Monday, January 31, 2005

Health Care Is Not a Widget

Bee and flowerThis essay begins a series on problems and possible solutions to the current mess we call health care in our country. It takes no small amount of hubris to assume that one has all the answers to the health care quagmire -- I most certainly don't -- especially when far smarter and more knowledgeable folks have been beating their heads against this problem for ages, with little apparent results. But I have observed that basic principles of common sense, human behavior, good business principles, and yes, morals and ethics, are often ignored when crafting solutions to health care. What I hope to accomplish in these posts is to lay out some defining principles based on many years of experience in patient care and managing a medical practice business, seasoned with a life perspective of grace, and hopefully humility, derived from my faltering, but ever enlightening, journey in the Christian faith.

And so we begin with Lesson I: Health Care Is Not a Widget

Ahh, widgets: those ubiquitous fictional entities seemingly discussed everywhere, yet unseen by human eyes. They are defined thusly:
Widget: A fictitious good, commonly used by economic instructors to demonstrate economic principles or undertake hypothetical analyses ... If such a good exists -- and there is no clear evidence that widgets have every existed -- it is a small mechanical device, constructed of interlocking cogs, several knobs, and at least one handle. Widgets are most often used when thingamajigs and dohickies are unavailable.

Widgets are used as instructional tools to demonstrate the effects of economic principles, such as supply and demand. Health care being an industry with broad economic reach, its component services are sometimes thought of in classical economic supply-and-demand terms. Yet health care economists and politicians seem puzzled that medicine is so often unresponsive to the typical economic rules governing most other industries and service sectors.

There is a reason for this: health care is not a widget.

The problem is not that health care services are entirely outside the laws of economics; indeed, many of our health care financial problems stem from distorted or perverse economic incentives. But the nature of the services themselves differ from virtually every other service industry. How so, you wonder? I thought you'd never ask. Here's just a few key distinctions:

 Health care services are not generally subject to choice.

At the heart of free-market economics is the idea of choice -- you are free to buy my product if it is something you want or need, and the price is agreeable. You are also free not to purchase it, or to buy it elsewhere if you find a better price or quality. To a limited extent this is true in health care -- if I want a tummy tuck or facelift, I can shop around for the best balance between surgical expertise and price, and if I fail to find that balance, I can choose to forego the service.

In most cases, however, such detached rational decisions do not apply to health care, since the service is non-optional. If you have crushing substernal chest pain, you are not in a position to evaluate the optimal price or quality of the service you require: you need to get to the hospital before your heart attack kills you. The ER physician who sees you is someone you have never met; you do not know his skill or credentials; you have not negotiated a price for her services. While you may have some choice about which hospital to attend, even here your choice is severely limited by expediency -- you drive (or are taken) to the nearest one, lest you die en route.

Even in health care situations more routine and less urgent than such medical emergencies, many factors preclude free choice and free market decisions in health care. In the marketplace, the buyer typically judges the value of the product, then judges whether the asking price is appropriate to this value. In medicine, the true value of the services provided is extremely difficult to determine. We must often make choices of physician or facility purely on hearsay, or the recommendations of another physician or friends, or other factors unrelated to quality, such as proximity to home or work. The system lacks transparency. So the quality of the product you are purchasing is extremely difficult to assess prior to purchase.

Further restrictions are introduced due to the high market penetration of managed care health insurance. Insurance carriers contract with specific physicians to provide care to patients enrolled in their plans. While often touting the "high quality" of their network providers in marketing materials, contract decisions are based either on the willingness of physicians to accept the insurance carrier's fees, or the desire of the carrier to provide broad physician access for their clients -- a "take all comers" approach. Either way, quality is a virtual non-issue. Insurance quality screens weed out only the most egregious offenders -- and sometimes not even those.

Lastly -- and most importantly -- those seeking health care are almost entirely shielded from the actual cost of the service. While you often pay a percentage of the cost -- through copays and deductibles -- this amount is totally unrelated to the quality of the service. The payment has been predetermined by your insurance carrier, and the premium likely paid by your employer, or the government. So virtually all the normal forces of the free market are constrained or eliminated.

• The satisfaction with the product is not uniquely dependent on its provider.

When you buy a car, you make certain assumptions: the manufacturer has taken pains in design and manufacture to ensure a high-quality product; that quality-assurance programs are in place to monitor its manufacture; should a major problem arise, the vehicle will be recalled and the problem fixed without cost -- save inconvenience -- to the owner. These assumptions are legally spelled out in the vehicle warranty - which also spells out the owner's responsibility to maintain the car at specified intervals.

Medicine is a different animal in many ways. There are a host of variables which affect the quality of the final product. Obviously, the skill and training of the physician providing care is a critical factor. The quality of the complex system which supports the service -- the hospitals, nurses, medical equipment, suppliers, pharmaceutical companies, etc. -- comprise together another key ingredient. Often overlooked is one other, critical factor, however: the quality of the purchaser of the service.

By quality, there is no inference or intent to disparage, but rather to point out a number of patient/purchaser-related factors which greatly influence outcomes and service satisfaction: the overall health of the patient/purchaser; the disease itself under treatment; other disease states which influence the performance and outcome of the service; the cooperation and compliance of the patient/purchaser with the instructions and healing program recommended; and the vast complexity and frequent unpredictability of the human machine, which far outstrips any manufactured item in sheer randomness and near-capriciousness of makeup, performance, and response. A perfectly-performed surgery can have a disastrous outcome; a miracle drug, rare but deadly side effects; an abnormal variant in anatomy can make a routine procedure treacherous or unsuccessful. Furthermore, should such an adverse event or circumstance arise, there may be harm to the patient which cannot be undone -- or if it can, which may require additional cost, procedures, or suffering to resolve. There are no product recalls in medicine; warranties are a fanciful dream when so many aspects of the service product are not under the seller's control.

• The relationship between patient and physician is less contract than covenant.

I will cover this more fully in another post, but the distinction is important. Most economic transactions occur in the context of contract -- the rules defining the terms of the agreement, what goods or services will be offered at what price, and perhaps most importantly, what will occur should the transaction prove unsatisfactory: e.g., the product is defective, the buyer does not pay the agreed price in the time or manner specified. Although medical care is becoming increasingly contractual (to its detriment), it is in its highest form closer to a covenant -- an agreement between two parties to pursue a common goal based on mutual trust. In a contract, the transaction is king; the contract serves to define its terms and boundaries. In a covenant, the relationship rules; trust and the best interests of the other party, toward a common goal, are dominant. In medicine, such a relationship by necessity means that the transaction -- the financial side of the interaction -- must be subservient to the goal. Hence the physician must put the patient's best interest ahead of his or her own financial well-being, and must intercede on the patient's behalf when third parties threaten the goal for financial reasons.

While I am sure I have not exhausted the unique nature of medical services in the economic realm, hopefully you can begin to see more clearly why simplistic economic models fail so often when applied to health care. Yet this framework of understanding can hopefully provide some guideposts out of the dark woods of our health care crisis.

Sunday, January 30, 2005

Hugh Hewitt's 'Blog'

Blog BookIn my free time, between practicing medicine, doing a major rewrite of my electronic medical records software, photographing my wife's product line and posting it to her web site, and of course, running a blog, I had the chance to read Hugh Hewitt's latest book, Blog. It was, I must admit, a surprisingly good and easy read.

In my experience, many Internet and media pundits who are superb and engaging in short opinion pieces or commentaries, do poorly when turning their talents to a book. There seems to be a different gift package for writing short concise commentary, versus a much longer work, where a different dynamic is needed to keep the reader engaged. Several recent authors who come to mind, who do not fare well in this transition, are Peggy Noonan and David Frum.

I have long enjoyed Hugh Hewitt's insight and writing style in the Weekly Standard, and his blog is a daily visit. Surprisingly, his book successfully leverages his skill at short, insightful commentary, while maintaining an easy readability. He does this, in part, by writing brief, topical chapters. In essence, his book is much like reading a series of his articles, albeit on the same general topic. If there is a shortcoming to this approach, it is the lack of overarching continuity, development and flow which a truly engaging book manifests.

The book started out a bit slowly for me, as many of the illustrative examples, such as Dan Rather and Kerry's Christmas in Cambodia adventure, were old news, having been an obsessive blog reader throughout the political campaign. The role of blogs in exposing Trent Lott and the Jayson Blair affair were somewhat less familiar to me, but nevertheless fell into the same general mold.

His chapter on the influence of technology with the printing press and the Reformation was far more interesting, and I learned a good deal about that period of time with which I had been previously only passingly familiar. Nevertheless, the analogy between the role of the printing press in the Reformation, and the role of the blogs in the media and information revolution are bit of a stretch, and the two are not entirely analogous.

Gutenberg's printing press was truly revolutionary, and represented a world-changing technology. The blogs, on the other hand, are more of an evolution than a revolution. The technology upon which they are based -- the Internet, web sites and web hosting, and the power of the hyperlink -- is long-standing and has already been revolutionary. The power of the blog resides the way in which it represents a perfect storm of communication technology. It is truly the democratization of journalism, and as such will change the way information is dispersed.

I am not nearly as skeptical as Hugh about the future of the large print and television media, however. While lacking the nimble agility of the Internet, the mainstream media has vast resources to place reporters and video in remote parts of the world on a sustained basis, and very deep pockets, which the blogs cannot reproduce. I suspect the mainstream media will evolve into more of a commentary and opinion vehicle rather than a rapid news source. After all, the Catholic Church survived the Reformation, and is a powerful force for good today. Nevertheless, the large media's stranglehold on information has been broken.

Hugh's emphasis on the role of blog communication in business is a genuine insight, and this thought-provoking even for a small business such as mine.

One aspect of blogging which Hewitt overlooks -- perhaps because he has been in the business of putting his thoughts on paper for so long -- is the personal impact of disciplining oneself to write cogent and thoughtful posts which will be read by others. My blog is oriented toward longer, essay-based writing, rather than the far more common link-quote-comment format. For me, the process of writing for a blog has forced me to organize my thoughts more clearly, and has motivated me to research topics in far greater depth. In more than a few instances, this research has resulted in a change in my own opinion, and almost always results in the deepening of my understanding of a selected topic. The power of research, meditation, focused prayer, mental organization, and disciplined writing can be genuinely transformational.

Blogs also have huge potential as agents of true multiculturalism and tolerance -- unlike the thought-police variety ubiquitous on campus or at the NY Times. In a short period of time I can read opinions on the right and left, from Hollywood or Iraq, from soldiers and academicians, from all races and parts of the U.S, Europe, and the world. I've even found a few attorneys I've grown to like (Hugh is one of them, and the guys over at Powerline) -- so the power to overcome bias and stereotyping through the blogosphere is enormous.

The appendices, where Hewitt reprints prior articles he has published on the subject, detract from the quality of the overall work -- one is left with the feeling of being shortchanged. The author should have rewritten these in the context of the other material, or cited short passages to support other parts of the book. Why buy a book to revisit articles one may have already read?

One last thought: I hate the word "blog". To me, it sounds like a cross between a computer geek's wildest fantasy and a GI condition caused by eating too many Pop Tarts. I hope as this information tool evolves, that a better descriptive term arises. Some have suggested the term cyber sherpa -- an accurate, but far too esoteric substitute. Surely, with the many creative and intelligent minds working on this phenomenon, a better term will evolve.

In short, if you are new or relatively new to the blogging phenomenon, you should read this book to better understand where the information age is heading. If you are an experienced blogger or regular blog reader, you should buy this book to expand your horizons about the potential of blogs. If you are a wild-eyed lefty who believes America is the cause of all the evil in the world, and a Michael Moore groupie, by all means don't buy this book. The religious references will give you heartburn, the political viewpoint will give you a high blood pressure, and most importantly, you may learn something useful to promote your worldview, which will be bad for the mental health of the rest of us. Besides, the book may raise cholesterol levels in susceptible individuals. As your physician, I would strongly advise against it.

Monday, January 24, 2005

Rocket Scientists

SeattleLike most states, Medicaid in Washington State has struggled to provide health care for the poor. In Washington, Medicaid has been on life support for least several years. Its shortcomings are legion: very low reimbursements for services to providers; a poorly-written provider contract which put physicians at a severe disadvantage in any disputes; retroactive computer-generated audits of providers demanding repayment for services provided four or five years prior, under different payment rules, based purely on computer algorithms without chart review. As a result, physicians have been fleeing the program in large numbers. Statewide, only 33 percent of Washington physicians accept Medicaid patients, and most of those who do are severely limiting the numbers of such patients they will see. This has created an enormous crisis of access to health care services for the poor, which has resulted in a surge in visits to emergency rooms by patients far sicker than they would be if they had ready access to routine health care. I have personally cared for numerous patients who drove two or three hours to see me, because they could not find a provider in my specialty any closer to home.

The large majority of Washington physicians would prefer to see Medicaid patients, but are quite simply financially unable to do so. For years, both Medicare and Medicaid have operated under an unspoken and hidden tax, paying for less than the cost to provide services while relying on providers to make up the difference from their insured patients. As insurance carriers have progressively ratcheted their reimbursements down in response to spiraling health care costs and insurance premiums, subsidizing patients insured under Federal programs such as Medicare and Medicaid is no longer feasible.

For most medical practices in our area, Medicare currently reimburses at, or slightly below, the cost of providing those services. It is not widely recognized that Medicare does not pay the same for services across the country. Because of historical cost formulas, reimbursements in areas such as the Southeast or large urban areas like New York or Chicago are substantially greater than in areas where care has historically been provided at lower cost. This, however, is not a dynamic formula, and therefore regions which previously provided care at lower cost when Medicare was new, but which have since become high-cost areas, are penalized by very low Medicare reimbursement rates. Washington is such an example, and despite the current high cost of providing care in the Puget Sound area, Washington State ranks 46th out of all states for Medicare reimbursement. Medicaid in Washington State provides significantly lower reimbursements than Medicare; according to recent statistics, Medicaid in Washington State is paying at 62 percent of the Medicare rate for its services.

The State government in Olympia has come up with an ingenious new plan to solve this crisis: it plans to tax physicians to generate additional revenue to pay for higher Medicaid reimbursements. In his final budget, our previous Democratic governor, Gary Locke, proposed a 67% increase in the state business and occupation tax on physicians. Unlike most states, Washington does not have an state income tax, but instead levies a business and occupation tax on gross receipts, as well as a substantial sales tax. The specific tax rate varies by industry and business type. Our new governor, Christine Yanukovich Gregoire, formerly Governor Locke's Attorney General, also supports this idea:
Gregoire said she supports the goal behind Locke's proposal. "I can't imagine that it wouldn't get us more providers," she said. "I hope that means that those who are in need actually have access.

The rocket scientists are hard at work in state government again.

Now, as a physician, it should come as no surprise that I am somewhat resistant to the idea that I have been specially singled out for this honored responsibility. But it really does go beyond my personal reluctance to pay higher taxes -- even narrowly targeted ones such as this proposal. The simple fact is, this legislation, if passed, will not result in "those who are in need actually have[ing] access", but will severely exacerbate the crisis of access to health care for low income individuals in Washington State.

According to Governor Locke's own statistics, Medicaid currently reimburses at 62 percent of Medicare rates. Hence, even without considering the issue of profit, physicians seeing Medicaid patients are already picking up over a third of the tab for provider services in Washington State. The proposed legislation would increase reimbursements to 75 percent of the Medicare rate. So, a substantial new tax will be added for providers, while still paying them less than the cost to provide this care. The income from services to Medicaid patients is not exempt from the tax on gross receipts, and therefore the higher reimbursements will also be taxed at the new rate.

Imagine you are selling computers. You build a computer with a supply cost of $1000 (not including your time and expertise to make it), and must sell it retail for $620. Needless to say, this business model will not win you any Nobel prizes in economics. Now the State comes in, and wants to buy a large number of your computers, and offers to pay you $750 a computer -- but is going to nearly double your tax on that $750. Such a deal! It is not hard to see what you will do: you are going to stop selling computers, or sell them only to someone who will pay you more than $1000 -- or go out of business. The end results of this brain-dead legislation is simple: physicians in large numbers will simply stop seeing Medicaid patients, as they will be increasingly unable to afford to do so, no matter how strong their desire to care for the poor.

I never cease to be amazed at how seemingly intelligent individuals in government so completely and utterly fail to understand the ramifications of these sort of policies. I guess I am setting my expectations far too high.

Nevertheless, there's not much value to another "this policy will never work!" commentary on health care, so in following posts I will explore some principles and reforms which I believe stand a much better chance for success.

UPDATE: My statistic that only 33% of Washington physicians accept Medicaid patients was based on incorrect interpretation of data. The actual percentage appears to be approximately 47%, based on WSMA surveys. I will try to confirm this and post an update when I have more accurate numbers.

Tuesday, January 18, 2005

The Pioneer Spirit

Blue and Red FlowersSome of my readers want me to stop startling the sheep with terrifying tales of wolves at the gate, but rather rest peacefully in pastoral bliss, secure in the knowledge that our appointed shepherds have their security measures and manuals close at hand. Blessed assurance, thy rod and thy staff meetings, they comfort me. Stick to the Marcus Welby script, they tell me. And so I shall (in due time) -- although the long-promised malpractice essay is still a work in progress. Patience, my flock -- like the Gallo vineyards, I shall release no whine before its time. But in the meantime, let me lead you beside restful waters, and revive your souls.

Indeed, I bear good news: the Pioneer Spirit is alive and well in America.

True, the American frontier was conquered long ago. But ancestors of those intrepid explorers are setting out anew to explore the unknown, the uncharted, to brave the savages and convert the heathen. To wit: Blue-staters are hitching up their wagons and heading Red. They may be coming to a town near you.

Two recent articles tipped me off to this modern-day Manifest Destiny movement, one on each coast, from the Washington Post and the Seattle Post-Intelligencer. One can only speculate on the motivation for such intrepid ventures: perhaps the electoral drought and near-dustbowl voter yields have prompted the search for more fertile land (although it is rumored that Seattle has genetically engineered new loss-resistant voter ballots, which may help avert the impending famine). But whatever the reasons, there is a spirit of adventure in the air.

David Von Drehle, writing in the Washington Post Sunday Magazine, begins with a tale of his journey to the Red Sea:
Early in December, with a photographer and his assistant, I drove from Nebraska, near the geographical center of the United States, to the heart of Texas -- more than 700 miles, through empty spaces and sprawling cities and all or part of four states. We headed pretty much due south, no dodging or weaving. And never did we pass within 100 miles of a county that voted for Democrat John F. Kerry in the recent election.

We were voyaging on the Red Sea.

Drehle actually paints a surprisingly balanced view of what he found on his journey - albeit in language whose flourish contrasts sharply with the simplicity of middle America. ("The sun was low in the south; its rays arrived languidly and aslant through the gray, tufted stubble of a cornfield.") He seems encouraged to find people who voted for Bush, even though they disliked him (as if this were an unusual phenomenom in national elections), but periodically reveals his confusion about Red America as viewed through his dark blue sunglasses:
Kern returned several times to his belief that cities have become dangerous, expensive, disorderly places, in contrast with the safe and dependable countryside. And he seemed convinced that there is some causal link between the unpleasantness of that other America -- the one beyond the Red Sea -- and the variety of people who live there. The idea of diversity appeared to be meshed in his mind with the specter of change, and change is clearly something he prefers to avoid. Monochrome Nebraska, as he put it, is "the last frontier. Where else do you have a place where you don't have to worry about crime, about juvenile delinquency, where you can leave your doors unlocked?"

Drehle seems unable to grasp that cities generally are dangerous, expensive, disorderly places (although obviously not without offsetting benefits for many), and that most Red state residents don't frame their view of the world through the lens of "diversity" (much less think of Nebraska as "monochrome"). And change -- that bogeyman that Mr. Kern is thought to dread -- is not an inherently good thing when it brings about crime, personal risk, and social disorder.

Far from home and feelin' Blue, Drehle is mystified and intrigued by these strange Red ciphers he has unearthed. He finds his Rosetta stone in a small Midwest bookstore:
I heard a lot about a book that claimed to explain how people ... have been tricked by the moneyed class into voting against their own best interests. I found a copy of What's the Matter With Kansas? at a bookstore in Ada and began reading it as we resumed our southward journey.

The author, Thomas Frank, grew up in a wealthy suburb of Kansas City and received a PhD in cultural criticism from the University of Chicago. ... In Frank's view, if Red Sea residents knew what was good for them, they would vote for capitalist-scourging Populists today. But they don't know what's good for them, Frank explains, because of 'a species of derangement.' The deranged people of the Midwest are no longer able to make 'certain mental connections about the world,' because those once-'reliable leftists' have been deluded into caring about moral issues ... Frank kept me reading until it was too dark to read anymore.

It doesn't get much deeper blue than a Ph.D in cultural criticism at Chicago University, now does it? Drehle has found comfort, like a kid reading a letter from home at camp, in his bunk, flashlight under the blanket.

He seems perplexed when encountering an Oklahoma woman who opposed Kerry for his position on abortion and gay marriage:
She was too polite to say, in so many words, that she felt John Kerry was a man of bad morals. Instead, she put it this way: 'When Kerry said he was for abortion and one-sex marriages, I just couldn't see our country being led by someone like that.'

Later, I double-checked what Kerry had said on those subjects. During his campaign, he opposed same-sex marriage and said that abortion was a private matter. But Joyce Smith heard it the way she heard it, and voted the way she voted.

Doesn't the poor woman understand that a Democrat man's word is his bond? Except when its not, of course. Sometimes eyes and ears comprehend things which Google searches don't disclose.

On the Left coast, another journalist in Seattle hitches his Conestoga to the Google search engine in search of the abominable snowman of electoral politics: the Christian voter ("I've seen their footprints in the snow, Myrtle, but have yet to spot the beast!"). Tony Robinson, in Who Are Those Christians?, rapidly dismisses the vile misconception that Christians are all narrow-minded, hate-filled moronic drones:
For some today, all Christians are closed-minded religious bigots whose politics are somewhere to the right of the Terminator. For others, Christians can be explained in terms of two-party theory: There are liberal and progressive Christians on one side and the conservative and evangelical Christians on the other.

Both explanatory frameworks are inadequate to the diverse and complex reality of Christianity in America today. Like much else in post-modern America, the situation is wonderfully messy. It doesn't lend itself to neat explanations or to a simple duality of liberal and conservative. Post-modernity is transgressive, that is, given to crossing boundaries. So today you have progressive evangelicals, theological post-liberals, the new orthodox, as well as ancient-modern Christians. Such stereotype shattering and boundary crossing strikes me as promising.

It is reassuring to know that Christians are not merely closed-minded religious bigots with bulging muscles and German accents, but rather boundry-crossing, stereotype-smashing, post-modern transgressives. Robinson finds this promising -- as do I. I think. And as any good teacher, he does not simply leave us wondering what such wonderfully messy transgressiveness implies, but expands the outline in exquisite detail. He has discovered that Christians fall into different categories: mainline, evangelical, fundamentalist, charismatic and, yes -- Catholic!

One can almost hear the audible gasp from Belltown readers, sipping their not-too-hot Chai lattes as they gaze over Elliott Bay: "There are different types of Christians -- who knew? Say, what time is that Mapplethorpe exhibit at the Seattle Center?"

Robinson's depiction reads like an African safari adventure written by a National Geographic reader: one gets the sense -- unlike Drehle -- that he's never actually met the people he's describing.

From a sociological point of view, his overview of Christianity in America is reasonably accurate. But as an overview, it approaches being entirely meaningless -- or at least irrelevant. He divides two broad stereotypes into five broad stereotypes -- then tells us that these stereotypes are, well, not stereotypical. For example, when contrasting the mainline churches with the fundamentalists, he says:
One broad-brush way to differentiate the dominate Christian groups is how they relate to modernity or what some call 'The Enlightenment Project,' with its hallmark values of reason, progress, optimism, individualism and tolerance. Mainline Christians have been open and receptive to modernity, working to accommodate Christianity and modernity. By contrast, fundamentalists circled the wagons against modernity, which they perceived as a threat.

Aahh, modernity -- who does not desire to be thoroughly modern, Millie? The red flag here is the "Enlightenment Project" -- a key element of postmodernism, which emphasizes, in essence, opposition to all forms of darkness and superstition, as exemplified by religion:
Enlightenment was defined as the project of dispelling darkness, fear and superstition. It was the project of removing all the shackles of free enquiry and debate. It opposed the traditional powers and beliefs of the church (branded as 'superstition') and raised questions of political legitimacy.

Without plunging the depths of the contrasts and conflicts between the relativism of postmodernism and the centrality in religion (especially in Judeo-Christianity) of an absolute Truth over and above imperfect human reason, it suddenly becomes clear why this sort of generalization about Christianity is so vacuous: the labels are meaningless. If the mainline churches espouse postmodern skepticism, rejecting ideas of absolute truth of divine origin (a characterization not far off, in many cases), then they are no longer Christian in any meaningful sense, other than by name.

Herein lies the source of enormous confusion for our intrepid explorers: you cannot rely on descriptions, like "Christian", or "fundamentalist", or "evangelical", because their meaning has become so amorphous, and they are overlaid with ambiguity and inferences which cripple their utility as vehicles of fact. For example, "fundamentalist" originally referred to Christianity's emphasis on absolute, transcendent Truth as opposed to relativism. While the specifics of exactly what that Truth entails remains controversial to a degree, even to this day, within Christianity, the fact that there is an absolute truth of divine origin is undisputed in the faith. Yet "fundamentalism" has become a societal codeword for rigid intolerance, ignorance, anti-intellectualism, and even violent repression. It has been linked by common usage to Islamic terrorism, adding additional baggage, though the two religions could not be more different. While many devout Christians acknowledge the fundamentals of belief in absolute truth and Christian doctrine, few today will publicly admit to being a "fundamentalist". The connotations of the word are too profoundly negative in our modern society.

To understand Christians, or those mysterious Red state middle Americans, you have to get down to individuals, without preconceived notions carried forward from the lofty towers of intellectualism and social theory. The fruits of postmodern relativism and social concepts, detached from the real-life problems and solutions of everyday living -- which many understand to require transcendent Truth and reliance on divine strength and guidance -- are increasingly seen as empty and destructive by a growing plurality of Americans. It is this, perhaps more than anything else, which divides Red and Blue in America today.

Friday, January 14, 2005

An Attack Averted

Moon Behind the CloudsI had a most interesting and troubling conversation with a patient of mine yesterday. The patient, a Federal Air Marshall, related an incident in which he was involved this past year.

He and his partner were assigned to a flight (the airline, airport, and destination were not disclosed) in their customary undercover security role. They boarded the airplane early in order to meet the flight attendants, at which time the cleaning crew was still on the airplane -- somewhat longer than expected. My patient and his partner sat together in seats near the middle of coach class.

The passengers began to board, and he and his partner noticed a single Middle Eastern man sitting near the front of first class. After a number of passengers had boarded, two Middle Eastern men walked by this man and made eye contact, but said nothing. They sat down together in the front of coach class. Shortly thereafter, two other Middle Eastern men also walked by the man in first class and made eye contact without speaking. They sat near the back of coach class.

Shortly after the flight attendants completed their post-boarding check of the overhead bins, an announcement came from the cockpit: the pilot stated that there had been a security breach, and everyone needed to deboard the plane for a second, more thorough, security screening. The Air Marshall and his partner were confused, as they had not triggered the security alert nor been notified of it prior to the announcement.

After all the passengers had deplaned, the Federal Air Marshalls checked with the flight attendants for more information. During a final check of the overhead bins, a flight attendant had noticed that one of the blankets was slightly unfolded, and he repositioned it in the bin. At this time, a razor blade fell out of the blanket. Concerned, but still believing this might be a straightforward mistake, the flight attendant began to check other overhead bins. Several additional incompletely folded blankets were noted, and hidden in each one was a box cutter: a total of five. It appeared that these had been placed there by the cleaning crew prior to the boarding of the airplane.

After the repeat security screening, the passengers reboarded -- all except the five Middle Eastern men, who were nowhere to be found. The flight proceeded to its destination uneventfully.

The man who relayed this story to me is a reliable and sober individual, and I have no reason to question his integrity or its veracity.

Anyone who believes the War on Terror is a fabrication trumped up for political gain needs to take a strong dose of reality medication and lie down until this hallucination passes.

Thursday, January 13, 2005

Kidney Stone Blogging

PanseyI have been working on a posting -- or series of postings -- on medical malpractice, a project which has taken longer than I anticipated. So, in the meantime, I thought I would treat you to some kidney stone blogging.

Say again? Kidney stone blogging.

Management of kidney stones has changed dramatically over the past 20 years. In the past, patients who formed kidney stones often required open surgery, with some active stone formers undergoing multiple open surgical operations. Things began to change in the early 1980s, first with the advent of percutaneous renal surgery -- a precursor of today's laparoscopic procedures. After placing a tube in the kidney using x-ray guidance, fiber-optic scopes were placed into the kidney, and kidney stones could be directly retrieved or fragmented.

The next, and perhaps most important, evolution in surgical technique was ESWL (extracorporeal shockwave lithotripsy). This technique was developed in Germany, after aerospace engineers noticed that a peculiar pitting was occurring on military jet aircraft which broke the sound barrier. Research determined that the sonic wave thus created was focused by condensation on the surface of the jet, creating a pit at the apex of the droplet. As perhaps only the Germans could deduce, this logically led to the use of focused sound waves for kidney stone fragmentation. The concept is not dissimilar to a magnifying glass in the sun. Solar energy, a quite comfortable temperature at the magnifying glass level, is intense enough to start a fire at its focal point. Similarly, soundwave energy at its source is weak, and can pass through water (and therefore human tissue) with virtually no damage, but at the focal point, creates a tremendous pressure wave. Using dual-plane x-ray control (for 3D imaging), the focal point could be directed at an internal kidney stone, and a series of shocks could break it into tiny fragments. This, somewhat amazingly, causes little or no injury to the surrounding kidney tissue.

ESWL, while ideal for stones that are still in the kidney, does not work well for stones that have moved into the ureter -- the thin drainage tube connecting the kidney to the bladder. For such stones, the development of small-caliber, high-quality optical scopes has proved an ideal solution. The scopes are introduced into the ureter by passing them through the lower urinary tract, the urethra and bladder. (This is done under anesthesia, of course, for the squeamish among you -- uncross those legs, now). Stones which are trapped in the ureter, even high above the bladder near the kidney, can be reached with such instruments, in most cases with little difficulty. The challenge then becomes: what do you do with the stone when you finally see it?

If it is tiny, you may be able to grasp it with a wire cage -- called a stone basket -- and extract it. In many cases, however, stones trapped in the ureter are larger, and cannot be removed this way. They must be fragmented.

The answer has been provided through laser technology. Using a tiny fiberoptic fibers -- 350 microns in diameter or less -- passed through the ureteroscope (as these delicate scopes are called), laser energy is used to fragment the stone. Darth Vader, meet Marcus Welby.

There are many different types of lasers used in medicine. Different laser types and wavelengths have markedly different effects on living tissue. Some, like the CO2 laser, work best in air, and are used to vaporize skin lesions, such as warts, with very little deep tissue penetration and virtually no subsequent scarring. Others provide deep thermal energy to destroy tumors or other tissues with minimal effect on the surface. For kidney stone work, a holmium laser in direct contact with the stone is commonly used.

The laser is fired at a very rapid repeating frequency. At the tip of the fiber, which is placed in contact with the stone, the intense light energy vaporizes the water used for irrigation, creating a rapidly-expanding plasma. An intense yet short-radius shockwave results. This has the effect of drilling into the stone, which creates areas of relative weakness and fracture. As a result, the stone breaks into increasingly smaller pieces, which can be extracted or flushed out. Because of the short energy radius, the surrounding tissues are unaffected.

A patient I treated recently shows how extraordinary an advance this is. He was morbidly obese, weighing nearly 400 pounds, a situation which precludes ESWL, as the focal length of the machine is not long enough to reach the stone. He presented with a very large stone just below the kidney, measuring about one-half inch in diameter. The patient also had very poor lung function and was at high risk for general anesthesia, and particularly at high risk for open surgery on the upper abdomen, which can greatly impair lung function. Using the ureteroscope and the laser, I was able to successfully treat his stone without the need for high-risk open surgery. Let's take a virtual walk-through of the procedure (the pictures are a bit grainy because of the low video resolution of the surgical camera).

This image shows the ureteral orifice (the opening in the bladder where the ureter enters, draining one of the kidneys) after the scope has been introduced into the bladder, before entering the ureter:

Ureteral orifice

This image shows the ureter below the stone as seen through the scope. The diameter of the ureter is about 3-4 millimeters:

Ureter below

This image shows the laser fiber in contact with the stone. The fiber is the dark blue linear object on the right, and green spot is the actual laser beam:


This image shows a large fissure created in the stone as it begins to break up:


This image demonstrates how the laser fiber can literally drill a hole through the stone. The central dark spot is actually a narrow cavity created from laser contact:


The patient had an uncomplicated surgery and anesthesia, and was discharged from the hospital several hours after it was completed. Contrast this with an open surgical procedure, which at the very best would have left him hospitalized for nearly a week, with a significant risk of requiring a respirator to support his breathing because of his weight and risk of lung complications secondary to the surgery. He also avoided the need for a long and uncomfortable recovery from a large surgical incision.

Life is good.

Wednesday, January 05, 2005

Life with Wrigley

WrigleyThe holidays have passed, so it's time to get back into the daily routines which provide predictability and productivity to life. As for many, the holidays provided both ample enjoyment and stress, as the compounding time requirements of work, family, and entertainment formed a potent - if exhausting - brew. The joy of Christmas was tempered by the need to be on call, which foreshortened time with my family. But there were many blessings in the gift of giving, gratitude, great food, and the time spent with my wife and children, now grown and increasingly independent of their parents through the centrifugal forces of adulthood, marriage, and career training.

There were other, more unexpected, blessings. One of our cats, a 13-year-old gray Persian, began to deteriorate rapidly in early December, developing progressive weakness in his hind legs, at first having trouble jumping, then ultimately deteriorating to the point where he was dragging his legs behind him. Several veterinarians - including a cat specialist - were mystified by the disease, and he was ultimately referred to a small-animal neurologist (yes, such specialties exist in veterinary medicine), who ordered an MRI(!). The initial report was bleak - the scan was interpreted as showing a spinal cord tumor. The prospect of euthanizing a member of our family (no, I'm not anthropromorphizing our animals, but anyone who has a special pet knows how deep your attachment to them becomes over the years) - at Christmas time, no less - was depressing, to say the least.

As a matter of course, all MRI scans from the clinic are sent digitally to Washington State University School of Veterinary Medicine, to be reviewed by a radiology specialist. After several tense days, the answer returned: It was not a tumor, but rather a rare parasitic infection called toxoplasmosis.

Toxoplasmosis is extremely common in cats, and rarely causes clinical disease. Spinal cord involvement with parasitic cysts is extremely rare, however - but treatable. After a week of antibiotics, our old friend is nearly back to normal - jumping up on the counters, getting into the butter, stealing the broccoli (he loves vegetables!) and causing his usual mischief. But somehow it's hard to get too angry with him. His recovery is one of our best gifts of the season.

And then there's Wrigley...

During the course of several vet visits for our cat, my wife met a neighbor with a 4-month-old puppy called Wrigley (pictured above). Wrigley is a Golden Doodle - a cross between a Golden Retriever and a miniature poodle - and one of the cutest darn dogs you'll ever lay eyes on. Our neighbor was looking to board him while they were out of town for the holidays, and my wife - in her passion for "cute" dogs - offered to watch him. It was love at first sight - Wrigley was playful, energetic, friendly, and good-natured. And she was easy on the senses, with button-black eyes, a soft coat, minimal odor, and gorgeous, subtle coloration. But love is fickle - and easily extinguished. The honeymoon lasted about one day.

Dogs have many fine attributes which make them wonderful companions. Pack animals by nature, they love the companionship of people. Easily trained, they can be taught to perform many remarkable tasks - service dogs, search and rescue, police work, personal protection, illegal drug detection, - even cancer detection. But above all, the most treasured characteristic in dogs is their loyalty. A dog will love you, and be loyal to you, even though you scold it, neglect it, punish it for misdeeds, leave it - even abuse it, God forbid. You can be a miserable sonofabitch and your dog will worship the ground you walk on. Their friendship and devotion is nearly unlimited. Wrigley was terminally cute and playful - but she was not loyal.

Wrigley was ecstatic to be with us - her true owner forgotten in a nanosecond once the door slammed shut. And ecstatic to be with anyone she met - man or beast.

Wrigley was classic ADD - when you called her, you were the most exciting thing on earth - for exactly two seconds. Then she was off, to the next most exciting thing she'd ever seen. Mixing two breeds can enhance their best traits, but such is not inevitable. With Wrigley, the rambunctious and independent playfulness of the poodle combined with the Golden's unconditional love for all mankind produced a gorgeous and engaging animal. She was all looks and personality - and no loyalty.

The bloom was off the rose rapidly with the liabilities of canine youth - the endless chewing, the hyper-frenetic activity, unceasing barking, the apparent inability to differentiate "indoors" from "outdoors" when tending to bodily functions. When her owner returned, we expressed our sheer joy at her visit through grateful, carefully engineered smiles, as Wrigley ran off, ecstatic to meet her newfound - if dimly-remembered - owner.

Yet she, too, gave us a gift at Christmas - the appreciation of the value of loyalty. How often are we drawn to the beautiful, the engaging, the gregarious - only to miss those quiet, invaluable treasures of devotion, commitment, endurance in trials, true friendship: loyalty, in a word. To have both - as I have been blessed with in my family - is to have all the treasure a man could desire.