Monday, May 30, 2011

Medical Care - Payment and Practice

There has been a major change in how medicine is being practiced in the United States - at least in the state of Maine. The New York Times described how Maine's physicians have seemingly moved further to the "left" politically as the manner of medical practice changes in the state. With the number of female physicians now approaching 50% - women who wish to combine medicine with mothering are opting for salaried hospital positions with defined hours, instead of opening practices. This refashioning of how medicine is being practiced is occurring nationwide, I believe. More and more physicians, male as well as female, are opting for a lifestyle-alteration, allowing more time for family and fun. As a general rule, such salaried positions are not as remunerative as are incomes from private practice - one way that will help in controlling soaring medical costs.

Some other ideas:

1) Limit, or eliminate, reimbursement for procedures and treatments for which there is no documented benefit, e.g. routine mammography before age 50, routine colonoscopy after age 75, certain cancer treatments.
2) License nurse practitioners and other similarly trained medical personnel (e.g. physician-assistants) to practice medicine - independently and without supervision by a physician.
There are 158,348 licensed nurse-practitioners in the United States (American College of Nurse Practitioners, 2008). Just imagine the increase in the availability of medical practitioners if even 50% of them would open family practices, supplementing the present number of family practitioners (95,075 in 2009, according to the American Association of Family Practitioners). Nurse practitioners (see Blog July 16, 2008) are perfectly capable of handling the vast majority of medical issues (I would guesstimate some 95%) for which patients visit physicians.
3) Implement a Ryan-Rivlin type plan (such a plan was advocated by the Simpson-Bowles Committee) which would include a limit on Medigap coverage as well as some form of defined-contribution plan for contributors prior to retirement.
4) Raise the eligibility age for Medicare. The Medicare plan did not anticipate life expectancy to reach 80 (77 for men, 82 for women) by 2011. As the number of aged Americans is increasing, the number of employed Americans contributing to the Medicare pool is decreasing.
5) Medicare supports the post-graduate training of physicians with substantial capitation grants to the medical institutions that carry out the training. Eliminate these programs from the general Medicare budget and assign them elsewhere, so that cost for education and cost for care are separated.

Of these, the one that would include no additional significant cost, yet provide meaningful benefit, is the licensing of non-physician personnel to practice medicine. Remember, the EMT that responds to emergencies and the medic treating field injuries in combat - people to whom we entrust out lives - are not physicians! Don't worry about a properly trained nurse practitioner making errors in clinical judgment. They rarely will, believe me! Being a physician is great - we are well-trained, intelligent, and knowledgable. But as competent as we MD's are, there are quite a number of judgement errors for which we've been responsible.

Saturday, May 21, 2011

"The Holocaust" v. Genocide

The Holocaust (with an upper case "H") is unique. Such a phenomenon had not occurred prior to or since the happenings of World War II. Comparisons have often been drawn between this horror and previous and subsequent genocides, which, to my mind, are not only incorrect, but serve to diminish the monstrous events carried out by the Germans against the Jews in the 1930's-1940's.

The Holocaust is unique from a number of perspectives: 1) it was perpetrated against an ethnic group that had lived peacefully in Germany since Roman times, had no political objectives, was very "German" in its daily existence (and was actually assimilating), contributed positively to German society and economic growth, expressed some of the same prejudices against "outsiders" as did the non-Jewish German, and was generally supportive of German customs and ideals, 2) it was devised and outlined in a clinical, economic, deliberate, well-constructed strategy that was to achieve its goal using an efficient, cost-effective methodology, in which "by-products" of the process such as hair, skin, teeth inlays, medical trials, and energy produced by crematorium-generated heat were to be used in a profitable manner, 3) Jews could not avoid it by conversion, surrender, cooperation, or any other means, and 4) it was to eventually include all Jews everywhere in the world, basically without exception

Ethnic cleansings typified by the Rwandan genocide, Armenian genocide, and the Bosnian genocide were hardly the same. They were rooted in long-standing tribal and ethnic disputes which included political differences, religious differences, border disputes, possible fifth-column activities, and dissatisfaction of one group with governmental control of a minority over a majority. In none of these genocides was systematic destruction at the level of the "Holocaust" ever reported.

The term "Holocaust" is not the same as the word "holocaust." "Genocide" is not equivalent to "The Holocaust." Chief Justice John G. Roberts, in an unrelated matter, observed in The New York Times of May 21, 2011 that "while the ultimate results may be the same - a dead body..... - it is the means of getting there that attracts notice."

Friday, May 6, 2011

Tony Kushner - Honor or Dishonor

Tony Kushner was initially "denied" an honorary degree by CUNY because of his perceived political views regarding Israel. Under pressure, according to the New York Times, the CUNY Board then reversed this decision. Benno C. Schmidt, Jr., the CUNY Board chairman was quoted in the New York Times as believing the board had "made a mistake of principle, and not merely of policy." He went on to say "it is not right for the board to consider politics in connection with the award of honorary degrees except in extreme cases not presented by the facts here." Jeffrey Wiesenfeld, the board member who raised objections to Kushner stated, in a letter to the editor, that Kushner's accusation of Israel participating in "ethnic cleansing" "crosses the line."

Was Wiesenfeld wrong in raising this issue? Apparently a sufficient number of board members thought enough of his remarks to postpone Kushner's nomination (they did not "deny" him the honor), and tabled it until more information could be obtained.

The much honored (including a Nobel Prize) South African Bishop Desmond Tutu has been said to have made anti-Zionist remarks, accusing Israel of apartheid, and more! ( He is hardly the only honored personage to whom such remarks have been attributed - there are many!

Before we jump on the Kushner bandwagon and latch on to the concept of the separation of politics from honorary academic acknowledgment, we should remember Schmidt's own cautionary words about "extreme cases". Is Tutu an extreme case? Is Kushner?

Thursday, May 5, 2011

Keeping History In Its Place

Today's edition of the New York Times includes an article about David Barton, whom the Times indicates is using "America's past to remake its future." According to the article, Mr. Barton advocates the fact that the United States was "founded as a Christian nation," and that the First Amendment has been misinterpreted by the Supreme Court. The Amendment, Barton maintains, does "erect a wall of separation between church and state," but the original intent was to insure government non-interference in religious activities, rather than to prevent the use of public spaces for religious activities.

Let us assume, for the moment, that Barton is correct. So what! The whole process of social and political evolution is to move history forward. There is no doubt that Christianity played a large part in the formation of this country, as it did in Europe - but that was then! Certain principles may still apply, but evolutionary forces will always modify them. History serves as a background to the studies of these forces of change - forces which will always be present, and will generally serve to improve rather than to worsen the societies affected. As a matter of fact, what radical Islam is attempting, I believe, is somewhat similar to what Barton is advocating - a return to historic principles with little concern for how societies have evolved!

The same holds true for the church-state issue. He may very well be correct in his interpretation of original intent. But so what! It's over. Events have progressed as our society has evolved into one far different from the one that was founded on these shores by English and Dutch settlers some 400 years ago! What was a principle at that time, has evolved into new principles acceptable to the society that adopted them.

In addition to expounding on the Jeffersonian or Washingtonian writings of the 18th century, one should consider what these giants would be ideating were they around in the 21st century!

History is a wonderful place to start. But it is only a start. Societies evolve, and their principles will necessarily evolve as well in order to adapt to society's changes. This is not to say that there are not certain principles, Judaeo-Christian or otherwise, that will always hold true, but we have to realize that the society of today can never again be the society of yesteryear. Though history can teach us much, it must constantly be considered in light of the present.

We should never become the prisoners of history. Our past can never be our future.