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The Winkler County nurse case and the problem of physician accountability

A MISCARRIAGE OF JUSTICE THAT HAD A (SORT OF) HAPPY ENDING

Back in September and then again last week, I wrote briefly (for me) about an incident that I considered to be a true miscarriage of justice, namely the prosecution of two nurses for having reported the dubious and substandard medical practices of a physician on the staff of Winkler County Hospital in Kermit, Texas. The physician’s name is Dr. Rolando Arafiles, and he happened to be a friend of the Winkler County Sheriff, Robert Roberts, who also happened to have been a patient of Dr. Arafiles and very grateful to him for having saved his life. The nurses, Anne Mitchell and Vickilyn Galle, were longtime employees of Winkler County Hospital, a fifteen bed hospital in rural West Texas. Although some of you may have seen extensive blogging about this before, I thought it very important to discuss some of the issues involved on this blog. Moreover, there is an aspect to this case that the mainstream media reporting on it has missed almost completely, as you will see. Finally, this case showed me something very ugly about my profession, not just because a doctor tried to destroy the lives of two good nurses through his connections to the good ol’ boy network in Winkler County

Let’s recap what happened, a story that reached its climax last Thursday. In 2008, Dr. Arafiles joined the staff of Winkler County Hospital (WCH). It did not take too long for it to become apparent that there were serious problems with this particular doctor. Mitchell and Galle, who worked in quality assurance were dismayed to learn that Dr. Arafiles would abuse his position to try to sell various herbal remedies to patients in the WCH emergency room and the county health clinic and to take supplies from the hospital to perform procedures at a patient’s home rather than in the hospital. No, it wasn’t the fact that Dr. Arafiles recommended supplements and various other “alt-med” remedies, it’s that he recommended supplements and various other “alt-med” remedies that he sold from his own business–a definite no-no both ethically and, in many states, legally. Mitchell reported her concerns to the administration of WCH, which did pretty much absolutely nothing. Consequently, on April 7, 2009, Mitchell and Galle anonymously reported their concerns to the Texas Medical Board (TMB). In June, WCH fired the two nurses without explanation.

That’s bad enough, but happened next is about as appalling as it gets. When Dr. Arafiles received a letter from the TMB informing him that he was being investigated, he went to his good buddy and patient Sheriff Roberts, who suddenly transformed from a small town sheriff to Jack Bauer on crack. Showing an initiative that one would think would normally be reserved for thieves, rapists, and murderers, Sheriff Roberts set himself to discovering the identities of the anonymous complainants against Dr. Arafiles with a vengeance. He interviewed each and every patient listed in the anonymous complaint, asked WCH administration to tell him which of its personnel would have had access to these patient records, and obtained a copy of the anonymous complaint. The description of the nurses as “females over 50″ allowed him to narrow down the possibilities to Mitchell and Galle. Sheriff Roberts then obtained a search warrant for Mitchell’s computer at WCH and found a copy of the letter of complaint on it. As a result, Sheriff Roberts charged Mitchell and Galle with the “misuse of official information,” a third degree felony that carries a potential penalty of 2-10 years in prison.

Yes, prison.

It also turns out that the sheriff had at some time in the past been in business with Dr. Arafiles selling a nutritional supplement called Zrii, even going so far as to hold meetings at the local Pizza Hut to recruit new sellers in what sounds very much like a multilevel marketing scam. Apparently unperturbed by his massive conflict of interest, the Sheriff apparently convinced Winkler County Attorney Scott Tidwell to forget Article 2.01 of the Texas Code of Criminal Procedure that is quoted so prominently under his name that “It shall be the primary duty of all prosecuting attorneys…not to convict, but to see that justice is done.” Although Galle was dropped from the case for unclear reasons, Tidwell pursued the case against Mitchell all the way to trial last week. It was a trial that had to be moved to neighboring county because the case had so polarized Winkler County. Fortunately, on Thursday, after less than an hour of deliberation the jury found Mitchell not guilty. It was a Pyrrhic victory. Yes, Anne Mitchell was not convicted and wouldn’t be going to prison for as long as 10 years. Yes, the jury had resoundingly slapped down Tidwell and Roberts, heaping humiliation on them. Yes, even the Winkler County judge (not the trial judge–remember, the trial had been moved to a different county) Bonnie Leck had testified in favor of Mitchell and that she had discussed her concerns about Dr. Arafiles with her. All of that is true, but Mitchell and Galle have been out of work since June and racked up huge legal bills, and their futures are anything but clear. Even though legally Mitchell and Galle are out of the woods, their futures are anything but clear. In the meantime, they have filed a civil suit that, if there is any justice left in this country, will result in Dr. Arafiles, Sheriff Roberts, County Attorney Tidwell, and the administration of WCH paying dearly for their misdeeds.

THE UNTOLD STORY

The story as relayed above and in the news was horrifying enough, but it’s worse than what was reported. The reason is that Dr. Arafiles is a lot worse than he came off in most news reports. In the news reports, Dr. Arafiles is mostly described as selling supplements, which doesn’t sound particularly bad. Even though evidence for the claims made for most supplements is lacking, so ingrained are supplements in our culture, in no small part thanks to the DSHEA of 1994, that many doctors do recommend them. Although I might frown on such recommendations as not being science-based, I couldn’t consider them so far outside the norm that on that basis alone I’d condemn Dr. Arafiles for anything other than being highly unethical in selling them to patients after seeing them in the emergency room or county health clinic. However, there was much more to the story than this. It turns out that Dr. Arafiles was much further down the rabbithole of woo than anyone reports. I learned of this when I was directed to a series of videos that Dr. Arafiles did with a man named Marc Neumann, in which both were guests on a television show that aired on God’s Learning Channel in October on Morgellons disease. I am listing them below, but don’t bother to try to watch them. Mr. Neumann made the videos private when they came to light, thanks to some bloggers. The reason I list them is in case Mr. Neumann decides to reactivate them. If he ever does, you’ll be able to see Dr. Arafiles himself in parts one, two, three, four, and five.

I’m really sorry that you can’t view the content of the videos. It’s painful to watch, and Dr. Arafiles buys into a whole lot of woo about Morgellons disease. I also didn’t know who Marc Neumann was but a little Googling quickly located his Morgellons Research Organization. Unfortunately, you can’t access the English language portion of the website because Mr. Neumann has removed it, again apparently in the wake of the attention he got from certain bloggers, but the German language section is still there. So is one page that I can find. If you peruse it, you’ll notice that Neumann blames Morgellons on genetically modified organisms (German version) and a whole lot of woo.

Although I haven’t, Steve Novella, Wally Sampson, and Peter Lipson have all discussed Morgellons disease before on this blog. Suffice it to say that it is a condition that probably doesn’t exist as a distinct, biologic entity. By saying that I don’t mean that patients who are convinced they have Morgellons aren’t suffering and don’t have something wrong with them, but rather that whatever it is is not explained by the wastebasket of woo that “defines” Morgellons:

Morgellons is a multi-symptom disease that is just now starting to be researched and understood. It has a number primary symptoms:

Physical

  • Sponanteously Erupting Skin lesions
  • Sensation of crawling, biting on and under the skin
  • Appearance of blue, black or red fibers and granules beneath and/or extruding from the skin
  • Fatigue

Mental

  • Short-term memory loss
  • Attention Deficit, Bipolar or Obsessive-Compulsive disorders
  • Impaired thought processing (brain fog)
  • Depression and feelings of isolation

It is frequently misdiagnosed as Delusional Parasitosis or an Obsessive Picking Disorder.

There’s a good reason for that, namely because Morgellons actually very much resembles delusional parasitosis. Indeed, that is very likely what many, if not most, cases of Morgellons are in reality–a form of delusional parasitosis. For example, one aspect that is always claimed are “fibers” or “granules.” However, no advocate of Morgellons has ever been able to produce these fibers and show that they are anything other than contaminants from clothing or fibers from the environment or that these “spontaneously erupting skin lesions” are anything more than the consequence of scratching or picking at the skin due to sensations of crawling, itching, or biting on or under the skin.

Peter pointed this out, but if you really want to see the weakness of the evidence for the existence of these fibers as anything other than clothing fibres, check out the “research” section of pretty much any major Morgellons website. How hard would it be to recruit a bunch of people who think they have Morgellons, take fiber samples and possibly skin biopsies, and then subject the fiber samples to real chemical analysis and have real pathologists look at the skin biopsies systematically. That’s probably because pretty much every Morgellons “fiber” that I’ve ever seen presented as evidence of the disease looks more like oils and dirt from impacted pores, fibers from clothing, or clumps of dead skin cells that we all flake off. It doesn’t help that all the “evidence” on various websites has not been subjected to anything resembling peer review or independent replication. Indeed, every Morgellons website I’ve seen save one (Morgellons Watch, which concludes that the fibers are environmental and unrelated to any illness; that Morgellons is not a distinct disease; and that eople who think they have “Morgellons” probably have a mixed variety of physical and/or mental illnesses) demonstrate serious crank qualities. Indeed, Neumann’s site, the one being hawked by Dr. Arafiles, goes beyond even this and postulates that that the organisms causing Morgellons are some sort of genetically modified organism, a “bacterial-fungal GMO used as a bioinsectizide,” as he puts it. Some Morgellons even blame that woo of woo, chemtrails.

Does this mean Morgellons doesn’t exist? Possibly. Or it might exist, although, to be honest I very much doubt it. Still, there are lots of patients with symptoms to which they have placed the label “Morgellons” who are genuinely suffering. Unfortunately, attaching a label to these patients that is not rooted in science and evidence does them a disservice, and the very best that can be said is that evidence is sore lacking that there is even such a disease as Morgellons. That’s why it’s really hard to say whether the disease exists, because the “evidence” for Morgellons disease can only be found on websites devoted to promoting the idea that Morgellons exists as a distinct clinical syndrome. If you do a PubMed search, pretty much all you’ll find are articles on delusional parasitosis and commentaries asking whether Morgellons actually exists as a distinct disease entity. About the best evidence suggesting that Morgellons may be a distinct disease is a single case series consisting of 25 patients carrying a diagnosis of Morgellons from whatever source. Let’s just say I’m not convinced. It’s a small case series; there are no statistics to speak of; the autoimmune measures reported are wildly inconsistent; and there are no consistent abnormalities that stand out as pathognemonic of a distinct disease.

Whether Morgellons exists as a disease or is in fact a form of delusional parasitosis, however, it is a magnet for quackery and pseudoscience (which is why attaching a fake label to a probably nonexistent disease does patients who can be labeled with that pseudodisease does them no service at all), and Dr. Arafiles’ video is chock full of both. The reason I mention the videos is that they were his undoing in terms of showing just how deep into pseudoscience Arafiles had fallen. In part 5 Dr. Arafiles mentions a website, Health2Fit. Although nowhere on the website is Dr. Arafiles’ name mentioned, it’s clear that it’s Dr. Arafiles’ website because its contact information lists Kermit, TX as where it is located and, more importantly, Dr. Arafiles’ LinkedIn profile lists him as the owner of Health2Fit. (I’ve saved a screenshot in case Dr. Arafiles decides to try to make the evidence disappear down the memory hole the same way Marc Neuman has tried to make the English language portion of his website disappear.)

Dr. Arafiles, if he is smart, has plenty of reason to try to get rid of the evidence, because on the website he reveals himself not only to be anti-vaccine but heavily into pseudoscience. One example is that Dr. Arafiles sells colloidal silver (yes, that colloidal silver!) to treat H1N1 and seasonal flu. Worse, the website claims that colloidal silver is FDA-approved for treating the flu. As Peter points out, that is a lie, pure and simple. Moreover, on the same page, there are links to antivaccine websites like the National Vaccine Information Center, a lawyer specializing in vaccine exemptions, and to über-quack Gary Null testifying in New York. That’s right. Gary Null. That Gary Null, who is an HIV/AIDS denialist, an anti-vaccine loon (I’m being generous here), and a supporter of cancer quackery. To top it all off, Dr. Arafiles has a presentation on the swine flu with his name on the first slide that includes slides like this:

SwineFlu-22

SwineFlu-23

SwineFlu-24

It looks as though Dr. Arafiles buys into the dreaded “toxin gambit” and the “aborted fetal tissue in the vaccines!” gambit. He even has a PDF of an article by the “Health Ranger” himself, Mike Adams entitled Ten Swine Flu Lies, as well as a link to an fear mongering article about mercury in the H1N1 vaccine. But it’s even worse than that. Dr. Arafiles appears to be selling colloidal silver for Morgellons disease as well. (Remember how I said that Morgellons disease is a magnet for quackery?) He’s also selling a very expensive water alkalinizer for $1495 on his website. Meanwhile, Dr. Arafiles actually testified in this case that diabetics heal as well as anyone else, which actually caused those attending the trial to laugh.

If anyone has any further doubt as to just how far outside the realm of science-based medicine Dr. Arafiles has wandered. I’ll mention two more tidbits. As Mike Dunford shows, in 2002 Dr. Arafiles appeared on a list of U.S. & International Physicians Who Offer IV Hydrogen Peroxide & Bioluminescence Therapy. But it’s even worse than that. In December 2009, there appeared a message from him on the Yahoo! newsgroup No Forced Vaccination to Sherri Nakken, an unabashedly anti-vaccine activist who bills herself as a “Hahnemannian Homeopath” and offers an online homeopathy course asking “When do I get my materials for the homeopathy class?” It would appear that not only is Dr. Arafiles anti-vaccine, but he is currently studying homeopathy as well.

The bottom line is that Dr. Arafiles is more than just a dubious doctor who has a penchant for supplements and a soft spot for a little bit of woo. He’s a doctor who has drunk the Kool Aid, someone who has been reported to the TMB on more than one occasion. Worse, Dr. Arafiles is in a position of power in an underserved rural area in far West Texas, and used that power, which derives from his privileged status as a doctor in the small town of Kermit and his connections with a sheriff who thinks nothing of ignoring his conflicts of interest, ignoring warnings from the TMB that what the nurses he pursued did was not wrong and was in fact state business, and abusing his power to punish two nurses for daring to try to do something to protect the citizens of Winkler County from him. Whether the TMB will do anything about it remains to be seen, but I’m not very optimistic.

BAD DOCTORS, QUACKS, AND THE PROBLEM OF REGULATION

It is hard to become a physician. It takes brains, patience, dedication, and, even in the age of 80 hour work weeks, an almost superhuman ability to take abuse. The flip side of this is that being a physician is a highly privileged position. After all, we hold human lives in our hands. People trust us enough to tell us things about themselves that they wouldn’t tell anyone else, possibly not even their spouses, in the hope that we can use that information to diagnose and treat them. Society has given me, as a surgeon, the supreme privilege of being able to take a knife to human flesh in order to try to cure women of breast cancer, and, back when I did more than just breast cancer surgery I used to joke that surgeons were allowed to forcibly rearrange people’s anatomy for therapeutic intent. We see parts of people that no one else sees, and we do things to people that no one else is allowed to do legally. It is a great power and a great trust.

Doctors like Dr. Arafiles abuse that power and trust.

Unfortunately, the sense of privilege has consequences. Once a person becomes a doctor, it shouldn’t be viewed by society as a right, but in effect it is. It is, in fact, very difficult in most states to strip a bad doctor of his medical license, and, even when sanctions are issued, it seems that every effort is made to get that physician back to practicing as fast as possible. You may recall a couple of years ago how I lamented the seeming powerlessness of the North Carolina Board of Medical Examiners in the face of Dr. Rashid Buttar’s autism and cancer quackery. Kim Atwood has also described how state medical boards often fail when confronted with physicians practicing medicine far outside the bound of what is science-based, tending to be lenient at first; sometimes even documented evidence of patient harm does not sway them. One reason is that state medical boards are often overwhelmed. It’s hard enough for them to keep up with disciplining physicians with substance abuse problems or taking sexual liberties with patients, much less adjudicating whether as treatment is science based and what is the standard of care.

However, I fear that it may be more than that. There is a strain of belief and attitude among many physicians that we really are a privileged class and that complaints against us are unwarranted. One need look no further than this post by the American Association of Physicians and Surgeons for this attitude. In a stunning post entitled Is there accountability for malice?, the AAPS takes Dr. Arafiles side against the nurses:

It has been open season for false allegations against physicians for too long. Each year too many physicians are distracted or even destroyed by malicious claims about them, whether in malpractice cases, sham peer review by hospitals or health plans, or witch-hunts by medical boards.

Is nurse Anne Mitchell guilty of acting in bad faith? The jury will decide.

Note the juxtaposition of complaints against false allegations against physicians with the disingenuous statement that “the jury will decide.” While that was literally true (the jury would and did decide–and it decided in under an hour that the allegations against Anne Mitchell were completely unjustified), it’s very clear where the AAPS stands on this issue, and it’s not with the whistleblowers or in favor of physician accountability:

The blogosphere is filled with rants against the doctor, Rolando G. Arafiles, Jr., M.D.; the prosecutor; and West Texas itself. The doctor has dark skin, a foreign accent, and some unconventional ideas. But his ideas and his practice are not on trial. The question before the court is whether the nurse, not the doctor, acted wrongfully.

This is an example of some spectacularly Orwellian misdirection. First off, the attacks in the blogosphere were against more than just Dr. Arafiles. They were against the Winkler County Sheriff who went to great lengths to hunt down the two whistle blowing nurses. They were against a clueless and vindictive prosecutor who decided to prosecute them. They were about payback against the nurse. In fact, the uproar was about about exactly the opposite of what AAPS thinks it’s about. It’s also spectacularly hypocritical of the AAPS to cry racism over this issue because Dr. Arafiles is Filipino when it has a history of some truly despicable and racist anti-immigrant rhetoric. Indeed, as I documented a year and a half ago, the AAPS is an organization that in essence believes that there should be no constraints on physicians “exercising their judgment.” They are an extreme example, but I’ve encountered such thoughts before. For example, on my Facebook page, a physician named Richard Willner weighed in:

This will have no effect on whistleblowing of RNs against MDs. I see them almost every day.

Followed by:

I also see outrageous RN complaints against MDs. If I was the RN Licensing Board, I’d discipline them for incompetence.

When I provided links to show what a miscarriage of justice this case is and to point out the information about Dr. Arafiles that I described in the first section of this post, Dr. Willner replied:

This Tx case is incredible. I have known all about it for a while. This is an aberation that can only occur in a local southern town.

My other opinion that many RNs write formal complaints on MDs for simply doing their jobs, writing correct orders that the RN are “not comfortable with”, that is a fact. If you want an unique view point just call me at 504-XXX-XXXX after rounds. This is a real problem for many MDs and it is not taught in Residencies.

To which I replied:

Nurses are supposed to question orders they aren’t comfortable with. They aren’t mindless automatons who are supposed to follow orders without question. They are professionals.

Now, I’m not going to deny that sham peer review based on anonymous complaints isn’t a problem in some hospitals. Physicians, however, appear to have an exaggerated view of just how common it is. As often as sham peer review is alleged by doctors, the AMA (not exactly a source that would be opposed to physicians rights) investigated and concluded:

Abuse of peer review is easy to allege but, for the reasons discussed above, can be difficult to prove. Considering the nature of the proceedings, it is to be expected that such charges will be raised by physicians who disagree with the results. In fairness, though, those who raise such claims should have the burden of proving them. Since the passage of HCQIA in 1986, the AMA is aware of only exceptional, isolated instances of peer review determinations that have resulted from improper motivations, rather than a good faith desire to improve patient care.

This may partly be explained by the difficulties in proving such a case and the legal disincentives against bringing this type of lawsuit. More likely, though, is that peer review abuse is a rarity. The legal obstacles make a claim of inappropriate peer review difficult to prove; they do not make it impossible. If abusive peer review were indeed “epidemic,” there would probably be a more substantial track record of definitive and proven malfeasance. The absence of such a record suggests that the claims of widespread or frequent “sham peer review” are speculative.

No doubt I’ll get an angry complaint or two, either in the comments or by e-mail, for taking this position, but you can be pretty sure that the AMA would be unlikely to cover up evidence of sham peer review, given its mission to promote the interests of physicians as a profession. Yet such is the widespread perception that peer review by hospitals resulting in false accusations and unjustified sanctions against doctors that doctors have a tendency to side with other doctors, particularly when it is nurses making the accusation. So powerful is that perception that it’s not just cranks like the AAPS who immediately doubted the Winkler County nurses and lept to defend Dr. Arafiles. And it doesn’t just stop there. Hospitals, state medical boards, virtually the entire establishment is tilted in favor of physicians when it comes to matters of physician misconduct. Our physician culture is to tend to close ranks when one of the tribe is attacked, and state medical boards are loathe to do anything about any but the most egregious offenses. That tendency has led some physicians to wrongly conflate the Winkler Nurses case with sham peer review and conclude that the nurses deserved to be punished for making what they assumed in a knee-jerk fashion to be a bogus complaint against the poor sainted Dr. Arafiles.

And that attitude is a threat to science-based medicine, arguably as serious a threat as the infiltration of quackery into bastions of science-based medicine and the corruption of medicine by “integration” with that quackery.

Dr. Arafiles’ case is about more than just Dr. Arafiles. It revealed serious problems with how physician misconduct is reported and how it is dealt with by hospitals and the governmental entities charged with protecting the public from bad doctors and even outright quacks. Perhaps most disturbing is the utter silence from major medical organizations other than the Texas Nurses Association, which rallied to set up a legal defense fund for Galle and Mitchell, and the American Nurses Association. To our disgrace as a profession, not a single major national physicians organization that I’m aware of stood by the nurses and their duty to report physician malfeasance or, at the very least, against the prosecution of fellow professionals who were being punished through the loss of their jobs and the potential loss of their freedom. The only physicians organization that spoke up was a crank organization that took exactly the wrong position on this matter. Instead of siding with patients and the need for physicians to be accountable, the AAPS supported punishing the nurses, likening them to nurses making false charges against physicians. All of this occurred in the face of the TMB having sent a very harsh letter telling County Attorney Tidwell that his prosecution was wrong, not based in law, and that it had “potentially created a significant chilling effect on the cooperation of any other hospital personnel who might have been able to provide additional information needed by the Board” to carry out its investigation of Dr. Arafiles.

Of course, that was almost certainly exactly the intent of the sheriff’s vendetta against these nurses, to keep his good budy Dr. Arafiles’ medical license safe and secure against the actions of the TMB and to intimidate other potential witnesses into silence. As Dr. Kate Scannell put it, the medical establishment send a clear, unmistakable message to nurses and non-physician health care professionals and workers: Don’t rock the boat. Doctors are supreme. Don’t question them. If you do, you risk everything, your job, your money, even your freedom.

This is hardly a situation that promotes the practice of science-based medicine or even something more basic, patient safety.

Posted in: Health Fraud, Homeopathy, Politics and Regulation, Science and the Media, Vaccines

Leave a Comment (89) ↓

89 thoughts on “The Winkler County nurse case and the problem of physician accountability

  1. arclight says:

    It was more than just two “brave maverick” or “rogue” nurses with a problem with Arafiles. At least three nurses, one doctor, and the ED had voiced concerns to the hospital administrator who then quashed the internal complaints by rescheduling and canceling meetings about Arafiles. The hospital administration needs a spotlight aimed at at it; hopefully Mitchell’s civil suit will flush out the roaches there.

    This really sucks for the people in Winkler County, losing two good nurses, finding out the county government is a good ol’ boy fiefdom, and that Dr. Nick from The Simpsons is happily practicing at the local hospital. Not to mention what it’ll cost to settle this civil suit. All because of a quack and his petty tyrant business partner.

  2. SD says:

    I’m going to be uncharacteristically civil to you today, Dr. Gorski, just to see if I can.

    Your entire post demonstrates my point from the other thread. In it we see all the pathologies of regulation in perfect detail: regulatory capture (your observation of the “thin green line” in the medical profession), failure of regulations and regulatory agencies to adequately address real concerns (patient safety), and black/grey market creation (“woo”). Observe that a priori the supply of doctors is limited by regulatory authority; consider that a “consciousness of rationing” mentality may also be in place. (“If we get rid of this guy, when can we replace him? Does it make his patients worse off to have him, or to have nobody…?”)

    I’ll say it again, without rancor this time: Regulation does not do what you think it does. This is not “my opinion”, it is ineluctable economic fact. Understanding increases when you examine things through the lens of economic logic.

    It does you credit that you believe that it is important to strive for higher medical standards. There are better ways to achieve this goal than those you have traditionally favored.

    “velvet glove”
    -SD

  3. David Gorski says:

    It was more than just two “brave maverick” or “rogue” nurses with a problem with Arafiles. At least three nurses, one doctor, and the ED had voiced concerns to the hospital administrator who then quashed the internal complaints by rescheduling and canceling meetings about Arafiles.

    True, and perhaps I didn’t mention that enough. It came out in the trial, for instance, that at least one nurse decided to resign than to put up with Dr. Arafiles and his substandard medical care and that one other nurse besides Mitchell and Galle filed a complaint with the Texas Medical Board. That other nurse was not prosecuted, and the sheriff was forced to admit on the stand that he didn’t even try to track her down.

  4. Peter Lipson says:

    This is not “my opinion”, it is ineluctable economic fact.

    I love this because it takes care of any possible criticism. It’s right up there with “Goddidit”.

    People who say things like that reveal a deep problem with the way they think and analyze reality.

  5. Zoe237 says:

    Interesting comments on the AAPS link. Glad to the support of nurses here though.

  6. SD says:

    What the hell, I’ll even try to be civil to Mr. Lipson.

    “I love this because it takes care of any possible criticism. It’s right up there with “Goddidit”.

    People who say things like that reveal a deep problem with the way they think and analyze reality.”

    This may be foreign to you, but not every topic is subject to empiricism, and empiricism is not equally useful on all scales. The best examples I am aware of are higher mathematics and symbolic logic; neither of these fields of endeavor rely upon empirical observation to draw conclusions, instead relying on induction from particular axioms. I doubt you can seriously argue that there is a “problem” with the way that mathematicians and logicians think, or analyze reality.

    The conclusions I state stem from observations about the nature of human agency that hold true except in cases of extreme insanity or vegetative states. They are not disputed by *any* economist or school of economic thought, as far as I am aware. Perhaps you claim that the dismal science does not refer to reality. (I might be inclined to agree in some cases.)

    Do you have a problem with the points I raised?

    “bein’ nice”
    -SD

  7. aeauooo says:

    “My other opinion that many RNs write formal complaints on MDs for simply doing their jobs, writing correct orders that the RN are “not comfortable with”, that is a fact. If you want an unique view point just call me at 504-XXX-XXXX after rounds.”

    Great – New Orleans area code!

    Thank you very much for this article.

    aeauooo, RN, MPH, New Orleans, LA

  8. Peter Lipson says:

    So you make an empirical statement and then say it’s immune from empirical study. Sounds like…homeopathy.

    What if my “observations” are diametrically opposed to yours? Does that make yours prima facie wrong?

    Of course not. I believe that you are wrong, but I will not claim that I can prove it or even that I’m sure I’m right.

  9. daijiyobu says:

    Per: “the [Texas!!!] medical establishment sent a clear, unmistakable message [...] doctors are supreme. Don’t question them.”

    This may be a culturally hard-wired trust, per the explicit social contract of an actual profession…but hugely exploited, in this instance, by way of ‘that old paternalism / authoritarianism thang.’

    Them self-proclaimed Medical Deities fixin’ to tell all how it is!

    Knowing what I know about naturopathy weaseling in on the medical realm, such authoritarianism / paternalism is an excellent cover for their absurdity / science-less claims.

    Shake your fist at the gods and proclaim that ‘evidence is our authority!’

    Of course, Texas is the state that has decided that we are an explicitly Christian nation

    http://preview.tinyurl.com/ycrq2lc .

    So, you may get a jolt from above, if you are defiant.

    So much for our ‘freedom of conscience’.

    -r.c.

  10. SD says:

    @lipson:

    “So you make an empirical statement and then say it’s immune from empirical study. Sounds like…homeopathy.

    What if my “observations” are diametrically opposed to yours? Does that make yours prima facie wrong?

    Of course not. I believe that you are wrong, but I will not claim that I can prove it or even that I’m sure I’m right.”

    [patience... fraying...]

    Okay. Suppose I frame the observation like this. Again observing that SBM is big on “prior probability” in evaluating treatments, i.e. “plausibility”, I will note an analogue of this here so that it will perhaps be easier to understand.

    There are empirical statements and then there are empirical statements. Let’s say that I make an empirical statement that “Humans must breathe in order to live.” This is because all humans observed to date die when they stop breathing. The observation is “empirical” in the sense that it is derived from observation, but “universal” – all humans do it, and prima facie true without the need for observation, since the necessity proceeds from a basic principle (all animals need oxygen to live, based in turn on principles of biochemistry). Studies to determine whether or not humans can survive without breathing, then, are pointless, besides being unethical.

    Economic laws are observed to act similarly. All humans except the very profoundly insane or those in vegetative states (which groups may be reasonably said to be excluded from the definition of “human” for these purposes, since the critical human element of sapience is not present) are observed to be affected by them – that’s why they’re “laws”. Law of supply, law of demand, law of diminishing returns, law of marginal utility, und so weiter. Even ordinary madmen and the mentally deficient can be observed to behave according to these laws. These laws do not have anything to do with money – they appear to be universal invariants of behavior for sapient lifeforms in conditions of scarcity, and are very probably universal for any such lifeform in any such conditions. Most of these laws seem to have analogues in biology, if that helps – in particular, Liebig’s law can be thought of as the “natural” analogue to the laws of diminishing returns and of marginal utility, and le Chatelier’s principle can be thought of as a sort of prototypical example of the laws of supply and demand. Moreover, the truth of Liebig’s law (for example) does not depend on how many statistical analyses are performed to verify it – it is prima facie true without reference to particular cases or collections thereof. Logic alone suffices to prove Liebig’s law to satisfaction. Do you see what I’m getting at here?

    “… must… resist… urge…”
    -SD

  11. grendel says:

    SD – I haven’t kept up with your comments on other threads, but am I correct in assuming you suggest that the medical system would operate better with less regulation?

    Are there areas you would still regulate? and why those?

    I am not sure I would go so far as to claim that economic laws are nearly so universal as you suggest since they rarely if ever have existed in the absence of regulation of one form or another (and which differs from culture to culture) and thus any observation made is already tainted by that fact.

  12. Anne says:

    Hm, my browser crashed when I tried to submit a lengthy comment to this excellent post. Probably just as well.

    Anyway, let me say that Anne Mitchell and Vickilyn Galle have filed a civil rights case in federal court, Mitchell et al. v. Winkler County, et al., US District Court for the Western District of Texas. Justia.com is making the documents filed in the case available for free here. This was such an outrageous abuse of authority, I hope they get a good recovery.

    Thanks for the post, Dr. Gorski. As somebody from outside the fields of science and medicine, I find the info and discussions on this site fascinating, especially when you take on professionally difficult subjects like this one.

  13. Anne: “Thanks for the post….” Seconded.

    I’ve heard local unsubstantiated reports of a mental health practitioner who is a sexual predator who believes that aliens implanted a penis-control device when he was six. He also allegedly asks patients to return unused prescriptions to him for “disposal,” and falsifies his reimbursement records. While I have sympathy for whatever horrible childhood abuse he might have endured, he seems to be a menace. Unfortunately the people who have evidence of his misconduct are hesitant to report him…

    I hesitate to ask given SD’s anger, but I’m also having trouble following SD’s argument. I reached the same conclusion as grendel. I envision Liebig’s barrel analogy and regulation as shoring up the leaks. Wouldn’t lack of regulation create more holes in the barrel?

  14. SD says:

    @grendel:

    “I am not sure I would go so far as to claim that economic laws are nearly so universal as you suggest since they rarely if ever have existed in the absence of regulation of one form or another (and which differs from culture to culture) and thus any observation made is already tainted by that fact.”

    [facepalm... serenity now... serenity now...]

    Okay. Let’s use an example to illustrate what I mean by “invariant”, which does not differ from the standard meaning. We will use the “Law of Diminishing Marginal Utility” as our example. Simply stated: “Ceteris paribus, in the limit, as the number of goods X possessed by some party increases to infinity, the value of an extra additional unit of X tends to zero.” (There can be finite “humps” in the marginal utility of a good for “all-or-nothing” uses of some number N of those goods – the common example is bedsheets, where N bedsheets allow one to, say, tie a rope and escape from prison, but less than N do not suffice to achieve this goal – but this law holds true in the limit nonetheless.)

    A simple example to demonstrate the principle:

    To a man with absolutely nothing to eat, a bushel-basket of wheat has a great deal of value. (“Hey, I can eat this – I won’t die today!”)

    However, to a man who already has one bushel-basket of wheat, one *extra* bushel-basket of wheat has somewhat less value. (“Hmm. I can eat pretty good for awhile now!”)

    If we give this man one *more* bushel-basket of wheat, that basket is, ceteris paribus, valued less than the first two. (“Cool! I can eat for a couple of months and have enough left over to make some bread to sell!”)

    Let’s say we get to 100,000 bushels of wheat. The value of one extra bushel of wheat to the recipient is trivial. (“Like I don’t have enough wheat already. Put it over there with the rest.”)

    A million bushels? At this point, it may well be negative. (“Christ, what the hell am I gonna do with all this wheat? I need to get it out of here. Maybe I need to pay someone to take it away.”)

    You get the idea. This is deeply connected to the idea of a subjective ordinal valuation of goods; we satisfy greater desires before we satisfy lesser desires. (Shades of Maslow’s hierarchy, here.)

    Regulation does not affect these laws; the laws operate in spite of regulation. This has been tried – see any Socialist or Communist nation on Earth (Soviet Union, China, N. Korea, “that” Germany, any of the Eastern Bloc countries, Cambodia, the list goes on) for examples of how the operation of economic law was *not* affected by regulation, although that outcome was heartily striven for.

    Note also that this has absolutely nothing to do with culture, either: the process works the same whether I am talking about cubits of maize being given to an Inca, or hogsheads of beer to a Liverpudlian, or blocks of ice to a Chinaman, or whatever. Ceteris paribus – “all else being equal” – the more I hand over, the less each extra unit is worth in the limit. This is one of those ways in which we are all, refreshingly, “the same”.

    It is in the context of such laws that I observe that “regulation does not do what you think it does”, and decry it on that basis. To answer your question: to my mind, the limits of justifiable and “good-idea” medical regulation are limited to instances of outright fraud or assault (medical personnel claiming things that are not true, medical personnel engaging in sex with patients, &c.) which require no more regulation than the standard definitions and proof-standards of their respective felonies (fraud/assault/murder/&c.) There are no specific “areas” that are immune to regulation, from my perspective; nothing is “special”, or “sacred”. Lies are to be punished. Force is to be punished. Other sins and bruises are to be reckoned and made right as the circumstances warrant.

    Note that this gets rids of concepts such as “medical licensing” and “standards of care” as being properly the subject of organizations not subject to the flaws of a political regulatory structure, and moves the arguments for serious violations (force/fraud) to a court, where they properly belong. Case in point: in such a world, such an organization as SBM might serve as a gold-standard and de facto incorruptible certification body, something like Underwriters’ Laboratories or the Orthodox Union. Those who wish the SBM Mark of Approval – and the benefits of instant credibility and satisfied patients that go with it – do not get to peddle dried camel dung capsules from the back of a pickup truck with the engine running, or their Mark *instantly vanishes*. Do not underestimate the value of the service an impartial certification agency provides, nor the extent of compliance it can compel even without coercive authority. Note carefully that quacks love regulation and credentialism of all kinds, since it offers them a multitude of places to “hide” and continue to ply their trade, but absolutely loathe the idea of an agency both morally and legally able to withdraw their sanction (and hence legitimacy) at whim upon the slightest evidence of malfeasance. Such a *voluntary* regulatory structure develops, over time, an ironclad reputation if it resists the urge to seek political power; this reputation is its source of power and profit.

    In time, such standards develop ecosystems – examine in this context the position of Underwriters’ Laboratories, whose sanction for equipment determines its suitability or lack thereof for multimillion-dollar capital projects for insurance and lending purposes, and therefore enforces a discipline on the market for durable goods (particularly electrical devices and machinery) without possessing any coercive power over any manufacturer thereof. You don’t *have* to have a UL sticker on your product… but good luck selling it to anybody if you don’t have one.

    I grant that this is strange to the average MD, having existed as he has in a universe of near-total regulation. It is natural, in such a milieu, to imagine that there must not be any other ways of dealing with the possibility of bad things happening that might be more effective and less ruinous to the body politic, to imagine a multitude of horrific what-if scenarios, to wonder how we shall eat if indeed Caesar does not give us bread. I suppose that begs the question: *Is* it so strange to imagine that more people might actually listen to SBM advocates and choose the treatments they describe under a voluntary, laissez-faire regime with a ruthlessly fair take-it-or-leave-it information-dispersal strategy, than would do so in a system where their choices were circumscribed? (Cue obligatory quote from the Matrix: “99% of the test subjects accepted the program, so long as they were given a *choice*.”) Do you think that idea might be worth *thinking* about?

    “imagine all the people”
    -SD

  15. SD says:

    @Anthro:

    “I hesitate to ask given SD’s anger, but I’m also having trouble following SD’s argument. I reached the same conclusion as grendel. I envision Liebig’s barrel analogy and regulation as shoring up the leaks. Wouldn’t lack of regulation create more holes in the barrel?”

    Aheh, ha ha, heh.

    [I am beginning to detect 'tactical sandbagging' here - refusal to accept apparently simple concepts triggers RAEG(tm), because after spending a certain amount of time at "See Dick Run"-level clarity, the only reasonable conclusion is that the audience is playing the "intentional obtuseness" card. And people wonder why I'm not *nice* and *accommodating*. Gee, I wonder.

    Serenity now.]

    Liebig’s barrel analogy is not relevant to the discussion; go back and read the last post again until you understand what the post is talking about and what is being explained. It *is* clear enough to be understood with reference to simple English. However, if it helps, you can use that analogy this way: the fact that there always must be one shortest barrel stave above which the water level in the barrel cannot rise *does not need to be proven by observation*, which goes right back to my point that it is possible to obtain truth through apodictic deduction and not solely through empirical observation. Which forms the core of the fact stated, “regulation does not do what you think it does”.

    “sisyphus”
    -SD

  16. Alexander Han says:

    SD, your arguments about the laws of economics are like explaining that since a Toyota Camry at 65 miles per hour has 1.315 megajoules of energy, and octane’s heat of combustion is 33.76 megajoules/liter it takes 40 ml of octane to accelerate it to that speed. It’s just not the case in the real world, since so many assumptions go into that calculation. To flip your phrase, ‘ceteris imparibus sunt’.

    Free markets will work in medicine when patients grade their doctors on things besides friendliness and cleanliness and someone having a heart attack asks to go to the cheaper hospital 15 minutes down the road.

  17. Versus says:

    Excellent post! If I may take a step down from the lofty philosophical conversation going on here, I will point out some other problems with the current regulatory scheme: Medical Board members (as with other health care boards) are in many states political appointees. Thus, if you are the governor’s physician, you get on the Board if you want, no matter your qualifications. The investigators and prosecutors have scant resources due to budget issues, and, let’s just say, attorneys with other opportunities are not often attracted to these positions. Investigations move at a glacial pace. Expert witnesses are crucial but there is little money to hire the best. An MD defending his livelihood has far more resources than the prosecution. Board members who have a Perry Mason complex have been known to provide the accused MD with perfect grounds for appeal. (E.g., bringing their own exhibits and putting them into evidence.) And so on. Until the regulatory process is (at least) adequately funded, I don’t see any prospect for change.

  18. qetzal says:

    SD,

    I think you make some good points about the problems of regulation. It’s a shame you feel compelled to be such a condescending prick, even when you’re supposedly being civil.

    Question for you: are you aware of any country that treats medical practice approximately as you suggest (e.g. the medical equivalent of UL)? Note that this is a sincere question, despite my flinging a little scorn back in your direction. (Sauce for the goose, right?)

  19. BillyJoe says:

    The problems with regulation pale in comparison to the problems without regulation.

  20. David Gorski says:

    The problems with regulation pale in comparison to the problems without regulation.

    Precisely. We’ve tried no regulation before, at least as far as food and drugs go. There was a reason the Food and Drug Act of 1906 was passed, and it wasn’t because the lack of regulation was working out so swimmingly. It was because of a number of scandals due to adulterated food and food-borne illnesses, thanks to practically nonexistent laws to prevent them. All regulation (or lack thereof) is a balancing act between regulating so little that anarchy and fraud reign and so much that innovation is stifled. It is not an all-or-nothing, binary issue, although SD sure seems to think it is, or at least that it’s close to a binary issue, with regulation almost always being bad.

  21. grendel says:

    SD – an interesting approach – and while I certainly agree than in practical application a demand for a thing will always encourage a supply for that thing to take the view that regulation has no place in the economic arena misses the point that there are times when ‘the thing’ being sold is not the same thing as what is in demand – ie the seller substitutes a fraudulent item. Caveat emptor? True, but what if the buyer cannot be aware of the nature of the fraud without specialist knowledge – such as the content and active ingredients of a medication?

    It is impractical to require the individual of any marketplace to contract their own testing, and while reputation in the market may regulate the activity of larger players there is usually no shortage of those willing to substitute.

    At some point regulation – either through criminal sanction or control over the marketplace becomes an almost natural result – as David alludes to above.

  22. Stroh says:

    The reasons why we need regulation in the medical market is apparent to most, but I guess I could restate some of them for the case of discussion.

    - Consumers are in general incapable of identifying good producers by results alone. Results are almost completely dependent on the nature of illness being treated – not on the skill of the producer. Hence, result comparison indexes will fail.

    - Consumers lack sufficient expertise to comparison shop. They can not differentiate between good and bad care and will therefore act on other factors, such as location, promotion and reputation. CAM shows us the ultimate backlash of this – something gold standards outside government control will not solve. To the consumer, a stamp of approval from Homeopaths of America will be as valid as one from SBM.

    - Consumers are often put in a position of extreme duress when seeking care and are ripe for being taken advantage of. Especially if they happen to be unconscious.

    To summarize: the greatest flaw of free market economics is the belief in the enlightened consumer, despite the obvious fact that he is a rare being. Without him most theories break down. Enter regulation: forcing producers to provide a given standard to begin with and lightening the load on the individual consumer.

    Simple to say, if we force everyone to provide good care there is no risk of anyone choosing bad care as it is non-existent.

    A market without regulation is of course possible but will punish the weak consumer in favor of the strong. It may even be efficient but will not be what we want in national medical care.

  23. Draal says:

    I wish someone would give me 1,000,000 boxes of gold coin. (“Like I need any more but you can put the extra one’s over there.”)
    I see a problem with the law of diminishing returns in the example as x approaches infinity. It’s a nifty thought exercise on paper but economically infeasible to maintain. By bushel 1E9, the resources to produce additional bushels becomes limited and the selling price for the next bushel reaches a limit. You can’t sell x+1 bushels for less amount if the maximum production output has been reached or if the cost to produce additional bushels requires additional investment to acquire more resources. The take home message is that there is a finite region where ‘economic law’ fits a curve before it deviates too much and additional variables must be added to reestablish a smooth curve. How quickly it deviates is case by case. It may not even fit when other behaviors such as price fixing are introduced.
    [Hulk smash!]

    Ron Paul for President. (ha!)

  24. daniel says:

    I’m generally a small-government type, and economics was my official concentration at MIT. As best as I can tell, SD is trying to argue from first principles, which is typical of beginner economists, or people who have just read Atlas Shrugged, or high school students.

    Rest assured his debating tactic wouldn’t get very far in any economic circles. There are concerns among economists about the supply of doctors being artificially constrained by a cartel, but debates from first principles don’t carry water, because whose first principles do you use? How do you know how fast market pressure would react to bad doctors? SD can insist that it works, and I would suspect he’s right, but demonstrating it takes more than a hunch.

    You would need to do studies on the effects of licensing on public health, and get them submitted to a journal, and then you would have someone else showing an opposite effect published in another journal. It’s a hella lot of work — the kind of thing economics PhD theses are made of — so you can see why someone would skip all the hard work of doing the research and just post comments on a blog insisting he’s right.

    Figuring out whether (say) a vaccine works is trivial in comparison, and I’m not saying that that is easy.

  25. nathan says:

    “What maybe in a vaccine”. It may be that this is a grammatical error. Maybe.

  26. SD says:

    @daniel:

    “I’m generally a small-government type, and economics was my official concentration at MIT. As best as I can tell, SD is trying to argue from first principles, which is typical of beginner economists, or people who have just read Atlas Shrugged, or high school students.”

    Ah, an economist. Thank God.

    Okay, so where we’re at right now: we aren’t even arguing *from* first principles. We are arguing the existence *of* first principles, from which it is possible to reason, and the existence of a method to reason from those first principles. Goofy, huh? How we got to this sticking point: the assertion “Regulation either increases costs for suppliers of a particular good, or accomplishes nothing” apparently doesn’t have enough studies cited to establish its validity to this crowd, despite its easy provability with basic logic. Hell, even the observation “Regulation affects supply, not demand” is apparently too much to handle.

    I know of no economist who seriously maintains that the basic laws of economics (supply and demand, marginal utility, diminishing returns) do not exist or are invalid. They may argue for special cases in which they don’t apply, but that’s where the schisms usually start.

    “Rest assured his debating tactic wouldn’t get very far in any economic circles. There are concerns among economists about the supply of doctors being artificially constrained by a cartel, but debates from first principles don’t carry water, because whose first principles do you use?”

    Well, the supply of doctors (“doctor” being loosely defined) *is* constrained – otherwise the legislation mandating graduation from certain schools, board certification, &c. doesn’t *do* anything. (If there exists nobody who would claim to be a doctor without those requirements in the absence of the regulation, then what is the regulation good for?) It’s observations like that that cause this crowd to go “Nuh-UH!” The argument would be over whether other mitigating factors ameliorate this condition, or whether the substitution of a “less qualified” doctor or medical professional accomplishes the same goal, or whether (as is maintained on SBM) medicine is a “magical” profession which is somehow immune to the effects of economic law by virtue of its awesome important awesomeness. (I maintain that this attitude is a textbook case of rent-seeking, and that the assertion that this field of endeavor is somehow “special” to be disingenuous and profit-driven. That’s just me, though.)

    “if a, then b”
    -SD

  27. SD says:

    @draal:

    “I see a problem with the law of diminishing returns in the example as x approaches infinity.”

    Nicely spotted, but the example is of marginal utility, not diminishing returns. Different concepts.

    “a, not b”
    -SD

  28. mikerattlesnake says:

    SD seems to think he needs to explain things to us in simpler and simpler terms (because clearly we lack his diverse and nuanced education in the world of economics) and he keeps referencing Econ 101 or the like. The thing is, though I never was an economics major, I know that my 400 level classes often contradicted concepts from my 100 level classes, or at the least added layers of complexity that made those simple concepts less simple. In short, SD, you’re oversimplifying, and while these lessons in imagining can be kind of fun, they don’t really seem to describe anything real.

    I don’t think it’s a stretch to assume that most people here grasp basic logic, the problem is that basic logic can be manipulated. I remember being shown a ‘proof’ in algebra class in high school that showed that a man running faster than another man would never catch up to him. From that I learned to be skeptical of oversimplified logic, which is what you are employing. I don’t dispute the basics of what you’re saying, I dispute that it can be applied practically on a large scale.

    Cue “now lets say you have a bucket of apples…”

  29. Anne says:

    SD, we’re talking about a tiny county-run hospital that serves Medicare and Medicaid patients in a rural area of Texas. According to this news report, there’s a big problem getting doctors to practice in this geographic area. The choices of this patient population are already severely circumscribed. If there were no regulation of medical practitioners, I fail to see how a voluntary, laissez-faire regime with a ruthlessly fair take-it-or-leave-it information-dispersal strategy would spring up in its place. The “laws” of supply and demand, in these circumstances, couldn’t work the way you think they would.

  30. SD says:

    @anne:

    “SD, we’re talking about a tiny county-run hospital that serves Medicare and Medicaid patients in a rural area of Texas. According to this news report, there’s a big problem getting doctors to practice in this geographic area. The choices of this patient population are already severely circumscribed. If there were no regulation of medical practitioners, I fail to see how a voluntary, laissez-faire regime with a ruthlessly fair take-it-or-leave-it information-dispersal strategy would spring up in its place. The “laws” of supply and demand, in these circumstances, couldn’t work the way you think they would.”

    No shortage of nurses, is there?

    The heroine(s) of this story, as styled by SBM, were heroines because they knew something the doctor apparently didn’t.

    Let’s cut over to the Bizarro Universe for a moment, where the laws currently applicable to medicine do not exist.

    Here’s a reasonable scenario: nurses Mitchell and Galle put their heads together for a moment, and decide that Dr. Arafiles is full of what is medically termed “bullshit”, and say “Hey. You know what? The needs of the patients around here can be *mostly* satisfied with what *we* know. We know how to work a stethoscope, we have basic medical training, we’ve seen enough to be able to handle basic diagnostics, we can write notes, we can understand medical textbooks, we know what most of these medications do, and who needs them. Why don’t *we* hang up a shingle and treat some of these patients? It’ll be better than handing them over to Dr. Quack. When we don’t know what’s going on, or there’s a problem we can’t deal with, we’ll refer to an MD, DO, or specialist – maybe we’ll contract with one and have him show up once a week for the problem cases.”

    Does their medical knowledge exceed that of an MD? Well, I guess that depends on which MD you measure them against, doesn’t it now? >;->

    As currently styled, they cannot do that. It is against the law. They cannot offer diagnostic or treatment services, because the state medical board – the same state medical board that is covering for Dr. Arafiles – does not consider their experience and education to be sufficient to join “the club”. However, that neatly sidesteps the question of whether they actually know enough to help a patient or not, particularly in light of the fact that there are few options for the residents of that geographical area.

    Part of the problem with regulation is that it does not adequately address “corner cases” of this type. Would it be better in this instance for nurses Mitchell and Galle to become the equivalent of primary-care physicians in this area? Regulation says “no”, that they do not possess the knowledge necessary, that they must defer to a licensed MD or DO. Is the regulation part of the problem in this case? I maintain that it is. (Actually, I maintain that it *always* is, for this an other reasons, but we’ll stick with baby-steps for the time being.)

    “let a thousand views contend”
    -SD

  31. SD says:

    @mike:

    “SD seems to think he needs to explain things to us in simpler and simpler terms (because clearly we lack his diverse and nuanced education in the world of economics) and he keeps referencing Econ 101 or the like. The thing is, though I never was an economics major, I know that my 400 level classes often contradicted concepts from my 100 level classes, or at the least added layers of complexity that made those simple concepts less simple. In short, SD, you’re oversimplifying, and while these lessons in imagining can be kind of fun, they don’t really seem to describe anything real.”

    Well, there’s where you’re wrong.

    I concede the existence of the “Absolute truths in XXX 101 are shown to be comforting lies in XXX 401″ phenomenon, in general. However, where this tends to *not* be true is mathematics. (Yes, there are instances where hidden assumptions made to “teach the concept” in lower-level mathematical studies are highlighted and used as the springboard for teaching deeper concepts in higher-level studies; nevertheless, the principles are not invalidated. Typically, they are shown to be special cases of a deeper principle with wider scope.) While the use of mathematics in economics can frequently be suspect, the use of mathematical *thinking* (as in, “apodictic proof from axioms”) is not.

    “I don’t think it’s a stretch to assume that most people here grasp basic logic,”

    I’m beginning to wonder.

    “the problem is that basic logic can be manipulated. I remember being shown a ‘proof’ in algebra class in high school that showed that a man running faster than another man would never catch up to him. From that I learned to be skeptical of oversimplified logic, which is what you are employing. I don’t dispute the basics of what you’re saying, I dispute that it can be applied practically on a large scale.”

    So because you got tricked with Zeno’s Paradox, you decided that inductive logic is bullshit? Now *there’s* a reasonable conclusion.

    Hint: you got tricked with “logic” that contained a subtle flaw. Part of the purpose of that “trick” is to figure out or find out where the flaw is.

    (I won’t even address the fact that tricks pulled on you in a high-school algebra class are not exactly stellar arguments from which to draw.)

    Here’s a thought for you to chew on for awhile: the mathematical results used – indeed, *REQUIRED* – by science were arrived at through precisely the process you object to, namely “proof as a chain of ineluctable logic from first principles”. Your opinion about that does not make one whit of difference to the fact that your entire world has been constructed on precisely such proofs. Hell, the tools SBM claims to use (poorly, in my estimation) were *created* by that process. How the hell do you think the statistical tools used in RBCTs were *created*, anyway? What do you think they were tested against? How do you think that their suitability for estimating bulk parameters of a population was established?

    “now, let’s say you have a bucket of apples…”
    -SD

  32. qetzal says:

    SD,

    I’ll ask again. Are you aware of any country that treats medical practice approximately as you suggest? If not, how about one that at least gets substantially closer than what most of us are familiar with in the US, UK, EU, Canada, etc?

  33. David Gorski says:

    I second that question.

    Data talk. Speculation based on “first principles,” “unalterable laws of economics,” and “mathematics” walks. As we’ve seen time and time again in various sciences, what seems as though it should work based on logic and reason alone can turn out not to be the case. Even the most magnificently logical-seeming hypothesis, even one that seems to be rooted in pure mathemetics, needs to be tested empirically and experimentally. Analogies aren’t enough.

    It’s not practical to do a “pure” experiment to test whether a system such as the one proposed by SD will work, nor is it even desirable without some indication that it is likely to work, some “preliminary data,” if you will, to allow us to estimate its prior probability before trying it in the real world with real people and their health. The NIH won’t fund my grant if I can’t show preliminary data suggesting that my scientific reasoning is sound, nor should we accept SD’s speculation, as logorrheic as it is, without at least some real world examples to compare to our present system. So show us a nation where health care is treated close to the sort of free market model described ad nauseum. What are its results in terms of health outcomes, as well as quality and cost of care? Are the results what are predicted? Are they better than the U.S.? Better than the U.K., Canada, or other nations with universal, government-supported health care?

  34. Scott says:

    As we’ve seen time and time again in various sciences, what seems like it should work based on logic and reason alone can turn out not to be the case.

    Particularly true in economics, actually, because virtually all “first principles” arguments in economics are actually dealing with homo economicus, a purely rational value-maximizer. Particularly these days it’s recognized that homo sapiens doesn’t bear that much resemblance to homo economicus and that such arguments are therefore EXTREMELY suspect.

    SD pays only lip service to this problem.

  35. pmoran says:

    SD: “Regulation either increases costs for suppliers of a particular good, or accomplishes nothing” apparently doesn’t have enough studies cited to establish its validity to this crowd, despite its easy provability with basic logic. ”

    ??? Why hark back to this? I don’t think anyone has argued that regulation doesn’t increase costs, or that it cannot have unintended adverse consequences.

    The question is surely whether the benefits of regulation justifies those costs and risks. Answering that may indeed require data, for some contexts.

    Where the regulations concern the selection and training of surgeons and physicians, many might argue that basic logic also offers some guidance in this matter.

  36. MI Dawn says:

    @SD: There are places in the US where nurse-practitioners run a clinic, with physician backup. However….nurses are not doctors. We do not have the same education or training as doctors. We are educated in a different way. As professionals, we can identify physician practices that appear to be inappropriate. We can question them (and indeed, are encouraged to do so). We cannot entirely take over for physicians without changing nursing education so much, it will be medical training.

    I was an advanced-practice nurse – a CNM to be exact. I knew a lot about OB and gyn, but I never knew the stuff Dr Gorski knows about breasts, and medicine. Different training. We can work together. We cannot work without them, just like they can’t work without us.

  37. David Gorski says:

    Damn it, Peter, I was going to bring that example out after SD responded. :-)

  38. SD says:

    Comrade Gorski:

    “Data talk.”

    No, they don’t – people talk, data just sits there. People can talk quite cunningly, sometimes, particularly as you just did. This challenge is two rhetorical tricks wrapped up in one:

    (a) a very clever lawyer-trick you appear to be very fond of: “When the principles are weak, argue the data. When the data is weak, argue the principles.”

    (b) an invitation for an opponent to get sucked into a tunnel of infinite regress, with argument over “how good the statistics are”, which ends with no clear winner, since statistics of this type can be argued *ad infinitum* with no clear result. While this is fun in a “Mortal Kombat” sense, it does not lead to the Truth.

    (I note in passing that you appear frequently to have a problem with “data talking” when it does not support your conclusions. Curiously, the reason you use to discard this data is “prior probability”, i.e. “reasoning from things I think I already know”. Typically such data gets sucked into a vortex of “Nuh-uh!” and subjected to a selective picking-apart using arguments not applied to data supporting *your* conclusions.)

    But sure, why not. Let’s use Comrade Lipson’s example of China. Here are some statistics about China and comparison to the United States:

    http://www.nationmaster.com/red/country/ch-china/hea-health&all=1
    http://www.nationmaster.com/red/country/us-united-states/hea-health&all=1

    The difference in total life expectancy? Five years. (Six for women, four for men, +/-; well within one standard deviation, I believe. Interestingly, this is in a country with substantially increased tobacco use. Unless you’re arguing that tobacco really isn’t that bad for you…?) How many other statistics would you like? It looks like they’re on a par with the US in terms of “births attended by skilled health staff”, better in terms of HIV per capita deaths and prevalence (though worse in absolute terms, they *do* have four times the US population), better in terms of hospital beds, better in terms of intestinal-disease death, reasonably close in terms of immunizations…

    Huh, and look at that: all that with only 1.5 doctors per person, instead of 2.3 as we have here.

    While I’m not touting China as a laissez-faire paradise, it seems that they’re doing pretty decently, based on the *ahem* “data”. Unless – *gasp* – you’re suggesting that a goverment would COOK THE STATISTICS?!?! (No! Madness! Such a thing cannot be!) Perhaps you’re biased against the Chinese for some reason?

    Let’s take them as a given and assume the cooking works out about the same on both sides, since we can expect that everybody cooks the stix for national-prestige reasons. So: What precisely was your point again about laissez-faire medicine? Looks like it’s working pretty well to me, there. An de-Bolshevized system of “letting the market handle the details in bulk” doesn’t appear to be working too shabbily, there.

    “oh snap”
    -SD

  39. SD says:

    Oops – scratch that “better in terms of hospital beds” bit – China’s actually words. (Mixed up the windows for a moment.) Mea culpa.

    “2 wins 1 site”
    -SD

  40. SD says:

    “Worse”, even. (Crap!)

    “this post certified typo-free”
    -SD

  41. Basiorana says:

    Regulation is essential in any field that is both a matter of life and death (ie, a malicious, negligent, or ignorant professional or company can cause serious physical harm) and beyond the comprehension of the majority of those not in the field who will be served by them (ie, while a person can do a lot of physical damage as a butcher by selling rancid meat, I’m not actually sure we need a regulation on that since everyone knows rancid meat is bad and would thus be unlikely to eat it, and would clearly understand who to sue should they become ill from the meat).

    The difficulty with medicine, as with hardrock mining or genetic modification, is that the public doesn’t actually understand what is involved on the remotest level. If a person gets sicker after following a doctor’s regimen, they don’t actually understand their body, their disease, and standard practice enough to know who to bring a civil suit against– the doctor who didn’t diagnose them right or prescribed a quack treatment? the pharmacist who gave them an expired medication? the drug company who created a bad drug? the hospital for allowing a bad doctor to practice? or nobody, since no one actually could have prevented or mitigated the outcome? The patient may not even realize they should sue, or should see another doctor. If they are lucky, they might realize when they should switch medications, at least.

    Thus, since patients can’t actually understand the medical practice well enough to know how to regulate doctors, hospitals, pharmacies and drug companies through their consumer choices, truly free capitalism will not provide for a safe, effective system– unlike, say, oil manufacturing, where consumer decisions to avoid oil produced by companies that pollute their waterways have led increasing numbers of oil companies to enact environmental reform, or nuclear power plants, who have the strictest self-regulation imaginable in addition to the rather unnecessary laws. People understand that oil, dumped from a tanker, pollutes water; they understand that radiation leaks from nuclear power plants cause cancer and radiation poisoning. Those are straightforward, easy to understand concepts. Not so in medicine, where there are large numbers of potentially liable parties, and where complex the standards of care and disease processes cannot always be understood even by a doctor who is simply in another FIELD, never mind a person with zero medical training.

    Regulation, then, exists to do what free-market capitalism cannot– provide medical personnel and hospitals with incentives to be ethical, and hold the proper party responsible when egregious harm has been done. Is it effective? Well, not entirely; there are holes. However, any small amount of regulation is superior to the almost complete lack of free-market regulation by consumer choice of medical professionals.

    In a world where we all were specialists in all fields of medicine, lawyers, experts in environmental health, economists, and where scientific journals were commonly read and understood by the masses, SD’s point would make sense– regulation would be unnecessary and potentially cause only more hassles. That is not our world. Thus, we chose to enact regulations so that people who DO understand the issue can hopefully protect us without us needing medical school.

  42. SD says:

    @Basiorana:

    “Regulation is essential in any field that is both a matter of life and death (ie, a malicious, negligent, or ignorant professional or company can cause serious physical harm) and beyond the comprehension of the majority of those not in the field who will be served by them.”

    [remainder of drivel snipped]

    Oh, good. Then can you explain how, in the presence of a similar lack of general knowledge about how electricity works, the public is sufficiently intelligent to understand that a “UL” label on a lamp means that there is a reasonable chance that the lamp won’t set their house on fire?

    I do not propose a lack of regulation – I propose a lack of *coercive* regulation. I outlined one possible method in the other thread: Cde. Gorski et al. decide that they are going to switch from a program of “Gettin’ Our Lenin On”, and towards a “certification” model, where physicians and treatments that operate on a sound scientific footing receive their Stamp of Approval, and everyone else can just go pound sand unless they’ve got the data to back their claims up. Since Comrade Gorski et al. are motivated purely by the well-being of all the patients in the universe, and are not shy of decrying things that do not meet their high standards, and furthermore because *seeking this certification is voluntary*, they have every incentive to do the best job they possibly can do. Patients, knowing that the SBM label means “the best medicine and medical professionals that exist given our current knowledge”, understand that patronizing a doctor with the SBM Stamp of Approval means that they’re getting the best odds in the health-care casino. These patients receive the best care possible. These doctors find they have lots and lots of patients, and get lots and lots of profit off of those patients. Other doctors – realizing that they are losing patients, and therefore money – decide that they’d better get on board the SBM wagon too, or find another line of work. Further, they do this *of their own accord*. Eventually, competing systems are marginalized to the extent that they do not provide as many benefits as SBM does.

    See how that works? This is one of those “natural incentive” systems that tend to work, as opposed to “artificial incentive” systems, which don’t.

    (If you make a reply based on how well CAM is doing, be sure to pay attention to the fact that it has been doing so in the context of heavy medical regulation in favor of MDs ["allopaths"] to date. Be sure to explain how the cure for failure is “more and better failure”. I could use the laugh.)

    [Addendum to previous post on China: that number should be "1.5 doctors per thousand", not "1.5 doctors per person". Doh!]

    “all about the incentives”
    -SD

  43. Joe says:

    @SD on 16 Feb 2010 at 8:13 pm “(a) a very clever lawyer-trick you appear to be very fond of: “When the principles are weak, argue the data. When the data is weak, argue the principles.””

    You forgot the third part “When both the data and principles are weak, just argue.” Which seems to apply to you.

  44. SD says:

    Cde. Gorski:

    “Speculation based on “first principles,” “unalterable laws of economics,” and “mathematics” walks.”

    Y’know, now I get to have a little fun.

    “Speculation”, is it? Oh, good. Then *you* can explain to the class how exactly it is that you “know” that the statistical methods you use are valid. I mean, how exactly is it that you “know” that X% of N people will respond to a treatment based on a subsample of N, without testing all N? Is that just an *assertion*? Do you have any *data* to back it up?

    Be thorough and concise. Make sure your proof is formatted in TeX. Since you won’t be using any “axioms” – those are dirty and misleading, apparently – you can tell me what “studies” you are using to “prove” your assertion about statistical theorems. Go ahead, Comrade, don’t be shy. I wanna see you prove the Central Limit Theorem by reference to “studies”, and tell me how you *know* it’s true.

    “*you* do the math”
    -SD

  45. Joe says:

    I was going to scroll down and ignore the rest of the rant; but something jumped out:

    @SD on 16 Feb 2010 at 8:13 pm “Huh, and look at that: all that with only 1.5 doctors per person, instead of 2.3 as we have here.”

    Do you really think we have 690 million doctors attending a total population of 300 million? That sure sounds like the type of calculation for which economists are famous …

  46. Joe says:

    I was going to scroll through and ignore the rest of the word-salad; but this jumped out:

    @SD on 16 Feb 2010 at 8:13 pm “Huh, and look at that: all that with only 1.5 doctors per person, instead of 2.3 as we have here.”

    Are you really suggesting that a (USA) population of 300 million contains 690 million doctors?

    “*you* do the math”

  47. SD says:

    @Joe:

    “Are you really suggesting that a (USA) population of 300 million contains 690 million doctors? ”

    Corrected later, in my response to Basiorana:

    “[Addendum to previous post on China: that number should be "1.5 doctors per thousand", not "1.5 doctors per person". Doh!]”

    “thank you, please drive through”
    -SD

  48. Calli Arcale says:

    SD:

    the same state medical board that is covering for Dr. Arafiles

    Minor clarification — the medical board is siding with the nurses, not Dr Arafiles. While I generally am not impressed with what medical boards allow to go on, at least in this case they seem to be paying attention. Hopefully they will follow through an actually revoke what license the guy has (it’s a restricted license, and he’s not board certified for much of anything).

    1. David Gorski says:

      Minor clarification — the medical board is siding with the nurses, not Dr Arafiles

      That’s hardly a minor clarification. It’s exactly the opposite of what SD is saying. SD got it exactly wrong here. The Texas Medical Board actually did the right thing and wrote a scathing letter telling the sheriff and county attorney (1) that the nurses did not commit any HIPAA violations and (2) strongly criticizing any prosecution of these nurses. The TMB was not covering for Dr. Arafiles. It is investigating him.

  49. Peter Lipson says:

    The Texas State Medical Board took a VERY aggressive stance in attempting to preserve it’s regulatory power and the integrity of its investigation of Arafiles. Arafiles had already been censured once and had not yet fulfilled his censure agreement. The Board sent several strongly worded letters to the sheriff and prosecutor explaining how they were “doing it wrong”.

  50. bolese22 says:

    According to SD’s logic, the following should be true in any high school in the U.S.:

    1. Teachers are certified as professionals who know BEST what it takes to educate students.

    2. Teachers who have teacher’s aides should never be questioned or “turned in” for anything they see go on in the classroom because they really have no training to make such judgements.

    3. Teacher’s aides may think that if they can get rid of the teacher, they can do just as good a job teaching.

    4. No one should ever take it seriously when a teacher is reported for inappropriate behavior (either teaching-wise, in the area of discipline, or for other preceived infractions).

    I know we teachers/administrators are by no means “as educated” as doctors nor as “needed”, but this seems to be a parallel comparison.

    Your line of thinking about nurses turning in bad doctors is a BUNCH OF CRAP.

    From what I gathered, after I sifted through all of your talk of economics, is that you are upset that two nurses (with other motives – at least in your eyes – would have the audacity to report a doctor doing subpar job). So why should we ever listen to anyone who says a teacher is doing a subpar job or worse…what do they know? they arent trained like a teacher, they do not know what is BEST for the student……..

    Just trying to put your arguement into words a simple teacher might understand…..

  51. David Gorski says:

    Then *you* can explain to the class how exactly it is that you “know” that the statistical methods you use are valid. I mean, how exactly is it that you “know” that X% of N people will respond to a treatment based on a subsample of N, without testing all N? Is that just an *assertion*? Do you have any *data* to back it up?

    You want frequentist or Bayesian reasoning?

    Of course, yours is a silly question because we can test statistical models versus reality and see if they fit, for example, by observing the same results in different populations. But, then, you’re a troll.

  52. David Gorski says:

    I do not propose a lack of regulation – I propose a lack of *coercive* regulation.

    Which is, of course, what we had before the Food and Drug Act of 1906, for the most part, and that worked out sooooo well, didn’t it?

    As I said before, we’ve more or less tried it your way already.

  53. SD says:

    Govorit’ Cde. Gorski:

    “You want frequentist or Bayesian reasoning?”

    Either will suffice.

    Well, no, wait: Give me Bayesian. No reason to make it easy on you.

    “Of course, yours is a silly question because we can test statistical models versus reality and see if they fit, for example, by observing the same results in different populations. But, then, you’re a troll.”

    *evil chuckle*

    No, Comrade. I’m afraid you misunderstand the question.

    You seem to believe that “proof from first principles” is garbage. The question, Comrade, is this: Without using proof from first principles, exactly how do you know that any of your statistical techniques are “valid”, i.e. that they do what you think they do? Recall from your Stat 101 course – if you recall *anything* from it – that the purpose of statistics is to estimate bulk parameters of a population by testing characteristics of a subsample of that population. Derivations of individual statistical distributions and theorems – normal distribution, binomial distribution, hypergeometric distribution, Poisson distribution, chi-squared, Student’s t, Snedecor’s F, &c; Central Limit Theorem, Law of Large Numbers, Bayes’ theorem, validity of nonparametric tests, &c. – are a product of the process you clearly despise. So, since you don’t like it, now you get to prove how these things work without using it, or admit that you have no idea and take their correctness on faith. As noted: make sure your proof is in TeX. It’s kind of the standard for mathematical typography. I’m sure that as a noted sciency type, you’ll have no problem accomplishing this mundane goal.

    “gotta have faith”
    -SD

  54. SD says:

    Govorit’ Cde. Gorski:

    “Which is, of course, what we had before the Food and Drug Act of 1906, for the most part, and that worked out sooooo well, didn’t it?”

    Oh, Comrade. Data, please, to support the assertion that the Food and Drug Act improved medical outcomes in America post-1906. Control for all other variables, including the march of technology. Contrast with outcomes in American territories where this act would not necessarily have been applicable – Alaska, Hawaii, Puerto Rico, &c.

    We wouldn’t want to argue just on the basis of ideology, would we now?

    Also, while you’re at it, provide some data to show that the standard of medical care was improved by the FDA of 1906 in comparison to other countries of the time which had no such regulations, or where those regulations were ineffective.

    Because data to back up assertions is important, right? Otherwise you’d just be arguing from first principles, and look where *that* gets you, huh?

    “As I said before, we’ve more or less tried it your way already.”

    Have we? I don’t recall seeing any data about that, or how bad it was. In fact, it looks like they’re sort-of “trying it my way” in China right now without the apocalypse of malpractice and horrible deaths you claim take place in such a scenario. Or anyway, that’s what the *data* seems to suggest. Five years off the average lifespan in a country where everybody smokes doesn’t appear to be a real convincing argument for continued Bolshevization of the medical system; rather, it looks like reasonable evidence that perhaps we are dealing with an archaic grant of privilege to rent-seekers that should reasonably be abolished. Would you like to provide better data?

    “data please”
    -SD

  55. SD says:

    @bolese22:

    “From what I gathered, after I sifted through all of your talk of economics, is that you are upset that two nurses (with other motives – at least in your eyes – would have the audacity to report a doctor doing subpar job). So why should we ever listen to anyone who says a teacher is doing a subpar job or worse…what do they know? they arent trained like a teacher, they do not know what is BEST for the student……..

    Just trying to put your arguement into words a simple teacher might understand…..”

    Huh-whuh?

    Dude. Drugs, much?

    I don’t care about the nurses, to be frank. The doctor either, for that matter. My beef is with a regulatory system that grants doctors special privileges (diagnosis, treatment, prescriptions, &c.) and seeks to exclude competition (CAM, whatever) by fiat instead of destroying it by being so much better that no sane person would choose to use anything else. I see this as both morally wrong and counterproductive. I object to a certain arrogant presumption on the part of SBMsheviks, as well – medicine is not science, and statistics of the “social-science” type do not constitute scientific proof, though medicine may use certain scientific results in treating patients, and may use such statistics to identify places where scientific truth about the human body may be found if one is willing to dig hard enough. That’s more of a sideline, though.

    Clearly, the Politburo, Outer Party, and associated wannabes here disagree with me vehemently (and frequently incoherently). I don’t think that even they would credit me with being a friend of the doctor in this case, though, or a supporter of his privilege to do as he pleases without complaint or objection by the nurses involved. I guess I don’t see where this came from.

    So, in conclusion: Drugs, much?

    Oh, and “argument” only has one ‘e’ in it. But I expect you probably know that, being a “skoolteecher” and all.

    “duuuuuuuuuuuuuudddddddddeeeeee”
    -SD

  56. tanha says:

    Dude, SD

    I enjoy reading blogs from a variety of perspectives. Was wondering if you have a blog?

  57. BillyJoe says:

    SD,

    “Oh, and “argument” only has one ‘e’ in it.”

    Correction: “Oh, and “argument” has only one ‘e’ in it” ;)

    “My beef is with a regulatory system that grants doctors special privileges (diagnosis, treatment, prescriptions, &c.) and seeks to exclude competition (CAM, whatever) by fiat instead of destroying it by being so much better that no sane person would choose to use anything else.”

    Unless you consider:
    - the power of placebo.
    - the harm of CAM
    - the science illiteracy of the population
    - that a level playing field would actually disadvantage CAM.

    BJ

  58. Basiorana says:

    “Then can you explain how, in the presence of a similar lack of general knowledge about how electricity works, the public is sufficiently intelligent to understand that a “UL” label on a lamp means that there is a reasonable chance that the lamp won’t set their house on fire?”

    They don’t. Seriously, have you ever met an average person? People don’t know what “UL” means. But at least with lamps they know that if a lamp with bad wiring sets the house on fire, the fire department can discover that was the cause and the homeowner can sue the lamp manufacturer, thus encouraging the lamp manufacturer not to make shitty lamps, and to advertise that fact through a voluntary certification. Not a lot of mystery there– the responsible party is obvious, thanks to fire investigations (a socialist idea!).

    So your system of “SBM” as a voluntary certification won’t work because most people don’t actually understand that science-based medicine is the best kind of medicine, and often don’t have their choice of any doctor in the country, including those with SBM certification– they just have one or two doctors in their town who take their insurance, and can’t shop around. What’s more, while the SBM label is encouraging people who like science and generally think it’s a good thing in medicine to chose well, another group will decide to certify people as “EBM,” or evidence-based medicine, then basically say, well, okay, any doctor who feels they deserve this label can use it. And the majority of people won’t see that the EBM label and SBM label are different and have different meaning.

    We are currently having this problem with logging industries– people want to buy certified lumber that is ecologically friendly, so one organization started certifying lumber as eco-safe (a good label, as it’s a buzzword and understandable by laymen, unlike “UL”). But now we have like three or four kinds of voluntary certification out there, and only one of those actually involves anything more than the company saying “Yeah, trees are pretty and animals are cool.” The system failed there, too. That method only works when companies have OTHER reasons (like lawsuits) to enact the reforms anyway.

    “…destroying it by being so much better that no sane person would choose to use anything else.”

    They can’t do that because people don’t understand medicine. I know a woman who is using homeopathy to treat her breast cancer. It is obviously failing; she’s getting sicker. She previously treated herself with chemo and recovered; she knows lots of women who treated themselves and recovered; logic says she should go with the system that works. But her lack of understanding of basic science and her body means she thinks that a) homeopathy CAN work, and b) her recurrence is the chemo’s fault, instead of in spite of it. Again, your ideas only work in a world where we all are educated enough to understand our bodies enough to truly make informed decisions about them (an expectation of education I find in many deregulation arguments, and a confusing one, since often those same individuals argue for less regulation of the education sector too).

  59. qetzal says:

    SD,

    You still haven’t answered my question:

    Are you aware of any country that treats medical practice approximately as you suggest? If not, how about one that at least gets substantially closer than what most of us are familiar with in the US, UK, EU, Canada, etc?

    The whole discussion on China is a red herring. The question is about regulation of doctors, not about socialized versus free-market approaches to medical payment.

    To your knowledge, are there any reasonably developed countries where the government does not regulate and control who can practice medicine? Are there any countries that rely substantially on anything like a medical version of Underwriters Laboratory to ensure that doctors meet appropriate standards?

  60. Calli Arcale says:

    David Gorski:

    Minor clarification — the medical board is siding with the nurses, not Dr Arafiles

    That’s hardly a minor clarification. It’s exactly the opposite of what SD is saying.

    I know, but since SD was only mentioning it in passing, I figured it wasn’t that significant to his overall point. After all, he’s clearly not here to discuss the topic of the thread, but rather to use it as a jumping off point to discuss his personal pet issue.

    I moderate a message board elsewhere, and this thread would likely have been split by now, and SD would have been warned for deliberate thread derailing….

  61. David Gorski says:

    Yeah, it’s probably true that I moderate with too light a hand–as in almost not at all.

  62. Peter Lipson says:

    Arafiles has tried to dump his website in the memory whole, but google cache knows all.

  63. David Gorski says:

    As does the hard drive on my laptop, where I’ve stored web archives of every page in his site. :-)

    I note that his swine flu presentation is still there:

    http://www.health2fit.net/SwineFlu.pdf

    Actually, the cached version is interesting in that it includes a picture of Dr. Arafiles, which was not there when I wrote about his website.

  64. Rhettfairy says:

    @ Calli Arcale:

    I finally made it through this entire thread, and couldn’t believe it took this long for someone to point out SD’s high jacking. He even admits it himself, in a way:

    “I don’t care about the nurses, to be frank. The doctor either, for that matter. My beef is with a regulatory system that grants doctors special privileges (diagnosis, treatment, prescriptions, &c.) and seeks to exclude competition (CAM, whatever) by fiat instead of destroying it by being so much better that no sane person would choose to use anything else.”

    That’s basically an out-and-out admission of using this story as a platform from his same, tired drivel (which people much more intelligent than him constantly smack down) and condescending BS.

    Even though it IS off-topic, I still wish he would address how he thinks the majority of the population with absolutely no medical background whatsoever would fair in his non-regulatory model. Is it in his plan to just let the ignorant die? A little thinning of the herd, if you will? This is one point he keeps completely ignoring.

    *waiting anxiously for my dose of condescension – I feel so left out*

  65. SD says:

    @qetzal:

    “You still haven’t answered my question:

    Are you aware of any country that treats medical practice approximately as you suggest? If not, how about one that at least gets substantially closer than what most of us are familiar with in the US, UK, EU, Canada, etc?

    The whole discussion on China is a red herring. The question is about regulation of doctors, not about socialized versus free-market approaches to medical payment.

    To your knowledge, are there any reasonably developed countries where the government does not regulate and control who can practice medicine? Are there any countries that rely substantially on anything like a medical version of Underwriters Laboratory to ensure that doctors meet appropriate standards?”

    Short answer: No. If there were one, I’d probably be living there.

    Medium answer: Sort-of, if you squint your eyes a bit and look at the situation hazily. Asian countries seem to be a little looser than the West is, in this realm; the price structures of medicine in Asia tentatively suggest a partial explanation of a less rigid adherence to the bondage-fetish for medical regulation and a deeper adherence to “caveat emptor” than we currently enjoy in the West. Procedures of similar quality can be done in places like Thailand for fractions of the price the same procedures would cost in the US, for example; this is increasingly popular, as many of these doctors were trained in the West and reportedly operate with modern equipment and techniques. Neither quality nor cost-of-living differential are sufficient to reasonably explain this price differential. Numbers about actual compliance with regulatory regimes are going to be hard to find, however, since it is difficult to get a believable answer from a government for statistics about how well its population is not complying with its laws.

    Longest answer: This is not my first rodeo, and I am aware of the nature of this request. It is a crypto-request for “data”, which in this context means “numbers that we can claim are bogus in order to head off serious discussion of the problem”. To beat you to your next punch, the fact that there are no countries in which this is obviously the case is kind of the point – the fetish for “regulatory control” of the medical industry seems, laughably, to be a universal product of the same “reasoning from first principles” that I receive such opprobrium for here. To make matters worse, the argument is always circular: “Regulation of medical practice is necessary, because obviously regulation is necessary to prevent quackery.” I maintain that the reasoning behind this is obvious when one considers the rent-seeking incentive on the part of the profiting clientele (medical professionals) and the empowerment of the privilege-granting group (the political class), in contradiction to the rights and benefits of the victims (the rest of the general public). Doing bad things in order to maybe (poorly) prevent bad things from happening at some indeterminate point in the future is pretty obviously neither moral nor practical, yet I hear nothing but support for this practice from this crowd.

    I will also note that the existence or lack of existence of a laissez-faire or “voluntaryist” approach to medical quality issues is not “proof”, either in the sense that I use it (apodictic), or even in the sense that *you* use it (empirical). The fact that “everyone does X” is not proof that X is a good idea or that it leads to a good result; likewise, the fact that “nobody does X” is not proof that X is a bad idea or leads to a bad outcome. It is only proof that people do or don’t do those things. (Example: Lots of people are “doing CAM” these days. Is that a good idea?) You may argue that “coercive regulation is part of the human condition, whether or not it is a good idea or leads to good outcomes”; well, I’ll won’t even bother arguing that point, since history is full of evidence to support precisely that conclusion. I take exception to the claim that it is moral or practical on that basis, though – history is full of examples proving that humans like to rape and murder each other, but I doubt anybody could claim with a straight face that these are moral or practically useful activities. I claim only that coercive regulation does not do what people think it does; in other words, that there are second- and higher-order consequences to the act of regulating something by fiat, *visible and predictable using first principles*, that militate against the effectiveness of that regulation, without even considering the moral implications and effects on human liberty and economic well-being.

    Let’s turn this around: Are *you* aware of any place where this has been done and where it has turned out poorly? Since “argument from first principles” is off the table, don’t jerk out the US pre-1906FDA without data controlled for the effect of medical, sanitation, and economic advances post-1906 to support a conclusion that the improvement in medical outcomes was reasonably due to this regulation.

    “back atcha”
    -SD

  66. SD says:

    @Calli:

    “I know, but since SD was only mentioning it in passing, I figured it wasn’t that significant to his overall point. After all, he’s clearly not here to discuss the topic of the thread, but rather to use it as a jumping off point to discuss his personal pet issue.

    I moderate a message board elsewhere, and this thread would likely have been split by now, and SD would have been warned for deliberate thread derailing….”

    The thread is not “intentionally derailed”; everything so far is directly topical. The thread is about a pair of nurses who dimed out a doctor who was allegedly handing out bad advice. This is, at its core, an issue about regulation (the regulating authority in this case being the Texas Medical Board), which, despite vehement complaints, *is* an economic issue. It is also another embodiment of the question of “Who gets to decide?” According to the SBMsheviks, because medicine is a special magical field of cosmic importance (instead of just another job that people do to make profitable use of their time), it is immune to economic analysis, and the decisions are so precious that they must be rationed to a select few in order to protect the great stupid unwashed masses from their own idiocy. I dispute these claims, since they are prima facie self-serving, are unsupported by any data (ha!), and also completely unsupported by any analysis from first principles.

    If Cde. Gorski et al. would like people to *not* dispute these claims, perhaps this should be a private kaffeeklatsch. If y’all would like to invite participation from teh Intarwebs, then be advised that it is full of lots of people who are (a) not nice and (b) frequently not susceptible to being spoonfed bullshit of the type shoveled here on a daily basis. Sorry. I guess the best advice I have is, “deal”.

    (I note in passing that the banhammer comes into the conversation when people are being pushed out of their mental “comfort zone”. Question: Exactly how scientific is it to seek to avoid leaving that comfort zone? Second question: If you’re serious about your goals, don’t you think it might be useful to have some legitimate answers to the objections raised that would shut someone like me up?)

    The practice of medicine is not immune to economic analysis – sorry. The practice of regulation itself can be seen to have many flaws, many of which are visible here, making this a good “teaching moment” for those allergic to economics – sorry again.

    “not sorry”
    -SD

  67. pmoran says:

    SD: “The practice of medicine is not immune to economic analysis – sorry. The practice of regulation itself can be seen to have many flaws, many of which are visible here, making this a good “teaching moment” for those allergic to economics – sorry again.”

    We can agree with these statements and still argue that some regulation is inevitable, as you do yourself on occasions.

    I share the view of those who think you know very little about of the economics of medicine.

    For example, in most countries the government or other third party payers hold the purse strings and medical services are largely free at the point of use. The public is encouraged to consume as much conventional medical care as they can fit into their day. What effect does that upon the medical marketplace and the need for certain regulations?

    Thus Canada and Australia once tried to control expenditure by limiting provider numbers, in the partly true belief that doctors can generate their own income out of almost nothing (one of your a priori economic principles — discovered first by homeopaths, but now known by every quack and health fraud).

    Expenditure on many medical services is capped, in Australia, the UK and probably Canada. How laissez faire does that leave medicine in such countries?

    I suppose relatively rarely invoked piddling little regulations intended to sustain a basic level of quality and safety for medical products and services add something to the mix, but I refuse to lose much sleep over it.

    PM

  68. qetzal says:

    SD writes:

    I note in passing that the banhammer comes into the conversation when people are being pushed out of their mental “comfort zone”. Question: Exactly how scientific is it to seek to avoid leaving that comfort zone? Second question: If you’re serious about your goals, don’t you think it might be useful to have some legitimate answers to the objections raised that would shut someone like me up?

    I call bullshit. SD likes to ask what he thinks are hard questions, but he’s not willing to answer questions himself. As has been pretty clear for a long time, his only real interest is in trolling. No different than pec, really.

  69. lillym says:

    It’s interesting how, although they argue different points, SD and lizkat are both very similar.

    They both outright refuse to answer direct questions, they dance around in circles instead of being clear on topics, and they both use a lot of words to say nothing.

    I am wondering if SD will actually answer qetzal’s question so I’ll repeat it:

    Are you aware of any country that treats medical practice approximately as you suggest? If not, how about one that at least gets substantially closer than what most of us are familiar with in the US, UK, EU, Canada, etc?

    Although I’m not expecting much more than blah blah communism blah blah .

  70. SD says:

    @lillym:

    “I am wondering if SD will actually answer qetzal’s question so I’ll repeat it:”

    Actually, I have answered it. The comment is awaiting moderation. It may be visible at this link:

    http://www.sciencebasedmedicine.org/?p=3864#comment-42766

    I wonder if the talk of moderation has encouraged Cde. Gorski to find ways to cleverly impede the argument of others by delaying responses?

    “you be the judge”
    -SD

  71. Chris says:

    PalMD has blogged some more details about this. It seems that the legal counsel for the AAPS, Andrew Schlafly, was Arafiles’ lawyer in the issues surrounding his licensing in New York. I guess this helps in understanding their defense of this doctor with some questionable ideas.

    To many of us veterans of UseNet the Schlafly brothers were amusing diversions, and at least one was very good at avoiding direct answering direct questions. Since he was teaching at a west coast university at a time when measles was being imported from Japan and Korea I asked Roger how he was going to protect his daughters from measles without vaccinating. His reply was on the order that he had had measles and would be okay (I really tried finding it, but failed… I found other conversations, if you do find it you will know my last name… big deal, there are only about 32000 hits on Google on my name that are not me, also I left Usenet years ago, it is a silly place).

    (Note: I ignore SD because he is a junior comic version of the Schlafly brothers. A long winded troll who is really very boring.)

  72. Chris says:

    My comment is in moderation. Just note that PalMD at WhiteCoatUnderground (link on this page under Medical Blogs) has more interesting information on the relationship with AAPS.

  73. BillyJoe says:

    “I wonder if the talk of moderation has encouraged Cde. Gorski to find ways to cleverly impede the argument of others by delaying responses?”

    I’ve often had my comments in moderation.
    One of the problems is that no one ends up reading it because they’ve all moved on when it finally appears. At least that was my impression, which could be wrong.

    In any case, I’ve never been able to work out why comments go to moderation (even ones without links)

  74. Chris says:

    Moderation is certain keywords (which are secret) and having certain web links (there may be some that are automatic, and others that are random… my last one was to a posting by someone who contributes here).

    Sometimes the moderation is just random!

    (really, my moderated comment had a link to a blog of one of the authors here!)

  75. SD says:

    @Chris:

    “Moderation is certain keywords (which are secret) and having certain web links (there may be some that are automatic, and others that are random… my last one was to a posting by someone who contributes here).”

    Yeah, I know how moderation works. I just can’t pass up a chance to torment Comrade Gorski. >;->

    “le marquis de sade”
    -SD

  76. SD says:

    On the topic of tormenting Comrade Gorski, a note for the audience:

    Cde. Gorski still hasn’t responded to the requests for either

    (a) data supporting the conclusion that the FDA1906 actually *accomplished* anything, or

    (b) a proof of *any* statistical theorem that does not employ induction from first principles; hell, *any* indication that he had a deeper understanding of statistics than “Muhhh, one in ten is bad odds, er, uh, p-value! Poop!” would be impressive.

    Since I’m getting heat for “not responding to qetzal” – which I have, should Cde. Gorski ever release the response from Purgatory – I may as well turn up the heat on the Comrade to deliver the goods for the questions *I’ve* asked. Answering criticism is important, after all. >;->

    I suspect that (b) is a lost cause – I imagine he’s as ignorant of statistical theory as of basic economics. That’s not a crime – most MDs are, they usually cheat their way through the “tough” courses in the hopes of achieving a fat salary by the time they’re 30, ask any chemistry professor at any university anywhere for confirmation of this fact – but it’s kind of a shame, since I was hoping to get some nice tasty Fail to pick apart.

    “you fail math forever”
    -SD

  77. BillyJoe says:

    I think that sort of moderation is unfair (based on some words, or random). I was quite discouraged a while back when I spent some time crafting a response to someome which then went into moderation. It recieved not a single reply, probably because no one ever read it.

    I could be wrong, of course. Maybe my post was just irrefutable :D

  78. BillyJoe says:

    SD,

    I don’t think Mark is going to respond to questions that he might need to spend considerable time researching and/or answering when he knows he’s just going to be dacked on whatever he says.

    I think you deserve your non-response.
    I myself would be loathe to respond to you in anything other than an offhand manner.

    I mean I don’t mind a little harmless sadomasochism amongst consenting adults, but you would have to identify yourself as female to qualify.

  79. David Gorski says:

    Heh.

    Indeed. I myself admit to having a weakness for feeding trolls like SD from time to time, but eventually I come to my senses–usually when I get bored with said troll’s antics. Maybe if SD came up with a new schtick I’d be lured back in again.

    No need to worry about that, though. SD hasn’t changed his schtick since he first infested this blog.

  80. SD says:

    @Comrade:

    “Indeed. I myself admit to having a weakness for feeding trolls like SD from time to time, but eventually I come to my senses–usually when I get bored with said troll’s antics. Maybe if SD came up with a new schtick I’d be lured back in again.”

    Ah, Comrade.

    I note that no portion of your fake-blase’ response involves any comment about your understanding of statistics, your ability to prove it without reference to axioms (do you even know what the axioms of probability theory *are*?), or data regarding whether your cherished shibboleth that FDA1906 Saved Us All from a medical apocalypse is actually demonstrable with empirical data.

    Thank you for releasing my responses from Purgatory, though. I *knew* you weren’t cowardly enough to selectively block responses in the middle of the debate. I believed in you, Comrade, and you came through. Perhaps you are not lost to Error and Folly quite yet.

    “trust, but verify”
    -SD

  81. SD says:

    @Billy:

    “I don’t think Mark is going to respond to questions that he might need to spend considerable time researching and/or answering when he knows he’s just going to be dacked on whatever he says.”

    Well, duh. *Of course* he’s gonna get ganked if he produces something and it’s not unassailable. Are you fucking kidding me? What do you think this is, kindergarten?

    The audience will decide whether or not the ganking is merited. This is a function of how well Comrade Gorski defends his point, and I mine. Comrade Gorski will of course perform poorly, shrieking like a little girl and running for cover. I will ask lots of pointed questions, Cde. Gorski will drop a couple of snide non-answers, and I will therefore win on the preponderance of the evidence. (I will also win by planting seeds of doubt in the mind of observers, but that’s a “second-order effect”.) The Tao will flow, and life will go on.

    Are you new here?

    “gank!”
    -SD

  82. SD says:

    @qetzal:

    “I call bullshit. SD likes to ask what he thinks are hard questions, but he’s not willing to answer questions himself. As has been pretty clear for a long time, his only real interest is in trolling. No different than pec, really.”

    Ah, qetzal. You don’t get off *that* easily.

    The question is answered above. It was stuck in moderation.

    “not so fast”
    -SD

  83. qetzal says:

    @SD

    Response to your short answer:
    Thanks (finally). I actually hoped there would be an example so we could see how well that works in the real world.

    Response to your medium answer:
    I don’t see much justification for “sort-of” in that response. Again, I wasn’t asking about regulation of the cost or payment models. I was asking about who gets to call themselves doctor, and how their training and compentence is ensured. If there’s something about Thailand or any other Asian country’s system that relevant to this, please try to state it clearly. Otherwise, we can stick with the short response.

    Response to your longest answer:
    You’re flat wrong here. This was not any kind of “crypto-request.” I am neither stupid enough nor dishonest enough to claim that the lack of such systems in any developed country is proof that they don’t work. I only asked because if such a system existed, I wanted to see how well it works in practice.

    I don’t claim expertise in economics or regulatory theory. However, I’m still quite aware that gov’t regulations often have unintended effects, and that just because ‘everyone’ regulates something the same way, it doesn’t prove that’s the best way.

    At the same time, just because something is best “in theory” doesn’t prove it’s the best way in practice either. Theories have this annoying habit of being limited and incomplete. Even if they work well in one situation, it’s no guarantee that they’ll work well in another, seemingly similar situation. That’s why we like to test them empirically. Apparently, your laissez faire theory that gov’t shouldn’t regulate doctors has not been tested in any modern, developed country.* So if anyone is trying to play games with data, it’s you. You’re claiming virtual certainty in the absence of key data.

    [*I expect there are examples from poorly developed countries, as well as historical examples. For the moment, I'm assuming they wouldn't be useful comparators for the relatively sophisticated medicine of today's developed countries.]

    P.S. I don’t consider it getting off easy when I have to ask the same question three times to get a straight answer. But in your case, I guess I should count myself lucky. Straight answers are apparently a real challenge for you.

  84. Harriet Hall says:

    Re moderation:
    I don’t know why some comments are held for moderation. There appears to be some kind of software glitch. Some of my own comments get held for moderation, and I can’t see any pattern to explain which ones are held. Several of us have the power to release comments from moderation and we try to do so promptly, but sometimes it takes a while for one of us to notice. Please be patient and not paranoid.

  85. @SD:

    We at SBM are not unanimous in our opinions about governmental regulation of health care, even if we are probably unanimous in the opinion that your comments are exceptionally abrasive (save the first few in this thread). My own view is similar to Peter Moran’s and is found in an old thread that involved only two messages: a comment from tarran and a response from me. See: http://www.sciencebasedmedicine.org/?p=272#comment-10526

    And: http://www.sciencebasedmedicine.org/?p=272#comment-10554

    I don’t consider you a troll, even if I think that you are sadistic. You write very well and your points are mostly cogent and topical–once you get past the insults, which I find entertaining to an extent. But you aren’t winning any converts. You even managed to piss off tarran, the only ally you’ve had on this blog who isn’t a functional illiterate:

    http://www.sciencebasedmedicine.org/?p=348&cpage=1#comment-12318

    Not that you necessarily want converts, I understand, but then neither, necessarily, do we. I’d love to be king, but I view my role here as telling it like it is, so to speak, and letting the chips fall where they may. Anything more is unrealistic and a prescription for insanity.

    “There’s a sucker born every minute”

  86. BillyJoe says:

    “Well, duh. *Of course* he’s gonna get ganked”

    Point made then.

    ” if he produces something and it’s not unassailable. Are you fucking kidding me? What do you think this is, kindergarten?”

    I never went to kindergarten, but does it have to be a Hollywood style police interrogation?

    “The audience will decide whether or not the ganking is merited.”

    Well, apart from the ganking, nothing much else seems to happen, so all we get is a side-show freak-act making out it is the main attraction.

    Are you new here?

    Depends what you mean by new. I’m not brand spanking new, but I wasn’t here last year. Is that new enough?

  87. LawMed says:

    Someone who is not a fan of the good Dr. has posted the videos back to YouTube!

    http://www.youtube.com/watch?v=dCsyUbMLBi4

    ENJOY

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