Some weeks ago I read your comments regarding the propagation of mad-cow disease into humans. I noted your statement that mad cow has so far been detected in a very small percentage of the human population, hence your opinion was that mad cow per se did not represent as large a threat to humans as some would believe, due to the protection offered by the species barrier. That is comforting but does not take into account the large numbers of people dying of various dementia disorders, of which a critical few cannot be differentiated until autopsy. Very few autopsies are actually performed on institutionalized dementia patients, who apparently die as a result of their primary dementia disorder. Therefore, it seems quite likely that the real scope of human infection and mortality from mad cow may be much larger than officially acknowledged.

Having had both of my parents die of compound dementias (multi-infarct, apparent Alzheimer’s, Parkinson’s….no autopsy or cerebral section post-mortem on either parent), I have spent a lot of time in nursing homes observing the ocean of very demented folks out there.

JOHN CLARK
Cleveland, OH

Dear John,

First, I’m very sorry to hear how you lost both of your parents. You raise a very interesting question. It is certainly conceivable that some of the various dementias reveal underlying causative agents that are either subclinical or are yet to be determined. A recent article in The New York Times Magazine looked at atypical presentation for mad-cow disease in humans, and it is possible that there are more prion infections than have been reported. However, prions do cause certain characteristic brain changes including vacuoles, and I do not believe that we can pin the vast majority of dementias on mad cow.

The politicians who have repeatedly failed to create a just and efficient universal health insurance system depend on the idea of greedy, uncaring doctors to help distract the public from their crimes. The public understands (in a general way) that physicians are required to care for anyone with a medical emergency without regard to the patient’s ability to pay. This gives them the erroneous idea that “everyone can get care.” They similarly are encouraged to accept the idea that physicians should rightly shoulder this burden of non-reimbursed care alone “because they are so rich anyway.” It is certainly “less unjust” for a physician to bear this than someone less well compensated. However, being “less unjust” doesn’t make something just. Moreover, it distracts from the real point. No individual, regardless of income, should have to pay for care individually that should be provided by society. Using the “greedy physician” scapegoat simply distracts from the real culprits: the insurance and pharmaceutical industry and the politicians they purchase.

While I deplore behavior I see sometimes as an ER physician who must piece together care for uninsured patients, I much more frequently deplore having to ask already overburdened physicians to provide care for a critically ill patient for which they will be completely uncompensated. While I hate the minority of my colleagues who have the wrong attitude toward the profession, I more frequently hate heaping huge mounds of work on colleagues who willingly do so for nothing more than knowing they’ve helped another person. This is especially the case when these patients never would have reached this stage of disease had they been able to access decent preventive care that should have been their right.

Blaming physicians for complaining about uncompensated care simply distracts from the far greater crime that places these physicians in this unfortunate position in the first place.

RYAN NICHOLAS GORTON
New Orleans, LA

Dear Ryan,

I agree with you. I actually find our positions very compatible. I am for a national health service, with the provision that it somehow not be implemented by the same pocket-lining bureaucrats who get rich while doctors get poorer and patients remain poor and underserved. All I was saying in my earlier exchange was that I’m skeptical of many physicians who plead poverty as a reason for not providing necessary care in their community.

As a physician employed by a small rural hospital district not too far from the reader in Kirkland, Washington, whose provider complained about the poor Medicare reimbursement rates in this state, I’d ask you to look beyond personal greed as explanation for the doctor’s complaints. I am sure you recognize that primary-care providers are on the bottom of the compensation scale. Take that together with the fact that the cost of operating an office is becoming exceedingly expensive and we have a big problem.

Our hospital was recently granted critical-access and rural-health-clinic designation, which averted a projected $4 million loss this year (with reserves of about $5 million), and essentially kept the doors to our twenty-five-bed facility open. It’s the only hospital for sixty miles in all directions, and it provides a fair amount of uncompensated care both in the hospital and our clinic. We don’t have many “big-ticket” procedures, but we do provide compassionate, high-quality care to our neighbors.

Until another means of financing medical care for our aging population is available, I expect plenty of complaints from both my patients as well as my colleagues.

P.S. I truly do feel fortunate to have my job.

GARY FORBES
Port Townsend, WA

Dear Gary,

Thanks for stating this view. There is no doubt in my mind that physicians and most hospitals are no longer at the top of the pecking order in terms of healthcare profits. But I do think we doctors need to continue to see medicine as a calling rather than an economic equation. I can tell that you are one doctor who is properly motivated, and I share your concern that doctors don’t have the ability to organize ourselves or the skills to protect our income, in part because many of us are too busy trying to help our patients. But the skill to help people is a great job to have no matter what, and I do not feel that grousing helps us very much either in terms of how we are perceived or in terms of maintaining our solvency.

I think that the legal profession has tried to make some reforms. The efficacy of these reforms, however, may be doubtful. For example, under Federal Rule of Civil Procedure 11, attorneys can be sanctioned if they file frivolous lawsuits. Under Rule 11, in signing a pleading filed in federal court, an attorney is presumed to have investigated the factual background behind the complaint to insure that it is meritorious and not frivolous.

Perhaps the rule is not being enforced sufficiently, but it is there. Also, the Supreme Court has recently ruled that punitive damages can be reviewed de novo, or as a matter of law. In other words, the reviewing court does not have to defer to the jury’s findings that punitive awards are excessive. That is why many punitive verdicts are reduced or eliminated altogether on appeal.

Finally, the sheer shortage of federal judges has made them much more willing to toss out plaintiffs’ cases, such as by summary motion. The same may not be true in state court. Personally, I hope that we have some form of socialized medicine. I think that it is infinitely preferable to the patchwork system that we have now.

DEV PARIKH
New York, NY

Dear Dev,

Frivolous lawsuits need to be regulated and discouraged as much as the practices of frivolous doctors. Punishing doctors by delivering large verdicts that come out of the pockets of insurance companies is far from the best way to regulate doctors. More peer review is needed, and fewer incentives for ambulance chasers.

I discovered your column in The Nation a few months ago, and I’ve been following it religiously ever since. From reading your column I get the feeling that the flaws of the American medical system tend to go underreported. But here in Canada, the right-wing media does its best to cast our single-payer system as inadequate and irreparably broken.

One aspect of the debate I’d very much like to know your opinion on is: How is a doctor’s life different under the American system compared with a single-payer scheme? Surely there’s a lot more money cycling through the system, but on the whole does this add to comfort or stress to a practicing physician?

PETER WOODFORD
Toronto, Canada

Dear Peter,

It’s an interesting question. Here we have a managed-care-heavy system, where most doctors deal with an enormous amount of paperwork, rushed visits, dwindling reimbursements and an uneven system of referral. (You can never be sure if the doctors you are used to referring to still accept a certain insurance or not.) Despite this, the quality of medical care in certain pockets, such as the top university hospitals, remains quite high. Private interests suck the money out of the system, which is driven mainly by profit, as you might expect. So the technology is lavish in many places but based on the ability to charge a lot for its use. Doctors are not getting rich here right now, but patients suffer a far worse fate when they can’t get adequate care. How does this compare with the current Canadian system? I’m not sure. But at least theoretically, single-payer should remove a lot of the distortion and self-seeking behavior that contribute the most to the enormous rise in healthcare costs.

My 15-month-old son is due for an MMR vaccination. If it were up to me I would skip them all but my wife insists on whatever our doctor says. I’ve heard some doctors endorse splitting up on the MMR vaccine. What are your thoughts on the subject? And is there any way to minimize the risks? Also is there somewhere to get objective information for the layperson?

JASON KALB
Arcata, CA

Dear Jason,

I know no information about the advantage of splitting up this vaccine. Better, in terms of trauma to your child, to get it over with at once. I believe the risks are minimal, though I also believe more studies need to be done; and I am in favor of vaccines that don’t used bovine serum or mercury-based serum. Don’t forget, the diseases too have risks, and in fact there was a measles outbreak in Britain the last time the vaccine was suspended for a period a time. The risks of these diseases outweigh the risks of the vaccines, and we also need a herd immunity to help us keep the numbers down.