False Positives

Posted on June 17, 2020 by ddxdx
Prototype

The lab in the basement of the Idaho Freedom Foundation was abuzz. The tests were looking good.

“When can we roll this out?” the Lab Director Ben wanted to know.

“It’s ready for beta testing.” Lab Tech Jerry beamed.

“Explain it to me again, like I’m a five-year-old this time. No more of that technical jargon.” The Lab Director knew he’d need to explain this to the Board.

Jerry paused. “Well you see sir, this Covid 19 hoax has gotten everybody aware of the validity of testing, you know, false positives and false negatives.”

“Simpler” Ben interrupted.

Jerry frowned and tapped his lower lip. “Ok sir, how about this? Imagine if we could have a way to know if someone was really a conservative of not. We finally have a test that can prove it.”

“Go on.” Ben smiled a little.

“We’ve had our Freedom Index for years, and it has worked, sort of.” Jerry continued. “We have taken the votes legislators make, multiplied that by the Freedom value of the bill and then scored each legislator.”

“Don’t get too technical about the formula. We just focus on the score, right?”

“Yes, but the scoring has given us some false positives.”

“So, this test is better you say.”

Jerry beamed. “Very much. In the past, legislators would look at the bill score and vote to pad their scores. We were getting a lot of false conservatives mixed in with our true conservatives. This test is much more accurate.”

Ben nodded. He didn’t quite smile. He was thinking of the Power Point he’d have to create to sell this to the board. “OK, Jerry. Now explain how we do this test. Again, keep it simple.”

“Yes sir!” He walked over to the desk top, strewn with screwdrivers and pliers, pieces of wire and rolls of tape, and pulled the sheet off his pride and joy. “Here we have the Con37 analyzer.”

It looked like a modified microwave oven with pair of old rabbit ear antenna sticking on the top. It had wires running to other modules and machines around it on the floor and adjacent tables.

Jerry smiled with pride and patted his creation. “The Con37 analyzes a sample and determines the conservative value with a 98% accuracy.”

Ben frowned again. “Sample?”

Jerry nodded. “It can analyze audio signals, digital, even tissue. Here let me show you.” He flipped a switch and lights came on. There was an irritating buzz that went away when he slapped the side. “First we’ll try the audio spectal analyzer.” He twisted the rabbit ears so they were perpendicular to the Director. “Go ahead, say something. We’ll take a reading.”

Ben looked at the glowing dial on the face of the old microwave. He thought long and hard for something conservative, maybe liberal to test this new-fangled device. Jerry nodded at him with excitement. Ben cleared his throat. “We the people, in order to form a more perfect union, insure domestic tranquility…” He watched the dial barely register as he finished the Preamble.

He frowned.

Jerry said, “Boy, that’s a low score. Try something simpler. Just say ‘Freedom’.”

“Freedom” Ben echoed. The meter pegged. He tried “Liberty”; another high score. “So, it likes simple phrases.”

 Jerry nodded with excitement. “Yes, it knows conservatism in its programming. Let me show you how it analyzes digital content.” He showed how the dials climbed when Rush Limbaugh came through the speakers and dipped when he tuned to NPR. Ben nodded, knowing how this would go with the board.

“How will we analyze candidates for endorsement?”

Jerry got excited. “I would recommend a full spectrum evaluation. We could enter recordings of their speeches, take digital content from their websites, but for the best accuracy we should use the tissue analyzer.”

“Tissue?” Ben asked.

“Yes, we have found conservatives have special tissue markers. We just need a biopsy, just a small piece, then we put it in here.” Jerry swung the oven door open. “We’ve found the accuracy goes way up when the biopsy is more painful.”

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Defund Health Care

Posted on June 10, 2020 by ddxdx

The chant “Defund Police” is bouncing off the walls of the buildings next to many demonstrations. They are protesting an unjust, cruel death of a nonviolent black man under the crushing knee of a white cop, while three other uniformed officers stood by. Indeed, the “defund” idea is gaining traction in some city councils, some state houses and even our nations capital. If “defund” means to fundamentally, even radically change, I suggest we take this step with whatever institution is failing us.

I don’t just chant. When I was an elected Idaho State Senator serving on the budget committee, I proposed defunding a broken part of Idaho government. The Commission on Pardons and Parole had been poorly run for decades and we just kept sending them tax dollars. P&P couldn’t keep data that allowed an analysis of their efforts.  They couldn’t publish minutes of their hearings, as required by law. Idaho had a huge backlog of offenders clogging our prisons. I saw their dysfunction as part of a bigger problem, but I had no doubt they were a problem. So, in my second year on the budget committee, after studying their dysfunction, I proposed sending them $0. I got a couple Republicans to vote with me, but no Democrats.

 When you are on the budget committee, you can either vote to give them money, or not. So, I proposed the sledge hammer because I didn’t have a wrench.

If defunding police will change something that’s broken, I can support it. Honestly, I don’t think the police force in my town is dysfunctional or broken, so I don’t really want Boise or Washington DC “fixing” anything. I trust our local government to do the right thing. If you think somethings broken, get to work on it. Usually, sledgehammers don’t fix things.

But if we are going to look around for broken things, why don’t we turn our gaze on one of our biggest, cruelest institutions: health care.

Do I need to convince you of the cruelty? Do you need the data on bankruptcies? Would a graph on the incessant rise in costs stir your emotions? Should I reiterate how much we spend and how poorly we perform? Does the declining life expectancy in this county motivate you that we need a change?

I don’t have a viral video to galvanize your emotions. Maybe that’s my problem.

The medical industrial complex is a huge part of our economic engine chugging away.  Lots of folks make their living in this sector (including me!), and defunding would greatly disrupt. Maybe we should just take a wrench to it, not a sledgehammer.

And that’s, unfortunately, all the Affordable Care Act was; a crescent wrench compromise with the health care insurance industry. All it accomplished was to slightly decrease health care inflation, decrease the number of folks uninsured, and slightly limit the profits of health insurance companies. The cost curve has not really bent downward, as promised, because the cost containment strategies have been undercut by, guess who: our congress.

It seems the wrenching process can be politically fraught. All a politician has to do is scream “Death Panels” and the crowd starts cheering.

The “Medicare for All” proposal that didn’t carry Bernie or Elizabeth to the Democratic presidential nomination isn’t really a sledgehammer either. It looked more like a hot air balloon and most voters saw it as too big. But the health insurance industry saw it as a five-ton wrecking ball breaking loose from its chain.

The calls to “defund” are cries of outrage, a demand for change. I can understand why folks may be focused on police right now, but the mess of our US health care system needs an overhaul, badly. A crescent wrench won’t do it. And right now, we don’t have the courage for a sledgehammer. What tool do you propose?

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When Compassion Fails

Posted on June 3, 2020 by ddxdx

 It was near the end of my three-year residency. I had gotten up after midnight to admit an elderly woman complaining of headache. The ER had given her large doses of narcotics to help her pain, and they depressed her breathing. All the tests for bad things, blood tests, CT scan were negative. She already took many narcotics and high doses of valium at home prescribed from her regular physician. The ER recognized her as a regular. I came down to examine her in the wee hours, but she was sleeping, hard to arouse on the only occupied bed in the small hospital ER. The ER doc had already slipped off to a nap, but the nurse and the-foot thick medical record told me the story. She lived alone, had been a heavy drinker in the past, but seemed to have quit in recent years with all the prescriptions. She still smoked; her nicotine stained fingers and smoke colored curly forelock confirmed this as she snored on the cot. But her lungs were clear, and as she slept the deep drug-induce sleep her vital signs were normal and her examination, limited as I could do, was normal.

“Don’t wake her,” the ER nurse cautioned. “It’s better she sleeps.” So, I spent an hour reading through the old charts, wrote admission orders, and looked in on her before leaving as the eastern sky lightened. Her creased face and skinny limbs where relaxed, even peaceful, but she woke. I introduced myself and told her I would see her in a couple hours before breakfast on my morning rounds.

I found my resentment building, I could feel it inside. I felt anger at some of the people who needed my help. I had my excuses: the fatigue of long hours for these three years of training, my young wife and daughters who I was called away from to tend these folks. I often judged these folks weren’t “really sick”. I had developed a belief that a “good doctor” didn’t enable unhealthy behaviors. Good care would mean good health. So, someone was to blame here, the doctor, the patient, maybe even the medical industrial system.

I rounded on the woman after my breakfast but before hers. She was sitting up, wanting to smoke, wanting something for her nerves, complaining. The nurse was exasperated. I told them both we would stick with the schedule until her regular physician came by. We had given her so many drugs in the ER, her breathing had almost stopped and we didn’t want her to die.

Her doctor rounded on his lunch hour and I went with him to the bedside. I watched how he listened to her whining and complaints with downward gaze. I found myself wanting to slap the woman, the doctor even. I wanted things to be so different, for them, but probably more for me.

I can’t remember what exactly I did say, but I was unkind. I think I mocked the woman’s complaints of pain, since we were giving her near lethal doses of narcotics, and we could find no cause for this pain. I don’t think I said anything directly to the doctor, but I know I did not respect his treatment, his choices.

I was called into the Residency Directors office a week or two later at the end of a long clinic day. The three years of training were almost over and graduation was near. He showed me the handwritten letter from the woman’s doctor, pointing out my cruelty, my unkindness, my lack of compassion. The Director looked at me, “Dan, you can do better.”

We are now watching compassion fail, in our systems, in our leaders, in ourselves. When compassion fails, there can be excuses and blame. But compassion is a life-long effort we must all work to build within. Though Justice is blind-folded as she lifts the scales of judgement, it is our compassion that gives the judgement meaning. Let us have compassion.

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Rotunda Showdown

Posted on May 23, 2020 by ddxdx
Not Idaho

It was a sunny May morning in Idaho. The primary election was over and Governor Little was in pretty good spirits. He was looking to back his ¾ ton Ford pickup into a metered space by the Capitol when a Prius with a “COEXIST” bumper sticker slipped in behind and took it. Brad laughed, “Damn Democrats. You won’t be so cocky come November!” he muttered with a smirk. He circled the block.

After plugging the meter, he looked up at the trees, accepting that the starlings would speckle his dusty truck. His mood was coming down. But the sunny stroll buoyed him as he crossed State St. and climbed the steps. A young man stood near the door looking at him, anxious, holding a manila folder. “Can I help you, young man?” Brad offered. He noticed the Idaho Freedom Foundation lapel pin.

“Um, Governor Little?”

“Yes?”
“This is for you. You have been served.”

“Oh Jeez, not another lawsuit.” Brad slapped the folder against his thigh.

The young man blushed and fidgeted. “Um no, Governor Little. This is a summons to a duel.”

“A duel?” Brad slapped his thigh again with the folder and guffawed. “You Freedom Foundation guys don’t like the election results huh?”

The young man’s nervousness eased and he launched into what sounded like a practiced speech. “Under Idaho Territorial law, matters of honor must be addressed between gentlemen when duly served. Chapter 7 Section 33(b). You are hereby notified that the honor of your opponent has been challenged and you are to respond.”

Brad thought quickly. “Didn’t we get rid of that law when we cleaned up all those regulations this last year.”

The young man smiled. “Indeed. You removed the section that repealed this section. The law is restored. You have two days to respond to the challenge. It’s all spelled out for you in the summons.” He gestured to the folder.

Brad couldn’t help laughing. “So, what does Wayne choose for weapons? Sneers at ten paces? He knows I can’t sneer as good as him.”

Here the fidgeting resumed. “It’s all in the summons there Mr. Governor. Honor will be settled. And Mr. Hoffman is serving as the second; he will discuss the weapons, the dueling ground and the time with your second, as is the time-honored custom.” Then he skipped down the steps and trotted off to the west.

Brad took the folder into the marble floored dome and read the contents. Then he headed to the second floor.

He burst through the Attorney General’s office and slapped the folder on the big desk. “What the heck do I do with this?”

AG Lawrence Wasden scanned the one-page piece of paper and blanched. “I was hoping it wouldn’t come to this” he muttered.

“You mean this is legal?” Brad exploded. “How can this be?”

“Well, we did eliminate a lot of stuff last year. It turns out we also got rid of the law repealing the chocolate ordinance, so chocolate is now illegal in Idaho if you can believe it.” Lawrence said amused, then frowned. “My deputy on honor laws just told me about this last week. It sure doesn’t take those Freedom Foundation boys long, does it?”

“But I’m supposed to duel the Lieutenant Governor, Janice McGeachan, not the Freedom Foundation!” 

Wasden frowned, then he hit an intercom button and barked, “Jerry, get in here!” He muttered to Brad as the door burst open, “He’s my honor code deputy.” He handed the paper to the deputy who scanned it.

“Well, Jerry?”

“Oh, there’s a problem with this sir.”

Brad rolled his eyes. “I know that! What do I do?”

“You cannot respond sir. This is an invalid duel summons.”

“Really? I thought dueling in Idaho was now legal.”

Now Jerry fidgeted. “Well, because of the repeal of Chapter 23, Section 3(d), technically it is, but under territorial law, dueling can only be done by men, so this summons is not valid.”

Lawrence put his hand on Brad’s shoulder. “It’s Idaho Brad. It’ll be OK.”

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Health Care Slowdown

Posted on May 21, 2020 by ddxdx

Isn’t it ironic that one of the largest economic sectors contributing to the Covid-19 recession is health care? Almost half of the massive first quarter US GDP drop comes from losses in health care spending. Just when the “best health care system in the world” is needed to kick into high gear, to be on its toes, agile, responsive, it slows to half speed. Are you surprised?

Your response to this news might be foretold in your response to the above phrase in quotes:” the best health care system…”. Nearly 70% of Republicans agree with that statement, while only 30% of Democrats do. The partisan divide in this country pivots on just what we expect of health care. We need some alignment of expectations.

Many analysts considered healthcare a “protected sector” in a recession, since they saw demand as inelastic, and funding stable. In the 2008 financial sector driven recession, health care spending stayed pretty constant while people were losing their jobs and homes. Maybe that gave some heath care investors the confidence they needed. Indeed, health care spending in the US has grown to be almost a fifth of our GDP. What bubble?

I doubt many of these analysts had spent a weekend covering the ER in a small Idaho hospital. For every broken hip or heart attack that needed those emergent services, there were ten rashes and colds that could have been treated in the office on Monday, or might have gotten better with some watchful waiting. But the way we have built our health care economy, the way we pay for these sometimes-vital services, requires all those runny noses and worrisome rashes to keep the money flowing so the nurses and doctors will be there when the car crash victim rolls in. With this pandemic isolation, the true elasticity of health care demand has been exposed. Will we go back to the good old days? Do we want to?

The job losses in health care are tragic as are the deaths from this novel virus. But so is wasteful effort. We have an opportunity now to build the system we want. But first, we’ll have to be honest with ourselves about just what we want.

Most people want what they want when they want it, and healthcare is no exception. Politicians know what we Americans want from healthcare. We have had two Presidents in a row promise us just that. Remember Obama: “You can keep your doctor…”? And now Trump: “If you want a test you can get a test…”. Fools love empty promises. Let’s stop being fools.

Hospitals nation-wide are feeling the cash crunch as elective procedures are postponed and emergency rooms waiting rooms are empty. Small hospitals, always closest to the margin are looking at buying red ink by the barrel.

This last weekend, around a fire pit, safely distanced, I heard a novel suggestion from a friend. He and I are in the same high risk, older male age category. He suggested, to save our local, small-town hospital we set up a schedule amongst our similar risk factor friends. Each of us, on separate days would go to the ER and complain of chest pain. We’d get the full-bore treatment, labs, EKG, maybe even spend a night there. The hospital could bill Medicare for our services and the local institution would be saved. We all laughed, even though it’s not really funny.

The years of growth in health care spending in the US has long been held to be unsustainable. The causes, the blame for this predicament are worth understanding if we expect to turn it around.

I sincerely don’t recommend setting up a chest pain schedule with your older buddies to save your local hospital. But I do ask you to start having some considerate conversations about just what healthcare should be in this country. It’s way past time we made the effort.

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Counting Deaths

Posted on May 17, 2020 by ddxdx
Monty Python Holy Grail

I have written before about the value of knowing the cause of death to a community. Obituaries used to be reported in the newspaper, not paid personal notes as they are now. The cause of death was usually included in the reporter-written, editor reviewed piece. But the business of reporting the news has changed, and now obituaries, written and paid for by the family, rarely include cause of death.

Then I was referring to the “opioid epidemic”, since the wave of deaths from that cause seemed to sneak up on the general public. I argued before that public awareness of the growing numbers might have raised an alarm and changed some things earlier in that “epidemic”.

But now we are in the middle of a different epidemic, and the number of deaths attributed to Covid-19 are reported daily on the news. But the accuracy, the validity of these numbers is easy to question. We all know the inaccuracy of the testing. Are we undercounting Covid-19 deaths? Probably.

There is a way to get around this issue of squishy test accuracy. It has to do with measuring “excess deaths”. This is calculated by comparing the average number of deaths from all causes in a region for the previous three years to the current reporting period.

The CDC updates this information regularly, but there is a significant lag in reporting time. As of May 11th, the CDC listed 49,000 Covid-19 deaths, while most news reports put the US total at almost 82,000. Currently, according to the CDC, the United States has only 95% of the expected deaths for the period February 1st 2020 through May 9th. No big deal, huh? Don’t forget the lag time.

So, if you don’t have confidence in the accuracy of testing to give the cause of death, “excess deaths” might be a better figure. Maybe it tells you if you are being hit by a train, or just panicking when you hear a whistle. But a long lag time before you respond to a warning whistle can be fatal. Most regions are right near baseline. Idaho has only 16 Covid-19 reported deaths (to date) and our number of total deaths for the period February 1st to may 11th is right at 93% of the previous three-year average.

Further, Idaho has very timely reporting to the CDC. On average, it only takes 8 calendar days from death for Idaho to submit data to the CDC. That ranks us at 10th nationally for how well this small branch (Department of Vital Statistics) of Idaho government is doing its job.

So, what’s the big deal, why not open up the doors of businesses or go to a baseball game? We’re safe here in Idaho, right?

But some states are well above average for this period: New York State at 123% and New York City at 224%.

This sort of comparison has been done for countries too. In almost all cases, the number of excess deaths above baseline is significantly greater than the number of reported deaths from Covid-19. This supports that we just don’t have accurate testing.

Maybe more people are dying for other reasons in this “excess death” category. I have heard it argued by folks wanting to reopen our state that the excess deaths (in other states) could be attributed to people not accessing care due to the shutdown. Many ongoing treatments have been suspended and elective procedures have been postponed. Hospitals are bemoaning this loss of revenue. Health care workers are unemployed. Interesting argument, since I would have thought that most such believers agreed with Raul Labrador’s statement: “Nobody dies from lack of access to healthcare”.

I respect our governor’s caution in response to the train whistle. Some places have been hit by the train. Let’s be safe.

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Response to Protest

Posted on May 6, 2020 by ddxdx
“Ohio” CSN&Y

There were pictures of armed protesters in the Michigan state capitol last week. They came to publicly disagree with governor-ordered restrictions on activity in response to the ongoing viral pandemic. No shots were fired, but the internet flamed with outrage. I remember a day when protests were a bit more dangerous.

Please don’t dismiss this old man’s reflections, but protestors got shot in my day. Unarmed protestors on college campuses were fired upon and killed by the state-run “well ordered militia”: The National Guard.

It’s been quite a while since a public protest has been met with such sanctioned violence. I don’t pine for the good old days. But when I looked at the images of the Michigan protesters with their long guns and side arms, I wonder if any would have had a smidgen of recognition if I’d whispered to them “Kent State”.

When the armed protesters wander through the halls of the Idaho Capitol, declaring through public brandishing of a semiauto their “inalienable” Second Amendment rights, I wonder, do they really expect to be fired upon? Maybe they do. Martyrdom can be powerful. It is less so when sought.

Last week, the Idaho Freedom Foundation organized a protest at a closed Meridian playground. They publicized their intent to protest and filmed it. Unfortunately, the woman who got arrested had to beg for the cuffs for a half hour. She only got them when she refused to leave after being politely asked to do so a dozen times. Her attempt at martyrdom was a sham.

I suspect the Freedom Foundation hoped to inspire widespread civil disobedience in response to Governor Little’s stay at home orders. People are frustrated and anxious. But a sham doesn’t inspire. Maybe they were hoping for shots fired.

Maybe Ammon Bundy was also hoping so when he and some followers, also egged on by the Freedom Foundation showed up at the home of the arresting officer that night to protest and deliver a “citizens summons”. They were asked to leave and they did, no casualties, though I’ll bet showing up at the Ammon ranch near Emmett with a citizen’s summons might get you a warning round or two.

No, sanctioned civil violence against our citizens these days isn’t about protests for a cause. You won’t get shot demonstrating against abortion or marching about global warming. The sanctioned violence that occurs today happens at a traffic stop or a response to a domestic violence call, or even when you are called to dispatch your injured bull on the highway, as Jack Yantis experienced in Council, Idaho a few years ago. Police kill us, though not as often as we kill each other. We are an armed, restless populace. And staying at home can make us grumpy, unsociable, maybe even stupid.

The unarmed students that got shot by Ohio State militia at Kent State fifty years ago were protesting what they considered an illegal war, raging in South East Asia. Our government was drafting their colleagues, sending them to kill and die without following the Constitutional requirement that a war can only be declared by an act of congress. Nixon had just expanded the war to invade Cambodia. The students were outraged. They were protesting. And they were fired upon, nine wounded, four killed.

I remember my mother’s reaction to the deaths. I was a junior in high school, wondering about my draft status and the right and wrong of that war across the Pacific. “They deserved it!” she said. “They shouldn’t have been protesting!” I still get fundraising mailers to her from the Republican Party, though she’s been dead 14 years.

I can’t say I ever protested, though I don’t always like what our government is doing. I did run for political office and served. It was the best I could do to fight for justice. Public service isn’t as inspiring as martyrdom, but neither is it a sham; though it can sure feel like it at times. It shouldn’t.

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Last Wish

Posted on April 30, 2020 by ddxdx

About a month ago when the shutdown was starting and the Corona virus was just starting to kill people in serious numbers in this country we had an uncomfortable conversation in our kitchen.  It didn’t go well. I share it with you so maybe you can do it better.

Two of my grown daughters live just down the street from Martha and me. We have dinner together most nights. Sometimes we even play pinochle after dinner.

It seems so long ago, but the news was full of the concern for medical supply shortages. I had experienced in the clinic the difficulty with getting tests done, but the shortage of personal protective equipment was hitting my daughter who is an ICU nurse. What got the conversation going was the talk of the shortage of ventilators.

When people get really sick with Covid 19, their lung tissue leaks fluid and they can’t get oxygen in. Lungs are delicate sponges and they don’t function well when those little air sacs are full of your serum. I had read about the seriously ill patients in China and Italy and how many needed ventilator support to oxygenate. A month ago, I could not find good information how well patients responded to the mechanical ventilation, but I assumed they had a high mortality rate. Indeed, a recent report from New York suggests 90% of Covid patient who get intubated and placed on ventilator support do not survive. It’s 97%+ for those of us over 65.

The difficulty in the conversation with my daughters came up when I said, “Don’t let them put me on a ventilator!” They thought I was saying I don’t want to live. But that’s not what I wanted to say. I just don’t want to be treated like that.

I have intubated patients. When a gunshot or car wreck victim shows up in the ER and can’t breathe because of chest or lung injuries, we paralyze them with drugs and slip a tube past their vocal cords, inflate a little cuff near the end and now, their air way is secure and we can pump oxygen into their lungs, then treat their injuries.

I don’t resent patients who might want this level of care. Most patients want to be treated in a way that reflects their values. But unfortunately, when doctors need to slip that tube past your vocal cords, we usually don’t have time to have a comfortable, honest conversation about how the patient wants to be treated. That’s why it is so important that your loved ones can speak for you about your values.

And that’s what caused the difficulty with my daughters. They don’t want me to die. I don’t want to die either. But I will, and so will they. And I want my life, and my death to reflect my values. Mechanical ventilation doesn’t suit me. They came to accept this.

It is a hard assignment for family members to speak for the patient who can’t. So often, the “Do everything, doc” sentiment is a surrogate for an expression of love. If we don’t do “everything” it means we don’t love them. I wanted my daughters to know I felt their love, I know their love, but they could best express their love by sharing my values with my caregivers.

I gave the legislature grief this last session for not updating the End of Life document (POST) the state authorizes. If you’ve filled on out (I have) the piece of paper with your check mark and signature have been in a filing cabinet in the Secretary of States office. The legislature killed a bill to move this to a secure data base managed by the Department of Health and Welfare. But when the Department brought back the same proposal with a 75% discount on the cost, it passed easily; good job.

I encourage you to fill out the form. But more important, share your values with your loved ones. Let them know.

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No Column This Week

Posted on April 22, 2020 by ddxdx
The rudder really is banged up

I’ve been plugging away at writing this column for over three years now so I thought I’d take a break. There will be no column this week.

Initially I’d thought, since we are nearing the primary election, I could say something about Idaho politics, but honestly, what’s the point? It’s the same old story.

We have the super-majority Idaho Republicans crowded into their big tent arguing over who really represents the conservative values of Idahoans. There are so many in the tent they can’t all see each other, hear each other, let alone know each other. They can’t even agree on what to eat, so they keep taking a bite out of each other.

Meanwhile, both remaining Idaho Democrats are sitting outside at a picnic table looking at the noisy tent trying to figure who will pay for their lunch. The baloney sandwiches weren’t free. There’s no news here folks, so I will pass on Idaho politics.

I try to focus on Idaho healthcare issues but this pandemic is perplexing, so there’s no point writing a column about that. Once we know if it was just a bad flu or truly the apocalypse, we’ll think we know what we should have done different. But that could be years from now. I choose not to speculate at the moment, so I have decided not to write a column this week.

It’s no news that the natives are getting restless, as natives should, about what authorities are telling us to do. After all, who put them in charge?

At least our wise representatives in Washington DC have decided we all need a check in the mail. They fired up the presses at the Treasury and printed them up pretty fast, didn’t they? I haven’t got mine yet, but I’m comforted knowing it might come soon, so I can’t really write about that. I’ll let you know.

In the meantime, most of us are staying home and wondering where all those spider webs came from. I really have noticed a lot of spider webs, but who wants to read about spider webs? So, I won’t write a column this week.

And there’s no point sharing all the projects I’ve been puttering on. Yours are probably more interesting. I got the 1949 Chevy dump truck running like a champ, but I can’t haul the roof I need to tear off to the dump. It’s closed.

So, I fixed up an old lawnmower a neighbor left me. I’m now blessed with four lawnmowers. See why I shouldn’t write about how I’ve been filling my time?

There is one thing I’ve put off for quite a while that I am tackling now in all this isolation. It’s not really much of a story. I have this old wooden sailboat that takes more time to keep shipshape than it spends in the water; kind of like our government. I’ve sanded and varnished and patched and replaced more than I can list. That too, sounds like this Republic.  It has really big sails and it can go really fast with the right wind, but right now it’s in storage, also like our country. I can get it out in a couple weeks. See, there’s not really a story here.

Right now, I’m fixing the rudder. It was really dinged up and cracked. The third coat of varnish is drying now, and it’s really quite attractive. The image of a beautiful rudder for a boat that doesn’t sail somehow resonates with me right now. But like I said, it’s not a story.

So, to all my readers I apologize for not doing a column this week. We suffer in these troublesome times, socially distanced and worried about the plague upon us. Since you won’t be wasting time reading my column, maybe you can share a story with a loved one. We need to feel close; tell a story.

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Pandemic Placebo

Posted on April 15, 2020 by ddxdx
Pat Wellenbach/AP

The buzz drummed up around hydroxychloroquine by our President as a treatment for Covid19 doesn’t surprise me. Honestly, a lot of politics is snake oil and he’s proven to be really good at selling it to some of us.

But it’s a great opportunity to consider what pills we are willing to swallow. I find hydroxychloroquine quite bitter. Maybe you don’t.

Lots of what we do in this modern medical industrial complex is mysterious, but don’t think for a minute its more complicated than human nature. Placebos tell us something about human nature, so it would be wise to understand them if we can. It might tell us something about ourselves, and about the prescriber.

Kind of like Idaho Democrats, placebos have a bad name they don’t deserve. Why disparage something that really has an effect? I guess it depends on the effect you want. It turns out, our bias effects our outcome. What you believe about your treatment influences the effect the treatment has on you.

They frequently do work; placebos I mean, not politicians.

When a placebo is given to a patient it can have an effect on the measured outcome; the “placebo effect”.  Placebos make headaches better, lower blood pressure, improve pain, ease anxiety and improve performance, the list is long. Believe it or not, they can have side effects too. They can cause nausea, ringing in the ears, all number of unpleasant things. Don’t forget that these effects, desired or not, are as real as we perceive them to be. Even the color of the pill can have an effect. We are such marvelous mysterious creatures.

For a drug to be FDA approved it has to show an effect greater than a placebo. That requires a lot of hard, expensive work. The patient has to be blind to whether the drug is a placebo or “real” and further, the treatment team needs to be blinded to the nature of the treatment also. The faith that patients place in their treatment, and the faith that providers have, has an effect. The standard for an effective drug is that it must clear the placebo hurdle of faith. That’s a high bar. Isn’t it refreshing to know our faith is so powerful?

The effect of hydroxychloroquine on the Covid19 illness has not been held to these standards. One very small report without blinded patients or providers reported some benefits; two larger ones showed no effect. Trying a novel treatment in the face of a novel virus in the midst of uncertainty is not irresponsible. Honestly reporting it for others to consider and test is responsible. Testing the treatment against a placebo would be responsible. Such testing might provide some evidence. But such testing takes time, effort and discipline. Do we lack such resources now? Should we be buying snake oil?

I remember my pharmacology lectures in medical school. The pharmacist professor wore a long white coat as he stood on the stage addressing the large theater of students. He spent a whole hour, after beta blockers and before tricyclic antidepressants, talking about the placebo effect. He emphasized how real the placebo effect was, how powerful it was, and how foolish we would be to minimize it. He encouraged us to tell patients the treatment would work. “Use this effect for your patients benefit.” At the time I felt he was leading us down the road to be snake oil salesmen. But it’s really not as simple as that. I think he was encouraging us to choose a treatment we had faith in, and impart that faith to our patients. The foundation for that faith should come from tested evidence. It’s a sad fact that many medical treatments have no such evidence, yet they are prescribed daily.

Maybe that was why I was such a lousy Idaho politician. I couldn’t sell blue pills when red ones were in demand.

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