Self-interested in Liberty

For years it has rubbed a raw nerve whenever some pontificating pundit has put forth the idea that red-state individuals vote against their self-interests, but the discussion has been perverted so far that it took Frank Rich’s 4000+ word screed in New York magazine bashing readers about their heads with an almost mechanical redundancy to make me realize precisely where the problem lay. His extended article fired my imagination about what the true self-interests of the voters actually are, for I believe that Trump voters made a statement that does, per se, express their self-interest, but in so doing showed a preference for ideas which fly right over the pointy and outsized heads of the misguided unfortunates on the left.

Rich’s extended naval-gazing exercise regarding the arguments among many ‘progressives’ about the recent election was one of the most depressing pieces about America that I have read in a while (and that is time I will never get back). Not because of his premise, that working-class white Trump voters are all just bigoted rubes too dumb to realize that they need government to help them get ahead in life. No, the depressing part about this article was just how far the left has allowed the frame of the discussion to shift over the past few decades. Milquetoast conservatives of the Bushie brand have certainly contributed to this apocalyptic shift, but the distortion has largely been driven by ‘progressives’ and their toadies in the press, the government bureaucracy, and colleges and universities throughout this land.

So what is this seismic shift that has led to increased partisan divide and an inability of blue-staters to comprehend the thought processes of half of our population? It unfortunately has become part of the accepted narrative of our current politics that people who vote for less government are voting against their own self-interest.

Now this supposition may not seem remarkable to many of you, and in fact this new narrative may seem like just an ‘obvious’ statement – certainly to more ‘progressive’ readers. Many people may even believe that this is just a self-evident ‘fact’ and may even reject my hypothesis that this is a ‘new narrative’. But for those of us in the enlightened ‘traditional liberal’, i.e. conservative, camp this is a point that remains highly in doubt and one that should not be accepted without vigorous opposition.

Rich makes an argument that Trump’s working-class voters are so lost in their own red-state bubble that it may not even be worth the trouble for the Democratic party to try to reach out to them:

The most insistent message of right-wing media hasn’t changed since the Barry Goldwater era: Government is inherently worthless, if not evil, and those who preach government activism, i.e., liberals and Democrats, are subverting America. Facts on the ground...do nothing to counter this bias.

The ‘facts on the ground’ he refers to are the loss of working class jobs (which he attributes to greedy free market corporate robber barons) and the opioid epidemic (undoubtedly the fault of greedy pharmaceutical robber barons). He then goes on to say that:

The notion that they can be won over by some sort of new New Deal — “domestic programs that would benefit everyone (like national health insurance),” as Mark Lilla puts it — is wishful thinking.

But herein lies the fallacy of his thinking: believing that the only thing important in the lives of these people is the number in their bank account, health insurance, and the accumulation of material things around them. He makes the case that great unwashed hordes of hillbillies are really just out-of-work losers who don’t have enough brain cells to realize that the government has freed them from work (via NAFTA) and furnished them with financial aid and cheap imports from China, and that instead of being grateful and taking the blue pill for more of the same, they have opted for OxyContin induced bliss and early death. Only their always benevolent betters in government can save them from themselves.

By voting for Trump, however, they have cried out for a change in the national course. Glenn Reynolds’ article in USA Today makes a strong argument for one of the reasons why they have done so – the abject failure of so-called experts to solve our problems. The people want to be free of their overseers and provide for themselves. And one of the biggest barriers preventing these people from pulling themselves up has been the heavy hand of government, enshrining in regulation a Rube Goldberg apparatus of occupational licenses which purports to ensure competency of virtually every working person but instead offers a government provided protection racket to those lucky enough to already have a job while simultaneously reducing ‘expertise’ to the lowest common denominator.

Rich laments that Reagan’s dictum “The nine most terrifying words in the English language are: I’m from the government and I’m here to help” ‘remains gospel’ on the right, but it does so because for so many regular people it rings true. The media has repeatedly lambasted Trump and his supporters as anti-immigrant and used the words on the Statue of Liberty “Give me your tired, your poor, Your huddled masses…” to try to rebut his policy proposals but usually stops there without finishing out the phrase. It is instructive that to examine the rest of the poem, “The New Colossus” by Emma Lazarus, to see that Lady Liberty stands in contrast to the fallen Colossus of Rhodes, the “brazen giant of Greek fame, With conquering limbs astride from land to land”. She is not a monument to empire, or to what government has built. The “huddled masses” do not yearn for a handout from some self-titled ‘elite’, but yearn to breathe free: free from tyranny, free from the heavy hand of an unelected bureaucracy, free from self-righteous, patronizing, and smug pronouncements from urban pomposities who know nothing of the way of life or the values of half of their countrymen.

 

A Thought Experiment

A thought experiment: everything about you and everyone else is made public knowledge. Anyone can look in on your life and see everything you do. They can see what you eat, they see all of your interactions with other people, and they even see all of your sexual peccadilloes and when you masturbate. All affairs are revealed and all theft, fraud, and corruption free for anyone to sort through. The only things that you can hold secret are those things you keep in your own brain – never expressed to anyone or written down. Your diary is open.

 

What would you be ashamed about? What would you not want other people to know? This goes straight to what you consider to be right and wrong. This dives deep into religion and even sense of self.

 

This is essentially the state we find ourselves in with the most recent revelations of the extent of the spying ability of the United States government. And with the exponential advancements being made in technology – artificial intelligence, ubiquitous cameras and drones, aerial surveillance, facial recognition software, DNA storage capabilities – it is only a matter of time before all of our activities all of the time from birth to death will be captured in some huge database. Of course the spymasters will say that the only access to that database will be through judicious use of warrants. But if the policeman can get access to the database, certainly hackers will get access to the database, and sooner or later it is going to be fair game for everyone.

 

There are people who say ‘I have nothing to hide. Only people who have done something wrong need to worry.’

 

I fear the implications of this are much more dire. When employers can know all the employees’ medical results, when businesses can pull up the dirty laundry on the executives of their competitors, and when governments can monitor any activity that they may not approve of, where will we be? Forget about negotiations and market tactics – useless. Economies would crumble.

 

There are fundamental questions here. It all has to do with the power some people hold over other people. I wonder whether humans can live and work together without any personal privacy. I don’t know that I would want to live in that type of society. I don’t know that I will have any choice. This may solve the question of why we have not been contacted by other advanced civilizations. This may be why civilizations die.

Old school

A recent post at db’s medical rants addressed the question of whether or not the skills of history taking and physical exam have declined in recent years, and he asked the question ‘What does old school mean to you?

To me ‘old school’ means taking a good history and then performing a focused physical exam. So what exactly does this entail?

History:

Old school:

Questions are asked regarding the patients known medical conditions and the problem at hand. Relevant information is discussed, often but not always including some details about the patient’s occupation and family. If I am sewing up a laceration on someone’s leg from a chainsaw accident, I don’t need a family history, (but I might want to ask if any substances were involved). Treating a swimmer’s ear does not require much history at all, unless this is a recurrent problem or unusual presentation. On the other hand, a patient presenting with heart failure may need an hour’s worth of history, exploring other medical problems, current and past occupations, extensive family history, living conditions, and any history of substance abuse. The history adapts to the situation. I personally do not take notes or use a computer when taking a history – talking with the patient and looking them in the eyes

Modern reality:

In order to bill for the visit you need to make sure that you have checked enough items under the history of present illness, that the past medical history is documented, a social history is documented, a family history is documented, and an extensive review of systems is documented. Most of this is clerical data entry and is done by nurses or medical assistants. If you are very efficient you can click through the boxes to get a level 4 visit paid in a few minutes.

Physical exam:

Old school:

Hands on exam including (for me) listening to the heart and lungs of every patient, and then a focused exam regarding the issues that need to be addressed. In patients with diabetes or hypertension, a (gasp!) fundoscopic exam can be very useful. Looking at a patient’s hands can provide an encyclopedia’s worth of information. When patients complain of gout we actually have them take off their shoes and socks and (double gasp!) touch their feet.

Modern reality:

Too many doctors do not even examine the patient. They look at the electronic health record and click off the boxes. The entire physical exam section of the clinical note is boilerplate to fulfill billing rules. Patients tell me that they have seen doctors who did not examine them at all but stood by the door and diagnosed them based on what was in the computer. Some doctors seem to think that their patients are ‘icky’ and do not want to touch.

The problem of modern medicine

The problem today is a mentality that the history is all you need and then technology – lab tests and imaging – will make the diagnosis clear. This mentality has been driven by a number of forces. The most important force that drives everything in medicine is money. The way doctors are paid is insane. Take, for example, a challenging patient with a rare medical condition seen by two different doctors:

Doctor #1

Doctor #1 was the top of their class, well educated, sharp, engaged, and takes time to do a thorough history and physical exam on the patient. The doctor comes up with a presumptive diagnosis and sends a lab test to confirm or exclude the condition. After one hour, doctor #1 bills for 1 level 5 visit and a lab test. The insurance company refuses to authorize the lab test because it is for a rare condition and the bean-counter there has never heard of this test. They also question whether doctor #1 is billing too many level 5 visits. The patient then gets a huge bill from the lab company and makes an angry phone call to the doctor. The doctor’s practice goes broke and he burns out.

Doctor #2

Doctor #2 was at the bottom of their class and has no clue as to what could be wrong with the patient. He spends five minutes with the patient, orders 100 lab tests, and refers the patient to a specialist. He then goes on and treats eleven other patients that hour in the same way. After one hour, doctor #2 bills for twelve level 4 patient visits, 1200 lab tests, and laughs all the way to the bank.

 

Which doctor do you want? Doctor #2 may be just fine if you have pink-eye or a stubbed toe, but what if you have amyloidosis and need a heart transplant? Why does the system favor doctor #2 so much?

 

Old school

You must put hands on the patient. There is a tremendous amount of information that is gathered by simply listening to the heart and lungs. Patients often do not tell everything up front. You can take a history that you think was complete and all of a sudden you see a scar and ask about it. A patient will then spill out ‘Oh I had heart surgery as a kid’ or something similar. (it would have been helpful if they had mentioned it before)

Check-boxes and past medical history forms are not sufficient to obtain a medical history –they are only tools to get paid.

What ‘old school’ seems to mean is actually being a doctor. Taking time with patients, touching patients, and examining them is essential to medicine.

Some doctors think that it is OK to not learn about different heart murmurs – just get an echo. What a waste of resources! This is why medical care is so expensive. Yes, an echo can tell you more about the heart, but the way the medical system is now this requires time, money, and lots and lots of paperwork – er, computer data entry.

If we were paid a salary as doctors instead of fee-for-service everything would be much easier. Then we could use echo machines for diagnosis and not worry about what billing code we need to use and making sure that we have a complete study. If our payment system were different we would all be using mini echo devices just as we (well, at least some of us) use a stethoscope today.

This is why doctors switch to concierge practices. Unfortunately this is not an option for most specialists.

Medical Thinking

There are two main ways of thinking in today’s medicine. One is the mentality of Obamacare and the use of business techniques – specifically from manufacturing – to improve throughput of the system and reduce cost. The goal is to improve ‘justice’ in the system by proving care to the most people possible. The quality of the care is measured by population metrics – cost, number of infections, mortality, etc. Doctors and patients are essentially interchangeable widgets in this system, and all medical problems can be reduced to a basic set of algorithms that will dictate care. Actually, because thinking is no longer required in this algorithmic, guideline driven system, the role of the doctor is not that important, and physician ‘extenders’ may be used as interchangeable parts. If some patients fall through the cracks and are misdiagnosed, mismanaged, or ultimately die, that is the cost of increasing ‘justice’ throughout the population.

 

The second way of thinking is ‘old school’. Each patient is considered unique, and every doctor/patient interaction is precious. Time must be taken to get a good history, which will then guide a hands-on physical exam, lab tests, and ultimately diagnoses and a plan of care. The process cannot be rushed, but takes the amount of time needed to come to a good outcome. Extensive training is required to be able to consider the multitude of possible diagnoses. This way of thinking is clearly better for the individual patient (and for the doctors) but is resource intensive.

 

If I were to devise a health care system for this country, I would take a cue from business and the way technical support is handled. This approach would maximize the benefit of both approaches above. Young and/or generally healthy patients would use a ‘level 1’ system which is the first option above. NPs, PAs, and primary care MDs would handle the vast majority of complaints (URIs, UTIs, minor injuries) in an urgent care type setting. Patients with multiple problems or who have failed treatment at ‘level 1’ would then be elevated to ‘level 2’ where experienced general internists would see the patients, optimally no more than ~8 per day, and take time to go through all of the medical problems, take time to educate, and diagnose more severe problems. ‘Level 2’ internists would then consult specialists as needed.