Saturday, December 21, 2013

Some Issues About Evaluating Blood Pressure

A new report by an expert "guidelines committee" has shifted blood pressure norms for people over 60 years of age up to 150/90 from the previously accepted level of 140/90.  This has huge implications for many individuals presently taking anti-hypertensive medications, many of which have decidedly negative side effects.

This blog is not meant to evaluate the validity of this conclusion but to educate individuals about possible errors in blood pressure measurement.

Blood pressure is most often measured by using an inflatable cuff wrapped around the upper arm, a manometer (either a column of mercury, or a clock-face dial with a needle) and a stethoscope with which the examiner listens for the appearance and disappearance of pulse sounds in the crease of the elbow.  The blood pressure can vary based on a number of factors that affect these elements. Techniques used to record blood pressure in a doctor's office are "indirect."  The only true,"direct" method of measuring the pressure in a blood vessel is to attach a measuring device to the blood vessel directly - a procedure normally performed only in emergency rooms and hospital settings.

There is room for variability and some differences when the indirect measure of blood pressure is used. For instance:

1. The cuff may not be appropriately sized for the circumference and length of the upper arm - cuffs that are to short, or do not comfortably fit around the arm are apt to give falsely high pressures.  The reverse is true of cuffs that are too loose or to large.  The cuff must also be properly applied to the arm so that the bladder inside the cuff covers the brachial artery (the large artery in the upper arm.)
2.  Blood pressures are determined by the appearance and disappearance of sounds the blood makes as it moves under the stethoscope for which the examiner listens.  Clearly the auditory acuity of the examiner means something here. The ability to hear the initial and final sound depends not just on the examiner's ears, but also on the rate at which the air is released from the inflated cuff.
3.  Blood pressure may vary with body position.  It may also differ from one arm to the other.

Given the variables involved in the indirect recording of blood pressures, using absolute numbers as guidelines is fraught with the potential for error.  A blood pressure recorded as 154/90 could easily be an inaccurate reading of a pressure which may actually be 148/86, or even 158/94.

It would be more helpful to provide a "range" of normal (or abnormal) rather than an absolute number, given the variables discussed above.  And remember, one blood pressure recording is never enough to make a diagnosis of hypertension - there should be at least three such recordings over a period of a few weeks before a diagnosis is confirmed.

Tuesday, December 17, 2013

Children with Down Syndrome - How Times Have Changed

Susannah Meadows's book review in the Dec. 17 NY Times Science Section (Raising Henry, by Rachel Adams) discusses how the attitude towards children with Down Syndrome (also known as Trisomy-21) has changed.  Ms. Adams, a professor of English and American studies at Columbia University declined the amniocentesis which would have made a pre-natal diagnosis.  In describing Henry, who is now six years old, she makes the following heartwarming comment about what is described as Henry's essence:  "I couldn't have ever known about his great sense of humor or the sound of his infectious laugh.  Or the smell of his hair.  The delight he gets from singing along with music or pouring bathwater from one cup to another."  Her son is "separate from the diagnosis," she writes.

Ms. Adams goes on to describe the "abysmal" bedside manner of her physicians - the OB-GYN resident who "sewed her up"then "sprints out of the room," the pediatric geneticist who used Henry as a "teaching prop," without a word to Ms. Adams, and her obstetrician who assured her that "I wanted to make sure I didn't miss anything so I showed your records to my colleagues, and everyone agreed there was nothing."  So many doctors remain poorly trained in "people skills."  Medical schools must begin to realize that their job is to graduate not just physician-scientists, but physician-healers - doctors adept not just in the science of medicine, but in the art of healing as well.

When I was a young pediatric resident, Down Syndrome was often termed "mongolism" because of the "Asian" appearance of these children.  My chief of pediatrics routinely advised all parents of such children to institutionalize them immediately lest they adversely affect the family dynamic.  His "advice" frequently sounded more like a requirement and was, to the best of my recollection, most often followed.

Statistically 50% of children with Down Syndrome have congenital heart deformities, often rather severe forms, unfortunately.  When I was a trainee in pediatric cardiology, our team routinely declined to offer cardiac corrective surgery to these children, feeling that such treatment was far too involved for patients with Down Syndrome and that their lack of co-operation during the post-operative recovery period would add greatly to the risk and preclude a satisfactory outcome.

Attitudes have clearly changed.  No one is routinely institutionalized.  Surgery is no longer denied, and outcomes are excellent.  It has been a lifetime of change for me, especially as a pediatric cardiologist.

But one must remember that not all children with Down Syndrome have Henry's essence.  Some are extremely difficult to manage and very delayed developmentally - but so are some children without Down Syndrome.  And, finally, one needs to remember that children with Down Syndrome will become adults with Down Syndrome - and that is another issue altogether.

Thursday, December 5, 2013

Should We Mess With Aging

Studies on aging are primarily concerned with controlling the process rather than coping with the process.  A recent article discussed the frequent features of the aging male - namely the development of the "pot belly," loss of muscle mass and a decrease in sexual desire.  These processes of growing older are mediated in large part by a fall in the level of testosterone.

Articles describing research in the field of aging refer to this change in testosterone level as a "decrease in the normal level of testosterone."  But it is not a decrease in the normal level of testosterone -  it, in fact, is a normal level of testosterone commensurate with the aging male.

Studies directed towards reversing the aging process by abnormally increasing a level of a hormone, be it testosterone, estrogen, or some other such agent, are concentrating on converting us from the normal aging process to an abnormal one.

Anti-aging research continues.  Why?  Are we truly interested in extending life expectancy to 150, or perhaps even further?   Is government expense for research to provide us with the proverbial "fountain of youth," - to control the aging process whereby we will live far longer, but at a great human and economic cost to society -  treasure well spent?

As Daniel Callahan (age 83), emeritus president of the Hastings Center, recently wrote in a NY Times Op-Ed article (Dec 1):  "We may properly hope that scientific advances help ensure……that young people manage to become old people.  We are not, however, obliged to help the old become indefinitely older.  Indeed, our duty may be just the reverse: to let death have its day."

Tuesday, November 26, 2013

The Three Considerations in Medical Care

Your health care requires three significant considerations and decisions on your part (not in any particular order).

1.  Cost and availability
2.  Expertise of providers
3.  Whether treatment is really required.

The Affordable Care Act is primarily, if not solely, concerned with the first of these.  It's intent is directed at making health care "affordable," as is clearly stated in its title.  I am not getting into the pluses and minuses of the act, except to say that I feel very strongly that everyone is entitled to basic health care, and it is the responsibility of a government to insure that such care is available to all citizens - as it is for the availability of a citizen's personal security (police and military "care") or the security and safety of his body and property (fire and safety "care").  Though military, police, and fire services are expensive, the cost is not borne by the individual directly, but indirectly via the tax structure.  Therefore the expense is not "felt" as is the case in medical care.  For the record, I am in favor of a form of single payer system, so common in most other developed countries, but available in our country only for people who have reached a certain age, or are below a certain income level.

The Affordable Care Act does not help you determine the expertise of the providers.  Medicine, is a provider-based service, not a product.  Various agencies, governmental or private seem to regard it as a product and wish to furnish you with the "product" at the lowest possible cost.  But there is variability in the expertise of the medical providers, which is just as important, if not more important than cost and availability.   Is your physician skilled at recording your medical history and performing your physical examination?  Does he know which tests to order and, perhaps more importantly, which tests not to order?  Is your surgeon skilled at the surgical procedures he may be advocating?  Additionally, much of medical practice today is guided by evidence-based medicine - recommendations for management of sundry medical diagnoses after evaluation by committees of universally regarded experts.  Physicians should be aware of, and should be following these recommendations, which are based on numerous well-researched published studies.

Lastly, and perhaps most importantly, is the question of whether or not the advocated treatment is really necessary?  A patient should be properly informed of the risks and benefits of the advocated therapy as well as the risks and benefits of no therapy.  Not everyone who is referred for heart surgery actually requires it.  Not everyone who is told to have a colonoscopy really needs it.  Not everyone is informed that surgery is not always the solution to a back problem.  Be aware that medical errors leading to death may befall some 400,000 patients a year,  according to a recent study in the Journal of Patient Safety.

Get all the information you can about cost, expertise and necessity.  If you feel uncertain, find someone to guide you.  Provide yourself with some basic knowledge of medical statistics to help you ask the appropriate questions when visiting your physician.  And try to have someone accompany you to help you understand what you are being advised to do and why.

Sunday, November 10, 2013

Michael R. Bloomberg has just been awarded the first "Genesis Prize," a prize that the organizers are terming the "Jewish Nobel Prize."  The NY Times (Oct 21) explains that the prize "aims to honor 'exceptional people whose values and achievements will inspire the next generations of Jews.'"

The prize was created by a group of Russian-Jewish oligarchs and is administered in partnership with the government of Israel.  The Times goes on to say that this award "is open to those who have succeeded in various fields, including science, the arts, business and diplomacy."

Although not specifically stated, it appears that only Jews are eligible to receive this award.  Or are there, perhaps,  non-Jews who may be meet the criteria of "exceptional people whose values and achievements will inspire the next generation of Jews."  I certainly hope so.  As a Jew I can easily declare that I was inspired by the "values and achievements" of many non-Jews and went on, hopefully,  to do the same for both Jews and non-Jews.

Jewish success in science, arts, business, etc. is not restricted to inspiration from other Jews!  

Monday, October 14, 2013

The Unnecessary Annual Physical

Danielle Ofri, ('Doctors' Bad Habits', Sunday Review October 6) after evaluating data that pointed to the lack of benefit in performing annual physical exams on young, healthy, asymptomatic patients, concluded that they were still worthwhile - at least for her.  Without citing any data of her own, the doctor concluded that an annual visit "establishes a solid doctor-patient relationship." We are not told, however, what her patients think about this medically unnecessary visit.  After all, they are asked to come to see her for no medically established reason, and in the process may be losing a day's work, or having to find someone to provide child care, etc.  I feel quite certain that a fee is involved as well.

Medicine should be practiced using well established guidelines.  Physicians often practice methods taught years ago, or practice by some "grandfathered" idea, if you will, that actually has no basis whatsoever in fact.  Evidence-based medicine is the path that all physicians should follow.  If they feel otherwise they should offer their patients a good explanation before he is asked to give up his time and spend his (or, more of then than not - our) money.

Dr. Ofri has decided that annual physicals are worthwhile despite data showing otherwise.  Why not semi-annual physicals, or quarterly physicals?  Why has "annual" become the standard for Dr. Ofri?  Maybe weekly phone calls would be even more beneficial for the doctor-patient relationship, Dr. Ofri.

Thursday, October 10, 2013

Non-MD Medical Providers Performing Abortions in California

We are getting there!  As you, my readers know, The Blog has been a champion of non-physician medical care, knowing full well that properly trained, skilled nurse practitioners and physician assistants are highly qualified to provide such service.

Gov. Jerry Brown of California has signed into law a bill that will permit nurse practitioners, midwives and physician assistants to perform all forms of abortion, including surgical abortions.  Those opposed to abortions are maintaining that the new law will "reduce the medical standards for abortion," thereby "reducing safety."(1)

Ridiculous.  This bill will put the procedure within reach of women who often live in settings where physician-provided abortions are difficult to access, and provide them with skilled practitioners.

You do not have to be a physician to perform an abortion.  You do not have to be a physician to perform many forms of surgery.  You do not have to be a physician to perform many emergency medical procedures. You do not have to be a physician to provided excellent general (or even specialized medical care).

An interesting article in the recent edition of The New England Journal of Medicine (2) concluded that he best surgery is carried out by the physicians with the greatest "skills," not necessarily those with the best training.  "Our study showed wide variation in technical skill among fully trained, practicing surgeons." (2)

Academic training is one thing.  Developing the necessary skills is something else.  And, you know, there are many skilled non-MD practitioners who may be far more skilled than those with MD degrees.  Trust your experienced, skilled non-MD medical provider - your physician often does, the city government does (EMTs, etc.), the armed services do (front-line medics) - and so should you.

1. New York Times, Oct. 10.
2. The New England Journal of Medicine, Oct. 10.

Tuesday, October 1, 2013

What a Hospital Ad Does Not Tell You

"The thousands of minimally invasive procedures performed by our cardiac surgeons have shown shorter hospital stays and reduced recovery time, among other benefits.  This proven record of strong outcomes is why we are nationally ranked in cardology and heart surgery by U.S. News and World Report."

This full page advertisement by NYC Langone Medical Center,  on the back page of the Business Section of The New York Times (Oct 1) must have cost quite a bit.

You need to notice what it does not say.  It says nothing about actual long-term outcomes.  It says nothing about the success of the procedures.  It says nothing about re-admission rates, it says nothing about infection rates.  It says nothing about morbidity and mortality rates.  It says nothing about actual diagnoses and statistics regarding each form of abnormality treated.

Please readers, pay no attention to such ads.  The only useful information contained therein is that minimally invasive heart surgery techniques are available at Langone (as they are, by the way, at most all major cardiovascular surgical centers in the United States).

Below is a summary of the state of minimally invasive surgery from a recent NIH review:

1. Minimally invasive cardiac surgery (MICS) represents a safe and effective approach for a variety of cardiac surgical diseases.
2. MICS does not appear to result in differences in short- or long-term survival compared with the sternotomy approach.
3. MICS may be associated with lower rates of perioperative complications in certain instances.
4. MICS appears to result in decreased length of hospitalization, improved pain control and faster recovery to normal activities.
5. Continued research is necessary to assess long-term outcomes of minimally invasive approaches.
6. With regard to outcome measures such as quality of life, minimally invasive approaches may be the standard on which to compare evolving percutaneous technologies.

Pay particular attention to statements No. 2 and No. 5.

When choosing your medical center and your surgeon, ask the right questions - be fully informed.  Do not pay attention to these expensive marketing techniques that many medical centers are now using to increase their market-share!

Wednesday, September 25, 2013

This Is a Hospital, Not a Hotel

"You have to realize that this is a hospital, not a hotel," was my standard response to the "hospitality" criticisms offered by the parents of my patients (I am a retired pediatric cardiologist).

Apparently this attitude no longer applies.  In a NY Times Sunday Review article entitled "Is This a Hospital or a Hotel?" (Sep 22)  Dr. Elisabeth Rosenthal analyzes the new approach that hospitals are taking.  The chief executive of a new hospital opening next year "exulted" in saying: "You feel like you could be at the Marriott."  The hospital "business" has become extremely competitive, for better or worse, and hospitals are improving their bottom line, not by increasing quality of medical care, but by increasing the quality of "hotel" services - such as hiring "celebrity chefs" to provide special menus, including quality wines.  Major hospital systems are averaging $4.5 million annually in advertising alone! Dr. Rosenthal points out that reducing the rate of medication error is not what "sells" beds. More and more it has become amenities, amenities, and amenities.  She goes on to point out that the Henry Ford health system in Michigan recently hired a hotel executive to run its newest hospital, located in the upscale city of Bloomfield.

Believe it or not, a hospital is a business with a bottom line.  Yes, most are "non-profit," but what does that actually mean.  Nothing.  It is a complex operation that pays its executives well, with the CEO's of major hospital systems easily earning seven figure incomes, not to mention the associated perks.  Many have a horde of vice-presidents (I recently counted the number of VP's of a major New York hospital system and was quite astounded when I reached 70 and hadn't finished yet!)  Yet these hospitals are extraordinarily dependent on government subsidies and, as Dr. Rosenthal indicates, this striving for luxury may be adding to the already vast cost ($2.7 trillion) of the nation's health care.

Hospitals want (and need) patient-dollars (i.e. government or insurance dollars).  They are in competition with each other and will do what it takes to bring in patients.  Dr. Rosenthal's article concludes with her description of the VIP rooms at the hospital where she trained.  "Though the views were spectacular, the cardiac arrest team could not get there as quickly as it could to the regular wards.  We called it 'a hotel near a major teaching hospital.'"

Going into a hospital? Assess re-admission rates, infection rates, mortality and morbidity rates for various procedures.  Marketing should not be what "sells" hospitals - success of outcome is what should "sell" hospitals. "You have to realize that this is a hospital, not a hotel!"

Tuesday, September 17, 2013

When Does a Fetus First Experience Pain

An extraordinary discussion is taking place as to when a fetus first feels pain.  At issue is whether pain can be felt prior to 24 weeks of fetal age.  Does it really make a difference?  If one is in favor of abortion, does the fact that that the fetus reacts to pain really matter?  If so, should those performing abortions actually anesthetize the fetus prior to aborting it?  Should the fetus be "put to sleep," so to speak, before the abortive procedure?

Now there is absolutely no consensus as to the exact time when fetal neuronal development matures to the point where pain can be experienced.  Moreover, if one argues that pain can first be manifest at, lets say, 24 weeks, there are invariably going to be fetuses that may have developed this ability sometime before that age, and others sometime after - just as a newborn babies vary in development.  Some babies can sit up at six months, others somewhat earlier, still others somewhat later.  One cannot pinpoint such things!

Believe it or not, there are still those who believe that eight-day old boys undergoing circumcision require no anesthesia as they are "too immature to feel pain."  The circumcision is performed nevertheless - without anesthesia.

For those who oppose abortion the decision is easy.  Whether a fetus does or does not experience pain is not an issue.  Abortion is wrong.  For those who are pro-choice - should it matter?  In a properly performed abortion, any pain that the fetus may feel would be extremely short-lived.  Is this enough to precede the operation with anesthesia?

Doesn't it seem strange to have to anesthetize a fetus prior to aborting it?  

Tuesday, September 10, 2013

Rivera or "Ree-vey-rah."

A recent story on National Public Radio featured an interview with a superintendent of schools (I do not remember his city) whose surname was Rivera.  I do not remember his first name, but I recall quite clearly that when he spoke, his American English was totally accent-free.  Now I don't know how he pronounces his name, but I'll bet he pronounces it the way I would, or most English-speakers would - the way you would - that is without a Latino inflection or accent.  The reporter of the piece, however, constantly referred to Mr. Rivera as Mr. "Ree-vey-raah" reading his surname with a distinct Latino accent in a way that the name would be pronounced in a Spanish-speaking country.  The reporter, by the way, who, judging by his surname (also not specifically remembered), had a Latino background,  spoke perfect accent-free English, giving a Latino accent only to the name "Rivera" and to his own name in his narration of the piece.

I have never heard reporters pronounce Irish names with an Irish brogue, or Scottish names with a Scottish burr, or German names as they would be pronounced in a German-speaking country, etc.  But this is not the first time that I've noted the exception made for Latino names when uttered by Latino reporters speaking accent-free American English.

I seriously doubt that Mr. Rivera, or other English-speaking native-born Americans with names such as Fernandez or Morales, would actually prefer to have their names voiced as they would be in their ancestral Spanish-speaking countries.

But, maybe they do!  And if so, "mea culpa" (pronounce this in the original Latin manner, please).

Nurse Practitioners Good - Physicians Bad

An internal investigation by the Department of Veterans Affairs has found that one of its hospitals in Jackson, Miss., did not have enough doctors in its primary care unit, resulting in nurse practitioners’ handling far too many patients, numerous complaints about delayed care and repeated violations of federal rules on prescribing narcotics.
The investigation found no evidence that care had been compromised in the primary care unit, the vital first stop for many patients. But it concluded that there were enough problems “to suggest there may be quality of care issues that require further review,” a copy of the investigators’ report says.
These were the leading paragraphs from an article in the Sep 9 NY Times about major problems affecting a VA hospital in Mississippi.  Further along the article goes on to describe other concerns, particularly those regarding a radiologist (a physician, by the way - not a nurse practitioner!) who misread multiple X-rays and CT scans.  A large number of patients will now have to be recalled for re-evaluation.  
With this real issue of medial malpractice, not to mention, complete physician incompetence displayed by the radiologist, I was astonished to see that the opening paragraphs deal not with this horror, but with the fact that many patients, in the absence of an adequate number of physicians in the primary care area, actually had to see nurse practitioners!!  God, how bad is that!!  But then the reporter informs us that there was "no evidence of that care had been compromised....."  Is that supposed to be a surprise??  
This Blog has always been a strong supporter of nurse practitioners.  They are well trained and extremely capable.  It is wrong for the NY Times to highlight primary care by nurse practitioners as a "failure" of care in its initial description of the problems of this hospital.  Care by nurse practitioners can easily be equal to (and sometimes even exceed) that of a primary care physician!!  The major issue of poor quality of care at this VA center wasn't in the area of primary care, but the physician-radiologist - the MD, not the NP!

Tuesday, August 27, 2013

Reproductive Technology - What is the New Morality?

Reproductive technology is advancing at "the speed of light."  Science has now afforded us the ability to extract the abnormal chromosomal mitochondrial DNA (that part of the chromosome that is responsible for transmitting certain inheritable characteristics) and replace it with the "normal" mitochondrial DNA of a donor egg.  So, for instance, a mom with an inheritable defect transmitted by her mitochondrial DNA can have the mitochondrial DNA of a donor substituted for her own, thereby eliminating the possibility that her child will be subject to some devastating disorder that would have been transmitted by her own mitochondrial DNA.

The child who would be the product of this reproductive technology would, in fact, have the genetic makeup of not two, but three parents - that of the natural mother and father, and that of the donor egg with the normal mitochondrial DNA.

Are these techniques morally justifiable?  How should we react to these feats of genetic engineering?  Such processes are not ones that can be ignored or barred.  We will have to come to grips with a new moral clarity.  The identity of the traditional parent will have to give way to a new concept of "parenthood," and the whole concept of who contributes to the parenting of a child will take on an entirely new meaning.

Monday, August 19, 2013

"Who Am I To Judge?"

Here's an interesting take on Pope Francis's words "Who am I to judge," as editorially analyzed in a recent edition of the Jewish Daily Forward.  The entire comment, not often fully cited, is as follows:

                  "If someone is gay and he searches for the Lord and has good will, who am I to

The editorial goes on to cite Francis's words as being "conditional."  Judgement was limited to persons of good will and those who believe in "the Lord."  Personal judgement is suspended only on the condition that certain behavior is followed.

Do we ever actually have the right to judge?  Is judgement of human behavior something that should be  reserved for a deity?   Of course we have the right to judge.  "Who are we to judge?"   We are  human beings to whom society gives the right to judge.  It is only through such judgement that societal mores and ethics develop.  When we judge others, however, we should always remain aware of how those being judged may judge us, given a reverse of circumstance.

The issue is not whether or not humans have the right to judge, but that they (we) make judgements honestly, without prejudice, without vested interests, and with the objective to better the welfare of society.

Whether or not there is a "final judgement," made by God, is a question best left for believers.  Perhaps that is the judgement that Pope Francis was referring to.

Saturday, July 20, 2013

Thoughts on the Martin-Zimmerman Case

Of course there are profiling issues and racial issues in the Trayvon Martin-George Zimmerman incident.  There almost always are when a non-black individual representing law enforcement or something like a neighborhood watch team has an encounter with a black man whom he regarded as "suspicious."  But these issues are socio-political issues.  They are NOT legal issues.  It is a mistake to conflate the one with the other.

Though profiling may be "wrong," most, if not all of us, engage in it.  We may profile by ethnicity, we may profile by dress and appearance, we may profile by behavior, etc.  It's one of those human foibles that just seems to define who we are as human beings.  Profiling may be a fault and may be unethical or  even immoral, but it is not illegal.  The use of racial epithets may be unethical or immoral, but it is not illegal.  One may "profile" George Zimmerman as being over-attentive and over-zealous in his trailing of Trayvon Martin, but this was not illegal and can play no part in decisions regarding the facts.

A court must be the place where a jury knows to apply the law narrowly and "to the letter."  It is not a forum for discussion of, or judgements on, issues such as racism, profiling, and the like.  Any one of us who may stand accused of a felony would wish to be judged only by the facts - not any mitigating circumstances that may becloud them. Whether whites are more apt to kill blacks, or Hispanics are more apt to kill Asians has absolutely no bearing on an individual case.  It is just plain wrong to consider race or ethnicity, or any other "profile" when adjudicating a specific altercation.

Social issues must be addressed by legislatures - not by juries in courtrooms.  

Tuesday, June 25, 2013

IsThere a Limit on the Reach of Neuroscience?

David Brooks, in his recent op-ed piece Beyond the Brain (NY Times June 18),  discusses the marvels of neuroscience, but concludes that neuroscience has its limits.  Neuroscience will never be able to explain "the passions aroused by Macbeth," or the difference between lovers and friends.  The "brain is not the mind."

I find it difficult to understand why Brooks and others of the same mind (no pun intended) choose to place limits on the reach of neuroscience.  Why does he feel that "it is probably impossible to look at a map of brain activity and predict or even understand the emotions, reactions, hopes and desires of the mind." Is it unreasonable to believe that at some future time such emotions and passions will be mapped, will be understood, or will be predicted?

There is no reason to imagine that what cannot be interpreted today, will remain uninterpretable forever.  And, let's eliminate the idea that being able to "map" a thought or an emotion makes the thought or emotion any less extraordinary.  Understanding that water is, in fact, a combination of hydrogen and oxygen doesn't render water less extraordinary.   Understanding the sun - its composition, its size, its origins, its chemistry - doesn't make it less extraordinary.

If one doesn't believe that all functions of the mind and brain may be ascertained and understood at some future occasion, I would urge a hard retrograde look at what was once thought to be not understandable, and now is.  Let's not be short-sighted.  Tomorrow's knowledge has probably not even been contemplated yet today.

Tuesday, June 18, 2013

Let's Hear it For Tracking in Education

Guess what.  The New York Times reports that "Grouping Students by Ability Regains Favor in Classroom." (June 10)

It seems that some school systems and teachers are realizing that the "old-school" technique of assigning children to classes based on their proficiencies actually works - if education's target is to actually educate to one's fullest potential.  If, on the other hand, the primary aim of the school is not education, but the promotion of self-esteem and equality - grouping, or tracking, may clearly be anathema to that concept.

Goals have to be prioritized.  If we, as a nation, believe that egalitarianism in education is primary, then perhaps educational resources should not be directed towards the natural separation that would result from grouping or tracking policies.  If, on the other hand, actual education rather than egalitarian education is our priority we should be doing the utmost to customize it according to level of ability.

It is quite obvious that we are not "created equal" in every respect. We should not delude ourselves into believing that promoting equality of ability - whether it's scientific or investigational, artistic, mathematical, creative, athletic, or whatever - will be constructive.  We should not deceive ourselves with thoughts that "we can be whatever we want to be."  It may be the politically correct "belief," but the facts say otherwise.

Being "gifted and talented" is not a curse.  It should be cherished, nurtured, and promoted - whatever the gift or the talent.

Tuesday, May 28, 2013

Membership in Reform Synagogues - Necessary -- or Not?

Reform Judaism, a publication of the Union for Reform Judaism, contains an interview the editors had with Allison Fine, president of Temple Beth Abraham in Tarrytown, NY.  Reinventing the Synagogue deals, yet again, with the apparently never-ending problem of the "alarming rate" of attrition among memberships of Reform congregations in North America.

Here is what Ms. Fine feels synagogues should do to stem the tide:
1.  Rethink the top-down hierarchy of synagogues
2.  Stop treating members like a "cog."  Be sure members are aware that each of them "matter."
3.  Move to a networked model to create a more authentic and fulfilling engagement between leaders    
     and congregants.
4.  Increase transparency - do not strategize behind closed doors.  Use social media to bring 
     congregants into conversation.
5.  Leaders should talk more openly about money - synagogues always ask for money but are very
     reluctant to share "where it goes."  Create a financial narrative.
6.  Leaders should be better listeners, especially to the young.

Sound familiar?  Think any of this will really perform miracles in ending the "alarming rate" of attrition.  If so, I think I know of a bridge that you can buy very cheaply.

If a member of a synagogue feels that he is not properly regarded or treated, or that the service, clergy, or sermonizing is not to his liking, he will, in a fitting and proper manner, resign from that synagogue -- and join another!!  Surely there is one in this vast metropolitan area that he will find suitable.  A family departing one synagogue and joining another is not attrition - just a switch.  Not bad for Judaism - just bad for the losing synagogue.  Synagogues may lose when members depart, but if the unhappy members join other synagogues, total membership is unaffected. Synagogues worried about their own membership rather than synagogue membership as a whole, may well benefit from altering their modes of operation, as per Ms. Fine.

The "alarming rate of attrition," however, probably has nothing to do with synagogue behavior.  It may  likely be related to the absence of the notion for a need to be a member of a synagogue at all.  In a country such as ours, particularly in our metropolitan area - an area so comfortable for Jews - identifying or affiliating with "your people" may rank very low on the scale of personal and social satisfaction.  

By the way the "alarming rate of attrition" doesn't even approach the number of Jews who already have  elected not to affiliate with a synagogue - and who form the vast majority of American Jewry.  

I don't know why Jews don't care to join synagogues - and neither, I believe, does anyone else.  I can only guess.   I am not aware of any properly designed study to answer this question.  If the Reform movement wants to "market" Judaism, or "market" synagogue membership, it must not deal in solutions a priori.  Before deciding how to sell your product, see if a market actually exists!  And if, indeed, the market does exist, question the consumers (the non-affiliated, or never-affiliated) and determine what has to be done to create and sell the right product.

Want to sustain synagogue membership in this country?  Want to increase synagogue membership in this country?  Changes in style won't work -  understanding substance is the only true road to success.  Those of us who see the importance of the synagogue in American Jewish life must try to sell the general non-affiliated Jewish population on the need for this connection, using proper tools we have yet to discover.

If you can sell it, the rest will follow.  

If you can't, don't expect changes in synagogue management or programs to solve this huge issue.

Tuesday, May 21, 2013

The Recollections of Holocaust Survivors

A recent article in a Jewish publication described the sensitive story of an elderly woman's recent return to the German village of her childhood.  The story, though compelling, raises some issues.  Ms. B, a 90-year-old woman, discusses life in her little village, including memories of laws restricting Jewish participation in certain professions and government positions. She described how it felt to be "forced from her home." Ms. B emigrated to the United States in 1934.  At the time she was only 10 years old.  I would have to question the recollections of a 90-year-old about the effects of laws on Jewish life in her village during her very early childhood, especially in those initial days of the Third Reich.

Though it is true that restrictive participation of Jews in various professions and activities, and some "unlawful" acts of vandalism did exist to some degree prior to Ms. B.'s emigration in 1934, the very repressive Nuremberg laws, actually banning Jews from certain aspects of public and professional life (1935), and the restriction of schools that Jewish children could attend, did not come into force until after her departure.  Anti-Jewish riots and physical brutality first became a major issue with the events of Kristallnacht in 1938.  I am not aware of any national policy in Germany to forcibly remove Jews from their homes in 1933-1934.

As the Holocaust recedes into history, eye-witness recollections understandably become more vague.  Present-day survivors, now in their late 80's and 90's were very young in 1933-1934.  Jews who emigrated out of Germany as early as 1934-1935 were, indeed, very fortunate.

Wednesday, May 8, 2013

Religion Is Part of Our History - by Ordinance!

We are all familiar with the Constitution's "Establishment Clause," as outlined in the First Amendment of the Bill of Rights - passed by Congress in 1787 and ratified by the states in 1791.  This amendment is cited as the basis for our present policy of total separation of church and state -  basically prohibiting religion from having any place at all in the public schools.  However, the Constitution's wording is clear  only in prohibiting the federal government from passing laws establishing some form of religion - nothing more, really.   The prohibition of inclusion of religion in a public school's curriculum or  public school's activities is the result of the Supreme Court's interpretation of that amendment.

I was surprised to discover that there is actually a federal ordinance that encourages religion as necessary for "good government." I thought my readers, like me, may not have been aware of this document.  The document cited is the Northwest Ordinance, passed by Congress in 1787, the same year as the Constitution, and intended to apply to the territories being settled in what was then considered "The Northwest."

As a supporter of the "wall of separation" between religious and civic activities, I must concede that it seems the "founding fathers" had considered religion an important as well as a necessary building block for "good government" and "happiness."

Here are the pertinent citings:

Amendment 1 of the Constitution
Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof; or abridging the freedom of speech, or of the press; or the right of the people peaceably to assemble, and to petition the Government for a redress of grievances.

Article 3 of the Northwest Ordinance
Religion, morality, and knowledge, being necessary to good government and the happiness of mankind, schools and the means of education shall forever be encouraged. 

Tuesday, April 30, 2013

Medial Malpractice Claims - How Can They Be Reduced

Nicholas Bakalar (NY Times Science Section Apr 30) reports that a study published in the British Medical Journal Quality and Safety, concluded that diagnostic errors are the "most common cause of paid claims for malpractice."  Researchers reported that these claims resulted in 28.6 percent of malpractice payments, more than errors resulting from various forms of therapy, or the combined total of payments for errors in obstetrical care, medication error, monitoring mistakes, anesthesia complications combined.

I feel certain that some of these awards may have been made in cases where there, in fact, was no diagnostic error, or that the error played no significant role in the eventual outcome.  But I am also certain that there may have been other serious errors which never were brought to a lawyer's attention.  In any event, the number is what it is - and should be addressed.

Diagnosis is the result of algorithmic evaluation of data by the physician.  A physician begins his diagnostic journey with a detailed history and physical examination.  Progressing algorithmically, he then pursues additional data by requesting various diagnostic tests or procedures.  These may raise the possibility of a number of diagnostic probabilities leading to further, more involved diagnostic plans.  Eventually(and quickly one would hope) he arrives at the actual diagnosis, or the most likely diagnosis.

A computerized form of such appropriate diagnostic methodology will significantly reduce the possibility of physician diagnostic error.  Most physicians are not the "Dr. House," or some other amazing diagnostic genius, depicted of various TV dramas.  Physicians are human - they consistently make mistakes.  Development of this technology should significantly decrease diagnostic errors - especially where major diagnostic dilemmas exist.

But no technology will be able to correct improper input.  The physician who does not take an accurate history, or who does not detect an abnormal pulse, or who does not hear an abnormal heart sound, or who evaluates the size of a person's liver incorrectly will not input correct information.

 "Garbage in - Garbage out!"

Thursday, April 25, 2013

Gender Attributes - Is There a Distinction?

In "The Tangle of the Sexes" (NY Times Sunday Review, Apr 21) Carothers and Reis argue that men and women are "less different than we like to think."  The implication is that  the sexes belong to the same taxon (sort of like "species") and any noticeable difference between the sexes such as in emotional reactions, scientific abilities, social support manifestations, or intimacy are really just "dimensional" and that there are no real gender differences. We are all basically from the same species-specific gene pool and any distinctions are not sex-related.

The authors evaluated 122 attributes from more than 13,000 individuals and found that "one conclusion stood out:  instead of dividing into two groups, men and women overlapped considerably on attributes" such as those given above as examples.

But wait a minute - what have we really learned here.  We have learned that there is more overlap than there is distinction.  This, however, proves nothing about whether significant distinction exists in areas that do not overlap.  If we were to compare the attributes of rocket scientists with those of ordinary workers, I feel certain there would be considerable overlap in most of them.  It's not the overlap - it's the distinction that matters!  It's the distinction we notice - not the commonality.

Men and women are genetically distinct.  It is not reasonable to believe that the only difference this yields is one of gender.  Though the overlap of similarities is obviously huge, both physically and attitudinally, one cannot conclude that no distinctions of significance exist at the non-overlapping points on the curve.

Remember - 90% of human DNA has commonality with that of a chimpanzee.  It's the differences that that make us distinct - not the similarities.

Thursday, March 28, 2013

Aesop's Future

A quote  from a piece by Edward Hoagland which appeared in the Sunday Review Section of the March 24, 2013 edition of the New York Times.  Entitled "Pity Earth's Creatures" Hoagland bemoans the potential future loss of Aesop's animal metaphors as we, as Hoagland puts it, "shred our habitat."

Mostly that's over......The tortoise and the hare, the lion saved by the mouse, the monkey who would be king, the dog in the manger, the dog and his shadow, the country mouse and the city mouse, the wolf in sheep's clothing, the raven and the crow, the heron and the fish, the peacock and the crane.  From where will we draw replacement similes and language?.........Hogging the spotlight, playing possum, resembling a deer in the headlights, being buffaloed or played like a fish.  Will the clarity of what is said hold?  A "tiger, a "turtle," a "toad."  After the oceans have been vacuumed of protein and people are eating farmed tilapia and caked algae, will Aesop's platform of markers remain?

Monday, March 25, 2013

"Three Cheers for the Bloomberg Ban" - What??

In "Three Cheers for the Nanny State" (NY Times Mar 25) Sarah Conly argues for the Bloomberg Ban on large-size sugary drinks.  The argument is that the general public is just too uninformed or is just not able to fully research the data, or that we, as human beings, all suffer from the bias that bad things just won't happen to us.  In other words, we, as a species, are incapable of making proper, well analyzed decisions affecting our health and welfare.

One has to wonder if we are capable of deciding who to marry, what professions to pursue,  or when to seek medical help etc. - or are these decisions also best left in the hands of a more sophisticated and knowledgable party.    I am certain that such decisions may also affect the general health and welfare.

Though, admittedly, many drinkers of these large-sized sodas will remain quite healthy, Conly proceeds to equate a ban on these drinks to government-imposed bans on excessive highway speed.  After all, she says, many of us are capable of "safe driving" at 90 mph, so why should we "safe drivers" be limited.  It could also be argued that a ban on excessive alcohol intake, or a ban on cell phone use is a similar infringement on individual rights.  After all there are many who can drive very safely with excessive alcohol blood levels, and many who may drive with, perhaps, even greater caution when using a hand-held device.  Those bans are in place for the greater good, so why not ban large sugary drinks?

But there is a great difference between banning acts that affect others and banning activities that affect only the concerned individual.  We do not ban individuals from smoking - only in places where it affects the health of others.   The limitations on drivers clearly affect the health and welfare of those who share their vehicles and their roadways.

Children comprise a separate category.  It is assumed that children cannot be aware of certain dangers and are unable to make appropriate judgements.  The government does have the right as well as the duty to protect them from undue injury in the event that the parents neglect to do so.  Government may ban the sale of cigarettes to children - and even the sale of large-size sugary drinks to children.

But not to an adult.  Unless a large number of purchasers are not just drinking these sodas themselves, but are forcing others to drink them, they should not be banned.

An afternote.  With the ban now in place,  it is the duty of the banning agency to scientifically evaluate the data to determine whether or not this ban has achieved the desired result.  This is not as easy as it sounds.  Controlling variables is such a study will be difficult.

Tuesday, March 19, 2013

Non-Indicated Medical Diagnostic Procedures - Who Should Pay?

A recent article in the Science Section of the New York Times examined a very prevalent and difficult problem for physicians, namely the right of a patient to "manage" his own diagnostic evaluation, in opposition to the opinions of his physician (Working Together on Costs, February 26.)   The article maintained that patients often "do not want their doctors to take cost into account.............even if those (more expensive) options were only slightly better than the cheaper alternatives."

The issue, unfortunately, frequently results in a physician complying with a patient's request and ordering a potentially expensive diagnostic procedure (e.g. MRI, ultrasound, etc.) even if he feels it is not indicated - "adjusting" the medical record accordingly.  Though, as the article maintains, it is the patient who bears major responsibility for this added cost to medical care, one cannot overlook the physician's complicity.  The doctor often rationalizes that if "I don't order the test, Mr. X will find another physician who will."

Medical insurance should not cover non-indicated procedures.  A patient, however, should not be denied the right to "purchase" a test.   If, in fact, he insists on a non-indicated MRI, he should have the freedom to "buy" one.  Perhaps there could be a new form of insurance policy, priced accordingly, for individuals who are interested in having the option of purchasing such highly-priced, non-indicated diagnostic procedures.

Saturday, March 9, 2013

Faith and the Unknown

I find it extraordinary how god-believers use the absence of knowledge as an explanation for the presence of something.  All god arguments are eventually reduced to this principle - since we have no factual explanation, only the existence of a god can be the answer.  It is far more logical to conclude that what is unexplainable today may be explainable tomorrow.  If one uses well-documented history, one must accept this conclusion.  I won't even attempt to argue how far science has already brought us in the understanding of who we are, where we came from, and the universe in which we exist. 

Sure, we do not have all the answers - but what we should really be saying is that "we do not have all the answers yet." One can never logically conclude that the final explanation, for a lack of understanding, is a god - unless, of course, the term god is defined as the repository for what is presently unknown, but may very well be explained at some future time.  It would then follow that this repository is ever-modified, of course, as the knowns and unknowns change.

Faith (or god), some maintain, is necessary to "explain" human emotion and morality.  How else to understand the poetry of a flower, the exhilaration of love, or the human drive to "do the right thing."

Faith can explain nothing.

Faith is believing in something blindly - "blind faith" is a well accepted and, I should add, accurate term.  It is a "fall-back" position.  The fact that science has yet to completely understand the synapses and cells and transmitters and genes involved in certain emotive cerebral processes cannot mean that they do not exist!  In fact, logic demands that one must consider that they do exist and will, one day, be fully understood.  

Historically humans have always used god or faith to explain the unknown.  When we grow to doubt our faith or god-belief, it has been suggested we pay attention to the innocent faith expressed by children - that is how and where our faith may be restored.  Just remember that the vulnerable, innocent child may well believe that the moon is made of cheese.

One cannot logically conclude that what can't be explained is, in fact, explained by faith and god.  There is no answer to what is unknown - that is why it remains unknown!  

Sunday, February 17, 2013

Health Care - Lets Face Some Realities

David Goldhill, in an op-ed article in today's NY Times (Feb. 17), has calculated that a 23-year old employee recently hired by his company at a starting salary of $35,000 will, over her lifetime, have borne a cost of $1.8 million in health care costs - assuming no growth beyond current estimates, that she never has a working spouse, and that she and her dependents never contract a serious illness.  (See full article for the details.)  His piece ends with yet another plan to mitigate this circumstance, suggesting that health insurance be limited to "truly rare, major and unpredictable illnesses."  "In other words," he goes on, "let's cover everyone but not everything."

Yet another potentially reasonable solution to a problem that will be ongoing as long as people demand "life at all costs."  If I were to offer you the choice of virtual poverty v. one more year of life, what would your choice be?  If I were to offer you the choice of virtual poverty v. one more year of your child's life, what would your choice be?  If I were to offer you the choice of virtual poverty v. one more year of life for your 80-year-old parent, what would your choice be?  Until we come to some sort of understanding as to what the actual problems are can we truly get a firm grip on a solution.

The marvels of medicine will continue to grow - new technology, new drugs, new techniques, new prostheses, new computer-activated appliances, the blind will see, the deaf will hear, the lame will walk - new hearts, new lungs, new livers, etc.  but at an extraordinary cost!  To provide all services to all people seems an improbable, if not, impossible achievement.  At some point soon we will have to face the reality of the cost of perpetual health and perpetual life.  At some point soon we will have to face the reality that this goal may be economically and societally unsustainable and that some limitation of services will be required.

Sunday, January 27, 2013

Employers and Health Insurance Rights

New lawsuits are challenging a government policy under the Affordable Care Act - a policy that requires employers to provide health care coverage that includes birth control.  The law exempts employers whose organizations' purpose is to promote religious values, that primarily employ and serve people who follow their religious views, and who qualify as non-profits under the tax laws.

Private employers who hold strong religious convictions about the immorality of birth control and abortion feel that the government, by requiring them to support birth control coverage, is infringing on their First Amendment rights.  This has, in their eyes, become a separation of church and state issue, and has found its way into our courts.

They do not, however, feel that by refusing to comply with the federal requirements, that they are, in turn, infringing on the rights of employees who do not share their views.  I, assume, under a decision to edit the terms of health insurance, employers may also require documentation that procedures such as tubal ligation, hysterectomies, vasectomies, and orchidectomies (excision of the testes) have a clear medical indication unrelated to birth control.

If an employer were to discover that a salaried employee had actually used this money to purchase birth control devices, should the employee be terminated?  After all the employer is, though indirectly, supporting an act that he feels is morally reprehensible.  Perhaps he should not employ anyone who does not, first, indicate in some manner that he/she will not expend salaries for such objectives.

I know of no taxpayer, individual or corporate, who is allowed to refuse to pay taxes to a government that supports efforts that the payer may find morally reprehensible.  We all have to pay taxes whether we are pacifists or not, whether we believe in abortion, or not, whether we believe in capital punishment or not, whether we believe in charter schools or not, etc.

In refusing to provide the coverage (e.g. the financial wherewithal) for birth control and the like, it is not the employee or the government who is acting immorally, but the employer!

Thursday, January 17, 2013

Saving on Gas With Your Prius - Forget It!

In a previous Blog (The "Nanny State," Taxes and Bad Behavior, Aug 2, 2011) I indicated how governments have come to rely on "sin" taxes to support their budgets, suggesting that prostitution and smoking may be "bad behavior" on moral or medical grounds, but profitable for the tax base of certain states.  A significant decrease in these activities will negatively affect revenue.

Now, it seems, that the reduction in fuel taxes resulting from the increased efficiency requirements for automobiles has adversely affected tax revenues, both federal and state.  Taxes on gas use are said to have fallen precipitously.  Not to worry.  Representative Earl Blumenauer of Oregon has suggested that the fuel tax be replaced with a VMT tax - a tax to be based on "vehicle-miles traveled."  Drivers who use roads more should pay more for that use - similar to a toll, I guess, but now all roads would, in effect become toll roads.  The tax would be collected at gas stations; miles being calculated by installed GPS systems which would transfer the data and calculate the appropriate tax at the time of re-fueling.

Pretty creative, don't you think?  When one revenue source begins to dry up because of changes in behavior mitigated by a government, another source of revenue must be devised.

But don't think you can get away with a gas-guzzler now.  VMT rates may be related to vehicle-efficiency with higher taxes for the less-efficient.

Wednesday, January 9, 2013

Thoughts on Theodicy and Newtown

I am fascinated with the subject of theodicy - the vindication of the presence of evil, given the existence of an omnipotent and omnibenevolent God.  The search for reasons for the world's ongoing parade of horrors, has kept a plethora of philosophers and theologians busy theorizing ways in which such absolute evil can obtain in God's world.

God is usually vindicated in one of the following ways:
  • God's plans defy human understanding, and his actions should not be questioned
  • Humans, or some humans, have behaved immorally and God is exacting retribution
  • It is not God, but the Devil who has gained control
  • God is no longer involved in human behavior - he is merely an observer, exacting punishment for the wicked and granting rewards for the righteous in the world to come.
  • Some other explanation which would be equally difficult to comprehend
Some musings:

Bringing the existence of God into the discussion of such profound evil acts as demonstrated by the horror of the recent annihilation of 20 elementary school children in Newtown, CT is, to say the least, daunting.  We are a compassionate people.  We refuse to hold a God responsible for such evil, but have no issue invoking him when things go well.  Though, according to some beliefs, God may have had a hand in the tragedy,  people continue to pray to him for his guidance,  for his protection, and for his continued love and understanding.  

People believe God understands what mere mortals cannot understand, and we mortals ask him to help us understand the incomprehensible.  Some may argue that perhaps God wanted these little children and their teachers to join him; and who are we to question his actions.   However, the reasoning of mere mortals cannot escape the fact that this argument must then consider the killer an agent of God.  This concept must be very difficult, if not impossible to accept.

If there were a God,  is it possible that he was unaware of what was to transpire on Dec. 14, 2012 in Newtown, CT?  If he were unaware, what does that say about his "omnipresence." Alternatively, if he were aware of the killer's intent, yet did not stop him, then either God decided to remain a simple bystander (for reasons known only to him) or was powerless to control the act.

Nevertheless, people still feel the need to "believe."

God (either as a reality or as a concept) serves a purpose here - but only, unfortunately, after the fact.  People seek him out for solace in their grief - he fills that need somehow.  People pray to help them understand the incomprehensible - and often, if not most often, some peace may be found.  God is there for the grieving survivors - but was, apparently, not there to protect the victims.

People seek God for answers to "How could this happen?"  They should also seek answers to "How could God allow this to happen?"  If the reasons cited at the very beginning of this piece provide that answer for you, I believe you to be very fortunate.

Evil in the world is far more easily understood by non-believers.  Not requiring divine explanations allows human reasoning to draw human conclusions.   

Life - its tragedies and its wonders alike - is a manifestation of our natural world and, God or no God.  We can look only at ourselves to understand it.