Month: December 2015

Do No Harm: Stories of Life, Death, and Brain Surgery (Marsh) offers readers a window into the world of neurosurgery. The author chronicles the assault on the top neurosurgeon’s privileges by mediocre software developers and hospital bureaucrats and highlights the fact that paperwork has advanced way beyond human capacity. Here is part of one vignette:

‘Informed consent’ sounds so easy in principle – the surgeon explains the balance of risks and benefits, and the calm and rational patient decides what he or she wants – just like going to the supermarket and choosing from the vast array of toothbrushes on offer. The reality is very different. Patients are both terrified and ignorant. How are they to know whether the surgeon is competent or not? They will try to overcome their fear by investing the surgeon with superhuman abilities.

I told him that there was a one or two per cent risk of his dying or having a stroke if the operation went badly. In truth, I did not know the exact figure as I have only operated on a few tumours like his – ones as large as his are very rare – but I dislike terrorizing patients when I know that they have to have an operation.

Taking the pen I offered him he signed the long and complicated form, printed on yellow paper and several pages in length, with a special section on the legal disposal of body parts. He did not read it – I have yet to find anybody who does. I told him that he would be admitted for surgery the following Monday.

‘Sent for the patient?’ I asked as I entered the operating theatre on Monday morning. ‘No,’ said U-Nok the ODA (the member of the theatre team who assists the anaesthetist). ‘No blood.’ ‘But the patient has been in the building for two days already,’ I said. U-Nok, a delightful Korean woman, smiled apologetically but said nothing in reply. ‘The bloods had to be sent off again at six this morning,’ said the anaesthetist as she entered the room. ‘They had to be done again because yesterday’s bloods were on the old EPR system which has stopped working for some reason because of the new hospital computer system which went live today. The patient now has a different number apparently and we can’t find the results from all the blood tests sent yesterday.’

Is it any better here? A friend who is a doc at a Boston-area hospital said that they’re hoping in about two years to get back, from their $2 billion Epic system, most of the capabilities they had in their old (home-grown) electronic medical record system.

Where does the experienced brain surgeon fit into the hospital hierarchy?

‘What’s all this about cancelling the last case?’ I asked. The anaesthetist was indeed a new one – a locum recently appointed to replace my regular anaesthetist who was on maternity leave. We had done a few lists together and she had seemed competent and pleasant. ‘I’m not starting a big meningioma at 4 p.m.,’ she declared, turning towards me. ‘I’ve got no childcare this evening.’ ‘But we can’t cancel it,’ I protested. ‘She was cancelled once already!’ ‘Well I’m not doing it.’ ‘You’ll have to ask your colleagues then,’ I said. ‘I don’t think they will, it’s not an emergency,’ she replied in a slow and final tone of voice. For a few moments I was struck dumb. I thought of how until a few years ago a problem like this would never have arisen. I always try to finish the list at a reasonable time but in the past everybody accepted that sometimes the list would have to run late. In the pre-modern NHS consultants never counted their hours – you just went on working until the work was done. I felt an almost overwhelming urge to play the part of a furious, raging surgeon and wanted to roar out, as I would have done in the past: ‘Bugger childcare! You’ll never work with me again!’ But it would have been an empty threat since I have little say in who anaesthetizes my patients. Besides, surgeons can no longer get away with such behaviour. I envy the way in which the generation who trained me could relieve the intense stress of their work by losing their temper, at times quite outrageously, without fear of being had up for bullying and harassment.

When our department was moved from the old hospital to a newly built block at the main hospital some miles away, the entire second floor of the new building was dedicated to neurosurgery. As time passed, however, the management started to reduce our facilities and one of the neurosurgical theatres became a theatre for bariatric surgery – surgery for morbidly obese people. The corridors and rooms were starting to fill with unfamiliar faces and patients the size of small whales being wheeled past on trolleys.

How does IT help?

As she talked she typed on the keyboard and the slices of a huge black-and-white brain scan started to appear, like a death sentence, out of the dark onto the white wall in front of us. ‘You won’t believe this,’ one of the other registrars broke in. ‘I was on yesterday evening and took the call. They sent the scan on a CD but because of that crap from the government about confidentiality they sent two taxis. Two taxis! One for the fucking CD and one for the little piece of paper with the fucking encryption password! For an emergency! How stupid can you get?’ We all laughed, apart from the registrar presenting the case who waited for us to calm down.

I went down to my office where I found my secretary Gail cursing her computer again while she tried to get onto one of the hospital databases.

‘This may take a while,’ I added. ‘The scans are on the computer network of your local hospital and this is then linked over the net to our system…’ As I spoke I typed on the keyboard looking for the icon for his hospital’s X-ray network. I found it and summoned up a password box. I have lost count of the number of different passwords I now need to get my work done every day. I spent five minutes failing to get into the system. I was painfully aware of the anxious man and his family watching my every move, waiting to hear if I would be reading him his death sentence or not. ‘It was so much easier in the past,’ I sighed, pointing at the redundant light-screen in front of my desk. ‘Just thirty seconds to put an X-ray film up onto the X-ray screen. I’ve tried every bloody password I know.’ I could have added that the previous week I had had to send four of the twelve patients home from the clinic without having been able to see their scans, so that the appointments had been entirely wasted and the patients made even more anxious and unhappy. ‘It’s just like this with the police force,’ the patient said. ‘Everything’s computerized and we are constantly being told what to do but nothing works as well as it used to.

‘Have you tried your password?’ ‘Yes, I bloody well have.’ ‘Well, try Mr Johnston’s. That usually works. Fuck Off 45. He hates computers.’ ‘Why forty-five?’ ‘It’s the forty-fifth month since we signed onto that hospital’s system and one has to change the password every month,’ Caroline replied.

‘When can I start?’ I asked, unhappy at being kept waiting when I had a dangerous and difficult case to do. Starting on time, with everything just right, and the surgical drapes placed in exactly the right way, the instruments tidily laid out, is an important way of calming surgical stage fright. ‘A couple of hours at least.’ I said that there was a poster downstairs saying that iCLIP, the new computer system should only keep patients waiting a few extra minutes. The anaesthetist laughed in reply. I left the room. Years ago, I would have stormed off in a rage, demanding that something be done, but my anger has come to be replaced by fatalistic despair as I have been forced to recognize my complete impotence as just another doctor faced by yet another new computer program in a huge, modern hospital.

What role does management play?

I returned to the Training and Development Centre. The second session had already started. The PowerPoint presentation now showed a slide with a long list of the Principles of Customer Service and Care. ‘Communicate effectively,’ I read. ‘Pay attention to detail. Act promptly.’ We were also advised to develop Empathy. ‘You must stay composed and calm,’ Chris the lecturer told us. ‘Think clearly and stay focused. Your emotions can affect your behaviour.’

The new chief executive for the Trust, the seventh since I had become a consultant, was especially keen on the twenty-two-page Trust Dress Code and my colleagues and I had recently been threatened with disciplinary action for wearing ties and wristwatches. There is no evidence that consultants wearing ties and wristwatches contributes to hospital infections, but the chief executive viewed the matter so seriously that he had taken to dressing as a nurse and following us on our ward rounds, refusing to talk to us and instead making copious notes. He did, however, wear his chief executive badge – I suppose just in case somebody asked him to empty a bedpan.

How does all of this affect Dr. Marsh?

Not for the first time, I thought of the trivial nature of any problems that I might have compared to my patients’ and felt ashamed and disappointed that I still worry about them nevertheless. You might expect that seeing so much pain and suffering might help you keep your own difficulties in perspective but, alas, it does not.

More: Read Do No Harm: Stories of Life, Death, and Brain Surgery.

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I have volunteered to tutor a student in AP statistics at the local high school. Stats: Modeling the Worldis the textbook and I hate it so far. It starts with statistics and doesn’t get into probability, which to my mind is the basis of statistics, until Chapter 14. On the theory that nobody likes looking at equations it is crammed full of words that make it difficult to find the mathematical principles to be communicated. Fundamentals of Applied Probability Theory is the book that we used at MIT back in ancient times. It is mostly about probability and not much about statistics, though.

Have any readers helped a student in this class? If so, what materials were useful? Or has anyone taught himself or herself statistics and found something concise and good?

Separately, the student is quick to say “I can’t do this” or “I don’t know” when in fact a few minutes of thinking would have resulted in the answer or a procedure for getting the answer. My personal theory is that this comes from being given so many trivial problems in the earlier years of K-12. Students who are brighter/quicker than average get the idea that every problem can be solved very quickly and therefore that, if a problem cannot be solved almost instantly, there is no way to solve it. Any ideas for working on patience/persistence with respect to math/stats?

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At a recent seminar at Harvard University, a professor described Obamacare as “not working because insurance rates going up.” Her facts are confirmed by a letter that I recently received regarding my basic ($2000 deductible) Obamacare plan: the rate in 2016 will be 18 percent higher than in 2015. But the person sitting next to me laughed at her interpretation. “I don’t think the companies that lobbied for Obamacare would characterize higher rates as ‘not working’ for them.”

[Meanwhile, the saga of my October strep throat test continues. Because of the regulations that make it impractical for the small group of doctors to do quick strep tests, my sample was sent to a local hospital. They decided to charge me $88 for the test. My insurance company had a right to purchase this service for $14, apparently, but decided not to pay any of the $14 due to the policy’s $2000 deductible. Thus the hospital generated a hardcopy bill (now buried somewhere under a stack of important catalogs and therefore unlikely to be paid any time soon) and mailed it to me. The doctor tried to charge hundreds of dollars but was beaten down to about $50 (see previous posting).]

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At least in some Scandinavian countries it is illegal to neuter or spay a healthy canine companion (Psychology Today).

There are a lot of differences between the U.S. and Scandinavia (the cash value of children is a lot lower over there, for starters!), but could this be an area where they might have something to teach us? Here’s one reference looking at the overall effects of sterilization.

What do readers think? Can it be the case that doing something so unnatural is actually beneficial to an animal’s health? And if it is so great for dogs, why don’t we routinely do it to ourselves? We could bank our genetic material at a young age and then have our reproductive organs removed. If we wanted to have children we could then simply hire surrogates in countries that hadn’t realized the important health benefits of sterilization.

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“Some Families Earn Six Figures and Still Need Help With the Rent” is a December 1 Wall Street Journal article on Americans’ increasing aversion to using markets to allocate resources:

Cambridge, Mass., a hub for prestigious universities and biotechnology companies, is setting aside apartments to help an unexpected group of people find lower rents: families with incomes topping $100,000.

The city recently held a lottery for 15 units with below-market rents, in a new building a few subway stops from downtown Boston. A family of four with an income well into the six-figure range—a maximum of $118,200—could qualify for some of the apartments.

In Cambridge, home to Harvard University and the Massachusetts Institute of Technology, median rents have soared about 36% since late 2010 to $2,750 a month, according to Zillow, a real-estate information company. That’s higher than the median rents across the five boroughs of New York City, which run about $2,295, though not as steep as the $4,128 median rents in Manhattan.

“People who have been able to be here in the past without assistance are now facing challenges,” said Chris Cotter, Cambridge’s housing director, raising concerns “about a hollowing out of that middle.”

I.e., the government will decide who gets to live in Cambridge.

Related:

• “HUD Homes at Half Price” is a New York Times piece on how government workers can buy houses at a different price than can private sector workers

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After consuming three spatchcocked turkeys (Tuesday: experimental 89 cent/lb. bird from Market Basket in Ikea-brand oven (complete failure at temperature regulation); Wednesday: experimental 89 cent/lb. bird from Market Basket on grill; Thursday: $4/lb. artisanally produced Vermont turkey on grill (taste: identical to 89 cent/lb. turkey)), I decided that it was time to get serious about my health. What better way than to use the Health app from the world’s most profitable tech company?

Step 1: Tell Apple Health that I am male:

 

Actually that isn’t possible from the screen one gets to by clicking on “Sex”. Need to back up and notice the upper-right “Edit” option:

 

Step 2: See what my options are for tracking age-related decay:

 

Step 3: In case not enough folks show up here to claim asylum/refugee status, perhaps we will be told to have more kids (and the childless will pay us to do it!). Let’s see what Apple can do for us, now that the software knows that the phone owner is of the “Male” sex:

 

Step 4; It is the mucus season here in Boston, so let’s see what’s underneath “Cervical Mucus Quality”:

 

Apple will help me “gain a better understanding of when [I am] ovulating.” Now I know why the phone cost $900. Here are a couple more helpful screens for the typical “Male”:

 

 

 

 

What else can a male iPhone owner do with the Health app while waiting for his next ovulation? Generate a height-by-hour or height-by-day graph:

 

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Mark Zuckerberg previously demonstrated an awareness of California family law by waiting until just after Facebook went public to get married. I’m wondering if his new non-charity charity shows a sophisticated approach to estate tax avoidance.

The letter to our daughter works pretty well as comedy, e.g., “Medicine has only been a real science…” (emphasis added). It also works pretty well as a dictionary example of “optimism”, with Zuckerberg imagining that a $1 billion annual budget is going to move the needle (NIH spent $31 billion in 2010, according to Wikipedia, and the drug companies keep telling us that they are spending some of their Irish dough on research). Apparently he and his wife think that the folks behind “Why Most Published Research Findings Are False” can’t waste another $1 billion/year.

The letter is a significant addition to the literature of comparative American victimhood: “Can we truly empower everyone — women, children, underrepresented minorities, immigrants and the unconnected?” (we were talking about this line at the airport and it evoked the question “So which is worse? Having a pussy or not being able to download porn at home?”)

I’m wondering if these small delights are distractions from the main point: working around the estate tax. The non-charity charity is apparently organized as an LLC. Let’s suppose that Baby Max owns shares in this LLC. If she acquires them today, before any Facebook stock or proceeds from selling Facebook stock are transferred in, she hasn’t received anything of value and has no tax liability. The LLC can invest its assets however it wants to, e.g., it could buy shares in an Ireland-based pharma company or fund a startup medical device firm in Singapore or China. If those investments prove more productive than Zuckerberg’s adventure in the Newark public school system, Grown-up Max will own a stake in something worth tens of billions of dollars.

What do readers think? Is this all about doing good or more about avoiding the world’s fourth-highest estate tax rates (actually we are higher than #4 if you add in estate taxes imposed by states)? Can it truly be this simple to say goodbye to $18 billion in federal estate taxes (plus potentially additional state estate taxes, depending on where the happy parents choose to live out their golden years)? (The links below suggest that a “family LLC” can substantially reduce but not entirely eliminate estate tax.)

Related:

• “Using an LLC for Estate Planning”: “In a family LLC, the parents maintain management of the LLC, with children or grandchildren holding shares in the LLC’s assets, yet not having management or voting rights. … After you have established your family LLC according to your state’s legal process, you can begin transferring assets. … Here’s where the tax benefits really come into play – if you are the acting manager of the LLC, and your children are non-managing members, then the value of units transferred to them can be discounted quite steeply, often up to 40% of their market value. This discount is based on the fact that without management rights, LLC units become less marketable.”
• “Limited Liability Company – Cutting Edge Estate Planning”

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I inadvertently attended the 2015 AAGL Global Congress on Minimally Invasive Gynecology in Las Vegas at the MGM Grand. (I also attended the Latin Grammy awards and met Nicky Jam, along with some other folks who were younger and cooler than the gynecologists.)

Sitting at a casino restaurant next to four gynecologists, I learned that two of the four had been asked by patients “Is there a pill that I can take to ensure pregnancy after a one-night stand?” and “How can I get pregnant starting from oral sex or from a used condom on the side of the bed?” [Answers: Clomifene, but watch out for twins, and they refused to prescribe it; cervical cap, which was dispensed.]

The two gynecologists who had never been asked these questions were from Nevada (child support capped at $13,000/year for 18 years) and Texas (child support capped at about $20,000/year for 18 years).

The two gynecologists who had been asked to assist with pregnancies from casual and/or non-traditional sexual encounters were from California (potentially unlimited child support revenue by formula for 18 years) and Massachusetts (23-year revenue stream; first $40,000/year by formula plus 11 percent of defendant’s pre-tax income over $250,000/year),

 

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From NBAA 2015, “I give you the Derek Zoolander Airplane for Kids Who Can’t Fly Good”:

(Context: “Center for Kids Who Can’t Read Good”)

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Andrea Wulf’s The Invention of Nature: Alexander von Humboldt’s New World contains a lot that I didn’t know about Americans. Thoreau turns out to have been a great illustration of David McCullough’s point about dealing with failure (previous posting):

For all his enjoyment of solitude, Thoreau did not live like a hermit in his cabin [at Walden Pond]. He often went to the village to have meals with his family at his parents’ house or with the Emersons.

During his two years at Walden Pond, Thoreau filled two thick notebooks, one with his experiences in the woods (the notes that would become the first version of Walden) and another containing a draft of A Week on the Concord and Merrimack Rivers, a book about a boat trip he had taken with his much missed brother some years earlier. When he moved out of his cabin and returned to Concord, he tried and repeatedly failed to find a publisher for A Week. No one was interested in a manuscript that was part nature description, and part memoir. In the end, one publisher agreed to print and distribute it at Thoreau’s own expense. It was a resounding commercial failure. No one wanted to buy the book and many of the reviews were scathing, with one, for example, accusing Thoreau of copying Emerson badly

The enterprise left Thoreau several hundred dollars in debt and with many unsold copies of A Week. He now owned a library of 900 books, he quipped, ‘over seven hundred of which I wrote myself.’

Today Thoreau is one of the most widely read and beloved American writers – during his lifetime, though, his friends and family worried about his lack of ambition. Emerson called him the ‘only man of leisure’ in Concord and one who was ‘insignificant here in town’, while Thoreau’s aunt believed that her nephew should be doing something better ‘than walking off every now and then.

John Muir would have been imprisoned for draft dodging in our time, not wandering around the Sierra Nevada:

As Muir was falling in love with botany in Madison[, Wisconsin], the Civil War ripped the country apart, and in March 1863, almost exactly two years after the first shots had been fired at Fort Sumter, President Abraham Lincoln signed the nation’s first conscription law. Wisconsin alone had to raise 40,000 men, and most students in Madison were talking guns, war and cannons. Shocked by his fellow students’ willingness to ‘murder’, Muir had no intention of participating.

A year later, in March 1864, Muir left Madison and avoided conscription by crossing the border into Canada – his new ‘University of the Wilderness.’

Then, in spring 1866, when a fire destroyed the mill where Muir was working in Meaford on the shore of Lake Huron in Canada, his thoughts turned home. The Civil War had ended the previous summer after five long years of fighting, and Muir was ready to return.

Muir anticipated modern tree-huggers:

Muir lived and breathed nature. One early letter – a love letter to sequoias – was written in ink that Muir had made from their sap, and his scrawl still shines in the red of the sequoia’s sap today. The letterhead stated ‘Squirrelville, Sequoia Co, Nut time’ – and on he goes: ‘The King tree & me have sworn eternal love.

There were no strip malls in Florida back then, but Muir caught malaria on his way to Cuba (travel to which country was not restricted, of course). Regarding the unsuccessful attempt to block the Hetch Hetchy dam from being built within a national park, Muir noted that “Nothing dollarable is safe, however guarded.”

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