Medical insurance

Hilzoy at Obsidian Wings posted on Why We Need Universal Health Insurance, pointing to Kate Michelman's account in The Nation of what her family has gone through. In the ensuing discussion, I wrote -- in response to one of the local libertarians:

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Brett:

What I honestly don't understand is why you're more frightened of the government than you are of the medical insurance industry. I wrangle with some government agency maybe once a year, twice if you count taxes automatically; I wrangle with a medical insurance company or their effects at least once every six to eight weeks.

I have not been personally *afraid* of what the gov't will do, even when we discovered we owed $2K for last year -- they can cope, they'll listen to reason. I have been *afraid* of insurance companies, I have had to experience direct physical pain because of their decisions -- like, for instance, not approving a medication I need before a weekend. Or the time when my coverage lapsed for a month, and I had to cut back on my meds to skirt the edge of illness. Or my husband being in constant knee pain but the company not having agreed to surgery for him, because it hasn't hurt *enough* yet.

You say the government works by coercion and the frequent threat of violence, but I honestly do not see that as realistic threat. The threat I feel from medical insurance companies is direct and personal, a matter of my daily health. What Kate Michelman is experiencing -- what Gary Farber here is, for another -- is closer to a literal life-and-death struggle.

Are you saying that this isn't familiar to you, either personally or in people close to you?

Serendipity, Medicine, Pain

Steven Brust & his housemates have a new blog at dreamcafe.com, and kit just posted on fibromyalgia, based on a NYT article on a new drug to fight the disease, even though not all doctors believe it's "for real". My comments:

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Speaking as a science writer and historian of medicine, the article is full of crap. Yes, it is always problematic when medication drives diagnosis. But it is practically dereliction of health-writer-duty to talk about the problems with fibromyalgia without even mentioning the pervasive problems modern American medicine has with chronic pain: acknowledging, diagnosising, and treating it.

Not to mention that one consequence of finding a drug that treats a mysterious condition is that you have a better chance of finding out what’s actually going on. Though I will also bet good money that “fibromyalgia” is a “lumping” diagnosis, including several very different conditions under a single name.

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It could be (I’m no expert either) that some medical research is similar

O my heavens, yes. In fact, we call it "serendipity" and pretend that we meant to do that all along.

For instance, the Vinca alkaloids I mentioned above. The Madagascar periwinkle is a tropical plant, widely grown in gardens for the past couple hundred years.

It's also been widely used in folk medicine, and was first scientifically studied as a remedy for diabetes, one of its traditional uses. The scientists working with it couldn't find any effect on diabetes, but noticed that it reduced the white blood cell count in their study animals.

"Hey," they said, "if it reduces white blood cells, maybe it could help with leukemia!" About a zillion tests later, they had a collection of substances -- the Vinca alkaloids -- that were some of the first effective cancer chemotherapies.

The Vinca alkaloids had been used in chemotherapy for a while before the chemical they bind to, tubulin, was even discovered, and it was years more before scientists knew that that's what they were doing.

Yes, GWW, medicine is *incredibly* empirical -- I don't know if there's any other science that is more focused on "find me something that works, find out *why* it works later." I'm so used to this fact that I really appreciate being reminded how chary doctors are about conveying it to the general public.

I'll hop down from the soapbox with a book recommendation: The Spirit Catches You and You Fall Down, by Anne Fadiman. A wonderful, heartbreaking story of culture clash and medicine.

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I find it so hard to consider that scientific…

LOL! Some people have been known to say medicine is an "art" instead; others use the term "voodoo".

My experience is as a science & medical writer & historian. I think it's *necessary*, because medicine is (a) intrinsically very difficult, but (b) can't afford to wait for results.

Generally speaking, the "hard" sciences are the ones that are easy, the "soft" sciences are the ones that are difficult -- and medicine is positively squishy.

Physics is intrinsically easy because it works (by definition) with the minimum number of different kinds of things: these days we're down to a few quarks, a few leptons, a few fundamental forces. Physics seems "hard" because it's easier to get reliable results when you limit yourself so strictly, and because you can build longer trains of thought by making each thought very precise.

With medicine, though, you're working with at least at least 22,000 kinds of basic units, some of which can be modified to produce millions of useful variants

So if the intrinsic difficulty of physics (using say 20 elements) is 20!= 2.433 × 10^18, the intrinsic difficulty of medicine (with say 20,000 elements) is at least 20,000! = in the range of 10^77000. Since we don't want to wait until the heat death of the universe to shuffle all the combinations, we have to use the "empiricism first & devil take the details!" methodology. Often, it's while trying to figure out what we've done that we can see what should be done instead.

Doctors are a lot like medieval master-builders working on a cathedral: putting up a massive complex structure without being able to analyze too much beforehand, just trust to past experience, knowledge, and keen observation to adjust as you go. Yeah, a good many cathedrals fell down -- but just think of the one that stayed up, with no architect's plans or engineering feasibility studies to show that the builder knew what he was doing. He knew what worked, even if he didn't know why:

http://en.wikipedia.org/wiki/Notre_Dame_de_Paris
and
http://en.wikipedia.org/wiki/Cologne_Cathedral

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skzb @50: You’re right, every scientific discipline has serendipity stories. I wonder if serendipity is one of the signs that “science is happening here”, one of the things that distinguishes science (& engineering) from other ontological methods.

As I think about it, it seems to me that serendipity comes from the way scientists focus on the metaphoric trees instead of the forest — not just the trees, but the specific bark of this specific tree, and I never noticed those moths before, did you?

Science is anti-holistic, in that little discrepancies *do* matter. The evidence for light’s diffraction is much less obvious than reflection, and from a well-balanced Ancient Greek POV it’s kind of crazy & obsessive to make explaining diffraction (light is a wave) as important as explaining reflection (light is a particle).

It’s a real problem in medicine, because human beings in pain need to be treated holistically, but the best treatments often come out of studying their problems in a reductionistic way.