The Resuscitational Imperative, II

On the other hand, there is now definitely a culture (measured by off-hand comments by residents, facial expressions assumed when discussing families who do not make the "correct" decisions, and the like) which promotes the DNR order. It is taken by some as the very goal of goal-of-care discussions. If a patient is very sick, has been so for a long time, and the prospects for recovery of functional status (meaning a significant quality of life) are minimal, we are pleased when a DNR/DNI order is obtained, and even more pleased when comfort care is decided upon.

But I also want to talk to the patients fully and frankly about what "significant quality of life" means. If the patient (or her family) wants to be kept on a ventilator indefinitely, even if there is no chance of life off the machine, that would be valid - because medical futility, like all medical decision-making, involves ethical assumptions which patients and families might not share; and because health-care costs and resultant rationing, so often in the back or front of our minds when discussing such issues, are not significantly affected by long-term ventilator support. (See this brief article in the New England Journal for a discussion of both these issues.)

My goal this rotation, when I admit patients overnight at Bellevue, is to include as part of the problem list the category Goals of Care and to discuss these with the patient. This won't happen for everybody, and maybe for nobody (it gets busy). But it's something to work towards.

The Resuscitational Imperative

It's not a technological imperative that drives the resuscitation of so many patients who (if you had asked them while they were of sound mind and not about to die) would rather not have been resuscitated, it's a philosophical imperative. Most doctors, in my admittedly limited experience, are biased towards doing something rather than nothing. Or - rather - biased toward the assumption that taking a positive action is more helpful, because more active, than doing nothing. But sometimes doing nothing is not doing nothing at all. Letting someone die can sometimes accomplish more than a breathing tube or a defibrillator ever could.

Who will have a mandate for a mandate?

Laszewski says it again:

I worry that both [Clinton and Obama] have cost containment strategies that would do little more then dent the continued escalation in health care costs and undermine both of their guarantees for affordable coverage.

Applied Nostalgia

My daughter and I had a fight last night (she's four; it happens) and we made up with me singing songs to her. The songs were in Yiddish, the language we speak at home. I was randomly singing whichever Yiddish songs happened to come into my head, and in the middle I thought: Isn't this ridiculous? The last three songs were a Bund ballad about blowing up a German ammunition convoy; a paean to Vilna; and the Partisans' Song. (I'm not usually so historical, but there you are.) It struck me, not for the first time, how unrooted my Yiddish language and culture is in my individual, quite ordinary-American-Jewish experience, and how an outside, Eastern-European-born observer might think that my use of these historically freighted songs is disrespectful, jokey, or obscene. (Some do.) What do I know of guerilla warfare, Jewish Vilna (I mean its physical bricks-and-mortar), or the routes of the Baal Shem Tov (the subject of another song)?

I used to answer "No" (a little hurt) when asked if my attachment to things Yiddish was due to nostalgia. How can I be nostalgic for something I wasn't born into? But that's precisely the point. We yearn for what we are not conditioned against. The tension of my ideological attachment to Yiddish is to be aware of the sunken past while not drifting away from the present in which Yiddish, very much extant, is quite un-Eastern European.

As for nostalgia, Jews couldn't get along without it. One of my daughter's favorite songs is Yah Ribon, whose last verse recollects the Temple. I never saw that either.

Youth! Youth! Yeth?

Yugntruf gets its yugnt back. (Hat tip: Byuralistke.)

Distress and disease: inextricable

The important lesson to be drawn from studies of medical-psychiatric comorbidity is that distress and disease both produce physical symptoms. It is not productive to dichotomize symptoms as "somatogenic" and "psychogenic" because physiologic and psychological processes are involved in all symptom production and perception. "Rule out" diagnostic strategies that search for either a medical or a psychiatric cause of a physical symptom are not supported by epidemiologic findings of high rates of medical and psychiatric comorbidity.

-from Katon W, Sullivan M, Walker E. Medical symptoms without identified pathology. Ann Intern Med 2001;134:917.

I remember last year when I started the night float rotation; the interns passed around a handout, compiled a few years ago by some previous interns who were now attendings, about how to diagnose common inpatient complaints. Anxiety languished far at the bottom of the list for diagnoses explaining chest pain. "This is a diagnosis of exclusion!!" said the handout - the implication being that no one should ever diagnose anxiety (or other psychological complaints) on the hospital floors. The cultural supposition is that chest pain is either a heart attack, or an aortic dissection - or else it's "bullshit." (No one would write this, of course . . . it's understood.)

Unintended IRB humor

From the directions to an IRB form I'm filling out:

Describe potential benefit(s), if any, for subjects participating in the research. If there are no anticipated benefits, this should be stated. [Note: Payment to subjects is not considered to be a benefit of research (see Payment section below)].

What is payment to subjects if not a benefit? (Shades of "Guinea-pigging.")

R and R

Regret
slips its noose
around the neck.

Remorse
sinks its tooth
into the corpse.

-Samuel Menashe

There I was today (by now yesterday) at Rizzoli's in front of the poetry section on the third floor, the elevator doors open and an older man calls out, "You're right in front of my book and you don't even see it!" He plucked it off the shelf in front of me. "I saw you read at the Harvard Club," I said to him. "Yes, the place was packed," Menashe agreed. "Three hundred people, and for some reason they didn't let me sell any books there."

Now I feel guilty I didn't buy his book today. There's always next time! (I did buy this one, which bears some distant spiritual relation.)

(Oh, and I didn't embarrass myself by telling him I'm a poet. Personal Dignity 1, Networking 0.)

Cool vs. High-Strung

Obama has been anointed the Cool Candidate on the strength of his spellbinding stemwindery. I feel my inborn contrariness (rhymes with orneriness) pulling me away from Coolness and toward hard-bitten (maybe even a little embittered) experience. Hillary, anyone?

A shot of panic becomes the rustle of glucocorticoid

Speaking of Kathleen Graber, she has a great poem in the newest issue of the New Yorker.

Nothing To Complain About Right Now

Every biting winter
was fall's soft cliché,
every aperçu
was a drunken bawl.
The queer tongue of our ancestors
is enlivened by the dead
and cobbled by curses.
I've been to countries
where that all lives on.
They saddle up their sins
and shout after the nag:
Improvement by degrees!

Unfair One-Off Ignorant Assessments, and Short Snippets of Poetry (without line breaks), From Last Night's Readers

Kathleen Graber: thoughtful, careful, with an intermittently epic reach, sometimes too grounded. I bought her book because I wanted to get the best impression of her poetry. "The form of stone is the form of attrition. It becomes itself by what is lost."; "[...]delicate rigid body of a bird[...]"

Catherine Pierce: concrete, domestic, honest. From her love poem to America: "America teach me how to strut . . . I love how afterward you roll over and snore like a locomotive before I even catch my breath."

Shin Yu Pai: I didn't write anything down to quote. I learned from her that the food industry is bad-bad-bad!

[Christopher Stackhouse read after Pai, but I must have been sleeping after my one beer; I don't remember what I thought of him.]

John Keene: earnest, professorial. "Driving at what is arriving, you must parse it out."

Ross Gay: by turns terrifying (not him, but his poem about unspecified violent little creatures) and nastily funny (about his friend's racist girlfriend). From the former: "the little one sat curled in a lump pretending he was dead"; from the latter (the girlfriend, white, speaks to her black boyfriend about how he is not "street" enough): "What does your Hegel say about funk? Your Dubois? / I only date hood."

Daniel Nester: Definitely the guy I liked most. Funny, self-deprecating. When I went up to him afterward and asked him if he was selling anything, his look of mild surprise and unfeigned delight was a pleasure to behold. "I brought one copy of a book of mine, if you want to buy it for five dollars," he said - so I did. From a poem: "When I said you were as old as my mother I wasn't trying to make you old or make you my mother. I was trying to give you details."

Talking about Jesus, II

The comment from "Hashem is Magic" got me thinking. Is it true that the injunction against "letting the name [of other gods] be heard on our lips" is meant to prevent our invoking them by utterance alone? Not quite.

There are two parts to the verse: first, that their names not be mentioned (ושם אלהים אחרים לא תזכירו); second, that they not be heard from the mouth (לא ישמע על-פיך). On second thought - are they two separate parts, or elaborations with differing emphasis of one central prohibition? This seems to be the central issue of the commentaries.

To summarize before getting into particulars: The Talmud grounds the whole verse in the prohibition of collaborating with idol worshipers. One does not swear by an idol (more precisely, a subject of avoyde-zore) because in that context one might come to work together with those who worship it. This short discussion is prefaced by another prohibition: one must not say to one's fellow, "I will meet you by the [name of idol]."

What the Talmud doesn't entirely clarify is the difference between לא ישמע and לא תזכירו. The Gemara connects the later phrase ("don't mention") to its disapproval of using an idol's name to identify a meeting place, while the former phrase ("don't let be heard") is glossed in the following way: "that one not make an oath in their name or carry out a promise in their name, nor cause others to do so."

The Talmud makes two other stabs at the meaning of לא ישמע על פיך. It could serve as a warning not to lead other Jews to sin in making oaths by idols; or it could be an injunction against collaborating in business with worshippers of avoyde zore. The latter opinion (of אבוה דשמואל), standing unchallenged, seems to be the final interpretation.

However, this approach does not square with that of the later commentators. For example, the Ramban says explicitly that any kind of mention at all, whether or not it has anything to do with idol worship (or collaboration with idol worship) is forbidden. (How Ramban understands the strength of this prohibition is unclear.) The Rambam, in his Laws of Idol Worship, cites the passage from the Talmud (nearly) verbatim. He holds that making an actual oath in the name of an idol is forbidden and subject to punishment by a rabbinical court, while a mere utterance of the kind mentioned by the Talmud is prohibited, but without explicit punishment.

The Sefer Chinuch, a compendium of commandments and their justifications, indicates that לא ישמע על פיך is a הרחקה i.e. an ancillary edict meant to strengthen a central prohibition.

The most sensible commentary, both true to the structure of the verse itself (לא תזכירו and לא ישמע על פיך are not different injunctions, but parallelisms) and the understanding of the Talmud (that the central prohibition has to do with swearing by avoyde-zore and collaborating with its practitioners) is that of the Shadal:

והוסיף לא ישמע על פיך, והוא כמשמעו לא יהיה שם האלילים נשמע על פיך, כלומר אפילו לפרקים ודרך עראי, אך לעולם הדבר למד מענינו שאין איסור אלא להזכיר דרך כבוד לתהילה ולתפארת או דרך תפילה ותחינה, ולא שתהיה הזכרת שם האלילים אסורה בהחלט, כי הנה משה אמר ( דברים ד' ג' ) : כי כל האיש אשר הלך אחרי בעל פעור וכו'.

"And [the verse] adds "it shall not be heard from your mouth," and this means that the names of other gods should not be heard from your mouth, that is to say even intermittently and casually. But of course the basic point here is that the prohibition is only that of mentioning [them] with honor and glory or in prayerful fashion, not that the mention of the names of other gods should be completely forbidden, since even Moses said 'every man who followed Baal Peor.'"

The above assumes that Jesus, for example, is a subject of avoyde-zore. I don't think this to be true.

The Yiddish FBI

The Forward's Allan Nadler favors us with a biting overview of the most decadent of history's rebbes. (Note that not all rebbes are decadent, and that Nadler speaks from a Misnagdishe viewpoint. He is biased, to put it mildly.) In the middle he says:

And so, Mayseh Ushits might be viewed as a cautionary tale for the alleged informant at the heart of today’s scandal. The Russian despots who persecuted the Hasidim and imprisoned their leaders were motivated by a lethal hatred of both Jews and Judaism, while the FBI is quite simply enforcing the laws of a just and uniquely philosemitic land (with the assistance, by the way, of a small team of FBI Yiddish translators, as a fascinating little footnote in the Bureau’s transcripts revealed). But this distinction is lost on the Spinker Hasidim, to whom the very idea of historical evolution is entirely foreign and whose main concern, now that the Rebbe is “free,” is to wreak God’s bloody vengeance upon the despised informant.

I could have been one of the FBI's Yiddish translators. Now the tale can be told (because no one cares at the Department of Justice whether I breach my little corner of confidentiality). There was a Web advertisement for free-lance Hebrew and Yiddish translators, so I bit. There was a written test (inexpertly typewritten, then mimeographed), featuring reading-comprehension questions based on passages that read like they were taken from pre-spelling-reform Forverts about how many troops were massing against what enemy on the northern front. ("Question 23. How many tanks does the enemy have rolling towards us right now? A. 1,000. B. 250. C. Those are not tanks. They are horses painted to look like tanks.") Then a telephone interview with a pleasant speaker of Polish Yiddish.

And then the lie detector test. At one point, the interviewer looked crossly at me and said, "Look, I really want to help you get this. I want to help you land this job. But you have to help me out. Why aren't you telling me the truth?" I think the problem was that I was associated with "foreigners" (e.g., the foreign-born editor of the Forverts) and so my answers to some questions ("Are you in cahoots with the Russkies?") might have been suspect. So I failed.

I'm not an FBI Yiddish translator . . . because I'm a liar.

Why not saying "Jesus" is silly

There are Jews in this world who are punctilious about not mentioning the names of others' (putative) gods. The verse [Exodus 23:13] they mention to support this practice includes the words לא ישמע על פיך, which is to say "[the name of other gods] should not be heard from your mouth." But these particular punctilieurs are careful not to mention these names even when such a mention could not possibly be interpreted as approval (much less worship) of these religious figures! Yes, there are people who really won't say the names Jesus, or Zeus, or (I guess) Zemu, and use made-up names like "Simcha [not Santa!] Monica."

That this is silly is well-known, but the reason has always been hard for me to articulate: until now. Language Log does a nice job dissecting the use-mention distinction.

Chinese for Doctors

You'd think that would be the title of an easily available book, right? But it isn't I thought it isn't. There's the Medical Chinese web site - very useful, to be sure - that some NYU medical students put together; I'm sure there are a number of other sites like it. Then, on the other end of the spectrum, are the thesauruses and dictionaries that are only useful for someone who already reads Mandarin fluently. But [I thought until now] there's no handbook that I could carry around.*

. . . I swear, I didn't start this post thinking I was going to advertise their book. But now they have one! I'll buy it tomorrow and review it here.

*There's Chinese Medical Chinese, which is euphoniously named but not relevant to Western medicine.

The literary virtues of Communism

Mikhail Krutikov in the Forverts:

The time when Jews in America felt unsure of themselves is probably over, and it's no longer necessary to feel ashamed of realistic portrayals of past Jewish life. American Yiddish literature was possessed of many artistic virtues which are impossible to separate from its predominantly left-leaning worldview: sharp anti-capitalist criticism, naturalism, and universality.

All the regulations: whose fault are they?

Whenever I complain about the bureaucracy attendant on every decision in our residency program - squashing us like bugs - the answer comes back: "Yes, JCAHO makes things hard for us." But the Joint Commission includes corporate members: the American College of Physicians, the American Medical Association, and the American Hospital Association. If my home institution, for example, thought that the JCAHO requirements were needlessly onerous, couldn't it organize opposition together with its fellow institutions? Or are we all just being sucked into a bureaucratic vortex?

The Moral Imagination

Steven Pinker's essay on the moral sciences (Adam Smith, anyone?) in the Times is written in the excited tone of a true believer, and I'm a heretic. The claim is that morality is hard-wired into the brain, and that experimental psychology (with its LiteBrite phrenology, the fMRI) is the window into that wiring.

The main problem I have, grosso modo, is lightly touched upon by Pinker about midway through his article where -- in the context of categorizing the moral priorities of various cultures -- he tosses off a brief disclaimer about whether a given anthropologist is a "lumper or a splitter." The implication is that, if one lumps enough, one can find a useful number of moral categories whose distribution can be predicted by presumed psychological laws.

But morality (which Pinker, if you notice, never gets around to defining) is the very art (or science, or discipline-of-thought) of making such distinctions. Recourse to broad generalities of human behavior (that millions of people around the globe tend to respond the same way to a an Internet survey about counterfactual trolley accidents) is not the same thing as discerning the sources - let alone the definition or guiding principle - of morality. That various approved opinions or behaviors are "moralized" (smoking) or "demoralized" (premarital sex) does not mean they are indicators of changing boundaries of morality, merely that high dudgeon is fungible.

Lumping and splitting is particularly tricky when it comes to religion. This is important, because comparative religionists like to lump. I don't know about the details of many religions, but when "the holy ablutions and dietary restrictions of [...] Orthodox Jews" (that 'Orthodox' drives me nuts, but never mind) is taken as an exemplar of the moral categorization "purity," I raise an eyebrow. The same mistake is made here by which Chomsky facilely lumps all languages into the same hard-wired diagram. Which "holy ablutions" are meant exactly? There are a number in the Torah, and they don't all serve the same purpose. The aim of kashrut, in the Biblical worldview, is a vexing question. I think Milgrom has it right with his proposal that the dietary restrictions are a way to separate out the Jewish people in holiness from the nations. But this is a crucial distinction and something different from "purity."

I don't deny that moral psychology is a science that will contribute to our understanding of morality. But definitions, and fine distinctions, make morality a very tangled tissue to see with any scan.

Hillary Clinton's Health Care for All

Cost Containment, Individual Mandates, and Free Choice - Too Good to be True?
[See a comparison of the Giuliani and Clinton plans at Clinical Correlations.]

Hillary Clinton's health care plan is only a few pages long, but the difference between a health care plan and a piece of legislation is the difference between a paper airplane and a space station. Let's look at some of the details of her plan and see where complications might ensue. Clinton's proposed plan would require every individual to choose an insurance plan of some kind. Anyone could keep their current insurance if they were satisfied with it. If they weren't satisfied, two choices would be available: one a menu of private options offering the same benefits as the health insurance that members of Congress are provided with, the other a public plan similar to Medicare. Tax credits would be offered to working families to make it easier for them to afford insurance. How would this be paid for? One answer of Clinton's is a traditional claim of politicians from time immemorial: savings will be achieved through eliminating waste, fraud, and abuse - but with additional savings from the use of medical informatics.

The details aren't spelled out, and those are where the complications come in. (The following discussion owes a great deal to the blog Health Care Policy and Marketplace Review.) Through the two insurance options envisioned by Clinton - a private menu offering the same benefits as those available to members of Congress, and a government-run insurance plan similar to Medicaid - the government would do two things: establish an individual mandate (i.e., requirement) for health insurance - everybody would have to purchase some - and, second, place the government in direct competition with the private sector. How this competition would be legally implemented, and which side the eventual legislation would favor, is impossible to know. Clinton also promises a reduction in premiums. This will happen only if the promised reductions in waste, and increases in efficiency, translate into greater savings for the healthcare "consumer." Neither of these are guaranteed. In particular, Clinton mentions two routes to cutting costs which are trickier than one might imagine: preventive care and information technology. Preventing, you'd think, is cheaper in the long run than treating, and electronic medical records are cheaper than paper. But neither assumption has been borne out by the literature. (A third often proposed salvation, pay for doctors' performance, or for positive outcomes, is just as difficult - but it's not among Clinton's proposals.)

I mentioned earlier one of the key provisions of Clinton's plan: an individual mandate for health insurance. This is paired with other requirements that other participants in the system must follow. To quote:

• Insurance and Drug Companies: insurance companies will end discrimination based on pre-existing conditions or expectations of illness and ensure high value for every premium dollar; while drug companies will offer fair prices and accurate information.
• Individuals: will be responsible for getting and keeping insurance in a system where insurance is affordable and accessible.
• Providers: will work collaboratively with patients and businesses to deliver high-quality, affordable care.
• Employers: will help finance the system; large employers will be expected to provide health insurance or contribute to the cost of coverage; small businesses will receive a tax credit to continue or begin to offer coverage.
• Government: will ensure that health insurance is always affordable and never a crushing burden on any family and will implement reforms to improve quality and lower cost.
  

What "fair prices," "high quality," and "large employers" are taken to mean has been a source of debate even before the first Clinton health plan. How will affordable coverage be mandated when some estimates place the cost of family health coverage at $12,000 per year? If twenty-five employees is the cutoff definition for "large business" (as the Clinton campaign has indicated), what would smaller businesses be required to provide?

The two other pillars of Clinton's proposal are making health care affordable and fiscal responsibility. Health care affordability would be made possible by tax credits for families and for small employers, and for limiting the cost of premiums as a percentage of income. Affordability in this case means - affordable for the end consumers of health care, individuals or employers. This is different from affordability for the Payer of all Payers, the federal government, and, by extension, the individual taxpayer.

What about fiscal responsibility? The Clinton plan predicts that "most savings [will] come through lowering spending due to quality and modernization." As Robert Laszewski of the Health Care Policy blog says, this could be Clinton's most dangerous assumption. If quality and modernization cannot ensure savings by themselves, (a much safer assumption), if providers and payers cannot agree on cost-limiting measures, if more taxes on the higher brackets (i.e. the rich) will not be enough to balance the books (as Clinton assumes), what will happen to the Clinton plan?

Laszewski points out that "from thirty thousand feet," all Democratic healthcare plans look the same: lots of new spending to guarantee access for all Americans to some sort of health care plan, whether public, private, or in between. Republican plans, for their part, tend to invoke individual mandates, a vibrant free market of competing health care choices, and technological efficiency. Informed consumers with the proper incentives would know to allocate their resources efficiently. (Whether Medicare Part D proves this assumption is open to question.) If Clinton's health plan stakes out a centrist position in between these two, in what direction will the "sausage factory" of legislation push the finished product? We'll see . . . if she gets that far.