On Speech On “Skanks”

My civil libertarian friends are “worried” about the precedent set in the recent Liskula Cohen case. In the case, a formerly anonymous blogger said some nasty things about Cohen. So nasty that Cohen sued to unmask the blogger’s identity and was successful in doing so. The blogger is now suing Google alleging that the company owed her a fiduciary duty and should not have revealed her identity.

Critics of the Cohen case tend to focus on the fact that the blogger called Cohen a “skank.” They argue that the word is mere hyperbole and not an objective fact. But the blogger said and did much more than that. From the opinion (PDF):


I think the civil libertarians are wrong on this case. Privacy is not an unlimited right. Cohen pierced the blogger’s veil of anonymity, but to do so she had to go to court and prove some merits of the case. Maligning another as promiscuous has always been defamatory, and the First Amendment has always allowed punishing such expression. This type of speech carries with it serious harm to women, especially those who rely upon their reputation in their work.

Surgical Internship

You might have noticed I’ve been busy for the last couple of months. This is because I’ve started my surgical internship, and when not working, am usually either sleeping or eating. I’m going to endeavor to write more though, because I think important things are going on in the world, and because it’s somewhat therapeutic.

I’ll tell you first about a day in the life. What does a surgical intern do? Well, pretty much what most interns do in medicine. We are the ones who run the floor, who do the day-to-day stuff that keeps a medical or surgical service running. The work isn’t that exciting. We put out fires, do a lot of administrative work, and deal with the moment-to-moment issues with patients admitted to the hospital. But it is important work and necessary to keep the system running.

A day usually starts around 5-6AM, when you show up on the floor and get “sign out”, or information on the patients on the service from the person covering them at night. We then start collecting data from the previous day, the vital signs and labs that let us know the status and trends of our patients, and put them together in a list. The list, they say, is life. It becomes the vital piece of reference information the team uses throughout the day to determine what has happened with our patients so far, where they stand now, and what needs to be done in the future. Usually consisting of a few pieces of paper, in tiny print it contains the information we use for rounds that morning, and then use to refer to our plans for the patients on service for the rest of the day.

Rounds are critical. Rounds are when everyone on the team learns what is happening with every patient, we talk to them to hear about any new issues or new complaints, do a physical exam, discuss plans with members of the team and the nurses, write our notes for the day and address acute issues that have come up in the previous night. On surgical services, because the first cases are usually scheduled to start between 7-8AM, rounds have to be efficient and succinct.

Then between 8AM and around 5PM my day is dividing between implementing the plans decided on by the chiefs and attendings during rounds, addressing issues that come up during the day, and hopefully getting into the OR once or twice a day to continue to improve my surgical skills. Internship is mostly about the basics of patient care though, and keeping the service rolling to the patients get better and out the door so a new batch can come in and get treatment.

Around 6PM the night call person usually gets sign out from us, and we endeavor to communicate the critical issues for our patients that need to be addressed during the night, and the problems we anticipate coming up. It’s an under-emphasized aspect of hospital medicine, the day-to-day communication that makes sure nothing falls through the cracks and when we try to make the care of patients as seamless as possible, despite the need to hand-off care to the next guy. We are only human after all, and can only keep the plates spinning for so long before we need to eat, sleep, and get cleaned up for the next day’s work. During the day you’re running from task to task as quick as you can, and I lost about 15 lbs in the first month (unintentionally) from the constant activity and lack of time for meals. Fortunately I can miss the weight. My second month has been a bit calmer and there is free food, so I’ve stabilized, but I’ll start to melt again once I get back on one of the more crushing services.

Every 3-4 days, or just on weekends if there is a night-float system, you have call. This means you start at 6AM and work until about 11AM the next day in a 30-hour marathon shift. At 6PM you pick up a couple of other surgical services you will have to cross-cover overnight. It’s brutal, but necessary, and you learn to deal with issues as they come up efficiently, and even more importantly, to ask for help from the covering chiefs when you’re out of your level of comfort or expertise. Post-call you sleep for about 12-14 hours and show up the next day at 6AM to start the process all over again. Amazingly, despite these requirements we have to keep our total hours under 80 hours a week on average.

We’ll talk some more about what it’s like to be a new intern. Specifically, we’ll have to talk about the July effect (whether or not it even exists), the 80-hour workweek, and the impact medical reform may have on graduate medical education. It’s an exciting time to be in medicine, I can only hope we get past the current noise and nonsense to make some real improvements in how we apply the science of medicine to human health.

Welcome Back to Denialism Blog

Despite rumors to the contrary, I am not dead. Instead I’ve been working hard as a new surgical intern and sadly not finding the time to write for the denialism blog. However, now more than ever, it seems that we need to talk about the problem of denialism.

Two major new issues for denialism have cropped up, and both are major new forms of political denialism. The first, I’ll broadly describe as Obama-denialism. Obama is a muslim, Obama was not born in the US, there is a giant conspiracy involving the Hawaii Secretary of State, the Democratic Party and muslims worldwide to take over the US government with a madrassa-trained presidential double agent etc. These are of course nonsense. FighttheSmears a website created by Obama supporters has most of the more ridiculous rumors debunked, including the absurd birth certificate/birther conspiracy theory. appropriately mocking LA Times blog entry. Whatever. As readers of denialism blog, it should have been clear from the get-go that this is just the usual conspiracist-drivel propagated by people who are upset at having a black president, and, just like the truthers, holocaust deniers, AIDS denialists, or any other group driven by racism, paranoia or just plain stupidity they won’t be satisfied by any evidence that contradicts their illogical conclusions. The format of the arguments is prima-facie absurd. The conspiracies are non-parsimonious, and lead immediately to more questions that just don’t make any sense. Despite this, bigots and crackpots like Fox News and Lou Dobbs “cover the controversy” to keep it stirred up. We must address it for what it is, closet racism and sour grapes over losing an election.

The second major issue, even more distressing to me now that I’m fully immersed in our health-care system, is that of universal health care denialism. Most upsetting to me was pronouncements like that of Sarah Palin that health care reform will lead to “death panels”. This is where the political opponents of progressive governance have crossed the line from the usual political ignorance and lies to truly despicable tactics designed to sink health care reform at any cost. The reality of the language originally in the bill was that it was designed to encourage physicians to have end-of-life discussions with their patients by paying them for such consultations. This is an area in which our health system currently fails miserably to the detriment of our patients. We truly need to have all patients interacting with our health system to have frank discussions about their wishes at the end of their lives, to have living wills, and make their desires for their level of intervention clear before they end up in the ICU, on a ventilator, and having invasive treatments performed ad nauseum that they may or may not approve of if they were able to communicate their wishes. But no, the political opponents of health care reform have instigated a scorched-earth policy, and even something as noncontroversial as asking people what they want their physicians to do when they’re sick has been thrown under the bus by the denialists. Other lies? Universal health care reform will turn us into communist Russia! A belief inconsistent with the fact that every other country in the industrialized world has survived the conversion to universal systems without requiring Stalinist dictatorships to enforce the dastardly public option. These arguments transcend mere denialism and can only be described as ideological insanity.

There is a legitimate debate to be had over health care, but we clearly are not having it. One legitimate question is how do we pay for it? I’m confident that reform will pay for itself and it is more expensive not to have universal access. As we discussed in our health care series, every other country in the world has accomplished this feat, provide equivalent or measurably better care in terms of access, health of populations, and life expectancy. Despite their universal coverage they all spend less than half as much per capita than the US on health coverage. Having people access the system in our ERs, lacking preventative care, and failing to provide the universal inexpensive interventions costs more than just providing care to people. After all, we already pay for the uninsured, hospitals and doctors are ethically obligated to provide care for everyone who walks in the door, insured or not. The costs of covering the uninsured are already built into our excess costs. Worse, having a administrative system designed to deny care is costly and unnecessary. The “privatization” or “subcontracting’ of medicare administration under Bush increased the cost of healthcare administration by 30% in three years despite the number of patients covered increasing by only about 4%. Paying for things in a planned, thoughtful and systematic way is cheaper than allowing problems to stew and boil over. I’ve already had way too many patients showing up in the ER with disastrous and expensive health problems requiring a huge expenditure of resources that if they had been addressed early would have cost next to nothing. And yes, they always tell me they didn’t get it addressed before it was critical because they lacked insurance. This is stupid and not the kind of care I want to be providing. Another legitimate question is will universality damage our technological and research prowess? Again I believe the answer is no. The US has excellent technology and research because we pay for it through government agencies like the NIH. The technology won’t go away because that has more to do with the culture of our healthcare system than the fact that we have oodles of money to pay for it (because we don’t really). It’s also not a fact that our technology necessarily makes our care better. CT scans, and MRIs are not as important to provision of health care as having ready access to services and adequate access to primary care physicians and preventative care. Another good question, is a public option necessary? Again I believe not. While I believe countries that provide a public option like Australia are ones on which we may model our system, other countries such as the Netherlands or Germany have developed excellent healthcare systems through insurers by tightly regulating them and not letting them screw their citizens. Here’s a great question, would anyone under these systems choose the US one? As evinced by the commentary from our health system, the critics of universal healthcare are speaking from ignorance when they claim citizens of other countries are suffering in their systems. The data we presented, and reinforced by commentary from all over the world, was that these systems have problems, but no one in their right mind would trade them for the US system.

Let’s get back to having a public debate that is not overwhelmed by the ideological fanatics and deniers and instead focus on the very real and critical problems that this president was elected to address. The denialists and their scorched earth tactics have done a great deal of harm to our debate on reform. Now more than ever, we need to talk about the difference between denialism and debate.