Hopping off the Hopey-Changey Express

During my evening commute last night, I caught an excerpt of the President's speech at Penn State yesterday on the radio. In the brief bit I heard, he talked about increasing energy efficiency in buildings around the country as a way of helping both the environment and the economy.

The content of what he had to say seemed reasonable enough, and on its face appeared to be part of a sensible economic plan. What left me musing wasn't what little I heard him say, but rather my response to it.

I didn't find him annoying.

Sad to say, the last couple of times I've heard President Obama deliver major addresses, I've come away unimpressed. I'm still very much a supporter, but his much-vaunted oratorical skills have been leaving me cold. Both his speech in Tucson after the Giffords attack and his State of the Union sounded hackneyed and formulaic. Given that most of the reviews I read gave him positive marks, at least regarding the former, clearly it wasn't just that he had given lousy speeches. Why did I find him such a thrilling speaker as a candidate, only to watch the bloom come off the rose when he assumed office?

I think I figured it out. Both his Tucson speech and SOTU were heavy on broad themes. Lots of rhetoric about unity and America's character, lots of grandiloquent language and orotund prosody. In many ways, they were reminiscent of some of his more famous speeches, going back to his heralded (and, in my opinion, brilliant) speech at the 2004 Democratic National Convention.

The problem is that we all know what happened after all those fabulous speeches about changing the culture and tone of Washington, and Hope and Change and such. I remember 2008 fondly, but 2009 came immediately thereafter and blew any illusions about changing DC to smithereens. It was, if anything, even more rankly partisan than before. And while I place the blame for that almost entirely with the GOP, it was a bummer to see that part of my hope for the Obama administration was nothing more than idealistic hooey.

(Yes, yes. I should have known better. Shame on me. But it's not like that was the ONLY reason I voted for him. Hell, with Palin on the other ticket, I would probably have voted for Captain Kangaroo.)

Having now come back to my misanthropic, politically cynical senses, I no longer yearn to hear the POTUS wax poetic about American virtue or character or beauty. Heard it, thanks. Didn't take. Not sure it's his fault, but no longer interested in hearing any more about it. Even if the Tucson event called for such rhetoric, I'm no longer personally receptive to it. (And, sorry, but I still think all the audience whooping was inappropriate.) Any time I hear it now, it sounds hollow and devoid of much merit.

When he gets to specifics, on the other hand, I'm happy to hear him speak.

A question for our media overlords

If I just make crazy shit up, can I be a[n overpaid at any price] pundit, too?

On humility

Yesterday's Times Magazine has a harrowing article about shaken-baby syndrome. Its tragic and shocking subject matter makes it particularly challenging to read. I have (blessedly) never been directly involved in the care of a shaken infant. I remember a case being discussed at morning rounds once during my fellowship in New York City, but my subspecialty is unrelated and I heard nothing further about it. I hope I am lucky enough never to encounter this diagnosis again in the course of my career.

What I know about shaken-baby syndrome (on which I will not dwell in detail) is retained from residency, with a medical education conference or two on the subject since then. There is a constellation of findings that, viewed together, are pathognomonic for the syndrome. That is, if you find these things, they point conclusively toward shaken-baby syndrome. If these, then that, QED.

Except, maybe not?

A dozen years ago, the medical profession held that if the triad of subdural and retinal bleeding and brain swelling was present without a fracture or bruise that would indicate, for example, that a baby had accidently fallen, abuse must have occurred through shaking. In the past decade, that consensus has begun to come undone. In 2008, the Wisconsin Court of Appeals, after reviewing a shaken-baby case, wrote that there is “fierce disagreement” among doctors about the shaken-baby diagnosis, signaling “a shift in mainstream medical opinion.” In the same year, at the urging of the province’s chief forensic pathologist, the Ontario government began a review of 142 shaken-baby cases, because of “the scientific uncertainty that has come to characterize that diagnosis.” In Britain, after one mother’s shaken-baby conviction was overturned, Peter Goldsmith, then attorney general, reviewed 88 more cases. In 2006, he announced doubts about three of the convictions because they were based solely on the triad; in the other cases, Goldsmith said, there was additional evidence pointing to the defendant’s guilt.

I found this genuinely startling. There was such certainty in how I was taught regarding this diagnosis. If this, then that. If retinal hemorrhages and subdural hematomata are present, shaken-baby syndrome is the horrifying but clear diagnosis. Nothing left but to find the perpetrator. While this emerging information doesn't mean a baby with these findings wasn't shaken, it seems this diagnostic certainty is unfounded.

In my current position, I am not on staff in an emergency department. It is supremely unlikely that I will ever be called upon to make this diagnosis. The impact of this new controversy on my particular practice is likely to be minimal.

And yet, this was rather a dizzying article for me to read. It serves as an important reminder that, as a physician, there must always be humility in my approach to individual patients and accepted treatments. As a profession, we must always be willing to admit new information, and to question even the most seemingly unimpeachable evidence. It's good to be reminded of this now and then.

(As an addendum, this might lead regular readers to question if I would be willing to accept a link between vaccines and autism if evidence emerged to suggest it. My reply to this hypothetical question is that I have always been willing to accept a link between the two, were said evidence to meet the standards required of medical science. Given that the supposed link was first introduced through fraud [a fact his supporters are all too happy to blithely ignore] and no compelling science has actually supported a link despite vigorous and good-faith efforts to investigate it, I remain confident in my convictions. Should credible evidence emerge that causes me to question even this belief, I would give it my honest attention.)

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.