Federal Consortium Issues Comprehensive Annual Report on Health and Behavior of Children

In case you were paying attention to other things this weekend (like the Tour de France), a report was issued Friday that is basically a report card on several parameters of children’s health in the U.S. The report, America’s Children: Key National Indicators of Well Being, issued by a consortium of federal agencies, has some good news and some bad news. Of surprise to no one who has watched Bush slash every program related to children’s health and education:

• The percentage of children covered by health insurance decreased from 2004 to 2005;

• The percentage of low birth weight infants increased;

• Sixty percent of children live in counties with air pollutants above maximum federal levels.

On the good news side of things, the birth rate among teens 15-17 went down and immunizations of children are improving. For conservatives, the biggest news of “success” was that fewer high school students are having sex. The improvement, however, is less than stellar: Forty seven percent of high school students in 2005 report having intercourse, down from fifty four percent in 1991. While that’s encouraging, that’s still about half of all high school students, and this includes 10% of high school girls and 4% of high school boys forced to have sex.

What's the Definition of Sex?

Also, it only gives the statistic for sexual intercourse, not sexual activity. Traditionally, it has been noted that children who delay sexual intercourse have fewer lifetime partners, lower rates of STDs, and do better overall. However, with the pornification of the U.S., sexual activity as opposed to just intercourse, appears to be practically ubiquitous among teenagers. It would be interesting to see a study that surveyed all sexual activity among teens, since many of these activities are at least as effective at spreading STDs as intercourse.

If the popular media is to be believed, the “girls gone wild” phenomenon has become an intractable rite of passage for young women and, optimistic national reports notwithstanding, shows no sign of abatement. The question remains, then, when will the current sexual revolution end?

The End of Girls Gone Wild?

For an answer, we need only look at the history of the last sexual revolution and its demise. The baby boomers’ sexual revolution, the “free love” phenomenon, fueled by hippie morals, widely available contraception, and the assurance that antibiotics could fix any disease, ran into a brick wall in the 1980s.

Hippies Gone Straight

The former-hippie baby boomers were by that point living in the suburbs and voting republican, and the generation reaching adolescence was caught up in a perfect storm combining the rise of the Reagan Youth and the appearance of AIDS. With lots of pompous morality posturing in the media to keep up appearances coupled with a horrific disease to ensure compliance, the sexual revolution of the sixties and seventies was dead and gone. If you were carving a headstone for the absolute final demise of the FL revolution you could pinpoint November 7, 1991, the day that basketball legend Magic Johnson announced he was HIV positive.

Six More Years

What replaced FL, of course, was the era of “hooking up,” with emphasis on oral sex, nontraditional sex, and complete removal of all pubic hair to facilitate the aforementioned. The result, from a disease standpoint, has been the rise of HPV, to the point that some estimates have HPV as pandemic among adolescents, teens and twentysomethings. While not nearly as deadly as HIV, it can lead to unsightly genital warts and cancer, which has at least gotten the attention of many young people.

But don’t look for an increased virulence of HPV to be the death knell of the GGW sexual revolution. Like Magic’s announcement, the end will come via the media, although this time not by a single celebrity’s press conference. And it’s still a few years away: It will occur July 1st, 2013, via the internet.

The date of the final demise is just an estimate, of course, but we will probably be seeing the beginnings of the end soon, and here’s why: The first of the GGW videos came out in 1998. Since the videos are mostly college and spring break related, assume an average age of 20. The average age of having a first child for women in this country is 25. Assuming a normal distribution of birthdays across the calendar, the “average” child born to the “average” woman displaying herself in video format for all to see would be about four years old as of now.

Mom Did What? That is so Gross

One trait of adolescence that has been absolutely invariable across generations is a complete disgust at the thought of their parents doing anything physical. Today’s children are internet savvy. Assuming the normal curiosity of preteens, it will be at about age 10 when these children of the GGW will stumble across the internet videos of mommy being taken doggie style by an entire frat house. Their disgust, coupled with the natural desire at that age to be very different from one’s parents, will be the doom of the GGW revolution.

The Next Revolution

What will replace it is anybody’s guess. Since hormones will always be there to stir young people into some kind of sexual experimentation, something will certainly come along. Given their love of computers, maybe it will be some type of virtual reality. Or maybe, if they really want to try something different, it will be the SWL (sex with love) revolution. How’s that for a far out idea?

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Want great care in the hospital? Don’t try to pull rank!

True story: A man, let’s refer to him as Junior VIP, comes into a major hospital in the wee hours of the morning with abdominal pain, mostly located to the right and downward from the belly button. His lab values indicate he has some type of infection, and he has been running a slight fever. Appendicitis is suspected. A CT scan is obtained, which neither rules in nor rules out appendicitis. At this point, about two hours after presenting to the ER, Junior VIP has been seen by the ER physician, ER nurse, senior surgical resident and chief surgical resident. The attending physician now examines the patient and agrees that appendicitis cannot be ruled out and admits Junior VIP to the hospital, explaining to JVIP that we don’t want to miss anything but we also don’t want to do an unnecessary surgery for what may turn out to be a viral illness. Therefore, we will admit, obtain further labs, give fluids, keep him from eating, and observe his condition during the day. If he improves, there will be no need for surgery. If he gets worse, we will take him immediately to the operating room. JVIP agrees to this plan, but soon becomes agitated in the ER. “When am I going to get my room,” he complains to the ER nurse, followed by “It smells in here. Did someone crap their pants?” followed by “There are drunks in here, get me out of here right now!” The ER nurse, then the ER physician, as well as the residents, explain that the hospital is very full but they are working as fast as they can to obtain an available bed as soon as possible. JVIP tells them to hurry, and make sure it’s a private room. But after one more hour of being in the ER, JVIP decides he can’t stand it any more, and checks out Against Medical Advice.

Being a (Junior) VIP, he is incensed at his “shabby” treatment, and uses his connections to contact the local newspaper outlet, the local television news outlet, the mayor’s office, and several prominent friends who are tight with the hospital board members. The attending surgeon, who saw the patient two hours ago, and is now in the OR where he plans to finish his first case of the day and then check on JVIP to see how he is doing, gets a phone call from the CEO of the hospital, demanding that he break scrub to discuss this “unacceptable” matter. This, within five minutes of receiving a phone call from the surgical resident explaining that the patient has checked out AMA, another phone call from the local television news asking for a comment on a story they are doing about Delays In Diagnosis For Severe Medical Conditions, another phone call from a physician colleague in the hospital who wants to know what happened with her friend JVIP and why he didn’t get treated, and a phone call from JVIP’s lawyer. Two more phone calls from the Chair of Surgery—all this while the attending surgeon is trying to operate—and it is established that JVIP will be returning to the hospital, will go directly to preop and be taken immediately to surgery. No more tests, no observation, no more “flimflam” is the word from above.

Eight hours after checking out AMA the patient is seen by the attending surgeon in preop, advised that his problem may have nothing to do with his appendix and that this surgery may be unnecessarily exposing him to risks of infection, bleeding, and further surgery in the future, to which JVIP answers: “Get on with it!” He is taken to the OR, a diagnostic laparoscopy is performed, no intra-abdominal pathology is noted, and per protocol the appendix, although it does not appear inflamed, is removed. The patient is discharged home the following day. Final pathology on the appendix shows a normal appendix with no infection.

Not only is this story true, it is repeated every day in hospitals across the country. It even has its own name: VIP Syndrome. The VIP Syndrome has been a recognized phenomenon in medicine since at least 1964. It is described as generally poorer care that is given to a patient of particular influence—due to money, fame, political power, or connections to powerful community members—because of deviation from the standard of care. The changes made to the standard of care can be too much of something, too little, or things totally inappropriate. These decisions are made because of fear of causing discomfort, or embarrassment or lack of privacy to the VIP, the VIP’s own demands, and the feelings of caregivers that they must do something different for the special patient.

As a surgical resident, I spent many months on trauma rotation at a very busy "Level One" trauma hospital. As there were dozens of traumas every day, we got very good exposure to trauma care, and consequently became very competent at it. The Chief of Trauma used to admonish us often that he hoped if his wife was ever the victim of a motor vehicle crash and brought in as a trauma patient that we would treat her exactly like a Saturday Night Drunk. Starting at about 11 p.m. Saturday and continuing until dawn Sunday, the SNDs would crash their cars, sustain various injuries, and be brought to us by ambulance. They would he bloody, messy, smelly, often screaming and cursing, and reeking of alcohol. We followed the same procedure on everyone: Primary Exam, with a quick look at airway, breathing, major circulatory problems and immediate threat to life, with life-saving interventions as needed; Secondary Exam, head to toe, every body part inspected; standard labs; standard set of X-rays called a trauma series; a decision made to proceed to the OR or obtain further testing; followed by a series of CT scans determined by the findings of the xrays, usually including head, cervical spine, chest, abdomen and pelvic CT scans; then admission to the appropriate ward of the hospital, followed by another complete head to toe exam several hours later, to ensure nothing was missed. To accomplish this took at least two ER nurses, two surgical residents, an attending trauma surgeon, an anesthesia attending, a nurse anesthetist, two OR nurses, an ER technician, a radiologist, as well as consults from many specialists, depending on their injuries (eg, orthopedics, head and neck surgery, neurosurgery). The process took hours to get through, often with the SND screaming and puking all over us, all in the middle of a busy, noisy, smelly ER, all of which we ignored and carried on with what we knew was the right thing to do. Yes, they were drunk and annoying, and many of them were repeat customers, but they were also very at risk for severe injury. Yelling and cursing, for example, might be due to the alcohol, or it might be a sign or severe pain or a head injury. We knew the protocol and we knew if we followed it we were not going to miss anything.

Now imagine a scenario in which the Trauma Chief’s wife comes in to the trauma bay, with the following results: We can’t cut her clothes off, it might embarrass her, meanwhile missing a major injury. Or: We can’t put this cervical collar on, because it might be uncomfortable, and then it turns out she has a c-spine injury and is paralyzed because of our “niceness”. Or: Don’t put such a big IV into her, it might hurt, meanwhile having no way to resuscitate her when it turns out she has a major bleed. Or: Let’s not get so many CT scans, it’s too scary for her to be in there all alone, meanwhile missing any number of internal injuries. Examples abound, but the bottom line is VIP = substandard care. In the end, the SNDs were getting the best care, which is what the Trauma Chief wanted for everyone, including his wife.

I had many opportunities to witness this phenomenon as a resident. Many patients have the idea that residents are not “real" doctors and therefore provide a lower level of care, and insist that the attending physician is the only one who they will talk to. What these people never realized is that they are hurting their own health. The general practitioner “one doctor for everything” phenomenon works fine when all the GP has to do is prescribe physics and pull teeth, but that concept has no place in modern medicine. Medicine today is a team sport, involving, in a typical hospital stay, 50-100 professionals—attending physicians, consultants, residents, nurses, technicians, physician assistants, pathologists, lab assistants, radiologists and a host of other hospital personnel. It’s expensive but comprehensive. Removing integral parts of that team is like trying to fly an airplane that's missing several of its components, or having a patient tell me to operate blindfold and with one hand tied behind my back. Both can be done, but with similarly disastrous results.

The greatest irony in the case of Junior VIP is that the reason the hospital was full on that particular day and he didn’t get a room right away—beyond the bed shortages that are now endemic to hospitals that must operate at 100% occupancy or go bankrupt—is that another VIP, let’s call him “Super VIP,” had given the hospital a substantial donation so that he could have an entire wing to himself for recovery after an elective surgery. The wing was needed to accommodate all his guards and gofers and general hangers-on, all of whom provided a blockade to his health care providers. Which meant that nurses and residents and fellows and lab techs were sent away, which added up to care way below the standard for Super VIP. A homeless drunken man who trips and falls in front of the hospital will receive better care than either Junior or Super VIP, because Mr. Homeless Guy will get the standard of care with no deviations, while the VIPs use their power to hurt themselves.

The most annoying part of all this is that Junior VIP is probably going to sue. For what? It doesn’t matter. Lawyers know that juries often hand out large cash awards, not because the doctor did anything wrong, but because they feel sorry for the patient. After all, it’s only insurance money, those insurance companies have plenty of money, and who cares if the doctor’s career is trashed. And who writes the laws that allow this foolishness? Other lawyers, of course. So JVIP will sue for Delay of Care (even though that was his own fault) or Pain and Suffering (never mind that he caused way more of that to the people around him than he suffered himself) or Unnecessary Surgery (even though he demanded it). And caught in the middle of all this is the surgeon, who just wants to do his job, treat his patients, make them well, and send them home healthy.

Even for those rich enough or connected enough to have a personal physician follow them around the world, that’s not going to help with anything except little stuff. For anything major, someone needing medical help is going to end up having to talk to a specialist, a surgeon for example, or a neurologist or whatever, and then have to be seen by that doctor either in a clinic, if it can wait a few days, or in an ER, if it’s an emergency. And on any given day in any ER in this country, even to foo-foo private ones that cater to the rich and powerful (like the Frist family’s Hospital Corp.), there are going to be drunks, and nasty smells, and noise, and lots of chaos. And bed shortages. Screaming and complaining and calling your congressman won’t change that.

This is not to say that patients shouldn’t be advocates for their own health, of course they should. They should ask questions, and read all about their diseases, and get second opinions (or third and fourth opinions if they're not satisfied). But anyone who thinks that pulling rank is going to improve care should conduct the following experiment: The next time you get on an airplane, first go to the air traffic control tower and fire everyone in there, since you know so much; then fire the aircraft mechanics and service the plane yourself; then fire the pilot and fly the plane yourself. And afterwards, if you survive the crash, consider not making those same mistakes when you get sick.

We may not be as well-connected as politicians, or as famous as celebrities, or as rich as lawyers, but we do know about health, and we do try to do our best for our patients' health, even those patients who do everything they can to prevent us from helping.

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Want your daughters to be protected against cervical cancer? Get them immunized against HPV. But good luck finding the vaccine, thanks to high costs and political roadblocks.

The term "sexually transmitted disease" is a term charged with emotion. The effects of STDs range from gross, like the draining sores of herpes simplex, to lethal, such as AIDS from HIV. For most STDs there is treatment but no cure or prevention. Recently, a vaccine was found that prevents a potentially lethal STD—human papilloma virus. But the HPV vaccine, which has the potential to save hundreds of thousands of lives, has run into serious political and legal roadblocks.

HPV is an STD nearly endemic in our society, the low estimates being tens of millions of affected Americans. As one medical school professor once described it to our class during a lecture on STDs: "If you have ever had unprotected sex with a partner who has had unprotected sex with anyone else, you have been exposed to HPV." Because a person can be infected but show no symptoms it is easily passed from partner to partner. Also, it can take weeks to months for symptoms to appear. To further complicate the issue, HPV has multiple strains, each of which has a different effect. To date, more than 100 strains have been identified, with more than 30 of the strains being sexually transmitted. Some of them are cleared from the body without any symptoms ever presenting, others cause genital warts, and some cause cancer. By age 50, according to the Centers for Disease Control estimates, at least 80% of women will have acquired genital HPV infection.

While HPV can lead to several types of cancer in men or women, including cancer of the penis, vaginal area or anus, the concern about HPV has always focused on cervical cancer, because it is a silent killer, typically without symptoms until it is very late stage and too late to do anything about it. Until the development of a vaccine, prevention of cervical cancer has relied entirely on women getting regular pap smears, which can detect changes in the cervix, leading to early treatment. In 2004, according to the American Cancer Society, over 10,000 women contracted cervical cancer and nearly 4,000 women died of it. Almost all of the deaths occurred in women who had not had regular pap smears.

The FDA approval in 2006 of Gardasil, an HPV vaccine that targets four HPV strains that together account for 70% of the cervical cancer and 90% of the genital warts caused by HPV, was a huge leap forward in the fight against cervical cancer. It is recommended by the FDA for women age 9 to 26 who have never been exposed to HPV, with immunity provided for close to five years. But even before it appeared on the market it met with strong opposition. Among the first to fire preemptive sorties against the vaccine was the group Concerned Women of America, a Right Wing Christian Conservative organization that seeks to “bring Bible principles into all levels of public policy.” Prior to the vaccine’s FDA approval, CWA Executive Vice President Wendy Wright said her organization was against immunizing preteens against HPV. “It would seem to send a message that we’re expecting the girls to be sexually active,” she said. The ferociously conservative Family Research Council, initially vocal in its opposition to the vaccine, has softened its tone, if only a little. FRC Vice President for Policy Peter Sprigg, in a July 15, 2006 opinion piece for WashingtonPost.com, shied away from opposing the vaccine outright, but opposed states making it a mandatory vaccine. In other words, the great defender of states’ rights while the Democrats held the presidency now wants to take power away from the states, so that the vaccine will remain out of the public eye and most girls won’t be immunized.

But even with FDA approval and CDC support, the HPV vaccine has slammed into another wall: cost. Merck, the company that owns Gardasil, charges $120 per dose, with three doses required to provide immunity. But insurers are barely willing to pay for each dose, much less the costs of administering it. CNN.com reports in a Feb. 2, 2007 article that doctors are expected to stock thousands of dollars in inventory, store the vaccine in highly specialized refrigerators, pay for any broken or damaged vials at $120 each, provide syringes, administer the vaccine and pay for disposal of the sharps all for as little as $2 over the cost of each dose administered. Thus, being forced to lose money by providing the vaccine, many pediatricians and family practitioners have stopped providing it. With the public spotlight on the vaccine, some insurers have relented and are raising their reimbursement. But for those without insurance, or insurance that doesn’t provide coverage, or only partial coverage, the vaccine remains out of reach.

There’s an old saying in the pharmaceuticals business: The first pill costs you half a billion dollars, everything after that is profit. Merck says that it will provide the vaccine for free to those who can’t afford it, but the big drug companies say this about all their expensive products, and as any patient who has tried to apply for such fee waivers or any physician who has tried to help their patients apply for the waivers can tell you, cutting through the red tape involved in actually getting a waiver requires a bulldozer. In fact, Merck gave away only about 800 doses in the last three months of 2006. To have an idea of how expensive $120 per vaccine is, consider the following CDC list of vaccine costs, per dose, in 2007: Diptheria/Tetanus/Pertussis: $12.25; Hepatitis B: $26.25; Hepatitis A: $35.57; Mumps/Measles/Rubella: $17.28; Varicella (chickenpox): $56.90.

It is expected that the overall cost will decline over time, but given the prevalence of HPV, the high cost of the vaccine, the reluctance of the insurance industry to pay that cost, vocal opposition from politically connected Right Wing organizations who think money is better spent telling youngsters to wait until marriage, and tepid support from a presidential administration that sees eye to eye with the Conservative Christians, it is likely that cervical cancer will continue to be a killer for a long time. For parents who would like their daughters immunized and young women who would like to be immunized against HPV, and thus drastically reduce their chances of contracting cervical cancer, the struggle continues.

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Miami is set to party, the death watch latches onto the latest details, and Cuban ministries insist Fidel is just fine

Fidel Castro, borrowing a line from Mark Twain, would like you to know that reports of his demise are greatly exxagerated. Fidel Alejandro Castro Ruz, the 80-year-old dictator of the island nation of Cuba, transferred power to his younger brother on July 31st after “intestinal surgery” and has been recovering ever since. The city of Miami is planning a mega-party to celebrate his death, but many of Castro’s most bitter critics have been down this road too many times before and say they won’t believe it until they can spit on his corpse. It’s not surpsing that it is not known what his illness is, or that there are conflicting stories about it, given the web of secrecy, fabrications and double talk that has swarmed around Castro since the inception of the revolution that eventually toppled the Batista regime. But based on what little is known, using a little surgical detective work, we can get a pretty good idea of what happened.

The first report out of Cuba was a statement from the government that said Castro had undergone surgery for stress-related gastrointestinal bleeding. His condition was reported as serious, but his return was to be expected in a few weeks. According to the official statement, Castro said his intense schedule “promoted in me a sharp intestinal crisis with sustained bleeding that obligated me to undergo a complicated surgical procedure.” But during the next several days, when he didn’t appear in public, rumors began to swarm: Was it cancer? Was he dying? The Bush administration, always last to know what’s going on in the world, said it was caught off-guard by the reports of Castro’s illness and had no idea what his condition was.

As the speculation whirlwind reached tornado strength, the Cuban government released four photos of the recovering Castro, including one in which he is seated in a chair, holding up the August 12th edition of the state-run newspaper Granma and dressed in a red, white, and blue Addidas jumpsuit. The irony of the Communist leader dressed in a workout suit with the same color scheme as the American Flag and advertising a US corporation was lost on most Americans, as all attention focused on whether the photos were real or photoshopped. But Venezuelan President Hugo Chavez stopped over for a visit and had some photos taken with Castro, convincing the world that Castro was indeed alive, if not well. Additional state visits followed, with more pictures, an October video with Castro again reading from the current edition of the paper to prove it was not file footage, and lots of speculation.

The statements of any of the politicians who have visited or spoken with Castro can be discounted outright, as they are not physicians, and all have their own axe to grind. The first report of reasonable veracity on Castro’s condition came from Spanish surgeon Jose Luis Garcia Sobredo, the Chief of Surgery of Madrid’s Hospital Gregorio Maranon, who responded to a “humanitarian request” of the Cuban government. He confirmed that Castro did not have cancer and was recovering. Subsequent reports leaked out of Maranon gave further details: Castro was suffering from an infection of his large intestine and had undergone at least three failed operations to repair damage from complications of diverticulits. And here at last the story begins to make sense.

The diagnosis of diverticulitis is likely to be true, not only because of the reports, but also because they match his age, history, and survival this far into this illness. To start with, examine all the major candidates for bleeding intestinal illness: diverticulitis, vascular problems, cancer, pre-cancerous lesions, inflammatory bowel disease, hemorrhoids. Vascular problems, a large group of problems having in common compromised blood flow to the colon, can be excluded because they have very different presentation and course of action than has been seen with Castro, and are almost exclusively treated with medical treatment rather than surgical treatment. Inflammatory bowel disease, including Crohn’s disease and ulcerative colitis, are chronic diseases that present long before the ninth decade of life. Hemorrhoids and pre-cancerous lesions (polyps) are easily treated and would not require a 6-month recovery, even in someone Castro’s age. For colon cancer to have been the cause of his illness, given the known symptoms and lengthy recovery, it would have to have been at least Stage III colorectal cancer, but the treatment of Stage III and Stage IV colorectal cancer (meaning that it is a large tumor that had spread at least to the lymph nodes and possibly to surrounding organs) includes chemotherapy, and there has been no hint of Castro having undergone chemo. Also, chemotherapy or not, survivability of Stage III or IV is poor, which could explain his failing health, but does not match with the repeated surgeries. What remains from our differential diagnosis is diverticulitis.

Diverticulosis is a condition of the large bowel in which little outpouchings develop over the course of a lifetime. Think of a long skinny balloon, and along the balloon there are weak spots where the balloon pooches out. Changing –osis (presence of a condition) to –itis (presence of inflammation) means that an infection has set up shop in the outpouchings. This diagnosis agrees with his symptoms, his condition (as much as has been released by the Cuban government) and his history. Brazilian journalist Claudi Furiati, author of History Will Absolve Me, Castro’s authorized biography, reported that Castro suffered from diverticulitis 20 years ago. Again, this agrees with the course of the disease, which develops later in life and can recur at any time.

Diverticulitis can lead to abscess, rupture, inflammation of the abdominal cavity, and if untreated, death. The medical sources close to Dr. Sobredo said that a recurrence of the disease emerged last summer with large amounts of blood loss into the intestine. Why, then, three surgeries? The treatment of diverticulitis depends on its severity and location. It can be treated with antibiotics, CT-guided drainage, or surgery. If left untreated or improperly treated, it can spread to peritonitis (an infection of the lining of the abdomen) and ultimately sepsis and death.

This leaves us with a likely cause and timeline of Castro’s illness: He gets a bout of severe diverticulitis. The disease is more aggressive than the treatment, whatever medical or radiologic-guided treatment was attempted, and it progressed to the point of requiring surgery. A common story and still very treatable, but Castro is no typical patient. This is the same man who in October 2004 tripped and broke his left knee and right arm, but when he had to undergo surgery for his knee was reported to have refused tranquilizers and general anesthesia so that he would not have to hand over power. In all likelihood, he was not inclined to do everthing his doctors told him this time around either. When it came time for surgery, the usual procedure is to open the abdomen, clear out the pus, resect any dead or infected bowel, and if there is severe enough infection, perform a colostomy, with the possibility of being reconnected in 3 to 6 months. Did Castro consent to a colostomy? Probably not. More likely, he put extreme pressure on his doctors to restore normal continence. According to the reports from Madrid, at the initial surgery part of his colon and rectum were removed, and the proximal colon was connected to the distal rectum. But that kind of anastomosis will never heal in the face of ongoing infection, which would lead to the repeat surgeries, including further complications from the abdominal abscess.

There’s an old saying in surgery: Complications beget complications. Especially in the edlerly, you don’t want that first complication, because the treatment for each complication can lead to several more. To put it another way, kill one fly and two come to the funeral. So at this point in Castro’s belly there’s an incompletely treated abscess and a broken down anastomosis, which is spilling more stool into the abdomen, leading to more infection, more abscesses, and further complications. Again according to the Madrid sources one of these complications was an inflammation of the gallbladder and bile duct from the liver. The bile duct inflammation is a horrific complication and very difficult to treat. When the common bile duct, which drains bile from the liver into the intestines, breaks down, it’s game over. By the reports, stents were placed to keep the bile flowing, with poor results. And all of this infection would make for a non-healing incision and lots of drainage from the wound, which leads to fluid loss, nutrient problems, and lots of other problems, all of which also agrees with reports.

What next for Castro? First, he will never return to power. At his age, with this amount of complications, he will never fully recover. A study done several years ago on healthy medical students confined to bed for one week showed that it took months to return to their baseline weight, muscle mass, and conditioning. For 80-year-olds who are six months into a severe illness, there is only a downward spiral. How long will it take? That depends on his condition at the moment. Once a person with severe illness such as this gets to a point of disability where he cannot move his own body weight without assistance, survival is measured in days to weeks. As long as he is still able to move as he appears to be in the October video, he may have months to years. But, the complications leave him fragile and highly susceptible to a sudden event such as a heart attack, meaning he could go any day. And he has no realistic chance of being able to return to his former power, except in the most limited way.

Not that anything is likely to change that much in Cuba any time soon anyway, whether Castro survives or not. The 76-year-old Raul, who has been with his older brother since the beginning of the 26th of July Movement began and has been his close confidant, has shown no sign of changing Cuban policy and is unlikely to make radical changes any time soon. More likely, major change in Cuba is to have to wait until a new generation of politicians moves into power. For the moment, the death watch continues.

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Boston Physician Goes After Other Docs. Author and Physician Jerome Groopman goes after physicians' "flawed thinking." But Groopman himself is guilty of flawed logic.

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It will be very interesting to see what the media and the public make of Chief Justice John Roberts assertion that $160,000 a year is slaves’ wages and that anybody with any sense could make much more than that in academia or the corporate world. In medicine, the massive rewards to be had by ceasing to actually work with people and become a corporate shill are not seen as a major cause of brain drain. Any doctor can multiply by a factor of 10 his or her salary by becoming an “adviser” to the drug companies, product manufacturers, congressional lobbyists, or trial lawyers suing other doctors. But only a few choose this route, because we do what we do not for the money but because it’s who we are. (See Millionaire Doctors? for more on that sore subject.) I would have thought the same thing would be true for lawyers, that the chance to have such a tremendous influence over the way this country operates as to be a federal judge would outweight any monetary concerns. So far, the public has reacted with a big yawn, which works heavily in Roberts’s favor: no complaints=no controversy=easy amendment to massive spending bill=big raise for him and his cohort. Prediction for 2007: Lawyers’ pay will rise, doctors’ pay will fall.

Doctor or Waiter?

Ask any doctor, especially those who have been practicing since before the insurance giants ruled the land, what the biggest loss to his practice has been, and the answer is likely to surprise you. The predicted answer is dramatic salary reduction, but actually that is far less troublesome than the loss of autonomy. First it was the HMOs that said, You must prescribe this not that, or No this patient is not a candidate for surgery. (If you ever wonder why doctors are sometimes seen as icebergs, imagine the emotional stamina that it takes to have spent 16 years, working 80-100 hours a week, to become an expert in subspecialty surgery, and after examining a patient, reviewingthe chart, discussing the case with colleagues, and consulting current literature, all in agreement that the patient needs surgery, only to be told by a 23-year-old MBA who just fell off the beer float that the patient is NOT a candidate for surgery.) Next, hospitals, which having much more bargaining power (dollars, lawyers, congressional lobbyists), get a very large chunk of cash for its services, turned around and said that as a cost-cutting measure doctors must ONLY use certain drugs, products, or devices. Never mind that other devices, drugs, products work much better. And to complete this Sisyphean triad, doctors are now being told how to practice medicine by their patients. Thanks to direct advertising and our short-sighted Entitlement Society, patients now come in and demand certain drugs, procedures, tests, or equipment: Don’t bother with the physical exam and I don’t care that you went to medical school thank you very much, this is my body and your job is to do as you’re told. “It’s just like the waitress job I had in college,” says one Denver pediatrician who asked not to be identified. “I used to go from table to table, ask them what they want, hint at a few suggestions but never contradict them act like I knew more than they did, and then make it happen just the way they ask. Now I go from room to room and do the same thing with my patients.”

Case Files

Fine, except that waitstaff are not asked to make life or death decisions about their patrons. Case in point: A patient comes to my clinic with abdominal pain. I perform an exam and order tests. The result is that the patient’s pain is caused by a stomach condition, but one that will heal with medicine not surgery. A prescription is given to the patient for the appropriate medicine (after checking with the patient’s insurance company, to make sure the medicine is covered, of course). Additionally, the patient is given a prescription for a narcotic pain medicine, and advised that the narcotic is just a temporary stopgap, that if the pain persists, it means the insurance-approved stomach medicine is not working and we will have to discuss other options. A followup appointment is made for three weeks later, with the standard admonition that if things get worse to call or come to the ER. Two weeks later this patient, having not communicated any problem since the office visit, shows up unannounced in clinic and demands of my secretary that she page me out of the OR to write a refill prescription for the narcotic pain medicine, because the patient still has some pain and is going away on vacation the next morning and has no time to be seen in clinic or the ER.

Nevermind what we talked about at the first visit about the possibility of needing other treatment. Never mind that the patient is quite capable or reading a calendar and knowing about her vacation ahead of time. Never mind that the patient is quite capable of counting pills in a bottle and noticing when they are running out before reaching the very last one. I should mention that this was not a drug-seeking patient, as in, someone who is addicted to pain medicine trying anything and everything to get more pain medicine. Those patients are not that hard to spot and referred to addiction specialists. This was rather the more common entitled patient who figured she knew better than her doctor and just wanted me to do as I was told. Let me also mention that I bend over backwards for my patients, seeing them between cases in the OR, early mornings, in the middle of the night in the ER, wherever, and my pager is always on. I get pages at three in the morning from patients wanting to know if they can reschedule an appointment that is still three weeks away. But I draw the line at them sacrificing their own health through ignorance.

No more Mr. Nice Guy

The end result for this patient was a stern lecture, a change in medicine, and close followup by phone while she is away on vacation. To some degree I am lucky, in that I can get away with this. As a surgeon, I already have fewer patients than an internist or pediatrician, since I have to spend a lot of time actually doing the operations, and with a smaller pool of patients, the number of headache-causing patients is smaller. Plus, as a subspecialist in a tertiary-care center, I’m the last stop. If they don’t like what I have to say, there aren’t a whole lot of other options. Which is not the case for most physicians. For most docs, patients see things they like on television or in a glossy mag, they show up for their 15-minute appointment and demand it. So now the doc has a draconian choice: Give them what they want and speed them on their way, or spend 30 to 60 minutes arguing with and educating the patient. The textbook answer is that the ethical thing to do is educate the patient. Except that there are forty more patients to see, and every hour spent on a “problem” patient makes everyone else that much more late, and adds another hour to what is already going to be a 60 to 70 hour workweek. And even if you opt for spending that extra hour with each and everyone of these “problem” patients (and there are many of them, believe me), they will then just go to another doctor, and another and another, until they get what they want, adding additional burden to an already overwhelmed medical system. And they will call their insurance company and complain about that “insensitive” doctor and you will get a snarling phone call from the MBA frat boy, telling you that if you’re going to continue to irritate “his” patients, he will remove you from “his” group.

An impossible task

I watched this scenario play itself out many times as a medical student, and fought this uphill battle many times myself as a resident before conceding the inevitable. (Sissyphus had the advantage that when he rolled the rock up the hill, at least he was able to get out of the way when it ran back down the hill. Every boulder I tried to strongarm out of the valley just ended up rolling over me and crushing me like a bug.) This had a lot to do with my chosen career, in that being the “last stop” I had a little (a very little) more freedom to fight back against this grim trend away from medical practice and into “service excellence.” Emphasis on service.

What can be done to stop the assualt on health care? Patients can try to see their physicians as equal partners. If the aura of “doctor knows best” is long-gone, at least trust that your physician, with decades of very arduous training, might know something worth listening to. Would you try to tell your plumber how to fix your pipes? You might try, knowing that the worst result will be a wet floor. But are you likely to ignore your electrician’s advice and wire things any which way? Not likely, because the results could be deadly. Same thing with your health.

As for what physicians can do to stop the erosion of good healthcare by the tsunami of know-nothing CEOs, we will continue to fight Big Insurance and Big Pharmacy and Big Government, so that we can always get you the best medicine, product, treatment or device. And we’ll do it with a smile, and for a lot less money than your average lawyer.

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