Category Archives: Education

Newspapers

When I was growing up,  it seemed that every city had several newspapers—often a morning paper and an evening paper. In Toledo, they were owned by the same company, so there was not a lot of divergence of opinion—the biggest diversity was in the comics.

In the 70s and 80s, many cities began to lose newspapers, only offering one. (I remember reading Sherlock Holmes—written during my grandparents’ lifetimes—in which there were multiple editions of multiple newspapers. Wow!)

Over time, in many places, local reporting waned and most of what they printed came from the news services to cut costs. (Sorry Peter Parker and Clark Kent, we’re not hiring.)

The number of news services dwindled as Associated Press overtook and bought part of United Press International. Today, much of what you read in the morning newspaper you already read online.

Newspapers got smaller, and the cycle continues.

Is it better or worse than when I was young? Probably neither—just different. However, I appreciate a well-written article. After it was written, the author probably re-read it and made some changes. An editor tweaked it—or sent it back to the author for another rewrite. Written news is polished, at least a little. It took a significant event to “Stop the presses!” and change the headline—an expensive operation.

A news video, on the other hand, has no style and certainly no cachet. It’s kind of thrown together, with too many stories labeled as “Breaking News.” To add insult to injury, the talking head’s intro, repartee, and smile, of course, is as much a part of the story as the content.

More’s the pity.

I think I’ll go listen to Don Henley’s “Get Over It.”

Only a Loan

Mother Nature loans us many things, but we need to remember that they’re only a loan.

Hurricane-Katrina-FloodingNorfolk, Virginia has much of its downtown built on filled in waterways and swamps. The area already tends to flood with nor’easters, and tropical storms, but with rising sea levels, flooding is expected to happen more often. Since there are people and businesses already established in the area, government officials are exploring possibilities such as levees, flood walls, and whatever the latest technology offers to prevent loss of life and property.

I understand. Where I live used to have a moderate risk of flooding, but as more of the area was developed the waterflow reversed. Low-lying wooded areas were clear-cut, raised five feet, and houses built so that instead of absorbing the rainwater, it now flows into my neighborhood. Bummer. Maybe if I replace my lawn with rice it will work better.

Mother Nature only loans us geography. I used to live in Louisiana. Mother Nature wants to move the Mississippi River west into the Atchafalaya basin. The United States Army, Corps of Engineers have been tasked with keeping the Mississippi River where it is. They’ve been mostly successful, except for the occasional world-class disaster like Katrina. History has shown that if weather doesn’t satisfy Mother Nature’s requirements, the occasional earthquake will. The New Madrid Fault in the early 19th century caused the Mississippi to flow backward for several days and reroute itself.

These issues are not unique to Norfolk and Louisiana. I grew up in Toledo, Ohio, which is built on what was the Black Swamp. Part of Downtown Chicago is built on the rubble from the great Chicago Fire, which was tossed onto the shore of Lake Michigan. Enough of Florida is built on drained swamps, or the equivalent, and so much groundwater is extracted that sinkholes routinely swallow cars or even houses.

Mother Nature loaned us these areas. I hope she doesn’t want them all back too soon.

Fixing Healthcare – Part Three

Physician’s Assistants (PAs) and Advanced Registered Nurse  (ARNPs) are helping lower costs and increase access. While some nurse practitioners, can operate relatively independently; other nurse practitioners and most physicians’ assistants, cannot. Why?

Physicians are adamant that they maintain a high degree of control over these and other healthcare workers. This is a throwback to the nineteenth century—which is kind of interesting in a weird sort of way. The story, and I cannot vouch for its accuracy, although all my research seems to support it, is that the country was besotted with traveling medicine shows hawking patent medicines (You’ve seen it in the movies—“One for a man, two for a horse”). The physician industry supposedly promised to get things under control if they were put in charge of medical practitioners, i.e., physicians and surgeons (MD). It, at best, minimized, if not blackballed, osteopathic physicians (DO), chiropractors (DC) and chiropodists, now known as podiatrists (DPM).

A physician, at the time, could authorize any hireling under his license to perform any duty under the concept that the doctor was “the captain of the ship” and was responsible for everything. Therefore, he had authority to authorize any employee to do anything—hopefully, but not necessarily, after some training.

Today, many non-physician healthcare workers are licensed in their own right; in most states this includes nurses (of all levels), therapists (of all varieties), and technologists (ditto). These people are trained and possess technical skills that physicians do not. Generally speaking, only television doctors leave their practice in order to operating high technology devices. It’s good theater but bad economics.

Many of the other healthcare careers such as nurse practitioners, physicians’ assistants, etc., have made significant advances Unfortunately, old attitudes die hard, and there are too many physicians who try to maintain an inordinate control over everything, including these other professionals. Nurse anesthetists and physicians’ assistance must be “supervised” by a physician, although such supervision does not require actual observation or even the presence of the supervising physician.

Efforts to keep others under control have led to some bizarre arrangements. In radiology, for example I’m told that the technologists are now required to periodically retake the examination that initially proved their competence even though there has been continuing education requirements for 40 years. If true, I believe this is a unique requirement, but a warning to all others. Of all the physicians’ assistants, only those specializing in radiology are not permitted to interpret x-ray or other diagnostic images.

Why?

Some blame the American Medical Association, a very powerful organization with effective lobbyists. However, it apparently speaks for a self-selected group of physicians. Out of 923,308 practicing physicians, the most recent numbers available indicates that only 228,000 belonged to the AMA. If you don’t round, that’s just less than 25 percent.

Nobel Laureate Milton Friedman and his wife, who wrote the book Free to Choose, asserted that the AMA functions more like a guild with the goal of increasing physicians’ wages and fees by limiting both the supply of physicians and the competition from non-physician groups.

This is yet another issue that must be addressed if we are truly interested in fixing healthcare.

Medical School Rationing

Fixing Healthcare – Part 2 — Doctors

I’ve known many intelligent, talented, committed young people who aspired to become doctors, but couldn’t get into medical school. Some were resigned to their fate and used their degree in biochemistry to become medical technologists; others made arrangements to attend medical school outside the United States—primarily in the Caribbean. In one case, in order to study at a school in the Caribbean, the aspiring medical student’s parents sold virtually everything to finance her education. She’s nearly complete with her rotations back here at US hospitals and plans on serving rural or tribal underserved areas.

While we don’t have enough graduates of United States medical schools, we grant 85,000 special visas to foreign medical graduates every year because it’s a “critical shortage.” Today, roughly one quarter of all practicing physicians are foreign medical graduates. I’ve worked with many, and while their initial desire is to return home, after about six months the sports car and the arm-candy significant other appears. When I ask if their plans have changed, I’ve been told, “If I return home, I will be paid in chickens and melons. If I stay here, I will be paid in dollars. I like dollars better than chickens and melons.”

So, we import thousands of non-American doctors every year even though we have many Americans who want to study medicine but are turned away.

A decade or so ago, when more students wanted to study law, the educational industry had no difficulty in adding seats—even if they had to build new schools. Why won’t (not can’t) we do the same for medical schools?

Some claim there wouldn’t be enough residency opportunities if we graduated more doctors from US schools, yet foreign medical graduates can and do get residency positions at US hospitals. In any other industry, this might be viewed as restraint of trade.

I suggest that the goal of US medical schools should be to increase their capacity so that by 2030 ALL US residency openings can be filled with US citizens who graduated from US medical schools.

Next, I would change the entry criteria to include the following:

  1. Accepting students with a commitment to actually practice medicine; better yet a commitment to practice whatever type of medicine is in short supply, wherever needed, for at least three years. After that, every accommodation should be made to place that individual in a residency or fellowship of their choosing for which they have the talent, without a decrease in salary.
  2. While academic achievement is important, the ability to work as a team is critical. History is full of brilliant people who didn’t succeed because they could not work with others, and medicine is now a team sport—whether the person with MD or DO after their name likes it or not, they are teammates with the nurses, technologists, therapists, etc. No one is a superstar.
  3. Children of doctors or other elites should have to prove themselves more—not less—than other medical school candidates. They’ve grown up exposed to the field, often in an environment of privilege, so they should demonstrate their desire to serve, not their pedigree.

In short, we need more doctors, but our current method of selecting them is less than optimal.

Fixing Healthcare in America

First in a series

To correct healthcare and get costs under control, we must first acknowledge, then change the healthcare industry’s unique and outrageously dysfunctional business model.

  1. Physicians and other practitioners who decide which resources will be used in a hospital are often neither the direct provider, the one who pays, nor the beneficiary of the service. Basic economic rules, therefore do not apply. Medical tests, which are intended to provide information that will in some way impact the patient’s course of treatment, don’t. Many test and other procedures are ordered even when the outcome of the test will in no way affect the treatment of the patient or its results.
  2. Medical products and services are priced without any rationale. Often, prices are set artificially high in order to allow large discounts to insurance companies. This means that patients without insurance can be charged list price; eighty dollars for an aspirin or $100 for a BandAid®. Hospitals, which were once a ministry, stewardship, or public service have changed their priority to the bottom line. Some hospitals now own and operate their own collection agencies augmented by a small army of lawyers to guarantee that they collect what they have billed. This is why it is not uncommon for a small-town hospital to have millions of dollars in the bank—and still retain their not-for-profit status.
  3. And the insurance companies that get those big discounts? The hospital needs a staff of trained bureaucrats to generate the paperwork that is sent to the insurance company in order to receive payment. Payments may not be received for several months (for the MBAs out there—remember the first rule of finance—a bird [dollar] in the hand is worth two in the bush [accounts receivable]). When payment does arrive, administrative staff must reconcile the payments and file additional paperwork as necessary. All this adds to the hospital’s costs without adding any value. The insurance companies, on the other hand, are usually quite profitable, even after spending a lot of money on lobbyists. But just like Don Corleone said, “It’s nothing personal, it’s strictly business.”

So, what do we do?

First, it would be valuable to have the physicians evaluate how tests really affect the outcome for their patients and develop appropriate protocols. Malcolm Gladwell relates an excellent example in his book, Blink. The cardiology staff at Cook County Hospital was able to reduce tests while simultaneously improving patient outcomes.

[Gladwell, Malcolm (2005). Blink: The Power of Thinking Without Thinking. New York: Little, Brown.  ISBN 0-316-17232-4 (Especially the chapter on Cook County Hospital Cardiologists)]

Second, revise medical pricing so that it reflects reality—and that must include adequate margin to offset costs for necessary but expensive services. Emergency rooms are expensive to operate while an intensive care unit for patients suffering from burns is actually cost prohibitive. However, hospitals have an obligation to the community to provide necessary services—either directly or by affiliation—to the community. The community, in turn, must ensure the hospital is resourced to provide a wide range of services. If hospital prices reflected cost plus a reasonable margin to offset other costs, and everyone paid the same price—patient or insurance company, it might lead to more rational decisions—outcomes first, but economics as a consideration. If Grandpa—God love him—is a 96-year-old heavy smoker with high cholesterol and other morbidity factors who was hospitalized because of a stroke, a battery of tests that will not affect his quality of life or his longevity are not appropriate, and the insurer should not be expected to provide carte blanche payments. However, if the prices are realistic, the family may decide that they would be willing to pay for those additional procedures on their own.

Third, emphasize cooperation over competition. Is there any other business, other than hospitals, that would allow someone to work in their facility AND directly compete with it? Radiologists have their competing imaging centers, surgeons may have their private surgery centers, etc. Should specialty practitioners be entitled to benefit from the hospital’s patients and compete with the hospital for those same patients? It should be the practitioners’ choice—one or the other, but not both.

Two excellent resources for these issues are:

Brill, Steven (2015), America’s Bitter Pill: Money, Politics, Back-Room Deals, and the Fight to Fix Our Broken Healthcare System. New York. Random House. ISBN 978-0812996951

Rosenthal, Dr. Elisabeth (2017). An American Sickness, New York: Penguin Press. ISBN 9781594206757

If you want to fix American healthcare, pass this along to your friends, neighbors, doctor, etc. I’ll get a lot of hate mail, but we need to have the discussion.

More to follow.

Inspiration from the Movies

Indiana Jones and the Last Crusade

Indiana Jones and the Last Crusade

I love movies, although I no longer have the time to devote to watching as many of them as I’d like. In a few years, when I retire, I hope to correct that problem.

Movies aim to elicit feelings, not thoughts, but sometimes feelings actually lead to critical thoughts. Take, for example, the Indiana Jones movies; while “The Search for the Lost Ark” was wonderful, the “Last Crusade” was important. It touched on some lessons that we don’t teach in schools, but are critical nevertheless.

Indian Jones, a fictional archeologist from the time when archaeologists were more “pot hunters” than scientists, seeks the Holy Grail—the cup Jesus drank from at His last meal. To reach the grail, he must pass three challenges:

  • The Breath of God – “Only the penitent man will pass.”
  • The Word of God – “Only in the footsteps of God will he proceed.”
  • The Path of God – “Only in the leap from the lion’s head will he prove his worth.”

    (http://indianajones.wikia.com/wiki/Temple_of_the_Sun)

What can we learn?

“Only the penitent man will pass.”—None of us are perfect, and we must be sorry for how we’ve hurt one another.

“Only in the footsteps of God will he proceed.”—God has given us direction through so many means, all of which come down to, “Love God above all things, and love your neighbor as yourself.”

“Only in the leap from the lion’s head will he prove his worth.”—It takes faith to live, grow, and do good in this world. Logic alone is not enough; logic applies only to this world, while faith touches the next.

God, in his infinite wisdom, touches us through scripture, religious communities, and even the movies. But then, since He is God, why wouldn’t He?

The Decision and the Declaration

Today, on July 4th, we celebrate the Independence Day, when the Declaration of Independence was approved by the Continental Congress in 1776.

However, history is more interesting than just the event and the date.

On June 7, 1776, the senior Virginia member of Congress, Richard Henry Lee introduced a resolution stating:

Resolved, That these United Colonies are, and of right ought to be, free and independent States, that they are absolved from all allegiance to the British Crown, and that all political connection between them and the State of Great Britain is, and ought to be, totally dissolved.”

Congress adopted the Virginia motion on July 2, 1776, thereby refuting our status as a colony; this is why John Adams believed that we would celebrate our independence on July second, the date of the decision.

The Declaration of Independence was approved two days later, on July 4, 1776.

While the Declaration of Independence is a masterpiece, and I recommend that everyone read it today, it was not the decision, but merely the explanation to the world as to why the decision had been made. Although we have seen many portrayals of all the Founding Fathers assembled together in Independence Hall to sign the document on the fourth of July, most, but not all, signed on August second; one signer, who was not a member of the congress until later in the year, signed in November.

As is often the case, history is more complex, and far more interesting than the snapshot presented in civics class.

* Thanks, once again to Wikipedia. If you use it, kick in a donation—even a dollar helps.