May 17

Why I am Leaving Medicine

Kenneth A. Feucht, M.D., Ph.D.

I formally decided to quasi-retire in October of 2016. This meant for me, getting out of the surgical oncology profession. My intention is to continue working until 31MAR2018 in an outpatient wound care clinic associated with the hospital in Puyallup, WA where I live. Remember that training in my profession consisted of 15 years past the 12 years through high school, so that I have completely identified myself as a surgeon, making my profession not easy to give up. I would have liked to continue practice until I was 65 or more, but frustration with medicine and the changes which have occurred since becoming a physician have led to my desire to leave medicine. This is not an easy decision. I have a deep love for my patients, and found the profession to be quite rewarding. It was particularly satisfying dealing with patients not only for the relief of their physical ailment, but also to help them psychologically and spiritually through a major crisis in their life, which is usually the situation when somebody is given a diagnosis of cancer. With my decision to retire a bit earlier than I had wished, I felt that chronicling the root causes for my decision would be appropriate. The list of my grievances with the health care profession is in no way intended to be comprehensive, but to cover the major areas of frustration for me as a surgeon. This is NOT an in-depth, heavily researched paper with references and documentation, but an off-the-cuff rendering of my feelings regarding the status of health care. Perhaps someday I will take the time to render a more academic version of this treatise.

Health Care Orientation

Hospitals began in the fourth century in central Turkey in a region called Cappadocia. At that time, the poor and destitute who were ill were abandoned by the community and sent away into the woods, where they were often eaten by wolves or other forest beasts. This allowed for containment of communicable diseases, but did not reflect well on the care of the ill patient. It was St. Basil who took these poor people and reincorporated them into a caring community environment. Thus, we get our word “hospice” or “hospital” from the latin word which would be translated as “hospitable”. Hospitals became defined as an agency that attended to and offered the patient an ability to return to the community of the faithful while under care.

Germans have two names for hospitals. The most common is “das Krankenhaus”, though they also use the term “das Hospital”. Translated literally, “Krankenhaus” simply means “sick house”. It is a vastly more fitting word for what we have today, and the term “hospital” should go out of existence. Hospitals are no longer places of caring, and they do not offer the patient a gracious return to the community, or hospitality. They are places where patients are treated with sterile rigor, where children dump aging parents once they have become a nuisance, where occupants are considered to be more work for already overworked nurses, where physicians rapidly fly by patients, knowing that they dare not say either too much or to little, but where everything needs to be documented in a complex electronic database, and where nurses spend most of their time making sure that those databases are replete with boilerplate (and thus useless) data to fulfill various government mandates over what needs to be documented. The entire orientation of healthcare is a narcissistic reflection on themselves looking past and ignoring the raison d’être for their existence, the patient!

Defining “Healthcare”

What is healthcare? What is involved? What is health? What is wellness? How do you define something nebulous? The dictionary defines it as “the maintenance or improvement of health via the diagnosis, treatment, and prevention of disease, illness, injury, and other physical and mental impairments in human beings.” This definition can be strewn out to as broad of meaning as life itself. Is my mental stress over an upcoming test in school a part of healthcare? Is my desire to become and identified as a female when I started out genetically and physically a male a part of healthcare? Is my carelessness in attending to my mental state when I accidentally kill somebody while driving a motor vehicle under the influence of alcohol actually a healthcare problem?

But, why do we even waste the time to precisely define the full nature of healthcare? Is it really important that we have a narrow versus broad definition of healthcare? From a personal point of view, the manner of defining healthcare is unimportant, but from a health care policy perspective, it is vital. The government promises that healthcare will be paid for, but exactly what that means is quite vague. In Germany, going to the spa for a week or two rest is covered. In the USA, the breadth of coverage constantly changes according to what is politically expedient. Oregon attempted to identify and rank cost-effective treatments to determine what might be covered. Since physician assisted suicide is very cost effective, it ranked quite high up. Is this proper? Assisting somebody in suicide seems to be counter to the entire goal of the medical profession, but nobody could doubt that much expense is saved by terminating the patient. If trans-sexual surgery is covered by government policy, why isn’t all cosmetic surgery covered, since it is aiding to personal well-being and how a person defines themselves? Why isn’t food free, since it is really taken to prevent healthcare problems? Why isn’t our housing and the cost of maintaining housing covered, since it all contributes to me maintaining and improving my health?

What about health itself? How do you define health? Is it just the absence of sickness? If so, then obesity would not be a health problem, or smoking, or any other dangerous activity, until it caused a problem. Some people choose to live through disabilities that would be viewed as insurmountable by others and refuse to identify their disabilities as an “illness”.

A frightening result of having an all-encompassing definition of healthcare that is provided for by government, is that they then must adopt the role of supervising our behaviors in order to maximize the government definition of health and well being. Does somebody really want the government telling them that certain activities are forbidden? Does anybody really want government prescribing exactly what you can eat and how much you can eat in order to stay healthy. When Michelle Obama attempted to regulate school lunches in order to decrease obesity, it was found that the children actually became more obese who were on the lunch program. When do we decide that decisions in our life become none of the government’s business? If we allow that government is responsible for health and well-being, we must realize that we are then completely giving away our freedom.

In reality, the public definition of healthcare is impossible and it would be best if we remove any attempt at defining the realm and coverage of what we think as healthcare.

Government interference

We are constantly being bombarded in the news that a new regime of politicians will correct the messes that former regimes have created in federal health care policy. I will speak of ObamaCare specifically a bit later, but here address specifically issues of government policy in health care. Over the course of the last century, we have gone from a situation where there was no government involvement directly in healthcare, to where government pervades virtually every aspect of the healthcare scene. Government first became involved in healthcare in Germany during the tenure of Bismarck. In 1883, he created a national healthcare system which provided insurance to all citizens. Many countries today follow the Bismarck model, though we do not in the USA. (ObamaCare seemed to be a model that attempted to simulate the Bismarck model though not utilizing many of the most important aspects of the Bismarck model.) Through the introduction of Medicare by president Johnson in the 1960’s, there has been a slow invasion of government into the healthcare scene. Government continues to fund increasing amounts of healthcare, and thus has taken an increasing stance toward controlling health care costs. At the same time, the innocent introduction of internal means of quality improvement (such as the JCAHO, which was started by surgeons as a means of voluntarily improving surgical quality across hospitals in the USA) has evolved into a beast that neither improves the care of patient nor the quality of healthcare delivered. More will be spoken on JCAHO later.

In times past, physicians generally took the Hippocratic oath on graduation from medical school. If not the Hippocratic Oath, then a somewhat similar oath (see article on the Hippocratic Oath, referenced below) was offered. In the Hippocratic Oath, three parties are involved, which include the patient, the physician, and the god(s). Glaringly omitted from the ancient oaths were the health care system, insurers, the government, and anybody else outside of the three mentioned. This is only right, and an article I’ve written on the oath covers why such an arrangement is so vital to the doctor-patient interaction (http://feuchtblog.net/die-veroffentlichungen/the-hippocratic-and-other-oaths/ ). Healthcare is now run by a multiplicity of bureaucrats and idiot savants who love to tell physicians and patients what is best for them without any knowledge of either the patient or physician. Government makes a cookie cutter mold that all diseases and persons are supposed to fit into. Diagnoses have a number assigned to them according to the ICD-10 manual, and no diagnosis will fail to have a specific number. Treatments and procedures also have their number, called the CPT code, with a one-size-fits-all mentality.

Government healthcare is run by bureaucrats. These are the self-serving policy wonks and bean counters that control the health care of all occupants of the United States, citizens and non-citizens, consenting and non-consenting, the sick as well as the healthy, the only exception being the politicians themselves. Most often, these healthcare pundits have been in the health care profession as either physicians or nurses, but are now removed from actually providing care, and thus not experiencing the consequences of the policies they implement. Being removed from health care, they may act with heartfelt concern for their colleagues in the trenches, but will never be able to properly address the constantly changing healthcare scene that affects healthcare delivery. In addition, their policies will fail to address all contingencies and variations in the disease process or patient goals and needs.

The government, since they intend on paying for healthcare, are obsessed with the cost of healthcare. Yet, they strangely seem to be the most clueless as to why healthcare costs so much. Perhaps healthcare costs are high because of government interference?

Two organizations from the federal government have been particularly harmful to healthcare, that of the food and drug administration (FDA) and the other the center for disease control (CDC). The FDA started as a well intentioned idea to protect the public from potentially dangerous drugs. The thalidomide incident in the 1960s is instructive. Thalidomide is a medication designed to decrease morning sickness in pregnancy, but was noted well after the fact to occasionally cause phocomelia, very short limbs, in some of the babies exposed to this drug in utero. I’m not sure that thalidomide babies could have been prevented even if the FDA was functioning as they do now, but a good crisis has not gone to waste by the government. It now takes many more years for a drug to go from creation to market in the USA as compared to Europe and other countries in the world. Drug development costs have risen to exceed a billion dollars to get an new drug to market in the USA. Yet, American patients are not safer than European patients, though we are denied rapid access to potentially useful medications.

While the FDA “protects” us against dangerous drugs, the CDC is here to “protect” us from various communicable diseases. I have less of a problem with the CDC than the FDA, though the CDC remains over-reaching in so much of what they do, and persist in trying to justify their own existence. The flu vaccine is a perfect example. It is close to impossible to predict which flu antigens would be dominant in any flu season, and the antigens of choice are made by “educated” guess. I know of no randomized trials that have proven within reasonable doubt that mass forced administration of the flu vaccine decreases morbidity or mortality from the flu. Health care personnel that work for hospitals are mandated to take the flu vaccine, and we have no other options. It matters not that we might have strong personal preferences against the flu vaccine. Another example, Gardasil, the vaccination against HPV, is sold to prevent genital warts, and thus cervical cancer, and is recommended for all males and females between 10-12 years of age. It is of value only for the sexually promiscuous female, but is strongly encouraged that all children receive this vaccine. Long term effects of the vaccine are essentially unknown. The CDC would love to have this vaccine mandated, and there is great pressure on all children to receive the vaccine, even from family physicians. This represents an over-arching hand that doesn’t allow for patients to make personal choices regarding their behaviors and actions, but assumes that all patients (or children) will be irresponsible and not have to take account of their actions. The CDC in effect takes the roll of parent, and displaces the biological parents as having a say in the behavior of your children.

ObamaCare Mess

ObamaCare is presented as the great revolution in healthcare, the solution to all of our problems, the defining policy that will allow all people in America to have adequate health care without obstruction from inability to pay. The health care bill was so voluminous that nobody in congress was able to read it in its entirety, and the proponents demanded that the bill be passed before one could discover what was in it. I won’t belabor the nature of ObamaCare because I have not read the bill, nor have any interest in reading the bill. What I will discuss is how it has affected physicians attempting to care for patients.

Obamacare wished to improve everybody’s access to healthcare, including that of illegal aliens. To do so, health care insurance was mandated to all. If you didn’t purchase healthcare, you were fined. You could either purchase private insurance, or the state would provide options. The rules were tightly defined for enrolling or switching health care plans. The presumption is that all people then had health care. Wrong! The cost of healthcare has continually escalated, and all plans had a copay for any service rendered. Copays were intended to prevent flippant and casual care. In actual fact, it has served to be more restrictive than anything to actual access to care. There are many patients that have turned down a proposed treatment plan for them simply because they could in no way afford the copay. In essence, care became more difficult to get.

ObamaCare also sought to assure that increased value was offered. This had multiple aspects, including patient satisfaction surveys, increased demands on providers to be fully “educated” through CME (more on this later), and increased demands of JCAHO. Patient satisfaction surveys were reported through what are called Press-Ganey scores. For employed physicians, bonuses were heavily dependent of the Press-Ganey scores. While Press-Ganey scores reflected how patients feel about their physician, it had minimal correlation with the competence of the physician. A physician that is the bearer of bad news, no matter how well it is delivered, will often be viewed with less favor than a physician bearing good news. Physicians oftentimes need to reprimand patients or cajole them into healthy behaviors, which is usually not viewed favorably by the patient. Some physicians are quite excellent, but do not have jovial personalities, which patients don’t like. Or, they have a jovial personality but are incompetent, something that a patient might not realize until it is too late. ObamaCare has allowed feelings to supplant honesty and truth, and the end-result will ultimately be disaster. Meanwhile, ObamaCare has flunked in its attempt to define quality in health care, and I’m not sure the ObamaCare act really cares about quality; they simply want the illusion that everybody is getting quality healthcare.

Are people truly having good coverage of their health care problems? The answer is complex, as there are a few people that have coverage that otherwise would have been out. Before government got involved in healthcare, most large cities and all counties had a county hospital that would take care of the indigent. Everybody ultimately received health care. Pharmaceutical firms were good about providing reduced rates on expensive drugs to the poor, and almost all people were able to survive. Now, coverage is actually worse, and many no longer have actual coverage of expensive treatments because they are responsible for a copay, which might be unaffordable. The only group of people who are better covered are those who should not have coverage, such as illegal aliens, or those who are mostly responsible for their own illness, such as burned out drug addicts.

Are the physicians getting rich? Definitely not! Over the last thirty years, physicians had to work harder and longer and more hours to make commensurate pay of the past. As a result, physician burn-out has become a true problem. The solution for physicians has been to become employed. I won’t belabor the problems of employed physicians, save to mention that employment essentially strips them of the definition of a true professional. They are nothing but expensive, sophisticated hired hands, and they will behave as such. People who serve administrative positions in health care are getting rich, and hospital CEOs as well the insurance companies are making out quite well. For the most part, physicians are getting poorer.

ObamaCare has not addressed the reason why healthcare is so expensive, and has diverted the attention from health care costs to health care availability. I am grateful that illegal aliens can receive the best health care in the world for free at my expense. In fact, I am waiting eagerly for anybody to provide an honest analysis of health care costs, and an explanation as to why health care costs in the US are much higher than in Europe or the rest of the world. I can think of many reasons, and simple explanations such as the absence of free markets deflects from serious analysis of costs, which has multifactorial roots.

Physician Regulations

The state has deemed it vital to make sure that physicians are competent. In order to define competence, the state has had to set some sort of prevailing standard, which is an amalgam of current practice and best practice recommendations based on the latest research. This assumes that best practice can be codified and then enforced. It assumes that current prevailing practice is the standard for all physicians and all patients,  and that our knowledge of disease pathology and physiological processes for disease are correct and well understood. Sadly, history is replete with countless times where the medical profession has been wrong and has had to eat their words. It is no wonder that much of what I had learned in training had to be unlearned as simply wrong. Medical practice is in constant change, and not necessarily in the correct direction. One dares not fight the system if the system is going in the wrong direction.

The state needs a way of making sure that physicians are keeping up with the latest and greatest developments in health care. The current standard is to require physician recertification, usually every ten years. The other is the requirement for continuing medical education, or CME. There are serious problems with both of these systems. For recertification, the physician needs to be placed in a box that defines who they are. These boxes are the selected specialties that the physician identifies with, whether that be in family practice, pathology, internal medicine, general surgery, or a host of other specialties. But, these specialties are too vaguely defined, such as in my specialty of general surgery. I am a surgical oncologist, and the American Board of Surgery only recently created a board specific for surgical oncology. Surgical oncology itself is heavily fragmented, between melanoma surgeons, breast surgeons, hepatobiliary surgeons, sarcoma surgeons, and a smattering of other organ specific surgeons. Within the last 20 yars, surgical oncology has essentially lost head and neck surgery, endocrine surgery, thoracic surgery, and colorectal surgery. True, one would like their surgical oncologist proficient in all aspects of cancer surgery, yet reality states otherwise. Regional referral patterns and practices also affect a surgeon’s expertise. Certain diseases are just more prevalent in some areas as compared to other areas of the county. In Chicago, I saw much pancreatic pathology. In Seattle, there is very little pancreatic disease, but a proliferation of other diseases. The truth is that as a professional, one is always reading and educating oneself, and each individual physician will develop a differing broad area of expertise. A simple test imposed by the state is not capable of defining what only the test of real life scenarios can clearly define. Recertification has become a horrid pain to take. I’ve re-certified twice, have done well in my re-certifications, but swore on the last re-certification that I would never do it again, ever, for any reason. Most physicians reach the same conclusions as I have, and the net result is to drive out the aged but experienced physicians. The only exception is in academia, where the surgeon is somewhat protected.

Keeping up with CME is a pain. It is not enough to simply subscribe to various specialty journals and read them on a regular basis. Now, one must answer sets to test questions to assure that you’d acquired the information attempted to be taught by the article. The Journal of the American College of Surgeons would do this for four articles each month, and I dutifully answered their questions for a number of years. About 2 years ago, I realized the stupidity of most of the questions, and how they were usually completely unrelated to my field of practice. The questions were intended to quiz whether you had read the article, but often assumed you had knowledge well beyond that of the article; thus, there was no education of the physician, and failure to judge whether I’ve read and learned from the article. The problem is compounded when articles relate to my own specialty, since I usually read into the question the controversies involved and uncertainty about the information in the article. The multiple guess questions really fail to assess my true knowledge of a subject, yet is mandated in order to assess whether I’m actually staying on top of my specialty. CME updates are demanded by the American Board of Surgery every three years, and I will be letting the next update slide.

Increasing surveillance of physician behavior is happening. This relates to both social behavior, as well as practice outcomes. Hospitals are simply not turning a blind eye to behaviors that would be publicly unacceptable. There has been a change from historical norms, where previously the physician acted mostly without accountability. This is a good thing, and physician antics with the treatment of patients, colleagues or nurses must be now accounted for. The only problem is that it is the hospital that is performing most of the policing, and they have a very strong bias for protecting themselves. Thus, there is predictably unfair judgement against unemployed physicians, and usually it is by someone clueless. I recall, for instance, being reprimanded by the chief medical officer at my hospital for not responding in person to an emergency room call, even though I was in the middle of a case in the operating room. I informed the CMO to no avail that it would be considered unethical and immoral by the American College of Surgeons for me to leave a patient open on the table to attend to another person. Such madness has only gotten worse under ObamaCare. Physicians are still held liable as “captains of the ship” yet are not given the power or authority to maintain that captainship. We are constantly being told to alter our behavior or practice in the most minute ways that have no real bearing on patient outcomes or hospital well-being. The focus has turned from outcomes to process, without any evidence-based data to suggest that behavior changes would be good.

The discussion of “captain of the ship” bears more intensely on issues of hierarchy within the hospital structure. Traditionally, physicians were the main drivers for hospital decisions, dominated the board of directors of a hospital, and were held as primarily responsible for the success or failure of the hospital. Now, responsibility falls to the CEO and his minion of subordinates, most of whom are not physicians, though they might be nurses, pharmacists, physical therapists, or simple business types with no training in medicine. Because of the increasing commercialization of medicine, spread sheets and the color of the bottom line have become the most vital aspect at determining the survivability of a hospital. The physicians have silently gone from being the leaders of the hospital to being nothing but another cost center to be dealt with.

Documentation/HIPPA issues

Until recently, documentation was performed in paper charts, usually a combination of typed text and handwritten notes along with printed reports, lab work, and outside information. Marginal notes would be made in the chart to facilitate jogging the memory of the physician. A typical note would take a few minutes to write, but would be highly effective at documenting an encounter. With the rise of third party indemnification (insurance), the desire to have confirmation of services rendered demanded improved documentation. The saying, “If it isn’t documented, it wasn’t done” became the hallmark message for mass documentation. This led to automation of means of documenting, including boiler plating encounters and procedures. This naturally led to the reverse problem of the past, in that much “documentation” might not have ever been performed. Because boilerplating made possible getting information quicker into electronic format, and with the rise of improved databasing and need for distribution of data, the electronic medical record (EMR) saw its rise. What was once a convenience became a mandated necessity. Many payors no longer accept handwritten charts, and the federal reimbursement systems require EMR for full reimbursement. EMR systems are very expensive, not only to implement, but also to maintain. They solve the problem of a plethora of charts and storage of these charts, as well as issues of lost charts, and the need for multiple simultaneous access to these charts. The down side is harder to see but more destructive. With a combination of requirement for increased documentation, and through the use of boiler plating, excess information now exists, and it is quite challenging to quickly identify the relevant information on a patient. Because of multiple sources for input to the EMR and restricted ability of access users to correct faulty information, the EMR slowly becomes less and less reliable. Errors become quite plentiful, from basic patient information, to diagnoses, medications and treatments.

Meanwhile, privacy of the data has become a greater concern. Physicians were instructed not to talk about patients in the elevator with outside people present, or to share patient data with people outside of the immediate family, unless given permission by the patient. Now, privacy has become a fanatical issue. In the past, I would walk onto a ward, and at the nurses station, a chalkboard list of all the patients and their room number was present. At the door of each room, the patient(s) name(s) were again posted, allowing for re-identification of the patient. This doesn’t happen any more, all in the name of patient privacy. The problem is that it is now easier to confuse or mix up patients, and more errors occur because of that.

Privacy in electronic data is a greater issue. The need for highly secure servers to manage patient data has become the norm, all mandated by HIPPA (federal policy). Yet, the skill of hackers has not been thwarted from obtaining any private patient data that they wish. True privacy is a myth, but the expense that we go through to maintain this illusion of privacy is astronomical. Indeed, true privacy is impossible. Perhaps all patients should present themselves to the physicians office or hospital in full covering like a Burqua or KKK outfit? Yet, the one area where privacy is zilch is with the government. They now know EVERYTHING about you. I fear the government more than I fear some stranger knowing that I happen to be on a β-blocker or some other medication. Yet, the feds have access to every aspect of my health care record.

Big Pharma

I don’t view big pharma as an intrinsic evil, and much of their perceived evil comes from government and legal policy imposed upon them. There is no doubt that the large equipment and pharmaceutical firms have vastly improved the quality of healthcare in our country, as well as throughout the world. It is without a doubt that drugs exist and are available today that never would have been possible without these large companies. But, the large pharmaceutical and equipment firms comes at a terrible cost to all of us.

The large pharmaceutical firms must deal with a host of regulatory agencies, the FDA being the largest of them. One would think that big pharma would be fighting the FDA tooth and nail, yet the opposite is the case. The pharmaceutical firms have seen the FDA as a wonderful means of keeping out smaller competition, which is why you don’t see small pharmaceutical firms in this country. The assistance of the FDA in the assault on the nutritional supplement and vitamin industry is shameful. Big pharma has relished the protection to their industry by the FDA, leading them to become even more powerful at controlling the drug market. Concomitantly, we see larger firms buying up the smaller pharmaceutical firms, and thus becoming ever more powerful.

A secondary problem is created when insurers pay for medication costs, so that the consumer never sees those costs. This becomes problematic if a patient is unable to perform a cost-benefit relationship to determine whether a drug is worth taking. A perfect example are the statin drugs to lower cholesterol. I wait eager to see any statin demonstrate improved survival over the best alternative therapies out there. Statins have a high chance of significant side effects, yet has never been shown to be significantly effective at preventing death from atherosclerotic heart disease. And, they are expensive drugs. Too often, the patient assumes that the physician is using critical judgement in determining the need for a drug, yet the greatest determinant tends to be how good of lunch the drug representative brings to the doctor’s office.

Insurance

A system of third party payment for health care has created the worst possible solution for healthcare. It is a serious misnomer to title health insurance as such, since it does not operate like insurance, but simply as a mode of funding. Insurance supposedly should be most active when there is an acute need, such as with a car accident or a heart attack or a new diagnosis of cancer. Instead, it covers every possible aspect of health care, including runny noses in kids to health maintenance examinations. Under ObamaCare, health insurance is not an optional decision, but mandated by the state. In such a situation, you would expect the health care insurers to making out quite well, and for the most part, they are, with executives of the major insurance companies making exorbitant profits. Yet, there are strains on the system. Insurance is not able to reign in the ever-rising cost of health care, and can only raise premiums and copays to a limit before the system breaks. And, the system is about to break.

Ultimately the big winners in todays system are the insurance companies, but that is a bittersweet win, as they continue to merge with other systems in order to survive. Time will ultimately pass a severe judgement on insurance companies.

Legal Aspects

If you read the popular press, they would suggest that legal issues are a small portion of what’s “broken” in medicine. Whenever malpractice tort reform becomes a subject of referendum up for vote for the public, the advertisements and press attest to litigation being a small part of costs for doing medicine. Yet, those most entrenched in the health care system and actually paying attention what is going on realize that legal aspects of medicine are probably our worst enemy, and that politicians and lawyers who know little of the actual functioning of healthcare are essentially orchestrating how things should be done in the health care world. If a physician suggests changes in the legal world, lawyers tend to attack the physician as ignorant, befuddled, or clueless as to how law actually works. Perhaps outsiders see the legal world a little more clearly than lawyers? Yet, it is most true that lawyers and political meddling in the world of medicine have only left medicine far worse off.

When a physician attends conferences, there are numerous sessions offered on how to avoid or deal with lawsuits. It is made very clear that the physician should understand that everybody gets sued, and that a lawsuit often is the “luck of the draw”, and that a physician should never take a lawsuit personally. Yet, in court, it is presented as just the opposite, and the claim is that there is something wrong with the physician that caused the medical “error”. I place the word error in quotes because it is too often that an error is not an error at all but simply the course of the disease. The lawyer presents a disease process as an entirely controllable phenomenon, and that good outcomes will happen when the standard of care is closely followed. Of course, they will deny this mentality until they are in court, where acts of “nature” serve to reward the lawyer quite generously. In public referenda regarding tort reform, there are usually two most serious claims. The first is that bad physicians need to be punished in order to improve the system. This goes contrary to all evidence yet seen. The second claim is that the tort system preserves patient rights. In actual practice, it does just the opposite, and patients end up with less options and choices in their care because of the malpractice climate which physicians and hospitals have to work in.

Whenever a referendum for tort reform hits the public, the claim defending current practice is that malpractice claims are actually decreasing and that malpractice premiums continue to be less expensive on the physician. Especially after a referendum, this is briefly the case, until the public forgets about matters, after which lawyers come back in force, hungry for more litigation. The malpractice situation has not improved, but remains a crapshoot, where a physician remains highly likely, no matter how excellent they are as a physician, to get sued and lose. The tragedy is that physicians can oftentimes see colleagues that truly are dangerous and yet manage to avoid suits. Cases that hit the public scene are often the most revealing. A few years ago, the leading transplant center in the USA made an error in typing an organ, leading to a hefty lawsuit. But, to what avail? This transplant center defined excellence in care for their service. Does human error necessitate lottery type outcomes for the lawyers and unfortunate patient? That is what happened in the transplant error to a distinguished center of excellence. There are many more similar stories.

What about if the legal profession is eventually proven to be wrong? Do they refund their ill-gotten gains then? I recall the colossal sums won against Dow Corning for the silicone breast implant lawsuit. Not very long later, it was proven beyond doubt that the manufacture of the implant or the nature of silicone did not lead to the alleged autoimmune diseases that the lawsuit purported to have happened. In this situation, the funds should have been returned, at least in part. This only shows that truth and justice are not served in courts of law, and the legal system has no interest in pursuing what is right.

My claim that litigation raises cost of everything is quite easily supported. Think about matters for a brief second. When you stay overnight in the hospital, with minimal attention rendered to you, you could expect a bill for upwards from $20K. I cannot think of any but the most exclusive hotels in the world that would even approach a fraction of that cost, even with servants and the most lavish attention. Why does it cost so much? Medications that are sold for veterinary use typical cost under 10% of what they charge for exactly the same medication with adults. Why? Medical equipment tends to be quite unreasonable in cost compared to similar products in the non-medical market. Oftentimes it is absurd, from a simple little staple gun costing several hundred dollars which if sold as a non-medical item would be several dollars. Why? Incorporated in those costs are both the higher cost of development for the human market, and the potential for litigation. Cows don’t sue, but people do. Yet, there are other subtle cost drivers. Physicians assuredly often act against their best judgement by over-ordering tests and x-rays, and over-treating, all in an effort to protect themselves against litigation. The patient is not given a choice in the matter, or allowed to assume risk. This is because with informed consent, it is still assumed in court that physicians should know better and not have offered choices to the patient if one choice was not assumed to be “standard-of-care”. The physician can’t win, and so plays the game by following the rules, even when the rules are wrong or don’t make sense.

JCAHO

This actually belongs in the “government interference” paragraphs, since the JCAHO is a government organization. Yet, it is so pervasive to all aspects of healthcare, with such overreaching influence on the way medicine is practiced, that it deserves a category of its own. As I write this, my hospital is currently undergoing a JCAHO inspection, and the anxiety of the administration is sky high. They have come by, and declared how various improvements must be made, how there are defects to the system which has so capably served patients. In essence, they are fixing “issues” that are not problems, never were a problem, and never will be a problem. Typically, the fixes are expensive, time consuming, but also require extensive documentation to prove that the fix is actually implemented by the hospital.

One of the most troubling changes in recent years has already be discussed, which are regulations imposed by HIPAA in order to preserve patient privacy. Sadly, HIPAA has failed to recognize that if somebody wishes to bust into the system, it can be done regardless of how intense the security measures are applied to the electronics of the system. The result is the physicians can no longer speak easily with each other about a patient’s care, and the detriment is ultimately to the patient.

JCAHO has long filled any possible useful purpose for itself. Yet, it has become a burgeoning business that must be sustained at all cost. Thus, they have sought desperately to find ways of justifying their own existence. They have accomplished that by creating new and novel regulations each year which they impose on hospitals. They will review hospitals every third year, and if sufficient inadequacies are found, will return a year after their visit to review the hospital for correcting their “mistakes”. During the triennial visit, they will disclose the new regulations, holding the hospital immediately responsible to correct their behaviors and adapt to the regulations. This causes a fleury of anxiety, panic, and hasty development of new hospital policies to match the new regulations. One year, they decided that if a patient was placed in restraints (usually in the ICU), then the order for that had to be renewed weekly. This had never before been a problem, and when there were restraint problems, they were of a nature that a policy would not fix. Another year, it was decided that used instruments or laundry could not be transported to their appropriate destiny in an open environment but had to be completely enclosed. One could hypothesize that bacteria could be spread with these instruments and laundry in open air, yet there has never been an instance where this had ever been a problem. The fix is indeed costly, and must be done in order for a hospital to continue operations. But, the hallway transportation rule defies notion that the hallway itself or the patient room could be transmitting disease between patients. Perhaps the entire hospital needs to be systematically sterilized between patients?

But, JCAHO will continue to work their evil deeds. Health care will become more complex, impersonal, and expensive, and ultimately, less safe. JCAHO is an organization that holds others responsible, but submits to nobody else’s authority. It is a true creature from the black lagoon.

Commercialization of Healthcare

It used to considered immoral for physicians or hospitals to advertise. Pharmaceutical firms were forbidden to advertise prescription products to the public. The American Medical Association held policies forbidding their members from advertising, as found in their code of ethics. The goal for these rules was to keep medicine out of the realm of commercial enterprise. All of that changed in the year 1975, when the federal trade commission considered the AMA policy as an illegal restraint of trade. The AMA rolled over dead. What was immoral one day was considered right and proper the next day. Advertising among health care emerged slowly. Early in my private practice, there was a rule that physicians in our community would not advertise, or even to have their name in bold print in the yellow pages. That disappeared slowly. Soon, one could see a plethora of drug advertising, with elderly patients in perfect health dancing vigorously across the tv screen, proclaiming the miraculous benefits and health giving effects of a medication with multiple side effects and toxicities. A few little lies won’t hurt, would they?

The end result of healthcare commercialization is that it has caused anybody and everybody to seek for a portion of the health care dollar. The highest paid person in a medical community is often the CEO of the hospital. While hospitals still designate themselves as “not for profit”, the non-profit hospital has gone the way of the dodo bird. Quite often, the most vigorously trained physician taking the greatest risks and responsibilities get the least cut of the health care dollar. The pharmaceutical and medical equipment suppliers are making massive profits unheard of in yesteryear.

One could argue that commercialization has led to improved competition and desire for innovation. Yet, competition has always occurred in health care, and innovation has also taken a great toll on our profession, not commensurate with the benefits offered. The most heavily advertised physicians are oftentimes the most marginal physicians. It would be hard to argue that patients are truly better off with advertising. For the reader interested in a erudite discussion of this issue, please read this article… https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2563279/ .

The Flexner Report and its Evil children

The Flexner report was funded by the Carnegie foundation, supporting Abraham Flexner in a review of the existing medical schools in the early 20th century. The report was published in 1910, and intended on promoting standardization of medical education and the removal of marginal medical schools. We now see the evil children of the Flexner report, with regulation of the health care professions at an unprecedented level. The net effect we have had on physicians is increased regulation and requirement for continuing education, which was previously discussed. It has restricted the number of physicians in the health care community, and medical schools have not been able to keep up with the demand, especially in an age where increasing numbers of physicians retire early. It is difficult to just build more medical schools, since the cost of medical education is prohibitively expensive, and the state has had to bear part of the burden of these costs in order to keep the supply of physicians at adequate numbers.

There have been several ways in which the health care community has met the demand. First is through the influx of ever greater numbers of foreign medical graduates (FMG’s) from countries where health care education is not so aggressively monitored. The second is the rise of alternative providers, which include physician assistants and nurse practitioners. Both of these groups of providers have much shorter training periods, which would fail the current minimal standards for medical school training as defined by the results of the Flexner report. In essence, the Flexner report has forced its own extinction, and bred an alternative to the physician.

Conclusion

I am not unhappy that I ever became a physician, and feel that it has been a rewarding career. I am very unhappy with what has happened to medicine. It is like a public good has been stolen and no hope for recovery.

I am particularly sad that most people do not identify root causes for problems, but continually ask for immediate, self-serving, quick fixes to the health care problem. It is a truism that until congress and all of government has to live under the same health care plan that they impose on others, there will be no hope for improvement. I wouldn’t count on it ever happening in my lifetime.

Ultimately, health care will kill itself. It is unsustainable. It has lost its soul. Its original driving force was a Judeo-Christian Weltanschauungen, specifically, the belief that all people, young and old, born and unborn, of all races and creeds, were created in God’s image and of intrinsic value. Humans were not viewed as the accidental product of the primordial slime. Human relations were viewed as important as health itself. Suffering had meaning, which oftentimes led patients to delay in seeking a remedy. Pleasure and euphoria (feeling good) were not considered goals of worthy pursuit. Among health care professionals, the pursuit of “health” and prolongation of life seem to be more in line with personal challenges and a game to be played, the chance of honor for a great discovery, rather than the sympathetic concern for the whole person, body and soul. Purpose and meaning in life are oriented around maximizing pleasure and minimizing pain and suffering. Healthcare is the agent responsible for restoring maximal pleasure, either to the individual or to the community, when things go mentally or physically wrong. The greatest creed of healthcare, the Hippocratic Oath, provided the framework for practicing our profession. Without either a framework or a direction, we flounder. Healthcare, rather than being a true profession, becomes the utility of the state to maintain function and order, rather than the pursuit of a higher good. We have lost our soul in medicine. I am leaving medicine because my profession no longer is a profession of Hippocratic orientation. I have no interest in being a duped servant of an evil state.

Tagged with:
2 Comments »
May 13

Pacific Crest Trials: A psychological and emotional guide to successfully thru-hiking the Pacific Crest Trail, by Zach Davis and Carly Moree★★★

Zach Davis wrote this book as a parallel to a similar book he wrote soon after completing the Appalachian Trail, called Appalachian Trials. Zach seems to admit that at the time of the writing of this book, he had not yet hiked the PCT, though his co-author and friend Carly Moree has done both the AT and PCT. Sections of this book are now written by Carly. This book focuses on the mind games that play on the hiker leading to an unsuccessful attempt to complete the entire trail. The book emphasizes appropriate mental preparation for the hike, discusses how one can avoid the temptation to bale out and return to the comforts of house and home, but also includes the mental problems that are common among those who complete the hike. Advice is good, in that it helps to know what sort of mental issues are going to be at issue. His solutions are often in need of great personal modification. To mentally prepare, he encourages hikers to truly examine why they are wanting to hike the trail, what they expect to get out of it, and what will be the consequences of failure. There are several addenda to the book, one written by Carly Moree on the differences in the PCT and AT and how one would adapt to those difference. Then, a fairly experienced and multiply accomplished thru hiker Liz “Snorkel” Thomas wrote a chapter on gear.

I appreciated the author discussing something that is usually not addressed in planning a long thru-hike, that of the mental issues of enduring the trail. Most people focus on gear, resupply, planning, and other matters, and this book conveniently informs one of the mental anguish that will occur, allowing the hiker to be prepared for these issues. The main author also runs a website, which is quite informative in preparing for the PCT. It might have been nice if he had at least once done the PCT, and one could tell that much material seemed to be cut-and-pasted from the Appalachian Trials book, in that it continues to reference the AT.

 

Tagged with:
No Comments »
May 07

Trip Report — Germany 20April -06May 2017 with Jonathan ★★★★★

I felt it necessary to return at least once more to Germany, and this time, to also do a long bike ride. Jon became very interested in doing that with me. The plan was to ride from Benningen am Neckar to Krefeld am Rhein, then take the train to Berlin, then Würzburg to see Katja and Hannes, and then home from Frankfurt. In Benningen, we would spend time with Heinz and Debbie, and in Krefeld, with Herbert.

After arriving at the Seatac airport, we were informed that the Lufthansa computers were shut down, and taking a while to reboot. Thankfully, they got everything ultimately fixed, and we were checked in. It was quite easy to get the bicycle on. There was a group from Moses Lake on the same plane, headed for Nigeria for a medical/dental project, and I was pleased to see an old acquaintance, the retired surgeon Jim Irwin.   After boarding the plane, a brief moment of panic ensued when we realized that Jon left a bag in the terminal; fortunately it was able to retrieve it right as the plane was closing its doors. The plane was a 747 and fully loaded. I can’t really describe the flight because I slept through it, thanks to a sleeping pill. Our arrival in Frankfurt and getting our bags with Jon’s bike was uneventful.

Arrival in Germany

Friday, day 1 Much of what happened the first day we don’t remember. We were able to get the bike box to the bike shop without a problem, and get it reassembled. On checking with the Deutsche Bahn, we were informed that we could not take the train route that I had planned and used before, but had to go through Karlsruhe. They gave us a schedule with a number of transfers. At first things seemed ok, transferring in Weisbaden and then Mainz, but on the way to Karlsruhe, we were informed that there was a problem with the track, and that the train would go no further. No advice regarding what we should do was offered. Thankfully for a young student with a bike next to us, we caught a train in another direction, then transferred again, and after a bit of hassle, finally made it to Karlsruhe. Even then, the train to Karlsruhe stopped at every stop like a bus, and ended short of the Hauptbahnhof, making us figure out what to do from there. We were late with that connection, the transfer in Stuttgart was again late, and 20 phonecalls later to Debbie Fuchs, we finally had Heinz just get us in Ludwigsburg. It was a delightful evening with Heinz and Debbie, but jetlag had us zoned early. Debbie made us a wonderful meal with Spatzele, and the things she wanted from America were dug out, making our bags lighter.

Debbie and Heinz Fuchs

Jon and I ready to roll

Saturday, after breakfast, I realized that the bike was missing its front rack. Thankfully, Heinz was able to find it in the garage and it easily installed. The Neckar Radweg was quite easy to follow, and we rarely had any problems with feeling lost. It was a beautiful ride, passing mostly through wine country. I did not record this 30+ mile segment on Garmin. The weather was overcast and cool, with only a light rain, atarting just becore we got to Heilbronn. The owners of a hotel Die Grüne Krone were most friendly. We took showers, went out to dinner at Die Barfüßer, were they brewed their own beer. Beer never tasted so good! It was nice having real German food again.

Riding the Neckar, with a light rain.

vineyards along the Neckar

Heilbronn Rathaus. Probably seen by grandfather on his way to America

Wonderful hotel, die Grüne Krone.

Sunday 23April —  Today was fairly uneventfkul. There was no tain, but  it was mostly cloudy and cold. The Neckar valley was broader now, with fewer wineyards. There were plentiful castles and ancient structures along the, most of which  could not be nicely photographed. A moderate amount of the trail was gravel, but still easy to ride on. The bikes worked well without problem. Arrival in Heidelberg brought back old memories, and Jon and I stayed at a hotel where Betsy and I stayed, the Tannhauser. Dinner was delicious, and Jon and I crashed early, ready for another day.

Jon in excellent form

Typical Travel

Castles everywhere

Gutenberg house

Jon loved the Spargel

Monday. 24April —Today was absolutely beautiful, riding through both countryside and industrial areas. Starting in Heidelburg, we crossed over the Neckar and rode though fields that flanked the Neckar. It was sunny all day, and reasonably warm. The trail eventually ran close to the Neckar as we came into Mannheim, coming right to the junction of the Neckar and Rhein. We decided to stay on the right side of the Rhein until we got to Worms. The bridge at Worms was a mix of the old brick Niebelung Brüke and modern construction. After quickly finding a hotel, we toured the Luther Denkmal, as well as the cathedral (Wörmer Dom), probably a site for Luther’s trial. After a Wörmer Diät of Schweinemedallions und Spargel, washed down with sufficient beer, we crashed for a bit, then went out for a beer, engaging in conversation with a very nice German software salesman from Northern Germany. Bedtime was a little more normal today.

Niebelung Brücke

Luther Memorial in Worms

Wörmer Dom, possibly where Luther was held for trial

Worms city wall

Tuesday, 25April—Last night, the conversation at the bar strongly advised us to stay in Mainz. Unfortunately, there was a Messe in Mainz (convention) which tied up all the hotel rooms well outside the city. Bike travel went quite well, but it was very cold. We were quite bundled up. When we got about 10 miles past Mainz, we looked for a recommended hotel in Heidesheim but they also fully booked because of the convention in Mainz. The most fascinating thing about Heidesheim was a complex of old historical buildings. A person saw us looking bewildered at the structures, and then came out to explain to us that these buildings were used in 1941-1945 by Hitler to house invalids and Lebensunwertiglebens before they went off to the gas chamber. But, we didn’t (couldn’t) stay there. Therefore, we had to make some hard decisions. It was about 5 pm, and Jon was able to reserve a room on the internet in Bingen. We quickly caught the train from Heidesheim to Bingen. Bingen was a lovely town. We stayed at the Hotel Krone, went out to dinner (no photographs tonight), we had regional dishes and wine, and crashed at a reasonable hour. Jetlag was finally moving behind us.

Real food

One of many castles along the Rhein


Wednesday 26April — Both Jon and I slept well. The weather report said “rain” but it remained mostly sunny with no rain, and not nearly as cold and windy as yesterday. Today gave absolutely no challenges to route finding, and no hills, so travel was smooth. We got to see many castles, as well as the Loreley. I also saw a hint of several Rheinmaidens poking their heads up out of the water. Lunch was in the Roman colony of Boppard, also a part of the Hunsrück region of Germany. Koblenz came soon after. We quickly found a lovely hotel in Koblenz, feeling great about our travels.

Die Loreley

Real food


Thursday 27April — The hotel in Koblenz was a fairly small mom and pop operation of an elderly couple, and very friendly. We found our way back to the Rhein, took note of the Deutsches Eck (where the Mosel flows into the Rhein), and rode on. We stopped for lunch in Remagen, after inspecting the remaining support structures of a famous bridge. Lunch was our first Döner in Germany. After arriving in Bonn, we found our hotel, dumped our stuff, and then hurried to the house where Beethoven was born. It was a small but nice museum, but unfortunately, we were not allowed to have cameras in the museum. We had a late dinner before retreating back to our hotel. Tomorrow means a new phase in our travels, in that we will not be bicycling any more. We had to make a change of plans since Herbert was needing to be in Würzburg on an urgent basis. We will spend two nights in Hamburg and then three nights in Berlin.

Deutsches Eck

Bridge at Remagen

First Döner in Remagen


Friday 28April—today makes it one week in Germany. We woke up a bit late, had breakfast, and then checked out. We had a few hours to spend before the train, so drifted around the downtown area for while before heading to the train station. We got to Hamburg late in the afternoon, it was rainy, and the hotel was a bit removed from the downtown area. It took us about an hour to reach the hotel. It was a Holiday Inn, we were able to stow our bikes in the room, and they upgraded us free to an executive suite room. Nice.

Beethoven birth house in Bonn

Saturday 29th April—Hamburg; the walk back to the train station now took us only 40 minutes, and we spent all day walking the city. We went to the Rathaus, Alster area, and the Brahms museum. Jon was able to actually play on a piano that Brahms played on. We had a Hamburger hamburger in the St. Pauli area, and then went to the Speicherstadt area, hoping to get into the model train museum. The wait would have been over two hours, so we skipped it. We saw the new Elbphilharmonie building, a fairly impressive site. Lastly, we slowly wended our way back to our hotel. All in all, it was a successful day.

Hamburg Rathaus

Entrance to Brahms museum

Jon plays on a piano that Brahms actually played on

Jonny eating a Hamburger hamburger in the Reeperbahn Burger King

Typical train station site

Sunday, 30April—This was a busy day for us. We woke up at 4 am in order to catch the 6 am train to Berlin. This train had almost nobody on it, so were able to catch up on the sleep we lost waking up so early. Berlin was mostly sunny but cold. Even though our bikes were loaded, we were able to work our way around the city, visiting many of the usual sites that are in Berlin, like the Seigesäle, the Gedachniskirke, the Brandenburgertor, Checkpoint Charlie, Alexanderplatz, Hackeschermarkt (where we had lunch), and finally checking into our hotel (Ibis) across from the Hauptbahnhof. I zoned out and hit the sack early. Jon wanted to enjoy a cigar, but it was just a little too cold out for that. We were prepared for a big day tomorrow.

Jon didn’t want this photo with Marx and Engels

Brandenburger Tor

Berliner Dom

Inside the Berliner Dom, the largest Protestant church in Germany. The Beatitudes are displayed in the Dom ceiling.

Jon high on the Dom

Monday 01May—Today was supposed to be museum day. We discovered that only a few of te museums were open owing to today being a holiday. So, we toured the Berliner Dom, an awesome work of reconstruction (see photos above). We walked around town, and then hit on the Naturkunst Museum (natural history museum) which held the worlds tallest dinosaur, a trex recently uncovered in Montana, countless stuffed animals, illustrations on how the animals were prepared, rocks, insects, and slimy creatures in glass bottles of formalin. It was a huge but most fascinating museum. Coming back to the hotel, we discovered the Medicine history museum founded by Virchow, a must to see tomorrow. We did a late dinner at a Bavarian style restaurant, and hit the sack afterwards.

Berlin Döner

Berlin Currywurst

Stuffed Knut in Natural History Museum

Tuesday 02May—This was a little lazier day, but for the best, since the weather was cold and drizzly. Jon and I did some more walking around the city, then visited the Neues museum of Egyptian artifacts, as well as the Pergamon museum, which had some major walls and gates brought back from the mid-east, including the Ishtar gate from Babylon, which Daniel from the Old Testament surely would have frequently walked through. It is incredibly beautiful. We had lunch again in the Hackescher Markt, then hopped the train back to our hotel, freshened up, and ran to the train to meet Marike in the Zoological Garten area. Marike pointed out where the recent terror attack occurred. We had coffee, then all three of us went back to the hotel. I showed her my bike (she really needed a new bike), and she decided to take it. We went out to dinner, and finally had to bid her farewell. It was nice to see Marike again.

Kaiser Wilhelm Gedächtnis Kirche

Isar Tor

Schweinehaxe

Marike enjoys her new bike

Wednesday03May—no pressure today. We caught the 8 am train to Magdeburg, and had three transfers, all of which went well. The last was a little strange, since the train was marked differently from what was indicated, and it was packed to the brim… Sort of. By the train doors, a large group of young students aggregated, blocking entry and exit for everybody else. Then, the train poorly indicated next stops, making us think we might have been on the wrong train, or gone past our stop. But, we ended up correctly, and met Hannes. I rode the bike up to their home, while Jon went with Hannes and the bags. It was pouring down rain, so I arrived a bit wet. It was nice to see Katja and Hannes again, but we expected Herbert to be here. He wasn’t. A phone call to Herbert suggested that he had never left Krefeld, but would come tomorrow. So, we spent the evening chatting with Katja and Hannes.

Thursday 04 May—today was another lazy day. Originally, the Wagners wished to take us to Bayreuth, but then we heard that Herbert would be coming, so we laid low. After breakfast, we went to an area that was a walking path up in the vineyards above the Main. Gustav came along for exercise. It was a beautiful site overlooking the river valley, and we could also see the Radweg that Peter and I had done a few years ago. Coming down, we went through the old city of Karlstadt, and then spent a quiet afternoon waiting for Herbert to come. No Herbert. So, we went out to a phenomenal restaurant, where we went when Peter and I were with the Wagners. The food was incredibly good, and the ambiance was an arched cellar. Once we got home, we finally found Herbert waiting for us. The Wagners (and I) were not too happy that he showed up so late. But, it was good to see Herbert again, and to talk with him. He did not appear in the best health though he had not had medical encounters of a serious nature. The time with Herbert was all too brief before we needed to hit the sack.

Walking with Hans-Jurgen and Gustav

View of the Main from above

Marienweg

Wege Wein – well marked routes through the vine yards

Old city street, with Hans-Jurgen

The restaurant Keller

Herbert at last!!!!!

Friday 05 May—it was an early wake-up and breakfast, and a quick goodby with Herbert. I rode the bicycle down to the train station, and Jon came with the Wagners. The train ride was smooth, but the bicycle car was loaded with young school students, apparently on an overnight field trip. We didn’t get to sit down for most of the trip to Frankfurt. On arrival in Frankfurt, we first had our last Döner, took the bike again to the bike shop, and then went for a walk around Frankfurt. We were able to check in early to the hotel, leaving us free to roam without luggage. We had a very small dinner, repacked al of our goods, picked up the boxed bike to bring back to the Ramada Inn hotel. Bedtime was early.

Saturday 06May—last day in Germany! Neither Jon or I slept well, as there was too much noise outside. We got up by 6 am, completed packing, and headed to the train station. We decided to make two trips to the airport, since we both had heavy luggage, plus a large bike box. That was successful, though we probably didn’t need to get up quite as early as we did. We were able get checked in very easily, and got some duty free shopping done before boarding the plane. We slept on the plane. The only strange event was the transfer in Chicago. I knew that we only had a little over an hour to accomplish the transfer, so ran like mad, dashing through customs, collecting our bags and bike, re-loading our bags and bike, then dashing through security again, and finally making it to the terminal about 2 minutes before the plane was supposed to leave. At the counter, the man told me that I had an hour to go. I had NO idea where that hour came from, regardless of how many times I rechecked our schedule and timing. Anyway, we got home, lovely Betsy was able to pick us up, and was able to get unpacked that evening. Of course, with jet lag, I couldn’t sleep all night, but that’s another story.

Germany was great and it was so nice seeing wonderful friends. My only regrets were being unable to ride the bike more, see the Kretschmars, and spend more time with Heinz and Debbie and Herbert. I would maybe do it more in the summer or fall with a foldable bike, and spend a month or two again at the Goethe Institute.

Tagged with:
1 Comment »
May 07

Twilight Forever; the complete saga, starting Kristin Stewart and Robert Pattison ★

My son Jon and I spent a night in Forks on a week-long bicycle ride looping around the Olympics, and there was much talk in Forks about this film series. I had no great interest in watching this series, but then, curiosity killed the cat. It is a series of three episodes, the last episode dived into two parts. The movie is based on a series of books, written by Stephanie Meyer. The plot is easy to summarize. A girl (Bella Swan) moves from her mother in AZ to her father, who is a town sheriff in Forks, Washington. She is in her last year of high school, and needs to find friends. She first encounters a native Indian (Jacob Black), who is quite attracted to her. She also encounters another dude (Edward Cullen) who looks and acts more like a creep than anything else. The creep also has other family members attending the school who are just as creepy. Through a variety of events, Bella becomes attracted to the creep Edward as well as the Indian boy Jacob. Eventually, she discovers that Edward is actually a vampire with remarkable talents and doesn’t age with time, and that Jacob is a werewolf, but worse, that the vampires and werewolves really don’t get along too well together. Eventually, she totally falls in love with Eddie the vampire, partially because she fears growing old and thus would like to become a vampire herself. After many sub-events, she eventually marries Edward, has a baby from him which almost kills her, but is saved by becoming a vampire herself. Her baby though becomes imprinted to Jacob, making a crazy threesome.

There is just too many things wrong with this movie series to know where to start. First, this movie really doesn’t have good acting, and how Kristin actually became famous by playing the lead role testifies to the desperation of the Hollywood audience. None of the acting was remarkable. The visuals were good, but not outstanding. Secondly, the storyline was just plain stupid. Too many things were inexplainable, or inconsistent. Why would a 107 year old vampire wish to place himself in a high school situation? Why would the vampire father masquerade as a doctor? Why would the vampire family move away in order to keep their identity concealed, only to return later for no good reason? Similar questions could be asked of the werewolves. Why would the lead female fall in love with a creep? Why didn’t the female experience the problems of becoming a vampire and losing her soul, as she was warned? In both the vampire camps and the werewolf camps, there were bad vampires and “good” vampires, bad werewolves and “good” werewolves. What’s going on there?

My only explanation to this story is that the author really wrote with flight of thought, not even giving thought to what she previously wrote. Perhaps the books offer a better explanation? The mindset of the entire tale is with teenagers living in a solipsistic world of their all important selves. After all, high school is so great, and even 107 year old vampires would eagerly love to re-experience high school. So, my advice to anybody curious about this series—don’t waste your time. It isn’t even good entertainment. There are too many other reasonable movies to watch to waste your time on the stupidity and poor acting of this series.

Tagged with:
1 Comment »
May 07

Bad Science

By Kenneth Feucht books No Comments »

Bad Science, Quacks, Hacks and Big Pharma Flacks, by Ben Goldacre ★★★★

This book was recommended to me by Dr. Tate, and is an enjoyable read. It is not about science, per se, but about research and science in health care. It is a book that I wish most people (who choose to be opinionated about health care problems) would read. The slightly less than excellent rating is not because it was a mediocre book, but for reasons to be explained below. The book is good because he hits at many of the issues that is encountered by popular medicine, whether it be conventional or alternative. So many people are deeply opinionated in things they know little about, and health care ranks at the top of the list. The book has 12 chapters, which I’ll briefly review.

Chapter 1, Matter, is an attack on a potpourri of crazy alternative health options, focusing on detoxification methods. Sadly, these treatments suggest that they are based on “science”, though worthwhile studies are virtually non-existent. Chapter 2, Brain Gym, attacks a ritual that I guess is quite popular in the British school system, but was exported from the US. In it, students go through a number of silly rituals to improve their “brain power”. Such a concept needs minimal argument as the method is so ad hoc and untested. Chapter 3 Homeopathy, is explored in a bit more depth. Goldacre’s biggest rant is against the extremely shoddy nature of their studies, as he begins to explore with the reader what it takes to engage in a legitimate clinical study. As a side comment, these were issues that were even of serious concern to the bench scientist. He spends some time introducing the issue of the Cochrane collaboration, and organization of scientist/statisticians which will take a given topic, research as many studies as possible that addressed the given topic, combine the studies through fancy statistical analysis, and then come to a conclusion. Chapter 4 is about the placebo effect, clarifying in many ways the power of a placebo. Chapter 5, titled The nonsense du jour, explores more about issues of bad science, how studies are poorly controlled, etc., but then focuses on nutritional studies and and anti-oxidants. Chapter 7, Nutritionists, develops an all out attack on people making ridiculous food claims, which are most plentiful. Chapter 8, The doctor will sue you now, goes into a personal story of Dr. Goldacre being sued by Dr. Matthias Rath for libel regarding Rath’s claims for the benefit of high dose vitamins, but lacking any substantial research to support that claim. Of course, the claim is so typical, that physicians and Bid Medicine are in collusion against alternative treatments, yet alternative treatment practitioners do not repel those claims by offering a legitimate scientific study. Which leads to chapter 9, Is mainstream medicine evil? Here, Goldacre takes a hard look at big Pharma, and instances where they have twisted or concealed data. The example used was of Vioxx, whose problem would never had been found if sloppy science was being used. But, Goldacre makes a claim that big Pharma has gone wrong in the past, and how pressures on the pharmaceutical industry will continue to manifest serious problems. In this chapter, I think that Goldacre was a little too kind to big Pharma. Yet, he also published an entire book attacking Big Pharma, so, perhaps he is leaving much to another book. Chapter 10, Why clever people believe stupid things, summarizes why very intelligent people, including those who have had scientific training, can be so wrong with healthcare studies. Not understanding randomization and statistics, preformed bias, drawing conclusions after the fact of the study all lead to wrong conclusions. This is probably the best chapter in the book. Chapter 11, Bad Stats, hits even harder on how study design, randomization, abuse of data, lack of critical thinking, etc., has led to so many false conclusions, and even major lawsuits, where the uncritical mind (especially lawyers) can draw conclusions from data that just isn’t there. Chapter 12, The MMR hoax, is a rant about the bad science used to suggest that the MMR vaccine is bad for you, causes autism, etc., etc.. His case is strong. I’m glad he didn’t attack the fight against the flu vaccine, whose science is pathetic. So, the book is good about detailing how bad science, bad statistics, and bad thinking can lead so many people (including very bright people, scientists, doctors) to wrong conclusions regarding issues related to health.

So, what did I not like about the book? I felt that Goldacre was completely lacking in humility, and his assumption that science can avoid issues of investigator bias are wrong. His assumption that with “good” science, all truth will be fore coming is fitting of a positivist mindset, which has been otherwise been thoroughly destroyed as a philosophic construct. Science depends on paradigms which so often are just plain wrong. It’s been shown that predictably, paradigms will change every 20-40 years, whether it be in health care, or in the hard sciences. He remains hyper-critical about everybody but himself. This is the greatest failure of this book, and Ben could use a dose of humility.

Tagged with:
No Comments »
preload preload preload