August 4th, 2008

I love convergence

One of the reasons I am so suspicious of large chunks of what passes for medical care in this country is how hard it is to find convergence of opinion when I sample the field. By convergence, I don't mean everyone agrees. That's never going to happen on any topic of interest; in those rare instances where it seems to, it's an illusion, delusion or worse. I mean, I see trends, I see stuff headed in the same direction, I see repetition, I see pattern. I can collect meaningful information from people I agree with and those I disagree with. Anyone who still reads movie reviews has a reasonably good sense of what I'm talking about.

At the Boston Globe today:

An article about heating costs. Decent coverage; nothing spectacular. Some numbers which are relatively new to me (expect 30% increase in New England this year; average bill could top $3000 for the heating season). They found some "human interest" in the form of an 82 year old in Dorchester, a WW2 vet still living in his own 4 bedroom home. Of course, any sensible person is sympathetic; who would ask an 82 year old veteran of that particular war to move at this point? I mean, come on. That would be mean. (I'm serious here; it would be mean. But wait. There's more.)

I'm also slogging my way through _There's No Place Like Home_, a history of nursing and home care (this is the what-was part of the nursing home reading project). Regular readers will not be surprised to learn that I Have Issues with this book (like there's a book out there I _don't_ have issues with), which I will cover in more detail in a later post. But let us just pause at this moment to contemplate what the world was like in cities like Boston and NYC not so very many years before our resident of Dorchester was born, say, any time between 189- and 191-. There were a lot of public health workers called visiting nurses who did rounds to help out with very poor, very sick people (altho they tried very hard not to go inside if the person was really contagious with, say, scarlet fever, diptheria, smallpox -- yeah, back in the bad old days), but instead give "doorstep advice". The assistance they could provide -- over and above airing the place out, cleaning the folk and the bedclothes etc. -- was limited, to say the least (while the author goes into no details, it seems clear that mitigating bedsores and other wound care must then, as it is now, have been a major contribution to easing suffering and extending life).

The health workers were supported through a variety of makeshift means: hospitals, charitable organizations, a few publicly funded efforts in larger cities. Depending on who was funding them, their mission varied, and thus who they visited varied. The poor were pretty suspicious of them (this was back when they might force you out of your home and take you to a TB hospital and quarantine you, for example, so you can sort of understand the suspicion); the nurses had to make their case. And they had to do this for people who were _typically_ living a family in two rooms with shared privy in the courtyard (multiple flights down) and often living one family in _one_ room _and taking in boarders_.

While I would _never ever ever_ be mean to the 82 year old ww2 vet living in Dorchester, I will merely note that in another time and another place, one guy living by himself in a 4 bedroom house wasn't the guy we were expected to feel sorry for. Impressed that he's managing to hang in there on a social security check (remember that our tenement dwellers did not have those). Sad to hear he's living on the college student diet of instant noodles. But I _am_ thinking he might at least contemplate a roommate, to ease the pain this coming winter.

But hey -- maybe he's already got three. It's not like the Globe has never left out salient details before.

The concluding sentence I wholeheartedly agree with:

""The good news is that people are talking about it now . . . when the weather is 85 degrees," Hailer said."

a sane voice in the wilderness: stop the PSA testing madness at 75

I've complained about PSA screening in general (if you're symptomatic, that's a whole other thing). Finally, someone (US Preventive Services Task Force) has finally had the guts to say, stop with the silliness. If you _want_ to be screened, whatever; but we're not going to tell anyone over 75 they should be screened with this never-to-be-sufficiently-damned test (altho we don't blame the creator of the test, because he's said he's sorry already).

Nice quote at the end of the article:

“Taking an 80-year-old and telling him he has cancer and telling him he needs radiotherapy or surgery uses up medical resources and puts him at risk. It’s a step toward rational thinking.” Kudos to Dr. Derek Raghavan, director of the Cleveland Clinic Taussig Cancer Institute.

ETA: So, the _next_ time I run across someone who got really horrible medical care due to some form of cascade -- whether it's going to the hospital while in prelabor, or getting an epidural too early or something like PSA screening or mammography while 75+ -- who is all happy about it happening to them because in _their special bright and shiny case_, the intervention was totally justified and they were Saved! By their Heroic Medical Team, remind me to just say quietly to myself: I support Assisted Suicide. This is No Different. I support Assisted Suicide. This is No Different. The comments on this blog entry are bone-chilling. A scattering of sensible guys who know the score, a bunch of people posting their PSA and Gleason scores, and then a whole _lot_ of people looking for a conspiracy on the part of USPSTF. Yeah. Right. I don't think they have it in them. If you think there's a conspiracy somewhere, it's not there. A lot of people asking, but how can a blood test cause all these problems? Just you _wait_ until you sign up for some inadequately sensitive and/or specific blood test and find yourself agreeing to all kinds of additional crap to get a Real Answer. Which may kill you.