Patient Care

Historical evidence suggests that the three measures of quality patient care we're infant mortality, bedside teaching and autopsy rate. We once ranked hospitals on these three considerations. We can blame politics/greed, misplaced confidentiality and stupidity respectively for their decline. Thr Global Burden of Disease statistics confirms, with the US at near the bottom in every category. Some of the poor outcome is behavioral and environmental, but dumbing down medical education to met the lower standards is not a solution. Furthermore, where we once lead in compulsive public health, today it's hard to find.

Infant Mortality

5.8 / CIA World Fact Book

56th or 58th depending on the listing of the Organization for Economically Cooperation and Developement 

GDP China 19.8 t

        EU.     19.4

        USs.    17.8

Are things really, "ok and getting better"?

The Cadusus vs. the Rod of Asclepius

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The Cadusus characterized by a rod with two snakes wrapped around it with wings, originates from ancient Greece, the winged herald’s winged staff, carried by Hermes, the messenger of the gods, also viewed as a protector of herdsmen, merchants, travelers and thieves.

The Roman adaptation, associated with Mercury, became the certification of fair trade, commerce and balanced exchange, the wings denoting protection by Roman law.

The Rod of Asclepius, on the other hand, stood for healing; from Asclepius a physician lost in pre written history but so venerated he became a god and his daughters, gods of hygiene, healing and health. By 4,500 BCE Asclepiads were of a school or guild of ethical and scientific physicians, physics as they were called then, later medicine (Greek, mindfulness) as taught in Greek medical schools by Hippocrates and his successors. The rod of Asclepius symbolized a concept of ethics, art and science that persists to this day despite epic periods of religious and political interference.

In North America, the Winged Cadusus comes to represent much the same as under Roman law, a symbol of protected trade, the commerce of healthcare, directed by politics and law.

DNA

One might be curious as to the structure of the most primitive, oldest DNA and from what it evolved. Also, what might be the uniqueness in Leonard Bernstein's or Einstein's genome. Evolutional pressure appears to no longer favor Inteligence, rather the opposit. Is such a healthcare issue? If so?? One fears to ask.

Evidence Based Medicine

If evidence based medicine were a stock market entity, it would be time to sell as a post mature overhyped entity. There is nothing wrong with the concept, needed in many ways, a handy reference but now a medical cliche. 

Despite the rigorous academic basis, the statistical validation, the scientific approach, which it is, the resulting best evidence protocol stifles the imagination, the trial and error, the inductive reasoning of the scientific method and the focus on individual patients. Medical-legally, best evidence tends to overshadow, well documented past studies, antidotal wisdom and individualized imaginative initiatives - progress itself and time - focusing instead on education reform, and training young physicians to a rigid structured algorithm, physicians who will follow the rules. Furthermore, mass studies of distant populations, fail to account for the environment, DNA, local epidemiology or personal concerns. It may even codify some highly profitable practices contributing gladly to the terms of best evidence.

Considering the cost, the dismal status of EHRs, professional communication and continuity of care, one might "sell short" and look beyond best evidence for the next higher level of academic and professional excellence, perhaps the genome and quantum biology, requiring a PhD MD rather than a Feldsher.

Victor McKusick 1921-2008 Genitic Disorders

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OMIM® Online Mendelian Inheritance in Man® An Online Catalog of Human Genes and Genetic Disorders Updated 4 March 2016 Advanced Search : OMIM, Clinical Synopses, Gene Map | Search History Need help? : Example Searches, OMIM Search Help, OMIM Tutorial Mirror sites : us-east.omim.org, europe.omim.org

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Clinical Genomics

IThe goal from my perspective would be, synthesis of the entire human genome on each of my patients with a realtime, ongoing statistical correlation between his or her genome and that person's ongoing experience with the environment, disease and longevity, known correlations with disease as well, but those existing correlations cannot be trusted due to the distorted data from insurance claims and the attempts to match individuals to a population at large. 

Legislators in their ignorance or vested interest stipulate that medical records may be destroyed after seven years or less, in some cases three. Administrators too are anxious to rid themselves of the burden of data collection and storage for both financial reasons and the burden of liability. What you can not prove is hardly actionable. A single clinition over the course of his or her professional lifetime collects some 30,000 to 50,000 clinical records, a group of physicians in a group practice obviously many more. Furthermore, groups perpetuate long beyond the life of the origional physicians creating a vast and priceless database of credible clinical information relating closely to the individual and a narrow geographic location. By contrast, massive clinical data thus far comes from customer questioners, such as from 23 and Me,  or insurance data which is so distorted as to be near meaningless.

The advancement and benefit to patient care as well as a quantum leap forward in our understanding of the causes of disease seems obvious. The rapid, affordable, access to the whole human genome makes up the other side of the above equation. So far that has been only a dream frustrated by burocracy, inertia and a steep learning curve. Competition, Silican Vally and inventiveness, however, work maricals. Unfortunately, free enterprise, the very driver of innovation, now threatens the access and developement of an affordable, rapid whole human genome device. Ilumina is suing Oxford Genomics, once a strategic partner, over patents to a promising nanopor technology, a sad developement that may significantly delay the dream. Fortunately, there are other competors knocking at the door. Hopefully, Moor's law will prevail.

"The Oxford machines will be configured as scalable computer clusters, so that new ‘nodes’ can be added to them, so that users can customize the machines. The initial system will feature [a] nodes containing 2,000 nanopores that can read DNA at a rate of hundreds of kilobases per second, the company said. Next year, the company will begin selling nodes containing 8,000 nanopores; 20 of these combined would theoretically be able to sequence an entire human genome in 15 minutes, says Gordon Sanghera, Oxford’s chief executive." From Nature Feb 25 Erika Check Hayden

Physician Assisted Dying

Share | JAMA January 19 2016 315 No 3 p 249 on the subject lists a paragraph titled Evidence Evaluating the Practice of PAD


What more can the evidence show? The morbidity and mortality of PAD is near 100%. The long term survival near zilch. We might as well be back in the days of ancient Athens when Hippocrates ranted against the charlatans, and the priests jailed him 20 years for defying their political edicts -- defining disease and directing treatments. We espouse an arrogance of modernity while in reality nothing much has changed. The question is, can we as physicians defy political dictates, correctness and greed while sustaining the Asclepian convictions and pledge of our profession. Politicians demanding PAD seems a bit like men defining women's reproductive rights, misdirected social engineering at the least. 

Heroin Addiction in New Hampture

For over a decade there has been an intense campaign to treat our patient's pain. It may have started with a successful lawsuit against a physician for not providing adequate pain relief in a suffering patient. It may have been a political thing. In any case, students are taught to always ask patients to rate their pain on a scale of 1 to 10, and meaningful use, or at least the EHR records, take up substantial space with its documentation. Doctors have seemingly lost all caution and restraint in prescribing narcotics for pain relief. We give the patient a pain delivery system affixed to their IV that gives them however much narcotic they think they need. All of this showcasing gives people the idea that any pain is a bad thing and must be eliminated.

A generation ago, two things were different: patients did not experience pain as they do today wheather due to advertising, social norms, or our preoccupation with pain management, and physicians were much more circumspect in limiting narcotics to less addicting amounts understanding that any amount is addicting and addiction is always a risk. Pain is not a bad thing, however; it is put there for a purpose. What is bad is how we interpret it. 

That is not to say we don't mitigate pain and help patients deal with it, we do and we should, but I submit, we as physicians and some of our other providers are a major root cause of the heroin epidemic. It starts with the prescription and our promotion of pain as a more important target for treatment. (And profit SIC)