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Medicine and Obama’s Third Term.

Friday, June 4th, 2021

Obamacare changed American Medicine forever. I am becoming convinced that was a major purpose. Since 1978, Medicine and doctors have become the most regulated sector of the American economy.

Five years ago, I predicted one consequence. A doctor shortage. Why ?

A few years ago, it was reported that 10,000 doctors were leaving UK every year. How has the NHS dealt with this shortage?

By importing third world doctors.

The UK’s National Health Service (NHS) will soon begin a major campaign to recruit health workers from other countries to meet growing staff shortages.

Reports suggest a strategy has been drawn up to target a number of countries around the world, including poorer nations outside Europe.

One estimate in March this year said the NHS will need 5,000 extra nurses every year – three times the figure it currently recruits annually.

But what about the countries that it will recruit from – what impact will it have on them?

Where do non-UK staff come from?
The NHS already recruits globally to meet its staffing needs.

More than 12% of the workforce reported their nationality as not British, according to a report published last year.

How are we dealing with our doctor shortage ? By adding “Practitioners” instead of doctors.

How did this begin? In 1978, a new federal program was created called “Professional Standards Review Organizations.”

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George Harrington MD

Saturday, May 16th, 2020

I was thinking about Psychiatry today and the problems of deinstitutionalization. The best source for the latter is “My brother Ron,” by Clayton Cramer.

My book review of this book is here.

I was a medical student in 1962 when I got a summer job working in a VA psychiatric hospital doing routine physicals on the inmates. They were all men and some had been there for years. They were all “chronic hospital cases,” as described in this excellent history. Mr. Cramer gives a very thorough history of psychiatry leading up to the introduction of psychiatric drugs that actually worked and the social upheavals of the 60s that led to the emptying of the state mental hospitals. At the time I had my personal experience with the chronic schizophrenic, the deinstitutionalization movement was just getting started. My own days with these patients were similar in many respects to Mr Cramer’s experiences with his brother, Ron. Fortunately, none were my relatives and I could go home every night and leave their troubles behind. Still, the experience of talking to them all day was exhausting. My job was to do annual physicals since the psychiatry residents did not want to do so.

This was the height of the psychoanalysis influence on psychiatry. Fortunately, the chief of the service where I was working was a former analyst who realized that Freud had nothing to offer the psychotic patient. He taught me to talk to the sane part of the patient and ignore the “crazy” part. The early drugs, like chlorpromazine (Thorazine), allowed much better interaction with these chronic schizophrenics. Some of them explained what it was like to be “crazy,” their preferred term. I witnessed Electroconvulsive treatment (ECT) and saw the “lucid interval” that often followed the session. The patients usually lapsed into psychosis again after a few hours but the desire was to try to prolong the effect and this led to repeat sessions.

The author does a great job with the history and goes into far more detail on the legal aspects than I did in the chapter on psychiatry in my own book, A Brief History of Disease, Science and Medicine. He writes about “The fever treatment” that won a Nobel Prize for Wagner-Jauregg, the advocate, in the 1920s. This was a result of success with syphilis using fever when the drugs were inadequate and toxic. The legal history is important as the legal maneuvers of anti-psychiatry forces were the proximate cause of the disaster that followed. The homeless problem appeared in the 70s as the mental hospitals emptied and the former patients found nothing to replace them. The Community Mental Health Centers, as the author so well describes, were intended to take the place of the state hospitals but were never adequate, especially in the era of “talk therapy,” where a single psychiatrist could only see eight to ten patients a day.

I teach medical students and take them to the homeless shelters in Los Angeles every year so they can see where their County Hospital patients come from, and return to after hospitalization. They are able to see the futility of prescribing medicines when the patient has no clock or refrigerator to time the dose or preserve the drug between doses. The author relates the incidence of mental illness among the street population. The managers of the shelters tell me and my students that 60% of the homeless are psychotic and 60% are drug and alcohol addicts. Half of each group is both. For the first few years, we had an amazing guide, a former homeless man now working for the city. He would regale us with stories of his ten years on the street addicted to crack cocaine. He took us to shelters and to homeless hideouts where he warned us not to go there without him.

This book is a source for anyone who wants to know how things got so bad and why the families of psychotic patients are so frustrated with the “advocates” who block treatment or commitment of those unable to care for themselves. One of my students’ patients was a man with a severe leg infection that threatened amputation. He lived on the sidewalk in front of a Pasadena church. He refused parishioners’ offers of housing, telling them he was waiting for the perfect apartment. He barely kept his leg with intense treatment. After treatment, he returned to the street. This is a national tragedy and the reasons are well explained in this book. I can’t recommend it highly enough.

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My experience described above was with George Harrington MD, the most impressive man I have ever met in Medicine. His obituary:
Born in Independence, Missouri, Dr. Harrington attended the University of Kansas, where he received his medical degree in 1941. He also played football for the university. He then interned in Chicago, and during World War II served in the Pacific theater as a Navy flight surgeon. He was the recipient of a Personal Citation, Distinguished Flying Cross, and four Air Medals as a result of his service. In 1946, Dr. Harrington began his residency training in psychiatry at the Menninger Foundation of Psychiatry, and became a faculty member at the Menninger School of Psychiatry. He also served as chief of professional services at the Winter VA Hospital in Topeka, Kansas and was a member of the American Psychiatric Association. In 1955, he moved with his family to Pacific Palisades, where he began private practice. He was also a clinical professor of psychiatry at UCLA and head of psychiatric services at Brentwood VA Hospital until 1965.
After he served as staff psychiatrist in charge of a research project on chronic mental illness at the Brentwood VA Hospital, his work culminated in the 1965 book, “Reality Therapy,” written by William Glasser. The book, offering a new approach to psychiatric treatment, was dedicated to Dr. Harrington. He counted many noted writers and entertainers among his patients, many of whom dedicated works to him. The playwright George Furth dedicated his Broadway play, “Company,” to Dr. Harrington, who was an avid sailor and continued this activity until his death.

Harrington was a big rugged looking guy who walked with a limp from a femur fracture incurred in an auto accident soon after he finished his residency at Menninger Clinic. He told me his father had been a minister who became a lay psychoanalyst and spent time in Vienna with Sigmund Freud. In fact, he told me that he had sat on Freud’s knee as a child. From the time he was 17 he wanted to be an analyst. His father was at Menninger hence his MD from U of Kansas. After the war, he began his residency at Menninger and found that analysis had little or nothing to offer psychotic patients. He told me that every summer, the staff psychiatrists would leave the state hospital on vacation, leaving the medical students to take over. It didn’t take long for him to realize that he was getting nowhere with psychotics using analysis. He was a funny guy with a great sense of humor and an ability to mimic.

He became a clinical professor of Psychiatry at UCLA and took over a ward at the Sawtelle VA hospital sometime before 1962 when I met him. He told me that staff at the VA were very skeptical of his new ideas on therapy so, early in his tenure, they lined up a “hard case” for him to demonstrate this new “talk therapy. ” The new drugs had made things much easier to deal with schizophrenics and he wanted to go beyond with some sort of behavioral therapy. He said the patient was a typical schizophrenic little guy. Harrington asked him how things were and the patient responded with a long stream of typical crazy talk. Harrington listened to all this, then responded that something very similar had happened to him. He then repeated almost verbatim the same stream of crazy talk the patient had related. Half way through, the patient he said began to laugh. He was no longer psychotic, if he had ever been so. He liked having a bed and three square meals a day. He had memorized enough crazy talk to keep everyone convinced that he belonged there. Harrington cautioned me that anybody who wanted to live in a nut house was not normal. Still, the guy was just not that psychotic. He convinced the ward staff that there was something to his ideas. After that, everybody on the staff was part of the treatment team. Even the guy who ran the floor polisher was invited to the Wednesday staff meeting.

What Harrington did was to set up a program of rules that taught these psychotic patients that we knew they were crazy and we were not about to throw them out into a world that scared them so badly. We also, me especially, talked to them and focused on the part that was not crazy. It could be exhausting to do so but patients would respond. One of them told me as I was leaving at at the end of the summer to go back to school that talking to me allowed more of his mind to come out of the psychosis. Of course, he didn’t put it that way but that is what it sounded like to me. It was an intense summer and George Harrington was someone I will never forget.

Most of my job was to do annual physicals on these man, many of whom had not been examined in years. It was an interesting experience to do prostate exams on these psychotic men. It turned out to be no big deal as they all appreciated someone looking after them. I even found a prostate cancer that summer. Psychiatry was still in the grip of analysis then and the residents from UCLA did not want to touch patients.

After returning to medical school, I met some academic psychiatrists and lost interest in the specialty. Harrington was almost unique although Glasser’s book, which explains much of Harrington’s methods, had a wide popularity and is still in print.

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The Corona Virus Timeline.

Wednesday, April 1st, 2020

It is now becoming a theme on the left that Trump was not quick enough to recognize the coming epidemic.

For that reason, I think it valuable to keep a record of the time line.

Here is the January 12, 2020 WHO report on the virus epidemic in China.

The evidence is highly suggestive that the outbreak is associated with exposures in one seafood market in Wuhan. The market was closed on 1 January 2020. At this stage, there is no infection among healthcare workers, and no clear evidence of human to human transmission. The Chinese authorities continue their work of intensive surveillance and follow up measures, as well as further epidemiological investigations.

Here is the January 30, 2020 report by WHO on the epidemic in China.

The Committee believes that it is still possible to interrupt virus spread, provided that countries put in place strong measures to detect disease early, isolate and treat cases, trace contacts, and promote social distancing measures commensurate with the risk. It is important to note that as the situation continues to evolve, so will the strategic goals and measures to prevent and reduce spread of the infection. The Committee agreed that the outbreak now meets the criteria for a Public Health Emergency of International Concern and proposed the following advice to be issued as Temporary Recommendations.

The Committee emphasized that the declaration of a PHEIC should be seen in the spirit of support and appreciation for China, its people, and the actions China has taken on the frontlines of this outbreak, with transparency, and, it is to be hoped, with success.

Trump stopped incoming flights from China on January 31, 2020.

At this point, sharply curtailing air travel to and from China is more of an emotional or political reaction, said Dr. Michael T. Osterholm, an epidemiologist and director of the Center for Infectious Disease Research and Policy at the University of Minnesota.

“The cow’s already out of the barn,” he said, ”and we’re now talking about shutting the barn door.”

A Minnesota epidemiologist’s opinion.

Nancy Pelosi tours Chinatown on February 24, 2020.

House Speaker Nancy Pelosi made a point of taking a walk through San Francisco’s Chinatown on Monday to show that it is safe, after some merchants have seen a 50% drop in business as some fear they could be exposed to the coronavirus.

As her visit began, a large portion of Chinatown had lost power. That didn’t deter the Speaker from walking along Ross Alley and Grant Avenue.

“I’m here,” she said. “We feel safe and sound with so many of us coming here. It’s not only to say it’s safe but to say thank you for being Chinatown.”

On March 16, 2020, Mayor de Blasio was still enouraging people to attend crowded events.

For most of last week, as Mayor Bill de Blasio continued to urge New Yorkers to mostly go about their daily lives — sending their children to school, frequenting the city’s businesses — some of his top aides were furiously trying to change the mayor’s approach to the coronavirus outbreak.

There had been arguments and shouting matches between the mayor and some of his advisers; some top health officials had even threatened to resign if he refused to accept the need to close schools and businesses, according to several people familiar with the internal discussions.

So much for the urgency in dealing with the epidemic.

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It is time to start the economy again.

Saturday, March 21st, 2020

UPDATE: Here is a pretty good discussion of the economy right now.

I have previously described the COVID 19 virus, which is also referred to as Wuhan virus, to the annoyance of the China friendly US Media. The consequences for the US economy have been severe. The most affected states, New York, California, Illinois and Washington, have virtually shut down their population. Arizona is less affected with 78 positives cases as of today, and no deaths.

Italy and China have had the most deaths. There are a number of factors that probably affect these cases. China is notorious for air pollution and smoking, especially men smoking. There has been a dearth, so far, of listing comorbidities but age has been a major one.

One study lists mortality at age 80+ at 15%. The overall death rate in China was listed at 2.3%, which may reflect smoking and air pollution. South Korea, which has had a big spike as testing progressed much more rapidly than in the US, has a case mortality of less than 1%

South Korea has the dubious distinction of suffering the second-highest number of Covid-19 infections after China – but can also boast the lowest death ratio among countries with significant numbers of cases.

According to the WHO on March 6, the crude mortality ratio for Covid-19 – that is, the number of reported deaths divided by the number of reported cases – is between 3-4%. In Korea, as of March 9, that figure was a mere 0.7%.

AS US testing finally gets going, after the FDA and CDC delayed matters for a month, we will see a big spike in number of cases but, I am convinced, a big drop in mortality rate.

Telephone consulting services, drive-through test centers and thermal cameras – which, set up in buildings and public places to detect fever, swiftly came online. South Korea has undertaken approximately 190,000 tests thus far, according to KCDC Deputy Director General Kwon Jun-wook, and has the capacity to undertake 20,000 per day. Turnaround times are six-24 hours.

Tests are highly affordable. “The test kit is about $130, and about half is covered by insurance the other half by individual,” Kwon said. Those who test positive get the test free, “So there is no reason for suspected cases to hide their symptoms,” he said.

We should be doing the same.

At the same time, we are risking severe economic damage to the country by shutting down business activity. I believe that much of the drastic steps taken by governors, especially in New York and California, is unnecessary. High density cities like New York City and Chicago may have more reason to fear spread of the virus. Most of the country, a source of annoyance to left wing politicians, is of low population density.

Another failure of the US response is the absence of masks, which may play a role in limiting transmission in densely populated areas, as in Asia cities. There are reports that China has controlled most of the manufacturing and resists export.

China made half the world’s masks before the coronavirus emerged there, and it has expanded production nearly 12-fold since then. But it has claimed mask factory output for itself. Purchases and donations also brought China a big chunk of the world’s supply from elsewhere.

Now, worries about mask supplies are rising. As the virus’s global spread escalates, governments around the world are restricting exports of protective gear, which experts say could worsen the pandemic.

Also, there is now evidence that treatment of the infected may not require new drugs but be available with known drugs like chloroquine and its analog, hydroxychloroquine

Israeli pharmaceutical company Teva is donating millions of doses of a malaria drug that is believed to be effective in fighting the symptoms of the coronavirus.

The Jerusalem Post reports that the six million doses of hydroxychloroquine sulfate will be shipped to US hospitals started March 31. By the end of next month, 10 million will be shipped.

It is uncertain how effective the malaria treatment will be against coronavirus, but research is currently ongoing.

In fact, there is good evidence that it is effective.

The in vitro antiviral activity of chloroquine has been identified since the late 1960’s (Inglot, 1969; Miller and Lenard, 1981; Shimizu et al., 1972) and the growth of many different viruses can be inhibited in cell culture by both chloroquine and hydroxychloroquine, including the SARS coronavirus (Keyaerts et al., 2004). Some evidence for activity in mice has been found for a variety of viruses, including human coronavirus OC43 (Keyaerts et al., 2009), enterovirus EV-A71 (Tan et al., 2018), Zika virus (Li et al., 2017) and influenza A H5N1 (Yan et al., 2013). However, chloroquine did not prevent influenza infection in a randomized, double-blind, placebo-controlled clinical trial (Paton et al., 2011), and had no effect on dengue-infecteds patient in a randomized controlled trial in Vietnam.

I had speculated that they might be effective in Influenza but this appears to not be the case.

Clinical trials have already shown effectiveness.

According to Sun, patients treated with chloroquine demonstrated a better drop in fever, improvement of lung CT images, and required a shorter time to recover compared to parallel groups.

The percentage of patients with negative viral nucleic acid tests was also higher with the anti-malarial drug.

Chloroquine has so far showed no obvious serious adverse reactions in the more than 100 participants in the trials.

The first case report using remdesivir was dramatic.

The drug is now in clinical trial but the chloroquine evidence reduces the urgency of the study.

What do we do now ?

My wife and I are at high risk but it is easy for us to self isolate. The mortality rate for those under age 50 is about equal to that of influenza. For those between 50 and 70, only those with pre-existing morbidities have a serious risk.

It is time to reopen the economy certainly by next week. The damage done by unemployment and bankruptcy will far exceed that of the disease.

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Healthcare as an election issue in 2020.

Wednesday, February 26th, 2020

There is a good deal of talk about healthcare among Democrats in the coming election. The latest is a Washington state Congresswoman telling us that American healthcare is causing people to die.

“Well if you did it on Wall Street speculation and obviously on the people who invest on the stock market who make enormous amounts of money would be paying that tiny financial transactions tax on their financial transactions. And I think the thing here to think about is we have a health care system that literally causes people to die.
… the system as a whole will cost us $55 trillion over the next ten years, so the question becomes, why would you protect the status quo? How do we make sure that every person has universal care?”

“Medicare for All” is a slogan, not a plan. I am a Medicare beneficiary and paid both halves of the Social Security tax since 1972 and Social Security tax since I was 16 years old. Ten years ago, I wrote a series of posts about what I considered a good choice of alternatives.

Since then, the American health care system was partially destroyed by Obamacare. I published a number of posts on those changes when it was introduced.

The net effects, in my opinion, were to destroy the small group plans (To the consternation of many Obama supporters in big cities.) while employer plans were left alone. The original intent was to roll those plans into Obamacare but the Democrats recognized that the electoral result would be catastrophic for their union support.

The Obamacare plans were approved by most hospital administrators who believed that the result would be greatly to the advantage of “vertically integrated” health care systems. As a result, many hospitals bought doctors’ practices and groups to control utilization and increase revenues. The failure to roll employer plans into Obamacare has limited the success of these plans but the control of doctors has proceeded apace. The hospital, where I spent 20 years in practice has now required staff members, some of whom have been on the staff 25 years, to get “permission” from salaried ER doctors before they are allowed to admit ill patients.

The Trauma surgery team I organized in 1979, was eventually fired and replaced by an anonymous group of surgeons from elsewhere.

At present, from the best I can discern, Obamacare consisted of an expanded Medicaid with intensified cost controls, applied through intrusive Electronic Health Record software, which is resulting in physician burnout.

While aimed at improving the quality of healthcare, CMS quality measures have had two unintended side effects:

Increasing data-entry demands on clinicians.
Creating a focus on fulfilling measures for reimbursement versus quality of care.

I was an enthusiast on electronic systems in the 1980s and 90s. I thought they would add quality and convenience. That has not happened.

Reevaluation of documentation to change policies to reduce regulatory burden. In a letter to CMS in February 2018, the American Association of Family Practitioners (AAFP) described its principles for reducing administrative burden on clinicians. The AAFP’s proposals included minimizing health IT utilization measures and implementing medical record documentation guidelines, data exchange policies, standard representation of clinical data models, prior authorization guidelines, measures harmonization, and certification and documentation procedures.

These are suggestions which are likely to be ignored unless the political situation changes.

What are the probable changes to come ? It depends on the election. The status quo ante was actually satisfactory to 85% of Americans. The poor was eligible for Medicaid which provided a baseline but was widely abused. Choices of insurance options were available. Young people could buy cheap catastrophic plans that protected them from accidents. Those are all gone. More young people are actually uninsured since the Obama administration shrank from enforcing mandates. Costs are higher as insurance companies make their money from processing claims. Bernie Sanders is actually correct on this topic. The solution would be to go back to an indemnity system of coverage and allow cash discounts by providers. There is no reason to spend $75 to process a $100 claim.

The French system would still be an option but the chance for real reform was lost with Obama care and the political will to try again is just not there.

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Some thoughts on what reform in healthcare would look like.

Monday, April 1st, 2019

I have previously posted some articles on the French healthcare system, which is the best in Europe.

Here is an article on the French system.

The French citizen or resident joins Caisse Nationale d’Assurance Maladie deTravailleurs Salariés (CNAMTS)—health insurance organisation for salaried workers. That covers about 80% of the population now and it pays 80% (often more like 70%) of a fee schedule for the doctor visit although specialists are allowed to charge more. French doctors are divided for payment and fee schedule purposes into three “sectors” after 1980. Sector 1 doctors agreed to abide by the fee schedule established in 1960, modified for inflaton and technological changes. They are mostly primary care doctors although some had waivers from the fee schedule prior to 1971 because they were more experienced or had great reputations. Few are still practicing. Sector 2 doctors could set their own fees but reimbursement was still determined by the fee schedule. These two categories correspond roughly to Medicare assignment in the US. If you accept assignment, you agree to accept Medicare payment as the full payment (or 80% of it plus the Medi-Gap payment).

The French have private insurance companies that provide what we call “Medi-Gap policies for Medicare. Theirs cover everyone.

It seems unlikely to me that Democrats would accept a health plan that allowed balance billing, which is the only way to control costs, short of pure rationing. The French basically provide a fee schedule that is the same for everyone but which allows doctors to charge more if the patient is willing to pay. For example, I called the office of a new internist last week to schedule an appointment. The clerk required that I submit all my insurance information, not my health status, and the doctor would decide if he would see me. If he is that busy, perhaps he could justify charging more.

Here is another article from that series explaining the French system.

French primary care physicians are paid less than American but medical school in France does not require a college degree and is free. I suspect that system might be more attractive in the US than many realize.

Unfortunately, such a radical reform is unlikely. There are other options under consideration.

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From Russia to healthcare in one day.

Saturday, March 30th, 2019

Last Friday, the Mueller report was submitted to the DOJ. Monday, left wing media saw ratings collapse.

What next ? Why Healthcare, of course.

Obamacare, which is a form of expanded Medicaid, costs too much and provides too little care (high deductibles) unless you are a Medicaid recipient. It was designed to shift costs to the insured from the poor. It also was a gift to certain sectors of the healthcare industry. Ted Kennedy criticized healthcare as a “cottage industry” with lots of independent doctors doing their own thing as small businesspeople. That is why doctors have traditionally been conservative. Obamacare changed that. Healthcare is now an industry with doctors mostly on salary and controlled by administrators.

I talked to a young ophthalmologist last week, who had treated a mild eye disorder. He told me he moved to Tucson to work at U of Arizona medical center, which used to be called “UMC” by everybody in Arizona. He explained that the UMC administrators had gotten deeply into debt installing a new “Electronic Health Record” system and sold the UMC to Banner Health. This is a chain that runs the former UMC and has seen an exodus of university faculty physicians. Even my barber noticed. He told me several weeks ago that his surgeon, who had operated on him, got tired of constantly being told he only had 15 minutes to see each patient and left for the VA. The ophthalmologist was disappointed as he had looked forward to working at the academic center.

Traditionally, administrators hated doctors. We made their lives more difficult by advocating for patients. I once told an administrator that if the hospital did not reduce the markup on pacemakers, I would testify for the patient if they sued him for the balance of the bill. They didn’t like it but knew I could go elsewhere,and take my patients there. If I had been an employee, I would not have that choice. Several years ago, I explained how we started a trauma center in our hospital. Since then, the hospital has been sold to a non-profit run by nuns. The surgical group that ran the trauma center for 35 years was fired two years ago. They had declined to sell the group to the hospital. They were replaced by six female surgeons no one had ever heard of and who had never applied for privileges at the hospital or been evaluated by the Surgery Department. No one knew anything about them except one member of this new group had applied for a job at the trauma group and been turned down.

There were a few comments about some less satisfactory results on trauma cases but that has quickly gotten quiet.

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Where is health care going ?

Saturday, August 25th, 2018

UPDATE: A new analysis of Obamacare’s role in the conversion of American Medicine to an industry with corporate ethics.

The health system is now like a cocaine junkie hooked on federal payments.

This addiction explains why the insurance companies are lobbying furiously for these funds alongside their new found friends at left-wing interest groups like Center for American Progress. The irony of this alliance is that the left-wing allies the insurers have united with hate insurance companies and want to abolish them. The insurance lobby is selling rope to their hangman.

Hospital groups, the American Medical Association, the AARP and groups like them are on board too. They are joined by the Catholic Bishops and groups like the American Heart Association and the American Lung Association. (If you are donating money to any of these groups you might want to think again.) This multi-billion dollar health industrial complex has only one solution to every Obamacare crack-up: more regulation and more tax dollars.I practiced during what is more and more seen as a golden age of medical care. Certainly the poor had problems with access. Still, most got adequate care, either through Medicaid after 1965, or from public hospitals, many of which were wrecked by Medicaid rules and by the flood of illegal aliens the past 40 years.

Obamacare destroyed, probably on purpose, the healthcare system we had. It had been referred to by Teddy Kennedy, the saint of the Democrats Party as “a cottage industry.” As far as primary care was concerned, he was correct. What we have now is industrial type medicine for primary care and many primary care doctors are quitting.

So why is there waning interest in being a physician? A recent report from the Association of American Medical Colleges projected a shortage of 42,600 to 121,300 physicians by 2030, up from its 2017 projected shortage of 40,800 to 104,900 doctors.

There appear to be two main factors driving this anticipated doctor drought: First, young people are becoming less interested in pursuing medical careers with the rise of STEM jobs, a shift that Craig Fowler, regional VP of The Medicus Firm, a national physician search and consulting agency based in Dallas, has noticed.

“There are definitely fewer people going to [med school] and more going into careers like engineering,” Fowler told NBC News.

There are several reasons, I think. I have talked to younger physicians and have yet to find one that enjoys his or her practice if they are in primary care. That applies to both men and women. Women are now 60% of medical students. This has contributed to the doctor shortage as they tend to work fewer hours than male physicians.

A long analysis of physician incomes shows that 22% of females report part time work vs 12% of males.

Physicians are the most highly regulated profession on earth. The Electronic Health Record has been made mandatory for those treating Medicare patients and it has contributed a lot to the dissatisfaction of physicians.

THE MOUNTING BUREAUCRACY
This “bottleneck effect” doesn’t usually sour grads on staying the course, Fowler finds, but he does see plenty of doctors in the later stages of their careers hang up their stethoscopes earlier than expected. Some cite electronic health records (EHRs) as part of the reason — especially old school doctors who don’t pride themselves on their computer skills. New research by Stanford Medicine, conducted by The Harris Poll, found that 59 percent think EHRs “need a complete overhaul;” while 40 percent see “more challenges with EHRs than benefits.”

If I remember my arithmetic, that adds up to 99% unhappy with the EHR.

Most primary care physicians I know are on salary, employed by a hospital or a corporate firm. They are require to crank out the office visits and are held to a tight schedule that does not allow much personal relationships with patients. The job satisfaction that was once a big part of a medical career is gone.

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The story of language gets more interesting.

Sunday, February 25th, 2018

I’m tired of politics.

I’ve been interested in autism for some years.

Some of autism is involved in language. Now we are starting to learn about the genetics of language.

It had long been suspected that language has some basis in genetics, but this was the first time that a specific gene had been implicated in a speech and language disorder. Overeager journalists quickly dubbed FOXP2 “the language gene” or the “grammar gene”. Noting that complex language is a characteristically human trait, some even speculated that FOXP2 might account for our unique position in the animal kingdom. Scientists were less gushing but equally excited – the discovery sparked a frenzy of research aiming to uncover the gene’s role.

Several years on, and it is clear that talk of a “language gene” was premature and simplistic. Nevertheless, FOXP2 tells an intriguing story. “When we were first looking for the gene, people were saying that it would be specific to humans since it was involved in language,” recalls Simon Fisher at the University of Oxford, who was part of the team that identified FOXP2 in the KE family. In fact, the gene evolved before the dinosaurs and is still found in many animals today: species from birds to bats to bees have their own versions, many of which are remarkably similar to ours.

This gene has many roles, some of which are involved in language. However, it is not that simplae.

All bird species have very similar versions of FOXP2. In the zebra finch, its protein is 98 per cent identical to ours, differing by just eight amino acids. It is particularly active in a part of the basal ganglia dubbed “area X”, which is involved in song learning. Constance Scharff at the Max Planck Institute for Molecular Genetics in Berlin, Germany, reported that finches’ levels of FOXP2 expression in area X are highest during early life, which is when most of their song learning takes place. In canaries, which learn songs throughout their lives, levels of the protein shoot up annually and peak during the late summer months, which happens to be when they remodel their songs.

So what would happen to a bird’s songs if levels of the FOXP2 protein in its area X were to plummet during a crucial learning window? Scharff found out by injecting young finches with a tailored piece of RNA that inhibited the expression of the FOXP2 gene. The birds had difficulties in developing new tunes and their songs became garbled: they contained the same component “syllables” as the tunes of their tutors, but with syllables rearranged, left out, repeated incorrectly or sung at the wrong pitch.

What is next ? How about Neanderthals ?

The unique human version of the FOXP2 gives us a surprising link with one extinct species. Last year, Svante Pääbo’s group at the Max Planck Institute for Evolutionary Anthropology in Leipzig, Germany, extracted DNA from the bones of two Neanderthals, one of the first instances of geneticists exploring ancient skeletons for specific genes. They found that Neanderthal FOXP2 carries the same two mutations as those carried by us – mutations accrued since our lineage split from chimps between 6 and 5 million years ago.

Pääbo admits that he “struggled” to interpret the finding: the Neanderthal DNA suggests that the modern human’s version of FOXP2 arose much earlier than previously thought. Comparisons of gene sequences of modern humans with other living species had put the origins of human FOXP2 between 200,000 and 100,000 years ago, which matches archaeological estimates for the emergence of spoken language. However, Neanderthals split with humans around 400,000 years ago, so the discovery that they share our version of FOXP2 pushes the date of its emergence back at least that far.

“We believe there were two things that happened in the evolution of human FOXP2,” says Pääbo. “The two amino acid changes – which happened before the Neanderthal-human split – and some other change which we don’t know about that caused the selective sweep more recently.”

Language and autism are somehow connected.

Some of this is pretty primitive as yet.

Moreover, the striking conservation of both FoxP2 sequence and neural expression in different vertebrates facilitates the use of animal models to study ancestral pathways that have been recruited towards human speech and language. Intriguingly, reduced FoxP2 dosage yields abnormal synaptic plasticity and impaired motor-skill learning in mice, and disrupts vocal learning in songbirds. Converging data indicate that Foxp2 is important for modulating the plasticity of relevant neural circuits. This body of research represents the first functional genetic forays into neural mechanisms contributing to human spoken language.

This has got to be important if we can figure it out.

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Does Hillary Clinton have Parkinson’s Disease?

Sunday, September 18th, 2016

The Hillary collpase last Sunday has prompted a lot of speculation on her condition. Early on I was inclined to blame her neurological condition on her history of concussion and cerebral vein thrombosis.

That seemed logical, given her history. However, it does not explain her quick recovery. It also has nothing to do with pneumonia.

This video has now convinced me that she has Parkinson’s Disease, and it is fairly advanced. In the video, the physician mentions Apomorphine, which is not morphine but an alpha adrenergic drug used in Parkinson’s Disease.

Currently, apomorphine is used in the treatment of Parkinson’s disease.

What use does it have in Parkinson’s? It is used for “Non-motor symptoms.”

What does that mean ? Parkinson’s Disease is characterized by a serious of motor disabilities.

The cardinal symptoms of Parkinson’s disease are resting tremor, slowness of movement (bradykinesia) and rigidity. Many people also experience balance problems (postural instability). These symptoms, which often appear gradually and with increasing severity over time, are usually what first bring patients to a neurologist for help. Typically, symptoms begin on one side of the body and migrate over time to the other side.

These symptoms are typically controlled with Dopamine like drugs, such as L-Dopa. There are other symptoms less easily controlled.

For example, in advanced cases, difficulty swallowing can cause Parkinson’s patients to aspirate food into the lungs, leading to pneumonia or other pulmonary conditions. Loss of balance can cause falls that result in serious injuries or death. The seriousness of these incidents depends greatly on the patient’s age, overall health and disease stage.

Hmmmm.

There are also side effects of L Dopa.

L-DOPA therapy is further complicated by the development of movement disorders called dyskinesias after 5 – 10 years of use in most cases.

Dyskinesias are movement disorders in which neurological discoordination results in uncontrollable, involuntary movements. This discoordination can also affect the autonomic nervous system, resulting in, for example, respiratory irregularities (Rice 2002). Dyskinesia is the result of L-DOPA-induced synaptic dysfunction and inappropriate signaling between areas of the brain that normally coordinate movement, namely the motor cortex and the striatum (Jenner 2008).

(more…)

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