Category: Medicine

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The Cost of Death

From the Washington Post, June 11, 2009

In the final two years of a patient’s life, for example, they found that Medicare spent an average of $46,412 per beneficiary nationwide, with the typical patient spending 19.6 days in the hospital, including 5.1 in the intensive-care unit. Green Bay patients cost $33,334 with 14.1 days in the hospital and just 2.1 days in the ICU, while in Miami and Los Angeles, the average cost of care exceeded $71,000, and total hospitalization was about 28 days with 12 in the ICU.

Some differences can be explained by big-city prices, acknowledged Elliott Fisher, principal investigator for the Dartmouth Atlas Project, “but the differences that are really important are due to the differences in utilization rates.”

Much of the evidence suggests that the more doctors, more drugs, more tests and more therapies given to patients, the worse they fare — and the unhappier they become, said Donald Berwick, president of the independent research group Institute of Quality Improvement.

The kicker here is that there is evidence that the more treatment a patient receives late in life, the less happy he or she is.

I believe it. Anyone who has spent time in a hospital or nursing home can’t help but believe it.

Billions of dollars of health care spending in the United States is guided by a very simple and pernicious logic: don’t you love your mother? (Or father, or grandparent, or…). And if you love your mother, don’t you want to do everything possible to extend her life? Everything? Even if the odds of the treatment actually extending her life or improving her quality of life are not very good?

I’m sure some elderly people simply want to live for as long as they possibly can even if it bankrupts their families, but I don’t believe most of them want that. I think most people in their 70’s and 80’s accept that life comes to an end eventually and probably hope, more fervently than for anything else, to die in peace, close to friends and family, and without unbearable pain. They don’t want to spend their last weeks or months strapped to a bed with tubes going in and out of every orifice, nauseous, drugged out. And they don’t want pallid substitutes for pain killers because the pharmaceutical industry has succeeded in establishing a monopoly over drugs.

The average American works hard all of his life, buys a house, builds up his assets, sends his children to college, saves something for retirement, spoils the grand kids, and then, just when he thinks he’s survived the economic snake-pit of American capitalism, the health care system sinks its fangs into him and sucks him dry. If you want to leave something for your grandchildren, you need to drive your car off a bridge before you become incapacitated.

Perhaps one of the most depressing facts of American life is that the medical-industrial complex has managed to convince many Americans– and almost all talk radio hosts– that the cruelest, least fair, and least efficient health-care system in the Western World is actually the best. They stand there bankrupted and ruined, dropped by their insurance companies, buried under piles of arcane incomprehensible forms, denied critical treatments because their insurance companies simply refuse to pay out… and they look at us Canadians and go, “Oh my god! You have to wait three weeks for an MRI?”

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Dear George Will: About Canadian Health Care

George, I know you strive to be fair and balanced though your basic worldview is conservative.  As a Canadian who “suffers” under our single-payer system, I would ask a very simple, very important question: having lived under a single-payer system for almost fifty years now, could you persuade a majority of Canadians to give it up, and let a “market-based” system prevail?  Do you think most of us believe that will drive down health care costs and give us more “freedom”?

George Will on Health Care

Most Canadians I know can’t even believe that there is a debate on this issue in the U.S.  We are all mightily impressed that America believes it’s system is better and everyone else is wrong even though Americans seem to know nothing about any system but the one that is failing them now.  It’s possible that everyone else is wrong.  Sometimes everyone else is wrong.  It’s also possible that the sun orbits the flat earth.

Anybody can find a few Canadians who don’t like our system, and few horror stories of delayed care and inept management.  No reasonable person can deny, however, that the U.S. system costs astronomically more to administer, and that almost all Canadians receive basic health care without the slightest impediment, and that the actual results in Canada are better than in the U.S.

Furthermore, I have no idea of where you would find any proof that Canadians do not have a choice of doctors or hospitals or treatments.

True– we can’t choose to opt out.   But Americans can’t really opt out either.  They can’t!— an American without insurance will still receive treatment at any nearby hospital.  Who pays for it?  Everyone, through taxes and astronomical charges for treatment for the insured.

Isn’t that the basic principle of insurance?  Any of us could suffer a serious illness or injury.  Why not agree to contribute to a plan that covers everyone?  Especially since we all know that those who “opt out” will still receive medical care one way or the other, but certainly less efficiently.

Finally– this is one gripe I do have about conservatives in general:  I think they are far more likely than liberals to persist in believing something long after it has become overwhelmingly clear that the results show they are wrong.  Example:  McCain actually stated at one time that Obama’s idea of talking to Castro was ridiculous because, with his long experience, he knows that it wouldn’t work.  Excuse me!  Exactly how many more years must the embargo continue before it “works”?  That is absurd.  Why not just admit that the embargo has failed and try something new?  Liberals, who have a mind-set that entertains alternative realities, are by nature more inclined to consider other possibilities.  McCain would still be in Viet Nam.  McCain will be in Iraq for 100 years (a joke really– the oil won’t last that long and then we will go back to indifference to human oppression).  And McCain will continue to believe that through some miracle, health care costs can be reduced by letting it “compete in a free market”, as if  dying of cancer is a commodity that could be sold to a hedge fund.

For the record, I’m not sure the Canadian system couldn’t stand a few modifications, and I am very interested in Obama’s hybrid ideas.  Not sure about them– but– as a liberal– I can consider the possibility that different points of view have something to contribute to our ultimate success on any issue.  Hey George, why not be the first reasonable conservative to admit that, as a family values kind of guy, you would like to see all of the nation’s children covered, and it clearly– the results show!– isn’t happening under your free market system.

Sincerely,

Bill Van Dyk

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Period Period

Things I didn’t know until now:

“We don’t want to confront our bodily functions anymore,” Ms. Andrist said. “We’re too busy.” Doctors say they know of no medical reason women taking birth control pills need to have a period. The monthly bleeding that women on pills experience is not a real period, in fact.”.

NY Times, April 20, 2007

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Wah Wah Wah – Juries and Tort

“Whenever Merck was up there, it was like wah, wah, wah,” one juror told the Wall Street Journal. “We didn’t know what the heck they were talking about.”

Vioxx is suspected as a cause of heart attacks in patients who have been taking the drug for 18 months. As much as I dislike pharmaceutical companies, the culture of litigation that has reared its ugly head again, is almost as contemptible. Everyone who ever came near a Vioxx pill has got his lawyers gunning for millions. Unfortunately, juries, moved more by compelling testimony about hardships and pain than facts, love to slap the pharmaceutical companies down… in a way that doesn’t really solve any of the long-term issues.

What is needed is for the government to regulate drug prices. Americans, however, still believe that there can be competition between a product and a product that does not exist.

If you don’t feel like paying $30,000 a month for a cancer treatment that cost about $30 to manufacture, you can shop elsewhere. Or die.

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S.S.R.I.’s And Teenage Mental Health

British Drug regulators just announced that doctors must stop writing prescriptions for an entire generation of anti-depressant drugs for depressed children under 18.

After reviewing 11 different studies of the effects of these drugs, including Paxil, Zoloft, and others, on children under 18, they came to the conclusion that the risk of harm outweighed the potential benefits.

According to Mother Jones, more than 50% of the studies performed on these drugs have shown that they have no greater beneficial effect on people than placebos do.

But it’s hard to convince a doctor with scientific evidence. I’m only kidding. No, I’m not. Dr. Flemming Graae of Westchester Medical Center in Valhalla, N.Y., says he has treated more than 2,000 children with S.S.R.I.’s. (Selective Serotonin Reuptake Inhibitors) and, he says, not a single one of them tried to commit suicide because of the drugs.

That’s a really strange statement to make. Didn’t any of the 2,000 ever try to commit suicide? If not, that’s remarkable.  If any of them did, how do you know it wasn’t because of the S. S. R. I.?

The Heritage Foundation reports that about 14% of all sexually active teenage girls and 5% of all the others attempt suicide. Just about every other study reports that some teenagers try to commit suicide.

These are truly wonder drugs if the results are that good. Or Dr. Graae’s statistics are wonderfully contrived.

Of course, the Heritage Foundation is trying to prove to you that girls that have sex are unhappy, miserable, and suicidal, while girls who don’t have sex are contented, smart, and rich. So don’t have sex. Or learn to do unbiased studies. The Heritage Foundation thinks you are still gaining weight because you don’t eat enough diet cookies.

I suspect that doctors are willing to defend S.S.R.I.’s because they give them something to give people who are desperately desperate. Since you can’t give them a happy life with healthy peer relationships and a morally satisfying profession, you give them a pill.

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Dr. Sell – Are You Mad?

Not even mental health experts agree on this. The American Psychiatric Association, which supported the government, argued that mental illness is a physical disease that should be treated like any other. “The brain is an organ just like the liver is an organ and the heart is an organ,” said Dr. Renee Leslie Binder, a psychiatrist who advised the association on its court brief. “If someone has an infection, you don’t tell them to breathe deeply. You give them antibiotics to fight the infection. When someone has a brain disease, the main form of treatment is medication.” New York Times, June 21, 2003

Rather mechanistic view of the brain, don’t you think? All of your behaviours, your personality, your fantasies, your desires, your hopes and dreams– are all the result of chemical processes and physical properties. The brain is not really different from your liver or your heart. If this is true, somewhere in the distant future, we will be able to fix your brain.

How will you know if your brain needs fixing?

You don’t want your brain “fixed”?

Well, that is the issue, isn’t it. Who gets to decide? Who decides if your brain needs to be fixed?

Dr. Charles Thomas Sell was charged with Medicaid fraud five years ago. When he appeared at trial, he cursed, spat, and screamed, according to the New York Times. He was deemed “emotionally disturbed” by the judge and incarcerated in a hospital. Not fit to stand trial, mentally.

The government– the prosecution– asked the courts to allow it to force Dr. Sell to take medications for his illness. They believed that the medications would make him sane. They wanted to help Dr. Sell. After curing him, they could put him on trial and then imprison him for his crimes.

Of course, if Dr. Sell needs medications to make him sane, it raises the possibility that he was not sane when he committed his crimes. Is the prosecution willing to argue that he is sane enough to stand trail because we have cured the insanity that caused him to commit crimes? I somehow doubt it.

Is this a little like the police charging someone with a murder committed with a high-powered rifle. After discovering that he couldn’t shoot straight, they decide to send him out for fire-arms training before they put him on trial? Or an impotent man charged with rape. Can they require him to take Viagra before going on trial?

A similar case was ruled on in Ontario in June 2003. A 47-year-old gentleman named Scott Starson, who is regarded as something as whiz in physics, had asked for the right to refuse to take medication which, he claimed, prevented him from working on his physics. Starson wrote a paper on physics in 1991, with the collaboration of a Stanford physics professor. However, his doctors and his mother felt that he should be ordered to take medication for his mental illness. Starson believes that the medications his doctors want to forcibly inject him with slow down his brain. He says that that would be “worse than death”.

Here’s the clincher. At a hearing, Starson’s doctors admitted that none of the medications had helped him in the past, and that they could not be sure that any of the medications would help him in the future. Not only can we try to force you to let us mess with your mind, but we can even do experiments on it.

The courts in Ontario ruled otherwise. Mr. Starson, it ruled, has a right to think for himself.

What if we had a doctor of society who said that our society was sick? We engage in a mad pursuit of dubious gratifications. We exploit poor people and oppress the powerless. We sell tools of murder and destruction. We destroy the environment.

What we need is for a doctor of society to decide that our society is no longer capable of making rational decisions and, therefore, it should be fixed. All Third World Debt is forgiven, and we will move to a 30-hour work week, with six weeks guaranteed vacation every year. How do you like that? This doctor goes to court and asks a judge to give him the power to fix society.

So who gets to decide?

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Surgical Error

In some kind of documentary to be shown on television in the near future, a brilliant Toronto brain surgeon comments on how discouraging his work can be when so many of his patients die.

As discouraging as having a doctor give you an option with little real chance of a success, but a large probability of reducing your quality of life for what little time you do have left?

You know all those ads urging you– if you are a woman– to do a breast self-examination regularly? Check, check, check! Early detection will save your life!

Maybe. But then again, maybe not. A recent study conducted in Denmark showed that the results of therapies administered after “early” detection do not show a marked improvement over the results of therapies administered upon “late” detection. I suppose the latter refers to a situation in which a woman never checked herself until she experienced some obvious symptoms.

A few years ago, it was de rigeur to insist on DREs for men over 40. Digital Rectal Examinations. Then again a similar study came to the conclusion that early detection did not improve the chances of survival for the patient, though it certainly resulted in drastic changes to the patient’s quality of life.

Some people occasionally snipe at me for daring to question the wisdom of doctors. Are you a doctor? Then how do you know whether someone should have surgery or not? How can you possibly make a judgement like that?

Fine. So let’s consult a doctor. (But first, since you are so high on “experts”, what’s your opinion of Global Warming?) The trouble is, these new studies are conducted by the same “experts” that set us on the wrong path initially. Doctors vs. Doctors. Which ones are right? Doctors in North America are quick to install tubes when children develop repeated ear-aches. In Europe, they almost never insert tubes. Doctors used to like to have pregnant mothers lie on their backs on an operating table to deliver their babies. We now know– from other doctors– that that is about the worst possible position to be in to deliver a baby. Doctors prescribed Thalidomide and removed your tonsils and maybe parts of your brain and still perform triple-bypasses.

The vast majority of doctors probably do still believe in breast self-examinations. But established wisdom is often wrong (you can’t swim for one hour after eating?) and it gets entrenched, and it should not be surprising that it takes a few years for it to be dislodged.

Sometimes, a radical new idea has hallmarks to it. It “rings true”. It seems strikingly to address vacancies in the established wisdom. But the idea that any cancer should be surgically removed or bombarded with deadly radiation has the kind of simple logic to it that you just know might not make as much sense as it seems to at first glance. It flies in the face of something that seems more logical: do no harm.

For example, how do you explain this fact: the professional group least likely to consent to surgical treatment is…. get ready… surgeons!

You are getting ready to travel by air for the first time. Your best friend– a frequent traveler– has been urging you on. Maybe he even sold you the airline tickets. He escorts you the check-in desk.

Then he waves goodbye.

“Aren’t you coming?”

“Are you nuts? I never fly. I’m taking a boat.”

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A Victory in the War of Drugs

Russell Eugene Weston Jr., 44 years old, walked into the Capitol Building in Washington DC on July 24th, 1998, in order to save the world from cannibals, and to retrieve top secret information from a satellite system that was capable of time-travel. I’m not sure why he thought the government would be of any use to him, but he did, and when the government didn’t listen he shot and killed two guards.

He is imprisoned in Butner, North Carolina, in solitary, because, after all, he is mad. In what used to be the civilized world, he would be in some kind of treatment program where smart people with degrees in psychology would be trying to help him recover his senses. But this is America of the 21st century and bloodlust over-rules compassion so the government wants very badly to put him on trial for murder and sentence him to death.

The trouble is, of course, that Mr. Weston appears to be insane. It is a well-established facet of the modern justice system that a person who is not responsible for his actions cannot be convicted of crimes committed while he was not responsible for his actions, ie., in possession of his faculties, his reason, his ability to discern right from wrong.

A small obstacle to be sure. In a new, significant skirmish in the real drug war– the war waged by pharmaceuticals to get everybody onto drugs– a three judge panel of the U.S. Court of Appeals for the D.C. circuit ordered him to be medicated!

Mr. Weston’s lawyer– a public defender (and we all know how awesome public defenders are)– is considering an appeal. Of course, appeals ultimately end up in the hands of those robed dildos of Partisan Politics, the Supremes.

Well, what is wrong with medicating this guy so he can be ruled sane so he can be tried for murders committed while he was insane?  And then executed?   We need to provide a nice deterrent to all those crazy UFO-believers out there with guns.

Apart from the obvious– that just because medications can make him appear to be sane doesn’t mean he was sane at the time of the murders– there is the absurd circumstance of the government drugging people into certain specified conditions (guided by the high priests of mental sanitation, psychiatrists and psychologists) in order to obtain particular results from the justice system.

I know– it’s hard to wrap your mind around this issue, especially if it’s medicated. But break it down. The drugs in question are those very powerful psychotropic drugs the mission of which is to alter a person’s personality or emotions.

Is this allowed by the constitution? The very question is insane– of course not. The idea that a constitution that protects the right of privacy and freedom of speech and presumes innocence until proof of guilt is established and  validated by a duly constituted jury or judge, would permit any government body to forcibly alter a person’s mind with powerful psychotropic drugs— it’s absolutely outrageous.

But that’s not even the most objectionable part of it all. Of what use is this procedure to the prosecution? The man was probably insane when he shot the two guards. The prosecution wishes to argue that he was not insane. They are allowed to specify how his mind should be altered in order to present him as evidence in support of their view????

The precedent is shattering. With the pharmaceutical companies already revving up the corporate cheer-leaders, every prosecutor in the country will now consider the option of obtaining a court order to force prescribed personality alterations of defendants in criminal actions.

You think I’m getting carried away? What if I had told you 50 years ago that we were headed towards the kind of society in which people who are unhappy or dissatisfied with their lives in any form would go to their doctors and readily obtain prescriptions for powerful mood-altering substances that would help them cope with their terrible little lives?

You would have thought I was insane.

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The Best Doctor

Whenever I hear someone talking about some surgery or cancer treatment or whatever that they had, they always assure me that the doctor who did the work was “the very best” there is at that specialty. Think about this: how often will someone tell you that the doctor they saw was “the very worst”? Never, right? But if someone is the “very best” that means that someone else out there, practicing medicine and making a living at it, is the “very worst”.

A Massachusetts study from 1996 found that 1/3 of terminal cancer patients received useless chemotherapy treatments in the last six months of their lives.

They were given a useless treatment with terrible side-effects by a doctor who undoubtedly was “the best there is”.

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Harold Shipman

In Great Britain, if you took a sampling of 1000 women between the ages of 65 and 74 who see a doctor regularly, you would normally find a death rate of 4.5 per year.

Of 1000 patients of Dr. Harold Frederick Shipman, the death rate was 45 per year. He began his own practice in Hyde in 1992. He was caught this year.

Uh yes… the numbers are not the result of chance or coincidence. Dr. Shipman has been injecting some of his patients with a fatal dose of diamorphine. He seems to have murdered 300 this way. Yes, does seem like it took a little while for anyone to notice.

Sometimes he would go into a patient’s file and alter significant facts, in order to establish the “illness” of which the patient died at his hands. No one noticed because the families of deceased patients do not get access to the deceased’s medical records.

A few people over the years became suspicious. The police were even called. But when the police went to the General Medical Council, which oversees doctors in Great Britain, they told them that unless an official complaint was received they could do nothing.

Since Dr. Shipman never summoned an ambulance or called for a coroner after any of the suspicious deaths, there were no records except his own, and therefore, no details about the exact circumstances of death, except those which he provided.

The local health authority investigated and found nothing suspicious. Again, it appears that they relied on Dr. Shipman’s records to verify Dr. Shipman’s performance. There is no system in place to monitor the performance of doctors. Think about that. There is no system in place to monitor the performance of doctors. In other words, a doctor could kill 300 patients and no one would be the wiser. Well, yes. That’s what happened.

The first public reports of the investigation of Dr. Shipman were met with outrage by the citizens of Hyde who felt that a good doctor was being tarred with a broad brushstroke. Obviously, the good citizens of Hyde hadn’t noticed anything odd either. Here was a doctor who murdered patients with great frequency. The patient’s families were notified of the death. The bodies were cremated or buried. Nobody kept score.

The police finally seized Dr. Shipman’s medical records. Ah, but they didn’t obtain the proper paperwork beforehand and had to return them. Imagine the police seizing a knife or a gun from a suspected murderer, and then being ordered to return it to the suspect because they hadn’t said “may I”? To get around this little technicality, the police charged him with homicide. Then they were permitted to investigate.

Altogether, as I said, Dr. Shipman may have killed more than 300 women.

Sometimes he did the killing in his office and saw several more patients before reporting the death.

Now this may sound like a bit of stretch, but ask yourself this, in connection with Dr. Shipman’s offenses: how do you know that your doctor is doing a good job? I’m serious. I mean, you know that your doctor is not likely to inject fatal quantities of diamorphine into your veins, but if a doctor in a developed country can get away with doing this to hundreds of women over a period of ten years, how much less likely is it that your own doctor can get away with being completely incompetent?

In other words, who is keeping score?

You can read the sports pages every day to find out if Delgado is earning his millions for the Blue Jays. How many home runs did he hit? What’s his batting average? Is he making a lot of errors over there at first base?

Why don’t we have the same thing for doctors? It doesn’t have to be ridiculously detailed. Just a simple table of visits, total number of operations, drugs prescribed, x-rays, cures, improvements, and… deaths.

There were signs of trouble with Dr. Shipman back in 1976 when he was convicted of stealing drugs and issuing fake prescriptions. But he was able to pay a modest little fine and move on. This was his minor league record. Mediocre. Not expected to make the big leagues.

But he worked at it and re-established himself and went on to establish a new record: 300 murders. That’s about 287 more than Klebold and Harris at Columbine. How many Nightlines do you think they’ll devote to this story? How many Newsweek Covers?

How many people are going to throw up their hands and scream, “What’s happening to our society! We should have zero-tolerance for deaths at the hands of doctors!”