YDS: The Clare Spark Blog

March 18, 2017

Dr. James Pagano on the reasons for a doctor shortage

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The doctor shortage is real and most acute in certain specialties, like family medicine, internal medicine, and pediatrics.  There are various reasons for this.  Economics of course-these specialties pay less that others.  But over the course of the past 7 years under the ACA the bureaucratic and regulatory burden that has been placed on office-based primary care doctors has become so onerous that many are retiring early and fewer students are willing to enter those areas of medicine.

To counter this graduate schools are cranking out ever-increasing numbers of ‘mid-level providers’—physicians’ assistants and nurse practitioners.  As I’ve mentioned previously, these providers can do an excellent job in certain situations, but they don’t have the breadth and scope of knowledge a physician has.  Another trend of Obama era medicine was the development of ‘best practices’, ‘core measures’, and various diagnostic and therapeutic algorithms.  The alleged purpose was to identify the most appropriate approach to various illnesses and presenting complaints and to create a checkbox system of treatment.  Financial penalties were instituted against providers and hospitals for non-compliance.

My own suspicion was that CMS wanted to create a centralized system for delivering health care that did not rely upon physicians to administer it.  A mid-level could use the guidelines and get it right for something like 85% of the people 85% of the time.  Population medicine was the focus of the physicians and politicians working for the Obama CMS—and much of the paperwork being required of office-based doctors is providing data on treatments and outcomes to generate more algorithms.  Not all of this is bad.  Some useful information will be gleaned and some more effective or efficient or affordable treatments will be developed.  It is not, though, the type of practice doctors of my generation were taught.  We were taught to study the evidence and then use our clinical skills to tailor our therapies and diagnostic evaluations for the benefit of individual patients.

An example of check box medicine run amok is the core measure for the treatment of sepsis.  Briefly, sepsis is a condition of systemic infection with abnormal vital signs and evidence of failure in one or more organ systems.  It has a high mortality rate, especially if not diagnosed early and treated aggressively.  As part of the core measure for sepsis, patients have to have lactic acid levels drawn and repeated.  This value is used to determine whether or not sepsis is present, and if so, to what degree.  Unfortunately many other conditions besides sepsis can cause an elevated lactic acid level.

For ‘severe sepsis’, defined by the CMS as a lactic acid level greater than 4, the patient is supposed to be given a 30 cc per kg bolus of saline IV.  Regardless of whether or not the patient has another underlying condition, like renal failure or congestive heart failure, that would make this fluid bolus dangerous and possibly fatal.  If the fluid isn’t given the case falls out of compliance, the doctor and hospital don’t get paid, and this ‘poor performance’ is published on line by the CMS for all to see and few to understand.  Even if the physician documents clearly why the fluid is being withheld or the amount modified the case is still considered a fall-out.  This absurdity was recently reviewed by the CMS and kept in the protocol.

This sort of governmental interference leads to cynicism among physicians, nurses, and hospital administrators.  It would be more honest for the CMS to simply say they don’t want to pay for certain care than to create a bogus protocol that needs to be gamed in order to be compensated.  A study was done and published in the New England Journal of Medicine a year or so ago in which the authors compared the outcomes of patients with sepsis treated either according to protocol or according to clinic judgment.  The study found no significant improvement in outcomes among those patients subjected to the protocol.  The Obama ‘science administration’ did much to pervert science across its broad spectrum, from the environment to healthcare.  Maybe some of this gets fixed over the next few years.

 

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March 8, 2014

“America is in decline”: cui bono?

decadencemeaninglessnessFirst read these: https://clarespark.com/2011/04/03/progressives-the-luxury-debate-and-decadence/, and https://clarespark.com/2012/09/22/materialist-history-and-the-idea-of-progress/.

Would be rescuing heroes love the idea that an “America in decline” desperately requires their services to lift “America” out of the Slough of Despond.* These malefactors could be politicians or pundits. Each has its intertwined sets of villains: creeping fascism, laws legalizing marijuana, gay rights (especially flamboyant parades and gay marriage), uppity feminists, the “do-nothing” Republican establishment, hip-hop culture that destroys the black family, modern technology that harnesses us to “the machine”, noisy atheists and other “haters” out to get “Christianity”– hence the heart and soul of American [Christian?] identity.

The most interesting item in this turn toward pessimism and fear of “weakness” is the widespread premise that America was once a “superpower.” The same persons may tell us to read Jean-François Revel, who complained that America did not fight the Cold War hard enough. See https://clarespark.com/2011/04/09/jean-francois-revel-and-father-mapple/. (Would the US ever had been a superpower had not Europe destroyed itself in the follies of two world wars? Is our power to be defined in military might or in industrial capacity, respect for entrepreneurship and the work ethic, science/technology, encouragement of intellectual and cultural diversity (the marketplace of ideas), and natural resources?)

supermanentrepreneur

As far as I can tell, “power” is a contested term, so argued over and vague that it is almost useless in ordinary conversation. What is it, who has it, who wants it, and how do we measure it? Unlike the powerful followers of Michel Foucault and the postmodernists for whom all texts are ambiguous, I go with the Frances Bacon definition “knowledge is power.” Bacon was an empiricist and a father to the scientific revolution and thus the confidence-builder for ordinary people wanting to improve their mastery of the self, the world and its institutions. (Nothing that I have written here should indicate that I approve of Obama’s and Kerry’s weakness in the face of real threats from communist nations, Islamic jihadists, or antisemites. National security is crucial, while personal emotional identification with an aggressive dictatorship is despicable.)

It is my view, constantly reiterated on this website, that European aristocrats and their social democratic offspring (see https://clarespark.com/2011/07/16/disraelis-contribution-to-social-democracy/) have indulged in psychological warfare to bind “the lower orders” to views that undermine knowledge and the habits that spur competence. These aristocratic radicals have created the pseudo-progressive movement with its dire view of the paranoid people (see https://clarespark.com/2009/08/24/the-people-is-an-ass-or-a-herd/), popular unteachability, and indecipherable documents from the past. Meanwhile “experts” have offered “compassion” and the informed “heart”) i.e., self-control and social control as the best methods to govern the unruly masses. Similarly, they have demoralized ordinary people with proclamations of decadence and decline, apocalyptic fantasies, escapism and pervasive death imagery (horror movies and “Romantic necrophilia” for instance).

opheliaimitator

The same miscreants deceptively align themselves with “science” but fail to define their terms; they support unlimited government (and all institutional) secrecy, so that ordinary people are deprived of the facts and skills that enable them to test their “betters.” In my playbook, all political factions are scaredy cats. Why do “conservatives” lobby for local control, while failing to address the curriculum that could enable their children to test all authority, including their own? Why do “progressives” deflect the curiosity of their children into channels that do not threaten the authority of their own world view?

Why will health care professionals, parents, and all teachers not agree that the search for truth is superior to “adjustment” to a misery-making and unhealthy status quo? With all the chatter around socialized medicine or the ACA, why are not the questions I have posed more widely publicized and addressed?

* I do not mean to imply that there are no problems in American society. I reject the notion that a cultural entity called “America” is “in [irreversible] decline.” Compare to Richard Epstein’s concrete specifying of problems that he would correct with a classical liberal constitutionalist approach to what are now “progressive” “solutions.” From the “Conclusion” to The Classical Liberal Constitution (Harvard UP, 2014, p. 569): “The motivation for [my] argument should be apparent from the major disarray that infects every area of modern American life: steady decline in the average standard of living; constant battles over debt limits and fiscal cliffs; uncertainty over key elements of the tax structure; massive overregulation of the most productive sources in society (health care and financial services); government-inspired brinksmanship in labor negotiations; and runaway redistribution programs that undercut the economic production that makes these programs viable.” (See http://www.hup.harvard.edu/catalog.php?isbn=9780674724891)

Professor Epstein has responded by email to my blog as follows: “You raise some hard and fair issues. There is no doubt that most people in this country work hard, have decent values, do actions that help advance their welfare and that of those around them.  It is indeed the politics that draws the situation down.  But there is little doubt that these policies from above have had their long lasting effect.  It is not that the situation is irreversible .  It is that we need to find the collective will to reverse it, which depends on taking specific measures of the sort that I talked about in the book.  It is sad that most constitutional theorists either ignore how the system runs and leave it all to Congress, or are so concerned with issues at the periphery that they pay no attention to the organization of basic systems from production to education and so on. Just think of the new NYC mayor Bill who will wreck education if he can and whose vision of the real estate market will not produce 1 percent of the new affordable units that he wants and that the city needs (but which can only come by liberalization, not by further edicts.”

March 6, 2014

Crises: real and manufactured

MAD“What, me worry?” Someone looked up this blog, written last year on the D-Day anniversary. https://clarespark.com/2013/06/06/morale-in-the-time-of-crisis-overload/. D-Day, 6 June, 1944, was a true crisis, not a mass media manufactured one. This blog is about both real crises and those emergencies that are ideological in origin.

Giving too much weight to crises that are not “real” can affect physical and mental health, not to speak of where we should put our primary efforts in coping with problems, both personal and social. I got the idea for this blog after reading all of “U” a periodical put out by the David Geffen School of Medicine at UCLA. Although positive in outlook, this important public health magazine is worried about the size of the Baby Boomer generation and the shortage of trained physicians who understand the needs of geriatric patients that is likely to result. It should be mentioned that this is a generally liberal magazine, optimistically progressive, reformist in tone, and certainly not alarmist, as they support ACA without reservation, including a warning about the pointless excessive cost of end of life critical care (i.e., death panels are not mentioned). As good multicultural liberals, they write to everyone (including veterans with PTSD and brain injuries), celebrating both recent discoveries in medicine (e.g. the Genome project, genetic sources of schizophrenia), and the healing power of “faith” and “happiness.”

And as good liberals, they published a letter from a doctor irate with the notion that faith heals, as opposed to science. But that letter is immediately followed by another celebrating faith and spirituality. There is no problem with the marketplace of ideas at UCLA, not here at least.

The rest of this blog lists some emergencies that I, from the distance of my years, can identify as real crises. Some are personal, some are social in origin. All affect personal and public health. As one example of a manufactured crisis, think of “anxiety and depression.” What sane person is not anxious and depressed given the real intertwined crises listed below in capital letters.

REAL CRISES.

True of false? According to Marxist-Leninist theory, capitalism is in a permanent state of crisis, being a “weak and unstable system” [Hyman Minsky’s diagnosis]. For lefties I have known, such an emphasis on the past and future crises (that either should have led to socialism/communism, or are guides for future action, sans errors), can lead to a carelessness or minimizing of personal crises: the ageing and death of parents, divorces, troubled attachments to lovers, families and children. Such persons, it has been widely observed, are living in hopes of a future utopia, not a past Golden Age, as reactionaries do. Their Leninist critiques of the present tend to be framed as “will it advance the working-class revolution?”, or will this or that movement advance such disasters as “false consciousness” allegedly caused by mass media and consumerism. Or, they may infiltrate reformist groups such as environmentalism, in order to turn “Greens” into Reds. Such tactics can lead to alarm over irreversible climate change, an alarm that is intended to delegitimize current types of energy usage. Or, and this is the worst: leftists have bonded with Islamic jihadists on the theory that they are correct to destroy “imperialist” Israel.

Here are some crises that should receive more attention from those of us who give at least lip service to capitalism as either social democrats, neocons, libertarians, or conservatives. Each of these has preoccupied me for the last four or five years on the website. I will not attempt to specify the causes of the intertwined crises that I have emphasized, but I have no love for the progressive activist reading of the “living” Constitution.

DUMBING DOWN.  THE CONFUSION OF PAIN WITH PLEASURE (systemic masochism).  LOSS OF FOCUS (CHANGING THE SUBJECT). THE LEFTIST TAKEOVER OF THE HUMANITIES AND MASS MEDIA. USE OF THE INTERNET TO FIND PARANOID CONSPIRACY THEORIES OR TO VENT RAGE. COUNTER-ENLIGHTENMENT/ANTI-SCIENCE. POSTMODERNISM. NEEDLESS POLARIZATION. NONCHALANCE and DROPPING OUT. THE ADMINISTERED STATE.* MULTICULTURALISM/IDENTITY POLITICS. INDIFFERENCE TO TERRORIST THREAT FROM ISLAMIC JIHADISM.

*By including “the administered state” I do not imply that concern with progressive statism is not a crisis, but that it is the source of  most of the other crises as listed. In this I am following Richard Epstein’s new book The Classical Liberal Constitution: The Uncertain Quest for Limited Government (Harvard UP, 2014). By including “postmodernism” I am agreeing with Epstein’s claim that all text are not inherently ambiguous, hence unresponsive to interpretation. This postulate of his is more significant than many would imagine.

December 1, 2013

Reflections on the Affordable Care Act

demondoctor“Obamacare” is rightly the domestic issue that is upsetting the nation, so although I am neither a lawyer, nor a physician, I will lay out some of the difficulties that I see in the debates to date. In no particular order, then

First, the Democratic Party’s obliviousness to the enforced changing of doctors is indicative of a pandering and incompetent mind-set: Compassionate beings that they claim to be, Democrats would never argue that it is no big deal to change mothers. The benefit of a doctor who knows your history, and is invested in your good health, is comparable to the trust we place in our mothers (and present loving fathers).  How to explain this blind spot? Society (like the body) is not a machine, with interchangeable parts, though some political groupings seem to be.

Second, to what degree are we responsible for our health? With the body, we can choose not to drink to excess, not to smoke, to practice correct hygiene, to eat for maximum nutrition and to exercise. It is not so clear how we can control our mental states, which in turn impact our immune systems and the degree to which we take care of ourselves. I cannot understand why these matters are not taken up in our school curricula and in the media, though I suppose that religious diversity plays a large role, with some belief systems rejecting the physiological lessons of modernity.

Third, don’t look to the hip universities to be sympathetic to either medicine or psychiatry. At the university where I received my graduate training in history, the history of science encompassed the history of medicine and psychiatry, and the Foucauldians and the Left were in charge. Science was held to be a joke, and amusing, just as eighteenth century quacks were to be written about and mocked. The radical historicism I encountered at UCLA could not possibly distinguish between antique fads and misconceptions and modern medicine. Post WW1 German Expressionism has a grip on many academic mentalities–those sports who inhabit “the dark side” or, who are irresistibly drawn to the femme fatale.

cabinet of doctor caligari

Fourth, when I was much younger, I recall the responsibility that doctors and dentists alike felt for the poor. So they volunteered at free clinics, or might travel to the central valley in California to treat farm workers. Medicine, like dentistry, was held to be a noble profession, perhaps because parents or grandparents were immigrants.  Nowadays, many doctors expect to be multi-millionaires; ironically, their wives and children benefit from a life of luxury, while the physician (male or female), is expected to care for too many patients. This is a world I did not know in my youth, and do not like now.

Finally, the chant from ACA boosters that the Republican Party is simply obstructionist and has no alternative proposals, is tiresome and ludicrous.  Tort reform and competition across states lines for insurance companies are only two of oft-repeated suggestions. I would be even happier with the ACA opposition if they proposed changes in the curriculum that would put health, physical and mental, at the top of the list in curriculum reform.  That will never happen here until outdated notions such as demonic possession and/or fallen flesh are finally banished from our public schools and related institutions.

fallen flesh

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