From: sbharris@ix.netcom.com(Steven B. Harris)
Subject: Re: "Board Certified" questions
Date: 05 May 1997
Newsgroups: sci.med

In <5kjne5$grc@dfw-ixnews4.ix.netcom.com> jehurley@ix.netcom.com(James
Hurley) writes:
>
>> To be board eligible one must complete an accredited
>>residency program.
>
>If you fail the exam then you take it again. I agree it does not assure
>you that the physican is certified in technical ability or bedside
>manner. It only says that the doctor is a good test taker. This does
>not alway mean you are getting the best doctor. My psychiatrist keeps
>telling me that she has trouble reading, and he is board certified.



   It's damned difficult to design a test which tests for even a
fraction of the qualities that a good doctor must have.  The boards do
the best they can with the money they have.

   A far worse problem than the boards is the qualifications we require
of students to get into medical school.  These tend to be heavily math
oriented, and (quite frankly) most of medicine doesn't have a lot to do
with math beyond simple algebra.   I've met a lot of very smart and
compassionate people who would have made excellent docs, but never got
the chance because they couldn't see the light in calculus and physics.
That's just plain silly, and I speak as one who never had any
difficulty in calculus or physics.  Frankly, aside from basic empathy
you want your doctor to be the sort of person who loves trivia and
physiology, and who pays attention to details and answers phone
messages.  You don't give a fig whether or not he or she can integrate
e^-(x^2)dx.

                                            Steve Harris, M.D.

From: sbharris@ix.netcom.com(Steven B. Harris)
Subject: Re: Allopathy (was: I need help)
Date: 09 Jun 1997
Newsgroups: misc.health.alternative,sci.med,sci.med.pharmacy

In <5nfr9c$rc2@senator-bedfellow.MIT.EDU> shapere@athena.mit.edu (H. E.
Shapere) writes:

>Norma and her cohorts accuse Harris of being uneducated when he's the one
>who went through (the alleged hell of) medical school. (And, BTW, anyone
>with "M.D." after his name has had at least some clinical experience.)


   Just to set the record straight, hell doesn't (or didn't) start
until internship, the year AFTER you graduate from medical school.
Once upon a time, staying up 36 hours at a stretch (or more) while
doing really stressful and critical work, was routine (you did it about
every 3 days).  They've started to slack off on that kind of thing
these days, however.  They figured out that you don't learn anything
much after you've been without sleep for 24 hours, something I could've
told them in 1983 (and tried to many times).  Idiots.

   I will freely admit that American medicine has had a few blind
spots.  One is in making sure doctors and patients get enough sleep.
Another is in making sure they get proper nutrition.  These things are
changing, but it hasn't been easy.  I think quite frankly that the
recent large influx of women into medicine (more than half of new
physicians these days) has been the driving force.  Medicine up until
about 1990 was run way too much like a marine boot camp.  That tends to
happen with male dominated professions.

                                         Steve Harris, M.D.

From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: misc.health.alternative,sci.med
Subject: Medical Training (was:  To JUSTME -- MY MD VS. DC VS. DO "FACTS")
Date: 15 Apr 1998 01:10:47 GMT

In <6h07ts$s1b$1@gte2.gte.net> kalalau@NOTgte.net (KalalauRich) writes:

>There is no question that a medical residency is a grueling process.
>One of the main ideas behind the long shifts that residents must do
>has to do with the importance of personalling observing the
>progression of an illness over an extended time period and the
>response to treatment.


Comment:

   An argument that was always a crock, since it can be used to justify
any length of shift you like.  Six hours or six days-- one can find
pathological processes to fit them all.  I sometimes wonder what my
"mentors" would have said had they been trying to train me in
agriculture or (horrors) geology.  Is there no limit to the amount of
foolishness people can make themselves believe in, when the object is
some kind of ritual, or semi-religious initiation?  What, Yahweh-- you
say you want us to cut the ends of our *pricks* off??  Did I get that
right?

   Yes, I hear that the marine corps mentality of medical training is
at last beginning to die.  I'm glad to hear it.  As sociology, it was
interesting, but as participatory living theater it was sad and
dehumanizing and completely unnecessary.  If you want to hurt people
for the sake of hurting them-- and I mean just to cause them pain
because pain is the object--- there are more efficient and more honest
ways to go about it.  You first.


> We could certainly argue about the adverse health consequences to the
>residents putting in such long hours and the adverse consequences to
>their patients as a function of their fatigue but I believe that
>generally the long hours add to the education of the resident and help
>prepare him/her for stressful practice.

    I don't.


 >> There is a point however in which sleep deprivation works against
both the resident and the patient.<<

    Which occurs just about 24 hours into a shift.  If all are lucky.
Earlier, if not.  I've seen a lot of unlucky people.

   >> As I have said, reforms are occurring to address this
>problem.<<

    After how long?  It's been said that it's easier to relocate a
graveyard than change medical school curricula.  Or residency
programs.

    You know, in all the insulting arguments I've been party to on the
net-- the ones about how senseless medical doctors really are (dispite
all their protests to the contrary)-- I've half waited for somebody
outside of the profession to put to use the one best and really
definitive argument that this is actually true; the one that really
nails the case that medical doctors aren't really any more rational
than any other profession, and probably, in certain circumstances,
less.  But so far, I've yet to see it.  Because people outside the
profession generally cannot conceive that medical doctors would REALLY
be so stupid and so unkind, and so goddamn *irresponsible* as to train
as they actually HAVE trained, as housestaff, for most of this century.
They really do not even suspect things could really be as bad as they
have been.  That's kind of sweet, in a way.  Almost, in a way, a
compliment.  Gee, thanks.  But in this case we don't deserve it.

                                Steve Harris, M.D.

From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: misc.health.alternative,sci.med
Subject: Re: Medical Training (was:  To JUSTME -- MY MD VS. DC VS. DO "FACTS")
Date: 15 Apr 1998 22:50:32 GMT

In <01bd6869$16c7f5a0$205971cf@parrot> "Harmon" <dontspamme@spam.not>
writes:

>>It's been said that it's easier to relocate a
>> graveyard than change medical school curricula
>
>A lot of medical schools are in the process of changing over to the
PBL (Problem Based Learning) method. There are some promising
preliminary results of studies done over the last few years available
through Medline, if anyone's interested.<


   Yep.  A change that's been going on for 20 years, at least.  My own
medical school class complained that long ago that we never saw enough
patients in our first years.  Which translates to a request to start
learning medicine as an apprentice would-- by jumping in and doing it,
problem by problem.  That's the best way to learn almost anything.
It's the basic reason that doctors get more out of their internship
year than any other-- because finally they start getting trained in the
correct way.  The long hours really are not critical-- it's how you
spend them.

   The med school of the future will start you as an "intern" the
moment you walk in the door in the fall of year one.  You'll get
assigned a patient (just one patient, at first), and you'll have to
start learning, by doing things as part of the team that cares for that
patient.  At first you'll be worthless, and will need to be watched
moment to moment (total supervision, no critical responsibility).  But
long before four years are up, you'll be a far better doctor than most
residents are now at the end of their formal "training" at 7 or 8 years
into the process.

                                   Steve Harris, M.D.

From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: misc.health.alternative,sci.med
Subject: Re: Medical Training (was:  To JUSTME -- MY MD VS. DC VS. DO "FACTS")
Date: 16 Apr 1998 04:05:09 GMT

In <3535663C.3B9A29A8@gw-tech.com> Carey Gregory <cgregory@gw-tech.com>
writes:

>Steven B. Harris wrote:
>>
>>    The med school of the future will start you as an "intern" the
>> moment you walk in the door in the fall of year one.  You'll get
>> assigned a patient (just one patient, at first),
>
>
>Just promise me *I* won't have to be that patient.    ;-)


Sorry, you're it.  But you'll have a lot of more experienced docs also
on the team.  Your beginning intern wil be there to hold your hand,
since that's all he/she will know how to do.  It's tomorrow we teach
how to do the lumbar puncture.

                                   Steve Harris, M.D.

From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med,sci.med.cardiology,alt.activism,talk.politics.medicine
Subject: Resident Training Costs and Subsidies (was: The Patients' Bill of 
	Rights (was Backlash against HMOs: a declaration of war)
Date: 13 Apr 1999 05:21:12 GMT

In <7eubuc$ib$1@nina.pagesz.net> henryj@nina.pagesz.net (George
Conklin) writes:

>In article <7etsll$r39$2@ash.prod.itd.earthlink.net>,
>Kurt Ullman <kurtullman@sprintmail.com> wrote:
>>In article <7essj0$kkg$1@nina.pagesz.net>, henryj@nina.pagesz.net (George
>>Conklin) wrote:
>>
>>>   The training is what raises costs.
>>
>>        So, if you say it enuff times we will eventually believe it??
>
>   It was the reason why the Clinton administration wanted
>to cut back on the training.  You can deny that as much as
>you want, but important decisions were based on the truth of
>the statement.  You are good reason why the medical world
>should not be left unchecked because you apparently want me
>to believe that you believe your own sob stories.



     In an argument of this type, it's always so nice to have a few
facts.

    First: George's statement that Federal subsidies are $200,000 per
resident are doubtable.  Ten years ago they were only $20,000 per year
per resident ($60,000 total) in a very expensive state like California.
The state added 20% more-- enough to just about cover salaries of
residents at that time.  I'd like to see George's source for the idea
that Federal subsidies have tripled California rates since, and now for
all states.

    Second, when the Veteran's Administration Hospital (VAH) system
looked at the cost of resident training programs vs hiring doctors,
they found the whole system about a wash economically.  Residents
assume more responsibility and do more of the care in VA systems (as
anyone who has worked in one knows).  In private systems they seem to
pay about 50% of their way, and that is about what the Federal and
State grants cover.  If grants are not counted, OB residents are a net
loss their first year, a wash their second, and begin to make money for
the system their third year.  Pretty much the standard apprentice
economy.

    I don't mind the end of government doctor "education" subsidies.
Somebody pays for this anyway, and it may as well be the patients who
use the trained doctor's services down the line, as the taxpayer (why
George, who wants all this socialized, thinks it makes any difference,
is beyond me).

   But we also need to realize that residency programs do more than
train doctors-- they also are student programs which evaluate them,
too.  Residency programs wash out a few genuinely bad doctors, and they
would surely be less likely to do this if they were being paid
completely privately.  How do we replace the essentially 3-year
practical test which a residency represents?  With a written test?
Strangely, the horror stories I hear on these forums don't have much to
do with written test screwups.  If the government is going to take
responsibility for ensuring the quality of licensed doctors, how does
the government propose to pay for the extensive performance based
testing which is needed to do so?

   One last thing: the VAH system demonstrates that training programs
CAN pay for themselves.  Part of the reason is that the VAH system has
long been immune from a lot of the paperwork which the government
foists on private hospitals.  Now that this is changing (VA's have to
bill medicare--- God), perhaps it won't even be true of VAH's.  Part of
the cost of training residents is due to stupid government
overregulation.  Why then, should not the government pay for the cost
of the paperwork requirement it imposes?

                                        Steve Harris, M.D.


Fam Med 1991 Nov-Dec;23(8):620-3

Transferring hospital sponsorship of a family practice residency:
financial implications.

Kahn NB Jr, Pugno PA, Brown TC

Department of Family Practice, University of California, Davis.

Family practice residency programs close each year, many in which there
is a perception by the sponsoring institution that the program was too
costly. Upon the imminent closure of a program's sponsoring hospital,
we analyzed and projected the residency's budget and revenues to
convince another community hospital to accept transfer of the
sponsorship of the program. Revenues directly attributable to the
residency (family practice center, grants,
Medicare graduate medical education reimbursement) were identified. In
addition, we identified that portion of new inpatient revenues
necessary to offset the balance of the residency budget. We found that
the program could account for reimbursement of 51.8% of its budget
through patient care services, requiring 5.2% to be subsidized through
state grants and 43.1% through federal graduate medical education
reimbursement. Consistent with studies by several
authors, family practice residency programs continue to require
financial subsidy to balance their budgets. The nation's need for
family physicians can only be ensured if state and federal priorities
for needed primary health manpower are translated into continued and
enhanced financial support.

PMID: 1794675, UI: 92175479

----------


Inquiry 1991 Fall;28(3):288-99
The effects of residency training programs on the financial performance
of Veterans Affairs medical centers.

Campbell CR, Gillespie KN, Romeis JC

St. Louis University School of Public Health, MO.

This study examines financial performance and physician productivity in
Veterans Affairs teaching hospitals following the elimination of a
separate payment for the indirect costs of medical education. Financial
performance of teaching hospitals in the VA system was no worse than
nonteaching peers even without a teaching subsidy. Residents were found
to provide patient care but this contribution to output was offset by
indirect teaching costs of resident training. Physicians were less
productive in teaching hospitals, possibly reflecting the time spent in
training and supervising residents, while nurses were more productive.
Finally, as staff size increases, the indirect costs of
medical education decrease. Future downsizing of residency programs
would financially benefit smaller-staffed VAMCs; larger-staffed
facilities would lose.

PMID: 1833339, UI: 92010227

----------

J Fam Pract 1989 May;28(5):567-72
Cost-benefit analyses of California family practice residencies.

Barnett PG, Midtling JE, Burnett WH, Dornfest FD, Hughell JE, Kahn NB
Jr, Larsen FS

Department of Family and Community Medicine, University of California,
San Francisco.

Several national commissions have recommended that family practice
residency training be subsidized, but without stating how much support
is needed. Financial studies of graduate medical education have used
the methods of cost allocation or joint-products cost analysis.
Previous cost-allocation studies indicate that one third of family
practice residency costs are met by extramural subsidy. Cost reports of
eight California public hospitals with a single family practice
residency program were evaluated for the 1984-85 fiscal
year. Discrepancies in the education costs reported to Medicare and
those reported in state hospital disclosure reports demonstrate the
arbitrary nature of the cost-allocation method. The Medicare medical
education reimbursement was an average of $20,444 per resident. State
and federal grants provided an average of $5,190 per resident. The
Medicare payments and grants met an average of 35.7% of the education
costs reported to Medicare. A joint-products cost analysis was used to
estimate the pure cost of education in an 18-resident family practice
residency. Replacing the residency with salaried physicians
would have decreased the hospital's net return by $143,534. If neither
grants nor Medicare education payments had been received, elimination
of the program would have increased hospital net return by $428,083.

PMID: 2654326, UI: 89235615


Obstet Gynecol 1995 Dec;86(6):1014-7
The cost of teaching residents outpatient obstetrics and gynecology in
a university medical center.

Flanagan T, Mitchner B, Weyl-Feyling D, Laros RK Jr

Department of Obstetrics, Gynecology, and Reproductive Sciences,
University of California-San Francisco, USA.

OBJECTIVE: To quantify the cost of teaching residents ambulatory
obstetrics and gynecology, expressed as the difference in revenue
generated between a faculty physician practicing as a private
practitioner and a faculty physician serving as a resident supervisor.
METHOD: Outpatient revenue generated by faculty generalists and
residents was analyzed. The net gain in revenue was calculated
per half-day session for faculty and residents by subtracting
contractual allowances and expenses from gross patient charges. Net
revenue gain per half-day clinical session per year for a faculty
member practicing as a private practitioner was compared with that of a
faculty member functioning as a supervisor. The net gain for the
faculty supervisor was based on the revenue generated by the residents
supervised. RESULTS: The faculty member serving as a
private practitioner generated a net gain per session per year of
$23,947. The faculty member acting as supervisor for two residents per
session generated a net gain or loss per session per year of -$9678,
-$972, and $15,542 for first-, second-, and third-year residents,
respectively. The cost of teaching, expressed as the difference in the
net gain of a faculty member as private practitioner and the net gain
of a faculty member as supervisor, for first-, second-, and third-year
residents was $33,625, $24,919, and $8405, respectively, per session
per year. CONCLUSION: This analysis shows that first-year residents are
an expense to the practice site, second-year residents are close to
breaking even, and third-year residents begin to generate a net gain.

PMID: 7501324, UI: 96072939

----------

From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med.cardiology,alt.health.policy.drug-approval,alt.activism,
	talk.politics.medicine,sci.med
Subject: Re: Doctor-bashing
Date: 9 Mar 1999 09:29:09 GMT

Somebody wrote:

>>Hoo, boy.  It costs millions to make a doctor.  Tuition pays a small
>>percentage of that.  The other professional degrees -- architecture,
>>law, bizness, etc. aren't remotely as expensive.


Comment:

    It's a little hard to tell how much money it takes to make a
doctor.  Interns and residents do a lot of things in a hospital which
make a lot of difference-- tangible and intangible.  Yes, they order
more tests.  The flip side of that is that people are watched far more
closely.  It's very common in a non-teaching hospital, for instance, to
have to move a patient from floor to ICU, who in a teaching hospital
could continue to be managed on the floor by virtue of housestaff there
who can watch and manage on the spot. Here the housestaff functions as
rotating "Super ICU nurses," but typically don't get paid as much (per
hour) as an ICU nurse.  That's not a bad deal.

  Alas, the typical hospital does not get to see that savings, since
the cost of transferring a patient to the ICU is passed on to third
party payers, like Medicare (perhaps the hospital even makes MORE money
if its floor patients get ill enough for ICU care more often).  DRG
payments based soley on admitting diagnosis are no more.  So at this
point, the only people left who really would see such profits resulting
from less need to get people out of medical holes which housestaff
prevents-- the HMOs--- have decided out-of-hand that medical education
is expensive, without having really run the careful controlled
experiments to see if it's true or not.  And that's a well-nigh
impossible question to get at epidemiologically, due to the very
different kind of patients who get seen in primary care private
hospitals without housestaff, and teaching hospitals, which tend to get
more referal and teriaty care patients, who are sicker and costlier to
begin with.

    I'm also convinced (but cannot prove) that housestaff help to pay
for themselves in malpractice liability for hospitals and attendings,
also.  This due to the simple fact that people are less likely to sue,
the more time the doctor spends with them and their family, and that's
somewhat independent of actual quality-of-care.  And housestaff run
that "face-to-face with the doctor" time per patient WAY up.  People
are not stupid.  They know very well that a certain amount of disease,
pain, and death are facts of life.  They sue pimarily not because of
pain and death, but because of pain and death AND the feeling of being
neglected.

    Reading the above, it sounds like I'm an intern or resident
somewhere <g>.   Nope, I haven't been a resident for 13 years.   Dr.
Kildare was a resident.   I'm starting to feel like crabby old

                                -- Dr. Gillespie.

From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: alt.health.policy.drug-approval,alt.activism,talk.politics.medicine,
	sci.med
Subject: Re: Doctor-bashing
Date: 16 Mar 1999 03:32:09 GMT

In <7cipqd$7ke$1@nina.pagesz.net> henryj@nina.pagesz.net (George
Conklin) writes:

>>  To expect that every single doctor, regardless of where
>>they practice and what they usually do, to be up to date on every single
>>medical and surgical procedure and will be able to give us enough
>>information in a single visit to make decisions is wishful thinking,
>>"magical" thinking that implies the public wants "witch doctors" rather
>>than real doctors.  Real doctors have to train for years to understand
>>the human body and how it works -- patients also have to be willing to
>>do a lot of study and research about their conditions if they expect to
>>participate in their own care.
>
>  That is what former surgeon-general Koop said doctors need
>to have on CDs so they CAN look up such information quickly
>as needed where needed.  Too much trust on memory, and so
>little work being done on the best treatments.



A scene comes before me:  It's a doctor's office of the future:


Doc:  Hello, Mister-- what did you say your name was?

Patient: My name is Conklin.

Doc:  Right.   Now what seems to be the trouble, Mr, ah..  sir?

Pt.  I have a pain right here when I climb stairs.

Doc.  You mean right in the middle of your chest?

Pt: Yes.  Feels like an elephant sitting on me for a minute, until I
stop to get rest.

Doc: Just a minute, I have to look this up on my medline CD.  Here's
the body, and let me see, that part looks like it's the "sternum."

Pt:  They didn't teach you that part in school?

Doc:  Oh, we had a school which emphasized problem solving rather than
memorization.  Now, is this pain right on top of your "sternum" or
underneigh?

Patient.  Underneigh.  Feels like a big belt tightening around me.

Doc: You said an elephant.  There's nothing on here about elephants,
anyway.  What kind of a belt?  Maybe I could use that as a MESH term.

Pt:  Look, does it matter?  It really hurts.

Doc.  I've got "hurts," as term, and it links to "pain."  But there are
thousands of hits here, even with "sternum."  Wait a minute, I need to
look up the definition of "chostochondral," and "arthritis."

Pt.  How long is this going to take?

Doc:  I don't know!  But we'll figure it out.  In my medical school,
they emphasized problem solving, not memorization, you know.

Pt.  You said that.

Doc:  I did?  Well, anyway, let's try something about climbing stairs.
You know, when we have this figured out, it will make it easier when I
see the next person with the same problem.

Pt:  Why is that?

Doc: Because I'll remember what we found here.

Pt:  But that will be memorization, won't it?  Didn't you disaparage
that kind of learning?

Doc:  What kind of learning?

Pt.  Memorization.

Doc:  What about it?

Pt:  Your medical school emphasized problem solving.

Doc.  It did!  And they didn't encourage rote memorization.  How did
you know that?   Have you been there?  Did we meet before, Mr...

Pt.  Conklin.

Doc.  Right.  Now, Mr. Conklin, what can I do for you today?

From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: Public (Alternative) Medical Advice
Date: 1 Jun 1999 13:23:29 GMT

In
<118BCACF232F1F07.D93FA2033F2AE5EE.94F704744381E443@library-proxy.airne
s.net> jrfox@no.spam.fastlane.net.no.spam (Jonathan R. Fox) writes:

>For some reason, we in the medical profession are now being taught to
>pronounce "centimeters" like the French.  I saw a local newspaper that
>quoted a physician who was talking about mammography.  She mentioned a
>2 cm mass, and the newspaper wrote "two sontimeters."  I suppose the
>journalist just smiled and nodded when she had no idea what the
>physician had just said, and guessed the spelling.
>
>--
>Jonathan R. Fox, M.D.


   That affectation is at least 50 years old, and seems to be
particularly common in OB-GYN (as in "5 sontimeters dilation of the
cervical os, nurse").  The mammo doc was probably of that school, and
came by it that way.  It's rather silly, inasmuch as nobody says it as
the French really do, swallowing that last r.  Instead you get this
faux Frenchified front part, followed up by this hard Yankee R:
sonht-i-MEET-TUR.  It's like yer gas meet-ur.  From the same doughboys
who said they read the signs, and were near the town of Wipers, don't
you know.

    I'm never so embarrassed for my profession as when they set out to
prove presense of a little kultur.  Look at all those artsy fartsy
paintings in JAMA, for example.  Doesn't it make you cringe?

From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med.nursing,sci.med.cardiology,alt.travel,alt.lawyers,
	sci.physics
Subject: Re: Heart machines at the airport
Date: 8 Jun 1999 08:09:37 GMT

In <7ji0u4$o7j$1@oak.prod.itd.earthlink.net> kurtullman@sprintmail.com
(Kurt Ullman) writes:

>In article <375C7215.87057DA8@alum.mit.edu>, Neal Lippman <nl@alum.mit.edu>
>wrote:
>
>> overeager intern (why is it always an intern or medical student who
>>is overeager).
>
>        Largely because by the time you get through the first year of
>residency, any eagerness has been well and truly beaten out of you by the
>system (g).



    Hell, that happens the first 3 months.

From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.physics,sci.chem,sci.research.careers,alt.usage.english,
	soc.history
Subject: Re: What does DR. mean?
Date: 1 Aug 1999 23:13:23 GMT

In <37a65d1b.3758737@news.mindspring.com> njk9@spamfree.cornell.edu
(Mimi Kahn) writes:

>On 1 Aug 1999 09:45:32 GMT, sbharris@ix.netcom.com(Steven B. Harris)
>wrote:
>
>>In <37a5ca9f.48063613@news.mindspring.com> njk9@spamfree.cornell.edu
>>(Mimi Kahn) writes:
>>
>>>On 1 Aug 1999 04:06:58 GMT, jac@ibms48.scri.fsu.edu (Jim Carr) wrote:
>>>
>>>> I have not noticed if anyone has mentioned the Ed.D or the other
>>>> johnny-come-lately doctorates.  In any case, the main difference
>>>> between the Ph.D. and the M.D. is that in the latter case there
>>>> is no independent research -- mostly just training as distinct
>>>> from education.
>>>
>>>If you were marooned on a desert island, which sort of doctor would
>>>you rather have with you?
>>
>>
>>
>>   I'll trade you Robin Cook and both brothers Mayo for Thor Heyerdahl.
>
>But what if you broke your leg?
>
>Well, I suppose Thor Heyerdahl could splint it with some smaller
>logs....

   Which is all the others could do in the circumstances.  Alas, most
of the knowledge of a doctor is pretty useless without a lab, drugs or
surgical tools.  It is astonishing how handicapped a trained person is
(genius or not) without thermometer and blood pressure cuff.  The rest
of medical knowledge which would be useful without whatever serves you
as medical tricorder and hypo-spray (ie, what a time-traveling
physician might find useful) amounts to some familiarity with first
aid, wound care, and chronic nursing (often not as much as is known by
your average paramedic or nurse, unless your doc happens to be an
emergency medicine type or ICU specialist), plus a good enough grasp on
biology to reject many clearly bad (unphysiologic) suggestions about
care (which may come from who-knows-where).  That's it.  They don't
teach ethnopharmacobotany of the islands in US medical school.

   If we took a modern doc and stuck him in the middle ages, he or she
could do a lot by forbidding purging and bloodletting, and being
fastidious about nutrition, sanitation, and antisepsis (they were doing
a hell of a lot in bad environments without medical technology a
century ago, just by dint of these understandings-- see the history of
the Panama Canal, etc).  As for drugs, the modern physician would have
to hunt up the local herbalist and start learning (time to get
aquainted with opium and foxglove leaf again).  He/she *might* know
enough chemistry to make chlorine gas (and thus chlorinated limewater
or some type of Dakin's solution), from sulfuric acid, salt, and black
manganous earth. And perhaps ethyl ether from sulfuric acid and
ethanol.  But don't bet on it, since they don't teach this in medical
school, either.  And even this requires technology far in advance of
what you can construct on an island, unless you are The Professor and
it's Gilligan's Island.

   Most of the kind of immediately useful stuff I'm talking about, even
some of the botany, is known by adventurers anyway, and adventurers in
particularly bad surroundings which they have spend much time in (which
is most of them) know a good deal more about the kind of specific first
aid and care which is needed for local problems than anyone but a local
doctor with some advanced training will.  If you are marooned with
weakness and a bad headache in the Himaliyas, or a fever somewhere in
the tropics, you'll be better off doing what your guide says, than
relying on the tourist MD schlub from Iowa or NYC.  Who is likely to be
helpful as monitor (as any good doctor can usually recognize when
somebody is getting sick, or sicker, with time), but may well be
clueless as to what is the best thing to do to help under the
circumstances.   Same on an island (though if it's a desert island, ie
no fresh water, you're dead soon no matter what you do, so stay in the
shade, think about rescue signals, and contemplate your personal
philosophy).

>Does Robin Cook actually practice medicine, or does he just write
>thrillers?

   No, he practices.  Medicine changes constantly.  If you don't
practice, pretty soon (about 5 years) if you don't practice, you find
you're a "retired physician," not a physician.  Artur Rubinstein the
pianist used to say that if he missed a day of practice he could tell
the difference, and if he missed two days the critics could tell, while
with three days the audience could tell.  He was exagerating, of
course, and (in truth) it's not as bad for physicians as it is even for
musicians and computer consultants.  But it's bad enough.

   While we're on the subject I might as well comment on the rather
silly debate about how much difference it makes that doctors aren't
REQUIRED to do any original research to get their doctorate.  The
answer is that it doesn't hurt their performance as doctors much, any
more than the same lack hurts the performance of the average engineer
with an M.S. (a near equivalent, except that the practice of medicine
usually also requires a good deal of practical sociology).  Though
medical doctors are ALSO sometimes scientists (when they engage in and
publish original medical research), the bare-bones training to be, and
practicing as, a medical doctor doesn't make physicians scientists.
Medical doctors, as a rule, know this very well, and don't make any
such claim.  So long as we leave that straw man aside, that's the end
of the argument.

   Having said this, that doesn't mean physicians, as a matter of
course, don't get a fair amount of scientific theory.  Scientific
methods are the core of engineering, too.  With the current emphasis on
evidence-based medicine, your average graduate of a medical residency
program knows a lot about how to read a scientific paper, what the
setup and design of the study implies, what the statistical methods
employed are, and what can and cannot be legitimately infered from the
conclusions, and what conclusions can be argued either way (ie, what
things can be infered provisionally, or differentially as based on
one's confidence in the applicability of better controlled mechanistic
animal research, plus one's own experience and practice needs).  Since
that's a chunk of what graduate students in the sciences also learn
during their training, it may be thought by some of them that this part
is unique to science grad training also.  It's not.  On the other hand,
I may be bringing up a straw man there, also.

   Gosh, this message did run on, didn't it?  Apologies.

From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.physics,sci.chem,sci.research.careers,sci.med
Subject: Re: What does DR. mean?
Date: 2 Aug 1999 05:33:01 GMT

In <7o30md$djr$1@news.fsu.edu> jac@ibms48.scri.fsu.edu (Jim Carr)
writes:
>
> Your question is also a nonsequitur, since it has nothing to do
> with whether an MD has done independent research or not.  You
> could also ask which you would rather have around when a new
> disease came along: one that acts like an expert system with an
> empty data base or one who will approach it as a research problem.


Comment:

    Very good thought, and way more relevent than many readers here may
first realize.  The "new disease" you're seeing the doctor with, does
not need to be something like AIDS in 1980, that you happen to have one
of the first cases of.  It may not be fatal, or even be making you miss
work.  The key, however, is that it's distressing to you, and it's
"unrecognized" fully by your doctor.

    Now a litle thought will suggest to you that this is not a rare
situation.  Most recognized disease entities (ie, things with a name)
do not have full pathologic pathways worked out, and in that sense are
not diseases in full standing, like sickle cell anemia, but rather (at
least in part) clinical/lab syndromes, like the old "anemia" or
"jaundice," or even "infectious hepatitis."   We may sound learned that
we have stuck a handle on them, but there is still a good chance that
they are a number of things, all looking so much alike now that we
can't tell the differences.  Like typhus and typhoid of old.  Or
hepatitis A, B, and C.  Or "Bright's disease" which is now dozens of
kinds of (mostly) autoimmune glomerulonephropathy, each with a
different mechanism (the ultimate cause of many still unknown-- it's
fractal).  Indeed, many mental "diagnoses" are ENTIRELY syndromes, and
we know nothing of the underlying pathology at all.  In all these
cases, there may be, and no doubt is, a great deal in your "disease"
which your doctor dosen't recognize, even if you have a "firm"
diagnosis.

   Next, consider that there are several thousand skin diseases alone
which have been described.  Even dermatologists only know a fraction of
them.  It's almost that bad in every medical subfield.  Thus, whatever
you have, unless it's something very common, it's likely that even if
some doctor somewhere knows a lot about it, the doctor you're standing
in front of does not.   In that sense, it also may as well be an
unknown disease, unless you and your doctor are smart enough, or
stubborn enough, to keep looking until you get to the proper
specialist.  If you are in an HMO and are not too ill, good luck
getting that to happens real soon.  Also, please remember that you
don't want to hear your doctor say he or she has no idea what you've
got, and also your doctor doesn't want to say that, either.  So you
both have a very powerful incentive not to admit that a search for the
specialist is in order.

   Finally, I should not have to convince everyone that Edison was
(qualitatively if not quantitatively) probably on track when he
observered that, we (mankind) don't know a millionth of one percent of
what there is to know about anything.  Biology, physiology and medicine
are very complicated.  Probably there isn't a much more complicated
object on this planet than the 3 pounds of tapioca between your ears
which which you're digesting this message. And that's just part of your
body.  Thus, when you consider that it seems rare that you show up at
the doctor's with a disease that nobody's ever seen before, or for
which there isn't a name yet, that's probably NOT because that isn't
what actually happens.  Probably it happens all the time, and you're
simply misdiagnosed with whatever is the current version of "cholera
morbius," and treated.  The art of medicine lies in entertaining the
patient while nature cures the disease, as Voltaire notes.  Today, the
art of medicine also lies in controlling pain and inappropriate
inflammation, removing dead or non functional tissue where necessary,
grossly putting things back together, fending off microbes, and
metabolically supporting the patient, while the body heals itself (if
it can).  But the reality that most things are probably misnamed, and
or misunderstood, and merely treated supportively or symptomatically
until the body can recover by itself, using its superb self-repairing
mechanisms, remains.

   This is not to denigrate doctors (of which I are one, as the joke
goes).  Symptomatic treatment beats hell out of no treatment, and
supportive treatment very often makes the difference between life and
death.  However, we were speaking of the your doctor's attitude toward
the unknown, which he (and you) will be confronted with, every single
waking second.  YOU may not like to be reminded that your doctor does
not know a heck of a lot about what (s)he is doing, by the standards of
(say) doctors of 100 years from now.  And your doctor may not really
want to remind you of this, either, except as necessary (nobody wants a
doctor who unnecessarily creates anxiety, and I'm no exception when I
see a doctor).  However, it is necessary that your doctor not lie too
much to him or herself that most problems are (in a sense) research
"problems," since the unknown is faced most of the time.

   So how your doctor approaches problems is the key.  Science only
provides some help, since any given patient cannot be approached as a
scientific project, either.  If you have an unknown problem, you're a
"one rat experiment."  An unblinded crossover study with n of 1.  It's
dirty, and there are so many variables that they generally can be
expected to obscure clear results.  In such circumstances, the trained
scientist will simply scream and run, leaving the rest of the world to
cope as best it can.  If your doctor does science also, he or she will
find it necessary to deliberately change patterns of thinking when
seeing patients in any kind of humane way.  (As for the FDA, bent on
doing science, they often do NOT allow clinical trials to be conducted
humanely, and in any case, you don't have the resources or the time to
do it their way, as single doctor or patient, even if they did).

   So, DOES your doctor act like an expert system without a database
match?  "You must have this, you must have this.  Keep taking these.
Keep taking these.  See me in six months.  Click.  See me in six
months.  Click.  Have a nice day, ma'am.  Nice day.  Click."

   Or do you sense some flexibility?  Knowing the underlying importance
of the body's own self-repair systems and of general metabolic support
to keep them operating efficiently, is your doctor concerned first
about nutrition, prevention, physical therapy and exercise?  Knowing
that physiology does not lie, does your doctor pay more attention to
your vital signs and lab results than to what your treatment and your
disease is "supposed to" be doing?  Does your doctor suspect your
pharmaceuticals first and your body second when it comes to new
symptoms?  Does he regard many diseases as simply labels of
convenience, useful only as guides for what treatments to try first,
but not in any sense as generators of treatments to be slavishly
followed?  Is he or she open to new ideas?  Does he or she at least
read something about alternative medicine?  Subject to time
constraints, is he or she interested in information you've
independently obtained?  Does he or she cheerfully set limits and
goals, and agree to refer you for second opinions and to specialists,
if things don't get better by themselves in a time frame you're
comfortable with?  Does your doctor suggest several possibilities for
you in treatment, and encourage you to experiment with them (including
appropriate drug treatments), and keep a diary?  Do you know what the
plan is, and are you part of it?   Do you know the risks and share in
them, for each course of action, such as they are known?   None of this
is particularly science, but all of it is the difference between how a
machine "thinks," and how a human being does.  How you deal with
uncertainty is the test of wisdom, and the first test of wisdom is to
recognize uncertainty in reality when it is there.  Does your doctor
have wisdom?  Can you tell?  Do you dare?

                                     Steve

From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: misc.health.alternative,sci.med
Subject: Skills (Re: Quackwatch??)
Date: 29 Aug 1999 11:14:40 GMT

In <19990829013215.17349.00001120@ng-fc1.aol.com> jdrew63929@aol.com
(JDrew63929) writes:

>>In some fields, our society has decided to set upa gatekeeping system to
>>ensure that only those with adequate education can practice in the
>>field. Medicine is one such field, as is the law. ANd engineering. All
>>of those fields have degree requirements and licensing procedures. Would
>>you go to a surgeon who had "experience" but never went to medical
>>school? Not me.
>
>
>
>
>Off topic. Noone is talking surgery here.



    Actually it's on topic.  Some years ago, the Russians, with a great
shortage of battlefield surgeons, decided to see what would happen if
you took an intelligent layman with no medical training at all, and
taught him to do just one surgery, but do it very, very well.  Would it
be a disaster?  No, it wasn't.  As with all fields, education is mainly
hanging around until you catch on. If you have talent and good
teachers, you can apprentice-learn anything.  There is nothing magic
about parking your rear for some time in a room with seats at some
institution, paying money, and getting a Diploma like the Scarecrow of
Oz, to show you have a brain.

   I once knew a renal perfusionist who'd been taught by a surgeon,
then contined to teach himself, how to do delicate bypass cardiac
surgery on dogs.  It was his job as research assistant, and he was
quite good at it, though slow.  Every so often a cardiac surgical
fellow would come down to learn on an animal model, and would try to do
dog surgery in a same way they'd done humans, and would kill every one.
Dogs are a bit different, and though cardiovascularly in many ways
superior, are also delicate in the way that all fine machines are.
These regular medical surgeons finally had to learn the finer techique
from the master-- a guy who in this case had not only no medical
degree, but no veterinary one, either.  He did happen to have a degree
in philosophy, and all this would probably have made him philosophical,
except that he'd also been in the special forces in Vietnam, and had
done quite a lot of watching of officers (West Point new grads, vs
non-coms who'd been in-country a while). So he was just cynical.  One
of the most cynical people I've ever met, in fact.  I don't blame him.

    That being said, it's quite hard to keep track of who's done what,
and knows what, without such pieces of paper.  We should remember,
however, that they are markers only.  It is the legal system which
transforms them into licences.  That, in many ways, is a shame.  Some
system as have has to be in place-- but at the same time, there should
be room for what the military calls mustangs, for men and women of
ability who have risen from the ranks by means both conventional and
not.  Medicine needs its battlefield commissions, too.  No true
meritocracy can afford to be without such mechanisms, and my own field
is the poorer for not having them.

   There was once a Shakespeare scholar named G.L. Kittridge, who was
acknowledged in his day to be the greatest all around authority in the
field.  The trouble was, he hadn't ever gotten a Ph.D.   One of his
students, toward the end of his career as a professor at Oxford, once
suggested that he finally get one.  "My dear," he said patiently, "who
would examine me?"

   Just so.

                                        Steve Harris, M.D.

From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: misc.health.alternative
Subject: Re: Skills (Re: Quackwatch??)
Date: 30 Aug 1999 20:10:16 GMT

In <amieBB7550A6.217.266@edgebbs.com> George Lagergren
<gl@edgebbs.com.REMOVE.ME.TO.REPLY> writes:
>
>sbharris@ix.netcom.com(Steven B. Harris)  wrote:
>> That being said, it's quite hard to keep track of who's done what, and
>> knows what, without such pieces of paper. We should remember, however,
>> that they are markers only. It is the legal system which transforms
>> them into licences. That, in many ways, is a shame. Some system as have
>> has to be in place-- but at the same time, there should be room for
>> what the military calls mustangs, for men and women of ability who have
>> risen from the ranks by means both conventional and not. Medicine needs
>> its battlefield commissions, too. No true meritocracy can afford to be
>> without such mechanisms, and my own field is the poorer for not having
>> them.
>
>     Perhaps, the medical profession would be better served if medical
>     schools taught common sense folk medicine and nutritional medicine,
>     along with allopathic medicine.





   And perhaps they wouldn't.  Most things get better by themselves,
and the doctor's main function is metabolic support and symptom control
while that happens.  For chronic problems, it's much the same-- except
you can only experiment until you improve things, but you can't fix
what's aged and broke, since the repair machinery wasn't invented by
mother nature.

   And in all these things, a major problem is trying to keep from
harming the patient with the symptom control while you're dealing with
the disease.  Drug side effects are a major problem in medicine, and if
you haven't got the time or the respect to use them wisely, you should
stay away from them.  "Don't just do something, sit there!" is often my
advice for students.  Tincture of time.  Folk remedies are useful as
harmless kinds of amusment for all, so long as you know enough to know
you're not trying to treat urosepsis with garlic, or a segment of dead
bowel in an 85 year old woman, with fennel.

                                 Steve Harris, M.D.

From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.physics,sci.med
Subject: Physcian Intelligence (Re: "The Einstein Hoax")
Date: 29 Oct 1999 09:47:34 GMT

In <941163949.756857@news.tir.com> "JimVal" <jimval@tir.com> writes:

>  There's a huge difference between booksmarts and
>intuition. I feel that intuition is mostly based on the ability to see,
>feel, touch, and understand the theory from a perspective that is just
>not given to those that have no ambition to learn at all, yet finish
>within the 10% of their class mearly because they could memorize things.
>That is such an empty view and offers nothing but a dull and boring
>scientist, not to mention a dangerous one (in the medical profession).



Comment:

    I will note, however, that you cannot even get into medical school,
let alone through one and then an internship and residency, on the
ability to memorize alone, without at least having also better than
average ability to synthesize information and evaluate probabilities.
In other words, without also the ability to "think" in certain useful
ways.  That it is in fact possible to do all this on memorization
alone, is an amazingly durable myth.  I wonder how it got started?  It
certainly does not survive experience.

   I've known hundreds of physicians in my own career, some of them
very well.  I've worked with them, seen them succeed and fail, triumph
and screw up.  I've yet to see one who did not have better than average
ability to sythesize information and evaluate evidence.  Which is to
say, who wasn't fairly bright at solving certain kind of problems, in
addition to having a good memory.

   Now, notice what I'm saying, which is that more than a good memory
is involved in becoming a physician, and that extra ability is
certainly one of the key things we mean when we use the word
"intelligence."  There are many other kinds of "intelligence", of
course, and many of them are unfairly slighted.  And doctors do not
alwyas have them. I have seen physicians with fairly poor "EQ"s and
mechanical ability.  These, too, are forms of intelligence.  There are
docs I would not trust to take appart a toaster, and am glad they are
endocrinologists or psychiatrists.  There are docs who cannot tell when
somebody is genuinely angry with them, but hiding it, or cannot
recognize anxiety.  This can be a great handicap in the profession, and
I'm glad when I find out these people are anaesthesiologists,
radiologists, radiation therapists, and orthopedic surgeons.  But all
this is beside the point.  Nobody ever claimed that doctors are
universally intelligent (I don't know anybody who is-- was it Feynman's
mother who said "If that's the smartest man alive, then God help
us.."?).  I'm simply taking a swing at notion that doctors, as selected
by the American system of medical education over the last two
generations, are very ordinary sorts of folks, who just happen to have
good memories.  Balderdash.

From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: misc.kids.health,sci.med,misc.health.alternative
Subject: Re: Medical Control, Medical Corruption
Date: 23 Jul 2000 23:51:34 GMT

In <8lfe8e$bgk$1@nntp9.atl.mindspring.net> "CBI"
<c_ishnospam@mindspring.com> writes:
>>
>I'll give that one to you. I assure you psych residencies are famous for
>being easy. You would not find the same to be true for an internship in
>family practice, pediatrics, or internal medicine. Surgery internships
>are another step up in difficulty from primary care.


   Yep. Medical residencies are difficult in proportion to the
probability that your sick patients might die in the next couple of
hours if you don't get up (or stay up) at night, and go see them. The
exception is emergency medicine, which has a well-defined system for
limiting hours of "risk" by handing off patients when (limited) shift
time periods end. Of course, this same system could be used in surgery,
OB-GYN, and indeed in primary care areas.  It isn't done, however,
basically because the patients don't like it. When it comes to ED
services, they put up with a more changes in doctors because they don't
expect any continuity of care.

From: sbharris@ix.netcom.com (Steve Harris  sbharris@ROMAN9.netcom.com)
Newsgroups: sci.med
Subject: Re: Can a cold last a month?
Date: 8 Nov 2004 18:37:57 -0800
Message-ID: <79cf0a8.0411081837.5ccd544@posting.google.com>

Carey Gregory <tiredofspam123@comcast.net> wrote in message
news:<526uo0d21p691r2fdkn12doue59e3gjrbl@4ax.com>...

> mha@TheWorld.com (Martha H Adams) wrote:
>
> >So however you look at it, maybe your best course is -- find a doctor
> >you can talk to.  Alternate / backup choice: a postdoctoral / premed
> >student.
>
> Huh?  A pre-med student is nothing but an undergrad who hopes to go to med
> school someday.  They have zero medical training and zero medical
> experience, but sometimes they imagine otherwise.  Almost anyone with any
> sort of actual experience or education would be better.


COMMENT:

Yes. The same goes even for a medical student. Very little of the core
of what you need to know to be an effective physician is taught in
medical school. Just as little of what you need to practice law is
taught in law school. Or for that matter, what you need to know to be
a good officer in officer's training school.  In all cases, the
effective learning is on the job, afterwards.  The first two years of
med school is mostly irrelevent books. The next two years are learning
to kiss ass. (In this, it differs from officer's training, which is
learning to kiss ass the whole way through.)

You could in theory design a medical school cirriculum which was
maximally efficient.  But then it would look so much like a
physician's assistant program, what would you then call it?

SBH