Race relations?

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Well, the news is out, in the event you haven’t heard, a grand jury did not indict police officer Darren Wilson in Michael Brown’s death.

Since I no longer live in the US, one question would be “why do I care?”

How about “most of my friends live in the US and I seem to be caught between worlds, where people in the US believe I am European, and my European friends believe I am American?”

Ok, since I have an almost masochistic attitude when it comes to hate-mail, let me just come right out and say it. From the news I have seen, I believe officer Wilson made the best call he could have at the time. This decision was made without benefit of hindsight, without benefit of multiple camera angels, and there was not a lot of time to ponder the various implications of the action. I am not saying Michael Brown deserved to be shot; I am not saying it was the right thing to do. It seems to me a lot of people don’t seem to be able to separate those 2 concepts. However, an undesirable outcome to an undesirable situation is not criminal.

Almost immediately, there were reports of anger and violence from the community. Many in the circles I associate with have decided to take it upon themselves to respond to this with Facebook memes and posts about how those protesting do not work, attempt to stir trouble, are using this as an excuse for anarchy and lawlessness, etc. These people are not helping. In fact, they are probably fueling the anger that puts public safety workers at risk. Not the best plan.

To believe community outrage and the level of community outrage being witnessed, similar to past incidents, like the LA riots of the 90s, is because of individual actions of individual police officers, in a given circumstance is extremely short sighted. You see, there is a problem, a big problem, which is only getting worse. It is not simply a matter of race; that would be easy to fix.

In my younger days, I was involved with a “sub-culture,” a fancy word that is quite misleading. It would imply we were a subset of a larger group or culture. It wasn’t really true, we were outcasts; in effect, our own culture. If you take an anthropological idea of what culture is, a set of behaviors and customs that identify one as part of a group suitable for mating and resource allocation, in the modern world, whether it is the US, UK, Poland, or any other country, multiple cultures exist within national borders. All of these cultures must share the same resources. Somebody is going to be left without, and those without, like any desperate animal, are going to resort to tactics such as violence or underhandedness in order to protect what resources they have.

Sometimes this cultural divide is mistaken as a social or economic class divide. I think perhaps it may have been at one point, but that point has been surpassed a long time ago. In an earlier post I wrote about the altered morality about being poor. I think it is fair to say that the Ferguson issue demonstrates not only a cultural divide, but also why public safety forces, by extension through the emergency medical system, and into other healthcare sectors are really making things worse.

Whether you are a firefighter, paramedic, police officer, doctor, nurse, or whatever, you are part of a group. These groups have very specific values, and when faced with conflicting values, we as individuals like to retreat into our group for reassurance our values and behaviors are “right” or the most valuable. That ethnocentrism, group-think, insular behavior, whatever we want to call it, unfortunately leads to the conclusion that those outside of the group are “wrong” or misguided. This is the behavior that leads to disorder and violence in society.

You see, as a culture, our group is comprised of people who have certain benefits. We are often well respected within the population as a whole. In many countries we form part of a protected or privileged class. We have not only learned, but became skilled in manipulating the political and legal systems to our values and will. Using not only our social status, but also our money, we have basically secured our resources and mating pool. In some nations like Poland, it is relatively easier to move into this group from outside of it than in places like the US. The main reason is money. You see, when you fit in to a culture, members will not only make economic opportunity available, but will also value you during your journey to being a full member, in essence supporting you emotionally, intellectually, etc. Once you are initiated, you are expected to reciprocate.

But what is given to those not in the group? The answer is becoming “less and less.” No matter what country we live in, our world is becoming more polarized. There are not enough resources in any country or even the world in order to attain the most basic quality of life for everyone. As such, we are more and more guarding our resources instead of sharing. Let’s make it easy to understand shall we?

Let’s define an upper lower class or even middle class Western lifestyle is 10. Let us now understand that many of us reading this probably started at 10 as children. We grew up in 10, and some of us, depending on the success of parents and family may have started at 11 or higher. (for those reading who grew up in a family dominated by generations of physicans, lawyers, accountants, stock brokers, etc, 10 would be a significant downgrade.) Some of us start at say 8. Now it is fairly obvious that in order to get from 8 to 10, it doesn’t take a lot of resource investment. So people already at 10 or higher, don’t have to invest much in order to bring the 8s up. But what about those that starts with say 4? How about those who start with 0? It takes considerably more to get them to 10. It takes double what it takes to bring an 8 to a 10 in order to get a get a 4 to an 8.

Unfortunately, resources are finite, and the more you have, the easier they are to get. It takes tremendous effort in order to maintain what we have. That is why the less you have, the more painful the loss. In societies around the world, there is a growing resource gap. That is an observation, not a call to some Marxist ideology. This so called “social/economic” divide creates and exacerbates a cultural divide. It creates the “us vs. them” mentality that is described as “racism” or “class warfare.” No matter what country we are in, we are not the same. We are not equal. We will never be. It doesn’t matter what color a person is, or how much money they have or don’t, we have taken to vilifying and dehumanizing “them.” But this misidentification of who constitutes “us and them” is why there is no understanding of why rioting, etc. happens and what the flashpoints are.

To explain it simply, us in the 10+ category have not only made it undesirable to not be in the 10+ category, we have criminalized it. We can and have done so because we have resources like money and time in order to utilize and master our economic, political, and legal systems. Those less fortunate simply do not have the collective resources, time, or knowledge in order protect their interests within our system. As such, they eventually resort to violence and “lawlessness.” It is often said “violence is the last act of the desperate.” It works both ways. Whether you are a 10 or a 0, when faced with losing resources, (For poor people, family members are resources) our last desperate attempt is violence. You can see this play out in murder suicides of the wealthy and middle class when faced with becoming poor. You can see this is the poor when they turn to looting in order to obtain resources they otherwise cannot as a form of “justice” when they lose something like a family or community member. You can see it in the militarization of the police when protecting the “order of the state” which maintains the resources of the 8+ groups by virtue of rule of law. You see it in the +10s when faced with competition or taxation in the form of war.

All of this leads to a major conundrum for groups such as public safety and medicine. As our core value, helping and protecting is paramount. We claim to want to help all people as much as we can, but we are faced with the real duality that we must also protect our own resources and interests. Whether we like it or not, it is a fact we cannot help anyone if we cannot provide and take care of ourselves. In fact I stipulate one of the major contributors to mental illness in our respective groups is that our desire and efforts to help others leads us to self and family neglect; even to destructive behaviors. But that is another topic for another day.

In order to protect ourselves from violence, we must remain a protected and valued class in society. In order to take care of others, we must provide for ourselves and protect our ability to do so. In order not to lose, we must constantly use our money and resources to promote ourselves and our agenda. These are undisputed facts. In order to do all of this, we must first understand what the challenges are.

In remaining true to our cultural value of helping others, we must understand what their challenges are. We must take purposeful steps to minimize their losses. Whether you identify as a police officer, firefighter, paramedic, doctor, or nurse, “helping people” is more complex than just performing your particular set of skills and behaviors. We must help the “person,” not simply try to cure the disease or enforce the law, which we are prone to focus on to the detriment of all other aspects. WE MUST NOT VILIFY OR DEHUMANIZE the less fortunate. I know we do this and I know we do it too often. From cops who just “know” certain people are criminals to the doctor who doesn’t want to treat the “drunk.” Certainly they are partially responsible for their coping or failed coping mechanisms, but they do not have the same resources and opportunities we do. They may be choosing the least evil they are presented with. It will take us more effort and resources, sometimes seemingly fruitless, in order to help them maintain what little they have. While we may not ever want to become “them,” and it is certainly beyond our power to make everyone like “us,” by realizing the values of their culture and understanding our own, we can find ways to avoid the violence of desperation on all levels, from suicide, homicide, civil unrest, and even war.

We must stop isolating ourselves from the people we are trying to help and seeing our interactions as “us and them” instead of “we.” The more we secure and fortify ourselves, not only will we make it impossible to reach out to us, we will make it impossible to reach out to others. Once that happens, we can no longer help. When we cannot help, we are no longer what we believe in. We are no longer valuable or sacred. At that point, we become competition, not consolation, and the violence will only get worse.

Think about that the next time you post a blog about undesirable patients or memes about the lazy and poor.

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primum non nocere

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“First do no harm.”

As of late I am starting to think this phrase is more befitting of homeopaths than doctors. After all, medically, homeopaths don’t do any harm, their ‘treatments” actually don’t do shit.

Of course, over the last year, it has been my observations most doctors don’t do shit either. As such, I think a new mindset and slogan is in order.

When this phrase was originally spoken as a value of doctors, medicine was in its infancy. Most of the disease processes and sicknesses people were afflicted with were poorly understood. Even the basic knowledge of how the human body worked when healthy was largely incomplete. Treatments, both surgical and medicinal were just as, if not more likely, to physically harm or kill you than the disease. The warning was clear, do not be quick to apply medicine to a patient, because it is likely to do more harm than good.

However, that dogma has persisted to the modern era. Medicine has changed considerably. In fact, it is barely recognizable as the same thing it was in its early days. Most medicine and surgery actually helps more than it does not. Scientific testing, retesting, and even moral and ethical issues have to be addressed before any medicine, surgery, or medical device is permitted to be used. Admittedly, there are some shortcomings of both science and how easily scientific methodology applies to medicine, but by far it is an outstanding tool. It is definitely the best tool we have.

Medicine has long been described as both a science and an art. Certainly I do not dispute that. In fact, I actually consider myself more of an artist than a scientist. That probably sounds rather strange coming from somebody who has a piece of paper demonstrating I am a scientist, but I do not have a paper attesting to my ability as an artist. I should probably explain this dichotomy.

In my younger days, I was involved with performing arts of various disciplines. In performing arts there are basically 2 types of artists; those with raw talent who do not commit to studying their art and just “perform” and those who are “trained” in their respective arts at academies. Whether it is music theory, dance techniques, drama techniques, etc., they are all based in exacting scientific and mathematic concepts. This “science” of performance is studied by the second type of artist in what is known as “classical training.” It is probably called “classical” because the types of performance, such as symphony, ballet, Shakespearean theatre, etc. are rather conservative and seemingly rigidly basic compared to more modern forms of expression. However, it is well known within the artistic circles and evident by more than a few successful and popular performers, that an artist with raw talent usually has fewer employment prospects or ability to make a living in the arts. This is mostly because while they are quite specialized in a narrow range, they lack the basic foundations to move out of that range. Some of you may be thinking right about now, that sounds an awful lot like medicine… Because it is.

Medicine is not really “an art and science”, as many would like to believe. Medicine is wholly an art. If you think about it, you can see where there may be some confusion. After all, many doctors are involved in science and constantly doing clinical studies. They like to create guidelines and justify their actions both legally and for pay using these “scientific” studies. However, despite an introduction to the scientific method, statistics, and other parts of science in professional education, they are not required to perform independent research or write and defend a dissertation as scientists are. Historically, biomedical research and medical practice were undertaken by 2 entirely different groups. Medical science was for all intents and purposes a collection of observations by clinicians. In the modern age, this “clinical science” as we call it, is scrutinized by various statistical models in order to lend credibility to it, and very deftly reclassify it (aka rename it) as something other than a collection of anecdotes.

The role of the physician or “doctor” (I am just going to stick with “doctor”, for no other reason than I like that term better) is to attempt to apply scientific knowledge in a practical way for the purpose of preventing, treating, palliating, and investigating disease. This is what is professed and taught in medical school. After medical school, during “residency training,” basic scientific knowledge is slightly expanded upon and a set of behaviors and some psychomotor skills are imparted upon residents that define them as a specialist in a given field. In my observation, it is actually a step backwards rather than forwards because in practicality, it limits responsibility and therefore knowledge rather than expanding upon it.

The very practice of residency is not historic to doctors. It is actually a practice of non-physician surgeons that was adopted by doctors in order to get surgeons to accept formal medical training in medical school. This further demonstrates the case that residency is in fact, not advanced knowledge, but specifically limited knowledge. Doctors like to defend this practice by claiming there is so much to medicine, no one doctor can be good at all of it. This I find extremely suspect since all medical school students are expected to have knowledge and skills in every major medical discipline, where post resident specialists are not.

The role of the scientist is quite different from a doctor. This is the person undertaking the role of advancing knowledge using the scientific method and mathematics. Because of the vastness of modern knowledge, scientists have to be specialized in various disciplines in order to achieve the required level of knowledge in order to discover more. There was a time and exact citations of individuals mastering all of human knowledge. It has been a few hundred years since the last of them. However, unlike doctors, scientists are not subject to much variability in their professional endeavors.

Many times I am asked by colleagues, how a person goes from being a firefighter to a paramedic to a doctor and even a scientist. I would like to think from my personal standpoint it is something like being a renaissance man. But despite both my artistic and professional accomplishments, I don’t think it is fair or accurate to say I have achieved such greatness yet. What I often say is that my role has actually never changed. I have always been the one to help people. My cloths (uniforms) change. The tools I use at a given moment change. The skills and knowledge I need to use those tools change. My experience is continuous. From the point of view of helping people, I have not changed at all; I have simply added more ways to do it to my repertoire. My pursuit of knowledge through science is in essence the classical training I have learned and use in order to best perform my art.

I am sure many doctors who have not also undergone advanced education in science would like to think they are just as capable as those who have, but I would simply compare it to my discussion of talented and narrow based performance vs. the classically trained artist above. I suspect if you ask many doctors who are also scientists, they would agree with my assessment. (I wonder if I will see as many “not me I am the exception!” comments from doctors as I get from paramedics?)

But what does any of this have to do with doing no harm?

Doctors harm people. I have observed that the hyperspecialization of medicine leads to patients seeking help from doctors who either do nothing for them and send them to another doctor, or guess at what the likely diagnosis could be and use the most minimal treatment, forcing the patient to endure extended courses of disease, loss of work and quality life, and in some areas, increased economic costs. Often far beyond what the treatment they received prevented loss of.

Given that is basically the exact same thing achieved by homeopaths, right down to demanding payment for it, I think what needs to happen is to set doctors apart from homeopaths by adopting a new philosophy.

Primum succurrere

“First hasten to help”

This sounds more like it befits a firefighter than a medical doctor. But where do people turn to when they really need medical help? The emergency department. It is open 24/7/365. No appointment necessary. No formal dress required. All comers taken. In places where point of service fees are required, emergency sends the bill after, payment upfront is not mandatory. Whether payment comes direct from a patient or a system, the doctors in the emergency department are the 1 stop shop to diagnose your problem, take care of your problem and send you on your way (Treat and street), or send you directly to the specialist that can help you. The hospital usually has everything from X-rays, to CT scans, a lab operating 24/7 to a host of specialized consultants. The emergency department answers the most pressing of all patient questions. “How bad am I now?” In today’s world, unlike in my childhood, patients probably don’t even have a regular primary care provider. They go to whichever one can get them an appointment the fastest when they are sick. Primary care as a medical specialty is obsolete. Nobody needs to make an appointment a month from now to get help for basic ailments like strep infections, yeast infections, Urinary tract infections, or even to find out “how bad they are.” Parents don’t want or have the luxury of skipping multiple days of work to find out how sick their kid is or if they can go to school or not. Parents don’t want to see their kid suffering for days, weeks, or months to get an appointment. Plus most primary care providers will either start with a pitiful underpowered treatment based on a guideline for initial presentation, at no point taking into account the time of initial presentation of the disease is different than initial presentation to the appointment, which will not help, and force prolonged sickness, more doctor visits, etc. or they will collect a middleman fee and send you on to a specialist. (This middleman fee is even worse in single-payer system countries, because it is the epitome of being paid for doing nothing, in fact practitioners should probably face criminal charges of extortion)

Many emergency providers become frustrated with the fact they are the primary care provider for most patients they see. They didn’t sign up to be in primary care. Much of their specialization revolves around cases that are a minority of what they do see. What is more, even when they want to help, they do not always have the organizational support or resources to help even when those resources are simply on the other side of a door in their building. The Emergency Department is the modern version of primary care by necessity and function.

Even most specialists outside of primary care, working 9-1500 or less do not meet the needs of patients. An excellent example of specialists who recognized they are primary care providers as well are OB/Gyns. They have identified, accepted, and adopted the role of being not only the primary care provider for their female patients, but all; the point of first resort for the male partners of female patients! We all know in the modern western world, a man is motivated to go to the doctor for 2 reasons. 1. He cannot tough it out anymore and 2. Because his wife, girlfriend, mother, sister, aunt, etc. forced him to go. OB/Gyns are both personally and via their professional bodies stepping up to the challenges of the modern day. Why aren’t the others?

This applies both ways. Traditional medics (nonsurgical physicians) can expect to have to actually perform minor surgical procedures they learned in medical school. They should expect to have the basic equipment needed on hand. Doing something like prescribing an antibiotic and then referring somebody to a surgeon for wound care is completely a waste of money, everyone’s time (including the surgeons’) and doesn’t actually help the patient. In fact, as described initially here, it harms the patient in multiple ways. Surgeons should likewise need to recognize when patients under their care or consultation have minor medical problems (like skin infections, upper respiratory infections, etc.) and take care of them without referral or as I have seen, completely ignoring them.

The other day I broke character and attempted to demonstrate to some asinine anti-vaccer vaccines don’t actually harm. I shouldn’t have done it. I know you cannot convince the crazy to be sane with logical argument. I know you cannot possibly convert the beliefs of a true believer. It was a foolish waste of my time to try. But I bring it up because this psychopath did remind me of something I had not thought about in a while. He asked me what kind of doctor I am.

When I was growing up, my family doctor was Dr. Kolliker. I don’t know his first name. He liked to be called “doc.” His office was cool. In the waiting room he had a collection (that would make any museum jealous) of antique medical texts, pharmaceuticals, and medical equipment. Whatever your problem was, doc would take care of it, often preemptively for the whole family. “Here is a prescription for you, and one for the sibling you share a room with so when she starts getting symptoms in a few days, you don’t have to come back.” “By the way, here is a prescription for your acne too,” and when mom wasn’t looking a handful of condoms. (which I must admit never did me any good, but some friends had appreciated them) When we were sick in the middle of the night we didn’t go to the emergency room. Whether it was mom or dad or us kids, we called doc. At home. His patients had his number. No answering service, when the call was answered, it was doc. (in fairness sometimes you had to call a couple of times before he answered) His solution? “Meet me at my office.” (at 0 dark 30, not tomorrow, next week, next month.) Not only could he do everything, from stitches to prenatal care, you could ask him anything; about anything. Usually he knew, and if not, he simply said he didn’t. While he did refer to specialists on the rare event he felt help beyond him was needed, only one time did he send a family member to the emergency room and not until after we went to his office.

What kind of doctor was Dr. Kolliker? The doctor kind; the type who you went to when you needed help, large or small, night or day. I would say he was a great doctor. While I see my exact future role as being different than his, I think every doctor needs to be the doctor kind. Not like homeopaths, who “do no harm.” Like firemen, who “hasten to help;” Classically trained, knowledgeable, available, capable, accurate and precise, and above all dependable and decisive.