A Cross Necklace

Being a Christian refugee in this part of the world is a dangerous affair.

Unlike in America, where counting oneself a Christian is increasingly perceived as a designation that affords privilege, sometimes to an unfair degree (I have my doubts on that one), there is no question that the opposite is true in much of the Middle East.

It is easy to see that militant Islamists are actively focused on the eradication of Christianity in at least “Muslim” lands, if not the whole world. This is true to some degree in the refugee camps as well.

Even still, many of the refugees we worked with this week are either committed Christians, or are actively exploring the faith.

The stories of how these people came to their decisions for Christianity vary widely, but most are eye-opening. Few in the Middle East can come to Christ as easily and risk-free as nearly every American can if they wish. Apostasy from Islam is often regarded as an offense punishable by death.

One man I saw this week was openly wearing a prominent silver and gold cross around his neck. I didn’t notice it at first, but as I was listening to his heart with my stethoscope the bright golden object swinging in front of me was suddenly hard to miss.

crossRealizing I wasn’t in America, where crosses are so ubiquitous they’ve become a little trite to me, I exclaimed, “You’re wearing a cross!”

“Yes,” he nodded.

I pondered the implications of wearing that specific symbol in the Islamic world. A cross is better described as cross-hairs for a man like him. Yet he wore the symbol proudly, unapologetically. Should our roles be reversed, would I have the same courage?

“You are a Christian then.” I said, continuing in my new role of Dr. Redundant.

“Yes.” He nodded again, smiling.

Through my translator, I learned that a few months ago in Iran he was awoken in the night by the figure of a man calling him to follow Christ. He said he was convinced that the man speaking to him was Jesus, the Son of God. He knew almost nothing of the Christian faith, as he was raised a Muslim.

Still, upon waking the next day, my patient committed himself for following Christ. He felt he had to do this. It was an inner compulsion; he had been called to a new faith, a new life, no matter the cost to him.

But it was indeed a ‘costly’ decision. Read anything about the Islamic regime of Iran (I recommend the the wonderful autobiography Persepolis as a cursory intro if interested), and you will know that the government of Iran is itself a religious organization. Along with typical functions of any secular government, like providing running water, working roads, electricity and health care (which in many instances, the Iranian government does quite well), it also enforces a highly conservative interpretation of Shia Islam.

How do they enforce such a thing, you ask? How do you get a nation of 77.5 million people to follow extremely strict religious rules? How can you enforce an entire nation to put every woman in robes and headcoverings, to allow no music, no dancing and to enforce frequent observance of Islamic practices like 5x daily prayer?

With “religious police” of course!

As a kid from the suburbs of America, following a Christian faith I was always free to reject, it took some reading and imagination for me to even comprehend such a notion.

It was only in 1979 that the Iranian Revolution took place. Prior to that, Iran probably looked much more like America than it does today. But in ’78-’79, things changed dramatically, as that was the year of the Iranian Revolution. It was then that the Pahlavi dynasty, led by Mohammed Reza Shah Pahlavi was overthrown by the Islamic Republic.

Supporters of the Revolution. Didn’t Turn Out Like Many Expected.

The Republic was initially a political movement, comprised of a collection of leftist thinkers, activist students and numerous Islamic movements. It was led by a powerful Islamic leader named Ruhollah Khomeini, a scholar, author, politician and political revolutionary.

After the Shah was forced from power, to the surprise of nobody, Khomeini was designated as the Supreme Leader of Iran. However, TO the surprise of many, Khomeini was given final authority on both political and religious matters.

The irony of this transformation is hard to miss. Criticism of the Shah centered around how difficult it was for the commoner to be heard. The Shah’s rulership was a dynastic monarchy, with power passing from father to child generation after generation. This meant that nobody could rise from, say, a community organizer and member of a minority comprising 13% of a nation’s population, like Barack Obama, to the highest position of power in the land (Huzzah! Huzzah! Democracy!).

Yet the solution to this problem that emerged in Iran was the Islamic Republic, which consolidated both political and religious power in one man. The power of the rulers of Iran was, effectively, broadened as a result of the revolution. The “little people” never got their say. And, I suspect, many of those who supported the Revolution experienced colossal disappointment. Power just went from one ruling class to another. To this day, a Khomeini rules Iran.

Some version of the above rushed through my mind as I stared at the cross hanging from my patient’s neck. An Iranian, 4 months in Greece, wearing a bright silver and gold cross. Wow.

As it turns out, the father of this man was a member of this religious police force. This patient had chosen to convert from Islam to Christianity as the son of a man who is tasked with enforcing and promulgating Islam in the country. More irony.

Imagine the shame on their family for such an act! Aside from endangering himself, my patient was possibly even endangering his own father (and mother).

Many immigrants come to Europe because they think it is rich, with jobs and money flowing like wine at a wedding party. Increasingly, they are finding that Europe is no utopia. Millions are unemployed. Millions are poor. Upward mobility is rare.

But one reality of Europe is that it does remain a place where you can follow a religion in nearly any any way you choose, to include no religion at all. Say what you will about the EU, but it remains a place of tremendous religious freedom, rivaled perhaps by only the U.S.

So it is understandable that this man left Iran. But it is still amazing that he was willing to do it. He left with nothing. No family, no friends. He slunk away in the night, alone. As the son of an important man, his life had no doubt been comfortable and safe. He upended all of that.

Pireaus Port. Lucky you if you have a tent.

My patient arrived at the Pireaus Port of Athens after crossing the Agean Sea from Turkey. He arrived nearly destitute, having given most of his money to a trafficker to get him to Greece. I think he slept on the concrete sidewalk the first night.

The next morning, he says he prayed that the God of his new faith would spare him, and shortly thereafter was approached by members of a Christian church in Athens who offered him a bottle of water. It was through this church that I met him.

ellenikoGreek authorities soon placed this man in the Elliniko refugee camp, where he made no secret of his faith, sharing it with any around him who would listen. Not long after his arrival, a riot broke out in the camp with Muslims targeting Christians.

The violence carried on for quite some time, as Greek police made no move to stop it, one even pointing out that if some of the refugees died, “there will be fewer of them for us to deal with.” My patient was beaten severely in the melee.

It is inhumane, of course, for anyone to think as these police did. But their attitude is understandable nonetheless. Would you wade into the middle of that mess?

Somewhere in this story, my patient picked up his cross. I don’t know if it was in Iran or somewhere in Athens. But he wears it daily. It is not merely jewelry to him, given at some Christmas party. It wasn’t bought from one of the ubiquitous Christian Book Stores in America, with every possible permutation of “cross trinkets” available for sale. It was bought for a price; worn for a higher one.

This isn’t necessarily a Christian story, although as a Christian I find it inspiring. But from this anyone can recognize the deep human desire to worship in freedom. This man’s life story is a reminder that people are willing to die for the right to think and act honestly in relation to their understanding of the divine.

The cross symbolizes the reality of this man’s beliefs, even if that symbol marks him for suffering or even death. Would that all Christendom be so committed. Would that all who cherish freedom be so as well.

Headed Back to Athens


The Acropolis in Athens, Greece.
Athens, looking pretty. A rarity, IMHO.

For the second time in less than a year, I’m on my way back to Athens. This will be a short trip with virtually no team. My colleague organizing things in Athens has stated that she “feels sorry” for me, as the number of people signed up for the clinic appears to be quite large.

From what I can tell, the situation in Greece has only gotten worse since I was last there. Many borders and routes into Europe have closed, and migrants are being turned away at far greater numbers than they were last year. But by “turned away,” I’m not describing from Greece itself. Nope. Thousands continue to arrive on the shores of Greece every day. I’m talking about further into Europe. So, the migrant population continues to swell in Greece, especially Athens. Although authorities have begun shipping back some migrants (numbering in the hundreds) in the past few days, this is a small small number.

I say I’m bringing ‘no team’ this time, but in reality this isn’t accurate. Aside from what sounds like a great number of willing helpers in Athens, I also will bring my 14 and 16 year old daughters with me this time. I don’t know what sort of role they will be able to play in the work we do this time. It could be simply watching the children of the patients while they’re waiting the doc.

migrantsHopefully, they can learn a bit about medical care in a refugee and/or underserved situation. As their lives are largely consumed with cheerleading, skinny jeans, teen-lit, French horn, Cello, soccer and boyfriends (ex…EX boyfriends), this might be quite an eye-opening experience for them. I hope so.

My biggest concern is that we will successfully collect accurate data on the patients we see. Last time we did a fair job, under the circumstances, but in my spare time I’m STILL working through the XL spreadsheet and trying to come up with data summaries that will be of some use to the wider medical world.

This time, I hope to have time to ask better questions, and to formalize how we input the data. It is well known among those who do medical research that 80% of the study is done before the study begins. Developing a means to collect data, to college USEFUL data, and to do it in a way that is searchable and accessible at a later date is difficult. It is especially difficult when at that later date, you are dealing with hundreds, maybe thousands of data points.

I’ve had enough training in this element of the medical world to feel a gnawing sense of anxiety as I approach the issue. My medical school heavily emphasizes epidemiology and biostatistics, and I was part-way through an Master’s in Public Health degree until I ran out of money. So I have a sense for how easy it is to do this stuff badly. But I wish I had a collaborator or better skills to know I could do it well.

Still, I’ve had some help from a colleague at work who maintains a quizzical affection for XL (I can’t judge, I was once in a steady relationship with Photoshop), and he has helped me clean up our data from October. And I have a much better sense for what I need to do this time around.

14_athens_imgIt should be mentioned that most relief agencies don’t actually do any of this, even the good agencies who actually help people (lots of them are there for the photo-op and little else, it seems). I received some generous help from a professor at the London School for Hygiene and Tropical Medicine prior to my last trip, and he noted only a small number of agencies who provide care AND do good, statistical research on the populations they serve.

So, it makes sense that I’m somewhat on my own here. It’s not easy to focus on research and practical care at the same time, as one is more empathy-driven, the other much more analytical and “cold.”

Example: if someone comes in coughing up blood, you can either turn and enter “hemoptysis” into your spreadsheet (and then get the heck out of there because…ew), or you can throw on some gloves, hopefully a mask, get them on a bed and start working them up for any of the many many possible reasons for that symptom (most of those reasons being prit-TEE bad).

So, we will see how this goes. We leave tomorrow (Sunday) afternoon.


‘Concierge’ Medicine – A De Facto Manifesto

My blogging output has been at an all-time low since moving to Europe.  Who knows why…this place is such a bore.  I continue to hack away at my book, which never seems to get close to done – the literary equivalent of Sisyphus’ ever-rolling stone.

The other day a reporter contacted me to hear my thoughts on so-called “concierge” medicine.  It was a timely query, since I’m considering a loose offer to join a concierge practice back in the States.  In my email reply to him, I found myself writing my own little manifesto on the subject.  A treatise, if you will.  A declaration.  A primer? A resolution, a promulgation…

William Osler (1849 - 1919), Professor of Clin...
I have a idea...how 'bout I actually know who you are, AND care about your medical issues?


I’m a big believer in concierge medical practice, although I use the term “concierge” only as a nod to already-established norms.  Really ‘concierge’ medicine is a throw-back to true primary care medicine before it was ruled by other industries.  So the idea isn’t new.  It’s old – old as William Osler and Johns Hopkins and William Carlos Williams.
This industrial “take-over” I mention isn’t entirely due to craven insurance businessmen.  It’s also due to the allure of “Wal-Mart” pricing that so captivates Americans.  I suppose you’ve heard the adage that as a consumer, you can only have 2 out of 3 options in the market: Fast, Good and Cheap.  If you want something fast (hamburger), you can get it cheap (McDonald’s) but it won’t be good.  Or, you can have it fast and “good” (quality, taste, etc), but it won’t be cheap (maybe, Red Robin?).
This principle is true in medicine too.  Americans, over the past 20 years, have been trending toward Fast and Cheap medicine, just like they want clothes, household goods, food, etc. quickly and cheaply.  Hence, the rise of WalMart, which provides easily acquired things of questionable quality.
Concierge medicine isn’t “cheap,” by WalMart standards.  It requires real cash investment.  But it IS better.  And, while there is little problem with wearing nondescript, zero-style golf shirts to work every day, primary care is different.  We’re talking about your life, here.  Not only are you likely to live longer and healthier with good primary care, but it really is cheaper over time because it is so effective in offsetting gigantic medical calamities later.
I dispute the notion that no one can afford concierge medicine, by the way.  Most people in the richest nation on earth perceive they can’t afford it, but really can.  I blame this perception on the invention of the 10-dollar co-pay.  This idea was such poison in American medicine.  It made medical care seem like the equivalent of a few iTunes, or sunglasses from a roadside gas station – just another in the ocean of cheap, disposable and generally worthless products. Yet so many Americans shell out enormous amounts of money on alcohol, cigarettes and fast food.  They don’t think twice about coming up with over a thousand dollars to fix the clutch on their car, or to trick it out with lights and racing wheels.  But when it comes to good, relationship-based primary care, they resent anything more than “10 bucks.”
I’m currently in a line of work that provides “free” care to everyone (the military), so at the moment I have no vested interest in the above comments.  But I continue to feel strongly that it is not immoral to require a reasonable, even significant, amount of money for true primary care, especially when obtaining that care may require cutting out things that are terrible for your health.  I see major problems with a medical system that tries to provide unlimited access, especially when coupled with zero perceived cost for that access and care.
More health care is not better health care; worse, it can be dangerous.  On a daily basis, people needlessly lose breasts, prostates (read: sex life), resistance to microbes, and countless other quality of life measures in the process of hunting down phantom maladies or responding to false-positive tests.  High-quality primary care offers good, analytically based work ups of genuine symptoms that justify that work up.  NOT investigating something further can often be the best medical care available.
I mention ‘analytically based’ decisions because most mid-levels (a cost-cutting invention in American medicine) are trained to provide algorithmic decision-making:  that is, if X symptom, then Y action with little analysis involved.  recipe medicine.
Often algorithmic medical decision-making is just fine, but it easily leads to over-testing and over-treatment.  When it comes to possibly dying from cancer, for example, most of us want someone who knows us, knows how we communicate, and what is important to us (e.g. dignity vs. “full court press”). Further, we want that same person to be well-trained in weighing the risks vs. the benefits of treatment vs. non-treatment, based on the latest available medical knowledge.
Doctors seeing 20 patients a day can’t provide this adequately.  Mid-levels are not trained to provide this type of risk-benefit analysis, and don’t have the hours of training experience even if they wanted to.
Disclaimer:  I’m speaking in generalities here; there are fantastic PA’s and NP’s out there, many of whom are compassionate and professional; better than many physicians.  Most I’ve met are smarter than me.  But in general, the care from a mid-level is fundamentally of less quality because the training of a doctor is an average of 3 times more than any mid-level (roughly 3,000 hrs vs. 12,000).  This differential limits mid-levels to algorithmic, rather than analytical, decision-making.  When it comes to your health care, the mantra should be “reason, not recipes.”
These days, you can’t get this care from HMO’s (Group Health in Seattle is getting very close), you can’t get it from mid-levels.  The only place I know where you can get this level of care, is in a ‘concierge’ practice, where the benefits of the increased cost are immeasurable.

I KNOW What This Is

No, you don’t.

In medicine, certainty is a very dangerous thing.  It’s ok to be certain about things like the price of gas or your dislike of prunes (couldn’t blame you).

Certainty in medicine is quite another.

And, although politically incorrect to say it, I’m finding a frustrating amount of unjustified certainty among the ranks of the “mini-docs”.  By mini-doctors, I mean all the permutations of lesser-trained white coat-donners.  The PA’s, ARNP’s, Dr. RN’s, LPN’s, etc.

Hello. I'm not-quite-a-doc. I know EXACTLY what you have.

Exposed to about 1/3 of the training of the average primary care M.D. (if that), these sorta-doctors function in American medicine with nearly complete autonomy (and are constantly pushing for more).

I have no problem with these relatively new additions to the medical field.  I myself criticized my training as too long, redundant and costly while enduring it.

But the more I work with patients who see them, the more I run into decision-making that is flat-out problematic.

I should mention that many P.A.’s I’ve trained with were clearly smarter than me.  A couple of the ARNP’s I currently work with are easily as  bright or brighter than my – shall we say – earth-friendly mental wattage.

But I’ve learned that smart brains often don’t  lead to good medicine.  In my opinion, what makes the best medical decision-maker is an acute awareness of ignorance.

You could call it intellectual humility, if you wish.  It could be that all the hours of training in medicine really just cultivates this humility to refinement.  I can see the value of that.

In the last week, I have dealt with numerous decisions of certainty in medicine that were completely unjustified.  All were made by PA’s and ARNP’s.  As patients described their experiences, I could tell their previous providers were of the para-doc variety even before they confirmed it for me.

“I’m here for antibiotics, Dr. Secretwave101.”

“Really?  What for?”

“I have pneumonia again.  I had it 5 times last year.  I just have to come in and get antibiotics for it.  It’s such a pain!”

“PNEUMONIA?  FIVE times in a year?  Are you sure?  Confirmed by chest X-ray?  Do you know the organism?  Bacterial each time?  Which lung?  Was it a particular lobe?  Were you hospitalized?  Did you have pulmonary scarring as a child?”

“Uhhh.  I don’t know any of that stuff.  I just need the medicine.  I always just come in with this cough and get the medicine.”

Pneumonia is a big freaking deal.  Real pneumonia kills people.  Like, healthy, not-old, not-sick people.  Real pneumonia almost never hits someone 5 times in a year.  Once, and you’ve had a tough previous 12 months.  You get it 5 times and you’re basically telling me that you’ve spent the previous year in a hospital with chest tubes, IV meals and a bag to catch your pee.

There were two problems with the patient encounter.  One, the patient wasn’t well educated by her provider, who clearly had numerous opportunities to clarify things for her over the previous year.  She didn’t have pneumonia 5 times, she had a cough.

The provider also never worked up the cough to see what it actually was.  No X-rays.  No sputum cultures.  No pulmonary function tests.  Just antibiotics.  Broad-spectrum antibiotics.

gas1In another post, I will describe why throwing antibiotics toward a cough with no evidence of bacterial involvement is absolutely catastrophic for the long-term survival of the human species.  That statement is a rare instance on this blog where I’m not stating hyperbole, either.

Antibiotic resistance is real, and the results of it will kill you.

I also recently recommended that my sister-in-law take her son into an urgent care center to be evaluated for what sounded like strep throat.  That would be, Streptococcus Group A pharyngitis.

“Did you know,”  I asked her, “why we treat strep throat?”

“Well, he could get really sick, right?”

“Yes, but not from the throat infection.”

“So, we’re not treating the throat?”

“No.  That goes away.  Most pharyngitis is viral and goes away.  Even bacterial goes away.  We only need to treat one specific cause of pharyngitis, Group A Strep, because it can also cause heart disease, kidney disease and all kinds of other stuff.”

“I didn’t know that.”  She replied.

I didn’t either.  Not until years into my training.

The next day, I found that my nephew was taken to a P.A. at the local Urgent Care and without a culture or any other objective work up, he is diagnosed with “strep throat” and given antibiotics.

“I don’t even need to test this, the symptoms are so classic.”  The “doctor” reportedly said.

Two days later, the boy’s little sister gets sick.  There’s no culture from the back of brother’s throat.  We have no idea if what he had was viral, bacterial, fungal or nothing at all.  He may not have even needed the antibiotics, and likely didn’t have the right ones if he did need them.

Now we have no idea what his sister has.  Is it the same thing?  Is it something new?  I guess we’ll just throw some antibiotic at her, too and say they both had STREP THROAT, even though we have no evidence of this.

Did my nephew's throat look like THIS?  Did anyone even look?
Did my nephew's throat look like THIS? Did anyone even look?

Certainty in medicine flat-out leads to bad medical care.  Everybody has the urge to think they’ve got this or that totally nailed from time to time.  Doctors too.  Maybe doctors more than other health professionals.

But my experience so far is that certainty increases with less training.

My warning to you is this:  If your health care provider is CERTAIN about your health problems, you don’t have a very good doctor.  Humility comes from a wide differential diagnosis.

In nature, the humble survive; the proud die.

Another Study

A group called The Physicians’ Foundation came out with yet more evidence (check it out here) supporting what you probably hear from most of the MedBlog community in different forms all the time.  If you read my blog regularly, you’re probably also aware of some of my cyber-colleagues like Kevin M.D., Dr. Wes, The Happy Hospitalist, Fat Doctor, Shadowfax and others espousing similar concerns.

We’ve all talked about how primary care is becoming untenable.  Now there’s a questionnaire survey that was mailed to every primary care doctor in the country, and it backs up our claims too, essentially asserting:

Primary care medicine sucks if you can’t spend time with your patients.

We didn’t go into medicine (and enormous debt) to do paperwork and argue with insurance companies.  People who do paperwork and filing for a living don’t understand our intolerance for their way of life, but it’s a fact that not everyone likes the sterile confines of alphabetization, algorithms and cubicles.

Some argue that the answer is more allied-health providers for primary care, like N.P.’s, Dr. Nurses (weird one, I know), P.A.’s, etc.  I disagree.  Excellent health systems provide excellent health care, and that starts with well-trained providers with doctorate-level education.

Residency-trained family medicine doctors average 12 THOUSAND hours of training before practice.  Nurse Practitioners average around 3500 hours.  Same for P.A.’s.  These people are easily as intellectually-equipped as doctors, but I think the idea that they are as well trained or can replace physicians is ludicrous.

I also hope lawmakers intent on saving our system don’t rush to the EMR (electronic medical record) as the messiah of American medicine.  It isn’t.  I use one every day, and it does very little to improve care and absolutely nothing to improve efficiency.  If EVERY doctor used an EMR that talked to all other EMR’s, efficiency might improve somewhat.  But our capitalist system has provided us with dozens of competing companies and, given our obsession with medical privacy, none of these programs communicate with each other.  Digital charting takes hours and is only slightly improved by hacking away on the keyboard during the entire patient encounter, detailing everything as it happens.

And, for a future blog, those records do nothing to protect doctors from litigation.  Trust me.  Nothing.  If anything, they help the plaintiff.

Also on the EMR topic, it is colossally more expensive to sustain than just some basic paper and dictated notes.  Companies LOVE the idea of EMR’s because the required tech support, and database maintenance, and program upgrade requirements are virtual gold mines.  In the end though, it’s another of thousands of examples of business and enterprise making money on medicine – the real reason American medicine is falling apart.

Like the canary in the coal mine, as Family Medicine goes, so goes American health care.  If well-trained doctors are getting out of the business, the natural corollary is that you, over time, will be getting sicker (and poorer).

Kennedy Pulls Through

Pay cuts to doctors who take medicare (this would be virtually all of us) have been blocked by Congress today after a dramatic vote led by Senator Edward Kennedy.  It was a heady day in the world of medical politics.

A few years ago, the government decided it would be a good idea to ‘balance the budget’.  A balanced budget is nothing more than making sure you spend at least a teensy bit less than you make.  My readers of conservative mind will probably find this balancing act a rather good idea.  This includes me.  Always good to not spend money you don’t have.

The problem is that under the guise of ‘balancing the budget’, politicians decided to cut doctors’ pay.  This decision does nothing to help fiscal matters, but is very politically-expedient.  Insurance companies have a tremendously powerful lobbing organization, and most officials figured it was smarter to knee-cap docs than insurance billionaires.  Thus, they voted to continue directing the jet-wind of dollars toward an industry that exists by preying on sick people.

Recently the first of two MAJOR pay cuts finally arrived, set to begin on July 1st.  The AMA – an organization I generally regard as a lifeboat filled with “The Others” from Lost (they’ll probably kill you…but they just might save you if they feel like it) – actually focused themselves and put up a good fight.  They lobbied hard, went public and pressured wavering lawmakers.  Eventually, the Democrats (Max Baccus kinda got the ball rolling) put up a proposal to block the cuts, and after some wrangling, a law passed in the House by a landslide vote 355 to 59 vote.  Good.  Now all that was needed was the Senate to pass the same law.  Then doctors across America could go back to wondering how they’re going to pay for the rising costs of insurance with Medicare payments that haven’t kept up with inflation since the ’90’s.

The problem is that the Senate is where the insurance lobby has more traction.  It put more lobbying effort there in the first place.  Furthermore, they have George Dub in their pockets as well.  He’s so strung to them he has vowed to flat-out veto a bill that blocks the pay cuts.

“WHY?”  You might ask.  “WHY would he do that?  Oh, that’s RIGHT!  Dubbage is a conservative.  He’s hewing to good, conservative economics.  It must be that the one expense we can’t pay for while keeping a balanced budget is doctor’s salaries. “

Not even close.  Bush is more liberal than Clinton when he was a barefoot hippie not inhaling Russian weed and perpetually copulating in the back of astro-turfed pick-ups.  Bush has no principles.  He did once, but he’s been bought.  By insurance companies, among others.  He threatened to veto the new law for the simple reason that it pays for itself by lowering payments to something called “Medicare Advantage”.

Medicare Advantage is medical insurance from a commercial insurance company, but instead of the patient paying the company – like normal – the government pays for it instead.  Medicare pays for medical care for 44 million elderly and disabled Americans.  For 80% of these people, Medicare simply sends money to doctors when the doctor sends Medicare a bill after seeing a patient.  The other 20% (approximately 8.7 million people) use MA (Medicare Advantage). Enrollment varies widely across states.  Over half of the enrollees are located in CA, FL, NY, OH, PA and TEXAS.  Most of the rest are in a smattering of states and some states have almost nobody on the plan.  The plan is ostensibly accessible to everyone, but in fact is unevenly utilized and by definition costs the system more because TWO payers are in the mix rather than just one.

Bush wants to protect this system by lowering doctors’ salaries.

Medicare doesn’t pay great (if the doc bills $100, they’ll just sorta figure they’ll send about $75…somewhere in the world, that’s called stealing, but not here), but they do pay.  Until we come up with a more comprehensive system, Medicare is worth keeping around.

The Senate was initially dead-locked on the bill.  Democrats were united in favor of it, but a number of conservatives were against it (the ‘big business’ thing, you see).  Today, however, just at the Senate began to re-vote on the issue, in walked a weakened but determined Ted Kennedy – recently released from the hospital – leaning on many assisting arms.  He slowly made his way to the podium and cast his vote in favor of the bill to thunderous applause from both the gallery and the representatives – traditionally a no-no in the staid and musty Senate chambers.  Caught up in the moment, numerous Republicans switched their votes, and the bill passed by a solid margin, 69-30.  If Bush has the bald temerity to veto the bill, and everyone re-votes just as they did today, the bill would survive even the President’s craven attempt at pandering.

The answer to the woes of our medical system do no lie in harassing doctors or paying them less – a trend that has been gaining prominence over the past 20 years.  Sensible liability, insurance profit constraint and funding for primary care is what will save American Health Care.  Our government needs to figure this out quickly, because currently we’re relying on the common-sense and courage of a feeble, white-haired lawmaker dying of brain cancer.


Recently I began providing my email address to my patients.  I’m not the only one, either.  You can read about how surgeons are starting to stay in touch with their patients, and how both parties are generally happier about it.  There’s a quick article about this issue here.

One of the big-time medical blogs out there, Kevin M.D., also weighs in on the subject and points out that there are some problems with this new practice.  One of the big ones he mentions is that email communications are probably often not HIPAA compliant.  If you don’t know what HIPAA is, I recommend that you NOT educate yourself.  HIPAA is classic D.C. armchair policy-making that is meant to protect patient privacy, but in reality does less for this goal than intended.  I’d prefer the acronym HIPPO.  The policies are minute and voluminous, arcane, endless, cumbersome and impossible to follow perfectly.  Worse, they’re meant to apply to every single health system in America.  No regional variation.  No State individuality.  EVERYBODY. 

In general, of course, the idea (initiated in ’96 by Bill Clinton) is a good one.  Nobody wants their health info on YouTube.  But while health information certainly is sensitive, the frank truth is that it isn’t high-value stuff.  I’d be much more worried about someone using my identity information than my medical history to ruin my life.  HIPAA policy – and the enforcement of it (they call it compliance) – has become an entire career field…all to protect information that is almost never interesting to anybody, even to the guys in ski-masks and dark glasses.

privacy_lock_72_jpg.jpgAt any rate, it appears that doctors may not be able to talk to their own patients by email unless the system is hyper-encrypted to keep bad guys from getting the info and…oh, selling it on the medical info black market in Paraguay or whatever. 

You can see that I have a dim view of government policymaking.  I think government policy is often nothing more than a cathartic exercise for people with an above-average need to feel important.  Writing stuff – even stupid stuff – that other people have to obey will make you feel important.  In fact, the more stupid, the better.  You’re in control.  “DO IT!” you can demand, “Even if you think it’s dumb.”  You’re The ALPHA.

Government wonks do this all the time, resulting in thousands of rules – which fulfills their own subconscious needs – that tend to be laughable and illogical when applied to every single human in America.  HIPAA is supposedly in place to protect patients from losing their info.  With respect to email correspondence between doc and patient, shouldn’t the actual patient themselves have the right to correspond with their doctor however they choose?  No.  You, dear ignorant patient (and doctor).  You have no idea what is good for you.  We here in Rached, D.C. will take care of you, whether you want us to or not.

The truth is that doctors, me included, HATE making phone calls.  They take forever.  The number is invariably wrong.  You have to find somewhere to talk where your conversation isn’t going to be overheard.  You NEVER get paid for them (unlike lawyers, who must have listened in their business classes).  And often the patient isn’t there and you have to fret over leaving a message or not, never knowing who is going to hear the message, etc. (violating HIPAA, again)  Ultimately, I feel bad that it takes me so long to get back to a patient when they leave me a message.  Email is a perfect solution. 

Or was…until policymakers totally remove this option from patients and their doctors. 

The number of people edging themselves between patients and their doctors over the past 30 years is truly amazing – government, lawyers, insurance agents, pharmacy, to name a few.  The evolution of this new army of medical middle-men, I believe, will be what is remembered about American medicine 100 years from now.  And I think it will be looked upon as a largely aggressive and capitalistic change that generally harmed patients, not helped them.