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Has Western medicine lost its soul?

If there’s one message that I’ve been trying to promote, regardless of whether it’s on this blog or my not-so-super-secret other blog, it’s the concept that there should be one standard of evidence—one scientific standard of evidence—for evaluating health claims and medical treatments. It doesn’t matter if it’s the latest drug from big pharma, the latest operation from a hot shot surgeon with a lot of creativity and not necessarily the most rigorous dedication to science- and evidence-based medicine, the woo-filled claims of alternative medicine practitioners, or the seemingly “evidence-based” claims of physicians deluded enough to “integrate” quackery with medicine and call it “integrative medicine.” That’s the beauty of science. Unfortunately, those who would “integrate” pseudoscience into medicine have been very successful in promulgating a double standard, in which the pseudoscientific medicine is held to a lower standard of evidence.

Coming in a close second as a theme of this blog is the demolition of a false dichotomy promoted by purveyors of “integrative medicine”—or “complementary and alternative medicine (CAM)—or whatever the buzz word du jour is to describe it. That false dichotomy is the claim, seemingly endlessly repeated by everyone from Andrew Weil to David Katz to just about every advocate of “integrative” medicine willing to join with naturopaths, practitioners of traditional Chinese medicine, reiki practitioners and other “energy healers,” and homeopaths in their quest to be a “holistic physician.” In fact, that’s the dichotomy. They argue that, in order to be a truly “holistic physician,” you have to embrace pseudoscience of the sort practiced by the aforementioned practitioners of pseudoscientific medicine, or, as David Katz seems to argue, that you’re “abandoning patients” if you don’t consider these modalities seriously. Of course, David Katz is (in)famous for a quote in which he advocated a “concept of a more fluid form of evidence than many of us have imbibed from our medical educations” and was willing to embrace homeopathy based on anecdotal evidence.

So why is this happening? Well, I know one reason it’s happening is that too many physicians buy into some seriously bad logic, logic that was unfortunately on display on the blog of a cardiologist named Michel Accad, who wrote a post describing (he thinks) How Western medicine lost its soul. Whether or not you ascribe to the concept of a “soul” or not, the post is the very false dichotomy I introduced this post with—on steroids. It also irritates the crap out of me that he chooses to use the term “Western medicine,” which is, as I’ve described more times than I can imagine, a rather racist construct, in which we (white and European) “Western” doctors are dedicated to science, in contrast to those “Eastern” practitioners, who are more “holistic” and “spiritual.” It’s just a gussied up version of the old racist trope about “mysterious Orientals.” I’m sure Dr. Accad didn’t mean it that way, but that doesn’t mean the term doesn’t imply a difference where there is none. Let’s just put it this way. I’ve met a lot of kick-ass doctors using science-based medicine who are Asian, particularly Japanese surgeons. Science is science, and science-based medicine is science-based medicine, no matter where it is practiced.

My pet peeve aside, I tried to ignore the number of times Dr. Accad referred to “Western medicine” and looked at his arguments:

Today, someone who needs attention for a health matter can seek conventional “Western” medicine or opt to receive a “holistic” treatment from the realm of so-called alternative medicine. For most people, there is a clear distinction between the two. Sure, some licensed physicians claim to provide holistic care, but this usually means that they might add an alternative form of therapy to standard treatment, or perhaps that they strive to be exceptionally considerate. The holistic character of the care rarely, if ever, comes from Western medicine per se.

But holism shares with health the same etymological meaning: the Greek holos and the Old English hale both refer to the idea of wholeness. So why does conventional medicine seem so unable to attend to the complete welfare of the patient? Why, despite the manifest efficacy of scientific treatments, do growing numbers of patients consider their medical care altogether unhealthy?

The response to Dr. Accad’s first observation is rather trivial. There’s a reason why doctors claiming to be “holistic” use some alternative medicine is because purveyors of “integrative medicine” have been exceedingly successful in promoting that very false dichotomy, that concept that in order to practice “holistic medicine,” you have to embrace various forms of pseudoscientific medicine. This message has in particular permeated large swaths of medical academia, leading to a term that I like to use to describe this phenomenon, quackademic medicine. It’s become, in essence, a matter of definition: Holistic is basically defined these days as using some form of alternative medicine.

How frequently do you recall hearing homeopaths, naturopaths, and practitioners of TCM claim that, unlike that nasty, reductionistic “Western” medicine, they treat the whole patient. Often they will even add the phrase “body, mind, and spirit,” as in “We treat the whole patient, body, mind, and spirit.” My typical response is that this claim is utter poppycock. It’s marketing, not a real statement of what these alternative practices actually entail. After all, a good primary care doctor using science-based medicine does provide “holistic” care—and effective holistic care because it’s based in science. It is true that it’s become quite difficult to provide holistic care under the current model, in which spending more time talking with patients is not incentivized (quite the contrary, unfortunately). However, that’s a problem with the system that doesn’t require embracing pseudoscience to fix. It’s a problem that requires money and a will to change our reimbursement model.

Actually, though, there’s another reason why an unfortunately large number of doctors seem to be attracted to nonsensical quackery to the point of wanting to “integrate” it into their practice. Two rasons, actually, but they are related. The first is a belief in dualism, which is the concept that the mind is separate from the body, that there is “something” (be it soul, mind, or whatever) that is separate from the meat and machinery that make up our bodies. Related to that is the concept of vitalism, which is the concept that there is a “vital force” that animates living matter, that makes it living. There’s a reason why so much alternative medicine, such as homeopathy, is rooted in vitalism. TCM, with its concept of qi, or the life energy, is largely based on vitalism, in which acupuncture redirects the flow of qi and

Dr. Accad makes it very clear that he wants the “soul” back in medicine, believing that that nasty science has removed it. He even quotes Thomas Aquinas:

The bodily unity in matter and form—a holistic concept in the fullest sense—has been a foundational principle of Catholic anthropology ever since 1312, when the Council of Vienne declared this account of man to be doctrinal truth. And for Aristotle and Aquinas, this substantial unity is not unique to mankind. All natural things necessarily exist by virtue of the union of these two essential principles: each material body is brought into existence as such by a particular substantial form. In the case of living organisms, the substantial form is also the animating principle, or soul, of the body.

Dr. Accad then goes on to point out (correctly) that this is not a concept unique to Catholicism and Christianity, but that it was widespread in many cultures. So what’s the problem? What do you think? It’s modernity and those nasty scientists like Descartes, who taught materialism and his “conceptual sundering of body and soul.” Yet, even complaining about this development, Dr. Accad has to concede that materialism has resulted in science that has produced some fantastic results in medicine:

The heightened attention given to the material aspects of the universe promoted the achievements of a bewildering revolution in the empirical sciences. And under the influence of the new sciences, diseases came to be conceptualized in similar terms: illnesses are accident of nature due to defective arrangements or to faulty motions of material stuff. Fix the defect and you fix the patient. This approach has yielded such astounding benefits to mankind that Descartes’ dream of conquering illness through the methodical application of empirical science seems to be well under way.

Well, yes. Given that human beings are biological organisms, if you figure out the biological cause of a disease it becomes possible, through the “methodical application of empirical science” (as Dr. Accad puts it) to intervene and even reverse the course of the disease. No spirit is needed for science to do its job in medicine, and that is clearly what bothers Dr. Accad. He goes on and on, lamenting the severing of the soul from the body, conceptually speaking, and discussing how scientists sought to identify the “vital principle of living organisms” through the study of vitalism, mesmerism, romanticism, and idealism in the eighteenth and nineteenth centuries. He especially laments how “when these efforts at grasping the essence of life proved futile or problematic, the inconvenient soul fell into neglect and was finally abandoned altogether as a subject worthy of inquiry or acknowledgment in polite scientific company.”

Of course, this is how science works. When scientists seek out a phenomenon to study and fail to find it, sooner or later there comes a point when they give up, when they conclude that the phenomenon doesn’t exist or isn’t as they believed it to be and move on to more promising areas of inquiry. This is as it should be. As I like to put it, you can believe in a soul if you like, but in the absence of evidence for its existence that’s all you have: belief.

So what’s the problem? Dr. Accad thinks we as “Western physicians” practicing “Western medicine” need to somehow bring the “soul” (whatever that means) back into medicine:

Thus deprived of spirit, the human body assumed for the scientist the status of a mere, albeit complex, machine. And as the material successes of biomedical science multiplied, the mechanistic metaphor was adopted by the practicing physician as well. Over the last 100 years, the medical profession, with the help of government, academia, and big business, has turned Western medicine into a “health care delivery system” where biological material is the input, and health the hoped-for output. Accordingly, the noble medical enterprise must now be pursued in the most efficacious, safe, efficient, and accessible manner. Standardization has become its prime mode of operation.

Gee, Dr. Accad, you say that as though it were a bad thing. Sorry, I couldn’t resist. I promise not to interrupt his finale:

The only wrinkle, of course, is that the raw material under process is a person: individual, substantial, rational, and—as Karol Wojtyla emphasized—self-determining and “incommunicable.”³ Ill-suited for the assembly line, that person is now protesting. Increasingly, men and women seek the holistic practitioner to attend to the neglected half of their being. Meanwhile, the massive delivery system, wobbling on a foundation of faulty mechanistic assumptions, threatens to collapse at any time. Yet the remedy seems so simple. But will Western medicine ever bring the soul back to the patient’s body?

So let me get this straight. In order to “fix” what he calls “Western medicine,” Dr. Accad thinks we should do … what, exactly? How does a system of medicine “bring the soul back to the patient’s body”? What, exactly, does that mean? Dr. Accad doesn’t tell us. Rather, he pines for a day when the soul was considered. The most charitable interpretation is that Dr. Accad means the soul as a metaphor for the psychosocial needs of the patient, for a human being’s need for empathy, caring, and the “human touch.” Certainly, near the top of the list of valid criticisms of our current system of delivering health care would be how it disincentivizes physicians, particularly primary care physicians, from spending a lot of time talking to their patients, often leaving them 12 minute time slots to deal with complicated patients. How would “bringing back the soul” fix that problem? It wouldn’t. It’s also a fallacy that patients seeking “integrative medicine” are dissatisfied with their medical care. Most are not. Whatever Dr. Accad is trying to say, in the context of his post I do not think he is using the soul as a metaphor. He really seems to mean “soul,” as in the religious concept.

Be that as it may, what Dr. Accad posits is a variant of the same false dichotomy that argues that you have to embrace pseudoscience in order to be a truly “holistic” physician. In this case, all you have to do is to embrace the concept of something that science can’t measure or identify. According to Dr. Accad, medicine would return to the halcyon days of yore, when doctors were doctors, patients were patients, and everything, apparently, was awesome if only modern medicine would “bring back the soul.”

Whatever that means.

By Orac

Orac is the nom de blog of a humble surgeon/scientist who has an ego just big enough to delude himself that someone, somewhere might actually give a rodent's posterior about his copious verbal meanderings, but just barely small enough to admit to himself that few probably will. That surgeon is otherwise known as David Gorski.

That this particular surgeon has chosen his nom de blog based on a rather cranky and arrogant computer shaped like a clear box of blinking lights that he originally encountered when he became a fan of a 35 year old British SF television show whose special effects were renowned for their BBC/Doctor Who-style low budget look, but whose stories nonetheless resulted in some of the best, most innovative science fiction ever televised, should tell you nearly all that you need to know about Orac. (That, and the length of the preceding sentence.)

DISCLAIMER:: The various written meanderings here are the opinions of Orac and Orac alone, written on his own time. They should never be construed as representing the opinions of any other person or entity, especially Orac's cancer center, department of surgery, medical school, or university. Also note that Orac is nonpartisan; he is more than willing to criticize the statements of anyone, regardless of of political leanings, if that anyone advocates pseudoscience or quackery. Finally, medical commentary is not to be construed in any way as medical advice.

To contact Orac: [email protected]

193 replies on “Has Western medicine lost its soul?”

…“bring back the soul.”

Am I the only one thinking of the Blues Brothers here? That´s the only kind of soul that is and that´s needed.

It is true that it’s become quite difficult to provide holistic care under the current model, in which spending more time talking with patients is not incentivized (quite the contrary, unfortunately). However, that’s a problem with the system that doesn’t require embracing pseudoscience to fix. It’s a problem that requires money and a will to change our reimbursement model.

So, doctors should get paid more, and then they will be willing to talk to their patients.

Sounds like a very soul-oriented plan.

Well, yes and no. The problem is that, although most doctors would love to spend more time with their patients, the current reimbursement model makes it very difficult to make a living and generate enough income to keep the doors of the practice open if a primary care doctor isn’t seeing 4-6 patients per hour.

“Well, yes and no.. the current reimbursement model makes it very difficult to make a living…”

Well, there’s making a living, and then there’s making a living.

If the service can be provided by someone who will do it for less, then that’s what’s going to happen in a (somewhat) free market system.

The “free market” actually has little to do with it. Rather, government insurance programs have been ratcheting down reimbursement rates for decades now, and insurance companies follow suit, because they can. But we’re starting to drift off topic here.

There is a reason scientists often take a reductionist approach: real systems are often too complicated for simple analysis, so one often gains more insight by considering a simplified version of the problem. The “spherical cow” jokes told about physicists are an extreme form of this, but it is easy to come up with a system that does not have an exact analytical solution. For instance, the general problem of three bodies moving under their mutual gravitational attraction can only be solved numerically. But most of the time, the influence of complicating factors is small enough that we can get an adequate solution by ignoring them, at least until we need sufficient precision to worry about those other things. This is why, if you are computing the orbit of a satellite which is not part of a GPS-like constellation, you don’t need to worry about general relativity. GPS engineers have to worry about it because they depend on timing with sufficient precision that the effects become noticeable (a part-per-billion error in timing accumulates to a position error of about six miles after a year). There are cases where the approach of neglecting small corrections backfires spectacularly, but part of physics training is learning to recognize these exceptions.

Medical science deals with systems far more complicated than anything a physicist deals with. So the reductionist approach is essential to understanding how treatments work. If you have acute pain in a specific location, it can be treated with a local anesthetic, and as long as that anesthetic is non-toxic, the doctor doesn’t have to worry so much about what it will do to a distant part of your body. Likewise, many medical conditions can be treated with specific medications. Physicians do have to worry more than physicists about interactions between different parts of the system (drug interactions, for example), but without a reductionist approach, how would scientists have a systematic method for thinking that substance X might treat condition Y? Even homeopaths have something like this: they note that macroscopic doses of substance X cause condition Y, so they conclude that diluted-ad-absurdum solutions of substance X treat condition Y.

All this is a long-winded way of saying that Dr. Accad is full of bull. The soul, if it exists, is a biochemical process, like anything else about us. We may not understand the biochemical process involved, and will not as long as we haven’t identified candidates for that process. But science marches on, and there is a chance that some future generation will either understand the process, or show that there is no such process. The approach Dr. Accad advocates will certainly not work.

I still want Dr. Accad to explain what he means by “bringing back the soul to the patient’s body,” given that the soul is a religious, not a scientific, concept. Does he mean that medicine should incorporate religious beliefs?

“ratcheting down reimbursement rates”

First, that’s a non-sequitur even in the context you intend, but you misunderstand my point.

Those 4-6 patients are mostly not suffering from anything but anxiety; if they didn’t see the doctor most of them would experience no ill effect. But they get reassurance by participating in the ritual.

That’s what the alternative system provides, at a lower cost to everyone. And almost certainly, alternative practitioners are better at that part of the process than MDs, for their patients.

@ zebra

Well, there’s making a living, and then there’s making a living.

It’s easy to ask other to sacrifice themselves.

The professor/surgeon star in the city’s main hospital may have a nice multi-digit income, thanks to his/her multiple titles.
The general practitioner, a.k.a. the family doctor, on the other hand… If he/she is conventioné (adhering to the state’s medical reimbursement system), he/she is limited on how much could be asked per consultation. And this income should suffice to pay the flat, the secretary and the office bills. Plus himself/herself, if there is some left.

Well, it’s like this in my country. From the little I have seen during my stay in North America, while there are some differences, the overall view is about the same.

I don’t like the term holistic and I would prefer if it was left to the alternatives. If normal doctors start using it I wont know who to steer clear of.

I attend a clinic with 4 clinicians. 2 just zoom in on what I require to get better the other 2 are holistic and ask me all about my life, every time I see them. I much prefer the zoomers. I feel like telling the holistic docs to mind their own business. Sorry I’m in a bad mood.

“If the service can be provided by someone who will do it for less, then that’s what’s going to happen in a (somewhat) free market system.”
The question then becomes “will they do it competently for less?”

“The bodily unity in matter and form—a holistic concept in the fullest sense—has been a foundational principle of Catholic anthropology ever since 1312”

That indeed was the golden age of medicine. Just read Barbara Tuchman’s “A Distant Mirror – The Calamitous 14th Century” to discover how holistic medicine can be (the section on plague is particularly illuminating).

I think physicians like Accad are exaggerating the extent to which patients want “soulful” medicine. In my family we see health care as akin to going to a mechanic to get the faulty parts fixed and take care of preventive maintenance. Oh, and to get those prescriptions filled. Aristotle and Aquinas we do not need.

@ zebra

Those 4-6 patients are mostly not suffering from anything but anxiety

Ah. I see your point, I think, but I have two issues with it right now.

1 – how to you triage between the “worried-well” patients and the ones with serious issues?
You perceive someone will have to do it, in order to spare the doctors from wasting time with them.

2 – how do you keep the patients happy?
You cannot exactly tell the “worried well” that you send them to a false doctor to spare the real one. They may feel a bit let down. After all, that they want is the attention of a real professional.
And if you let them believe they are seeing a real health practitioner, what do you tell them the day they have something serious?

I won’t even go about the hazard of letting people with a warped view on reality giving health advice. A number of alt-med types have proved again and again they cannot be relied upon in sending people with nasty diseases to see a real physician, save for true emergencies (and even so, not always).
Case in point, the recent post about the baby who died after 3 weeks of an ear infection, left untreated, save for useless homeopathy.

I won’t even go about the hazard of letting people with a warped view on reality giving health advice.

Actually, I should, since it’s more or less the thread’s topic.
Apologies for drifting OT.

#13 Helianthus,

Glad you understand my point. Maybe you are smarter than Orac?

Anyway, there are obvious solutions, but it requires a change in the conventional medicine approach that will be resisted for economic reasons– not just by the doctors, but the entire establishment. Does the person who does triage need to be trained to do surgery as well?

Note that in the case of the ear infection, unless I missed something, there was no practitioner involved at all. That was about mistrust of the system and poor education of the parents. Another reason to fix the system.

I don’t know but I’ve been told Science Based Medicine ain’t got no soul.

Glad you understand my point. Maybe you are smarter than Orac?

Your point was not at all clear in the original comment, and I’m the only one who appears not to have guessed at what you meant the first time. When you said “someone will do it for less,” in the context of this post, which was discussing doctors pining for “soul” and embracing woo, it was not unreasonable to think that you meant that other doctors would do it for less, particularly in the context of your invocation of the “free market”—hence my reply that the free market has little to do with it.

After all, this post was not about alternative practitioners. It was about doctors embracing alternative medicine in order to be “holistic” and a misguided physician who wants medicine to “put the soul back into patients.”

What you meant did not become clear until your third comment.

#8

In which Zebra dismisses mental illness…Anxiety being a debilitating and life-limiting condition.

If you mean something like “worried well” say so, don’t misuse a term like “anxiety”.

The foolishness of integrative/holistic/functional medicine becomes apparent when applied broadly. Who would want their brain MRI read by a holistic radiologist? Who would want their ventilator settings adjusted by a functional ICU doctor? Who wants their biopsy results read by an integrative pathologist? Who wants to be operated on by a surgeon who believes in alternative anatomy?

To those of us who like to think of ourselves as grounded in science-based medicine as much as possible, all of “alternative” medicine sounds as ridiculous as the examples I gave above.

#17 Orac,

I assumed you still didn’t get it after my third comment. I observe that you still are not responding to that point.

Like several others who have commented, I don’t see doctors because I want a buddy and spiritual guide and reassuring mother-figure. But I have to pay for those who do, because doctors are unwilling to give up that woo part of the business.

How about cutting out all those “yearly checkups” that science has established as having no effect? Or is that woo sacred woo because it provides a revenue stream?

The question then becomes “will they do it competently for less?”

This is a key question to ask of any cost reduction scheme. Better, faster, cheaper–pick any two. And that’s only in ideal situations, which does not describe medical practice in the US. In such situations you will only be able to optimize one of those three variables.

Here’s the catch: the “cheaper” option often proves more expensive in the long run. Those of you who drive on American highways have firsthand experience with this phenomenon: every one of those highways was paved by the lowest bidder, and as a result they have to be repaired more often than otherwise. Same thing with short patient consultations: the doctor (or more frequently nurse assistant–for several years I was assigned to a PCP I never once saw) is more likely to overlook something important when (s)he only has 10-15 minutes (if that) to spend with the patient.

@zebra: You really are getting tedious.

As regular readers know, I do call out “conventional” treatments and tests that aren’t really evidence based. One example is vertebroplasty for osteoporotic spine fractures. I’ve enumerated the shortcomings of mammography in terms of overdiagnosis and overtreatment and concluded that a less aggressive screening regimen produces the same or better results, to the point where, at my not-so-super-secret other blog, I had to respond to an angry attack by a prominent radiologist and mammography advocate. I’ve described how laparoscopic cholecystectomy was adopted too rapidly, before its safety had been demonstrated, resulting in higher rates of common bile duct injuries. I’ve discussed unethical practices of drug companies during clinical trials, as well as how “less is more” with respect to screening for disease in Europe as opposed to the US. When I say I advocate a single science-based standard for all health claims, I mean it.

Personally, as regular readers also know well, I do not respond kindly to complaints that boil down to nothing more than, “Why don’t you blog about what I consider to be important?” as your bit about how I should write about the yearly physical does. My response is almost always: I write about what interests me, and me alone. This blog is my hobby. I’ve been fortunate that enough people like to read what I lay down on a near-daily basis, which gives me some minor influence in the media, but even if my readership were only 1/100 of what it is I’d still be doing it.

That is why I really don’t care if you approve of or agree with my choice of blog topics.

As a patient, zebra’s assumptions immediately made me angry. It is implied that a majority of patients are nothing but attention-seeking neurotics. Is this really the preferred mindset for doctor-patient interaction? There is enough mistrust of medicine these days without introducing “placebo” medical personnel.

The real problem is finding a model that better manages the cost of providing medical treatment to patients that doesn’t so severely limit the time spent with their doctors. That would bring the “soul” that is missing back to medicine.

@zebra #20 – who on earth would waste the time of a doctor to have them be a mother figure or spiritual confessor? For pity’s sake – get a real friend (less expensive) or join an atheist church if you aren’t religious. I have adored many of my doctors for the way they treated me. My PCP refused to let me give up finding what was wrong with me after the first few diagnostic referrals yielded nothing. I was ready to write it off as “normal for me” or maybe just “unconscious attention seeking.” It doesn’t make them my friends. There isn’t time to develop friendship in fifteen minutes with less than ten face to face.

Why do our doctors have to be friends? I admit to wanting empathy and understanding. That is only natural. But friends? That requires a social context outside of doctor-patient. They are no more my friends than the girl at the gas station counter. It is impractical.

#22 Orac,

You seem to have a problem understanding; maybe you should read slower.

I’m asking you to respond to my on-topic point:

If some doctor wants to substitute one non-science based ritual for another, what exactly is the problem?

I don’t want to pay for people to get yearly checkups, nor do I want to pay for people to have their chi aligned. I am interested in a competent diagnosis, delivered in a timely and convenient fashion, not conversation.

I want the practice of medicine to be scientifically based, and the US system at least is completely irrational– forget being a “good” design. You offer no solution; you just want to spend even more money without improving care.

Those 4-6 patients are mostly not suffering from anything but anxiety; if they didn’t see the doctor most of them would experience no ill effect.

Citations needed. “Mostly” would of necessity translate to one more than half, so you’re stating that between 66.7 and 75% of all patients physicians see in the course of an average year would be none the worse if they didn’t seek medical care. That’s a pretty extraordinary statement.

And I’ll note that you haven’t limited this to a particular medical specialty–you haven’t, for example, suggested that most of the 4 to 6 patients general paracticioners see are mostly suffeing from anxiety”. Do you beleive that most of the patients cardiologists see are similary suffering from anxiety and would be fine woithout intervention?

How about most of the patients Orac sees–would they be fine without surgery?

Generally the person triaging the regular doctor’s appointments at any place I’ve ever gone is usually a nurse.

Not sure why zebra seems to assume almost all medical care and all other practice functions are only or mostly provided by MD’s who either are surgeons or at least might do something other than an office procedure. Everyone else is just window dressing or something?

You’d think the team-based approach with CMA’s and case managers and others handling a lot of the managing who is worried well vs who needs more intensive care would appeal. Sure we are working out how to pay for that (rather than how many minutes a physician sees you and how many things you got poked with) and there are issues for a business on when to adopt changes (too early and you do a lot of unpaid work that may never pay off and wait too long and you may not be ready to get paid the way the new way)

Or does zebra assume the fee for service model cannot ever be changed even if people say it will change and the only question is when and how?

The funny thing is that Accad is pretty muddled in his philosophy to begin with.

He likes “holistic” medicine because it acts on a “unity” of body and soul that somehow “reductionist Western” medicine doesn’t. Clearly this means that he believes that there actually is a mechanistic, purely physical body that interacts with the soul. It’s possible, somehow, for evil reductionist science to separate the soul from the body in a way that needs to be fixed with “holism.”

Descartes should really be right up his alley. They have the same premise, that the body and the soul are two separate things; it’s just that Accad thinks it’s possible to mix them back together or something, and “bring the soul back to the patient’s body.”

Clearly, if one is to actually reject dualism, it follows that acting upon the body is acting upon the soul. They are the same thing.

Spinoza > Descartes

#27 JGC,

Like the in-efficacy of yearly checkups, it is well established that most things (yes, at least 75%) people see a doctor for would resolve on their own. I’ve even had diehard Oracians here agree with that.

And obviously, from the context, we are talking about PCP-type interactions.

Where has it been well-established that 75% or more ofa ll patients seen by primary care physicians would be none the worse for the wear if they never sought treatment? I’m afraid an assertion that “it is well established” isn’t enough to convince me you’re correct. (I’ll note also that “resolve on their own” isn’t quite the same thing as “experience no ill effect”.)

#32 JGC,

“patients seen by primary care physicians”

I’m not interested in playing word games. If you want to address what I actually said, do so.

“[S]omeone who needs attention for a health matter can seek conventional “Western” medicine or opt to receive a “holistic” treatment from the realm of so-called alternative medicine.”
I love this quote. For some years now I have been referring to these “holistic” practices as So-Called Alternative Medicine in order to use the acronym. Now a proponent uses it too (albeit without the caps).
I award myself the Nobel Prize in Irony with poison ivy leaf cluster for humility above and beyond the ordinary.

@ Orac

Re: zebra

Your point was not at all clear in the original comment

I will even go so far as to say the two first comments from zebra bring two different points.

@ Kaymarie

Generally the person triaging the regular doctor’s appointments at any place I’ve ever gone is usually a nurse.

As I was the one bringing this point into the discussion:

In medical centers/clinics, sure (i.e. 3 or more doctors banging together and sharing resources). In my country, the usual model is more like a regular flat, shared by at most 2 doctors, with maybe a secretary with limited medical background if they have enough practice.
Sharing resources and having non-physicians at hand to sort out patients, treat the easiest/more casual cases, and do the paperwork is certainly an efficient organization. I wish we had the workforce and the resources in my country for this. We are lacking in nurses and general practitioners willing to settle outside big cities..

I can;t believe I blew my own nom de ‘net. I am still your Old Rockin’ Dave, though from time to time I might actually be Od(d) Rockin’ Dave.

I did it again. I’m going to the store for some over-the-counter maximum strength Jack Daniel’s Sovereign Remedy #7.

Discussions about “yearlies” are interesting. When I have mine, it includes an EKG to check on my minor heart issue. It also includes discussion of sleep habits, medications, any OTC drugs/vitamins/supplements, any changes in living arrangement, questions about mental health, blood work which is done ahead of time, etc., and usually takes about 30 minutes. Sometimes it’s a doctor and others a NP whom I prefer. I just assumed the same was true for everyone.

@ Helianthus

We do have rural areas where you do get the one doc + 1 receptionist type practices as there is no one else. Although we do see a fair number of 1 mid-level provider (nurse practitioner) with an assistant of some sort to fill in some of the gaps between MD’s. One of the reasons telemedicine is getting some thought especially to get more specialized care to people where traveling a long distance to find out if it is likely a something or not just isn’t going to happen.

However, it seems lately most have either been bought up by larger healthcare systems or even if staying independent have joined up with several other practices. Both instances allow for sharing of support staff which hopefully adds value while being affordable enough to keep the doors open.

Orac, I think that you briefly touched on the reason for “holistic approach”, which is basically due time and the compensation model in medicine, and this model isn’t the same for Alt med. I can’t speak for the US, but in Ontario Canada, our doctors are limited by government funds. Basically, doctors are paid per patient or a specified amount (in low population areas), and doctors have to make enough money to cover their overhead (staffing, tools, computers, rent, etc.), and pay themselves a wage. In order to cover these costs they need to see roughly 1 person per 15 minutes for about 8-10 hours a day, followed by a doctor’s 2nd or 3rd job. There’s also the issue of not enough doctors in Canada, but that’s another story. That’s a lot of people and very little time to take a more personal approach. In other words “holistic” is really about taking time to get to know a patient on a personal level and digging into the problem. There’s a reason why the doctors with the fewest number of malpractice suites are the ones whom patients like on a personal level. They spend time paying attention to a patients complaints and are therefore liked and trusted. In contrast, “Alt Med” practitioners are generally paid by private insurance which doesn’t have the same constraints as our public health care system. These practitioners can easily spend up to an hour on a patient. This is a very easy way to build a rapport between the practitioner and patient. Accordingly, real doctors suffer from a public image problem of not caring for patients while fake doctors appear to be savior merely by spending more time with patients. Anyway, I’m not sure if this as applicable to the US situation but it’s definitely true here in Canada.

In reference to comments making passing denigrating reference to physician extenders, I was a physician assistant for twenty years.
PA’s and NP’s are licensed practitioners who have passed an approved course of study (now at the Master’s level) and a national certifying exam; every six years PA’s must pass a recertification exam. There are PA residency programs in many specialties, such as surgery, emergency medicine, OB/GYN, oncology, etc.
I was not some kind of inferior or junior doctor, but a practitioner in my own right. I worked under the license and direction of a physician who would determine the scope of what I was allowed to do, and we were often trusted with a wide scope. I took a lot of the grunt work off my bosses, but depending on the setting I and my colleagues also served as eyes and ears, flying squad, sounding board, temporary coverage, and performers of complex procedures. I take a little pride in having done complex consultations, diagnosed rare conditions, identified a previously unknown adverse reaction from an experimental biologic, saved a few lives, changed a cutting edge treatment, and a few other things. I was not the only one of us doing important work.
During my time in the profession, studies showed PA’s producing better results than MD’s in treating hypertension and other chronic conditions, and having a lower rate of incorrect/inappropriate prescribing.
The denigration of the possible importance of NP’s and PA’s to a practice is unjustified. We did and do real work of real importance to real patients and the real practice of medicine.

I must have missed it, because no one makes denigrating comments about NPs or PAs on my blog without catching hell from me.

I’m sorry, zebra: I assumed the abbreviation “PCP” in the phrase “seen by PCP-type physicians” stood for “primary care physicians”. What did you intend to communicate instead?

in any event the what you’ve actually said that I am addressing is your claim that 75% or more of all patients “would experience no ill effect” if they never botrhered to seek treatment. that seems a rather extraordinary claim, for which you’ve offered no evidence.

In which Zebra dismisses mental illness…Anxiety being a debilitating and life-limiting condition.

If you mean something like “worried well” say so, don’t misuse a term like “anxiety”.

Oh, I dunno; “anxiety” was a synonym for “worry” long before it became a medical term. Using terms like “GAD” or “PTSD” or something in a similar manner would be a different story.

The bolded bit above is definitely true when discussing “anxiety” in a medical sense.

In any case, it’s not always easy to tell when symptoms are “just” caused by anxiety and when there’s an underlying condition. Sometimes it’s your friend’s well-established anxiety disorder that is causing him abdominal pain and lack of appetite, and sometimes it is something else. Not a mistake to get those kinds of things checked out, I think.

I was not in anyway trying to denigrate NPs just reflected the reality in some of our poorest and most under-served rural areas we often get solo NP practices. (to compare with a country where most areas are too rural to support a group practice so most docs work alone)

The gaps was not about the KIND of service provided but the LACK of any kind of medical services in some areas. For whatever economic or professional reasons it seems that the NPs willing to be the entire medical care system available for our poorest, and usually sickest, regions of our state as many do not have the resources to travel long distances for medical care. If anything that earns them more respect in my eyes.

#43 JGC,

I didn’t intend to communicate anything since that is your language not mine.

#46 so you will not clarify what the abbreviation PCP in #31 means?

Is it primary care physician or did you mean something else as your obviously is not as obvious to others as it is to yourself.

Or did you really use PCP as nonsense characters that were meant to communicate nothing at all? Or is it your purpose here has nothing at all to do with communicating with others and it’s just exercise for your fingers?

In ancient Rome, if you were put in charge of designing and building a bridge, you were required to stand UNDER it after completion, as it was tested. Hole-iistic, integrative, alternative engineers died out this way. Dr.Accad has forgotten that medicine is as intensely practical as engineering. Science-based medicine is, indeed, restrictive. It is restricted to what is known to work. And the methods of finding out are restrictive, too. To what has been shown to work. Anything else is treating patients like lab rats, or worse.

@ zebra #15 and 8

Anyway, there are obvious solutions

Would be nice if you were to introduce them, instead of vague assertions as to the possibility of things being improved.

Like the in-efficacy of yearly checkups, it is well established that most things (yes, at least 75%) people see a doctor for would resolve on their own.

Well, back to my initial questions at #13.
The triage of patients is already done where PA and NP are available, as some regulars explained (and if there was any doubt, I don’t denigrate their competence and usefulness, it’s just that, as luck has it, I haven’t meet many).
Let’s accept the idea that this triage could be improved to send back home a meaningfull number of patients, with minimal to no care provided.

There is still my other question, which you didn’t answered:
How do you keep these patients you turn away happy and trusting in the medical system?

I understood your comment #8 as meaning that these patients may simply go see some alt-med guy and be happy over there. Let me quote:

That’s what the alternative system provides, at a lower cost to everyone. And almost certainly, alternative practitioners are better at that part of the process than MDs, for their patients.

If you meant this, to recap, MDs will save time by sending your 75% of “no-really-sick” to alt-med providers, then could you explain to me how that’s going to increase the trust of these patients into their regular MD?
Because when Mr Jones is telling me “I can’t do nothing for you, go see Mr Smith”, and Mr Smith welcomes me and listen to me, in the future I will just keep going to Mr Smith.
Hypothetically*, even more so if Mr Smith is all about Holistic care and there are plenty of people yammering all year long how it is superior to “western” medicine.
(hence me mentioning the issue of people going for homeopathy and sticking to it, even when facing a deadly situation, because they came to trust it more than MDs)

*”holistic” wouldn’t work for me, but I would be honest and admit that some other meaningless buzzwords may have a chance in entrapping me. I can be fooled as well as the next person.

So, in short: regardless of the true of these 75% and where they go if MDs turn them away, the question remains: how is turning patients away going to increase the trust in MDs?

#49 Helianthus,

Your analysis is pretty good but I don’t really get this “increasing trust in MD” part.

If the doctor says to me “I don’t want to take your money because your symptom will go away by itself”, then why would I not trust the doctor more?

But when I say there are obvious solutions, I don’t mean that I have the exact model or paradigm worked out. Maybe, we could begin by asking whether health care should be a business or a public good? (Remember, I am only talking about USA.)

Then, the kinds of specifics we can all imagine– triage practitioners, what is the role of a PCP or GP or whatever you call it, what is their training, and so on. Do we need them at all?

What doesn’t work is the kind of thinking I hear from Orac and others, who can’t imagine a system that differs from what they are used to.

If the service can be provided by someone who will do it for less, then that’s what’s going to happen in a (somewhat) free market system.

I believe it was Ruskin who said “There is hardly anything in the world that someone cannot make a little worse and sell a little cheaper, and the people who consider price alone are that person’s lawful prey.”

I have had doctors tell me on several occasions that whatever ailment I had at the time would “go away on its own” & there was no need for a follow-up.

I still have no idea what problems that zebra is trying to address, since he appears to lack the ability to speak plainly or explain himself.

“Maybe, we could begin by asking whether health care should be a business or a public good?”

It can be both. It’s not necessarily an either/or.

zebra wrote:

If the doctor says to me “I don’t want to take your money because your symptom will go away by itself”, then why would I not trust the doctor more?

It’s less than clear what sort of scenario you’re imagining here. Is the doctor supposed to be waiving your fee because you weren’t in fact ill, or turning you away without having looked at your symptoms (possibly following triage by a nurse or whomever)? Something else?

If the doctor says to me “I don’t want to take your money because your symptom will go away by itself”, then why would I not trust the doctor more?

Like Lawrence, there has been a time or two my doctor has told me my concern was nothing to worry about. However this was after I’d seen the doctor, and he had spent some amount of time to arrive at that conclusion. For his time, I expect he wanted to be paid by somebody (even me), and I think that’s fair. That the payment included not only his wages, but also overhead (lights and running water, which all my doctors seem to want, cost money) is also fair.

Any doctor that can preform an exam for free has to be making up that lost time and materials somewhere else, or is loosing money. I really don’t see a way around that.

Perhaps zebra is advocating a system somewhat like my HMO*. If I notice, say, a different sort of skin growth and want it checked out, I first have to make an appointment with my PCP. My PCP will then say ‘It’s not cancer, it’s just age spots’, or, I suppose (because it hasn’t happened yet) ‘Gee, a dermatologist should look at that, let me make you an appointment’. Except, I suppose zebra would have some other person, who isn’t a doctor, act as a gatekeeper to even determine if I should be able to see a doctor in the first place. Like maybe an accountant. Because more layers always helps. /sarcasm

*I also have the option of calling an ‘Advice Nurse’ if I think that something may or may not need a doctors attention, however, at least in my case, the Advice Nurse has never told me ‘don’t worry about it’.

A general comment:

I find it interesting that Helianthus, who is apparently not a native English speaker, is able to engage in a constructive dialogue, clearly getting the point of the discussion.

Others, not so much.

Perhaps it is because (as I’ve found with non-native students that I’ve taught) bilingual individuals are more attentive to detail and nuance, by virtue of having worked back and forth in the two tongues.

It’s not like anyone else here is fluently bilingual, or trilingual.

#55 Johnny,

“Because more layers always helps. /sarcasm”

So, could you explain again why you want a PCP to look at your skin growth before the dermatologist?

The “spherical cow” jokes told about physicists are an extreme form of this, but it is easy to come up with a system that does not have an exact analytical solution…

What? That problem is so more undergrad than the ‘frictionless cat’ assumptions of pulley mechanical advantage.

Eric Lund #6, a frictionless cat is impinged upon….
It occures to me that the ‘reductionist approach’ is applying ‘Bandaid™ brand adhesive patches when there is no actual understanding or only a timorous understanding of the underlying mechanisms(?). ; This has proved valid over the last few millinea but it is still a ‘cop out’ for a physicist.

…Medical science deals with systems far more complicated than anything a physicist deals with. So the reductionist approach is essential to understanding how treatments work. If you have acute pain in a specific location, it can be treated with a local anesthetic, and as long as that anesthetic is non-toxic…

Have physicists dropped the ball here? Of course, everything reduces to physics. I agree that the biological systems are complex but perhaps it only seems overwhelmingly so as (published) physicists have not adequately ‘drilled down’ into and codified them yet.

You speak of ‘systems’ yet fall back to the mechanistic view of taking out the busted AE-35 unit to make it so that all is Dave without understanding why.
https://www.youtube.com/watch?v=Sbw8_e_qp00
————————————————-

It doesn’t matter if it’s the latest drug from big pharma, the latest operation from a hot shot surgeon with a lot of creativity and not necessarily the most rigorous dedication to science- and evidence-based medicine, the woo-filled claims of alternative medicine practitioners, or the seemingly “evidence-based” claims of physicians deluded enough to “integrate” quackery with medicine and call it “integrative medicine.”

What are you then left with, Orac? How do you get the ‘evidence’? Trial and error? Even if it is not so ‘kosher’ to admit so, I believe that there must be and is a considerable amount of ‘trial and error’ in the field as it stands now. The field as Eric Lund #6 describes it.

There is this ‘wall’ to do a procedure… What if some surgeon came up with a simple yet unconventional solution that tying a rubber band around the ‘stalk’ of a tumor would starve it of blood and kill it? However, the solution would require a ‘zipper’ instead of clean sutures so as to clean out the rot if it worked? I’m pretty sure ‘tit-zippers’ are not FDA approved so…

There used to be a time when Man recognised that he did not get it. There used to be a time that followed the doctrine of ‘do no harm’ when the only prescribed treatment then known to be efficatious was ‘prayer and herb’ –Luke, ‘The Good Physician, Jesus’ brother, was not handing out incisions but cannabis:

She had suffered a great deal under the care of many doctors and had spent all she had, yet instead of getting better she grew worse.

http://biblehub.com/mark/5-26.htm

Please don’t misunderstand me… I want ‘doctors’ to not just follow the ‘status quo’, as was done with cannabis prohibition, but instead follow a direction that benifits their patients.

Don’t follow the lights (any farther than necessary to recognize them as ingrained bunk) – Gollum.

Egads, Dr. Michel Accad is quite the tool. Another bit of his pseudo-intellectual musings can in for some insolence just days ago on the other-not-so-super-secret blog… The guy writes broad platitudes without ever specifically suggesting concrete policy positions regarding ‘complementary’ medicine, so he can dance away from attacks as being pro-quack. But his missives are so full of BS, if your in the properly cynical mood, they’re actually funny.

Basically, he’s spinning a variety of ‘patient’s-rights-free-choice’ Libertarian rhetoric. He’s all bent out of shape that Western medicine is ‘authoritarian’. He actually seems opposed to State licensing laws governing medical practitioners! Because ”information asymmetry”.

Patients, as object of scientific medicine, can no longer freely choose their care as the State intervenes to ensure safety and efficacy according to objective, scientific norms.

Yup, he says that as though it were a bad thing. Anyway, his blather about being ‘holistic’ references a rather idiosyncratic take on the on concept, as most people would call what he thinks WestMed has ‘lost’ not “soul” but “mind”: “individual, substantial, rational, self-determining” blah, blah, blah. Some ideology of ‘people act rationally on self-interest’ apparently borrowed from Economics — from whence he gets that ‘information asymmetry’ shtick he so thoroughly mis-applies to doctor patient ‘transactions’, as if such things were similar to insider-trading or used-car sales. Oy vey!

Alas, Accad seems be up to nothing so rational as giving due care to the psycho-social needs of patients now experiencing empathy-fail from the bean-counter-driven 12-minute-and-out mandates. Because those needs manifest themselves in ‘irrational’ behavior — patients being less likely to follow to sbm standard-of-care “Dr.’s orders’ because they don’t ‘feel good’ about how they’re treated.

An argument FOR ‘holistic’ clinical practice (a very lame one, but at least an actual argument) would be that it improves outcomes because the ‘complementary modalities’ act as a form of psychotherapy to ease patients through the rigors and pains of conventional treatment, making them more likely to seek care when they need it, more likely to have a positive outlook that encourages them to actually do what the Dr. tells them to do, etc. The idea would be essentially that TPTB have squeezed physicians out of attending to the empathy part of the equation, and deferred that to a separate group of ‘professionals’. The MD repairs the broken mechanical part while the ‘energy healer’ does the hand-holding. Now, that ain’t the song Accad’s singin’, but it makes more sense than some wacky rational-choice, free-market-economics argument for de-regulating medicine. So I shall address that take on ‘holistic’ med in a subsequent post anon…

So, could you explain again why you want a PCP to look at your skin growth before the dermatologist?

Because if it’s a rash he/she can diagnose and treat it and you don’t have to wait/travel to see a specialist (many people in this country don’t live in metropolitan areas with a plethora of medical choices). Why bring in an M101 when an M60 will do the job?

@Shay: Yup. Also, the lesion can be evaluated much faster by a professional who can triage it, which, given that the vast majority of such skin lesions do not require the attention of a dermatologist, is far more efficient. Also, in some areas, access to specialists can be problematic. When I lived in NJ and wanted to refer one of my patients to a dermatologist, it was not infrequent that there would be a 6-8 week wait for a new patient appointment. It’s far less of a problem where I practice now, but why should a patient wait that long if she doesn’t need to when a PCP can look at the lesion and decide if it needs a specialist? A lot of PCPs can even do simple punch biopsies to see what lesions are.

Élan Vital (there are some who call me, Tim?)

Your mother, perhaps. I’m sick of adding killfile entries for you.

#63, #64

“Decide if it needs a specialist”.

So could that accountant Johnny mentioned.

Once again, the only way Orac can see this is BAU, status quo.

The question is, what exactly qualifies someone to make that decision? Is it knowing all the bones in the human body?

So, could you explain again why you want a PCP to look at your skin growth before the dermatologist?

Well, it’s not necessarily what I want, it’s just one of the features of my HMO – PCPs act as gatekeepers for the specialist. I bring it up first as an example of a doctor saying we don’t need to spend any more resources to take care of this (keeping my premiums and co-pay as low as possible), and second as a springboard to try to flesh out your proposal, which seems to be more than you want to do.

#66 Johnny,

I guess you like sarcasm only when you use it.

If PCP instead of dermatologist, why not PA instead of PCP, or RN instead of PA, or that accountant instead of RN, or grandma instead of the accountant? Or those woo people everyone likes to rant about?

You can’t fix the system by keeping the system the same.

#62 and #63

That and there are some specialists around here that don’t take new patients without a referral from another provider, I always assumed some of that was to try to manage the wait times that Orac mentioned. I’ve had a few horrendous wait times for specialists and it probably would have been worse if they just booked appointments for every person who thought maybe they might need one.

To Eric Lund #6:

“All this is a long-winded way of saying that Dr. Accad is full of bull. The soul, if it exists, is a biochemical process, like anything else about us.”

And since your little dissertation here is the result of just a biochemical process flowing like effluent from your accidentally evolved brain, I can safely ignore what you say.

Because MY “biochemical process” says YOU are full of bull.

And please, please think twice, or thrice, before criticizing my criticism.
Don’t blame me. Blame my biochemistry. Blame evolution.
I just mutated this way.

I believe that there must be and is a considerable amount of ‘trial and error’ in the field as it stands now.

You seem to be unacquainted with the process of running clinical trials (yes, they are actually called that). Basically, you start with a drug that you have reason to believe will treat a certain condition. You then need to establish that this drug meets all of the following conditions: (1) The drug is more effective than a placebo at treating the condition. (2) The risk of dangerous or debilitating side effects is sufficiently low. (3) The drug represents an improvement, for at least a subset of the patient population, over existing treatment modes for this condition. And it turns out that, for every drug that is found to meet all three of these conditions, 8-10 others fail at least one of these tests. These trials are carefully vetted before they even begin to make sure there is a reasonable expectation of success, and watched closely so that they can be terminated if the adverse risks prove to be greater than thought. Yes, it’s expensive–if you aren’t already a major pharmaceutical company, you will need a substantial amount of venture capital to get through, but there are venture capitalists willing to invest in such things. Yes, it isn’t perfect–once in a while a drug will turn out to be more dangerous in real-world usage than the trials indicated. But it’s better than any alternative that has ever been tried, and the vast improvements in medical treatment over the last century or so are almost entirely due to this process.

One of the points Orac makes repeatedly is that “alternative medicine” or “integrative medicine” or whatever they’re calling it this week doesn’t have anything like this process. How did acupuncturists figure out that you need to stick the needle in here, and not a centimeter or two to the left? How did chiropractors find out that you have to manipulate these vertebrae, and not those other ones? They didn’t, because they don’t have any systematic way of doing so–and because these systems turn out to be useless at best. Some of them are actually much worse than useless.

Zebra, can you provide any credible evidence indicating that grandma, accountants, or those woo people anyone likes to rant about are as capable of assessing whether or not a skin lesion requires the attention of a dermatologist as is a PCP (whatever you’re using taht abbreviation to refer to in this instance)?

I mean, I trust your ‘solution’ isn”t to have medical triage performed by whoever is both available and cheap, regardless of their training and demonstrated competence…

#67 Maybe I have a different assumption about the amount of training it takes to be a PCP than it takes to be a grandmother or a reiki master than you do.

That and around here usually NPs and PAs are included in the primary care provider group (other than NPs who are specialists), but that may vary by state.

You can’t fix the system by keeping the system the same.

Which is the same old observation that Z. tediously invokes whenever he takes it into his head to complain that his navel-gazing Master Plan is being ignored.

It’s all-purpose. Laden’s place?

Seriously, knocking down one more zombie attempt to question the energy imbalance– which is what these claims about mean surface temperature all are– is, in fact, letting them waste precious time, and keep that meme alive.

Scientists should be (and some are) trying to improve data collection, and short term and regional prediction and projection. Public policy is not going to be driven by equilibrium sensitivity calculations. It will be driven by linking concrete phenomena that people experience– drought and flood and heat and cold and so on– to that imbalance.

Short version: You are stupid person to write about actual papers!

Jeezums, you’d think he could start his own blog where he offers bland pronouncements about how everybody else is Doing Everything Wrong and then condescending issues gold stars to those among the flood of commenters who Begin To Glimpse His Brilliance.

It would beat these zero-S/N whinefests.

#71 RE “to have medical triage performed by whoever is both available and cheap, regardless of their training” that seems to be ho opponents of SB 277 want vaccine scheduling to go…

Well hello again, zebra! Have you decided on what meanings you’re going to give to words today, or are you going to continue pouting that us big meanies keep listening to what you say, not what you mean. Of course, what you mean happens to change every time you post.

As for your last post, no, that’s utter rot. That part of the system does not need to be fixed because it isn’t broken. An accountant is not capable of determining which type of skin lesion requires a dermatologist’s intervention, and a PA would have less training in that matter than a GP.

Also, are you insulting Orac in every post in the hopes he’ll ban tou and you can cry about your “FREE SPEACH” ?

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