John Tyndall, Science and Man
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| l-'3 Greatly, abbreviated froiii an article in Hospital Practice, Dec(,iiiber, 19,-0, p. 53. 'I'lie whole article is well wc)rtli reading, as well ,is "Is l'otir CCU [Cardiac Care Unit] Electrically Safe?" by Dr. Hans A. %'on dc-r Nlosel, in Iledical-Siirgical Review for Octol)er, 1970, p. 28, in which the "tri,,7ial" iiiieroshock that catises death is vividly Ciescribecl.
14 Dr. D. Short, Briti-~h Medical Journal, 4:673, Dec. 14, 1968. 1-5 Dr. Bernard B. Eichler, Journal of the Medical Society of New Jersey, 66:582, October, 1969. 22
Here are some fascinating statistics on blood examinations. In 1936 red blood cell counts on the same blood showed a gross variation of between 16~'c and 17 28~Ic error when done by different technicians. In 1969, except where an electronic cell counter was used, the error was still at least 16~(-, which doesn't permit the distinction between microcytic and macrocytic anemia, often the only purpose in doing the count. Doctors aren't always happy with the results of their augtiries. They make periodic surveys of their techniques. I don't know why. After they're done, nobody seems to pay much attention to them. if you think red cell counts were bad-look at blood chemistries. A survey showed that in hemoglobin determinations 22~'(- were grossly wrong and of those, 677c were beyond the reasonable bounds of error. Blood glucose tests were so far out of the way that 377c were worthless for diagnosis. Total blood protein determinations677c wrong." Some enterprising biochemical engineers have tried to do away with the human errors inherent in measuring, diluting and testing the blood. They have made ingenious machines working on the computer principle, machines that take a sample of blood and run it through a series of operations, ending up with figures that prestinial)ly could not be more accurate. But a machine slightly off I)alaiice may make the same rriistake repeatedly. And with an automated analyzer doing eleven tests at oiice, let us say, there will be eleven more chances for error. Too bad the engineers have not reii-teii-ibered the litimaii being who uses the figures. I quote again: "The woi-.dei-ftil accuracy of laboratory data done Nvitli modern apparatus may increase the credulity of those who employ them. A dial or scale accurate to the third significant figure triples the credulity of the Liser. He forgets that multiplying the complexity of the insti-timent multiplies the opportunity for Purely mechanical error."" Especially in mass screenings the computer laboratory may be niisleadiiig. Iii a group of healthy subjects having fifteen tests done, aboi-it half of that gr would show one or more abnormal values due purely el-iance. NN'itl-i fifty tests, nine out of ten would sbon%' least one false positive test. Arid that's with good chinery with a tolerance limit of 95~'r accuracy per t N~'liv? Plain mathematics. In one test the probabili that a healthy iiidividtial will have an abnormal test is (.95), or 5""r. For two independent tests, it is 1-(.95 .95), or almost 10~~(. For 15 tests, it is 1-(.95) 15 over 50"( chance of error. Dr. Bruce Schoenberg of t National Cancer Institute says there is not much phN. cians can do al-)otit these results except live with the Or-iise their heads when they find a result that doesn jil)e with other findings. Unfortunately, many docto have so little confidence in their diagnostic skills th they believe the machine rather than what they see bear. Even in the absence of error, too much data makes forest out of trees. In medicine this has been calle dia 'gnostic overkill. If a very large amount of information is offered, say the communications engineers, the general effect is that which they call noise. To make the information meaningful, irrelevancies must be filtered out or the relevancies exaggerated. And finally, too often human frailty bits the most accurate laboratory work when the figures are transcribed onto the hospital chart or the office form. The laboratory reports a blood urea nitrogen of 10.2; the floor clerk oii-tits the decimal and it appears as 102. Mrs. Mary Smitli in Room 203 has a white blood cell count of 23,000; '~irs. NI. (for Madeline) Smith in 207 has a couiit of 7000; 1 have seeii the counts transposed. The urine analysis on Nir. Jones shows sugar but the plus mark is put alongside the albumin box. That's all technique. You can't put all the blame for error on the doctors. What about interpretation? That's strictly his job. A true (and sad) story: Some busybody in a hospital suspected that the doctors weren't looking at the laboratory reports. He checked on his suspicions by covering the figures with masking tape, thus forcing the doctors to do a minimum of physical work if they really wanted to see those figures. About a third didn't bother to peel off the tape! Worse yet, of those that did, another quarter paid no attention to grossly abnormal 16 Todd and Sanford, Clinical Diagnosis by Laboratory Methods, Tentb Edition, p. 177. 17 Drs. \Iagath et al., Aniericati Journal of Clinical Pathology, 1936, vol. 6, p. 568. 11 Drs. W. P. Belk and F. W. Sunderman, same journal. November, 1947, vol. 17, p. 853. '~' Dr. XN'. B. Bean, Archives of Internal Medicine, 105:188, 1960. The Oracles results! They looked without seeing or they saw without perceiving. The laboratory tests need interpretation as much as X-ray pictures do. An o\~erzealous doctor worries when the hematocrit drops from 41 to 39 or the blood cliolesterol rises ten points. He forgets the errors inherent in technique. A difference of ten per cent in blood counts, for example, is insignificant, as is the change from 180 to 190 in a blood glucose determination. And when the norm lies between 150 and 200, as in total blood cholesterol, what difference does it make if one report says 175 and another 190? Another mistake in interpretation arises from scientism: if the test is positive, that's proof. Not so. An example: Increased serum enzyme acti\,ity has been regarded as diagnostic of acute coronary thrombosis. But a 1968 report to the College of American Patbologists pointed out that false positives were common in various gall-bladder disorders, so much so that clinical judgment was more valuable tl-ian the enzyme test in the differential diagnosis of the two conditions. Why go on? A long list of laboratory reports may look good on the patient's chart, but how much does it contribute to his getting better? Now let's go back. There's no denying that the X-ray tube, the ECG machine and the blood analyzer are necessary in some cases for the doctor to establish a diagnosis or to follow the results of his treatment. But the doctor must be aware of the perversity of inanimate objects and not rely on machinery alone. He needs to use his senses and his brains as well. He must be able to interpret tests properly, to discard grossly deviant findings and to take to heart the mistranslated but true Hippocratic dictum that experiment is fallacious. (The original said experience.) Dialectics: it's up to the patient to ask why the repeated tests, why the daily electrocardiograms, why the weekly chest X-rays. To ask why-and not be put off (or down) by double IL-alk. More dialectics: it's also up to the patient not to ask for irrelevai-it tests because they're fashionable (for example, monthly Pap smears). The doctor will undoubtedly oblige the patient by having the test done. Cui bono? Still more dialectics: NVben a doctor tells you a test shows that you have a condition you could not possibly have, tell him be's wrong. Insist that he repeat the test in another laboratory or do a more thorough medical examination. Two examples: The X-ray series shows gallstones in the gall bladder, but your gall bladder was removed years ago (I bad such a case!). The Wassermanii 'Lest for syphilis is positive, but you are a very moral person and never even use public toilets; maybe you have mtiiiips or infections mononucleosis, both of whicii sometimes give the same positive reaction as syphilis. By now you realize that doctors are almost as credulotis as their patients when it comes to laboratory tests. Right there is a danger to liealtb-and sanity. NVben the medicine iiiaii I)elieN,es that his din,iiiatioiis mean something, that's worse for the patient than when he cynically ptits on an act for the sake of impressing the suff erer. I give you no\N, ~iii example of !-low far credulity can go. Suppose you had no si,,-iis or symptoms of diabetes melitis, I)tit you li~i% e ~i N-er\- careful doctor- on the alert for latent disease. Ui-i~~ic analysis shows no sugar. The doctor checks ~,otir fastiii,, blood sugar and your blood stigar two hours aftei- a iiieal. They're normal. Then be does a glucose tolerance test and then what is kiio-,N,ii as a provocati\-e cortisone ,Iticose tolerance test. They're normal, too. YoLi tliiiil.N-oti'i-e off the liook? Not at all. The doctor, a specialist in his field, says sadly, "Too bad. You have pi-eclial)(,tes." And if you tl-~ink that's a made-up stoi-N-, I i-efer N-oti to a pai)iplilet 1)~, Dr. Ai-tbtir Krosiiick under the iiiipi-iiiiattir of the New Jersey State Department of Health. Ttiei-e the clia-,nosis of prediabetes is said to be confirmed by negative laboratory and clinical findings. There is also a treatment prescribed for this condition. The treatment consists of blood tests ever-,- six months for the dduration of the patient's life. NN'heii the m~,.,,iciaii I)elie\-es in his ina,,ic, beware! The Medicine Vil A Commercial Note "Rielies and honor are what men desire; but if they attain to them by improper means, they should not con tiiiue to hold them." -Confucius, Sayings Clinical laboratories have progressed from the homemaiiufactory stage to modern atitomated assembly line techniques. As in industry in general, each new machiiie represents an outlay of capital that must be recotiped, but it also leads to a lessening of the man-hours needed for finished products. Furtbermo.-e, the number of highly trained (and hence expensive) operatives is reduced; the new techniques can be taught quickly to the equivalent of semiskilled workmen. A conventional twelve-test blood chemistry profile thus may cost less than five dollars-aiid even less in large laboratories. Automation, therefore, can give more and more services at lower and lower costs to the consumer, in this case, the patient. It can but does it? Dr. Herbert Lansky, past president of the New York State Society of Pathologists, has said that doctors contracting with large laboratories have not passed on the. low cost to their patients. Dr. E. G. Shelley, reporting for the American Medical Association judicial Council, describes one bill sent to a patient: "Serolog~,, $7.50; cholesterol, $7.50; ,Ilkaliiie phosphatase, $'1.50; complete blood count, $12; sedimentation rate, $6; glucose, $5; urea, $7.50; uric acid, $7.50." All these tests were done for a charge of $6 to the physician. For an outlay of $6 the doctor got $60.50. Not a bad markup, huh? The College of American Pathologists denied in February, 1969 that it tried to cut down competition and keep prices high, but it agreed, nevertheless, to a cojisent decree rather than fight an antitrust suit. Senator Philip Hart, in February, 1970, chairman of a Senate Antitrust and Monopoly subcommittee, reported that his staff found that a quarter of a billion dollars could be saved annually by reducing the fees paid to hospital pathologists for unneeded but mandatory token supervision. (Nlandator~,-by state laws and the joint Committee on Accreditation of Hospitals. NVlio would dare accuse such honest men as our legislators and our top doctors of having no sense? It's more charitable to say they are in collusion.) A common method of paying hospital pathologists is by a percentage of the gross laboratory charges, 9.57c of which are for routine work which the pathologist did not order, perform, interpret or record. The pathologists say that a laboratory test without interpretation is worthless. They are right, but one wonders whether the cost of that interpretation is not set at what the traffic will bear. (Besides, they don't interpret the tests. The attending physician does-if and when he does.) It is now possible for doctors to enter into contracts with commercial laboratories for a flat fee ranging from $75 to $300 a month. Such a contract entitles the docto to an unlimited number of tests for any number of patients. Naturally he passes on the cost of the service to his patients, just as he passes on the cost of bandages or hypodermic needles. Unfortunately, two temptations arise, one mindless and one mercenary. Because the cost is so little the doctor may order tests indiscriminately, with the expected consequences: the level of informational noise is raised; the doctor is lulled into a sense of complacency that be is giving good medical care; and the patient is deluded into thinking that laboratory tests are essential for diagnosis and treatment. The second temptation is yielded to too often. The doctor, by charging his patients "for laboratory tests," can make a very good profit on a service which was originally intended as a help to him. Such overcharging exists, enough to bring about complaints to medical societies, threats by insurers to refuse payments, and warnings of governmental action. The judicial Council of the American Medical Association has clearly stated its position: let the patient pay the laboratory for his tests; let the doctor be the interpreter of those tests. Thus the suspicion of markups or commissions will be avoided and the doctor will not be tempted to be a profiteer. The statement sidesteps the issue. It looks backward to the time when tests were "handmade" for each patient and doesn't take cognizance of the new contractual laboratory arrangemeilts. Considering that the public spends three billion dollars each year for laboratory work, the question of fees is not trivial. Who is to benefit from the advance in technology-the patient by lower costs or the doctor by increased income? Vill Members of One Body "The art of medicine in Egypt is thus exercised: one physician is confined to the study and management of one disease; there are of course a great number who practice this art; some attend to the disorders of the eyes, others to those of the head, some take care of the teeth, others are conversant with all diseases of the bowels; whilst many attend to the cure of maladies which are less conspicuous." -Herodotus, Euterpe Holy Church is indivisible and one, yet it varies in its observances and rituals. The same with medicine. just as theology's aim is the salvation of souls, so medicine's avowed goals are the prolongation of life and the alleviation of stiffering. And medicine, too, has Byzantine rites and special services for special occasions. Unfortunately no councils, conferences or synods exist in medicine for the guidance of the patient. The honest citizen is left on his own, standing before the directory in the Medical Arts building while be decides on which thaumaturgist he should call on to relieve his headache. Should he see an ophthalmologist, an otolaryngologist, a neurologist, a psychiatrist or (if he's old-fashioned and believes all troubles start in the bowels) a gastroenterologist? Often he pays his money and makes his choice and if he's lucky he makes the right one. What's a specialist? All physicians are licensed by the states of their residence and are presumably equally competent. The license is acquired after a course of study, a period of apprenticeship and the passing of an examination. A specialist is a doctor who has been further tested by self-constituted superiors in a sharply delimited area of practice. If he survives the ordeal, he is admitted to a College or to a Board or to a Society, and he can charge higher fees for his services. It then follows by circular reasoning that if he charges more money, he is better qualified, money being the criterion of worth in society, and if he is better qualified, he deserves more money. The specialist chooses his field not for the love of science nor for the sake of mental exertion, but because the hours of labor are sborter and the work is easier. This was said as long ago as 1876 by Dr. John Shaw Billings in the American Journal of Medical Sciences. The training and initiatory ordeals have become more rigorous since that time, but the postulants' reasons for undergoing them remain the same. The work doesn't always look easier. Sympathy is readily aroused by the sweat streaming down the tribal dancer's body as be circles around the patient or by the complicated maneuvers he makes with the sacred gourds. The newspapers record and television shows how the specialist manipulates with dexterity the awesome, shining instruments of his trade. And everyone knows of the tremendous advances that have been made in the medical specialties. Only a carping critic, a sotir-puss reactionary, would dare to denigrate those Diplomates and Fellows. Or an innocent child who can't see the emperor's new clothes. Or a tribal malcontent who's seen the wizard's all-too-buman nakedness under his feathered robes. 2. "Anyone who goes to a psychiatrist ought to have his head examined." -Samuel Goldwyn Let's start with an easy specialty, one that's been the target of innumerable jokes. But remember Freud's dis covery-that the mocker of sacred subjects is showing his fear (and respect) in a distorted fashion. Wits have been shooting barbs into the psychiatrist's couch for so long that the stuffing's coming out. We'll leave wits (but not our wits) aside and look with an unprejudiced eye at the ministers to the mind diseased, the savants whose specialty is omniscience. These hierophants are unique among specialists in that they freely discuss their methods in lay publications, and in spite of that they remain invested with the aura of magic. Why not? Mental aberrations are the closest thing we moderns have to the possession of the ancients or the stolen souls of aborigines. One who undertakes to treat such aberrations is almost automatically looked on as a mystic, as one who has a key to the secrets of the unknown. The psychiatrist enjoys being thought so: though be modestly disclaims any knowledge unavailable to the educated man and points to the wide distribution of psychiatric articles in the popular press, be hesitates not to give opinions on the sanity of Presidential candidates, advice to educators, and analyses of the motives of revolters against this best of all possible worlds. Some psychiatrists make no bones about being magicians. On April 24, 1968, Professor Morton L. Kurland, a psychiatrist, gave an address at the Academy of Medicine of New Jersey on "Oneiromancy-A Brief Freudian Study of Dream Interpretation." And on March 22, 1971, at the annual meeting of the American Orthopsychiatric Association a paper was presented entitled "What Western Psychotherapists Can Learn from Witch boctors," in which the point was made that witch doctors use the same methods and techniques as do Western psychotherapists-and with about the same results! Psychiatrists have a standard formula for prognosis, the foretelling of the course of a psychic disorder. They say, "This is a complex situation. Time and extensive [and often expensive] treatment will be necessary." They are not being mercenary. The very rich may be treated differently from the very poor, but time and expense remain the same, maybe even more time for the patient and more expense for the taxpayer in the case of those confined to public asylums. (An excellent study, Social Class and Mental Illness, by Drs. Hollingshead and Redlich, points this up quite well.) But it would be supererogatory to confine criticism for the present state of affairs in the treatment of mental illness to the poor (not in the economic sense) psychiatrists, already the butt of night club comedians, ignoramuses and those members of the intelligentsia in The Medicine Mei search of novelty. The last, because of their vocality, help to set the public image of the psychiatrist. They have decided opinions about psychotherapy, a branch of the medical art, more so than they would dare to have about another branch, such as neurosurgery. Their opinions lean now in one direction and now in another, depending on what the book reviews have to say about the latest "discovery" in the field of mental illness. The fact remains that psychiatrists are in great demand, an indication either that as a nation we are getting nuttier or that Parkinson's Law has found another application. In New Haven, Connecticut, for instance, in 1940 there were only three psychiatrists; in 1958 there were 24 full-time psychiatrists, 33 part-timers, and 32 residents in training who took care of patients in clinics, Veterans' Administration hospitals and a private psychiatric hospital. During those eighteen years New Haven's population rose by only 5000. In Iowa, part of the supposedly stable Midwest, where the population increased only from 2,621,736 in 1950 to 2,757,537 in 1960, the number of psychiatrists rose from 15 to 95. In ten years the membership of the American Psychiatric Association more than doubled from its 5534 in 1950 and reached 16,000 in 1967. The increasing supply is the result of the increasing demand. Why? Do the psychiatrists get such good results with their therapies? Are asylums being emptied? Are the couch springs regaining their resilience? Let's see. Take psychoanalysis, for instance, in any of its orthodox, schismatic or heretic forms, a branch of psychiatry many believe to be fundamental to the treatment of the sick psyche. (Psyche comes from the Greek, meaning soul or butterfly. Both develop in grubby darkness and both aspire to the heavens.) Very few careful evaluations of the results of psychoanalysis are available. That's not because of negligence or because the analysts are afraid of what the surveys will show. It's because evaluation is so difficult. Is the patient better because he no longer worries about wetting his bed (You've heard that joke before?). Is she better because she no longer argues with a stupid superior at work or an equally stupid husband at home? Is the insomnia or the palpitation or the weepiness gone? The problem of evaluation is one of goals, and too often the goals are as nebulous for the doctor as the patient. Nevertheless, some studies have been made. Dr. Frederick Wertham, a Voice of Authority, a former president of the American Association for the Advancement of Psychotherapy, says that 60~'c of psychoanalyses are more harmful than Members of One Body helpful and that four out of five analyses are not indicated in treatment. The most extensive study of the results of psychoanalysis showed that fewer than half of the analyzed patients were cured." More recently, the American Psychoanalytic Association, who might be supposed to be prejudiced in favor of their own specialty, undertook a survey to test the efficacy of psycboanalysis. The results observed were so disappointing that they were withheld from publication .2 ' There is a little semantic problem here. Cure may not be the correct word (unless used in the religious sense of a ctire of souls) for a therapy aimed at relieving the anxieties and the discontents caused by upbringing and civilization. But only one-twentieth of psychiatrists are analysts. Do the other nineteen-twentieths do better? Not so you could notice it, especially in the major psychoses. Fortyseven per cent of the hospital beds in the United States are still occupied by the insane, a percentage that has not varied from 1950. The number of patients confined as "schizophrenic" has risen .22 Enthusiasm for lobotomies gave way, when the cold statistics were in, to excitement over insulin shock therapy and electric shock therapy, and that in turn subsided in the face of sober examination of their results. Insulin shock therapy is still used in a few hospitals (despite the occasional accompanying fatalities, euphemistically called irreversible comas) on the ground that schizophrenia is such a hard condition to treat that anything that ever gave the slightest chance of improvement should be continued. Undismayed by their previous failures, the psychiatrists turned to the marvels of psychotropic drugs, and as the latter multiplied, their beneficial restilts became less noticeable. An old adage in medicine states that the more remedies there are for a disorder, the less likely any one of them will be of value. That seems to be true in the psychotherapies. Directory: 2013 2013 -> Annual InStructional unit plan 2013 -> The Ministry of Education and Science of Ukraine 2013 -> #1 a lifesafer of virginia inc 2013 -> Name(s): your name here team or Group #(if applicable): Professor’s name 2013 -> Alcott Local School Council (lcs) Meeting Minutes 2013 -> Table Of Contents introduction 2 2013 -> Supplemental demographic information 2013 -> 【Education&Working Experience】 Download 468.23 Kb. Share with your friends:
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