What cardiologists can teach economists

A tribute to Kanu Chatterjee

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I wrote an earlier version of this post in 2011.  In light of the current economic and financial turmoil, it seems all the more relevant.

I had the great fortune and pleasure of studying under the late Kanu Chatterjee during my cardiology fellowship at the University of California San Francisco.

In the early 1970’s, Dr. Chatterjee was among the first to understand the benefits of “afterload reduction” for the treatment of congestive heart failure:


Prior to that time, giving medications that could lower the blood pressure was often seen as heretical.  In fact, during the 1950’s and 1960’s, the treatment of heart failure sometimes consisted in applying measures to raise the blood pressure and increase the work of the heart.

The concept of afterload reduction introduced by Dr. Chatterjee and his colleagues was revolutionary.  With such a treatment, mortality rates in heart failure were improved for the first time.

An economic history of the American health care system-Part 1

From the pre-Flexner era to the great depression

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Q: What is the starting point in the history of the American health care system?

A:  The American health care system was born in the 1910’s out of the so-called “Flexnerian reform” in medical education and the resulting licensing laws.

Q: Why is that the starting point?

A: Prior to that time, medical care in the United States was essentially unregulated.  Anyone could open up a medical practice, and many did so with little training.

Patients had complete freedom to obtain medical care from whomever they wished.  When such complete freedom exists, one cannot realistic talk about a “system.”

Q: What were the main features of this “pre-historical” period?

A: There were competing forms of medical care.  “Regular” medicine continued the tradition emanating from European institutions and medical schools.  It was ostensibly represented by the American Medical Association (AMA).

The regular form of medical care tended to be more disposed toward aggressive interventions (blistering, bloodtletting , and toxic purgatives), but over time, it also increasingly incorporated scientific knowledge into its mode of practice.   Surgery was part of regular medicine, and surgical techniques were improving rapidly in the latter part of the nineteenth century.

Other forms of medical care, such as Eclecticism, herbalism, and homeopathy tended to be less inclined toward aggressive treatments, and each had its own diagnostic and therapeutic philosophy.

There was a multitude of medical schools, and most of them were privately owned.  In many cases, the curriculum lasted one or two years after high school.  Given this large number of schools, the United States had the highest number of physicians per capita in the world.

Reduced posting frequency and Amazon affiliate status

Since A&O was revived 4 months ago, I have tried to post twice weekly (and sometimes more frequently).  Due to other writing commitments, I must now reduce the posting frequency to once a week, aiming for every Thursday.

Also, to help support the effort of maintaining this website, I have signed up to become an Amazon affiliate, which means that if you enter Amazon through this website to make a purchase (say, by clicking on a link for a reference or by using the widget in the sidebar), Alert & Oriented will receive a small portion of the price of your purchase from Amazon.

Thank you for your support and continued readership!


5 must-read articles about what good medical decisions are all about

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I told you before that I would do my best to avoid bringing up phronesis, but a superb essay by Lisa Rosenbaum, national correspondent at the New England Journal of Medicine, is forcing my hand.

In “The Paternalism Preference — Choosing Unshared Decision Making,”  Rosenbaum calls into question the gradual shifting of the burden of decision-making onto patients in the name of informed consent and autonomy.

The essay begins by examining the issue from the patient’s perspective, but Rosenbaum’s reflection then turns to the role of the physician.  She remarks:

But science cannot answer a question at the core of our professional identities: As information-empowered patients assume greater responsibility for choices, do we assume less?

The answer to that question has to do with our understanding of what constitutes good medical decision-making.  Clearly, the prevailing notion assumes that good medical decisions come after a rational approximation of an objective biological reality, a “predictive analysis” that forms the core of “evidence-based medicine.”

Evidence-based mania: an intoxication of the intellect

And an attack against reason

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For many years, thoughtful commentators have highlighted the shortcomings of evidence-based medicine (EBM).  Among them was Alvan Feinstein, one of the great pioneers and theoreticians of clinical research, and arguably one of the founders of the EBM movement.¹  But despite the increasing discontent with this mode of thinking, EBM remains an extremely prevalent intellectual vice that has captured the mindset of the medical community.

In the last few days, I came across some particularly striking examples of how EBM dominates the medical psyche.

Prohibition: Then and now

Arguments against banning or taxing our way to health

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The following editorial was first published in September 2014 on the blog of the San Francisco Medical Society. At the time, a ‘soda tax’ was on the ballot for voters to consider. The measure was defeated but the debate continues, as seen in these recent BMJ editorials. Note: the version below is slightly modified from the original.

Nearly one hundred years ago, the eighteenth amendment to the United States Constitution made it illegal to produce, transport, or sell alcoholic drinks. The prohibition was the culminating action of a “temperance movement,” a century-long grassroots effort aimed at curbing the consumption of alcohol. The movement arose in response to an epidemic of alcoholism and was guided by the compelling argument that alcohol is toxic and that alcoholism brings along serious social evils: chronic unemployment and family neglect or abuse.

Today, a similar movement is taking shape in response to the obesity epidemic. Excessive consumption of sucrose and fructose in ubiquitous “sugary” drinks has been identified as a main cause and found to be responsible for the high prevalence of diabetes and its associated health and socioeconomic complications: cardiovascular and renal disease, blindness, premature death, and exploding health care costs. The new temperance movement decries the excessive use of sweet beverages and calls for restricting their sale. These restrictions can come in the form of taxes or outright bans.

But is resorting to taxation and to the strong arm of government always a wise move? I propose some arguments to ponder:

From DPC to CPC – part 2

A cardiologist is humbled

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To summarize W’s case up to March 17, here were the salient features:

  • Baseline signs of conduction system disease
  • Progressive, and now severe, dyspnea on exertion
  • Unexplained relative hypotension, not due to adrenal insufficiency
  • Weight loss and early satiety
  • Hypercalcemia, initially mild, now more pronounced, with suppression of PTH
  • Markedly active urinary sediment with severe dipstick proteinuria, but also microscopic hematuria and calcium oxalate stones
  • Worsening renal function, possibly pre-renal azotemia.

The 50-mile distance separating W from my office made frequent visits impractical, but from March 17 onward I was essentially on daily contact with the patient either by phone or email.

I could not tie everything together, but the thought occurred to me that he might have systemic sarcoidosis with cardiac involvement: hypercalcemia, heart block, shortness of breath, gastrointestinal symptoms.  In fact, I was clearly hoping for this diagnosis as something potentially treatable in what otherwise looked like an ominous illness.

On March 19, however, a 2-view chest x-ray was normal and the light bulb that had gone off in my head a few days before was quickly burnt.

From DPC to CPC – part 1

An extraordinary case in a direct primary care setting

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A couple of years ago, as I was trying to determine the best business model for my practice, I offered direct primary care (DPC) services to a few patients.  Among them was WW, a then 57-year-old man who was well when I first saw him, but who ended up dying a year later in a very sad and dramatic way from a rare condition.

The extraordinary illness that struck W is worth describing simply on account of its rarity and its highly unusual manifestations.  But in addition, it occurred to me that my experience with W may be of particular interest to the growing number of physicians and health care professionals intrigued by, or involved in, DPC as a practice model.  This case exemplified the challenges and rewards of taking care of people with no insurance and with limited financial means.

I hope you will find this “clinico-pathological conference” to be of value.  Although W’s ultimate outcome would likely have been the same under any circumstance, I’m sure his clinical course may have been tackled differently by another doctor. 

Feel-good medicine: yesterday and today

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I’m on summer break but I thought you might enjoy this piece, published a year ago in the August 2014 issue of the Nob Hill Gazette.  The version below is slightly edited compared to the original.

In their recent book titled, Dr. Feelgood: The Shocking Story of the Doctor Who May Have Changed History by Treating and Drugging JFK, Marilyn, Elvis, and Other Prominent Figures, Richard Lertzman and William Birnes chronicle the startling career of Max Jacobson, a physician who specialized for decades in treating celebrities with his personally concocted injections of vitamins, human gland extracts, and high doses of amphetamines.

Operating from a filthy office in Manhattan, Jacobson showed no regard for basic medical hygiene and never obtained a basic medical history from his patients. Yet, over the years, he dispensed untold quantities of his “cocktails” to political and show business superstars suffering from fatigue, pain, or lack of stamina. For some of his patients, such as Cecil B. DeMille, the German-born doctor was a paragon of modern medicine. But others saw their careers and personal lives ruined as they became addicted to the treatments, and a few might have actually died as a result of it. The authors of the book relate instances where, under the influence of Jacobson’s amphetamines, President Kennedy’s behavior became wildly erratic. They even speculate that a motive for his assassination might have ensued.

Max Jacobson’s story might seem like a sordidly entertaining tale from a bygone era. Nevertheless, given our current love affair with medications (one in five adult Americans takes a psychiatric drug, and 70 percent of the U.S. population takes some form of chronic prescription medication), it behooves us to reflect on the professional and ethical failings of Jacobson’s practice to help keep our way of “better living through pharmaceuticals” within healthy boundaries.

Canadian medicosclerosis and American medicomania

Impossible to compare

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I follow several physicians from Canada on Twitter.  Since I do not have first hand experience of that health care system, I find their accounts instructive.

Some tweets are sadly biting:

Shawn Whatley, a Canadian physician I also follow, wrote in a recent blog post entitled “Medicine resists change” that:

Canadians took a bold, progressive move in the 1960s and created Medicare. And we’ve blocked change ever since.

Sure, we dribble in new technology. Embarrassment demands we buy at least a few PET scanners and robotic surgical assists. But our core system is unchanged.

Government and Organized Medicine insist that basic clinical services work the same as in the 1960s. Patients see their family doctor. Doctors send patients for ‘high-tech’ X-Rays, ultrasounds or blood tests. Patients drive to licensed and controlled lab facilities. Then they trudge back for results days later.

That sounds grim.