Our friends the Republicans

The more I study the current crop of Republicans the more convinced I am that there is one common trait which seems to run in the majority: selfishness. It was well characterized by the British in the comment "I'm all right Jack – the hell with you".

Republicans seem to feel that if they are fortunate, hard-working, and skilled enough to have a good life or what they think is a good life, they should denigrate and scoff at those who were not fortunate or hard-working or skilled or all of the above.

They point out that this attitude is what made this country great and the more I think about it the more I agree with them. During most of the 19th century expansion, development and industrial growth were in the hands of single-minded entrepreneurs whose only goal was success in their endeavor and cared little if at all for the people they brushed aside or stepped on in the process.

But the side effects were disastrous, leading to a severe and deprived underclass, labor strife up to and including attempted murder of factory owners (such as Henry Clay Frick), and a dramatic gulf between the very rich and the working poor. The Republican Theodore Roosevelt recognized this social disaster and began the process of government regulation which has been expanded ever since as the entrepreneurs found more and more devious and clever ways of getting around regulation.

So the Republicans would like to return to those days with no income tax and little regulation so that they could again trample on the less fortunate, aggressive or ambitious of our citizens, without a single thought of what got them to be successful and whether it was indeed morally justifiable.

From the standpoint of creating a great nation, the Republican state of mind was extraordinarily effective but from the standpoint of creating a just and smoothly working society is totally disastrous and that's where we stand today, on the brink of a disintegrating social contract. The Democrats are not very effective in countering this since some of the emphasis of the party is controlled by plaintiff's attorneys whose primary goal is tort litigation against industry and its leaders rather than support of and aid to the working poor, the disabled, the mentally disturbed and deficient, and the chronically ill and dis-functional.

This could all be nicely taken care of by the voters, especially those who do not want to see our country deteriorate into the situation we found in the 19th century. But I keep hearing, from people who would agree with the above, that they have "given up on politics" and are not interested in redressing the problem at the ballot box. Talk about your self fulfilling prophecies! There are so many nonvoters whose hearts are in the right place but who sincerely believe that politics is merely a game and they're not playing. That attitude is so scary it makes my hair stand up and it is a major cause for the mess we are in now. I don't know what can be done about it except to express my opinion, so there it is. What do you think?

Christian Hypocrisy?

I have no quarrel with Christians who are trying to follow Christ's teachings, albeit with many failings, as long as they don't start trying to change society to fit their ideals. Then they become hypocrites.

For example, those who say that the Bible is the given word of God, and that everything written in it is to be taken literally, then claim to be following God's commands, and are praying to a group in a church or on TV. Then they flout the command in Matthew 6:5 -

"And when you pray, do not be like the hypocrites, for they love to pray standing in the synagogues and on the street corners to be seen by men. I tell you the truth, they have received their reward in full.
6 But when you pray, go into your room, close the door and pray to your Father, who is unseen. Then your Father, who sees what is done in secret, will reward you.
7 And when you pray, do not keep on babbling like pagans, for they think they will be heard because of their many words.
8 Do not be like them, for your Father knows what you need before you ask him."

And those with worldly goods, who claim to be devout Christians, and flout the command in Matthew 6:19 -

"Do not store up for yourselves treasures on earth, where moth and rust destroy, and where thieves break in and steal.
20 But store up for yourselves treasures in heaven, where moth and rust do not destroy, and where thieves do not break in and steal.
21 For where your treasure is, there your heart will be also."

So TV evangelists, who scoot around in private jets and live in palatial surroundings (whether or not the title is in their name) are, by Jesus' own words, hypocrites. So why do Christians treat them otherwise? And wealthy citizens who profess to be devout Christians, are likewise.

Advertising, Bribery and the First Amendment

I have almost stopped watching network TV. Once in a while I'll catch an important sports event, but that's about it. Network news is marginally interesting at best, scheduled programming is boring to revolting, but the real reason I have stopped is advertising. Not only are the advts. creeping up on program content in length and number (most egregious is the number posted just before the weather forecast on the news) but their material is more and more nauseating. One of the reasons that I watch international soccer is that there's no stoppage of play and thus no advts. can sneak in.

Advts. are not only upsetting of themselves but they destroy the carefully crafted mood of good drama. How can you follow a demonstration of major grief or anguish or terror with a smarmy housewife pitching floor wax with a stupid grin?

Anyway, commercials are here to stay. And anyone who can stand them should be able to watch. But, then, why the ineffectual and ludicrous regulations about content? Take the clearly mandated ones about automobile leasing. First, the hype. Then come the legally required facts about the lease, printed in dirty grey, 10-pitch lettering, scrolled at unreadable speed. Or on the radio, spouted by a trained pitchman at half volume like a tobacco auctioneer. No wonder our government is regarded as a toady to commercial interests. Here's proof all can see or hear every day. Whom are we kidding? It's literally nauseating.

And drug ads. As a retired physician I have been as guilty as most in accepting largesse from Big Pharma and believing some of what I am told without confirming through scientific studies and double-checking the claims. But I'm not proud of it, and would be delighted if all ads. for prescription drugs, and all pitches to physicians were to stop. It's dead wrong and it's dangerous.

But there is the First Amendment. Corporations are as free as individuals to speak out on any (well, almost any) subject. I would love to see a law banning marketing of prescription drugs, both to patients and to physicians. But I fear that such a law would be unconstitutional.

I would love to see the FTC really force advertisers to comply with the spirit of regulations, not just their letter, and stop the hypocrisy. But as long as the electoral process is like an auction of influence and power to the highest bidder, that ain't gonna happen either.

Comments?

Second Amendment thoughts

I have been reading some ideas from the second amendment debate. Those who favor gun control use the argument that if the framers had intended free use of guns by the citizenry regardless of participation in a militia, they would have left out the first part of the sentence and just stated that "the right of the people to bear arms shall not be infringed". But they didn't leave it out.
Opponents of gun control use legal precedent to bolster their argument that the courts have largely favored individual rights, starting with the Reconstruction when freed slaves were allowed to arm themselves against lethal Klan aims. They favor the right of law-abiding citizens to arm themselves for hunting and self defense.

To me, the problem comes down to this: what do we do about law-abiding citizens who buy arms and then become non-law-abiding? And what about non-law-abiding citizens who haven't been caught yet? I don't hear much debate on this question, which is buzzing along just beneath the surface. Just yesterday an employee in Henderson, KY blasted away at work, killed 5, then himself. Up until the moment of his action, he was law-abiding.

What do we do about him and his ilk? Do we treat him like a tornado or a lightning strike? Shrug, and say that there is no way to protect us against him? Or do we all start carrying concealed weapons, so that if he shows up at work or on the campus and pulls out his gun, there's a slim chance that one of us will plug him before he opens fire? Why is this dilemma so egregiously American? We don't read about this in Sweden or France or Germany (gang violence excepted). Why is it such an exclusively American phenomenon?

I'd love to have a dialogue on this.

Fixing the Healthcare Mess

As a retired physician, I am aghast at the state of the art in my chosen field. There is no doubt that marvelous tools exist to diagnose and treat as never before, but at what cost? And who can take advantage of them?

The cost of drugs is too great. Primary care is spotty and hard to reach. Specialty care is a cottage industry. Politicians haven't a clue. Health Insurance is an oxymoron.

As I see it, there are three main areas of attack: funding, motivation and organization. Listen up, then please respond. Together we can start to deal with this farrago.

Let's start with motivation, which will lead into funding. Let me state from the outset that I believe that the majority of my colleagues are motivated to heal the sick and many, even at the risk of financial setbacks. However, the whole issue of motivation is on its head. All the major forces in healthcare motivate the physician and surgeon to perform. See patients, do tests and procedures. That's where the money is.

The word doctor comes from the Latin "docere", to teach. Not to perform. Teaching patients and other laypersons is widely neglected in the field, and poorly motivated, if at all. Yet the best weapon we have in Medicine is the informed patient.

Therefore, to begin the correction process, we need to address this error in approach. We need to motivate our professionals to teach. And there is no more powerful motivator than money. I have a suggestion on how this might be accomplished.

First of all, diminish the reward for doing to be equalled or surpassed by the reward for teaching. This will accomplish the admirable goal of having the physician pay more attention to what his patient understands about his body, its troubles, and his options.

Each physician would receive a base yearly stipend determined by his years of training, years of experience and the inherent risks of his field (i.e., neurosurgery would be paid at a higher rate than dermatology). On top of this, a bonus system would increase the stipend based on three criteria: maintenance of continuing education, patient satisfaction, and hours of practice.

Continuing education would be revamped. Isolated courses would be downplayed and ongoing, home-based, programmed learning substituted, with frequent pop quizzes for credit, and periodic reviews. The subjects for the programs would be chosen by each physician based on her actual clinical encounters. What she sees most often and what he feels most in need of study. However, the program would be structured to include eventually the broad scope of the field.
Scores on the quizzes and reviews would be determinants for the bonus.

Patients would receive from the office at each visit a confidential questionnare, to be mailed to a secure site, on their degree of satisfaction with the visit. They would be clearly led to understand that the physician's income depended on their submitting the questionnaire. This would lead to a form of passive rating of the visit. Non-submission would be a subtle criticism. Beloved doctors would get a higher percentage of responses. On the questionnaire would be such questions as "Were you seen in a timely fashion? Were the staff friendly? Did you understand what you were told? Were you given the opportunity to ask questions? Did you feel rushed? Were you given materials to refresh your memory? On a scale of 1-10, how satisfied were you with the visit?" The ratings would be analyzed and the bonus adjusted according to the answers and the percentage of submissions.

The physician would be invited to submit his hours of operation, including study time, and this self-rating would be checked by the payor against objective measures such as number of patients seen coupled with patient satisfaction, submisison of quiz results, and the like. A bonus would be paid but there would be a maximum time allowed for increased reimbursement to discourage burn-out.

There would be reimbursement for doing procedures, but it would be scaled down to discourage doing them for their own sake. The reimbursement for doing should never equal, let alone exceed, that for teaching.

The result of this approach should be that of empowering the patient to make more rational decisions, and reducing the moral bullying that goes on in so many medical and surgical offices. The patronization that says "I am the expert here, so do what I say". This should reduce the all-too-frequent occurrence of expensive and marginal medical adventures and therefore the cost of care.

Next, we should do away with the whole concept of "health insurance". An underwriter once pointed out to me a simple truth in the insurance business in the form of an aphorism: "never insure against the inevitable". This introduces the concept of "actuarial risk". To put it simply, if something is likely to happen, it is financially unwise to insure against it. That is not to say that one shouldn't plan for it and prepare for it. But insurance is a special kind of preparation that is designed and engineered to reduce the burden of infrequent to rare occurrences, such as tornadoes, forest fires, car crashes and the like. Not health care. Especially not preventive medicine.

In the insurance model, if you are insured against an occurrence, you and your fellow subscribers pay a stipend to an agency each month and then if you are hit with a disaster, funds are disbursed to pay for reparation. In the health insurance industry, you pay the stipend, but then turn around and collect with each medical encourter, which is far from uncommon. This has the result that you pay the health insurer to cover your office visit and tests plus the cost of administration. So if the administrative cost, is --say-- 20%, you end up paying $120 for every $100 of care you receive. This is definitely not in your best interest.

So do away with "health insurance" and substitute a more direct and less costly way to pay for care. I like the model of "health savings accounts" in which each patient sets aside income to cover the cost of health care, and each patient decides how it is to be spent. But, this model needs much tweaking. Many, if not most people will not be willing to spend their own money for preventive care, unless they are taught its importance and the cost of ignoring it is made crystal clear. This requires education and motivation, and those cost money. Perhaps a hybrid model would work. Doctor income would come from a public pool and procedures would be paid from health savings, with a catastrophic insurance backup. That is, you pay for your mammogram, but if you get hit by a truck or require a liver transplant, insurance covers it. I need feedback on this from wiser heads.

As to the cost of drugs, there is a simple and effective remedy: outlaw advertising of all prescription drugs. This includes TV ads and pharmaceutical reps in doctor's offices and medical meetings. A large percentage of the cost of drugs is in marketing. When the choice of a drug comes from -- as it should -- the results of objective controlled studies done by disinterested third parties, plus recommendations of expert panels when such studies are missing or inadequate, the cost will plummet. Pharmaceutical companies will spend their income on research and development, instead. If the profit motive leads (as it has recently) to disincentives to create certain classes of medication, such as antibiotics, a public utility would be created to develop them.

I want to hear contrary or supplemental ideas and will debate them gladly and enthusiastically with anyone. But no ad hominem arguments will be entertained!

Tax rebate?

So, our leaders are thinking of giving us all a tax rebate, adding to the federal deficit. We might as well be getting it from Beijing, since the Chinese are rapidly buying up our debt with their trade surplus. And what will we do with the money? Many of us, myself included, would use it to repay credit card debt. In that case the money will pass from one lender to another. Can anyone tell me how this will help our economy?

President McCain?

There are many things to like about John McCain. He is trying to be honest about his beliefs, even in the face of hostility from his own party. He is avuncular. He is a war hero. He has a low-key, down home delivery.

But, oh, some of his ideas! They sound hare-brained to me, even dangerous. Like using ex-Chair Greenspan as a principal financial advisor. That devotee of Milton Friedman and Ayn Rand wants to do away with most government regulation. The ghosts of Jay Gould, William Frick and Diamond Jim Brady must be stirring in whatever special hell they reside thinking of the fun their present-day counterparts would have. We've already seen a taste of it, with the attitudes of the FCC, the CPSC, and the FDA toward industry.

And then there are his ideas about health care. One was to pay physicians to keep people well instead of caring for their illnesses. How many of them would switch out of cancer therapy, AIDS treatment, diabetes care etc. into running gyms and fat farms? John, John! Perhaps his critics are right. Perhaps the Cong did a bit of damage.

I still like and admire him, though.