The failings of modern day academic medicine

Taking a tangent from previous postings, I wanted to turn my attention on the topic of our broken healthcare system in the United States.
As a physician myself, I have seen firsthand the failings as well as the moments of glory and success that can happen in the care of patients.
One issue that particularly troubles me is the condition of academic medicine today. Ask the common man or woman in this country what their opinion of the quality of healthcare that is delivered in an academic medical institution versus a private practice setting, and I would bet that most people would hold acadmic medical institutions in higher esteem. Most physicians, too, look up to academia. The ideal of a physician who takes care of patients, teaches students and residents, and engages in original research certainly seems more distinguished than a physician who takes care of patients all day in a private practice.
The reality I discovered firsthand during my medical training is that things don't always add up for most academic physicians.
The modern day academic medical institute has become focused on a few things: 1) money - in the form of wooing wealthy donors and grants from government or private sources, and 2) research, measured by the metrics of publications and NIH grant dollars secured. The other two items that are assumed in the responsibilities of an academic medical center - teaching and patient care, are becoming the neglected step-children of modern day medicine.
With respect to teaching, I found an abysmal inconsistency among the attending physicians I worked with in a large, urban academic center. Some attendings were quite good at teaching, others had no idea how to teach. There was no support on the part of the academic center to develop teaching skills on the part of the faculty. An academic physician was assumed to have the ability to teach, after obtaining the requisite degree and clinical or research training. The reality couldn't be farther from the truth. Simply knowing something in no way confers the ability to teach it to others. Furthermore, there is little supervision of faculty with respect to observing their teaching skills. If a particular faculty member is a horrible teacher, or worse, is teaching wrong things to medical students and residents - who would know? As a student and resident, I on occaison would submit critical evaluations of faculty who had no business involved in medical education, yet these faculty were never removed from their teaching rotations. It is astounding to me that the people who are teaching the future doctors of America often have less formal instruction in teaching than an elementary school teacher.
The other issue I would bring to light is that of patient care. The explosion of knowledge, therapeutic agents, and research in various specialities of medicine is enough to overwhelm most practicing doctors. The academician, especially the classic "triple threat" physician who teaches, takes care of patients, and runs a research lab, is left having to triage his or her focus on the things that keep the job going - namely research output. Clinical care often becomes quite rusty along the way. In the academic center where I trained, research tract faculty were required to attend on the inpatient wards for one month out of the year. These researchers spent most of their time in a lab, generating data and writing papers and grants, were briefly thrown into a position of supervising the care of some of the sickest, most critically ill patients around for only one month out of a year. It is no wonder the amount of mistakes I witnessed and lack of attending oversight that occured at my institution. I recall going on rounds with the chairman of rheumatology, witnessing how many times he could not figure out the diagnosis in a patient, when I was able to. This chairman spent only one month out of the entire year seeing inpatient consults, seeing maybe 5 or 6 consults a week. The remainder of the time, he focused on his bench research. It is no wonder that such low clinical volume results in a deficiency of clinical skill, even from a department chairman!
The data from many studies, especially in the area of surgery, clearly show that the volume of patients a physician sees can correlate to quality of care and outcomes. Would you rather go to a doctor who treats a dozen patients with your condition or 1,000? The problem with academic medicine today is that many academicians, especially those who engage in research, do not see enough patients to gain any degree of clinical excellence. Though I would not generalize my comments here to all academic physicians, I would urge academic medical centers, and their patients, to closely scrutinize the issue of the quality of care, and the clinical and teaching abilities of academic physicians, lest we be lulled into a false sense of security within the ivy towers.

The Madness of King George W and Don Quixote

Having recently read the newest English translation (by Edith Grossman) of Cervantes' classic Don Quixote, I cannot help but identify parallels between the character of Don Quixote and that of George W. Bush. Both men are stricken with madness - Quixote suffers under the madness of chivalry, while George W. Bush lives under the madness of an alternate, faith-based reality. Quixote, after reading scores of books on knights errant, decides that he himself is living in a mystical world like those described in his books - he attempts to create his own reality based on these beliefs, recruiting a trusty squire, Sancho Panza, and dedicating his exploits to his maiden, Dulcinea of Toboso, whom he does not really know personally. GW Bush, in a similar vein, attempts to create his own reality, whether it be on rationale for war, or the view of our occupation in Iraq, or the economy, or stem cells. The views of GW Bush are quite clearly more founded on faith than facts. Like Don Quixote charging the windmill that he perceived as a terrible giant, GW Bush rushed into Iraq, attacking the terrible threat that turned out not to hold such danger at the time, but is becoming more and more of a threat every day.
Don Quixote, however, lived in a world where those around him could easily tell that he was mad. Sancho Panza would try to advise his so-call knight that he was about to do something unwise. When Don Quixote encounters a duke and duchess, they take joy in playing games with Don Quixote, teasing him for his chivalrous fantasies and visions of the world.
Unfortunately, in this day and age, we have lost the ability to tell reality from fantasy. GW Bush is surrounded by advisors and fellow countrymen who suffer the same madness that he does. Where are the reality-based people to stand up and call the exploits of GW Bush as madness?! Those who might see the fantasy world that GW Bush lives in as false? A world where human influenced climate change doesn't happen, where evolution takes a back seat to the fantasy of Genesis, where mercury pollution is safe, where oil consumption is encouraged over conservation, where the will of big money trumps the will of the common man, where the embryo is more greatly protected than the men and women in our armed forces.
In Don Quixote, at least the protagonist woke up from his fantasy at the end of the novel, apologizing for his mistaken ways. Would GW Bush ever have such a revelation in his lifetime?

The fallacy of Islam as a peaceful religion.

After the Sept. 11 attacks in the U.S., the general Muslim community attempted to put a face of peace on the religion of Islam. Our president and other non-Muslim individuals stood by the Islamic religion with the message that Islam is largely a religion of peace, and that people like Osama Bin Laden who support violence in the name of Islam are an extremist minority in this religion.
Anyone who looks at the modern day history of Islam would conclude otherwise.
In world of literature and art, there are 2 names that reveal the bubbling undercurrent of violence that exists in Islam, even among so-called peaceful followers who are not part of any extremist groups. Those 2 names are Salman Rushdie and Theo Van Gogh.
Rushdie's plight started after publishing The Satanic Verses in 1988, over a decade before the 9/11 attacks. The reaction of the Muslim community to Rushdie's book was a unified condemnation of the work. Ordinary Muslims took to the streets in protest over this work. A bookstore in the United States of America was firebombed for carrying this book! And, of course, a fatwa was ordered against the author. Mind you, Rushdie's book is a work of fiction - never identifying the religion as Islam, or the prophet as Mohammed, or the religious text as the Koran in the passages that were deemed offensive by Muslims.
In 2001, long after the fatwa against Rushdie was lifted, I was having a conversation with a physician colleague of mine who is Muslim. When the topic of Rushdie arose, he had a very quick reaction - "if I ever meet that bastard, I'll choke him with my bare hands."
Ask yourself, is Islam really a religion of peace? How could any religion be "peaceful" when a follower who is a physician, entrusted with healing fellow humans, quickly turns to talk about murdering others when his religion is attacked in words?
More recently, the brutal murder of Theo Van Gogh in the Netherlands, after the release of his short film Submission, follows a similar pattern of violent reprisals against any artistic criticism against Islam. In this instance, the film in question highlighted the abuse and oppression of women within Islamic culture. Ayaan Hirsi Ali, a Dutch member of Parliament and the screenwriter for Submission, has received death threats and lives under constant police protection. The message from Islam is clear - do not criticize, satarize, or otherwise offend us, or we will murder you in defense of our religion.
In order for Islam to be truly accepted in the Western world, its followers must be willing to accept criticism in all forms, without resorting to violent reaction.
Those interested in reading for themselves the violent imagery that fills the Muslim holy book, the Koran, can view the Skeptic's Annotated Koran online.

The hypocrisy of Bush's stance on human embryonic stem cell research.

GW Bush and his Christian conservative base are of the opinion that human life begins at conception, hence a human embryo is considered a human life. Thus, in order to defend these "human" lives, Bush has taken a stance against any research that might lead to the destruction of these embryos.
If GW Bush and his Christian conservative base want to be morally consistent with their position, however, they should stand against the procedure of in vitro fertilization. GW Bush has remained completely silent on the topic of a procedure that is producing thousands and thousands of excess human embryos every year. These thousands of human embryos are left in a state of suspended animation - frozen in liquid nitrogen, and for the most part, unlikely to ever be allowed to develop into a human being. Some of these embryos might lose their viability over time, or through events such as power failures or incubator malfunctions, may die. There are currently an estimated 400,000 such frozen human embryos in the United States, trapped in what could be termed a physical purgatory.
And yet, GW Bush and the Christian conservatives don't seem to care about this. A few of them are taking the crazy mission to try to adopt these embryos to bring about a fully developed human life - the Snowflakes foundation is one such group, exploited by Bush in a recent East Room photo op. Good luck finding nearly half a million women willing to provide their wombs for such a cause.
I wonder how Bush and the Christian conservative base would do if we developed a technology to generate a viable human embryo from any human cell - so-called therapeutic or reproductive cloning. Would we be forced to care for every hair, skin cell, or other part of our body, at the risk of destroying a potential "human life"?! Or would they simply denounce such technology as an abomination? The parallels between cloning and in vitro fertilization are that excess human embryos would be generated in both techniques, yet one technique would be abhorred while the other is accepted by the Christian conservatives.
The misguided views of GW Bush and the Chrisitian conservatives has one key source - the Christian Bible. We need to realize one fundamental issue - the Bible is not a science text. To attempt to derive any scientific truth from the Bible is lunacy. If we would view the Bible as scientifically accurate, we would still view the world as flat!!!! Again, refer to the Skeptic's Annotated Bible for numerous references to a flat world in the Bible, and other scientific falsehoods.

Moral relativism and Christianity

It is astounding to see the efforts of those who preach extremism and moral absolutism inspired by the Christian Bible. The current Pope, former Cardinal Joseph Ratzinger, denounces moral relativism and continues to build outrageous arguments against birth control, including the use of condoms.
One wonders, though - has Ratzinger even read his own holy book, the Bible?
What does he have to say about the plethora of moral relativism or contradictions that exist in this so-called inspired word of God?
For instance, God, in his wisdom, orders us in commandment number 6 - thou shalt not kill. Yet, in the course of stories recounted in the Bible, God has no problem killing people - even innocent children! What about his prophet, Moses - who kills an Egyptian while no one else is watching, just for kicks!
If the Christian God, as recounted in the Bible, cannot keep any degree of moral absolutism or adherence to his 10 commandments, what right does Ratzinger or anyone else have to preach against moral relativism?
Meanwhile, people like Ratzinger who preach absolute doctrine, such as standing against the use of condoms, have blood on their hands - the blood of millions of people becoming infected and dying with HIV. Where is the concern when misguided dogma contributes to human deaths?
I would urge anyone who really wants to see the injustice, contradictions, and frank absurdities present in the Bible to peruse the Skeptic's Annotated Bible online.

Terri Schiavo, the Schindlers, the Pope, and the misguided and manipulative vision of fundamentalist Christians

The autopsy findings on Terri Schiavo were released yesterday, confirming what reality-based individuals knew already - that Mrs. Schiavo suffered massive and irreversible brain damage, consistent with her clinical diagnosis of persistent vegetative state.
It astounds me that Mrs. Schiavo's parents and siblings had such a twisted view of reality that they believed that Terri could communicate purposefully to them, and even speak! Further, they used manipulative snippets of a 4 hour video to sucker others into their faith-based view of Terri's condition.
To relate what it might be to suffer in Terri's condition, imagine being in a state where you had no free thoughts, where every action you did was either a reflex or a random movement. Imagine not being able to will your body to raise your arm, or scratch an itchy spot on your back. Imagine not being able to process images with your mind - to be cortically blind, where you can't tell what you're looking at. Imagine being erased as a human being in everything but basic bodily functions - breathing, feeling pain and other primitive sensations, maintaining a heart beat. This was the tragedy of Terri Schiavo. Terri was not simply a "handicapped" individual - she was a neurologically devastated person. The reality was that Terri's condition would never improve from that. No amount of prayer, no amount of pleading to any supernatural force would change that.
We would all agree that individuals in this devastated state or any other clearly deserve compassion and care. But one must truly understand the medical severity of the situation to see the logic and compassion in allowing someone like this to die peacefully, without artificially extending such a medically hopeless existence through artificial means. The withdrawal of feeding tube support for Terri Schiavo was a compassionate act - an act of letting the body naturally follow where the mind had already gone. It is a cruel joke to call the death of Terri Schiavo a murder or a senseless taking of human life. Modern day medicine is based on the respect of autonomy, and the respect of surrogate decision makers such as a husband. The delusional views of the Schindlers had no merit in this case.
The reality revealed in this case and others like it is that in the modern era of medicine, we can decide how we die. No God or other supernatural being makes those decisions - the decision lies in our hands and with our physicians. We have tools - the modern intensive care units, ventilators, feeding tubes, and other supportive means - to extend life in quite an astounding fashion. None of these tools should be used without the express consent of the patient or a surrogate decision maker. Imagine the Pope, in his last days, being carted to the ICU against his wishes, forced onto a ventilator, poked and prodded with IVs, blood draws, intensive antibiotics, all in the name of tapping every second of life - precious or painful - by any means necessary! The Pope chose how he died - in the peace of his own apartment, with minimal medical supportive care. He did not wish to give Terri Schiavo that same privilege.
This case should make America and the world wake up to the dangers that fundamentalist Christian can bring. Would you want such people dictating your medical care?

The mission of this blog - to discuss, expound, and promote the views of a modern Gadfly in the tradition of Socrates, using rational argument to shake the complacent from the nests of irrationality.