Medicine • Philosophy
The war on medical error was officially launched in 1999, when the Institute of Medicine (IOM) published its landmark report To Err is Human, alleging that up to 98,000 yearly deaths in US hospitals were due to human missteps.
Despite significant ambiguities in the definition of a medical error, numerous militias known as Patient Safety Organizations (PSO) sprung up almost overnight to help combat the terrible enemy.Continue reading “Are patient safety organizations losing the war on error?”
I keep getting served a Facebook ad from the American Association of Medical Colleges imploring me to ask politicians to fund residency training for medical school graduates. The link leads to a webpage with neat graphics and a series of well-designed cartoons dramatizing an ominous shortage of 90,000 doctors expected to occur by 2025.
Now, the notion of “doctor shortage” by itself is meaningless. Doctors—like plumbers—are a scarce resource and therefore always in shortage. Patients have always had to contend with waiting rooms, whether at the outpatient clinic or in the emergency department. People have always had to wait to see a specialist, especially a good one, and this will never change. The supply of doctors must be judged in the context of the needs of patients and the economics of supply and demand.
But here’s the rub.
[On May 18, the website of the Ludwig von Mises Institute ran a slightly edited version of this article. You can find it here.]
In its current usage, the phrase “dismal science” is a disparagement leveled against mainstream economics for its failure to provide a coherent account of economic activity.
According to Austrian school critics of the neo-Keynesian synthesis, this failure is in large part due to a foolish determination to bring into economics the mathematical precision of the physical sciences. To achieve this precision, neo-classical economists disproportionately focus their inquiry on global measures of economic activity: gross national product, aggregate demand, global supplies of money, goods, or labor, and other variables that lend themselves to quantification and numerical modeling. Lost in mainstream economic analysis is the attention due to the individual economic actor who, by virtue of his or her power of self-determination, is ill-suited for the equation or the graph.
A similar love affair with quantitative methods has rapidly taken over the medical field over the last several decades.Continue reading “Population medicine: The other “dismal science””
[As part of the debate on physician-assisted suicide, the San Francisco Medical Society kindly invited me to write an article taking the “contra” position. Below is the text of the article. You can find the print version along with the article taking the “pro” position here.]
When a terminally ill but mentally competent patient wishes to die, should a physician be allowed to bring about such wish? The California legislature is considering that question, and physicians will soon be asked to weigh in on it. Until recently, so-called “physician-assisted dying” (PAD) garnered little support among doctors. Currently, however, enthusiasm in its favor is growing. What are the reasons given to justify this emerging practice? Do they truly warrant legal sanction? And do they justify an about-face from the medical profession’s long-held stance on this matter?Continue reading “A deadly choice for the medical profession”
Gnosticism describes a religious movement flourishing at the beginning of the current era, as Roman paganism was foundering but before Christianity became firmly established.
The main belief of the Gnostic sects was a doctrine of “Salvation by Knowledge (gnosis),” the idea that a privileged class of human beings can, by special insight, obtain possession of the mysteries of the Universe.
Gnostics held a deprecating view of the material world, and favored instead the spiritual realm. Gnostic elites would profess a severely ascetic lifestyle as the path to enlightenment, although some have been accused of hypocrisy for shunning the austere discipline they would demand of their followers.
American medicine in the 21st century bears resemblance to the Gnostic movements of old.Continue reading “The apostles of “less is more””
Celebrity Mark Cuban set off controversy a few days ago with a Tweet expressing his recommendation that people should get quarterly blood tests “for everything available.” If you have not followed the story, you can quickly get up to speed by reading a couple of posts on Forbes.com written specifically about this opinion firestorm.
Apart from their disagreement with Cuban’s specific recommendation, many physicians seemed particularly concerned that he and other celebrities who express medical opinions exert undue influence on the public. In my opinion, this concern is misplaced.Continue reading “Mark Cuban vs. guideline writers”
The release of the latest report from the Joint National Committee on Hypertension (JNC-8) has been delayed for several years. It’s already been a decade since the prior report was issued.
Until recently the reason for the delay was obscure, but in the March issue of Cardiology News inside information is provided by cardiologist Sidney Smith. The UNC professor of medicine, who has made a career out of writing practice guidelines for the American Heart Association, is a senior writer on the JNC-8 panel and this is what he had to say:
The delay has been due in large part to an unprecedented degree of prerelease review by numerous government agencies at a multitude of levels. This extensive and time-consuming advance scrutiny was instituted mainly because many health officials felt blindsided by the publication of the U.S. Preventive Health Services Task Force controversial mammography guidelines, which kicked up a hornet’s nest of criticism in the breast cancer and public health communities. Government officials don’t ever want to be caught by surprise like that again, explained Dr. Smith, professor of medicine at the University of North Carolina, Chapel Hill.
That’s right. There is nothing more frustrating for a government official than to be caught by surprise by a body of medical experts sifting through scientific data for the benefit of practitioners. The report must first be approved by the authorities!
We suppose that when the government pays for so much of health care and medical research, it’s only natural it would try to ensure that scientists have the national interest in mind, No?
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There’s been a bit of a buzz following the release of the latest edition of the ACP’s Ethics Manual. For the first time, it seems, the manual includes a section on “stewardship of resources” with directives summarized in Box 4.
The Left hailed the new change as “truly remarkable” and an important first step to “break the logjam” of health care deficits, while the Right was quick to denounce the set of instructions as an “ethical game-changer,” a surreptitious undermining of the doctor-patient relationship, or an overt step toward health care rationing.Continue reading “Box 4 of the ACP’s ethics manual”
In 1793, Georges-Francois Danton led a Committee of Public Safety to ensure application of the revolutionary ideals of Liberté, Egalité, Fraternité. In the months that followed, the so-called Reign of Terror, the committee sent to the guillotine thousands of individuals deemed to be a threat to the French Revolution.
The bulk of the offenders were initially identified from among the aristocracy and the clergy, but it soon became necessary to also purify the revolutionary ranks from the less ardent supporters of rhetoric. Soon enough, Danton himself was condemned to the same end that so many before him had met.
The heart.org issued a news report about Dr. John Wang, a Maryland doctor who was part of a safety committee, the Technical Advisory group on Oversight of Percutaneous Coronary Intervention, tasked by the Maryland Health care Commission (MHCC) with “stopping improper stenting in Maryland.”
According to the report, Wang himself is accused of “improper stenting in his own practice,” and the Society of Cardiac Angiography and Intervention (SCAI) and the Maryland Chapter of the American College of Cardiology (ACC) criticized Wang’s committee for “not going far enough” in ensuring that “all citizens of Maryland are afforded equal, high quality healthcare.”
The MHCC, ACC, SCAI and countless committees, commissions, and task forces around the country are fervently working to ensure application of the modern medical ideals of Quality, Equality, and Appropriateness.
May the just God protect us all from the zeal coming out of utopian ideologies.
Update 2015: A couple of years ago, the New Yorker magazine published a terrific piece by cardiologist Lisa Rosenbaum on the very topic of improper stenting. It can be found here.
“The artifactual disease” is the phrase George Pickering coined to describe hypertension in the 1950’s and 60’s. In those days, he dominated the debate about the nature of hypertension, arguing against those who thought hypertensive patients who developed complications comprised a distinct entity of subjects. “The higher the pressure, the worse the prognosis,” he would repeatedly affirm. To my knowledge, he did not expound on the J-curve phenomenon, but he surely made a convincing case that defining a disease on the basis of arbitrary cut-off numbers is most foolish indeed.
But since the 1970’s, after clinical trials established the success of anti-hypertensive therapy, and with the growing enthusiasm for “risk-factor modification” and the inexorable rise of population medicine, any attempt to expect rational nomenclature or clarity of thought has seemed increasingly futile.
Instead, we must be impressed by discussions of studies where “Patients were categorized by their mean SBP level over follow-up as very low normal (<120 mm Hg), low normal (120 to <130 mm Hg), high normal (130 to <140 mm Hg), high (140 to <150 mm Hg) and very high (>150 mm Hg). ”
I recently tested myself on a 24-h ambulatory blood pressure monitor. My SBP varied from 90 to 142 mmHg.
No wonder I was feeling out of sorts.
