A Medical Perspective on the Negligent Homicide of Eric Garner

I am not going to get into the larger sociopolitical issues surrounding the death of Eric Garner.  I don't want anything to distract from sharing one observation that has not been widely reported, and which may lead to at least one change that every police department in the country should implement.

Is Obesity more like Crime, Cigarettes, or Sex?

Obesity is a massive problem.  35℅ of America is obese.  Democrats are worried that their prized social welfare programs will collapse under the weight of the problem.  Republicans are worried that they will only be able to invade 1 country every 8 years, as the military finds itself forced to accept increasingly sluggish recruits.  Regardless of how you look at it (and how many puns I can make), this is a serious issue.  But how to frame it makes a massive difference in what tactics and tools it makes sense to pursue.

The Lost Glory Days of General Practice, and a Vision of it's Resurrection

I'm on my family medicine rotation right now.  One of my preceptors is ~80 years old, and went through medical school in the 1960s.  He is still sharp as a tack, and quite possibly the most BAMF-ing family practitioner of all time.  He used to do c-sections, hernia repairs, appendectomies, fracture repairs, and get this- emergency burr holes for subdural hematomas (aka neurosurgery).  He stopped ~1997, mostly because he got tired of his morning cases getting bumped constantly for overnight emergencies and throwing off his schedule for the rest of the day when he had clinic in the afternoon.  He has since moved out to Palm Springs, where he still sees more patients than any of his fellow physicians in the group, still does all his own trigger finger release surgeries and SCC/BCC excisions, and still administers the group.  In addition to all this, he is one of the nicest people I've ever met, beloved by his patients.  He truly epitomizes the fading glory days of family medicine, the ideal of the General Practitioner who could truly do it all.

Ebola, Texas Health Presbyterian Hospital, and Medical Errors

Ebola is in the United States!  Everybody (please don't...) panic!  Quarantine all Texans!  Though that might be a good idea anyway (just kidding).  More on Ebola in general in another post if I have time.

First off though, we've found out more information about the sequence of events leading to the hospitalization of the patient, Thomas Duncan.  Apparently, he came to the hospital, told people he'd come back from Liberia, and was still discharged home.  He was only admitted 2 days later when his nephew called the CDC.  The tale reveals a fascinating story of medical quality and system error.

Informed Consent is a Chimera

This post by Paul Levy got me thinking about informed consent, and a case I saw recently got me to take a little time and write about an issue frequently ignored in medical school.

A bit of background for non-medical readers: Informed Consent is a term in medicine for when doctors get the agreement of the patient to do something to said patient.  For example, before a patient is cut open for surgery, the patient has to say "yes I want to be cut open and have _____ happen".  Less extreme examples abound- the patient has to consent to anything from a blood draw for a lab test to a CT scan.  Part of informed consent is that the patient has to be "informed".  It is acceptable for a patient to say "tell me nothing, just do it", but the patient has to be offered information regarding their disease as well as the risks and benefits of the procedure they are consenting to.  For example, "This x-ray will tell us whether or not you have pneumonia or something else, but may slightly increase your risk of cancer in the long run.  I recommend you get it.  Do you agree?"

The Coming Downfall of Medicine: Scientific Corruption

Some recent news about a(nother) scandal in the pharmaceutical industry has led me to post on something that is critical to the future of medicine and science.

Let me start off by saying that I believe strongly in most medicines. I think the data behind their safety is incontrovertible. But for medicines that were invented recently, that same data would still leave me quite suspicious.

Here's why.

America Doesn't Have a Gun Violence Epidemic- We Have a Poverty Epidemic and an Outbreak of School Shootings

Many people are talking about a gun violence epidemic.  This is understandable, in light of what seems like a never-ending stream of horrific school shootings.  Sandy Hook Elementary School, Santa Monica Community College, Arapahoe High School, UC Santa Barbara- the list goes on and on.

Those with more liberal views are responding to all this chaos and violence by going so far as to call for a repeal of the 2nd Amendment.  As you can imagine, this has predictably gone over quite well with the NRA and it's allies.  These are the folks who, in the immortal and inconceivably badly phrased words of President Obama, "cling to their guns and religion."  Matching the President's lack of tact with an insensitivity that borders on psychopathy, Joe the Plumber addressed the parents of the kids killed at UCSB by declaring, "your dead kids don't trump my constitutional rights."

Amidst all this back and forth between right and left is a shared delusion:  There IS NO gun violence epidemic.  There IS a school shooting epidemic.  These two problems are not the same.  And the solutions that can actually save hundreds if not thousands of lives become clear once the problems have been elicited and defined

Why Colleges Fail at Punishing Rapists, and a Radical Idea for Justice

Sexual Assault on campus is problem that has been receiving unprecedented amounts of attention lately.  Just a few days ago, it was announced that 55 colleges are under investigation for failing to adequately handle sexual assault and create a non-discriminatory environment under Title IX, a federal law that prohibits discrimination based on sex in all institutions that receive federal funding.  It is commonly held that 1 in 4 female students will be assaulted during their time in college, though it must be acknowledged that all such statistics are disputed.  Nevertheless, it is increasingly clear that no American college does anything approaching a decent job of punishing rapists and doing justice to survivors.

Why Your Doctor Doesn’t Work For You

Many doctors are ambivalent about the Affordable Care Act. This is not due to the primary aims of the bill- after all, more people with health insurance means more paying patients, so what’s not to like? Rather, doctors are worried about the other, less publicized pieces of the bill, and related changes to Medicare and Medicaid that have quietly reshaped medicine- and often not for the better.

The Political Picking of a Surgeon General

There's a bit of buzz in the news recently over President Obama's nominee for Surgeon General, Dr. Vivek Murthy.

What's Going on in Ukraine, and Why?

There's been a lot of uproar recently over Ukraine.

Cliff notes version: Pro-Russian dictator in the making was driven out by protesters longing for closer ties with the US/EU, and Russia responded by sending in troops to its existing military bases.  War is imminent.  Pro-democracy protesters vs. autocrats is always a sure draw for readers, so journalists are trying to catch every minute of it in any way possible.

(Only Slightly) Longer version:

Gay Marriage, "Drawing the Line", and the Media

EDIT: I suggest you all read to the end- I'm not making the point you may think I am making.

I'd like to preface this post by saying that I fully support gay marriage.

A Tea Party-backed Senatorial candidate in Kentucky, Matt Bevin, was doing an interview, and giving a rather typical anti-gay marriage stock answer.   Surprisingly, it had less direct gay-bashing than usual for a Southern Tea Party candidate- Bevin mostly made points about state's rights.

Of course, we have to remember here that historically, racist policies and segregation were defended by southern (then-Democratic) politicians under the guise of state's rights.  Starting with Nixon, the Republican party purposefully adapted the rhetoric of "state's rights" as a code word for segregation, to attract white southerners who became disaffected from the Democratic Party after President Lyndon Johnson passed the Civil Rights Act and the Voting Rights Act.  This was the infamous "Southern Strategy", and has been publicly confirmed by a recording of the late, great GOP strategist Lee Atwater.

Back to Bevin.

Why I'm (Probably) Not Going Into Primary Care

I have to say when I was applying to medical school originally I was interested in primary care.  One of my role models was my aunt, a PCP, whom I worked for as a scribe/medical assistant.  She walked me through her differential diagnosis for each patient and I was hooked at her level of knowledge and thought process.

Why More Pay (Probably) Won't Create More Primary Care Physicians

There have been many, many calls recently to increase Primacy Care Physician(PCP) pay, and decrease that of Specialists. I'll link to just one example here. (The link in question also features some AMA RUC bashing, a topic I've covered before). This is part of a drive to lure more medical school graduates to Primary Care specialties such as Family Medicine and Internal Medicine.

Are CT Scans Giving Us All Cancer? If So, Who Should We Sue?

Two doctors, a cardiologist and a radiologist, published an Op-ed in the NYT about how CT scans are giving us all cancer.  They cite a claim that in 2007 the National Cancer Institute (NCI) estimated that CT scans will cause an estimated 29,000 excess cancers and 14,500 excess deaths.  They extrapolate that this means 3 to 5 percent of all future cancers may result from exposure to medical imaging.

This to me is rather overblown.  CT scans are getting better and better, and get better images while using lower and lower doses of radiation.  The percent of cancers from medical imaging is a highly controversial topic, with recent estimates (from an admittedly biased source) coming in at .04%.  Apparently, the higher estimates from the NCI are based off of post-WW2 cancer rates in survivors of the nuclear attacks on Hiroshima and Nagasaki.

A Blow to the Self-Regulation of Medicine

The American Board of Obstetrics and Gynecology reversed itself and allowed it's members to treat more cases.  This I think is a case of a FUBAR'd attempt to take a strong and necessary step forward on self-regulation, followed by too much fall back after getting called on some mistakes.  The initial problem was that Ob/Gyns (who are specialists in child birth and women's health) were calling themselves "Board Certified" while doing cosmetic procedures.  To solve it, the Board initially ruled that 75% of someone's practice had to be Ob/Gyn (presumably the rest would be staffing the local ER/urgent care complaints), and that Ob/Gyns couldn't treat men with a few exceptions.  Unfortunately, they missed a few categories, prompting a howl of outcry from two groups:

1) Male (mainly gay) patients with HPV who are at risk for anal cancer (sometimes seen by Ob/Gyns used to treating women at high risk from cervical cancer due to HPV)

2) Male patients with pelvic pain, who are seen by Ob/Gyns used to seeing women with similar complaints

Thus, the board was forced to go back to no limits on seeing men and a "majority" of practice being Ob/Gyn.  Consequently, Ob/Gyns with terrible ethics (one of which was apparently about to sue under anti-trust regulations, according to the article) can continue to call themselves "Board Certified" while practicing medicine they are completely untrained for.  Self-regulation of the medical field takes another blow...

A Medical Perspective on Ohio's "Botched" Executions

The death penalty has been in the news lately, what with a "botched" execution in Ohio, using a 2 drug method that Louisiana has also recently adopted for it's administration of the death penalty.

These changes come on the heels of a new tactic by death penalty opponents: getting European countries to ban their pharmaceutical manufacturers from exporting drugs that may be used to execute people.  These bans were partially responsible for nationwide shortages of several anesthetic drugs a few years ago.  Long story short, propofol, the 'Michael Jackson drug', went into shortage due to the contamination of a major supplier, and a perfect storm of low prices( due it being a generic drug) and extreme difficulties in manufacturing it correctly and with sterility.  Sodium thiopental, the older back-up to propofol, came into demand.  Promptly thereafter, the manufacturer stopped selling it in the US due to it's use in lethal injections, leading to a nationwide shortage of anesthetic drugs and the temporary importation of drugs from Canada.

In any case because of chronic shortages and problems with vein access (more on this later) the traditional method that had been used, a three drug combo of sodium thiopental, pancuronium bromide and potassium chloride, has been abandoned in many states.

Primary Care vs. Specialist Pay, the RUC, and the News.

The Relative Value Scale Update Committee (RUC) of the American Medical Association (AMA) is back in the news, courtesy of the New York Times.  It's more of the usual story, published by the WSJ less than 4 years ago: specialists are paid too much, primary care physicians are paid too little, and it's all because of an evil committee of doctors who are members of the evil medical trade union group known as the AMA who set payments.  (Full disclosure, I'm a proud member of the AMA).  A good perspective on the debate from Paul Levy, a former non-physician hospital CEO, is here.

On Guns and the Misuse of Science

Part 1 of 2, on Science and Gun Control
Part 2 of 2 will focus on more on the logic (or lack thereof) behind many gun control arguments.

Guns are one of the the most emotional topics in the United States today.  They mean such different things to different people.  In a sense, it's nearly useless to use science in the debate, because rather like abortion and civil rights it's not a scientific debate in the first place.  That said, it's deeply annoying when science (or more specifically, statistics) are used to justify any proposed gun policy.  I'm going to focus more on the gun-control side here, because the pro-gun-rights side really ignores the science anyway to cite moral arguments which are futile to argue against- how do you fight with someone's claimed right to defend themselves against others/their government?  And really, it is the pro-gun control advocates who are most guilty of misusing science and really abandoning all logic in their misguided crusade.

Olympic Advertising, Gender Norms, and Politics

Proctor and Gamble has some new ads out in their "Thank you Mom" campaign, to coincide with the Sochi Olympics.

Here's the most popular one. Here's another.

The purpose is pretty obvious: P&G makes mostly household goods, and since women still do a disproportionate share of housework, it makes total sense for P&G to appeal to "moms" who make the purchasing decisions when it comes to toothpaste (Crest), batteries (Duracell), detergent (Tide) and diapers (Pampers), etc.

While quite popular and seemingly innocuous, These ads have the insidious and toxic effect of reinforcing gender norms- with "Mom" being portrayed as being the most concerned with the children, with Dad nowhere to be found. (There isn't a single "Dad" in any of the ads).