Baseball Hall of Fame Permanently Contaminated

August 20, 2008

Walter O’Malley was recently inducted into Baseball’s Hall of Fame. If you grew up in Brooklyn when the Brooklyn Dodgers were still there as I did there is no worse villain than Walter O’Malley. O’Malley who moved the Dodgers to Los Angeles was recently elected to baseball’s Hall of Fame. The honor is as apposite as the Pope bestowing sainthood on Vladimir Putin. If you ask Brooklynites who are old enough to remember the Dodgers who the three worst people of the 20th century were you’ll get the same answers – Stalin, Hitler, and O’Malley.

O’Malley gave all sorts of phony reasons for moving the Dodgers. He claimed to be losing money in Brooklyn though his franchise was in fact the most profitable in baseball. See Roger Kahn’s The Era for the full details on O’Malley’s perfidy and mendacity. Bums: An Oral History of the Brooklyn Dodgers also details O’Malley’s deviousness as well as depicting the role occupied by the Dodgers in the life of New York’s most populous borough. O’Malley left because no matter how much money he was making in Brooklyn he knew he could make more in LA. Forget about Baseball’s unique exemption from federal antitrust laws, forget about fan loyalty or player allegiance – Jackie Robinson retired rather than be traded to the hated New York (soon to be San Francisco) Giants. It’s just a business which of course it now is. Anyone who make an emotional investment in a professional team is terminally confused. I’d sooner root for Exxon than a collection of itinerant millionaires who change uniforms as frequently as a feather changes direction in a whirlwind. And Exxon pays a dividend.

The Dodgers were the soul and spirit of Brooklyn. They were put together by Branch Rickey. Rickey was famous for his baseball perspicacity and his stinginess. O’Malley hated him because of his success and eventually forced him out of the Dodger’s front office. But Rickey made him pay through his padlocked wallet before he left. The Dodger’s flawed excellence animated life in Kings County. Over the decade from the end of the forties until just before they left for the lush but addled climes of southern California they had the best team in baseball, yet except for their win in 1955 they always found a brilliant way to lose the World Series to the Yankees. The also found ways to lose two National League playoffs – 1946 and 1951. Their loss to the New York Giants in 1951 in the bottom of the ninth inning of the third and final game of the play offs, Bobby Thomson’s shot heard round the world, was the blackest day of my young life. After the fatal home run my best friend and I walked around our neighborhood in shock. It was worse than the electric chair. But there was always next year – until they were gone.

The Dodgers lived in Brooklyn and were often seen around town. Consider some of their starters. Pee Wee Reese was the peerless shortstop who was a 10 time all star and who had his best years after he was 30. This despite losing three seasons to military service during World War II. Reese was the sort of guy whose numbers rarely looked remarkable, but who always managed to get the clutch hit or make the brilliant fielding play. I hope his Hall of Fame plaque is far away from O’Malley’s. In the final game of the 1955 World Series, the only series won by Brooklyn, Reese was part of a legendary play that saved the game for the Dodgers. Sandy Amoros a left handed outfielder who is only remembered for this play was put into the seventh and deciding game when the starting left fielder Jim Gilliam was moved to second base in the sixth inning. Gilliam was right handed and couldn’t have made the great catch Amoros made. With two men on base in the Yankee half of the sixth Yogi Berra sliced a ball into left field. The left handed hitting Berra was a pull hitter and Amoros was moved into left-center field. He raced towards the left field line and just made the catch. Gilliam who was right handed and thus wore his glove on his left hand would have had to make the catch back handed; he wouldn’t have been able to reach the ball which the left handed Amoros just got to. Reese who had run to the third base line screamed at Amoros for the ball and then made a brilliant relay to first base doubling up Gil McDougald and killing the only scoring chance the Yankees had. The Dodgers won 2-0.

Jackie Robinson and Pee Wee Reese

Jackie Robinson and Pee Wee Reese

The right fielder on the great Brooklyn Dodger teams was Carl Furillo. Baseball seems to have largely forgotten him, but he was the best right fielder of his time. He was a great hitter; he won the National League batting championship in 1953 with a .344 average. In the field he was remarkable. Called the Reading Rifle because of his great arm, he played the problematic right field wall in Ebbets Field with psychic brilliance. The scoreboard was part of the wall which had a sharp angle in it. No one but Furillo was able to tell where a ball that hit it would go. So a ball off the scoreboard or any part of the right field wall was always a double except when Furillo was in the game. He knew where the ball would come down and with his strong and accurate arm he held opposing hitters to a single when the ball hit the wall. His arm was so strong that he once threw a man out at first base after what should have been a single to right field. I was at that game. The hitter was Mel Queen said to be the slowest man in baseball. He hit the ball on one bounce to Furillo who charged the ball got it on a single bounce and threw a one hopper to Gil Hodges at first. Queen was out by a step.

Branch Rickey and Carl Furillo

Branch Rickey and Carl Furillo

Gil Hodges, who along with Carl Furillo is not in the Hall of Fame, was a peerless first baseman. Now that O’Malley’s in the Hall they’re better off out. Posthumous contagion is still a possibility. Hodges started out as a catcher. He was too big and clumsy for the position. Moved to first base he became Nijinsky. Despite being right handed he perfected the throw from first to second base. He was also a power hitter. On August 31, 1950 he hit four home runs in a single game – only the second man along with Lou Gehrig to accomplish the feat in a nine inning game. I remember watching each home run on a different TV set as I was traveling all over south Brooklyn that evening for some forgotten reason.

Duke Snider

Duke Snider

Duke Snider was one of three Hall of Fame center fielders simultaneously playing in New York. He was the most emotionally fragile of the three. Mantle and Mays were godlike. Snider would sometimes sulk when things went wrong, he had slumps which verged on clinical depression; he was sensitive to the charge that he couldn’t hit left handed pitchers and that he did so well because everyone else on the Dodgers was right handed and thus opposing teams were reluctant to pitch left handers against Brooklyn. But he was a great fielder and he hit 407 home runs in his career. He also hit 40 or more home runs in five consecutive seasons (1953-57). He was a great player who was loved by the Brooklyn fans as much for his flaws as for his extraordinary talent. As of this writing he is the only member of the 1955 World Series champions still alive.

Campanella in action

Campanella in action

Roy Campanella was both the best and sunniest catcher in baseball. He was the most valuable player in the National League three times. There wasn’t anything required of a catcher that he couldn’t do except be mean. He hit for power and handled pitchers like a pediatrician reassuring a first time mother. A broken neck suffered in an automobile accident left him paralyzed for the last 35 years of his life. Most people with cervical spine injuries similar to his are dead after 10 years. No one made better use of “The Tools of Ignorance” than did Campy. A catcher for the ages.

I’ve saved the best for last. Everyone knows about Jackie Robinson’s immense social standing in ending baseball’s shameful color barrier. What seems to get lost is what a great athlete he was. In my opinion he was America’s greatest all around athlete. UCLA’s only four letter man. He was a All American football and basketball player. He was great on the track and the favorite to win the long jump in the 1940 Olympics that were canceled by World War II.

Robinson sliding home

Robinson sliding home

Everyone said that baseball was Jackie’s worst game; yet on a great team he was the best player. The color barrier and World War II conspired to make him a rookie at age 28. His talent was so immense that he should have been in the big leagues before he was 20. Robinson had the most complete game of his time. There wasn’t anything he wasn’t a master at. Fielding, hitting, and base running – he was as good at each as you could get. Add this skill to a competitive drive unequaled by any I’ve ever seen in any athlete and you get the perfect player. His career only lasted 10 years owing to the late age it began at and to the ravages of diabetes that he developed a player and which killed him at age 53.

Watching Jackie Robinson on third base was a life altering experience. He threatened to steal home on every pitch, darting down the line as the pitcher delivered the ball. It droveĀ  pitchers crazy and though he actually did steal home 19 times there’s no telling how many wild pitches, balks, and bases on balls his unique base running skills caused. If you were a Dodger fan it was heaven. If you were an opposing pitcher it was hell.

Robinson stealing home in the 1955 World Series

Robinson stealing home in the 1955 World Series

I met him on several occasions along with several other of the Dodgers. He was as mild off the field as he was fiery on it. Little kids in Brooklyn at the time were not aware how important his appearance in baseball was to the country. All we knew was the he was the greatest player on a wonderful team. Everyone tried to copy his pigeon toed gait which was so distinctive. Robinson was an athletic hero who really was a hero. So now both Robinson and O’Malley who despised each other are in The Hall of Fame. Don’t invest your emotions in professional sports. It’s not a game.

Finally, I knew Rudy Giuliani would never be president. Kids who grew up in Brooklyn when the Dodgers were there and who rooted for another team always had something seriously wrong with them. Giuliani rooted for the Yankees.


Screening for Prostate Cancer – Again

August 8, 2008

I’ve already reviewed this topic in an earlier post, but it keeps coming back. The Aug 5, 2008 issue of the Annals of Internal Medicine contains two papers dealing with this issue. The first presents Screening for Prostate cancer: US Preventative Services Task Force Recommendation. It concludes what has been obvious to those not carried away by reckless enthusiasm – “Current evidence is insufficient to asses the benefits and harms of screening for prostate cancer in men younger than 75 years.” It goes on to state with directness unusual in the Annals of Internal Medicine: “Do not screen for prostate cancer in men age 75 or older.”

The second paper Benefits and Harms of Prostate-Specific Antigen Screening for Prostate Cancer: An Evidence Update for the US Preventative Service Task Force concludes that “PSA screening is associated with psychological harms and its potential benefits remain uncertain.”

These conclusions seem counter intuitive especially after all the propaganda emanating from the American Urological Association and the American Cancer Society which vigorously recommend PSA screening in almost anyone. Actually the same people write the advisories for both groups. The current Task Force recommendations will almost certainly have no effect on AUA’s or the ACS’s positions on PSA screening. The problems with screening are many fold. First about 90% of prostate cancers are so mild that the patient will likely die from something else before his prostate cancer gets him. In these patients you get all the side effects of diagnosing and treating a disease without any benefit. These patients are said to die with prostate cancer not from it.

The side effects of treating prostate cancer are formidable. Depending on the modality employed they include impotence, incontinence, and radiation-induced bowel injury. These are complications that one would tolerate only if sure of a benefit. The incidence of these complications is 25 to 50%. The remaining 10% of prostate cancers are the ones that may prove lethal and are thus the group that might benefit from screening. Let’s assume that early treatment (this is only an assumption not a fact) saves one out of these 10 patients that have a lethal form of the disease. This is a 10% reduction in prostate cancer mortality, an impressive achievement. But you have to treat 100 patients to save one. Fine if you’re the one saved, not so good if you’re one of the 99 that gets no benefit from the treatment and is at high risk for the side effects described above.

Screening for prostate cancer, under the assumptions above, has a 1% chance of benefit versus a 25 to 50% chance of harm if the screening reveals the disease. But since many patients with elevated PSAs do not have cancer, many patients will under go prostate biopsies that show benign disease. Thus we might have do 200 biopsies (probably more) to find 100 patients with prostate cancer which will find one patient who benefits from all this frenetic diagnostic activity. This is why routine PSA screening makes little sense.

The problem would be greatly simplified if we could tell in advance which are the prostate cancers that are potentially lethal and which are not. If we could do this the risk/benefit ratio would be much more favorable; but alas we lack the knowledge to make accurate predictions. And on top of this we still don’t know whether treatment of the disease applied early is any better than that offered after the disease has declared itself.

Sadly, most doctors are not up to speed on this issue. Before you consent to PSA screening have a discussion about its value with your doctor. If he hasn’t read the papers cited above ask him to. PSA screening, as is true for most medical screening, should be an individual decision based on sober consideration of the data for and against its use.

Finally, the strong recommendation against screening men 75 and older should be obvious as you’ve gotten this far. These patients have a reduced life expectancy by virtue of their advanced years. There’s little reason to screen for a disease that takes many years to kill people especially if such screening is of unproven value in any age group.


Why Your Doctor Doesn’t Need a Raise

August 5, 2008

An article in Boston Magazine entitled Why Your Doctor Needs a Raise could be the emblem for what’s wrong with the delivery of medical care in the Western world. The article examines the condition of medicine in the Bay State a year after the start of its government sponsored system of medical insurance. The article says the good news is that everyone now has insurance. But there’s a worm in the apple and its keeping the doctor away. How? It’s very hard to actually see a doctor. This seems to come as a surprise to the article’s author who is married to a physician in training. But even if she didn’t see the problem coming she has a solution – “Pay primary care physicians more. Lots, lots more.” Forget that the program is already way over budget in just its first year.

Most of the article repeats the argument (it was worn out 25 years ago) that primary care doctors are payed less than specialists and hence tend to attract new doctors with greater difficulty than say cardiology or dermatology. It’s true, but pay primary care doctors a million dollars a year and Massachusetts will still be in the hole. The demand for medical care is of almost infinite elasticity if some else is paying for that care.

If you’ve already paid for a service your incentive is to use as much of it as you can. If you’re the government paying for medical care you want to pay providers as little as possible. The provider who always gets the sharp end of the scalpel is the primary care doc. Why? Because he doesn’t do anything that’s easily quantified. He performs routine maintenance and treats many straight forward diseases. But if your heart goes bad you’ll see a cardiologist. If you get a bad rash you’ll got to a dermatologist. If you lose your mind you’ll look for it in a psychiatrist’s office. In fact most patients could pick the specialist they need without a referral from a primary care doctor if their insurance plan didn’t require that they first see a generalist before heading to the specialist.

Paying generalists more would doubtless make their services more readily available. It would not, however, diminish the need for specialists. It would almost certainly increase the demand for specialty services. The generalist would make more diagnoses of diseases that would require the care of a cardiologist or a urologist – pick your specialty. That might improve the population’s health, but it might also result in the treatment of diseases that would do just as well untreated – see the debate over prostate cancer screening and treatment. What it (paying more to generalists) would certainly do is make medical care even more expensive than it is.

The Massachusetts plan is already over budget. Just how much is hard to say because it contains many mandates that are diffused over the medical economy and are thus partially hidden. The state is trying to deal with the problem of cost by ignoring it. The cost of medical care relentlessly continues to increase twice or more as fast as our national income. Making more care available, indeed mandating more than may be wanted, only postpones the financial reckoning which will soon hit like a stroke. There is no way to make affordable medical care available to everyone without first making medical care affordable. That this tautology escapes notice year after year demonstrates the triumph of ideology over evidence. Groucho Marx said it best: “Who are you going to believe? Me or your own eyes?” We will not answer the question of how to contain costs without first asking it. And having asked this question we must cast a cool eye on what the government’s role in medicine is and should be. A dose of reality would help, but the drug companies charge too much for it. In the meantime primary care physicians are going to have to make do with the reimbursement rates they now have and new patients in Massachusetts are going to have to queue up. The line will last until someone in the state with more elite institutions of higher learning than any other figures out how to ask the right question.