering curtains of cloud.
The ocean was vast and unconcerned, and much too loud;
It had been there all week, without end.
A little girl has other things to attend.

And the surf rushed up around my soles,
Soaked the edges of my jeans.
I was not yet ready to turn away.
I could have used another day.
I don't so much return to the sea
As the ocean returns to me.
(Words and phrases apt to fail the more I wish to convey)
It returns to me is the best I can say----
Albeit older now, chastened, more gray;
While the dark waters remain changeless.
And as the shore yields slivers of itself to the inexorable surf
My mind yields to forgotten shame, repressed pains, when it all seemed to hurt----
Inchoate fragments of images and phrases

....Skeletons of shells lie scattered on the sand in the retreat of fallen swells....

It will always be there, the abiding sea.
May it someday be there for her too----
When the dance is done, when her songs go silent,
When the clouds part and blue shines through.
One day she too may turn to the sea in quiet terror, in sorrow, or defiant,
And gaze into an endless, merciless roiling gray----
Into her past, the days lost, a life episodic----
And vaguely recall a summer she watched her father rhapsodic
Turning slowly landward, down below, his form misted in sea spray


Tuesday, June 6, 2017

Dr Ferrari

Kevin Williamson wrote a piece last month in the National Review bemoaning the hand wringing he sees occurring across America surrounding the threat of millions of Americans losing their health coverage with the intended repeal of the ACA and its replacement with TrumpCare.  He calls this piece:  The "Right" to Health Care, with the scare quotes performing the task expected.  (What? Did you think you had a "right" to health care when you get sick, silly boy?) appended with the self-answering subtitle There isn't one boldly patched in the space before the opening lede.

He then goes on to construct a thought experiment utilizing children and apples to demonstrate that health care is a just scarce good and that all the nail biting over making sure all the kids get an apple is just cheap moralizing and coastal elite performative antics when, in the end, you only have 3 apples for 4 kids.  Market forces, you see.  Supply and demand.  What is needed is not a national reckoning--- the likes of which every other advanced western democracy has done--- with the idea that health care is a service/good that ought to be made available to all Americans, like schools and public safety and national interstate highways, but rather we just need to empower laissez-faire super entrepreneurs to plant a few more apple trees. This is thought-experimenting in its most primitive form, using the bare minimum of neurons.  Maybe 3 or 4 synapses get traversed at this cognitive level of "thought experiments".  This is like turning around and going home hungry because someone has placed a medium sized stone in the middle of the sidewalk on the way to the store.  The inability to conceptualize the apples as a totality, to be divided and sliced in such a way to ensure that everyone gets a fair nutritional share is punditry malpractice.  But Williamson doesn't care.  He has followed his thought bubbles to the terminus of his own choosing.

Rationing is posited as the true villain in this piece.  For Williamson, universal coverage is not worth the price we might have to pay in consequence; longer wait times for elective non-life threatening procedures, cost effectiveness barriers for new treatment approvals, lower profits for the holders of Capital etc etc.  This is his true dystopia, not the recent American past of a sparsely insured population wracked by medical bill induced bankruptcies.  For Williamson, health care is just another good on the market.  And the more it increases in demand, the higher its price ought to be.

And so we get this hopefully career defining quote:  "Rich people always get better stuff.  That's what it means to be rich." Let them take aspirin for their cancer, indeed.  Because hey, if you live in Africa and have HIV, that's all you get.  That's life.  Deal with it.

Meanwhile back in the world of Kevin Williamson, when a head cold just won't seem to run its course, he usually just struts into his fancy doctor's office in the suburbs, brandishing his American Express Platinum card, to see a doctor who is "always pleased to see me because I paid him out of pocket".  His insurance plan, you see, is called "American Express".  Cash is best.  What is wrong with all you dolts?  Are you plebeians not able to just whip out some plastic or peal off a couple hundies when it comes time to settle up with ol Doc Blowhard?  Not mentioned is the "thought experiment" of what might happen if Kash-man Kevin didn't need just a little Z-pack and, instead, came down with viral meningitis or perforated diverticulitis that resulted in a 12 day ICU stay and a charge master hospital bill of $79,850.  Even elite credit cards have maximums.

As Kevin gazes around at the opulent setting of his favorite doctor, he notices several pictures of Ferrari sports cars on the walls.  He kiddingly, nudge-nudge wink-wink, queries Dr Wonderful about the Ferrari's, suggesting that maybe he might be paying him too much.  And the good doctor replies: "Do you really want a doctor who can't afford a Ferrari?"  Yes, that groaning you hear is not some pipe swelling with the temperature change in your basement.  Kevin Williamson is the one person out of 100 who is impressed by a guy bragging about his luxury car.  I mean, I can just smell the overly administered Drakar Noir cologne emanating from my laptop as I read that.  This is either a doctor who does not exist or he is a guy who obtained a medical degree from the boardwalks of Jersey Shore, undid the top two buttons of his contrast collared Oxford, perfected his best shit-eating grin and went about the business of marketing himself to insecure but healthy dunces like Kevin.  It's a good gig if you can stand it.

Somehow, in a very short piece, Kevin Williamson of the National Review was able to accomplish more than even a well written parody could ever hope to achieve.  Parody works best when the target is limited and precise.  Nuance and complexity are the enemies of successful satire.  Somehow Kevin is able to be both obtuse (not understanding how health care is not a "good" like, say, lawn chairs or sausages to be purchased on the open market) while also revealing himself to be the embodiment of the crass materialistic John Galt elitist superman, so easy mocked by second rate late night talk show hosts.  He is the guy who thinks the dude with the muscle car revving at a stop light is the coolest person on Myrtle Beach.  He is the guy who thinks the tank-topped meat head grunting and squelching at the Gold's Gym must be "really strong and masculine".  He is the guy who notices when other men wear cuff links, and what kind.  He is the guy who must find out what car you drive within 10 minutes of meeting you in order to more properly form a judgment of your character and usefulness.  

Not to mention the complete lack of moral imagination that would prompt most intellectuals, from both the right and the left of the spectrum, to wrestle with the discordance of finding ourselves living in the richest nation in the history of human civilization while still somehow being unable to provide affordable, accessible healthcare  to 100% of its citizens......

Monday, June 5, 2017

Vacation Poem

Pour It Out

What we start with is not limitless.
The cask is not an abyss.
But I have always said: “Pour yourself out young man!”
Don’t be stingy;
Dispense yourself into many vessels
Don’t hoard it all within fortified castles
Allocate on the fly, improvise---- and soon.
A life can’t be meted out with a teaspoon;
A bit here, a splash there, a shot glass, a snifter, a highball, a mug runneth over with foamy head.

All these empty cups to be filled!
Choose them at your leisure.
Choose wisely and always pour with pleasure.
Cups for love, for work, for hobbies, for nothing, for something, for purses or mittens or coats,
For things forgotten and things that lodge in our throats.  
----But pour it all out we must

Have no pity for the obsessive workaholic; he has poured himself out
No mourning for the hollow eyed doctor wandering wards at night; he has poured himself out
Laugh not at the perpetually broken hearted; she has poured herself out
And never mock the failed poets; they too have all poured themselves out

They leave nothing to grieve.
They are empty bottles of wine sprawled like bowling pins
In alleys the morning after New Year’s Eve.
The only sin in lost time
Is leaving too much behind;
Trying to ration a vast reservoir,
Always in fear of having no more.
You save what’s left for a wave that never crests;
All that ambrosia sloshing around in your chest