Sunday, January 28, 2018

Patients Bill of Rights - Time for Version 2.0?

How often do we read or hear, “I have a right to …”   Everyone wants to have his rights respected.  Gun owners, prisoners, civil libertarians, union members, non-smokers, protesters and ordinary citizens all want our rights to be validated and respected.  What happens when the exercise of my rights encroaches on yours?  It is these questions that occupy much of our judges’ time and attention.  These are not easy calls to make.  The fact that so many of our Supreme Court decisions are decided by a 5-4 vote indicates that these issues are controversial, complex and vexing.

While we all pride ourselves here in America on our individual rights, these may be at the expense of our community’s rights.   I don’t envy societies such as China or Russia where the state’s rights are paramount.  But, there is no consensus, even here, as to where to draw the line between protecting an individual and society at large.  Consider how vigorous the debate has been on the tension between protecting individual civil liberties and national security. 

'My Rights Outweigh Your Rights'

If it were true that reading our e-mails without a warrant would prevent a full stadium from being blown up, would we support this?  What if our kids were in this stadium then?

The conflict between an individual’s and the community’s rights is active in the medical arena.  Consider a few examples where one patient’s benefit is at other patients’ expense.
  • Physicians give out free samples of medication to patients, who cherish this giveaway.  The cost of this largesse must be borne by the rest of us who must pay higher drug costs.  Nothing is really free, is it?.
  • A man has a right to ride a motorcycle experiencing the thrill of the open road with the wind blowing through his helmetless hair.   If a tragedy occurs, who picks up the bill?
  • A physician prescribes a biologic treatment for Crohn’s disease.  It costs $2,500 each month and is to be administered forever.  If the drug delivers as promised, which is usually not the case, one individual will benefit.   Should the physician consider how many folks could have been helped if these funds were devoted to influenza vaccines, mammograms or smoking cessation?
  • Salvage chemotherapy is given to a patient who is unlikely to benefit.  The aggregate costs of these kinds of treatments could pay for family health centers in underserved neighborhoods. 
The ethos in the medical profession has been that a physician is solely concerned with the patient in the office, and not the population.  This is how I practice.  But, the argument that physicians should be concerned with the greater good and a fair allocation of finite medical resources is potent and reasonable.  For the time being, my patients understand that my advice is directed to protect only their interests.

When you’re in your doctor’s office, do you want him to be thinking about you or everyone else?

Sunday, January 21, 2018

Amazon's New Headquarters Sweepstakes - A Plan to Win

Northeast Ohio, where I reside, won the lottery and was selected for two Amazon fulfillment centers which will employ thousands.  Let’s leave aside whether those jobs will be sustained, or replaced by robots, drones or some yet to be discovered job-killing advancement.  Of course, our win here was not quite like cashing in on a lottery ticket.  Lottery winners purchase a very cheap ticket and then cash in with a huge return on investment.  That’s why folks buy them; they pursue the dream of winning a huge windfall.  Would lotteries be as popular as they are if ticket prices were ten times as expensive?  I’ll answer that.  No.  

It's Time for this Foreigner to Step Down

The grand prize of the Amazon Sweepstakes is the site for their 2nd HQ.

Applying to become an Amazon HQ center is no cheap lottery ticket.  Cities across the country have been tripping over each other as they raced to genuflect in front of Emperor Amazon promising him zillions of dollars of tax abatements and infrastructure development over many years.   The contest started with 238 cities participating in a corporate version of the Hunger Games.  This week we learned that only 20 contestants remain.  Cleveland, my city, was jilted.  Our local government has refused to share their spurned offer with us – their bosses – presumably from embarrassment of what they were willing to give away.  City residents who are starving for social services, pot hole repair, crime prevention, educational reform and neighborhood renewal may have balked at giving away zillions of dollars to a wealthy, corporate behemoth. 

Cities across the nation and beyond shamefully fawned for attention.  Tucson sent a huge Saguaro cactus to Amazon’s Seattle HQ.  The mayor of Kansas City wrote 1000 5-star Amazon reviews.  Stonecrest, a Georgian town, offered to rename itself Amazon.

New York City, one of my favorite locales on earth, is still in the running.  Here’s what I would suggest to Mayor de Blasio to separate his city from his competitors.   Tear down the Statue of Liberty, which the Trump Administration may be planning anyway.  This foreign female colossus doesn’t comport with his America First vision.  And, it fits in well with today’s mission of monument and statue revision.  Then, rename Liberty Island to the Isle of Bezos and lease it to Amazon for a buck a year.  If de Blasio reads this post, his initial reaction will be ‘why didn’t I think of that?’

In the perfect world that we don’t live in, all cities, states and nations would agree to offer no inducements for corporations to choose them for new plants and factories.  Amazon pulled in about $44 billion in the 3rd quarter of 2017.  Are they such a fledgling company that can’t afford to set up shop on their own?

Sunday, January 14, 2018

Is Trump Mentally Unfit for Office? The Goldwater Rule Violated

Many of my readers do not know who Barry Goldwater was, let alone of the Goldwater rule established by the American Psychiatric Association in 1973.  The rule advises against psychiatrists commenting on the mental health of public figures they have not examined.   Obviously, a psychiatrist or any physician who has treated a public figure is prohibited to offer any public comment unless he has been authorized by the patient to do so.  On Tuesday, Dr. Ronny Jackson, the president’s personal physician, will discuss the results of the president’s recent medical examination with the press.  The boundaries of what Dr. Jackson can report will have been set in advance by the president.  

Senator Barry Goldwater

In the past month, the Goldwater Rule has appeared in our newspapers and all over cable news and commentary programs.  Goldwater has probably been a 'trending topic'.  This is in response to suggestions that the president may be mentally unfit for office.  I have heard physicians who have never examined the president making this claim.  And, seemingly beyond the reach of the Goldwater Rule, I have heard pundits and politicians – presumably with no medical training – suggesting or asserting that the president is non compos mentis. 

It is beyond obvious that many of these ‘mental health experts’ are simply using a new tool to attack a president whom they oppose politically or despise personally.  I oppose this practice both as a physician and as a citizen.  We cannot normalize average citizens or medical professionals on the sidelines offering psychiatric assessments of folks they don’t really know.  If this objectionable process were to become accepted, then it would be ultimately applied throughout society.  There would be an inexorable mission creep that would make all of us potential targets of these inquisitions.   If a boss at work, a teacher, an athlete or a customer started arguing, might this individual be labeled by onlookers as having a condition?

This practice disrespects those among us who truly have mental illnesses.  It furthers the societal stigma associated with these diseases that we have all worked hard to reverse.
There may be instances when it seems inescapable that a person is psychiatrically afflicted.  For example, folks who claim they are Napoleon, came from another planet or wrap their heads in tin foil likely have some psychiatric dysfunction.  But we don’t make policy based on rare anecdotes.

Mental illness is serious business.  Mental health professionals train for years and throughout their careers to gain and maintain necessary skills for diagnosing and treating these illnesses.  Leave it to the professionals. 

Political adversaries, columnists, cable news jockeys and average citizens have enough fodder to criticize the president without shooting arrows from psychiatric quivers.  

The wisdom of keeping silent is aged and timeless.

Those who guard their mouths and their tongues keep themselves from calamaity.
Proverbs 21:23.


Sunday, January 7, 2018

Al Franken Fed to the Wolves

Al Franken is out.  He volunteered to be thrown off a cliff.  Now, this gives me one less liberal, or ‘progressive’, that will give this gastroenterologist heartburn.  However, as a man who does his best to use honest weights and measures, I find his ouster to be deeply troubling.  This was not the senate’s finest hour.

What caused the stampede of his fellow Democrats last month to demand his ouster?  Yes, there were new allegations, but they didn’t seem to be qualitatively different from the prior ones. What pushed a largely silent Democratic caucus into a chorus of indignation?  Was this fair?

'Mmmm, that was tasty!'

If the charges against him – which he largely denies – are true, then he was clearly a sophomoric boor, who behaved improperly during his prior career as an irreverent comedian.  While his prior actions were offensive and wrong, I don’t think he merits being swept into the expanding cesspool of sexual harassers – men who preyed upon women using their positions of power to commit repugnant actions.  Such men deserve appropriate punishment and public opprobrium.

While I fully support the current movement to achieve a true reckoning, I am concerned about the lack of uniform standards and fairness.   With Franken, for example, there was a rush to judgment as a mob of Democrats tripped over each other as they raced for the microphones to denounce him. 

I am sure that when I hung out with the guys in college that I was present and participated in conversations that if publicized now would not show me to be the enlightened individual that I claim to be today. Am I unfit to serve as physician today?  Dredging up gutter talk and boorish behavior in a past life shouldn’t disqualify a person from his job or his place in society. 

I worry that Franken’s political demise has lowered the standard for tolerable behavior to an extent that legislators’ positions and everyone’s jobs are vulnerable for minor offenses that are alleged to have occurred either on the job or previously.  Could a senator now be brought down by a few lurid accusations that may be unproven or might even originate with the political opposition?   

For those who somehow don’t know where the boundaries of decency lie, we need uniform standards in place.  All offenses are not equal and should not be treated as such.  While we properly target sexual harassment for extinction, we should remain true to our cherished principles of a presumption of innocence and due process.  If you were charged with committing disgraceful acts, and you were innocent, wouldn’t you want a fair opportunity to defend yourself?