Another Strategy for Defunding NCCAM

I have been as thrilled as others with the prospect of science regaining its rightful place as the driving ideology behind medical care in America, and I agree that defunding the wasteful and intellectually dishonest government agency known as the National Center for Complementary and Alternative Medicine is an important start.

There is a nifty discussion on the blog Science-Based Medicine (which still hasn't been able to get rid of the sidebar ads for alternative medicine; I can't decide if this is funny or pitiful) that points out NCCAM is a political creation and as such, will require politics to successfully dismantle it. I believe another --additional -- strategy will be helpful:

If the next Surgeon General were to adopt the elimination of Quackery -- whether known as "alternative," "natural," "complementary" or "integrative" medicine -- as his or her major issue, that bully pulpit might help generate enough of a popular political groundswell to overcome the few credulous members of Congress who pushed the whole thing onto us in the first place.

Somehow, I don't think Sanjay Gupta is up for that, so I hope President Obama picks someone else.

Oil and Water (Sometimes): Guidelines and Real Life

I had another case the other day when I had no choice but to throw well-documented guidelines for the care of diabetes right out the window.

The patient was a man in his forties with a terrible case of diabetes. The main reason it was so terrible was that he was either completely incapable of or unwilling to comply with lifestyle changes such as limiting carbohydrates in his diet and engaging in regular exercise. His hemoglobin A1c was 13% (good diabetes control being considered less than 7%.) He'd come in at irregular intervals through the years and swear he would do better, but never did for more than a few months at a time.

He recently had a colonoscopy for some rectal bleeding, and was found to have a 4 cm. sessile polyp that was too big to remove through the scope, but did contain cancer in the biopsy specimens. The required procedure is an operation to remove the section of colon containing the cancer.

I only found out about this three days prior to the proposed procedure, when the surgeon's office faxed me a form requesting "medical clearance."

What to do?

All surgery carries risk. The risks in diabetics are magnified; both short term risks like infection and the longer term risk of impaired healing. Surgery for immediately life-threatening conditions (ie, appendicitis) trumps these risks, and the patient must be taken to the OR regardless. But the biology of cancer is such that in this particular case, a delay of three to six months -- or even a year -- is not going to realistically affect the clinical course of the patient's malignancy.

This can be counterintuitive to the general public. How is it possible that cancer is not a surgical emergency? Aren't women with breast masses rushed into surgery? Well, yes, but frankly because it is more of a psychologic emergency than a true medical one. The stress of knowing one has cancer is significant, and it would indeed be cruel to prolong the wait for definitive treatment. But when there are other conditions that significantly increase the risk of surgical complications, that risk/benefit ratio becomes a lot trickier to calculate.

In this case, though, the answer was clear. The surgery needed to be delayed at least 3-6 months so that he could get his diabetes under better control. I called the surgeon, who acknowledged that the cancer posed no immediate threat to his health and agreed to cancel the procedure for now. He told me to call him when the patient was ready to be re-scheduled.*

I hadn't seen the guy for two years, so I made him come into the office, mainly so I could explain to him face-to-face why I thought the surgical risk was unacceptably high while his diabetes was so dreadfully out of control. Here were some other things he said to me to try and persuade me to allow him to proceed with the surgery now:

1. He had already arranged to take time off from his job for the operation (which had been scheduled for the next day) and
2. If he didn't have the surgery now and lost his job in the next few months -- as he was afraid might happen, as his company was planning layoffs -- he wouldn't have health insurance to pay for it.

Add this to the stress of "I have cancer," and I had to think about it for a moment; but it wasn't a very long moment. The bottom line was appropriate medical care, even if it might be socially or financially inconvenient.

Here was the biggest problem: the patient absolutely positively could not swallow pills. Any size; any shape; couldn't swallow them. He had tried. He had swallowed one metformin tablet and it had "gotten stuck." He suffered with the sensation of a foreign body at the base of his neck -- the pill -- for days. There was no way he could do it. Even to save his life -- which he recognized was the case; if he didn't have the surgery at some point, the cancer would eventually kill him -- he just could not do it.

On the other hand, he had no problem with insulin. He had given it to his father for years before the father died (of diabetes complications, of course) so he was at ease with measuring and administering it, even to himself. (He later confessed that he had been on it for a short time many years ago with a previous doctor.)

So along with the most explicit, emphatic discussion of diet and exercise ever provided, I gave him a prescription for insulin: long-acting at bedtime, regular for meal coverage, syringes, new strips and lancets for his meter; the works, but with no oral medications.

There's no guideline in the world that recognizes this as a valid approach for the treatment of type 2 diabetes. But I don't have the luxury of treating guidelines; I treat patients, limitations and all.


*(For all you purists out there, what if the patient doesn't come through with improved control in the given time frame? As time goes on, the urgency of removing the cancer will grow and will eventually outpace even the risks from uncontrolled diabetes. Then he'll get his surgery -- as well as a postoperative infection and non-healing wound -- but at least we'll have done everything possible to avoid it in the first place.)

Just When I Thought I'd Heard it All

The latest reason to prescribe a new drug (request made by a patient who works for the drug company that makes it):

How about writing Drug A for me. Sales of it have have gone up like crazy over the last six months.

Whether or not it's approved for his condition or can possibly do him any good.

Oy.

Neologia

Neologism: a made-up or created non-word; words that have meaning only to those who use them; can be a symptom of schizophrenia.

What's with all the new words being made up hither and yon? The latest is contained in a communication from the hospital at which I have to maintain privileges in order to participate with insurance companies where I am on staff.

The topic is hospital acquired infections; specifically, preventing them. Back in the olden days, when I actually went to the hospital on a regular basis and was required to serve on a committee, the committee to which I happened to have been assigned was the Infection Control Committee.

Infection Control is a noble pursuit. I have tremendous respect for the Infection Control Nurse (later, "Officer") who ran the meetings and basically kept the hospital Infection Control program running full steam ahead (with fabulous results; our rates of hospital acquired infections, as I recall, were always the anti-Wobegon: well below average.) But now, the title "Infection Control Officer" is no longer good enough. What do you think has replaced it? I'm so glad you asked:

INFECTION PREVENTIONIST

Ouch. That was my language cortex wincing.

Cut me a break. This must be what administrators do to keep themselves occupied earn their outrageous salaries. They come up with brand new titles for people who are busy doing things that are actually useful for patient care. I don't know if this comes under the heading of "morale-building," which usually means coming up with creative ways to make people think you value them without paying them more money (hint: it doesn't work) or what.

What's next?

• Emptying Bedpanist
• Injectionist
• Sterilizationist
  
• Documentarian (Actually, I kind of like that one.)

Aw hell; why not just call everyone a Vice President? It works on Wall street:

Vice President of Infection Control

Now that has a nice ring to it.

I Have Arrived

I have noted previously that I blog for myself. I've been though (and gotten over) sitemeter addiction and other assorted cravings for various awards. But I have to confess that there was one new-ish award out there that was so cool, I really was hoping to garner one for myself to add to my sidebar. It was this that prompted me to enter the following contest by Rob at Musings of a Distractible Mind. Of course I was too lazy to compose a limerick, as originally requested, but when he got desperate and began pleading for anything, "Even a haiku," I jumped at the opportunity:

Random neurons fire
impulses hither and yon,
distracting the mind.

Obviously written especially for Dr. Rob. A few days later, I was tremendously touched as he returned the poetic favor:

Dinosaur, Dinosaur,
Where have you gone?
Dinosaur, Dinosaur,
What has gone wrong?

The world was unfriendly,
The atmosphere mean,
The predators many,
The nourishment lean.

The world once was fertile,
With plenty to reap,
The food was abundant,
For both strong and weak.

But terrible predators
Invaded the land;
Too hungry to fill,
And too strong to withstand.

And so now your number
Is regrettably shrinking.
The stalwarts remain
With their prospects still sinking,

Will anyone save you,
Our dinosaur friend?
Can anyone fix
What is causing your end?

But sadly I see no way
From your distress;
For forces too potent
Are making this mess.

And what seals this fate
Of your fatal condition?
The fact that your only hope’s
From politicians.

And now, the icing on the cake (and not the nasty fake-whipped-cream-Costco icing, but the rich, sweet, supermarket buttercream kind) is the reward of the Golden Llama:

Thanks, Dr. Rob. Really.

THIS IS A JOKE; PLEASE DO NOT TAKE IT SERIOUSLY

New evidence just in about the recent airliner water crash being termed the Miracle on the Hudson, in which a US Airways jet was disabled by a flock of birds before being forced to make a watery landing in the Hudson river, with no fatalities thanks to the skill and courage of the pilot and flight crew:

The latest reports are stating that the birds involved, a "flock of geese," were Canada geese. This is clear evidence that the incident was in fact an act of terrorism by Canada against the US.

Calls for the Department of Homeland Security to investigate the incident ought to be forthcoming.


Ed.: Not bad. After 24 hours, only 1 of 9 commenters lacking a sense of humor.

Chiropractor Rant; or Time to Split

Got a call this afternoon from a lovely little old lady who had just been to the chiropractor. He was doing a manipulation on her hands (presumably for arthritis in her fingers) and had split the skin on the back of her hand. He was worried because it was "pretty close to a vein," and had asked her to get it checked out.

WTF?

She came over to let me see the wound. Sure enough, there was a 3.5 cm (that's 1 and 3/8 inches to y'all you haven't gotten metric into your head) laceration of the skin on the back of her left hand. It went all the way through the skin, gaping wide open, leaving the subcutaneous tissues clearly visible. The thing is, the skin on the back of the hand is pretty thin, especially in little old ladies. There isn't any subcutaneous fat to speak of. The wound did come close to a superficial blood vessel at one end, but the vein was intact. By the time I saw her, the bleeding had stopped. There was some old dried blood under the skin, but the wound was clean. She said it didn't hurt at all.

I used steri-strips to approximate the skin edges, and they came together beautifully. (The last thing I'd want to do would be try to numb it up and stitch it.) I put a large band-aid over it to keep it clean and asked her to come back in a week so I could be sure it was healing.

I asked her why she went to a chiropractor. She said he made her back feel soooo good, and I believe her; she's got a significant rounding forward of the upper back, common in little old ladies. I have no problem with a chiropractor acting like a glorified massage therapist, at least for the axial musculature (ie, neck and back.) But what on earth would possess him to think he could do anything for arthritis by "manipulating" her hands!

So for those who believe chiropractors are mostly harmless back-crackers, beware of dangers that go beyond anti-vaccination rhetoric and the occasional stroke from cervical manipulation in patients with vascular disease in the neck. This guy actually split the patient's skin with his hands.

If you happen to be reading this in a chiropractor's office, my advice to you is: SPLIT, before he does it to you.

Is There a Doctor on the Blog?

I get email:

Greetings and salutations from a humble med student.

Oh great dinosaur, long have I enjoyed/appreciated/laughed my ass off at your blog.

Obviously not someone who has read this. He continues:

Please, please, PLEASE could you repost and comment on this past post from angrypharmacist that I stumbled across today while sitting in physiology class.

http://www.theangrypharmacist.com/archives/2007/11/pharmacists_are.html

I would appreciate it if you would shed some of your Solomon like wisdom on this post for me. And possibly repost it on your own blog so that we can get input from your insightful readers?

First things first: someone pass that guy a tissue to wipe off his nose; I'm sure that stuff smells awful.

Next: The post at hand (which is over a year old, though that's neither here nor there) is about the appropriate use of the term "Doctor;" who can use it "legitimately" and who is just putting on airs. It's a nice post; not one of The Angry Pharmacist's angrier ones, but it can be tiring to keep up that level of rage all the time (as I well know.)

Here's my take:

One of TAP's commenters is correct, in that the word "Doctor" originally meant "teacher," and that medical, dental, law and pharma doctorates are not actually graduate degrees in the purest academic sense. None of which matters.

The use of the title "Doctor" is a purely cultural convention and its usage varies from one country to another. In Europe, for example, PhD's use "Doctor" much more freely than here. In fact, German doesn't even force a distinction between Mr./Mrs. and "Doctor": my grandmother was "Frau Doktor" all the time before she came to this country. (PhD in Mathematics from the University of Vienna in the 1920s, per an oral history recorded by my aunt; awesome stuff.) Furthermore, my understanding is that physicians in several countries are routinely called "Mr." instead of "Doctor."

What this means is that there is no objectively "right" answer to question about who can use the term "doctor" legitimately. All we have are cultural conventions.

In the United States, the convention is that term "Doctor" is reserved for medical professionals, specifically physicians, dentists and veterinarians. Those with academic doctorates may use the term professionally, and optionally in social situations. Because the sine qua non of a graduate degree is a thesis, other bastardizations that do not require one (law; pharmacy; nursing) to obtain the degree may not use it without appearing to be arrogant asshats with hypoplastic egos.

As it happens, I have sufficient ego strength that I do not need to be called "Doctor" all the time. I don't scorn social invitations that lack my "proper" title, nor do I pointedly correct anyone who fails to use it. I often tell patients I encounter after hours that I like to leave the "doctor" at the office; in the supermarket, I'm just "Dino." Actually, my favorite appellation is one of three possessives usually heard at a school event or Ultimate tournament:

1. Jock's Parent
2. DinoDaughter's Parent
3. NinjaBaker's Parent

Solomonosaur has spoken.

Why You Really Can't Please Everyone

Verbatim phone call received in my office this morning:

Dr. D: Good morning, Dr. Dinosaur's office.

Caller: Oh, I wanted to talk to a machine. [click]

Whiskey, Tango, Foxtrot; over?

(Thanks to CrankyProf for new twist on old rejoinder.)

Another Article

Many thanks to Medscape for publishing yet another article(with pictures this time) about solo practice by yours truly:

My Waiting Room

Look at the third picture carefully and see if you can see someone small and cute peeking around the edge of the wall.

Sweetest Comment

From the NinjaBaker on Same vs. Different; talk about getting right to the heart of the matter:

As a biochem student and a former pharma intern [ed: say that five times fast], I can appreciate generalizations in the human race. After all, if everyone were different, we would need 6 billion different drugs for one condition.

And wouldn't that be just ducky for the aforementioned pharma industry.

Also, as a child of a certain saurian doctor, I appreciate being special.

I love you too, NB.

The More People Think They're Different...

One of the cries dominating the medical landscape is the false truism, "Everyone is different."

Patients use it as an excuse for why amoxicillin doesn't work for them so they need Biaxin (when what they have is a viral infection.) Or why they don't want to try an antidepressant; "How do you know what it's going to do to me?" Or why they need brand name Nexium instead of generic omeprazole over-the-counter. After all, Doctor, everyone is different.

Doctors use it as an excuse to avoid following guidelines. Don't get me wrong; there are a myriad of guidelines out there, promulgated for everything from preventing blood clots in hospitalized patients to managing ear wax, devised by all kinds of different bodies, using assorted methodologies. Certainly they don't always apply to every patient, but there are still far too many doctors ignoring what are now accepted treatment protocols for reasons that aren't terribly convincing. To do otherwise is to be accused of practicing "cookbook medicine." Still, there is a balance to be struck between individualizing therapy and re-inventing the wheel. Because we doctors should know that everyone is different.

Nonsense.

We spent four years learning about the human body; its structure and function, how and why it malfunctions and the basic principles of how to fix it. This entire body (pardon the pun) of knowledge is predicated on the idea that the information is generalizable to all humans.

We understand that there are variations. Congenital defects produce an incredible variety of abnormal anatomy. One of the things that always strikes me upon first examining a newborn baby is that I can't take anything for granted anatomically. That's why we count fingers and toes, and examine the kid carefully from head to foot, while still wondering what abnormalities might lay beneath an otherwise perfect-appearing surface.

We also understand that there are genetic variations in metabolism, but they are far more specific and narrow-ranging than people seem to think. We are beginning to personalize anticoagulation by becoming aware of genetic differences in the response to warfarin. Eight percent of Caucasians are missing the gene for the enzyme that converts codeine to morphine; when they say "Codeine doesn't work for me," they're right. Of course there are countless others we know about, and undoubtedly many more yet undiscovered.

Yet the default assumption is that for medical purposes, people are pretty much the same.

This is a good thing. When someone comes in with a nausea, vomiting, fever and right lower quadrant pain, I usually don't have to worry that they have a herniated disk in their neck. If they're having crushing chest pain and tombstoning on EKG, you don't have to treat them for prostate cancer. Hell, if everyone were truly different, protocols for ACLS and CPR would be impossible. The reason they work is that one human body really does function pretty much the same as every other.

Certainly when patients have multiple problems, the permutations and combinations of their co-morbidities create the need for individualized treatments (though even then, it usually consists of tweaking the usual treatments for each problem.) This kind of complexity will always be part of both outpatient and inpatient medicine.

And people are different, even though their bodies all work the same. Everyone has two eyes, one nose and one mouth, and yet faces demonstrate infinite variety. No one likes being sick, although different people can approach the experience differently. (Even so, there are behavior patterns in illness that can be mighty predictable.) By and large, they tend to be more alike than different, preferring to be treated with dignity and caring. Some thrive on more touchy-feely attention; others prefer to be left alone in their suffering. Without a doubt, the art of medicine has more to do with discerning how patients want to be treated when ill than any actual difference in medical care provided.

But the bottom line is that people are basically the same, even though they're all different.

It's also intensely human to feel unique; special; one of a kind. At the same time, the great irony of at least 50% of my practice is reassuring people that they are normal. In this context, that translates to "not different," or "the same as everyone else." So I suppose the true art of medicine is making everyone feel as if they are different, ie, special and unique, while recognizing that everyone is fundamentally the same.

Why Not Run Hospitals Like Firehouses?

Have you noticed that everyone always says the same thing whenever there's a true medical emergency: "Go to the nearest hospital."

This implies that a hospital -- any hospital -- is qualified to provide some basic level of medical care. In fact, with all the assorted evidence-driven protocols out there these days, that assertion isn't too far off. So why is there so much duplication of effort? There are so many hospitals in such close proximity that they're all squabbling over the same patients -- and spending mega-bucks on advertising and other publicity campaigns. Why not make hospital care on par with protection from the fire department?

Each neighborhood has its own firehouse, charged with protecting a given geographic area of the community. There are uniform policies from one department to another. When necessary, they share resources, generally working well together. Because the training is generally similar from one company to another, you don't have huge, expensive advertising campaigns touting the superiority of the Main Street Fire Company over the one on Church Street. Where you live determines which firehouse protects you. If you do happen to have a preference, then you make it a point to live in proximity to your preferred fire company; just like researching the schools when you buy a house.

What if each community were in charge of providing hospital care? Hospitals would be funded like fire and police departments, provided with a set annual budget that would cover all medical services provided there, including the services of hospitalists, emergency physicians, anesthesiologists, radiologists, pathologists and so on. Think of it as the ultimate in capitation: pre-paid care at the community level.

Get rid of JCAHO and put a federal cap on pain and suffering awards for malpractice (which is working great in Texas) so that the only documenting you had to do would be what you really need to take care of the patient. Implement a nation-wide computerized Personal Health Record (not technically the same as an EMR) to avoid duplication of studies from one institution to another and you're in business. Everyone working there earns a decent living. The only difference is that there's no profiteering from cherry-picking better insurances or healthier people.

Think about it: no more coding or billing for anything received in a hospital. Doctors could see patients as many or as few times a day as they needed. Nurses could actually care for patients instead of wasting seven hours of their eight-hour shift documenting. All those Utilization Review nurses would be out of a job; actually, they could hit the floors and actually go back to nursing.

How to pay for all this? Once you eliminate the need for all that advertising and redundant administration, there would be plenty left to pay doctors, nurses and people who actually take care of patients.

So what's stopping all this? I guess there are enough people who think things are working just fine the way they are. Too bad it's mainly administrators, PR firms creating all those marketing campaigns and other folks who aren't actually involved in providing medical care. As long as there's so much money to be made with the status quo, I suppose patients and the people who care for them are just out of luck.

How About Italian for Dinner

Sometimes I think we don't give our patients enough credit. To read about all the woo on the web, you'd think that patients are in our offices every day demanding all kinds of alternative remedies when in fact, there are times when it's the woo-mongers trying to force it down their throats -- and other orifices.

I saw a very nice lady with a vaginal yeast infection the other day. Vaginitis with candida albicans, the typical "yeast infection," consists of an intensely itchy, thick white curd-like discharge that, it is sometimes noted, smells like bread. Technically, it smells like bread dough. Why? Because both contain yeast.

I offered the lady medical treatment, which she accepted gratefully after telling me a story about a previous practitioner who had suggested the following regimen:

Peel several cloves of garlic and wrap them in cheesecloth. Pound the crap out of them with a mallet or other similar implement, and then insert the whole mess into the vagina.

Suffice it to say, the patient's preference was for Western medicine; that is to say, real medicine.

But it did get me to thinking that a woman who tried that particular remedy would probably just end up with a discharge that smelled like garlic bread.



(In conjunction with this post, I wonder how Coke wold taste with garlic bread; if you didn't happen to have a nice red wine on hand, that is.)

Limits Gone Wild

I saw a little girl the other day with a splinter in her knee.

Her parents had done their best to get it out, but didn't think they had gotten all of it. When I took a look, I saw what looked like a tiny splinter remnant about 3 millimeters long (ie, really small) nestled in the bottom of a small cut. I pressed on it gently and asked the kid if it hurt. From experience both clinical and personal, I've found that this is a fairly decent way to tell if there's anything still in there. She didn't complain much, so I wasn't all that worried.

I got my splinter forceps, pushed upward on the visible part of what might have been the rest of the splinter and managed to grasp it. Then I pulled...

And kept on pulling, until lo and behold a full half inch (11 mm; I measured) of splinter materialized before my eyes. It was impressive, given that it must have gone straight "down" into her knee, as opposed to tangentially along the skin, which is what the original wound looked like. The kid did great; nary a wince and not a peep. I put the splinter into a little tube and gave it to her to take home to show Daddy, along with stickers (my office goodies-of-choice.)

What does this have to do with limits? In the course of the visit, the mom mentioned to me that school nurses are no longer allowed to take out splinters when kids acquire them at school. That struck the both of us as pretty stupid. Why make a kid suffer with a splinter all day instead of at least trying to give it a little tug. It doesn't really apply to this case, but it struck me as just the latest in the slow and lingering death of common sense as it succumbs to the continued onslaught of the lawyers. The new prohibition is clearly the result of increasing liability fears.

I've posted several times bemoaning the failure of assorted medical personnel to recognize their limits. As it happens, I do feel that there are some groups of people who are better at this vital life skill than others. Among them tend to be school nurses (and often, parents.) This family only brought the kid to me after giving it their all to get this nasty splinter out on their own. I'm pretty confident that a school nurse would be even quicker to punt. But forbidding them to even touch it in the first place? The nanny state strikes once again, when fears of lawsuits outweigh a child's comfort.

That was one impressively big-ass splinter, though.

Insufferable Twits and "Shitty Consults"

One small agreement doesn't make for much of a truce, at least when certain insufferable twits post nonsense like this.

The topic is so-called "shitty consults." A certain hospitalist of ill repute reduces all consults into a punnet square of time and effort, in which any virtually every encounter with a consulting physician can be labeled "shitty." Qualities which enhance the "shittiness" of the consult include those that take time (too much, presumably) and dealing with patients who are awake, hospitalized, sick and/or have multiple problems. Of course the level of payment that can be expected is a major contributor to the "shit" factor, as are those consults that occur at inconvenient times of the day (or, more frequently, night.)

Look, I understand as well as the next guy that the internet in general and the medical blogosphere in particular is a place to vent. I don't deny that much about hospital medicine can be frustrating, and I have no problem with generalized bitching and moaning about it. But in spite of the world's wimpiest disclaimer ("Docs, you know it's true, however crass that statement is,") labeling sick people in need of help -- whatever their insurance status -- as "shitty consults" is over the line. Hey, emergency medicine has a set of patients they hold in similar contempt, but at least they have the finesse to use euphemisms like "frequent flyers" or cool neologisms like "fibromyalgeurs" and "crayzees." We in outpatient medicine have our PITA patients as well, but as a rule, even we call them "bullshit" instead of just plain "shit."

Tell you what: I think we should eliminate all payment to doctors for hospital services. Just pay the hospital and let them deal directly with the hospitalists, a profession that ought to expand to include inpatient versions of all the other specialties. Surgeons and OBs are moving to this with surgical hospitalists and "laborists." Expanding it to include interventional cardiologists, pulmonary intensivists and all the others HH has to consult with (but very rarely, because his skills are so broad he can handle just about everything his hospitalized patients may need) is just the logical next step. Let them all work out a schedule so there's all the in-house coverage they need. Hell, maybe the hospital can truly become operational 24/7 instead of shutting down at 5:00 every day (4:00 on Fridays until Monday morning.) If nothing else, they may come to realize that taking care of hospitalized patients is actually their job, as opposed to just a series of "shitty consults" imposed on them while they're trying to cobble together a living taking care of ambulatory patients.

Seems to me there are far more shitty consultants than there are "shitty consults."

Joining the Discussion: Public Smoking Ban

Finally, I have a little extra time on my hands. So what's the first thing I do? Wade into the dangerous territory where the Happy Hospitalist and the Cranky Professor are at each other's throats over the topic of a federal smoking ban in public places. Strange idea of fun, I know.

Much as I hate to admit it (and I can only hope the general public recognizes as well as I'm sure Cranky does just how much I hate it) HH is correct in this particular case. Cranky is (I assume unintentionally) misreading HH's point to generate invective against the nanny state. I actually agree with Cranky and others who bemoan the nanny state, but the problem here is that it is not the issue being argued.

I believe the premise involves a Federal smoking ban IN PUBLIC PLACES. This is not the same as criminalizing all tobacco use, thus the anaology to Prohibition simply does not apply. The issue is that of second-hand smoke; my right (and Cranky's; and her kids') to fresh air unsullied by the carcinogens emitted from tobacco products smoked by others. Frankly, I don't give a rodent's patootie about the health of public smokers (when they aren't my patients, and even when they are my patients, when they're not in my office they're out of my jurisdiction.) Thus, all the ranting about the futility of legislating healthful behavior, while correct, is irrelevant to this specific discussion.

Cranky: say you were out somewhere with your kids swimming in a lovely, clean pond and saw someone on the shore relieving themselves into the water. I'm pretty sure you'd have the same, visceral "ewww" that I would (though I know your invective would be orders of magnitude more colorful than any I could ever dream of crafting.) Would you be so quick to condemn the powers-that-be for putting up a sign saying "SHITTING IN THE POND IS PROHIBITED" for trampling on the rights of the poor, benighted shitters who choose to continue their unhealthful ways despite massive public campaigns about the dangers of disease contracted from shit-filled water?

Laws against dumping toxic waste have nothing to do with the dumpers, and everything to do with the general public. The idea of a smoking ban is more analogous to laws against pollution than to seatbelt or helmet laws. A proposed federal PUBLIC smoking ban has nothing to do with the smokers and everything to do with me and you (and asthmatics) and the air we breathe. Nothing about such a ban would prevent people from filling their homes and cars with all the toxic fumes they want. Of course, this begs the issue of their children. Adults may have the right to poison their own lungs, but the nanny state could easily make the case that children need to be protected and thus remove kids from the homes of smokers. This is the real slant of that slippery slope you deplore.

You're trying to run a thoroughbred at a NASCAR event. Come on back over to the right racetrack and I'll buy you a beer.

How Does She Do It?

There are times when I find myself struck with awe at being in the presence of greatness, even when it's only as an email recipient. Bowing my head in shame at the audacity of calling myself a writer while reading the words of the truly gifted:

He's got the bedside manner of a rattlesnake with shingles.

(In reference to a mutual acquaintance whom we hold in mutually low regard.)

Cranky Prof: I am not worthy.

Happy New Year!

From all of us to all of you.

A happy and healthy 2009!