Americans invented the idea of  “McDonaldization” in which consumer services are standardized to be efficient, predictable, and controllable.  When we want something, we want it now!  We want to be able to understand it, predict it, and control it.  However, healthcare isn’t a service that’s amendable to McDonaldization.  Cooking and serving up fast food has a relative small number of variables that can easily be controlled and predicted such as the size of the hamburger patty and the heat and time required to cook it. The diagnosis and treatment of human illness has literally hundreds of millions of variables to deal with. This is why medical care is not anywhere near as “convenient” as fast food.

But the folks at X-prize want to change this.  Their solution is to open a competition for inventors to develop a Star Trek style “tricorder” to detect and diagnose disease just as the fictional medical tricorder was used in the science fiction series. What is the specific problem to their tricorder solution? According to their promotional video, consumers are faced with a paradox.  From the video;

You want to know what’s wrong. Is this normal?  Is this urgent?  Do I need to see a doctor? But, today, the only way to know if you need to see a doctor is . . . to see a doctor. And that’s not fast, not convenient, not easy. So you wait . . .

The average time to get an appointment is 21 days. The average visit to the doctor takes nearly 2 hours.  Cause you’ve got nothing better to do, right? And then you only receive the right diagnosis or treatment 55% of the time.

Correct. Medical care is nether efficient, convenient, predictable, or controllable and this drives Americans crazy. Part of the reason is the massive complexity of human disease. Part of the reason is how our health care system is organized with way too much emphasis on advanced medical care and procedures and too little emphasis on health care access, primary care, and prevention.

The X-prize foundation’s approach to this problem is to empower consumers and patients with a quick and easy home or outpatient mobile  device to provide real time data on critical health metrics such as vital signs to accurately diagnose disease.  The requirements appear to be only that the device is mobile and be able to accurately diagnose a set of 15 diseases. There is no information on what these “diseases” would be.  The device should also be able to give information to the patient as to whether everything is “OK” or not.

The push to develop a more patient friendly health monitoring device is certainly laudable.  However, it’s not likely that such a device will work in the way that they intend it to. The problem won’t necessarily be with limitations in technology. The problem will be in how we interpret and act on information. The limitations and complexities of the diagnostic and treatment process is something that doctors have to deal with every day. Doctors take a limited set of data and formulate what they believe is the best diagnostic and therapeutic course of action that is uniquely tailored to each patient and each  situation.  They take into account not only the data but their training, experiences, statistical probabilities, and “educated guessing”. This is why medicine is still an art.

And data is not the end point of the diagnostic process. Each abnormal data point could have multiple meanings depending on what you are looking for (the pre-test probability) and the statistical likelihood of disease in your particular population. For example, an elevated blood pressure could mean that you have hypertension or it could mean that you are anxious or because of medications or because of renal artery stenosis. A high heart rate could mean anxiety or a pulmonary embolism. Abnormal laboratory results have the same problem. A low sodium level could be caused by anxiety or a brain tumor. Anemia could be caused by a poor diet or colon cancer. Even imaging is tricky. A mass seen on an XRay or CAT scan could be benign or malignant. There is even the fixed and known possibility of false positives and false negatives for each test that has nothing to do with error or technical variability. Detecting abnormalities is easy. It’s the interpretation that is hard. To say with confidence that your device will be able to diagnose a specific disease with “accuracy” is dangerous thinking.

And who or what will interpret the data for the tricorder user? A computer algorithm can be used but is likely to come up with a diagnostic differential list that may not be accurate and will certainly not be exhaustive. This is because the initial evaluation of a patient is often followed up by more advanced evaluation and it is currently not possible to put every diagnostic modality (Xray, CT scan, PET scan, nuclear imaging, EKG, EEG, biopsy, stress testing, and exploratory surgery) into a mobile phone. Maybe in the far future we will develop a “universal” diagnostic device that includes everything but this is not one of the stated goals of this X-prize.

Even worse than diagnostic uncertainty is the false sense of security that could be provided by normal data in the setting or real disease (i.e. a false negative). The FAQ page from the X-prize foundation states that the tricorder should be able to “give confirmation that everything is ok with a consumer and notify that something is not ok (a “check engine light”)“. This approach is simplistic and absurd to the extreme. Show me a person with completely normal vital signs and blood tests and I’ll show you a patient who is has undiagnosed HIV or a smoker who has a malignant growth in their lung. The danger is that whatever limited data this device does provide will, if normal, give consumers a false sense of security and lead them to cancel that trip to the doctor.

The biggest problem is that such a device is either not required for it’s intended purpose or won’t make any difference in outcomes. Will it really be able to help people make a decision on whether or not to see a doctor or go to an ER? True medical emergencies almost never present subtlety. Ironically, PAIN is one of the biggest indicators that something is seriously wrong and the measurement of pain is not something that can currently be directly done by a tricorder or any other device.  Bleeding, passing out, shortness of breath, vomiting, decreased consciousness; patients rarely have a problem knowing when something is seriously wrong because their bodies do a much better job than any tricorder could do in letting them know. And when should you go to see a doctor in an non-emergent setting? The best way is to use a simple rule of thumb. If you have to consider it then likely you should go. And as far as prevention, do we really need a device to tell us to stop smoking, loose weight, and get some exercise?

There yet may be some uses for such a device. More frequent monitoring of metrics like blood pressure and blood glucose levels in the outpatient setting may, if accurate, help doctors to better control such chronic conditions as hypertension and diabetes and better control can lead to better outcomes. Cheaper and mobile medical devices would help health care workers enormously in areas of the world that are remote and/or lack access to modern medical care.

But to develop a device with the stated goal of “empowering” consumers in their health care decisions by helping them know when they can avoid the inconvenience of having to see a doctor is amazingly shortsighted and ridiculous. And it’s potentially dangerous by giving people a false sense of security that they do not need to see a doctor.

I foresee one main outcome of the development of this tricorder. The typical civilian users of such a device are likely to be suburban, middle aged, relatively healthy and health obsessed. These are the types of patients that doctors in affluent areas dread. These patients Google the differential diagnosis for every single symptom or strange noise coming from their bodies and make frequent trips to their doctor with pages of printouts about their “condition”.  Congratulations X-prize! You’ve begun the process to develop the most important enabler for hypochondriacs that the world has ever known.

Once upon a time, video pirates were limited to taping movies off cable and selling the tapes to their friends. But this didn’t put a dent in Hollywood’s ability to make and profit enormously from crappy movies. Then came the internet (or the internets for those of you in Texas) and people could easily share digitized copies of music and more crappy movies. Then came the Digital Millennium Copyright Act of 1998 (DMCA) that brought copyright protection into the digital domain to outlaw the intentional sharing of copyrighted material.  But the problem with the DMCA was that it was ineffective outside of US court jurisdiction.  Other than war, how does a greedy media mogul prevent foreign internet sites from providing illegal downloads to Americans? Answer; make US internet service providers (ISPs) liable and responsible for blocking access to these illegal sites. Enter the Stop Online Piracy Act.

The SOPA would allow media companies (or any owner of copyrighted material) to ask the US Attorney General to demand that American ISPs directly block access to any foreign web site that is believed to be violating US copyright law. But that’s not all! The bill allows the Justice Department to seek to prevent internet search engines (Google, Bing) from listing the offending site and stop US internet advertizing companies and internet pay services like PayPal from doing business with the offending site. Additionally, internet companies  that take the initiative and block access to a foreign web site that they believe violates US copyright law would be immune from litigation. Much has been written about this pile of dung pending legislation but I would like to add a few NON-lawyer observations.

1. SOPA appears to circumvent the 5th and 14th Amendment guarantees of Due Process. All it takes for the US AG to order a web site blocked is to obtain a court order. The order remains in effect indefinitely. There does not appear to be any provisions in the act to  allow for a hearing or trial to give the offending site and/or the ISP a chance to present their case even if the “foreign” site is owned by a US company.
2. The lack of Due Process makes it more likely that SOPA could be used to restrict free speech by a person or organization seeking to abuse the law.
3. Lack of Due Process misplaces the burden of proof. Any involved party can  petition the court to overturn the order but since the initial order remains in effect indefinitely the burden of proof is placed on the accused (the ISP or other domestic internet company).  This is exactly the opposite of our innocent until proven (by the government)  guilty legal traditions.
4. SOPA is a huge departure from current law that limits the liability of  Internet Service Providers for the activities of their customers. Under DMCA, providers are liable for copyright law violations only if they directly participate  in or directly benefit from illegal activity.  Simply providing internet access that MIGHT be used to download pirated music is not in itself illegal. This is consistent with existing law that does not require telecommunication companies to verify that their products are being used only for legal purposes.
5. SOPA places the burden of monitoring and preventing international digital copyright violations on the internet service providers instead of with law enforcement and foreign governments.  Cell phone companies are not required to monitor nor guarantee that pre-paid cell phone are being used for family friendly activities.  Lawmakers need to learn to differentiate between the illegal act and the medium that made such an act possible.
6. Immunity from litigation for blocking web sites is a legal mess waiting to happen.  What is to prevent a US internet service provider from blocking a “foreign” web site that is actually owned by a US company and direct competitor of the ISP in question? Does Congress really want to dole out liability protection and the power to block web sites to ISPs?
7. SOPA does not make any exceptions for non-profit sites, archives, educational sites, etc.
8. SOPA will not be effective if utilized as intended. Piracy sites and services are notorious for finding technical ways around censorship. The technology neophytes who wrote this legislation seem to be blissfully unaware of the dynamic nature of the internet. Pirate web sites are not like illegal bordellos that can be raided and shut down.  New DNS addresses and servers can be set up and the new address disseminated online via social networks in a fraction of the time it takes for a court to issue an order.  A more likely scenario is for a game of “cat and mouse” to be played out over weeks to months as pirate sites stay several steps ahead of the Justice Department.
9. A SOPA that does not work as intended could lead to an actual American firewall. If trying to block access to individual addresses only leads a futile cat and mouse chase across the internet, the Justice Department may decide to broaden its court order to the blocking of entire foreign ISPs, networks, or even entire countries. This is not a slippery slope. This is a realistic technical solution and logical end-point for a law that aims to prevent the illegal sharing of copyrighted material. There is nothing in SOPA to prevent this from happening.
10. Is SOPA really needed? There is no hard evidence that illegal file sharing has had any large or lasting impact on the legal sales of nor the production of  intellectual material. If the Justice Department were able to successfully block every single global illegal file sharing site, would it really result in any significant additional revenue for the entertainment industry? Is it worth the potential chaos, abuse, and damage to the freedom of the internet just to secure a few million more in income for an entertainment industry that is in no danger of becoming extinct anytime soon?

Congresses’ repeated attempts to focus more attention on preventing illegal downloads of such American classics as Freddy Got Fingered than they do in passing laws to prevent internet censorship and guarantee internet access is more than a clear indication that our representatives are by-and-large older white men who don’t known how to use a computer, think that the internet is literally a system of tubes, believe that freedom and commerce can be protected by restricting it, and frequently get calls and visits from a nice gentleman who works for the MPAA or the RIAA and would like to treat them to a little lunch or a round of golf in Tahiti.

Please write your Congress-person or Senator. Also, let the sponsor of SOPA, Rep. Lamar Smith (R-TX), know what you think of him and his bill.

It’s stunning to think about the national debt in these terms.  What’s even more stunning is how brazenly both parties, liberals, and conservatives are willing to risk long term economic security to feed their own ideological interests.  A case in point is the NYT’s Paul Krugman who dismisses any short or long term concerns about the US debt with a fanciful wave of his a priori wand. What is Dr. Krugman’s calming tonic in the face of a 15 Trillion dollar IOU? Basically, he implies that the debt doesn’t matter as long as you can raise taxes and interest rates remain low.

Deficit-worriers portray a future in which we’re impoverished by the need to pay back money we’ve been borrowing. They see America as being like a family that took out too large a mortgage, and will have a hard time making the monthly payments . .

First, families have to pay back their debt. Governments don’t — all they need to do is ensure that debt grows more slowly than their tax base. The debt from World War II was never repaid; it just became increasingly irrelevant as the U.S. economy grew, and with it the income subject to taxation.

So as long as we have rich Americans from which the US government can feed from then we will be OK. After all, the top 5% of income earners pay 60% of the US income tax even though their income is 35% of all personal income. For liberals, as long as we can raise taxes, we can continue deficit spending ad nauseum.  For conservatives, it’s even worse. The mantra appears to be deficit spending with low taxes now (trickle down) and to hell with the future.

Of course, Krugman is correct . . . .  about the present. The enormous US debt does not pose a serious short term threat to the stability of the US economy or economic recovery.  Given the sheer size of the US economy, there is no credible risk that the US government would default on it’s debt nor is there any reason to believe that the market for US Treasury bonds would dry up or become unstable. And interest rates are at an all time low, thanks mostly to the severity of the recent recession and the efforts of the Federal Reserve to stimulate the economy through borrowing and investment.

But, like the sky diver falling without a parachute, the danger for the US economy lies not in the present while tumbling through space but at some point in the future when the ground makes its presence known. It’s inevitable that the economy will pick up steam and with growth will come a rise in interest rates. Even small increases in rates can have a profound impact on the interest we pay on the debt.  Right now the interest payment on the national debt is about $242 billion a year.  Interest rate increases over the next decade have the capability of causing the interest on the national debt to exceed $1 TRILLION a year! Chew on this number for a while. This amount represents mandatory spending that does not go towards any social program, military asset, or regulatory agency. These billions pay investors in the US debt of which almost 50% are now foreigners (mostly the central banks of China, Japan, the United Kingdom and Brazil).

There is a very real possibility of a spiraling and out of control situation to develop as the interest on the national debt becomes bigger. Growing entitlement programs (Social Security, Medicare, Medicaid) combined with the increased interest payments could cause mandatory spending to exceed total government revenue. At this point the government’s ability to manage the debt would become even more difficult from a budgetary and political standpoint. The remaining choices, massive cuts in discretionary spending (including defense), massive cuts in entitlement benefits, and/or massive tax increases would become ever more drastic and unpopular.  Just like today there would be government gridlock, indecision, and political pettiness all resulting in  action that will be too little, too late. Meanwhile, the spiral continues, with increased budget deficits creating an ever larger national debt with increased interest payments

What happens then? The problem is that nobody really knows, not even Dr. Krugman. There is a great amount of debate among economists about how big the national debt burden could become and when the economy would become negatively affected. There is evidence that among industrialized countries, those with national debt below 60% of GDP had better annual economic growth (3-4%) than those with debts of 90% or more of GDP (1.6%). Though it’s unclear whether the larger debts were due to a slower economy and a decrease in tax revenues, the possibility remains for a negative impact on economic growth. Krugman further tries to differentiate debt held by households from the national debt.

This is the point almost nobody seems to get — an over-borrowed family owes money to someone else; U.S. debt is, to a large extent, money we owe to ourselves.

No it’s not.  As mentioned, almost 50% of our debt is held by foreign banks. And we can’t just stop paying interest on the debt because it’s “money that we owe ourselves.”  A US default on its debt or even a perceived inability of the US government to pay interest on the debt would result in volatility in the bond market causing falling bond prices and increased interest rates which would worsen the budget crunch as previously stated.  The US government is very much like a household that is very overextended on its credit. It’s like a family taking advantage of a credit card with no limit and ridiculously low interest rates.  A default would wreck the world wide economy and impair the government’s ability to borrow more money at low interest rates.

But lets assume that Krugman is correct and we can go on borrowing forever because it’s money that we owe ourselves that we don’t have to pay back. The problem with this “all is well” approach is it does not take into account the possibility of a “perfect storm” of different economic factors combining with our debt burden to result in economic catastrophe. Greece is a good example. They were forced by the Economic Union to adopt the Euro at inflated exchange rates for the old drachma that severely impaired their ability to borrow and service their national debt.  Though the US does not face the same type of monetary problems, the recent collapse of the sub-prime lending market is a good example of an entirely new economic variable that was unforeseen by almost every economist.  Hence, like earthquakes, economic disasters are very hard to predict but inevitable. The US national debt is like the proverbial sword of Damocles hanging over our heads. It has the potential to dramatically worsen and complicate what would normally be a survivable economic crisis.

Above all, however, Krugman and everybody else want job growth combined with economic growth. The problem is that the current massive amount of government spending is poorly designed to deliver this.   John Maynard Keynes famously called for the government to “prime the pump” with government spending for goods and services to stimulate the economy but the 2011 Federal budget included over $2 Trillion in mandatory spending and most of it was spent -quite literally – on people who are NOT WORKING. Social security for retirees and people with disabilities. Medicare for people older than the traditional retirement age of 65. Medicaid much of which is for children and those on disability. Unemployment benefits for . . . . people who are unemployed! And the recent bank bailouts designed to keep bank employees who already have jobs from becoming unemployed.  Even recent massive spending on two wars was primarily spent overseas during the occupations to employ Iraqis, Afghanis, and other foreigners. In theory and except for Federal employees, US government spending does not result in the creation of a single new American job.  It helps to maintain the status quo. No wonder the recovery has been jobless and sluggish.

During World War II the US government spent several hundred billion dollars to directly employ Americans to provide goods and services for the war effort. The economy responded with the biggest peacetime expansion in history. But today we have a multi-Trillion dollar economy and a few hundred billion dollars in domestic spending here and there is not going to cut it. What is needed is a multi-Trillion dollar domestic spending bill for the direct employment of Americans for nationwide infrastructure improvements. Unfortunately, we’ve already used up our political capital with year after year of massive deficit spending regardless of crisis. At least World War II had an end. By 1946 we no longer needed thousands of tanks, planes, and ships to fight the fascist threat and so spending decreased dramatically to prewar levels. This fiscal rationality no longer applies. For three decades, nearly every Federal budget has been followed by an even bigger budget. We no longer have either the political foresight or will to constrain spending so that we can reserve massive spending increases for times of true emergencies.  We have been spending our “rainy day money” on sunny days and now we have nothing left.

Answer:      It depends on how much the client pays them.

Doctors don’t usually have the luxury of choosing when they will need to be contacted for some “emergency” or whatnot. Throughout history, physicians have needed to depend on a messenger service of some type to remain in contact with their patients. Before 1950, physicians were paged over a hospital’s public address system or called at their home or office but then Charles F. Neergard,  a radio engineer annoyed by the constant overhead pages for doctors, developed the first wireless paging system. After this, pagers gradually evolved from radio voice paging to alphanumeric pagers and then digital. Answering services were added to streamline the service and add multiple physicians to the same service with a single number.

Then came cell phones. Now, it’s not that personal wireless phones are a bad thing. The biggest problem with having a pager and an answering service was having to hunt around for a land line phone while in a restaurant, or at the ball game, or the movies, or while watching naked midget wrestling, or whatever. With a cell phone, a return call was as near as your belt or purse.

But then the hospital staff or the ER physicians or whichever moron is in charge of these kind of things decided that since pretty much every physician these days has a cell phone on their person, it would be the best idea since ritual sacrifice to bypass the whole answering service-pager route and make the calls directly to the physician’s cell phone. Aquiring a physician’s personal cell number is as easy as taking the number from the caller ID and disseminating said number to any and all interested parties. So instead of having to deal with the “hassle” and time of calling an answering service and leaving a message to have Dr. So-and-so call them back, all they have to do is to place the call directly. It’s easier than ordering pizza!

It took all of a few days for the staff at the hospital where I started working a year ago to begin bypassing my answering service and call me directly. At first I just dismissed it as an occasional annoyance but then it became so common that my answering service was rarely used. It continued in mass even after I tried to politely ask the staff to use the answering service on every call. I found my cell phone number on slips of paper and on cards tacked up at most of the nurse’s stations.  After  several meetings with the hospital administration and department heads the calls became much less frequent  and yet they continued intermittently.

So what’s the bid deal? What could possibly go wrong? A direct call to a physician minimizes a delay that may occur when an overloaded answering service has a backlog of pages to send through and it eliminates the need to wait for the doctor to call back. Certainly in an emergency situation time is critical and this has to be the best way. Except it’s worst way.

First off, during business hours when I am seeing patients in the hospital or office, I treat my personal cell phone as my primary business phone. This means that I do not answer it when I am having a delicate and complex conversation with a patient or family. I am not going to stop to answer my phone in the middle of a conversation with a patient about their diagnosis of cancer (I have it on vibrate only). Nor do I allow phone calls to interrupt conversations with other physicians or consultants or the nursing staff.  And I hate to get interrupted with a cell phone call while I’m in the middle of a dictation over the hospital phone system.

So I started ignoring phone calls during these times and an interesting thing happened. I found that having initially allowed these calls gave the hospital staff a new sense of entitlement; an expectation that they would be able to reach me instantaneously and easily with one phone call. And when I didn’t answer I started to get complaints such as “Dr. Rangel doesn’t answer his phone when we call him and he is hard to get ahold of.” Amazingly enough, I was very easy to get ahold of when the staff utilized my answering service. Even more amazing was their reactions when asked if they had tried the answering service in the first place. They often seemed confused as to which method was supposed to be utilized first and which was intended only as an emergency backup. Or they didn’t particularly care.

The primary motivation for the hospital staff to call me directly appears to be laziness rather than any concern about efficient communication. With a single call direct to my phone, a staff member or ER physician need not hang around waiting for the answering service page to go through and for me to return the call. But my job description does not include being at the “beck and call” of the hospital staff nor to make their jobs easier.  Only after I stopped answering direct calls from the hospital did I realize how many were frivolous or inappropriate rather then for urgent patient care needs. I noticed that the nursing staff began to seek me out or to make themselves more available to talk with me during rounds about any questions they had regarding patient care rather then knowing that they could just call me later.  I had fewer confused calls from the ER docs about admitting patients who were already established with other physicians. It had been easier for the ER docs to call me directly than to contact the patient’s primary care physician.

What about emergent communications? Isn’t a direct call faster and safer? Actually, a direct call, in an age of texting and alphanumeric paging can be detrimental in the event of an emergency since the caller ID provides only the calling number and not the reason for the call. In other words,  I can’t tell which phone call is emergent and which is from a nurse asking for an order for  a stool softener. On the other hand, my answering service can text me the number to call back and whether or not it’s an emergency. This allows me to prioritize tasks so I know if I need to interrupt a patient’s detailed description about their bowel movements to return a call. Besides, there are multiple resources that the hospital staff can utilize (ICU rapid response team, nursing supervisor, in-house ER medical staff) for an emergency in addition to contacting me. They shouldn’t be paralyzed with inaction while waiting for me to answer my phone.

And there are many other excellent advantages to utilizing my answering service. The service knows when I am off or out of town and to direct calls to the covering physician.  The service will call the hospital unit back to confirm with the nursing staff whether or not I have returned the call and if not they will page me again.  The service keeps a log of every call which will help me defend myself against hospital staff who claim to have called me for an urgent situation when, in fact, they didn’t.  As mentioned above, the service can provide other additional information in a text that can’t be provided in a direct phone call.  And lastly, I’m paying for the dam answering service so the hospital better well use it!

Admittedly, there are many physicians why actually prefer to be called directly for reasons that I don’t understand (maybe they’re too cheap to pay for an answering service). I’m not one of them.  Just because technology has advanced doesn’t mean that we should automatically use it and abandon older proven systems.

New data show that total spending by insurers, government agencies and individuals amounted to $6,238 per resident in 2009, well below the national average of $6,815. That puts California on a bottom tier with Arkansas, Georgia, Texas, Utah, Nevada, Arizona, Colorado and Idaho.

God forbid that California be in the same category of anything with those red states! It must be like west coasters finding out that Newt Gingrich is a diehard 49ers fan. Then came the blanket statements that blames lower health care spending for a sicker population, less productive work force, and the general downfall of civilzation.

“The state is essentially under-investing in healthcare and ending up with an unhealthier population as a result,” he said. “If people aren’t healthy, they are not able to work or to be as productive as they otherwise would be.”

But it’s not at all certain how spending on health care directly or indirectly affects worker productivity and economic growth. The problem is one of being able to separate the variables from each other. For example, health care spending is well known to directly correlate with older and wealthier populations.  States with a higher percentage of older citizens such as those in the North East and Florida spend more on health care than states with a younger median population like California and wealthy countries spend more on health care than poorer countries.

The overall health of a population (as measured in higher life expectancy, lower infant mortality, lower rates of disability, etc.)  certainly does correlate with better productivity.  But economically advanced and productive populations tend to be healthier which promotes increases in productivity which increases wealth and so on. Ergo, this self defining metric is not very useful and it not at all the same as the level of health care spending.

Another problem with trying to study population health and health care spending is determining cause and effect. Obesity is a good example. There is very good evidence that obesity and obesity related health problems directly leads to $40 Billion per year in excess costs to the Federal government. But there is no good evidence of the reverse.

Indeed, health care spending in this country is almost all reactionary and not preventative. States with older populations spend more. States with higher rates of unhealthy lifestyles such as obesity, smoking, and substance abuse spend more to deal with these miladies. The primary philosophy of US policy makers regarding health care spending appears to be little more than, “the squeaky wheel gets the grease.” And right now California has the benefit of being one of the healthiest states with low rates of obesity and smoking as well as being one of the states with the youngest populations.

In the same way that lower spending on fire fighting equipment and supplies is due to the fact that there were fewer  rather than more fires, the total level of health care spending should not be confused with worsening public health. Better metric analysis should focus on the numbers of and access to primary care providers, basic and affordable medications, neonatal and women’s medical care, and efforts to reduce pain and suffering in the elderly and terminal patients. Right now the US spends far too much on expensive and often frivolous medical care.  A smarter question should be, “are we spending enough on the right things” and not just “are we spending enough?”

Enter the late Senator Ted Kennedy who advocated for a government run long term care insurance program and thus CLASS (Community Living Assistance Services and Supports program) was born as part of the mega health care reform of 2009. Except it was stillborn.

Basically, liberals looked at the long term care of rich retirees or at least those who had the foresight to purchase a long term care policy and decided that this is a new entitlement that everyone should be able to get regardless of financial ability! So they decided that they could perform a magic trick and create a government sponsored and run long term care insurance program with monthly premiums as low as $5, a short 5 year purchase period before becoming eligible for benefits, no apparent age or time limits for benefits, and no underwriting in the selection of beneficiaries. Basically it was an insurance plan without any of the rational limits and restrictions that real insurance companies use to prevent themselves from going bankrupt.

CLASS didn’t even provide all that great a benefit compared to most private policies which usually provide $200-400 per day coverage. But even a $50 a day in-home care assistant to help with cooking, cleaning, and bathing would cost over $18,000 a year.  Nursing home care would cost even more. And with no signup restrictions and no increased premiums based on overall health and age at the time of signup, the possibility that the vast majority of beneficiaries in this program would be the sickest and most infirm was too much to be able to assure that the program would be solvent in 75 years. Thankfully, an amendment was added to the act that required the department of Health and Human Services to prove to Congress that they could perform magic and create a stable and self sustaining program.

They couldn’t. And perhaps for the first time in history, a disastrous social program that would have cost the tax payers an additional $75 Billion per year was stopped before it could join the phalanx of entrenched entitlements. Once again, liberals have proven that you can’t pull water from a stone, create gold from lead, have your cake and eat it too, or buy something without paying for it.

CLASS failed for the same reason that Medicare is failing. The amounts that people pay into the system are falling short of matching the actual costs. Like CLASS, Medicare has few restrictions on the amount and types of care that beneficiaries receive. Liberal egalitarianism (“health care is a right”) demands that a severely demented 99 year old nursing home patient with terminal cancer receive the same life extending care as a 65 year old with no medical problems.

In a way, CLASS was even worse. It tried to create a new social entitlement where it’s debatable if there even is one. Despite hysterical claims otherwise, long term care boils down to one single benefit. Comfort. There is no proof that nursing home care or home assistance care or assisted living or adult day care increase life expectancy or prevents such old age maladies as falls, hip fractures, pneumonia, or strokes.

Severe cost over-runs raise the issue of whether Medicare should continue to provide for such aggressive care in those over 80 and CLASS raised the question of whether long term care is even the way to approach caring for our elders. Only about 50% of the population needs a nursing home stay at any point in their lives and the average nursing home stay is usually less than a year. The majority of elderly patients who do need assistance are cared for at home by family members or in some community care setting. Home and community care is far less expensive than facility care or having daily private assistance. More attention should be paid to assisting those families who do make the time and effort to care for an elderly loved one at home.

Then there is the rational approach to caring for the elderly. Statistically, a patient who has deteriorated in their ability to care for themselves and live independently as a result of advanced age and/or progressive medical conditions has a far shorter expected survivability than one who is relatively healthy regardless of aggressive medical care. The CLASS act does not appear to concentrate or particularly promote the option of hospice care (even for patients without a specific terminal illness) nor is there a provision to promote comfort over continued aggressive medical care. I can guarantee you that the vast majority of patients in a long term care situation continue to receive aggressive health care including blood pressure medications, statin medications to lower cholesterol, mammograms, colonoscopies, frequent testing and office visits, and frequent trips to the ER for any cough or fever or issue other than one strictly of comfort. Aggressive medical care accounts for a big part of the cost of caring for the elderly.

The Medicare lunacy of continuing to treat elderly patients in the last few weeks, months, or year or two of their lives with aggressive medical care designed more to extend lifespans rather than to promote comfort is a big part of what sank the CLASS act. Rather than concentrate on keeping the elderly alive and warehoused in facilities or with expensive home services indefinitely for the benefit of the working poor, the CLASS act might be still viable with a change in philosophy. The same goes for Medicare.

A colleague recently told me about a case that perfectly exemplifies this problem. When he was in medical training he was directly involved in a case of an older gentleman who presented to the ER department complaining of vomiting blood.  The medical attending and training staff evaluated the patient and explained to him that he would need to be admitted to the ICU for an emergency endoscopy of the upper gastrointestinal tract. Upon hearing this the patient refused and signed a form in which he acknowledged that he was leaving against medical advice and may die as a result of his illness.  About 2 months later the patient died. My colleague doesn’t even know the eventual cause of death but 2  months seems like an amazingly long time to die from massive blood loss (as any service member or trauma specialist will attest to). The family sued the attending attending’s malpractice insurance company for several million dollars.

On the surface this case appears to be straight forward. The patient was notified that he had a serious condition that may lead to death but he declined treatment and left anyway.  Physicians don’t have the legal right to force a competent patient to get treatment against their will. But ah! The key word here is “competent” and sure enough the plaintiff’s lawyers used a technicality to question whether the patient was competent to decline treatment. Apparently a blood glucose level was not obtained in the ER (an unusual claim as this is a basic lab test done on almost all patients) and so they raised the question of whether the patient was hypoglycemic (low blood glucose level) and so not competent to make treatment decisions.

Never mind that the patient was not diabetic, was not taking diabetic medications or insulin to lower his blood sugar levels, was documented in the physician, RN, and ER notes as having a normal neuro-psych exam, any doubts about his competency were not raised by his family, and hypoglycemia severe enough to degrade a patient’s cognitive abilities is not subtle and is easily recognized by such symptoms as shaking, tremulousness, nausea, vomiting, dizziness, confusion, lethargy, and even coma.  The lack of any corroborating evidence makes the likelihood that this patient had any hypoglycemia to be extremely remote and should have made irrelevant the issue of the blood glucose level not having been taken.

The problem is that a laboratory analyzed blood glucose level is the gold standard for diagnosing or excluding hypoglycemia.  Without this level there could not be 100% assurance that the patient was not hypoglycemic and so there would have been some doubt, no matter how small, about the patient’s competence.  The right lawyer could have convinced a jury to view this doubt as evidence to the contrary about the patient’s competence. The plaintiff could have won this case based on a LACK of evidence rather then a preponderance of the evidence. It is likely that the threat of this doubt based on the technicality of a test not performed is what lead the defense to settle out of court for over $900,000.

Why settle when the plaintiff’s claims don’t match the evidence and historically the majority of medical malpractice cases that do go to trial are decided in favor of the defendant? It’s a simple cost and risk adjustment on the part of the insurance company. Going to trial dramatically increases the legal costs regardless of victory or defeat (the benefit to the plaintiffs for not having any form of English Rule in this country). Juries made up of non-medical experts are notoriously difficult to predict and rule in favor of the plaintiff in about 1/3 of cases. With several million at stake the insurance company estimated how much it would have to spend on a trial regardless of the outcome and made an offer to limit their potential losses.

This is how the litigation game is played in this country. Two sides maneuver, bump heads, match wits, and play a game of chicken until someone blinks. What about truth and justice? Forget it. Those are for superheros.

Most people are less likely to know that the burden of proof in a civil trial is far less.  In legal parlance, this is stated as a “preponderance of the evidence”.  Quantitatively stated, this is a greater than 50% weight of the evidence for one side or the other.  In layman’s terms, it’s more likely than not that one side is guilty. But there can still be a 49% range of doubt. Additional definitions include, ” just enough evidence to make it more likely than not that the fact the claimant seeks to prove is true.”

It’s understandable that criminal trials have such a high burden of proof in convicting the defendant given what is at stake.  Not being a legal scholar, it’s not at all clear why this standard is so drastically lowered for civil trials. Maybe it’s because civil trials were traditionally considered to be more straight forward and easy to prove or disprove. But they are not. Certainly in the case of medical malpractice the issues are complex and a lack of definitive evidence can be misconstrued by a jury to be evidence to the contrary. I’ll give an example.

A nurse recently told me about an incident many years ago. An older female had been admitted to the hospital with a heart attack. She had been evaluated, treated, and stabilized appropriately per standards of care and was doing well. The night prior to her scheduled discharge she was being monitored on a telemetry floor and while eating dinner she had sudden onset of shortness of breath. She called the nursing station and was immediately evaluated. Within a minute she became unresponsive and went into cardiac arrest. Initially believing that she may be choking on her dinner the staff tried abdominal thrusts and clearing of her mouth and airway but no food or obstruction was found.

Simultaneously CPR was begun and the patient was intubated (a breathing tube placed through the mouth and into the trachea).  They found it was extremely difficult to ventilate the patient (i.e. to use a bag to manually force air through the endotracheal tube into the lungs) and despite their heroic efforts the patient was unable to be resuscitated.

Lawsuits for choking deaths in hospitals and other health care facilities are favorites for families because the concept is easy to understand and they believe it to be near 100% avoidable. Had this case been litigated, there is no doubt that the plaintiffs attorney would have argued that quite obviously this patient died from choking and from the negligence of the staff and physicians.  It would have been stated that the patient should not have been given solid food to eat because of her advanced age or because she did or did not have her dentures provided to her or because the heart attack had made her weak and she should have been evaluated by a speech therapist prior to being given solid food or one or more of her medications depressed her mental status or made her weak so that she was unable to swallow normally or so on and so forth. There would have been no direct or definitive proof for any of these claims but “specialists” would have provided testimony (actually their opinions) that any one of these factors is plausible so that enough doubt is placed into the minds of the jury.

Then the attorney for the plaintiff would have argued that in trying to clear the patient’s mouth the staff actually pushed the food bolus further down into the windpipe. And then it was pushed even further down during the intubation so there was no hope of it being removed and that it completely blocked the airway. The inability to ventilate the patient through the tube will be given as “proof” that the airway was totally obstructed with food.

Granted, there was no definitive proof for any of this. Scientists would call this argument a “theory” but NOT proof and would certainly try to follow this up with actual . . you know. . evidence. But in the make-believe land of civil litigation, a preponderance of the evidence could easily be interpreted by the jury as a preponderance of doubt in the defense’s claim that the patient didn’t choke. I.e. the plaintiff’s argument seems so reasonable and plausible and all the defense can do is to deny it. Even if this case never went to trial it would have been an excellent candidate to settle out of court.

But this case never went to litigation. The family of the patient decided to get an autopsy. Why? I don’t know. Maybe they really were looking for the truth. Maybe they were looking for the food impacted into and blocking the airway just to make the case that much easier. But instead what they found was the truth.

It turns out that the left side of the patient’s heart had been weakened so much by the heart attack that the wall of the left ventricle literally and suddenly split open. Blood poured out under high pressure into a space surrounding the heart called the pericardium. A thin membrane normally surrounds the heart like a balloon and as the blood poured into this virtual space, pressure built up and squeezed the heart so much that it was unable to beat anymore and stopped. This happened within seconds and is what caused the initial symptoms of shortness of breath. As more blood filled the area around the heart, this increased pressure was transmitted to the chest cavity including the airways and lungs thus making it very difficult to pump air into her lungs against this pressure.

Rupture of the free wall of the left ventricle following a heart attack is unusual and occurs in less than one percent of cases. It is unpredictable and can occur despite appropriate and timely treatment for heart attack. Emergent surgery is usually the only treatment option but the mortality rate is very high especially in severe cases as this one. In short, no one was to blame.

This example typifies why physicians and other health care works don’t feel like the current civil litigation system is fair or protects them against malicious and baseless litigation. Most malpractice cases in this country are filed not because of actual provable malpractice, but because of an unexpected and severe outcome regardless of fault.  Plantiff’s attorneys threaten to pervert the principle of a preponderance of the evidence into a preponderance of doubt for juries made up of people with the same level of expertise in the complexities of health care as Joe the Plumber. Many of these cases are settled out of court for this very reason.

What is needed is tort reform so that plaintiffs attorneys cannot hope to game the system by taking advantage of weak burden of proof requirements and gullible juries.  What is needed is a system of specialized malpractice courts with sitting impartial panels of medical and legal experts and consumer and patient care advocates. A panel that would reasonably be expected to believe that the odds of a patient choking who has no risk factors for choking are far less than the odds that a catastrophic cardiovascular event occurred in a patient only a few days removed from a heart attack.  A panel would be more likely to understand that a theory is not evidence and doubt is not evidence to the contrary.

At some point (probably just before complete economic collapse becomes inevitable) the deficit will need to be paid back and right now that amounts of almost $50,000 per every single American.  Of course, this only applies to tax payers and inevitably those with higher incomes will be “called upon” to shoulder more of the debt burden. But beneficiaries will also have to pay the price of decades of deficit spending as social programs and entitlement benefits are slashed to bring spending under control. Essentially, everyone will pay in one way or another.

Fortunately, deficit spending can probably continue for many more years before the bottom falls out and we all end up taking night classes in Chinese. This is just what the current bunch of drunken sailors on a Tijuana spending binge that passes for the US Congress is counting on.  Re-election is more likely as long as members can continue the spending insanity and delay the inevitable hang-over until well after they have left office.

The health care industry and physicians in particular are doing almost exactly the same thing.

The current reimbursement system (as directed by Medicare) rewards volume over quality and invasive procedures over good medical management. Therefore and in the face of shrinking reimbursements, physicians have continued a pattern of high volume and high utilization of health care resources.

Currently there are absolutely no good incentives and fewer reasons for physicians to practice good resource utilization and try to contain health care costs.  A few managed health plans will “reward” their participating primary care providers by “sharing” a little of the savings from their efforts to reduce costs. But these kick-backs are usually a very small percentage of the over-all savings.  What about passing savings on to their patients? In my experience, patients infrequently ask their providers to help them out with less costly tests and treatments and any concerns are usually limited to medications. This is what happens in an insurance system. Costs are separated from the source. This disconnect impairs how both providers and patients understand and react to costs.

But not truly understanding and being separated from the economic consequences of their practice is only the background of how physicians are contributing to the escalating cost crisis.  There are so many other factors that “reward” physicians to totally ignore resource utilization and order more expensive tests and treatments for their patients. There’s ignorance among doctors that more expensive tests and treatments are better. There is fear of litigation and other reprisals and having to explain why they didn’t get the test instead of why they did. And then there is outright greed either to see a ton of patients a day (on the part of primary care docs) or to perform a ton of procedures (among specialists). There is even institutionalized greed among health care facilities to admit and treat the most patients and to perform the most expensive procedures which simply enables those aggressive, high cost physicians.

If you’re not part of the solution then you are certainly part of the problem. Unless physicians take responsibility and assume (or rather, re-assume) some leadership in our health care system the consequences of ever increasing health care costs will be ever drastic and larger funding cuts.  If physicians don’t stop responding to decreasing reimbursement rates by exploiting new revenue sources or simply increasing volume then the system will bring back managed care . . with a vengeance.

Our wild spending spree will have consequences. The problem is that no one knows when the tipping point will come. I’ve tried to talk to other physicians about this. The blank stare or shrugged shoulders they give me is similar to the responses I get when I talk to 20 somethings about the dangers of smoking.  The threat is currently too abstract. Like Congressmen, the hope is that they will be long retired and out of the profession before the proverbial excrement hits the fan. At that point, it will be someone else’s problem.

I’m not advocating for socialized medicine or some universal health care government scheme. I’m certainly not an anti-capitalist. The problem is that the current health care system is not so much capitalist as it is a gigantic privatized government program. As such, there are few  classic capitalist mechanisms as cost transparency and free markets in this system, which is great for recipients of the funding. It’s great, until the bottom falls out.

In concert with such actual and true reforms such as malpractice tort reforms and reimbursement reforms and stabilization, physicians need to convert from simple “consumers” of the health care system and start acting more like advocates, reformers, and preservationists of the good things about our system (freedom of choice, efficiency, advanced care) before the US gets it’s own National Health Service nightmare.

A team from Rutgers University in the U.S. asked 11 non-pregnant women between 23 and 56 to stimulate themselves while they lay inside a [functional PET scanner]. 

Stimulation of the nipples caused activity in the same part of the brain (neocortex) as stimulation of the genitals.  This revelation was followed by the requisite “this strange research could actually lead to further  evaluation, breakthroughs, and possible treatment of non-sexual disorders so we are not just perverts and doing this to freak out conservatives and the American Family Association” statement.

Dr Komisaruk hopes that in addition to helping people who can’t orgasm learn how to, his research will help unlock wider secrets of the brain. ‘If we can control a part of the brain that produces pleasurable sensation, what would that do in the case of, say, depression or anxiety or addiction or obesity?

And it’s a lot more fun and interesting to study sexual physiology than depression and obesity.  But this study raises more questions than it answers;

1. Does self stimulation of erogenous areas like the nipples have the same brain activity patterns as actual sexual activity or external stimulation?
2. To test this, would “volunteers” be used to stimulate the nipples of the test subjects or in the interests of prudishness and standardization, would some kind of external device be used?
3. Would such an automatic external nipple stimulator be made available for purchase on the study website?
4. How many conservative and religious fundamentalist commentators have publicly denounced this area of research while being secretly titillated?
5. If this type of research were to get Federal public funding, would Congressional floor debates on C-span get a lot more interesting and possibly include pictures?
6. Could a website be set up where people would send in suggestions on which body part is to be stimulated and studied next?
7. Do fetish body parts like feet cause different brain patterns in people with these fetishes compared to “normal” subjects?
8. Why does the MailOnline web site covering this story have a picture of an actress faking an orgasm that has nothing to do with breasts or nipples?

Clearly, there is much work yet to be done.