The Fault Lies Not Within the Stars, But Within Thyself

Martha Zoller created an incredible treasure trove of discussion points when she posted to Pajamas Media on March 12. I am now going back to this wellspring of fascinating comments for the third time.

In "Can We Still Afford to Cheat Death", I wrote off of her comment:

Fifty percent of health-care costs are incurred in the last month of life and those costs rarely change the outcome of the patient’s illness.

But immediately after this, she went on to say:

In addition, most ailments in this society are brought on by behavioral choices. The amount of money we have spent over the years treating ailments brought on by abuse of alcohol, food, and nicotine is alarming. The government shouldn’t regulate the purchase or intake of these things. People must take responsibility for their own actions.

It is true beyond any question that the vast majority of the medical problems that I or any other doctor takes care of on a daily/weekly/monthly/yearly basis is caused or significantly aggravated in whole or in substantial part by lifestyle choices. Or rather, the wrong lifestyle choices.

Type 2 diabetes mellitus (aka adult onset), which accounts for approximately 85% of cases of diabetes, is in large part a lifestyle disease, brought on by years of overeating the wrong kinds of foods and then not exercising enough or at all. Diabetes then contributes to coronary artery disease, peripheral arterial disease, renal failure, retinopathy, et cetera, et cetera, leading to blindness, dialysis, limb ischemia/chronic wounds/amputations/cerebral strokes, myocardial infarctions/congestive heart failure, and above all death, as well as all the costs associated with caring for all this morbidity.

Use of tobacco, the delivery system of nicotine, is the leading cause of cancer in this country. top of the list is lung cancer, which is now the leading form of cancer and cancer death in both men and women. (It has been estimated that if genus Nicotiana had never existed, there might be only 5000 cases of lung cancer a year in the entire United States.) But it also contributes to increasing the rates of many different cancers, including but not limited to cancers of the breast, esophagus, stomach, colon, mouth, head and neck, and just about any other body part you might want to mention. In addition, good ol' tobacco is the primary cause of emphysema/COPD, another leading cause of morbidity and mortality. Anyone who has any exposure to what is entailed in treating a person with any kind of cancer can just begin to grasp the immense sums used to treat this nationwide.

Alcohol is a special case. It not only causes medical problems when overused, most notably cirrhosis but also brain damage, increased risk of cancer of the esophagus and breast, and even heart muscle injury, but it also causes injury, in the form of trauma from falls, motor vehicle accidents, and other injuries from the poor judgment of inebriation, both to the user and to anyone who might have the misfortune of being at the wrong place at the wrong time. I'll throw in with alcohol the misuse of other drugs of abuse, both illicit and prescription, though the direct medical effects of these are somewhat less problematic than their effect on increasing traumatic injuries.

And this just addresses the poor lifestyle choices Ms Zoller mentioned. There are many others that I could discuss -- unsafe sexual practices, daredevil stunts and other risky behavior, use of stereo equipment and headphones at levels louder than jackhammers, cell phone use while driving, et cetera -- but you get the idea.

Ms Zoller adds:

If you’ve smoked for 50 years and Medicaid stops paying for your $400-a-month respiratory medicine, you shouldn’t complain. You had the money to smoke all those years; don’t expect the government to take care of you when you did this to yourself. So while the government is having this debate, you should quit smoking, start walking, moderate your vices, and we’ll all do better.

I have said something similar to this before. I like the way she said it better.

Moralistically, ethically, legalistically, is it right for someone, anyone, to abuse their bodies and then expect everyone else to pick up the tab? Of course not. You infringe on my rights when you request or even worse require me to pay for your care (through taxes) against my will or without my consent. Yet this is where President Obama's healthcare "reform" is taking us. (I am going to have to find another word to use for his plan; reform implies an improvement in that being reformed, and Mr. Obama's plan is definitely not going to be any kind of improvement.)

The big problem that we must face with all of this is that what we currently consider the healthcare system is NOT designed to deal with this problem. In this point, Mike Huckabee almost has it right. He says that we must try to improve health, as opposed to improving healthcare. Be aware that what we call healthcare or the healthcare system is nothing of the sort. It is actually a medical care system with a centuries-old tradition and legacy of diagnosing and then treating medical and surgical illnesses. The emphasis of this system has never been to try to improve health but rather to restore health as best as that can be done. To ask this system to take on the more Herculean task of improving health while continuing to serve as the nation's medical care system and while "reducing costs" (cutting payments to healthcare providers) is not only asking more from these providers than human beings can be expected to give, it is also a recipe for mediocrity at best and utter failure at worst.

No matter how hard I try or how much I might wish to have the ability or the power to do so, I cannot improve your health. Only you can do that. Each and every one of you. Only you can put down the fork, get out of the chair and exercise, throw away the cigarettes and pour out the booze. And even then there's no guarantee. Sometimes bad things will still happen to you, and you won't be healthy. You'll be sick. That's when my job begins. But even so, I still try to cajole you into taking better care of yourself. And maybe 5% of the time, usually less, I am successful in getting you to do it.

Why don't you? What does it take to get somebody to take on their responsibility to themselves? I wish I knew. Because that's what it's going to take to improve health -- figuring out how to incentivize people to take better care of themselves. I can tell you from experience that trying to motivate them by promises of better health or warnings of dire consequences is not enough for most people. But I'll be damned if I know exactly what it's going to take to fix this problem.

But I do have an inkling of what it's going to involve. Money. Figuring out some way that a person can achieve a monetary gain from taking care of themselves is what it's going to take. Appealing to someone's higher nature isn't going to work when the food, tobacco and alcohol are appealing to the baser instincts. To win this fight, we're going to have to win over the reptilian core at the center of all of our brains. The only two things left to work with are sex and money. And somehow, I don't see sex as being a societally acceptable solution.

I Agree with The Light of the World!

It feels good to know that I am not alone in my stand.

mailloux on the blog RedState agrees with my plan on how to handle "Earth Hour":

Between 7:30pm and 8:30pm on March 28, I will throw financial caution to the wind and turn on as many of my home’s lights and electrical appliances as possible. I might even break out a string or two of blinking Christmas lights. I’ll put on a DVD for the kids, pop some popcorn in the microwave, do a load of laundry, and . . . wait for it ... set the thermostat to 73 degrees! (Gasp!).

My interest is political in nature. On Saturday March 28th, 2009 . . . between 7:30pm and 8:30pm . . . I’ll be voting with light switches and appliances. My vote will be against the maniacal, oppressive, and utterly divorced from reality lunacy of Global Warming. You see, “EarthHour.org” wants you to vote for the Earth and against Global Warming by turning off all your lights at the designated hour. I plan to do the opposite and vote for Anthropomorphic Global Warming only because I know it’s a crock . . . Earth won’t be taking any hurt by my turning on a few extra lights.

And from the looks of the comments on RedState, we won't be alone.

But remember, time for lights on is 8:30-9:30 PM local time.

Saving the Earth by Plunging It Into Darkness

The enviro-wackos are at it again. This time the inanity comes under the name of "Earth Hour".

As described on the site run by the World Wildlife Fund, the organization promoting this nonsense and whose own website obscures their organization's actual name behind the acronym WWF:

Earth Hour began in Sydney in 2007, when 2.2 million homes and businesses switched off their lights for one hour. In 2008 the message had grown into a global sustainability movement, with 50 million people switching off their lights.

Demonstrating once again the liberal tendency to prefer symbolism over substance, they have now turned this "protest" into a "vote" (and they even use the word "symbolize" in the process!):

A global event created to symbolize (emphasis added) that each one of us, working together, can make a positive impact on climate change...

This year, Earth Hour has been transformed into the world’s first global election, between Earth and global warming..... Switching off your lights is a vote for Earth, or leaving them on is a vote for global warming. WWF are urging the world to VOTE EARTH and reach the target of 1 billion votes.... It is the chance for the people of the world to make their voice heard.

So we're supposed to turn off our lights (all of them) and sit in the dark for an hour so we can feel good about "doing something" to fight AGW. Why just lights? Why not turn off the heat or the air conditioner? Unplug the TV and the computer -- they use power even in the idle mode. Your relative in the back room using the mechanical ventilator? They can get by without it for an hour, can't they?

WWF is hoping for a billion people to participate in this tripe to send a message that something more serious must be done to avert this tragedy. Meanwhile, what kind of message is being sent by the other 5 billion people (a number I note that is 500% greater) who are not participating in this dog and pony show?

If you have a house, like mine, with 14 rooms (counting hallways as rooms) and each room is lit with the equivalent of 4 100 watt lightbulbs (an overestimate based on my house), then turning off all these lights is going to "save" 4 x 14 x 100 x 1hr = 5600 W/hrs, or 5.6 kWh. Replacing only one of these bulbs with a CFL bulb which you run only one hour a day will "save" the same amount of electricity in only a little over 75 days. Or 4.8 times as much electricity over 1 year. For each bulb you replace, multiply the savings by the number of bulbs. Since most CFL multipacks come with 5 bulbs, buying and using just these 5 bulbs would save in one year 24 times as much energy (134 kWh). For those of you deluded enough to actually believe in this AGW nonsense, which action would have more of an effect on reducing AGW? Changing out the bulbs, naturally. But without making the big symbolic "statement". And if you've already changed out all your bulbs to CFLs, then just how much of a statement are you really making?

I however would only advocate changing these bulbs if you want to save the money on your electric bill, though I haven't taken the time to see if the extra cost of the CFL bulbs ever gets recouped. I suspect that it would not. But then, since the incandescent bulbs are being phased out anyway......

Let's make a mockery out of this ridiculous example of political theater. "Switching off your lights is a vote for Earth" -- Horse rot! "Leaving them on is a vote for global warming" -- no, leaving them on is an act of defiance, a shout to the heavens and all who will listen that you have not bought into this doomsday farce.

On Saturday March 28, 2009, from 8:30 PM to 9:30 PM (local time), I encourage you to turn on every light in your house. Turn on every device you own that uses electricity. Turn up the heat or turn down the air conditioner. Light a fire in your fireplace. Leave your relative on the ventilator. Start up your car and let it idle in the driveway for that hour. Lights on bright of course!

Join me in my protest! My house will be the one you can see from Mars.

Addendum 3-17-09: I am not the only one decrying the insanity of this idea. James Hudnall takes on Earth Hour and AGW at Big Hollywood Blog. And let's not forget eSurance and all their enviro-wacko ads. It was one of their commercials that turned me on to this scam (pun intended). Boycott them, please. What has environmental politcal correctness got to do with insuring cars anyway?

Can We Still Afford to Cheat Death?

In my last post, I issued the first in what I guarantee will be a multitude of diatribes against the Obama Administration's misguided attempts to deconstruct and destroy the greatest healthcare system in the history of mankind. In that post, I referenced a blog post discussing the early stages of this process. But at the end of this post, the author, Martha Zoller, went off on an interesting tangent:

Fifty percent of health-care costs are incurred in the last month of life and those costs rarely change the outcome of the patient’s illness.

I am not quite sure that the statistic of "50% of healthcare costs are incurred in the last month of life" is exactly correct. I have previously heard that it is more like 50% in the last six months of life. Either way, the point is that for most people, the majority of the dollars spent on their healthcare will be spent right before they die. This is, however, a rather specious statistic. Of course one's healthcare costs go up right before one dies! It would be much more remarkable if the costs went down. Most people get sick with the illness that eventually kills them right before they die. Saying "these costs rarely change the outcome of the patient's illness" is also specious. If the costs (i.e., treatment) changed the outcome of the illness, it wouldn't be the last months of your life; those months, and the costs accompanying them, would come later.

But let's ignore the speciousness of this argument and acknowledge that the point being made is that in this country we spend a tremendous amount of resources and money on care that ultimately turns out to be futile. The dirty little secret is that most of the time -- not all the time, mind you, but most of the time -- the doctors providing this futile care know, or at least have a pretty good idea, that this care will be futile almost from the get-go. So why do we not say so?

Would you, if you were the patient or the family member of the patient, want us to?

Be honest now. Think before you answer that question. I am sure that most readers here will respond to that question with an immediate "Yes, of course I would want my doctor to be honest and up front with me!" But put yourself mentally into that position, especially in the position of being the family member, and turn off your brain and let your heart answer the question. Because that is how you are going to answer the question when your time comes to answer it. For your time will come. I've been there as the family member -- twice. And being a physician doesn't change the fact that I am a human being as well and I respond with my heart just like all the rest of you.

I am not going to go into the details of my personal experiences with this type of situation. For one thing, it's none of your business. For another, the details don't matter. It's the decision making process that's the issue. Anyone -- everyone -- can look at these situations when they are the dispassionate outside observer and easily say that it is clear what the 'right' decision to make should be. But when you are faced with making those decisions for yourself, or for someone you love (which in my experience as a doctor seems to be more common and more difficult), it's not that easy. Because you need time to come to grips with the fact that you are face-to-face with the ultimate no-win situation, and the very last thing the human heart gives up is hope.

So now imagine that I come to you, the emotional, brain-deactivated relative, at the outset of some horrendous disease process for your cherished loved one, which almost universally you have had no preparation for, and say to you, "I know that what I have just told you comes as quite a surprise. But we have to think about how we are going to address this problem. In my experience and training as a physician, this condition has virtually no chance of recovery. The most reasonable thing to do at this time is to consult the hospice service and keep him as comfortable as possible." How do you think you'll be likely to react? I'll tell you how you'll react. You'll think I am the most callous human being you have ever had the misfortune to meet. You'll ask for a second opinion. You'll fire me. You'll tell me to go to hell. You might even take a swing at me. And I would deserve it.

Why is it this way? It has to do with how the human mind deals with grief. Because when faced with the inevitable loss of one's own life or the life of a loved one, there is grief involved. I cannot describe this any better than it was outlined by Dr. Elisabeth Kubler-Ross. This process cannot be rushed, and every person goes through it in their own time. Biological reality often forces some people to have to deal with such an issue in a compressed time period, and those poor souls are usually devastated. Believe me when I tell you that you would handle being told that your relative had died in a car crash better than if I told you that your relative was going to die in a short number of hours or days and there was nothing that could be done to stop it. Why? In the first instance, the loss is instantaneous, and there is nothing you can do about it. In the second, the loss is still at a point in the future, and your heart refuses to accept that the situation is hopeless.

And now we have the Obama Administration seemingly heading down the road to creating a healthcare system that will arbitrarily say what can be done and when it can be done. By arbitrarily, I mean based on factors that you would not consider were it you making the decision, and that is primarily the factor of cost. This is unfortunate, because they are going about this in the wrong way. And the only really unfortunate thing about it is the way they are going about it, for the reality really is we cannot afford to continue doing things the way we have been.

I have a colleague who has been pushing for quite some time for organized medicine (e.g. the AMA) to call for the establishment of rules regarding futile care. He proposes that when a doctor determines that care for a condition will likely be futile, that he tell the patient/family, and at that point if the patient/family wants to pursue that care, it will become solely their financial responsibility, that they can expect no assistance from insurance or the government (whose monies are the confiscated property of other people). I think this is a dreadful idea, because it puts the doctor in the position of deciding what should or shouldn't be done, and I feel is should always be the patient doing that. Besides, it sounds callous, and I rightly predicted that the first group to make such a proposal (of de facto rationing) would receive a firestorm of criticism regarding it. Just look at the opposition the current reform plan is generating (even from me!) just because it hints at rationing. It's best to leave that job and the subsequent fan-propelled feces to the politicians!

The sad part of this is that to a great extent this situation was brought about by us doctors, by our stubborn refusal to accept death as an acceptable outcome (for it is and always shall be inevitable), even at a time in the past when we were truly impotent. And now, when we have more abilities to try to intervene and cheat death than we ever have before (as puny as they are), a growing number of us are coming to the realization that to do so is often a disservice to our patients, but we have a great deal of difficulty saying this because we have (or rather, or forefathers have) convinced the public that we are nearly omnipotent. So the public, our patients, can't accept it when we might suggest that there is no point to fighting to the bitter end -- what's going on here, this isn't what the doctors used to say!

So, how do we change this situation? It isn't going to be easy.

My suggestion has always been that the AMA, and now I will include the government, begin an educational campaign to teach doctors how to have realistic end of life discussions with their patients. I would hope that the medical schools and the residency programs would have already started this. When I went through my training, such a thing didn't exist in a formalized way at all, and it was more or less on-the-job training. Some doctors learned it well, and some didn't. My observation of some of my younger colleagues doesn't give me a lot of encouragement in this regard. This education needs to extend, at first subtly and later more overtly, to the general public at large as well. As one example, TV shows give a totally unrealistic expectation of how successful CPR will be; it seems as if the majority of patients survive the attempt, when the reality is that CPR even in the hospital (much less outside the hospital) leads to a patient leaving the hospital only about 3% of the time. (This statistic is for CPR for conditions other than the setting of an acute coronary event like a heart attack, where the odds are much better, around 55% or so.)

But in addition, there needs to be a change in our society's attitude toward death. Currently, death is seen as an enemy to be feared and fought against with all our might. But this is a fight that we all must someday lose. Death is merely the final stage of life that we all must go through. For me, and I hope for you, death does not mean an end but rather a new beginning. The results of this poll, however, are not hopeful on this idea, and I fear that as fewer people believe there is a life after this one, protecting and extending earthly life will become ever more crucial. Whatever your religious views or lack thereof, my hope is that we can all begin to cherish each day of life we have, whatever their number, and make the most of each and every one.

Health Care Reform School

Well, it has begun. He promised us that he would reform the healthcare system, even though we have the greatest healthcare system in the world (though, as I have said previously, we could stand to fix some of the problems we have in financing it), and he has started the process.

The "he" I refer to is of course President Obama. (I had no idea how hard it was going to be to type those words: President Obama. My fingers locked up in protest.) You will recall what I thought about his healthcare reform plan before the election. It's a pity we can't send him and his cronies to reform school.

My county medical society just had a meeting at which our state medical society president attended and spoke to us at length about the process that is now unfolding. It was somewhat vague and lacking details about the plan, mainly because the details haven't been fleshed out yet. However, this hasn't stopped people from speculating about what the plan will be like, based mostly on the fact that, though kept out of a direct leadership position in the debate due to his seeming inability to report and pay income tax on over half million dollars of income, Tom Daschle will still be having a significant behind-the-scenes influence on the plan. And unfortunately, he will likely be more dangerous in this new, non-public position. Why do those of us who prefer a free-market healthcare system (though we haven't had one in this country in over a half century) fear Daschle so? Because he's already told us where he wants to take healthcare in this country, and it's a place most reasoning people don't want to go.

Take a look at this speculation. I love some of the statements made here.

But tucked into the 700+ billion dollar “stimulus” plan is the digitizing of medical records and a board that will decide whether a type of care is necessary. This is merely code for the rationing of health care.

No, this is a description of how they intend to carry out rationing. It is a promise, not code words.

Larry Summers of the National Economics Council chaired a session on tackling costs, which included suggestions to change the way doctors and hospitals are paid and even placing limits on how much and what kind of care patients can receive. Again, this is simply code for rationing.

Again, not so much code words as a promise that care will be rationed.

Tort reform has got to be part of any health care reform package but at the “summit,” it wasn’t discussed.

Anyone holding their breath waiting for that to be a part of this reform package is going to die of hypoxia. When the party of the trial lawyers is in charge of the reform, does anyone really expect there to be any limitations on the ability of the sharks to feed? No, by limiting what we doctors can do to protect ourselves, this "reform" will be more akin to throwing chum in the waters to attract more of the sharks. Our state medical society president holds the opinion that tort reform will be considered. I'm watching her to see when she's going to start turning blue.

Finally, the article quotes Democratic Senator Max Baucus:

"...so we have to have our uniquely American health care solution, it has to be both public and private. My goal is to keep that mix of public and private, that uniquely American result with which a lot of Americans, the vast majority of Americans are very comfortable.”

I don't hold out much hope here. I expect these idiots to ram down our throats a system that will be completely run or at least under the complete control of the government. Furthermore, I expect this system will be set up such that no doctor will be allowed to operate outside of the system (because otherwise they couldn't control the costs) and that any doctor that tries will be hunted down and prosecuted with a fanaticism that we could only wish had ever been applied to the war on illegal drugs.

There's an even more interesting passage in this essay that comes toward the end. I'll take that on in my next post.

When Is 45 Million Not 45 Million?

Been gone a while -- my day job keeps getting in the way of new posts. (Winter: the busy season for a doctor. Who'd've thunk it?)

Hat tip to Laura at Pursuing Holiness for putting me on to this video. It's worth the nine or so minutes of your time. (One of these days I'm going to figure out how to embed or link YouTube videos into my blog. I just can't seem to get it to work. Follow the link or the rest of this post won't make much sense.)

Don't try to add up the numbers in this video without making some adjustments. Otherwise, you'll come up with 78 million uninsured. The quoted numbers for the "young invincibles", >75K and >50K incomes, the government-program eligibles who fail to apply, and even likely the illegal aliens must have some overlap built into them. I have seen other statistics quoted in the American Medical News (the AMA's newspaper) that agree with the bottom line of 6-8 million hard-core uninsured -- those who simply cannot afford, cannot get [due to pre-existing conditions], or are not functional enough to obtain insurance on their own.

The video is enlightening, and infuriating, mostly due to the quotes from the interviewees. The worst offender is the young woman we are introduced to at the beginning of the clip. I'll call her Ms Freeloader. Why? She can't recall how much her hospital bill was after being hit by a car on her bicycle as she "didn't bother to pay for it" -- most likely because she thinks "it's ridiculous that you have to pay for basic health care in this country". Being hit by a car is "basic health care"? Since when? And what about the driver's auto liability insurance? All of the interview subjects admit to spending large amounts of their income on dining out and entertainment, with nary a care about what's going to happen to them when their health luck runs out; the reason they're referred to as "invincibles" is because in their own minds they are healthy and this isn't going to change so why do they need insurance? Though I'll bet they insure their car or motorcycle or wave-runner or whatever.

Then there's the policy analyst. If his figure is correct, that the system spends an average of $1000/yr for every one of these uninsured individuals, then that means the system is taking on $45 billion per year in non-reimbursed care. This $45 billion is either absorbed by the system -- that means written off as uncollectable by hospitals and doctors (who alone among all businesses cannot legally deduct that loss from their taxes) -- or is passed on to the responsible people who pay their bills in the form of higher healthcare costs. A certain small portion is covered in whole or in part by governmental programs. Very little of this cost is paid by the health insurance industry, which goes out of its way to try not to pay that which they actually owe, much less what isn't properly their responsibility. $37 billion of this is for people who for whatever reason have chosen to shirk their responsibilities. If that does bring your blood to a rolling boil, then consider the compassionate entry program, where foreign nationals are brought into this country to receive uncompensated care that adds to our tab even more. My blood transitioned completely to the vapor state long ago, so this merely increases the pressure in my steam-powered circulatory system.

So let's consider some numbers. If we accept the 45 million figure as the uninsured, with an American population of 300 million, that means there is a 15% uninsured rate. If the number is only 8 million, the rate is only 2.7% Since the American population is actually almost 306 million as of this posting, those rates are really 14.7% and 2.6%. With the current economic collapse and increasing unemployment, I'll accept that these numbers are the lower end of the estimate and that the real numbers are actually higher, but it's hard to pin them down as the unemployment rate is still fluctuating.

For a problem that is costing us $45 billion max (mostly because of the shirkers), with an underlying core of 2.7% truly uninsured individuals, we are now being asked by the new 'enlightened' Administration to pony up hundreds of billions of dollars to 'reform' the healthcare system. At last count this includes $643 billion in the 2010 budget, with more to follow in 2011 and beyond, as well as untold billions in the so-called stimulus spending bill (I haven't seen a solid number for how much in that bill is for "healthcare", if you consider creating a national healthcare network healthcare, which I don't). Once again the numbers don't add up, but this time it's because the money isn't really going to "healthcare".

This 45 million (and climbing!) figure that we've been hammered with for all these years is just a bunch of smoke and mirrors, part of the (Democrat/Liberal) plot to seize more power and control over you by taking more control over more and more of your life. And like lambs being led to the slaughterhouse, most of the American people don't see what's coming. It won't be pretty. But then, slaughterhouses rarely are.