Truth = an abundance of belief

https://m.youtube.com/watch?v=mRlWwoam9fk&feature=youtu.be

The New Socialists

There are times when I simply stare in disbelief at what I am reading. Today in the New York Times, there was a piece titled "The new socialists" (Link). It was a commentary on the wave of younger politicians, mostly on the local level, following the lead of Bernie Sanders with an unambiguous embrace of socialist policies. The article is written by Corey Robin, a professor of political science at Brooklyn College and the City University of New York Graduate Center. Mr. Robin writes:

Self-identified socialists like Bernie Sanders, Alexandria Ocasio-Cortez and Rashida Tlaib are making inroads into the Democratic Party, which the political analyst Kevin Phillips once called the “second-most enthusiastic capitalist party” in the world. Membership in the Democratic Socialists of America, the largest socialist organization in the country, is skyrocketing,especially among young people.

Mr. Robin delves into the source of the appeal. He goes on write that:

The socialist argument against capitalism isn’t that it makes us poor. It’s that it makes us unfree. 

Socialism means different things to different people. For some, it conjures the Soviet Union and the gulag; for others, Scandinavia and guaranteed income. But neither is the true vision of socialism. What the socialist seeks is freedom.

Under capitalism, we’re forced to enter the market just to live. The libertarian sees the market as synonymous with freedom. But socialists hear “the market” and think of the anxious parent, desperate not to offend the insurance representative on the phone, lest he decree that the policy she paid for doesn’t cover her child’s appendectomy. Under capitalism, we’re forced to submit to the boss. Terrified of getting on his bad side, we bow and scrape, flatter and flirt, or worse — just to get that raise or make sure we don’t get fired.

The socialist argument against capitalism isn’t that it makes us poor. It’s that it makes us unfree. When my well-being depends upon your whim, when the basic needs of life compel submission to the market and subjugation at work, we live not in freedom but in domination. Socialists want to end that domination: to establish freedom from rule by the boss, from the need to smile for the sake of a sale, from the obligation to sell for the sake of survival........
The socialist, by contrast, believes that making things free makes people free.

Say what? Making things free makes people free? However, things are not free and cannot be free. We are inherently dependent upon others for our existence, unless we can take care of all our needs without anyone else's help. That is essentially impossible. Yes we are forced to enter the "market" to live, but remember what markets are. They are places where people are free to enter into voluntary agreements with other like minded people who are free to interact or not. That is the nature of freedom.

What alternatives do we have other than voluntary exchanges or interactions?  The alternatives are limited to no exchanges or forced exchanges. Humans can function at three basic levels; as single individuals, as individuals as part of groups where members participate voluntarily, and part of members of states where the state has the power to coerce its members. Market exchanges are marked by freedom to participate or not. States are defined by their authority to force members to comply. States have the proverbial ability to hold a gun to your head. Socialism highlights state ownership and control.

I believe that in a world that seems to be marked by political gridlock, one of the attractions of Socialism is its promise to use the power of the state to force those who might be viewed as hindering getting things done into complying with those who believe themselves to be right. For those who hold a strong and unwavering vision of being right, this perspective can act as a siren's song. However, one needs to remember that creating pathways increasingly unbridled power will attract those who are most motivated to harness that type of power, and tend to be least constrained by moral scruples that would limit their exercise of power.

It is reasonable to have pointed discussions regarding the failings of market based systems. However, those discussions need to be coupled with honest discussions of failures and catastrophes of unbridled state power. There might be disagreements as to all the particulars of how to define Socialism, but there is agreement that it is at its most basic level, an expansion of state power.

What criteria are important in selecting leaders

As most of you likely realize, I live in Georgia. We are in the midst of a contentious election for governor which has made it on to the national stage. I am not at all happy about by choices. On the Republican side we have Brian Kemp, who out-maneuvered current Lieutenant Governor Casey Cagle for the nomination by out-Trumping him. Don't get me wrong, I was no Casey Cagle fan and I suspect I would be in the same boat if Brian Kemp had lost the primary. However, Kemp prevailed because he sent a xenophobic and gun and chain saw worshiping message to the voters and connected with their inner reptiles. It was simply mean-spirited.

 Just to give him a fair shake, I visited him website. It did not instill any confidence.  It is filled with platitudes but there is little content. He wants to "take a chainsaw" to state regulations. I am all for limited government but there are NO specifics on how this portion of his platform will be implemented. He makes a strong appeal to rural Georgia which I sense is reaching back to the past.

Then there is the Democrat candidate Stacy Abrams. In contrast to Brian Kemp, her website is rich with content describing her proposed agenda. I agree with her on her social agenda and have my disagreements with her on fiscal policy. The cloud that hangs over her is one relating to her personal finances, which she has been completely transparent about. She has over $50K of deferred Federal Taxes and It has been reported and commented on by both state and national press including the New York Times. Today there was an OpEd piece which commented on the Kemp attacks:

This line of attack throws a pernicious political dynamic into high relief. The financial problems of poor and middle-class people are treated as moral failings, while rich people’s debt is either ignored or spun as a sign of intrepid entrepreneurialism.

Reading interviews of Ms. Abrams fill in details which point to her use of financial options available to her to meet the needs of her family, shedding a more positive light on her particular circumstances.  She took on the role of saving her extended family from financial calamity after the convergence of a host of factors. Ms. Abrams is clearly a financial risk taker, which has it upsides and downsides. She is not afraid of personal debt.

I still have to ask the question as to whether it is appropriate for voters to be skeptical of an individual's ability to make good decisions regarding state government finances when they have made perhaps poor decisions with their own? The Times clearly thinks this to be inappropriate. I think it is reasonable to ask what they have learned from their experiences. Ms. Abrams accrued heavy debt to finance her education and has continued to use debt to further her career. She does not regret doing this and does not believe it to be a mistake, yet. Does that approach to debt translate into how she will govern? No matter who she is and where she came from, this is a legitimate question to ask. 

Anger, fear, the reptile brain, and electoral success

It appears that it is perpetually election season. For a creature like me who is fundamentally skeptical of the ability of political systems to actually solve problems, I would rather think about almost anything except politics. I realize that my own take on the evolution of politics and the nature of political competition is but a brief flash in the long history of how politics has been conducted in human history stretching back millennia. However, it appears to me that earlier in my lifetime, my perception was that politicians at least tried to appeal to the electorate's ability to reason, at least early in campaigns. Maybe this was an aberration,

This all takes me to thinking about studies over the past 50 years on human decision making. How do we decide what party and candidates to support and what issues to champion? It turns out that we pick candidates an issues much the same way we any other choice, whether that be a pair of shoes, a menu item in a restaurant, or where to buy a house. We are endowed with two decision making machines in our brains which have been described as system 1 and system 2. The former is an evolutionary ancient tool which operates below our threshold of consciousness. It can process huge amounts of information with little or no effort and its readouts are emotional. System 2 is a more recent evolutionary development. It is what we are conscious of. It is slow and plodding, a serial processor, capable of more nuanced thought. It is also a resource hog which can be used only sparingly without exhausting its user.

My observation is that campaigns historically have started by trying to appeal to system 2, but over time as campaigns heat up, they quickly more to strict system 1 appeals. Over most recent years, it appears that all attempts to appeal to system 2 have gone away. It makes sense. Why bother appealing to the rational and thoughtful brain when we all know that the election will be decided by system 1 appeals directed to fear, anxiety, anger, and envy?

Much has been made of Donald Trump's appeal to white rage and anger. I think what made Trump stand out is his immediate dismissal of any need to appeal to the rational side of voters. In that sense he was very efficient in the use of his resources. His success derived from this strategy is very concerning, but also concerning to me is the strategy of his opponents, rejecting his aims but embracing his approach. They match anger with more anger.

My question to my readers (all five of you), is "Is anger a good starting off point for political movement?" I think not. There is no question anger and fear are powerful motivators in politics. They may be able to get you elected but they are terrible motivations when governing. Is it possible for those who get elected by appealing to system 1 can govern using system 2? Perhaps that does not matter when governing becomes a secondary priority.

Medical Pricing Opacity Madness

I blog worth reading
https://johnhcochrane.blogspot.com/2018/07/cross-subsidies-again-hip-replacement.html

This is not going to change from within.

Immigration horribles

We face an avalanche of horrible news regarding immigration and the challenges are not limited to the US. All throughout the world there are people running from violence and poverty to places where there is less violence and poverty. This is not a new story.

I have been trying to track my family history. I had my DNA sequenced and discovered relatives I did not know I had. Their grandmother and my grandfather may have been brother and sister and at least first cousins. They both left Russia in the late 19th and early 20th centuries. It was at a time when the country welcomed immigrants, at least on paper. That all changed after WWI. Until the Great War broke out, there was great demand for labor to support the growing industrial giant that was the US.

My ancestors were escaping the mess that was the Russian Empire and the about to collapse Austro-Hungarian Empire. I am grateful they did. Since that time, humankind has gotten better at moving people around. The great migrations of the late 19th and early 20th centuries was facilitated by the steamship. Fifty years earlier it would have been unthinkable that so many people could have immigrated so far and so fast.

Fast forward a century and we have chaos in South and Central America, in Africa, in the Middle East, and parts Asia.  There is violence, bad government, and poverty. There is also the internet which allows for even the poorest people to know what they might be able to attain and transport of all sorts that allow motivated and intelligent people to migrate. And they are migrating in droves from Africa to Southern Europe, from Central and South America to the US, from Burma to Bangladesh, from North Korea to China.

No one seems to know what can or should be done to deal with these migrations. The pressures of migrations make normally well functioning governments look awful. Put bad leadership in place and they look even worse. However, no matter how bad the leadership might be, we are still left with choices that may make even the best of leadership look bad.

What are our options. At one end of the spectrum we could simply try to close the borders and let no one in. That will not serve our needs in that we need immigrants. Furthermore, we do not have the ability to close the borders, On the other hand, we could simply open the borders and let everyone in. How would that work? We did that 100 years ago but we needed the infusion of immigrants to propel our economy and there were physical limits on how many people could actually get her. What would happen now if we opened the borders to ALL interested parties. Is that really a viable option? How many people would end up entering the country and how would we handle them?

That leaves us with the need to come up with workable rules and the resources to allow some people in and some not. How does that look? I have not heard a single voice out there that has framed this issue within workable limits to immigration .Perhaps this is what they are talking about in terms of comprehensive immigration reform. I did a basic search on the terms "comprehensive Immigration Reform" and there are a number of parties that have issued position papers. It is surprising how little meaningful discussion has made it into the mainstream press.

As noted in the "Catholic Vision of Just Immigration reform (Link)

We do know that policies that indiscriminately separate children from their migrant parents at our national border violate the sacred sovereignty of families. They need to be stopped.

But it’s not enough to condemn the treatment of a mother separated from her child without asking what should happen instead. There have been, unfortunately, too few solutions proposed to address a real problem: how should the identity of family members be verified at the border, to ensure that children are not being trafficked? That issue needs more than moralizing or grandstanding. It needs a real solution.

It’s also not enough to call for an end to family separation at the border without asking what led to this humanitarian crisis, and what kind of reforms will really make a difference.

For that reason, no matter how discouraged they are, Catholics need to lead efforts to develop comprehensive immigration reforms rooted in the principles of justice. Only serious reforms, which create a system that protects security and the right to migrate, will end humanitarian crises at the border, mass detentions and deportations, and the deaths of migrants crossing through the desert.

When do we get to this discussion?

The Danger of The Regulatory State

The regulatory organs of clinical medicine not only hand down and enforce trivial, silly and costly diktats, as a recent blog on this site related, but also impose dangerous constraints on the practice of medicine.  Case in point is the College of American Pathologists (CAP) which acts as the surrogate laboratory inspector for the government.   CAP’s inspection of our academic training program’s “lab,” which consisted of two microscopes, shut down an entire clinic building’s laboratories in a major academic medical center because, as an untrained and uncertified physician, I was performing gram stains.  

I have been doing gram stains since I was taught to perform them 50 years ago in my 7th grade science class; preparing slides is trivial enough that it can be mastered by a 13 year old.  Performing gram stains was a requisite competency in my medical school as it has been for virtually all medical students in the 134 years since Christian Gram published his technique in 1884.   And I have been interpreting them for over thirty years of medical practice.  As an intern thirty years ago when seeing a febrile patient with purulent sputum I would have been severely reprimanded for not having personally done a gram stain and had it available for the attending physician to review.  Now it is a cause for action on the order of the breaching of a Level 4 biohazard unit with commensurately severe disciplinary proceedings to follow for the responsible “untrained” and “uncertified” practitioner.  

Gram stains offers important, often essential and not infrequently time critical information that may not be obtained from culture or at least not obtained in a timely manner. 

1. Gram staining gives immediate results: infectious vs. non-infectious; gram positive vs. gram negative organisms; mycotic vs. bacterial, and does so days before culture results are available.

2. Culture requires viable organisms; gram stain does not.  Gram stain works on bacteria that are alive or dead so where an infectious etiology is suspected but only purulent material with non-viable organisms is available a gram stain can still direct treatment.

3. Gram stains can identify the presence of fastidious infectious organisms, especially fungi, that will not culture out on conventional media such as Sabouraud’s dextrose.  Mycotic infections can be missed or inappropriately ruled out if the results of cultures are accepted as definitive.

4. It is inexpensive: pan-culture for multiple organisms including fungi will run $500-$1000.  Culture may be completely avoided by the gram stain if there is a clear cut clinical correlation; or it can restrict culturing to the class of organisms seen under the scope to determine sensitivity.  

Multiple cases from my inpatient service underwrite these attributes.  In just the six weeks before the CAP inspection threatened disciplinary action against me the cases below relied heavily on my performance and readings:

1.   A 7 day old premature infant in the NICU with KID syndrome, possible sepsis and a localized pustular rash was evaluated; beginning empirical antibiotic treatment would further complicate management of this ventilator dependent baby.  The gram stain showed numerous budding yeast as the sole finding and with the clinicopathologic correlation of the rapid appearance of pustules this indicated candida.  The contemplated systemic antibiotic therapy was avoided and the parents reassured.  Candida was subsequently confirmed by culture but only several days later.

2.   A 44 year old man with HIV, toxoplasmosis, mental status changes and cerebral infiltrates on CT scan presented with multiple fungating nodules thought by infectious disease to be either Kaposi’s sarcoma or T-cell lymphoma.  A gram stain of scant exudate from these lesions showed dense gram positive cocci making the clinical lesions consistent with the rare staph infection botyromycosis.  ID challenged this diagnosis and instructed the primary service to discontinue vancomycin but photos of the gram stain taken with an iPhone convinced them to continue vancomycin before culture subsequently confirmed staph infection as the sole cause of these tumor like nodules.   

3. A 65 year old man post-op for glioblastoma on high dose prednisone with mental status changes presented with a rapidly evolving, acneiform facial rash raising the concern for crytptococcal infection.  A gram stain from pustules showed a dense infiltrate of gram positive cocci (characteristic of Staph epi), gram positive rods (diphteroids characteristic of P. acnes) and round to oval non-budding yeast (characteristic of Pityrosporum), the classic findings of steroid induced acne avoiding both a biopsy and empirical antibiotic therapy for crypto and permitted his discharge from the hospital the next day.

Again, these were just in the previous 6 weeks of one attending encompassing only 6-9 days of actual inpatient service.

A more critical example from our institution was the early diagnosis of a 50 year old man with a high C-spine fracture from an MVA, in the ICU, septic and rapidly deteriorating. A generalized pustular eruption that I gram stained disclosed candidiasis days before blood culture demonstrated candidemia allowing earlier intervention.  And going back in time to when I was expected to perform a gram stain, as a third year resident 30 years ago I evaluated a septic patient transferred in in the middle of the night with multi-organ failure.  Blastomycosis was suspected but empirically giving him amphotericin, the only antimycotic available at that time, risked destroying what was left of his kidneys.  I called blastomycosis on a gram stain from one of the rare pustules on his leg underwriting the necessity of using amphotericin despite the risk.  That diagnosis was subsequently confirmed—but only weeks later by culture.

The exclusion of physicians from performing gram stains has left the microbiology lab techs as the sole authorities on their interpretation. There are many capable lab techs performing and reading gram stains; as noted above preparation and interpretation is typically straightforward as I demonstrated as a 13 year old. But reliance on lab techs should not be taken at face value.  My personal observations from the concurrent processing and interpretation of slides with them discloses significant variations in their capabilities particularly in difficult cases.  Techs follow the guidelines for performance of the procedure which were developed by bacteriologists for uniformly dense specimens skimmed from culture media. This does not account for variations in specimen thickness or content when obtained from necrotic, infected, inflammed or hemorrhagic tissue where variations in the preparation of slides is necessary.

A case that illustrates this occured following the CAP injunction when I was ordered to discontinue gram stains. I saw an 18 year old boy hospitalized for multiple large ulcers on his leg that began several months previously after he cut himself at the farm where he lived.  HIs parents consulted infectious disease and multiple cultures including fungal cultures were obtained, all negative for microorganisms.  I performed a touch prep from a biopsy and submitted it to the micro lab for evaluation.  At this point I was prohibited from performing gram stains myself and the prep was read by the lab tech as negative.  I asked to take a look and pointed out multiple large aggregates of yeast that were missed by the otherwise conscientious technician.  Culture was again negative but initiation of itraconazole resolved the ulcers in several weeks confirming the mycotic nature of an otherwise undeterminable fungal species. 

If physicians are not performing, interpreting, teaching and supervising those doing gram stains the results will often result in the above scenario.  For example, virtually every technician I’ve observed places the stained slide on the stage, immediately applies immersion oil, goes straight to 1000x and evaluates several fields, likely what they were taught.   However in a 2 x 1 cm smear of a specimen the evaluation of ten 1000 sq micron fields surveys less than 1% of the sample.  As the case above illustrates low and medium power surveys of a specimen that are not performed by the technician can miss infectious infiltrates.  I have pointed this to our micro lab techs on a number of occasions when concurrently reading slides.  I do not relate this in disciplinary terms but as a teaching opportunity and the techs are universally grateful for such oversight.  But I am one physician—and one who is been told to physically stay out of the main lab.

Regulatory diktats have subcontracted these tests to technicians and physicians have lost this skill and have no incentive to push back and take on such regulatory entities as CAP.  Those are not good reasons for abdicating responsibility and subordinating what should be a physician performed microscopic exam if the clinician desires or where a practitioner is in the best position to make a clinicopathologic correlation from the results. This is especially true in an academic medical center which should be setting the standard.

  

CAP’s injunctions resulting in our suspending performance of gram stains and other advanced physician performed microscopy need to be forcefully challenged.  Moreover, we need to reinstitute training in these techniques.  Gram stain is simpler, more definitive, easier to learn and often critical to the undertaking of acute therapeutic interventions in seriously ill patients—or avoiding undertaking them at all.  If CAP or anyone else doesn't think that’s important—just ask the mother of that premie in the NICU.