Tag Archives: medicine

Cutting Up an Ox

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Ben Sasse fears for our youth.

He is a U.S. Senator, and therefore he is a very busy man with little time to spare for side projects. Yet, so great is his concern for our kids’ predicament, that he has taken the time to write a book about it. It is not a bad book, even if you do not agree with what it says. You will have to trust me (or not) on the exact contents, because, “You may not make this e-book public in any way”, is all I will quote directly from it.

His thesis is laid out in the book’s title, The Vanishing American Adult, and he has summarized the gist of his prescription in the subtitle, Our Coming-of-Age Crisis – and How to Rebuild a Culture of Self-Reliance.

In the text, he depicts a generation afflicted by aimlessness. They have been stunted by coming up in the shade of social media and cultural relativism. Deprived of the harsh choices and bright lessons of social responsibilities and traditional rites of passage, kids have grown passive. They lack the ‘grit’ to sustain our society.

I won’t quibble with his depiction. Social media is a blight. The current generation operates on the assumption that ‘someone will take care of it’. Giving up is always an option for them.

I do disagree with his diagnosis and prescription, however. He seems to think that helplessness and hollowness result from a deficiency of citizenship. The correction would then involve a big shot of citizenship. He is completely mistaken. In fact, emptiness is the natural outcome of citizenship, and helplessness is just a reactive symptom.

On the most basic level, citizenship is a position in which one gets told that one’s life is fungible. One’s time, attention, motivation, and psyche can be chopped up and traded for goods to satisfy certain needs. Of course, Sasse recognizes this situation. He mentions “development of the individual” on a couple of occasions as a worthy pursuit, but only if it is pursued to certain ends (becoming responsible, self-sacrificing, ‘gritty’ – in other words, all those things that make a solid citizen). As far as I can tell, only the ends distinguish healthy developmental activities from selfishness, in Sasse’s estimation. And in a shocking coincidence, healthy ends are those for which the goods of citizenship come in handy.

“Why won’t my blood sugar go down?”

Maybe my analysis is unfair. Sasse contends that we are all a little defective, and our institutions may be a little defective, too. We should not expect a perfect synergy between man and social machine, even though the basic program is sound and actually the best that we can do.

But I hear differently all the time.

“I’m doing all those things that the diabetic educator told me to. I have changed my diet. I am walking every day. I am taking my medications like clockwork. So why is my blood sugar still high?”

This person is in my office every day, wearing a different, outfit, a different ethnicity, or a different gender. Yet they are the same person. They have a sit-down job, or two, in which they spend 40-60 hours per week dealing with an incestuous dataset – something so about itself, whether it is driving a cab or processing claims, that it demands attention to automatisms rather than any  particular skill. To ensure that their attention does not waver, an overseer tracks their activities and rates their efficiency. Their extraneous physiological and psychological functions are regulated by the employer as distractions.

The citizen in my office sleeps 6 hours per night, or less. They drink energy drinks to keep going, and eat foods which the package or the vendor says are healthy, because they haven’t the time or energy to prepare their own food. They are too exhausted to exercise properly.

As a result, they are obese, diabetic and hypertensive. As a result, they now require one of the goods for which they can sub-divide themselves: medical care.

Which brings us to where the defense of citizenship as a natural-born fertilizer for human development, breaks down. The trouble with the whole thing is not the palate of goods on offer, their costs, or the means of valuation. The trouble is the chopping, because the roots of experience (attention, motivation, responsiveness, etc.) can’t be cut up for a purpose, especially for delayed gratification of a specific need. The very notion mistakes the nature of needs and the relationship between our needs and our activities. Here, Sasse may have been better served by spending a little more time reading Nietzsche, and a little less time reading Rousseau and the Bible.

For an organism’s needs can’t really be parsed. The motivations underlying our activities are merely aspects of a single motive which Nietzsche labeled ‘will to power’. Even when we try to perform an isolated act of attention, we feel something about it, our neuro-hormonal system responds to it, and it tires us globally.

But Sasse seems to think there’s a neat way around the problem of dividing the indivisible.

Life on the Farm or 8 Pitches Up?

In the latter half of the book, Sasse talks about how he sent his daughter to work on a ranch. The idea was to teach her how to enjoy work – not any particular task, but work itself. Basically, he sought to teach her how to thrive as an instrument. It’s pretty clever, really.

He explains the strategy in a vignette:

Martin Luther met a man who had just become a Christian and wanted to know how best to serve the Lord. He asked Luther, “How can I be a good servant? What should I do?” He expected Luther to tell him that he should quit his job and become a minister, monk, or missionary.

Luther replied with a question, “What do you do now?

“I’m  cobbler. I make shoes”, the man answered.

“Then make great shoes”, Luther replied, “and sell them at a fair price – to the glory of God.”

In other words, find integrity in being a good instrument. I think the flaw in this reasoning is obvious: Why not make great shoes to the glory of Satan? It’s the devotion part that really matters, right? This notion of the human lost at heart and essentially in search of a set of rails (any rails) undergirds fascism through the ages, and it works superficially, so long as the social venue is stable.

But I took another path with my kids, because I learned more from sitting on a ledge, than I ever did from a job.

We have climbed several long routes together. We have looked up, down, and out from ledges in the middle of those routes and soaked in the lessons: however precarious the position, what falls to us is to pass the water around, check the system, and find our way through the next rope-length of terrain; trust your partners as you trust yourself; no matter how cold, hot, tired or thirsty you are, the beauty of the sky and landscape remain; achievement, i.e. ‘ticking the route’, doesn’t really matter – it is only a means to get you to the ledge.

In taking them on those climbs, my hope was to offer them a way of life which put making a living in perspective, rather than telling them that making a living would put everything in perspective for them.

A different vignette illustrates my point:

     Cook Ding was cutting up an ox for Lord Wenhui. At every touch of his hand, every heave of his shoulder, every move of his feet, every thrust of his knee — zip, zoop! He slithered the knife along with a zing, and all was in perfect rhythm, as though he were performing the Dance of the Mulberry Grove or keeping time to the Jingshou Music.
“Ah, this is marvelous!” said Lord Wenhui. “Imagine skill reaching such heights!”
Cook Ding laid down his knife and replied, “What I care about is the Way [“Dao”], which goes beyond skill. When I first began cutting up oxen, all I could see was the ox itself. After three years I no longer saw the whole ox. And now, now I go at it by spirit and don’t look with my eyes. Perception and understanding have come to a stop and spirit moves where it wants. I go along with the natural makeup, strike in the big hollows, guide the knife through the big openings, and follow things as they are. So I never touch the smallest ligament or tendon, much less a main joint.”
“A good cook changes his knife once a year — because he cuts. A mediocre cook changes his knife once a month — because he hacks. I’ve had this knife of mine for nineteen years and I’ve cut up thousands of oxen with it, and yet the blade is as good as though it had just come from the grindstone. There are spaces between the joints, and the blade of the knife has really no thickness. If you insert what has no thickness into such spaces, then there’s plenty of room — more than enough for the blade to play about it. That’s why after nineteen years the blade of my knife is still as good as when it first came from the grindstone.”
“However, whenever I come to a complicated place, I size up the difficulties, tell myself to watch out and be careful, keep my eyes on what I’m doing, work very slowly, and move the knife with the greatest subtlety, until — flop! the whole thing comes apart like a clod of earth crumbling to the ground. I stand there holding the knife and look all around me, completely satisfied and reluctant to move on, and then I wipe off the knife and put it away.”
“Excellent!” said Lord Wenhui. “I have heard the words of Cook Ding and learned how to nurture life!”
— Zhuangzi, chapter 3 (Watson translation)

I do not see the current generation as sissified hedonists, any more than previous generations. The hypersensitivity, the passivity, the absorption (self and otherwise) all look like symptoms of a bunker mentality. They see what’s in store for them and they don’t like it, but they don’t seem to know how to resist.

A Sasse-type message has gotten through. The citizenry coming of age does think that it must learn to embrace a social role (little worker, little voter, little contributor) wholeheartedly in order to fully mature, and it just can’t bring itself to do so. The instinct is right. Kids growing up in this era are being asked to pursue a sort of faux-maturity which involves merely “giving up childish things”, and the achievement of that state will leave them empty and utterly dependent on a structure which deals with them on the basis of a flawed methodology.

They need a little less Ben Sasse, and a little more Cook Ding, when it comes to advice about how to grow up. Because maturity means dealing with your situation – not just endorsing it – and dealing with it artfully. It means getting over being The Cobbler, The Christian, The Cobbler-Christian, or even The Cook.

In Sasse’s terms, I have laid out the Romantic counter-argument to his Realist argument regarding the nature of the individual’s relationship to civilization. But I reject that characterization to some extent. There isn’t an inherent conflict between the individual and the civilization. We are stuck with our civilization. It lies before us like the carcass of a great ox, and it is just as indifferent.

We get chopped up in our interaction with it, but our own hand is on the knife. And I agree with Ben Sasse here,  maturity is the solution. Not the faux maturity which the senator espouses, which is just a form of selling out, but actual maturity which sets limits and carves its own way, not towards some magical future, but like the cook’s knife, in the present where we all reside.

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They Solved It! They Solved It!

Geriatricians have solved the hard problem of consciousness! From the July 1st issue of American Family Physician: “Some validated scales, such as Pain Assessment in Advanced Dementia…use objective measures to assess pain intensity and response to intervention.” The objective measures: abnormal breathing pattern, increased vocalizations, observed tension in the face and body, and capacity to be calmed by caregiver voice and touch. In short, agitation is synonymous with pain. And how do we know this? Because the researchers have observed that opiates attenuated agitation in their subjects with advanced dementia. That’s how the scale and its underlying assumptions were validated at once.
Many have questioned the utility of philosophy. Well, here it is. The PAINAD scale is valid, no doubt. This is something that can be determined by definition. If two different people observe the same demented patient, it is quite likely, predictably likely, that the observers will come up with the same score on the scale. But that begs the question. The real problem is not coherence. Coherence does not make truth. The real problem is the truth of the claim that agitation represents pain in a person with advanced dementia. Such information is not available to us, at least not in the defined, quantifiable way which we would prefer.
We can’t know anybody’s pain, really. That’s because it is everybody’s pain that gives us the concept of pain in the first place. The sensation I experience when I grab an electric fence, for instance supervenes on the action of the fence charger, the conductivity of my body and the ground, activation of peripheral nocioceptors, mediation by inter-neurons in my spinal cord, and finally my thalamus and cortex where it is contextualized as my very own experience of shock. My experience of the shock from the fence, indeed all my pain experience, is unique. In the case of a shock from the electric fence, my experience is trivially unique – to the extent that I can predict my friend’s response if I tell him why he shouldn’t touch the fence. But the pain-concept supervenes on all those unique experiences in the same way that my own experience supervenes on the collection of events surrounding my hand’s contact with the wire. A thing called pain doesn’t appear out of the process. If that were so, I should have ready access to it and the PAINAD scale would be unnecessary. I would just slap some electrodes on the patient’s skull and watch for the pain signature in his cortical electrical activity. But I can’t, nor will I in the future, though I might have such a tool. Cortical electrical patterns might be the narrow point in the pain experience, the place where the difference in my experience and the patient’s is most trivial. But I must still correlate the activity with some report from the individual or a set of individuals in a similar condition. Some kind of PAINAD-type analogy will always be the best that I can do.
So what does this application of philosophy to pain treatment tell me? What use is philosophy? First, it tells me that I should not expect to fix everyone’s, or anyone’s, pain by stimulating their opiate receptors. The experience becomes pain-type only when it is put in context. We can easily imagine pain experiences where the opiate receptors play a very different role. Take the poet’s description of the pain of a broken heart. Do we write off his report entirely as a quaint analogy as opposed to our serious ones? If so, how is his report effective in communicating a sense of the experience to us? What do we say when we find out that he used laudanum and found some partial relief? Addressing the mechanisms of pain can only go so far, because mechanisms only go so far in explaining the painfulness of an experience.
The application of philosophy to pain can save me from a different pragmatist’s mistake in treating pain as well. I’ll pick on my surgical colleagues for a moment. On multiple occasions, I’ve had a surgeon tell me, “Nobody ever died from pain.” Inevitably, this little bubble of wisdom surfaces in reference to a patient whose pain management has passed from the surgeon to myself. My knee-jerk response is to point out that nobody ever died from hip arthritis either, but surgeons are still quite happy to replace hip joints. Yet I understand the pragmatic meaning of the statement: people have died from opiate overdoses, so we can’t just capitulate to a person’s demands for ever-increasing doses of opiates to treat their pain. As noted above, the notion that simply stimulating opiate receptors necessarily fixes pain is misguided. But there is a subtext. Death is measurable. Respiratory suppression due to opiates does something, and therefore it is real in way in which pain is not. When you get right down to it, pain can be ignored. But it isn’t that easy. The human condition won’t be ignored anymore than it will be medicated. The hard problem remains hard. It isn’t hard because our subjectivity is some spooky ectoplasm or narcissistic property. It isn’t hard because our experiences will never move a dial or tip a scale. It is hard because things which explain and are explained have a reality to them as much as things which do something, yet we’re stuck working with the functional things, like the observed behaviors in the PAINAD scale. So we have a tightrope to walk. We can only ever come close to helping others with problems like pain, and only then if we act comprehensively. We can never completely succeed. But that doesn’t mean we must fail. We can just never get too sure of ourselves when we do something like suppress a demented patient’s agitation with an opiate – and think we can call it good.

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The Chthonic

It had a periodicity to it, but not like anything man-made. Instead, it was like a geyser. As it rose to the surface it swirled chaotically around hidden shelves and side-channels, so its interval was uneven. The uncertainty contributed to our tension, the nephew’s most of all.
“Yeeeeeeeeeee!” she screeched, then closed her mouth and relaxed again.
Between screams, she looked as peaceful as a Buddha. Perhaps, her caretakers speculated, the discomfort of prolonged immobility or some occult infirmity drove the screaming. We had given her increasing doses of pain medication, to no avail. Perhaps she somehow had enough consciousness remaining to experience the dislocation of facing the present without access to the immediate past, not knowing moment to moment how she got in the bed, why she felt like she did, whose arm lay at her side, whose mouth was screaming. We had given her anxiolytics and she just kept screaming. Perhaps she was bedeviled by visions. We gave her our best potions against inner demons and her timing did not falter.
“This is Hell,” said the nephew, “She is in Hell. I want this to stop.”
She had chosen well, or someone had. Sometimes, the decision about who would oversee the death defaulted to hereditary proximity, geographic factors, and availability. This nephew had some connection to her beyond practicality. Of course, he spoke for himself. No one knew what her vocalizations signified. We had taken our best guesses and come up short. What he wanted now was not a treatment. He wanted a cure for it all. To be clear, it was not euthanasia he was requesting. He wanted us to ablate whatever remained of her consciousness. He wanted oblivion, or at least its appearance.
It wasn’t killing, but it was taking something away from someone who appeared to have so little. We were always wary of treating extrinsic things, of giving medications to fix a person’s bad relationships or discomfort with herself. It was different for the dying though.
Everything was becoming extrinsic for her. She couldn’t be crying out for something. That time had passed. At best, her screams expressed something which we could not know, but something which was less specific, less relevant to anything inside, as she came closer to death.
He was right. The screams meant what he said: this is Hell; I want this to stop. I had an obligation to her and no choice in the matter. Of course he spoke for himself.
“I will do as you wish,” I said.

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Dr. Van Helsing Does Not Practice Primary Prevention

As recommendations for treatment of hyperlipidemia become broader and more generic, drifting toward the poly-pill conclusion, I can’t help but think of Dr. Van Helsing’s predicament in Dracula. In the story, though he has information which suggests the possibility of primary prevention, he practices secondary prevention. It is only after the symptoms appear – Lucy’s mysterious anemia and the rash of similar cases following her death – that the doctor suggests putting garlic around the windows. He has to wait. He’s in a story, so he knows the horrible truth all along, but he can’t reveal it without his patients sending him packing. Every doctor understands Van Helsing’s predicament. Few can see his patients’ logic however. It is one thing to indulge a crazy old man’s belief in vampires. It is quite another to indulge a crazy old man’s belief that a vampire has moved into the old mansion down the street and has begun to prey upon the household.
When doctors tell patients to treat public health problems, like cardiovascular disease prevention, on an individual basis, the patients take it as if they were being asked to put garlic around their windows because there have been vampire sightings in their neighborhood. They are slightly incredulous. And, the patients are right.
If we medical professionals are to treat asymptomatic individuals based on a 10 year risk calculated from epidemiologic data, for a disease which they have may or may not have started to develop, we must be honest with them. We have to admit that medication is the best that we can do, ask for their help, as a group, and then make it easy for them to help. Doctors don’t like to treat populations, though. Individualized care and patient centered care are the current watch words. But the greatest successes of medical science have been the opposite sort of effort. Nobody thinks that we should stop immunizing people for pertussis and move to an individualized prevention program with regular swabs for the pertussis bacteria and antibiotics for every runny nose. The approach is ostensibly patient centered, and it really is in a way, just like Dracula’s interest in Lucy and Mina is patient centered. Looking down from the established high ground, it’s easy to recognize the shift to an individualized strategy for preventing whooping cough as impractical and myopic. Medical professionals are clever enough to avoid bad moves from the general to the specific. However, decisions to move from a dysfunctional individualized program to a population based program can trip up anyone, even though the determining factors are the same.
The problem is Van Helsing’s problem. At the level of the vampire hunter’s interest, garlic around the windows is garlic around the windows. He’s like Dracula that way, for whom young ladies full of blood are young ladies full of blood. Dracula and Van Helsing are at risk of availability bias, cognitively and practically, as are all the physicians with lipid profiles, risk calculators and statistical correlations at their fingertips. There is a insidious, vampiric class of maneuver from population-based conclusions to individualized care. But the patients’ motivations lie outside of the action’s focus, and that focus is therefore myopic. It does matter to patients whether the doctor is asking them to deck the sills in order to cut down on the incidence of vampire attacks or because they should fear the vampire staring at them through the window. The latter request involves adopting an astringent manner of thought and behavior, the stuff of anxiety disorders. The former is an appeal to solidarity and public safety. We shouldn’t be surprised when the same people we’ve been instructing to fear the vampire outside their window come in demanding that we do something about the pale figure lurking behind their cough, in their prostate, or under their nipple. Having ceded the high ground, we’ve no credible response.

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The Word from the Land of Absolute Relativism

“Look at all this shit!”
He waved the stack of envelopes at me.
“Look at this one.”
He held up the letter on top. It was from another hospital and marked, ‘Important: Do Not Discard’.
“These are the ones you have to be careful to discard.”
He threw it in the wastebasket, and followed it with the rest of the unexamined mail. I was far enough into my training not to be shocked by this sort of thing. I’d weathered surgeon’s tirades and soaked up jaded, callous humor in the emergency room. Still, my experience with this psychiatrist had me believing for years afterwards that, in his specialty, like sought like.
“This kind of clutter is the enemy,” he continued, opening the top drawer in his desk.
He scooped out a handful of keys.
“Look at these! I don’t know what this is for,” he said, holding up a sturdy door key. Into the bin it went.
He tossed a few more, then dumped the remainder back in the drawer with an expression of disgust.
“We’ve wasted enough time,” he declared, “better show me the case.”
I handed him the chart, with my history on top. He lingered on the assessment at the bottom of the page. Residents sometimes began to sweat when attending physicians paused too long in their documentation review. I did not in this case, because the assessment was not mine in the first place; the patient brought her diagnosis with her from the last admission. He grunted and moved on to the ancillary notes, containing the comments from psychiatric nurses who had evaluated the patient.
“Jesus Christ! Did you read this?”
Now I began to sweat. I hadn’t read the nurse’s notes. He handed me the chart with a shake of his head. I’d gotten lucky; the question was rhetorical. Curiosity displaced my anxiety and I began to read with interest. Immediately, I realized what he was on about.
At the bottom of the page, several of the nurses (a cabal?) postulated that dark forces were at work in the patient’s life. The assessment dwelt upon the young lady’s practice of witchcraft, not as an expression of alienation in a personality dangerously adrift, but as an activity with sinister efficacy. I looked up at him as I finished reading.
“How can we hope to do anything for the patients when we’re up against this kind of stupidity from the staff? Borderline,” he stated, returning to my assessment, “Do you really believe that?”
I shrugged. She had the black nail-polish sign, which every trainee knew was pathognomonic for borderline personality disorder.
“There are some people that fit the bill, but mostly the term is an epithet applied to people who we don’t like because they are frustrating. It’s the DSM used as a cudgel, and it justifies our bringing these people into the institution when their community becomes too frustrated with their behaviors. They come in for a few days or a few weeks until they’ve cooled off, then they go back out with the same problems, to the same problems. So this kind of inpatient treatment is like firing into the tree line: it’s good for keeping the enemy’s head down, but it’s not good for hitting anything.”
His words were familiar in structure and reference. At home that evening, I poured through my memory and my boxes of books, and I eventually placed them. They recalled an image from Heart of Darkness.

Once, I remember, we came upon a man-of-war anchored off the coast. There wasn’t even a shed there, and she was shelling the bush. It appears the French had one of their wars going on thereabouts. Her ensign dropped limp like a rag; the muzzles of the long six-inch guns stuck out all over the low hull; the greasy, slimy swell swung her up lazily and let her down, swaying her thin masts. In the empty immensity of earth, sky and water, there she was, incomprehensible, firing into a continent. Pop, would go one of the six-inch guns; a small flame would dart and vanish, a little white smoke would disappear, a tiny projectile would give a feeble screech – and nothing happened. Nothing could happen. There was a touch of insanity in the proceeding, a sense of lugubrious drollery in the sight; and it was not dissipated by somebody on board assuring me earnestly there was a camp of natives – he called them enemies! – hidden out of sight somewhere.

The image stuck and grew stronger over the years until I ceased to see my preceptor as chief among madmen and came to see him as Marlow on the boat. He was the lone relativist in a wilderness of absolutists who considered borderline personality more than a label on a charge sheet (it is that at least, for the Diagnostic and Statistical Manual which codified the term is a tool intended to itemize mental illness for billing). For his fellow wardens of the institution, there existed a borderline personality fact about certain people, caused by borderline personality pathologies and amenable, potentially, to borderline personality treatments. He saw them firing into a continent. He did not, of course, live in the land of absolute relativism, where everything is an onion made of layer upon layer of motives and relations with no pertinent core. He believed in borderline personality as a country over yonder. It recognized certain commonalities, but those commonalities arose in the villages. They accrued; they did not come down from on high.
He cared about how seriously the nurses, psychologists and patients took diagnoses, not because relativism was true. He cared because absolutes did not obtain. Worse, absolutes destroyed. On occasion, bullets fired into the tree line did hit something, and that something was an enemy by definition. Over his career, he’d seen victory declared over schizophrenia and the state institutions emptied onto the street. He’d seen the profession take a pass on intractable diagnoses, like personality disorders. He’d heard from his predecessors about neurosurgical solutions considered quite successful in their time. It wasn’t that relativism was true, it was just that truth didn’t work that way. It wasn’t diagnosis-friendly, and the truth about psychology all the less so.

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Cult of the Range-Fed Turtles

When my best childhood friend grew up, he decided to become an archaeologist. During his graduate training, he was in charge of  a dig in the Mississippi river valley which unearthed an odd structure. In the midst of the native people’s dwellings, was found a circular enclosure made of closely spaced wooden posts and containing a large pile of turtle shells. The undergraduates were eager to speculate about the purpose of the structure, but my friend cautioned them against it.

“We can’t be sure of its use,” he said”, and we can’t just guess based on what we might use an enclosure like that for today. We can’t just assume they were running a turtle ranch here. Why would they do that with a river full of turtles just a quarter-mile away? We have to put it in context of the surrounding village and the environment of the time, look for other examples and see if there are any modern structural analogs. Then we can make a guess, but it will still just be a guess.”

The next day the professor in charge of the dig came around on a rare site visit to see how things were proceeding. The students were eager to show him the mysterious ring of posts with its pile of shells.

Upon seeing their find, the professor remarked without hesitation, “Huh, must have been a turtle pen,” and promptly resumed his walking tour of the dig.

I don’t know if archaeology has an excuse for this kind of thinking, but medicine does:

Life is short. The art is long. Experience is difficult.

– Hippocrates

We can be forgiven for resorting to teleological assumptions now and again in medicine. With limited time and incomplete information, we must sometimes act on hypotheses which attribute function to structure and purpose to processes. Lucky for us, there’s plenty of slop in the system, so even if we’re wrong at the start, we usually get a second chance. We are trying to get away from teleology, though. “Evidence based medicine” and “scientific medicine” are the names that we have given that effort.

We are trying to get away from teleology because we have been burned by it. We thought that the body made pus to fight off bacterial infections, so for years, when we saw people with respiratory illness cough up phlegm with pus in it, we gave them antibacterial medications. We were wrong, not just about the purpose of pus, but in attributing a purpose to pus. Again, it was an understandable mistake, given the long history of debate regarding the merits of pus. Was it a good sign, or a bad one? Should we encourage or discourage its formation? It turns out we shouldn’t have been focusing on the pus at all, but on    the outcome of our purposeful intervention in the underlying process that produces the pus.

Purposeful results and final causes apply prospectively to human endeavors alone, and even there it’s often difficult to tell whether, when our actions are associated with the desired result, the outcome is due to our actions or simply due to fortuitous circumstances. Applied retrospectively or to processes and structures beyond our control, teleology is a sure mistake.

When we assign an endpoint to a process, we presume causation and correlation must be proven. Humans are notoriously bad at that. In systems which we can’t duplicate or control, we can always tell a causal story (I’m looking at you evolutionary psychology, intelligent design, cosmological fine tuning). But those stories are just interesting rationalizations, sharing the merits of a fairy tale in that they reveal more about us than the subject matter. Our fairy tales are harmless when they are about the universe, the origin of life, turtle ranches or anything else beyond our control. When we tell teleological stories about processes we do seek to influence (and can) we court tragedy.

The practice of bleeding was based on one such tale: the story of homeostasis. We still tell it today, but we tell it as metaphor instead of fact. The story is based on the simple observation that, when a person becomes ill, they go through a series of changes in their physical state which ultimately ends in either the restoration of their previous state, or death. Having observed other systems, the Greeks thought that the process of illness looked like a disequilibrium. Having observed associated changes in fluids which emanated from the body, they attributed the disequilibrium to an imbalance in those fluids. We can hardly blame them for the limits of their observations. We can’t fault their hypothesis. However, we can fault their method.

They didn’t just postulate an imbalance in the humors as a cause of illness, they presumed a balance of the humors as a state the body sought. The difference in these two points of view is subtle, but crucial. If  the balance of fluids is seen as descriptive  then restoring health by balancing the fluids remains a working hypothesis. It admits that other factors may determine the observed equilibrium. It leaves open the possibility that the observed flux of humors is a secondary phenomenon. Most important, it leaves physiologic equilibrium as a simple description, instead of presuming that it is a purpose with causal powers.

Given a description and a working hypothesis, physicians would look at their efforts to balance a patient’s humors with a critical eye. As a teleological assumption, with equilibrium as a “final cause” under Aristotle’s system, the idea creates an entirely different viewpoint. With  humoral balance rooted in the body’s design, variances in expected observations must be due to inadequate methods or incomplete knowledge of the humors. For this version of the “balancing the humors” hypothesis, failure is not an option.

Now, the ancient Greeks may have weathered this kind of assumption better than their heirs. They loved to fight with each other. In the face of inconsistent outcomes from humor-balancing interventions, they were likely to call Aristotle and Hippocrates idiots or just ignore the under-girding theory of causes altogether in favor of their own pet theory. Definitive statements naturally took a healthy beating in the Greeks’ intellectual environment. The Romans, and the Europeans who came after them, were much more pious.

As a result, no one questioned the teleological assumption, out of reverence for its sources, and the vital fluids persisted in medical thought owing largely to the idea of homeostasis by design. No matter how apparent the flaws in our understanding of the blood, bile and phlegm, they were somehow attached to the homeostatic goal of the body. As long as physicians saw that equilibrium as the body’s goal, they could reconcile any discrepant observations with the over-arching story and persist in practices such as bleeding. It fell to investigators outside of the medical profession to discover the secondary nature of the humors. Only then did the practices aimed at balancing the fluids truly begin to fade.

But long after bleeding and the balance of fluids fell by the wayside, the tale of homeostatic purpose continued to plague medical science. Physicians continued to view physiology as directed toward an end. For example  the heart was seen not to pump blood, but to be a pump. Therefore, medical students were instructed to never administer medications called beta-blockers to patients with heart failure.

Beta-blockers stick to proteins in the membranes of  heart cells called beta receptors, which normally bind adrenaline. Via the beta receptor proteins, adrenaline stimulates the heart to pump faster and with more force. In heart failure, the heart can’t contract forcefully or fast enough to keep up with the volume of blood returning to it from the veins. If the heart is a purpose-built pump, beta blockers should be anathema in the setting of heart failure. But in reality, when given to stabilized heart failure patients, beta blockers reduce long-term mortality by about one-third.

We don’t yet know exactly how these medicines achieve such a feat. We do know why they are not inevitably detrimental in heart failure. It is because the heart pumps, but it is not a purpose-built pump. The heart is instead a group of cells which inhabits a specialized niche in a system of many cells all with complimentary and competing characteristics, existing in a state of equilibrium which, in deference to tradition, we call homeostasis.

Our physiology doesn’t try to maintain homeostasis any more than erosion tries to form a natural arch. The arch forms (rather than crumbling like the sides of a stream-bed) because it is geometrically stable given the geology. The arch persists because it is geometrically stable, and so we frequently see natural arches where the climate and geology allow. Nobody marvels at this, speculating about a conspiracy between sandstone and weather patterns. Then again, few people have an emotional stake in natural arches. The same is true of our physiology, minus the low stakes. There is no overall homeostasis sensor or hormone in the body. There is no homeostasis conspiracy.

So, we have abandoned the notion of purpose in physiology, and that simple maneuver has allowed us to discover things like the survival benefit which beta blockers produce in heart failure. This move is the principle behind the randomized, controlled clinical trial. All along, it wasn’t ignorance holding us back, but the project of rationalizing our knowledge to traditionally understood, teleological models.

Of course, the questions driving evidence based medicine don’t start from nowhere. Scientific medicine asks questions based on the results of previous investigations and hypotheses derived from basic science discoveries regarding the components of physiology and their relationships. Some of these hypotheses are even most easily stated in terms of purpose. But those statements are now understood as metaphor, rather than bare fact.

Beyond the fecundity of this change in method, the move away from teleology finally brings some redemption for poor Hippocrates. Rather than using it as an excuse, we can understand his aphorism, “Life is short. The art is long. Experience is difficult “, properly again – as an admonition about method. Be skeptical. Remember that your viewpoint is limited. Watch out for overarching narratives. Good advice, and not just for medicine, but for all those turtle-ranch theorists out there (I’m looking at you intelligent design, cosmological fine tuning, evolutionary psychology…).

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Carnival of Adverse Selection

A Canadian friend once told me that he did not understand the American political system and asked if I could explain it to him. I told him that it was basically an exercise in pest management. On the one hand you have your smarmy rats (Democratic politicians) and on the other you have your vicious rats (Republican politicians). The first kind you don’t even want near you, the second kind you just want to stomp. Either way you’ve got an intractable rat problem, so mostly you just try to ignore them as best you can and get on with your life.

Sometimes though, they crawl across the kitchen counter in broad daylight and then you have to pay attention to them. That happened to me during the last Presidential debate. I was doing my best to ignore it, but we have a radio in the garage with a power switch stuck in the ‘on’ position and the debate was playing in the background. I had it successfully tuned out until they started talking about health care and Romney, who’s turning out to be a particularly nasty little ankle-biter, came with the crazy talk.

Here’s what he wants to do about health insurance:

  • Block grant Medicaid and other payments to states, limit federal standards and requirements on both private insurance and Medicaid coverage. The state can structure a cost-share program however it wants?  It can still shift costs to the Emergency Rooms of Medicare-participating hospitals and to the Medicaid programs of richer states (a kind of internal ‘self deportation’ which already happens to a limited extent)? I can’t imagine what the states might do? These changes are supposed to lead to innovation, and they will – just more the sort of innovation that financial system deregulation allowed.
  • Unshackle Health Savings Accounts by eliminating the minimum deduction requirement and allowing people to use the account funds to pay premiums. HSA’s are a nice product for a very limited income range. If you make too much money or too little to make the tax savings worthwhile, a HSA makes no sense. The proposed changes won’t change that. So, why make the changes? Hang on a minute, I’ll get to that.
  • Allow consumers to purchase insurance across state lines. Recall this is the now minimally regulated insurance product. Watch the insurance companies gobble each other up as they try to recruit all those newly available good risks. Watch high risk people get filtered out of the broader  insurance pool as the generous benefit plans become increasingly burdened with these individuals, and the prices for those plans go up and up, in turn prompting lower risk people to leave for cheaper, less generous benefit plans. Will Romney & Co. adequately fund a reinsurance plan to keep this from happening? Not to worry, people with chronic problems can still go to the ER, right? People can preemptively accomplish this adverse selection themselves via purchasing pools, right?
  • Medicare will become a premium support program. The premium support and benefit requirements will be fixed at the current levels in Medicare. If costs go up, the market will determine how people make up the difference. And in time, like gravity takes care of shoddy construction projects (who really needs architects or building codes), the market will take care of things by channeling the high risk people into the more generous plans (Medicare), driving those plans’ costs out of sight and eventually, driving those plans and high risk  people out of the market. I can almost hear the invisible hand slapping – see adverse selection and cost shifting above. (It’s actually worse than that – Medicare has a normative effect that goes beyond its simple economic effects but that is a story too long and tangential for the moment.)

So, why make the changes if they entail all these predictable distortions? Free market fundamentalism is the answer. Markets aren’t a highly effective tool for these guys, they are a moral imperative. So in their view, markets must be good for every application. Just set up a market and have faith; it will solve any problem. Regulation and critical analysis aren’t caution, they’re apostacy. I’d usually ignore this crap, like I ignore people praying for rain, but this is more like praying that your kid gets better from leukemia in lieu of consulting an oncologist. I feel like I’ve at least got to say something.

So, for all who wondered what could be worse than Obamacare – it’s this happy horse shit. These two rats are scampering across the counter in broad daylight with this mess, and they need stomping, (metaphorically of course).

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Templates

When I was a kid, our family doctor kept my medical record in a card file. He kept everyone’s medical records in a card file, each visit documented on one side of a 3×5 index card. The format gave him about two dozen words to put down the reason for the visit, a few salient physical findings, his conclusions and prescribed treatments. For easy, clear-cut problems, it was plenty of information. For the tough stuff, it was woefully inadequate, and he had to recapitulate the entire history and decision making process with every return visit for those complicated problems.

So, the next generation of doctors moved to dictated medical records. This new tool captured better the details of a patient’s past history and the doctor’s thought process . No return visits needed to be from scratch, the doc. just jumped back into the stream of consciousness where he, or the last treating physician, left off. The problem with the thought-to-paper system only became apparent when our society started to spend ridiculous sums for medical care.

The current pricing and payment system is a modified command system. It’s not optimal for a few elective procedures, like LASIK surgery. But given the practical impossibility of  determining individual value for medical care in all other cases, it is about the best we can do. Payments go with terms, defined processes (whether the type of stitch used or the number of steps in a decision), and sometimes even specific words. To get paid, doctors have to extract the valued information from the stream of consciousness. Or rather, the doctors  need teams of technicians to do the extracting. To compensate, doctors are switching from thought-to-paper to paper-to-thought records, otherwise known as templates.

Templates are forms tailored to individual diagnoses or complaints. Each form has billable terms to check off and short narrative sections for processes that produce a charge. As account sheets, they are wonderful. As a means of communication, they are abysmal. At worst, they are checklists gone bad, outlines for linear thinking. Some doctors even propose using data extracted from digital templates for research and quality control in their practices. Except in very limited circumstances, such endeavours will yield more information about the cognitive/behavioral effects of template usage than anything else.

Still, if doctors can learn to adapt their methods to the use of templates, the forms may help after all. The dictated record has dangers of it own. Because it looks so comprehensive, it encourages passivity. It also codifies miscommunication; it is the doctor’s interpretation of the patient’s words, often set down as from an omniscient narrator(“the patient recalls some chest pain, but was experiencing a number of severe stressors at the time”). A template can convey the reason for a visit, a few physical findings, conclusions and treatments – about two dozen useful words. Templates need intermittent narrative summaries as background, but if doctors can remember to use them like 3×5 cards and are granted the time to do so, we may just be off to a good, fresh start.

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