First published on on June 19, 2013

In 1905 Dr. William Osler – the great co-founder of Johns Hopkins Hospital, who was cursed with a terrific sense of humor – jokingly proposed that all men over age 60 should be euthanized. Unfortunately for Osler, the newspapers took him seriously. A gigantic controversy erupted, and Osler spent the rest of his time in America trying to explain himself, before fleeing to Oxford.

Being a man not far from the aforementioned age, let me be clear: I do not support any form of mandatory euthanasia as a method of reducing physician workload. There are much better ways.

I think that physicians should do only physicianing. The trends in medicine, however, are exactly the opposite: physicians are wasting increasing amounts of time doing un-physiciany things. They are being de-professionalized.

Two art works that Dr. Abraham Verghese of Stanford University, likes to compare, illustrate one such erosive trend.

The painting, titled “The Doctor,” appeared in 1891. The sick child commands every ounce of the doctor’s attention and concentration. The drawing, untitled, appeared in 2012. The sick child, who is also the artist, sits on an examination table, amid family. The physician is at the left margin, his head down, the hospital information system commanding every ounce of his attention and concentration.

If you talk to physicians today, every single one of them will begrudge the time they spend feeding the gaping, information-eating maw of insurers and medicine-practiced-by-teams. Some may admit there are benefits, but every single one will talk about the costs, which are all too obvious.

If Dr. Leonard “Bones” McCoy were among us, he would rightly and indignantly remind Captain Kirk that, dammit, he’s a doctor, not a stenographer.

First published on on June 18, 2013
In response to the question: What changes would you like to see in the way physicians are paid?

This sounds like an “If I were King” question, so I’ll answer it that way.

If I were King, I would want all my subjects to die at age 120, by accidentally falling into an ice crevasse while descending from the summit of Mt. Everest. At night. In this kingdom, physicians are paid according to how close they come to achieving that outcome for each patient.

The incentives in this system are perfect: both the physicians and patients want exactly the same thing. Implementation is tricky, however. Naive approaches would spur physicians to cherry pick healthy patients and then spend lavishly to keep the patient alive and well.

Suppose, however, that each patient is treated, financially, like a public corporation. Each would have a fixed number of shares, and each share would pay an annual dividend based on the improvement in the patient’s health status over the past year. Referrals to other physicians would dilute the holdings of the referring physician, forming a financial disincentive to excessive care that must be balanced against the goal of keeping the patient healthy and vigorous. Perfect.

Aiming the healthcare delivery system squarely at outcome improvements would encourage a long-term outlook, preventive care, and close follow-up of patients. It would transform medically underserved areas into the most lucrative places to practice, ultimately erasing disparities in health. Administering such a system would be data-intensive, but that heavy burden is already upon us.

In this kingdom, healthcare reimbursement derives from clear, results-oriented goals, with inherent checks and balances on spending. Our real-world system is, alas, far from that – it is deranged.

First published on on June 17, 2013

I’m going to dodge the “American” part and go global. I’m doing that because researchers have very carefully documented what the absolute worst disease in the entire world is.

Can you guess?

It’s hypertension.

And this means that you should slash your salt intake.

Hypertension, also known as “high blood pressure,” is today the leading risk factor for death on planet earth, according to the gigantic Global Burden of Disease Study, published last December.

This finding is related to diet because hypertension is a new disease for human beings. Studies in the 20th century showed that humans living in undeveloped, primitive societies simply did not get hypertension, nor even the mild age-related rise in blood pressure that your doctor would label “normal.”

With the coming of civilization, however, blood pressures rise, because salt intake rises. Salt is the sine qua non of food preservation, which is itself a signal characteristic of civilized life that appears much earlier than automobiles or drops in physical exercise.

Modern medicine is still debating the benefits of salt-restricted diets. I suspect that one reason is because even highly restricted diets today are still much saltier than our stone age physiology is tuned for. I do not think it’s too much of an exaggeration to say that one restaurant meal in America will give you more salt than your ancestors 200 generations ago ate in a month.

And, of course, salt is a fellow traveller with fat in today’s diets, so drastically cutting salt will likely cut your fat intake as well – also a good thing. The dangers of excess calories are not news to anyone.

NB: If you have high blood pressure, please take your pills. You can work on dietary changes once the pressure is well controlled.

Flying duty in the military has a certain reputation for softness. To see why that is inaccurate, look no further than the B-17.

B-17 Flying Fortress

The B-17 was a heavy bomber, first built in 1935, that played a major role in World War II, especially in the campaign of daylight bombing against Nazi Germany.

It was horrific duty, in which anoxia, frostbite, and burns supplemented gunfire as physical threats to the 10-man crews. Half of all men suffered some degree of anoxia during their combat tours. More were disabled by frostbite than by gunfire – not surprising given the air temperatures of 30-to-50 below zero Fahrenheit, and the large openings in the side of the fuselage through which the waist gunners fired their weapons.

A normal tour was “only” 25 missions, but just 35% of aviators survived their tour (i.e. alive and not in German hands). On one raid against the heavily defended German city of Schweinfurt, 60 of 291 B-17s did not return – a 19% loss rate on one mission. Here is the mortality curve for all heavy bombers in Europe during World War II:

Survival in American heavy bombers in the European theater during World War II. Two studies, with some data overlap, in: Medical Support of the Army Air Forces in World War II, table 85.   Book - On-line   (Thanks to Dr. George Norbeck)
Survival in American heavy bombers in the European theater during World War II.  Two studies, with some data overlap, in: Medical Support of the Army Air Forces in World War II, table 85.   <a href=''>Book</a> - 
<a href=''>On-line</a>   (Thanks to Dr. George Norbeck)

All told, the Air Force (then called the Army Air Force) suffered horrific casualties in its 3.75 years of European combat operations: 20,000 killed, 8400 wounded, and 35,000 missing (ref.: table 86). This does not include psychiatric casualties.

Fear was pervasive and severe. The traditional greeting for new arrivals at a bomber base was “You’ll be sorry,” without humor. Psychiatrists found that the effective men were able to convert fear into aggression. All feelings unrelated to combat drained away, and “No values existed other than those meaningful in combat.” Ninety-five per cent of crewmembers developed definite symptoms of “operational fatigue,” 34% suffering severely. At a special rest-and-relaxation base, aviators were routinely put into 3-day medical comas to break their stress.

Tragically, the losses were amplified by stupidity at the highest levels of the Air Force. Until late in the war, American fighters were not equipped with extra fuel tanks so they could protect the bombers all the way into Germany and back. Once they were – a simple fix – bomber missions became far more successful and far safer. Hermann Goering feared the war’s outcome was decided as soon as he saw the first American fighter over Germany.

Two utterly remarkable books can be highly recommended to anyone with even a small interest in the topic:

On the lighter side, see also: Cultural echoes of the B-17.

B-17 flying duty was a horrific experience. However, on a far lighter note, I’ve not seen it mentioned elsewhere that the B-17 ball turret must certainly have inspired the spaceship Discovery’s pods in the 1968 Stanley Kubrick film 2001: A Space Odyssey:

Ball turrets from B-17 bombers must have been the inspiration for the pods in 2001: A Space Odyssey
Ball turrets from B-17 bombers must have been the inspiration for the pods in 2001: A Space Odyssey

The B-24, introduced some years later, also used the same model of ball turret, according to this interesting web page. Here is another good picture of a ball turret module.