Doctor Locutus of Borg

Google Glass will be like the Segway. It’s really cool but it will have only a few practical uses and won’t be a paradigm shifter. Segway never won widespread acceptance in a culture dominated by cars and Google Glass is unlikely to win over people who prefer to wear their smart phones on the waist instead of on their face.

Still, Google Glass may yet find some niche uses for people who need to use both of their upper extremities in their jobs . . like doctoring. But utilizing a glasses based computer to access medical references while treating patients is not going to go over well unless doctors learn to perform procedures and study at the same time. “Just hold this clamp in place across the aorta for five minutes while I brush up on my open heart surgery.” Yea, that’s not going to happen.

Neither will point of view video capture be of much use. The video documentation of procedures or exams for the clinical record has not yet been proven to be worth the effort and a point of view  recording is likely to be inferior to that of a fixed camera.  And how will patients react to having a doctor that looks like a family friendly version of Locutus of Borg record video of them while asking detailed questions about their bowel movements?

No, rather the best chance for a super-medical-Google-Glass-app will be as a new and novel way to enter information into an electronic medical record (EMR). Data entry has always been an Achilles heel for EMRs. Keyboard entry is slower than phone dictation or even hand written notes and point and click EMRs can have significant deficiencies when it comes to the ability to enter clinical details.

Then there is the problem with the various devices used for data entry. Most mobile devices that can port EMRs such as laptops are cumbersome and intrusive to use in an exam room during a patient encounter. This can be mitigated – somewhat – by shrinking the EMR devices into tablets or smart phones but the trade offs are that data entry becomes more difficult without a full sized keyboard and smaller screens usually mean less data that can be displayed at any one time.

However, devices like the prototype Google Glass have the potential to display a full sized (virtual) screen of information for the clinician user to quickly reference while appearing not to deviate his or her attention from the patient. Data entry using Google Glass could come in the form of a point and click (or blink) structure or one combined with real time dictation at the point of care. Quite literally, the physician of the future would use eye movements to review a patient’s prior records and switch between data entry fields while dictating the relevant information into each field as the clinical encounter progresses.

Though this won’t happen unless and until data entry is perfected for Google Glass type devices. A physician attempting to review their patients’ recent CAT scans on Google Glass can’t appear to be having a partial focal seizure or any semblance of confidence in the doctor wearing the funny glasses is going to be lost.

Rat Lungworm AKA Angiostrongylus cantonensis

A. cantonensis begins life as an egg laid in the pulmonary arteries of infected rats. After hatching, the first stage larva travel to the rat’s pharynx and are swallowed and exit the rat by way of its stool. These larva are then eaten by a slug or snail where they develop into a second stage and then finally into a third stage larva. The infected snail or slug is then eaten by a rat and the third stage larva travel to the rat’s brain and mature into adult nematodes. The adults then travel back to the rat pulmonary arteries to lay eggs and complete the circle of life.

Other animals including humans can become “incidental hosts” to A. cantonensis by accidental ingestion of the third stage larva. With the exception of the French, most people don’t eat snails or slugs however, the third stage A. cantonensis larva can be found in snail slime trails, small pieces of snails or slugs, and even the neonate forms of sails and slugs. These can be very difficult to see and easy to accidentally ingest. Infected sails and slugs can even contaminate water sources with larva for up to 72 hours after crawling into the water and drowning. Because contaminated food or water sources are impossible to detect, most people infected by A. cantonensis don’t know how it happened but it’s almost always a case of ingesting improperly prepared food such as fresh fruits and salads. Children who play in the dirt in tropical climates are also at risk because young children invariably will ingest some of what they are playing in.

Life and times of the Rat Lungworm

Just as with the rat host, A. cantonensis will travel to the central nervous system in infected incidental human hosts and cause an eosinophilic meningitis (the immune system’s response to a parasitic infection is the proliferation of white blood cell known as an eosinophil which can be detected on a lumbar puncture or spinal tap). Symptoms start anywhere from a few days up to a month after exposure most commonly with a severe frontal headache in 90% of patients. Additional symptoms include stiff neck, nausea, vomiting, fever, and in 75% of patients increased sensitivity and tingling (hyperesthesias and paraesthesias) of the skin of the trunk or extremities. Occasionally, infection can lead to partial paralysis of facial or other muscles but this usually resolves with time and in unusual cases, the larva can infect the eye and cause blurred vision without meningitis symptoms. Thankfully, mortality from A. cantonensis infection is as low as 0.5% of all infections. The larva rarely travel to the pulmonary arteries in humans since we are not the usual hosts and so transmission from human to human is not known to occur (with the theoretical exception of cannibals).

The diagnosis of “Rat Lungworm headache” (cerebral angiostrongyliasis) is almost always made by the clinical presentation and the finding of large numbers of eosinophils in the cerebrospinal fluid from a lumbar puncture (spinal tap). The actual larva are rarely detected and CAT scans and MRIs of the brain are usually non-specific or difficult to interpret. However, the body is almost always able to clear the infection and the treatment is mainly supportive and limited to pain control, occasional lumbar puncture for CSF removal to reduce pressure, and steroids.  The vast majority of patients recover completely though some can have hypersensitivity and/or tingling of parts of the skin on the trunk or extremities for several weeks.

So the good news is that despite the fact that this infection involves brain invading microscopic worms, rats, gigantic snails, infected slime trails, and bad fruit, it’s rare to see fatalities and cases of permanent neurological damage though an infection can really ruin your vacation. The take home point (THP) on this is that prevention is the best medicine. If you find yourself in a tropical area, make sure that your food, especially fresh fruits and vegetables are properly prepared by completely washing and cleaning prior to serving . . don’t play with giant African land snails . . and don’t eat the dirt.

To say that we are mired in stalemate seems the only realistic, if unsatisfactory conclusion . .  it is increasingly clear to this reporter that the only rational way out then will be to negotiate, not as victors, but as an honorable people who lived up to their pledge to defend democracy, and did the best they could.

On March 26th, conservative stalwart Bill O’Reilly appeared to end his nonchalant pseudo-libertarian stance on the issue of gay marriage and actually endorsed a rational and secular argument for the legalization of gay marriage.

The compelling argument is on the side of homosexuals.  That’s where the compelling argument is.  We’re Americans. We just want to be treated like everybody else. That’s a compelling argument, and to deny that, you have got to have a very strong argument on the other side. The argument on the other side hasn’t been able to do anything but thump the Bible.

Like the end of the war in Vietnam, the complete legalization of and acceptance of the reality of gay marriage will take several more years but beginning with O’Reilly’s capitulation it’s now more of a forgone conclusion than ever.

People have been predicting the end of the world since . . . . the beginning of the world. And how do these privileged few come by this precious information? Well, no one really bothers to ask this obvious question. Prophets get a pass on this little detail while all the focus is put on the predictions. The ability to portend future events is just accepted as a priori. Yet, there are only a limited number of possible mechanisms for predicting the future and none of them make any sense.

The most common way to obtain the knowledge of future events is the metaphysical route, i.e. via a divine message from one or more deities. This is a popular method used by many people in many religions to rally converts and the faithful and to indirectly “prove” the existence of their God or Gods by predicting the end of the world. It’s certainly an effective recruiting method though a rather curious one. It’s like getting a gym membership right before it goes out of business. Regardless, a metaphysical mechanism for prophecy is not provable but the real world results are measurable and so far these end of times prophets have an exactly 100% failure rate.

The next plausible method of predicting the future is the “Weather Service” method. It’s not really prophecy per se since it’s a utilization of scientific mechanisms to analyze repeatable patterns in the past to predict the future. The Maya certainly were accomplished astronomers so what if the they discovered something that we don’t yet know about? What if they discovered an asteroid or other object in the solar system and by careful observations have calculated exactly when it would impact the Earth and based their calendar on this date? What if it’s a near Earth object that has not yet been detected by modern astronomers? This is certainly not impossible. But there are two major problems with this theory.

The first is that despite being very advanced mathematicians for their day, there is no evidence that the Maya were able to perform the kind of complex orbital mechanics calculations that would be required to predict an impact hundreds of years into the future. But let’s assume that they were able to perform incredible calculations without the use of a computer or other automatic counting machine. They still could not get around the principle of Chaos Theory. This mathematical theory states that it is not possible to exactly predict outcomes in dynamic complex systems – such as the orbital motions of everything in our solar system. Patterns can be predicted but not the exact movements of individual elements within a complex system. Predicting a cataclysmic event on a specific day hundreds of years into the future is like the Weather Service being able to predict the course of a single snowflake in a single snowstorm for the next winter. Even with a supercomputer it is impossible. There are simply too many variables.

The only remaining possibility of gaining knowledge about future lottery numbers and such involves time travel. This does not even need to include people or objects being  moved through time and space. It only needs to involve the transmission of information – in any form – from the future to the past. In fact, the essence of any prophecy is the transfer of information from the future to the past. This can be initiated at either end of a time continuum; from the past to future to retrieve information or from the future to past to send information.

However, time travel requires far more power and technological complexity than that provided by a Delorean or a hot tub. Almost all plausible proposed mechanisms for time travel into the past involve massive amounts of energy in order to warp space time to create a wormhole and allow the travel of people, objects, telephone booths, or information from the future to the past. The amounts of energy involved are massive and far beyond the ability of our current civilization to produce let alone the Maya. What about the reverse? What if advanced aliens or humans from a distant future – who somehow survived December 21th 2012 – sent back information to the Maya so that they could build their calendar? This is a logical assumption given the Mayan inability to build a real Delorean much less to develop a device to warp time and space.

If course this begs the question, why would future information about the end of the world only be sent to the Maya ? They were not the most advanced civilization at that time or in the history of the planet. Why provide them with no other specifics then the date? Why provide them with no other information such as the inevitable collapse of their own civilization? What’s the point in not providing specific information that could be of some survival benefit? Was the date for the end of the world the only part of the temporal email that survived the transmission to the Maya? These lapses in logic don’t seem to be actions that would come from a super advanced civilization that is capable of time travel.

But speculating about the incompetence of super future civilizations to warn ancient humans about the end of the world is moot since time travel to the past is likely to be impossible. Granted, no specific physics theory absolutely prohibits retro time travel but there has never been a plausible theory postulated with any sort of proof that gets around the problem of  a causation paradox that is introduced in travel to the past. That is, transmission of any information to the past will change the timeline that could prevent the future transmission of the information in the first place.  Take the famous grandfather paradox of time travel and apply it to the transmission of information. What if I send a message to an assassin in the past with instructions to kill my grandfather. If the task is completed then I would never have been born and could not have sent any message back to instruct the assassin to kill my grandfather. Hence, the paradox.

There are theories proposed that try to get around the causation paradox including the possibility of a multiverse in which an infinite number of universes and time lines exist so that changes in the past spawn new time lines that are different from the one where the information was sent to the past. However, this is so hypothetical that there is no proof of a multiverse and speculation that travel or communication between multiverses would not be possible. So future time travelers would never see the results of any information being sent into the past. So what’s the point?

What about using postselection in quantum entanglement? Without going into the technical details, this seems to imply that changes in particle quantum states in the future can change the states of particles in the past. However, this requires assumptions about the linear or non-linear nature of quantum mechanics and requires quantum entanglement of particles which itself requires part of the time travel mechanism to already exist in the past. No such device existed at the time of the Maya. The fact that we do not yet have the technology to create a time machine may help explain why we are not constantly visited by time travelers and messages from the future . . if travel into the past is possible.

Precognition is one of those abilities that everyone takes at face value without requiring any more of an explanation then that of a “gut feeling”. But as we have seen, the acquisition of future knowledge of exacting detail (such as a specific date) is a massively impressive feat. It is far more plausible for me to claim to be able to read minds, move objects through telekinesis, or sit through an entire episode of Gray’s Anatomy without nausea than it is for me to be able to predict the future. So the next time someone claims to be able to predict the future or references a prophecy or the predictions from the past, pepper him or her with questions about how this is supposed be to done and watch them quickly change the subject  . . . . or un-friend you from Facebook.

• Substance Abuse: Conservatives loved to call President Bill Clinton a “pot smoking hippie” back in the 1990s and loved his ridiculous remark about not inhaling. This was followed by President G. W. Bush who was arrested for DWI in 1976, admitted to problems with alcohol abuse, and who was widely believed to have used cocaine back in his youth.

• Draft “Dodging”: Clinton was called a “draft dodger“in-part by enrolling, but not joining, the Army Reserve Officer Training Corps (ROTC) while in College in the late 60s. But while Clinton received a high draft number (luck) and a Rhodes scholarship to Oxford (talent), George Bush served in the Texas Air National Guard – a position he garnered as a result of his families political connections – and Mitt Romney received a deferment in 1966 to go perform missionary work for the Mormon Church in the deepest darkest jungles of . . . Paris France.

• War Hero: While Bush was struggling to show up for his training duties in the national guard, future Senator John Kerry was getting shot at in Vietnam after volunteering to serve and being injured three times. Kerry was famously vilified by the Swift boat organization that disputed or tried to minimize every aspect of Kerry’s combat service but couldn’t get around the fact that Kerry went to Vietnam and Bush didn’t.

• Flip-Flopping: John Kerry was attacked by Republicans as a “flip flopper” for changing his mind on several issues that he originally voted for. However, Mitt Romney took flip-flopping to a whole new level in reversing positions on such core political beliefs as abortion, gay rights, gun control, and — most amazing of all – after signing into law one of the most far-reaching health care reform laws in the country in 2006,  he came out against “Obamacare” – a very similar though less inclusive reform measure.

• Religion: President Obama is often accused of being a “Muslim” which is apparently a derogatory comment in the conservative lexicon. Mitt Romney is a member of the Church of Latter Day Saints that actively and officially discriminated against African-Americans until 1978.

• Birthplace: There is no end to the number of conservatives who claim that Barack Obama was born in Kenya but few conservatives questioned whether or not the fact that John McCain was born on a US military base in the Panama Canal Zone meets the constitutional requirement of “Natural-born”.

The obvious patterns of attacking and magnifying various “faults” in Democratic presidential candidates and then nominating a GOP candidate with the same or worse “faults” should give us a very accurate idea of what the next Republican presidential candidate will be like.

In 2016 look for the GOP nominee to be a converted Muslim, former Communist and ACLU member, who was openly gay and militantly pro-choice but who now claims to be an ultra conservative who denounces gay rights and believes in “guns for all and abortions for no one” while claiming that his father’s private jet accidentally flew him to Canada in 1967 instead of to a local recruiting office to volunteer for duty where he was awarded a Purple Heart for a severe paper cut he received while mailing letters in support of the war effort, and who’s only copy of his US birth certificate was destroyed by a mysterious meth lab fire while he was residing at his families ancestral home in the south of France where he was studying English as a second language.

This was the norm as long as the practice of medicine was strictly local . . . . say, 30 or more years ago.  However, technology has advanced to the point where medical professionals can consult, monitor, diagnose, and even perform surgery remotely limited only by technology and not distance. Additionally, an aging and growing population combined with reimbursement inequalities and inadequate medical school planning has worsened physician shortages in multiple areas especially when it comes to primary care.  Physicians need to be far more mobile in order to meet these demands in a timely manner.

Currently the main hindrance to getting medical care to where it is needed is the often byzantine nature of individual state licensing agencies. Texas is one of the biggest offenders in this regard. Despite having one of the worst doctor-patient ratios in the nation, it can take as long as 6-8 months to get a medical license in Texas. The state is notorious among new medical graduates and other physicians for its expensive and lengthy licensing process.

No other credentialing in the long road to becoming a physician is dependent upon individualized state bureaucracies.  Diplomas from accredited medical schools and residency programs – as long as they are within the United States – are accepted across state lines. Board certification is national and does not need to be taken in the same state where the doctor is practicing. Even the actual medical licensing test series (USMLE) that every doctor in training much take and pass to be eligible for state licensing is not state dependent.

Currently the National Council of State Boards of Nursing (NCSBN) has organized to standardize the process so that these licenses are accepted in 24 of 50 states. A nurse licensed in one of the member states can go to another member state to work without having to go through another licensing process. Obviously, a severe shortage of nurses in certain areas has lead to this common sense approach but so far, the national Federation of State Medical Boards has not shown the same initiative.

State medical boards serve a dual purpose. Not only do they license physicians but they also are tasked with investigating complaints and disciplining physicians.  The second part must be individualized for each complaint but licensing is a process of specific requirements that can be standardized. In the same way, a drivers license in one state allows you to drive in any other state but traffic violations are investigated and punished locally.

The national Federation of State Medical Boards needs to push for the standardization of medical licensing and legislation in each state to allow US licensed physicians to practice across state lines. Otherwise, the Federal government may need to step in and mandate that each state that participates in Medicare and Medicaid needs to pass legislation to accept medical licenses from other states.

The obvious advantage of this is to allow parents to bypass an initial or follow up visit to a crowded pediatrics office by sending in iPhone photos instead. This seems great if you’re a busy helicopter parent. This seems like a potential problem if you’re a pediatrician.

Like other primary care doctors, pediatricians get paid only per visit and per procedure. Reimbursement for tele-medicine (reviewing pictures of infected ears) is likely to be far lower than an in office visit. This could both reduce the overall income and increase the workload for a pediatrician who sees fewer patients but has to review dozens of ear pictures every day.

One also has to worry about the potential for an increased number of injuries from perforated ear drums caused by aggressive parents who’s level of competence means that they should not be sticking anything in their child’s ears. Though use of this device may have the potential to lower rates of unnecessary antibiotic use for viral ear infections since parents may feel less entitled to a prescription if all they did was send in a picture as opposed to waiting for hours in a crowed office for a two minute visit.

• “There is no well established common-law rule that a physician owes a duty to warn or advise a patient for the benefit of another person.”

• The accident was not foreseeable since Dr. Troncale had no reason to suspect that his patient’s ability to drive was impaired or could be impaired (the patient had not passed out before) or that the victim was known or could have been known beforehand.

• It is unfair to hold a physician liable for not warning their patient against driving because it is not possible to predict whether or not the patient would have followed this advice. “The plaintiff assumes that a patient who has been warned will discontinue driving without recognizing that not all patients will necessarily follow their physician’s advice.”

• People injured by negligent drivers have access to compensation from the driver or the driver’s liability insurance. The costs of any potential gaps in compensation would be far exceeded by the expense in increased malpractice premiums and additional litigation that would result from expanding liability to the physicians of negligent drivers.

• The physician’s duty to the patient is “explicitly relational” . . and as such the physician should have “undivided loyalty” to the patient.  Extending their liability to include third parties would divide a physician’s duty between the patient and a third party which could result in conflicting duties and cause a degradation of their loyalty to their patient.

• Confidentiality in the doctor-patient relationship is critical to maintaining good communication between both. Extending liability to third parties would require making public the medical records of a patient in order to serve the litigation needs of a third party. This would degrade the sense of confidentiality in this relationship and impair communication.

• The public’s safety is not the same as the patient’s safety and this can lead to conflicting duties. Most medical conditions present and progress gradually while many sudden conditions are unpredictable. As such, a physician’s decision on whether or not to restrict the patient from driving must be individualized since unnecessary or aggressive limits on a patient’s lifestyle can have negative repercussions on their quality of life such as their independence via their ability to drive.  However, public safety considerations cannot be individualized and would require much more aggressive and earlier restrictions on a patient’s lifestyle due to the possibility, however small, of an adverse event. This would not be practical from a doctor-patient perspective since it could potentially include almost any medical condition. The resulting frequent and common warnings to patients would impair the doctor-patient relationship by desensitizing a patient to the warnings of their doctor and impair their ability to discern the difference between advice and warnings that are warranted and warnings given mostly for liability reasons.

• The alleged failure to warn in this case applies only to the underlying medical condition and not to the potential effects of prescribed medications or other treatments. A physician’s duty to warn the patient of the effects of medications and treatment is well established law under informed consent and does not automatically apply to the often vague nature of and possibly unpredictable course of a specific medical condition. Exceptions include epilepsy or narcolepsy where sudden and unpredictable impairment is a hallmark of the disease or an infection which could be  unknowingly transmitted to a third party. But again, each case must be individualized and the presence of one of these conditions does not mean that liability is extended to a third party.

• Allowing for the possibility of intrusion by investigators, litigators, courts, and jurors into what is supposed to be a closed and confidential relationship without the consent of either the doctor or the patient would be a massive breach of the legal protections of this arrangement.

I agree with the court’s assertion that most medical conditions by themselves do not automatically imply an impairment or the significant potential for an impairment. Hepatic encephalopathy associated with liver cirrhosis almost always presents as a gradual clouding of thought processes. It is very unlikely that the patient’s known conditions would have resulted in a sudden loss of consciousness without any preceding symptoms though I was unable to find any information on what was believed to have caused this patient to black out.

It’s not clear why Mr. Jarmie sued Dr. Troncale. Maybe the patient didn’t have auto insurance. But it’s more likely this was a case of trying to grab more in compensation by attempting to extend the concept of liability. Let’s face it. Americans sue other Americans for anything and everything and expect the maximum in compensation for every perceived injustice. The only reason not to sue is the inability to collect. This is the only reason Americans don’t sue God . . . . or Santa Claus.

Admittedly this sort of case is uncommon. But the ruling is still important in placing limits on liability by association. One action can have a series of consequence like “ripples in a pond” as the majority opinion put it. A driver passes out and hits a pedestrian transporting a critical drug to a nearby hospital resulting in the death of a seriously ill patient who was a key employee resulting in the failure of a company and the loss of hundreds of jobs and pensions and on and on ad nauseum. Where does the madness end? After all, only six degrees (or 4.74) separate everyone from everybody else.

One of the more common treatments for back pain is the injection of a steroid formulation into the space between the outer membrane covering the spinal cord – the dura – and the spinal bones. The pain relief theory behind these epidural injections is that back pain is caused by localized inflammation involving spinal nerve roots, spinal disks, or other structural components of the spine as a result of protruding disks or degenerative changes.  The corticosteroids  in these injections are supposed to reduce this inflammation and thus reduce the pain.

One source estimates that almost 9 million epidural injections were given in 2010. The use of this treatment in Medicare beneficiaries alone increased 160% from 2000 to 2010 and the cost is not insignificant.

Medicare and Medicaid guidelines call for paying between $200 and $600 per injection, depending on whether it is given in a doctor’s office, an outpatient facility or a hospital. The Centers for Medicare and Medicaid Services said it paid providers $106.4 million for 252,288 injections last year, an average of $421.74 each.

And this cost is for the injections alone. It does not even include the price of complex spinal imaging such as MRI scans and initial and follow up office visits associated with this type of care.

What’s even more surprising is that the data for the long term effectiveness of epidural steroid injections for the treatment of chronic lower back pain – the most common type of back pain – is not very good. According to the American Society of Interventional Pain Physicians (ASIPP) and the North American Spine Society (NASS), the evidence that epidural spinal injections provide effective relief of chronic lower back pain beyond 6-12 weeks is limited to poor. The Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology found similar results as well as no evidence that these injections result in improved functional ability or that they change the eventual need for back surgery and as such they recommend against the routine use of epidural steroid injections for the treatment of chronic lower back pain.

Because of the theoretical risk of infection and adverse effects of the steroids, the current standard of care is to limit the use of these injections to three or less per year. Given their limited effectiveness in the long term relief from chronic back pain and the fact that these injections have not been shown to reduce the long term use of chronic pain medications, they do not seem to be a particularly reasonably therapy choice.

Yet, despite a dearth of evidence for their effectiveness physicians continue to utilize this treatment in ever increasing numbers including for patients in whom they are not indicated. The best evidence for the limited effectiveness of epidural spinal injections is for use in patients who suffer from radicular pain (back pain that spreads down the back of one leg) from a protruding spinal disk but an audit of 433 injections of Medicare patients from 2007 found that a third didn’t meet Medicare requirements including medical necessity or sufficient documentation.

Physicians certainly would not regularly utilize a very expensive antibiotic that has been proven to be only marginally effective on long term cure rates. But unlike serious bacterial infections, chronic pain is a purely subjective symptom that is difficult to measure and does not directly result in death. As such, physicians who treat chronic pain are given a wide leeway for their treatments, free from the constraints of evidence based medicine and oversight of appropriate resource utilization.

Epidural steroid injection treatments also benefit from the dysfunctional method in which Medicare reimbursements are heavily skewed towards invasive treatments without regard for effectiveness or outcomes. In our current system, physicians get paid far more for an invasive procedure than they do for managing a complex condition with medications and conservative therapy. A logical system for the treatment of chronic pain would be a pyramid construct where the vast majority of patients are treated conservatively while steroid injections and surgery would be at the very apex for rare and/or extreme cases. But our system is more like a cylinder where patients are just as likely to get conservative treatment as to get more advanced and invasive therapy.

Part of the problem involves patients with chronic pain. Americans in particular tend to prefer invasive treatments under the belief that since surgery and other invasive procedures for many conditions such as gall bladder or heart disease is very effective then the same logic must apply to the treatment of chronic pain. But it doesn’t. Conservative treatment such as  a guided physical therapy program has been shown to be effective for the long term reduction in chronic back pain. But because of the prevalence of advanced imaging and invasive therapy, physical therapy is probably drastically under-utilized as a treatment for this condition.

Another part of the problem is that we really don’t understand what causes chronic pain and how to treat it. Obviously the poor effectiveness of steroid injections means that chronic back pain is not as simple as localized inflammation affecting pain fibers in the spinal cord and nerve roots. As a purely subjective symptom, pain is highly susceptible to modulation. For example, take someone with chronic lower back pain and drop a brick on their foot. Suddenly they don’t have back pain anymore. Most of us have experienced this phenomena. The trick is to find out how to modulate chronic pain without the use of addictive medications or broken feet.

Invasive procedures also carry the risk of complications and adverse outcomes. Recently a contaminated batch of an estimated 17,676 vials of the steroid methylprednisolone acetate used for epidural injections resulted in at least 91 cases of fungal meningitis and several deaths. Though the complication rate of  steroid injections is low and the risk of a contaminated vial is exceedingly rare, that anyone would die as a result of an invasive treatment that is not very effective for it’s intended purpose is a tragedy.  Maybe the increased attention and scrutiny of epidural steroid injections brought about by this outbreak will lead to policy and funding changes in the way we reimburse for and treat chronic back pain in this country.

Rationing is inevitable whenever the government controls medical spending. He who pays the piper calls the tune. Under ObamaCare, government control of health spending will quickly expand to affect most Americans, not only the elderly.

Note that we don’t debate how to ration cellphones. That’s because our relatively free market has driven cellphone prices so low that even many of the poorest Americans can afford one.

This is not a coronary artery bypass graft.

Of course health care is not the same as a cell phone and neither is an apple the same thing as an orange. Health care is a huge and complex industry with a vast array of both services and products. Cell phones and cellular services are relatively straight forward consumer products that are easily subject to such free market principles as standardization,  mass production, and economies of scale in order to control costs.

Other then food and water almost all consumer products and services are not dictated by biological need. Health care is not one of them. At some point in their lives almost everyone will seek out relief from physical pain and suffering. Despite what most teenagers will claim, it is biologically possible to live without a cell phone regardless of your economic station.

And rationing does occur at the consumer level. Notwithstanding the relative low cost of a cellular phones, up to 25-30 million Americans do not own one – interestingly similar to the number who lack health insurance – likely mostly because of the expense of the phone and cellular service.  Additionally and unlike almost all of health care, most consumer products scale based on quality and cost. Consumers “ration” their purchases based on what type and what quality of goods and services they can afford. Largely this does not happen with health care. Patients do not chose the cheaper and less effective antibiotic to treat a serious bacterial infection. Patients who are uninsured simply put off seeking out any type of medical services until they cannot survive without them.

One cannot simply claim that free market principles should work for health care in the same way they work for cell phones. Unlike almost all consumer products the vast number of health care goods and services are paid for by a third party – either the government or private insurance through an employer. The vast number of both patients as well as medical providers are unaware of the actual costs associated with health care. This lack of  cost transparency is antithetical to the very principles of a free market. It’s like claiming that democracy can exist without direct representation.

Additionally, Dr. Hsieh inadvertently provided an example of another quirk of the third party payer system. Patients who have the costs of their basic medical needs covered will often pay out-of-pocket for extraneous and often unnecessary medical services. Being a radiologist it’s not surprising that Dr. Hsieh chose calcium scoring CAT scans of the heart as an example of the free market in health care.

The free market can also work in health care. Many patients can now purchase “calcium scoring” heart scans, which measure how much calcium is deposited in the coronary arteries. These scans are one of the safest and most reliable ways to measure one’s risk of future heart attack.

Calcium scoring scans do not require a doctor’s order and are not typically covered by insurance. Because patients generally pay out of pocket, motivated consumers shop around. Normal market forces have thus driven down their price dramatically. Several years ago, these scans cost $500; now some centers offer them for under $100. This pattern of rising quality and falling prices can and should be the norm in all of health care.

These scans use Xrays to detect the amount of calcium in the coronary arteries surrounding the heart. They are used to predict the risk of a heart attack in patients who have not yet had any symptoms. However, these scans have never been proven to change outcomes even in patients who start treatment based on the findings. One randomized  placebo controlled study found that cholesterol lowering medication use did not result in a decreased calcium score or a lower risk of heart attack in patients with an initial high calcium score. A high calcium score has not even been shown to influence patients to make appropriate lifestyle changes (like smoking cessation) to reduce their risk of a heart attack. In short, a calcium heart scan is a useless test since it has not been shown to change anything.  This is why it is not typically covered by insurance.

In much the same way that food stamp beneficiaries will use the money they save from not having to pay for basic nutrition to buy cigarets and alcohol, patients with government health insurance often pay cash for things like Botox injections and other medically unnecessary services. To say that the free market works in these circumstances and can be applied to the rest of the health care industry is a ruse. There is no evidence that patients utilize free market principles when faced with a severe or emergent health condition or the recommendations of their physicians enough to lower overall costs through competition while remaining within a third party payer system.

Dr. Hsieh didn’t even bother to prove that the lower cost of the calcium heart scans was due to competition strictly for these scans. It may have been that these imaging centers were offering these low cost scans as a lure to get patients to bring in their repeat business that usually includes medically indicated, insurance covered, and much better paying scans. Sure, there was competition and price lowering but not for the reasons that Dr. Hsieh claims.

It is not logical to describe the behavior of an animal in a zoo as typical of what it would do in the wild just because it’s the same animal. As such, it is not logical do expect that the economic behavior of individual patients within a third party payer health care system would be the same as individual consumers of products in a free market system just because they are the same individual.

To sum it up. A cell phone is not the same as a coronary artery bypass graft.