Hamilton's doctor and his plants

kw: book reviews, nonfiction, biographies, doctors, history, horticulture, botany, botanists, early united states history

On the left, Manhattan (except the north end) in 1811. On the right, the same view in 2018. The 1811 image is from the book American Eden: David Hosack, Botany, and Medicine in the Garden of the Early Republic, by Victoria Johnson.

Who was David Hosack? He was the most famous doctor I'd never heard of. If I heard the name in an American History class, I didn't retain it. Two items in the 1811 view indicate his importance. The first, a spot that matches the location of Rockefeller Center, which is marked in the 1918 image, is a tiny rectangle labeled "Botanic Garden". The second, across the Hudson River and farther north, is a spot labeled "Monument of Gen. Hamilton". The monument marks the spot where, on July 11, 1804, Vice President Aaron Burr shot former Treasury Secretary Alexander Hamilton in a duel over Hamilton's opposition to Burr in his bid to be Governor of New York State. The attending physician was David Hosack. Though he failed to preserve Hamilton's life, he had saved many lives that other doctors considered lost causes.

David Hosack (a Scottish name pronounced "Hozzick"), born in 1769, had studied both medicine and botany, and spent time in his late twenties in Scotland, where he first encountered botanical gardens in Edinburgh. he developed a passion for learning medical uses for plants. He already knew how to cure, or at least alleviate, symptoms of malaria and other fevers using "Peruvian bark", which contained quinine; the few effective medicines besides mercury were all plant parts or plant extracts.

After returning to New York and establishing a medical practice, Dr. Hosack bought 20 acres of land on the Middle Road in the middle of Manhattan Island where he established Elgin Garden in 1801. In just the ten years he had the garden, he gathered plants of all kinds, trained numerous medical students to recognize and use the medically useful ones, and corresponded with numerous botanists and botanical-medical men all over Europe and the American colonies. He corresponded with Jefferson, who had some interest in botany. He became the most famous doctor of the time, and his garden inspired others to set up gardens and arboreta that became the network of horticultural establishments found all over the U.S.

Ms Johnson's book outlines all this, with a wealth of fascinating details about life in and around New York two centuries ago, when Manhattan was mostly farmland. Only later, but in Hosack's lifetime, was Middle Road renamed Fifth Avenue. In 1810, after a few years of lobbying effort, Hosack sold Elgin Garden to the State of New York, though the state took its own sweet time to pay him. He could not continue the massive financial burden of maintaining the garden and its workers. It wasn't but a few years before the state divested itself, turning the garden over to Columbia University, which later sold the land to the consortium that began to build Rockefeller Center, which almost exactly covers the footprint of Elgin Garden, between Fifth and Sixth Avenues.

Whenever you see paintings by members of the "Hudson River School", some of which depict scenes in and around Manhattan and the other areas that now comprise New York City, take a moment to reflect upon the lovely scenes that once filled the area before it all became paved over and built to the sky with monuments to corporate power. And remember to be thankful that only a few percent of this nation has been paved and built upon, that large areas were set aside to retain their natural splendor. Also remember to be thankful for scholars such as David Hosack, whose passion for learning from nature inspired many of the medicines we take for granted, bestowed by the plants that grow all around us.

How do we restore appropriate doctoring?

kw: book reviews, nonfiction, medicine, ethics, doctors, memoirs

In all the various stories I have gathered of troubles I have had with or about medical doctors over the years, the problem has always been competence, not ethics. If the experiences Dr. Sandeep Jauhar has described are truly typical, it seems I've been quite lucky. His new book is Doctored: The Disillusionment of an American Physician. The main title is a reflexive jest, because he was the one "doctored", or taught, through his experiences. He got an attitude adjustment, and not one that I would applaud.

General Norman Schwarzkopf said (I paraphrase), "Hardly anyone goes to work daily expecting to do a bad job." In the same way, very few begin a medical career intending to do harm or to get rich off the poor. In his former book Intern Dr.Jauhar described his trials after completing medical school and entering residency. There, he was the abused one, and he harks back to those days a few times in Doctored, when he meets residents and interns who callously take advantage of new ways of doing things, going home at the end of a shift, regardless what is happening, seemingly without caring a whit for the patient being handed off to the next shift's physician. While he never saw one stand up in the midst of CPR because "it was time to go home", but it almost came to that.

To become a family doctor these days is the fastest way to get into practicing on one's own, but it still takes a good while: four years of medical school and at least two years of residency, and perhaps a year or two of fellowship. At the earliest, a newly minted family physician can begin practice, whether privately or with an organization, by age 28 or 29. Dr. Jauhar is a cardiologist. The residency was longer—I am not sure whether he did one or two—and he performed a few years of fellowships before being hired as the attending cardiologist at Long Island Jewish Medical Center at age 36. This accords with the experience of a family friend who also got free of his "education" at age 36 and is now in practice as an orthopedic surgeon.

When you are pushing 40 and have a quarter-million in education loans to pay off, it's hard to make ends meet, even if your pay is well above the national median of $52,000. The book covers a period of about eight years, just the right span of age for most of us to get around to having a midlife crisis. Dr. Jauhar didn't really have time for a midlife crisis. He had a career to jump-start, and soon found the jumper cables were badly frayed. We read a lot about his wife's increasing distress as their savings dwindle after one child is born, and then when another is on the way.

Urged, berated, and nearly bludgeoned by his wife and by circumstance, he began to work part time for another doctor who is in private practice. He soon learned that is it all about business. He didn't have the heart, or the right way of thinking, to do well in business. Ask a doctor why there are so many tests ordered these days, and why nearly everyone gets the same tests regardless how sick they are. The standard answer you'll get is likely to be something about "defensive medicine", the need to "cover all the bases" to avoid litigation. The answer you won't hear is that the insurance companies pay better for some tests than others, and it is the high-dollar ones that are the most overused. Dr. Jauhar found himself "doing scut work for peanuts", to use a phrase he doesn't use, but that I've heard from others. Though he could now make ends meet, he felt he was beginning to lose his soul, helping a doctor game the system and get rich at the expense of the American public.

Make no mistake about it, we all pay for unethical medicine. Most of Medicare is paid for by a payroll tax, and its losses are covered out of the general Federal budget, from taxes we all pay. Insurance companies are not in business to subsidize health care, and must indeed make a profit, so premiums increase and increase to cover the actual costs they incur. Don't pay any mind to a few blind guides who boast that American medicine is the best in the world. Yes, there are a few areas in which treatments in America are the most effective, but in general we pay more than twice as much per capita as in any other developed nation for the thirtieth or fortieth best medical system.

The book is in three parts, titled "Ambition", "Asperity", and "Adjustment". In the end, he adjusted. That, I find rather sad. He got doctored all right. I remember once remarking that a good subtitle to the musical Grease would be "The corrupting of Goody Two-Shoes." Here, I cannot say Dr. Jauhar has been corrupted, not quite, but he has to admit there is a stain on his soul. The incentives built into moderm American medicine, which will be only partly relieved and otherwise exacerbated by the Affordable Care Act (AKA "Obamacare"), practically force a doctor to defraud the system to make a living, and yield incredible riches to those most adept at doing so.

I recall the "traditional" insurance plans called "Major Medical." Patients were expected to pay out of pocket for all the ordinary stuff: doctor visits or office visits (in a day when the doctor visited you a third of the time), and most pills or shots. If you needed something less ordinary such as setting a bone, or sutures, or an operation, the Plan paid 80%, and rates were such that most middle-class Americans could afford their 20%, maybe with a little short-term loan. Now that insurance plans purport to "cover everything" (It's not true, but that's what they advertise), where is the incentive for anyone to economize? When everyone pays thousands and thousands yearly for their medical plan, they feel entitled to go to the doctor for every little thing, and they're OK with the doctor ordering dozens of tests of all sorts, because "the Plan will pay for it". The next year, premiums go up, and the few who are wise realize that once "the Plan" has paid, it has to get the money back, and premiums are its only source of income.

Our system isn't just broken, it is devastated. Dr. Jauhar doesn't have much in the way of solutions to offer. I do. Vote with your feet. Get your "ordinary doctoring" from a local physician. If you need something major, assuming you're capable of travel, go to India or England or somewhere else with one of those 30-40 medical systems that outperforms ours, where you'll pay less at full price, including your travel costs, than you would for the "Co-pay" demanded by the hospital here. Medical tourism is on the increase, for good reason. If enough of us do so, the American medical system will respond to the only force mighty enough to change it: Competition.

Getting doctors to be doctors again

kw: book reviews, medicine, doctors, advice

There is a strong parallel between medicine and religion. Even more, the contrast between "doctoring" and genuine medical practice is like that between religion and faith. My favorite proverb about religion is

The core of religion is a checklist. You can hang it on the wall. A robot could perform the checklist perfectly. You cannot.

This is why I say that my faith is not a religion. Faith is a divine relationship; religion is a specified practice. What about doctoring? Doctors today make explicit use of checklists, which they often call "pathways", to "work up" a patient who comes to them with a particular "chief complaint". A wry joke going around is, to get seen quickly in an emergency room, when you tell the receptionist why you are there, make sure that you mention your chest hurts. Of course, that means you'll be there at least 24 hours and spend an extra $10,000.

If you actually try this, you will find yourself on the "Chest Pain Pathway", which involves a series of tests, including a CT scan, and an overnight stay for "observation". If you don't actually have any chest pain, you will still have a hell of a time getting off the pathway. There are hundreds (thousands?) of such "pathways".

The modern doctor will listen to you only for a few seconds, until you say something that triggers one of the pathways. If 10-15 seconds pass and no pathway is yet identified, the doctor will interrupt you with a series of questions, always of the yes/no variety. Once you mention the "right words" that trigger a pathway, even in passing, more yes/no questions follow, and pretty soon the doctor will stand and say "we'll do a couple of tests" while heading for the door. Less than a minute will have passed. If you happen to be a rambling storyteller, particularly if you are under great stress and confusion, you may not yet have talked about the real reason you are there! But now you are on a pathway, and you may never get off it (because you may die, or be sent home with "no finding").

It is estimated that at least 100,000 people die in U.S. hospitals due to "misdiagnosis". In most cases, it would be more accurate to say they died without a diagnosis, because they were killed by the hunt for one.

To literally save your life, you first have to do everything you can to stay off one of these pathways, because here's the dirty secret. A pathway is designed to minimize the chances you will sue the doctor, or at least make it very unlikely that you could win a malpractice lawsuit. They are NOT designed to lead to a diagnosis. But, it is becoming apparent that pathways themselves are a kind of malpractice.

Drs. Leana Wen and Joshua Kosowsky call this "cookbook medicine". I call it "robot medicine". A robot can do it; you don't need a doctor for that (look up "Symptom checker" and try the one at WebMD, for example). Robot medicine is a practice of "ruling out", and you'll hear a doctor say, "This may be a heart attack," (you mentioned chest pain) or, "We have to rule out a cranial hemorrhage" (you used the words "worst headache"). Drs. Wen and Kosowsky have written When Doctors Don't Listen: How to Avoid Misdiagnoses and Unnecessary Tests to help you and me learn to stay off such pathways and drive a doctor to diagnosis.

Another proverb you probably know: To a man with a hammer, everything looks like a nail. The very availability of CT scanners, and the readiness of insurance companies to pay for CT scans, means that scanners are massively overused. Ditto for MRI and PET and other scanners, and for increasingly specific (and costly) blood tests. Excess CT scans are particularly worrisome, because even the most modern, low-dose scan exposes you to 500-1,000 times the radiation of an old-fashioned X-ray. ER's ought to have a chart on the wall:

• Got chest pain? Prepare for an overnight stay, 3-4 blood draws and a CT scan. Equivalent radiation dose (ERD): 400 chest X-rays.
• Terrible headache? 2 blood draws and a CT scan of the head. ERD 500 dental X-rays.
• Abdominal pain with diarrhea? Prepare to spend the night, plus 3 blood draws, a sigmoidoscopy [actually a good idea!] and an abdominal CT scan. ERD 600 X-rays.

And so forth. Just for grins, if the radiologist has any trouble reading the CT scan, or notices any anomaly, you'll get a second CT scan (or if you are lucky an MRI scan: there is no radiation), with a different IV of contrast "stuff". Many folks are allergic to the contrast injection, such as my wife, who is allergic to both media that are used for kidney X-rays. Meaning she can never have another X-ray looking for kidney problems.

Properly used, CT scans save lives. But they come with a known risk: a 1-2% increase in the chance of getting cancer after 20 years or so. If, as some contend, 98-99% of CT scans are unnecessary, then it is a wash, a life lost to cancer for every life saved.

In the past it was not so. An early chapter of the book traces medical history over the past 20 centuries. Of the four stages of medical practice, the third may have been the best. From the time of Pasteur and Koch, and into the early era of antibiotics, doctors were very diligent to get a good "history" from a patient, plus they had a growing number of effective remedies, both medicines and surgical techniques. Prior to the 1960's, diagnosis was king. The most effective doctors had a quality known as Augenblick (German for "eye blink"). My uncle's father was one such. He could diagnose many, many conditions at a glance, yet he always took time to hear what the patient said (or the person who brought the patient in, if the patient was unconscious). The history might modify the eyeblink diagnosis. He took nothing for granted, but also had enormous common sense. If a patient arrived at the hospital with a note from him, the doctors there knew the diagnosis was a good one.

Diagnosis is still king, but the king is in hiding. Doctors practice defensive medicine, particularly in the ER. This consists not in driving to a diagnosis, but in "ruling out" rare conditions that could lead to a lawsuit if they are missed. The way a good entry interview ought to go is simple. You tell your story and the doctor listens to all of it. If you aren't a good storyteller (some doctors use the disparaging term "poor historian", but such doctors ought to go be plumbers or something), the doctor will ask questions to move the story along; preferably, questions not of the yes/no variety. At some point, the doctor will have a short list of possible diagnoses. The questions that follow are designed to distinguish among these competing diagnoses. This is called differential diagnosis. At some point, one idea is the most likely, and this is the working diagnosis (sometimes there will still be two, and that may be the actual case, that you have two things wrong at once). A good doctor won't just do all this in his head, but will discuss the possibilities with you, and will tell you the working diagnosis, or perhaps the last two possible diagnoses, with suggestions for making a final distinction. Only then can effective treatment begin.

It helps to learn to be a better storyteller. Consider chest pain. It is sure to trigger a "chest pain pathway", unless you first mention that you helped your cousin move yesterday, and carried one end of her piano. If you can also press a finger to one spot, saying, "It hurts the most right there", you have a chance of knocking your doctor off the pathway, and getting appropriate help for a pulled muscle in your chest. If not, you could be swept along with the momentum of the pathway, and go home a day or two later, with a CT scan or two under your belt and at least 3 fresh needle sticks. And, nothing for your pulled muscle.

The word "doctor" means "teacher". Prior to "modern medicine", a doctor taught all her patients how to recognize what symptoms meant, and what to do about it. Doctors didn't ask yes/no questions until late in the process, to distinguish provisional diagnoses from one another. During the history-taking phrase, the questions were open-ended, intended to get every scrap of information you could deliver.

To help your doctor arrive at the right diagnosis, and thus to treat you for the right condition, these days you have to help out, a lot! To this end, Drs. Wen and Kosowsky spend half the book training us to use their "8 Pillars to Better Diagnosis":

1. Tell your whole story. This means making sure the doctor gets it all, particularly that which worries you the most (don't let embarrassment hold you back; tell it all). And don't answer yes or no to yes/no questions; use them as a springboard to tell more of your story. When the doctor interrupts, interrupt right back (as nicely as you can).
2. Assert yourself into the doctor's thought process. I'd have used the word "insert", but the authors are emphasizing that you have to be assertive, almost pushy, to keep the doctor collaborating with you.
3. Participate in the physical exam. Of course, show the doctor "where it hurts", so to speak, but also ask what he is thinking. Ask for jargon words to be explained.
4. Make the differential diagnosis together. Ask for the doctor's list of ideas. If none make sense, say so and ask, "What else could this be?" The initial net needs to be broad, but seek a balance. 100 vague possibilities are not a differential diagnosis.
5. Partner for the decision making process. Continue to ask how this or that possibility can be most simply eliminated, or how any one could be confirmed.
6. Apply tests rationally. Don't agree to "ruling out" tests for low-probability conditions unless your doctor can make a good case why every symptom you have described fits that condition, and none of them in themselves make it less likely. Be sure you understand what every test is meant to distinguish or determine.
7. Use common sense to confirm a working diagnosis. The visit is not over without a working diagnosis. But it has to make sense.
8. Integrate the diagnosis into the healing process. The doctor must tell you what to expect from the treatment she prescribes or recommends, and how it relates to the diagnosis. The working diagnosis may not have been the right one, so knowing what to expect can clue you in that something isn't quite right.

Nobody will remember these points during an ER visit, or even an office visit, so one third of the book consists of exercises and practices to help you get very familiar with the process. No longer can you and I afford to passively "let the doctor do the doctoring", because we will almost always find ourselves being pushed toward one of the "pathways". These pathways are not helpful to you, but to the doctor's malpractice insurance carrier. Throughout, the authors stress that we must be respectful with the doctor, not confrontational, because, after all, we went to him for his help, and such help will be harder to elicit if we offend him. If your doctor is thin-skinned and arrogant, do everything you can to change doctors.

My most important take-away from this book is a question that I need to ask: "Doctor, what will this test determine? What is the diagnosis you wish it to confirm?" If the doctor intends to "rule out" something, don't agree to it. Demand (nicely) a differential diagnosis, and ask where the test fits into that.

I am in the process of getting a new doctor. A couple weeks ago my wife made an appointment for me (shoulder strain) with my primary care physician. John is a good doctor, one who listens much better than most, and we've developed a good working relationship. But a week later, his office called to say that he had retired, there is now a new doctor taking over the practice, and did I still want the appointment? Well, what choice do I have? Now that I am on Medicare, it is hard to find a doctor who will take a new patient. I accepted the appointment. Now I have a new doctor to train. I'll make copies of the relevant parts of WDDL and study up, so when I see him a couple days from now, I can start off on a good footing and gain an appropriate collaborative relationship.

Oxymoron of the day - Straight-talking Doctor

kw: human nature, human relations, doctors

Doctors see a lot, much of it tragic. And many of their patients do not particularly want to know what is really going on. I imagine this is the reason most of them have lost the ability to speak in clear terms. I have had the misfortune to be a patient of many doctors, and only two, my current G.P. and my gastroenterologist (or GI), seem able to speak frankly, avoiding vagueness or even untruth.

At the time I had cancer surgery, there were four doctors involved: The G.P. I had at the time, the same GI I still have, the surgeon, and an oncologist. I clearly remember when I met the oncologist, two days after the surgery, he said he was optimistic because my cancer was Stage 2. When he left the room, he talked to a nurse right outside the door, and told her, "Late Stage 3." Only weeks later did I get a chance to pin him down, without letting him know what I'd heard, and got him to admit Late Stage 3, and that he was most concerned because 7 lymph nodes had been cancerous; the threshold of worry is 4. Thereafter, he was more forthcoming with genuine information.

During the hospital stay, the surgeon and the GI came by to see me, at different times. I asked each for a prognosis. The surgeon would only say, "Well, the cancer was rather large, and I had to remove a lot of stuff, but I think Dr. [Oncologist] will be able to help you a lot." But the GI said, "It looks pretty bad. Dr. [Surgeon] is excellent, and he thinks he dug out everything." I asked what the percentages were, both with and without chemotherapy (I was still mad at the oncologist for what I'd heard). He looked right at me and said, "Today, you have a 15% chance of one year survival. With chemo, it ought to improve by 25% or 30%, to the 40-50% range."

My G.P. came by a couple times, but he was clearly clueless. I realized he was too young, and afraid to speak in any quantitative way. Hey, I am a quant kind of guy, and I am hardheaded enough to take a frank assessment about the chances of my own demise. My primary desire to avoid death was that my son was only 12 at the time.

Fortunately for me, that G.P. moved his business 30 miles away, so I went looking for a new doctor. The one I have now is a great deal better. He is old enough to know the score, but not so old that he'll retire any time soon. During my physical a few weeks ago, I told him I appreciated how clearly he would say things. He said something about being frank, "perhaps too frank." I said, "Just remember the motto of the Diplomacy Dept.: We say the awfullest things in the nicest way." And I told him I thought there was no such thing as too much information.

I feel very lucky. The stories I hear from others, you'd think their doctors went to school to learn how to be vague. Just today it occurred to me, they are like teenagers who don't want to tell Mom where they were, who was there, or what they did. Their arsenal is every vague term in the book: Some, More-or-less, Kind of, Perhaps. I realize not all medicine is cut-and-dried, quantitative knowledge. But, doc, if you know something, tell it to me clearly. Thank you.

Make your doctor happy

kw: medicine, doctors

This last year has been a pretty good one for me, including physically. I had my annual physical exam this morning, and my doctor hardly spent any time scolding me. Overall, he was pleased.

While I don't always work out consistently, it is more than before, in other areas I have done well. The primary matters: Eating less but eating better and getting a new pet cat. The results:

• Blood pressure used to average 150/100. Now it is 125/80. No more talk about medication.
• Weight went (on the doctor's scale) from 235 to 205 (107kg to 93kg). Still overweight, but going the right way.
• LDL cholesterol a little down (99 to 95), and HDL holding at a low, but livable 38. A few years ago HDL was 25, which is scarily low.

Starting a year ago, at the doctor's suggestion, I got a blood pressure machine, and used it almost daily for six months. Then I went to weekly. Five months ago we got a kitten (urged, nay coerced, by our son). BP went below 140/95. The next month I began losing weight, on purpose. That gradually brought BP down further. Today's measurement by the nurse was 118/70, but I think that might be a bit off. People are more subjective than BP machines. It made my doctor happy, though.

I lost the weight by the "Chinese proverb method": eat breakfast like a king, lunch like a clerk, and dinner like a pauper. The joke behind the proverb is, kings get up too late to eat breakfast, clerks usually skip lunch, and paupers don't get any dinner. Anyway, I take it at face value, having a substantial breakfast, a slender lunch, and nearly no dinner. That's good for losing 2-4 pounds weekly. Adding back a little more dinner makes it a maintenance diet. I plan to hold in the near-200# range to get used to it, before trying to lose more.

Life is like Tetris: you can keep clearing blocks but eventually one stack will reach the top deck and the game is over. I feel like I've cleared a few layers and given myself some breathing room. Maybe I can't do much about my life span, but I've done something for my health span.