Absent from any ledger

I've been meaning to write an additional follow-up post about one thing President Obama mentioned in his State of the Union address, and am only just now getting around to it. As a bone he seemed to throw toward the ascendant GOP, the POTUS mentioned a willingness to consider malpractice reform as the health care reform bill is tossed around during this next Congress.

I, of course, think this is just dandy. I am, after all, a doctor. However, I think it's dandy because I really do believe it will lower health care costs in America.

During my morning commute the next day, they were fact-checking the speech on Morning Edition. Among the things they questioned was how much malpractice costs contribute to health care costs overall. The take-home lesson is that tort reform would save very little money. A similar argument was made a while ago in the Times, and the amount that could be saved was described as a "rounding error" because it would be so small.

I think this misses the mark. Buried in the Times piece is this exchange:

Q.

But it’s not just the cost of premiums and litigation. What about the charge that it causes doctors to practice “defensive medicine,” ordering tests that are expensive and unnecessary?

A.

A 1996 study in Florida found defensive medicine costs could be as high as 5 to 7 percent. But when the same authors went back a few years later, they found that managed care had brought it down to 2.5 to 3.5 percent of the total. No one has a good handle on defensive medicine costs. Liability is supposed to change behavior, so some defensive medicine is good. Undoubtedly some of it may be unnecessary, but we don’t have a good way to separate the two. [italics in original, but emphasis added]

In other words, nobody really knows how much so-called "defensive medicine" (or "CYA medicine" -- you figure it out) really costs. Allow me to suggest that it costs a whole hell of a lot.

I defy you to find a medical provider who has never ordered tests he or she knew to be unnecessary in order to placate an anxious or irate or demanding patient or parent. This is not to say that anxious/irate/demanding health care consumers do not sometimes have real medical problems that are discovered because they pressed for further testing; medical providers are fallible, and sometimes the tests prove to be more important than initially suspected. But there are, I guarantee, innumerable instances when tests or consultations are ordered with low suspected yield, and with little or no useful outcome.

Speaking merely for myself, I try like the dickens to avoid ordering unnecessary tests, and I go to great lengths to explain why I don't think they are indicated. I try to do this in a way that addresses parents'/patients' concerns, so as to avoid making them feel ignored or dismissed. But sometimes the demand persists, and it's a hard call whether it's better to acquiesce or have a pissed-off patient.

Nowhere is there a box to check "I am ordering this to appease a demanding mother" or "This test is to cover a plausible number of obscure diagnoses, thus creating the appearance of due diligence and limiting potential liability." No provider is going to put any indication of this reasoning in the medical record. In fact, just the opposite is likely, with physicians and other practitioners making an effort to explain why they did what they did in case the chart is ever audited by insurance carriers. These costs are, and will remain, hidden.

How much of an impact would tort reform have? I have no idea. But I suspect it is much greater than any study would be able to determine a priori.

Almost makes me wish I ate there

I have never eaten a Chick-fil-A sandwich in my life. I've seen it in various mall food courts (mainly back in the day when I lived in Missouri), and have never been moved to try the food. Something about the weird way they spell the chain's name, with the bizarre phonetics and hyphens and capitalization, gets on my nerves. For an unapologetic nerd like me, that's reason enough to take my chances on the reheated pizza next door.

It seems I've inadvertently been making a sound dining choice. From the Times (with a tip of the hat to my friend Ken):

Nicknamed “Jesus chicken” by jaded secular fans and embraced by Evangelical Christians, Chick-fil-A is among only a handful of large American companies with conservative religion built into its corporate ethos. But recently its ethos has run smack into the gay rights movement. A Pennsylvania outlet’s sponsorship of a February marriage seminar by one of that state’s most outspoken groups against homosexuality lit up gay blogs around the country. Students at some universities have also begun trying to get the chain removed from campuses.

Damn. I can't stop eating at a chain I never tried in the first place.

On a petition posted on the Web site change.org, [Georgia Equality] asks the company to stop supporting groups perceived as anti-gay, including Focus on the Family, an international nonprofit organization that teamed up with Chick-fil-A a few years ago to give away CDs of its Bible-based “Adventures in Odyssey” radio show with every kid’s meal.

Can I just say that a CD of a Focus on the Family radio show may quite possibly be the crappiest kid's meal prize ever? It's like getting a box of dessicated raisins on Halloween.

I think attempts to get the chain booted from college campuses are misguided. While I find the organization's support of fundamentalist Christian, socially-conservative policy odious, it's a free country and the owners of a privately-held company can do whatever they want with their money. I support the rights of people to hold views I consider anathema. The answer to objectionable speech, as my pal Burt would say, isn't to silence it, but to counter it with more speech.

I support the drive to inform people what their money may be subsidizing. People who object can choose to clog their arteries with chicken sandwiches purchased elsewhere. If enough people choose to penalize Chick-fil-A (that is incredibly irritating to type) where it counts, they may choose to stop funding dogmatic bigotry.

---

OK, this is totally off-topic, but since I've already mentioned by nerdish tendencies I'm going to gripe about an unrelated pet peeve in the article.

But Douglas Quint, a concert bassoonist who operates The Big Gay Ice Cream Truck in New York during the summer, said he believed that people should make informed decisions about their food.

“It literally leaves a bad taste because I know the people who are putting this food in my mouth actively loathe me,” he said. “I’m all for freedom of religion, it’s just that I know where I want my money to go and I don’t want my money to go.”

I agree with Mr. Quint about where people spend their money. I love the idea of a concert bassoonist who operates The Big Gay Ice Cream Truck. I only wish he knew what "literally" means. Because unless the actions of Chick-fil-A's owners have altered the flavoring of their sandwiches or the function of Mr. Quinn's taste buds, I believe the word he was looking for was "figuratively."

A less beautiful place

You know, I have no idea how much it costs to have illegal immigrants in this country. I suspect that, being undocumented, it's nearly impossible to get accurate information about how much they contribute to the country by doing hard, unpleasant, low-prestige work for low wages. Maybe they cost more than they contribute, but somehow I doubt it.

No matter the costs, however, I just can't get myself all that riled up about illegal immigrants. Perhaps it's my weak, liberal soul that insists about seeing them as people seeking a better life for themselves instead of menacing parasites. Perhaps it's because fully half of my family arrived in this country after fleeing the Ukraine at the turn of the last century (cue "Anatevka"), and I suspect if you'd polled Americans at the time they wouldn't have been too thrilled at having them here. Perhaps I'd feel differently if I lived in Arizona or another border state with an undeniable problem with drug cartels and crime. Who knows?

However, this just makes me angry (via TPM):

Sen. David Vitter (R-LA) and freshman Sen. Rand Paul (R-KY) have now teamed up -- and they're aiming very high. The two have proposed a constitutional amendment, to get rid of birthright citizenship for the children of illegal immigrants.

From their joint press release, their proposal will declare "a person born in the United States to illegal aliens does not automatically gain citizenship unless at least one parent is a legal citizen, legal immigrant, active member of the Armed Forces or a naturalized legal citizen."

I sought clarification from Vitter's office as to whether this would be a full-fledged amendment to the Constitution, or a lesser legislative route. It is indeed a proposed amendment to the Constitution.

I hope they fail. I hope they fail spectacularly.

One of the things I love most about this country is its embrace of its immigrant past, and its symbolic welcome to oppressed and suffering people from around the world. I thought (wrongly?) that it was a source of national pride. We were ready enough to affix words to that effect in one of our most famous monuments. (Given our more recent disdain for all things French, should we give it back?) It makes America more beautiful, as far as I'm concerned.

Clearly this vision isn't shared by the likes of David Vitter and Rand Paul. Which I don't find surprising. Tragic, but not surprising.

You only get one brain

A few weeks ago, I went onto The Google to look for running resources in my hometown. I enjoy running a lot (except when the Powers that Be insist upon dumping piles of snow on New England every few days *shakes fist angrily at sky*), and was looking into resources for a family member who had indicated an interest in running herself. By searching with "[hometown]" and "running" I found nothing helpful for her, but I did come across a YouTube video of high school running back being interviewed after a game. The description caught my eye, so I watched it. (Sadly, I'm not particularly keen to tell everyone where I'm from, so readers who don't already know my hometown won't be able to find the video in question. Were they so inclined.)

In the video, the player describes taking a hit and blacking out briefly. However, as the interviewer approvingly notes, the player "manned up" and got right back in the game, wherein he apparently made a some impressive plays.

Suffice it to say, my own reaction was less approving. While I am loath to make any diagnosis without my own history and physical, what the player described was almost certainly a concussion. Presuming this diagnosis is valid, he absolutely should not have returned to play, and should have instead received medical attention shortly thereafter. But that wouldn't have been "manning up," I suppose, and would have lacked heroic appeal.

Ben McGrath has an excellent article about football and concussions in the most recent issue of The New Yorker. Anyone who is interested in the subject would do well to read it. It is a subject that deserves as much attention as possible, because the long-term effects of repeated concussions are only just now coming to light. Parents of athletes, particularly in contact sports, should read it with care.

I encounter a lot of patients who have sustained some kind of head trauma during sports participation, and I'm glad to say that coaches and trainers in the area increasingly seem to be treating concussions with appropriate vigilance. I work in a relatively affluent and well-educated area, so it's no surprise that parents here would be more attuned to shifting norms and health care recommendations. While the best approach to concussion management is an area of ongoing research, and there's still a lack of clarity in how best to advise and treat these patients, it is definitely a condition to be respected, and not downplayed or shrugged off.

I don't want to make too much of one video found randomly, even if it is from my hometown. But it certainly reminded me that there are plenty of players and coaches and fans who don't appreciate the long-term significance of concussions (especially more than one) in athletes. We are learning new and encouraging things about brain plasticity, but brain-damaged patients can find themselves progressively and permanently disabled. No sport is worth that.

My long-awaited SOTU reax

Meh.

I'm with Jonathan Bernstein on this one. I thought it was a pretty lackluster speech. I didn't hear anything important or newsworthy. There were still umpteen tedious standing ovations, they just weren't as entertaining because they weren't as obviously partisan due to the seating arrangements. (I was all for the mixed seating in principle, but having sat through the speech and realized once again how full of meaningless theater the SOTU often is, the least I could hope for is entertainment in the future. Switch back.)

I still like President Obama a lot. I think he's shaping up to be a very good president in many ways. There are things I'd like him to address that he hasn't because they're political kryptonite (like entitlement reform), but generally I agree with his policies more than I disagree. I can (almost) guarantee I will vote for him again (given the lack of any GOP candidate I could even conceive of voting for), and I will likely contribute to his campaign.

But man, I just no longer enjoy his speeches. I hear all the rhetorical flourishes and modulations in tone and get annoyed, not inspired. I find him heavy on boilerplate and light on specifics. To quote one of my favorite lines of all time from "The Simpsons," his reference to our "Sputnik moment" smacked of effort. But at least I like him more than this guy.

I consider it something of a duty to watch major presidential addresses, no matter who's in office. It seems like a necessary part of being an informed citizen. But even for a political junkie like me, the State of the Union felt more like a visit to the dentist than even an enjoyable piece of political theater, much less a forum for introduction of anything important. Maybe next year I'll skip it.

Funniest thing I've read all day

This side-splitter from the Dish:

The Dish doesn't hate Palin.

Baaaaaaaaaaaaaaaaaah, hahahahahahahahahahaha!!

*whew*

Look, I think Sarah Palin is the pits. I think she is the embodiment of all that ails American politics these days. If she were to eschew all thoughts of running for high office for perpetuity, I would breathe a sigh of relief and consider the country safer. I make no bones about this, and would be fooling nobody to pretend otherwise.

I am practically the president of the "Up with Palin!" fan club compared to Andrew Sullivan. He haaaaaaaaaaates her. He hates her so much that pretty much everyone who reads his blog has started rolling their eyes whenever he talks about her. It's drawn plenty of commentary and criticism within the political blogosphere, and he occasionally even publishes letters from readers saying "enough already!" His hatred for Palin so clouded his judgment that he embarrassingly embraced the obvious reprobate and famewhore Levi Johnston because Levi possibly had dirt about her. (It didn't hurt that Johnston is good looking.) In fact, this isn't the first time I've said this.

Now, it's his blog and he can bash whom he wants to. But this high-minded sniffing that he doesn't "hate" Palin is galling. It's annoying and fools nobody.

That's it. I'm old -- redux

I remember, in the misty reaches of my youth, a time when Madonna was considered provocative. (Young readers [if you exist], don't snicker. It's true.) Why, watching her writhe around on stage in a bridal gown while singing a song that implied she wasn't a virgin anymore was downright scandalizing!

I was a teenager when MTV decided not to air her "Justify My Love" video, a decision that was considered newsworthy for some reason. I was very into Madonna at the time (what some might consider an example of "foreshadowing"), and was really, really interested in knowing what my favorite pop star had done. My father, being an obliging chap, recorded the episode of "Nightline" during which the video was aired and discussed. I was, as the kids these days would say, totes excited. Imagine my dismay then, when I eagerly pressed "play" on the old VCR, only to find that someone had paused the recorder during the part where the video was shown, and restarted it for the subsequent analysis and discussion. Someone, it turns out, was not so very obliging after all. This was an example of what I understand to be "parenting." (I have since managed to pollute my mind with the video in question.)

I bring all of this up to make two points about the new MTV series "Skins," which they gleefully ripped off from the BBC. I've seen a couple of episodes of the British original, which seems to revolve around the louche lives of a bunch of desultory teenagers. I found it kind of dull, but then again I'm old. Here's what the Times has to say:

Last week, my colleague Brian Stelter reported that on Tuesday, the day after the pilot episode of “Skins” was shown on MTV, executives at the cable channel were frantically meeting to discuss whether the salacious teenage drama starring actors as young as 15 might violate federal child pornography statutes.

Senior executives are now considering additional editing for coming episodes, but that’s a little like trying to lock the door after a naked 17-year-old has already busted out and gone running down the street, which is precisely what one of the characters does in Episode 3 — with a pill-enhanced erection, no less.

Charming.

In retrospect, MTV's refusal to air Madonna's video seems downright quaint, doesn't it? In two short decades they've gone from a firm "no stylized video orgies" stance to possibly violating child pornography laws. Strong work, MTV! Shall we expect hard-core porn in another twenty?

The other thought that crossed my mind reading the Times article this morning was that today's well-intentioned parents are pretty much outta luck if they wish to keep their kids from watching this show. (Lord knows, if I were still an adolescent now, the chances I would be allowed to watch "Skins" are somewhere between "diddly" and "squat.") Media technology being what it is, would-be viewers of any age can find the content with minimal effort on the Internet.

Now, the debate about whether shows like this corrupt otherwise innocent youth or merely reflect the already-corrupt state that they're in is nothing new, and I'm not going to cluck my tongue that society is going to crumble before our eyes because of this particular program. I do think that MTV has done more than any other single media outlet to make our popular culture more obnoxious, idiotic and crass, and yes, I am including Fox in that statement. However, I suspect the Republic will survive yet another assault on its crumbling sense of taste and decorum.

What are modern parents to do? Here's my plan for when the Critter wants to watch whatever horror MTV or the like has made popular when he's a teenager -- I plan to suffer through watching the damn thing myself, and then make him talk to me about it. (If I can suffer through "V," I can suffer through anything.) Trying fruitlessly to prevent him from watching what will then probably be streamable right into his visual cortex seems a waste of effort. Watching it myself and making him listen to my opinion will serve two purposes -- I will be able to at least temper the malign influence of the show with my own perspectives, and I will be able to suck all the pleasure out of his watching it by making it a chore. Nothing is less cool than something your parents make you talk about.

If I can ruin something tantalizing and prurient for my own adolescent son, I will consider myself a success as a parent.