Greetings, Dear Reader. Dr. Cranky is once again at his keyboard, prepared to vent his spleen for your personal edification and enjoyment. Your faithful host would like to assure you he has not forgotten those nearest and dearest to his heart. “My goodness, Dr. Cranky,” you might say, “where have you been all this time and what has taken you so long to return? Have you been working more night shifts? Has your cynicism reached a fever pitch, requiring intense therapy? Have you finally plunged headlong off the deep end and into the abyss, mixing your metaphors with wild abandon? Has it taken you this long to chew through your restraints so you might return to us?” No, the reason your humble servant has been remiss in his literary endeavors is much more mundane. Dr. Cranky has been involved in a tedious and time-consuming project at work. This, in addition to his usual clinical duties, has not left him with much free time to write. Unfortunately, this situation will continue for at least another two to three months and it is most likely that his posts during this hectic period will be infrequent at best. Nevertheless, keep in mind that all good things come to those who wait.
The topic of today’s post has given Dr. Cranky pause. He has thought about this subject for quite some time but has questioned whether he should dare to discuss it at all. Some things are simply taboo, and are not to be discussed in polite company. The mere mention of such kinjite incurs the risk of cultural disapproval so intense that anyone with the temerity to mention it finds himself at risk of the most severe opprobrium possible. However, it was during one of his daily constitutionals with Sparky, the Wonder Lab that your intrepid chronicler came to the following conclusion: as a public service, he must put these thoughts to keyboard regardless of the consequences. He must brave the turbulent seas of political correctness; not out of malice, but of a deep and genuine concern for the health of his patients. And so it shall be done. Your host is more than pleased to present, for your intellectual consideration, a brief discussion of American stupidity as it relates to healthcare.
Although Dr. Cranky has attended to many stupid patients in the course of his career, his most recent case involves a gentleman we shall refer to as Mr. S. On the evening in question, not too long ago in a galaxy just down the street, your fearless scribe found himself stamping out disease and saving lives at an Emergency Department located in Small Town, USA. The evening shift had been quite busy and things were worse than usual because Dr. Cranky was teamed up with one of his slower partners, a gentleman by the name of Dr. Charles. Your host has known Dr. Charles for many years and is very fond of him as a person. However, Dr. Cranky has found this particular partner-in-crime none too fast when it comes to operational efficiency and the result is usually a hectic shift. Dr. Cranky picked up a chart and read the chief complaint. The triage nurse had written the patient’s words verbatim: “I have a urinary tract infection and need to be admitted to the hospital.” “This should be quick,” your faithful scrivener thought to himself as he made his way to the patient’s room.
Upon opening the door Dr. Cranky discovered, as he often does, something far more complicated than he had expected. Before him lay a whale of a man, the corpulence of whom far exceed the degree of adiposity oft referred to as “Orca fat.” He had not shaved for several days and was wearing a dirty t-shirt and shorts which had not been washed for several weeks. Somewhere along the way, an urologist had placed a suprapubic catheter into Mr. S. This is a tube which is inserted through the skin above the groin and directly into the urinary bladder. It is used in those patients who are unable to urinate on their own. The noisome odor of stale urine, which emanated from his general direction, was truly noxious. He was bedridden, unable to ambulate because of his enormous girth. His wife and daughter were also in attendance and likewise appeared to be hygienically challenged. And Mr. S., despite his obesity and diabetes, was eating from a bag of McDonald’s french fries. To add additional insult to injury, your humble correspondent also noted from the chart that Mr. S smoked.
Dr. Cranky sat by the open door, the better to catch the odd wisp of fresh air as it made its way into the room from the hallway. “Why have you come to the Emergency Department?” your faithful penman began. “Well doc, it’s like this,” Mr. S related, “I’m disabled and the home health nurse came out to the house today. She told me she thinks I might have a urinary tract infection and that my blood sugar was up, so she called Dr. Friendly. He told me to go to Mooretown Hospital and he would admit me there.”
Dr. Cranky looked down at the chart and noted where the triage nurse had listed diabetes mellitus and hypertension as two of Mr. S’s chronic medical problems. Curiously, she had also written “and others” as well. In the Medications section she had transcribed the patient’s own words, which were “I take a lot of pills, but I don’t know what they are.” Your host pondered this situation for a moment. “What medical problems do you have besides your diabetes and high blood pressure,” he inquired as he looked through the rest of the nurse’s notes. Mr. S grinned. “Hell doc, I don’t know,” he said, “All this medical stuff is way too complicated for me.” And with that he let out the most god-awful guffaw Dr. Cranky had ever heard in his entire life. It was unreal. With a little imagination he could imagine the sound as coming from some weird extraterrestrial world where two large alien creatures were trying to mate and, at the moment of ecstasy, realized they had gotten the wrong proboscis into the wrong orifice and fell noisily down an embankment into a sea of sulfuric acid. A more terrestrial description would be to say that the laugh was a combination of what one might expect from the following two icons of television and radio history:
The wife and daughter of Mr. S then joined in and the combined sound of their jocularity was almost more than Dr. Cranky’s tortured soul could bear.
Dr. Friendly’s plan of hospital admission was not unreasonable, however. Patients with diabetes usually have some degree of immunocompromise and are not able to fight off infection as readily as someone in good health. Overwhelming infection, also known as sepsis, was a real possibility. That, combined with Mr. S’s co-morbid problems of obesity, a suprapubic catheter, hypertension and God knows what else made him a ticking time-bomb. “Alright then,” Dr. Cranky continued, “what medications are you taking?” “I don’t know doc,” Mr. S replied, “It’s a lot of different pills. Dr. Friendly has a list and he can tell you.” Your ever-diligent yeoman closed his eyes and slowly counted to five. The good Dr. Friendly did not take call after office hours, and even if he did it was unlikely he would know all of Mr. S’s medications from memory. Dr. Cranky asked Mr. S one final question. “Dr. Friendly told you to go to Mooretown Hospital to be admitted,” he began, “but that hospital is 5 miles down the road. Dr. Friendly does not have admitting privileges here. Why did you come to this hospital instead?”
The answer Mr. S gave was not unexpected. “I told Dr. Friendly this hospital is closer to where I live and is more convenient. I didn’t want to drive that far.”
“Really,” Dr. Cranky said, “and what was his response to that.”
“He said that was no problem,” Mr. S, replied, “he told me to come here and you would admit me.”
“How kind of him,” Dr. Cranky remarked.
Your host then performed a basic workup and confirmed that Mr. S did, indeed, have a urinary tract infection. His serum white blood cell count was significantly elevated at 18.9 (the high-normal value is usually about 10). His blood sugar was 750 (normal is about 100), and his renal function tests were abnormal, probably the result of kidney damage from his diabetes and hypertension. Fortunately for him, his serum acetone was negative so he was not in diabetic ketoacidosis. Dr. Cranky agreed that Mr. S needed hospital admission. He phoned the internist who was taking unassigned call, a gentleman by the name of Dr. Whitlock, and told him Mr. S’s tale of woe. After hearing the details, the unfortunate Dr. Whitlock let out a long sigh. “And what other medical problems does this person have?” he inquired.
“He doesn’t know,” Dr. Cranky answered.
“I see,” Dr. Whitlock continued, “well then, what medications is he taking?”
“He doesn’t know,” Dr. Cranky repeated, “and there are no old records of previous visits.”
Another sigh was heard over the phone. Dr. Cranky then told his compatriot of Mr. S’s dietary noncompliance with the McDonald’s fries as well as his tobacco habit. “So what you’re telling me,” Dr. Whitlock concluded, “is that this patient is too stupid to live without our assistance.”
“That about covers it,” Dr. Cranky concurred.
Why, you might ask, has Dr. Cranky hesitated to tell you the tale of the fatuous Mr. S? What has he been afraid of? Have the paranoid voices in his head returned, warning him that clowns were out to get him once again? No, quite simply it is this: we live in a politically correct society which frowns upon the idea of being judgmental toward others. Dr. Cranky has always found this amusing, since it has long been his observation that those who are the most PC tend to be the most judgmental people of all. It is with the greatest irony that those who are imbued with the doctrine of political correctness are convinced their dogma is the only correct way to think. Unfortunately, they are also not afraid to use all sorts of unpleasant social punishments to enforce their views on anyone who might disagree. Dr. Cranky’s trepidation comes from the possibility of social and professional sanctions which might arise should his feelings become known. No one seems to realize that everyone constantly judges everyone else, be it for better or for worse. If it weren’t for this trait, we would not have survived as a species for very long.
Regardless, Dr. Cranky earnestly strives to keep the intensity of his personal feelings turned down to a dull roar; at least when he is at work. Yes, he is a bit of a curmudgeon, but your humble servant really does try to understand his patients as individuals. To use the vernacular, he constantly tries to give them the benefit of the doubt and cut them some slack. However, Dr. Cranky has noticed a trend in American society, which is amply illustrated by the story of Mr. S. It is a trend which has insidiously increased in strength over the past several years. It is something which threatens the financial stability of our national healthcare industry. Dr. Cranky has given this trend the appellation of Creeping Stupidity.
The first thing we must do to understand this concept is to define the difference between stupidity and ignorance. Ignorance occurs when one honestly does not know that something he is about to do is harmful, either to himself or to society at large. He has no malicious intent, he simply does not know any better. If you were to inform him of the consequences of his actions he would be mortified and immediately desist from such activity in the future. As an example, consider the disease known as kuru. For many years, certain tribes in New Guinea, as part of their cultural heritage, would engage in ritual cannibalism and consume the flesh of their recently-deceased kin. Unbeknownst to them, the consumption of brain tissue can result in the transmission of small protein molecules known as prions, which slowly destroy the brain over a period of years. This results in a horrible demise and the word kuru literally translates into English as “shaking death.” The bovine equivalent of this is known as “Mad Cow Disease.” Once Western Medicine had identified the etiology of this infirmity and notified them of the findings, the tribesmen of New Guinea decided that, cultural heritage or not, it was time to stop eating their dead.
Stupidity, on the other hand, occurs when one knows ahead of time that what he is about to do is harmful but goes ahead and does it anyway. If you were to inform him of any deleterious effects resulting from his errant behavior he would not care a wit, and would assiduously pursue similar endeavors. For example, everyone in the United States knows that smoking tobacco is ruinous to their personal health and that second-hand smoke harms those surrounding them, including their children. The idea that there might be someone ensconced away in some secret bunker, cut off from society since the late 1950’s, and unaware of the harmful effects of tobacco products is ludicrous and worthy of the most intense scorn. And yet, year after year, scores of heart and lung disease patients continue to smoke and many teenagers make the “personal decision” to start the habit anew. As a Cranky Resident, the Big C warned your faithful correspondent to beware of any patient who smokes through his tracheostomy stoma.
A good part of the problem with Creeping Stupidity is the fact that many Americans are under the mistaken belief that their main purpose in life is to try to get away with as much deleterious personal behavior as they can. They smoke when they know they shouldn’t, they drink to excess and drive, they engage in risky sexual behavior without the benefit of a condom, they eat a constant diet of fast food, etc. We almost regard this as a national sport. Dr. Cranky recalls watching Law students on television in 1995 cheering O.J. Simpson’s acquittal for murder, not because they thought he was innocent, but because Jonnie Cochran was able to get him off the hook despite his obvious guilt. This attitude has mutated into entertainment on a grand scale, as People Magazine eagerly gossips about the latest pecadillos of Paris Hilton, Naomi Campbell and Lindsay Lohan to name but a few.
Now, combine this progressively worsening attitude of “what can I get away with today” with the cultural platitude that “no one is supposed to feel bad about themselves” and you have a monumental disaster just waiting to happen. The cultural elite tell us that any personal admonition (other than their own) is detestable, as your judgment might hurt someone else’s self-esteem. To them, it seems far more preferable for people to suffer from heart disease, strokes, diabetes and kidney failure as a consequence of bad social habits than it is to risk hurting their feelings by pointing out how their health is being ruined by such behavior. The human body is about as un-PC as one can get and doesn’t care how good you feel about yourself. If you abuse it, it will break down. Dr. Cranky recalls a quote he read on the internet by some wise sage on a similar topic. He does not recall the exact words but, to paraphrase, his statement went something like this: “In nature, stupidity is a capital crime. The judgment is final, there is no chance for appeal, and the sentence is often death.”
Through our misguided attempt at compassion, we are creating a class of people who, were it not for great expenditures of time, energy and money would not be alive because they are too stupid to live. We have become a nation of enablers. If no one can be told their behavior is inappropriate then how are they to know their behavior is harmful? Good health is not one’s right, it is one’s responsibility. And people cannot be responsible if they are never told their behavior is wrong. But what about personal freedom, you might ask? Don’t people have a right to engage in any behavior they want, so long as it’s not illegal? That sounds great. Just peachy, as Mrs. Cranky (who is not at all cranky herself) is fond of saying. However, all the personal freedom in the world means nothing when you consider this: everyone else in this country is left holding the bag because they are the ones who have to pay for the consequences of these personal choices. By all means, feel free to live your life the way you please. Use all the healthcare resources you want and go to an early grave, if that’s your wish. Bully for you! However, Dr. Cranky draws the line when you expect him to foot the bill for your indiscretions through higher taxes and skyrocketing insurance premiums. And nationally, a bankrupt healthcare system is little better than no healthcare system at all.
The medical profession needs to start telling people these things, and they need to do so devoid of all the wishy-washy, feel-good platitudes which are currently all the rage. Our job is to look out for our patient’s health and well-being and, if some overly tender feelings get upset along the way, tough scones. Perhaps a sense of personal discomfort is what the patient needs to feel if they are to be motivated to improve their health. This does not have to be done in a cruel way. Dr. Cranky would never dream of telling Mr. S that, as a result of his personal habits, he is being a stupid moron. On the other hand, Dr. Cranky feels he would be remiss if, as the Patient Relations weevils would have it, he just smiled at his patient, showed him extra sympathy, and “ministered to his obviously complex emotional needs.”
Dr. Cranky recalls the time during his training when the Big C first spoke with him about the topic of patient stupidity. As always, this giant of a man summed it up beautifully in a concise, pithy aphorism. “Everyone has a right to be stupid,” he said, “and our job is to constantly interfere with the process of natural selection.”
At the time, Dr. Cranky did not realize just how true those words were. He does now.