So I’d recommend seeing the movie Collapse. Its got me thinking a lot lately and I am trying to balance my ‘gut feeling’ that takes its prescriptions seriously, with a balanced and restrained skepticism. I do however think there is some truth in what the protagonist of the film advocates (”Michael Ruppert, a police officer turned independent reporter who predicted the current financial crisis in his self-published newsletter, From the Wilderness” – From IMDB) .

He describes what he considers to be the inevitable ‘collapse’ of government and economic stability as we know it now, and specifically in this country.   He bases this fear on the diminishing amount of oil (as we are probably past peak oil), a product  basically is used in everything from generic energy, to physical products we construct, to growing food and cultivating agriculture, and of course fueling transportation. He imagines the subsequent consequences of hyperinflation and the devaluing of our current conception of currency and goods exchange. While hes not advocating collapse into a bleak apocalypse of no hope (as in Cormac McCarthy’s ‘The Road’), he is suggesting that there will be a very ‘bumpy’ transition period as the human race begins and embraces a new paradigm of existence and society. In this, one will have to act and change to survive.

NOW. I’m not sure how to decipher this doom scenario. I’m skeptical of my own intuition to trust this, but scientifically I think he’s making many verified assertions. It does not feel to me like the often very dubious chatter of the 9/11 conspiracy community and its brethren. And his recommendations make sense to a certain extent. I should be able to know how to protect myself, and how to grow food, and about first aid / homeopathic medicine.

I guess, I am also sympathetic to what he philosophically embraces and projects in how one should face challenge and life in crisis. He wants one to attack life with fervor, humility, spirit, a belief in one’s own survival, and passion for living.  I very much like this mindset. I also like his prescriptions for preparedness. They don’t seem as irrational as most conspiracy and future fear-mongering strikes me. I do not think wants you to build a bunker. He says get gold if you can, learn how to grow food and prepare your land to grow food among other things.  Think about how it might happen, and consider the science of the problem. Do not be afraid to accept bleak truths and prepare because of them. So I’m at a point where I’m considering an individual education and training of certain skills and knowledge I don’t have.

STILL. There is a suspect and silly side of the survival obsession. Watch the video above, I think it nails it down perfectly.  With this in mind however, denial is often silly as well. We have seen this first hand in the contemporary inability to accept and adapt to the climate change problem effectively, in a timely fashion, and with possibly extreme consequences because of it.

SO. Where am I at? Well – see the movie and tell me what you think. I’d like to have a conversation on this topic that is scientific, rational, and open-minded. I do think there is probably a way to have a balanced reaction while still accepting the validity of such a enormous and bleak assertion as possible. Perhaps this reasonable reaction is to carry on one’s normal life and actions, with hopes and future planning for the possibility of it being a very flawed projection. Nevertheless, it seems useful to develop skills that have utility in either way and an honest conceptual framework for the possibility of disaster, and a plan if that possibility materializes.

What do you think, do I sound like I’ve lost my grip?

to you I have to say:

By Zane F Pollard, MD

I have been sitting quietly on the sidelines watching all of this national debate on healthcare. It is time for me to bring some clarity to the table by explaining many of the problems from the perspective of a doctor.

First off the government has involved very few of us physicians in the healthcare debate. While the American Medical Association has come out in favor of the plan, it is vital to remember that the AMA only represents 17% of the American physician workforce.

The AMA is not actually in favor of the plan in its entirety.  This is simply not true.  The AMA does not support the public plan for some of the reasons he later states.  The AMA supports health care reform in general which is meaningless.

I have taken care of Medicaid patients for 35 years while representing the only pediatric ophthalmology group left in Atlanta, Georgia that accepts Medicaid. For example, in the past 6 months I have cared for three young children on Medicaid who had corneal ulcers. This is a potentially blinding situation because if the cornea perforates from the infection, almost surely blindness will occur. In all three cases the antibiotic needed for the eradication of the infection was not on the approved Medicaid list.

This is 3 children over 6 months who are on Medicaid.  Note that he makes no mention of what ultimately happened to these people, (because they were probably treated anyway), nor does he mention the fact that they are seeing him mainly because of Medicaid, a government sponsored insurance program.  Without this government sponsored insurance program, they likely would not even be at his office.

Each time I was told to fax Medicaid for the approval forms, which I did. Within 48 hours the form came back to me which was sent in immediately via fax, and I was told that I would have my answer in 10 days. Of course by then each child would have been blind in the eye.

Each time the request came back denied. All three times I personally provided the antibiotic for  each patient which was not on the Medicaid approved  list. Get the point — rationing of care.

Upon quickly reviewing treatment for corneal ulcers, it is apparent that there are many different antibiotic regimens for treatment of infected ulcers.  This leads me to believe that Medicaid covers an antibiotic regimen.  However, this ophthalmologist feels that, for whatever reason, one regimen is better than another.  Whether that is true or not would require a more extensive review of literature and I would have to know what his options were.  This is often a problem when people try to spread fear about rationing of care – a physician wants to use a treatment that might be more expensive and has no proven benefit over a cheaper alternative.  This is not rationing – this is practicing what is called evidenced based medicine and is the purpose behind comparative effectiveness research.

It is for this reason he probably does not go into what happened with these three children.  My guess is that he used the Medicaid approved antibiotic, he was frustrated, but the children were fine.  This argument is fueled by pharmaceutical companies and medical device manufacturers who are concerned about what will happen if their products are required to be better than existing cheaper alternatives in rigorous studies.  This was the voice of the opposition to comparative effectiveness research.

Over the past 35 years I have cared for over 1000 children born with congenital cataracts. In older children and in adults the vision is rehabilitated with an intraocular lens. In newborns we use contact lenses which are very expensive. It takes Medicaid over one year to approve a contact lens post cataract surgery. By that time a successful anatomical operation is wasted as the child will be close to blind from a lack of focusing for so long a period of time.

Again, this is misinformation.  Medicaid in most states covers surgery for congenital cataracts and intraocular lens.  Again, there are many types of lenses that can be used.  I again imagine it is likely that this physician and Medicaid have a difference of opinion about what is best for the patient.  This difference of opinion is not likely based on facts or randomized clinical trials but if you actually know this person I would be happy to hear his argument.

Again, extreme rationing. Solution: I have a foundation here in Atlanta supported  100% by private funds which supplies all of these contact lenses for  my Medicaid and illegal immigrants children for free. Again, waiting for the government would be disastrous.

I imagine this is something like a pharmaceutical assistance program, which are helpful, but have the alternative motive of making physicians/surgeons comfortable with certain medical devices/drugs in an attempt to encourage prescriptions of these drugs in indications other than those on the assistance program.

Keep reading after the fold :

Last week I  had a lady bring her child to me. They are Americans but live in Sweden, as the father has a job with a big corporation. The child had the onset of double vision 3 months ago and has been unable to function normally because of this. They are people of means but are waiting 8 months to see the ophthalmologist in Sweden. Then if the child needed surgery they would be put on a 6 month waiting list. She called me and I saw her that day. It turned out that the child had accommodative esotropia (crossing of the eyes treated with glasses that correct for farsightedness) and responded to glasses within 4 days, so no surgery was needed. Again, rationing of care.

I seriously doubt this is true based on my knowledge of the Swedish health care system and the fact that they place a very high importance on limiting wait times.  Now, the patient may have seen an optometrist much sooner who would have provided this patient with glasses.  One may argue that the optometrist cannot manage difficult problems, but like my dad, who works with an optometrist, I bet this ophthalmologist also does.

Last month I operated on a 70 year old lady with double vision present for 3 years. She responded quite nicely to her surgery and now is symptom free. I also operated on a 69 year old judge with vertical double vision. His surgery went very well and now he is happy as a lark.  I have been told — but of course  there is no healthcare bill that has been passed yet — that these  2 people because of their age would have  been denied  surgery and just told to wear a patch over one eye to alleviate the symptoms of double vision. Obviously cheaper than surgery.

Saying I have been told in an article is a way to free yourself of any responsibility to tell the truth and throw out a ridiculous comment citing what you “have been told”.

I spent two year  in the  US Navy during the Viet Nam war and was well treated by the military. There was tremendous rationing of care and we were told specifically what things the military personnel and their dependents could have and which things they could not have. While I was in Viet Nam, my wife Nancy got sick and got essentially no care at the Naval Hospital in Oakland, California. She went home and went to her family’s private internist in Beverly Hills. While it was expensive, she received an immediate work up. Again rationing of care.

Again, what is this work up? Did it actually benefit her?  Was it indicated?  What was it that he wanted and couldn’t get at the military hospital?  Don’t private insurance companies do this already?  My insurance certainly tells me what they will and won’t pay for.

For those of you who are over 65, this bill in its present form might be lethal for you. People in England over 59 cannot receive stents for their coronary arteries. The government wants to mimic the British plan. For those of you younger, it will still mean restriction of the care that you and your children receive.

As an internest, I know this argument is not just flawed, but grossly untrue.  People in England over 59 can receive stents, if they presents with a heart attack, the only situation in which they have been proven to be better than medical management of coronary artery disease.  In the US, we error on the side of placing more stents for unclear and debatable reasons, but in head to head trials, they have never been proven better than medical management outside of the setting of an acute heart attack.

In my mind, England is avoiding a procedure which, although fancy, has measurable risk and no clear benefit when compared to medications which have considerably less risk.  Of course if you do the procedure you still take the medications so you get all those risks anyway.

The other problem with this statement is that it makes a gross exaggeration and directly contradicts the fact that he states earlier that the specifics of a senate bill do not exist.  This is not in the house bill which is public but he clearly has not looked into it but rather describes “what he has heard”.  I could just as easily write that the bill will demand everyone exercise for two hours per day to cut down on health care costs or that all pregnant women will be forced to have C-sections.  They are not.

While 99% of physicians went into medicine because of the love of medicine and the challenge of helping our fellow man, economics are still important. My rent goes up 2% each year and the salaries of my employees go up 2% each year. Twenty years ago, ophthalmologists were paid $1800 for a cataract surgery and today $500. This is a 73% decrease in our fees. I do not know of many jobs in America that have seen this sort of lowering of fees.

How many more cataract surgeries are done per day now compared to twenty years ago?  Ask your dad Jake, it’s a lot more.  They make less per day, but this is just overdramatic.  If it were truly a 73% pay cut he would not be in practice.

But there is more to the story than just the lower fees. When I came to Atlanta, there was a well known ophthalmologist that charged $2500 for a cataract surgery as he felt was the best. He had a terrific reputation and in fact I had my mother’s bilateral cataracts operated on by him with a wonderful result. She is now 94 and has 20/20 vision in both eyes. People would pay his $2500 fee.

However, then the government came in and said that any doctor that  does  Medicare work cannot accept  more than the going rate ( now $500) or  he or she would be  severely fined. This put an end to his charging $2500. The government said it was illegal to accept more than the government-allowed rate. What I am driving at is that those of you well off  will not  be able to go to the head of the line under this new  healthcare plan, just because you have money, as no physician will be willing to go against the law to treat  you.

This paragraph implies that he feels ethically comfortable with rationing of the best doctors and treatment for those who are financially well off.  Earlier he hated rationing and now he embraces it.  This is outrageous and from my point of view unethical.  In general this article, the examples he cites, this paragraph, all point to a central tenet in the health care debate – do we take care of a population or do we take care of individuals.  As an individual you have no responsibility to care what happens to anyone else and if your doctor is solely responsible for your well being then he should do whatever is best for you.  However, we live in a society, and I have many patients.  I am responsible for care of all of them and act as such.  I make some patients wait for appointments and see others immediately.  This is rationing.  If one patients needs more expensive care because he will ACTUALLY BENEFIT from it while another just wants it because he FEELS HE WILL BENEFIT from it, I believe we should give the appropriate care to the person who will actually benefit.  The rich person who feels he will benefit but won’t, should wait.  I’m sorry, but this is not rationing, it is being an ethical physician and a responsible member of society.

I am a pediatric ophthalmologist and trained for 10 years post-college to become a pediatric ophthalmologist (add two years of my service in the Navy and that comes to 12 years).A neurosurgeon spends 14 years post -college, and if he or she has to do the military that would be 16 years. I am not entitled to make what a neurosurgeon makes, but the new plan calls for all physicians to make the same amount of payment. I assure you that medical students will not go into neurosurgery and we will have a tremendous shortage of neurosurgeons. Already, the top neurosurgeon at my hospital who is in good health and only 52 years old has just quit because he can’t stand working with the government anymore. Forty-nine percent of children under the age of 16 in the state of Georgia are on Medicaid, so he felt he just could not stand working with the bureaucracy anymore.

The system with the least bureaucracy would be single payer health care.  Private insurance companies make the same if not more bureaucratic nightmares as the government.  IF it is money he is concerned with, that is fine.  I will have trained for seven years post college (9 with my fellowship since we are tacking on completely arbitrary things like the guy in this article).  I don’t think I should get paid as much as someone who trains for longer.  But I probably should get paid something at least damn close.  Try to go find a primary care doctor who is good and you might have some difficulty.  You are infinitely more likely to benefit from having a good primary care doctor than you are a neurosurgeon over the course of your lifetime.  Sure, neurosurgeons are important to, but I bet if that guy mad what a primary care doctor made he wouldn’t have quit – because he wouldn’t have enough retirement savings.

We are being lied to about the uninsured. They are getting care. I operate at least 2 illegal immigrants each month who pay me nothing, and the children’s hospital at which I operate charges them nothing also. This is true not only on Atlanta, but of every community in America.

This paragraph is reprehensible.  To completely dismiss the uninsured in a three sentence statement saying he cares for two illegal immigrants per month is outrageous.  Yes, there is charity care.  Has he seen the lines outside a county hospital or the recent lines in LA to get care when offered for the uninsured?  They get care, but they have no options and no prevention.  They are not even privy to the options that he abhors Medicaid patients having.  Their situation is even worse.  Yes, some can find care.  I would like to know how many patients he turns away, how many patients he sends to the county or not-for profit hospitals to get surgery because he won’t take it as a charity case?  What about his colleagues?

The bottom line is that I urge all of you to contact your congresswomen and congressmen and senators to defeat this bill. I promise you that you will not like rationing of your own health.

This is a good idea.  Contact everyone you know, tell them to stop believing crap like this guy writes.  Start imaging what it would be like to be one of the people who gets screwed by the current system and imagine if you lost your job tomorrow and became one of them.  Where would you stand then?  Would you still have such great fears about a government health care system that rations care in a more ethically appropriate way than does the current system?  Would you still be worried about getting to choose which antibiotic you got for your corneal ulcer or would you just want one that works?  The injustices in health care in this country are maddening.  This man and this article fight to preserve them so he can make money and practice in a way that he finds appropriate but may be disastrous for your health.

Furthermore, how can you trust a physician that works under these conditions knowing that he is controlled by the state? I certainly could not trust any doctor that would work under these draconian conditions.

This is another outrageous fear-mongering claim.  Most physicians train in VA hospitals which are controlled by their government.  I do, most other residents I know do, and most older physicians I know did.  Is our training at the VA any different than at our other hospitals – no.  Sure, there might be more rules about what you can and can’t do but you know what, the attending physicians at the private hospital acknowledge that those rules are right.  They work for patients, improve their quality of care, and save money.  In the end they do constrain physicians practice but its for the patients benefit and often prevents unnecessary or inappropriate medications and/or procedures saving money in the process.  Hey, that sounds like the goal of health care reform.

One last thing: with this new healthcare plan there will be a tremendous shortage of physicians. It has been estimated that approximately 5% of the current physician work force will quit under this new system. Also it is estimated that another 5% shortage will occur because of the decreased number of men and women wanting to go into medicine. At the present time the US government has  mandated gender equity in  admissions to medical schools .That means that  for the past  15 years  that  somewhere  between 49 and 51% of  each entering class are females. This is true of private schools also, because all private schools receive federal funding.

Wait, all schools receive federal funding?  Doesn’t that mean all of my education has already been under government control?  Crap. This 5% estimate is grossly inaccurate and has not been cited.  No one knows what will happen to physician supply because no one knows what the reform is, as he stated earlier.

The average career of a woman in medicine now is only 8-10 years and the average work week for a female in medicine is only 3-4 days. I have now trained 35 fellows in pediatric ophthalmology. Hands down the  best was  a female that I trained  4 years  ago — she  was head and  heels above all  others I have trained. She now practices only 3 days a week.

I don’t know what this has to do with anything else in the article.  Is he implying we should not train women?  Wouldn’t that be rationing access to higher education?

My responses are probably equally polarized as his originals.  The truth, however, is somewhere in the middle.  The government has the power to influence health care and improve health care for the entire US Population.  Raising the bar for the lowest half does not mean the upper half will be lowered.  It also does not mean government insurance is a panacea.  It has many problems which are no secret.  However, the private industry has had its chance and failed.  Continuing with the status quo is not an option.  At least trying something new with a public plan gives people a new option.  The government has more successfully controlled costs and provided high quality care but often does so in a way some (those with other options) often find inconvenient.  If it is as terrible as critics think it will be, no one will sign up.  Why don’t we see what happens?

Jason

Other animals aren’t so lucky.  Ants are fragile little things who get stuck in glue traps.  They can’t learn from experience, so that have to be ruthlessly efficient in order to achieve anything.  And that’s why they evolved perfect rationality.

Dr. Stephen Pratt of Arizona State University has concluded that the collective mind of ant colonies are more capable of making rational decisions than the singular intelligences of hummingbirds (and humans, although he doesn’t mention that part).

The ants were put to the test: choosing a new home.  Higher order (whatever that means) animals have a well-known tendency to become very confused when faced with decisions of three or more:

For instance, when honeybees and hummingbirds have two equally tempting choices of nectar, a third alternative inferior to both can sway them to prefer one of the initial two options over the other. The animals apparently compare the inferior choice against the originals and conclude that one of the originals is better, even though nothing about them has changed.

Pratt wanted to know if ants could handle these tough decisions.  Did they have the mustard?

The researchers made two artificial nests as potential homes. Nest A had a larger, less defensible entrance but a dark interior that suggested strong, thick walls, whereas nest B had a smaller entrance (more defensible) but a bright interior (weaker walls). As expected, when the researchers ran 26 ant colonies past these nests, the insects split roughly equally on the nests.  Then they provided inferior “decoy” nests to spur irrational choices. For instance, if they presented a decoy that was similar to nest B yet had an even brighter interior, the ants might irrationally prefer nest B over nest A, if past results with humans and animals are any guide.

Surprisingly, the decoys had no effect on the colonies—they always made rational decisions.

“All minds, both collective and individual, have limited capacity—they have to use shortcuts and rules of thumb to solve difficult decision problems, and those shortcuts are expected to sometimes cause mistakes,” Pratt says. “The ant colonies, however, were unfazed by a challenge that often elicits such mistakes in other animals.”

What makes ants so smart?  Surprisingly, it’s their limited intelligence.  Individuals within the colony usually only know one option and can’t trick themselves into false comparisons.  Pratt notes these findings “underscore a nonintuitive point—getting lots of information about a problem may not help decision making if you have only limited computational capacity to process it. You might do better with a strategically limited set of information.”

Lesson learned.  Next time you have a tough decision, ask an ant, or best yet, ask the whole colony.  They will not lead you astray.

Full story at SciAm