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Schizophrenia and civil rights.

Wednesday, December 19th, 2012

In June 1962, I had just finished a year of active duty in the Air Force (actually 9 months) and was looking for a job until I went back to medical school in September. I had been pulled out when the reserves were called up by Kennedy in the wake of the Berlin Wall, built by the Russians in August.

I found an ad in the LA Times for medical students to work at the VA hospital in west Los Angeles. I was a medical student although I had had only one month of medical school. I had, however, been a corpsman in the Air Force so had a little more clinical experience than many first year medical students.

I applied and was accepted. I learned the job was to do annual physical exams on 200 chronic schizophrenics since the psychiatry residents, in the grip of the psychoanalytic phase of psychiatry, did not want to do so. I started about the 15th of June and soon met my boss, a professor of psychiatry at UCLA named George L Harrington.

He was a striking individual, a big man who walked with a pronounced limp from a previous femur fracture. The effect of this combination was powerful on the chronic schizophrenics of Building 206 at the Sawtelle VA Hospital.

Harrington was one of the two or three most impressive men I ever met in medicine. He had trained as an analyst and his father was one of the first lay analysts, a former Baptist minister. Harrington had met Sigmund Freud and actually sat on his knee as a child. He grew up near the Menninger Clinic in Kansas and went to Kansas Medical School. He told me that one of his first summers in medical school, he got a job at the state mental hospital and tried his psychoanalytic theories out on chronic psychotic patients. They didn’t work. When summer was over and the state psychiatrists returned from vacation, they treated one depressed female patient with shock therapy. Harrington had spent the summer trying analysis on her with no success. With one ECT session she was much improved. That was enough to convince him that analysis did not work, no matter that the psychoanalytic school of psychiatry had taken over the specialty and the departments of all the medical schools.

Harrington was sure this was all wrong and was convinced that schizophrenia was an organic disease. He told me that it might even be a deficiency of an unknown vitamin. It wasn’t so many years since beri-beri and pellagra had been discovered to be vitamin deficiencies. I have previously referred to this experience, and I am convinced that he was on the right track when most psychiatrists were wrong.

Unfortunately, the psychiatry profession held on to psychoanalytic thinking far too long. A friend of mine from medical school is an analyst and has made a good living from it in Malibu. That is a good choice of location since analysis works best on rich mildly neurotic patients. Psychotics tend to be poor and difficult to work with. Now, with huge advances in neurobiology there is more hope but the public is still reluctant to trust psychiatrists with any authority. I am afraid that the profession is still suspect from the years of the Freudian blind alley.

A fellow named Clayton Cramer, who has a schizophrenic brother named Ron, has written an excellent book about the legal history of the deinstitutionalization movement that emptied the mental hospitals since 1960. On his blog, he posts that the shooter in Connecticut may have been taking Fanapt, an antipsychotic drug that is prescribed for schizophrenia. A rather hysterical post on what looks like an anti-treatment site alleges that SSRIs, a class of drug that is unrelated to anti-psychotics, are responsible for mass shooting incidents. It is this sort of misinformation that muddies the waters around the issue of violence and mental illness. The drug, iloperidone is an “atypical anti-psychotic” which means it is a serotonin receptor antagonist. It was nothing to do with SSRIs, which are selective serotonin reuptake inhibitors. The effects are very different as are the mechanism.

The battle for intelligent treatment of schizophrenics goes on.

A summary of treatment options does not mention the most serious problem. That is that schizophrenics commonly stop taking the drug, either because they feel fine and believe they no longer need it, or because they have no insight into their condition and refuse the drugs unless coerced. This is the reason why commitment, even outpatient commitment which involves supervision of the drug taking, is desirable.

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Posted in medicine, science, social issues | Comments Off

A big day tomorrow.

Wednesday, June 27th, 2012

The US Supreme Court will probably announce the decision on Obamacare, known by its supporters as “the affordable care act,” tomorrow. If it is overturned, as I sincerely hope, there will be the need to provide an alternative. I don’t trust Obama to accept the verdict anymore than he accepted the partial victory for Arizona. His antipathy to that state is palpable and is demonstrated by this laughable headline.

Official: Obama administration will enforce its priorities, not Arizona’s

The fact that Arizona’s priorities include US law enforcement notwithstanding.

Obama administration officials said Monday the federal government would not become a willing partner in the state of Arizona’s efforts to arrest undocumented people — unless those immigrants meet federal government criteria. And they said the administration is rescinding agreements that allow some Arizona law enforcement officers to enforce federal immigration laws.

The administration made the announcement hours after Monday’s Supreme Court decision on whether states can enforce immigration laws.

The fact that Arizona wants to enforce a federal law that the feds are not enforcing is ignored. There is a reason why CNN was called “The Clinton News Network” in the 1990s.

I expect something similar if the Court strikes down Obamacare. The law is massive, unwieldy and still a mystery to most of those affected.

Opinions on the law and its provisions are available here. Topics include age based medicine. Here is where rationing will be applied in spades.

It is unfortunate that one cannot engage in a dispassionate and objective analysis of the Progressives’ ideas on age-based medicine and end-of-life healthcare without being immediately accused of invoking “death panels,” and thus of displaying the dearth of sophistication, the lack of understanding, and the primitive logic commonly attributed by Progressives to Sarah Palin.

I must remind my readers that I have yet to use the term “death panel” to refer to any of the multitude of expert commissions created by Obamacare, whose charge will be to dispassionately examine the scientific evidence in order to determine which patients will get what, when and how. These bodies, in fact, will be explicitly aiming to optimize the medical outcomes of the entire population (titrated to the amount of money we’re allowed to spend on healthcare), and not actively prescribing death for anyone.

Judging from the histories of governments which have adopted a collectivist philosophy, if death panels should appear on the scene they will not be aimed at determining which patients may live or die. That job, of course, will fall to the doctors at the bedside, who will offer or withhold medical services according to the dictates (i.e., “guidelines”) handed down by those sundry expert commissions. Rather, any death panels which might eventually materialize will more likely be aimed at keeping those doctors themselves (and any other functionaries whose job is to do the bidding of the Central Authority) in thrall.

So why has the term “death panel” caught on to such an extent that conservatives so often use it as shorthand to express what they see as the “sense” of Obamacare, and Progressives so often use it to accuse rational and mild-mannered critics of Obamacare (such as your humble author) of belonging to the Neanderthal persuasion? Read the rest.

Anyone who has done some reading about health care in other countries, such as the UK or the Netherlands knows what this means. In the Netherlands, ten years ago, any physician who admitted a chronic lung (COPD) patient to ICU with respiratory failure would be looking for a job the following day. The burden will always fall on doctors, which is why we are so interested. The stories of delay in admitting critically ill patients to the ER in the UK are another cure for boredom.

The French have some interesting ideas about such issues as pre-existing conditions, which will no doubt be a prominent issue if the USSC acts tomorrow as I expect. In the French system, certain conditions that affect insurability are covered by the plan 100%. However, the coverage is ONLY for the condition, such as Diabetes, and not for unrelated conditions, such as appendicitis.

Some cases are eligible for exemption for co-payment. Serious medical conditions such as diabetes, cancer and AIDS are exempt. The exemption pertains only to the diagnosis and other conditions require co-payment. A cancer patient with appendicitis, for example, must pay the regular rate for the surgery. More complex services and hospital stays over 31 days are also exempt. The exempt class of patients, such as children, maternity and war pensioners are the third category.

I spent some time several years ago analyzing alternatives to what became Obamacare. Those blog posts are here. The history and evolution of the French health system are included. I think it offers the best model for the US to us for reform. Of course, Obamacare has nothing similar to the French plan. It was designed to appeal to rent seekers in the health care industry.

More will be added tomorrow.

UPDATE: Well, we now know that the Court upheld the constitutionality of Obamacare. This is disastrous for the health care system that we have, although it has deteriorated since 1978 when the government began trying to rein in health care costs under the guise of “improving quality.” The rationale for approving it was that the “Mandate” is a tax, not a fine. The politics of the decision are not yet clear and may not be before November.

No doubt Obama and his supporters will hail the decision as a victory and it may well be so. My concern is with the effects of the law, itself. It is not reform and it is not workable. The question I have is whether the law will be recognized as unworkable before it has destroyed the present system. I fear not. For those who want to understand the effects, I suggest reading this explanation of health insurance and why the insurers supported Obama. Note this statement:

In return for its support in the healthcare reform battle, President Obama offered the insurance industry the graceful exit strategy it so desperately needed. Under Obamacare, for at least a few years the insurers hope to get One Last Windfall – namely, profits from the influx of previously-uninsured Americans whose premiums will be paid, or at least subsidized, by taxpayers. Here, the insurers are relying on the likelihood that the inflow of new premiums will, for a year or two at least, greatly outweigh the outflow of money they will have to spend caring for these new subscribers. Obviously, they will use every trick in their well-worn book to stave off expenditures for these new subscribers for as long as they can, but if they actually knew how to avoid paying healthcare costs indefinitely, they wouldn’t be seeking a government bail-out today. In any case, an inflow of new subscribers will be a very temporary source of profit for insurers. Hence, at best it is One Last Windfall.

What happens to the insurers after they exhaust this last windfall is still up in the air. Obamacare may, of course, eventually transition to a single-payer system, an outcome which many conservatives desperately fear, and many liberals fervently desire. In this case, there may very well be some final compensatory buy-out (or a buy-off) for the insurance companies. But more likely, the insurance companies under Obamacare will continue to exist essentially as public utilities. That is, they will exist as companies chartered by the government, which administer healthcare under the direction of the government, with the products they may offer, the prices they may charge, the profits they may keep, and the losses they may incur, determined solely by the government. It’s not glorious, but it’s a living.

This, in fact, is the business plan of health insurance companies. They view HSAs and other conservative attempts to control costs by modifying behavior as the enemy.

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Posted in economics, geriatrics, health reform, medicine | 3 Comments »

The Trayvon Martin case

Tuesday, May 29th, 2012

There have been astonishing new developments in this case in the past week or two. Naturally, the new information is the work of private bloggers and it has not yet reached the news media. When it does, and it may not until the George Zimmerman case comes up for judicial determination, there may be an explosion.

First, the research done by bloggers began with Trayvon’s Facebook page, which until last week was on view. On it he had open discussions with friends about drugs, both marijuana and a concoction of Dextromethorphan, Arizona Iced Tea watermelon juice flavor and Skittles, the candy. These components, mixed together, make a cocktail which gives a potent high from sipping it over an hour or two. The mixture is referred to on the street as “purple drank,” and the process as “sippin.”

Trayvon’s Facebook page contained many of the references to this cocktail. There is information that chronic use, which is evidenced by the entries on Facebook for nearly a year, can lead to brain damage and behavioral abnormalities. Some of that behavioral effect can be seen in the 7-11 video recently released. Some of the networks showed part of the video, edited and speeded up to make Trayvon’s behavior look more normal. The comments at most of the sites showing the video mention that his encounter with George Zimmerman was “moments later.” It was actually nearly an hour later and there is considerable discussion about what took place. Some versions of the video show three other men meeting Trayvon and may show him conducting a transaction with them.

He has an interaction with the 7-11 clerk. The audio is edited from this segment but the clerk points to a shelf behind the counter and shakes his head. That shelf is where Dextromethorphan is kept. The drug, also referred to as DXM, is the effective cough suppressant in cough syrup and those brands containing it are labeled “DM.” When I was a child, codiene, a more effective cough suppressant, was in popular use but abuse of it for recreational purposes made it prescription only. DXM is headed the same way for the same reason. In fact, chronic use of DXM is dangerous and may cause behavioral changes including rage reactions to minor stimuli. The Arizona Iced Tea watermelon juice flavor and Skittles were found in his pockets, as well as a lighter but no cigarettes.

The best site for explanation of this new information is here (a video), an here, and it is especially important to read the comments, which will take an hour, but there is a lot of information there. The reference to “Treepers” refers to the parent site, Conservative Tree House, a group site with two major bloggers, Sundance and Dedicated Dad, who tell most of the story.

Prepare to spend a couple of hours going through all this but it contains the answer to what happened, I believe. The purple drank concoction, is also referred to as “lean” because it makes the user lean and move slowly, which describes Trayvon’s behavior in real time in the 7-11. This has not yet hit the news, and may not until the court date, but it is powerful. There are also some suggestions from the Facebook entries that Trayvon was selling marijuana to classmates but that is secondary to the story of the shooting.

It is also significant that the father and the girlfriend went out to dinner leaving Trayvon and Chad, the son of the girlfriend, alone. The father turned off his cell phone when he went to bed and did not know anything was amiss with Trayvon until the next day. There are many questions about all this but most are covered at the links I provided.

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Posted in media, medicine, racism, social issues | 1 Comment »

Why Obamacare is much worse than many think and why it must be stopped.

Monday, May 14th, 2012

The Supreme Court will rule on he constitutionality of Obamacare this year. The arguments and the issue which got the most publicity was the individual mandate. I don’t actually care much about this although it may well violate the Constitution. There are far worse things in the legislation and they should be emphatically rejected by the Supreme Court. The worst of the issues is discussed in detail here. This is a really frightening piece of legislation and I cannot imagine that the Court will let it stand. Of course, given the absence of argument, the Court will have to find this itself.

Perhaps nothing in the Obamacare legislation embodies the top-down, command-and-control nature of Progressive healthcare more than the Independent Payment Advisory Board (IPAB), a 15-member panel of “experts” to be appointed by the President. There are three particular features of the IPAB that illustrate this fact: The IPAB will control all healthcare spending, public and private. The IPAB has been awarded near-dictatorial power. And the IPAB is designed to be a nearly immutable entity.

How is this accomplished ?

Specifically, Section 10320 (in the Managers’ Amendments portion of the legislation) grants the IPAB, beginning in 2015, the authority to limit all healthcare expenditures, that is, all healthcare expenditures, and not just expenditures by Medicare or government-run programs.

To emphasize this expanded authority, Section 10320 changes the name of the “Independent Medicare Advisory Board” to the “Independent Payment Advisory Board.” It directs the IPAB, at least every two years, to “submit to Congress and the President recommendations to slow the growth in national health expenditures” for private healthcare programs. Furthermore, it designates that these “recommendations” may be implemented by the Secretary of HHS or other Federal agencies “administratively” (that is, without any action by Congress).

Thus the federal government can control, under penalty of criminal prosecution of doctors, private health care spending ! This goes well beyond Medicare and Medicaid. It will prevent, unless stopped, people from spending their own money on health care.

That is not the worst of it. The IPAB cannot be changed or repealed by Congress. This is unprecedented in US law. Even the ill-advised Prohibition Amendment, promoted as another moral obligation by progressives after World War I, could be repealed by another constitutional amendment.

A quick reading of Section 3403 might leave one with the impression that the IPAB is a sort of Mr. Rogers of healthcare – a mild-mannered, friendly, always-helpful, but ultimately undemanding agent for good. This is the impression imparted by the first few paragraphs of the Section, which paint the new entity as an “advisory” board, whose main task is to develop “proposals” and “advisory reports,” which “proposals” and “advisory reports” would solely consist of various “recommendations,” that ought to be “considered” for the purpose of cost reduction.

Nothing could be further from the truth. This language is simply another example of supplying a new law, which is far more radical than the authors would like people to know, with a soothingly misleading introductory paragraph. The IPAB is actually designed to be as all-powerful as it’s possible to be.

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Posted in health reform, medicine, politics, social issues | 1 Comment »

Hairy surgery story

Wednesday, May 2nd, 2012

I’ve sort of lost my enthusiasm for Gerald and Sara after having the copyright farmer creep around here. A commenter said he would like to hear a hairy surgery story so here goes.

About 20 years ago, I got a call from the emergency room at San Clemente Hospital. They had just admitted a man who had had an aortic aneurysm repaired at Kaiser about six weeks before. He was now passing blood per rectum and was shocky and pale. This is a diagnosis you can make on the telephone. It is also an extreme emergency. A leaking native aneurysm is bad enough. I’ve seen patients survive for hours in that case, including a couple who refused surgery until it was almost too late. When the patient has had aortic aneurysm, or aortic bypass surgery, this story means that the suture line at the junction between the graft and the neck of the aorta above the graft has eroded into the small intestine, the duodenum usually, adjacent to the graft junction. The aortic flow is being blocked from the gut only by a clot. When that clot goes, the patient will exsanguinate into the gut, a matter of a couple of minutes.

I called the OR at the hospital and asked everybody to come in as fast as they could. It was about 9 o’clock at night as I recall and, fortunately, the elective surgery for the day had all been completed. That was a small hospital with two big operating rooms, whereas the trauma center that my partner and I ran had 14. There was no time to think about transferring him.

When I arrived, everybody, including the anesthesiologist on call, was there. There had been some problems with anesthesia in the past but that night we had a good sturdy gas passer. Faint heart has no place in a case like this.

An internist friend happened to be there and he liked to assist in surgery, unlike most internists. He was fun to have around, even in a big hairy case, so I asked him if he could stay. It was going to be an all-nighter, but he was enthusiastic. Fortunately, I had used self-retaining retractors for years and these are almost an assistant surgeon in themselves. The types I used fastened to the table and had multiple blades, including some that were malleable, so they could be positioned and left in place. They never got tired.

The anesthetist put the patient lightly to sleep and we got the blood bank to get some type-specific blood on hand, there was no time for cross match but it would be done as we went along. I made the incision about 30 minutes after he hit the ER door.

What we found was what I expected; a large hematoma around the aortic suture line where the duodenum crosses the aorta. In the days when I was still in training, we saw quite a few of these cases because the anastomosis had been done with silk sutures. Silk lasts for years but not forever and the pulsatile aorta never heals completely to the graft. To make things worse, many of the early grafts were made of Teflon, which just does not heal to tissue at all. The combination of silk sutures and Teflon grafts gave those of us of that generation plenty of experience with “false aneurysms” at the suture line of prior aneurysm repairs and bypasses. In that case, the suture line had come apart but the surrounding tissues were strong enough to prevent complete rupture. I can remember a couple of cases where, when I opened the false aneurysm (having clamped the aorta above), the graft was lying free in the center, not attached to anything.

In this case, the cause of the problem was either a suture line that had not been adequately separated from the duodenum by pulling tissue between them as a barrier, or an infection. No matter the cause, it was infected now as duodenal contents were bathing the graft. Once, in a previous case, a gastroenterologist had endoscoped a patient for mild GI bleeding. Far down in the duodenum, he saw what looked like a piece of celery. He asked if we wanted it biopsied. My partner laughed and said, “No, that’s the graft.” It was stained green and had eroded the duodenum but the suture line was intact. Her aortic surgery had been years before.

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Posted in medicine, personal | 2 Comments »

Dick Boggs

Thursday, March 15th, 2012

When I was a medical school junior, we had a rotation on the Neurology service at LA County Hospital. One of my classmates was planning a career in neurology but the reason it was so popular with the students like me who were interested in surgery was that we got to do tracheostomies. A number of patients with severe neurological lesions would require respirators or had trouble with airway secretions requiring a tracheostomy. This was our one chance to do surgery, even a minor procedure as things go. It was good practice and I later did a lot of tracheostomies, some quite difficult and rushed.

Our resident was a very interesting guy named Dick Boggs. He was tall and looked a lot like Orson Welles did when he was young and making “The Third Man.”Boggs was quiet and aloof but let us do trachs and work up any patient we wanted to. I had some very interesting cases. One was a woman who showed all the signs of alcoholic neuropathy, which is very similar to diabetic neuropathey. It was a popular rotation for juniors. Boggs was popular among the residents and was elected the president of the Interns and Residents Association, which under his leadership took on some of the characteristics of a union.

At the time, intern and resident pay was very low and, aside from a new dormitory that was built for single house staff, we were on our own. I was married with one child, born in March 1965, so I was really on my own. My wife quit her job as a teacher in January 1965 and I was working after hours doing histories and physicals at private hospitals for $7 per hour. Fortunately, my tuition was covered by scholarship but living expenses were tight. We lived on $200/month contributed by our parents, $100 from my father and the same from Irene’s parents. Half of that went for the rent of our two bedroom house in Eagle Rock, near Pasadena. I’m spending some time on details to emphasize what Boggs accomplished for us all.

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Posted in Chicago, education, medicine, personal | 7 Comments »

Another Powerline deleted comment.

Monday, November 14th, 2011

Apparently, the webmaster at Powerline does not approve of some of my comments and deletes them. The latest example;

“strategery123@hotmail.com (signed in using Hotmail)
I think this series would have a lot more impact if you just called it annals of british medicine…I don’t recall a single instance where you referenced any other government medicine (horror) story. surely there are stories out of spain, france, canada, italy, belgium, etc etc.
it is also disappointing (but not surprising just thought you were above that sort of stuff) that you equate the NHS with Obamacare…they are not the same…government medicine (nhs) versus government insurance (obamacare).the NHS is the equivalent of a federal dept where all employees, doctors, nurses, etc are actual employees of the government and the government owns the hospitals, clinics, etc. That is not the same as obamacare where it amounts to government insurance unless you actually believe that all the doctors and healthcare workers will be employees of the government.”

My comment in reply to this was two words; Natasha Richardson.

Natasha Richardson the actress and wife of actor Liam Neeson was skiing at a Canadian ski resort in Quebec when she had a seemingly trivial head injury. Over the next few hours she developed signs of an intracranial bleed. No CAT scan or MRI was available and, in spite of frantic efforts to transport her, she died of an intracranial hemorrhage( an acute epidural hemorrhage). Grace Kelly had a similar history but, of course, that was in 1982 when CAT cans were very new. In both cases, the high tech device was not available.

Does anyone think that a US ski resort would lack immediate access to a CAT scan ? If Natasha Richardson had been skiing at a US resort, she would be alive today. Epidural hematomas are eminently treatable, even without a CAT scan. The lucid interval is almost diagnostic of the lesion. Decompression of the hematoma is curative.

Posted in medicine | 6 Comments »

Australian health care

Saturday, November 12th, 2011

I posted a comment in response to a question on the blog but WordPress ate it so I will try to Post some thoughts about the Australian system. In the 1970s, Australia may have had the best system in the world but politics, as usual, screwed it up. When I was first starting out in the 1970s, we were out for dinner with a couple of Australian surgeons. They explained the system as it existed at the time. The hospitals were almost all owned by the states which funded them. There was a private health care system, called “Medicare” in which individuals who wanted private care paid a monthly premium though the Post Office. All hospital care was in the state owned public hospitals. The hospital based specialists cared for everyone regardless of insurance status in the same setting.

In the early days of the National Health Service in England, a similar situation existed with private patients in NHS hospitals. Then, in the early 1970s, under the Labour government, the unions of NHS employees refused to care for private patients. The result was that Harley Street specialists and their patients left for Belgium. A few years later, there was a small scandal in which the Labour Health Minister had her hysterectomy performed in Belgium by a private specialist. Such hypocrisy is an old story.

In Australia, the Labor Party campaigned in the 1984 election telling voters that, if they were elected, health care would be free. They would abolish the Medicare premium. As it happened, they had made no provision to pay doctors. It’s not clear if this was the result of ignorance on their part or if it was a calculated risk in an election they did not expect to win.

I visited Australia a few years later and saw the remains of the mess. Big states, like New South Wales, had no private hospitals and hospital based specialists, like surgeons, had no source of income. Patients dropped their Medicare premium and the doctors were screwed. With time, there has been a reorganization and official descriptions gloss over the story. If you read this description, for example, there is no description of the chaos that I found in 1988. There were daily newspaper stories, at the time, of patients going without treatment.

I was visiting friends, two GPs in Toowoomba, in Queensland. From them, I learned considerable background. Queensland, the most conservative Australian state, had both private and public hospitals. The public hospitals were not on the same level of sophistication and equipment as the private ones. The doctors in Queensland told their patients that, if they wanted private care, they had better pay their Medicare premiums. My friends owned their own office building and surgery center (called day-surgery). The public hospital also had a day surgery across the street from the private one. A year after my visit, the public hospital approached the two GPs and asked them if they would take over management of the publicly own day surgery as well as their own.

I think most of the major mistakes of the Labor government have been corrected with time. I don’t think the system is as good as it was 30 years ago.

Posted in medical history, medicine, politics | 1 Comment »

Is socialized medicine bad ?

Thursday, November 10th, 2011

There was a post on Powerlineyesterday, which attracted a lot of comments, including one of mine that never appeared. Maybe it was too long but I was trying to respond to a question.

This is a better place to respond so I will try here. The questioners seemed to be single payer advocates.

“Brody Halverson · Top Commenter · College for Financial Planning
Where is Michael’s response? I’m eager to learn of your findings after years of studying this.”

I had earlier posted a comment that I had studied medical errors and medical quality for years. The issue was whether the NHS has better outcomes than the US record.

I have had some experience with the NHS going back 15 years. In 1995, I went to northern England as part of a group from Dartmouth to advise primary care doctors on how to cope with the new “Fund Holding” system introduced by the Conservative government. Fund Holding was a way of dealing with a chronic NHS problem. In the NHS, hospitals and hospital-based physicians have almost no contact with the general practitioners. The GPs find it nearly impossible to find out what happens to their patients while hospitalized. Fund holding allowed the GPs to send their patients to hospitals that are not the local district hospital. The payment for treatment followed the patients. The result was a considerable improvement in the relationship between hospital based-specialists and GPs. A lot more information was shared, similar to what happens in the US system.

A personal friend of mine, a surgeon and teacher of anatomy at a London medical school, has told me that he cannot get Muslim female students and nurses and junior doctors, to scrub their forearms before going into surgery. Hospital infections in NHS hospital are high and rising. NHS hospitals are described as “dirty” and there are problems with obvious issues as changing bed linen. This is pretty bad.

Then there is the notorious order from the health ministry to reduce ER waiting times or face fines. The response of NHS hospitals was quite a bit different from those of US hospitals, even public hospitals. In the NHS, the “target waiting time is four hours. Even at that some hospitals have refused to allow ambulances to bring patients to ERs if the wait will exceed the rules. Instead, the ambulance have been forced to wait in the parking lot until the wait time is reduced.

For one thing, patients in the UK have spent 30 million pounds when ambulances were not available or wouldn’t come. THere are stories of patients dying in ambulances during the wait.

Some commenters have described Medicare as “socialized medicine.” This gets into definitions. Fee-for-service medicine is what is at issue here. There are some patients who prefer HMOs, like Kaiser. That is not a problem because they have a choice. The French have the best medical care system in Europe because they have kept most of it fee-for-service. The patient has a choice. Some of them go to community clinics, similar to our HMOs because choice of physician is not important to them.

However, the fact that the French system is largely fee-for-service makes the single payer segment responsive. Those doctors know that their patient volume may drop precipitously if the patients lose confidence in the system.

Canada has had a modified fee-for-service system for years but it has been starved of funding to the point that patients have begun to seek non-government care. The same thing is happening to Medicare here. The changes are still small and not that many people are affected yet. Most of the problem has to do with the elderly. There are severe restrictions on care of the frail elderly, how frequently the doctor can see them, for example. A government official complained recently that surgery on the elderly is useless because ‘most of these people die anyway.’ In fact, that is a distortion of the data. Only those patients who died were included in the study. I have done major surgery on 90 year old people. The key was that they knew the facts and wanted the surgery.

In Canada people are seeking private care. Technically, it is illegal however a recent decision of the Canadian Supreme Court ruled that a government health care system does not mean that care is available. We are seeing an increasing level of private care used by Medicare patients in this country. Expect this trend to increase if Medicare is subjected to increasing cuts, as in the Obamacare plans.

My recommendations for reform follow the pattern of the French system and I have tried to provide some detail on my reasons.

Posted in economics, health reform, medicine | 4 Comments »

Why socialized medicine is a bad idea.

Tuesday, November 1st, 2011

For many years the term “Socialized Medicine” has been a watchword for reactionary and out of date doctors who think we still live in an era of self-reliance. Everybody knows that health care should be a communitarian responsibility because no one can afford their own healthcare. I can’t afford a car crash, either, but I have car insurance for that.

Now, we have evidence that we can’t afford, as individuals, community health care either. The federal government now has a powerful agency named “United States Preventive Services Task Force (USPSTF), which by its name one would think is in charge of making sure we get our preventive medicine testing as advocated by Nancy Pelosi. Except Nancy has changed her mind.

The Obamacare legislation has transformed the USPSTF from its former status as a mere (one might say milquetoasty) advisory board, which made recommendations on preventive health that doctors and patients could take or leave alone, into an extraordinarily powerful GOD panel (Government Operatives Deliberating) that determines, definitively, which preventive services are to be covered and not covered by private insurers, Medicare, and Medicaid.

If USPFTF determines that something will not be paid for, God help you in getting it done. I first noticed this when I was at Dartmouth. It was found that many men with positive PSA tests, which suggested the presence of prostate cancer, did not die of prostate cancer, at least for many years. These tended to be older men and men with lower levels of PSA. The result was a drive to educate men to NOT have PSA tests. Too many men were having the test and undergoing radical prostatectomy.

I was in some sympathy with this view. I had seen examples of overtreatment. Still, it seemed more fair to allow the patient to choose. I see no similar movement to deny mammography to women although the recent dustup about youngest age at which Medicare will pay from mammography does seem similar

just yesterday, the New York Times published a “news analysis” which aggressively begins selling the public on that very notion – that medical screening tests are, by and large, a bad thing to do.

Even DrRich thought the Progressives would be somewhat circumspect about breaking such remarkable and counter-intuitive news to us in the great unwashed – especially considering that they have just spent the last three decades teaching us just the opposite. But then he recalled their smooth, unapologetic and entirely unremarked transition, around twenty years ago, from sounding the alarm about global cooling to catarwauling about global warming.

And he reminded himself that when you are a Progressive, history always began 10 minutes ago. And this turns out to be a great convenience.

In this case it is particularly convenient, when you consider the passionate declarations by Ms. Pelosi and others in 2009 that the watchword of Obamacare – indeed, the very key to the dramatically lower costs we would realize with this new legislation – would be “prevention, prevention, prevention.”

Expect to hear about this. Here’s another way of

The British medical journal Lancet reported last month that 32% of elderly American patients undergo surgery in the year before they die, a statistic culled from Medicare data. In an accompanying editorial, Dr. Amy Kelley of Mount Sinai School of Medicine labeled the 32% figure a “call to action”—to reduce costly surgeries, intensive-care stays and other high-intensity care for the elderly. Her call was parroted in hundreds of media outlets nationwide. But advocates for limiting health-care spending on the elderly are distorting science to make their argument.

Don’t be bamboozled: The Lancet investigators looked only at patients who died, making surgery appear unsuccessful. That’s like saying Babe Ruth struck out 1,333 times so he must have been a poor ball player—even though he had a .342 lifetime batting average and 714 home runs. Investigators should have considered how all surgery patients fared, including those who recovered, returned home from the hospital and resumed active lives.

The day is coming when divided loyalties will be the most serious problem in medicine. Who has YOUR best interest at heart ?

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