June 15, 2023
Practicing medicine these days can present some significant hurdles to the practitioner and patient. Today I finished my reading of the news and came across this article (https://www.nytimes.com/2023/06/15/magazine/doctors-moral-crises.html). The author describes how practitioners may suffer moral injury when working in the corporate health care system environment. The work environment pays a salary with incentives to the practitioner who gives up their autonomy in providing health care. Emphasis is placed on keeping appointment to a usual 10 to 15 minute time, prescribing medications and other care that are on the approved list unless alternative approaches to care are indicated. In those cases, the staff and practitioner or often the patient must interface with a gatekeeper screener who are sometimes very difficult to reach to get approval for this alternative care. The practitioner may work in unsafe conditions for themselves and their patients as occurred during the height of our COVID epidemic for example. They may experience pressures to provide care using more in house services and procedures that are more lucrative to the employer but not efficient or best practices for their clients even pressuring them to transfer services to other providers if their patients insurance is somehow deficient or requires the employer to continue care that hurts the employers profit margins. In summary, I'm describing a medical system fraught with coercion, incentives, and employment to meet corporate needs not health care needs.
What do I care you may wonder? Well, early on my career in psychiatry at mock awards dinner party for the residents of my class I was given the Spartacus award. Tongue in cheek my educators recognized my tendency to want to help the downtrodden and under privileged. But hold on, recently I experienced some of the problems I briefly described first hand. I had all the symptoms associated with a urinary tract infection which came to a panful head during the weekend. I called my PCP and received a prompt personal telephone call from her on call substitute. I described my symptoms and was prescribed a three day course of an antibiotic. By the third day my symptoms were much less painful and intense but were still present so I called my PCP who told me to get the refill from my urologist. I called but was told after I explained my current status and history to the nursing staff that my urologist wanted me to go to the emergency room and get catheterized! I thought to myself that my information shared was somehow misperceived along the way to the urologist so I asked to directly speak with him. I as told this was not possible and I needed to have an appointment which was available in a few months! So I informed my PCP via her email portal and she prescribed the antibiotic medication for me. I decided to change urologist and my PCP recommended another urologists' who worked in the same urological specialty office. When I called back to this office to speak with the staff describing my recent interactional history the staff member honestly informed me that the recommended other urologist was even more unavailable to the staffs and patients requests. So I now decided to try another urologist at another location. My urologist did call back and listened and had no comment to my disappointment in his responses. I thought to myself that the system of care he provides dictated by office managers and corporations has coopted a doctors duty to heal. I talked with my PCP also and she noted the deterioration of ethics and practitioners autonomy as wide spread.
Now my example is straight forward since UTI"s symptoms and treatment is usually straight forward. My children have interfaced with the health care system for care for themselves, spouses, and children where the diagnoses and treatments were problematic, unsatisfactory, and expensive. They are informed educated and assertive so they have been able to navigate the system and its faults though much suffering and confusion transpired along the way. How to get an accurate assessment and diagnosis is difficult and more problematic in todays medical system. Is organized government funded medicine or some similar alternative like in Germany any better? Hard to answer though statistical information suggests that the U.S.A. system is more expensive and results in poorer outcomes.
As part of my career I was the medical director in behavioral health for a non profit health care insurance company in Hawaii. I found myself influenced by the data in this system to see there were practitioners who appeared to over prescribed opiate medications. In addition our CEO approved a CME visit from Purdue Pharm. Oxycontin was their go to pain reliever drug that they wanted us to endorse with prescribing recommendations hard for us to implement. The Sackler family is still negotiating a deal to pay billions as long as there is no criminal charges against them for pushing the opiate epidemic! One of the providers of care in this non profit health care provider system was a physician medical director of a health care system we endorsed. He was prescribing opiates to many clients who had vague pain syndrome complaints. I reviewed many of the poorly recorded records and talked to the practitioner who defended his prerogative to prescribe for those suffering pain. The alternative diagnosis of drug addiction was not in his wheelhouse nor referral options. Not long afterwards I realized that my salary was not worth the efforts in the system I was working so I retired from that job.
As the chair person for The Physicians Health Committee under the umbrella of the Hawaii Medical Association for may year I recall one situation that highlighted these issues in another way. We had a physician who had an alcohol drinking problem. She was very cooperative and her employer who referred her agreed to support her recovery. She went to a residential mainland program for professional health care addicts graduated and then was monitored by our committee. She was clean and sober and functioning well in her specialty. Her employer who I knew well then terminated her employment in his group without informing us or negotiating some severance with her. This same CEO had previously referred another of his employee to me for counseling but there was no issues needing addressing and I suspected some other reasons behind this referral. This employee was let go also. Group practices run by physician CEO's can be lucrative for the group leadership but unfair to the employee. A long time ago I recall a friend who is a physician tell me that when employed at a group practice affiliated with a large hospital he was required to have a yearly physical examination by the medical CEO. As part of the examination he had a prostate examination. My friend opined that this ritual meant to show all physician employees who was boss.
Our curiosity into understanding our world and inner consciousness delights me. Recently I came across some research that explores a reported lucidity to people with dementia and cognitive decline just before death. The hypotheses included increased blood flow and oxygenation of brain associated with physiological changes near death. We visited a dear friend who recently passed away and I recall her telling us about her adventures at a tel in Israel where her group discovered a statue made from gold that they sneaked into a museum in Jerusalem. Her recounting of this adventure was vert interesting but I have no assurance any of it happened. Cognitive decline in friends and neighbors is now all too familiar and saddens me. The person in cognitive decline may have some awareness of their situation but eventually this is lost. So then it's up to the care givers to decide on the care given. Caregivers who are devoted and vested in the return of the personality and vitality of these very impaired can make informed decisions or give into hope, yearning, and avoidance of loss. The burn out in providing the care can be exhausting and cloud their judgment. That hopeful return to lucidity can fool us into pursuing longevity of living flesh over the person.
My wife showed me two articles in our local newspaper syndicated viewpoints one from Maureen Dowd the other Cal Thomas. Dowd's article is straight forward concerning Trump's multiple count indictment concerning his lying, hiding, and refusing to hand over classified documents he held illegally in his possession. She mentioned how he was given the opportunity to hand over the documents and could have avoided these charges. Both former Vice President Pence and President Biden also had documents in their possession which they promptly handed over saying that they did not willfully take them and keep them illegally.
Cal Thomas points out that the 27 count trail of former President Trump will further alienate his supporters and energize them to resist cooperating with the Democratic party. He alludes to a video showing Biden driving into his car garage where boxes of alleged documents were seen. He suggests that Biden may be guilty of accepting a 5 million dollar bribe and Hillary Clinton was never prosecuted for her using na private email server while at the white house.
https://calthomas.com/2023/06/the-trump-indictment-4/ So I did a little snooping into Thomas's columns and came across a recent posting in which he excoriated Trump "People like me who rationalized that a vote for Trump was a vote for his policies and not his corrosive personality made the political equivalent of a bargain with the Devil. With the exception of nominating three conservative justices to the Supreme Court, Trump increased government spending, failed to finish the border wall or make Mexico pay for it, and agreed to shut down the country over Covid, a mistake that curbed learning in schools and ruined many businesses. Then there are the lies he told and still tells and his low view of women. If he wins the general election – a dubious proposition given the abandonment of Independents – he is likely to ruin the Republican Party, as Wall Street Journal columnist Peggy Noonan credibly argues: “The GOP will disappear as a party. Meaning the primary national vehicle of conservative thought and policy will disappear.” Ah, thought and policy. William F. Buckley Jr. thought and had policy ideas. Far less so Trump." https://calthomas.com/2023/06/trump-then-and-now/. Well, are there two Cal Thomases? His last post is a sort of defense claiming preferential treatment. His previous post is more honest about his views of a corrupt narcissistic leader.
I continue to be amazed at the entrenched views of the Republican Party and its many spokespersons who support Donald Trump, espouse a political witch hunt against him for the document case, and try to counter by alleging that Biden accept a 5 million dollar bribe from Burisma Corporation (Ukraine). So far there is no data supporting this rumor. The deeper the scandals associated with our former president the more out of touch with the available data this party seems. Loyalty, belonging to a group that has been part of your life and even family heritage, being special and even privileged are threatened by the data. To me it's similar to the U.S. Baptist Church recent firing of women preachers in two of their churches. They quote the Corinthian guidelines that place men as the leaders and women as the caregivers, child bearers, and housewives. Certainly many Trump supporters here. Certainly no democracy here. There are other examples of this human tendency to hold onto loyalty to a group that has drastically changed for the worse. In our Monday group one participant shared her experience with a Chinese ethnic friend who seems to ignore the oppressions and group think domination of the government over their citizens. For these groups it's like they are saying don't bother me with the facets. I like my myth emersion much better.
I'd like to have you listen to some of the piano pieces I'm learning but I'm not ready for an audience. My son's wife's son a finalist for the Na Hoku Hanohano awards is immersed in guitar playing so here's one of his links (https://www.slackkeyalex.com/).
Leonard
Into the heart of Tantalus
Yesterday's hike
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