Thursday, December 09, 2004


Dear Reader,

For the past week I have been teetering on the edge of a new round of "bronchitis." I have stayed home resting, getting extra sleep, keeping my stress low. I have gone out a few times, usually in the evening after a day of resting, but largely I have been canceling my plans. I was unable to help my brother Rob finish moving on Friday; after a morning spent packing boxes, we held off on the move itself until Monday, but I had to cancel that, too. I canceled gaming yesterday; we watched "Down with Love" and "Coupling" instead. I was supposed to fly to Dallas today to visit with philosopher Kenneth Smith; I just wrote to him canceling my visit.

No one knows exactly what my "bronchitis" is. I have been getting it for years, and in recent years multiple times per year. It looks like bronchitis--I often have a bronchial infection treatable by antibiotics--but it is not bronchitis--when the infection clears up the mucus production and coughing continue until I have another infection. I took years of antibiotics before we figured out it was useless. We are better off letting the secondary infection run its course, since it is not the driver in this illness anyway, and antibiotics always hurt you with their side effects even when they do not help with their primary effects. I may have incurred long-term problems from the eradication of my intestinal flora by antibiotics, but I still get the "bronchitis," now more frequently than ever.

My primary doctor, Dr. Tom Ballard, is a naturopath, and he has helped me find ways to get healthier, so I can get this illness less often. Last year, following his advice, I managed to go a year without bronchitis. This year, slacking off his advice, I have had it twice and am skating around the edge of a third time. He is the first physician I have worked with who sought to treat the long-term problem rather than treat each case as completely separate and just try to suppress the symptoms.

My wife has an excellent ear-nose-and-throat specialist, Dr. Martin Greget, who was the first to ever take her frequent recurrences of sinus infections seriously as something more than random chance, bad luck, or bad genes. He searched for and discovered the cause for the frequency of her infections--crucial information none of her previous doctors could be bothered with--and when she has infections he takes cultures before he prescribes antibiotics to ensure he is prescribing something that will actually clear up the infection, something none of her previous doctors or mine every bothered with.

Consider that: out of two lifetimes of doctors, only one bothered to take cultures to make sure he was prescribing appropriate antibiotics. No wonder we are breeding superbugs. No wonder medical error in America is the fifth leading cause of death.

For twenty years I have made my career as a software developer and troubleshooter specializing in complex systems, specifically, the VistA medical software, and I know what responsible troubleshooting looks like. It requires scientific discipline, curiosity, investigation--in short, detective work. Martin Greget is the real thing. I could use him as a case study to teach new troubleshooters how to do it. Most of the doctors I saw before Tom Ballard I could use as examples of the converse.

Based on my experience, most doctors are rushed and sloppy, relying on habit, common industry practices, and assumptions, all of which are heavily informed by marketing copy from drug companies, which is why their first impulse nine times out of ten is to push pills. Pills promise an easy solution to suppressing symptoms, and they are the industry standard, which makes them the reflexive response to the overworked, highly stressed, overwhelmed state of mind most doctors find themselves in. The crazed working conditions begin with the hazing of internships, with sleep-deprivation and terrifying medical-school debts the norm for new doctors. The managed care movement, which is above all about extracting greater profits from healthcare, then pushes doctors away from time-consuming treatments toward quick "fixes" in a manic drive to minimize the hospital's investment needed to get the payoff from patients. A responsible, careful physician--and I refer here to practice, not intent--is resisting powerful economic and social impulses, and often pays a price for doing so. There are physicians out there like that--bless them--but you will have to search to find them, and you will have to learn a great deal about your illness and how it is treated to distinguish the good from the sloppy.

Responsible troubleshooting takes time, more time than doctors have available or than patients can sometimes afford to pay under modern market conditions, and it takes emotional reserves to embark into the unknown and question one's own responses and reflexes long enough to have any chance of finding the truth. It is emotionally taxing and time consuming to accurately troubleshoot complex software systems, but much, much more so with a complex biological system, which is profoundly more intricate than any software system. Nine out of ten software troubleshooters go for the quick fix rather than the difficult truth, and given how much harder biological troubleshooting is, you can work out for yourself how many doctors go for the quick fix.

In other words, Beverly's and my hit-and-miss ratio with the medical system and the high rate of medical error in America are not accidental; both are the logical and inevitable results of how the industry is structured.

Recently I began working with a pulmonary specialist. My counselor urged me to work with one to try to find the underlying causes of my recurring illness. Despite my frustration with corporate medicine, I agreed we should see if the best it has to offer could help find the underlying causes. On my first appointment with my pulmonologist, she wanted to send me home with sample packets of pills to try, despite having run no tests and despite my being between bouts and therefore showing no symptoms. I did manage to convince her that we should run tests first and make our prescriptive decisions based on the results, but I should not have had to be the one to argue for a scientific approach. It is easy to see how so many people wind up on unwarranted prescriptions. I hope that our tests will turn up some useful information, and that she will prove as interested in the diagnostic side of medicine as in the prescriptive side, but only time will tell.

Meanwhile, I am taking hot baths and showers, drinking tea, spending time in a sauna, getting sleep, and hoping this blows over. I will go back to following Tom Ballard's advice more assiduously and perhaps things will work out as well this winter as they did last year.

Keep your fingers crossed for me, Dear Reader.

Sincerely yours,

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