Another Arrow so soon?!?! Well, yes, because I screwed up on the last edition and failed to open the comments. There is whole long process that I have to go through to actually send the newsletter. I missed one small step and had a ton of emails from people who couldn’t post in the comments section.

It is all fixed now, so if you want to opine, just go to The Arrow #269 and comment away.

I did get an email from a lady about the 102-year-old doctor (who may or may not be AI). She wrote:

If anyone out there is still in the military, I would love to know if this is still the routine.

A Medical/Oncological Horror Story

I read a medical horror story a week or two ago that I just can’t get out of my mind. I’ve been in the medical field for a very long time, and I had no idea such a thing could happen. I’ve also been aware of the progressive shittification (as I call it) of the medical profession for a long time. Journalist Alex Berenson wrote about his own experience not long ago, which is pretty typical of the many other stories I’ve heard. But it pales in comparison to what I’m about to tell you.

Oncology (the treatment of cancer) is a big part of the revenue of large hospitals and an even bigger part of the revenue of large group practices. The various medications used to treat cancer can be obscenely expensive, running anywhere from a few thousand dollars per dose up to hundreds of thousands of dollars per dose.

The hospitals and the doctors who prescribe and administer these doses receive a percentage of this revenue as do the hospitals. Having never been an oncologist, I didn’t know what the margins are, so I queried Perplexity. Here is what I found.

• Community oncology offices: typically ASP+4–6% drug margin.

• Non‑340B hospital outpatient: similar order of magnitude (low‑single‑digit percentage margin), varying with acquisition price and payment method.

• 340B hospitals: effective margins on oncology drugs commonly in the 25–50% range, with some documented markups around 5× acquisition cost for high‑cost cancer agents, translating to thousands of dollars of gross margin per dose for drugs like Keytruda and Padcev.

I looked up Keytruda and Padcev, two drugs commonly used together, and discovered a combined dose of the two runs about $15,000 and are usually given every three weeks or so for months. Sometimes years.

A physician prescribing and monitoring the infusion of these drugs would receive a payment of ~ $750.00 (5% of $15,000). Most oncology clinics have a bunch of people getting infused throughout the day, so this can add up to a substantial sum. And that is just for Keytruda and Padcev. Many other oncological drugs are vastly more expensive.

The hospitals end up with anywhere from 25-50%, which would be between $3,750 to $7,000 per dose. Which tells you why hospitals are all building oncology centers.

As I’ve mentioned before in these pages, most medical associations have Standards of Care (SOC) they advocate. Doctors usually stick to these SOC instead of sometimes doing what is best for an individual patient because following the SOC keeps the doctor from getting sued. (Or from losing if he/she does get sued.) Trying to do the best for an individual patient by veering from the SOC invites a lawsuit if the outcome is bad.

The pharmaceutical industry weighs in heavily on the development of the standards of care. In its lawsuit against the American Academy of Pediatrics, the Children’s Defense Fund showed this graphic from the AAP website. I couldn’t find it there now, so they must have taken it down.

Now to the horror story.

If you develop cancer as an adult, consult with an oncologist on treatment, and decide to take some sort of repurposed drug or other therapy that doesn’t fit in with SOC oncological treatment, you can go for it without fear. You might get fired by your oncologist, but you can usually find another.

Until I read the article I’m going to post below, I did not understand that it doesn’t work that way with children.

I’m going to excerpt a bit of this story and provide a link. It isn’t that long, but it explains a nightmare that I never would have imagined.

A 6-year-old boy named Judah came down with some sort of cancer (the type wasn’t mentioned), requiring a 2.5 year treatment regimen. Judah’s parents were looking to optimize his care and do anything they could to supplement the chemotherapeutic regimen he was undergoing.

You would think an oncologist would be happy that a young patient was not suffering the typical effects of chemotherapy and doing fine instead. The lack of curiosity stuns me. There should be a medical diagnosis called curiosity deficiency disorder. I’m sure if there were such a diagnosis, a whole lot of oncologists would be afflicted.

Judah’s parents continued with all the oncological treatments, but since Judah wasn’t responding with the typical issues kids have with chemotherapy, the oncologist did make a complaint to Child Protective Services. The family had to fight desperately to keep Judah from being sent to a foster parent.

Reading this story made me think of the great H.L. Mencken quote:

You can read about the whole awful affair here. It’s not all that long, but it will make you aware of a hazard out there should, God forbid, one of your children or grandchildren develop cancer.

The story of Judah and his family is a sobering reminder that the medical system, however well-intentioned in its origins, can become something that serves institutional and financial interests at least as much, if not more so, than it serves patients. When a child heals better than expected, and his doctors respond not with curiosity but with threats, something has gone badly wrong.

Parents of seriously ill children already carry an almost unimaginable burden. To add to that the fear of losing their child to the state — simply for seeking evidence-based complementary care — is a cruelty the system should be ashamed of. If this story does nothing else, let it serve as a warning. Know your rights, document everything, and never assume that the people in white coats are automatically your allies.

The good news is that after what must have been a deluge of legal bills, the family did not have to send Judah away.

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The Courage to Be Disliked

When I started medical school, my ambition was to become a plastic surgeon, which requires a general surgery residency followed by a plastic surgery fellowship. When I started my clinical rotations in my junior year, I began with ob gyn. All the major specialties—ob gyn, medicine, surgery, pediatrics, and psychiatry—take up the third year. The senior year is for electives.

About halfway through my junior year, I had my psychiatry rotation, which was six weeks long. I was assigned to do my rotation at Fort Roots, and old decommissioned US Army post high on a bluff overlooking the majestic Arkansas River. It had been converted tto a psychiatric facility years before I set foot on the place.

For someone wanting to be a plastic surgeon, I was dreading spending six weeks in psychiatry.

But on my first day, I was absolutely dazzled by the chief resident and attending physician. I was there with one other medical student in my class, and two or three psych residents, and the above mentioned chief resident and attending. The patients would come in one at a time and would sit in a chair facing all of us docs in training. They would tell their tales of woe—be it a schizophrenic or major affective disorder episode, a neurosis, gambling disorder, or whatever. Then the chief resident would question them.

I was dazzled by how quickly the chief resident and/or the attending physician could cut to the chase with just a few questions and figure out what was going on with these patients. Then devise a treatment plan. To me, it seemed like absolute magic.

When I first showed up at Fort Roots, I wanted to be anywhere but there. After just a few days of seeing people who knew what they were doing in action, I was so impressed, I started thinking about psychiatry as a professional path for myself.

As is my wont, I headed to the medical bookstore as soon as I could to find a book or two on psychiatry. Along with the major textbooks, I found three little paperback books that presented brief summaries of the three gods of psychiatry in the 20th century: Sigmund Freud, Carl Jung, and Alfred Adler. Alfred Adler? I had never heard of him.

I, of course, had heard of Freud and Jung. Who hasn’t? But Adler? I knew nothing about him. I read the little Freud book first, then the one about Jung and his methodology. Neither of them sent me over the moon.

Then I read about Adler. His methods seemed to follow common sense and appeared to be the methods applied by the chief resident and attending of whom I was so enamored. By the time I had gotten to the Adler book, plus my assigned textbook reading, and the long days in the clinic, my psych rotation was over. I then started my surgery rotation and was soon back in the mindset of wanting to operate.

A few months ago, I heard about a book with the title The Courage to Be Disliked. I looked it up on Amazon and saw that there had been ten million copies of the book sold (the Amazon description says 13 million). Since most books sell at most a few hundred copies, 13 million is a lot. Any book that sells that many copies interests me, if for no other reason than it somehow appealed to that many people.

When I looked it up, I was in a hurry, so I did as I always do and stuck it on my Amazon Wish List. Then promptly forgot about it. With Christmas coming up, MD nagged me to update my Wish List because the kids were all wondering what to get for me…or more correctly which books to get for me. I went through, found the book, and took a look at the free section Amazon presents to entice you to buy. I discovered the book was written in the form of a dialogue between a youth and a philosopher. I don’t usually like those kinds of books, so I decided to abandon it and took it off my list.

What I didn’t realize is that one of our kids had already purchased it for me, so I ended up getting for Christmas after all. Of course. The one book I meant to take off the list, I get.

I decided to read it in early January, and I whipped through it. I realized it was about Adlerian psychiatry, but I still didn’t like the dialogue style. Then a couple of weeks ago, I picked it up again and started re-reading. It was a revelation.

Heraclitus Herodotus said a man can’t step in the same river twice. Truer words were never spoken. I couldn’t believe I just breezed through it the first time. The second time, I took my time and read it slowly with pen in hand underlining and folding down pages.

(Note: Speaking of Herodotus, I read a stupendous book last year titled Travels with Herodotus. It’s now one of my favorite books. It’s an old book that I’ve known about for years, but didn’t get around to reading it until the middle of last year. It’s another one worth reading again.)

Until I read The Courage to Be Disliked (which doesn’t have a lot to do with being disliked—I suspect that someone in the publisher’s marketing departments coined the catchy title)—I did not realize that Adler’s ideas were the basis for some of the best selling self-help books of all time. Dale Carnegie’s How to Win Friends and Influence People and How to Stop Worrying and Start Living were based on Adler’s work. As was one of my favorite books from years and years ago: Stephen Covey’s The 7 Habits of Highly Effective People. (If you haven’t read The 7 Habits…, you ought to give it a look.)

Not only that, my favorite personal relationship book that I’ve recommended several times in these pages, Take Effective Control of Your Life, by William Glasser, M.D., republished as Control Theory: A New Explanation of How We Control Our Lives is also based on Adler’s work.

Adlerian psychology lines up pretty clearly with Greek philosophy, but differs greatly from Freudian psychology. Unlike Freud, Adler does not promote the notion that previous events should affect us at a later time. In his view, that is a mistake. Adler doesn’t look to etiology (the study of causation), but looks to teleology (“the study of the purpose of given phenomenon, rather than its cause.”)

Adler suggests people reverse the equation of causality. The book provides a number of examples, but I have sort of a lame one of my own for illustrative purposes.

Let’s say a person is struggling at work. She says, “I’m struggling at my job because I don’t know how to code.”

If Adler were dealing with her, he would encourage her to adopt a different outlook and say, “I’m going to learn to code because it will help me in my job.”

The first example is etiological. It describes the cause of her dilemma—an inability to code—but doesn’t do anything to fix it. It becomes an excuse for poor performance. It’s not her fault. But switching to the teleological version gives her a plan and eliminates the excuse.

Adler also believes that all problems are interpersonal relationship problems. When I first read that years ago, my first impulse was that it was BS. Since I’ve thought about it and now re-read about it twice, I am persuaded that it is true. It is the underlying theme of all the books I wrote about above that are based on Adler’s psychology.

These are just two of the issues explained in depth in this little book. Don’t be put off like Mike because the book is written as a dialogue. It’s helpful for full understanding to get the back and forth.

Alfred Adler may be the most influential thinker you've never heard of. The Courage to Be Disliked makes a more than compelling case for why that should change. His core insight—that we are not prisoners of our past but architects of our purpose—is both radical and deeply practical, and it quietly underpins some of the most widely read self-help literature of the last century.

Reading about Adler is a bit like discovering the composer whose melodies you already know by heart. If the dialogue format gives you pause, push through it anyway. The ideas are worth the occasional awkward exchange, and as I discovered, the book has a way of revealing more of itself on the second read than it did on the first.

I would really encourage anyone—even if they are supremely happy—to grab a copy of this book and read it. Maybe twice. I’ll go through it a third time when I transfer my notes to a commonplace book in a few weeks.

Newsletter Recommendations

Time for the poll, so you can grade my performance in this issue.

That’s about it for this week. Keep in good cheer, and I’ll be back soon.

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This newsletter is for informational and educational purposes only. It is not, nor is it intended to be, a substitute for professional medical advice, diagnosis, or treatment and should never be relied upon for specific medical advice.

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