What to Think vs. How to Think
The conundrum of how to think versus what to think has been around for a long time. Never, in all my years of university education, have I been presented with more what-to-think demands than how-to-think options than I am today. When I was in medical school, the heat was on to learn a large dose of complex information in a hurry. What many might not know is that medical schools get graded too. Their product is to make sure that enough students pass the tests. Too many students failing to pass the tests is a sure-fire way for a medical school to fail its own federal rating requirements. If too many students fail, there will be unwelcome federal visits, then plans of correction, (which most often work), then financial holds or restriction, and, if that doesn’t work, loss of accreditation.
As proof of good medical school performance, a sufficient number of students must pass the sufficient number of tests in all areas of learning. Therefore, test performance is critical for students, professors, medical schools, and universities. You see this same phenomenon in public education, where teaching-to-the-test has taken over most of education today. Teaching-to-the-test is another way of instilling what to think. Medical school is four years of learning what-to-think. One week they would tell us the X+Y=Z and a few weeks later they would ask what X+Y equals. After the first month, I understood that I had the choice of passing the tests by learning what to think or trying to learn the material and learning how to think. I did realize, of course, it if I didn’t pass the tests, there would be no opportunity to later on learn how to think.
The 3 to 10 years of residency is the time when physicians make the transition from learning what to think to learning how to think and how to apply our thinking to the patients we see.
When COVID came along, there was just one more perversity to work under, one of many. In addition to the hopped-up worry about the illness itself, which was enough stress, there was the censorship, the multilayered dishonesty, and the demonization of science and medical thought. The how to think, what was left of it, was replaced almost completely by what to think.
Dr. Scott Atlas sums it up well in an interview with Marissa Streit, who says:
“In 2020, Dr. Scott Atlas was an advisor to the president (Trump) and a member of the White House COVID-19 Task Force. He was shocked to see how powerful figures in Washington, including Dr. Fauci, (with Brix and Redfield) were incentivized to politicize and monetize the response to the pandemic. In this candid conversation with Marissa Streit, Dr. Atlas reveals that many Americans may have died because of censorship, dishonesty, and the demonization of medical dissent. Will Americans allow this to happen again?”
The answer is not only yes, but probably they’ll even promote it.
As we saw with the COVID pandemic, how to think was replaced by what to think and most of what we were told was wrong and lacked scientific evidence. Some of the worst of medicine came to the forefront in the pandemic and unfortunately has remained.
The Hippocratic oath says first, do no harm. Years ago, most of us saw all patients. It didn’t matter what the patient thought, how they thought, or even if they thought. What I have always enjoyed most about the practice of medicine is objectivity. I’ve tried hard not to discriminate against people who don’t think the way I do. In my office, under my care, everybody was equal.
There have always been providers who, for one reason or another, refused to treat certain patients. One of the glaring examples during the COVID pandemic was the sadly mistaken idea that you shouldn’t treat people who chose not to be vaccinated. We have carried this to extreme levels. Now we have pediatricians who will not care for children whose parents have decided to not vaccinate them. It is not the children’s choice. It is the parent’s choice and the children should not be discriminated against for any reason. A few weeks ago, I read a story on ProPublica about family practice physicians who felt compelled to tell their OB patients who miscarried that their babies died because they did not get a COVID vaccination.
Such hubris!
There is no place in the medical literature that gives us the right to pour salt in wounds. We are here to take care of patients in a non-judgmental way. More importantly, there is absolutely no way to know for sure that the baby would have lived if the mother had received the COVID vaccination. The obstetrician does not know the baby died for lack of a COVID vaccination. This is the perfect example of what to think and not how to think. As a matter fact, I think time will tell us that exactly the opposite is true. Likewise, no doctor should tell an OB patient that her baby died because she did get a COVID vax.
Yes, there are doctors who think we should refuse to take care of drug addicted patients who have skin, muscle, or heart valve infections because of injecting certain kinds of drugs. To my mind, there is no excuse for so much hubris or judgment.
We know that journalists at ProPublica know what to think in their series about abortion bans leading to preventable deaths. In this title, there’s layers of assumptions. Years ago, when we listened to Walter Cronkite, Eric Severeid, or Huntley Brinkley, we didn’t know exactly what they thought, or even how they thought, but their presentations were objective. Today, there’s no shortage of opinions. Just go to ProPublica or Rachel Maddow and there’s absolutely no doubt about what they are thinking. It’s not news–it’s opinion.
Yes, if I could wave a magic wand and undo or modify Dobbs or course-correct the Georgia or Texas legislation, I would do so. And if I could wave another magic wand, and undo malpractice and avoidable deaths in states such as Georgia and Texas, I would do so. All of this trouble is attributable more to legislating what to think than legislating how to think.
A little bit of how to think would have resulted in vastly different legislation. Decisions in healthcare should be a result of careful deliberation, careful thought, and very careful consideration of the chaos and consequences that may result when the rule is by opinion or what you think rather than how you think.
To say that states such as Texas and Georgia have developed a draconian mass of legislation regarding obstetrics is a remarkable understatement. The penalties are so extreme and severe as to defy any kind of reasonable anticipation of consequences. What doctors want to be in prison for 99 years or to lose their licenses forever? I’d like to think that state legislators didn’t actively legislate in favor of malpractice. And finally, I’d like to think that these state legislators didn’t understand that their threats would result in scaring doctors enough to let pregnant women die from untreated complications of pregnancy. At least Wisconsin and Utah have taken steps to prevent the kinds of deaths we see in states such as Texas and Georgia.
When people (doctors included) are frightened, they become irrational. The abortion laws in states like Texas are so draconian that they pit patients against doctors. There is no guarantee that an imagined “abortion” would be fairly judged by Attorney Generals, Medicaid, or juries.
Doctors have much to fear from many sources. In the first place, because some of these penalties are criminal, medical malpractice insurance will not cover them. And good luck finding and paying a lawyer. The ethical requirements for lawyers are a lot less strict than for doctors. Physicians must treat people regardless of their ability or desire to pay. As I’ve said so many times, there is no equivalent of Medicaid for lawyers. Since most of our legislators are lawyers rather than doctors, we will never see lawyers accepting Medicaid-type payments for legal services.
I was one of the approximately 75 percent of doctors who accepted Medicaid patients. The patients were supposed to bring two dollars with them as their payment for their bill. If they didn’t bring the two dollars, we had to see them anyway, and if we didn’t collect the two dollars at the time of their visit, we couldn’t collect the two dollars at any other time. The point is that Medicaid made it so difficult to get paid that many physicians simply gave up trying and refused to accept Medicaid patients in their practices.
Doctors face many obstacles in the course of a normal day. Because of the label “criminal activity” that state legislators have built into their legislative opinions on pregnancy management, the medical malpractice insurance for which physicians pay dearly will not cover any of these crimes decreed by legislators to be criminal.
Physicians have much to worry about when the state or federal government criminalize medical care or weaponize the punishment for real and yes— imagined crimes. For the average physician, weaponization of laws is a constant and very real concern. The allegation doesn’t need to be the truth to be damaging. With state medical boards, a medical license is a privilege, not a right, so real due process and the Bill of Rights are generally missing from state medical board procedures.
How will the doctors who are only trying to save the lives of the mothers actually be judged? It’s hard to say...but that’s the driver of these maternal deaths. Unfortunately, there have been few attempts by states to correct the legislative course. The other rather sinister aspect is the composition of the state maternal mortality board in Georgia after ProPublica obtained internal details of two deaths.
Kavitha Surana has pointed out in her ProPublica article that the preventable maternal deaths in Georgia are very likely under-reported because the state maternal mortality reporting committee must remain silent. The legislators and the healthcare communities have a vested interest in suppressing this information because everybody looks bad and we certainly don’t want to look bad or stupid in spite of the fact that this situation is bad.
The alleged point is that these maternal mortality meetings are supposed to make recommendations without blame and come up with constructive advice for repairing problems, which is a little hokey because the world of medical care thrives on and sustains itself on finding a scapegoat, someone to blame so that there is at least an appearance of remedying a problem. Beneath the surface, there are many other reasons to keep this information out of the public eye. In the first place, the legislators don’t want to admit that they have caused a problem that they need to repair. So, keeping this mess as secret as possible allows the legislators to do absolutely nothing to course correct. And naturally there is then no recognized blame.
Neither are the doctors likely to speak much about it because they are between a rock and a hard place. On the one hand, they have the state and its draconian legislation, and they have medical malpractice on the other hand. In the middle, the thing we haven’t discussed, is the damage done to the patients. Full transparency would serve the public best, and in that regard, I think that ProPublica has done a good job. The problem of inappropriate legislation is best resolved by heat from the public. After all, the legislators are elected to serve the public, at least that’s what we have been told in 7th grade civics. Secrecy is the best way to thwart that responsibility, but transparency serves the public best.
Kavitha Surana reports in ProPublica that the Georgia state government fired the entire maternal mortality board because they couldn’t find the “leak,” not because the board had hidden maternal deaths.
The road from the Supreme Court to maternal death in Texas and Georgia and elsewhere is convoluted, with poorly understood consequences. The Supreme Court’s decision neither mandated malpractice nor the death of the mother.
Uterine infections can occur anytime during pregnancy and don’t necessarily need to be connected with retained products or incomplete abortions. Many can occur later on in pregnancy as well and even in the third trimester, which can be very deadly too.
The point is we learned early on in medical school that women can get very sick, very fast from what we call retained products or pieces of placenta that remain in the uterus after an incomplete miscarriage or abortion. There are all kinds of lethal bacteria, which are very happy to enter the bloodstream leading to sepsis through a highly permeable unprotected uterus. There is absolutely no excuse to not know and not understand the tremendous risk involved if you have been through an OB/GYN or family practice residency.
Some significant skill is required because all the dead tissue must be removed, but too much scraping is likely to cause infertility. Again, doing the right procedure at the right time is life saving, but doing the wrong procedure at the wrong time is deadly, as we see with Nicole Thurman, one of the patients in the ProPublica article.
What happened to Nicole Thurman? A single mother of a six-year-old boy Nicole worked in a hospital. She had taken the “abortion pills” and encountered a complication, which is said to be rare, but it is, indeed, not rare. Exactly what remained in her uterus was not stated precisely in the ProPublica article. According to the ProPublica article, Nicole was approximately nine weeks along, which was compatible with use of the two abortion pills, but she had twins, which probably made a difference because her uterus was significantly larger than it would’ve been with a single nine-week pregnancy. It is safe to assume that Nicole did not have a fetal heart beat when she presented to the hospital. According to the ProPublica article, the Maternal Mortality Committee decided that Nicole’s death was avoidable based on the 20-hour delay in treatment.
In the absence of a fetal heart beat the decision to intervene, that is to do a D&C would have been easier, less complicated and there would be no real reason not to do it. The procedure itself can be done with either a sharp curette to scrape the inside of the uterus or the procedure can be done with a suction curette. It can be done under local or general anesthesia, since there is a lot of pain associated with a D&C and an infected uterus. There are many choices and many decisions to make, which for the most part can be made between patient and provider.
Patients never do well with retained dead tissue. Whatever it is needs to be removed ASAP. There are several important steps in managing an infected uterus. First of all, treatment needs to be started and finished as soon as possible. No delay is acceptable. Once physicians decide to do the procedure on an emergency basis, they need to get at least one round of very potent IV antibiotics on board. We used IV Cleocin, gentamycin, and penicillin before the procedure. The idea is to have antibiotics circulating in the patient’s blood stream before the procedure to prepare for the load of bacteria which will escape from the uterus into the blood stream during the procedure. I’ve treated hundreds of patients with an infected uterus successfully. There were no failures and no patient died. No patient lost a uterus to a hysterectomy or for any other reason.
Propublica reports:
“Thurman waited in pain in a hospital bed, worried about what would happen to her six-year-old son, as doctors monitored her infection spreading, her blood pressure sinking and her organs beginning to fail….It took 20 hours for doctors to finally operate by then it was too late.”
What exactly happened in those 20 hours is not mentioned in the ProPublica article and at this time it is anybody’s guess, but this is the very crux of the situation, the cause of all the trouble The overturn of Roe v. Wade, plus the various state legislations combine in Nicole's situation to create an adversarial relationship between patient and doctor. The ProPublica article gets this. This patient-provider relationship is ordinarily extremely beneficent, and it’s beneficent in one direction...the beneficence that the provider has for the patient. When this relationship becomes adversarial, it also becomes problematic.
The legislators and the public probably don’t know how afraid physicians are of lawyers, including Attorney Generals, prosecuting attorneys, law suits, judges, juries with nuclear decisions, medmal, state med boards, and Medicaid and Medicare fraud units. Most of these government groups are so powerful they can call anything they want “evidence.” The so-called criminal offences offer prison sentences of many decades. And recently, with the extreme censorship and dishonesty from our three-letter agencies over the last five years, there have seen many licenses lost, jobs lost, and heavy fines leveled simply for speaking the scientific truth. The first amendment, the freedom of speech, has taken a big hit over the last four years.
Doctors are naturally afraid of lawyers like mice are afraid of cats. Many see lawyers as predators. In this case, the legislators are probably also viewed by many as predators. That fear is not going to change overnight, especially without justification. And the way we’re going, the adversarial position between physicians and legislatures is only going to get worse. If we really want to decrease preventable obstetric deaths, significant legislative and government course-correction will be required. There needs to be sincere legislation that promotes patient and provider safety. There is the mistaken idea from government agencies, legislation, and Centers for Medicare and Medicaid Services (CMS) actions that if a little belligerence doesn’t work, greater belligerence will work.
From my perspective, belligerence is unnecessary, extremely inappropriate, extremely counter-productive and dangerous. Less government belligerence and more goodwill is what patients and providers need.