For man also knoweth not his time; as the fishes that are taken in an evil net, and as the birds that are caught in the snare, even so are the sons of men snared in an evil time, when it falleth suddenly upon them.

But life is precious and people cling to it.  Even those with a terminal disease do not wish for death or want to hasten it, despite popular misconceptions about assisted and “rational” suicide.

In “Reflections on Doctors,”  a book of essays written by nurses, one of the essays - “A Physician’s Definition of Failure,” deals with the meaning of medical failure.  The author, a nurse, worked in a rehabilitation unit for patients with brain and spinal cord injuries.  One of her patients, paralyzed and confined to a wheelchair, was once a high school basketball player.

His high school varsity basketball team photo was hung in his room.  One day when the nurse and the medical director, a neurosurgeon, made rounds, she showed the doctor the picture.  When he saw the photo, the medical director became very upset.  Seeing the picture made the medical director feel as if he had failed the patient; he couldn’t “fix” him, restore him to his former state - the basketball player in the photo.

The nurse was shocked.  She says that “had it not been for this doctor’s skill, talent, and vision of rehabilitation, this young man would not have the future he had in front of him.  He would finish high school, go to college, get married, build a successful career, and have children.”

Many people who accomplish much less than this can’t necessarily be considered failures.  Doctors, nurses, and other medical professionals learn early in their careers that many of their patients will never function normally.  However, that shouldn’t stop medical people and their patients from getting on with life.

In several court cases, men who donated sperm to female acquaintances or friends now owe child support.

Admittedly, the men did have some periodic contact with the children, and visited or sent presents or cards.  These actions apparently established a “parental relationship.”

How’s that for gratitude?  THANKS!  THANKS!  THANKS!

Medicare Pays Dead Doctors to Take Care of Dead Patients

Have Medicare Bureaucrats Discovered the Magic Elixir - The Secret of Eternal Life?

Between 2000 and 2007 Medicare paid between $60 and $92 million for claims filed by dead doctors .  Some of these doctors had been dead for over ten years when the claims were filed.  Also, millions of dollars have been paid for services provided for dead patients.

Obviously, dead doctors can’t take care of dead patients.  The explanation is fraud.  Someone apparently obtained a list of Medicare patient and physician numbers and fraudulently submitted the claims to Medicare.  The claims were then paid by Medicare.

You would think that Medicare bureaucrats would be able to find a way to stop paying for these fraudulent claims.  After all, aren’t these the geniuses who want to take over the whole health care system?

Could it be that the Medicare employees are the only people in this whole sorry fiasco who are dead?  Brain dead, that is.

He Came Out of the Closet When He Came Out of the Operating Room

A man who had heart surgery in the UK had to have a vein removed from his leg to bypass the blocked arteries in his heart.  Part of a tattoo on the man’s leg, which read “I love women,” was removed along with the vein.  However, after the operation, the tattoo read “I love men.”

Che Guevara, a murderer and executioner, was also an obstetrician

Aren’t they all tyrants, many doctors’ wives and nurses say, facetiously we hope?  I don’t mean know-it-all physicians who are used to running things and getting their way, but violent political tyrants, dictators, or terrorists.  Doctors can be as violent as anyone else.  Doctors can take as much pleasure in political violence as nonmedical people.

Guess what?  Those Terrorists Were Doctors

Several would-be terrorists - Muslim doctors, were intercepted in the UK and Ireland  in 2007 before they could carry out bombings.

An Ugly Stain on the Medical Profession Which Will Never Be Forgotten

The role of World War II Japanese and Nazi doctors in committing medical atrocities and torture is well known.

The Unpleasant Truth About Che Guevara

Che Guevara, a Marxist revolutionary and an obstetrician, actually took pleasure in executions, as described in “Exposing the Real Che Guevara,” by Humberto Fontova:  

There was something seriously wrong with Guevara… (He) seemed to relish it.    He appeared to revel in the bloodletting for its own sake.  You could somehow see it in his face as he watched the men dragged out of their cells. 

Whether doctors are more or less likely than average to be terrorists or inflict political violence is difficult to determine.  But how can members of a profession dedicated to compassion and healing become terrorists or political murderers?

“Cutthroats in White Coats”

Theodore Dalrymple, a prison psychiatrist in the UK, in his essay “Cutthroats in White Coats,” discusses some of the reasons why doctors, of all people, might be prone to political violence.  For one thing, Dalrymple feels that medical practice can produce a cynical and disappointing view of human nature.

He also says that doctors are exactly the kind of people one would expect to become terrorists.  Not many doctors, but some.  This is in part because they have the right psychological qualifications, in that they have to be dispassionate in the face of suffering, and may have to cause suffering to achieve a benefit. 

Ideology – A Set of Political Beliefs, Can Lead People Astray

Political violence can result when this emotional distance in the face of suffering is combined with an ideology such as Islamism or Marxism which can lead to sadism and violence.  Educated classes are susceptible to becoming fanatically devoted to certain ideologies which can allow people to commit horrible acts with the intent of somehow producing a better world.  For these people, ideology makes the most absolute evil seem good.

Do You Hear a Ticking Sound When Your Doctor Walks Into the Room?

So should you put your physician through a metal detector before your next office visit?  Probably not. 

A Doctor’s Most Important Possessions Are Reputation and Moral Principles

Despite the chilling examples discussed above, the physician terrorist seems to be rare.  However, even one such example shocks us with extreme violations of the ideals of the medical profession.  Those ideals should be affirmed constantly, and there is no better statement of them than by Dr. Tinsley Harrison in the first 1950 edition of Harrison’s Principles of Internal Medicine, generally considered the “bible” of internal medicine:

No greater opportunity or obligation can fall the lot of a human being than to be a physician.  In the care of the suffering he needs technical skill, scientific knowledge, and human understanding.  He who uses these with courage, humility, and wisdom will provide a unique service for his fellow man and will build an enduring edifice of character within himself.  The physician should ask of his destiny no more than this, and he should be content with no less.

Out of Control

Everyone at the nursing station knew the drill by now.  Dr. X picked up the keyboard, turned it on its side and pounded it on the desk.  The Q-W-E-R-T-Y keys went to the left and the Z-X-C-V-B keys to the right.  Then he raised the keyboard above his head and smashed it against the floor.  Keys and plastic fragments flew in all directions.

As Dr. X stomped off down the hall, the ward secretary pulled out a backup keyboard and began to clean up the mess.  She had a supply of spare keyboards and phones in a closet, ready for the next outburst.

Coworkers Traumatized

The nurse across the desk from the computer terminal covered her face with her hands and cried quietly.  The charge nurse stood in the break room.  She was on the phone with the hospital administrator.  She rolled her eyes as she listened to him say “But he’s our top admitter.”  There was a long pause, and then the administrator said “Look, I’ll call the nursing supervisor.”

Some Behavior is Unacceptable

Behavior such as throwing charts and instruments, shouting, profanity, and the like, is obviously disruptive, unprofessional, and unacceptable.

“Disruptive” Can Be a Catchall Term

However, “disruptive physician” guidelines can be vague and subjective and may be used to harass physicians who challenge the hospital administration on the quality of care provided by the hospital staff.

“Disruptive physician” guidelines allow hospital administrations to dismiss doctors from hospital medical staffs for actions such as refusing to join a hospital-sponsored HMO, offering a service that competes with the hospital, expressing political views that are disagreeable to the hospital administration, and voicing concerns about quality of care.  

Shabby Treatment of One Physician

The case of Dr. W, a surgeon at a Charleston, SC hospital, illustrates these concerns.  Dr. W openly complained about the quality of care his patients received at the hospital.  The hospital subsequently accused him of being a “disruptive physician.”

Dr. W Had Legitimate Complaints 

Here are some problems Dr. W complained about.  Dr. W ordered antibiotics for a woman with abdominal pain caused by diverticulitis, a serious infection of the colon.  The antibiotics were not given for ten hours.  The woman suffered a perforated colon and spent a month in intensive care.  In another case, vital signs (temperature, pulse, blood pressure, and respiratory rate) of one of Dr. W’s patients were not checked for 48 hours. 

Is Making a Written Complaint “Disruptive Behavior?”

Dr. W made a number of written complaints to the hospital administration regarding such deficiencies in medical care. The hospital then claimed that Dr. W was guilty of disruptive behavior.  The episodes of disruptive behavior were these written complaints.

A Good Doctor Is Ruined For Trying to Do a Good Job

The hospital summarily dismissed Dr. W from the hospital staff.  The hospital then reported him to the national data base for doctors who have malpractice suits or disciplinary actions - the National Practitioner Data Bank (NPDB). His practice is ruined, and the NPDB report has made him virtually unemployable.

“Disruptive” Hospital Administrators

It’s interesting that there are no “disruptive hospital administrator” or “disruptive CEO” guidelines.  A CEO may fire a highly competent doctor who is trying to insure quality medical care.  Of course, in doing this, the CEO is being highly disruptive.

Parallels to Poe’s Short Story “The Cask of Amontillado”

My colleague’s desire for revenge grew over a long period of time, as did a similar desire in the protagonist of Edgar Allen Poe’s tale of revenge “The Cask of Amontillado.”  In that story, the narrator lures his victim, a wine connoisseur, into a wine cellar on the pretext of offering him a sample of a rare wine, Amontillado.  Poe’s narrator says in the opening sentence that…

The thousand injuries of Fortunato I had borne as best I could, but when he ventured upon insult, I vowed revenge.

Poe’s narrator buries his victim alive.  The payback in my story was not so extreme, but it was unique and humiliating.

Chief, Department of Insults and Abuse

In today’s post, the object of revenge - the chief of a clinical department, was no ordinary bully.  He was enormously insulting and vindictive, almost always without justification, and he was universally disliked.  Let’s call him Dr. Anu.

The details of Dr. Anu’s behavior and whether he deserved such dislike can’t be discussed here.  For now, you’ll have to take my word for it.

A Superdoc Has Had Enough

My friend who inflicted the comeuppance was a highly intelligent, skilled and conscientious physician.  Along with everyone else, he had endured Anu’s insults and abuse.  My friend was leaving the hospital to train at a very prestigious academic medical center, and he despised Anu. 

On my friend’s last day of work, as a parting gesture of affection, he pooped in a shoe box and left it on Anu’s desk.

This incident occurred years ago.  However, I only realized when I started to write up this piece that when Anu found the box, his misery was only beginning. 

What Is That Awful Smell?

Leaving it in the trash can would not be a good option.  First, he would have to abandon his office for the rest of the day.  Then, what if Anu went home, leaving the box in the trash can?  What if the cleaning staff or other employees entered his office to investigate the stench and found the box?  Hundreds of people would find out through the hospital grapevine.  The lack of any obvious explanation for the mess would make the story even more sensational and worthy of gossip. 

Hey Doc, What’s In the Box?

Did he take the smelly box out of his office and throw it away?  In that case, the entire hall would have smelled and people might have noticed.  They would have wondered:  Did Anu soil himself?  Did he contaminate himself with stool from a patient?  If Anu encountered another colleague or employee in the hall while carrying the box, would he have tried to explain the situation?  Wouldn’t the true explanation be the most embarrassing explanation of all?

Anyway, I Think the Statute of Limitations Has Run Out

Certain people can probably identify the relevant parties in this story.  Too bad.  Anu deserved his punishment, and my friend was proud of what he did.  I’m proud of my friend, too.

So remember, revenge is a dish which is best served steaming hot.

 I made a friendly comment about organic chemistry and asked whether he had a test coming up.  He answered no; he was studying for the MCAT, the Medical College Admission Test, and was applying to medical school.

I suggested that medicine is a less attractive career than it once was.  His girlfriend had apparently heard this before.  She gathered herself up, her face contorted by rage, stood up and slammed her notebook on the table.  She said “I don’t want to hear it!  Don’t even talk about it!”  I apologetically mumbled that I was a physician and was only trying to be helpful.

She turned and stomped out into the snow-covered street.  Her boyfriend sheepishly collected his things and walked out after her.

For the past several months, Medscape, the online medical education website, has been running a blog titled “So You Want to Be a Doctor?”  There are hundreds of entries from practicing physicians on the subject of whether they would advise young people to pursue a career in medicine, and whether they would still become doctors if they knew what they know now.

From this series, there seems to be agreement among the physicians on several issues.  First, most of the physicians find medicine a rewarding (but not necessarily financially) and enjoyable profession.  Here is a representative post:

I do agree with many of the negative opinions expressed here, but I think about our message to younger persons who approach us asking if medicine may be a good choice for them. I’d tell them that “Medicine is a calling more than a profession” (William Osler). If the individual who is asking the question feels a calling for medicine, regardless of remuneration and demands on personal time for family and leisure, I’d say “Go for it, by all means, and there will be no greater happiness” for saving one life is like saving the entire world. I’d also advise those who don’t feel such calling or who wish to make money to stay away from medicine. And finally and above all: One should be prepared to serve people and have humility.

Second, most of the dissatisfaction in the medical profession is due to interference in the delivery of care and limitation of income by the government and by insurance companies.

Many physicians would not enter medicine if they had it to do over again.

That’s very nice, but I do not believe that any of these visionaries had working for serf-wages while Insurance company execs make millions off our collective toil, and Medicare unloads their burden on us - at our expense - in mind when they stated these platitudes. It’s hard to believe in a higher calling, when you can’t even pay the bills. I do not believe that it is somehow against a higher principle to be able to pay your mortgage, kids’ educations and put money away sensibly for retirement rather than proving a burden on the society you served, in your waning years. I am not a Plastic Surgeon, I don’t drive a Mercedes (it’s a Subaru and its 5 years old, my other car is a 20 year old Dodge hatchback) and I did not make even six figures much less seven. No, in my last year of primary care in internal medicine I made less than $30,000. No; rather, like 70% of my colleagues, I would steer the prospective medical student in another direction.

I wonder what happened to the young man I met at Starbucks.  Immediately after the couple left, I felt guilty.  Many physicians are ambivalent about recommending that young people apply or not apply to medical school.  Many of these docs give a lengthy, nuanced description of the pros and cons of a medical career, without clearly recommending or not recommending medicine.  I am usually, but not always, in this camp.

Maybe the premedical student from Starbucks is in medical school now.  When I was applying to medical school, I remember how hurt and indignant I felt whenever anyone suggested that there were other desirable careers besides medicine.  This is an obvious truth, but such comments were mainly meant to comfort people who weren’t accepted to medical school.  However, in the 70s, it would never have occurred to anyone that medicine might not be a well paid career.  I hope it occurs to people now. 

Still, no path in life guarantees against hardship.  Pope Benedict recently said that the current financial crisis shows that money is an illusory goal.  I don’t think he meant to minimize the sufferings of poverty.  He also said that “Whoever builds his life on this reality, on material things, on success…builds (his house) on sand.  Only the word of God is the foundation of all reality.”

 Q:  When Mary and Joseph went to Bethlehem, why did Mary have Jesus in a manger?

 A:  They had Aetna HMO.

Enema Nation

In the Russian city of Zheleznovodsk, a monument has been dedicated to a medical procedure popular at local health spas, the enema.  The statue is a bronze enema syringe supported by three cherubs.  Dozens of spas in the surrounding Caucasus Mountain region give enemas from the area’s mineral springs.  (Internal Medicine News: 7/13/08)

Barack Obama and his advisors were in the area recently on a fact-finding tour to help them design a new government-run health care plan for the US.  Obama said “I’m an enema freak from way back.  I’ll bend over to make sure enemas are included in my new health plan.”

Doctor-Nurse Relationship is Like a Marriage         

The doctor-nurse relationship is in many ways a marriage writ large, with love, hate, mutual dependence, ambivalence, and uncertainties about power and responsibility.  As in many marriages, though, the two parties would sometimes like to take separate vacations and have separate checking accounts.

“Smart Enough Not to Be a Doctor”

One essay is titled “Smart Enough Not to Be a Doctor.”  The author, Pamela Gonzalez, RN, says that she has been told repeatedly throughout her career that she is “smart enough to be a doctor.”  She considers this an insult. 

Are Doctors Smarter Than Nurses?

Ms. Gonzalez complains that “This backward compliment suggests that choosing a professional path in the nursing field is for those with less intellectual abilities (sic) than those who choose to go to medical school.”   Ms. Gonzalez says that she wants to reply “Yes.  I was smart enough - and I chose not to be a doctor.” 

Ms. Gonzalez graduated from an Ivy League college and had good grades and test scores. She writes well and sounds like a very competent professional.  All of which suggest that she probably would have done well in medicine.

Some Aspects of Nursing Are More Appealing

So why didn’t she go to medical school?  Ms. Gonzalez gives some supposed advantages of being a nurse rather than a doctor, such as being more directly involved with patients.  She believes that patients will confide sensitive information to a nurse which they won’t disclose to a physician.  Still, it’s hard to imagine a relationship which requires more trust and disclosure than the doctor-patient relationship, so these arguments aren’t very convincing.  There may have been other reasons why she preferred nursing to medicine.  

In Some Ways Medicine Is Not So Appealing

According to Ms. Gonzalez, becoming a doctor requires spending years training before seeing patients, and HMOs often control the time physicians spend with patients.  Also, she wisely does not place much value on a high income.  These reasons seem a little closer to the mark.   I suspect, but cannot prove, that the reason Ms. Gonzalez didn’t go into medicine was the often extreme demands placed on physicians. 

Besides, what’s wrong with being a nurse?  Ms. Gonzalez must know that many physicians are unhappy with their pay and working conditions.  Whether medicine is still a wise career choice is a complicated issue which cannot be discussed here.  Ms. Gonzalez says she was “smart enough not to be a doctor.”  Perhaps many doctors now practicing wish they had been that smart.

There Is Something to Be Said for a Job Which Doesn’t Consume Your Life

My father was an engineer.  No weekend call, no 3 AM phone calls, no 80 hour work weeks.  He didn’t have the status, income, or maybe even the job satisfaction of a physician, but he went home every day at 5 o’clock, and then his time was his own.  I think there’s a lot to be said for that.

Maybe you’re old enough to have seen the TV series “The Outer Limits” in the 1960s.  I remember an episode in which an average guy is subjected to a process which increases his intelligence at a tremendous rate.  As his IQ goes up his head gets bigger, so that he looks like an alien with a huge head.  At the end of the show, he’s in a chamber which resembles an elevator with flashing lights.  Some forty years later, has science advanced enough so that we can accomplish the same thing by just taking pills, “smart drugs?”

Not exactly, but there has been some progress in that direction.  There are, of course, drugs which enhance mental performance in people with a variety of diseases.  However, to enhance mental performance in normal people, that’s the meaning of the term “smart drugs.”

Modafinil (Provigil) is an alertness-promoting drug which can be used for people with excessive drowsiness associated with shift work disorder .  This disorder affects 5-10% of night shift workers and involves excessive sleepiness during night shifts and insomnia during the day, when night shift workers usually sleep. Because modafinil also improves the deficits seen in normal people with sleep deprivation, it is inevitable that this drug will be used for fatigue or sleepiness in normal people.

Both amphetamines and modafinil are sometimes used in the military to counteract the effects of fatigue and sleep deprivation.   Nicotine and a drug used to treat Alzheimer’s disease, donepezil (Aricept), both enhanced the performance of pilots in flight simulation tasks . 

Scientists are always on the lookout for new candidates for use as smart drugs.  Some researchers think that Salvia Divinorum, the most potent hallucinogen known, may eventually have a variety of uses in treating depression and other diseases.  However, I can’t think of any drug which makes people hallucinate and see little green men, as did one loser, or user, which later turned out to be a useful drug.

Many users have documented their Salvia trips on You Tube.  Some criticize the “Tubers” as people who use the drug frivolously.  “They’re not really taking it as a tool to explore their inner psyche,” said Daniel J. Siebert, a Californian who pioneered the production of Salvia extracts.  “They’re just taking it to get messed up.”   So what’s the difference?

As for exploring your “inner psyche,” some years back a drug user told me of a great revelation of truth he had while using a psychedelic drug.  Despite the intense hallucinations caused by the drug, he managed to write down his revelation.  The next morning, he found a scrap of paper which read “This room smells funny.”

According to George W. Bush, “When somebody hurts, government has got to move.”  Doesn’t that make you cringe?  It seems that whenever the government moves, somebody gets hurt or even squashed.

Government programs often cause perverse and unintended consequences by creating “moral hazard.”  This term refers to the fact that insulating a person from the consequences of risk may have bad results.  The person may behave differently from the way the person would behave if fully exposed to that risk.  Here’s a familiar example: If you insulate people from the consequences of taking financial risks, they may behave recklessly and borrow or loan money for home mortgages which can’t be paid back.

I know you’re tired of hearing about government screw ups, but here are some outrageous government sponsored moral hazards I bet you haven’t heard about.  They all involve our health care system.

In 2005 it was discovered that in 14 states Medicaid was paying for Viagra for sex offenders.   In another example, in 1994 it was discovered that in many states Medicaid paid for infertility treatment for welfare mothers.

Wow!  That (fill in the blank) program didn’t work out as well as we thought it would!

Of course, bureaucrats and politicians were shocked, SHOCKED, to find that Medicaid was paying for Viagra for rapists and infertility treatment for welfare mothers.  But isn’t that the point?  Don’t these social engineering programs often cause negative, unintended consequences?

I’m having a crack attack, so give me my government check

Hospitalizations from cocaine abuse peak after checks are issued

Here’s another one.  In a study of veterans with schizophrenia published in the New England Journal of Medicine in 1994, researchers found that cocaine abuse and hospitalizations secondary to cocaine abuse increased at the beginning of each month when disability checks were issued, cashed and, presumably, used to buy cocaine.  In fact, cocaine abuse and cocaine-related hospitalizations decreased towards the end of the month but then began to increase again just before the first of each month when the checks are issued.  This suggests that drug dealers considered recipients of government checks good credit risks (”full faith and credit”).

Of course, members of Congress were shocked, SHOCKED, to discover this.  They promptly set about “fixing” a problem they created in the first place.  Doesn’t that remind you of OJ searching for the real killer or Barney Frank suddenly claiming to have a tight sphincter (which medical experts know, on the contrary, to be hard used, gaping and patulous) about finding the cause of the current financial meltdown?

In another study, using data from computerized death certificates for the entire US, researchers found that there were more deaths in the first week of the month from substance abuse.  Suicides, homicides, and deaths from accidents, all often related to substance abuse, were also more frequent in the first week of the month.  Of course, it’s impossible for this study to prove that drugs and alcohol bought with government money caused the increase in deaths at the beginning of each month.  But doesn’t it seem like an explanation worth considering?

Got our checks this morning.  Spanish Eddy was here an hour ago.  Gotta piece of the rock, things are very smooth now…

In fact, according to an article in the Los Angeles Times, government checks fuel the drug culture.  According to this report, “Mother’s day takes place early each month.  It’s the day when welfare checks arrive - a day when drug dealers know the extra money means more drug sales.”  (LA Times 7/8/99)

Is Uncle Sam failing upward?

Even though the federal government has wrecked our economy and almost everything else it has touched, many Americans want to let the feds work their magic on our health care system.  In fact, our government seems to be following that uniquely American trajectory, “failing upward.”  In Andrew Ferguson’s memorable essay “McNamara’s Brand,” failing upward refers to America’s curious tolerance, even friendliness, especially in politics, towards those who fail.

Where’s Bob McNamara when we need him to really louse things up?

Ferguson’s cardinal example of failing upward is the career of Robert McNamara, probably best remembered as President Lyndon Johnson’s Secretary of Defense during the Vietnam War.  McNamara consecutively screwed up the Ford Motor Company, the Vietnam War, and the World Bank, with promotions following each disaster.

Ferguson aptly depicts failing upward with the workaday example of the unbearable houseguest:

 Imagine a friend who comes to visit. The first night he cooks you dinner and sets fire to the kitchen. The next morning he accidentally electrocutes the cat. He blows his nose in the curtains and never flushes the toilet. He borrows your car and drives through the garage door, then spreads a rare contagion to your kids. By the third day you make the decision: You ask him to move in with you.

I’m tired of chewing my own food.  Can’t the government do it for me?

Many people seem to believe that no difficulty is too large or too small for the government to fix.  But isn’t it absurd to look to the government to solve our personal economic problems, end tyranny throughout the world, and heal the sick, to mention just a few unrealistic expectations?

Isn’t it time for some personal responsibility?

We once looked to our own personal resources, or to our religious communities and families to try to meet our needs.  With those institutions on the wane, many people seem to have developed utopian expectations of a flawed, often ineffective institution - government, which Thomas Paine described as “at best, a necessary evil, at worst, an intolerable one.”