March Hauser: The Denoument

I missed it at the time, but it turns out the Boston Globe obtained Harvard's internal investigative report a couple of weeks ago and it's about as ugly as can be.

To whit:

The 85-page report details instances in which Hauser changed data so that it would show a desired effect. It shows that he more than once rebuffed or downplayed questions and concerns from people in his laboratory about how a result was obtained. The report also describes “a disturbing pattern of misrepresentation of results and shading of truth” and a “reckless disregard for basic scientific standards.”

In a pistachio shell, when his experiments didn't get the results he wanted, he changed the data.

I find this very difficult to understand. Post docs competing for the dwindling share of faculty appointments, assistant professors desperately striving for tenure, frustrated non-entities seeing no chance for glory, yeah, they have motives to cheat and you can make all sorts of arguments about how academic culture, the social organization of science, the competition for grant funding as public support for science yo-yos, all contribute to scientific misconduct.

But none of this applied to Hauser. He was already tenured at Harvard, already famous, already positioned to suck up all the funding he needed. He had no discernible motive for fraud. And his general program of research does not appear to be a tissue of fraud; it's just some particular experiments that didn't go his way. People often write that an experiment "failed." There's no such thing. If it's well done, then the result is informative, no matter what it is. Maybe it turns out that your idea for a warp drive won't allow you to travel faster than light after all, but now you know something that you didn't know before. Maybe your monkeys can't figure out how to do division, but now you know. It still counts, and it has the virtue of being true.

Evidently Hauser is out on Cape Cod somewhere working with at risk youth. I hope he isn't purporting to be a role model.

Isn't there anything we can do about this shit?

I'm guessing you're probably like me, and you're starting to get a little bit tired of wackos committing random acts of mass murder. Yeah, it's a bad thing.

So everybody's got a diagnosis and a prescription. Better mental health services. Rooting out misogyny and delusional extremism from the culture. Making it harder for nutcases to get guns. All that sounds good, if not necessarily evidently possible, but . . .

Here's the problem, looking at this from a public health perspective. We really don't know how to predict that somebody is going to be violent. Well, that's not quite true -- past violent behavior is a useful predictor of future violent behavior. There is an elevated risk of violence among people who are simultaneously seriously and persistently mentally ill, and also have substance abuse disorder, but even there it's only a minority. But being mentally ill, as a general category, is not predictive of violence. Most people who commit bizarre acts of violence against strangers could be said after the fact to have a diagnosable mental disorder, but that's really tautological. Whether you want to say that people who behave in extremely deviant ways have a disease or not is really just a semantic argument, it doesn't mean anything. The point is, we can't predict.

And that's really nut. We aren't about to start restricting political speech in this country, and we shouldn't. Direct threats of violence can be against the law, but Glenn Beck's conspiracy theories and George Will's endorsement of rape and Bill O'Reilly's provocations against abortion providers -- you just can't draw the line. If the culture is full of angry, hate filled people with ideas that they use to justify violence, there isn't any law you can pass against it.

And, we can't start taking rights away from people who get a diagnosis of mental illness, that we extend to everybody else. In case you didn't know it, the vast majority of people qualify for a psychiatric diagnosis at some point in their lives, if not all the time. Getting a psychiatric diagnostic label is pretty much a random event that doesn't mean anything.

Finally, by now, the U.S. is saturated with firearms. We're never going to recall them. I'm all for reasonable regulation, just like we regulate cars and drivers, but that's not going to stop a nutjob.

So, if we could improve our ability to predict who's going to go postal, we might be able to do something. But until that happens, I despair.

Campaigning against motherhood and apple pie

Republicans are still insisting that the Affordable Care Act is a disastrous failure, and they still plan to build this year's congressional campaign around repealing it. But a funny thing happened on the way to the trainwreck. As Krugzilla shows, it's working just fine, thanks, in fact at the high end of expectations. The number of uninsured people in the U.S. fell sharply after the main provisions of the law went into effect, and gains in employment jumped at the same time.

But, most voters still don't know what's in the act, how it works, and why it works the way it does. They just know they're supposed to hate it, but they don't know why. I actually don't think it will be a winning issue for Republicans, but that it isn't yet a winning issue for Democrats is largely because of our dysfunctional corporate media, that dutifully transcribes politicians' fact free commentary without bothering to explain the reality. Until that changes, the long decline of the United States will continue.

PETA Bait

You'll often see people who I agree with about a whole lot of important subjects defending the importance of animal research to the advancement of medicine and the relief of human suffering and disability.

The picture most people, including scientists have of the typical course of biomedical research is that you first create an animal "model" of human disease; you study the animals to try to understand the disease better; then you test treatments in the animals. Ones that seem promising then get clinical trials in humans. According to this putative reality, If PETA gets its way, and we can't do this any more, we will never find cures for multiple sclerosis and Alzheimer's disease and pancreatic cancer and all those other horrors. It's too bad for the animals, but human welfare and survival are more important.

According to Pandora Pound and Michael Bracken, writing in BMJ, not so. In order to make the best judgments about what treatments work in humans, we do systematic reviews and meta-analyses to pull together information from all the available studies, assess its quality, and combine the highest quality information to generate conclusions and assess  how confident in them we can be. Lately, investigators have worked hard to overcome the problems of publication bias, cherry picking of results and other flaws in the scientific enterprise that often lead to overuse of treatments without good evidence. We have a long way to go, but we're getting better at it.

In animal studies, however, there is far less accountability for quality and synthesis of results. Pound and Bracken cite one survey that found only 12% of animal studies used random allocation and only 14% had blind assessment. Selective analysis and publication bias result in distortion of "entire bodies of research," according to another reviews. Meta-analyses are rare.

When treatments enter clinical trials in humans based on animal research, they are overwhelmingly likely to fail. P&B also note that decades of research have failed to yield a single treatment for stroke, ALS, and other conditions.

Not only are there problems with research quality, reporting and synthesis, but it is questionable how useful animal models are for understanding human health or predicting human responses to treatment in the first place. There are just too many differences between humans and rodents, or even other primates, for treatments to translate in most cases.

There is an enormous vested interest in animal research, and you know these claims will generate massive yelling and screaming. Note, of course, that this is unrelated to the conduct of basic research intended to understand the animals themselves. We're talking about biomedical research purported to ultimately benefit humans. That relationship is far more tenuous than most people believe, and the effort generates enormous waste and massive failure much more often than it generates anything useful. That's what Pound and Bracken are arguing. This is a debate that people need to approach with an open mind.

About those carbon emission regulations . . .

How important are the proposed EPA regulations on power plant emissions? Actually not too shabby, I would say. Ben Adler at Grist runs down the content of the proposal, which is more than your average newspaper or talking head has bothered to do. The regulations bind the states to reductions based on their (2005) baseline, defined as emissions per megawatt hour of generation, however they want to do it. The 2005 baseline is cheating because emissions are already down from that year, due to abundant natural gas and the recession, mostly. So there's a head start, and the target -- a 30% reduction by 2030 --is considered unambitious by environmentalists.

But -- this will establish a national policy and give the U.S. more credibility in international negotiations. That is if and only if a Democrat is elected president in 2016, of course, because the regulations probably won't even be implemented until then. As Ezra Klein explains, Republicans were actually for controlling carbon emissions until recently. In fact, John McCain and Sarah Palin ran on a platform of a cap and trade system that would reduce emissions by much more than Obama's proposal. Really. In 2008, John McCain said this: "Whether we call it 'climate change' or 'global warming, among environmental dangers it is surely the most serious of all." But then the Koch brothers purchased his withered soul.

The proposed EPA regulations are far too little by themselves to save us from catastrophe. But they will force a substantive public debate, for a change, and at least we're starting to do something. Dangerous and costly warming is inevitable, but we can still keep it to the low range of awful.

Highly Misplaced Fear and Trembling

It's been amusing (I guess that's the word) watching Republican politicians freak out over the exchange of 5 Taliban prisoners for a U.S. soldier. Yes, these guys were high ranking -- actually they were mostly civilian leadership of the Taliban government. They are described as "hardened killers" but that's because the Taliban regime was violent. The only people they ever bothered were Afghans. They can't be prosecuted because they haven't violated any U.S. laws. They were prisoners of war, which means they have to be released some day.

The U.S. has been trying for some time to arrange a peace deal in Afghanistan, as has the Afghan government. Qatar has been acting as intermediary all along. This is just part of that process, a necessary clearing of one obstacle which may help get to a result that will end the violence in that long-suffering country. Meanwhile, there are thousands of Taliban fighters. Adding five old guys to their numbers isn't going to suddenly make the Taliban more dangerous. It's inconsequential.

But we seem to view "terrorists" (which they actually aren't) as having supernatural powers. It's ridiculous. And oh yeah, whether Bowe Bergdahl deserted or was derelict in his duty is completely irrelevant. Get a grip, folks.

Progress report

For anyone out there contemplating arthroplasty of the thumb,  I can tell you that after nearly 8 weeks I am slowly regaining good use of my left hand. Wednesday and today I used the weed wacker, which actually doesn't require a contribution from the left thumb -- you pretty much grab the handle with the fingers -- but even so, that would have put unbearable pressure on the sore spot not long ago. I also used a chainsaw, briefly, yesterday and today, but decided not to resume major combat operations just yet.

So yeah, I'm hopeful that this will work in the long run. Still, it's a really violent intervention. They remove the trapezium -- the bone at the base of the thumb -- and stuff the cavity with tissue harvested from a wrist tendon. There has got to be a better way, but I'm guessing they figured out how to do this by experimenting with trauma reconstruction. You would never inflict it on someone with a useable hand, no matter how painful, purely on spec. That means they started out with people whose trapeziums were destroyed, so that's what they know how to do. There is, obviously, no animal model for the human hand so PETA will be glad to know that's out.

There are some slightly different approaches to this surgery but they've never had head-to-head trials. My surgeon does it his way and that's that. Unfortunately, this is true of many medical interventions. That's why there's a lot of emphasis these days on comparative effectiveness research but we have a decades long agenda ahead of us. I expect few people are really aware of how much we are still struggling with an insufficient evidence base for medicine. Obviously, we've learned a lot and medicine is getting more effective, but we still don't know, in many cases, how to make the best use of the technology we already have, nor do we necessarily understand what we're doing.

In the case of osteoarthritis, why is bone-on-bone contact painful in the first place? There are no nerve endings in bone. Yet we can only fix it by removing and replacing entire joints. I think we're missing something here.

Then, Now, and Yet to Come

The invaluable Brad DeLong and the invaluable George Monbiot today present us with bookend essays that define our essential -- our existential -- crisis.

DeLong tells the story of humanity. The human population was probably about 4 million in 10,000 BC, at the dawn of civilization; 170 million in Year 1, the crest of the Roman Empire; and 720 million in 1750. Then, boom goes the dynamite. 1.8 billion in 1900, and more than 6 billion today, just 100 years later. Wait, there's more: until 1750, nearly everyone lived at a bare level of subsistence, their growth stunted by chronic malnutrition. Based on plausible assumptions and definitions, GDP per capita remained unchanged from 100,000 BC to about 1500 AD at about $400-500, then increased very slowly to a little over $1,000 in 1900, then once again, Kaboom! to more than $6,000 today.

Monbiot explains:

Economic growth is an artefact of the use of fossil fuels. Before large amounts of coal were extracted, every upswing in industrial production would be met with a downswing in agricultural production, as the charcoal or horse power required by industry reduced the land available for growing food. Every prior industrial revolution collapsed, as growth could not be sustained. But coal broke this cycle and enabled – for a few hundred years – the phenomenon we now call sustained growth.

It was neither capitalism nor communism that made possible the progress and the pathologies (total war, the unprecedented concentration of global wealth, planetary destruction) of the modern age. It was coal, followed by oil and gas. The meta-trend, the mother narrative, is carbon-fuelled expansion. Our ideologies are mere subplots. Now, as the most accessible reserves have been exhausted, we must ransack the hidden corners of the planet to sustain our impossible proposition.

But, this cannot continue. As Monbiot also points out, with a growth rate of 4.5% per year, one cubic meter of fixed capital would grow to the volume of 2.5 billion billion solar systems in 3,000 years. We don't have to wait that long, however, to hit the absolute limit of economic growth. Maybe we have 50 years. As Monbiot concludes, "The inescapable failure of a society built upon growth and its destruction of the Earth’s living systems are the overwhelming facts of our existence. As a result they are mentioned almost nowhere. They are the 21st Century’s great taboo, the subjects guaranteed to alienate your friends and neighbours."

Well, we need to break the taboo. Loudly. Now.

What gets our attention

Mass shooting incidents account for only a small fraction of gun violence, but they become big news, while the everyday drumbeat of domestic and ordinary criminal violence fades into the background. I stopped by a couple of the popular blogs today and the postings on the mass murder in Isla Vista have attracted hundreds of comments. Viz PZ, who copies much of the killer's manifesto.

Not surprisingly, Myers uses this as an occasion to condemn his arch enemy Men's Rights Activists, but the comments don't have any particular discernible central concern or pattern, they seem all over the place. A lot of the argument is over whether we should blame mental illness, which I suppose just comes down to the semantic argument over whether you want to call whatever was wrong with the guy a disease.

Anyway, Mother Jones provides a handy dandy guide to mass murder in the U.S., of which they count 70 incidents in the past 30 years. (Definition: 4 or more dead, not counting the shooter, in one incident.) Most of the weapons used were obtained legally, almost all of the killers were male, and the venues were generally schools, workplaces or public places. But you probably knew all that just from your overall impression. Most of the weapons were semi-automatic handguns, which would not be affected by an assault rifle ban.

So, if we aren't going to eliminate routine sale and ownership of firearms, which we aren't, other than banning testosterone I'm not sure what to do. There always have been, and always will be, the occasional guy who goes amok. If he has a gun, the consequences will be worse than if he doesn't. That's the world we live in.

It's in the New York Times!

The Times does occasionally make mistakes (I know, I know, this news must come as a serious blow), but identifying Noam Chomsky as a professor at Harvard Divinity School has to be the weirdest ever. (Can't link to it because they've already corrected it on the web version.)

Equally weird was an ad that appeared therein today, from these folks. It's actually quite common for raving psychotics to have enough money to buy half-page or full-age ads in the Times. It's not a surprise that they exist, but how do they get rich? But the more important point here is that this drivel is actually indistinguishable from religion in general. It's no more meaningless than any theological language, just less familiar. No statement about God is meaningful, because the concept is nonsensical to begin with. I happen to know that Noam agrees with me.

Les Izmore

A couple of interesting, or should I say egregious items in this week's medical journals. (You'll probably just get the abstracts, if that.)

Barnett and Linder proffer a research letter to JAMA which quite frankly baffles me. We have known for decades that antibiotics are not effective for acute bronchitis. CDC and others have been working to reduce antibiotic prescribing for acute bronchitis, and the leading quality measurement system, the Healthcare Effectiveness Data and Information Set metric is that antibiotic prescribing for acute bronchitis should be zero. Zip, zilch, nada. Don't do it, doc!

And yet, and yet . . . Based on the National Ambulatory Medical Care Survey and the hospital equivalent, which includes emergency departments, from 1996 to 2010 the rate of prescribing went up. It's nearly 80% -- that's right, 80% -- in primary care and about 70% in emergency departments. And physicians are prescribing broad spectrum antibiotics which are a) expensive and b) contributing widely to antibiotic resistance. Also, too, antibiotics are bad for you because they kill your symbiotic microflora. Why on earth is this happening? Beats the hell out of me.

Meanwhile, over at the New England Journal of Medicine, members of the Swiss Medical Board explain why they recommend abolishing routine mammographic screening. It seems that based on survey data, U.S. women estimate that if 1,000 women 50 to 60 are screened every year, deaths from breast cancer will be reduced from 160 to 80. Seems worth it, no?

Here's the cold truth. Based on the best available data, the actual reduction in breast cancer mortality would be from 5 to 4. And it's quite possible that the one death averted would be replaced by death from another cause. At the same time, "For every breast-cancer death prevented in U.S. women over a 10-year course of annual screening beginning at 50 years of age, 490 to 670 women are likely to have a false positive mammogram with repeat examination; 70 to 100, an unnecessary biopsy; and 3 to 14, an overdiagnosed breast cancer that would never have become clinically apparent." "Overdiagnosed breast cancer" likely means surgery, radiation, chemotherapy, and terror. Maybe not so worth it?

Any time somebody makes an assertion of this nature, screaming vengeful hordes descend upon them, accusing them of not valuing women's lives and basically committing murder and mayhem. Oncologists and surgeons and radiologists and drug companies make big bucks off of this. But women should make up their own minds.

Oh yeah, that'll work

President Obama's chief counterterorrism advisor has written to the deans of schools of public health saying that the CIA has abandoned the practice of using vaccination programs as a ruse to collect intelligence. As you may recall, this is a response to the shitstorm over the fake vaccination program in Abbotobad they used to try to confirm that Osama bin Laden was living there.

The fake vaccination program didn't work -- they failed to get ObL's DNA -- but it did result in numerous vaccination workers in Pakistan being murdered, contributing to the resurgence of polio in Pakistan and putting the world in peril.

But that's okay now, if the director of the CIA says something, then clearly everybody in the tribal regions of Pakistan will believe him. They never lie, after all.

In case you're interested . . .

"Some guy's faculty page" in the sidebar has an updated link. This was a major technical enterprise that took two years and as far as I can tell didn't result in any improvement but what the heck.

This is a major peeve of mine. They keep updating software, from Windows to G mail to Word to EndNote, you name it, and it just gets harder to use and doesn't do anything it couldn't do before. It works just fine, leave it alone.

That is all.

News of the Day and various items

A reader asks if I have discussed prescribing Xanax to elderly people here. Actually I don't think I have, although I have discussed antipsychotic prescribing to elderly people. Advanced age is definitely a counterindication for benzodiazepines, one study even finding an increased risk of dementia, although this study is small and I haven't seen a meta-analysis. Still, elderly people metabolize benzos more slowly, so they get higher plasma concentrations, and they are therefore at higher risk for the usual side effects such as drowsiness. However, I also tend to think that belonging to the species Homo sapiens is also a counterindication. Finally, benzos have considerable potential for producing dependency.

As for searching my blog, I can do it myself with my credentials but I don't know if there's a way for the general public to do it. But if you have any requests, I'll consider them.

In other news, tomorrow is the 10th anniversary of the first legally recognized same sex marriage in the U.S. At the time, many of us were concerned that it had been brought about by judicial fiat, not the legislative process. However, as soon as people noticed that in fact, nothing bad happened -- fire and brimstone did not rain down upon the Commonwealth, other people's marriages were unaffected, and restaurants and caterers made more money -- it suddenly became fine with people. And that's what's been spreading all over the place. Once it's familiar, and all the horrific consequences manifestly fail to appear, what the heck, why not?

In less happy news, former New England Patriots tight end Aaron Hernandez has been indicted on 2 more murder charges, unrelated to the murder for which he is already awaiting trial. Why do I bring this up? He played the entire 2012 season after he allegedly murdered 2 strangers out of mild pique, apparently, over an interaction in a bar. Here's what he said to a reporter 11 days after the murders:

“Aaron, was your summer as crazy as Gronk’s?
“Um, more private,” Hernandez said to the delight of the crowd surrounding him. “But I still had some fun.”
Like what? Can you give us some examples of the fun you had?
“That’s still private but…” Hernandez said to more laughter. “Next question.”

 As it happens, he had already shot at least one guy, non-fatally, while he was on the Florida team, and there was a whole lot of other crap the Florida coaches new about, but they hushed it up. The guy's a total psycho thug but it's okay, he's a star athlete. We have some serious warpage in our culture.

Finally, it so happens I have met Jill Abramson, she is married to my buddy down the street while I was growing up. (Haven't seen Henry for years now.) Billions of people are discussing this, causing a serious depletion of electrons, but I will just say that in case you didn't know it, the NYT is owned by a hereditary dynasty and while no doubt working women face similar crap at all levels, another lesson here is that this is what you get when you live in a plutocracy.

Man bites dog

Specifically, that would be U.S. Postal Service public affairs officer Mark Saunders. Well, only metaphorically. He writes to remind us that it's not a myth or a funny cartoon scenario: 5,581 postal employees were attacked by dogs last year. That may sound like a lot but it's only a bit more than 1/1,000th of the 4.5 million people who were bitten by dogs in the U.S., half of them children. Sayeth the CDC,885,000 people required medical attention for dog bites, and 27,000 people needed reconstructive surgery.

We don't like to acknowledge this because most people love dogs and feel like their dogs love them. They probably do, whatever that means to  dog, but they're still wolves and they are also dangerous. Most people do not take this seriously. From CDC:

• Spay/neuter your dog (this often reduces aggressive tendencies).
• Never leave infants or young children alone with a dog. Seriously folks -- not a joke! You could really, really regret it. No matter how well you think you now Fluffy.
• Don’t play aggressive games with your dog (e.g., wrestling).
• Properly socialize and train any dog entering your household. Teach the dog submissive behaviors (e.g., rolling over to expose the abdomen and giving up food without growling).
• Immediately seek professional advice (e.g., from veterinarians, animal behaviorists, or responsible trainers) if the dog develops aggressive or undesirable behaviors.

Teach children basic safety tips and review them regularly:

• Do not approach an unfamiliar dog.
• Do not run from a dog or scream.
• Remain motionless (e.g., "be still like a tree") when approached by an unfamiliar dog.
• If knocked over by a dog, roll into a ball and be still.
• Do not play with a dog unless supervised by an adult.
• Immediately report stray dogs or dogs displaying unusual behavior to an adult.
• Avoid direct eye contact with a dog.
• Do not disturb a dog that is sleeping, eating, or caring for puppies.
• Do not pet a dog without allowing it to see and sniff you first.
• If bitten, immediately report the bite to an adult.

 

Ha ha!

I got an e-mail from Avalere Health:

According to a new Avalere Health analysis, 17 of the 26 states that did not expand Medicaid in the first three months of 2014 still reported growth in Medicaid enrollment, ranging from 0.1 percent in Texas to 10.1 percent in Montana. Since these states had decided not to expand Medicaid eligibility levels under the Affordable Care Act (ACA), these numbers show the impact of the “woodwork effect,” which is when individuals who were previously eligible, but not enrolled in Medicaid, newly sign up as a result of increased outreach and awareness. These enrollees may place a strain on state budgets, since states are required to contribute to the cost of their coverage based on traditional Medicaid matching rates. . . .

These states would have gotten 100% federal reimbursement for newly eligible Medicaid beneficiaries, had they chosen to accept the expansion. But they only get 50-70% reimbursement for these folks, who were already eligible. So their hospitals and docs won't get all that federal money, but they'll still have to cover more Medicaid beneficiaries. Lots of people left out in the cold, of course, but this is a good side effect.

Call me intolerant . . .

. . . if you will.

Last Sunday I was channel surfing toward the news when I saw the victor in that weekend's golf tournament getting interviewed. The teevee guy asked him the standard question, why did he think his game had been so good?

It turns out it's because this particular golfer has "gotten closer to God." He realized he couldn't do it on his own so he started relying on God to guide his swing.

Here's what I think, punk. You are a malignant narcissist. You are actually claiming, before a national television audience, that the immortal, omnipotent creator of the universe of billions of galaxies, each of billions of stars, gives a flying fuck on a rolling doughnut where your golf ball goes? That God favored your victory over all the other poor schmucks who aren't close enough to him?

At the same time, your God is petty and banal enough to fix your golf game while he's otherwise occupied burying people under land slides and afflicting children with malaria. You are actually worse than the people whose neighbors are killed by a tornado and thank God for sparing them. Your religion makes me want to barf.

Disease eradication

World Malaria Day was a couple of weeks go, and I missed posting on it due to my recent indisposition. Yeah, yeah, I don't usually pay much attention to these artificial occasions --- National Pickle Week, Administrative Assistant's Day, yadda yadda -- but the WHO and the Global Fund used the day to push hard to get attention and maybe raise some dough. Here's the UN Special Envoy's statement on the day, which was April 25. Malaria matters because it is a leading killer of children and because endemic malaria is a major factor that holds down poor regions of the world. With lots of people debilitated, economic welfare suffers.

And malaria is eradicable. It won't be easy, but it can be done. It's technically possible because the parasite needs a human host for part of its life cycle. If infected people can be cured, and the chain of transmission stopped, malaria can be gone forever, like smallpox. which was declared eradicated in 1980. Polio should be gone from the earth by now, but it isn't, because of civil conflict and religious fanaticism. Eradicating malaria faces some of the same problems -- many of the places where the disease remains are very difficult to work in. But these are potentially incredibly powerful investments. However, the eradication of smallpox followed a previous unsuccessful campaign to eradicate malaria.

These efforts require more social science, community organizing, business management, and political negotiation than they do biological science. They have the potential to strengthen civil society in poor countries, and international cooperation, but done wrong they can damage both. (See the last link.) Will we have the wisdom as a species to pull it off? 

Thumb arthroplasty

Well, the cast did come off yesterday and the pin came out. Both were big wins -- cast means I can use the hand more effectively, no pin means less pain. It sure looks ugly -- wrinkled skin, surgical scar, atrophied forearm. But, I'm typing with both hands so that increases my productivity big time. It used to be, when people asked me what I do for a living, I'd say I'm a medical anthropologist. But I realize now a more accurate job description is typist.

However, it ain't over. The hand is weak and stiff. I have to do rehab exercises every day, and it will be a month before I'm allowed to put any real stress on the hand and maybe three months or  more before I'm allowed to do heavy lifting. That cramps my style big time -- can't dig up the garden or use the chainsaw. I do plan to try guitar in a couple of days however.

So this is a big investment, a big ordeal. I'm not sure whether I'd do it again -- I was in pain and becoming more and more disabled as it was, so I guess it was necessary. But I don't know that it's for everybody. And I don't think the surgeon really gave me adequate warning of how difficult this would be. On the other hand, if he did, would anybody do it? Maybe a little soft pedaling will turn out to be good for me in the long run. This is a difficult question for me as moral philosophy. I'll have to ponder it.

Actively Dying

That's a strange term of art I have recently come across in the field of hospice care. I'm not sure how you would define it -- we're all actively dying, it seems to me, it's only a matter of degree. But, hospice care means we aren't working at prolonging life or trying to treat underlying disease, but rather at making a dying person as comfortable as possible. The WaPo wants me to steer you to this investigative report that finds, based on billing records and supported by anecdote, that some Medicare hospice providers are taking the money, but not really doing that.

My colleague Joan Teno is quoted as endorsing their deduction that a hospice that claims no skilled nursing care and zero hospitalizations is skimping. Yes, we aren't trying to prolong lfe, but some painful crises do require active intervention for palliation.

The reason is financial incentives, apparently. Lower level care is more profitable. Medicare could try to fix this by realigning reimbursement or more active oversight, but meanwhile if you have a loved one in crisis be a squeaky wheel.

Cast comes off Tuesday and hopefully I'll get back to more regular posting. In other personal news, you might be interested in this article of mine that just went open access on PubMed central. Federally funded research has to be publicly available after one year. The publishers, who make billions, don't like that and they're trying to overturn it. Don't let them.