Mert’s Musing: Outlaw Eating?

Merwyn G Scholten, Executive Director of the Fresno-Madera Medical Society, and author of the monthly column Mert’s Musing, is amused and amazed at the ridiculous way people use the court system trying to make society “better,” or healthier, or safer or whatever. Recently he discussed the lawsuit outlawing the sale of Oreo cookies in California. The attorney’s legal argument claimed the filling contains a high amount of trans-fatty acids that engender obesity in children. Filing a lawsuit to prevent the sale of a food product that has been around for years on the basis that its ingredients might make children obese is reaching the extreme. How could the attorney prove that any client he represented is obese because he/she ate Oreo cookies? Is that all this person consumed? And how many cookies per day for how many years? What other factors contributed to the obesity? Are there hereditary ties or evidence that the child never exercised but rather sat immobile in front of a television munching Oreos? Mert wasn’t certain if the lawyer only sought personal attention in the event that the suit became class action or if he was legitimately concerned about the health of a young client. Thankfully, the attorney withdrew the suit after a few days – he maybe came to his senses, caught too much public flak or realized the case was likely to be summarily thrown out of court. If Nabisco Foods was ordered to not sell its cookies in California, how would the measure stand up in a higher court? How would it be enforced? Would we see a black market with interstate smugglers? Would we need to finance new border patrols to confiscate the illegal booty? But Mert’s most important question, “Would preventing the sale of a brand of cookies make any dent in weight reduction for California’s obese?” As John Stossel would say, “Give me a break!” To which Mert muses, “We got one when the suit was withdrawn.”

Supply-Side Economics

Patrick D Daley, MD, President of the Kern Country Medical Society Bulletin, speaks of Supply-Side Economics. Many proposals in the last few years have addressed the health care crisis, managed care, increased deductibles, EPAs, PPOs, POS and cafeteria plans. All were meant to stop, or at least slow down, the rising costs of health care in this country. In short, they’re failing. All of these policies address only the supply side of the equation and ignore the demand.

A problem on the demand side is the American public’s insatiable appetite to consume health care. You have a new MRI test? I want it. You have a new PET scanner? I want it. I don’t want to pay the actual cost of the test, but I do want it done. Our sense of entitlement is high, our sense of attendant responsibility is low.

We’ve certainly come a long way in combating illness and premature death. Fighting the spread of infectious diseases through immunizations, hand washing and antiseptics, sewer systems, water purification processes and ICUs have made a difference in our lives. But what have we actually done? Do we really believe there’s a limited amount of disease in the world, and working hard and doing enough CABGs and cataract removals will , will cure them all? I don’t think so. In largely eliminating starvation in this country, we’ve substituted obesity. In lengthening life span, we’re faced with dementia and Alzheimer’s. In lessening poverty, we now deal with anxiety and depression. Where will this end? I don’t see an end in our country. And, if the demand for health care is not controlled, all the supply-side efforts will surely fail, with ever more persons uninsured.

Supply and demand are related only if the supplier (physician, hospital, provider) gets paid directly by those that make the demand (patients). This way, the patient can never demand more than s/he is willing to pay the physician, hospital and provider. A portion of that liability is insurable, but the total should never be covered because that would disconnect the basis of the law of economics.

A Second Look Back at Medical Writing

A Guest Editorial, by Thomas Gegeny, MS, ELS, in the Journal of the American Medical Writers Association (JAMWA), takes a look at physicians’ writing ability. He references What Medical Schools Can Do to Improve Medical Writing, by Dean F. Smiley, MD, Editor, Journal of Medical Education. Dr Smiley, in turn, references a 1957 reprint from A Group of Papers on Medical Writing, in collaboration with the American Medical Writers Association, Parke, Davis and Company Publishers, which discusses: The average medical student today does not have the ability to express himself clearly and concisely in writing.

Dr. Lewis J. Moorman, President of the American Medical Writers Association, recently sent a questionnaire addressing this problem to the deans of our country’s medical schools. He has kindly permitted the guest editor to study the returns, and Mr. Gegeny feels they definitely confirm the above statement.

He listed three possible causes of the inability of medical students to express themselves well in writing. “The first, though perhaps not the most important reason, is insufficient basic training in English composition in the liberal arts college. The second reason, and in my opinion the most important one, is the lack of practice in composition and the essay type of writing in medical college. The third reason is the greatly increased preoccupation of the medical student with text-book reading to the exclusion of reading of the current literature both general and medical. As lectures have given way to laboratory exercises, clinics, and bedside teaching, students have been driven by force to their textbooks for standard coverage. How else can they get ready for their State Board or National Board examinations? A few textbook writers like Osler, in medicine, Sir James Mackenzie in radiology and Edward Keyes in urology have written with unity, coherence and emphasis and, above all, conciseness in mind. Too many have, however, given up all ideas of readability, accepted their role as a producer of completeness of coverage. Continued preoccupation with the writings of such authors would naturally tend to develop in the student a style of writing which is ponderous, verbose, detailed, full of technical phrases, and little designed to attract or hold the reader…. In my opinion, it is extremely important that medical men be able to communicate and perpetuate their thoughts in writing. I feel, therefore, that improving medical writing is a real responsibility of our medical schools which somehow must be met.”

This serious deficiency is, however, not restricted to medical students. For many years, I taught courses in personal and community hygiene to undergraduate students at a large university. Having read hundreds of their examination papers, I would be inclined to say that the inability to express oneself in writing was even more marked in the engineering, agriculture and chemistry students than those students in the arts or preparing for medicine, veterinary medicine or law. I make this statement not to excuse or condone the deficiency in medical students, but to make sure that we visualize the problem in its full scope. The hard fact is that the vast majority of college-trained men and women today fail to gain proficiency in writing their mother language while they are getting their general educational or professional education.

Health Care as a Human Right

John D Longwell, MD, President of the Santa Clara County Medical Society, discusses human rights. In 1948, the United Nation’s Declaration of Human Rights included health care as a human right. Well, that certainly sounds good, but for many philosophers would be an impossibility. A “right” cannot be tangible, and since health care involves goods and services, it’s certainly tangible, though provided by someone else. For example, if two or more people were on a desert island, they could still claim the “unalienable” rights of life, liberty and the pursuit of happiness in our Declaration of Independence. But who would provide health care, if it were a right? What if one of them happened to be a physician? Does it become his/her duty to provide care because another person has a right to it? Or is it his/her duty because as a physician, s/he feels a moral obligation to provide it?

In most developed countries, our “expectations” have translated into “entitlements;” access to health care is mediated through some form of insurance. But health insurance is unlike any other insurance (although 60 percent of health care costs are paid for by taxes). When you buy home insurance, for example, you expect coverage for major accidents, fires, leaks, structural defects, etc., but not for replacing the roof, painting the house, adding a room, and certainly not for cleaning the carpets, washing windows or changing light bulbs. Similarly, we buy car insurance to cover major accidents, usually collisions and unforeseen events. We do not expect it to pay for gasoline, 50,000-mile check-ups, oil changes or a new set of tires. Somehow, though, we have the notion that health insurance should cover more than unpredictable major events; it should cover expected maintenance, minor sniffles and scrapes, and cosmetic enhancements. We want our insurance to pay first dollar, or maybe $100 deductible with a $5 co-payment. We want that insurance to be paid for by our employers, and we want immediate access to physicians of our choice.