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Pink Floyd and the Wisdom Books
One of the gems of the umpteen channels we receive on cable is Palladia. A few weeks ago, I was scanning through the channels one night after the family was in bed. I came across David Gilmore performing all of “Dark Side of the Moon” in Gdansk. Not only was the sound incredible, it stirred my Polish blood. A few years ago, Gdansk would have been one of the least likely places I would expect to hear Pink Floyd tunes. I suppose some of it is due to preconceived notions. But after a fellow music lover, and immigrant from Croatia informed me, during the waning days of the Iron Curtain, Anglo-American classic rock and heavy metal were quite popular.
As a frustrated guitarist, I reveled in the close ups of Gilmore’s fingers during his solos. The cinematography was quite well done and the sound recording top notch. I actually watched the entire concert, not alternating my attention between a book, or my laptop as I most often do when the tube is on. The next day I went to iTunes and downloaded ‘Dark Side of the Moon - Remastered’. The last copy of it I possessed disappeared somewhere. I recall having it on cassette and may have upgraded to CD at one time, but with the various moves I made during college, med school etc, it too is long gone. I suspect it may still be floating around the Sig Ep house at 2900 Wyman Park Drive in Baltimore, or was transported by an old friend from West Lafayette to parts unknown.
Of the album’s songs, my favorite is ‘Time’.
Time
(Mason, Waters, Wright, Gilmour) 7:06
Ticking away the moments that make up a dull day
You fritter and waste the hours in an offhand way.
Kicking around on a piece of ground in your home town
Waiting for someone or something to show you the way.
Tired of lying in the sunshine staying home to watch the rain.
You are young and life is long and there is time to kill today.
And then one day you find ten years have got behind you.
No one told you when to run, you missed the starting gun.
So you run and you run to catch up with the sun but it's sinking
Racing around to come up behind you again.
The sun is the same in a relative way but you're older,
Shorter of breath and one day closer to death.
Every year is getting shorter never seem to find the time.
Plans that either come to naught or half a page of scribbled lines
Hanging on in quiet desperation is the English way
The time is gone, the song is over,
Thought I'd something more to say.
Saturday morning was devoted to servicing my aging Toyota Tundra. She had a wash, a wax, and then off to Sears for a tire rotation and re-aligment. A warm, though overcast, morning. Windows down, stereo on. When ‘Time’ came on, I listened closely to the lyrics and made a connection I have never before considered. Ecclesiastes.
From the New International Version
Ecclesiastes
Everything Is Meaningless
1 The words of the Teacher,a son of David, king in Jerusalem:
2 “Meaningless! Meaningless!”
says the Teacher.
“Utterly meaningless!
Everything is meaningless.”
3 What does man gain from all his labor
at which he toils under the sun?
4 Generations come and generations go,
but the earth remains forever.
5 The sun rises and the sun sets,
and hurries back to where it rises.
6 The wind blows to the south
and turns to the north;
round and round it goes,
ever returning on its course.
7 All streams flow into the sea,
yet the sea is never full.
To the place the streams come from,
there they return again.
8 All things are wearisome,
more than one can say.
The eye never has enough of seeing,
nor the ear its fill of hearing.
9 What has been will be again,
what has been done will be done again;
there is nothing new under the sun.
10 Is there anything of which one can say,
“Look! This is something new”?
It was here already, long ago;
it was here before our time.
11 There is no remembrance of men of old,
and even those who are yet to come
will not be remembered
by those who follow.
A lot of parrallels. My favorite theologian, Peter Kreeft, wrote a wonderful book, Three Philosophies of Life: Ecclesiastes, Life as Vanity; Job, Life as Suffering; Song of Songs, Life as Love. In his intro, he compares Ecclesiastes to Hell, Job to Purgatory, and Song of Songs to Heaven. With his usual wit, Kreeft adds a footnote,
“Note to Protestant readers: please do not throw this book away just yet. I am not presupposing or trying to convert anyone to the Catholic doctrine of Purgatory. Here I mean by Purgatory any suffering that purges the soul. It begins in this life. If it is completed in the next, you can just as well call it Heaven’s bathroom if you like. A sanctification by any other name would smell as sweet.”
The basis of Kreeft’s comparison of Ecclesiastes to Hell is based upon vanity. “The lesson Ecclesiastes teaches is faith, the necessity of faith by showing the utter vanity, the emptiness, of life without faith.”
Later he adds,
“Vanity cannot detect itself, just as folly cannot detect itself. Only the wise know folly; fools know neither wisdom nor folly. Just as it takes wisdom to know folly, light to know darkness, it takes profundity to know vanity, meaning to know meaninglessness. Pascal says, “Anyone who does not see the vanity of life must be very vain indeed."
Compared with the neat little nostrums of comfort-mongering minds who cross our t’s and dot our i’s, Ecclesiastes is as great, as deep, and as terrifying as the ocean. If this philosopher were alive today and knew the reigning philosophy in America, pop psychology, with its positive strokings, OKs, narcissistic self-befriendings, panderings, patronizings, and bland assurances of “Peace! Peace!” where there is no peace, I think he would quote John Stuart Mill that it is better to be Socrates dissatisfied than a pig satisfied; and William Barrett;”It is better to encounter one’s own existence in despair than never to encounter it at all.”” (pp. 15-16)
Just some food for thought.
Fiduciary Responsibility - Part 3
There are two participants in any relationship. Both have responsibilities to the other party involved. Part two of this series discussed the responsibilities of the physician. Part three will delve into those of the patient.Ultimately, a patient’s health depends upon the patient. Assuming we are dealing with an adult, competent individual, he or she has absolute autonomy in regard to his/her health. Any treatment recommended can be accepted or declined.
As a physician, I have no control over what happens once a patient leaves my office. The patient chooses to fill a prescription, work on stopping an unhealthy habit, getting the imaging study I order, seeing the specialist I refer them to, etc. Autonomy is the basis of the doctor/patient relationship.
As a fiduciary to the patient, it is my responsibility to remain clinically informed, prevent illegitimate self interest from entering the treatment plan I recommend, and preserve both my integrity and that of my profession. I am to act in the patient’s best interest, not only medically, but also economically, spiritually, and socially. It is my hope that a patient accepts the treatments I recommend and agrees I am acting in his/her best interest.
The patient has ethical responsibilities as well. From Dr. McCullough’s Primer on Bioethics: they have a responsibility to themselves, their families, their physician, healthcare organizations, and society in general.
Regarding their responsibility to their physicians, patients owe them integrity and honesty. As with most relationships, honesty is a core value. If a drug I prescribe is not tolerated, they need to tell me. If they still smoke, they need to tell me. I recall a patient from when I was a resident. He was a thin fellow in his 50s. He smelled like cigarette smoke, his fingers were tinged yellow from smoke, and his breath smelled of cigarettes. In his pocket were a pack of Winston’s. He denied he smoked. He said the Winston’s belonged to a friend, and he was merely holding them. All of the evidence pointed to him being a smoker, yet he continued to deny it. Needless to say, it colored my view of the patient and made me question everything he told me.
The patient must also take an interest in his/her health. They must take their medical issues seriously. This is especially true in preventative care. Primary care is not sexy. We do not perform lifesaving surgeries. We do not stent clogged arteries. We instead try to prevent bad things from happening. There is not a great way to measure the lives we save. By controlling a patient’s diabetes, blood pressure, and cholesterol, as boring and mundane as that may sound, we may be preventing future bypass surgery or the loss of a limb, if not life. This is serious business. My goal is to keep my patients out of the hospital. This not only improves their quality of life, but also may prevent their death.
Recently, I sent a patient from my office to the hospital. He was in his early 60s and for several years has had high cholesterol, high blood pressure and smoked. Canceling or not showing for appointments was a regular habit of his. Over the last several years, I had only seen him once or twice. We discussed his cholesterol, which was high, but not frighteningly high. I had recommended he start medications to lower his cholesterol, which he never filled. He also declined to fill a prescription to aid him stop smoking. He didn’t accept my advice. He had bypass surgery last week.
Would following my advice have prevented his bypass ? Possibly. It is impossible to tell. Statistically, it would have lowered his risk of developing heart disease. The problem was he did not take my advice seriously as evidenced by not keeping follow up appointments, etc. Few imagine it (meaning any serious medical problem) will happen to them. Bad stuff happens to other people, not me.
Additionally, patients have an obligation to their families. In preserving their health, they help ensure the continued financial and emotional viability of their family. If one becomes disabled due to heart disease, he may no longer be able to generate the income necessary to support his family. Likewise, controllable vices, such as alcohol and tobacco abuse, can lead to financial, not to mention emotional, ruin. I have seen very few healthy families where one or more of the parents is an addict. Or has untreated psychological problems. Seeking treatment for problems such as this are part of the fiduciary responsibility one owes their family.
When we come to the discussion of the burdens one may impose on his family, we enter an even more contentious area. What exactly are our responsibilities to our adult relatives ? If our 85 year old mother has a stroke and requires constant care, are we required to provide it if it impairs our ability to care for our spouse or child ?
Dr. McCullough raises some of these questions in his Primer:“Family members and other 'informal" caregivers are important in the management of patient's health conditions, especially those of a chronic or debilitating nature that create dependencies on others. These caregivers have legitimate interests of their own that they are not ethically obligated to sacrifice forever. Just as the virtue of self-sacrifice can have ethically justified limits for healthcare professionals, so, too, the virtue is limited in the case of family members. After all, they have obligations to others in their lives, as well as legitimate interests in such matters as their own physical and mental well-being and living a coherent life. These interests can be jeopardized by the long-term care requirements of patients.”
Just as problematic, and less well defined, are a patients fiduciary responsibility to healthcare organizations, his employers, and society. We are foolish to think that our actions have no effect on others. I will again dwell on smoking. Smoking is preventable. It is an individual choice whether to smoke or not. One may have a genetic predisposition to become addicted to tobacco, but the choice to smoke is a decision made by an individual.
Smoking effects a person’s employer. Cigarette breaks mean lost productivity. It also increases the cost of providing health insurance. In companies that provide health insurance to their employees, there is often not a distinction made in the premiums paid by smokers and non smokers. Recently, St. Luke’s Hospital in Bethlehem, PA, stated it will no longer hire smokers. This is expected to save them quite a bit in insurance premiums. As insurance premiums have increased far greater than the general rate of inflation, this is not a trifling matter. By refusing to hire smokers, they will save monies which can then theoretically be applied to increased wages, lowered employee costs for insurance, etc. Societally, this also will save money. When a large percentage of our population receives their healthcare from the government (Medicare and Medicaid) these savings can potentially be used to provide care for more patients.
In the end, any of these relationships can be terminated. If you are not comfortable with your doctor, or do not trust her, or do not feel she is treating you appropriately, you have the power to end that relationship. Likewise, if your physician does not trust you, or feels you are not taking her advice seriously, she can end the relationship. This is not always a bad thing. Not all personalities match with all others.
Every relationship we enter has duties required of both parties. This may sound quite legalistic, but even in our friendships and non-business relationships, there are certain expectations placed on both parties. Many of these are self evident. Others are contractually codified. The relationships between patients, physicians, and health care organizations contain legal and emotional aspects. We must honor both.
Fiduciary Responsibility - Part 2
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The relationship between a doctor and a patient is unique. It is build largely upon trust. Physicians trained in the United States have at least 11 years of education/training beyond college. In some medical specialties, the physician trains for at least 15 years before entering practice. We entrust our very lives to our physicians. If one believes life is scared, it further augments this relationship. Most physicians do not take this lightly.
In family medicine, every treatment I prescribe is potentially life altering or life ending.
No matter what treatment plan I devise, the patient must consent to it. I cannot force a treatment upon a patient. Each adult, rational person has the autonomy to decide what is best for him. Even though they do not have the background in science, or familiarity with standards of medical treatment, they nonetheless have the right to decide to undergo or forego medical treatment. This is a where trust comes in. This is also where fiduciary responsibility enters the picture.
If we do not have expertise in a certain area, we place out trusts in those who do. I trust my accountant to prepare my tax returns for my business and home because I am not an expert in take law. His fiduciary responsibility is to apply the rules (in a legal fashion) to my benefit. He is not to take advantage of me. He is to act in my best interest. We expect the same of our physician.
The American College of Physician Executives publishes “A Primer in Bioethics”. the primer was written by Dr. Lawrence McCullough, a professor of medical ethics at Baylor. He outlines three prime fiduciary responsibilities for physicians: 1) The physician commits to becoming and remaining scientifically and clinically competent, by submitting to the intellectual and clinical discipline of evidence-based clinical reasoning and judgment;
2) The physician commits to making the protection and promotion of the patient’s health-related and other important interests the physician’s primary concern and motivation and to keeping self-interest systematically second; and 3) The physician commits to maintaining and strengthening medicine as a public trust for the benefit of current and future physicians and patients. (McCullough, Lawrence, A PRIMER ON BIOETHICS, Second Edition, 2006, American College of Physician Executives, p.8).
The first point, that of remaining competent and up to date is difficult. A never ending barrage of new, and often contradictory information, is continuously published in the recognized medical literature. Each month several hundred, if not several thousand, journals are published. It is not humanly possible to keep to absorb all of this information, much less critically examine it. This is a part of the reason we rely so much upon clinical guidelines published by various specialty colleges and organizations. One great resource many of us use is Journal Watch (http://www.jwatch.org/). Journal watch is a biweekly publication in which key articles from a number of journals are abstracted. Another valuable resource is the National Guideline Clearing House (http://www.guideline.gov/). This is an online collection of guidelines published by medical organizations throughout the world. One of my favorite resources is www. href="http://uptodate.com">uptodate.com . This an 80,000 page online textbook which is continuously updated by experts in the several medical specialties. Additionally, Most physicians are required to obtain at least 50 hours of continuing medical education each year. In reality most of us do more than the hours required.
Point 2 addresses the expectation that the physician will keep the patient’s interest first, and his self interest second. There are many facets to this. Primarily, we seek to find wellness and fight disease. Ethics invariably enter this picture. Especially when the evidence is blurred. Take prostate cancer for example. Is it in the patient’s best interest to do nothing but watch it ? do you perform surgery ? is radiation therapy the most appropriate treatment ? what about drugs which block the production of testosterone ? do you treat a 50 year old the same you do an 80 year old ? Then of course there is a financial bias. What if you are a radiation oncologist as opposed to a urologic surgeon ? Does the fact you need to generate income to pay off a million piece of radiation equipment color the advice you give your patient ?
In areas where the medical literature clearly demonstrates one treatment is vastly superior to another, the decision is easy - you follow the evidence. But what about cases where the evidence is not so clear ? Or what if new evidence proves the way you were treating a condition has not been found to be beneficial ? I have heard it said that we only have clear evidence for about half of what we do. The rest is based upon our clinical judgement and our interpretation of the literature.
Physicians are humans. Very few of us think we are God. Humans desire appreciation. We want our patients to be happy. But what happens when a patient requests a drug or test that is not warranted ? One of the big sins in primary care medicine is the over prescription of antibiotics for upper respiratory infections that are most likely viral in origin. Antibiotics do not work on viral infections. Yet many patients (and this is an American issue, not only applicable to medicine) want something done. Our society values action over inaction. In most cases colds resolve without any treatment. But quite a few patients want a prescription for an antibiotic. Thus arises the conflict between what a patient desires and thinks is best for him and what is truly best for him from medically. Solving this conflict is problematic.
Self interest is a prime motivator for us all. Often the self interests of the physician and patient mesh, and an agreement is reached. However, patients must consider that physicians have legitimate self interests as well. Primary amongst these is maintaining integrity. In order to prescribe a treatment it must be scientifically and morally defensible.
Financial concerns, to a point, are also legitimate.
As with any business or occupation, the worker, in this case the physician, has the right to be remunerated for delivering a service. As with all of us, physicians have business expenses, mortgages to pay, student loans to retire, children to educate, etc. The conflict here is when a physician recommends a treatment where financial considerations override what will benefit the patient and what is scientifically defensible. This conflict does arise, but less often than one would think.
The physician also must follow the laws, rules, and regulations of the region in which he practices. This is self explanatory.
Finally, the physician has a right to protect himself from bodily harm. Of late, there have been cases of physicians being harmed or even killed because they would not do what a patient wanted. (Prescribing excessive narcotic pain medications when a patient clearly has an addiction problem, or generating a prescription in the name of a patient’s spouse because the patient lacks insurance, etc.)
The third point, that of maintaining and strengthening the medical profession, is an ancient imperative of the physician. This idea has been articulated in many of the creeds sworn to by physicians dating back to Hippocrates. Medicine is a public trust. Maintaining its ethics and integrity benefits not only the physician, but society as well. There is something sacred about the trust given to a physician by a patient. Of all the above points, this perhaps is the strongest tie into the fiduciary duty expected of the physician.
Patients too have responsibilities involved in their care. I will discuss these in part 3, which will follow in 2-3 days.
Fiduciary Responsibility -Part 1
Through frequent use, a concept can take on a limited meaning; its depth and complexity often lost. By becoming jargon, a broad precept can take on too narrow a focus.
The concept of fiduciary responsibility has been diminished though this process.When we hear fiduciary responsibility, we tend to think mainly in financial terms. We picture Fortune 500 boardrooms with comfy leather chairs and stuffy old men wearing expensive suits. We imagine stock prices, returns on investment, expansion into new markets, and the allocation of dividends to be pertinent features of such discussions. (And all of these are important if you are a stockholder in a corporation or own shares of a mutual fund invested in it). Broadly speaking, and in theory if not practice, the directors of a company are to act in the best interest of the shareholders. They should make decisions that keep the company viable and insure a positive return to those who have invested in the corporation. Increasing the value of the organization and ensuring this is done so in a responsible and legal fashion are the responsibility of the board of directors.
From an online legal dictionary (http://legal-dictionary.thefreedictionary.com/fiduciary+duty) a fiduciary is defined as, “An individual in whom another has placed the utmost trust and confidence to manage and protect property or money. The relationship wherein one person has an obligation to act for another's benefit.” West's Encyclopedia of American Law, edition 2. Copyright 2008 The Gale Group, Inc. All rights reserved.
This seems simple enough. But the website I visited for the definition adds some further nuances from another legal dictionary. (emphasis mine)fiduciary 1) n. from the Latin fiducia, meaning "trust," a person (or a business like a bank or stock brokerage) who has the power and obligation to act for another (often called the beneficiary) under circumstances which require total trust, good faith and honesty. The most common is a trustee of a trust, but fiduciaries can include business advisers, attorneys, guardians, administrators of estates, real estate agents, bankers, stock brokers, title companies, or anyone who undertakes to assist someone who places complete confidence and trust in that person or company. Characteristically, the fiduciary has greater knowledge and expertise about the matters being handled. A fiduciary is held to a standard of conduct and trust above that of a stranger or of a casual business person.” Copyright © 1981-2005 by Gerald N. Hill and Kathleen T. Hill. All Right reserved
Still a simple concept, but the expanded definition adds expertise in a given area and a higher standard of conduct.
Unfortunately, the breach of fiduciary responsibility by many boards, accountants, executives, and the public at large have lead to the financial crises we now face.This concept is not however solely applicable to financial relationships. It is also the core of the government-citizen relationship, the parent-child relationship, and the various relationships between hospitals, insurance companies, patients, and physicians. When we expand the definition to include relationships beyond the financial, we enter the realm of ethics. We move beyond law and contracts into morals and behavioral standards.
From the on-line Merriam-Webster dictionary (http://www.merriam-webster.com/netdict/ethics) we find ethics defined as, “the discipline dealing with what is good and bad and with moral duty and obligation.” When we delve into the philosophical definition of ethics, it becomes a bit more muddled. Querying the online Stanford Dictionary of Philosophy, 692 entries were returned. For the purpose of this essay, we will follow the KISS method and use Webster’s definition.
In writing this piece, I proceeded with the following assumptions. 1) Legal does not necessarily equal ethical. Some actions may be legal, but are not necessarily ethical. Take abortion for example. Abortion is legal, but there are many rational arguments against it being ethical. However some actions are both legal and ethical (driving on the right side of the road), or illegal and unethical (murder). 2) Ethical standards are formed by a complex interplay between philosophy, society, theology, and empirical knowledge. They can change over time. They can vary from region to region, and culture to culture. And finally, 3) Some ethical standards ‘speak for themselves’. In many cases there is an overwhelming agreement as to what they should be. Being human, and each of us having various life experiences and values which form our outlook, there are bound to be disagreements about any standard, but in most modern cultures, acts such as cutting a baby in half with a sword are considered unethical (and illegal in most places).
PART 2 WILL FOLLOW IN 1-2 DAYS.PLEASE STAY TUNED . . . . . . . . . .
Patch Adams, the Medical-Industrial complex, and us . .oh, my
Patch Adams, MD is here in Fort Myers and will be visiting our children’s hospital over the Easter weekend. One of our local news folks interviewed him and asked Dr. Adams what he thinks of the health care reform bill. He was not complimentary. In essence he stated that the bill will not change much of anything and will further enrich health insurance and pharmaceutical companies. I think his statement ended with a little sarcasm, along the lines of “duh.”
For those of us who have been closely following this bill and its passage through Congress, this is no surprise. Most citizens will be required to buy insurance, not all will qualify for a government program like Medicare or Medicaid. This leaves the private insurers. The government has passed a bill which will force its citizens to purchase a product which will enrich one specific industry. From a party which has aimed so much rhetorical invective at the insurance companies and painted them as evil, this is quite a gift from the Democrats.
Ditto with the pharmaceutical companies. This bill does not support reimportation of drugs. Many of our citizens save money by ordering their pharmaceuticals from Canada or other nations. The savings can be tremendous. If I recall correctly there is language in the bill that forbids the government from using its potential buying power to negotiate lower drug prices for those in its programs. The Veteran’s Administration has been using its size and number of lives it provides care for as a powerful bargaining chip with the pharmaceutical companies. So again we see the Democrats throwing a bone to an industry who’s profits it has found excessive.
I do not find either the insurance companies or the pharmaceutical companies to be inherently evil. I do not even begrudge them their profits. They are corporations, and their boards have a fiduciary responsibility to their stock holders to generate profits. Regardless of your political views, companies need to make a profit. Profits allow them to expand, to hire more employees, to develop new products, to invest in research and development, and to create value for their stockholders. Every retiree is dependent on companies being profitable. Whether they have a pension, a 401k, or an IRA, the basis of these retirement vehicles are stocks. Most mutual funds are collections of stocks. My IRA consists of mutual funds made up of stocks.
Taking a broader view of companies, I recall a quote from the great Peter Drucker who said that there is no such thing as profit - there is only capital and expenses. In this case profit equals capital. If a company does not have capital it cannot expand. A large portion of any company’s ‘profit’ is invested back into the company allowing it to grow, which creates more jobs which in turn create mores capital to grow and hire more employees which creates more capital, etc. It is crucial to remember that the government does NOT create jobs. Think about that for a moment. Every employee of the government is paid for by taxes raised from its citizens. However, if a company hires employees, the taxpayers are not on the hook for their salaries, benefits, etc.
I think of my own small business. I employ three people. In about six months, I will finish paying off the loan I took to buy my Family Medicine practice. I plan on using the money devoted to retiring debt to cover the start up costs of hiring a nurse practitioner. If all works out, she will generate enough income to expand my practice further. When the nurse practitioner builds up her patient panel, I will probably need to hire another employee to perform clerical work and implement other services my practice plans on offering. Additionally, it will generate business for a contractor, because I will need to do some renovations to my office to create a better space for the nurse practitioner to work and see more patients. If this succeeds and generates more capital, I will look to hiring another nurse practitioner or taking on a partner, which in turn will create more jobs, etc. This also benefits society in a number of ways. It creates jobs and generates income for the employees which they can then spend on local businesses by purchasing goods or services. This in turn will help generate income for these business, so they can grow, hire more employees, etc. Given that I do not have any ‘under-the table’ eomployees, it will also benefit the government because my business will pay more into Social Security and Medicare. The government will then be able to tax the salaries of my employees, giving it more money to (hopefully) make a dent in our soaring public debt.
The problem with the government forcing people to buy insurance is multifaceted. First off, it may not be constitutional. Living is not a privilege in a legal sense (theologically and philosophically speaking is another story). We have a right to life, liberty, and the pursuit of happiness. The government does not have the right to impose taxes on us for merely being alive.
There are a number of privileges for which the government can tax us. Take driving for example. In a broad sense, one does not need to drive to live. The government maintains our roads and also enforces traffic laws which allow us to safely operate our vehicles. It needs revenue to do so, therefore taxes and fees are legitimate. One can choose whether or not to drive, one cannot choose whether or not to be born.
The second problem is that of the government enriching one industry based solely on the fact that its citizens draw breath. I cannot think of any other mandate based solely on living.
It also goes to show how money talks. The insurance industry is granted many boons by the government. Insurance companies are not subject to anti-trust regulation. Most government employees are insured through private companies. The fees they pay to physicians are kept artificially low because they are pegged to Medicare rates. Additionally, there are laws preventing physicians from collectively bargaining for better reimbursement. All of these add to the profits of insurance companies.
I have a little more sympathy for the pharmaceutical companies. Although, I often disagree with their business and marketing methods, they do create value and enhance our lives. Life saving drugs and medical devices come from these companies. The process by which a new product enters the market place is among the strictest in the world. It is also one of the most costly. Last I read, it takes nearly a billion dollars and at least a decade for a new drug to make it out of development and onto the market.
Ethically, the marketing of drugs becomes more blurry. I am opposed to direct to consumer advertising. In general, most patients do not have the understanding to decide if a drug is appropriate for them, or if it is safe.
Each day, at least six pharmaceutical sales representatives visit my office. I have recently decided to no longer meet with them. Some of the concerns are time related. If I spent 5 minutes with each of them it would add half an hour onto my day. It also delays attending to my patients. I believe my patient’s time is valuable.
Most of the sales reps are nice, intelligent, hard working people. However, I cannot let this cloud my judgement. The fact I like a salesman should not influence my decision to use the drug they are selling. I need to objectively examine if a drug is beneficial and safe. And if it is cost effective. Contrary to popular belief, pharmaceutical companies do not whisk the average doctor away to Hawaii, all expenses paid, to convince them their new drug is the best and that they should prescribe it to their patients. Nor are kickbacks paid to physicians.
Pharmaceutical marketing is far more subtle. As with most successful salesman, they use their personal relationship with the buyer to influence the use of their product. Until recently, they also gave physicians trinkets such as pens and boxes of facial tissue, all prominently bearing the logo of their product. For the physician, this seems harmless enough. It saves us from not buying pens and Kleenex. But it quite effectively keeps their product in the forefront of our minds.
‘Free’ samples are a canard. The ostensible idea behind them is to provide a patient with a limited supply of a medication to see if it is effective and tolerable. Physicians have expanded on this and often provide patients who cannot afford the medication with samples to use. However, I cannot always guarantee I will have samples to give. When the sample runs out, the patient must fill a prescription for the drug. Recently the companies have taken to providing coupons and cards which reduce the price of a medication. Unfortunately these tend to be time limited, and eventually the savings end. Far more important is the fact that there are usually cheaper alternatives for treating a condition. The cheaper medications are often equally as effective and tolerable, but cost a fraction of the name brand. Take for example blood pressure medications. For simple, uncomplicated hypertension, which is the majority of the hypertension we see, there is NO reason to prescribe a brand name drug. There are several options which cost less than $5 a month. Most name brand antihypertensives run at least $50/month.
I realize I spent several paragraphs criticizing the pharmaceutical industry, but I do not think they are evil. I am not even sure their profits are excessive. Given the costs of developing a new drug and bringing it to market, there is incredible risk involved. Generally, risk should be rewarded.
My biggest concern is how the government gives preferential treatment to the pharmaceuticals. When congress passed the legislation creating Medicare Part D, the drug benefit, the legislation prevented the government from negotiating lower prices for those receiving government subsidized care. We also see the influence Pharma has with the government. Former Congressman Billy Tauzin is now the head lobbyist for the pharmaceutical industry. He spent 25 years representing Louisiana in the House of Representatives. Do you think it is an accident he went on to become a lobbyist ? Twenty-five years in congress created an insider’s knowledge of the legislative process. It also created numerous connections with lawmakers and their staffers. Hiring him was a brilliant move by the pharmaceutical industry.
I am not ashamed to admit I am a capitalist. I believe that risk and reward are powerful motivators for one to perform at their best. It rewards hard work and determination. Socialism removes the desire to succeed and excel.You do not see Thomas Edisons, Henry Fords, or David Attenboroughs emerge from socialist nations. In many ways socialism creates more inequities than freedoms. When we look at socialist nations, where the government controls almost everything (think Cuba, and Venezuela) we actually see a greater division between the haves and have nots. I am sure Fidel and Hugo have much better food, healthcare, recreation, and personal freedom than the other citizens of their socialist nirvanas.
One of the key necessities of capitalism is a free market. A market composed of millions of individuals creates a more accurate value for a commodity. Unfortunately medicine is not a free market. This is a part of why costs continue to rise. Through legislative measures, our government has prevented medicine from becoming a free market. Various laws and regulations favor certain companies and industries. This prevents competition and thus raises costs.
With this tragic piece of legislation, we will see costs far greater than any government agency has predicted.
The Democrat controlled Congress, and President Obama have given a blank check to the pharmaceutical and health insurance industries. They have ignored rational suggestions which would have lowered costs. Removing antitrust protection from the insurance companies and allowing them to work across state lines would have allowed market forces to reduce costs. Giving the government leeway to negotiate lower priced medications with the pharmaceutical manufacturers would reduce costs for those in government health care programs (Medicare and Medicaid). Placing caps on non-economic awards in medical malpractice suits would cut costs by decreasing the number of tests ordered due to doctor’s fears of being sued. None of these measures would cost significant amounts of money, non of them would raise taxes.
Once again, special interests have trumped the national good. Our politicians lack the courage to make tough decisions. We have forgotten, as have our elected officials, that they serve we the people, not their cronies or themselves.
The Gordian Knot Untied
Great piece posted on of my favorite blogs - What's Wrong With The World.
The blog discusses a piece published last year in The Atlantic.
From the Atlantic piece (emphasis mine):
I’m a businessman, and in no sense a health-care expert. But the persistence of bad industry practices—from long lines at the doctor’s office to ever-rising prices to astonishing numbers of preventable deaths—seems beyond all normal logic, and must have an underlying cause. There needs to be a business reason why an industry, year in and year out, would be able to get away with poor customer service, unaffordable prices, and uneven results—a reason my father and so many others are unnecessarily killed.
Like every grieving family member, I looked for someone to blame for my father’s death. But my dad’s doctors weren’t incompetent—on the contrary, his hospital physicians were smart, thoughtful, and hard-working. Nor is he dead because of indifferent nursing—without exception, his nurses were dedicated and compassionate. Nor from financial limitations—he was a Medicare patient, and the issue of expense was never once raised. There were no greedy pharmaceutical companies, evil health insurers, or other popular villains in his particular tragedy.
Indeed, I suspect that our collective search for villains—for someone to blame—has distracted us and our political leaders from addressing the fundamental causes of our nation’s health-care crisis. All of the actors in health care—from doctors to insurers to pharmaceutical companies—work in a heavily regulated, massively subsidized industry full of structural distortions. They all want to serve patients well. But they also all behave rationally in response to the economic incentives those distortions create. Accidentally, but relentlessly, America has built a health-care system with incentives that inexorably generate terrible and perverse results. Incentives that emphasize health care over any other aspect of health and well-being. That emphasize treatment over prevention. That disguise true costs. That favor complexity, and discourage transparent competition based on price or quality. That result in a generational pyramid scheme rather than sustainable financing. And that—most important—remove consumers from our irreplaceable role as the ultimate ensurer of value."
"But fundamentally, the “comprehensive” reform being contemplated merely cements in place the current system—insurance-based, employment-centered, administratively complex. It addresses the underlying causes of our health-care crisis only obliquely, if at all; indeed, by extending the current system to more people, it will likely increase the ultimate cost of true reform."
"We will need to reduce, rather than expand, the role of insurance; focus the government’s role exclusively on things that only government can do (protect the poor, cover us against true catastrophe, enforce safety standards, and ensure provider competition); overcome our addiction to Ponzi-scheme financing, hidden subsidies, manipulated prices, and undisclosed results; and rely more on ourselves, the consumers, as the ultimate guarantors of good service, reasonable prices, and sensible trade-offs between health-care spending and spending on all the other good things money can buy."
"But let’s forget about money for a moment. Aren’t we also likely to get worse care in any system where providers are more accountable to insurance companies and government agencies than to us?"
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GULP - I agree with President Obama on a healthcare decision . . . .
For those of you who know me well, please take a seat before you read this entry.
I have been opposed to most of the policies President Obama has put forward. From a financial perspective, most are reckless, it not outright disastrous. I fear that this will become even more apparent over the next two decades.
His political appointees have likewise been generally poor choices. Our Attorney General, Eric Holder has acted against long standing precedent (not to mention the Geneva Convention and common sense) by advocating terrorists receive Miranda rights. Secretary Janet Napolitano is in over her head at Homeland Security. The same holds true for Secretary Katherine Sebelius at Health and Human Services. Need we mention the tax cheats, industry lobbyists, and leftovers from the Clinton Administration holding high positions in the administration which was supposed to be different; more open and honest ?
Although I disagree with him, President Obama is still the president, and deserves a certain amount of respect. Which is why I dismiss the birther and citizen arguments, the questions of his religious beliefs, and issues in his personal life. His political background and philosophy are however, free game. Even though he is POTUS, as a citizen my opinions, political philosophy, and view of our nation’s place in the world are every bit as legitimate as his. Remember, the President and Congress serve at our pleasure. When he makes a decision which will benefit our nation, I will support it. If I am wrong I will eat crow. In many ways, I’ve grown accustomed to the taste of feathers.
Few things President Obama has done since his election have surprised me. He is following through with the platform he laid out during his election campaign. If there is any cause for surprise, it is that an elected official is actually following though on his campaign planks.
Today however, I was surprised; by a political appointee nonetheless.
News reports claim President Obama intends to appoint Dr. Don Berwick to head the Centers for Medicare and Medicaid Services (CMS). Berwick is one of our ‘gurus’ of patient safety. He is the founder and president of the Institute for Healthcare Improvement, ( www.IHI.org ) ,a nearly 20 year old think tank devoted to improving safety and making healthcare more cost effective. This is an inspired choice by our President. (For a quick biography see his wikipedia entry http://en.wikipedia.org/wiki/Don_Berwick. )
Should Dr. Berwick accept and be confirmed, we may see meaningful reform in Medicare and Medicaid. Changes in these programs tend to trickle down into private plans. None of these reforms will be easy.
Dr. Berwick is an advocate of comparative effectiveness research (CER) which is a way of comparing various treatments and assessing both their clinical outcomes and costs. CER will be a hard sell. Treatments which are not shown to be effective, or only minimally effective may not be covered. Other treatments which may offer a modest clinical improvement but are quite a bit more expensive may not be covered. Many physicians will oppose any restrictions on the type of treatment they offer, even if it is not a proven treatment. It may also limit expensive treatments to certain defined patient populations in which they are seen to be effective. This would curtail ‘off label’ treatments, whether effective or not. If CER is implemented the cries of ‘rationing’ will echo through our profession. However this is not necessarily a bad thing. If an expensive treatment is no more effective than a cheaper alternative, there is no reason to pay for it.
Evidence Based Medicine (EBM) is, theoretically, the way we should practice medicine. But, we only have solid grade A evidence for about half of what we do. We need more rigorous studies of the therapeutics we employ. This must be unbiased and should not be sponsored by the maker of the drug or device at question. At times we tend to overlook data which does not support the way we practice medicine. Some of this is due to financial incentives, some is due to professional arrogance, some due to lack of information, and some because we legitimately disagree with the data, or find it insufficient to support the recommended treatment.
Rational use of CER and EBM, as well as pertinent guidelines will improve healthcare and decrease costs.
I am excited about Dr. Berwick being considered to lead CMS. The changes I suspect he will advocate may be contentious and painful, but our system needs it.
I found an interesting piece about Dr. Berwick’s potential nomination at the website for the Century Foundation.
http://takingnote.tcf.org/2010/03/dr-don-berwick-to-become-medicare-director-.html
Lawauits over Patient Protection and Affordable Care Act (PPACA)
The Attorney’s General of several states have sued to overturn the Patient Protection and Affordable Care Act (PPACA). Most of their opposition to the bill is based upon it’s mandate that individuals purchase insurance or face fines and potential imprisonment. ( I realize this sounds like a stretch, but I once knew someone who spent time in jail for driving with expired license plates).
As Florida AG Bill McCollum states, ‘This is a tax or a penalty on just living. And that's unconstitutional,'' McCollum said. ``There is no provision in the Constitution of the United States giving Congress the power to do that. So it's the absence of authority that is unconstitutional.''
From NPR - South Carolina Attorney General Henry McMaster is leading the charge. He questions the legality of a compromise exempting Nebraska from paying for an expansion of Medicaid.
But [Lindsay] Graham says the Constitution requires uniformity in taxation to avoid what he calls the "gang-up effect." He says it prevents lawmakers from hitting one state with a tax. "Now this is the reverse," Graham says. "This is one state basically being able to benefit because their vote was in play. The Founding Fathers understood if you don't have some uniformity concepts the passions of the moment can overcome reason."
http://www.npr.org/templates/story/story.php?storyId=121869650
Indiana Attorney General Greg Zoeller announced this afternoon that he will join a lawsuit with other state attorneys general, challenging the new federal health care law.
Zoeller said last week that he and attorneys general in at least 13 other states were pondering the legal challenge, but today said that he has reviewed the new law and thinks it is unconstitutional. He says the law requires people to buy health insurance and encroaches on states’ sovereignty by forcing them to set up health insurance exchanges.
“While I personally share the grave concerns that have been expressed regarding this law, I believe it is in the best interests of all — even those who have supported the new law — to raise the constitutional questions to the United States Supreme Court,” Zoeller said in a news release.
“When the federal government imposes unprecedented legal obligations of this magnitude on state government, it is my obligation as attorney general to join and participate in challenging the constitutionality of the bill.”
The initial cost to the state will be its share of a $50,000 legal contract, but Zoeller said it’s unclear how much of that tab the state would have to pay.
He also said it’s unclear how much joining the legal battle in U.S. District Court for the Northern District of Florida could cost Indiana, and Zoeller said he did not set a cap on how much the state would be willing to spend on the suit.
Last week, Gov. Mitch Daniels encouraged Zoeller to challenge the health care overhaul in court, noting that “there are some very good arguments."
Today in my e-mail I received an interesting piece about a medical society which just filed suit to overturn the PPACA.
"The Association of American Physicians and Surgeons (AAPS) became the first medical society to sue to overturn the newly enacted health care bill, the Patient Protection and Affordable Care Act (PPACA). AAPS sued Friday in the U.S. District Court for the District of Columbia (AAPS v. Sebelius et al.).
“If the PPACA goes unchallenged, then it spells the end of freedom in medicine as we know it,” observed Jane Orient, M.D., the Executive Director of AAPS. “Courts should not allow this massive intrusion into the practice of medicine and the rights of patients.”
“There will be a dire shortage of physicians if the PPACA becomes effective and is not overturned by the courts.”
The PPACA requires most Americans to buy government-approved insurance starting in 2014, or face stiff penalties. Insurance company executives will be enriched by this requirement, but it violates the Fifth Amendment protection against the government forcing one person to pay cash to another. AAPS is the first to assert this important constitutional claim.
The PPACA also violates the Tenth Amendment, the Commerce Clause, and the provisions authorizing taxation. The Taxing and Spending power cannot be invoked, as the premiums go to private insurance companies. The traditional sovereignty of the States over the practice of medicine is destroyed by the PPACA.
AAPS notes that in scoring the proposal the Congressional Budget Office (CBO) was bound by assumptions imposed by Congress, including the ability to “save” $500 billion in Medicare, and to redirect $50 billion from Social Security. HHS Secretary Sebelius stated that PPACA would reduce the federal deficit, knowing the opposite to be true if these assumptions are unrealistic.
AAPS asks the Court to enjoin the government from promulgating or enforcing insurance mandates and require HHS Secretary Kathleen Sebelius and Social Security Commissioner Michael Astrue to provide the Court with an accounting of Medicare and Social Security solvency.
Congress recognized that PPACA cannot be funded without the insurance mandates, and will become unenforceable without them.
Court action is necessary “to preserve individual liberty” and “to prevent PPACA from bankrupting the United States generally and Medicare and Social Security specifically,” AAPS stated.
AAPS is a voice for patient and physician independence since 1943. The complaint and more information about the suit are posted at http://www.aapsonline.org/hhslawsuit
More Doom and Gloom
CBO report: Debt will rise to 90% of GDP
Public Debt when President Obama took office - $6.3 trillion ($56,000/househould)
Current Public Debt - $8.2 trillion ($72,000/household)
CBO predicted public debt in 2020 - $20.3 trillion ($170,000/household)
Now this is a serious question, can any of you recall when the CBO overestimated the public debt, or the cost of any government program ? To my knowledge they generally tend to underestimate debt.
Think of our children and grandchildren. Think of our retirement. I will retire in 2040 at age 70. I do not expect social security or Medicaid to be in place by that time.
Granted, I cannot see 40 years into the future, but I do not see a rosy future ahead for our nation unless substantial change takes place in the neat future.
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AT&T will take $1B non-cash charge for health care
“AT&T said Friday that the charge reflects changes to how Medicare subsidies are taxed. Companies say the health care overhaul will require them to start paying taxes next year on a subsidy they receive for retiree drug coverage.”
“Under the 2003 Medicare prescription drug program, companies that provide prescription drug benefits for retirees have been able to receive subsidies covering 28 percent of eligible costs. But they could deduct the entire amount they spent on these drug benefits — including the subsidies — from their taxable income.
The new law allows companies to only deduct the 72 percent they spent.
AT&T also said Friday that it is looking into changing the health care benefits it offers because of the new law. Analysts say retirees could lose the prescription drug coverage provided by their former employers as a result of the overhaul.”
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Companies say health care costs hard to swallow
Another Ringing Endorsement for Health Care Reform
From Drudgereport
In the next few days I expect we’ll hear from Hugo Chavez and Kim Jong-il, and perhaps even Mahmoud Ahmedinejad.
I have had the pleasure of knowing and working with several physicians who were raised and trained in Cuba. I have found them to be as competent as their American counterparts. None of them chose to remain in Cuba. The opportunities offered in the United States are far greater than in Cuba for both physicians and patients. We have the ability to offer more to our patients. Currently there is little rationing of care. Enjoy it while it lasts.
Bio Link
Dr. Jon Burdzy is a family medicine physician in Fort Myers, FL. He is currently Chairman of the Department of Medicine for Lee Memorial Hospital and Health Park Medical Center. Additionally he serves as medical director of Visiting Nurses Association of Southwest Florida. He is a graduate of Nova Southeastern University College of Osteopathic Medicine and Purdue University. His wonderful wife Gwen is the mother of their two children Nathanael and Hannah. She has also been incredibly supportive and tolerant of his diverse opinions and interests.
