Medical Hell, Part III: 7.5 Minutes

Most doctors schedule four to eight appointments every hour. Eight appointments an hour, which seems to be the norm for orthopedic surgeons, means an average of less than 7.5 minutes per patient, given that the doctor must spend some time walking from room to room, etc. We're probably lucky to get five to fifteen minutes of our doctors' attention in the average appointment. Next time you visit your doctor, look at the sign-in sheet and figure out how little time the doctor has allotted for your consultation or examination.

In these short appointments, we are expected to make important decisions about our health: whether to take a medication, to undergo a procedure, or to just let things be. It is simply impossible to make a good decision in such a limited amount of time, and I can think of no other profession that gives such short shrift to its clients. Yet there is no profession more important than medicine.

I am confident of the problem, but I am less sure of the cause(s) and solution(s). Nevertheless, in the spirit of the internet (speaking out when you are not really sure if you know what you are talking about), here goes:

The underlying problem is that we simply do not have enough doctors to go around. There are two reasons for this. First and foremost, we do not have enough medical schools. There are only about 125 medical schools in the entire United States, about 1 for every 2,500,000 people. As a result, there are many capable students who would be more than happy to pursue a career in medicine, but who are not able to qualify. We would do well to close a few law schools and open a few medical schools.

Second, medical training is unnecessarily long. Many doctors --dermatologists, for example -- do not use even a fraction of what they learn in medical school. These specialists should be given separate degrees, with training focused on what they will need in their practice. Think of dentists, for example. Reducing the length of training means that each medical school can produce more doctors.

Clearly, there is a need for some doctors who know all fields well, and there is a need for all medical practitioners to have a certain minimum understanding of how the human body works. But, in a world of limited resources, it makes sense to allocate education more carefully.

Airport Security Has Become a Fraud

I fly frequently, and I care very much about my safety and the safety of my fellow passengers. Some airport security is necessary for that safety. But that being said, airport security in this country has become a very expensive farce.

All activities entail risk. Driving to the airport to catch a flight entails the risk of dying in a car crash. That risk is -- and always has been -- far higher than the risk of dying on the flight from all causes combined. Staying home is risky, too. There may be an earthquake or a hurricane. And, no matter what you do, you might die of cancer or some other horrible disease. Each of these different deaths is, in an important sense, the same. The victim is dead. To put it another way, I do not care if I die from cancer or in a terrorist attack -- I just want to put it off as long as possible!

But of course there are limits to what we can do. Even if we drive 10 miles per hour and wear helmets at all times, there is still a risk of dying in a car accident. Even if we go to the doctor every day, and have every possible test, there is still a risk that some disease will go undetected. We have to make choices about what steps we take to improve our safety.

So, we must apply some common sense. The amount of time, money and energy we invest attempting to mitigate any particular risk should be based on a simple cost-benefit analysis. How much risk can be reduced at what cost? People -- especially Americans -- like to put their heads in the sand and claim that there can never be a compromise when it comes to safety. But there always is such a compromise, whether we like it or not. Best to acknowledge that fact and make the smartest compromises. Refusing to acknowledge that we are making compromises prevents us from making good decisions and ultimately makes us less safe, not more.

The risk of dying in a terrorist attack is, in the scheme of things, trivial. No one has been killed by a terrorist in the United States in over eight years. Not one person. In the meantime, millions of people have died from cancer, heart disease and accidents of all kinds. A few unlucky folks have even died of being hit by lightning and as a result of shark attacks. Certainly, there is a risk of terrorism on airplanes. There always will be such a risk and, like most risks, it cannot be entirely eliminated. But that risk is already very, very low on the list in terms of actual size.

Moreover, there is very little we can do to reduce the risk further. We already spend millions of dollars, and spend millions of hours of people's time, trying to further reduce a risk that is already very small. As with any endeavor, there is a law of diminishing returns. The cost of improving something starts low and gets increasingly higher, while at the same time the benefits become smaller and smaller. At some point, there is nothing more that we can reasonably do. Airport security passed that point long ago.

Furthermore, even if we could make air travel "completely" safe from terrorism, it is unclear if that would make us any safer. Presumably, terrorists would learn that it is impossible to destroy an aircraft, and they would therefore turn their attention to other targets -- boats, bridges, stadiums and the like. Terrorists are going to hit the weakest point, so making one particular facet of our lives "terror-proof" would be of little benefit, even if it were possible.

The irony of all this is that the press and the government are playing directly into the hands of the terrorists by creating unjustified fear. The idea of terrorism is to scare people and to make them stop living their lives normally. The terrorist cannot hope to kill enough people to bring down his victim; terrorism is not war. Terror works through fear, not bombs. A "war on terror" should focus on stopping fear. But we seem to be doing the exact opposite.

The failed attack on December 25, 2009, provides a perfect example. All of our elaborate airport security was unable to prevent the would-be terrorist from getting his "bomb" onto the airplane. The attacker apparently was not particularly skilled nor persistent -- he simply stuffed a small bag into his underwear. Short of a real (or virtual) strip search, the next attacker can do the exact same thing and be all but certain to get his "bomb" onto the plane.

The attacker failed to blow up the airplane, but not because of anything the TSA did to stop him. He failed for two simple reasons. First, he was not very bright. Second, the passengers intervened (this is at least the third time that has happened -- the final plane on 9/11 and the "shoe bomber" being the other two examples of passengers intervening). Experience suggests we can count on both of these factors in the future. Competent terrorists are, fortunately, rather unusual. Brave passengers are not (and it only takes a few brave passengers on a plane to stop a given attack).

Ironically, however, the attack of December 25, 2009, did succeed in an important respect, but only because of the government and media reaction. The US government reacted by imposing more airport security measures. While those measures would not stop a similar attack tomorrow, they do impose a huge cost on travelers, airlines and ultimately the world economy. The stocks of airlines, for example, fell substantially. The attacker may have failed to take down that airplane, but he caused hundreds of millions of dollars of damage, based on the airline stocks alone. And he did not even have to blow himself up to do it!

The media did its part, too. Scaring the public is always a good way to improve ratings, and almost all major media outlets could not resist. No one said, "Here is just the second attack in eight years, and again it failed without the need for any security. This is proof that we are safe." Instead, the media ran the story so as to scare the daylights out of anyone who was planning to fly.

Terrorist attacks, like shark attacks, cause visceral reaction in most people. Mature, educated people can acknowledge that fear, but at the same time apply their reason and make decisions accordingly. Please, do not play into the fear game. Do not be afraid to fly. Even when there is another crash -- and sadly, there will always be another one -- use your common sense. Flying is, always has been and always will be, a very safe way to travel. If you want to fight terrorism, do it by not being afraid.

Should You Trust Yelp?

The review website Yelp provides a useful service. On the most basic level, Yelp is a good place to go if you want to get a list of businesses in any given city, whether it be restaurants, dry cleaners, dog kennels or whatever. Yelp seems to have reached critical mass, in that most businesses seem to listed. Going to Seattle, and want to find a good Thai restaurant? They are probably all listed by Yelp. Need the address of a specific restaurant? Again, it is probably provided on Yelp.

Yelp's reviews, however, are of dubious value. No review, reviewer or review website can ever be perfect, but Yelp could do a whole lot better. Most importantly, the reviews on Yelp tend to be overly positive. Remember, Yelp takes advertisements from the same businesses it reviews. No business would buy an ad of any kind on Yelp if their own review is negative. Because every business that is reviewed on Yelp is also a potential advertiser, it suits Yelp's on financial interest to keep as many reviews as possible positive.

Yelp does a number of different things to keep the reviews positive. Most obviously, Yelp allows a business owner to pay to have a preferred review at the top. And, at the top of each review is a purported "average" star rating. I did the math on Yelp's own reviews of itself, however, the average is just wrong. Guess which way!

Yelp also displays reviews -- and even deletes reviews -- in a manner that is far from transparent. Yelp will not release the algorithm it uses, but they do say popularity of the reviewer counts. Positive reviews are popular, so this pushes positive reviews to the top and keeps them listed. Yelp also fails to tell people when their reviews have been removed. I see no valid reason to remove a review simply because the reviewer is not popular. Let the consumer sort by popularity if he wants, but do not just take reviews down. And, when the reviewer logs in, he actually sees his own review, as if it is were published.

There have also been allegations that Yelp engages in practices that are little short of extortion, such as offering to move good reviews to the top for money, then doing just the opposite when the business owner refuses to pay. I have no personal knowledge of any such incidents, so I will simply provide a link to an article that contains more detailed allegations.

http://www.eastbayexpress.com/eastbay/yelp-and-the-business-of-extortion-20/Content?oid=1176635

Finally, I recently had Yelp remove one of my reviews, with notice to me, for an alleged violation of their rules. I was looking for a painter, and found one on Yelp. He had one five star review. But, when I called him, it became clear that he had written his own review on Yelp; foolishly, he did not even bother to use a pseudonym. The name on his answering machine matched the review. So, I never spoke to the guy and never used him, but I did post a review on Yelp calling him out for cheating. Yelp pulled my review, saying I had no personal experience with the business. I think they should have thanked me!

All that being said, Yelp is still useful. You can find a business, its address, phone number and website in a flash. Even the reviews are of some value, just so long as you know what it is you are getting.

Down with the Dow!

The American news media are addicted to the Dow Jones Industrial Average. Radio and television stations seems to believe that reporting the Dow (and, often, the NASDAQ) is an essential part of any news cast. Even NRP includes a mention of the intra-day progress of the Dow repeatedly throughout the day. CNN is the worst. It displays the Dow constantly in a corner of the screen. Watch CNN, and you will see ever little movement, refreshed every few seconds. What a waste of electrons!

These constant updates on the stock market are worse than useless. The fact that the market is up 0.4% on a given day is utterly meaningless to the vast majority of people. The stock market's daily, and even weekly, drift is no indication of the direction of the market, let alone of the economy. Even a relatively large move in the market, say a rise or fall of 3% in one day, is not meaningful. There is nothing that any intelligent person can or should do in response to it, nor does it change anyone's life.

Reporting the Dow is, at best, a colossal waste of time. At worst, such reports create paranoia and fuel speculation. People who listen to the news, with its moment-by-moment reporting on stock values, could reasonably infer that these reports mean something. The Dow is down -- the economy must be in trouble! The Dow is up -- things must be improving! But that is not true. The Dow is up 0.4% today as a result of random drift, not because "bargain hunters are snapping up shares," as ABC reported.

Worst of all, the reporting of the market's small random drifts encourages people to speculate. The true value of stocks, over the long term, is based on the value of the businesses. More specifically, the value of stocks is based on the dividends that they will pay. Therefore, the value of a stock does not go up or down on an hourly basis, absent some important event, e.g., Merck's latest drug obtaining FDA approval. In any market, however, there will always be an element of speculation as well, people who buy solely for the purpose of finding a greater fool who will pay more. They do not care what the stock is worth, only what others think it is worth. Focusing on ultra-short term fluctuations in the market encourages people to focus on what the market will bear, not on the value of what is being traded.

Finally, although this is really beside the point, the Dow is a poor measure of the value of stocks, as it takes into account just 30 large companies. If you need to measure the value of the stock market, look to the S&P 500 or the Wilshire 5000, which take into account the broader market.

State Funded Religion in America

Approximately half the funding for churches in the United States comes from the government. The Federal government allows its citizens to take a tax deduction for money they give to their church (or synagogue or mosque). So do States that have an income tax. In addition, churches are exempt from property tax, and some of the money their pay to their ministers is also tax free. Add up these tax benefits, and approximately half of the money given to churches comes from our tax dollars.

This government funding is available to all religions, regardless of whether they preach love or hate. The government pays, whether or not the religion treats blacks, women or gays as full human beings. The government pays, which means you pay. So, if you are an atheist, you pay for Catholic churches. If you are a Baptist, you pay for Muslim's mosques.

Some have claimed that the First Amendment guarantees the freedom of religion, and that it would therefore be unconstitutional to tax churches. That is an obvious fallacy. The constitution also guarantees free speech, but that does not mean that money you spend on books or newspapers is tax deductible, and it does not stop the government from requiring book stores to pay property taxes, income tax and sales tax. Hospitals pay property tax. Private schools pay property tax. But churches do not. And our taxes therefore have to be higher to make up the difference.

Freedom of religion means that there should be no laws designed to discourage religion. If you want to have a church, you should be free to do so. The government should not tax or otherwise burden something just because it is religious. On the other hand, the government should not be in the business of giving benefits just because something is part of a religion. That is forcing people to fund religions in which they do not believe and, ironically, violating the rights of the religious, as well as the atheists and agnostics.

What I have written here is hardly new. No one who studies law seriously disputes it. Yet, one rarely hears anyone complain about it openly. I want to go on record saying that I am outraged that the government takes my money through taxes, then gives it to anyone and everyone who runs a church.

If it is not torture, why bother?

There is an on-going debate in America about whether water boarding and other so-called enhanced interrogation techniques constitute "torture." On the surface, everyone pretends to agree that when pain or discomfort rise to a certain level, they become "torture" and are no longer morally acceptable. The entire debate is a farce.

No one really believes that mild pain or discomfort is an effective interrogation technique. Just image that hardened terrorist breaking down because of mild or even moderate pain. The very idea is comical, even worthy of a Monte Python skit. I do not know if real torture is an effective way to get information, but anything less certainly is not. (Of course, there are other techniques that do not involve any meaningful pain or discomfort at all; I am not referring to those here).

Reasonable minds can differ about whether torture is ever morally acceptable and/or a good strategy in the long run. But half measures are silly, and I cannot believe anyone seriously contends otherwise. Those who are advocating the use of these techniques must really believe that they inflict intolerable pain, otherwise they would not even bother.

So, let's give up the charade and either agree that torture is acceptable under some clearly defined and limited circumstances, or ban it altogether and stop fooling around.

Phasing Out Pharmacies

There was a time, or so I was told, when pharmacies and pharmacists played an important role in our health care system. If those days existed at all, they are now long gone. It is high time that we begin to phase out the pharmacy. We should do so by progressively making more and more medications available without a prescription. At the same time, we should ban advertisements for any medication.

Pharmacies add a significant layer of expense to our health care system. While I can buy aspirin or ibuprofen at the 7-11 store, I can only get meloxicam (an anti-inflammatory that serves the same purpose as ibuprofen and is no more dangerous) at a pharmacy. That creates two different kinds of expense. First, it adds to the cost of the medication. A pharmacy must have a highly trained -- and highly paid -- pharmacist on duty at all times. In addition to the pharmacist, there is almost always a second employee who hands out the prescription medications and often rings them up on a separate cash register. Furthermore, the pharmacy incurs expenses in complying with various regulations. Compare that to the cost of selling aspirin. A store simply stocks the shelves with bottles, and the customers help themselves.

The pharmacy also imposes a non-monetary cost, one which I find particularly vexing. I can get an aspirin at the 7-11 or Trader Joes at any hour, without a prescription and without an appointment. Getting propanolol (a common beta blocker) requires a prescription, which must be presented at a licensed pharmacy. I must then wait until the pharmacist fills the prescription, and stand in a special line to receive that one item. That process is a waste of time, in addition to a waste of money.

I suspect that the prescription system imposes yet another cost, which may be even more important than the two costs described above. The prescription system discourages patients from being good consumers and paying attention to the choices they are making. Prescription drugs are treated as holy: only the doctor decides which ones we take, when and in what doses. The insurance companies have their secret formularies, which try to impose on the doctor's choice. Then, only the pharmacist can actually deliver the goods. Even a patient who wants to get involved in choosing a medication will have a hard time doing so in the face of those three forces.

Compare the purchase of pain killers, where the patient can select from a variety of over-the-counter medications, in various doses, brand name and generic. These medications quickly lose their magic aura, and patients learn to make intelligent choices. Consumers feel free to think for themselves and experiment appropriately with the available products. They learn to avoid overpriced brand names, and they learn which medications work best for them. I suspect that eliminating the prescription requirement on a medication would quickly create more savy consumers and thus reduce the price the market would bear in many instances. I bet the big pharmaceutical companies would hate the idea of phasing out the pharmacy.

We do not get anything worthwhile from pharmacies. Few, if any, patients actually seek the advice of the pharmacist. If a few patients want to pay for such advice, they should of course be free to do so, but there is no reason to require everyone to pay for advice which very few of us want or even receive. Pharmacists do not tell us how and when to take medication; doctors do that. The pharmacist simply copies what the doctor wrote down and, in my case, often makes mistakes in doing so. Theoretically, a pharmacist could alert a patient to conflicts between medicines. That only works, however, if the patient always uses the same pharmacy. The only time I have been alerted to a conflict was by my doctor, and one of the conflicting medications was non-prescription, so a pharmacy could not catch it, even if it knew all of the prescription drugs I was taking.

The prescription system most certainly does not protect those who would abuse drugs from getting what they want. Even making a drug completely illegal does not prevent determined buyers from getting ahold of it. The prescription system provides even less protection than an outright ban. One who is determined to get his hands on a prescription drug can always find a crooked doctor, forge a prescription, fake a symptom and/or send the same prescription to ten different online pharmacies. Pharmacies are not in the business of preventing the improper sale of medications.

Far more importantly, only a small minority of prescription medications are drugs of abuse, i.e., fun. No one is going to pop Lipitor at a party. Sudafed, on the other hand, can be turned into a drug of abuse.

Most prescription medications are no more dangerous than over the counter medications. It is easy enough to kill oneself with all sorts of household items, beginning with alcohol. I doubt that taking an entire bottle of Crestor is any worse than taking an entire bottle of ibuprofen.

In the end, pharmacies are just another entrenched special interest. We take it for granted that they are necessary, but they are not. It is time to start phasing them out.