Thursday, July 02, 2020

Parlous Times—so Why Is My Dander Down?

Yes, these are parlous times, my friends, with all sorts of threat levels bouncing up and down and up again to all sorts of new heights. I've personally felt almost paralytic, in this present "Dander" series, about repeating the latest outrages from Trump-land and Corona-land.  (Lather. Rinse. Repeat.) What is there new to say? The outrages are all there, still, but with a single, over-arching theme.

To quote the great philosopher, Frankie Valli, "It's a sign!!!" The sign: a new system of governance run by a cabal of family and cronies, no inspectors-general in sight, and a whole lot of unconfirmed "acting" secretaries, under-secretaries, under-under-secretaries and under-under-under secretaries.

I've written about this syndrome in HCRenewal before, mainly in connection with the Veterans Administration. Look it up right here in HCRenewal (e.g. see here). It's a systemic neurological disorder we could call MS: Mar-a-Lago Syndrome. In this disorder the federal government is paralyzed not by the Deep State, but a pernicious Deep Nonstate of golf buddies, far-right pundits and other self-dealing defilers of democracy.

Oh, where are the mere managerialists we used to go after in HCRenewal? We do miss them so! Lather. Rinse. Repeat.

Anyway, we're in the summer of 2020 and lives have been lost. The system stays awash in waste and cronyism. But I just couldn't muster writing more about it: what was new? It's all MS and the thousand flushes of oppositional, know-nothing populist careerism that go along with it. All courtesy of a motley crew of hackers, sadly gullible flat-earthers and one particular political party busy pushing itself and the rest of us off the deep end. All exploiting the hell out of each other. Only one, the US Senate's leadership, has an internally-valid long-term goal—the judiciary—that purports to make the exercise worthwhile. Everybody else can just bump along in their miserable gerrymandered "corporations are people" lives, liking it and lumping it.

And yet: along the way, something strange seems to be happening. It's true that, yoked together and spurring on their steeds, our four horsemen of the apocalypse—America's flawed democracy, its corrupt GOP, the pandemic and its exposed systemic racism—just stay on the rampage. But look underneath all this, in health care and just maybe in the larger society, there are young hopeful shoots, sprouting somehow in the mud below. And that is something new and worth writing about.

So just now, oddly enough the dander's down. (Provisionally. Check in again in, oh, four to five months.)

Some years ago Dr. Poses, this blog's venerable editor, already pointed out how HCRenewal's message has begun to "go mainstream." Now and again, he points out further new examples.

Maybe this mainstreaming of the message—health care independence and integrity—somehow relates to a couple of major shifts in the medium, or mediums, that carry the message. The first, social networks, have worked in part to the detriment of good government. But they also enable ground-up protest in a new communications ecosystem.

Another part of this ecosystem, less evident to lay people and leaders but potentially a potent force, is the advent of a new and more independent-minded generation of science and medicine journal editors, with their accompanying editorial boards. Here we find some more of the tender young shoots, exemplifying the change that genuinely seems afoot. Let me cite three recent examples.

  • The Annals of Internal Medicine has gone from strength to strength in recent years. Under its current editor, Christine Laine, the first woman to hold that post, Annals now boasts its highest-ever impact factor [C. Laine MD, personal communication]. That's an impact in general medicine, the nation's largest specialty, boasting over a million page views per month.

    The current number of Annals, for mid-June 2020, offers an article entitled "a cautionary tale," describing last year's "orphaning" of the entire house staff of Hahnemann University Hospital. Both the content and the very fact of the publication of this article are noteworthy. The article that follows, in its title, asks "is it time to more fully address teaching religion and spirituality in medicine?" (answer: "truly caring").

    But stick for the moment with the Hahnemann debacle. The article, written by three former Drexel University College of Medicine (DUCOM) faculty members who're now spread to the four winds, probes the "diametrically opposed goals of hospital owners and educational leaders" that led to an enormously disruptive hospital closure on the verge of a pandemic, a tsunami that orphaned nearly 600 trainees and that faculty quite simply "found hard to believe."

    Those of who were around in the 1990s didn't find it so hard to believe. The authors allude to the prehistory of the Hahnemann bankruptcy in the earlier one endured by Allegheny, or "AHERF" in the late 1990s. They don't insist on the earlier one prefiguring the later one, "the largest orphaning event" in medical history, in any causal or direct fashion. But I'd argue precisely that: at the least, it made it much more likely.

    The reason, simply, a circumstance to which to their credit the authors point, was the original sin of the deal that bailed out a medical school (pre-bankruptcy MCP-Hahnemann, post-bankruptcy Drexel) and a group of hospitals (originally Tenet Healthcare). That original sin was a quarter-century earlier when the Philadelphians did a deal-that-was-never-gonna-work with Tenet Healthcare, a for-profit based west of the Mississippi. The original sin fast-fowards a quarter-century to the present authors noting that at the critical moment in 2019, "Drexel and Hahnemann released separate talking points for P[rogram] D[irector]s, but these documents contained discordant information." But the discord started in 1995 and never stopped. Graduate Medical Education run by frenemies.

    The American system of GME, like the US Constitution, contains any number of these ill fated compromises. When this happens, only a few norms serve as guardrails against disaster: in this case, the manner in which hospitals—recall that Tenet was a for profit system, and one for which both education and research are distinctively secondary—control the medical education dollars coming to them from Medicare reimbursements. "Discordant information": how can you lose?

    The departure of hundreds of residents, with all its displacement of both faculty and trainees, and with all its emotional turmoil, hardly seems like something that would cheer one up. And on its face, it's not. One can hardly overestimate the pain these authors and their colleagues went through. But what strikes me is the fact that this whole crummy system is no longer anechoic: that those within it are out there on the hustings, stating the lessons learned, trying to create the antibodies that might protect against future such occurrences. And Annals gladly published this excellent exposition-cum-cautionary tale.
  • In the same week that I received this number of Annals, I received the 25 June 2020 number of The New England Journal of Medicine. NEJM, also a super-high-impact journal, changed editorship—just a few months before the onset of the pandemic— much more recently than Annals. One waited to see whether it, too would be, shall we say, feminized. (Be clear: in this case "feminization" is for me an uncomfortable shorthand for what I dearly hope my commentators below will suggest a better word, and more or less an unmitigated good.)

    I grew up in a tradition of ritualistic CPCs—clinicopathologic conferences—in my own medical school and in key journals such as NEJM. A case would be presented of a patient who had to die. They had to die because the autopsy findings would be tortuously predicted by the academic physician as the solution to a diagnostic dilemma. This would be followed by a learned exposition of the histology and gross pathology of the disease that furnished the answer to the puzzle. Sometimes the clinician even got it wrong. The pathologist of course was always right, He—it was virtually always a he—always got the last word.

    But what the CPC model did was to reify the classic post-Laennec medical model of equating medical decision making to its laboratory-based problem-solving narrative. This began to change a bit beginning in the Journal's post-Ingelfinger and post-Relman eras, where editors began to stress correlations of clinical findings with those of the new molecular biology and immunochemistry. Now the patient didn't even have to always die! But the classic medical model, even then, was preserved. Riddle me a riddle: bench science, properly coupled with bedside wisdom, will provide the answer.

    Imagine my surprise then to find the CPC of a few weeks ago, entitled "a girl with severe psychological distress after family separation," focused on "trauma-informed care" in which the clinical outcome was not "a post-mortem examination was performed" or "a diagnostic procedure and laboratory study were performed." Here "a diagnosis and management decisions were made" and both clinical and patholgocial diagnoses were "post-traumatic stress disorder."

    The graphic is that of a cartoon pediatrician with an immigrant child, blowing bubbles together.

    Make no mistake: this is both a scientific and literary breakthrough, and a political statement. It is enormously heartening to view such a sea change in one of our most august journals. It tell us that a new, younger leadership in academic medicine is stepping up to address the socioeconomic problems that are now—far more than whether or not SARS-CoV-2 does or does not interact with ACE inhibitor agents—threatening health care in the more dire existential fashion.

    Can we extrapolate from these straws-in-the-wind? Is medicine becoming less anechoic and able to counter the threats against it? I know of no other recent precedent, but there's one from classical antiquity: the very bedrock of our medicine today, the Hippocratic tradition. In his magisterial 1995 work Hippocrates in an Age of Pagans and Christians, Owsei Temkin of Johns Hopkins showed how the classical traditions of independent medicine were able to persevere even in a later era in which they were threatened by religious authority. It was a close call then and it's a close call now: viz., the decision by a mere five to four, just a few days ago, preserving the physician's right without hindrance to provide services to a pregnant woman.

    Sometimes it comes down to one vote. And, granted, it ain't over until it's over: in November, voters in the United States will, in momentous fashion, decide the future direction not just of their own people but of the healthcare they're going to get going forward.
  • What's going on here? In truly extraordinary circumstances, leaders in medicine seem to be not abandoning the scientific model, but expanding it to incorporate insights and perspectives drawn from ethics and the social sciences, including economics. (The Allegheny-Hahnemann case is a classic example of business-economics-gone-wrong through failures of basic socioeconomic analysis.) Even in the non-clinical literature, if you take even a cursory look, you can find these tender young sprouts of freedom.

    The journal Cell, in a number published last month, began with an editorial entitled "Science has a racism problem," stating that "We are the editors of a science journal, committed to publishing and disseminating exciting work across the biological sciences. We are 13 scientists. Not one of us is Black." Cell also boats an editor of recent vintage (2018).

    But what followed was even more astounding. Amidst articles discussing matters such as how "Epitope pools detect CD4+ and CD8+ T cells," in the very next number of the journal, Duke neuroscientist and MD-PhD Kafui Dzirasa provides his account of how "[f]or Black scientists, the sorrow is also personal." This article has been widely reprinted and sent out to many thousands of physicians who practice in domains as far away from cell biology as orthopedics. It is worth quoting in extenso, and speaks for itself.

I am a medical doctor and a scientist; the first African American awarded a PhD in neuroscience at Duke University. I have led a National Institutes of Health-funded research lab for almost a decade, and I was awarded the Society for Neuroscience Young Investigator Prize in 2019. I am an American Association for the Advancement of Science Alan I. Leshner Public Engagement Fellow, and I have hosted TEDMED three times. I am a scholar, teacher, mentor, speaker, and mental health advocate. I have served on national commissions, I have advanced federal policy, and I have even held court with a president of the United States. I have published in Cell scientific journals, and as a peer reviewer, I have worked to advance the scientific rigor of my colleagues. Yet, most days, I am unseen and unknown. As I watched a knee slowly, mercilessly, and inhumanly extinguish yet another black life, I was overwhelmed by anger and sorrow, and at this very moment, I am terrified to run on the trail near my home. I am a black academic in America.

That these three examples of medical communication all point to inherent problems in American medicine, no doubt in world medicine as well, is daunting in one sense. But in another it is undaunting. It shows us how far we have left to go. By looking in the mirror and recognizing that they share the challenges of the larger society, medicine and science have at least a fighting chance of transcending them—and in doing so, regain their independence. The manner in which these authors have taken the knee, and in doing so stood very, very tall, shows us a path of speaking truth to power. In doing so, and in our anticipation of their being heard, they give us hope.

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