New Blog Location

Thanks for dropping by - this blog has moved to a new location:

The Doctor Is In

Please update your bookmarks and come visit my new site.

Moving to a New Location

It has been said that fools rush in where angels fear to tread, so April Fools seems an appropriate time to announce the new location of my blog: The Doctor Is In.

Blogger has been a great way to get started - free, instant setup, no host maintenance, virtually no development except a little CSS. But with ease comes limitations, and growing performance problems. My new location is powered by WordPress and hosted by HostingMatters. This combination is very robust and flexible, and has been a lot of fun getting up and running.

My most recent posts are also posted at the new location, although existing comments from this site cannot be moved. Most of my older posts are also linked under the "Best of:" blogroll categories, which makes them a lot easier to access by topic.

This site will remain up, and I will leave comments on for a few days, but all new posts will be at the new site.

So update your bookmarks and join me in my new home!

Thoughts on a Life's End

I have been avoiding any comment on the Terry Schiavo case for a host of reasons: first and foremost, I simply do not have enough information to make a reasoned judgment (nor, as far as I can tell, are the majority of people opining on her case). There is a huge amount of heat, and very little light, surrounding this case, and countless emotional, impassioned, and often irrational arguments have been made in the media and on the blogs. I despair of adding anything meaningful to this noisy melange, and frankly, the media frenzy, and excesses of both the pro-life and pro-death sides has become offensive and ghoulish.

Yesterday, however, Jerri at the always-thoughful Sue Bob's Diary, e-mailed me with the following comment and question:

I notice that you have stayed out of the Terri Schiavo issue. I figure that you have a good reason for that. But, I was wondering if you'd answer a question.

... I have a real problem with the idea of removing someone's feeding tube unless their systems are shutting down and they can no longer absorb nutrients ... I just heard a Medical Director of a nursing home on the radio talking about Alzheimer's patients losing their appetite and having feeding tubes inserted. The MD thinks removing the tube in such circumstances is justified. Perhaps it is if their systems are shutting down and they no longer want to eat...

I saw your post about extraordinary measures and agreed with it. But, as a Christian doctor, do you see acceptable parameters in all this?

Jerri has a habit of prodding me to write about things which I would prefer not to tackle. But not infrequently, such encouragement and the discipline of writing proves helpful in clarifying my own muddled thoughts about a difficult subject. So I'll give it my best shot.

My comments about Terri Schiavo herself will be very limited, based on what limited knowledge I have. As best I can ascertain, she appears to be in a persistent vegetative state, and it seems likely that her chances for any sort of cognitive recovery are virtually nil. On matters regarding her husband's and family's decisions, the courts, governor and congress, I won't comment for lack of sufficient information. Nevertheless, the issue of end-of-life decisions is far broader, and in my mind far more complex, then the current firestorm could ever resolve. My ambivalence on how best to handle such a situation is my strongest reason for refraining from posting on her case so far.

The challenge of end-of-life decisions is a byproduct of our successes and breakthroughs in preserving and sustaining life. They are the unintended consequence of technological advancement. 50 years ago, it is likely that a young woman with cardiac arrest would have died before she received emergency care, or if not, would likely have passed away shortly thereafter from complications, such as sepsis, embolus, or pneumonia. The advancements in acute emergency medical care and resuscitation have saved many lives, but some of these lives end up so severely impaired that the success proves a pyrrhic victory.

The moral and ethical dilemmas which have arisen from our dramatic improvements in emergency care go straight to the heart of what it means to be human, to be alive, to have meaning and quality in life. If one must use a pigeonhole, I would certainly be classified as a pro-life proponent. Life is perhaps the most precious gift given by our Creator, and cannot simply be measured by a superficial standard such as health, mobility, or even lucid mentation. Yet life is a gift, and not a god. As I have written in Dancing with Death, dying itself is also an integral part of life, and irrational and misguided attempts to prolong it can be very destructive, demeaning, and degrading to its dignity.

It seems to me that there is considerable confusion in our contemporary discussion of end-of-life decisions, engendered by such unfortunate and inexact terms as "pulling the plug." And each situation must be judged by its own merits, taking into account the overall prognosis for life, patient and family wishes, and the potential for the patient to return to some measure of meaningful relationship with family and others. Here are the core principles I fall back on when considering these difficult decisions. They are by nature generalizations, and exceptions will arise (especially in the very elderly), but they are useful guideposts nevertheless:

 • Life is more than any of its components.

We are more than our health, more than our bodies or mind. We are a composite of these things, and more: comprised of soul and spirit, defined as much by our relationships as by our physical or mental capabilities. Our lives do not become meaningless because of physical illness or disability, nor because of mental incapacitation -- hereditary or acquired. Our relationships with other humans and with God define us -- and not only our ability to relate to others (lost in persistent vegetative state and severe retardation or dementia), but also the relationship of others to us. This why, even though severely mentally impaired and unable to relate to others, an individual still has great value: they are of great value to God, and to others who love and care for them. When we narrow the meaning of life down to physical health or mental capacity, and deem it unworthy based on such factors alone, we are destroying that which is precious to others.

 • When the individual's outlook from a life-threatening acute or chronic illness is optimistic, or at least reasonably uncertain, we should choose to preserve life.

Consider two scenarios: a previously healthy man arrives at the emergency department with cardiac arrest of undetermined length. He is resuscitated, requiring placement on a ventilator. His cerebral function is impaired, perhaps comatose, but it is early in the illness, and his expectancy of return to a normal life is potentially optimistic. Ventilatory or other artificial life support in this situation, where the prognosis of the underlying condition and the chances for optimistic recovery are good, or uncertain, should be aggressively pursued.

This is an entirely different situation from stopping ventilatory support for patient who requires it to live, and for whom clinical evidence, such as length of time in a coma, or absence of brain activity on EEG, indicate little or no chance for functional recovery. In the first case, the cessation of life support will terminate the patient who may well have a very good outcome and lead a normal or nearly normal life; in the second, the patient's chances of recovering spontaneous breathing and cerebral function are nil, and therefore cessation of ventilatory support allows the underlying disease process to take its natural course. A similar scenario might be found in the patient who is dying of cancer and requiring ventilatory support, where the life support has no hope of changing the outcome -- death -- but only of changing its timing and prolonging its suffering. The outlook spoken of here involves both mental, relational, and physical, although mental and relation have a much higher priority. Few would argue that Christopher Reeves should have had his life support terminated, despite the fact that he required a ventilator to live, as his mental facilities and ability to have relationships was intact.

 • Those who have lost all functioning mental, social, and relational abilities, but whose underlying condition is not a threat to life (e.g., persistent vegetative state), should be sustained with basic care and life support.

The persistent vegetative state is very different from that in which the underlying disease is terminal or life-threatening, and poses a very difficult situation. The patient is physiologically alive, requiring no assisted ventilation or cardiac or vascular support to continue living -- in other words, their underlying disease will not kill them. In the early days and weeks of such as state, it is often very difficult to determine what the long-term recovery capability of the brain and nervous system may be. Healing of central and peripheral nervous system damage is often agonizingly slow, and may take a year or more to determine their final steady state. When it becomes clear that brain or central nervous system function has reached its maximum recovery, and it is at that time evident that no function associated with higher cortical function -- such as speech, comprehension, purposeful movement, or understanding of communication -- is possible, then, although the individual is technically alive, they no longer possess the capabilities of a normal functioning human being in society and relationships.

It is at this point that wisdom faces its greatest challenge. The question of whether to cease the most fundamental of life support measures -- food and water -- is a question which I myself have not completely resolved to my satisfaction, although I lean strongly toward basic life support -- food, water, basic care.

The problem I have with stopping food and water is the great risk of crossing a very dangerous boundary. If we define life only by our mental state, rather than as a union of mental, physical, and the relationships of ourselves to other and of others to us, it seems dangerously easy to move this boundary based on a subjective judgment about which specific mental capabilities constitute a meaningful life. An otherwise healthy patient with severe Alzheimer's disease most certainly has very little mental capabilities from a social interaction standpoint. Shall we deprive food and water from such patients? How about the severely mentally impaired who are younger, or unable to speak or hear? Certainly, none of us would choose a life with such severe quality constraints, given the choice. But forcing death when the underlying condition is not fatal, based on a subjective assessment of mental quality, strikes me as a very dangerous boundary to cross.

However, in a case where severe mental impairment or functional brain death is obvious, I would have no moral or ethical quandary with allowing another disease process which might prove fatal to run its natural course. An example would be a severe pneumonia or a septic condition. My own inclination would be toward a very non-aggressive approach in treating such a condition in a patient who clearly had no potential for recovery of higher mental or social function.

This may seem like splitting hairs, but it is not: in one case it is man who initiates death -- actively or passively; in the other death is determined by the natural course of a disease. I do not trust man to terminate life based on his own perception of quality of life, cost, burden, or ill-informed self-projection about what the patient might want. The power to initiate death (outside of the safeguards of a judicial context, when society deems a crime warrants it) will invariably lead to an ever-broadening array of "quality of life" issues for which death is "merciful."

This is, I understand, something of a compromise, and may be viewed by some as inconsistent with a pro-life position, or perhaps the opposite, of playing God. So be it. I believe the danger of actively terminating life, based on purely on an assessment of one's mental state or quality of life outweighs the obvious burden on society and individuals of preserving life at its most basic function, without functioning mental capacity. Nevertheless, when higher mental function is severely impaired, and the underlying disease process is invariably fatal, or potentially so, allowing that disease process to run its course without aggressive intervention seems to me both ethical and moral. Disease holds the power of death, rather than man.

 • Patient and family input on end of life decisions is vital, but not absolute.

Because the heart of human nature is relational, decisions about end of life must involve those in close relationship with the individual as well as the individual's own preferences. But these wishes are not an absolute. Our individual decisions are not autonomous, but affect others: we do not exist in a vacuum. This is why suicide is both morally wrong and illegal: suicide transfers the emotional pain and personal responsibilities from its victims to their families, and to society. A family's decision to keep a terminal patient alive on artificial support when hope is gone damages the dying person's dignity in death, and places the financial burden on society. Such issues are often very difficult to address, since there are many gray areas in predicting timing of death and recovery prognosis.

You see, it's not just about us, about our vaunted "quality of life." Jay Nordlinger, in his NRO Online column Impromptus, quotes a reader as follows:

I've come to understand that "the point" has little or nothing to do with what the Terri Schiavos, Aunt Winnies, and Aunt Maceys of the world have to offer, or even with their so-called quality of life. Rather, in expecting us to care for and continue to love those who no longer have the capacity to give anything in return, God invites us to pick up the cross. It's not really about them anymore, it's about us and what we are willing to give of ourselves in response to the challenge. I have watched hours of coverage regarding the Schiavo controversy; not once has anyone suggested that Terri's suffering presents an opportunity for her family to give of itself purely...

In far more words, I could not -- and have not -- stated it as eloquently as this.

Three Men on a Friday

Three men on a Friday, condemned to die. Ensnared by Roman justice, convicted, and sentenced to a lingering death of profound cruelty and excruciating agony.

The Romans knew how to do it right: execution designed to utterly humiliate its victims, and maximize their suffering -- a public spectacle and object lesson to others about the foolishness of defying Roman authority. First used by the Persians in the time of Alexander the Great, and adopted by Rome from Carthage, crucifixion was so horrible and debasing a fate that it was not permitted for citizens of Rome. Victims hung for days, their corpses consumed by carrion.

Our knowledge of these three men is incomplete. Two are described in ancient texts as thieves, the other a preacher run afoul of religious leaders, delivered to the Romans under pretense of imperial threat. There should have been nothing unusual about this event: the Romans crucified criminals often, sometimes hundreds at a time. Yet these men, in this spectacle, were different: on these crosses hung all of mankind.

Two thieves and a preacher -- an odd picture indeed. And even more peculiar: the most hated was the preacher. Taunted, insulted, ridiculed, reviled. A miracle worker, he, a man who supposedly healed the sick and raised the dead, yet now hung naked in humiliation and agony, unable to extricate himself from his dire circumstance. Even those convicted with him -- themselves dying in unbearable pain and mortification -- join the fray. Insulting the rabbi, demanding he set himself -- and naturally, themselves as well -- free. They know his reputation, yet selfish to the end, desire only their own deliverance.

But one thief is slowly transformed, in frailty considering his fate and the foolishness of demanding release when his punishment is just. And he marvels at the man hung nearby -- why? Why does this preacher, unjustly executed, not proclaim innocence nor demand justice or vengeance? Why does he -- amazingly -- ask God to forgive those who have so cruelly and unjustly punished him? Why, in the extraordinary agony only crucifixion can bring, does he seem to have peace, acceptance, perhaps even joy?

His revulsion at the baying crowd, at the arrogance of his fellow convict reviling this man of character and grace, bursts forth in rebuke at him who ridicules: "This man has done no wrong!" Turning to the preacher, he makes a simple, yet humble, request: to be remembered. Only that. No deliverance from agony, no sparing of death, no wealth, prosperity, or glory, no miracles -- only to be remembered.

The reply reverberates throughout history: "This day you shall be with me in Paradise." A promise of hope, a promise of relationship, a promise of forgiveness, a promise of comfort, joy, healing, peace.

Three men on a cross. In these three men are all who have lived: two are guilty, one innocent. Two are justly executed, one unjustly. All three have chosen their fate: one thief to revile, ridicule, hate, blaspheme; one criminal to trust, to seek consideration and mercy from one greater; one man to submit to brutal and humiliating torture and death, willingly, for no crime committed -- or for all crimes committed, everywhere and for all time. Yet only one promise given -- to the one who, though guilty, trusted and turned.

Who was this man in the middle, this preacher? A charlatan, perhaps - but an imposter abandons his schemes when such consequences appear. Delusional, deceived zealot, or presumptuous fool? Such grace in agonal death is inconceivable were he any such man. What power did he have to make such a promise? What proof that the promise was delivered?

An empty grave. A promise delivered by a cavern abandoned, a stone rolled away. A gruesome death transformed into a life of hope, meaning and purpose for those who also trust.

An Angel From God

Sometimes in the rush of the high-speed news cycle a story just reaches out and grabs you. Brian Nichols -- on trial for raping his ex-girlfriend at gunpoint for three days -- shot a judge and three others in a courtroom in Atlanta, before escaping as a an armed, hunted and highly dangerous fugitive. At 2 AM in a parking lot, he encountered Ashley Smith, and took her hostage in her own apartment:

[Smith] said Nichols tied her up with masking tape, a curtain and extension cord and told her to sit in the bathroom while he took a shower ... Smith told Nichols about her daughter and bonded with him after he said that he had a son who had been born the night before.

'My husband died four years ago, and I told him if he hurt me my little girl wouldn't have a mommy or daddy,' Smith said.

Smith's attorney, Josh Archer, said her husband died in her arms after being stabbed.

...'You're here in my apartment for some reason,' she told him, saying he might be destined to be caught and to spread the word of God to fellow prisoners. She also read the bible to Nichols ... 'He told me I was his angel, sent from God, and that I was his sister and he was my brother in Christ,' said Smith.

It is easy to be cynical about the religious experience described here; there may in time prove to be ample reason for such cynicism. A cornered and defeated criminal may turn to religious talk or claim conversion in hopes of gaining leniency in sentencing or to sway a jury in a region where religious conviction means a great deal, such as the deep South. Such leniency seems a remote hope when an accused rapist has murdered four people in the criminal justice system and taken a hostage, but desperate men take desperate measures.

But the story of Ashley Smith is a truly remarkable one -- one which should cause everyone to pause and consider what makes a women behave with such extraordinary grace and poise in such a situation.

Consider: Ashley Smith is a widow with a young daughter, her husband a victim of violent crime. She finds herself taken hostage at gunpoint, bound and gagged in her bedroom by a rapist who has just murdered four people. Her response? She engages her kidnapper, discusses her life with him and inquires about his. When finally unbound, she asks if she can read! Consider this remarkable description from the Wichita Eagle report:

Smith asks if he would mind if she reads.

Nichols says OK. She gets the book she'd been reading, "The Purpose Driven Life." It is a book that offers daily guidance. She picks up where she left off -- the first paragraph of the 33rd chapter.

'We serve God by serving others. The world defines greatness in terms of power, possessions, prestige and position. If you can demand service from others you've arrived. In our self-serving culture with its me-first mentality, acting like a servant is not a popular concept.'

He stops her and asks her to read the passage again.

It gets even better: Nichols needs to hide the truck he has stolen, and asks Smith to help. After moving the truck,

She drives him back to her apartment, where she cooks him eggs and pancakes, gives him fruit juice. They have breakfast together.

Smith washes the dishes and gets ready to leave.

Nichols asks her to come visit him in jail. 'You're an angel sent from God to me,' he tells her. "I want to talk to you again. Will you come see me?"

She tells him she will.

Now think about this for a moment - especially those of you who are skeptical, dismissive or even antagonistic about Christianity: what would a sane woman do in these circumstances? Indeed, what would you do? Perhaps you might have smooth-talked your way out of duct tape and hand cords (nice work, as a women alone with a rapist -- how'd you manage that?) Then you start reading the Bible and a devotional book (The Purpose-Driven Life) to him -- and he listens and asks you to repeat it. Then, when he decides to move a stolen truck -- having left his guns in the apartment (another nice trick, that)-- and has you drive alone in a separate car, you drive him back to your apartment (rather than drive away as fast as you can, calling the cops as you run) and you fix him breakfast, dine with him, and calmly clean up the dishes. He sets you free, then gives himself up.

Does anyone find this anything less than astounding? Either Ashley Smith is one of the shrewdest psychologists on planet Earth -- and a mind-reader and master manipulator to boot -- or something out of the realm of reason and normal human experience has happened here, and two lives have been utterly overtaken by its power. The word awe is not inappropriate here.

What drove Ashley Smith to respond this way? The answer, I believe, was that she was ruled not by fear, but by faith and by love. Fear is a natural response to a personal threat, and there is no doubt she experienced a great deal of fear in her situation. Yet her behavior arose not from the fear, but rather from trust. She understood that she was in the hands of God -- a God who had paid the ultimate price for her already, having given up His Son to torture and death to restore her to relationship with Him -- the most central tenet of the Christian faith. Such a God, whom she trusted to be in control of every situation in life, had allowed this very crisis for some good purpose, though her fear screamed otherwise. Her job was to trust, to pray, and to serve her God by communicating His love as best she could, no matter what the outcome. She did this through her words made verity by her service.

The concept of love is horribly twisted in our culture. It describes a host of things -- infatuation, attraction to superficial beauty, sexual desire, materialism -- which are peripheral, or even inimical, to its true meaning: the sacrifice of one's self for the good of another. Yes, Ashley Smith demonstrated love to Brian Nichols -- in seeking to build a relationship with him; to encourage his better angel which she trusted was present (though all evidence pointed to no such redeeming virtue in him); to avoid fleeing and calling police, as his demise was far more likely in a solo standoff with law enforcement; to risk her own life and safety to return to the apartment willingly; to grace this evil and fearful man with a meal prepared and shared; to demonstrate poise and inner peace in attending to routine chores in his presence.

Ashley demonstrated that she had learned the lessons of The Purpose-Driven Life in the brutal schoolroom of an evil world: that life has purpose and power in relationship to God, in service to Him in the mundane and the terrible, in happiness and in horror. God made her something she was not when she arrived in the parking lot that night. No doubt He had prepared the soil through the suffering of a husband murdered -- a pointless agony with incomprehensible pain, when you do not know whether to cry out to God or curse Him for allowing it, when life's plans are shattered and there is nothing left but a slender thread of faith to grasp. Yet grasp it she did, and slogged on in trust -- to be rewarded again for her trust as a hostage to a murderous rapist. It all makes no sense: God cannot be fair or just in reason's eye when such evil overwhelms. Yet her life will be forever changed by her experience, profoundly, for the better, as will those of many, many others.

And what of Brian Nichols? A foxhole conversion? Slick, manipulative religious words in hope of leniency? Time alone will tell; perhaps he will sink into the black hole of life imprisonment, never to be heard from again. But maybe, just maybe, his life -- and the life of many he touches -- will be likewise transformed by the extraordinary grace given to a woman in service to God. I for one will be watching for it.

Travelling East

I will be travelling with family to the East Coast tomorrow for the week (Washington D.C., Baltimore, and maybe Philadelphia), so there won't be much -- if any -- blogging until then. I was hoping to get a post up before leaving, but alas, work and trip prep were unrelenting. Looking forward to recharging the batteries with some much-needed time off.

God bless, and God willing, I'll be back soon.

Dancing with Death

The war rages on. It is a battle with ancient roots, deeply embedded in religion, culture, and the tensions between rich and poor. It is a war of contrasts: high technology and primitive cultural weapons; knowledge versus ignorance; speed and urgency against the methodical slowness of an enemy who knows time is on his side.

It is a war in which enormous strides have been made, with countless victories large and small.

The enemy is death. The avenger is medicine. And the war is going very poorly indeed.

In many ways, the gains of modern medicine against death and disease are truly impressive: longer life expectancies; progress and cures against heart disease, cancer, and diabetes; surgical and procedural marvels hard to imagine even 15 or 20 years ago. Yet, it is these very advances which seem to lie at the heart of a growing problem. We are so engaged in the battle, so empowered by our growing capabilities, that we have lost sight of the bigger picture. While pushing back the adversary of death, we are ever so steadily being destroyed by the very battle itself.

Several recent experiences have driven this dichotomy home for me. Last week, I was asked to evaluate a man who had been hospitalized for a over a week. A nursing home resident in his late 80's, his overall health was fair to poor at best, and he suffered from severe dementia. He was unable to communicate in any way, and could recognize no one -- not even his wife of many years, who remained in possession of her full facilities. He was admitted to the hospital with a severe urinary tract infection with a highly resistant bacteria, and septic shock. When he arrived at the ER, the full extent of his dementia was not apparent to the physicians there, and his wife insisted that all measures be engaged to save him. Aggressive medical care was therefore initiated -- intensive care unit, one-on-one nursing care, hemodynamic monitoring, drugs to support blood pressure, intravenous nutrition, and costly antibiotics. After nearly two weeks of such intensive therapy, the patient largely recovered from his life-threatening infection -- returning to his baseline of profound dementia. Yet the underlying risk factors which led to it -- his age, a chronic bladder catheter and bacteria-harboring stones, diabetes, -- remained in place, lying in wait for another, inevitable opportunity, in a matter of weeks or months. The cost of his hospitalization was easily in 6 figures.

In another situation, an elderly women presented to the hospital with signs of a serious, life-threatening infection in her abdomen. A healthy widower, she lived independently with her sister prior to her illness. Emergency surgery was performed, and an abscessed kidney removed. Her medical condition deteriorated after surgery, with coma due to stroke and failure of her remaining kidney brought on by the infection.

The patient's sister and living companion communicated the clear final wishes of the widower: a women of strong faith, she wished no extraordinary measures, such as ventilators or dialysis, to extend her life needlessly. She was comfortable with death, and not afraid. The staff prepared to allow her to die gracefully, comfortably, and in peace.

But such was not to be. There was no living will, and the sister did not have legal authority to make such decisions. But the widower's daughter, a nurse living out-of-state with little recent contact with her mother, arrived in town demanding that aggressive measures be taken to save her. A nephrologist (kidney specialist) was called in. A superb physician, compassionate and dedicated, he had been successfully sued in a similar case after recommending that dialysis be withheld in a patient with a grim prognosis. This was a mistake he would not make twice: the widower was transferred to another hospital, placed on dialysis, and died 3 weeks -- and a quarter of a million dollars -- later, in an ICU. She never woke up.

The issues which these two cases bring up are numerous, complex, and defy easy answers. They touch upon the subjective measure of quality-of-life and what it is worth; the finite limit of economic health care resources; the relative responsibilities of physicians, patients, and their families in end-of-life decisions; the pressures placed on the health care system and its practitioners by after-the-fact second-guessing in an aggressive tort environment; and a host of others greater or lesser in weight and substance, up to and including the meaning of life itself.

All the players bear responsibility in this passion play. Physicians excel at grasping what they can accomplish, but are woefully inadequate for the task of deciding whether such things should be done. In the urgency of acute care, delay to consider the ramifications of a decision to treat may cost an opportunity to save a patient for whom such treatment is desirable; better always to err on the side of salvage. Pressured by family, potential litigation, or instinct, the path of least resistance is to follow your training and use your skills. And physicians themselves are uncomfortable with death, though inundated in its ubiquity.

Family members naturally resist the agonal separation of their loved ones, often harboring unrealistic hopes and expectations of recovery in the face of inevitable death. A curious dance of denial often ensues between physician and family, as each, unwilling to face the unpleasantness of the inevitable, avoids the topic at all costs. The physician hides behind intellect, speaking of blood counts, medications, and ventilators, or at best tiptoeing around the core issue with sterile terms like "prognosis." Family members hesitate to ask questions whose answers they already know. Too rarely are the physician and family willing to place the subject squarely on the table, in all its ugliness and fearfulness. Decisions which need to be made are put off, unspoken and deferred. The clock ticks on, the meter is running, and only the outcome is not in doubt.

The tort system provides a ready outlet for the anguish and anger of death of a loved one. In such a period of intense emotional turmoil, the real or perceived indifference of physicians (often a mechanism of detachment by which doctors deal with the horrors of death and illness); the parade of unfamiliar medical faces as no-name consultants come and go during the final days; the compounding burden of crushing financial load from the extraordinary costs of intensive terminal medicine; the Monday-morning quarterbacking by the tort system of complex, often agonizingly difficult medical decisions in critically-ill patients: all present a toxic and intoxicating brew which impels the health care system forward to leave no avenue untravelled, no dollar unspent in prolonging life beyond its proper and respectful end.

This march of madness is not without resistors. Seizing on the high costs, the futility, and especially the lack of personal control fostered by impersonal, highly technical terminal care, the euthanasia movement is maneuvering into the gap. Cloaked in slogans of personal autonomy and "Death with Dignity", active euthanasia proponents seek to replace the sterile prolongation of a now-meaningless life with the warm embrace of Death herself. Terrified by an out-of-control dying process, an end of a life which embodies all meaning, they seek to control death as their final act of significance. But Death will not be controlled, and those who dance with Death are seduced by her siren. Euthanasia starts with compassionate intent, but ends with termination of the useless. Man does not have the wisdom to control death; The Ringbearer is corrupted by its power.

Our discomfort with death is our confusion about life. Man is the only species cognizant of his coming demise -- who then, in the ultimate paradox, lives his entire life pretending it will not happen. Our Western culture, enriched with a wealth of distractions, allows us to pass our living years without preparing for the inevitable. When the time arrives, we use all the weapons at our disposal -- wealth, technology, information, law -- to resist the dragon. We drive it back for a time -- at enormous cost, personal, financial, physical and emotional. Death always wins -- always.

I am not of course yearning for a return to the past, a passive resignation to the inevitable anabasis of disease and death. The benefits of medicine and the forestalling of death are precious and powerful gifts, which have greatly benefited many. But like all such great powers, they are useful for good or ill. When the defeat of death becomes an end in itself, detached from the meaningfulness of life lived, it has great destructive energy.

We must learn how to die. And to learn how to die, we must learn how to live -- how to seek the transcendent, the power of love, and sacrifice, and giving which makes life rich and enduring. The selfish, the superficial, the transient all gratify for a time, but when this is all we possess, we grasp desperately to their threadbare fabric when beauty and health give way to weakness, fear and death. All great religions understand this: the meaning of life transcends life. In the Judeo-Christian view, life is an opportunity to draw ourselves and others closer to the light and goodness of God, with the promise of an even greater life and deeper relationship after death. Yet even for the agnostic or secular among us, service to others -- personal and social -- has the potential to endure long after us. None of us will be remembered for our desperate clinging to life in its waning days, but rather for the lives we touched, the world we made better when we lived.

Comments on Comments

I have turned off comments on the site for now. After my last post, I received a flurry of comments, the basic premise of which was that I was an arrogant physician who cared nothing for patient autonomy, was a greedy SOB, and that I -- and all doctors with me -- deserve to be sued out of our BMWs. And that was the warm, fuzzy icebreaker -- it went downhill from there.

Now, far worse things have been said about folks on the Internet. But what was evident in the comments was the presumption that physicians are arrogant and greedy, and deserve every lawsuit they get and more. Most of the negative comments were anonymous.

Comments on a blog are a decidedly mixed bag. They are public, and become part of the post. This can be a good thing: well-thought-out comments may challenge the poster's facts or suppositions, or may add significant information on the topic which enriches the overall post. This is true even of negative comments, posted respectfully. Conversely, the anonymity of the Web seems to bring out the worst in some people. The idea that you are going to win someone over to your point of view by starting a conversation with a stranger, impugning their character and integrity, and smearing their entire profession, frankly strikes me as a bit odd, and certainly stupid. There is a great deal to impugn in my character, and no shortage of character defects and shortcomings, -- but that is why I have friends and family. They have earned the right to point out my defects based on a mutually strong and trusting relationship, and I accept such criticism -- though unpleasant -- far more readily. But from an anonymous moron on the Web with an ax to grind? Yeah, right. The public nature of such comment flame wars tends to demand a response, which in me brings out the snarky, sarcastic, condescending side of my nature. This is a character flaw I would rather not practice to perfection. Furthermore, there is barely enough time to post semi-intelligent essays on this blog. Devoting additional time to extinguishing ill-willed flamethrowers is utterly pointless.

And let's get a grip, folks. This is a personal blog. It is a labor of love, a useful tool to help me organize my thoughts, and hopefully provide some value to others. If you enjoy reading, I'm grateful, and appreciate your interest. If you're bored, perhaps some other post may be of more interest, or there's a million other blogs to interest you. If it enrages you to the point of seething anger, perhaps the issue is less me than you, and you most certainly need to find some other more enjoyable and less stressful activity. Of course, if you just want to spew venom at strangers whom you dislike or hate, perhaps it's time to do a little soul-searching of your own. Just do it elsewhere, please.

For now, readers who appreciate these posts and want to express that, or want to contribute other thoughts or corrections, are more than welcome to e-mail me. If you strongly disagree with me, and wish to carry on a conversation in a mutually respectful manner, I am more than open to that, time permitting. I most certainly do not have all the answers, and will treat every such e-mail with respect it earns. If you just want to rant and seeth, do whatever you need to do to vent your rage: kick your dog, punch the wall, sacrifice a goat to Satan, whatever it takes. But please don't waste your time, my time, or my readers time with this drivel.

One point raised by my erudite detractors is worth repeating, since my response in the comments is now hidden. This is the issue of patient autonomy. For me personally, -- and for every physician I know -- patient autonomy is extremely important. The myth of the paternalistic physician snapping orders to the passive and demure patient is utterly out of touch with reality. The common thread of comment criticism was that, as a patient, you pay me your money, and you get therefore to dictate my services. This is an extremely contractual view of the physician-patient relationship. My job is a physician is to use my skills, training, experience, and intellect to determine the nature of the patient's disease or problem, to educate them on the treatment options available, and make recommendations when appropriate. The patient is entirely free to accept or reject my recommendations. I may encourage them not to reject them, and explain the potential adverse consequences of such a decision, but it is their decision entirely. There is one important distinction, however. The patient is not free to demand that I performed a service or treatment which is unethical, or which I know to be harmful to the patient. This is both my responsibility and my autonomy in the relationship. If you find that arrogant, well, tough.

This is the exact point I was trying to emphasize in my prior post: the patient is entirely free to reject a recommendation that his testis be removed, because of the high risk of cancer, knowing that a small percentage of that time there will not be cancer present. He is not free to demand that I perform a biopsy which will pose a significant risk to his life or health, where the risk far outweighs the benefit. Patient autonomy is not unlimited, although it is broad. Physicians are constrained morally and ethically from doing harm to patients deliberately, no matter what the patient demands of them, or the economics involved. A society which penalizes physicians who make such moral and ethical choices, by means of lawsuits or otherwise, is one which will live to regret the destruction of this boundary.

Update: Thanks to the many folks who wrote and encouraged me about comment trolls and asking to restore comments. I'll turn them back on this weekend -- albeit with a short leash on morons. As I've said, I don't mind disagreement (in fact, I encourage other viewpoints -- "as iron sharpens iron", etc.), but ad hominem attacks on me or against other commenters, or otherwise abusive comments, will be deleted and IPs banned. Battling the morlocks is not a productive use of my time. But I am deeply grateful to those who appreciate the blog - come back often, and leave comments!

Sued for Proper Care

A recent brief AP wire story highlights the adversarial and often irrational legal environment in which physicians practice today. The article, Man sues over botched testicular surgery (hat tip: Kevin, M.D.), is very brief, and it is obviously not possible to determine the validity of such a suit based on a such a brief press release or wire story.

One wonders why such a story is newsworthy at all -- but the headline gives us all the clues: there's been a medical screw-up, and it involves a sexual organ. Titillating stuff indeed -- far more interesting to readers than, say, a story about a CNN executive claiming that U.S. troops were assassinating journalists. Problem is, I strongly suspect the physician here is being sued for providing good, appropriate care.

Here's the brief description of the case:

Danny Curtis claims the surgeon at Kern Medical Center did not conduct a biopsy before arranging urgent surgery to remove a testicular tumor in July 2004, according to the lawsuit filed in Kern County Superior Court.

Doctors later discovered that the tumor was not malignant and did not need to be removed, according to court documents.

Testicular cancer is a rare but very aggressive malignancy, typically affecting men between the ages of 18-35 years of age. It usually presents as a painless lump or swelling in the testes itself, and not infrequently is ignored by the patient or misdiagnosed by physicians as a benign infection called epididymitis. The tumor may grow rapidly and spreads by the blood stream or lymph system. Patients may present with huge metastatic tumor masses in the abdomen, chest, liver or brain. This was how Lance Armstrong -- perhaps one of the most famous testes cancer patients -- presented. Although aggressive chemotherapy has made huge advances in successful treatment of such often-lethal cancers in the past decade, testicular cancer remains a killer of otherwise healthy young men.

The diagnosis is suspected in most cases by physicial examination and ultrasound. A solid growth in the testes itself -- as opposed to the structures adjacent to it -- has an extremely high risk of being malignant - about 95-97% in most studies. While biopsy prior to removal would appear to be logical and prudent, it is in fact a very risky proposition.

When the cancer is entirely confined to the testes, it is curable by simply removing the testes and the accompanying spermatic cord surgically. Biopsy violates the natural barrier confining the cancer to the testes, and risks spilling cancer cells into the surrounding tissues or the blood stream. Once this occurs, far more drastic measures are needed to eradicate the cancer, including very toxic chemotherapy treatments, or possibly radiation or additional major abdominal surgery to remove lymph nodes or tumor. The risk of serious complication -- or even death -- rises dramatically.

This is a classic example of the risk-benefit decision-making process in medicine. All medical treatments carry risks; one penicillin tablet can kill you. In the realm of testicular cancer, the calculus is straightforward: if there is a solid growth in the testes, it needs to be removed surgically, with a known 3-5% risk of removing a testes which does not contain cancer. Performing a biopsy first, to spare this small percentage of testes which do not have cancer, exposes the patient to the more serious risk of spreading the cancer, and changing treatment from simple low-risk surgery to high-risk chemotherapy, radiation or major surgery.

The details of this specific case are unknown, but easy to imagine: the patient presents to the doctor with an abnormal testes, which the doctor finds very suspicious for cancer. The physician recommends surgical removal, the patient assents, and the pathology report shows the uncommon benign tumor. The patient is understandably unhappy about losing a testicle unnecessarily (as he understands it).

Perhaps the physician did not explain the above scenario to the patient; perhaps he did, but didn't document it, and the patient doesn't remember it. If it's not on paper, it didn't happen, from a legal standpoint. There are, of course, issues of informed consent here: patients have a right to decide on treatment after being presented with the risks, benefits, and alternatives. But very few patients, when presented with the above facts, will refuse treament and take the risk of unnecessarily spreading a curable cancer.

So the informed consent issue (likely the basis for filing this case) becomes a loophole through which the unhappy patient seeks redress for an undesirable outcome. The physician likely made the correct medical decision -- one endorsed as standard of care by every expert in testicular cancer -- and is rewarded with a lawsuit.

Now of course, the physician in this case may have been incompetent, and removed a testes at low risk for cancer, or failed to meet the standard of care for half a dozen other reasons. But far more often than not, this is not the case. The outcome was bad, the loophole was found, and the solution was a lawsuit.

These are the situations which keep doctors up at night, burden the doctor-patient relationship with highly detailed, patient anxiety-provoking, time-consuming and paperwork-generating counseling sessions, and undermine the trust between doctors and their patients. Much emotional and physical energy is diverted from caring for the patient and building the relationship to self-defense measures. This is the true cost of defensive medicine: not merely the ordering of expensive, low-yield tests in anticipation of future depositions and Monday-morning legal quarterbacking, but the undermining of the trust and relationship between doctor and patient.

The case may go nowhere, but there will be significant costs to litigation even then, and inevitable emotional, personal and professional detriment to the physician. The patient may win the suit, but the settlement received will not restore his testicle. Nor will the settlement change the behavior of the physician, who likely acted in accordance with proper professional standards and training. The only effect will be to make him or her more wary of patients, and perhaps slower to remove a malignant testes in the next patient who presents with cancer.

Is this really the best system we can devise for resolving undesireable medical outcomes?

Medical Bankruptcy

Considerable media attention has been paid to a recent study demonstrating a strong link between bankruptcy and medical illness. When I first read of the study in the Wall Street Journal, I must confess I was skeptical. Studies which receive large media attention are sometimes driven by an underlying agenda, and in some instances, have used questionable study populations and statistical analysis to produce a result less scientific than political in nature. One such controversial study was the Institute of Medicine (IOM) Medical Error Report of estimated morbidity and mortality from medical mistakes. The study has been widely criticized for its overly broad definition of a medical error, retrospective analysis of data over 10 years old, study populations which may not be representative, and the statistical sleight-of-hand of multiplying the findings in a small population nationwide produce a staggering estimate of deaths and injuries due to medical mistakes. Nevertheless, the study has fully entered the public consciousness, and is often quoted as a solid fact in health policy discussions.

The bankruptcy article, published in Health Affairs, initially raised some red flags. Its chief author, David Himmelstein, is a health care activist and strong proponent of nationalized healthcare -- a fact not mentioned in the media reports. While this is an entirely legitimate philosophy to promote, it is also true that such a bias might produce a study strongly inclined to reach conclusions supporting the authors preconceived philosophy.

However, after studying the article, I was pleased to find a thorough and detailed methodology which suggests a strong effort to obtain useful data as little influenced by bias as possible. Nevertheless, the big media splash suggests the authors conclusions were in line with their philosophical bent. Yet reading the study, such conclusions seem strained.

The authors reviewed nearly 1800 personal bankruptcy files from five federal courts (geographic locations not specified), and followed up approximately half of these with detailed, in-person interviews. The demographics showed bankruptcy filers to be predominantly middle or working-class, with women slightly outnumbering men. Approximately one quarter of bankruptcy filers cited illness or injury as the specific reason for bankruptcy, and a similar number cited medical expenses as a contributing factor, with uncovered medical bills in excess of $1,000. However, somewhat surprisingly, medical debtors were no less likely than other debtors to have coverage at the time of bankruptcy filing.

The media headlines trumpeted one conclusion of the study: that 55% of bankruptcies were related to medical illness or expenses. The inference in several of the newspaper articles was that lack of health insurance or high medical bills was the cause of over half of all bankruptcies. Reviewing the study, however, such a startling conclusion does not appear warranted. First of all, the 55% figure is a fruit salad of risk factors for bankruptcy. The study groups together medical bills in excess of $1,000 with major medical illness or injury resulting in loss of work time and work-related income. The more accurate conclusion, to my reading, is that illness or injury resulting in loss of job or loss of income is significantly more important, although often added to, unpaid medical bills. This conclusion is reinforced by the fact that many of those filing for bankruptcy were not without health insurance coverage. In many cases, the illness resulted in loss of employment, and subsequent loss of health insurance.

Somewhat surprisingly, few medical debtors studied had elected to go without insurance coverage. Furthermore, debtors out-of-pocket medical expenses were often well below catastrophic levels. In the year prior to bankruptcy, the average out-of-pocket medical expenses was $3,700, and the average out-of-pocket costs since onset of illness was less than $12,000.

A far more significant risk is the loss of work and income due to illness or injury. The intimate connection between employment and health insurance doubles the bet, as prolonged illness means lost income, lost jobs, and lost health insurance.

The medical dollar amounts -- annual medical expenses over $1,000, multi-year expenses over $10,000 -- certainly represent a significant burden to low or middle-income families. Yet to a far greater degree they reflect the extreme financial brittleness of those who end up in bankruptcy. The numbers cited are far less than many families spend on an automobile, or on car repairs, or to fix a leaking roof. How many of these families were living beyond their means, overextended by credit card debt or large mortgage payments, is not clear. How many women were abandoned by husbands with children to raise, and little or no income to support them? Such issues are social in nature, reflecting the breakdown of marriage commitment, the indirect effects on families from an epidemic of drug and alcohol abuse, public policies discouraging savings, individual lack of financial discipline, and a potential host of other social pathologies unrelated to health care costs. Indeed, the authors themselves admit that even universal health care coverage would not have prevented many of the bankruptcies. Medical expenses are certainly one factor, and medical catastrophy can and does result in financial devastation to some, but health care costs alone do not shoulder the responsibility of over half of all bankruptcies.

Health Care Is Not a Widget

This essay begins a series on problems and possible solutions to the current mess we call health care in our country. It takes no small amount of hubris to assume that one has all the answers to the health care quagmire -- I most certainly don't -- especially when far smarter and more knowledgeable folks have been beating their heads against this problem for ages, with little apparent results. But I have observed that basic principles of common sense, human behavior, good business principles, and yes, morals and ethics, are often ignored when crafting solutions to health care. What I hope to accomplish in these posts is to lay out some defining principles based on many years of experience in patient care and managing a medical practice business, seasoned with a life perspective of grace, and hopefully humility, derived from my faltering, but ever enlightening, journey in the Christian faith.

And so we begin with Lesson I: Health Care Is Not a Widget

Ahh, widgets: those ubiquitous fictional entities seemingly discussed everywhere, yet unseen by human eyes. They are defined thusly:

Widget: A fictitious good, commonly used by economic instructors to demonstrate economic principles or undertake hypothetical analyses ... If such a good exists -- and there is no clear evidence that widgets have every existed -- it is a small mechanical device, constructed of interlocking cogs, several knobs, and at least one handle. Widgets are most often used when thingamajigs and dohickies are unavailable.

Widgets are used as instructional tools to demonstrate the effects of economic principles, such as supply and demand. Health care being an industry with broad economic reach, its component services are sometimes thought of in classical economic supply-and-demand terms. Yet health care economists and politicians seem puzzled that medicine is so often unresponsive to the typical economic rules governing most other industries and service sectors.

There is a reason for this: health care is not a widget.

The problem is not that health care services are entirely outside the laws of economics; indeed, many of our health care financial problems stem from distorted or perverse economic incentives. But the nature of the services themselves differ from virtually every other service industry. How so, you wonder? I thought you'd never ask. Here's just a few key distinctions:

• Health care services are not generally subject to choice.

At the heart of free-market economics is the idea of choice -- you are free to buy my product if it is something you want or need, and the price is agreeable. You are also free not to purchase it, or to buy it elsewhere if you find a better price or quality. To a limited extent this is true in health care -- if I want a tummy tuck or facelift, I can shop around for the best balance between surgical expertise and price, and if I fail to find that balance, I can choose to forego the service.

In most cases, however, such detached rational decisions do not apply to health care, since the service is non-optional. If you have crushing substernal chest pain, you are not in a position to evaluate the optimal price or quality of the service you require: you need to get to the hospital before your heart attack kills you. The ER physician who sees you is someone you have never met; you do not know his skill or credentials; you have not negotiated a price for her services. While you may have some choice about which hospital to attend, even here your choice is severely limited by expediency -- you drive (or are taken) to the nearest one, lest you die en route.

Even in health care situations more routine and less urgent than such medical emergencies, many factors preclude free choice and free market decisions in health care. In the marketplace, the buyer typically judges the value of the product, then judges whether the asking price is appropriate to this value. In medicine, the true value of the services provided is extremely difficult to determine. We must often make choices of physician or facility purely on hearsay, or the recommendations of another physician or friends, or other factors unrelated to quality, such as proximity to home or work. The system lacks transparency. So the quality of the product you are purchasing is extremely difficult to assess prior to purchase.

Further restrictions are introduced due to the high market penetration of managed care health insurance. Insurance carriers contract with specific physicians to provide care to patients enrolled in their plans. While often touting the "high quality" of their network providers in marketing materials, contract decisions are based either on the willingness of physicians to accept the insurance carrier's fees, or the desire of the carrier to provide broad physician access for their clients -- a "take all comers" approach. Either way, quality is a virtual non-issue. Insurance quality screens weed out only the most egregious offenders -- and sometimes not even those.

Lastly -- and most importantly -- those seeking health care are almost entirely shielded from the actual cost of the service. While you often pay a percentage of the cost -- through copays and deductibles -- this amount is totally unrelated to the quality of the service. The payment has been predetermined by your insurance carrier, and the premium likely paid by your employer, or the government. So virtually all the normal forces of the free market are constrained or eliminated.

• The satisfaction with the product is not uniquely dependent on its provider.

When you buy a car, you make certain assumptions: the manufacturer has taken pains in design and manufacture to ensure a high-quality product; that quality-assurance programs are in place to monitor its manufacture; should a major problem arise, the vehicle will be recalled and the problem fixed without cost -- save inconvenience -- to the owner. These assumptions are legally spelled out in the vehicle warranty - which also spells out the owner's responsibility to maintain the car at specified intervals.

Medicine is a different animal in many ways. There are a host of variables which affect the quality of the final product. Obviously, the skill and training of the physician providing care is a critical factor. The quality of the complex system which supports the service -- the hospitals, nurses, medical equipment, suppliers, pharmaceutical companies, etc. -- comprise together another key ingredient. Often overlooked is one other, critical factor, however: the quality of the purchaser of the service.

By quality, there is no inference or intent to disparage, but rather to point out a number of patient/purchaser-related factors which greatly influence outcomes and service satisfaction: the overall health of the patient/purchaser; the disease itself under treatment; other disease states which influence the performance and outcome of the service; the cooperation and compliance of the patient/purchaser with the instructions and healing program recommended; and the vast complexity and frequent unpredictability of the human machine, which far outstrips any manufactured item in sheer randomness and near-capriciousness of makeup, performance, and response. A perfectly-performed surgery can have a disastrous outcome; a miracle drug, rare but deadly side effects; an abnormal variant in anatomy can make a routine procedure treacherous or unsuccessful. Furthermore, should such an adverse event or circumstance arise, there may be harm to the patient which cannot be undone -- or if it can, which may require additional cost, procedures, or suffering to resolve. There are no product recalls in medicine; warranties are a fanciful dream when so many aspects of the service product are not under the seller's control.

• The relationship between patient and physician is less contract than covenant.

I will cover this more fully in another post, but the distinction is important. Most economic transactions occur in the context of contract -- the rules defining the terms of the agreement, what goods or services will be offered at what price, and perhaps most importantly, what will occur should the transaction prove unsatisfactory: e.g., the product is defective, the buyer does not pay the agreed price in the time or manner specified. Although medical care is becoming increasingly contractual (to its detriment), it is in its highest form closer to a covenant -- an agreement between two parties to pursue a common goal based on mutual trust. In a contract, the transaction is king; the contract serves to define its terms and boundaries. In a covenant, the relationship rules; trust and the best interests of the other party, toward a common goal, are dominant. In medicine, such a relationship by necessity means that the transaction -- the financial side of the interaction -- must be subservient to the goal. Hence the physician must put the patient's best interest ahead of his or her own financial well-being, and must intercede on the patient's behalf when third parties threaten the goal for financial reasons.

While I am sure I have not exhausted the unique nature of medical services in the economic realm, hopefully you can begin to see more clearly why simplistic economic models fail so often when applied to health care. Yet this framework of understanding can hopefully provide some guideposts out of the dark woods of our health care crisis.

Hugh Hewitt's 'Blog'

In my free time, between practicing medicine, doing a major rewrite of my electronic medical records software, photographing my wife's product line and posting it to her web site, and of course, running a blog, I had the chance to read Hugh Hewitt's latest book, Blog. It was, I must admit, a surprisingly good and easy read.

In my experience, many Internet and media pundits who are superb and engaging in short opinion pieces or commentaries, do poorly when turning their talents to a book. There seems to be a different gift package for writing short concise commentary, versus a much longer work, where a different dynamic is needed to keep the reader engaged. Several recent authors who come to mind, who do not fare well in this transition, are Peggy Noonan and David Frum.

I have long enjoyed Hugh Hewitt's insight and writing style in the Weekly Standard, and his blog is a daily visit. Surprisingly, his book successfully leverages his skill at short, insightful commentary, while maintaining an easy readability. He does this, in part, by writing brief, topical chapters. In essence, his book is much like reading a series of his articles, albeit on the same general topic. If there is a shortcoming to this approach, it is the lack of overarching continuity, development and flow which a truly engaging book manifests.

The book started out a bit slowly for me, as many of the illustrative examples, such as Dan Rather and Kerry's Christmas in Cambodia adventure, were old news, having been an obsessive blog reader throughout the political campaign. The role of blogs in exposing Trent Lott and the Jayson Blair affair were somewhat less familiar to me, but nevertheless fell into the same general mold.

His chapter on the influence of technology with the printing press and the Reformation was far more interesting, and I learned a good deal about that period of time with which I had been previously only passingly familiar. Nevertheless, the analogy between the role of the printing press in the Reformation, and the role of the blogs in the media and information revolution are bit of a stretch, and the two are not entirely analogous.

Gutenberg's printing press was truly revolutionary, and represented a world-changing technology. The blogs, on the other hand, are more of an evolution than a revolution. The technology upon which they are based -- the Internet, web sites and web hosting, and the power of the hyperlink -- is long-standing and has already been revolutionary. The power of the blog resides the way in which it represents a perfect storm of communication technology. It is truly the democratization of journalism, and as such will change the way information is dispersed.

I am not nearly as skeptical as Hugh about the future of the large print and television media, however. While lacking the nimble agility of the Internet, the mainstream media has vast resources to place reporters and video in remote parts of the world on a sustained basis, and very deep pockets, which the blogs cannot reproduce. I suspect the mainstream media will evolve into more of a commentary and opinion vehicle rather than a rapid news source. After all, the Catholic Church survived the Reformation, and is a powerful force for good today. Nevertheless, the large media's stranglehold on information has been broken.

Hugh's emphasis on the role of blog communication in business is a genuine insight, and this thought-provoking even for a small business such as mine.

One aspect of blogging which Hewitt overlooks -- perhaps because he has been in the business of putting his thoughts on paper for so long -- is the personal impact of disciplining oneself to write cogent and thoughtful posts which will be read by others. My blog is oriented toward longer, essay-based writing, rather than the far more common link-quote-comment format. For me, the process of writing for a blog has forced me to organize my thoughts more clearly, and has motivated me to research topics in far greater depth. In more than a few instances, this research has resulted in a change in my own opinion, and almost always results in the deepening of my understanding of a selected topic. The power of research, meditation, focused prayer, mental organization, and disciplined writing can be genuinely transformational.

Blogs also have huge potential as agents of true multiculturalism and tolerance -- unlike the thought-police variety ubiquitous on campus or at the NY Times. In a short period of time I can read opinions on the right and left, from Hollywood or Iraq, from soldiers and academicians, from all races and parts of the U.S, Europe, and the world. I've even found a few attorneys I've grown to like (Hugh is one of them, and the guys over at Powerline) -- so the power to overcome bias and stereotyping through the blogosphere is enormous.

The appendices, where Hewitt reprints prior articles he has published on the subject, detract from the quality of the overall work -- one is left with the feeling of being shortchanged. The author should have rewritten these in the context of the other material, or cited short passages to support other parts of the book. Why buy a book to revisit articles one may have already read?

One last thought: I hate the word "blog". To me, it sounds like a cross between a computer geek's wildest fantasy and a GI condition caused by eating too many Pop Tarts. I hope as this information tool evolves, that a better descriptive term arises. Some have suggested the term cyber sherpa -- an accurate, but far too esoteric substitute. Surely, with the many creative and intelligent minds working on this phenomenon, a better term will evolve.

In short, if you are new or relatively new to the blogging phenomenon, you should read this book to better understand where the information age is heading. If you are an experienced blogger or regular blog reader, you should buy this book to expand your horizons about the potential of blogs. If you are a wild-eyed lefty who believes America is the cause of all the evil in the world, and a Michael Moore groupie, by all means don't buy this book. The religious references will give you heartburn, the political viewpoint will give you a high blood pressure, and most importantly, you may learn something useful to promote your worldview, which will be bad for the mental health of the rest of us. Besides, the book may raise cholesterol levels in susceptible individuals. As your physician, I would strongly advise against it.

Rocket Scientists

Like most states, Medicaid in Washington State has struggled to provide health care for the poor. In Washington, Medicaid has been on life support for least several years. Its shortcomings are legion: very low reimbursements for services to providers; a poorly-written provider contract which put physicians at a severe disadvantage in any disputes; retroactive computer-generated audits of providers demanding repayment for services provided four or five years prior, under different payment rules, based purely on computer algorithms without chart review. As a result, physicians have been fleeing the program in large numbers. Statewide, only 33 percent of Washington physicians accept Medicaid patients, and most of those who do are severely limiting the numbers of such patients they will see. This has created an enormous crisis of access to health care services for the poor, which has resulted in a surge in visits to emergency rooms by patients far sicker than they would be if they had ready access to routine health care. I have personally cared for numerous patients who drove two or three hours to see me, because they could not find a provider in my specialty any closer to home.

The large majority of Washington physicians would prefer to see Medicaid patients, but are quite simply financially unable to do so. For years, both Medicare and Medicaid have operated under an unspoken and hidden tax, paying for less than the cost to provide services while relying on providers to make up the difference from their insured patients. As insurance carriers have progressively ratcheted their reimbursements down in response to spiraling health care costs and insurance premiums, subsidizing patients insured under Federal programs such as Medicare and Medicaid is no longer feasible.

For most medical practices in our area, Medicare currently reimburses at, or slightly below, the cost of providing those services. It is not widely recognized that Medicare does not pay the same for services across the country. Because of historical cost formulas, reimbursements in areas such as the Southeast or large urban areas like New York or Chicago are substantially greater than in areas where care has historically been provided at lower cost. This, however, is not a dynamic formula, and therefore regions which previously provided care at lower cost when Medicare was new, but which have since become high-cost areas, are penalized by very low Medicare reimbursement rates. Washington is such an example, and despite the current high cost of providing care in the Puget Sound area, Washington State ranks 46th out of all states for Medicare reimbursement. Medicaid in Washington State provides significantly lower reimbursements than Medicare; according to recent statistics, Medicaid in Washington State is paying at 62 percent of the Medicare rate for its services.

The State government in Olympia has come up with an ingenious new plan to solve this crisis: it plans to tax physicians to generate additional revenue to pay for higher Medicaid reimbursements. In his final budget, our previous Democratic governor, Gary Locke, proposed a 67% increase in the state business and occupation tax on physicians. Unlike most states, Washington does not have an state income tax, but instead levies a business and occupation tax on gross receipts, as well as a substantial sales tax. The specific tax rate varies by industry and business type. Our new governor, Christine Yanukovich Gregoire, formerly Governor Locke's Attorney General, also supports this idea:

Gregoire said she supports the goal behind Locke's proposal. "I can't imagine that it wouldn't get us more providers," she said. "I hope that means that those who are in need actually have access.

The rocket scientists are hard at work in state government again.

Now, as a physician, it should come as no surprise that I am somewhat resistant to the idea that I have been specially singled out for this honored responsibility. But it really does go beyond my personal reluctance to pay higher taxes -- even narrowly targeted ones such as this proposal. The simple fact is, this legislation, if passed, will not result in "those who are in need actually have[ing] access", but will severely exacerbate the crisis of access to health care for low income individuals in Washington State.

According to Governor Locke's own statistics, Medicaid currently reimburses at 62 percent of Medicare rates. Hence, even without considering the issue of profit, physicians seeing Medicaid patients are already picking up over a third of the tab for provider services in Washington State. The proposed legislation would increase reimbursements to 75 percent of the Medicare rate. So, a substantial new tax will be added for providers, while still paying them less than the cost to provide this care. The income from services to Medicaid patients is not exempt from the tax on gross receipts, and therefore the higher reimbursements will also be taxed at the new rate.

Imagine you are selling computers. You build a computer with a supply cost of $1000 (not including your time and expertise to make it), and must sell it retail for $620. Needless to say, this business model will not win you any Nobel prizes in economics. Now the State comes in, and wants to buy a large number of your computers, and offers to pay you $750 a computer -- but is going to nearly double your tax on that $750. Such a deal! It is not hard to see what you will do: you are going to stop selling computers, or sell them only to someone who will pay you more than $1000 -- or go out of business. The end results of this brain-dead legislation is simple: physicians in large numbers will simply stop seeing Medicaid patients, as they will be increasingly unable to afford to do so, no matter how strong their desire to care for the poor.

I never cease to be amazed at how seemingly intelligent individuals in government so completely and utterly fail to understand the ramifications of these sort of policies. I guess I am setting my expectations far too high.

Nevertheless, there's not much value to another "this policy will never work!" commentary on health care, so in following posts I will explore some principles and reforms which I believe stand a much better chance for success.

UPDATE: My statistic that only 33% of Washington physicians accept Medicaid patients was based on incorrect interpretation of data. The actual percentage appears to be approximately 47%, based on WSMA surveys. I will try to confirm this and post an update when I have more accurate numbers.

The Pioneer Spirit

Some of my readers want me to stop startling the sheep with terrifying tales of wolves at the gate, but rather rest peacefully in pastoral bliss, secure in the knowledge that our appointed shepherds have their security measures and manuals close at hand. Blessed assurance, thy rod and thy staff meetings, they comfort me. Stick to the Marcus Welby script, they tell me. And so I shall (in due time) -- although the long-promised malpractice essay is still a work in progress. Patience, my flock -- like the Gallo vineyards, I shall release no whine before its time. But in the meantime, let me lead you beside restful waters, and revive your souls.

Indeed, I bear good news: the Pioneer Spirit is alive and well in America.

True, the American frontier was conquered long ago. But ancestors of those intrepid explorers are setting out anew to explore the unknown, the uncharted, to brave the savages and convert the heathen. To wit: Blue-staters are hitching up their wagons and heading Red. They may be coming to a town near you.

Two recent articles tipped me off to this modern-day Manifest Destiny movement, one on each coast, from the Washington Post and the Seattle Post-Intelligencer. One can only speculate on the motivation for such intrepid ventures: perhaps the electoral drought and near-dustbowl voter yields have prompted the search for more fertile land (although it is rumored that Seattle has genetically engineered new loss-resistant voter ballots, which may help avert the impending famine). But whatever the reasons, there is a spirit of adventure in the air.

David Von Drehle, writing in the Washington Post Sunday Magazine, begins with a tale of his journey to the Red Sea:

Early in December, with a photographer and his assistant, I drove from Nebraska, near the geographical center of the United States, to the heart of Texas -- more than 700 miles, through empty spaces and sprawling cities and all or part of four states. We headed pretty much due south, no dodging or weaving. And never did we pass within 100 miles of a county that voted for Democrat John F. Kerry in the recent election.

We were voyaging on the Red Sea.

Drehle actually paints a surprisingly balanced view of what he found on his journey - albeit in language whose flourish contrasts sharply with the simplicity of middle America. ("The sun was low in the south; its rays arrived languidly and aslant through the gray, tufted stubble of a cornfield.") He seems encouraged to find people who voted for Bush, even though they disliked him (as if this were an unusual phenomenom in national elections), but periodically reveals his confusion about Red America as viewed through his dark blue sunglasses:

Kern returned several times to his belief that cities have become dangerous, expensive, disorderly places, in contrast with the safe and dependable countryside. And he seemed convinced that there is some causal link between the unpleasantness of that other America -- the one beyond the Red Sea -- and the variety of people who live there. The idea of diversity appeared to be meshed in his mind with the specter of change, and change is clearly something he prefers to avoid. Monochrome Nebraska, as he put it, is "the last frontier. Where else do you have a place where you don't have to worry about crime, about juvenile delinquency, where you can leave your doors unlocked?"

Drehle seems unable to grasp that cities generally are dangerous, expensive, disorderly places (although obviously not without offsetting benefits for many), and that most Red state residents don't frame their view of the world through the lens of "diversity" (much less think of Nebraska as "monochrome"). And change -- that bogeyman that Mr. Kern is thought to dread -- is not an inherently good thing when it brings about crime, personal risk, and social disorder.

Far from home and feelin' Blue, Drehle is mystified and intrigued by these strange Red ciphers he has unearthed. He finds his Rosetta stone in a small Midwest bookstore:

I heard a lot about a book that claimed to explain how people ... have been tricked by the moneyed class into voting against their own best interests. I found a copy of What's the Matter With Kansas? at a bookstore in Ada and began reading it as we resumed our southward journey.

The author, Thomas Frank, grew up in a wealthy suburb of Kansas City and received a PhD in cultural criticism from the University of Chicago. ... In Frank's view, if Red Sea residents knew what was good for them, they would vote for capitalist-scourging Populists today. But they don't know what's good for them, Frank explains, because of 'a species of derangement.' The deranged people of the Midwest are no longer able to make 'certain mental connections about the world,' because those once-'reliable leftists' have been deluded into caring about moral issues ... Frank kept me reading until it was too dark to read anymore.

It doesn't get much deeper blue than a Ph.D in cultural criticism at Chicago University, now does it? Drehle has found comfort, like a kid reading a letter from home at camp, in his bunk, flashlight under the blanket.

He seems perplexed when encountering an Oklahoma woman who opposed Kerry for his position on abortion and gay marriage:

She was too polite to say, in so many words, that she felt John Kerry was a man of bad morals. Instead, she put it this way: 'When Kerry said he was for abortion and one-sex marriages, I just couldn't see our country being led by someone like that.'

Later, I double-checked what Kerry had said on those subjects. During his campaign, he opposed same-sex marriage and said that abortion was a private matter. But Joyce Smith heard it the way she heard it, and voted the way she voted.

Doesn't the poor woman understand that a Democrat man's word is his bond? Except when its not, of course. Sometimes eyes and ears comprehend things which Google searches don't disclose.

On the Left coast, another journalist in Seattle hitches his Conestoga to the Google search engine in search of the abominable snowman of electoral politics: the Christian voter ("I've seen their footprints in the snow, Myrtle, but have yet to spot the beast!"). Tony Robinson, in Who Are Those Christians?, rapidly dismisses the vile misconception that Christians are all narrow-minded, hate-filled moronic drones:

For some today, all Christians are closed-minded religious bigots whose politics are somewhere to the right of the Terminator. For others, Christians can be explained in terms of two-party theory: There are liberal and progressive Christians on one side and the conservative and evangelical Christians on the other.

Both explanatory frameworks are inadequate to the diverse and complex reality of Christianity in America today. Like much else in post-modern America, the situation is wonderfully messy. It doesn't lend itself to neat explanations or to a simple duality of liberal and conservative. Post-modernity is transgressive, that is, given to crossing boundaries. So today you have progressive evangelicals, theological post-liberals, the new orthodox, as well as ancient-modern Christians. Such stereotype shattering and boundary crossing strikes me as promising.

It is reassuring to know that Christians are not merely closed-minded religious bigots with bulging muscles and German accents, but rather boundry-crossing, stereotype-smashing, post-modern transgressives. Robinson finds this promising -- as do I. I think. And as any good teacher, he does not simply leave us wondering what such wonderfully messy transgressiveness implies, but expands the outline in exquisite detail. He has discovered that Christians fall into different categories: mainline, evangelical, fundamentalist, charismatic and, yes -- Catholic!

One can almost hear the audible gasp from Belltown readers, sipping their not-too-hot Chai lattes as they gaze over Elliott Bay: "There are different types of Christians -- who knew? Say, what time is that Mapplethorpe exhibit at the Seattle Center?"

Robinson's depiction reads like an African safari adventure written by a National Geographic reader: one gets the sense -- unlike Drehle -- that he's never actually met the people he's describing.

From a sociological point of view, his overview of Christianity in America is reasonably accurate. But as an overview, it approaches being entirely meaningless -- or at least irrelevant. He divides two broad stereotypes into five broad stereotypes -- then tells us that these stereotypes are, well, not stereotypical. For example, when contrasting the mainline churches with the fundamentalists, he says:

One broad-brush way to differentiate the dominate Christian groups is how they relate to modernity or what some call 'The Enlightenment Project,' with its hallmark values of reason, progress, optimism, individualism and tolerance. Mainline Christians have been open and receptive to modernity, working to accommodate Christianity and modernity. By contrast, fundamentalists circled the wagons against modernity, which they perceived as a threat.

Aahh, modernity -- who does not desire to be thoroughly modern, Millie? The red flag here is the "Enlightenment Project" -- a key element of postmodernism, which emphasizes, in essence, opposition to all forms of darkness and superstition, as exemplified by religion:

Enlightenment was defined as the project of dispelling darkness, fear and superstition. It was the project of removing all the shackles of free enquiry and debate. It opposed the traditional powers and beliefs of the church (branded as 'superstition') and raised questions of political legitimacy.

Without plunging the depths of the contrasts and conflicts between the relativism of postmodernism and the centrality in religion (especially in Judeo-Christianity) of an absolute Truth over and above imperfect human reason, it suddenly becomes clear why this sort of generalization about Christianity is so vacuous: the labels are meaningless. If the mainline churches espouse postmodern skepticism, rejecting ideas of absolute truth of divine origin (a characterization not far off, in many cases), then they are no longer Christian in any meaningful sense, other than by name.

Herein lies the source of enormous confusion for our intrepid explorers: you cannot rely on descriptions, like "Christian", or "fundamentalist", or "evangelical", because their meaning has become so amorphous, and they are overlaid with ambiguity and inferences which cripple their utility as vehicles of fact. For example, "fundamentalist" originally referred to Christianity's emphasis on absolute, transcendent Truth as opposed to relativism. While the specifics of exactly what that Truth entails remains controversial to a degree, even to this day, within Christianity, the fact that there is an absolute truth of divine origin is undisputed in the faith. Yet "fundamentalism" has become a societal codeword for rigid intolerance, ignorance, anti-intellectualism, and even violent repression. It has been linked by common usage to Islamic terrorism, adding additional baggage, though the two religions could not be more different. While many devout Christians acknowledge the fundamentals of belief in absolute truth and Christian doctrine, few today will publicly admit to being a "fundamentalist". The connotations of the word are too profoundly negative in our modern society.

To understand Christians, or those mysterious Red state middle Americans, you have to get down to individuals, without preconceived notions carried forward from the lofty towers of intellectualism and social theory. The fruits of postmodern relativism and social concepts, detached from the real-life problems and solutions of everyday living -- which many understand to require transcendent Truth and reliance on divine strength and guidance -- are increasingly seen as empty and destructive by a growing plurality of Americans. It is this, perhaps more than anything else, which divides Red and Blue in America today.

An Attack Averted

I had a most interesting and troubling conversation with a patient of mine yesterday. The patient, a Federal Air Marshall, related an incident in which he was involved this past year.

He and his partner were assigned to a flight (the airline, airport, and destination were not disclosed) in their customary undercover security role. They boarded the airplane early in order to meet the flight attendants, at which time the cleaning crew was still on the airplane -- somewhat longer than expected. My patient and his partner sat together in seats near the middle of coach class.

The passengers began to board, and he and his partner noticed a single Middle Eastern man sitting near the front of first class. After a number of passengers had boarded, two Middle Eastern men walked by this man and made eye contact, but said nothing. They sat down together in the front of coach class. Shortly thereafter, two other Middle Eastern men also walked by the man in first class and made eye contact without speaking. They sat near the back of coach class.

Shortly after the flight attendants completed their post-boarding check of the overhead bins, an announcement came from the cockpit: the pilot stated that there had been a security breach, and everyone needed to deboard the plane for a second, more thorough, security screening. The Air Marshall and his partner were confused, as they had not triggered the security alert nor been notified of it prior to the announcement.

After all the passengers had deplaned, the Federal Air Marshalls checked with the flight attendants for more information. During a final check of the overhead bins, a flight attendant had noticed that one of the blankets was slightly unfolded, and he repositioned it in the bin. At this time, a razor blade fell out of the blanket. Concerned, but still believing this might be a straightforward mistake, the flight attendant began to check other overhead bins. Several additional incompletely folded blankets were noted, and hidden in each one was a box cutter: a total of five. It appeared that these had been placed there by the cleaning crew prior to the boarding of the airplane.

After the repeat security screening, the passengers reboarded -- all except the five Middle Eastern men, who were nowhere to be found. The flight proceeded to its destination uneventfully.

The man who relayed this story to me is a reliable and sober individual, and I have no reason to question his integrity or its veracity.

Anyone who believes the War on Terror is a fabrication trumped up for political gain needs to take a strong dose of reality medication and lie down until this hallucination passes.