20 January 2011

Internet detritus

Happy/Sad Earth likes its moon. Reminds me of playing with my kids, especially when they are in the pre-toddler age.

via Bad Astronomy
The 50 most Loathsome Americans of 2010
Savage and hysterical (and bipartisan). Worth the full read. Fun examples:
30) Mitch McConnell
 Yet another example of the direct proportionality of evil to jowl size. In pronouncing that his most important job as Senate Minority Leader is to limit Obama to one term, McConnell accentuated the craven political discourse in which we now wallow. With two wars going and the worst economic crisis since the Great Depression, the opposition leader might think that, but he’s not supposed to say it. But the gaffe of the Senate’s most pandering shill barely registered in the era of “Don’t retreat! Reload!”
Aggravating factor: “I mean, let’s be honest. Who wants to hang out with guys like Paul Krugman and Robert Reich, when you can be with Rush Limbaugh!”
Sentence: Second turtle stand-in at the forthcoming Noah’s Ark amusement park.

 40) Charlie Rangel
 It’s understood that corruption is our legislators’ raison d’ĂȘtre. Rangel so aptly plays the character of a crime boss that his image should jump to mind whenever you hear the words “member of Congress.” He dresses like John “Dapper Don” Gotti, sounds like Marlon Brando’s Vito Corleone, and looks like the Joker as played by Cesar Romero. Rated by the Citizens for Responsibility and Ethics in Washington as one of the most corrupt congressmen the past three years.
Aggravating factor: If John Q. Douchebag used Congressional letterhead to solicit funds for a college center named in his honor, had $600K in unreported income and assets, and didn’t pay taxes on his Caribbean home—to name three of Rangel’s 13 known violations—he wouldn’t be read a sternly worded letter by Nancy Pelosi. He’d go to jail. For a very long time.
Sentence: Dancing With the Stars.”

Finally, this is just hysterical:

Use caution before deciding to watch it. Remember, what is once seen can never be unseen.

Reading the Tea Leaves: the PPACA and SCOTUS

As the PPACA wends its way through federal court, there have been conflicting opinions on its constitutionality issued by varying federal judges. When the lawsuits were first filed against the health care reform law, they were given little chance of succeeding by legal experts. The reason for this is that the key challenge to the law is based on an interpretation of the Commerce Clause which runs contrary to settled law for the last 60 years. The commerce clause has been something of a political football, historically. In the late nineteenth century and early twentieth century, judges used the commerce clause to restrict the power of the federal government, and then in the New Deal era, the Supreme Court changed its view and used the commerce clause to expand the scope of the federal government. The modern conservative court has begun to incrementally restrict the scope of the Commerce Clause, but the current Supreme Court seemed to set a limit of how far they would restrict the use of this power in a 2005 case upholding the authority of the federal government to criminalize marijuana which is grown, sold and consumed within a single state. Kennedy and Scalia concurred in this decision, and Scalia's separate concurring opinion reads in part:

"Where Congress has authority to enact a regulation of interstate commerce, it possesses every power needed to make that regulation effective. ... The power to enact laws enabling effective regulation of interstate commerce can only be exercised in conjunction with congressional regulation of an interstate market, and it extends only to those measures necessary to make the interstate regulation effective. As Lopez itself states, and the Court affirms today, Congress may regulate noneconomic intrastate activities only where the failure to do so “could … undercut” its regulation of interstate commerce."

More recently, a majority including Chief Justice Roberts wrote, “determining whether the Necessary and Proper Clause grants Congress the legislative authority to enact a particular federal statute, we look to see whether the statute constitutes a means that is rationally related to the implementation of a constitutionally enumerated power.” The healthcare market is inarguably interstate and thus a fit area for government regulation, and since the individual mandate is not only "rationally related" to the regulation of this market, but integral to its regulation, it seems that it fits quite clearly into the framework established by the Court as a constitutional exercise of the government's power.

So it was (and remains) reasonable for observers to expect the Supreme Court to stand by its own longstanding and recently upheld precedents to uphold the law. Indeed, a recent group of 100 law professors signed a joint statement (PDF) in support of the constitutionality of the law. But unfortunately 100 law professors are not worth one Scalia or half a Kennedy, and what the Court will ultimately do is not clear. Opponents of the law have an interesting if logically tortured argument that PPACA attempts to regulate economic "inactivity." It has been noted that the 1942 Wickard case justified regulation of economic inactivity, so even that would seem to fail the precedents set by the Court. What we really cannot guess boils down to three things: 1.) How political is this Court, and 2.) How activist is this Court and 3.) What will Kennedy do? While we like to think of the Court as nominally apolitical, the 2000 Gore v Bush case revealed how readily the justices can at times discard principle to accomplish a politically desired outcome. The stakes in this decision are just as high, and the partisan fervor no less intense than in a presidential election. It would not surprise me in the least to see Scalia switch sides in order to stick a finger in the eye of democrats. The Roberts court already has a shocking track record of judicial activism (which I say as an observation, not a criticism; I've never thought the idea of a neutral arbiter of law was possible or desirable.) and they may well leap at an opportunity to further restrict the power, size, and scope of the federal government. However, this may be a bridge too far for them, particularly for Kennedy, since a decision restricting the Commerce Clause to this degree could invalidate a whole host of federal laws and regulations far beyond this limited case. I'm not sure Kennedy is willing to endorse such a radical restructuring of the US government, and I'm also not sure he wants to be on the "wrong side of history" in invalidating such a monumental legislative accomplishment.

This is all just speculation and guesswork. It'll likely be years before we know anything on this case. But since we are engaging in idle speculation, it might be interesting to wonder what might happen if the Court does agree that the individual mandate does violate the Commerce Clause?

First of all, it's likely that conservatives will be disappointed that "ObamaCare" will probably not be struck down in toto. While it is true that Congress did not include a specific severability clause, it's a fact that the court has also held many times that legislation can still stand if just a single element of it is invalidated. More distressingly for opponents of the legislation, the conservative judge who did rule the PPACA unconstitutional did just that: severed section 1501 (the mandate) while leaving the rest of the law in force.

This is pretty key. It means that even if we lose at the Supreme Court, it is highly likely that the rest of PPACA stands. The subsidies, the medicaid expansion, the insurance regulations and exchanges, the independent payment advisory board -- all of it. Only the mandate goes.

What would that mean for reform overall? That's less clear. For sure, coverage would be less universal. There will still be millions of uninsured even under PPACA as it is, but surely more people would opt out of buying insurance, diminishing the risk pools and creating adverse selection problems for insurers, who will still be bound by regulations requiring them to live with medical loss ratios of 80-85%. In that case I can easily see the insurance industry coming back to Congress and demanding a fix for the situation. If nothing else happens, the prediction is pretty grim from a cost perspective: health care economist Jonathan Gruber estimates that removing the mandate only would result in individual premiums being 27% higher than they would under the act with the mandate, and that only 7 million more people would have insurance, compared to the 32 million newly insured under the PPACA.

So the mandates are pretty critical to achieving the goal of near-universal healthcare coverage. It would be pretty bad for reform if that were struck down. But it wouldn't be the end of the world, and it wouldn't even necessarily be the end of reform. If the partisan furor over this bill ever dies down in a few years, once the insurance exchanges and other regulations have been accepted as part of the political landscape, it is possible and even likely that a future Congress might be able to come together to amend the law to make it work better. Maybe I'm just dreaming on that point. But it is instructive to look back on the Medicare program, which was about as controversial and bitter a fight as this when it began, and after only a few years it was accepted and expanded in a bipartisan manner to be the program it is today.

18 January 2011

You're entitled to your own opinions

But you're not entitled to your own facts.

More pushback on the factually challenged criticisms of the health care reform act from the Center on Budget and Policy Priorities:

Claims that the health reform law relies on budgetary gimmicks to reduce deficits are false.

Claim: The law uses a gimmick to make it appear fiscally responsible: its biggest spending increases don’t take effect for four years, so CBO’s cost estimate for the first decade (2010-2019) includes ten years of revenue increases but only six years of significant spending. The unstated implication of this charge is that in subsequent decades, when ten years of revenue increases are accompanied by ten years of spending increases, the law will greatly increase deficits.
Fact: There is no gimmick here, and this charge is groundless. CBO estimates that the law will reduce deficits not only over the 2010-2019 decade, but in the second decade and subsequent decades. In fact, the law will reduce deficits by more in subsequent decades than in the first decade, because its most important cost-saving measures are phased in and produce larger savings over time.

Claim: CBO’s cost estimate double-counts the Medicare savings and additional Social Security payroll tax collections that the law will generate, because these savings and revenues could not both help pay for health reform and improve Medicare’s and Social Security’s finances.

Fact: This, too, is a canard. In estimating the law’s impact on the deficit, CBO counted the Medicare savings and Social Security revenues only once. The financial status of the Medicare or Social Security trust funds is a different matter, distinct from CBO’s estimate of the impact of the legislation on the budget deficit. The skilled CBO experts did not double count, as anyone familiar with budget estimates knows.

Claim: CBO’s cost estimate is misleading because it doesn’t include $115 billion in additional discretionary spending that Congress must provide to implement health reform.

Fact: The health reform law contains authorizations for a variety of grant and other programs, and CBO has estimated that if future Congresses chose to fully fund these authorizations — which Congress is under no requirement to do — the total expenditures involved would amount to $115 billion over ten years. But the large bulk of this amount is neither required nor necessary to implement the health reform law, and much of it doesn’t even reflect new expenditures. As CBO has stated, more than $86 billion is “for activities that were already being carried out under prior law or that were previously authorized.”[3] CBO has noted that the law’s actual implementation costs — that is, the cost that federal agencies will incur to administer the law — will be roughly $10-20 billion over the first decade.

Claim: CBO’s cost estimate inappropriately includes savings from the new CLASS long-term care insurance program.

Fact: Congressional leaders deliberately crafted the health reform bill so that it would be fully paid for without relying on savings from CLASS Act premiums. The CBO estimate clearly shows that if one excludes the net revenues of $70 billion from CLASS Act premiums, health reform still reduces the deficit by $73 billion over the first ten years.

Claim: CBO’s cost estimate for health reform is misleading because it doesn’t include the cost of the “doctor fix,” or fixing the sustainable growth rate (SGR) payment formula for physicians.

Fact: The cost of fixing the SGR formula is entirely unrelated to health reform, as can easily be proved — all of the cost of fixing the SGR formula would remain if health reform were repealed. None of that cost can be attributed to health reform.

There's much more there, and it's worth the full read.
There's a lot to critcize in the PPACA; I've never said it was perfect. But it's simply false to claim that it's not paid for or that it will increase the deficit. When the congressional GOP claims that "it's money we don't have," that's false: the Democrats found the money and the bill is paid for, unlike the republican-authored, deficit-financed Medicare Part D. Even if you permit a rhetorical sleight of hand, interpreting Cantor as meaning the health care reform bill was too expensive, that begs the question of why the GOP so vitriolically opposed the medicare "cuts" and other cost-saving proposals such as the public option as "death panels." It's either incoherent or hypocritical to simultaneously criticize the reform as both too expensive as well as too draconian in cutting costs (or restraining the growth in future costs).

17 January 2011

Some health care related policy and politics

Reading the blogs this morning, and seeing a lot of health care policy stuff out there:

Polls from Marist and the AP show that although opposition to the PPACA remains high among conservatives, the support for full repeal is not. The AP poll found that only about 25% of respondents favor repeal, while 20% favor leaving it as is, and 43% favor expanding the law so that it does more. As in previous polls, people like the rules prohibiting insurers from discriminating based on pre-existing conditions, and the individual mandate remains unpopular. Similarly, the Marist poll found a small majority want the health care reform act to be left in place or expanded. Does this mean the law is becoming more popular? I don't think so -- it remains deeply polarizing along ideological lines. But the take-home point from these polls might be that the intensity of opposition is easing now that the election is over, and that some of the top-line "opposition" to health care reform is, and always has been, from the left, believing that it should do more.

Nevertheless, House Republicans are ready to begin their symbolic attempt to repeal the law. I don't begrudge them their gesture: it was a clearly stated campaign promise. However, it is pretty telling that despite the Republicans' ostensible concerns about the deficit, they make no effort to find any offsets from the $230 billion cost of repealing the PPACA. While we know it's just a bit of political theater, since repeal has zero chance at the present time, the GOP hypocrisy on the deficit is nothing new. GOP policy priorities never have to be paid for, it seems, whether they be Medicare Part D or tax cuts or health care repeal. John Boehner made the curious argument that the CBO cost estimate for the cost of repeal was unreliable, since the "doc fix" costs were not included (a long-standing criticism of the PPACA from the right). Paul Krugman took advantage of his column today to shred that line of criticism, once again. It's worth quoting at some length:

Republicans have a small problem: they claim to care about budget deficits, yet the Congressional Budget Office says that repealing last year’s health reform would increase the deficit. So what, other than dismissing the nonpartisan budget office’s verdict as “their opinion” — as Mr. Boehner has — can the G.O.P. do?

The answer is contained in an analysis — or maybe that should be “analysis” — released by the speaker’s office, which purports to show that health care reform actually increases the deficit. Why? That’s where the war on logic comes in.

First of all, says the analysis, the true cost of reform includes the cost of the “doc fix.” What’s that?

Well, in 1997 Congress enacted a formula to determine Medicare payments to physicians. The formula was, however, flawed; it would lead to payments so low that doctors would stop accepting Medicare patients. Instead of changing the formula, however, Congress has consistently enacted one-year fixes. And Republicans claim that the estimated cost of future fixes, $208 billion over the next 10 years, should be considered a cost of health care reform.

But the same spending would still be necessary if we were to undo reform. So the G.O.P. argument here is exactly like claiming that my mortgage payments, which I’ll have to make no matter what we do tonight, are a cost of going out for dinner.

There’s more like that: the G.O.P. also claims that $115 billion of other health care spending should be charged to health reform, even though the budget office has tried to explain that most of this spending would have taken place even without reform. [...]

The key to understanding the G.O.P. analysis of health reform is that the party’s leaders are not, in fact, opposed to reform because they believe it will increase the deficit. Nor are they opposed because they seriously believe that it will be “job-killing” (which it won’t be). They’re against reform because it would cover the uninsured — and that’s something they just don’t want to do.

Emphasis added. I take issue only with Krugman's conclusion, that Republicans don't want to cover the uninsured. The real reason for the intensity of GOP opposition to health care reform is because it was a big win for the other team, and in the zero-sum world of electoral politics, a win for Team Blue is a loss for Team Red. The way to get back in power, beyond simply riding the economy, is to try to avenge that loss by repealing it. If the GOP was actually serious about health care reform -- which they manifestly are not -- they would be offering amendments to the law to improve it rather than blocking bipartisan fixes. They would be proposing an alternative rather than a return to the status quo. The primary goal of the modern GOP is the acquisition of power, not in governance, so they focus on repeal as a means to recover from the political wilderness.

However, the House GOP is ready to get to work protecting the profits of their allies in the insurance industry. Rep Carter (R-TX) is preparing a resolution to block implementation of regulations which would require insurers to spend at least 80% of premium dollars on medical costs. It, too, is a long-shot to pass, but the fact that the first priority of the GOP is to ensure that insurers can continue to spend as much as they like on CEO pay, profits and administrative overhead is also a telling sign of where their true intentions lay.

Austin Frakt at the Incidental Economist provides evidence that the individual mandate in Massachusetts is working as intended -- that the rate of uninsurance is very low (about 2%) and that adverse selection, or people gaming the system is so low as not to ba a problem. This is informative as to what should happen in 2014 when the PPACA is implemented nationally. He goes on to point out that this is not to say that the mandate will decrease costs or improve access to care -- those are separate issues that the mandate was not intended to directly address. 

On an unrelated note, I can't help but comment on the fact that Starbucks' is introducing a new larger-size drink, the "Trenta." At nearly a liter in size, it exceeds the average capacity of the human stomach. I leave it to you to decide what, if anything, that says about the state of American civilization.

14 January 2011

Why I hate medical journalism

In this heartbreaking CNN report, they tell the story of a child who, after a five-hour wait in an ER waiting room, developed Strep sepsis and nearly died. It's a terrible story, and a terrifying case both as a parent and as an ER doctor. To their credit, the authors treat the subject seriously, without too much sensationalism, and they provide a serious look at the status of the nation's ER overcrowding crisis and they shed some light on its causes. They obtain one of the greatest explanatory metaphors I have ever read on ER overcrowding: 

Dr. Sandra Schneider, president of American College of Emergency Physicians, says the backups occur as emergency departments struggle to find beds for admitted patients."Think of the emergency room like a restaurant where people come in and go out," she says. "Now imagine a restaurant where the customers come in, but never leave. They come in for breakfast, they stay for lunch and they're there for dinner." When a patient is admitted to the hospital and needs to remain for additional procedures, they take up available inpatient beds leading to a domino effect, Schneider says.

Lovely metaphor, and immediately accessible to laypersons trying to understand the complex dynamics of ER patient flow.

So why do I hate this article?

First of all, in this case, it sounds like the "human interest" example they used was wrong, or at least illustrates a different point than the authors wanted to. The real cause of this child's outcome is not just the overcrowding of the ER, but the error of the triage nurse. A febrile child with petechia or purpura is a medical emergency, and this is clearly one of those cases where the triage nurse missed it. This child should have been rushed back, regardless of what else was going on. While the overcrowded ER was a contributing factor, the proximate factor here was a medical error. A secondary (and unknowable) issue, medically, is that if the child was sick enough to have purpura on presentation, she was already in DIC and probably would have gone on to have the same outcome of the amputations, etc, regardless of the wait time. Obviously, the delay was not helpful to her, so that's more of a quibble that will probably be left for the malpractice attorneys to debate.

But that brings me to the larger point. It's not just that they got the "human interest" case wrong -- it's that they had to have one at all to make the story "work" according to the journalistic conventions. Why does there have to be a dead child for readers to care about ER overcrowding? Is it not enough to walk through an ER waiting room and see dozens of people waiting in pain for hours on end?  The guy with a broken fibula, appropriately triaged, who has to wait for three hours for an x-ray and pain relief? The dehydrated child who can't stop vomiting? The kidney stone? Is it OK that these non-emergent cases cannot be treated in a timely manner? Or walk through the halls of the ER and see the patients languishing on gurneys for hours and days. Is that not enough to communicate to a general audience that there is a crisis in the ER, and in the nation's hospitals? 

This aggravates me because the incredibly touching and tragic human interest element of this story completely overshadows and distracts from the real problem. People will read this and come away sad for the patient and family, or maybe angry at the medical providers. But the systemic problem, the one which affects so many ERs across America, is demoted to the twenty-first paragraph, when it should be the headline. It should be in 100-point bold font across the front page of CNN every day. But a little girl suffered a terrible disease, and readers will be given that to chew over and dwell on, and the crisis that contributes to these outcomes gets short shrift.

That's why I hate medical journalism.

13 January 2011

God-damned GENIUS

Tim Minchin on Conan

12 January 2011

The True Definition of Pain

It's been a slow shift. I have spent the last ninety minutes tossing pencils at the ceiling to see if I could get them to stick. There are fifteen minutes left until I get to leave. I am hoping my replacement won't be late.

I have three patients in the department:

  • An old guy with a broken hip, admitted and waiting for a bed. 
  • A psychotic dude with bizarre behavior. Off his bipolar meds and paranoid, disoriented and weird as hell. WBC up a bit but medically clear and waiting for his psych eval.
  • A dehydrated lady with gastro finishing up her IV fluids.

As I wander over the the nursing station to graze off of the candy in the dish, the nurse for the psych dude approaches me, timidly, and informs me that the patient felt hot so she checked his temperature.

I said a bad word.

She told me the temperature.

I said a series of increasingly bad words.

The fever meant he was no longer medically clear. With the elevated white blood cell count and the disorientation it now meant that he was going to need a spinal tap to rule out meningitis. I was pretty sure he did not have it, but it's medically inarguable and as a practical matter no psych facility would accept him without it.  (Rightly so.)  So instead of walking out right on time after a painfully slow shift, I would get to enjoy staying late to perform an aggravating procedure on an uncooperative patient.

As so many times before I prayed for the Rapture to come now and end my suffering.

It could have been worse. I hectored and harassed everybody and got the patient sedated and tapped in what seemed like record time. My partner was very gracious in agreeing to review the CSF and ensure an appropriate dispo. I left the ED less than an hour after the end of the shift. So I can't actually complain. 

But I left annoyed, with my sense of well-being completely shattered. (I'm getting annoyed again just remembering as I write these words.)

Fortunately, I had podcasts of Car Talk on my iPod and I listened to one of those on the way home. It's impossible to listen to those guys cackle and stay in a bad mood.

11 January 2011

More on Conservative Political Violence

I know that most of you don't tune in here for political stuff, so I'm going to indulge myself with one follow-up post on political violence and then I'll be back to medical stuff, I promise.

I can see from the comments from my last post that there is an unsurprising backlash from the right side of the spectrum regarding the linkage between the violent rhetoric of the right's politics and the assassination attempt on Rep Giffords. To a degree, that is understandable. This link implicitly inculpates all conservatives/Tea Partiers, and that isn't quite fair. What shocked me is the degree of tribalism in the debate -- the responses I got from self-identified or presumptive conservatives were all defensive to the point of being in extreme denial. Universally, the comments were along the lines of:

  • Liberals do it too
  • The shooter was a liberal

 On the second point, which I think we can agree is less relevant, whether the shooter is liberal or conservative is probably a meaningless question to ask. It's pretty clear that he's nuts, and not in possession of any coherent political philosophy.  The same probably applies to a number of the politically violent acts in the litany of recent political violence. They are all, almost by definition, nuts. Some are clearly political conservatives (like the Pittsburgh shooter worried Obama would take his guns), some are hard to define, like the guy who crashed into the IRS building, and some are probably nonpolitical nuts (the Hunstville shooter came up a few times, and that seemed quite bereft of political overtones). However, my response to this is that IT DOESN'T MATTER what a given nutcase thinks he is accomplishing when he or she take up arms. What matters is, "What were the factors that drove them to take up arms?" He may not have known how Rep Gifford voted on Cap and Trade, but he probably had seen ads like this, run by Giffords' opponent:


Or this, by Arizona Republican Pam Gorman:


Did these cause the shooter to pick up his gun and go the the supermarket? Of course not. Were they part of the environment that led him to think that shooting people was an option? Possibly. Is this a useful and valuable contribution to the political discourse?

Which brings us to the "Liberals do it too" point. It's incredibly frustrating to debate this, because the truth is that lots of liberals have behaved poorly and done nasty things, and when you get people posting in the comments half a dozen links to some rightwing blog it makes it appear that there might be an equivalence after all.  But there isn't. Trust me, I can use the google machine as well as any of you, and I followed all the links you posted, and there is still no equivalence. Sure, some democrats or liberal protests may have at times done or said things that are not defensible and I am not going to try to defend them. What is clear is that the conservative rejoinder of "You did it first!" is weak tea at best, and more honestly a product of self-delusion on the right.  The "liberals" cited as being "violent"  included luminaries such as Madonna, Alec Baldwin, Louis Farrakhan, Montel Williams, an anonymous Kos blogger and Alan Grayson. They range from the irrelevant to the "Who?" to the "Oh God, he's no liberal" end of the spectrum. Whereas the conservatives who fetishize guns and threaten insurrection are hugely popular LEADERS of the movement such as:

Sarah Palin

Glenn Beck fantasizes about shooting up federal agents coming to take away his gun

Glenn Beck, standing against violence, with a gun.

George Packer put it more eloquently than I could:

In fact, there is no balance—none whatsoever. Only one side has made the rhetoric of armed revolt against an oppressive tyranny the guiding spirit of its grassroots movement and its midterm campaign. Only one side routinely invokes the Second Amendment as a form of swagger and intimidation, not-so-coyly conflating rights with threats. Only one side’s activists bring guns to democratic political gatherings. Only one side has a popular national TV host who uses his platform to indoctrinate viewers in the conviction that the President is an alien, totalitarian menace to the country. Only one side fills the AM waves with rage and incendiary falsehoods. Only one side has an iconic leader, with a devoted grassroots following, who can’t stop using violent imagery and dividing her countrymen into us and them, real and fake. Any sentient American knows which side that is; to argue otherwise is disingenuous.

It's the LEADERS of the conservative movement who use the threat/promise of violence to stoke their base and bring the voters to the polls. It was Wayne LaPierre of the NRA who said at CPAC "Our Founding Fathers understood that the guys with the guns make the rules," and Rep West, R-FL who said that "If ballots don't work, bullets will." It is 28% of Republicans who believe that "violent action against the government is justified," more than twice the rate of Dems or independents agreeing with that proposition.

This is a UNILATERAL phenomenon. If I say that I hope Dick Cheney suffers terribly before he goes to hell, well, that's a nasty and mean thing for me to say. It is completely unlike someone RUNNING FOR OFFICE as a Republican, saying publicly that "Our nation was founded on violence. The option is on the table. I don't think that we should ever remove anything from the table." (TX; Broden)

What I am advocating that the people saying these things knock it the fuck off. You're not helping. This map has enough "bullseyes" on it; we don't want any more.


09 January 2011

On Right-wing Political Violence

I am sick at heart over what happened in Arizona. It's an appalling act, and while I am not one to pray I will be praying for the recovery of Congresswoman Giffords, and for the family of US District Judge Roll, who lost his life, for the family of the nine-year-old child who lost hers, and all the others affected by this tragedy.
But I cannot help myself from saying, in grief and anger, this was not a random tragedy.
The gunman was mentally unstable, to be sure, and his schizophrenia or whatever thought disorder he suffers from clearly was the proximate cause of today's terrible event. But the proximate cause was not the sole cause, not by any means.
Our political discourse is broken, badly broken.  The rhetoric, largely but not entirely from the right side of the political spectrum, has become dangerously unhinged. While threats of violence are nowhere to be found in the direct words of the right wing politicians and influential leaders of the movement, the language of violence is pervasive. Nowhere will you find a conservative directly inciting people to commit acts of violence against their political enemies, but the vocabulary used is that of war, in which no compromise is possible, in which the opposition is evil incarnate. For the past two years, many conservative leaders, activists, and media figures have made a habit of trying to delegitimize their political opponents. Not just arguing against their opponents, but doing everything possible to turn them into enemies of the country and cast them out beyond the pale. Instead of “soft on defense,” one routinely hears the words “treason” and “traitor.” The President isn't a big-government liberal—he's a socialist who wants to impose tyranny. This relentlessly hostile rhetoric has become standard issue on the right. On the left it appears in anonymous comment threads, not congressional speeches and national T.V. programs.


  • Congresswoman Bachmann: "I want people in Minnesota armed and dangerous on this issue of the energy tax, because we need to fight back," said Bachmann. "Thomas Jefferson told us, having a revolution every now and then is a good thing. And the people - we the people - are going to have to fight back hard if we're not going to lose our country," and, "Where tyranny is enforced upon the people, as Barack Obama is doing, the people suffer and mourn."
  • Sarah Palin famously tweeted, "Don't Retreat, RELOAD!"
  • Sharron Angle, Tea Party candidate in Nevada, famously suggested on more than one occasion that violent revolution was an option if the GOP did not win at the ballot box: "the Second Amendment is the right to keep and bear arms for our citizenry ... the Founding Fathers intended this to stop tyranny. This is for us when our government becomes tyrannical... I'm hoping that we're not getting to Second Amendment remedies. I hope the vote will be the cure for the Harry Reid problem." And also, in the same context, referred to "taking out" Harry Reid."
  • ''Our nation was founded on violence. The option is on the table. I don't think that we should ever remove anything from the table as it relates to our liberties and our freedoms.'' Tea Party-backed Texas GOP congressional candidate Stephen Broden
  • Radio host Michael Savage compared Obama to Pol Pot, adding, "Only vigilance and resistance to this baby dictator, Barack Hussein Obama, can prevent the Khmer Rouge from appearing in this country."
  • Glenn Beck -- well, it's hard to pick a single example of overheated rhetoric from this paranoic demagogue, since pretty much it's all the time, but he has said "Obama is trying to destroy the country and is pushing America toward civil war," or similar thoughts multiple times, and has had many many references to Obama and progressives as Satan, Hilter, Stalin, and has called for or warned of "revolution" multiple times. Also, ''I'm thinking about killing Michael Moore, and I'm wondering if I could kill him myself, or if I would need to hire somebody to do it. ... No, I think I could. I think he could be looking me in the eye, you know, and I could just be choking the life out.'' 
  • ''My only regret with Timothy McVeigh is he did not go to the New York Times Building.'' Ann Coulter
  • ''He has no place in any station of government and we need to realize that he is an enemy of humanity,'' - Rep. Trent Franks (R-AZ), on President Obama's decision to fund international family planning organizations that support legal abortion.
  • Rush Limbaugh almost comes across as the reasonable elder statesman, opining that Obama is a socialist and that Limbaugh is rooting for him, "to fail."
  • Erik Erickson, of CNN and Redstate.com, asked what is in hindsight a particularly sickening question: "At what point do the people ... march down to their state legislator's house, pull him outside, and beat him to a bloody pulp?"   
  • And, as is now well-known, Palin's PAC featured gunsight logos, crosshairs, over the district of Rep Giffords and 19 others. Her opponent in the election held an event "Get on Target for Victory; Help remove Gabrielle Giffords from office; shoot a fully automatic M16."  Rep Giffords, presciently, warned that symbolism like that "will have consequences." Tragically, she was right. 
  • And the popular movement of the Tea Party, while well-behaved and nonviolent in its rallies, also has a pervasive element of the threat of violence in many of its popular slogans; the quote "The tree of liberty must from time to time be watered with the blood of patriots." was popular on signs at many of the rallies, as well as the not-very understated threat in the movement to bring guns to rallies.

I am not aware of similar rhetoric coming from the left. If there is, from an elected official, candidate for office, or major media personality, please cite it in the comments and I will add it to the list. I will stipulate in advance that Alan Grayson was way over the line numerous times, and that Olbermann many times excessively demonizes his opponents. Still, the implicit threat of violence is as far as I know unheard of in the liberal public discourse.

Rhetoric Translating into Violence
The reason I am so worried and upset about this recent shooting is that while it appears to be the isolated act of a lone gunman, it is one of a series of events which have become increasingly common since Obama became president -- incidents which have been politically motivated or influenced and have caused multiple deaths, most commonly deaths of our public servants in law enforcement. I also remember a much-criticized Homeland Security report issued just after Barack Obama took office, which quite accurately warned of rising right-wing violence. It was decried by conservatives at the time and withdrawn. Consider, though, this sad litany of deaths and injuries caused by armed nuts inspired by the hyperbolic rhetoric from the right, just within the last two years:

These are the recent episodes that have actually progressed to true violence. One should not forget, not too long ago, there were the famous right-wing attacks on America in Oklahoma city, and the Ruby Ridge siege and the milita movement during the Clinton adminstration.  There have also been many less serious cases of right-wing violence, which were aborted by law enforcement in the pre-attack stages, as well as serious threats and near misses:

This is to say nothing of the innumerable kooks who have been arrested (or simply investigated) for sending threatening emails or leaving death threats. This is to say nothing of the routine vandalism of congressional offices during the health care debate. The fact that Judge Roll received "hundreds" of death threats after certifying a civil rights/immigration case to proceed is a sad example of how the hyper-intensity of the debate has consequences. Death threats against public officials have become routine, unfortunately. Normally, they are not serious, but unfortunately in some cases, the mentally unstable decide to follow through on the threats.
Again, for those who bring up the false equivalency of "both sides do it," I should point out that there was as far as I am aware not a single example of left-wing politically-inspired violence in the last ten years. And I'm not talking about scuffles at rallies, I'm talking about people with guns trying to kill other people for politically-inspired reasons.

Apologists for the right
Many reasonable and thoughtful conservatives who themselves would never use such loaded or vitriolic verbiage seem to feel compelled to defend Palin et al. "Palin never called for violence." They demur: rhetoric is just joking, just banter. These are just figures of speech, and are never meant to be taken seriously. They argue that there is no direct incitement to violence. They object that the link between the incitement by public figures and the actual violence is too tenuous.

To a very limited degree, they are right. Palin, I am quite sure, never actually wanted violence, and certainly never explicitly called for it. The responsibility for the violence lies with the gunmen. But is it false and dishonest to claim that the words, the language, the environment created by the political figures who deliberately cultivate for political gain an absolutist struggle of good versus evil have no relationship to the acts of the deranged who listen them and take what seems to be the next logical step.

Others object that this or that violent gunman may not have been actually motivated out of politics, or that they were actually liberals or democrats, or that their mental illness makes this all impossible to understand.  We don't know why the Arizona killer did what he did. If he is as delusional as his internet trail suggests, we'll never understand. But we know that it has been a time of extreme, implicitly violent political rhetoric and imagery: It is legitimate to discuss whether there is a connection between that tone and actual outbursts of violence, whatever the motivations of this killer turn out to be. This is not "Politicizing a tragedy," as apologists for the right are already complaining. The attempted assassination of an elected official is inherently political and it is completely germane to discuss the political environment that led to it. When MLK was gunned down, there was no controversy about discussing the role racism played in his murder; similarly, when right-leaning psychopaths are repeatedly taking up arms against the government, it is appropriate and necessary to examine the forces which are driving that sort of behavior.

Put more simply:  The point I am trying to make is that Republicans need to stop whipping up crazy people with violent political rhetoric. This is really not a hard concept to follow. There are a lot of nuts out there with access to weapons. Stop egging them on.

To be clear: I support the first amendment and I do not propose any sort of censorship or restrictions on political speech. I do not think that there is any individual on the right who should share legal culpability for the acts of madmen. I do think, however, it is incumbent on citizens of all political leanings to call out and reject overheated, absolutist, demonizing, or violent speech, wherever it may come from. And I wish we could make it clear to the professional rabble-rousers whose careers depend on generating fear and hysteria, that they are poisoning the public discourse.

And we should remember the remarks President Bill Clinton made on the anniversary of the Oklahoma City Bombing about the use of political rhetoric.

"What we learned from Oklahoma City is not that we should gag each other or that we should hold less passion for the positions we hold, but that our words really do matter. There is this vast echo chamber, and the words fall on the serious and delirious alike. Have at it. Go fight. Do whatever you want. You don't have to be nice. But be careful with what you say and do not advocate violence." 


As promised, a couple of examples of left wing violence: the guy who planned to bomb the RNC convention in 2004 is a legit counter example, and the ELF/ALF are also examples of leftist groups who employ political violence. I have no trouble denouncing them.


07 January 2011

The Cavalcade of Cancer Continues

I was lucky to be able to take some time off around the time of my wife's cancer diagnosis. But I had signed up for a couple of shifts: Christmas Eve and Christmas Day and the day after. I figured it was only fair to work those to give my partners some family time at the holiday.

So, Christmas Day I got the guy with Renal Cell Carcinoma, and the day after I diagnosed a 93-year-old lady with colon cancer.

I remember when I first got engaged, there was a sudden phenomenon that no matter what TV show or internet site or magazine I read there were dozens of wedding dresses everywhere, and when we had our first kid suddenly everything I saw was all about babies. When I was thinking about buying a BMW, I saw beemers on the street everywhere I looked. There is that selection bias that our subconscious does, where you notice the things that you are drawn to. 

But this is just ridiculous. 

I seriously can go five years without seeing a new cancer diagnosis in the ER. And in the last year I've had a dozen or more. Of course I remember them more, having noted the pattern and having been personally touched by the disease. But geez.

If you come to the ER and you see me, you might just want to ask for a different ER doc. I think I'm cursed.

06 January 2011

The life-saving kidney stone

I was a little surprised when I heard the unit clerk call out to me, "Dr S, the radiologist is on line three for you. Says it's about room 8."

Room 8? I mused as I disengaged from the patient I was with and went to answer the phone, That's odd. Why would he be calling me about Room 8?

The man in Room 8 was a guy with a classic kidney stone. Came in with sudden onset right flank pain, writhing and covered in sweat. He had blood in his urine. It was as clear as could be. He felt better after some meds and went off to CT.  Now as a rule, the radiologists only call us for Bad Things or Weird Things, and in this case I was not suspecting either. Would the radiologist call me just for a routine stone?

I pulled up the images on the computer as I answered the phone.  Sure enough, there was a big ol' stone there in the right mid ureter. I saw it just as the radiologist was telling me about it. 3x7mm -- that's gonna hurt to pass. But what? The kidney? OK, I'll scroll up through that as well.   


A largish dense mass on the inferior pole. Almost certainly renal cell carcinoma.  That's why he was calling me.

So the patient went back to scan for contrast-enhanced images to verify it, and sure enough, that's what it was. 

(image source; my patient's tumor was smaller -- about 5 cm)

The good news for my patient was that the cancer seemed quite localized and without evidence of metastases. This is very important, since Renal Cell Carcinoma is amenable to a surgical cure when caught early, and pretty lethal when it has spread. I reviewed the images with our urologist who thought that he was a great candidate for nephron-preserving surgery, i.e. a partial nephrectomy. 

So I had to drop the hammer on him. Worse, it was Christmas Day. Worse (for me), it was my first shift back since my wife's diagnosis. Neither of us were really in a good place to deal with a new cancer diagnosis. But this case had an unusual bright side. Were it not for that kidney stone, I told the patient, you would never have needed that CT scan. Without this early detection, we would never have found this cancer while it was still curable. Kidney stones suck, but this particular kidney stone saved your life!

Sometimes it's all about Luck.