Saturday, September 29, 2007

Shortage of Rheumatologists

In December 2006, just before New Years, my primary care physician ordered up some blood tests for me. I seemed to be in pain all the time, all my joints hurt, and I was exhausted everyday. I'd get home from work at 6:00 PM and just sit in the car for another twenty minutes trying to summon up the energy to walk into the house. Right after New Years she called me with the results. The tests indicated the possibility of rheumatoid arthritis. Since the blood tests for RA are not definitive, I would need to see a rheumatologist for a history and physical exam. That's when I learned that the closest rheumatologist was a 1 hour drive away (the closest!!) and that no matter how far I was willing to drive it would take at least three months before I could get an appointment. In fact, it turned out to be four months. Whenever I talked to anyone about it, I would joke that there must be a shortage of rheumatologists, and that if they knew anyone in medical school they ought to pass on the word.

I finally got my appointment -- in April -- and was diagnosed as being in the early stages of rheumatoid arthritis, and began medication. This past week I had my second follow-up visit, and while I was waiting in the waiting room (so aptly named), I picked up a copy of Arthritis Today Magazine put out by the Arthritis Foundation. The issue was only a few months old, and the cover story was "The Rheumatologist Shortage". It was one of those "ah-ha!" moments when I find the data to support one of my gut feelings or pet theories.

The story of the rheumatologist shortage, places in bold relief some of the problems inherent in our patchwork private/public/profit/non-profit medical care system in the United States.

Rheumatology is a specialty whose number of practicianers are steadily declining, and whose number of patients are steadily increasing. According to the article: "Currently, 46 million people have had a doctor tell them they have a form of arthritis, such as osteoarthritis (OA) or RA, or a related condition, such as lupus, gout or fibromyalgia. Within 25 years, as the over-60 population peaks, that number is expected to reach 67 million." On the supply side, the article states: "The ACR [American College of Rheumatology] Workforce Study estimates about half of practicing rheumatologists will retire within just eight years, and that by 2025 there will be a shortage of 2,600 rheumatologists in the U.S."

There have been enormous strides in the development of new medicines for rheumatoid arthritis -- you've probably seen the ads on television for Humira or Enebrel or Remicade. The problem, there are not enough rheumatologists available to get these drugs to the people who need them. It doesn't matter how wonderful the treatments are, if there is no one available qualified to prescribe the treatment.

So why is there this shortage? You'd think with such high demand, there'd be people clamouring to go into the field. There are several interacting causes, discussed in "The Rheumatologist Shortage". After completing medical school, the physician aspiring to the field of rheumatology must spend three years as an internal medicine resident and then another two or three years completing a fellowship in the sub specialty of rheumatology. This is a some what longer period of training that some other specialties, although there are others that are more popular that take more years. The biggest catch is the fellowship requirement. First there has to be a full-time faculty member in that specialty to supervise the fellowship, and with declining numbers of rheumatologists these are harder to find. Second, there has to be funding for the fellowship, funding that pays for the salary and benefits of the fellow -- who after all has to have something to live on while he or she is working. There's a shortage of funding for rheumatology fellowships. Arthritis after all does not have the cachet of some other diseases, and has not attracted as much attention or fund raising.

"According to the 2005-2006 ACR study, 395 fellowships were available, but only 366 were filled." Some of the unfilled fellowship slots remained unfilled because there was no money to pay the fellows. Some remained unfilled for the lack of a qualified supervising faculty member. And some remained unfilled because rheumatology, despite its slightly longer training period, is lower paying that other internal medicine specialties. Annual salaries for rheumatologists are about 60 percent of the salaries of specialists in such fields as gastroenterology and general cardiology. When the average physician is burdened with more than $150,000 of debt for his/her education, significant salary differences can be influential in choosing specialties.

In our current medical care system long-term chronic conditions (which require careful monitoring by a physician, but no surgical procedures or other types of treatments other than medication) receive much lower reimbursements from private insurance companies and federal government programs. When the course of rheumatoid arthritis does require surgical intervention (as it often does) a surgeon (not the rheumatologist) reaps the reward of the higher insurance payout. The perversity of this system is that a good job by a rheumatologists in early diagnosis, careful monitoring and supervised drug therapy can make surgery (and its high cost to insurance companies and government) unnecessary.

The shortage of rheumatologists is merely an inconvenience today, it is likely to become a crisis within twenty years, unless something changes in the funding and availability of fellowships and the relative pay for rheumatology practitioners.

Monday, September 24, 2007


I just ran across an 2006 interview with novelist Philip Roth, mentioned in today's (Sept. 24) New York Times Paper Cuts blog. Check it out for a video of the interview. Roth, in discussing the state of America today says "I've never heard people so despairing." Then goes on to compare this despair to the anger of the Vietnam era.

My take on Roth's statement is that while the anger of the Vietnam era fed a powerful opposition that generated huge political pressure -- enough pressure to bring down a president (LBJ)-- today's despair seems to have frozen us into political impotence. Think of it -- the great majority of Americas wish the war in Iraq to end and the troops to come home, and yet the Democrats with a majority in both houses seem unable to take any action.

Roth's contrast of 1960's/1970's anger with contemporary despair, certainly accurately captures my own contrasting feelings. I think about how I felt during an anti-war march in Cleveland in March 1970, versus how I felt during an anti-war demonstration in Abingdon, Virginia in March 2005 (the second anniversary of the Iraq war) -- not to mention how I feel today more than two years later. The terms anger versus despair definitely fit my emotions for those moments.

As Roth's interview continue, it is clear that his sense of despair comes not only from the war, but from an overall view that the current administration is a "disaster" (Roth's word but one with which I agree).

I think it is this despair of which Roth speaks that overwhelms me these days. There are some roads that we have gone down, as a nation (Iraq), as humanity (global warming), roads that were terrible mistakes; roads from which we must veer away. Yet our leadership seems unable to take even one small step off these doomed paths. Yes, I know that there will be negative consequences and prices to pay for turning aside from our current path. But, the current path ultimately leads off the edge of a bottomless pit, and the price of that plunge will be vastly greater.

Of course, there are those days when I think perhaps we've already gone over the edge of the abyss -- hence the despair.

Sunday, September 23, 2007

Sea Change for Sailors as Arctic Ice Melts

The video, from the Wall Street Journal shows actual footage of 2005 and 2007 travel. The difference in the amount of ice visible is dramatic.

Going to hell -- in a handbasket

I took a cultural geography course in summer of 1970 at the College of San Mateo. The instructor frequently referred to a book entitled Hell is a Hot Place, as an example of geographical determinism. The title stuck in my head, especially since that summer I was working as a field hand in the commercial chrysanthemum industry, where my days were spent in very hot (and often hellish) greenhouses. My understanding of the "greenhouse effect" is very intimate and personal.

This has been month for revelations from the Arctic. September 19, 2007 the Agence France-Presse (AFP) released news from Greenland, where "The Jakobshavn Glacier, on Greenland's west coast, is melting twice as fast as 10 years ago and advancing toward the sea at 12 kilometres (seven miles) per year, compared with six kilometres (three and a half miles) before." The story along with interviews with researchers from summer 2006, was also featured on the Weather Channel last week. Video of raging rivers of ice melt water pouring into moulins in the ice sheet dramatically drove home the rapidity of change in Greenland.

Increases in the size and rate of ice melt from the Greenland ice sheet have direct consequences for populations in coastal areas (about 60 percent of the world's population lives within 100 kilometers of a shore line). The dramatic increases in ice melt in Greenland in 2006, suggest that estimates by the IPCC for sea rise and shoreline inundation may be far too low, since the report is based on research collected prior to 2006. The media responses to news from Greenland that I saw all showed the same level of dismay and concern about the impact of ice melt on sea level world wide.

The other news, that got more media attention, was the report from National Snow and Ice Data Center University of Colorado at Boulder that the minimal summer ice extent for the Arctic ocean this year (2007), was 1.59 million square miles, compared to 2.05 million square miles in 2005 the previous lowest amount recorded. Before one of you global warming deniers goes ballistic, of course I know that the satellite record only goes back to 1979 -- that how long we've had satellite capability -- it is also known by every climatologist and Arctic scientist who reports on this. However satellite records are not the only thing we have. As reported by "scientists studied observable data for the same period [1953-2006], including shipping logs, aerial photos and satellite images, they discovered the actual figure for ice loss from 1953 until 2006 to be 7.8 percent." Which was more than twice what the climate change models had predicted.

And for pity sakes people, there's a huge difference between barely managing to scrape your boat through ice that constantly rubs against the hull and take 8 months to 3 years to get through the "northwest passage" to having an easily navigable ice free passage that any ordinary cargo ship could handle in routinely in less time than it takes to go through the Panama Canal. No that doesn't exist yet, but its appears from the data and the experience of arctic sailors a whole lot more likely now than any time in the history of written accounts of northwest passage voyages. Check out the YouTube from The Wall Street Journal -- not exactly a bastion of liberalism -- showing an sailors in the northwest passage in 2005 and 2007.

[My first attempt at embedding a YouTube video has not gone well -- so see the post above for the actual video]

I'm not sure which set of reactions to the news is most disturbing: the global warming deniers "ain't true, ain't true" chant, OR the industry/government "goody, goody now we can get the oil and gas" chorus.

The global warming denial approach, such as found on the Newsbusters blog, usually begin by reminding us that the "record" on Arctic ice only goes back to 1979 (see above). They especially like to trot out "Roald Amundsen, a Norwegian explorer who successfully navigated the Northwest Passage on August 26, 1905." Never mind that Amundsen required two long stops to "winter over" and only finally broke through the final stretches of the Northwest Passage on August 30, 1906 (more than a year after his self congratulatory telegram to Norway)-- check out the PBS maps and details of the voyage). I was particularly interested in the fact that the Newsbusters blog post criticizing concerns about Arctic ice melting was soundly supported by commenter's adhering to the "young earth" theory of creationism. Sometimes I think one really should judge an idea by who supports it.

On the other hand there is the excitement of Russian and Canadian government over the possibility of being able to safely exploit petroleum and natural gas reserves in an ice free Arctic. "Russia, Norway, Denmark, Canada and the United States are among countries in a race to secure rights to the Arctic that heated up last month when Russia sent two small submarines to plant its national flag under the North Pole. A U.S. study has suggested as much as 25 percent of the world's undiscovered oil and gas could be hidden in the area." (Huffington Post)

Thursday, September 20, 2007

On being overwhelmed

I have found myself feeling overwhelmed this week.

This is a phrase my husband uses all the time. For what ever reason life, and especially work, always seems to overwhelm him. It is not a feeling, however, that I experience often. I'm one of those people who thrives on having lots of "stuff to do." But this was one of those weeks when the feeling did hit.

The cause of this malaise was not merely time pressures from the confluence of essays to grade, exams to create, lectures to prepare and deliver, meetings to attend, fundraisers for which to bake and organize, Rosh Hashanah services to attend (with the attendant 5 hour round trip) and the ever present household demands of 10 cats, 1 big goofy dog, and one husband. We sociologists like to call these omnipresent demands upon our time role strain (to much to do in one role such as teacher) or role conflict (too much to do from competing roles such as wife/teacher/community member).

What overwhelmed me this week was a heightened sense of all the problems in our society (the U.S. of A.) and our world, of how much effort was required to have even the slightest impact on those problems, the knowledge that I should do much more than I am, and yet cannot imagine how to fit any more into my life. Not just in a sense of time, but in the sense of the emotional investment.

Just staying informed on all the issues I consider important in itself frequently overwhelms me. The need to follow the news and the blogs (where often the real news is found) on such varied concerns as: the war in Iraq and other mid-east issues (like what insanity our administration might get up to in Iran); global warming (with new dire information coming out of Greenland about ice melt); the need for national health care (highlighted for me by the problems of my best friend, retired but not yet 65, in obtaining health insurance); urgent Kentucky issues of economic justice, fair taxation, getting out from under the rule of "king coal"; mountaintop removal (which affects me right where I live); urgent local issues of obtaining minimal levels of services (water, sewer, animal shelters, drug treatment, etc.) all areas in which our rural Letcher county falls way behind not only the nation and the state, but even behind other neighboring Appalachain counties.

At the height of my funk this week, faced with an enormous to do list, I did the only reasonable thing -- procrastinated. I decided to spend some time reading a few of my favorite blogs, beginning with The Influence Machine by e.r. dunhill. I was dismayed to find, that e.r.d. was overwhelmed also -- sufficiently so to decide to resign from blogging for the time being. While deeply saddened by the discontinuation of e.r.d.'s enlightening and fascinating blog, I was chastened by reading his farewell. Compared to e.r.d.'s obligations (job hunt, graduate school, serious community obligations and impending fatherhood) my list of obligations suddenly seemed more manageable both in terms of time and emotional investment.

So e.r.d. "so long and thanks for all the fish."

Tuesday, September 18, 2007

What Purpose Do Grades Serve?

What is the purpose or function of grades in college? By extension, what is the purpose of college?

Only those hiding out in a cave in some very remote place, without television, radio, newspaper, or Internet for the last decade have not heard about "grade inflation." Indeed discussion of grade inflation at public colleges and universities has been floating about for more than twenty years. However, in the last five years, concerns about grade inflation have begun to surface at elite institutions.

Princeton University, concerned about grade inflation because between 2001-2004 47 percent of undergraduate grades were A's, issued a policy establishing "a common grading standard" and limiting "the proportion of A grades (including A+, A, and A-) to 35 percent in every undergraduate course." (The Chronicle of Higher Education's News Blog September 18, 2007).

As an academic I have been listening to the discussion about grade inflation for as long it has been occurring. However, it was not until I read the comments to today's Chronicle News Blog that it dawned on me that the debate had far more to do with different views about the purpose of grading, than it had to do with the toughness or strictness of grading standards.

Those people in academia, and in society at large, who express concern about grade inflation, and applaud efforts like Princeton's to reign in the number of A's, view grades as a sorting mechanism by which those who are most meritorious will be separated from those who are less meritorious. Grades are relational attributes. Grades function to determine who will have the opportunity for access to scarce resources (graduate school slots, top positions in corporations, government appointments). Since the number of top positions in society is limited, the number of A's must be limited, so that it is clear who does and who does not deserve access to those top spots. The good instructor is the one who is best able to differentiate the very best and brightest from the rest of the students.

The other camp in academia, and in society, who are less concerned about grade inflation, and who are opposed to the type of quota system employed by Princeton, view grades as a measure of the acquisition of specified knowledge or mastery of subject matter or skills. Grades to this camps are absolute attributes, determined by levels of performance against an objective scale. Grades function to determine who has mastered the knowledge or skills to entered into a particular occupational field or field of study. The number of persons obtaining mastery is not determined by the number of slots available in the occupational world. The good instructor is the one who is can assist the largest number of students to attain mastery.

But don't take my word for it. Here are portions of some comment posts from The Chronicle's News Blog that clearly illustrate my point.

Supporting Princeton's quota:
"If more than 35% of your students are getting A’s, your standards are too low. In a typical class, perhaps 10-15% of students should get A’s. In an exceptional class, that number may double, but it should never be more than one-third of the class. The primary purpose of grades is to separate students out by performance, and that cannot be done if everyone gets the same grade. [emphasis added]" M. Sundermann
"I’d be suspicious of any instructor or class where the 35% level was consistently exceeded. One would like to assume that an “A” at Princeton is different from / better than and “A” at a less prestigious and less costly university. But that assumes professors take the job of evaluation and assessment of undergraduate performance seriously..." Mike L.
Opposing Princeton's quota:
"What a crock. Princeton students peg the meter on their SAT scores, but evidently the quality of instruction there is so substandard that their faculty can only get 35% of these brilliant young scholars up to the A level. As a parent, I’ll send my kids to a university where they will be inspired to perform at their highest level, and will be graded accordingly, where faculty are not required to punish high achievers because of an artificial percentage." Mike A.
"What do students have to say who were told at the beginning of the course what the “standards” were? It’s my suspicion that the standards are not that precise. Therefore, Princeton has decided on norm-based grading—back to the old curve. So much for mastery learning or competency-based education. [emphasis added] I certainly would not recommend this school to anyone." P. DeWitt
The folks on the side that worry about grade inflation, and push for "higher standards" view discussions of mastery and competence with suspicion. As evidenced by this comment:
"I once talked with and Ed School instructor who was giving virtually all of his students a grad [sic] of A or A-. His justification was “If they master the material, they should get the grade.” Out of politeness I didn’t say the obvious: “If almost everyone can meet the standards, then the standards are a joke.” “Mastery learning” or “Competency-based education” is EdSpeak for low expectations. It is no wonder that grades in Ed Schools are typically a joke." Sven
Setting aside for the moment the possibility that the education faculty member of Sven's acquaintance may have indeed had low expectations, it does not seem implausible to me, as it does to Sven, that the overwhelming majority of college students after more than 12 or 13 years of personal experience in the educational system, are capable of mastering an undergraduate course on the educational system. There are some fields of knowledge and instruction that only a small minority of students could reasonably be expected to attain mastery -- advanced mathematics, neurosurgery, art restoration, cabinet making, are a few that come to mind. But others, such as composition, sociology (my own subject), education, religion, office practices, plumbing, are probably masterable by the majority of those with any interest. [Please no offense is meant to the practicianers of any of these fields!]

However, even in those fields where only a minority might achieve mastery, we often find that access limited to an even smaller number. For example, there is substantial evidence to demonstrate that far more people are capable of success in medical school than are allowed into medical school. The sorting and ranking functions of undergraduate education are very important to limiting access to medical education. Of course, limiting access to training, means a limited supply of physicians, which keeps competition under control and the economic benefits of medical practice high.

So what purpose do grades serve? What purpose should grades serve? Should grades be used to sort and rank people with only a specified number of top positions, preparing people to enter a highly unequal society and economic system in which there are a limited number of top positions? Or should grades be used to acknowledge the acquisition of specified levels of knowledge, skill and competency?

At present in U.S. education, how one answers those questions often reflects where one is in the educational system (and the social stratification system). Community and technical college faculty who are preparing people for skilled working class and technical middle class positions tend to emphasize mastery and competence of objectively defined knowledge and skill levels. Faculty at elite private institutions tend to emphasize the sorting and ranking by comparative merit.

Monday, September 10, 2007

Drought in Kentucky

Although not in as bad a shape as Tennessee and Alabama, Kentucky is experiencing its worst drought since the 1930's.

The long period of unusually dry and hot weather is having a dramatic, visual impact on the mountains of eastern Kentucky. The leaves are turning color. The hillsides look more like mid-October than early September. It seems that a frost is not the only form of environmental stress that can produce red and yellow leaves in our forests. An article yesterday in the Lexington Herald-Leader, spoke of some of the effects of the drought in the southeast:
In Alabama, for example, state climatologist John Cristy says that most areas have seen less rain this year than at any time since records started in 1894.

"I've seen oak trees that have died on the ridges, which means this is the worst drought they've experienced," Cristy said.
I first posted about early leaf color change in 2005, when I noted one particular species of tree turning red as early as mid-August. Well this year this species turned red in mid-July.

I'm still trying to get help pinning down the species of my mystery tree. I'm fairly certain I'm looking at something in the horse chesnut or buckeye family -- with five to seven obovate leaves in a fan like cluster. The catch is that the leaves of these trees turn scarlet -- not yellow -- and all the reference books depict bright yellow fall leaves for all of this tree family in my region. I was actually thought for a while thinking they were black tupelos (same leaf shape and red fall color, but the leaves aren't grouped in that tell-tail fan like configuration).

Hijacking the language

David Horowitz, who has made it his life's mission to root out all vestiges of liberalism from American universities, posted an article in today. His attack is focused on the University of California at Santa Cruz, for vioilating the “Standing Orders of the Regents,” (passed in September 2005) which states that "political indoctrination and partisan interest" are outside the purview of college curriculum. Horowitz primary evidence that UC Santa Cruz is in violation of this policy is the following statement: “The UCSC faculty offers courses related to social justice -- including broad structural and social changes and community based organizing...”

Silly me, I thought that "social justice" was one of the most broadly based American concept imaginable, with roots in the Declaration of Independence ["all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness. — That to secure these rights, Governments are instituted among Men, deriving their just powers from the consent of the governed, — That whenever any Form of Government becomes destructive of these ends, it is the Right of the People to alter or to abolish it, and to institute new Government, laying its foundation on such principles and organizing its powers in such form, as to them shall seem most likely to effect their Safety and Happiness"] and the Constitution of the United States ["We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defence, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity,"]. Seems to me that both of these documents (specifically the passages above) indicate that the concern of our founding fathers was in justice within our social life, or social justice.

I think David Horowitz's article says far more about the partisan, conservative political agenda that he wishes to promote, than it does about partisan politics as USSC.