Monday, 29 July 2013

Tirade cross-posted from TIE

This is from a thread over at The Incidental Economist. Looking back, I probably over commit to melodramatic language. You can't keep melodrama up for more than a paragraph or two.

The EMTALA requires for hospitals to stabilize patients. And in the maybe week before your death, you will get to spend it in the hospital getting intensive care. So all in all we don’t deny people heroic efforts to save their life.

But 99% of life is spent out of the hospital, and for all those times you aren’t lucky enough to expire, you collect medical bills that will cripple you.

The EMTALA has two huge caveats:

“A hospital cannot delay treatment while determining whether someone can pay or is insured but that does not mean they are completely forbidden from asking or running a credit check. If the patient doesn’t pay the bill, the hospital can sue the patient and the unsatisfied judgment will likely appear on the patient’s credit report. A 3rd-party collector for a hospital bill would be covered under the Fair Debt Collection Practices Act.

Hospitals and affiliated clinics are not required to provide continued outpatient care, drugs, or other supplies following discharge. ”

In practice this is how it works out for uninsured: A 50 year old man w/o insurance has a myocardial infarction, shows up in the ED & will have been seen. He will get a large work-up, and maybe a cardiac catheterization. Upon discharge he receives a massive bill, which due to inability to pay leads to getting sued. Finances are tight.

When he was discharged he was prescribed three important medications: An anti-hypertensive, an ACEi, an aspirin. These cost a lot of money, but there is no obligation to provide outpatient care or drugs. For the next 15 years he rarely pays for these medications. At 65 his PCP immediately starts these medications, cursing the fact he didn’t take these meds in the 2 years after his MI.

Also, he was likely hospitalized at least once more between 51 and 65, making the chance of ever getting out of debt nearly 0.

But no it is true – every American has some form of access. They can access the medical system, accrue massive debt and be bounced out. What tens of millions of Americans don’t have is ongoing access to a high-quality, available medical system.

Sunday, 5 May 2013

George Bernard Shaw

Doctors are just like other Englishmen: most of them have no honor and no conscience: what they commonly mistake for these is sentimentality and an intense dread of doing anything that everybody else does not do, or omitting to do anything that everybody else does. This of course does amount to a sort of working or rule-of-thumb conscience; but it means that you will do anything, good or bad, provided you get enough people to keep you in countenance by doing it also.

Saturday, 26 January 2013

On Bullshit

Excerpted from Harry Frankfurt's "On Bullshit:

When we characterize talk as hot air, we mean that what comes out of the speaker's mouth is only that. It is mere vapor. His speech is empty, without substance or content. His use of language, accordingly, does not contribute to the purpose it purports to serve. No more information is communicated than if the speaker had merely exhaled. There are similarities between hot air and excrement, incidentally, which make hot air seem an especially suitable equivalent for bullshit. Just as hot air is speech that has been emptied of all informative content, so excrement is matter from which everything nutritive has been removed.


What bullshit essentially misrepresents is neither the state of affairs to which it refers nor the beliefs of the speaker concerning that state of affairs. Those are what lies misrepresent, by virtue of being false. Since bullshit need not be false, it differs from lies in its misrepresentational intent. The bullshitter may not deceive us, or even intend to do so, either about the facts or about what he takes the facts to be. What he does necessarily attempt to deceive us about is his enterprise. His only indispensably distinctive characteristic is that in a certain way he misrepresents what he is up to.

This is the crux of the distinction between him and the liar. Both he and the liar represent themselves falsely as endeavoring to communicate the truth. The success of each depends upon deceiving us about that. But the fact about himself that the liar hides is that he is attempting to lead us away from a correct apprehension of reality; we are not to know that he wants us to believe something he supposes to be false. The fact about himself that the bullshitter hides, on the other hand, is that the truth-values of his statements are of no central interest to him; what we are not to understand is that his intention is neither to report the truth nor to conceal it. This does not mean that his speech is anarchically impulsive, but that the motive guiding and controlling it is unconcerned with how the things about which he speaks truly are.

It is impossible for someone to lie unless he thinks he knows the truth. Producing bullshit requires no such conviction. A person who lies is thereby responding to the truth, and he is to that extent respectful of it. When an honest man speaks, he says only what he believes to be true; and for the liar, it is correspondingly indispensable that he considers his statements to be false. For the bullshitter, however, all these bets are off: he is neither on the side of the true nor on the side of the false. His eye is not on the facts at all, as the eyes of the honest man and of the liar are, except insofar as they may be pertinent to his interest in getting away with what he says. He does not care whether the things he says describe reality correctly. He just picks them out, or makes them up, to suit his purpose.

Someone who lies and someone who tells the truth are playing on opposite sides, so to speak, in the same game. Each responds to the facts as he understands them, although the response of the one is guided by the authority of the truth, while the response of the other defies that authority and refuses to meet its demands. The bullshitter ignores these demands altogether. He does not reject the authority of the truth, as the liar does, and oppose himself to it. He pays no attention to it at all. By virtue of this, bullshit is a greater enemy of the truth than lies are.

Bullshit is unavoidable whenever circumstances require someone to talk without knowing what he is talking about. Thus the production of bullshit is stimulated whenever a person’s obligations or opportunities to speak about some topic are more excessive than his knowledge of the facts that are relevant to that topic. This discrepancy is common in public life, where people are frequently impelled— whether by their own propensities or by the demands of others—to speak extensively about matters of which they are to some degree ignorant. Closely related instances arise from the widespread conviction that it is the responsibility of a citizen in a democracy to have opinions about everything, or at least everything that pertains to the conduct of his country’s affairs. The lack of any significant connection between a person’s opinions and his apprehension of reality will be even more severe, needless to say, for someone who believes it his responsibility, as a conscientious moral agent, to evaluate events and conditions in all parts of the world.

The contemporary proliferation of bullshit also has deeper sources, in various forms of skepticism which deny that we can have any reliable access to an objective reality and which therefore reject the possibility of knowing how things truly are. These “anti-realist” doctrines undermine confidence in the value of disinterested efforts to determine what is true and what is false, and even in the intelligibility of the notion of objective inquiry. One response to this loss of confidence has been a retreat from the discipline required by dedication to the ideal of correctness to a quite different sort of discipline, which is imposed by pursuit of an alternative ideal of sincerity. Rather than seeking primarily to arrive at accurate representations of a common world, the individual turns toward trying to provide honest representations of himself. Convinced that reality has no inherent nature, which he might hope to identify as the truth about things, he devotes himself to being true to his own nature. It is as though he decides that since it makes no sense to try to be true to the facts, he must therefore try instead to be true to himself.

But it is preposterous to imagine that we ourselves are determinate, and hence susceptible both to correct and to incorrect descriptions, while supposing that the ascription of determinacy to anything else has been exposed as a mistake. As conscious beings, we exist only in response to other things, and we cannot know ourselves at all without knowing them. Moreover, there is nothing in theory, and certainly nothing in experience, to support the extraordinary judgment that it is the truth about himself that is the easiest for a person to know. Facts about ourselves are not peculiarly solid and resistant to skeptical dissolution. Our natures are, indeed, elusively insubstantial—notoriously less stable and less inherent than the natures of other things. And insofar as this is the case, sincerity itself is bullshit.

Thursday, 24 January 2013

Research We Need

This study (see below) creates a diagnostic framework for bacteremia based off of adding together a carefully selected combination of easy-to-obtain symptoms/signs. The criteria are deduced based off of a large retrospective analysis of which clinical measures had true predictive value. Then the derived method was tested on an out-group and validated. This combination of features (which is a combination of relatively imprecise features) offers an extremely high degree of sensitivity. This serves as a rule-out test that indicates the necessity for a follow up of a highly specific test (blood culture) to make the definitive diagnosis. By evaluating the patient in this order, we can save the invasive/time-consuming/expensive test for last, rather than going ahead and ordering it "just to be sure".

I wish a study of this type existed for every condition that warrants an expensive (& potentially harmful) diagnostic test, such as a lumbar puncture or CT scan. The benefits would be enormous. Any good clinician will understand why.

Who needs a blood culture? A prospectively derived and validated prediction rule. 

Shapiro NI, Wolfe RE, Wright SB, Moore R, Bates DW.

The study objective was to derive and validate a clinical decision rule for obtaining blood cultures in Emergency Department (ED) patients with suspected infection. This was a prospective, observational cohort study of consecutive adult ED patients with blood cultures obtained. The study ran from February 1, 2000 through February 1, 2001. Patients were randomly assigned to derivation (2/3) or validation (1/3) sets. The outcome was "true bacteremia." Features of the history, co-morbid illness, physical examination, and laboratory testing were used to create a clinical decision rule. Among 3901 patients, 3730 (96%) were enrolled with 305 (8.2%) episodes of true bacteremia. A decision rule was created with "major criteria" defined as: temperature > 39.5 degrees C (103.0 degrees F), indwelling vascular catheter, or clinical suspicion of endocarditis. "Minor criteria" were: temperature 38.3-39.4 degrees C (101-102.9 degrees F), age > 65 years, chills, vomiting, hypotension (systolic blood pressure < 90 mm Hg), neutrophil% > 80, white blood cell count > 18 k, bands > 5%, platelets < 150 k, and creatinine > 2.0. A blood culture is indicated by the rule if at least one major criterion or two minor criteria are present. Otherwise, patients are classified as "low risk" and cultures may be omitted. Only 4 (0.6%) low-risk patients in the derivation set and 3 (0.9%) low-risk patients in the validation set had positive cultures. The sensitivity was 98% (95% confidence interval [CI] 96-100%) (derivation) and 97% (95% CI 94-100%) (validation). We developed and validated a promising clinical decision rule for predicting bacteremia in patients with suspected infection.

Sunday, 18 November 2012

Einstein as Buddhist

A human being is a part of the whole, called by us "Universe", a part limited in time and space. He experiences himself, his thoughts and feelings as something separated from the rest — a kind of optical delusion of his consciousness. This delusion is a kind of prison for us, restricting us to our personal desires and to affection for a few persons nearest to us. Our task must be to free ourselves from this prison by widening our circle of compassion to embrace all living creatures and the whole of nature in its beauty. Nobody is able to achieve this completely, but the striving for such achievement is in itself a part of the liberation and a foundation for inner security.

-the big E

Friday, 26 October 2012

More truth

-At the heart of medical decision making in complex cases should be construction of a problem list. This process must satisfy two distinct requirements—analytical precision and thoroughness. First, each problem on the list must be defined at a level the current data support; for example, unproven diagnostic hypotheses should not appear on a problem list. Second, the problem list must be complete; that is, it must account for all abnormalities in the initial database as well as problems otherwise identified by the patient and caregiver. Failure to satisfy both requirements undermines order and transparency in complex cases.
-The problem list serves as a table of contents to the record. The utility is so obvious that maintaining a problem list became a common practice soon after the concept was introduced. But the practice is still not universal, due to lack of standards and enforcement for medical recordkeeping. Moreover, complete problem lists are not a common practice. In short, problem lists are treated as a convenience, not a discipline.
-Perhaps the most frequent and most serious omission from problem lists is social and psychiatric problems. This failing is critical, not only because those problems are important to address in themselves but also because they are essential to consider in diagnosis, and because they are relevant to managing other problems originating from purely organic causes.
-The health care system cannot change basic social, economic and cultural conditions. But the health care system can help document the harmful externalities associated with those conditions. In that way, the health care system can inform political and economic choices made in the public and private sectors. Equally important, by expending scarce resources with the maximum possible effectiveness, and by helping individuals cope more effectively with their own physical and psychological frailties, the health care system can engender greater public and private support.

Medicine in Denial

I've been considering what would happen if Romney actually wins this thing. Assuming he is open to productive changes in health care, I think the termination of automatic Republican opposition to everything would be an enormous asset to change. IMO we talk too much about insurance and not enough about this:

To overcome [the current disarray in medicine], all data collection must feed into a single, integrated, electronic medical record for each person. The foundation for each person's record must be a defined, comprehensive database maintained over time. Without that foundation, relevant data will not be accessible when needed, or will be duplicated unnecessarily. Most important, without the foundation of a unitary database for the whole person, patient care cannot become truly "patient-centered" or "consumer- driven." Care will always be provider-driven (or payer driven) as long as decisions are made (or imposed) based on superficial data collection serving the immediate interests of providers and payers rather than patients' total needs.
-Lawrence Weed. Medicine in Denial

I have more to say, but I don't think I have it in a digestible form yet. 90 pages of scattered notes don't really translate to blog posts very well.

Friday, 31 August 2012

Friday, 17 August 2012


Rainer Maria Rilke via Brain Pickings

I beg you, to have patience with everything unresolved in your heart and to try to love the questions themselves as if they were locked rooms or books written in a very foreign language. Don’t search for the answers, which could not be given to you now, because you would not be able to live them. And the point is to live everything. Live the questions now. Perhaps then, someday far in the future, you will gradually, without even noticing it, live your way into the answer.

I expect to start posting/writing more in the coming weeks. Summer has been gorgeous.

Sunday, 22 July 2012

The 21st century soul.

Straight from Wikipedia: Parfit is a reductionist, believing that since there is no adequate criterion of personal identity, people do not exist apart from their components. Parfit argues that reality can be fully described impersonally: there need not be a determinate answer to the question "Will I continue to exist?" We could know all the facts about a person's continued existence and not be able to say whether the person has survived. He concludes that we are mistaken in assuming that personal identity is what matters; what matters is rather Relation R: psychological connectedness (namely, of memory and character) and continuity (overlapping chains of strong connectedness). On Parfit's account, individuals are nothing more than brains and bodies, but identity cannot be reduced to either. Identity is not as determinate as we often suppose it is, but instead such determinacy arises mainly from the way we talk. People exist in the same way that nations or clubs exist. A key Parfitian question is: given the choice of surviving without psychological continuity and connectedness (Relation R) or dying but preserving R through the future existence of someone else, which would you choose? Parfit described the loss of the conception of a separate self as liberating:[2] “ My life seemed like a glass tunnel, through which I was moving faster every year, and at the end of which there was darkness... [However] When I changed my view, the walls of my glass tunnel disappeared. I now live in the open air. There is still a difference between my life and the lives of other people. But the difference is less. Other people are closer. I am less concerned about the rest of my own life, and more concerned about the lives of others.