Thursday, May 28, 2009

Unable to pull the trigger

I've written before about the hazards of the colostomy takedown. When they go well, the patient is eternally grateful. Nobody wants stool collecting in a belly bag the rest of their life. But we always tell patients that only about 70% of colostomies are reversible after a Hartman's procedure. Sometimes you get back inside a patient who has recovered from perforated diverticulitis and it's just an unholy mess, bowels matted together, anatomy distorted, the pelvis scarred and inaccessible.

Recently I took back one of my nicest patients for a colostomy reversal several months after emergency surgery for a complicated colovesical fistula. It took almost an hour just to get inside his abdomen as I chipped away cell layer by cell layer with the sharp scalpel, separating fascia from bowel. Finally I freed things up and was able to inspect the pelvis. Usually the rectal stump can be easily identified and isolated from the other pelvic structures. In this case, I saw a uniform sheet of peritonealized scar tissue running from the bladder to the sacrum. When the assistant introduced a probe through the anus, I could see a bulge somewhat posterior to the bladder but it wasn't clear to me that there was a distinct tissue plane between the two structures. The rectum was down there somewhere but I wasn't certain exactly where. And for a case like this I think you need 100% certainty. You're taking a patient who was living independently at home, healthy and symptom free, and you subject him to an elective procedure that, if it goes wrong, could potentially adversely alter his existence irreparably. First do no harm. Generally, we surgeons perform operations on ill patients to relieve pain and suffering. This was different. My patient suffered from the psychological pain of having a colostomy, but there was nothing physical or mechanical that reversing his colostomy would make better. So certainty was paramount. It had to be perfect. I dicked around a little while but ultimately I could not pull the trigger. I bailed. I closed him back up and kept his colostomy in place.

Failure in surgery can be defined in a lot of different ways, I've learned over the past three years as an Attending. Errors of omission (laziness, not following up on tests, ignoring a patient's complaints/symptoms) are inexcusable in my mind and I hope that the way I was trained and my own ethic will stave off any future such errors. Conversely, errors of commission are sometimes difficult to identify until one reviews a case in retrospect. Maybe I shouldn't have done that case laparoscopically. Maybe I should have kept those antibiotics on board a few days longer. Maybe I shouldn't have left a drain in that patient. These errors are the ones that keep us up nights and distract us from enjoying a quiet Sunday afternoon at home. The painful deliberation and doubt that creeps in after a completed act. By nature surgeons are aggressive and tend toward the supremacy of action over contemplation. It isn't natural to "do nothing" when a patient comes to us. It's especially hard for a young surgeon to recognize his own limitations, to understand when "action" is actually the wrong course of action.

After my patient awoke from the anesthetic, I went to discuss the operation with him. I wasn't looking forward to it. Even though I know I probably did the right thing, I couldn't evade this feeling of shame, that I had failed him, that I couldn't safely assuage his specific form of pain. I sat down in a chair next to him and spoke quietly, like a penitent schoolboy in the principal's office. I couldn't safely do it, I told him. I apologized. It's OK Doctor, he said. He appreciated my honesty. He's a terrific guy. He recovered uneventfully and went home in a couple days. I've referred him downtown to the Empire to see a colorectal specialist. (Perhaps he can be reversed with some sort of coloanal pull-through procedure which I'm not particularly comfortable doing.)

So no harm was done. My patient will get a second opinion from a specialist who can hopefully give him another shot at getting rid of his colostomy. But I can't seem to shake this hollow feeling that I failed him. Call it youthful hubris, inexperience, whatever. I wanted to be the guy who made him better. It's selfish, I know. It's not supposed to be about me. But maybe I could have done things differently at the original operation that would have made the take down procedure easier. I run things over and over through my mind and I'm consumed with self-doubt and uncertainty. But I think that's ok. It's allright to feel the sting of failure every once in a while. Nobody said this surgery business was going to be an easy gig. You can't get too comfortable. You have to be constantly vigilant for ways to change and improve. I don't want get complacent. I want to get better....

Friday, May 15, 2009

Orszag Encore

Peter Orszag, the most media-savvy director of the White House Office of Management and Budget in presidential history, has another op-ed piece, this time in the Wall St. Journal. Again, he focuses the healthcare debate on cost containment rather than the issue of universal coverage. Furthermore he asserts that the effects of cost containment go beyond the realm of health care. He's convinced that reform of just health care alone will attenuate a large chunk of our fiscal deficits in the future. (Assuming we aren't bogged down in Vietnam, er, I mean Afghanistan and Iraq fifteen years from now.)

So how is this possible? What is his plan? Well, as usual, our new administration likes to articulate Big Plans in very nebulous, non-specific terms (i.e "change" and "level the playing field" etc). The actual details are lacking, but Orszag does adhere to four general guiding principles that will facilitate this vision. Here's Orszag:
How can we move toward a high-quality, lower-cost system? There are four key steps: 1) health information technology, because we can't improve what we don't measure; 2) more research into what works and what doesn't, so doctors don't recommend treatments that don't improve health; 3) prevention and wellness, so that people do the things that keep them healthy and avoid costs associated with health risks such as smoking and obesity; and 4) changes in financial incentives for providers so that they are incentivized rather than penalized for delivering high-quality care.

Step one is simply a mandate for EMR. I don't think any physician has a problem with that. But who's going to pay for its implementation? Will independent physicians in private practice be penalized for not adopting a nationalized EMR and will they be subsidized for their investments?

Step two deals with Comparative Effectiveness Research. This is the foundation of Orszag's plan. He's smitten with the results of the Dartmouth Atlas paper which demonstrated that there is a wide variance in spending at different hospitals across the country, without a concommitant effect on quality or patient outcomes. But it's unclear what sort of guiding principle this will be. Will each physician get a "decision-making playbook" mailed to them every January to use to guide clinical practice? What sort of leeway will physicians have to veer off course a bit for a patient who doesn't quite fit into a federally constructed paradigm? What sort of evidence will be acceptable as CER? The best evidence, randomized controlled trials, take years to acrrue data and determine conclusions. Will physicians find themselves trapped in outdated, fossilized treatment algorithms while they wait for the data in the lab to catch up with the evidence on the battlefield? But again, there are no specifics. It's all on Congress now to come up with the details. I'm just worried that the effects of CER are being overly promoted and even exaggerated in some instances.

Step three is the usual bland, ambiguous drivel about "wellness" and "illness prevention". It's sounds very nice, of course. Obesity and smoking are lifestyle issues that, if corrected on a large scale, will go a long way toward reducing the costly complications of such behaviors (coronary artery disease, diabetes II, hypertension, etc). But what are the specific details? How will we incentivize the American population to avoid bad habits? I hope that step three will ultimately be about individual responsibility. If you're overweight, if you smoke, if you eat poorly, if, because of personal lifestyle choices, you contribute far more than the average American to the health care cost burden, then you probably should be more responsible for funding the public insurance option. Isn't that only fair? If you have ten speeding tickets, you pay more in car insurance. Money talks. When gas was four bucks a gallon, sales of the Prius went through the roof and now two of the Big Three are tottering on the verge of bankruptcy. Appropriately incentivized, the average American will change his/her behavior. If your insurance premiums are twice your neighbor's because you weigh 300 bones, being overweight then becomes a financial problem, not just something to feel bad about while watching American Idol. (And maybe in 2012 we'll see the CEO's of McDonald's and Burger King crawling to Washington DC for bailout requests.)

Step four is a little confusing. It's one of those very wonkish, earnest sounding lines that, upon reflection, could mean any number of things. Is it a call to pay primary care docs more? Is it referring to "never events" and other situations when outcomes are less than desirable (like refusing to reimburse for a patient readmitted to the hospital after recent surgery because you know surgery ought to be like an assembly line, no one should ever get an ileus or an abscess after like a colonic resection)? Again, it isn't clear what the goal of "incentivizing physicans" will be. Maybe it means forgiving med school debt for those who pursue a career in primary care. Who knows.

The bottom line is that Orszag/Obama are dangerously underestimating the cost of overhauling our national health care delivery system in such a way that will guarantee affordable coverage for every American. Focusing on cost-containment is, I'm afraid, rather simplistic and naive. And building an entire long term general fiscal plan around anticipated savings on health care (while at the same time expanding the number of people covered) has the effect of making this Administration seem disingenuous and overmatched.

It's time to stop painting such a rosy picture based on unrealistic hypothetical alterations. Obama would be better served by standing up, being honest, admitting that universal health care is going to be expensive, that future generations will be burdened by decisions we make today, but that health care, alone amongst most other issues, just may be worth it in the long run. And then let the American people decide.

Update: article from David Brooks in the NY Times worth reading.

Thursday, May 14, 2009

Primary shortages?

This is an off the cuff, outside the box ramble.

I was talking to a buddy of mine in the OR locker room the other day about how it seems the body starts to break down once you hit that 35th birthday. (Except mine of course. I'm a machine who will never get sick.) He mentioned that he was diagnosed with Essential Hypertension about a year ago. A routine yearly physical exam noted a diastolic BP of over 100. His primary care doc put him on an ACE inhibitor and, with time, his pressures have drifted back to within normal limits. Since his diagnosis, he has been seeing his doc every three months for "check-ups". I thought that seemed rather intense. He agreed. He waits in the office for 45 minutes, gets his pressure taken by a nurse, the doctor comes in, listens to his heart, tells him everything is fine, see you in three months. He's paying over a hundred bucks a month for the anti-hypertensive. And then there's the fifteen dollar co-pay for every visit.

I understand that primary care physicians cannot afford to have too many empty office hours. Staying booked three months in advance is not only stress reducing, but it's unavoidable if one wants to remain a financially viable entity. But we're talking about a 36 year old male with controlled hypertension. Does he really need to be seen four times a year? And does he need to be on an expensive ACE inhibitor?

It's dogma that primary care physicians are both underpaid and overworked. This is pretty much undeniable. Advocates also aver that any universal health care reform is going to require more primary care docs, because they're already maxed out in terms of availability.

I ask: Is this part entirely true? Is there any evidence to suggest that a 36 year old male needs to see his PCP four times a year? Or that the 50 year old obese female with hyperlipidemia on Lipitor needs follow up appointments every two to three months? Or the 60 year old diabetic who also sees an endocrinologist for blood sugar management?

What I'm getting at is this: Is the jam-pack scheduling driven by medical need or is it more a financial necessity? Will primary care scheduling patterns change once reimbursement is increased? Let's say you get paid the same no matter if you see 30 low maintenance, known patients versus 10 complicated or new patients. Which is more preferable? I'm not certain everyone would choose the latter. Sometimes it's nice to cruise quickly through a day without expending a lot of mental anguish. As a general surgeon, my schedule is very flexible, even unpredictable at times; I have no idea what I'll be doing or who I'll be seeing three weeks from now. I'd be curious to hear from primary care docs in the trenches....

Wednesday, May 13, 2009

How things change

Great read from Eric Martin (of the blog Obsidian Wings) who compiles a series of laughable quotes from leading Republican "intellectuals" immediately after the Abu Ghraib scandal broke.
"Obviously, it was a shameful moment when we saw on our TV screens that soldiers took it upon themselves to humiliate Iraqi prisoners -- because it doesn't reflect the nature of the American people, or the nature of the men and women in our uniform. And what the world will see is that we will handle this matter in a very transparent way, that there will be rule of law -- which is an important part of any democracy. And there will be transparency, which is a second important part of a democracy. And people who have done wrong will be held to account for the world to see. That will stand -- this process will stand in stark contrast to what would happen under a tyrant. You would never know about the abuses in the first place. And if you did know about the abuses, you certainly wouldn't see any process to correct them."
-George W. Bush

Naughty naughty

The orthopedic surgeon Dr. Timothy Kuklo, while at Walter Reed Army Medical Center, apparently falsified data in a paper on the bone growth protein Infuse. Dr. Kuklo had been a paid consultant for Medtronic, the company that manufactures Infuse. Dr. Kuklo hasn't responded to any emails or phone calls from NY Times reporters. He has been busy, apparently, with other clinical duties at Washington University (St. Louis).

During his time at Walter Reed Dr. Kuklo was extensively involved in research and writing about various Medtronic products, including editing two books published by the company and conducting three studies that were approved by his Army superiors, according tohis list of publications and an Army report.

The results reported by Dr. Kuklo in his Infuse study “suggested a much higher efficacy of the product being researched in the article than is supported by the experience of the purported co-authors,” according to the Army’s investigation.

Colonel Coots said Tuesday that the total number of patients Dr. Kuklo reported as having been treated for extensive lower leg wounds at Walter Reed during the study period — 138 soldiers — was greater than the number for which the hospital could find records.

Tuesday, May 12, 2009

Sarcomatoid Adenocarcinoma of the Large Bowel

This was an unusual case. An elderly lady presented with abdominal pain, fevers, and an elevated WBC. The CT above demonstrated a massive, locally invasive tumor arising from the rectosigmoid region. Intraoperative findings were discouraging. The tumor was enormous, filling most of the pelvis. It invaded adjacent loops of small bowel and the entire posterior wall of the bladder. The tumor itself was completely necrotic, with the consistency of Thanksgiving stuffing. The entire lateral wall of the sigmoid colon was blown out. It was a mess. I resected everything en bloc and gave her a colostomy.

At first we thought this was going to be a GIST tumor. But the final pathology actually strongly suggested an unusual variant of primary colorectal cancer; sarcomatoid adenocarcinoma, which is composed of a mixture of mesenchymal and epithelial cells. They tend to be extremely aggressive, fast growing cancers with almost universally poor outcomes. We'll enroll this lady in a experimental protocol once she has recovered suitably.

Saturday, May 9, 2009

China Cats....the old guys still get it done

Caught the Dead show in Chicago. Good times. And Phil Lesh near the end even made a plea for organ donation (he's a liver transplant recipient). So there's your surgical connection.

Thursday, May 7, 2009

The surgeon as neophyte torturer

Dr. Pauline Chen, in a piece for the NY Times last week, writes about the daunting moments right before a surgeon-in-training first takes scalpel to flesh. I remember my first incision as an intern as well. I barely broke the skin, so tentative were my motions. But after a while, the blade sinks deeper, the blood runs, and you don't even notice it anymore. It's like you aren't doing it to a real live human, so detached your act of physical violence seems--in this draped-off, sterile setting-- from the smiling, affable patient you just spoke to in the pre-op area. Dr. Chen attributes this to an "habituation" process that occurs over time. (I disagree with her on principle, and will have to adress why in a different post).

But then she takes a logical leap, presumably for the purpose of making some sort of poetic analogy, to compare the habituation that occurs during surgical training with the fact that the Bush Adminstration seemlessly implemented a state sponsored, systematic torture program that was carried out by willing participants. I'm not exactly sure what she's trying to get at here. That surgeons are similar to torturers in that they "get acclimated" to the commision of violence and can thus tolerate it? That torturers diverge from surgeons only in a manner of means and ends? Really, the only message to me is the patently obvious one that unpleasant acts become easier over time to the person who commits them. In this sense, a surgeon is a lot like the serial killer who perfects his craft the more the knife is brought to flesh. I guess that's true but it's an inconsequential truth; it represents willful neglect of the fundamental characteristics that differentiate the surgeon from the torturer. It's like saying Mt Everest and the hill in my backyard are similar because they're both examples of terrestrial elevations.

Torture involves the complete subjugation of a captive, helpless human being by any means for the purpose of eliciting answers that the torturer wants to hear. A surgeon cuts an anesthetized patient (after getting informed consent) for the purpose of alleviating the patient's conscious suffering. The fact that torturers "get used" to unspeakable cruelty is illustrative of Hannah Arendt's "banality of evil", where a seemingly average, normal citizen (think of Adolf Eichmann and all the number-cruncher accountant types who carried out the fine details of Hitler's Final Solution) could stoop to the level of pure evil. That a surgeon is able to quickly slice into a patient's belly without any qualms is just emblematic of the fact that he/she isn't bothered by the sight of blood, knowing that the patient cannot feel anything, knowing that the purpose of the procedure is to make the patient feel better.

Dr Chen has written some good pieces since taking up the NY Times gig. But on this one, she misses the mark widely....

Face Transplant Update

From the Cleveland Plain Dealer, an update on the first face transplant recipient in the US.

Monday, May 4, 2009

Going All In

A fascinating profile in last week's New Yorker on Peter Orszag, the budget director in the Obama Administration. This guy is a true believer. He's going all in on Comparative Effectiveness Research as a solution not just to health care reform, but to the entire financial infrastructure of this country.

Orszag is convinced that rising federal health-care costs are the most important cause of long-term deficits. As a fellow at the Brookings Institution, he became obsessed with the findings of a research team at Dartmouth showing that some regions of the country spend far more money on health care than others but that patients in those high-spending areas don’t have better outcomes than those in regions that spend less money. If spending more on health care has no correlation with making people healthier, then there must be enormous savings that a smart government, by determining precisely which medical procedures are worth financing and which are not, could wring out of the system. “I spent several months in very intense study,” Orszag told me. “The reason that I wanted to go to C.B.O. was I thought that was one of the key bodies that could really delve into what we could do about it.”

Seems just a tad audacious, no? A giant federal bureaucracy will need to be created to guide us silly doctors through the complexities of diagnosis and treatment. Clearly, a centralized planning behemoth will be able to stay on top of the latest innovations and evidence better than anyone involved in the actual delivery of medicine, and subsequently facilitate the smooth, effortless transmission of the new paradigms all the way down the line to your local podunk hospital. At least that's what Peter Orszag thinks. Added bonus: reduced deficits, save the banks, and end the recession!

Sunday, May 3, 2009

Baudrillard and the Hyperrealism of the Parathyroidectomy

This is going to be a bizarre post; I'm just warning you.

I've been reading from Jean Baudrillard recently. Baudrillard is a post modernist French thinker/philosopher who writes about the preponderance of images, signs and representations in our technologically-driven, post modern lives. A lot of what he writes is almost deliberately obscure and esoteric. You find yourself re-reading entire chapters two or three times because nothing makes sense and you get pissed off thinking hey I'm not a moron, I have advanced degreees why is this guy being so intentionally obtuse? I sort of hate Baudrillard, actually, for that reason. But he does have some interesting takes on the nature of reality that are rather illuminating.

Baudrillard comments on the deluge of signs and images that are pounded into our collective consciousness in modern America. We are overwhelmed by ubiquitous advertising, television, celebrity culture, media supersaturation of "important events", mass information, instant communication via the internet and Blackberry and Twitter, the constant forward march of technologic innovation. What happens after a while is that the the signs and images start to become more important than the actual events/objects that they represent. It achieves a reality of its own, which he dubs "hyperreality". After a while, the images and signs become so disconnected from the objects they represent, that the objects themselves start to disappear, leaving us with this unsubstantiated, hollowed-out simulation of post modern America. The hyperreal as depicted on "reality" television becomes more "real" than the lives we actually lead, becomes a model to pattern ourselves after. The manipulative images of advertising alters our perception of what is important, of what has value. Henceforth, commodities become not just objects of desire, but function to define who we are, our social status, our relative value in American society. The SUV isn't necessarily a utilitarian, modern transport device; rather it is now a status symbol, a sign of the successful, modern, happy, American upper middle class family. The function (mode of transport) of the object (vehicle) now assumes a secondary role, while the sign/image of the object takes on the primary role in shaping the identity of the subject who acquires said object. We have a strange reversal of the subject/object dichotomy where the the object now dominates the subject, reducing the subject to something more thing-like, rather than an autonomous subjective being. (Baudrillard calls this reification).

So what does all this nonsense have to do with hyperparathyroidism? You'll have to bear with me.

I was reading an article in the March 2009 American Journal of Surgery called "Surgery Improves the Quality of Life in Patients with 'Mild' Hyperparathyroidism". Hyperparathyroidism is defined as an abnormal elevation of one's parathyroid hormone level (PTH) in the setting of hypercalcemia. There are four parathyroid glands, intimately associated with the thyroid gland in the neck. They function to maintain calcium homeostasis in the body. If calcium levels get too low, PTH is released to help bring calcium concentrations back to normal. When calcium levels correct, the PTH is down-regulated. It's an simple, elegant design. In hyperparathyroidism, the negative feedback loop goes haywire (most often secondary to a single adenomatous parathyroid gland) and PTH production occurs independent of body calcium levels. The body then starts breaking down bone in order to liberate more calcium to keep up with the demand from abnormally high PTH. The resultant hypercalcemia leads to a wide range of symptoms. Classically, primary hyperparathyroidism manifests as "stones, bones, abdominl groans, and psychic overtones", i.e. kidney stones, bone pain/fractures, peptic ulcer disease, and depression. The treatment is to identify the source of the autonomous PTH production (usually a single adenomatous parathyroid gland) and remove it. We surgeons love these kinds of diseases; cut to cure.

As usually happens, however, in this new era of extreme subspecialization within the field of general surgery, once a disease is named, an entire brigade of academic surgeons gravitate toward said disease and crank out paper after paper on the intricacies of it, its biochemical basis, surgical approaches and of course papers that boast of superior results when compared to surgeries performed at "low volume" hospitals, with the overall purpose of defining it (hyperparathyroidism) as a separate entity from the discipline of mere "general surgery". Hence, the birth of the "Endocrine Surgeon".

Give them credit though. Parathyroid surgery used to routinely involve a large Colombian necktie incision, similar to the incision of a thyroidectomy. It was also routine to explore all four parathyroid glands, because you could never be sure you were dealing with a single adenomatous gland versus two adenomas versus four gland hyperplasia unless you eyeballed them all yourself. Obviously, the more you dig you around, the more risk of injury to important structures (i.e. the recurrent laryngeal nerves, the thyroid gland itself, the carotid sheath) and the more risk of post-operative complications such as recurrent nerve palsy, neck hematoma, respiratory compromise, and hypocalcemia, not to mention the unseemly cosmesis of a large neck incision. So for many years, parathyroid surgery was done strictly on patients who manifested classic signs of the disease. The surgical treatment was effective, but fraught with too many potential adverse side effects to justify it otherwise.

But things changed. Nowadays, we are able to pre-operatively determine where the offending adenomatous gland is with a high degree of certainty using a combination of ultrasonography and something called a sestamibi scan. This allows the operating surgeon to minimize the incision and avoid unnecessary dissection in potentially dangerous tissue planes. Furthermore, the development of intra-operative parathyroid hormone monitoring has allowed us to determine cure before we even leave the OR. A drop of PTH levels of over 50% from pre-op levels gives a surgeon the confidence to close up shop, leaving the patient with a tiny, cosmetically appealing incsion. Some surgeons are also approaching the adenomatous parathyroid bugger endoscopically via tiny incisions in the axilla, eliminating the need for any visible neck scars.

These are all exciting new developments. Parathyroid surgery has now become more precise, sleeker, faster, more definitive, more cosmetically appealing; in a word, elegant. It's almost a shame that primary hyperparathyroidism is such a relatively rare disease (incidence about 1 in a 1000). And based on some of the recent surgical literature, one gets the sense that endocrine surgeons are also a little frustrated that it doesn't occur more often. I mean, these are terrific new surgical innovations. Wouldn't it be a lot cooler if hyperparathyroidism occured more often?

With the ubiquity of screening blood draws in American medicine, we are identifying patients with hypercalcemia whom we would have missed twenty years ago. A PTH level that is inappropriately elevated in such a setting will instigate a referral to an endocrine surgeon. But many of these patients have never had kidney stones, they don't have peptic ulcer disease, and they don't recall any specific bone or joint complaints. So what do you do?

Well in 1990, the NIH published a consensus paper that determined the indications for parathyroidectomy in patients who were either mildly symptomatic or asymptomatic. Many have found these indications to be far too restrictive. And by "many", I mean endocrine surgeons. The surgical community has consequently responded to this consensus paper with a series of counter-papers arguing for the utility of parathyroidectomy in these minimally symptomatic patients. This article in the March AJS is yet another salvo from the front line of the endocrine surgery battalion.

The common denominator in these pro-surgery papers is an intense focus on that fourth realm of symptomatology, i.e. "psychic overtones". What they aim to prove is that a patient's "quality of life" is significantly ameliorated by successful parathyroidectomy. Generally this has been done via the comparison of answers to pre- and post-operative questionaires which address one's subjective appraisal of such nebulous categories as "energy levels" and "happiness" and "fatigue". How else are you going to do it? It's not like "happiness" can be measured in the same way your calcium level can be (and if it could, I'd be sending off assays of my daughter's every other week). So the data they use is not exactly hard data; it's subjective and contingent on a lot of factors outside of whether or not your left parathyroid gland is incrementally larger than the others.

For example, in the cited article in AJS, 151 patients were evaluated. 133 of the patients had "classic" disease (NIH criteria or stones/bones/groans) while only 18 were patients with mild or asymptomatic disease. Something called the SF-36 Health Survey was administered to all 151 patients. The SF-36 is "a standardized instrument used to assess general health and wellness". (Just reading that, I'm already on the verge of speed dialling George Orwell.) Using the data from the survey, 8 scales of "well-being" are fashioned: Physical Functioning, Role-Physical, Bodily Pain, General Health, Vitality, Social Functioning, Role-Emotional, and Mental Health (yes, they are all ominously capitalized). Moreover, a combination of all 8 scales yields 2 additional derivative scales (Physical Component Summary and Mental Component Summary). Scores are then tallied and compared pre-parathyroidectomy versus post. What they found is that patients with mild/asymptomatic disease had improvement in all 10 scales, while those with classic hyperparathyroidism had improvement in 9/10 scales. Ergo: patients with asymptomatic disease derive a greater efficacy from parathyroidectomy than those with stones/bones/groans. Or something to that effect.

Now let's just take a step back for a moment. Is measurement of Vitality standard operating procedure when you go for your yearly check-up? No? You mean your internist doesn't check your blood pressure, order an EKG, send off blood work for cholesterol, hemoglobin, and Vitality? I mean, Vitality? I feel like I've become embroiled in some bizarre surgical game of Dungeons and Dragons. Shouldn't we also measure Wisdom and Dexterity levels?

What we have is a very Baudrillardian situation where the object is now defining the subject. The surgical procedure, heretofore a response to the ravages of a disease, is now redefining the very disease that it purportedly hopes to assuage. The excellence and refinement of the procedure itself mandates a re-appraisal of where we draw the line between where the actual disease begins and ends. It's a classic reversal of the subject/object dichotomy and I think this sets a dangerous precedent. As medical innovation continues unabated, we will inevitably see more refinement (at great cost) of other procedures/operations, innovations that reduce complications, improve cosmetic results, and augment patient satisfaction, and there will undoubtedly be a corresponding demand to do these procedures more often, given the expense invested in research and development. Even now, for example, we take out way more gallbladders than we ever used to, simply because laparoscopy makes it worthwhile to do so. But at least biliary colic is a definable, reproducible disease. The current push for incisionless abdominal surgery (pull your gallbag out through your vagina!) is more concerning. Will we see papers advocating the removal of asymptomatic gallbladders with stones, based on questionaires and surveys?

Anyway, I have to go. I have a battle lined up with an Orc this evening; if I win, I earn 50 Vitality points.

Friday, May 1, 2009

Evidence based torture?

Great link from the Daily Dish on the treatment of German war prisoners by the British during WWII.
There is a significant difference between the German prisoners in the cage and the German spies captured by the British during World War II. The Germans in the cage were accused of war crimes, and the techniques was used to coerce confessions of guilt. It didn’t matter if what they said was true, and even then the success rate of the cage was terrible.

The Cage held 3573 prisoners. They were accused of war crimes. The techniques were designed to coerce confessions of guilt. But only about 1000 confessions, false or true, were coerced – either by torture or “not torture”. That is 70% refused to confess anything. These are, as I say in the book, surprisingly dismal results but pretty much in line with other dismal results for false confessions including Korean and Chinese torture during the Korean War and French ancien regime torture (which was even poorer). And these are cases where people don’t care if the information is true or false. They just want the confession.

By contrast, the German spies during the war were captured with standard British policing techniques and interrogated using “soft skills”. British counterespionage managed to identify almost every German spy without using torture—not just the 100 who hid among the seven thousand to nine thousand refugees coming to England each year, not just the 120 who arrived from friendly countries, but also the seventy sleeper cells that were in place before 1940. Only 3 agents eluded detection; 5 others refused to confess. The British then offered each agent a choice: Talk or be tried and shot.

Torture didn't work then (and the Battle of Britain represents more of a ticking time bomb scenario than anything we have seen over the past 8 years), why should it work now? Shouldn't Jay Bybee have included this nugget of past evidence in his "good faith" effort to render a legal justification for torture? Oh wait, the decision to torture had already been made. It just would have made for unseemly awkwardness at the intelligence briefings...