Tuesday, January 19, 2010

Appendicitis is a CLINICAL diagnosis

This is a pet peeve of mine. The loss of clinical assessment skills. I have seen over the past 20 years, an increasing reliance on tests of all sorts to evaluate things that might not need a test. I will also say that I have been guilty of this as well. However, some diagnoses are rather straightforward.

I had a patient a few years back who was a younger female patient with RLQ abdominal pain. Her story was classic. Started as periumbilical pain, migrated to the RLQ, complained of fever, nausea with no vomiting, and anorexia (lack of appetite). On exam she had tenderness at McBurneys, and a positive Psoas. She also had rebound tenderness on the LLQ, and guarding with palpation. WBC was around 12. I called our general surgery service and was confronted with the question. All ER docs know this question "What did the CT scan show?" I told the resident that there was no CT scan, and that she didn't need one. The resident proceeded to argue that perhaps it could be ovarian. I explained calmly that it was not ovarian. It was a CLASSIC presentation of appendicitis. Silence. I finally told the resident that I would only order a CT scan if they came DOWN to the ER, and LAID THERE HANDS on the patient. Otherwise, NO way. Resident comes down...not happy. (I don't really care) 5 minutes later she walks out, and says "Yep, we're taking her to the OR". The attending surgeon was so happy I thought that they were going to hug me. I saved that patient around 1700 dollars for an enhanced CT, and unnecessary radiation, which she DID NOT need.

We need to return to a focus on clinical exam techniques, and the development of a clinical gestalt.

Lastly, I would only add, that of course NOT every patient fits this scenario. Many have a mixture of symptoms that makes delineation much more difficult. But when it is clear.....

Sometimes less is more.

Now on Facebook.

Alright, so I finally figured out that Facebook thing. You can follow me on there as well, although most of my stuff on there is a bit more nonsensical. As if this isn't bad enough....LOLZ.


Sunday, January 3, 2010

Aughts the worst decade in modern times...

ZERO net job creation.....Does anything else need to be said? We took a decade, and started it with a dot com bubble that burst. Now, rather than examine the gaping fundamental flaws that were beginning to be exposed, we created another bubble...construction and housing, and people took out second loans to buy boats, and RV's, and take vacations...OOOPS. Yeah, the pesky MBS market blew up.

This article HERE, details it.

Here's a snippet:

For most of the past 70 years, the U.S. economy has grown at a steady clip, generating perpetually higher incomes and wealth for American households. But since 2000, the story is starkly different.

The past decade was the worst for the U.S. economy in modern times, a sharp reversal from a long period of prosperity that is leading economists and policymakers to fundamentally rethink the underpinnings of the nation's growth.

It was, according to a wide range of data, a lost decade for American workers. The decade began in a moment of triumphalism -- there was a current of thought among economists in 1999 that recessions were a thing of the past. By the end, there were two, bookends to a debt-driven expansion that was neither robust nor sustainable.

There has been zero net job creation since December 1999. No previous decade going back to the 1940s had job growth of less than 20 percent. Economic output rose at its slowest rate of any decade since the 1930s as well.

Middle-income households made less in 2008, when adjusted for inflation, than they did in 1999 -- and the number is sure to have declined further during a difficult 2009. The Aughts were the first decade of falling median incomes since figures were first compiled in the 1960s.

And the net worth of American households -- the value of their houses, retirement funds and other assets minus debts -- has also declined when adjusted for inflation, compared with sharp gains in every previous decade since data were initially collected in the 1950s.

"This was the first business cycle where a working-age household ended up worse at the end of it than the beginning, and this in spite of substantial growth in productivity, which should have been able to improve everyone's well-being," said Lawrence Mishel, president of the Economic Policy Institute, a liberal think tank.

Economic Contraction in 2010...Say it isn't so?


not often that two nobel laureate economists speak out on the same issue in agreement.

I don't always agree with Krugman's columns, as often he speaks from the more liberal portion of his conciousness. But I respect the man immensely, and find his economic predictions to often be right on the money.

From the Huffington Post....


Also, Joseph Stiglitz has been saying the same things, and actually, before Paul.


Part of the answer is both economists do not like the projections for GDP grow for 2010, before their recent revisions. They did not seem aware of the recent revisions. As Bloomberg has explained them –the economy is poised for a “surge” as Dean Maki, the most-accurate forecaster in the Bloomberg survey, sees it, with growth in the area of 3.5% for the year. The two economists do not consider even that a real surge, especially when recovering from a deep recession, implying that, although he has denied it, we should have more of a V shaped recovery than both have foreseen in the past. It is the last half of 2010 that bothers both economists. They don’t see where the source of recovery or engine of growth is going to come from, especially when the effects of the first stimulus package totally wears off. It is noteworthy here that we have two arch Keynesians recognizing that the stimulus efforts of government by means of deficit spending are transient and do wear off, giving us only transitory boosts in GDP.


Contractionary Monetary Policy...Oh boy

NOW???? Really....

I personally cannot think of a worse time to do this...but over at the economist, Ezra Klein posted this....


EZRA KLEIN notes that the Fed is plowing ahead with its planning for withdrawal of monetary supports for the economy, like:

"The Federal Reserve on Monday proposed allowing banks to set up the equivalent of certificates of deposit at the central bank, a move that would help the Fed mop up money pumped into the economy and prevent inflation from taking off later.

Under the proposal, the Fed would offer "term deposits" that would pay interest. Doing so would provide banks with another incentive to park their money at the Fed, rather than having it flow back into the economy.

The proposal comes as no surprise. Federal Reserve Chairman Ben S. Bernanke and other Fed officials have repeatedly said the creation of "term deposits" -- essentially the equivalent of CDs for banks -- would be one of several tools the Fed could use to drain money from the economy when the time is right."

"When the time is right" says the story, but the Fed's commitment to undo its interventions is already having an effect. In expectation of more of these moves to come (as well as, perhaps, increases in interest rates) markets have been bidding up the dollar, which has busily appreciated during the month of December. That, in turn, will deprive the American economy of a potential source of demand—growth in consumption of American exports thanks to the effect of a weak dollar.

More bluntly, we're seeing a move toward contractionary monetary policy at a time when unemployment is at 10%. Funny that.

And, over at this SITE:

I've been thinking about this question more and I've come up with a speculative possibility. Right now banks are earning their way back into profitability by playing the spread. They're paying close to zero on deposits and earning fair sums on long-term loans. Perhaps this term structure is sustainable because people are expecting little inflation in the short run but moderate inflation in the longer run, plus there is some risk on the loans. (These inflationary expectations may be changing; if you wish pretend I am writing this six months or a year ago.)

So let's say we move from zero expected short-term inflation to three percent short-term expected inflation. The nominal short rate rises to three percent and the real short rate remains more or less constant. Long rates would go up a bit but not much, since beyond the short run there is already an expectation of moderate inflation. In sum, the spread between short and long rates might narrow.

Here is the key point: from the bank's point of view, what is the correct measure of the real rate of interest? Is it defined by the nominal rate relative to the expected growth in the CPI? I doubt it. When you're near the bankruptcy or nationalization constraint, it's often nominal profits that matter (relative to fixed nominal liabilities, accounting standards, capital standards, etc.), not "real profits" defined relative to the CPI.

In sum, maybe three percent expected inflation conflicts with the desire to rapidly recapitalize banks through maintaining a wide interest rate spread. Maybe we need that zero nominal short rate or at least the Fed thinks we do.

I don't wish to push too hard on this hypothesis, it is speculative rather than confirmed by evidence. And propositions about the term structure of interest rates do not always run the way you think they will or should. I'm aware of other problems. What kind of zero profit condition is imposed on the banks? Given the odd objective function of the banks, how exactly does the Fisher effect work in the short run? Or is it imposed from without by competition from non-bank lenders? I'm not sure on these questions and they suggest possible holes in the above speculation.

I also regard this as a somewhat gruesome hypothesis. It means that "Main Street" is paying for "Wall Street" (forgive me the use of those awful terms) in at least two ways: high unemployment and inability to earn much on one's savings. Risk on the Fed balance sheet is also paying some big part of the bill, since presumably that is helping to maintain the interest rate spread.

The term structure also implies that the market is expecting rising short rates, so if the bank mess isn't cleaned up soon, heaven forbid. The spread, as a means of restoring bank profitability, won't last forever.

This combined with the possibility of hits to the export markets due to contractionary policy scares the living cr*p out of me. What a way to start 2010.

BTW- found the second link over at Angry Bear. Just want to make sure to give credit where due.

Economics Sunday....First up, Employment Forecasts

SO, the BLS releases their employment forecasts...

Found this over on Angry Bear, but it stems from the recently released BLS labor and employment report for 2008-2018.

Here's a snippet:


Here's the BLS report link:


Total employment is projected to increase by 15.3 million, or 10.1 percent, during the 2008-18 period, the U.S. Bureau of Labor Statistics reported today. The projections show an aging and more racially and ethnically diverse labor force, and employment growth in service-providing industries....and...

Projected employment growth is concentrated in the service-providing sector, continuing a long-term shift from the goods-producing sector of the economy. From 2008 to 2018, service-providing industries are projected to add 14.6 million jobs, or 96 percent of the increase in total employment. The 2 industry sectors expected to have the largest employment growth are professional and business services (4.2 million) and health care and social assistance (4.0 million).


The largest decline among the detailed industries is expected to be in department stores, with a loss of 159,000 jobs, followed by manufacturers of semiconductors (-146,000) and motor vehicle parts (-101,000).

...and more...

Occupations that usually require a postsecondary degree or award are expected to account for nearly half of all new jobs from 2008 to 2018 and one-third of total job openings. Among the education and training categories, the fastest growth will occur in occupations requiring an associate degree.

So the workforce is becoming older, and more service oriented. Does anyone think that in the absence of goods production that this is sustainable over the long term? Also, what will this mean for retirement?

Happy New Year everyone...

Whew, 2009...what to say...besides GOOD RIDDANCE.

Hopefully, 2010 will be better, but we might be in for some real bumps, particularly in the second half.

Anyway, we talk more about this.