While studying anatomy, I once spent a day with a cadaver whose stomach — normally located in the abdomen below the rib cage — had migrated up through the diaphragm and was now located behind the ribs. This was not simply a sliding hiatal hernia, but the rolling kind that occurs only about five percent of the time.
The body belonged to a small Asian woman. Her unusual condition may have been uncomfortable in life, but it had not prevented her from living for a very long time.
I wondered what prompted this woman to donate her complete body for use as a medical cadaver. Perhaps it was her unusual condition. By being a cadaver, she could acquaint thousands of students with the possibility of a rolling hiatal hernia. A description in a textbook is much less memorable than seeing the real thing. Of course with modern imaging technology, one almost doesn’t need to see a real cadaver these days.
I thought of this woman recently while watching an episode of Grey’s Anatomy, an extremely popular TV show that’s more soap opera than medical drama. I watch the show after it’s available on DVD, which is why I’m currently viewing last year’s episodes (season six). This was the season in which the young resident surgeon, George O’Malley (played by T.R. Knight), did not return. Read more
The New England Journal of Medicine has a number of articles this week on the Affordable Care Act (ACA) and the upcoming elections. In a discussion of challenges to the constitutionality of the individual mandate, attorney Sara Rosenbaum compares the ACA to Civil Rights legislation. I hadn’t thought of it this way before, but it makes sense. (emphasis added)
[I]n a remarkable shift whose precedent lies in the watershed Civil Rights Act of 1964, the ACA transforms health insurance into a public accommodation. The Civil Rights Act barred private businesses such as hotels, bus companies, and restaurants from refusing to sell their products or services to customers on the basis of race. The ACA bars state-licensed health insurers from refusing to sell products to individuals on the basis of health status. This prohibition, which bars rescissions — the canceling of policies of people who become ill — and which applies at both the point of initial sale and the point of renewal, is binding on health insurers nationwide, regardless of whether they sell their products in the open market or through state health insurance exchanges. This basic reconceptualization of health insurance as a good whose availability is a matter of national public interest essentially frames health insurance the way the Civil Rights Act framed other business interests.
The arguments for the constitutionality of health care reform seem legally sound. But you have to consider the current politicization of the Supreme Court, which everyone seems to agree will ultimately decide on constitutionality. See this recent article by Anthony Lewis. (emphasis added)Read more
We live in a time when almost all doctors – even those who practice in rural areas of the US – rely on advanced technology for diagnosis and treatment. But there are times when knowing the old-fashioned way to practice medicine comes in handy.
Dr. Jorge Díaz, responsible for the team of 15 doctors who monitored the health of the trapped Chilean miners, has been a physician for a long time. As he put it, he “practised medicine before it became as sophisticated as it is today.”
One of the first medical emergencies his team encountered was a miner with a urinary tract obstruction. If the miner had been above ground, imaging technology could have located the obstruction and, if appropriate, a trained professional could have inserted a urethral catheter. Since that wasn’t an option, Dr. Diaz relied on his older, more basic skills. Read more
An amusing discussion by Will Davies on the economics of selling infidelity. Ashley Madison is a discreet dating service for people who are already in a relationship.
Of course infidelity is as old as fidelity. But it is interesting to consider what happens once it is administered and economised. Firstly, it must surely become considerably less fun, as its taboo is lifted. I don’t doubt that there are people many years into marriage who seek out infidelity in a mundane way, to rival the search for other consumer goods; they may be the initial target of Ashley Madison. But beyond these people, infidelity is being parcelled up as safe and predictable, for those who presumably did their best to steer clear of it, until (for whatever unforeseen reason) they couldn’t resist it. Like hipsterism, the promise of administered infidelity is to have one’s cake and eat it, to experience the rush of living on the margins without any of the risks that once went with that.
I‘m now a monthly guest blogger on ConsultantLive, and my first post appeared today. It’s the one where Marcus Welby gives a speech on the rewards of general practice as opposed to specialization.
I’d like to give the ConsultantLive site a plug here, since I’m grateful for the opportunity they’ve extended to me. (Disclosure: My relationship with ConsultantLive is totally non-financial.) The site is designed for primary care physicians, with a special emphasis on practical advice that helps doctors diagnose and treat common medical problems. There are lots of graphics – some of them undoubtedly not too appealing to the lay reader. Doctors can receive CME (Continuing Medical Education) credits by reading articles online and answering questions on what they’ve learned.
My column on the site is called “How Health Happened.” It’s mainly about the history of 20th century medicine and how that relates to changing attitudes towards health. I’ll probably be writing more posts here that emphasize the history of medicine, especially in relation to primary care. Read more
When we hear the words “tyranny of health” these days, it’s usually a reference to the tyranny of a government imposing unwanted health care on its citizens. It brings to mind images of protesters carrying signs that denounce the “socialism” of Obamacare.
As recently as 1994, however, the tyranny of health had a different meaning. That’s when Dr. Faith T. Fitzgerald published an article in The New England Journal of Medicine with that very title. What tyranny of health referred to – and what Dr. Fitzgerald’s readers readily understood at the time – was the idea that doctors should coerce their patients into being healthy. She objected to this increasingly prevalent attitude that expected the medical profession to be a combination of nanny and big brother.
Healthy lifestyles and the definition of health
The article begins with a reference to the recent emphasis on promoting healthy lifestyles: “Once upon a time people did not have lifestyles; they had lives.” (In 2010, it’s easy to forget that we did not always have “lifestyles.”) Dr. Fitzgerald then reminds readers of the 1946 definition of health from the World Health Organization (WHO): “A state of complete physical, mental, and social well being, and not merely the absence of disease or infirmity.” Read more
The original “Tyranny of Health” article that I wrote about – published by Dr. Faith Fitzgerald in The New England Journal of Medicine in 1994 — is no longer available online in its entirety without a subscription. I plan to discuss it in more detail in the next post.
Here’s a rather lengthy response I wrote in reply to someone at KevinMD who asked: “In what way did the state turn over its responsibility of individual health to the individuals?” I’ve said these things before, both on this blog and elsewhere. It seems to be one of my pet topics. Read more
Here’s an editorial from an issue of The Journal of the American Medical Association published 100 years ago (emphasis added):
One of the cruellest and most despicable phases of the “patent medicine” business is the studied effort made by nostrum exploiters to frighten their victims into the belief that they are suffering from some more or less serious disease. Not content with the sale of their preparations to those who have—or who believe they have—one of the many diseases for which the products are recommended, the “patent medicine” vendors strive to create an artificial demand for their stuff by working on the imagination of the healthy and persuading them that they are sick. The scheme is an old one but none the less disreputable. One of the more recent modifications of this trick is the “gall-stone remedy” fake …
Compare this with a discussion of medicalization by Carl Elliott in his new book, White Coat, Black Hat . After describing how the condition formerly known as “urge incontinence” was repositioned as “overactive bladder” (to remove the stigma), he continues (emphasis added): Read more
When it comes to legislation that controls the health of its residents, New York leads the pack.
In 2006 the New York City Board of Health passed a law that required certain restaurants to list calories on their menus.
In 2008 Governor Paterson proposed a tax on drinks that contain sugar: the soda tax.
This past January Mayor Bloomberg announced a national campaign to persuade food manufacturers and restaurant chains to reduce the salt in their products. (It has to be a national campaign to be financially viable for manufacturers.)
In March a Brooklyn assemblyman proposed a bill that would make it illegal for restaurants to use salt when they prepare food.
And now Mayor Bloomberg has proposed a law that would prevent the purchase of soft drinks with food stamps.
The salt issue is controversial, and not the main point I want to address here. I do recommend, however, an excellent article by Gary Taubes called “The (Political) Science of Salt,” in which he says: Read more
These thoughts on the upcoming election really stuck in my mind, so I thought I’d share them. They’re from Michael Tomasky, American editor-at-large for The Guardian. The complete article, “The Elections: How Bad for Democrats?,” is available online from The New York Review. (emphasis added)
In American politics, Republicans routinely speak in broad themes and tend to blur the details, while Democrats typically ignore broad themes and focus on details. Republicans, for example, speak constantly of “liberty” and “freedom” and couch practically all their initiatives—tax cuts, deregulation, and so forth—within these large categories. Democrats, on the other hand, talk more about specific programs and policies and steer clear of big themes. There is a reason for this: Republican themes, like “liberty,” are popular, while Republican policies often are not; and Democratic themes (“community,” “compassion,” “justice”) are less popular, while many specific Democratic programs—Social Security, Medicare, even (in many polls) putting a price on carbon emissions—have majority support. This is why, when all else fails, Democrats try to scare people about the threat to Social Security if the GOP takes over, as indeed they are doing right now.
What Democrats have typically not done well since Reagan’s time is connect their policies to their larger beliefs. In fact they have usually tried to hide those beliefs, or change the conversation when the subject arose. The result has been that for many years Republicans have been able to present their philosophy as somehow truly “American,” while attacking the Democratic belief system as contrary to American values. “Putting us on the road to European-style socialism,” for example, is a rhetorical line of attack that long predates Obama’s ascendance—it was employed against the Clintons’ health care plan as well. … Read more
I can’t resist juxtaposing the end of Dr. Welby’s 1969 speech on general practitioners vs. specialists –
[P]erhaps you’ll remember that one of these after dinner chats was given by a moldy old fig, with overtones of megalomania. And that he almost convinced you to go into general practice. You’ll remember it, and you’ll look at your beautiful wife and your two beautiful cars and your beautiful barbeque pit and for maybe three seconds you’ll be sorry you didn’t take his advice. But then, a beautiful breeze off the ocean will restore you to sanity. And you will have missed a hell of a lot.
— with the Talking Heads song Once in a Lifetime (1980). “You may find yourself behind the wheel of a large automobile. You may find yourself in a beautiful house with a beautiful wife.”
Marcus Welby was not necessarily the inspiration here, of course. Alienation – and the dissatisfaction that comes with a midlife crisis — pervaded the zeitgeist in the seventies.
Whatever happened to alienation, anyway? Perhaps it fell along with the Berlin Wall. Or succumbed to Prozac. Read more
In the very first episode of the TV series Marcus Welby, MD, our hero delivers an after dinner speech to a group of young interns. As he’s introduced, he hastily scribbles the title of his talk and hands it to the hospital director: “The future of the general practice of medicine, if any.” The year was 1969.
In his introduction, the director somewhat tactlessly remarks that many “eminent specialists” have addressed the group in the past, but tonight they have a general practitioner. After acknowledging this, Welby continues:
Don’t apologize, You’re right. That’s what everyone thinks. Tell me, doctors, are you a specialist or a GP? Or sometimes they say “or just a GP?” But of course we are specialists. And our specialty, like any other, has certain advantages and certain disadvantages. The money is good, but you have to work three times as hard for it. But you people know all about that.
Since you’re about to choose your specialty, you’ve been amassing information about each. Psychiatry, we know, is practiced sitting down. Dermatologists don’t make house calls.
General Practice is performed standing up, sitting down, outdoors, indoors, wherever there’s illness. And that means everywhere. Because, gentlemen, we don’t treat fingers or skin or bones or skulls or lungs. We treat people. Entire human people. … Read more
The New England Journal of Medicine has an excellent article on what’s at stake for health care reform in the upcoming mid-term elections. It’s by Henry J. Aaron, a noted health care expert at the Brookings Institution, and the article is available online without a subscription.
Here’s a summary.
Republicans are currently campaigning on the promise to repeal the Affordable Care Act (ACA). They especially dislike the requirement that everyone have health insurance (the individual mandate). They favor certain reforms of the insurance industry that are popular with the public, however, such as denying coverage for pre-existing conditions and cancelling insurance once a policy-holder gets sick. Unfortunately, you can’t have one without the other. If people without insurance could wait until they get sick before buying a policy, the insurance industry would go out of business.
There’s a perverse upside to this. If insurance companies went out of business, the government would be forced to provide an alternative form of financing, such as the public option. That’s definitely not what the Republicans have in mind.
Repeal of the ACA is unlikely as long as Obama is President. But since most on the major provisions in the bill don’t take effect until January 1, 2014, there’s ample time for opponents to repeal the bill after the 2012 elections. Read more
It’s not easy being an American doctor these days. First Senate candidate Sharron Angle suggests paying doctors in chickens. Now Peter Orszag, Obama’s former OMB director, compares doctors to drug stores and wants them to work weekends. He also thinks doctors should be evaluated the same way TV networks compete for Nielsen ratings.
Doctors – especially those engaged in primary care – are already thoroughly depressed and distressed about their working conditions. Even surgeons complain that they’re not treated as professionals, but as employees hired to do bureaucratic shift-work. Is this the way to treat the people responsible for our health?
Here’s the opening paragraph from Orszag’s New York Timeseditorial:
Doctors, like most people, don’t love to work weekends, and they probably don’t enjoy being evaluated against their peers. But their industry can no longer afford to protect them from the inevitable. Imagine a drugstore open only five days a week, or a television network that didn’t measure its ratings. Improving the quality of health care and reducing its cost will require that doctors make many changes — but working weekends and consenting to quality management are two clear ones.
[S]trange as it may seem, bad times can also be good for health. Forget individual health for a minute. This is about the macro picture, the health of entire societies. And there statistics show that as economics worsen, traffic accidents go down, as do industrial accidents, obesity, alcohol consumption and smoking. Population-wide, even deaths from heart disease go down during recessions.
The report was based on the work of economist Christopher J. Ruhm – the favorite expert of journalists who want to attract readers with something counter-intuitive.
Two years later, no one is so glib. Yes, we did manage to pass health care reform. More people will eventually have health insurance, but that’s not until 2014. In the meantime, people are not just unemployed. They’ve been unemployed for a long time. And those people need to eat. Read more