Listening?

If God speaks not to us, then we are imagining him and all our time and energy thinking about God and praying to God and donating to God and discussing God is a fantasy and a self-invention.  At best a soothing distraction, at worst playing with razor blades.

The Time of Death

The question from the nurses:
“what was the time of death?”
I have been asked that enough times
That I do now sometimes look at the clock
Before I am asked.
I think about that moment
When it happened
When the final breath left
And the heart quit beating
Must be written somewhere
And everywhere
Such an important time it must be
The time of death

But the “time of death”
is a misnomer
It cannot be
for it is the end of time
At least for one
How can there be a time 
For the end of time?
When you are out of string 
There is no string
You can’t say:  “be sure to tie a string around your finger,
when you run out of string. 
Then you will remember to buy string.”
But then the analogy breaks down.
As all do, it is death we are talking about
Speech is gone
Thought is gone
Theories are gone
Life is gone
The person is gone

But still I am called
To pronounce the “time of death”
As if I the doctor
Have a magic key
To an invisible box
Wherein this life will hide
As long as I give it a time

Centrally Planned Healthcare

The lastest SGR Deal (click for article) sounds good, increasing doctor pay tied with quality.  However:

1.  Interventions from DC that purport to make doctors provide a higher quality of care by paying them extra for certain check-boxes and computer clicks are not effective.

2.  The doctor groups that are supporting these measures do not see, or choose not to see, the reality of #1

3.  The primary net results of these measures are:  more bureaucracy, increased cost for already overpriced medical care, more passing the buck on cost-control.

The Pessimist

Not many years ago when I was an atheist, if anyone had asked me, ‘Why do you not believe in God?’ my reply would have run something like this:  ‘Look at the universe we live in.  By far the greatest part of it consists of empty space, completely dark and unimaginably cold...Earth herself existed without life for millions of years and may exist for millions more when life has left her.  And what is it like while it lasts?  It is so arranged that all the forms of it can live only by preying upon one another.  In the lower forms this process entails only death, but in the higher there appears a new quality called consciousness which enables it to be attended with pain...In the most complex of all creatures, Man, yet another quality appears, which we call reason, whereby he is enabled to foresee his own pain which henceforth is preceded with acute mental suffering, and to foresee his own death while keenly desiring permanence.  It also enables men by a hundred ingenious contrivances to inflict a great deal more pain than they otherwise could have done...Every race that comes into being in any part of the universe is doomed; for the universe, they tell us, is running down...All stories will come to nothing: all life will turn out in the end to have been a transitory and senseless contortion upon the idiotic face of infinite matter.  If you ask me to believe that this is the work of a benevolent and omnipotent spirit, I reply that all the evidence points in the opposite direction.  Either there is no spirit behind the universe, or else a spirit indifferent to good and evil, or else an evil spirit.’

There was one question which I never dreamed of raising.  I never noticed that the very strength and facility of the pessimists’ case at once poses us a problem.  If the universe is so bad, or even half so bad, how on earth did human beings ever come to attribute it to the activity of a wise and good Creator?  Men are fools, perhaps; but hardly so foolish as that.  The direct inference from black to white, from evil flower to virtuous root, from senseless work to a workman infinitely wise, staggers belief.  The spectacle of the universe as revealed by experience can never have been the ground of religion: it must always have been something in spite of which religion, acquired from a different source, was held.

CS Lewis, The Problem of Pain

How Many Doctors Does It Take?

I had not realized that the Annals had posted my thoughts on this article a few years back, though only on the web site comments which probably did not get much read.  In any case, I think this is still relevant though perhaps too "insider" for many.

Click HERE to go to the article sample and my comment at the bottom.  Or just read my comments below.






Doctors as Bed Managers Inappropriate Use of Resources

Posted on March 7, 2009

Paul D Bunge

In the December 2 Annals, Howell et al present their case for "active bed management." In the intervention, they had hospitalists take turns doing twelve-hour shifts as bed manager, a position usually filled by a senior nurse (1). The bed manager typically coordinates the placement of the new patients from the emergency room and clinics onto the appropriate available ward. This person also tracks patients as they go in and out of the ICU and other units. The bed manager must keep track of all available beds, and negotiate as needed when beds, patients, and staff must be shuffled around to make room. Note that in the intervention, the hospitalists did not do any patient care while they filled this role.

I am not surprised at the result reported: The patients moved around the hospital more efficiently. The time that the patient remained waiting in the ER was shortened (a quality and hospital efficiency goal). The major problem with this intervention is not the result, but the cost: Whatever the possible short-term cost savings to the hospital and short-term benefit to patient comfort, the overall cost to the health care system must be factored in, which is essentially the huge cost of pulling 1/4 of the hospitalist staff out of direct patient care.

I am afraid that I must regard this intervention as both unethical and ridiculous. Unethical because "pressure from administration" lead to inappropriately removing doctors from patient care to achieve a financially-motivated efficiency goal. It is the doctor's responsibility to call foul when the administrator crosses a line and refuses the patient appropriate care. Yet in this intervention, the patients were left to the mid-level providers and others while the doctor was making phone calls.
This intervention is ridiculous in that it is already a waste that so much senior nursing time goes to administrative duties, including the role of bed manager. Are we to have the doctors do this job that would more appropriately be performed by a clerk? When the movement of patients around the hospital is dysfunctional, that is a leadership problem, not a clinical problem.

This article is an unfortunate illustration of some very important points:

1. We have strayed far away from our job, our profession, our calling: patient care. We have left it to a few weary, brave soles who we now call "primary care managers." The rest of us, with no apparent limit, gather specialty or hospitalist status, and make as clean a break as we can from the whole mess. Shame on us! And shame on us for blaming others (the government, the economy, the payment system).

2. We need to question the current band-wagon thinking that there is a shortage of physicians in this country. When our highest levels of medical learning can advocate using doctors as bed managers, we may actually have the opposite problem: an illness of too much. (see Shannon Brownlee's article for a look at this topic: http://www.theatlantic.com/doc/200712/health-care )

3. Common sense needs to find its way back into the hospital. In the days of Oryx measures and JCAHO rules and sub-rules, the doctors of the world must be the ones to bring some wisdom to the table to question quality measures that may actually decrease quality, the multiplication of pointless paperwork, and other like challenges.

Once as a young physician on the way to work, I stopped my car at the scene of an accident. I told the ambulance crew my credentials and asked if they needed my help. One wise EMT told me quite simply: "sir, it probably would be more helpful if you made your way to the hospital where you are needed and see the patients there. We can handle this part." I did just that. Perhaps more of us should do the same.

References
1. Eric Howell, Edward Bessman, Steven Kravet, Ken Kolodner, Robert Marshall, and Scott Wright Active Bed Management by Hospitalists and Emergency Department Throughput Ann Intern Med 2008; 149: 804-810

A path

A view is for gazing at, taking pictures, discussion. A path is for walking on. The Christian life is more a path than a view. It works much better when walked on and taken than when photographed and discussed.

A Framework for History

My daughter’s High School history class.  Her teacher is using an essay by Ian Johnson as an introduction to Western Civilization, to frame her students’ understanding of history.  I wrote her some advice after reading the paper.

"Beyond all that, of course, wherever liberal capitalism moves, we need to remember Marx's analysis of how capitalism in the long run generates increasingly unstable and unequal economic conditions, so that it will eventually provoke a forceful redistribution of wealth and the development of a different economic system, either within capitalist countries themselves or world wide.  As the gap between the rich and poor within the capitalist system continues to increase, with environmental disasters looming in many parts of the world, we have no reason to be complacent that the economic system which is apparently so triumphant at the moment will necessarily remain so."
                    -Ian Johnston

Basically a socialist, and a wanna-be communist.  As I once was.  Like Marx, his view of history is overly simplified as he tries to paint a picture of good and evil in the world centered around primarily breaking down ideas supporting current economic and political realities.  The promise therein is a utopian state.  A pipe dream that does not exist but for which over the years many have sacrificed many a decent government, family, and church.  Beware of such thinking, because it is naturally attractive in providing solutions to problems it purposely sets up in overly simplistic terms.  A way of thinking commonly found in educational circles and espoused by professors.  Don't pander too much to them.  Be respectful but you are allowed to respectfully disagree.

It is sad that your teacher is espousing a Marxist approach to frame your study of the history of Western Civilization.  Especially that the espousal of Marxism as a political framework nearly lead to the annihilation of Western Civilization within the last 50 years.  Beware the one who claims open-mindedness but requires a certain religious set of glasses through which to view the world. In this case the religion is Liberalism/Socialism.  Do not let this framework detract from objective learning and interpreting of facts and episodes in history.  For to only use history as bricks to build a pre-planned house is to miss the many lessons that history can teach.  Besides which the house may be quite on shaky ground.

Have a look:   https://en.wikipedia.org/wiki/Marxism   Note that if you are going to be in this class, you are going to have to work extra hard to learn truth.  However, it can be done.  But your grade may slip as you spend time reading a wider range of insights rather than succumbing to mind-numbing.  The world-view that Johnston is teaching (and apparently your teacher as well) is truly so, and it interferes greatly with a clear thinking about history and many other areas of life and study.