Weather Update

May 27, 2008

They (the weather forecasters) did it again. They predicted the end of the world for the second day in a row and all we got were mosquitoes. Don’t place your faith in man – or at least not in the weatherman.

Local Weather

May 26, 2008

Last night all the local TV stations interrupted regular programming to warn of an impending storm. The Weather Bug icon was flashing madly with the same warning. A severe thunderstorm was approaching Lubbock. Winds in excess of 70 mph were predicted. A wall of dust was said to be descending on the city. Hale was also predicted. It sounded like a mini Armageddon.

We had planned to go out that evening but with chaos on the way we stayed home. So guess what happened. Nothing. No wind, no hale, no lightening, no dust, no rain – nothing. It’s unusual to get the weather wrong when your time frame is only an hour; but the weather is a chaotic system (or complex if “chaos” disturbs you). The further out your forecast the more uncertain it gets. This uncertainty results from the quasi infinite input that determines the weather.

We can only guess what the weather will be like a year from today. We can be sure that it won’t snow in Texas; but we can’t tell if it will rain, if the wind will be calm, if there will be a tornado, if it will be cloudy, etc. We can give probabilities based on past observations, but that’s the best we can do.

Predicting the climate is an intrinsically uncertain business. I am not a climatologist, but I am a scientist. Accordingly, I know how hard it is to get everything right. There’s always some uncontrolled variable you forgot or which you (or sometimes anyone else) didn’t know existed. And I worked in a lab under very controlled conditions. Imagine the difficulties facing someone trying to predict the climate a century from now. Such an investigator must rely on computer models. These models in turn depend on the variables they contain and on the weight given each of them. Compounding the difficulty is predicting the effect on the environment of the climate change you expect. If your model misses one or more variables (virtually a certainty when you’re working with a century) your prediction will be way off. A variable off a little too much one way or the other will cause enormous error. Ignoring one altogether will make the data useless, or worse harmful if its believed.

About the only thing one can be sure of is that all the models will be wrong. The are an infinite number of possible outcomes, but only one will happen. It will seem inevitable in retrospect. The complexity of the problem of climate change explains the vociferous debate that its study causes. There are more global warming doomsayers than there are skeptics. But science is not settled by a vote. Evidence is the arbiter. If catastrophe is a possibility prudence dictates that the putative disaster receive careful consideration, but on the basis of the evidence currently available and its inherent uncertainty I wouldn’t bet a sizable chunk of the world’s economy on predictions of catastrophic change.

The weather bureau is again predicting meteorological Armageddon this evening. If I survive, I’ll let you know how things turn out when the power comes back on.

Erik Sjöberg – The Forgotten Tenor

May 24, 2008

Last January I wrote that Birgit Nilsson considered Erik Sjöberg one of her three favorite tenors; the other two were Gigli and Di Stefano. I had never heard of Sjöberg and asked if anyone reading the piece could supply some information about the Danish singer. Several months later I was contacted by Torben Sjöberg, the late tenor’s son. He sent me a biographical sketch and several CDs of his father’s singing. The following is adapted from the material he generously gave me.

Erik Sjöberg was born on October 31,1909 in Nexø on the island Bornholm in The Baltic Sea. He died in Rønne, Bornholm November 8 1973. After finishing school he was a shoemaker for seven years. Fond of singing, a friend arranged and audition for him in Copenhagen. Vilhelm Herold the noted Danish tenor and leader of the Opera School in Copenhagen offered him a scholarship and he joined the Royal Opera School in Copenhagen. Like many tenors he started as a baritone. Herold’s most famous student was Lauritz Melchior who also started as a baritone and debuted in the same opera house and in the same opera as Sjöberg.

Sjöberg made his debut at The Royal Danish Opera in May 1937 in Pagliacci. He sang both Tonio and Silvio in Leoncavallo’s opera. During the next six years he sang mainly small baritone roles He was Jake in the first Porgy and Bess performed by white singers.

In 1943 he went to Stockholm, Sweden to convert to a tenor. He studied first with Joseph Hislop. Hislop also taught Jussi Björling and Birgit Nilsson. Nilsson couldn’t stand both Hislop’s personality and teaching. He later worked with the great bass-baritone Joel Berglund. In December 1944 he returned to Copenhagen and made a successful debut as a tenor – Don José in Carmen. Flower Song – Carmen

Other roles that followed included Pedro in Tiefland, The Fisherman in Stravinsky´s The Nightingale, Don Carlos, David in Carl Nielsens opera Saul and David , and Canio in Pagliacci.

In 1947 he was the first Danish Peter Grimes.

He sang Fenton in Falstaff, Radames in Aida (also in Stockholm 1951 with Birgit Nilsson and Sigurd Björling – below). It was these Stockholm performances that so impressed Nilsson.

He also sang Max in Der Freischütz, Walter von Stoltzing in Die Meistersinger, and Lohengrin.

His last performance in Copenhagen was Bacchus in Ariadne auf Naxo in 1959.

He sang Lohengrin in France (Lyon and Toulouse) with the young Georges Petre as conductor. He also sang Lohengrin in Rome under Franco Capuana with Antonietta Stella as Elsa.

He gave concerts in Norway, Sweden, Germany, Holland (with The Concertgebouw under Erich Kleiber) and in France. He sang a Wagner concert in Cannes with Martha Mödl. He also appeared in oratorios in Denmark and Sweden.

He was appointed Kammersanger (Royal Court Singer) in 1951.

He only made a few recordings. Beethoven’s 9th under Fritz Busch has been released on CD. In 2005 a 1953 performance of Lohengrin from The Royal Danish Opera was released conducted by Erich Kleiber. In 2006 a portrait CD “Den glemte tenor“ (The forgotten tenor) was released containing folksongs in his native dialect from Bornholm. The disc also includes Danish songs and romances and arias all sung in Danish.

From the material I have he seems to have been at his best between 1947 and 1953. Thereafter his high notes become strained and the hint of vocal unsteadiness that was always apparent becomes more pronounced. His middle voice hints at his baritone origin. Here’s the last part of the Nile Scene from Aida recorded in 1950, the year before he appeared with Nilsson. He handle’s the scene’s difficult last line with ease and power.

The Gondola Song from Strauss’s A Night in Venice shows the tenors ability with a long vocal line as well as a little unsteadiness. But if you’re still mystified why Nilsson put Sjöberg in the same class with two of the greatest tenorswho ever lived the best I can offer are two excerpts from Act 1 and Act 3 of Lohengrin from a 1953 performance in Copenhagen. Here Sjöberg produces beautifully modulated tones along with a bright sound and ringing high notes.

His career was short because he started late and finished relatively early. His debut as a tenor was at age 35. He retired at 50. Whether he retired because of vocal problems or for other reasons I do not know.

In summary, I think this was a singer who didn’t deserve the total obscurity he fell into after his retirement and death. He’s clearly better than a lot of more widely known artists. I suspect he was an uneven performer who on his best nights was very good. He likely brought lightness and lyricism to Wagner rather than the typical gruff barking too often associated with that composer. I found his work very pleasing. Make up your own mind.

Blue Blues

May 21, 2008

This is a little off message, but every time my wife and I go to Grand Cayman (several times a year) we go to Blue – the five diamond restaurant at the Ritz-Carlton Hotel. Its an extravagance, but we rationalize by saying that our kids are paying for it. The place is noteworthy for its outstanding seafood and it equally outstanding service.

Last week we went and found things a little different than on previous visits. The menu had a rib eye steak on it that had a supplemental price (the place has a fixed price menu) that was greater than the cost of the best steak at many US steakhouses. So I ordered it – bad decision. My wife stuck to the red snapper. It was perfect. The steak, on the other hand, was an inferior piece of meat. It could be bettered at almost any restaurant you picked at random. What it was doing at Blue is impossible to understand. The moral – don’t order a steak at a seafood restaurant. But you already knew that. This is more a reminder for me than anyone else. The lousy beef shocked me so much that I forgot to send it back. This was not one of my best decision days.

The service was off too. The waiters didn’t bring me a steak knife. I had to ask for one. A chainsaw would have been more appropriate. Instead of bringing the dessert menu they brought the bar menu. OK even Caruso had off nights. Will I go back? Yes. Will I order beef? No. And neither should anyone else. Maybe the supplemental price for the steak was code for “Don’t order this”.

The Insurance-Hospital-Pharmaceutical Complex

May 13, 2008

The naiveté of the press when it covers medicine is wondrous. There isn’t any cockamamie nonsense they won’t swallow whole. Katherine Q Seelye has a piece in the New York Times that is about politics. I don’t know much about politics so I can’t comment on most of it. But in discussing the positions of the presidential candidates on universal health care she mentions the “insurance-hospital- pharmaceutical complex”. She appears to think that this nefarious complex has great influence over what happens to medical care.

I immediately asked myself how I could have missed this complex in over half a century of observing all things medical. I knew about the Oedipus complex, the Electra complex, the castration complex (this one may have something to do with politics), the Cassandra complex, the God complex (this may relate to medicine), the inferiority complex the messianic complex (think journalism), the Napoleon complex, the persecution complex, the superiority complex, and a bunch more. But I’d never come across the IHP complex.

Such a sinister and powerful entity implies organization. And if there’s one thing Medicine is not, it’s organized. Only the reality of immediate summary execution might change the way doctors or hospitals operate; it would probably take thousands to overcome the nonsystem’s inertia. And if there’s another thing we’re not, it’s closed mouthed. Even the CIA can keep a secret better than we can. Why do you think the government enacted the HIPAA law? An exercise in futility that any ride on a hospital elevator will prove. Do you think we could keep the IHP complex a secret from everyone but an intrepid investigative reporter? No body is in charge. Don’t worry about conspiracies. The reality is much worse.

So rest easy with the complexes you take to bed every night; there’s not a new one to worry about. Ms Seelye can keep this one for her very own.

Cisplatin Nephrotoxicity

May 11, 2008

The pdf file below contains a detailed review of Cisplatin Nephrotoxicity that we published the the August 2007 issue The American Journal of the Medical Sciences.


Who Should Die?

May 7, 2008

A recent report considers how physicians should triage patients in the event of a sudden catastrophe that overwhelms the medical system. “The suggested list was compiled by a task force whose members come from prestigious universities, medical groups, the military and government agencies. They include the Department of Homeland Security, the Centers for Disease Control and Prevention and the Department of Health and Human Services.”

The full report was published in the May 2008 issue of Chest the Journal of the American College of Chest Physicians. Rationing medical care elicits horror whenever the subject is broached, as it should. But if some sudden and overwhelming catastrophe strikes – a pandemic, an overwhelming act of God, an act of war – we will be forced to prioritize the delivery of medical care so that it matches our resources. There would be no choice after these events.

The report includes specific lists of those who should be denied care following a mass disaster:

_People older than 85.

_Those with severe trauma, which could include critical injuries from car crashes and shootings.

_Severely burned patients older than 60.

_Those with severe mental impairment, which could include advanced Alzheimer’s disease.

_Those with a severe chronic disease, such as advanced heart failure, lung disease or poorly controlled diabetes.

This, obviously, is not an all inclusive list. But what if the catastrophe sneaks up on us rather than appearing in an instant? When a boat starts to leak the first impulse is not to abandon ship – women and children last. Medicare, indeed all of medicine, appears to be on the verge of a mass catastrophe that is marching in slow motion. More and more numbers of old and very ill patients require more medical care at ever greater expense with less and less to show for the effort and expense.

Last month I made rounds on a general medicine service. Most of our patients had multiple medical problems that could only be treated at the fringes. We were barely keeping them alive, but at enormous expenditure of money, time and personnel. Everyone was frustrated, patients, their families, doctors, nurses – all were overwhelmed by impossible expectations. Patients who could not be restored to health lingered on for what seemed an eternity and like those around Tolstoy’s Nikolai in Anna Karenina everyone guiltily wished them dead even as they did everything to prolong finished lives. The dying deserve dignity and succor. But we ought to be able to provide them without mortgaging the future.

Dartmouth Medical School is pioneering a new approach to the care of very old patients which seems both humane and less expensive. “Slow Medicine” prompts physicians to consider the benefits that aggressive medical offers to the elderly and to offer more conservative and palliative treatments. Whether it will catch on is uncertain.

Patients who have problems that could be effectively dealt with are either treated as outpatients or are in the hospital for a brief time. Most of the chronically terminal patients we were caring for were over 65. Consider the following data from The Administration on Aging:

The older population–persons 65 years or older–numbered 37.3 million in 2006 (the latest year for which data is available). They represented 12.4% of the U.S. population, about one in every eight Americans. By 2030, there will be about 71.5 million older persons, more than twice their number in 2000. People 65+ represented 12.4% of the population in the year 2000 but are expected to grow to be 20% of the population by 2030.

Absent some medical miracle the number of very old and very sick people in our hospitals will be the equivalent of a sudden overwhelming catastrophe. How will we care for these patients? Who will care for them? How will we afford the expense? Will any one be willing to triage?

I don’t have the answer to any of the questions. But no one seems willing to seriously discuss them much less provide answers. 2030 will arrive with 80 million people on Medicare who will have a lot of chronic (and expensive) medical problems. How will we provide care for them? The needs of such a population are so far beyond our ability to provide them that a retreat to hopelessness is understandable.

Nevertheless, attempts are being made to deal with this impending tsunami of very sick patients. To analyze how this problem will manifest itself requires a book, but here are a few reasons why the problem is even more complicated than it appears.

Medical schools are increasing the size of their classes and new medical schools are under development. This increase in medical graduates is a response to the anticipated increase in demand which results from what I have described above. But there is much less here than meets the eye.

Increasing the number of graduates without increasing the number of residency slots available for them will not increase the number of doctors in practice. There are about 5,000 more first year residency slots available than there are American graduates of American schools. They are currently filled by foreign graduates. Residency positions are mainly paid by Medicare. Medicare is under such financial stress that it is very reluctant to pay for more doctors in training. Increasing the number of American graduates as things now stand will just decrease the number of foreign graduates in residency training.

Medicare can’t pay for the patients it now has. It will soon have to pay for about twice as many more. If we want more doctors to care for them Medicare will have to pay even more.

Another problem that no one talks about is the applicant pool. American medical schools are not deluged with qualified applicants. The national acceptance rate is about 50 %. This is a sharp increase from what it was one or two generations ago. For whatever reason, increasing bureaucracy, increased training time, life style issues, medicine seems to be a less popular career choice than it previously was. With more and more positions available for applicants the quality of those accepted may well decline. Do you want your doctor to be someone who went to medical school because he couldn’t get into business or law school?

But even if we do increase the number of high quality graduates and figure out how to pay for them and the costs they generate we still have a problem. More doctors doesn’t result in more hours worked. Rather they work less hours resulting in more doctors who work less hours per week than their predecessors. Thus doubling the number of doctors doesn’t come anywhere near doubling the number of hours worked.

There are at least two reasons for the decrease in hours worked. The first is the life style issue touched on above. Physicians no longer seem willing to work 80 hour weeks. This hardly surprising in an advanced society. The second is that about half of our medical graduates now are women. Women doctors work less hours than men. The reason for this is obvious. They want to have families. And despite almost two generations of nagging the responsibilities of family life fall disproportionally on the wife. Hence women doctors choose branches of the profession which have less time demands, work less hours, and are more likely to take prolonged absences (often years) from work.

But it’s not just more doctors that are wanted. More patients require more nurses, more technicians, more clinics, more hospital beds, many more administrators. And lots more money. More money than we’re likely to have.

A national health plan which seems ever more certain with every new election cycle is not going to increase the desirability of medicine, in my opinion. So how are we going to deal with all these patients. A triage system like the one described above will obviously not do. It probably won’t be accepted even for a nuclear holocaust – at least in advance. The only workable solution seems to be rationing by delay. Affluent patients will buy their way out of the system as they do in Canada (they come to the US) or in the UK (they go to private physicians and hospitals). In other words, a two tiered system, grossly unequal, is likely to result from a desire to provide more or less equal service to all. Cost will be the hammer that builds this system.