A small and pissy flame today about medicine up-close and personal.
An 80-year-old relative had been ignoring a skin infection on her forearm until it got painful. She is a Christian Scientist. She fears doctors. She shows some common-sense in doing so.
She went to the local clinic. She does not have a PCP. The clinic saw her, and sent her to the urgent care. The urgent care took one look, and sent her to the ER, where she waited 12 hours. She was pretty frazzled. 80-year-olds are rarely at the top of their game at 4AM.
The ER – massively understaffed like every other ER in the US – ignored her for a while, brought her in, put a heplock in the good arm, and proceeded to tourniquet up the painful, infected arm, restricting venous return until it really hurt. They drew all sorts of labs. They took x-rays.
They saw that she had a white count, but a low-grade fever. They gave her an IV dose of cephalosomething, and gave her a prescription for oral antibiotics that were probably not on her insurance formulary. They gave her a sheaf of papers warning about all the dangers of whatever they gave her.
They found a lesion on her back – a 25-year-old lumpy stripe that looks like dried-on refried beans. They told her it could be malignant, and set her up to see dermatology.
In the differential diagnosis of a smear-of-refried-beans that appeared during the first Bush administration, the diagnoses proceeding from the most to least likely:
- Seborrheic keratosis.
- Some other benign thing that looks exactly like a seborrheic keratosis.
- A streak of BULLSHIT overflow trickled down from the administration office upstairs.
- Bolivian black-winged condor droppings.
- Something worth giving a damn about, a metastatic zebraoma or something.
Such a diagnosis shrieks of inexperience by the caregiving team. Dermatology will spend three minutes with her, she’s going to rack up a $150 consult fee or something, and be pissed off at rude and uncaring dermatologists, which they’re not. They realize that the poor lady should be left alone.
The ER tests found her LDL was ‘elevated,’ and booked her a consultation with a cardiologist, even though:
- She has never had chest pain
- She shows no sign of systolic failure
- She smokes
- She is 80 years old
- She has an unconvincing family history of cardiac disease
The stress-test has been done, it’s called life, and it’s looking pretty normal. She should have died about 20 years ago if she was going to. Starting a statin now – which she’d never do, the antibiotics are hard enough to get her to take – might improve her chances of getting to 105 years old.
No cardiologist wants to see her. The history and exam will be cursory and uninformative, and she’ll feel dissed. In truth, the ER personnel wasted her time a lot.
She came home with about 50 laser-printed pages, about her O2 sat, about her need for regular exercise – about nothing, but required by regulation. She is old-fashioned; she will read this information. It will give her no peace.
If she lives that long, think of what sort of healthcare she’ll be getting in 2041!? Would YOU rather take the infarct, or live to see the sliver anniversary of Obamacare? (That was supposed to say silver anniversary but I like it as it is.)
She left. Technically, she received appropriate treatment that would likely succeed. We are toying with the principle of cost-savings through system incompetence. It does not save money. It does not save lives.
And she hasn’t even got the bill for her ER visit yet.
We behave towards this “medicine” business today, the same as we did a hundred thousand years ago. We have a superstition that the machine-god, the thinking-god will give us prosperity and health. We trust the machine-god to be smarter than mere humans – that is the superstition.
Really, our myth is no more delusional than the Heaven’s Gate cult, which believed that the Mother Ship had come in the disguise of the Hale-Bopp comet, to bring their souls up to the promised world, after they shed their Earthly bodies. Which they did.
Medicine, like almost every human endeavor, originates in the human mind; all else is instrument. The Cloud is no more capable of practicing medicine than the Slide Rule. We once lived the Renaissance hubris that humans, given enough knowledge and capacity, could do great things. Humans made it to the moon, and back. But now we turn our mind to worship the clay-brained idol of technology, that will whisk us away to lands unseen. Just drink the Kool-Aid.
Had my relative confronted an experienced physician with an actual human mind, the encounter could have taken ten minutes. We humans think with a heuristic logic that is far more complex than the thinking machines we invent. Every generation or so, we throw up a Tower of Babel to reach the sky, and become gods – and the outcome turns out fairly bad. We built the Titanic – reality gave us the Atlantic Ocean. The Titanic was mighty, but in the ocean, but a dot on the surface.
When we surrender our mind and/or our conscience to others, very bad things happen. Still, we do it in worship of the clay myth of the Rapture, the Tower, the greatness of the inventions of mankind. Why, when the secret of humanity is humanity itself?
Francis Peabody‘s great essay becomes once again timely.