“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” - Sir William Osler






Email Dr. Alice

 

 You Can Sell Your Soul and Still Lose

One of my longtime goals has been to write mysteries (I do write fan fiction but would like to write something I can sell to the public). In pursuit of this goal, I have started to follow several blogs about writing including According to Hoyt, Mad Genius Club, Robert Kroese, Monster Hunter Nation and Celia Hayes. 

These blogs and their authors have some things in common. They tend to work in the scifi/fantasy genres, though not all of them do; they publish independently, usually via Amazon (some of them also have conventional publishers but do at least some independent publishing); and they trend to the conservative/libertarian side of the aisle, or at the very least they keep politics out of their writing. As a result they have met more setbacks in the course of their careers than one might expect (and Lord knows, most writers face enough of those). They don't whine about it but they do discuss it. Most publishers strongly prefer "diversity" in the works they publish these days, as defined by issues related to race, sexuality or gender. If the author's work checks more than one of those boxes it's even better. That is not to say that the writers I follow limit themselves to tales about strong, silent white men who conquer new worlds and exploit their resources when they are not killing dragons and marrying princesses. Their works are far more interesting than that, often irreverent and tweak quite a few sacred cows. This, of course, is why they keep running into roadblocks. Publishers expect novels to meet certain criteria (see my recent post on Charles Stross and his Laundry Files series, which has turned into a labored metaphor for global warming). The rule for books, I feel, is that the work should be fun and interesting rather than grim and judgemental.

But... denizens of the scifi universe now appear to be turning on even the most rigorously diverse writers. The most recent example is an author named Stephanie Burke. She was a guest presenter at the scifi convention Balticon last month and her bio reads, in part, as follows: 

Stephanie Burke is a USA Today best selling multi-published, multi-award-winning author, master costumer, handicapped, wife and mother of two. From sex-shifting, shape-shifting dragons to undersea worlds, up to sexually confused elemental fey and homoerotic mysteries, all the way to pastel challenged urban sprites, Stephanie has done it all and hopes to do more.

So far, so diverse. I wish to point out here that I have not read any of her works and do not intend to analyze or criticize her writing, as I am unable to do so. My point is that today I learned from Twitter that midway through Balticon she was accused of making "offensive statements" (details unspecified) and was asked to leave. Her presentations were canceled even though the accusation was apparently unsubstantiated. Link is here. Ms. Burke was extremely upset by this incident, and rightfully so.

Example Number Two: right around that same time, author Mercedes Lackey was speaking on a panel for the Science Fiction and Fantasy Writers of America (SFWA) and used the term "colored" when speaking about an author and critic named Samuel Delany. He is well known, well-respected and, yes, African-American. Mr. Delany specifically said that he was not offended by the term or by Ms. Lackey, who was praising his work at the time. Not only was she kicked out of the convention after this incident, but so was her husband. 

Per Wikipedia, [Ms. Lackey] has... published several novels re-working well-known fairy tales set in a mid-19th to early 20th century setting in which magic is real, although hidden from the mundane world. These novels explore issues of ecology, social class, and gender roles.

I'm beginning to discern a pattern here. Are you? It doesn't matter how much diversity street cred you have, if you don't toe the political line your readers and publishers can turn on you in a heartbeat. If you need another example, look at the one everybody knows: J.K. Rowling. Her adoration ratings, already quite high, jumped after she stated that Dumbledore was gay and had been in love with his nemesis Grindelwald - until she stepped up to the plate to support the rights of cis women. Since that time she has been pilloried on social media. (Incidentally, I think this explanation of Dumbledore's motivations is consistent with everything we learn about him in the series. But it was not touched upon because it was a children's book series, and because as a product of the nineteenth century, Dumbledore would have had very good reasons to conceal his sexuality for his entire life.)

So my takeaway from these developments is as follows. Write what you want to write, but don't join the diversity conga line in a misguided hope for success. All it takes is one wrong turn of phrase, or even (as we have seen above) one wrong word. Your career will be instantly trashed. 

Labels: Politics, Pop Culture, Writing

posted by Dr. Alice at #

 

 Recent Developments 

I'm trying to blog more. Partly because of the new crackdowns and censorship on social media platforms (namely, F and T), and partly because so much has been happening here, most of it not good. 

I left full-time work a year ago and have not regretted it one bit, though I have been continuing to see patients part time. One main reason I left was my parents' and aunt's ill health. My mother in particular has been in a slow decline for months. Just before Christmas, their caregivers were diagnosed with COVID and my parents tested positive the day after Christmas; I tested positive one week later. Fortunately none of us had to be hospitalized. My father had basically no symptoms, I had the equivalent of a bad cold; my mother had a heavy cough and bronchitis but no fever. All the caregivers were out sick and it was a very rough two weeks, but things are much better now. 

Unfortunately my aunt has metastatic cancer and without giving details, she is not doing well. I will be staying with her to provide support as she tries to make a decision about stopping treatment. Ironically, my COVID infection could not have been better timed; I'm bulletproof now, at least for the next few months, and am no longer infectious. I tested positive 17 days ago.

The inauguration is tomorrow, I have no plans to watch. I am honestly disappointed with the results of the election. I don't see things going well, what with immigrants on the march from Central America and the president-elect's plan to shut down the Keystone XL pipeline (what the hell is that about?) - and the New Management hasn't even been sworn in yet.

As for the immigration issue, I have one word: COVID. Uncontrolled immigration into Southern California and other areas of the Southwest US, already a hotbed for COVID infection: what could possibly go wrong? Or to put it another way, how is our already overloaded health system supposed to cope with this? No one has thought to ask that question so far. 

I'm going to sign off for now and try to find something else to think about.

Labels: Medicine, Politics, Random Thoughts

posted by Dr. Alice at #

 
Perfecto!


I say, Your Majesty, you know how to handle a weapon. Rumor has it Jack Bauer took lessons from you.

Labels: Politics, Pop Culture

posted by Dr. Alice at #

 
Osama Eats Lead



YEAH BABY. YEAH.

Unapologetically, I'm thrilled that asshole is dead. And thank you President Bush (and to our current president, who authorized the mission). So freakin' glad this guy is dead. Click here to join the celebration.

What with this and the recent missle attack on Khadafi, I do rather wonder what the folks who voted Obama the Nobel Peace Prize are thinking right now.

Labels: Politics

posted by Dr. Alice at #

 
Sutton's Law Strikes Again


"Go where the money is," said Willie Sutton, famous bank robber. So they did:

A vast network of Armenian gangsters and their associates used phantom health care clinics and other means to try to cheat Medicare out of $163 million, the largest fraud by one criminal enterprise in the program's history, U.S. authorities said Wednesday.

Now tell me again why single payer health programs are a good idea. We're talking about what, a seventh of the U.S. economy? That's a hell of a lot of money. And where there is money there will be fraud.

The defendants...had stolen the identities of doctors and set up 118 phantom clinics in 25 states, authorities said.

Here's my favorite part:

Prosecutors said the phony paperwork showed eye doctors doing bladder tests; ear, nose and throat specialists performing pregnancy ultrasounds; and obstetricians testing for skin allergies.

Dudes didn't even try to make it look kosher. How did they ever get this far? Blatantly phony medical bills being sent in from 25 states and 118 clinics? Why weren't they caught after five, or ten, or 25 clinics were set up? Answer: because Medicare is a gigantic operation and a great deal of its employees know virtually nothing about medicine. They don't know enough to realize that an ophthalmologist doing bladder tests is unheard of. Now if the program gets even bigger, just imagine how ripe for fraud it will be.

On second thought, don't. I don't want to be responsible for your high blood pressure.

Labels: Medicine, Money, Politics

posted by Dr. Alice at #

 
No Wonder They Call Him 'Moonbeam'


Per the website Politico, Jerry Brown doesn't believe mammograms are effective. To back up his claim he cites a study in the British science journal Lancet, which has a long and honorable history but in the last few decades, frankly, has taken a turn more in the direction of the Weekly World News. (By way of example, consider its infamous 2004 "100,000 Iraquis killed since the invasion" claim, which has been debunked.)

So what's your alternative, Jerry? MRIs, which cost five to ten times as much per study? Self exams (which women were recently instructed NOT to do)? Hands-on exams by doctors, which can only pick up tumors large enough to palpate? The whole value of mammograms lies in their being able to screen for tiny tumors which can't be felt.

I'm going to make a rare political statement here. If you live in California, please do not vote for Jerry Brown. I remember his last stint as governor and it was a disaster. Write in Mickey Mouse if you have to, just don't vote for Brown. The state will thank you.

(h/t Instapundit)

Labels: Medicine, Politics

posted by Dr. Alice at #

 
To Boldly Go Where California Has Gone Before


Okay. This picture



And this site made my day. William Shatner as Governor General of Canada? You know you want it. If he ran Canada in full-on Denny Crane mode, think of the fun that would ensue.

That is all.

Labels: Politics, Pop Culture

posted by Dr. Alice at #

 
This Urologist Has, Um, Cojones

A urologist in Orlando, Florida has made no bones about telling his patients what he thinks about Obama's healthcare plan:

A doctor who considers the national health-care overhaul to be bad medicine for the country posted a sign on his office door telling patients who voted for President Barack Obama to seek care "elsewhere."

This is legal, as far as I can tell. The doctor in question has made it very clear that anyone who wants to see him won't be turned away. The sign he posted says:

"If you voted for Obama… seek urologic care elsewhere. Changes to your healthcare begin right now, not in four years."

He's right. My patients are all complaining about their drug copays being jacked up, increased fees to be seen by a doc, and so forth. I explain to them that the insurance companies raised their rates proactively, expecting the healthcare legislation to pass, and that the result will be higher fees for everyone. C'est la vie.

(via JammieWearingFool)

Labels: Medicine, Politics

posted by Dr. Alice at #

 
The Future of Healthcare: One Doc's Opinion


So, looks like the healthcare bill is passing. (I am writing this on Sunday afternoon.)

My feelings are mixed about this. Over the years I have seen many cases of patients who have lost their health insurance and come to me in flat out panic. If applying for individual coverage, they have been denied due to their health history or even, in some cases, incredibly minor things. If the bill will solve their problems that is a good thing but I'm not so sure it will. Plus it comes with a lot of baggage, not least the fact that nobody knows WTF is contained in the bill. Congress now faces the challenge of thrashing this thing into shape after passage, since they had to rush it through sloppily to get it passed at all. Even Obama doesn't know what all is in the bill and what isn't: see this interview. This procedure makes about as much sense as a museum buying a chunk of marble and then hiring someone to sculpt the Venus de Milo out of it.

Also, as I mentioned previously, there aren't enough doctors/healthcare providers to provide care to all these newly insured patients who presumably are going to sign up. Check out this Newsweek article, which I think explains rather well what is going on. The process of finding a doctor is going to be like musical chairs: when the triumphant "We Passed Healthcare" music stops playing, a lot of potential patients are going to find themselves with no place to go. Though I will report one piece of cheering news. The number of students entering family practice residencies has picked up this year. Perhaps, in a recession, med students have finally figured out that if you go into primary care you will never lose your job.

Prices will be higher for insurance all the way around. Employers will either go out of business (if they're small) or fire part of their staff and insist that those who are still employed pay a higher share of the bill. Your taxes will go up, I guarantee it. National debt will also skyrocket. If we - the employed/insured - are willing to put up with this, then so be it.

Why do I say all this? Can the government provide good, basic healthcare for less money? They probably can. Unfortunately nobody wants basic healthcare. My definition of basic healthcare is the following: Infertility isn't covered. Viagra and similar drugs aren't covered. Organ transplants: may or may not be covered, but the antirejection drugs you'll need probably won't be. Breast reconstruction after mastectomy? Not covered. You get a beanbag to put in your bra. Seeing a dermatologist for acne: not covered, your primary care doc can do that. And so forth. Most of this stuff won't shorten your lifespan if it is not covered, but my impression is the American public will be pretty pissed off to hear this.

The other issue is the iffy circumstances under which the bill was passed. A large portion of the population is against the bill, will remember who voted for it, will do their best to vote those who did out of office. Many states are preparing to sue the Federal government to fight the passage of the bill. They may well lose, but the money spent and the bitterness engendered will leave a lasting legacy.

The next few weeks are going to be a bumpy ride.

Labels: Medicine, Politics

posted by Dr. Alice at #

 
My Take on Healthcare Reform


You knew it was coming.

I don't really have the time or, at this point, the functioning thought processes to give you a heavily-researched, well-worded essay on the pros and cons of government health care. I'll just give you a few points that have occurred to me as a primary care physician. When it comes, and I have no doubt it will, a government funded health care program will fail unless a few points are straightened out first.


Before such a program is implemented we need more primary care doctors. There is a huge shortage of primary care providers in this country. There are a lot of reasons for that; compared to the specialties primary care is poorly reimbursed and involves much longer hours. We also get most of the scutwork - jury duty excuses, disability paperwork and Pay for Performance. This last issue is huge, but that's something for another post. The reason I say we need more docs in primary care is that in order for a huge unwieldy national program to work it has to be implemented at ground level. We are ground level.

Medicare has a big problem, and that problem is that no one doctor is in charge of the patient. In other words, it isn't uncommon for me to see patients who float from doctor to doctor, go off to see specialists, get tests and get their meds changed, and then turn up on my doorstep completely unable to tell me what type of test they had done or what the specialist's take on it was. Now, many times the patient does have a PMD, who does call the shots and is aware of everything, and that's great. But too often that is not the case. Before instituting a national plan I think the federal government should run Medicare more like an HMO, in that every patient needs to get a PMD to coordinate workups and testing.

Another problem with Medicare is that the government is slashing reimbursements to doctors and has been doing so for years. This means that a lot of doctors are now no longer accepting Medicare. These patients either need to pay cash, have a fallback private insurance plan or find a doctor or clinic who will agree to see them. This problem is not going away any time soon, and no proposal of which I am aware has addressed this issue, either.


Another issue is that there has to be tort reform. That could mean malpractice capping, or it might mean mandated arbitration. Did you ever wonder how Kaiser keeps its rates so low, or how the VA program holds its costs down? The answer, my friend, is arbitration. Before suing you must go through meetings in which both sides try to reach a compromise. I'm not claiming it's perfect or the best way to go, but I am saying that in order for the President to even come close to meeting his wild claim that a national health program wouldn't cost the country any additional money, something has to be done about runaway malpractice rates.


People will need to get used to waiting and being told "no." There's going to have to be a huge cultural change in the U.S. before the public will be happy with national health care. What do I mean by that? I'll give you a few examples. I have a British friend who lives in Brighton, but grew up in Nottingham. When she first moved to Brighton she couldn't find a doctor to take her, as all the medical practices were full. Yes, full. For over a year, if she needed to see the doctor, she had to travel to her MD in Nottingham. In case you are wondering, the two cities are 150 miles apart. She told me this story as though it were nothing unusual, and I'm sure it wasn't. The big, dirty secret about nationalized health coverage is this: just because you have insurance, it doesn't mean you'll get a doctor. As I said above, if there aren't enough docs to go around, the situation hasn't improved. Also, I accompanied her to her doctor's office the day she had an appointment for a Pap. Five minutes later she was back in the waiting room. You aren't going to have a chance to spend time with your doctor or to get many questions answered, if this is anything to go by.

"But what about physicians' assistants or nurse practitioners?" you might ask. "Can't they handle basic health care?" Yes, they can; but NPs and PAs are nobody's fools, either. Most of them get specialty jobs too. They work with plastic surgeons or orthopedic surgeons, or in outpatient oncology programs (most of my aunt's care is coming from NPs and PAs right now; she sees an MD only once a week). That means you're still SOL when it comes to finding a primary care provider, MD or otherwise.


Let's talk about wait lists for other stuff. Mammograms, for instance. The reimbursement for mammograms is minimal and it comes with a high malpractice risk. This means there's a shortage of radiologists who are willing to read them and there's a shortage of facilities providing them. When every woman in America over the age of 40 gets insurance and runs to the phone to schedule a mammogram, what do you think is going to happen? You got it. Say hello to six month waits for mammograms.


None of this is to say that people shouldn't have access to insurance, or that coverage should be predicated on their having a job. It shouldn't. And insurance companies should not be allowed to deny policy coverage to someone with diabetes or other chronic illness who's trying to buy a plan. I don't have a suggestion for a workable national insurance plan, though I wish I did. I'm just pointing out that it isn't going to be all rainbows and unicorns once everyone has insurance.

Labels: Medicine, Politics

posted by Dr. Alice at #

 
On Dramatic Structure


This weekend I saw the L.A. Theatreworks production of The Physicists by Friedrich Durrenmatt. If you live in Los Angeles and have never seen one of their productions, I highly recommend them. These plays are recorded for radio rather than being performed conventionally and are broadcast on NPR. Theatreworks also sells recordings of the plays, which are great to listen to while you're driving. During performances the audience sees the sound effects engineer create the sounds of doors opening, wine being poured into a glass and so on. The actors sit and wait until it's time for their characters to speak, at which point they come forward to the microphones and read from their scripts (being careful not to rustle the pages!) There are no sets or costumes as such, although the actors may choose to dress in a style reminiscent of their characters if they choose. At this weekend's performance some did and some did not.

The Physicists is a message play, the message in question being that Nuclear Weapons are Bad. It was first performed in 1961 and was written in German - our production was a translation, of course. It's a comedy-drama with an absurdist tinge to it and I found it a pretty typical example of this sort of thing. It was really the actors (Bruce Davison, John De Lancie and Gregory Itzin) who made the performance enjoyable. Their acting and the sound effects in the background combine to make the set almost coalesce in front of your eyes: it's amazing. It's such a pleasure to watch gifted character actors doing their thing. I find they're usually much better than A-list "movie star" actors, who seem to make careers out of playing the same basic character over and over again.

These message plays, though, all seem to have the same basic structure. They open with the whimsical, slightly absurdist setting and the audience getting to know the characters. Plot twist at end of first act! Second act opens with the ramifications of the plot twist. The characters' reactions segue into the Twenty Minute Lecture, as I call it, where the action comes to a grinding halt so that the playwright can air his thoughts and opinions and the audience just has to sit there and take it. Then the characters pick up their roles again and the play comes to some sort of resolution which may be hopeful, depressing or indefinite. A really classic example of this sort of play would be An Inspector Calls, which masquerades as a murder investigation but is really an anticapitalist polemic. I enjoyed it, but after the first ten minutes you know exactly where it's going to go.

This sort of play bugs me, but it isn't the message that is the problem. Good theater should challenge its audience, after all. It's the Twenty Minute Lecture that I dread: it ruins the flow of the play. I think the only playwright capable of getting away with this sort of thing is George Bernard Shaw and it's because his characterization and dialogue are so good. When his characters debate you believe they're having a debate, not that the playwright is arguing with the audience. Durrenmatt's characters are good enough at the beginning but turn into straw men, only there to expound on their creator's theories.

One could argue that blogs are guilty of this same crime, but I think most people read blogs specifically to get the writer's take on things. Besides, if the reader finds the post boring he or she can always click on to something else... now wait just a minute. Get your hand off the computer mouse! I'm not done ye

Labels: Los Angeles, Politics, Pop Culture, Science

posted by Dr. Alice at #

 
Tea and Taxes

Millions of Americans are paying their taxes today; in addition, thousands are participating in Tea Parties across the land to protest government spending and tax increases. Glenn Reynolds' essay today in the Wall Street Journal points out some interesting facts about the tax protests. This is a true groundswell movement which has just come into existence in the past few months. Without the Internet's ability to allow ordinary people to organize, a cross-country protest like this could never have happened. A few paranoiacs suggested the tea parties had been dreamed up and bankrolled by some large political group or other, but no one has enough money or organizational skills to mount something this big.

It will be interesting to see what happens next. As Reynolds points out, the movement could get bigger, give birth to a third political party - or flame out if everyone loses interest. I don't somehow think the last option is going to happen, at least not as long as the federal government keeps saying that spending mind-boggling amounts of money is the answer to all our problems.

Labels: Money, Politics

posted by Dr. Alice at #