Alas, Poor Newsweek

Next year Newsweek magazine will celebrate the 80th anniversary of its founding.  Earlier this month it was announced that the print edition will not reach that anniversary.  The magazine is going digital-only and will be called Newsweek Global.

Over the years I have subscribed, at various times, to the three traditional print news weeklies: Time, Newsweek, and US News & World Report.  As I reflect upon how long it has been since I received a print copy of any of the three of them, I realize it shouldn't surprise me in the least that Newsweek is succumbing to a changing market.  In the magazine business it is referred to as a "challenging" situation for print advertising.  Challenging, indeed.

It is difficult to make money on print advertising when print circulation is declining. Furthermore, it is easy for advertisers to tell whether online readers actually pay attention to the ads, because they click on them. No click means the ad was ignored.  You just can't tell, with a print ad, whether the reader even noticed.

[It is interesting, then, that in some lines of publishing - medical journals being an example - advertisers still want print ads in print journals, even though they know more and more readers are reading the journals electronically.  I'm still trying to figure that out, and I suspect they are, too.]

I cannot help wondering what the long-term future of news publications holds. There are so many sources of news and opinion online that are free (once you have Internet access and a device that allows you to connect and read).  People will surely expect it to be free, and if you want to charge for it, you will have to offer something of value readers cannot get elsewhere.  Otherwise they'll be thinking, hey, if your competitors can make it on ad revenues alone, why can't you?

When the New York Times started charging for online content, I started looking elsewhere for high-quality news reporting.  I thought, gee, if The Washington Post is still free, why should I pay for the Times?  It's not like their journalism is clearly superior.  They may be called the "newspaper of record," but they are also the newspaper of Jason Blair.  Woodward and Bernstein wrote for the Post.

By nature I am conservative, a creature of habit who prefers the traditional and opposes change that seems to have no impetus beyond a desire for change. However, as much as I am a creature of habit, even my habits change.  And sometimes they have help from unexpected sources.

I used to read a local newspaper.  Then we got a new carrier.  He refused to put the paper in the delivery box.  It was too much trouble.  Emails to the home delivery department of the paper resulted in his putting the paper in the box for a week or so, and then he'd go back to tossing it in the driveway.  The problem was inclement weather, in which a plastic wrapper was inadequate to the task of keeping the paper from becoming an unreadable, sodden mass by the time I got home.  A long series of emails, each followed by an all too transient change in delivery and then a return to bad behavior, led to the end of my print subscription.

I now read local news - when I want to subject myself to bad reporting and worse writing - online, without paying for a subscription.

Two years ago Newsweek merged with The Daily Beast, a news and opinion Web site.  Selected content from the new Newsweek Global will be made available via The Daily Beast.
Full subscription to Newsweek Global will be paid.  It will be interesting to see whether people will be willing to pay the extra money for that.  Maybe I'll start reading The Daily Beast to see what is being done under the editorial leadership of Tina Brown.

So far I haven't done that, largely because it never occurred to me that something with that name could be taken seriously.

I know one shouldn't judge a book by its cover, but how can one not judge a publication when its creators give it a name like that?

The target readership for Newsweek Global will be "a highly mobile, opinion-leading audience who want to learn about world events in a sophisticated context."  I'm not sure how highly mobile I am, because I've been living in the same township for 27 years.  I like being an opinion leader, however.  (Except when the drug companies want my help with marketing.  Then I just tell them they won't like my opinons.)  I desperately want to learn all I can about world events, and I long for sophistication.  So I may just have to check this out.  Except for that one nagging drawback: they'll expect me to pay for it.  Hmmm.  Maybe they'll have an introductory offer that will be too good to pass up.

I will still have to find something else to read in the barbershop.  Popular Mechanics, anyone?

Check the Earthquake Forecast

Last week I wrote about the decision by the Italian supreme court validating the claim of a plaintiff who said his cell phone caused him to develop a brain tumor. The science was, shall we say, sketchy.

But now another Italian court has rendered a decision that cannot be called anything but stunningly irrational.

On March 31, 2009, Italy's National Commission for Prediction and Prevention of Major Risks met to consider the significance of a series of minor tremors (an earthquake "swarm") in central Italy's Abruzzo region.  Enzo Boschi, president of the National Institute of Geophysics and Volcanology, was asked if the swarm was a portent of a major quake in the immediate future.  Boschi said it was possible but unlikely.  The city of L'Aquila was struck by an earthquake six days later: magnitude 6.3, causing the collapse of tens of thousands of buildings, leaving more than 67,000 homeless and 308 dead.

The international consensus among geophysicists and seismologists is that the current state of scientific knowledge does not permit the prediction of earthquakes with any sort of precision or accuracy.  Thus we read about the likelihood that a particular region will likely suffer a major quake some time in the next century.  This is not exactly the sort of information on which you can base any short-term decisions, such as whether to evacuate a city, although you might choose not to live in a quake-prone region, just as many decide against living along parts of the Atlantic coast frequented by tropical storms and hurricanes.

I live in southwestern Pennsylvania, where we don't get much in the way of natural disasters.  Earthquakes and tornados are rare, and we get only remnants of hurricanes.  But I've been in a few car crashes on icy roads, which folks who live in hurricane and earthquake zones generally don't have to worry about.  So nothing is perfect.  We all make our choices.

But now seven members of the Commission have been convicted of manslaughter for failing to predict the major quake and issue a warning.  Their sentence - likely to be appealed - is six years in prison.

This truly defies reason.  In June 2010 an open letter was sent to the Italian president from the American Association for the Advancement of Science, which is the world's largest general scientific society and publisher of the internationally renowned and prestigious journal Science.  The letter, urging the dismissal of charges against the Italian commissioners, said:

Years of research, much of it conducted by distinguished seismologists in your own country, have demonstrated that there is no accepted scientific method for earthquake prediction that can be reliably used to warn citizens of an impending disaster. To expect more of science at this time is unreasonable. It is manifestly unfair for scientists to be criminally charged for failing to act on information that the international scientific community would consider inadequate as a basis for issuing a warning.

In a disturbing similarity to the kinds of things that happen in American civil courts, there was emotional testimony from witnesses who had lost loved ones in the quake - the sort of testimony that should have been considered irrelevant and highly prejudicial, and therefore excluded.

It is very difficult to imagine how competent jurisprudence could have failed to rely on the best scientific evidence and reach the conclusion that, tragic though the outcome surely was, no standard of criminal (or civil) negligence could possibly exist under which the Commission should be held responsible.

We have so much more to learn about earthquakes and other natural disasters. Perhaps some day scientists will be able to tell us when and where an earthquake will strike, much as we now get fairly accurate warnings about hurricanes, giving authorities days to order evacuations and spare many lives.

In Japanese mythology, the Namazu (鯰) is a giant catfish who lives in the mud under the island nation and causes earthquakes.  He is generally restrained by the god Kashima, but when Kashima becomes complacent and lets his guard down, the catfish thrashes about, and earthquakes result.

In modern science, Namazu has been replaced by plate tectonic theory.  But it seems the Italian legal authorities think their seismologists must be Kashima.

Cell Phones and Brain Tumors

Are cell phones harmful to your health?  From personal experience I can say yes.

Over 20 years ago, when a cell phone had the size, shape, and heft of a brick, holding my phone for frequent, lengthy calls, the phone against the right side of my head, my right elbow flexed to a very acute angle, gave me a nasty case of lateral epicondylitis (often called tennis elbow).

Such conditions don't make headlines, but brain tumors do.  You may have read about the recent decision from SCORI.  (I made up that acronym.  The Supreme Court of the United States is often called SCOTUS for short, so why not do the same for the Supreme Court of Repubblica Italiana?  OK, OK, for those of you who are fussy about accuracy, the Italians actually call it Corte Suprema di Cassazione.)
Anyway, the Italian court ruled that a businessman who said he held a cell phone to his left ear, with his left hand, often while taking notes with his right hand, six hours a day for twelve years, had a valid claim when he said this caused him to develop a benign tumor of one of his cranial nerves.  Testifying on behalf of the plaintiff were a neurosurgeon and an oncologist who specializes in environmental factors contributing to cancer.

Dr. Marco Coppola,
Speaker of the ACEP Council

Never having made a study of the Italian system of jurisprudence, I have no idea what the standards of evidence are.
I also have no way of knowing what the expert witnesses said.
Even if I could get transcripts of their trial testimony, I would have to get someone to translate them for me.
(Marco, would you help me with that?)

What I do know, however, is that Italian courts must work a lot like ours do, because the overwhelming weight of the evidence in the published scientific literature fails to support a causal link between cell phone use and development of brain tumors.

To be fair, it is entirely within the realm of possibility that the amount of use described by the plaintiff in this case caused his tumor.  The scientific evidence does suggest that extremely heavy use might be a problem.  But if the standard of evidence were "clear and convincing," that wouldn't make his case.  Even with a "preponderance of the evidence" standard, it should have fallen well short.  So I am forced to conclude that in handling civil torts of this nature, the Italian courts operate the way ours do: maybe it was their fault, so we'll give you lots of their (or their insurance company's) money.

My own review of the literature found more than a dozen studies of varying design and variable quality in methods and statistical analysis.  Nearly all failed to find a link (let alone causation) between cell phone use and brain tumors.  Note that I said "nearly all."  There was one well-done Swedish epidemiologic study that showed a link to the development of a certain type of benign tumor (similar to the one afflicting the plaintiff in the Italian case) for people who were very heavy users of cell phones for more than a decade.  Again, this is an association, which doesn't prove causation.  But I suspect this is the study on which the Corte Suprema di Cassazione relied.

I found it interesting that, in an interview with the British tabloid The Sun, the oncologist said, "The court decision is extremely important.  It finally officially recognizes the link.  It will open not a road but a motorway to legal actions by victims.  We're considering a class action."  What this quotation tells us is that the witness was serving not as an impartial expert on the relevant scientific evidence but as an advocate for the plaintiff.  Such behavior on the part of experts, which is all too common in U.S. courts too, does not aid the search for truth or advance the interests of justice.  Those among my readers who know enough about the American legal system to have become appropriately cynical are now smirking at the notion that truth and justice play any role at all.

The more I observe use of cell phones and smartphones nowadays, the more convinced I am that all these concerns about brain tumors are rapidly becoming passé.  First, many users do more texting than calling.  A recent study showed three times as many texts as voice calls for the average user, and the proportions favor texting even more heavily among younger users.  Second, hands-free calling is becoming more common all the time.  In some states only hands-free use is legal while driving a car.  There was a time, not that long ago, when a person using wireless, hands-free (bluetooth) technology would be perceived by others as likely schizophrenic, apparently having an animated conversation with himself. But bluetooth is now so common that no one even notices such behavior.  All this hands-free use means the phone is nowhere near the head.

But for those who like to worry about adverse effects of technology on our health, go right ahead and keep worrying. You now have "texting thumb" to obsess about.  Not as frightening as a brain tumor, perhaps.  And you could solve the problem by using an Android phone with a Swype keyboard.  But then you'll have to find something else to fret over.

I am happy to oblige.  Phones cause far more trouble when people use them while driving.  In order of risk, texting > handheld calling > hands-free calling.  And how many people have you seen texting while walking? They shouldn't be trying to cross streets when they're texting.  This is like a blind person crossing the street with neither a guide dog nor the heightened sense of hearing that the blind possess.  We like to multi-task, but we should remember that some tasks are just not meant for "multi" - unless you like to live dangerously.

The Emergency Department as Health Insurance

It was bad enough when George W. Bush told us the poor have access to health care because they can just go to the ER.  We had come to expect W to say dumb things.  But Mitt Romney?  I expected better.  Yes, I know, I piled on when the Brits called him a "wazzock" for ill-considered remarks he made last summer in connection with the Olympics.  And, in fairness, he didn't say the ED is a substitute for health insurance.  He merely pointed out that the poor are not dropping dead of heart attacks in the streets for want of health insurance, because our EMS colleagues pick them up and take them to hospitals, where they receive care.  But, for those with little depth of understanding of the consequences of being uninsured, Romney's remark reinforces a very foolish notion.

Earlier this month I addressed the Council of the American College of Emergency Physicians.  My subject was the problem of the uninsured.  Here is an excerpt of that address.

                          **************************************************

Today I want to talk to you about a woman I met in August.  I’ll call her Nancy.  Nancy came to see me in the emergency department.  She was coughing up blood.  I took a quick look at her records.  Fifty-seven years old.  Diagnosed in July with lung cancer.  

Wait a minute.  That was July of 2011.  Not a month ago, but thirteen months ago.  She must be going somewhere else for her cancer care.

“Where?” I asked her.

“Nowhere.  I lost my job and my health insurance.”

I asked about COBRA, or the possibility that she might have become eligible for Medicaid or Medicare.  She looked at me blankly.  Everyone else she knew who had lost health insurance simply went without health care.  She assumed that was her lot.  She focused on finding a new job.  She was still working on that.

I ordered a CAT scan of the chest and compared it with the old one.  I explained the difference to her.  She told me she had a grandson who was about to start twelfth grade.  She looked into my eyes, through her tears, and said, “I’m not going to get to see him graduate, am I?”

ACEP has long had a policy position advocating universal coverage.  So have several other medical professional organizations: the AMA, the American Academy of Family Physicians, the American Academy of Pediatrics, and the American College of Surgeons among them.

Harry Truman sought universal coverage.  We made some progress in the 1960s with Medicare and Medicaid.  But we have fifty million uninsured.  And even with the passage of the Affordable Care Act, we stand to make only modest inroads.  Those newly covered under Medicaid are supposed to have equal access, but that is true only if you accept an Orwellian vision in which some are more equal than others.

Why can’t we get there?  Because most Americans have health insurance.  In the abstract they support universal coverage, just as we do.  But when you get down to particulars, they don’t want any changes that will affect what they have. And they balk at the prospect of higher taxes, even when they are told that access to longitudinal primary care for those with chronic diseases can save money.

The public must understand that the uninsured are everyone’s problem.  This is partly a matter of social justice.  It is also a matter of providing health care to all in the most cost-efficient way possible.

It is not enough to adopt this as an advocacy position if doing so does not influence the national debate. There are 850,000 licensed physicians in the United States.  If we all tell the public in a loud, clear, united voice that the status quo is unacceptable, we can transform public opinion.

Why should ACEP take the lead on this?

Emergency physicians provide more uncompensated care than doctors across all specialties by a factor of ten.  We can stand up and say this.  We can say we do this because we have always believed it is our ethical duty.  We wear this as a badge of honor.

But when the wealthiest nation in the history of the world has fifty million uninsured, that is a badge of shame.

We must take the lead in carrying this message to the public, and we must get all of our colleagues across all specialties to join us.

How do I know this is what we must do?

I know what Nancy’s grandson would say.  Shout it from the rooftops - and the studios of CNN.  Go tell it on the mountain - and the pages of the Wall Street Journal.  With strong physician leadership,  America can solve this problem. 

                         **************************************************

So, Romney is right.  If you're having a heart attack, you don't have to sit at home and wait to die because you have no health insurance.  You can call 9-1-1, and you will be taken to a hospital ED and receive excellent health care.

But you might never have gotten to that point if you'd had health insurance and primary care to manage your high blood pressure, high cholesterol, or diabetes. Sometimes an ounce of prevention is worth ... well, you know what it's worth. And so does Mitt Romney.  We all do.  So why are we being penny wise and pound foolish?

Nuclear Iran?

Earlier this week I attended worship services on the Jewish High Holy Day called Yom Kippur.  Falling on the tenth day of the month that begins with Rosh Hashanah, the Jewish New Year, Yom Kippur is the culmination of ten days of penitence and reflection and is called the Day of Atonement.  For me it is always a day of deep thinking - about the year past and the year just begun and what I must do to become a better person.  But this is also a time of more general reflection.

Often on Yom Kippur I remember how I felt in October, 1973, when a coalition of Arab states led by Egypt and Syria launched a war against Israel on this holiest day of the year.  It was a mere six years after the Arabs had been routed by the Israelis in June, 1967.  It was the second major event of the Arab-Israeli conflict to occur in my lifetime, and I was just a teenager.

This conflict is a subject that has fascinated me at least as much as any other in history.  It goes back to the late 19th century, to the rise of Jewish Zionism and Arab nationalism, the quest to create a Jewish homeland in biblical Israel conflicting with Islamic beliefs about their own religious and historical claims upon the land.

The early Zionists recognized that the Arabs would fiercely resist the creation of a Jewish state in biblical Israel.  They believed they must build a military power that would be capable of crushing every Arab effort to thwart the goal of a Jewish homeland.  They believed that with such an "iron fist" approach - with each new attempt to destroy their dream beaten back more decisively than the last - they could ultimately convince the Arabs that there must be a lasting, peaceful coexistence.

The wars of 1948, 1956, 1967, and 1973 did not seem to create much progress on the path toward Arab recognition that Israel as a Jewish state was there to stay.  Then, in the late '70s, the signal foreign policy accomplishment of the Carter Administration, the Camp David Accords, brought peace between Israel and Egypt, and Jordan soon followed.

During the three-plus decades since, however, there has been little peace.  The conflict between Israel and the Palestinian Arabs living in the West Bank and Gaza has waxed and waned.  Arab terrorist attacks launched against Israel from Lebanon and Syria, with strong state support from Iran, have been met by Israeli counter-attacks.  Ever-lengthening periods of intense bloodshed have been broken up by ever-shortening and increasingly tenuous ceasefires.

Peace has been most elusive.  Efforts by the United States and other Western powers to encourage negotiations have met with repeated failure.  No American president since Jimmy Carter has had so much as a glimmer of success in advancing the cause of peace.  The Israelis face an existential threat from an Arab world that mostly refuses to recognize the Jewish state's right to exist.

Militant Islamic fundamentalists have been especially intransigent on this point. On the flip side of Carter's success at Camp David was the change of regimes in Iran that took place during the late '70s, when the pro-Western ruler Mohammad Reza Shah Pahlavi was overthrown, after nearly four decades in power, and replaced by an Islamic Republic led by Muslim clerics.

Historians will surely long debate whether Carter deserves significant blame for the rise of the movement to establish Islamic religious law in Iran and throughout the region.  Surely the Shah himself deserves most of the blame.  The oppressive nature of his regime, the growing chasm between rich and poor, and the way in which he approached the modernization and secularization of Iran were all important factors.  But the end result was that the success of Camp David was historically paired with events that would prove an ill portent for peace in the region.

It now involved not only the Israelis and the Palestinians and the terrorist movements inflamed by the Palestinian cause.  The Iran-Iraq War consumed the 1980s with violence that cost at least half a million lives.  But the conflict between Israel and the Arabs continued, with the Intifadas of the late '80s and early '90s, and the first half of the first decade of this century.  There have been many battles between Israel and terrorist groups in southern Lebanon.  Iran and its surrogate Syria have fueled the incessant war with money and supplies for the terrorists.

Israel has long understood it is in a constant state of war over its very right to be as an independent Jewish homeland.  In June 1981 the Israelis launched an air raid that destroyed the Iraqi nuclear reactor at Osirak.  The United Nations Security Council passed a resolution condemning the raid.  The United States voted in favor of that resolution.  The irony of our participation in that condemnation when, a decade later, we launched the First Gulf War, was rich indeed.  President George H.W. Bush said Iraq's invasion of its neighbor Kuwait "shall not stand."  Would he have been able to say that with any confidence - if at all - had Iraq developed nuclear weapons by then?  And would that not certainly have been the case had Israel not destroyed the reactor at Osirak?

It is now Iran that represents the most serious existential threat to Israel.  Iranian President Mahmoud Ahmadinejad has repeatedly called for Israel's destruction. He has denied any biblical claim the Jews may have to the land they "occupy." He also denies that the Nazi Holocaust - perhaps the most obvious and tangible reason for the creation and security of a Jewish Homeland - ever occurred.

Now it is Iran that is fervently working to develop nuclear weapons, enriching uranium in an ever-growing number of accelerators.  Economic sanctions have proven to be no deterrent.  Israeli Prime Minister Benjamin Netanyahu has appeared before the United Nations to urge the entire "international community" to draw a "red line" that Iran must not be allowed to cross.

The United States has drawn no red line.  The United Nations will draw no red line.  Some in the United States seem to believe that it is none of our business if Iran wishes to acquire nuclear weapons.  Others say it will be regrettable, but that a nuclear Iran can be "contained" the way we contained the Soviet Union.  But can a doctrine of mutually assured destruction be effective in dealing with an enemy that is surely willing to trade many Iranian lives for success in (literally) wiping Israel off the map of the planet, when there are hundreds of millions more Muslims around the globe?

So it appears that only Israel will draw a red line.  When - not if, but when - Iran crosses that line, will Israel have to act alone to prevent the spectre of a nuclear-armed Iran from becoming a reality?  And if that happens, will the United Nations Security Council pass another resolution condemning Israel?  Will that resolution have U.S. support?  Will we ever learn anything history has to teach us?

Ask a Nurse - or Do You Really Need a Doctor?

There is a shortage of doctors providing primary care in the United States.  No matter how you look at the statistical projections of the growing population and the growing proportion of us who will be older and bear a greater burden of chronic disease, it is clear that we will need more doctors.  And, no matter how you look at projections of the supply of doctors, and especially those providing primary care, it is clear that the supply will fall well short of demand.

A colleague of mine recently sent me an article from one of the leading trade publications outlining the many reasons today's physicians find the practice of medicine frustrating and stressful, including ever-increasing and time-consuming government regulations that are seen as mostly inane and useless.  The other major stressor is constant worry about being sued any time there is an adverse outcome.  We live in a culture of blame, and when a patient experiences an adverse health outcome, the finger of blame will naturally point at his doctor.

So, at just the time when we need more doctors, today's physicians are less satisfied with their work, which means they are deciding to work less, retire earlier, and dissuade their offspring from choosing this profession.

Perhaps, as a society, we should be trying to reverse the trend and make the medical profession more attractive.  But wait.  There is another possibility. Physicians aren't the only ones who can do this job.  There are nurse practitioners.  They can do many of the things doctors can do in primary care. They will work for less money.  What a deal!

If someone can do a job as well as the last person for less money, that has great appeal as a "value proposition."  And the value proposition is important in healthcare when the percentage of our GDP that we spend on it has reached the high teens.

So what about nurse practitioners in primary care?  Do they do as good a job for less money?

To answer that question, we need a lot of data.  We need data on costs and outcomes.  And we need data on outcomes both short-term and long-term.  I'll come back to that in a bit.

If you have a cold or a sore throat and go to a retail clinic or urgent care center staffed by nurse practitioners, you will probably get a lower bill than if you went to see a doctor.  That suggests a favorable value proposition.  But sometimes things are not simple and straightforward, and sometimes you need someone with a deeper understanding of your problem.

Last week a woman sustained a minor head injury and went to an urgent care. The nurse practitioner looked her over and told her she should go to the hospital emergency department.  She followed that advice.  After waiting several hours - because it was Monday, and emergency departments are often crazy busy on Mondays, which means long waits for those who are not critically ill or injured - she saw a doctor.  The doctor took a history and did a proper neurologic examination.  Drawing on a deeper understanding of head injuries and a thorough familiarity with what the scientific literature tells us about the proper way to evaluate patients with head injuries, the doctor told the patient she did not need a CAT scan of the head - which was the main reason she had been sent to the ED.

So now the patient has a visit to an urgent care, to which has been added a visit to an ED, where she had to wait a long time, and for which she will get a second bill, higher than the first one.  How's the value proposition now?

About now you may be thinking, couldn't we just teach the nurse practitioner how to do a better job evaluating the patient with a minor head injury?  Sure we could. We could teach the nurse practitioner how to do a better job at just about anything.  That would take some time, though.  And the reason doctors are more expensive than nurse practitioners is that it takes longer to train someone to that level.  You see where I'm going with this.

To the best of my knowledge, there are very limited data on outcomes in primary care - and no long-term outcomes data - comparing physicians with NPs.  Such an absence of data leaves me free to answer the question based entirely on my opinions - which, as you know, are invariably carefully considered, unassailable in their logic, brilliant in their exposition, and wise beyond compare.  Oh, and they are always correct.  *Now extracting tongue from cheek, not without considerable difficulty.* 

My internist is a fellow who was several years ahead of me in training.  When I go to see him, I know he will follow all guidelines-based recommendations for primary and secondary prevention of chronic diseases.  I know a primary care nurse practitioner would do the same thing.  I admit to preferring the physician over the nurse, because if I have questions about the science underlying the recommendations, I know which one is more likely to be able to answer them to my satisfaction.

I am also aware that sometimes I need an internist to do more than follow guidelines and recommendations for my healthcare.  Sometimes I need him to figure out what is wrong with me.

And there is something else that comes into play here.  Sometimes knowing more and having a deeper understanding leads to doing less.  (Recall the simple example of the minor head injury.)  Very often a smart doctor can figure out what is wrong with you by taking a focused history, asking all the right questions, and doing a careful physical examination for signs of disease.  The doctor may be 93% sure about what is wrong with you without doing any tests.  Imagine how much money could be saved if you trust his clinical judgment and give him permission to refrain from spending any of your money on tests to raise the diagnostic certainty from 93% to 99%.

I have worked side-by-side with nurse practitioners for nearly three decades, including some I've thought were very capable.  I am still waiting to meet a nurse practitioner I might judge to be an astute diagnostician.

This is hardly surprising.  One can become a nurse practitioner by starting as an RN/BSN and taking an online master's degree program, while an internist has four years of medical school and three years of residency after the bachelor's degree.  To expect the two to have similar abilities in the aspects of practice that rely on a foundation of education in the sciences is quite unreasonable.

Let us begin with the assumption that, among bachelor's-degree RNs, only the best and the brightest decide to go on to earn master's (or doctoral) degrees and become nurse practitioners.  Now I'm going to look at that population of students and ask a simple question.  How many of them would do well in the year of organic chemistry required of pre-meds and commonly used as a "weeder" course?  My daughter Rose is very bright and hard-working.  I know this because I lived with her in the same household for nearly two decades.  And I saw how hard she had to work to get grades in organic chemistry last year that would meet with the approval of a medical school admissions committee.

Do you have any children still in school?  Think about the smartest kid in your child's class.  Maybe it's your kid.  That kid could go to medical school or law school or choose any other of a number of career paths.  Now remember, she's the smartest kid in the class.  When you are older and sick, what do you want her to be?  Do you want her to be the consultant other doctors call when they are trying to figure out how to keep a perplexing illness from killing or disabling you? Or do you want her to be the lawyer your family calls when things don't go well and they want to find out whether your doctors are to blame?

I believe the bottom line is very simple.  If we want excellent medical care in the United States, we need excellent doctors.  If we want excellent doctors, we must understand the importance of getting the best and brightest of our nation's youth to choose this profession.  Some of my older colleagues believe the "golden age" has passed for the medical profession, and the practice of medicine will never be as enjoyable or rewarding as it once was.  I believe we can and must bring back that golden age.

Of Politics and Facebook

Your repeated status updates, expressing your political views with ever-increasing fervor, have finally brought me around to seeing things your way -     said no one, ever.

I have seen postings saying something along these lines several times in recent weeks, from people who have grown weary of the Facebook polemicists.  It has gotten me thinking about the style of political expression in this forum.

Never having had any formal education in rhetoric, what I have learned through observation over the years is that the best way to influence the thinking of others is to set forth the various perspectives on an issue and carefully build an argument that demonstrates, in a cogent fashion, why one view is more compelling than others.

It seems there isn't much of that on Facebook.  Instead, from Facebook I have learned that Mitt Romney hates dogs.  He puts them on the roof of his vehicle and then drives at high speeds in the most extreme weather conditions, frequently passing through tunnels with clearance barely greater than the height of his conveyance.

I have learned that Barack Obama was born not in the United States but rather in Africa, or perhaps a distant galaxy, and his goal is to invite aliens from far away to take over the U.S., if not the entire planet.  Oh, and he is a Muslim whose lifelong best friend is an extremist black preacher who hates white America.

If Romney is elected, all of the important social welfare programs enacted in the 1960s will be immediately abolished.  Old folks will have no health care and will languish in poverty, eating the cheapest store-brand dog food they can find.  The poor will all be living in discarded packing boxes from large appliances, fighting each other for spots above the grates on city sidewalks that bring up warm air from below street level.

If Obama is re-elected, on the other hand, those whose family incomes place them just barely above the middle of the Middle Class will have every penny of income that they don't need for subsistence at a Third World standard of living confiscated.  It will then be used to "spread the wealth around," which means giving it to the least deserving of the undeserving poor: those too lazy to lift a finger to earn a living, who will then be able to keep themselves supplied with the latest electronic gadgets - and recreational drugs aplenty.

Romney will ensure that the super-rich get richer by the day, moving all of their money offshore to escape U.S. taxes, just as he himself has always done.  Not only will they not pay their fair share; they will pay no taxes at all, and they will receive subsidies so they can hire accountants and lawyers to make it look as though they have given plenty of money to the government and most of the rest of what they have inherited to charity.

Obama believes that no one has ever built anything by dint of individual effort.  He could come upon a five-year-old sitting alone while all her classmates are outside at recess playing, diligently working on a large and complex Lego project, and breezily assert: "You didn't build that.  The government built that. Don't expect any credit or recognition for your labor or creativity.  The only thing that matters is the collective."

Romney intends to shrink government.  He speaks with disdain of the Congress that spent a billion dollars in '89-'91.  Not 1989, but 1889.  That Congress spent money to help the widows and orphans of military veterans.  None of that bleeding heart stuff if Romney wins this year.

If Romney is elected, students will be able to go to college only if their parents have the money, but Obama will ensure that it's free for everyone - at least everyone who has always depended on the government to give them other people's money.

In Romney's America, everyone will borrow money from their parents and start small businesses.  If their parents have no money, the new generation will just have to find their own bootstraps and pull hard.  No such problems under Obama. We won't need any small businesses.  The government will build everything.  It always does.

Barack wants his daughters to have every opportunity that your sons have.  He also wants everyone's daughters to have all the birth control pills that someone else's money can buy.  Surely he will also fund a government program to arrange daily text messages to remind women to take their birth control pills.  Mitt will let you know exactly what he thinks of this immoral, profligate plan just as soon as he is finished waging his war on women.  Oh, and in case you were wondering, Mitt wears magic underwear.  Barack goes commando.

Obama will stop global warming and heal the planet.  Romney will focus on making life better for you and your family, comforted by the knowledge that people will really like the Atlantic and Pacific oceans much better as vast hot tubs. Never mind those rising sea levels.

Everything the two candidates and their surrogates ever say about the opposition is a lie.  The only real question is just how big the lies are, and how loudly and how often they are repeated.

All I can say is, it's a good thing we have fact checkers.  These are people we can depend on to ferret out the truth and give us the straight scoop, so we know what to believe and can make up our minds based on facts, not half-truths and innuendo.  These fact checkers have no agenda of their own, no political point of view, no bias that might influence their findings.  Their only interest is in finding the unvarnished reality and showing it to us.

And that bacon you're eating for breakfast came from pigs that were shot by hunter Paul Ryan as they flew overhead on their way to hear Joe Biden tell us how history will show Barack Obama is the best president the United States has ever had.