Posts Tagged ‘medicine’

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Medicine and Evolution.

Friday, February 7th, 2014

A Final Word: I went by that site today to see what additional comments might have been posted after I left. Here is what remained:

I was referring to your claiming that people were being dishonest in their claims not to be YECs. It’s not that you disagreed with the values expressed by their self-identification, it’s that you didn’t accept that they were who they claimed they were. This makes productive conversation much more challenging.

Does that make sense?

I didn’t claim that people were secret YEC members. I commented that I was astounded at the vehemence of people who described themselves as “non-creationist Christians,” at attacking a person who supports and thinks evolution will be important in medicine in the next 50 years. Read some of the comments in italics below to see if I am overstating this.

I am very concerned, after this, at the role of Fundamentalist Christians in the GOP. They are far less tolerant of other opinion and resemble the global warming alarmists in the unwillingness to allow dissent.

Update #4: I am saving some of the material from the thread to remember what Ricochet is like.

The pseudo sympathy: Mike, frankly, you never had them straight in the first place. The entire thread, you thought you were fending off attacks from a group of Young Earth Creationists, but there was only one YEC among them. The rest of them were believers in one form of evolution of another, and just upset with your attitude.

Attitude !

Do you bear any of the blame for making this thread so unpleasant? I’m perfectly willing to have a discussion with you, and I’m semi-sympathetic to your viewpoint. I’m definitely not a YEC. But I can’t understand why you are being so flippant.
Flippancy is the problem !

No, you’re not. You might try reading the thread. I’ve been listing all the insults over on my own blog as a study of how this happens.

“Mike, I am personally not a young-earth creationist, but I think you are confusing two concepts here. ”

I’m always the one confused. Explained by the Ivy League.

This: “Or would he create a universe that showed millions of millennia of age, even though it was only seconds old?”

Led to this: “It’s nice that you all believe this. Good luck. Let’s hope your doctor doesn’t.”

Now that was my mortal sin to the crowd here. From that the following resulted:

“You are very flippant in dismal of my case for faith. Once again I have no problem believing that someone who believes that God put together the world in 6 days .”can also understand the significance of mitochondria. ”

I doubt that. Instead: “I have a far greater trust of a doctor who believes in God and lives it in his own life rather than one who is merely technically competent and sees the universe, and my life, as a happenstance of evolutionary doctrine.”

Now, the folks who are denying this is about creationism and is about my “attitude” seem to ignore those parts.

“Well that’s a glowing example of inability to actually argue the point. When you encounter indications that people disagree with your conflating micro and macro evolution, imply that anybody who doesn’t believe in the warm puddle or whatever the popular origin of life theory is this week is incompetent. ”

Now there’s a thoughtful statement.

” If I’m just an expression of evolutionary pressures, he might want to trim it up. (Has the advantage of being supported by all the various eugenics of recent history, including the ongoing slaughter of those unborn suspected of having genetic illnesses.)”

So now abortion has been dragged into it.

“You slander many very good doctors with your dismissive remarks.”

And I’m the problem.

“But what followed was a long-winded series of examples that do not make a case that any student of what evolution teaches must believe any of the paleo-biology tall tales about the long long ago history of this and that.”

More friendly repartee.

“In my opinion, the whole argument is silly. Humans simply don’t have the intellectual capacity to comprehend the creation. It’s like a dog trying to understand how a television works;”

More brilliance. My tolerance for this is less than yours or you didn’t read it.

“Mike has argued that we should (or, at least, he would) place professional barriers before those who disagree with his creation myths ”

Another mis-statement of what I wrote. I only mentioned my own letter writing which was not a barrier the last time I checked admission requirements.

“You are the one who said that you would keep Creationists out of med school.”

More mis-statement.

“Believing that the paleo- fields have very badly miscalculated the age of the earth has nothing at all to do with the ability of a doctor to conduct medicine. ”

I guess you agree. I don’t.

I then gave up. This colony of creationists, even those who deny they are “YEC,” wore me out.

UPDATE #3: The attacks continue and it has been several days !

I am also a Christian who doesn’t hold to a YEC point of view. (I would also add, although I hate to flaunt credentials, that I am a more recently trained physician than you, Ivy-League-trained, and hold a faculty position at a medical center that’s a bit fancier than yours.)

So there ! I have decided that I am a Libertarian and not a conservative, if that is what this is about.

UPDATE #2 The pushback has finally succeeded in making me a villain.

(Yes, I know the things I cited don’t make him right about YEC, necessarily. My point is that he’s been successful despite Mike K insisting that people like him should be prevented from being doctors.) ·

This followed a long list of accomplishments by a supposed acquaintance who had had a successful career as, as best I can tell, a pediatrician. This all began with my comment that, aside from not being willing to recommend a student who did not believe in evolution for medical school, I was neutral. I think I am no longer neutral. The “Young Earth Creationist” community seems to have a determination to oppose any evolutionary thinking by anyone. They also seem to have an very convoluted way of explaining why obvious facts are not as they appear.

UPDATE: The pushback from creationists surprised me a bit. I guess it shouldn’t have. I expected “We will just have to agree to disagree” sort of thing. Instead I got an interesting series of attacks on me.

Is it impossible for the Creator to have built all the evidences of age into His new creation? The reality of natural selection isn’t necessarily required to have a long and indefinite period of activity to apply today.

and

Well that’s a glowing example of inability to actually argue the point. When you encounter indications that people disagree with your conflating micro and macro evolution, imply that anybody who doesn’t believe in the warm puddle or whatever the popular origin of life theory is this week is incompetent.

and

There are plenty of good Christian doctors and biologists who are well-versed in cell biology and in how mutations happen and in natural selection processes that affect microbes and higher organisms.

This all reminds me of the epicycles, which were used to explain why Ptolmeic astronomy could not explain certain phenomena like the movement of planets. It took Kepler’s discovery of the elliptical orbits to resolve the matter finally.

The creationists seem determined to ignore the implications of molecular biology about evolution and maintain “Young Earth Creation” in the face of the evidence of ancient biology.

But what followed was a long-winded series of examples that do not make a case that any student of what evolution teaches must believe any of the paleo-biology tall tales about the long long ago history of this and that.

Even Copernicus wanted to learn why the planets did not follow the rules of Ptolmeic astronomy. Today, that is considered rude. I may have to reevaluate my opinion of creationists. I have considered them harmless ill educated religious fundamentalists. They are far more aggressive than I had believed in attacking any disagreement.

I accidentally got into a debate about evolution at another site today. I didn’t want to get into this as I know there are many people, many of whom share my political affiliation, who are adamant about creationism, as the left often refers to it. Still, I have posted my opinions here in the past. I think molecular medicine is going to become even more important in the future and I do not understand how a physician can understand molecular medicine without molecular biology. There are many examples of evolution that must be understood to appreciate certain areas of medicine.

I think a physician can practice as a GP and not believe in evolution. I know a few. They are not likely to understand the future of medicine but they are my age and will not be practicing for long, if they are not yet retired.

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More Obamacare news

Saturday, January 18th, 2014

UPDATE: More News.

This is supposed to be reassuring.

Obamacare contains a $25 billion federal risk fund set up to benefit health insurance companies selling coverage on the state and federal health insurance exchanges as well as in the small group (less than 50 workers) market. The fund lasts only three years: 2014, 2015, and 2016.

The government’s risk management program for the insurers has three parts (the “3Rs”):
A revenue neutral Risk Adjustment System designed to level adverse claim costs between health plans.
A Reinsurance Program that caps big claim costs for insurers (individual plans only).
A Risk Corridor Program that limits overall losses for insurers.
Of the $25 billion, $20 billion is earmarked for the Reinsurance Program and $5 billion goes to the U.S. treasury.

First, the Reinsurance Program caps big individual claim costs for insurers––in 2014, 80% of individual costs between $45,000 and $250,000 are paid by the government, for example.

Then comes the Risk Corridor program. Participating health plans will receive payments from the federal government in any of the following circumstances:
The plan’s costs for any benefit year are more than 103% but not more than 108% of the health plan’s targeted amount. The feds will reimburse 50% of all costs in excess of 103% of the medical cost target.
If the plan’s costs are more than 108% of the annual target, the feds will first pay the health plan a flat 2.5% of the target and then reimburse the plan for 80% of their claim costs above the targeted amount––with no upside limit.
Target cost is simply defined in the new law as a health plan’s “total premiums (including any subsidies) reduced by the administrative costs of the plan.” It is whatever the health plan projected its premium needed to be to pay medical costs.

The CMS has a new contractor for Obamacare, not just the web site. The previous contractor, CGI Federal, has been replaced rather suddenly.

“Accenture, one of the world’s largest consulting firms, has extensive experience with computer systems on the state level and built California’s large new health-insurance exchange. But it has not done substantial work on any Health and Human Services Department program.
“The administration’s decision to end the contract with CGI reflects lingering unease over the performance of HealthCare.gov even as officials have touted recent improvements and the rising numbers of Americans who have used the marketplace to sign up for health coverage that took effect Jan. 1.”

CGI Federal is the company connected with Michelle Obama through her classmate, a fellow Princeton alumna.

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Update on cash medical practices.

Tuesday, October 29th, 2013

Titanic; Vancouver; 1912

I can’t resist this graphic as a metaphor for the present health care crisis.

Some time ago, in fact several years ago, I posted a piece on coming changes in health care. I didn’t necessarily recommend this for reform but it was something I saw coming.

Perhaps more than most people, Reitz, a senior HIV?AIDS scientist with the Institute of Human Virology in Baltimore, appreciated the need to be examined quickly. And thanks to a recent trend to help personalize physician care, he got an appointment the same day — but not because of his professional status.
Reitz, like any patient of Dr. Philip Henjum, can get a same-day appointment because Henjum and his partner, Dr. Robert Fields, practice retainer medicine in their Olney office.
Their patients pay a $1,500 annual retainer fee to see them as soon and as many times as they need to. They also make house calls.
As it turned out, Henjum diagnosed Reitz with Lyme disease, an infection from a tick bite, and prescribed antibiotics. If not diagnosed and treated early, Lyme disease can lead to severe headaches, muscle pain and serious heart problems.
Fields and Henjum are two of about a dozen doctors in Maryland and an estimated 600 nationally who won’t take insurance coverage. Instead, they charge a yearly or monthly retainer. Some work out of comfortable medical office such as Fields and Henjum, next to Montgomery General Hospital.

That was 2009. I added another post on Chicago Boyz in 2010. Here it is.

The reason why I believe this trend is growing rapidly is that some states, like Massachusetts, plan to pass laws requiring doctors to accept Medicare as a condition of licensure. If they were not worried, why write a law about it ? Medicare has a provision that they determine the price and there are no extra charges allowed.

A participating physician agrees that payment for Medicare services based on the fee schedule represents the approved and full charge. This means a physician cannot collect or balance bill an amount in excess of the approved charge listed on the fee schedule for services furnished to Medicare patients.

That, plus the rationing, drives most primary care doctors out of the field or, more recently, out of Medicare. Those who remain, hire Physician Assistants or Nurse Practitioners to see Medicare patients. That works for a while but PAs and NPs are still expensive.

With the passage of Obamacare, Forrest says he’s seeing more physicians aggressively search for alternatives, as he once did. Over the years, he’s helped a couple of dozen offices open across the country, and he’s started speaking at industry conferences about his practice. But in recent months, he’s been flooded with inquiries from fellow doctors. “Since the health care reform bill passed, you wouldn’t believe the number of doctors who have said they’ve had it and want to operate outside the system,” he says.

Now, Obamacare is here and we are seeing the first glimmerings of the problem coming into focus.

This was a week ago.

Health plans are sending hundreds of thousands of cancellation letters to people who buy their own coverage, frustrating some consumers who want to keep what they have and forcing others to buy more costly policies.

The main reason insurers offer is that the policies fall short of what the Affordable Care Act requires starting Jan. 1. Most are ending policies sold after the law passed in March 2010. At least a few are cancelling plans sold to people with pre-existing medical conditions.

By all accounts, the new policies will offer consumers better coverage, in some cases, for comparable cost — especially after the inclusion of federal subsidies for those who qualify. The law requires policies sold in the individual market to cover 10 “essential” benefits, such as prescription drugs, mental health treatment and maternity care. In addition, insurers cannot reject people with medical problems or charge them higher prices. The policies must also cap consumers’ annual expenses at levels lower than many plans sold before the new rules.

But the cancellation notices, which began arriving in August, have shocked many consumers in light of President Barack Obama’s promise that people could keep their plans if they liked them.

Just for curiosity, I did a search on cash medical practice in Orange County CA.

The results were interesting. Among other things, I found a bunch of family practices for sale.

I also found a long list of practices that accept cash. Quite a few have good Yelp reviews. For example:

regular physician normally does! And I was only charged $75 for the visit! (To put that in perspective, my PPO insurance copay would have been $60 had I waited another week for an appointment.

There are 15 pages of reviews. Children’s Hospital is even listed as taking cash: for his recent cold. Parking is underground $7 they take checks and cash only. Parking distance from emergency entrance is very close. We checked in soon after we were called, minimal wait… No mention of costs here but a good review.

The possible outcome of all this, and I don’t believe that employer health plans will survive, is a new system of cash payment for primary and routine care plus insurance for insurable events. That’s what we had in 1950 and it worked well. Doctors didn’t get rich but they often ran their offices with one person helping, sometimes the wife. I remember an orthopedic surgeon and family friend whose office had one large waiting room and telephone person for about 30 doctors. He was later the team physician for the Chicago White Sox so he was no slouch. He also did the first cup arthroplasties in Chicago. One of them was on my aunt.

The medical world will be changing.

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Conservatives and the health care mandate ssue.

Monday, October 28th, 2013

The latest meme I’ve noticed on the Obamacare implosion is that the Republicans are to blame. After all, it’s Romneycare, or it’s the idea of the Heritage Foundation.

In fact, the mandate was promoted by Hillary in 2008 and opposed by Obama. Of course, he doesn’t know much about what is going on so we can understand. In fact, the entire website fiasco, slipped by him, unnoticed.

President Barack Obama didn’t know of problems with the Affordable Care Act’s website — despite insurance companies’ complaints and the site’s crashing during a test run — until after its now well-documented abysmal launch, the nation’s health chief told CNN on Tuesday.

Of course he may just rewrite the code himself. After all, he is so talented that he is bored.

David Remnick, editor of The New Yorker, quotes White House senior adviser and longtime Obama friend Valerie Jarrett: “I think Barack knew that he had God-given talents that were extraordinary. He knows exactly how smart he is. … He knows how perceptive he is. He knows what a good reader of people he is. And he knows that he has the ability — the extraordinary, uncanny ability — to take a thousand different perspectives, digest them and make sense out of them, and I think that he has never really been challenged intellectually. … So what I sensed in him was not just a restless spirit but somebody with such extraordinary talents that had to be really taxed in order for him to be happy. … He’s been bored to death his whole life. He’s just too talented to do what ordinary people do.”

Oh well, at least we know if we really get in trouble, we have someone who can bail us out. I don’t doubt the comment about him never being challenged intellectually.

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Where health care may be going.

Wednesday, October 23rd, 2013

Titanic; Vancouver; 1912

I couldn’t resist this graphic. It’s so appropriate for the moment.

I have watched the failed rollout of Obamacare this past three weeks and wondered where it was going. I have some suspicions. There is a lot of talk about delaying the individual mandate, as Obama did with the employer mandate. Megan McArdle has a post on this today. I think it is too late to fix or delay Obamacare.

With Nov. 1 storming toward us and the health insurance exchanges still not working, we face the daunting possibility that people may not be able to sign up for January, or maybe even for 2014. The possibility of a total breakdown — the dreaded insurance death spiral — is heading straight for us. The “wait and see if they can’t get it together” option no longer seems viable; we have to acknowledge that these problems are much more than little glitches, and figure out what to do about them.

She has already described the insurance death spiral. I think it is here.

Am I exaggerating? I know it sounds apocalyptic, but really, I’m not. As Yuval Levin has pointed out, what we’re experiencing now is the worst-case scenario for the insurance markets: It is not impossible to buy insurance, but merely very difficult. If it were impossible, then we could all just agree to move to Plan B. And if it were as easy as everyone expected, well, we’d see if the whole thing worked. But what we have now is a situation where only the extremely persistent can successfully complete an application. And who is likely to be extremely persistent?

Very sick people.

People between 55 and 65, the age band at which insurance is quite expensive. (I was surprised to find out that turning 40 doesn’t increase your premiums that much; the big boosts are in the 50s and 60s.)
Very poor people, who will be shunted to Medicaid (if their state has expanded it) or will probably go without insurance.

Levin points out: It is now increasingly obvious to them that this is simply not how things work, that building a website like this is a matter of exceedingly complex programming and not “design,” and that the problems that plague the federal exchanges (and some state exchanges) are much more severe and fundamental than anything they imagined possible. That doesn’t mean they can’t be fixed, of course, and perhaps even fixed relatively quickly, but it means that at the very least the opening weeks (and quite possibly months) of the Obamacare exchanges will be very different from what either the administration or its critics expected.

The insurance industry is already reacting to Obamacare and this will quickly become irreversible. This article is from September.

IBM, Time Warner, and now Walgreens have made headlines over the past two weeks by announcing that they plan to move retirees (IBM, Time Warner) and current employees (Walgreens) into private health insurance exchanges with defined contributions from employers.

The article calls it “maybe a good thing” but that supposes the exchanges will function. What if they don’t for a year or more ? What will health care look like in November 2014 ?

What happens next — as we’ve seen in states such as New York that have guaranteed issue, no ability to price to the customer’s health, and a generous mandated-benefits package — is that when the price increases hit, some of those who did buy insurance the first year reluctantly decide to drop it. Usually, those are the healthiest people. Which means that the average cost of treatment for the people remaining in the pool rises, because the average person in that pool is now sicker. So premiums go up again . . . until it’s so expensive to buy insurance that almost no one does.

Will that be apparent a year from now ? I’m sure the administration, and the Democrats, will do almost anything to avoid that. What can they do ? They’ve already ignored the law to delay the employer mandates. It’s too late to delay the individual mandate because individual policies are being cancelled right now.

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Obamacare is coming next month

Tuesday, September 24th, 2013

UPDATE: So far, as October 4, there is no evidence that anyone has enrolled in Obamacare. The one person alleged to have done so has now been shown to have been lying and the details he offered to the eager press, were phony. It appears the IT collapse is continuing.

UPDATE #2 There appears to have been 1% or less of applicants who negotiated the maze actually signed up. The web site is closed for the weekend to fix “glitches.” I still suspect it would have been better strategy to allow the October 1 rollout of this mess and focus on the debt ceiling for a potential shutdown.

UPDATE #3: Here is an informed discussion of Obamacare and the IT mess that created it.

To add insult to injury, the administration outsourced the building of this costly contraption to CGI Group, a Canadian firm. CGI, whose U.S. operations are based in Northern Virginia, “just so happened” to increase the number of H-1B visas it requested from 172 in 2011 to 299 in 2012. It seems more than a little likely that the Obamacare project gave jobs to foreigners while needlessly leaving fully dozens or perhaps even hundreds of qualified citizen IT professionals on the unemployment line.

It gets even worse. CGI was “officially terminated in September 2012 by an Ontario government health agency after the firm missed three years of deadlines and failed to deliver the province’s flagship online medical registry.”

Oh well.

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The War on Drugs

Thursday, August 15th, 2013

My sentiments on the whole drug question have been influenced by some experience with the medical aspect of the problem. Drugs are slipping out of any control due to developments in synthetic variations of older substances that stimulate brain chemistry, sometimes in unknown ways. The traditional drugs, if we can use that term, are also slipping out of control with Mexican drug wars replacing the Columbian cartels even more violent than their predecessors.

What about marijuana ? It is widely used by the younger generation and, while I do think there are some harmful consequences, especially in potential schizophrenics, the fact is that the laws are widely ignored and do little good and much harm. First, what about the link to psychosis ?

Epidemiological studies suggest that Cannabis use during adolescence confers an increased risk for developing psychotic symptoms later in life. However, despite their interest, the epidemiological data are not conclusive, due to their heterogeneity; thus modeling the adolescent phase in animals is useful for investigating the impact of Cannabis use on deviations of adolescent brain development that might confer a vulnerability to later psychotic disorders. Although scant, preclinical data seem to support the presence of impaired social behaviors, cognitive and sensorimotor gating deficits as well as psychotic-like signs in adult rodents after adolescent cannabinoid exposure, clearly suggesting that this exposure may trigger a complex behavioral phenotype closely resembling a schizophrenia-like disorder. Similar treatments performed at adulthood were not able to produce such phenotype, thus pointing to a vulnerability of the adolescent brain towards cannabinoid exposure.

This suggests that adult use may be less harmful.

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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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The Connecticut Massacre

Saturday, December 15th, 2012

There is information still coming to light about this awful case. Early reports, such as the name of the shooter and the alleged murder of the father, were predictably wrong. It turns out that the shooter, named Adam Lanza, a 20 year old with a history of odd behavior and some evidence of mental illness, such as autism, was living with his mother who was his first victim. There are a number of suggestive reports, that she decided to “stay home to care for” her 20 year old son.

The treatment of severe mental illness in this country has been altered for the worse by a movement that began in the 1960s when mental illness began to be described as a “civil rights ” issue. Several books and movies described abuse of power in commitment of the mentally ill. The first such movie was “The Snake Pit” in which a young woman is committed for what sounds like schizophrenia. The treatment of the time (1948) can be seen as barbaric but there was nothing else available. She did recover, although we know that without adequate treatment, recovery from schizophrenia is unlikely.

The movie that really devastated the mental hospital system was called “One Flew Over the Cuckoo’s Nest” and starred Jack Nicholson.

As I type this, a black professor of psychiatry is talking on the TV and discussing gun control !! His mention of mental illness is brief and noncommittal.

The movie was powerful in showing the Nicholson character as a guy who just is “different” and harmless.

The film was the second to win all five major Academy Awards (Best Picture, Actor in Lead Role, Actress in Lead Role, Director, and Screenplay) following It Happened One Night in 1934, an accomplishment not repeated until 1991 by The Silence of the Lambs.

In 1963 Oregon, Randle Patrick “Mac” McMurphy (Jack Nicholson), a recidivist anti-authoritarian criminal serving a short sentence on a prison farm for statutory rape of a 15-year-old girl, is transferred to a mental institution for evaluation. Although he does not show any overt signs of mental illness, he hopes to avoid hard labor and serve the rest of his sentence in a more relaxed hospital environment.
McMurphy’s ward is run by steely, unyielding Nurse Mildred Ratched (Louise Fletcher), who employs subtle humiliation, unpleasant medical treatments and a mind-numbing daily routine to suppress the patients. McMurphy finds that they are more fearful of Ratched than they are focused on becoming functional in the outside world. McMurphy establishes himself immediately as the leader; his fellow patients include Billy Bibbit (Brad Dourif), a nervous, stuttering young man; Charlie Cheswick (Sydney Lassick), a man disposed to childish fits of temper; Martini (Danny DeVito), who is delusional; Dale Harding (William Redfield), a high-strung, well-educated paranoid; Max Taber (Christopher Lloyd), who is belligerent and profane; Jim Sefelt (William Duell); and “Chief” Bromden (Will Sampson), a silent American Indian believed to be deaf and mute.

Here is the picture of mental illness as a matter of civil rights. It was shown in 1975 when the deinstitutionalizing was already well along and it convinced the public, few of whom know anything of psychology, that mental hospitals should be closed. State governors, like Ronald Reagan in California, were only too happy to oblige. This is why I was not a Reagan fan before he was elected in 1980.

The new drugs, like Thorazine made all this possible. Patients on Thorazine made almost miraculous recoveries. at least until the side effects appeared.

The introduction of chlorpromazine into clinical use has been described as the single greatest advance in psychiatric care, dramatically improving the prognosis of patients in psychiatric hospitals worldwide[citation needed]; the availability of antipsychotic drugs curtailed indiscriminate use of electroconvulsive therapy and psychosurgery, and was one of the driving forces behind the deinstitutionalization movement.

Actually ECT or “shock therapy” was, and remains, effective for severe depression. When used on psychotics like schizophrenics, it often provided a period of a “lucid interval” that lasted for hours when the psychosis seemed to relent. The symptoms recurred but the hope of longer intervals resulted in repeated sessions. It was often depicted with convulsions and other horrendous effects but, in reality, anesthesia and muscle relaxants were used to avoid such scenes. Even insulin coma, which has a risk of damage from low blood glucose, was effective for periods when nothing else worked.

The alternative offered was outpatient centers, in California authorized by The Short-Doyle Act of 1957. There was never enough money and governors saw the closing of state hospitals as a budget issue, not a medical issue.

Throughout the 1970s and 1980s counties contended that the state was not providing adequate funds for community mental health programs. In addition, several counties were receiving less funds on a population basis than other counties. This disparity was addressed, with varying levels of success, in both the 1970s and the 1980s with the allocation of “equity funds” to certain counties. Realignment enacted in 1991 has made new revenues available to local governments for mental health programs, but, according to local mental health administrators, funding has lagged behind demand.

And As a result of declining hospital population, three hospitals (Modesto, DeWitt, and Mendocino) were closed. Legislative intent was to have the budget savings from the closures go to local programs. The “money was to follow the patient.” This did not happen in 1972 and 1973 as a result of the Governor’s veto.

The patients released from state hospitals ended up living in the streets as “the homeless problem” exploded. Others filled the jails. In 2000 I was told by directors of homeless shelters in Los Angeles that 60% of the homeless were psychotic, 60% were drug addicts and half of each group was both. About 10% of the homeless are neither and are quickly moved to shelters and “SRO” hotels, especially if there are children.

What percent of shizophrenics are violent or capable of it ? A national study suggests that the number may be higher than we are usually told.

The 6-month prevalence of any violence was 19.1%, with 3.6% of participants reporting serious violent behavior. Distinct, but overlapping, sets of risk factors were associated with minor and serious violence. “Positive” psychotic symptoms, such as persecutory ideation, increased the risk of minor and serious violence, while “negative” psychotic symptoms, such as social withdrawal, lowered the risk of serious violence. Minor violence was associated with co-occurring substance abuse and interpersonal and social factors. Serious violence was associated with psychotic and depressive symptoms, childhood conduct problems, and victimization.

Since schizophrenia is life-long, usually beginning in teenage years in males and a bit later in females, the total period of exposure to the risk of violent behavior is high. Treatment with modern drugs reduces this considerably but most schizophrenics who are not under good supervision do not take their drugs.

The mother of the shooter was the registered owner of three guns, two of them pistols and one a “bushmaster” rifle. These are military lookalikes that are mostly in 5.56 NATO round calibres. They are also very expensive rifles. The rifle found in the shooter’s care was described as .223 calibre and the Bushmaster site does not include any of this calibre. UPDATE: I did not recognize the .223 as the same calibre as the 5.56 NATO round. It is the same. The .223 is in inches and 5.56 is millimeters. A momentary lapse.

He did not use the rifle anyway but what was the mother doing buying this for her autistic son? Pistols might have been for her own protection but the rifle doesn’t make sense except as evidence of enabling behavior by the mother.

I will add to this post as more information comes out. This looks to me like an incident of mass violence by a schizophrenic 20 year-old male with possible assistance by his mother in allowing him access to guns.

The mother is now being described as a “survivalist” and used to target shooting. That does not explain why she had guns around her psychotic son. “Autism” does not develop during teenage years. It is a phenomenon that is recognized in infancy. The term may have been used by the older brother as it is a less “disreputable” term for schizophrenia. If this represents a form of denial by the family, it may be significant.

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Posted in media, science | 7 Comments »

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 »

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