My response to a misguided opinion piece about surgery

"There is no place for the surgeon myth in modern medicine" says writer Alexis Sobel Fitts in Aeon Magazine.

Having a sister in medical school apparently qualifies Ms. Fitts to critique the specialty of surgery.

She starts with an old joke "An internist can figure out what’s wrong with you, but he can’t fix it. A surgeon has no idea what’s wrong with you, but he’s happy to fix it." If you read it carefully, you should note that it’s not that funny, and it’s wrong on both counts. No surgeon would ever fix something unless she knew why, and internists have these things called pills which can successfully treat a number of diseases.

She goes on, "After all, fixing problems is corporeal, often removed from the more intellectually nimble task of diagnosis." Apparently she is unaware that surgeons often make diagnoses—occasionally even correct ones, and I’ve written before about the misconception that doing an operation doesn’t require thinking [here and here].

"Surgeons are descended from the barber or the butcher," she says. That was hundreds of years ago. Nowadays, surgeons complete four years of medical school just like her sister and all the other doctors.

"Any missteps might incite devastating consequences, as the surgeon navigates around the vagus nerve, which dictates facial response…" I hope her sister didn’t give her that information. The vagus innervates many structures, but the face isn't one of them.

"Before anaesthesia and antibacterials, a patient undergoing surgery could be assured of two things: immense pain and the likelihood of infection and death." That’s actually three things. Of course without surgery, patients experienced immense pain, infections, and death anyway.

"Since the 1950s, laboratory science has increasingly been the origin of medical innovation. Which is why, over the past four decades, merely a 10th of the articles published in The New England Journal of Medicine have covered surgical innovation." Or maybe it's because The New England Journal is a medically, not surgically, oriented journal.

Here’s the winner. "Surgery’s place at the bottom of the medical hierarchy can be attributed to the crude cruelty of early surgical procedures." Other than Ms. Fitts, who has placed surgery at the bottom of the medical hierarchy? It’s certainly not US medical students who make the surgical specialties among the most competitive of all.

In the 2015 resident match, surgical specialties filled their first-year positions with 80% or more US medical school graduates. In fact, orthopedics matched with 94.3% US grads. Compare those numbers to internal medicine and family medicine, which filled their first-year positions with 49% and 44% US graduates, respectively.

Here's what Wikipedia has to say about its Aeon Magazine entry:

This article has multiple issues. Please help improve it or discuss these issues on the talk page.

The neutrality of this article is disputed.

This article contains content that is written like an advertisement.

This article contains weasel words: vague phrasing that often accompanies biased or unverifiable information.

That pretty much describes the Aeon essay about surgeons too.

Sticks and stones ...

The New York City Department of Education wants to ban some 50 words from appearing on standardized tests because the words might upset some students. The story apparently first came to light via the New York Post, but Google “New York banned words” and you’ll see lots of coverage and comment.

You can see the complete list here. To give you an idea, I’ve selected a few of the more interesting entries for comment.

Alcohol, tobacco, or drugs—I suppose they get enough about those topics after school anyway.
Birthday celebrations and birthdays—On the list because some religious groups do not celebrate birthdays. Being of a certain age, I don’t like these words either.
Celebrities—Is just the word “celebrities” to be banned or is it about mentioning the names of specific celebrities? Either way, I’m all for it.
Dinosaurs—We wouldn’t want them to learn about that subject or be tested on it now, would we?
Disease—Said to be banned because it might upset students who have family members who are sick.
Evolution—See Dinosaurs
Halloween—A dangerous topic for young minds.
Junk food—Interesting in light of all the talk about an epidemic of obesity.
In-depth discussions of sports that require prior knowledge—How would one ask about this on a standardized test anyway?
Sex—Take care of that on your own time.
War and bloodshed—So students can’t be asked about war on a test? That’s going to shorten history class a lot. And how are the kids going to learn about stuff like when the Germans bombed Pearl Harbor?
Weapons (guns, knives, etc.)—See sex

It looks like New York City has taken the “Nanny State” concept to new heights. What do you think?

This post appeared on Sermo yesterday.

Life Expectancy and Health Care Expenditures: Fun with Statistics

Recent data from the University of California Santa Cruz show that although the United States spends far more on health per capita than any other nation, the average life expectancy of its citizens ranks only 28^th in the world.

To support this, the website displays the following graph. It depicts life expectancy as bars and the purple line denotes health care expenditures per capita.

Can you see any problems with the data or the way the data are displayed?

I can. Let’s look at the countries ranked ahead of the US. Of the 27 countries ranking higher than the US, 16 have populations of under 11M with 6 of those having populations under 513K [Luxembourg 512K, Iceland 318K, Malta 418K, Andorra 85K, Monaco 35K, San Marino 32K]. At 312M, the US is by far the largest country in the top 30. Japan is second with 128M people.

The US has a much more heterogeneous population than any other country on the list. The per capita expenditures do not take social factors into account. For example, when anyone twists a knee in the US, an expensive MRI is likely to be ordered, not because it’s necessary, but because it’s expected by the patient. There are issues of non-compliance with medications and self-abuse with drugs, alcohol and tobacco. We also expend a lot of money on futile end-of-life interventions.

The bar graph itself is deceptive in that the scale range is from 74 to 82 years old. This makes the difference between the US and Japan seem much larger than the four years it actually is. This is a chart showing the actual difference on a scale of 1 to 85.

Now scroll down the page on the UCSC website and find this:

Although Cuba has limited resources and many economic problems, it has made health care a priority. It is not alone. Sri Lanka, China and the Indian State of Kerala are considered "low-income, high well-being" countries, which have adopted policies that not only reduce inequality but also increase overall health and well-being. The results of these policy priorities are significant, and can be measured in survival indicators, such as average life expectancy.

Now go back and look at the figure. You will not find Sri Lanka, China or the Indian State of Kerala in the list of the top 30 countries in life expectancy.

I am not saying we should not try to do better with our health care dollars. But I think the discussion should not be distorted by those with agendas. The behavior and expectations of our citizens will have to undergo a real sea change before anything meaningful will happen.

Penn State Scandal: It Gets Worse

Yesterday I blogged about the many things wrong with Penn State and the way the child molestation scandal was handled. Little did I know that it would get much worse.

The Penn State Board of Trustees finally appeared to do the right thing by firing coach Joe Paterno. But according to an article in USA Today, they did it in the best interests of the school. Here’s a quote from the vice-president of the board [italics mine]: "The current situation we are in at the moment is not in the university's best interest. We believe a change is necessary to allow us to continue going forward without further damage to the university. Great difficulties have engulfed our university.” Damage to the university? Great difficulties engulfed the university? What about the children?

Speaking of children, what is going on with the students at Penn State? I realize we aren’t talking about high intellect over at Happy Valley, but the moral compass and sense of priorties seem to be missing. Someone is wasting a lot of money on tuition. Check out these quotes from some of the rioters on campus via the New York Times.

“I think the point people are trying to make is the media is responsible for JoePa going down,” said a freshman, Mike Clark. Yes, the media did it. I guess if this hadn’t been exposed by the media, everything would be just fine at PSU.

“We got rowdy, and we got maced,” Jeff Heim, 19, said rubbing his red, teary eyes. “But make no mistake, the board started this riot by firing our coach. They tarnished a legend.” Oh, the board tarnished a legend. I see.

“It’s not fair,” Mr. [Justin] Muir said hurling a white ribbon. “The board is an embarrassment to our school and a disservice to the student population.” No, the students are an embarrassment to their school.

“Of course we’re going to riot,” he [Paul Howard] said. “What do they expect when they tell us at 10 o’clock that they fired our football coach?” Of course. There’s a big game this Saturday against Nebraska. How could they fire Joe now?

“This definitely looks bad for our school,” he [Greg Becker] said sprinting away from a cloud of pepper spray. At least this guy is on to something. It does look bad for the school.

The article said, “Mixed in the crowd were a few dissenting opinions.” But it seems the vast majority of the rioters were protesting the firing of their football coach.

Meanwhile, what about the children who were the victims? Where's the outrage for them?

Penn State Scandal. Can Someone Dial 911?

This is away from my usual subject matter but I am so disgusted and appalled by the Penn State scandal that I must comment. The mainstream media do not seem to be asking the right questions or pointing out the obvious.

A former defensive coordinator for the Penn State football team named Jerry Sandusky was just indicted on 40 counts of child molestation spanning some 15 years. The athletic director and the head of the campus policy are facing perjury charges.

Warnings were sounded as far back as the mid-1990s and nothing was done. In 2002, then graduate assistant Mike McQueary, who is now an assistant coach there, told coach Joe Paterno that he saw Sandusky sodomizing a child in the football team’s shower. Paterno’s response was to tell his boss, the athletic director, and no law enforcement or social agency was ever contacted. The president of the school was apparently informed. Penn State’s sole action consisted of barring Sandusky from the campus, which was not enforced.

Meanwhile, Sandusky continued to run a program for at-risk [they certainly were] children, which gave him continued access to victims.

1. When he saw what was going on why didn’t McQueary simply grab Sandusky and beat the crap out of him?

2. Why didn’t the McQueary go to the authorities when it became obvious that the school was doing nothing?

3. Until a few minutes ago, the school had the audacity to tell the media that Paterno would not answer questions about the scandal during his weekly pregame press conference. They just announced that the press conference was canceled.

4. When did “We did nothing illegal” supersede “We did the right thing”?

5. Everyone involved with this [McQueary, Paterno, athletic director, campus police head, school president] is as big a scumbag as Sandusky himself. If they have not committed a crime, at least they all must lose their jobs. [Note: the head of the campus police has "retired."]

Post Script: Sandusky’s biography is entitled “Touched.” You can't make this stuff up.