Mother’s Medicine

My mother wants to tell you something.

She wasn’t a doctor, but that shouldn’t matter.

She should’ve been.

She could’ve been.

She could’ve taught those “fine” professors at the Mecca how to treat their students.

Had she been in charge, the first thing she would’ve done was tell many of them to go away.

Mom: If you can’t treat people nicely, why should you even be here?

She would have put a stop to their unwarranted and unsolicited condemnations.

Too many professors there believe in the whip.

Cruelty with a purpose. That’s what Trevor Howard, the ultimate British villain, the benchmark of British villains, playing Captain Bligh in the film Mutiny on the Bounty, said.

Those misguided professors believe that George S. Patton was correct in slapping that soldier in Italy around.

They really do. They believe that their humiliations and debasements will inspire their students to do better.

They are wrong.

My mom didn’t value smarts and know-it-all-ism as much as she did congeniality.

That is sadly missing in American healthcare today.

Indeed the current day Mecca drums the niceness out of doctors.

My mom must have understood on a certain level that arrogant doctors who scream and yell are often the doctors who make the most mistakes.

That’s what I noticed in my career.

I found that to be true in just about any field.

So if somebody treats me poorly, I walk away from that individual no matter how talented they are touted to be.

You have to treat people with respect.

Next in line would be hard work and diligence.

A doctor has to be thorough, diligent and hard working.

This is not valued in the Mecca today. Natural talent bums who wow the professors with esoteric facts are prized.

Worse than this, doctors who play Machiavellian tricks often win the day.

The professors value what they call roundsmanship.

Conniving gamesmanship would be a better term for it.

Students and residents are pitted against each other.

It’s a cockfight, and some professors revel in the bloodbath.

Style defeats substance. The professor, who is often buried within his research lab, can’t tell the difference between the bullshitters and the hard workers.

Or maybe he or she can.

The bullshitters come out ahead because they understand that rounds are a game. Plus they know how to answer questions that put themselves in the best possible light.

When I trained I had one fellow intern who would never say that he didn’t know. He was very clever. He would answer: I can’t answer that.

Isn’t that brilliant? He’s not saying that he doesn’t know. Yet at the time we all knew that he didn’t.

My mother believes, as I do, in hard work and honesty.

She wasn’t big on style.

Through her son she believes that rounds should be working rounds. In other words, jettison the beautiful presentation in favor of a working man’s approach to solving the days problems.

This is the true recapitulation of how a doctor works in the real world.

Get rid of group rounds which sets people up for humiliation and embarrassment. Very few students are learning from group rounds. They are too terrified.

You have to be fair to people also. That means you have to go the extra mile in putting your emotions aside when evaluating people.

Do the professors in academia do that today?

I’m not sure.

Many professors aren’t properly trained to do their jobs. Worse, there are a lot of part-time professors who don’t know a thing about education or evaluating people.

In fact, it is these part time professors who are the most dangerous.

You can’t wear two hats in life. You can’t be a practicing doctor and a good teacher at the same time. Nor can you be a researcher and a good teacher at the same time.

It’s not possible.

Let me be fair though. There are many good people there at the Mecca.

When I was in my first months of clinical rotation at University of Kansas I was having some difficulty in adjusting.

I had recently moved back to the United States and was having a difficult time coping.

It’s called culture shock in reverse. If you think going to a different country is tough, try coming back.

It’s difficult to return to the pristine nicety of the United States when you see how the other half of the world lives.

The experience transforms you.

One professor had given me what I thought was an unfair evaluation. It seemed to me that I wasn’t going to be able to pass the semester with that low grade. She had made it low enough so that it would be difficult for me to recover.

I was traumatized, so I decided to suspend my medical education for a bit.

Before I did though, I was able to talk to the acting Dean, James Lohman. I recounted my circumstances and what had transpired and my request to suspend my studies.

After carefully listening to me, he looked at me and asked one question: What is your support system here in Kansas City?

I wasn’t sure what he meant, so I asked him to clarify his question.

Well, he continued, do you have family here? Where are you living?

Since I had just transferred into the school, I told him I was living at the Holiday Inn. I told him that I didn’t have anybody here. I had no family here.

He didn’t have to make a comment after that.

With one incisive question he not only revealed to me what was going on but everything I needed to know to become a quality doctor.

This is the kind of doctor my mother would have approved of.

I knew surely as I speak these words now that there wasn’t anything that the University of Kansas could teach me that was more valuable than what he taught me that day.

To be a quality physician, you have to be empathetic, and you have to ask the right questions.

Knowing all the details and statistics about alpha-1 anti-trypsin deficiency and other esoteric diseases would have to take a backseat.

That was true then, and it is true today.

You can have all the facts and still miss the boat.

If we want to improve healthcare in the United States today we have to start with the medical schools and the kinds of people who are permitted to attend.

Currently the GPA and the MCAT score are used to measure the potential of a future doctor, but that in itself may be a poor measure.

What about empathy?

What about being a regular person who people can relate to?

Placing a premium upon GPA and MCAT score favors the malicious grade hound who will do anything to get a higher grade.

It also favors brainiacs and mathematicians, who may be over-represented in healthcare.

I tend to trust people who have studied biology and the life sciences.

Biology is a messy science. It’s an imprecise science. It’s filled with blood and guts. Biologists aren’t afraid of getting dirty. They aren’t afraid of imprecision either.

The field of medicine is too heavily weighted down by analytics, mathematics, P values, and Cox regression analysis. The people who embrace these methodologies tend to not like people. These are the kind of people who were running Sobibor.

My mother was a regular person. She was not a snob or an elitist. And she certainly did not instill in me any love for formality and pretense.

Formality and pretense are the hallmark of corrupt institutions.

Crooked people dress up to compensate for their crookedness. The mob dresses in a suit; Congress dresses in a suit; Wall Street dresses in a suit.

So do the officers of the Mecca.

They equate professionalism with fine dress.

My mother does not define professionalism by how well you dress.

Professionalism is better defined by how well you attend to your patients; how well you follow through; how well you listen to your patients.

The Mecca also believes in a formalistic, hierarchical methodology to teaching, learning and diagnosis.

Carol Linnaeus is their Jesus.

St. Carol the Dangerous codifies diseases into rigid categories; and these diseases in order to be diagnosed must be approached according to rules.

One, all symptoms and signs must be condensed according to Occam’s Razor or the Law of Parsimony. It’s impossible, according to orthodoxy, for people to have two things at the same time.

Two, you have to know precisely what you are looking for in order to order a test. No fishing around or hunches are permitted.

Three, a massive time-wasting differential diagnosis must be developed before proceeding to diagnose. According to orthodoxy you won’t consider all the available options in any other way but this way.

Four, diseases must be taught and diagnosed from the top down according to this bizarre classification scheme as pumped out by St. Carol and his successors.

This is not what my mother teaches. Of course my mother is not a physician, but she did inspire me.

Here is what my mother teaches:

Diseases, not classification schemes, come first.

Diseases do whatever the hell they want to do. They don’t follow any rules, and they haven’t read any books. They do what they do. They don’t even know who Carol Linnaeus is. Nor do they care. They consider him a loser and a third-rate piker.

People certainly do get two things or even three things at the same time.

It’s impossible to know everything that you are looking for in order to order a test. You’ll never be smart enough to figure everything out. The world is too vast. Diseases are too large in scope.

Skip the massive differential.

Diagnose from the bottom up, not the top down.

How do we do that?

By thinking practically, and by asking what tests will add value to our thinking or plan.

What do we want to know?

I used to call this a chef’s soup approach to diagnosis, but in honor of my mother who passed away yesterday, I am going to call it Mother’s Chicken Noodle Soup approach to diagnosis.

What will make Mom’s little boy or little girl better?

What will help Mom?

This seems to be a more humanistic way of diagnosing.

Yes, you are right, it lacks the precision that is taught at Harvard and MIT.

Since my mother does not approve of swearing, I will not say: So fucking what? I will say: So what?

MIT and Harvard are wrong, dead wrong.

Let’s start from the beginning. Suppose you see a rash on a patient’s face. Other than asking a basic routine history and physical, what would you do?

Would it be to your benefit to construct a massive differential diagnosis?

Do you have to know exactly what’s going in order to order anything?

The geniuses at Johns Hopkins think so.

Suppose you had no idea at all what was going on, what would you do?

Well, what did you do as a baby?

You cried for mommy.

That’s precisely what you need to do here. You need to call for help. In fact, the first thing that any medical student or resident needs to learn how to do is to call for help.

Indeed a medical student or a resident shouldn’t be allowed to write one single order unless they first make a phone call to a specialist for help.

That should be the first thing that a young doctor should learn.

Call for help.

This is ridiculed at the Mecca. If you wake that professor up he’s likely to chew you out or say: I would expect someone at your level to know this.

Nevertheless, the proper response is to call for help.

In this manner the young doctor learns that the fall back pitch is to call for help.

You don’t need to construct a massive differential in order to do that.

Let’s suppose though that you do know a few things. What would be the next step?

I don’t want to get too technical here, but let’s say that the rash is a pinpoint rash that does not blanch when you press on it. Let’s say that it looks like petechiae. Let’s say that it’s confined to the face.

Do you need to do a massive differential at this point? No.

You might be thinking that this rash is due to pressure from screaming. So you ask the patient whether they have been screaming, because when you ask a question, you are really ordering a test in a different form. It’s all information. Mom wants to know. Mom does not want you wasting your time and brain energy on nonsense.

The patient says: No.

The patient has also already said no to a basic set of questions that you have preliminarily asked in your history.

You might also ask whether there was any trauma, or whether they had put a band around their face or neck.

Maybe they were goofing around with a toy.

Assuming, that they were not, you might order a CBC to check for their platelet count.

Do you need a massive differential at this point? Not at all.

You don’t even need to know specifically what is going on.

Let’s say, though, that the platelets come back at 15,000. What are you going to do then?

What would I do?

I would order a different sort of test: I would go over my basic questions again, and I would redo the physical. I would check the spleen and the liver, I would check for lymph nodes, I would go over their medication history. I would carefully re-examine the skin on their body. I would especially want to know if there’s fever or has been fever.

I might even repeat the CBC.

Additionally, I am going to absolutely order another test: my fallback pitch. I’m going to call the hematologist and set up an appointment. I may admit the patient to the hospital.

And yet, I do not know specifically what is going on, nor do I need to know.

When the hematologist gets the patient, or when the hospitalist gets the patient, they will ask the same questions but proceed to a higher level. But they will go through the same steps.

Go away, Johns Hopkins.

Do you see what I am getting at, reader. It’s a colossal waste of time to approach a problem from the top down. Diseases do not follow rules. You cannot approach diagnosis or learning that way. It doesn’t work.

Think of diagnosing as a marble dropping down into a vertical maze of steel spikes sticking outward from a board. The spikes are your questions, physical exam, and tests. The marble will fall down and hit the first spike and move to either the right or the left. It will drop to the next level and hit another spike and again fall to the right or the left. Eventually it will reach the bottom which is where the diagnosis is. Sometimes the spikes repeat themselves at lower levels.

Your focus should be on not achieving a final diagnosis in your brain but in following the marble down to the bottom. Your focus should be on asking questions, doing a physical exam, and ordering tests.

You should not be emotionally invested in a final diagnosis from the beginning.

The traditional way, the academic way puts the cart before the horse. They want you to invest your emotional energy in a diagnosis. It’s very much like a player who focuses on winning the Super Bowl rather than taking the right steps that are required to win a Super Bowl.

Forget about the end result.

Now, this does not mean that you don’t take the time to learn about diseases and the characteristics of those diseases. You certainly do need to know how diseases present. You certainly do need to know the characteristics of various diseases. Knowing these diseases is what is going to allow you to ask the right questions.

Asking questions is important in healthcare.

There is no such thing as a dumb question, although you wouldn’t know it if you were trained in academia today.

Far too many academics laugh at people who ask dumb questions. They grade them down and laugh at them.

They’ll make a joke about the person and humiliate them in front of everyone. They have no tact.

Tact and agreeableness is important in life. You should never make people feel worthless.

That is important when dealing with students. Young students are like young seedlings in a garden. They are are fragile and need to be handled with care.

My mother’s name was Frances Ann Davis.

She could’ve been a doctor.

These are the kinds of things she believed in.

These are the values she taught me.

Sincerely,

Archer Crosley

Copyright 2021 Archer Crosley All Rights Reserved

Antimicrobial Resistance

What causes antimicrobial resistance?

Resistance is related to total antibiotic pressure upon available bacteria.

What contributes to total antibiotic pressure?

1.  Antibiotics used in farming and agriculture.

2.  Waste antibiotics released into rivers by Big Pharma.  

3.  Total antibiotics being prescribed by healthcare providers.

4.  Antibiotics that are being sold legally or illegally on the open market without prescription.

In summary, the greater the antibiotic pressure, the greater chance of resistance.

How do resistant bacteria form and propagate?

They mutate.

Once they mutate they can either reproduce or spread the mutated genetic material through plasmid exchange.

A plasmid is a small DNA molecule within a cell that is separated from chromosomal DNA and can replicate independently.

The bacteria come together and form a joining point like a handshake. Then the genetic information is exchanged.

How important is sanitation to Antibiotic Resistance?

There is a doctor from Australia named Peter Calignon, Ph. D. from the Australian National University Medical School.

He and his colleagues feel that contagion is an important factor in spreading antimicrobial resistance.

I agree.

He feels that poor sanitation and overcrowding plays a real and vital role in the spread of resistance.

If we examine where much of the antimicrobial resistance comes from – India, China and others – we can see that he may have a point.

These countries do not have the best sanitation services available for all their people.

It makes sense that if you have more available bacteria for antibiotics to be exposed to, you should get more resistance, especially if the bacteria are more prone to come from infected people.

Of course there are people who do not agree with him.  They feel that overuse of antibiotics is the main cause of resistance.

I am not so sure of that, and I will explain why.

WHERE DOES ANTIMICROBIAL RESISTANCE COME FROM?

Most of the deaths that arise from antimicrobial resistance come from Asia and Africa.

Is this because healthcare is sub-standard there?

Or is it because there are more resistant bacteria being generated there?

There are maps available.

I can go all day with these maps, but you can play with them yourselves by searching the web for CDDEP Resistance Map.

You will see that MOST of resistance is coming from India, China, Russia, Mexico, Argentina and Venezuela.  

Most of the resistance is NOT coming from the United States.

Assuming that antimicrobial resistance is coming primarily from these parts of the world, why would that be?

Here are some potential reasons.

1.  Poor oversight of Big Pharma allowing corporations to dump effluent into the rivers.

2.  Poor sanitation and overcrowding.

3.  Open pharmacy whereby antibiotics can be obtained without a prescription.

WHERE DOES ANTIMICROBIAL RESISTANCE NOT COME FROM?

Let’s turn the question upside down.

Why do we see less resistance coming from the more developed countries?

The United States and the West.

Here are some potential factors.

1.  Better oversight of Big Pharma.

2.  Better sanitation.

3.  Closed pharmacy.  You can not buy antibiotics at the supermarket.

WHAT’S MY POINT?

This is my opinion.

Maybe we are being too hard on ourselves in thinking that over-prescription of antibiotics is a major cause of antimicrobial resistance.

Maybe we are doing more harm by overly cutting back on our prescription of antibiotics.

If we can nip an infection in the bud, we can prevent much morbidity.  Morbidity is like a forest fire – catch it early and you can prevent a massive conflagration.

A massive conflagration of bacterial infection can paradoxically cause more antibiotic use.

Maybe what we should be more aggressive with antibiotics.

Some people argue that doctors prescribe too many antibiotics.

But it isn’t as if doctors are handing out antibiotics on the street corner.

We have a controlled process in the United States.

We have a closed pharmacy.

We are already doing enough to control resistance.

But by cutting back on antibiotic use for people WHO ARE SICK, we are effectively increasing contagion by allowing more people to get sick.

Let us define contagion in the following way:

Contagion = Number of Sick People x Overcrowding x Poor Sanitation.

WARNING!

By badgering doctors to stop prescribing antibiotics we will increase the number of sick people and cause more antimicrobial resistance.

Thus we will validate the contagion theory that this doctor from Australia, Peter Colignon, was talking about.

SO WHAT’S THE SOLUTION?

The solution is to develop new classes of antibiotics.

There are many areas worth investigating.

If we think we have developed all the ways to kill a bacteria, that is surely a testament to our arrogance.

Indeed, there are many exciting areas to explore.

Why, just the other day, I was cuddling up next to the fireplace with the latest issue of Molecular Cell, a lively, witty magazine.

I was looking at this article: Inhibiting the Evolution of Antibiotic Resistance. Molecular Cell. Volume 73.  Issue 1.

Surely this made the NY Times bestseller list.

In this particular article the authors, Ragheb, et. al, discuss a mutagenesis factor in the bacteria which if shut down could inhibit bacteria from mutating.

Now, this is an avenue, among many, that should be explored.

Yes, it may be a blind alley. Or, it may not even be advisable to shut down the mutability of bacteria.

That’s not the point.

The point is that Big Pharma should be aggressively investigating these avenues.

Are they?

Many say they are not.

Why not?

WHY DOESN’T BIG PHARMA CARE?

They don’t have to care anymore.

They’re too big to care.

There has simply been too much consolidation within the healthcare industry.

Big Pharma is too big.

Their only concern now is profits.

The leaders of their firms are financial guys, not pharmaceutical guys.

One of their false gods is precise cost accounting.

They believe that every single drug must be justified on its own merits.

If they can’t see the profits in it, they don’t go down that road.

This isn’t like the old days where the leader of the firm would take a chance on an idea.

Furthermore, the antibiotics that they have currently are already making them enough money.

They are not thinking ahead to the day when the new antibiotics might be necessary.

There are no profits in that.

They are not statesman; they are profiteers.

But that is not the only reason why they do not innovate.

There is an even darker reason.

THE NEW WORLD ORDER

Do you believe in the New World Order?

You better.

Although Big Pharma loves nothing more than profits, sometimes their profits have to take a back seat to a larger concern.

Control.

Big Pharma is now controlled fully by the elites.

The elites look at medicines as a weapon they can you use to control you.

Antibiotics are a major part of that arsenal.

By depriving you of antibiotics, the elites can keep you a little more sick and dependent upon them.

You see, the elites view antibiotics as medicines for them, not you.

Why, what would happen if the commoners kept using antibiotics, they ask themselves.

Pretty soon, they answer, we won’t have useful antibiotics for ourselves.

That just won’t do, they conclude.

So rather than spend money that can be better used for their new yacht, they convince you that antibiotics don’t work.

They enlist their academics to convince you.

But you know better.

You know that antibiotics work.

Antibiotics put out fires and keep you out of the hospital.

That is precisely the point.

If you get sick as an outpatient and can’t get timely medicines, you are more likely to enter the hospital.

This is a bad thing for you.

But it is a good thing for Corporate America.

They make more money this way.

That improves their bottom line.

Is this too dark for you?

Think again, Pollyanna.

In Pennsylvania not too long ago, a judge was sent to prison because he was sending children to juvenile detention in exchange for kickbacks.

Men are evil and will game the system any way they can.

The days are gone when Big Pharma engages in innovation unless there is an extreme profit motive.  They don’t have to care.

Big Pharma is a quasi governmental entity], entrenched with elites.  They are ossified.

We won’t see innovation like we used to.

Their CEOs aren’t emotionally invested in their company.

This is a bd thing because we need new antibiotics.

Antibiotics work.

I know it with my patients and with me.

Patients have figured it out also.

That’s why bodegas sell antibiotics over the counter.

People in the 3rd World have figured it out.

And we need antibiotics even though the academics say we have don’t.

Academics don’t understand how infections begin.

How do infections begin?

Most respiratory infections begin as viral infections.

After a few days, the bacteria set in and what you get as a mixed infection.

By the time you visit your doctor, you probably have a mixed infection. There are probably bacteria in there.

This is why antibiotics work. The antibiotics work against the bacteria that are in the mixed infection., Now, your academic will tell you that your infection is either pure viral or pure bacterial. This is not true.

The majority of infections are mixed.

By aggressively treating with antibiotics we can get people better faster.

Not only will we be decreasing morbidity and mortality, we will also be decreasing contagiousness.

Not prescribing antibiotics aggressively will cause increased contagiousness which in turn will cause more infections which will paradoxically cause more antibiotics to be prescribed.

The road to hell will be paved with good intentions.

Sincerely,

Archer Crosley

Copyright 2021 Archer Crosley All Rights Reserved