Health Care Reform: Marred by Conflict

This is the third or fourth article I have written about health care reform. There are so many ramifications with this reform struggle, that it lends itself to in depth analysis from innumerable perspectives. I have concerns about being labeled a "spoiler" or a "right wing extremist" but I am neither of these. I am just fascinated with the implications of this battle that come from our American culture and government.

First of all, I believe we do need some health care reform. Obama has said things that are correct such as the costs are one of the factors that are ruining our economy. We need to control costs, but I'm not certain what he recommends will do it. There are two fundamental truths that must give all of us some fear about this debate.

The first is, that all governments,including ours, lie to their constituents. I know this is not what one wishes to say about one's government, but it is simply the truth. History proves it. Take the "withholding tax" on our wages. It was instituted during WWII because they needed the money for the war effort. It was going to stop after the War ended, but it wasn't. Another more applicable example would be the title of the first paragraph of the Medicare law which reads,"Prohibition Against Any Federal Interference." The federal government interferes everywhere with the practice of medicine even though it promised not to. That's just what governments do!

Now,I don't believe that the "good people" up there in Washington would purposefully lie, but once a law is created, events happen that force revisions that frequently make the original concept contain lies that may not have been originally intended. History works that way. The trick is to figure out what might happen, and how a law might change in the future, and do everything to protect all of us from these unintended consequences.

A second, more serious problem with our government's proposals is the understanding that the Congress has a integral conflict of interest with this type of legislation. Without beating around the bush, they have promised too much, and they cannot afford all of their promises: Social security, Medicare, Medicaid, government pensions to name a few. It turns out that the shorter our life spans, the less our government has to pay to meet these obligations. Dead people don't collect Social Security!

Here, our government is walking a thin line. Counseling the elderly about "end of life decisions" approaches this conflict a bit too openly, and explains why this provision was removed from the bill. Unfortunately, this conflict does not go away with that small change. How about cancer therapy, or dialysis, or coronary bypass for the elderly? Does that prolong life and increase its financial obligations to us citizens? Unfortunately, our government, and not our lawmakers, is constructed to benefit when laws are passed that encourage all of us to die early. It's best if our government avoids tampering with laws that directly influence our longevity. Controlling our access to medical care does just that.

Again, we do need health care reform, but ObamaCare it too controlling and raises more conflict than it solves. The hostile reaction of our citizens is directly related to the underlying conflicts just raised, and they will not go away. Tort reform, insurance regulation, and futile care legislation would be a good start to the type of reform we really need. Where is it?

James P. Weaver,M.D.,FACS

Why So Much Trouble with Health Care Reform?

The battle is getting brutally fierce now at the town meetings. Congress folks are seeing the righteous anger of the people. Why, one might ask, is this happening? Don't we have a "broken health care system" and doesn't everyone want health care reform NOW!? Why are people acting so vociferously against this proposed legislation?

I believe that health care reform threatens the indispensable fundamental principles that have formed the foundation of the social structure of the United States: individualism, freedom, and most of all our basic distrust of government. In addition, there is charity. Americans are generous and they resent government stealing from one group of citizens to give to another group, especially when government acts like it deserves all the credit. All of the money that our government possesses has been taken(by force) from us citizens. I think most of us are tirelessly laboring daily to possess a little property, and watching our government throw it around ad lib (without reading the bills) is infuriating to us all.

Individualism runs through America's collective soul. Individualism also represents a quality of what is means to be an American. We are supposed to be FREE. Free to do what we wish, make decisions on your own, and free to face the consequences. Our freedoms define America, and give it the social energy for economic expansion and individual opportunity for success.

The problem with health care reform (and with the dreaded "public option" in particular) is that it threatens everything that represents FREEDOM. Will the government control what kind of medical care we can have? Will it control medical decisions so that we can't trust our doctors? Will it attempt to hasten our demise to lessen the entitlement debt it owes us- and that we were forced to pay for- as we get old? Doesn't our government have a fundamental conflict of interest in this debate anyway? After all, government is looking for ways to control costs, and our death would save the government money? These are genuinely frightening ideas because if they come to pass, and we can imagine they might, our freedoms will be taken away.

What it finally comes down to is our instinctive distrust of government. If this health care reform occurs, we are going to give our government a lot more control over our lives and our personal choices. As that woman in Philadelphia said the other day,"medicaid is broke, Medicare is going broke, Social Security is going broke, and the cash for clunkers program is failing. How can we give you (to Arlen Specter) control over another one-sixth of the economy? No way Senator, no way!"

I think we need to remember that the statue in the New York harbor is called "The Statue of Liberty." It is not the statue of safety through government handouts. The fundamental problem with this movement (appropriate term) is that it threatens the essence of what America is supposed to mean as a country of personal freedom. Somewhere in this demagogic attack on the previous promise of our God given freedoms is the source of the unrest with this Democratic health care push. Yes, we do need change in health care, but not because we have the worst system in the world, but because it needs some changes. What we do not want is the undoing of the essence of our social structure by allowing our government to make all of these personal decisions for us. We can't trust them now, can we?

What we need is tort reform first, but politics is preventing that, and that "prevention" adds to the distrust of this whole movement. Next, we need controls on the insurance companies to make the vast majority of the health care dollars flow into the "care" system, and not into the pockets of the insurance bureaucrats. Finally we need a futile care law that basically says that when three doctors determine that a situation is "futile" that the family has one week to understand or the care is withdrawn in spite of objections. At that point only comfort measures are given.

Oh, there are other things we could do like tamper with the "preexisting condition" problem, or waste and fraud in the system itself. Yes, we do need change but a government takeover is not the way to proceed. I do not believe that, justifiably, there is enough trust in our government to allow sort of change that the liberals are proposing. It threatens too many of our guaranteed freedoms. Remember, life, liberty and the pursuit of happiness?

James P. Weaver, M.D.,FACS

Open letter to the American College of Surgeons

I have been a member of The American College of Surgeons since the mid 1970s, and have watched many decisions by this body that have lessened the professional standing of surgeons in our nation (American College of Surgeons, Where are you?,Mychasecuts,March 2009), but the current health care debate has revealed, unfortunately, another mistake in leadership of our organization that will have far reaching consequences for our collective futures as surgeons.

The College has recently acknowledged that they are supporting this "reform" because they need to have a "seat at the table." Apparently the College is afraid that if it is not "at the table" Congress will not hear its opinions on issues it believes are vitally important. It seems that the College does not understand or value history. First of all, what makes us believe that we can trust the Congress? History proves otherwise. The first paragraph of the Medicare law has a title: "Prohibition Against Any Federal Interference." Does anyone believe that the Federal Government has not interfered with the practice of medicine? Of course they have, and they intend, or rather they MUST continue to do so for Congress has no choice.

In order to stay in office, Congress makes rash promises to voters. This forces them to tell half-truths, and twist ideas while they promise these "gifts." There is no way they can afford these "gifts" as their promises, especially on health care, are economically unsustainable. They promise, however, because they wish to stay in power. In a sense, they are "forced" to lie! I cannot understand why the College fails to see this fundamental truth.

It is clear that our government is tampering with the lives and sweat, in essence the freedoms, of highly trained surgeons, and not considering the details of the "surgical lifestyle," market forces, work environment and need for a surgeon's hope for the future. Surgeons are small minority in this BIG problem of medical care delivery, and the Congress is certainly going to roll over our rights. They will do it slowly, but THEY ARE GOING TO DO IT! After all, is the ruthless intimidation that has been used to "force" us to come to their table the work of a group that will listen to our position?

The College should have refused to sit at a table with this bunch of bureaucrats that, history has shown, are going to smile, and wish us well, and then do exactly what they want to. They have flagrantly violated the promise of "prohibition against any Federal interference."

Does the American College of Surgeons really want to be part of this fiasco? The American people are not and have not been told the truth. Once this plan is in, and time exposes the certain draconian consequences, we will fare better if we are not a part the original planning. Won't we be blamed also if we are "at the table?"

The College surely knows that there are only two ways to control the distribution of any resource: price or availability. In countries where price is excluded by politics, and there is a nationalized system, availability is the means of control of expenditures. That explains why it takes three months to have a MRI in Canada. Do we want the same? It would be appreciated if our representatives would at least admit publicly that we will have to have many objectionable ways to control costs in their incipient system.

Finally, I cannot understand how the College is so far distant from my personal understanding of this movement (appropriate term). I have been a practicing surgeon for almost 40 years now, and have an excellent feel for the essence of medical practice. Where does the leadership get their understanding of the desires of the members? A survey would be helpful. Do they believe that they know so much more than the membership that they can diverge completely from the desires and understandings of the group?

Surgeons, in the past, have been trained to persevere and approach obstacles with quiet courage and unshakable fortitude. Where is this attitude in our current leadership? Have they stood before the Congress and told the TRUTH? I do not believe so. Is the palace of government so intimidating that we cannot articulate the necessity of our personal God given rights to this bunch of charlatans? If the College cannot do it, who then, will? How many of our personal rights are we going to sacrifice by slobbering up to the government trough of handouts? This will inevitably affect our behavior with our patients and with that our professionalism. May God help us all.

James P. Weaver, M.D.,FACS

Our Brother's Keepers? Not Quite!

It looks as if ObamaCare is running into snags that may postpone or even stop the passage of this massive health care reform effort. It appears that now even the Democrats are balking at the projected expenditures. But on a purely social level, I think The People are having trouble accepting this idea. It is coming down to a question of exactly how much do we want to to be forced to help our fellow citizens?

This bill will eventually put all of us into the same health care system. After all, the "boss" has said that we are all going to have to "sacrifice" a bit to do this. But how much do we each have to sacrifice? And more importantly, how much are we each willing to sacrifice, and for whom are we going to sacrifice?

Most of us feel we sacrifice each day. We get up, go to work, and "put in our time." Most of us feel that work "gets in the way of living." If we are going to sacrifice, it has to be for a good cause, doesn't it? What then is a good cause?

How about sacrificing for the smokers who have puffed for 50 years and can't stay out of the hospital? And how about the "drugies" who get heart infections from using dirty needles, or even how about for those who eat themselves into enormity, and just can't walk across the room anymore? Do most of us believe that personal sacrifice is worth it for these problems? Don't kid yourself those who are "towing the line," and trying to make their lives decent and fruitful don't believe it is. That's one good reason why this idea is going to fail. The people don't believe it is fair.

I don't think most of us are willing to give to people who just don't try to take care of themselves. It is probably OK for those who run into unfortunate problems that are out of their personal control, because we all have this risk, and would want help if it happened to us.

Then there are more difficult questions. How about sacrificing for the 88 year old with cancer who continues on dialysis for months before death? How about continued feeding for a totally demented person who doesn't even know his own family? All personal choices that we will all pay for under this proposed systems. Why are these questions important? Because if the government (WE) is paying for health care, we will have to pay for these things. Do we want to?

Then there are the proposed taxes on the wealthy. Why should we single out the most successful people in the society, to pay for this. They are paying enough already aren't they? The upper 3% of tax payers pay about 60% of the taxes to start with. What is a fair tax anyway?

I don't think anyone should be forced through taxes to give more of their life to the government than anyone else. Why should one person have to work through May to pay taxes, and other people only have to work through February to pay theirs. I think it is morally questionable to take more "life" from those who have achieved the most in this society, and force them to work through May for the government. This is simply a case of class warfare, and it is not much different than "picking" on a group of people because of another unique characteristic like maybe the color of their skin!

This scheme raises too many questions about the fundamental relationship of our government to its people and the relationship of the people to each other. We are a people who believe in individuality and personal freedom. The collectivist concepts in this maneuver are difficult to sell to us. Thank God they are difficult to sell, for that implies that there may still be hope for all of us for a better future.

James P. Weaver, M.D.

Obama Care. Humbug!

I have been watching the developments in the Obama Care parade, and I have not commented, because he talks about the "nay Sayers" in an effort to discredit us, but I can't keep quite anymore. Too much astute distortion and half truths are flooding the airways that something must be said about this "obamination."I listened to most of his speech to the AMA. Listening to the applause of that bunch of sycophants, hoping that the income of the primary care doctors will be raised, made me nauseated. They don't care what happens to the field of medicine, or the patients, because anyone with half a brain can see that Obama's vision of health care will be a catastrophe.

His first two methods of financing this debacle will be the EMR (electronic medical records), and preventive care. What a joke. I do believe the EMR will help transmit information so it is not duplicated, but that is a drop in the bucket. Who, may I ask, will pay for the installation of this technology into any of the offices? The software people have not had to deal with "maximal allowable charges" as medicine has, so we cannot pay their exorbitant fees.

But the biggest fallacy of Obama cost saving ideas is "preventive care." He thinks we are going to get everyone to eat right, stop smoking, and exercise. I guess if they earn less than $250,000 per year he will pay them to live healthy. He has no idea what the practice of medicine is about. I have been trying to get people to do this for 30 years. They do what they want to. Maybe the government will FORCE people to do these things. His ideas like this make me wonder how unrealistic his other ideas will be about this topic. It's brutally frightening!

As for malpractice reform, physicians didn't get the time of day from this highly trained lawyer. Any physician knows that many dollars are wasted in defensive medicine. I guess the lawyers stick together. More importantly,I worry that the most powerful man in the world cannot get the perspective of physicians that are being robbed by the malpractice insurance companies each year with exorbitant fees. Why don't the patients foot some of this bill? They could purchase a policy prior to any procedure, to cover "insurance." That policy could stipulate that Obama's sacred "caps" would not apply.

Another area which is dubious is the total lack of discussion of the physicians in these plans. After all, our government is about to enslave a group of highly trained,educated, hard working people to "give" their talents to other citizens for a government controlled fee. In controlling these "fees" the government has a fundamental conflict of interest: they're paying the bills and they can't afford it. It doesn't look good for the physicians.

Each time the government puts in another program in place, they split the medical profession along specialist and generalist lines to gain the "support" of medicine. There are many more primary care physicians than specialists; it's easier to get that training, and the lifestyle is easier. I had eight years of training after medical school myself to become a vascular surgeon. Obama has promised the primary care doctors "more" to get their support. The problem is that primary care doctors may be replaced by nurse practitioners and physician "extenders" in the new Obama care. Their work comes cheaper, and, after all, he plans to "save money" to pay for this thing by cutting expenses in the delivery of medical care.

Finally, I agree with him that something needs to be done. But let's first be honest with our citizens. I'm sorry folks, but we cannot all have everything we want from medical care and, I fear, everything we might need to stay alive and comfortable.We will have to ration.

My suggestion for a good start would be to control the third party bureaucracies, cap malpractice awards, tax alcohol, and cigarettes, and continue medical savings accounts, but get the third parties out of them. Finally, the Congress should not have access to any better medical care than the rest of the country.

James P. Weaver, M.D., FACS

No Doctor's Rights in Health Care Reform

There's an interesting article in USA Today on June 1, 2009. It talks about the coming health care reform. It mentions how the insurance industry is lobbying because it has concerns that the government might create a government insurance industry competing with its interests. It also talks about the pharmaceutical industry that is worried about the imposition of price controls, and how it is fighting to prevent that from happening. Unfortunately, there is a notable absence of any mention of an important contributor to medical care delivery- the physician.

It's almost as if the physicians don't matter and, unfortunately, I don't think we do. We are regarded as "workers" in this system. We do what we're told, we continue to "provide" and why does anyone have to shape any of this imminent change to suite our needs? The government has cut our reimbursement for the past 15+ years, and no one has done anything about it. In addition, multiple regulating agencies have "controlled" us from every direction without much more than a peep from any of us. We are pushovers.

Someone better get into this debate that
represents the "interests" of the physicians. Those interests can be satisfied in a simple way. The message is, we need a health care system that considers the needs of the providers, and creates an environment that allows physicians to feel free to take care of patients without government oppression and manipulation. Is that possible? You bet it is, but not with the attitudes I see in the current news.

If it doesn't change, we will have too many disappointed physicians in their 40s who don't like the job situation they are in. They will provide perfunctory care, and neither the doctors nor the patients will be satisfied.

James P. Weaver, M.D.,FACS

Reunion and Change

I went to a 40th Class Reunion this weekend. Its been forty years since I graduated from medical school. It doesn't need to be said, but those years went by in an instant: marriage, children, internship, moving, residency, first job, residency again, moving, and then the long run of my most "productive" years of work. It goes by too, too fast.

Sometimes it was difficult to recognize those classmates who accompanied me on that educational journey of a lifetime- too much time had taken something away from them. Some could hardly recognize me either. We visited the rooms and laboratories that we haunted 40 years ago. I always get an inexplicable feeling about the passage of time when I visit a place I have not been to in years. I just don't understand where the time goes, and why everything looks as if it has not changed much even though all this time has passed. Remembering the chemistry, physiology, anatomy labs with all the struggle, and learning and discovery inspires one to reconsider what actually happened. A lot of growing happened during those years.

During the weekend we went to lectures, and dinners, and visited each other after a 40 year hiatus. I recalled that my medical school filled me with information galore, but it also filled me with a professional ethic that has carried me far into my surgical practice. It's the PATIENT FIRST. That's the "old time" professional ethic. It was a pleasure to be with 35 of my classmates who understood their calling the same way I have understood mine for all these years. I know times are different now, but when we graduated in 1969, the majority of us were not thinking about "life style" we were just going to be physicians-that was our "life style" choice.

The only discouraging experience of the weekend, was the lecture by the person who tried to teach us about "Medical Education in the 21st Century." Why discouraging? The message was that my generation was gone and out of touch. The new generation was concerned about their "lifestyle:" how much time they would have with their family, how much less work they would have to do, how short their work day would be, and possibly how much they would earn. I got the feeling they didn't want to work the same way we did. I worried about their understanding of Professionalism.

Now I don't want to criticise the younger generation, be it x'ers, or the me generation, or whatever, but I worry that this "life style" choice is a reflection of a deeper motivation that threatens the essence of what it means to be a physician.

An essential purpose in all of our lives is the positive effect we can have on others we encounter. Physicians have the privilege of working in a milieu where we can satisfy this need. We do it by becoming "professional."

According to Dr. Edmond Pellegrino, of Georgetown University, professionalism in medicine is played out on the stage of the physician-patient relationship. The patient comes to us vulnerable, frightened, confused, and in need, and for the physician to satisfy that need, we must have an ethic of self effacement, and sacrifice. This is the essence of professionalism. A "life style" choice does not seem like a creditable start towards this goal.

There are many forces in medicine today that are threatening professionalism and driving a wedge between the patient and the physician. I do not know what the result will be if the younger generation of physicians loses sight of the necessity of self effacement and self sacrifice as they enter this special field. Caring medicine cannot survive without a professional commitment of its doctors. I hope the younger generation can learn that professionalism in medicine requires a commitment to the patient that can hamper one's "life style." Unfortunately, that's what it takes to be a doctor.

James P. Weaver,M.D.,FACS

Addition to "The Hospice Threat"

A recent conference in the Congress deals with the "threat" of Hospice becoming the rationer for the elderly. Listen to this Professor give his opinion about this issue. There are few ways out of this money crunch. Saving dollars from medical care means cutting somewhere, and the elderly are a good target! See this video:
See :"The Hospice Threat", this blog, January 19, 2009.

Motorcycling and Surgery

I'm afraid to write this because it might cut into my credibility, but the internet is a "safe" place to write, so here goes.

I am a surgeon, and I also ride a motorcycle. I have ridden off and on for forty years! I rode for a while while I lived in Cleveland, Ohio, but it was too cold, and the children were too young, and it wasn't very safe in a big city. So I sold the bike (a 1969 Triumph tiger) and quit for about 20 years.

In my early 40's I picked up the bug again, and bought a Yahama Virago, and living in North Carolina then, I decided to ride the length of the Blue Ridge Parkway. If you have never ridden on this road it is a must. Probably one of the most beautiful roads in the United States.

Well, I practiced, took the Motorcycle Safety Foundation course on safety, and took a 10 day vacation and took the trip. It was beautiful. I stayed with friends along the way, and had a ball. I had intended to sell the bike after the trip, but I didn't and that was over 20 years ago. Since then, I have been up to Ohio to the Vintage Motorcycle Days meeting, ridden across the USA twice, and traveled up the northeast part of the country besides taken numerous smaller trips of a few days in the surrounding vicinity. Finally, I took a once in a lifetime 10 day trip over to Europe and traveled through the alps. It just never left my blood, and I still yearn for more travels.

But why do I do this, and for that matter, what can it possibly have to do with surgery? More that most of you folks that do not ride a motorcycle can imagine.

To get right to the point, motorcycling is like surgery because you have to know what you are doing or you get your butt in a jam. You have to know the rules, be careful, and watch our for unexpected circumstances. The major difference is that when you ride a motorcycle, you get a full sense of freedom and a deep appreciation of the nature of your surroundings.

It hurts me to go to a state (like Arizona) where there are no helmet laws, and see riders biking without a helmet. That makes me immediately think they do not understand the depth of the risk. They are being foolish as far as I can see. When I see someone drinking alcohol, and biking, I get the same feeling. I guess that's why they are not surgeons. There are more effective ways to demonstrate the idea of individual freedom. Our heads are fragile at 25mph, and it's just not worth it.

Because I do what I do, I feel at home on a bike. The best part is that even though I am in familiar surroundings, I can get the additional benefit of the feeling of freedom. I don't get that in the operating room.

So when you ride, I would advise you to ride safe. Wear good clothing, helmets, and shoes, and enjoy the experience. I have enjoyed it for years, and hopefully can continue to enjoy it for many more.

James P. Weaver, M.D., FACS

Safety and Liberty, always competing

Safety and Liberty, two ideals which are constantly competing for primacy in our tempestuous lives. Most of us do not even see this battle, but it is going on in many venues. We just have to look for it.

I became aware of this struggle, and ordered my priorities in the battle over motorcycle helmet laws. I wanted more liberty, because I believe liberty strengthens us to face life as confident people. Liberty gives us the essence of our yearning to be a whole person. To have liberty, to be free, is an instinct infused into our souls at creation. We continue to search for it.

With the motorcycle helmet laws, the "safety people" want everyone to wear a helmet at all times- it's safer. The "liberty people" want to have the freedom to choose. Yes, they are safer, and I always wear one when I ride, but safety is not the only, or for that matter, the most important issue to consider.

The safety people want to preserve life-their priority- by being safe. Understood. But in the choice between life and liberty, which is the most important? My assessment is liberty! It is certain that many of us have sacrificed life to preserve liberty. Isn't that why many of us have died in war? In a multitude of circumstances, liberty easily trumps safety.

I can think of many examples where this battle rages on lesser levels: bicycle laws about helmets, seat belts in cars, walking up a hill with your 8 year old child, playing high school sports, and almost anything where their is a danger to life or limb. I believe that a child raised without liberty and all safety will lack essential attributes to succeed in the world: self confidence, ambition, and creativity to name a few. But again, from my perspective, liberty is most important.

The latest area in medical care which illustrates this conflict is the area of "patient safety." I don't have anything against patient safety, but it can go too far. Currently, it has become such a craze, that it is threatening to remove any semblance of professional liberty from the practice of medicine. Not only do we surgeons talk to the patients about their surgery, and have them sign a "request" for surgery, but we have to mark the site of the surgery before the patient enters the operating room, and then do a "time out" and repeat it all over again. The latest potential addition to this liturgy is a World Health Organization check list that the followers of this movement are potentially going to lay on us!

In surgery, this control came about because of "wrong patient or wrong site surgery." But how many of these occur (the numerator) and how many surgeries are there anyway (the denominator)? Isn't there a little bit of throwing out the baby with the bath water here?

I do not think we have carefully thought this through. "Safety uber allis," and to hell with liberty. There is no understanding or concern of the culture that this oppressive system is creating.

Do the safety people believe that physicians cannot create a safe environment or that they do not think patient safety is laudable? We have been thinking about it since the Oath was first spoken.

Physicians, especially surgeons, are a motivated group. We have succeeded in elementary school, high school, college, and have gone through rigorous training to reach a high level of societal responsibility. This is the essence of the "professional liberty" that society previously granted for completing this training. For me, and many others, this quest for liberty, is one of the motivations that propelled us along this arduous road. Is it wise to take this liberty away?

"We hold these truths to be self evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, LIBERTY, and the pursuit of Happiness." These words were written by wise men. They were chosen because they understood the importance of liberty as essential to a full life. They didn't say "life, safety, and the pursuit of happiness." Many of them died in defense of their philosophy.

Patient safety must develop limits to its protocols. The continued erosion of professional liberty will not promote the excellence in medical care that we all strive for. Further equitable cooperation between practicing physicians and regulators must occur to preserve professional liberty and produce the optimal outcome for patient care that we all covet.


James P. Weaver, M.D.,FACS

Salary for Service: the Future Physician Payment Method

With all the talk of health care reform, I have been thinking about how physicians of the future are going to be paid. Obama says that we are going to control costs, and make the system more efficient. (Haven't we always been doing this?) The question I have is what will happen to the providers of care under this revolution. Anyone who reads the criticisms of the current system will see a peppering of the phrase "fee for service" with a quick mention of its detrimental influence on health care costs. "Fee for service encourages physicians to do more things to keep their incomes up."Anyone with common sense can see that this argument is irrefutable. It's just human nature. If you need to make a living, and who doesn't, the temptation will be there to do more things that will generate more income.

The classic argument against this proposal is that physicians are "professionals" and they have the good of the patient as their first duty. This argument doesn't hold a drop of water today. Look at the money making specialty hospitals, look at advertising, look at work schedules of many physicians, look at the way private physicians have turned away from the hospital care of their sick patients and placed them in the hands of the hospitalists. It doesn't take long to see that the standard of caring for OUR patient has fallen short of the ideal of self effacement for the good of the patient. Today, there is a looming question out there about the very existence of "professionalism" in the ranks of medicine.

Controlling costs, that's the most important aim of this health care revolution, and there is one major change that will accomplish this goal: Place all physicians on salary. A salary, no way! It's clear that this is going to happen. Examining the implications will make it clear.

First, this will eliminate the constant drive to do MORE to increase income. It will stop this incentive. Is it desirable for health care reform to "control costs?" You betcha!

Second, it will decrease the number of borderline cases that are done to increase income which drives up the cost of medical care for the nation. It will, to look at it another way, begin a system of surreptitious rationing. Does anyone believe that a sixty hour per week(future work rules) surgeon, on salary, will want to "invest" days and possibly weeks in a elderly patient with numerous co-morbidities and an "ify" prognosis? If I know human nature, it's just not going to happen. The argument to the patient will be," you're just too sick to have this operation." This type of interaction will ration care without anyone knowing.

All of these results are coveted by the health care reformers: less incentive to "produce," and less serious illnesses to pay for. Imagine the cost savings.

Many physicians are on salary already, and they will fall in line easily. It's the private doctors that will cause problems with implementation of this system. No doubt it will be a gradual movement of getting them into a corner and giving them no options when the "answer" of salary will become "apparent." Will it be eliminating the threat of malpractice litigation that will tip the balance? I can't be certain, but it will happen. It's too obvious.

In some ways, it will not be all that bad. Physicians can them relax, move into a different "life style" (a common phrase among younger physicians), and enjoy activities besides medicine. My guess is that the only problem these doctors will face is when they become the patient. By then, it will be too late.

James P. Weaver, M.D.,FACS

American College of Surgeons, Where Are You?

I have been a member of the American College of Surgeons for 30+ years, and I am still disappointed in its ability to defend the profession. Surgeons have lost any control of their work environment, and with that any true sense of a functioning professional. Where is the ACS on this issue?

In a previous article on this blog-A Problem with Patient Safety, Feb. 28, 2009- I explained how "patient safety" has taken a chunk out of professional freedom but that is not the only opportunity that has been squandered by the ACS (American College of Surgeons). In terms of "patient safety" I do not expect to hear a peep out of the ACS over the fact that I have discussed the absence of limits to the regulations over patient safety. In 2004, there were about 70 reports of "wrong site surgery" by the Joint Commission. My guess is that they included even wrong site anaesthetic blocks that were discovered and corrected prior to the surgery. They probably included "near misses." But the critical question is how many surgeries were done in the United States in 2004, and how far are we to go with the regulation of surgeons because of these few mistakes. My guess is that there is a baseline number of "wrong site surgeries" that will be done each year no matter how much control these many organizations impose. I do not condone mistakes, but I don't agree with regulations that are securing jobs for the regulators either. Where is the ACS on this issue?

Another area that illustrates the lack of attention to our professional freedom, is the ACS continued endorsement of regulations that disparage the profession. What does "pay for profession" mean anyway? I thought we were a profession, and that means that we do the best we can ALWAYS! Are they going to pay us more of we preform well? Does that mean that we don't do things well some of the time and we won't be paid as much for those procedures? The ACS should not agree to "pay for performance." Agreeing to this concept is disparaging to the principles of professionalism which the ACS is supposed to represent and protect. Where is the ACS?

Another example of "lack of fortitude" are the recent "should never happen" Medicare rules. Medicare is only looking for reasons not to pay for the work of physicians. Now, I can understand they will not pay for an instrument left in the patient, that makes sense. But what about mediastinal infection after heart surgery? This is clearly an attempt to enter a new area of "denial of payment." Where is the ACS?

I have been involved in hundreds of operations, and infections just happen. The rules are strict, and carefully applied, and IN SPITE of all the precautions, infections occur. It's clear that Medicare has added this exclusion to test our response. The ACS response should have been the same as mine: "Infections can occur in spite of rigorous precautions, and it is unacceptable to include mediastinal infection after heart surgery in this scheme." The ACS should mention the fact that Medicare attempts to withhold payment mainly because of their own budgetary constraints, but history predicts it will not be part of the discussion because the ACS will not bring it up. Where is the ACS?

I could add more, but finally, the Medicare reimbursement system. The ACS should go to Washington and tell them that there is no integrity in this system. The resource based relative value scale does not contain any mention of "value" to the patient. It's value that people pay for when they purchase any product. The RBRVS is a blatant lie, used to control the costs of the promises that the government cannot afford. The ACS should let Washington know that physicians have no trust in the determination of the "value" of their services because the government has a conflict of interest in determining this "value." Currently it has enslaved physicians, and is ruining the profession. It does not look good for the future of patient care under Medicare. Where is the ACS?

Another area that has had "no comment" from the ACS has been re-certification. Physicians are re-certified at all levels these days. The hospitals, the insurance companies, our societies, the state boards, the specialty boards all have a part in re-certification. Isn't that enough? Has the ACS stood up for surgeons, and stated that we have so many organizations and review groups watching us that re-certification is not necessary anymore. Where is the ACS?

American College of Surgeons, please reevaluate, and begin to take an active role in defending our profession.

James P. Weaver, M.D., FACS

A note on Obama's Health Care Summit

Interesting blog from the Cato institute clarifies the make-up of the recent Health Care Summit. According to this blog, there were only those who advocate socialized medicine. Doesn't look good for patients or doctors.

It is good to keep in mind that when the President of Russia, Boris Yeltsin, needed a coronary bypass, the Russian government had to fly a team of surgeons from the United States to get the surgery done. Governments always have expenses that are more important than health care: tanks, guns, bombs, roads, bridges, and more infrastructure. After all, those who are sick are a tiny minority, and most of us believe we will never get sick. If the President of Russia couldn't get a coronary bypass under his own socialized health care system, what will happen to the average person in ours? It's a good question to ask.

I worry about many things in the future of medical care. How will they control costs? What rights will the patients have? What rights will the doctors have? How will talented individuals behave in a system that will surely control their every behavior? I do not believe the "talent" will go into medicine once it's clear that it is government run system. What will happen to research? What will happen to the pharmaceutical industry with the demand for less expensive medicines?

Socialists do not believe in the need for PROFIT in industry. They simply control it. Medical care is a special field. We need talented people to go into it. We need materials to work with, and we need many levels of research to develop the gadgets, and the drugs to help people. Once the power of government begins to take over this system, the creativity will cease. Profit feeds creativity, and government control will squash profit.

I always worry that if I get too far ahead of the crowd in my vision, that everyone will not be able to follow my logic. With this one, it is closer than you think. I don't think I am too far ahead of the thinkers. Government means FORCE, and I am afraid we are about to feel it.

James P. Weaver,M.D., FACS

The Meaning of DNR

I had a provocative conversation last week with a Hospitalist. We talked about the meaning of DNR. I had always thought it meant if the patient stops breathing or goes into cardiac arrest, that one would not try to "bring her back" by external chest massage, electro shock, and iv drugs. The person I was talking with had a different interpretation of this term and stated that, "it means no heroic measures." I have thought about this for quite some time now, and it is a bit disconcerting.


What does "no heroic measures" mean anyway? Who determines what will be "heroic?" Heroic to one might be "necessary" to another. This is of concern, because the person who said this is a recently trained physician, a younger doctor. Is this what they are trained to think these days? I would like to examine this concept more closely.

In a recent post of mine on this blog-The Hospice Threat, January 19, 2009- I discussed my concern with the increasing population of elderly, decreasing dollars for health care, and overworked physicians, that the drive to treat the elderly will diminish. "That old guy has a pretty bad sprained ankle. Maybe we should just let him go,"is a phrase I have used to illustrate this probable future shift in physician behavior.

It seems to me that "no heroic measures" potentially is a much broader interpretation of the DNR concept. Is it heroic to treat a urinary tract infection in a 85 year old patient who has had a previous stroke and is hemiparetic? And how about using antibiotics to treat pneumonia in a renal failure patient with a previous amputation, cardiac disease, and a previous stroke, is that heroic? The problem with "no heroic measures" is that it is vague enough that it opens the door to RATIONING. This rationing, unfortunately, will be used in a "final" sense.

We don't like to say the "R"word, but it isgoing to happen; the question is how? Will certain services be denied? Will certain services be prohibited? My guess is that certain things will not be paid for, and others will not be available. The critical issue is that the behavior of physicians should not be influenced by societal pressures. I'm afraid that, in the future, the societal influences on physicians behavior will be covert and subtle. Physicians will just not do what they did twenty years ago to save an elderly patient.

I see this different understanding of DNR as another wedge into the physician-patient relationship, with the potential to weaken the physician's classical obligation for the care of the patient. This is yet another example of forces diminishing our Professionalism. With the financial pressures on medical care, this is just another brick in the foundation of rationing.


James P. Weaver, M.D.,FACS

A Problem with Patient Safety?

Don't think I'm about to write that patient safety is the best thing that ever happened to medical care. I'm not. I think it might be useful sometimes, and is occasionally a reasonable addition to procedures in medicine, but the problem with "patient safety" is that there are NO LIMITS to its implementation.

All this patient safety began around the time of the publication of the book, To Err is Human. It was published by the Institute of Medicine in 1999. There had been rumblings about safety before that, but that book began the major onslaught of regulations. JACHO, CMS, state agencies, leap frog, medical board organizations, insurance companies and others, too many to count,began to apply their own regulations to support the growing idea that the doctors were dangerous and needed to be controlled! After all, doctors kill over 100,000 patients/yr. with mistakes.

First of all, I'm not certain that figure is accurate. I have been in medicine for over 30 years, and I can barely remember deaths caused by errors. Is giving the "wrong" antibiotic prior to culture results a mistake; is an incisional hernia a mistake; is an infection after surgery a mistake (even in a malnourished patient); is a heart attack after a below knee amputation a mistake? These numbers added up, and fed the final conclusion of 100,000. These numbers are based on research done in the 1980s to discover why there were so many malpractice suits, and I have questions about these statistics. It sounded good, and this conclusion opened the door to control and regulation of doctors with no limits. After all, who can speak up against "patient safety?" Not me!
But there is problem with this crusade. "Outsiders" have been given authority to manipulate and control all aspects of physician behavior to the extent that any semblance of professionalism is being decimated. Professionalism includes the concept of PROFESSIONAL FREEDOM, and this has disappeared in medical practice. CMS demands some of these rules because of payment constraints, but they all jumble together to control the day to day behavior of physicians. Do they really believe we are trying to make errors? It just happens decisions in medical care are difficult, and that's why we used to be paid well for our work.

The words we use in our "private patient charts," the details of behavior in the operating room, the "time out," the concept of patient consult versus evaluation, instrument and sponge counts on cases with incisions only 3 centimeters long; updating a physical exam prior to surgery, re-dating the operative request;signing verbal orders within 24hours, dictating operative notes within 24 hours, and not to mention the continued devaluation of our services through reimbursement reduction, are just a few examples of the ever increasing infringement on professional liberty that physicians are forced to endure. Are these checks useful? Maybe some of them, we don't truly know. One thing, however, is for sure: they are selecting a certain type of physician who will practice in the future in this oppressive environment. This "new" doctor will be the type who will not live a life for medicine or for the patients. Medicine will become a job, a supplement to a "lifestyle" which offers time off, reasonable payment, time for family, and time for other "more important" activities. As long as these doctors follow the RULES, and stay under the radar of the regulators, they can continue to work at their job. Fortunately, it was not a job in the past, it was a profession.

Surgeons are now required to do a "time out" prior to operation. I have never operated on the wrong patient or wrong side in 30 years. But we are now required to mark the site prior to surgery, have the request signed before surgery, and discuss the site of surgery before we do it. I am surprised that we are not required to turn around three times after the "time out" and do it again to make sure we have the right patient!

If the specialty organizations-American College of Surgeons, American College of Physicians, American College of Cardiology, etc.- do not begin to speak up against the continued oppression of physicians, and begin to demand some reasonable limits to these oppressive regulations, I fear the patients of the future will be treated by physicians who are not particularly concerned or motivated to get the best for each patient. These new physicians will be a "physician bureaucrat" who is enforcing the RULES of "the system." I do not believe this is a bargain society wants. There can be no profession without "professional liberty." Professional behavior and motivation depends upon it.

James P. Weaver, M.D.

The Smoker's Choice: addiction

Apparently, there was a recent settlement for 8 million dollars in another "smokers" case. "They made me do it!" The plaintiff was the wife of a smoker who died at age 55 after years of smoking- he was ADDICTED. He died in 1997, at the age of 55. How long does it take for someone to hear the message? Smoking causes disease and death.

I used to smoke myself, and I knew in 1970, that smoking was dangerous for my health. I used to joke that the cigarettes I smoked were keeping the cancer cells quiet, and if I stopped, they would wake up and kill me. The above case is just another nail in the coffin of accepting personal responsibility for our behavior.

As a thoracic and vascular surgeon, I have thirty years of experience watching my patients smoke and struggle to stop. I have heard all the excuses in the world, "I've smoked for 50 years" and, "I'm addicted" are the most common. It's the "I'm addicted" that deserves further comment.

I think the people who make the "products" to help smokers stop want them to believe they are ADDICTED. Believing you are addicted means that you cannot stop WITHOUT buying their product to stop. That is what they want smokers to believe because it means money for them, but what they do not want smokers to consider is that addiction comes in different flavors. Their are addictions to narcotics, or alcohol, and these are serious. If you stop these drugs suddenly, you can die. Seizures, vomiting, and diarrhea are the consequences. But smoking is a special type of addiction that I call a "situational addiction."


As a previous smoker, I know what a situational addiction is. It's one that comes on under certain situations: up in the morning, read the newspaper, a cup of coffee, and a cigarette; an important telephone conversation and a cigarette; after dinner, a cup of coffee and a cigarette. All of these situations NEED a cigarette. I used to get up in the middle of the night, think about a problem that was bothering me, and have a cigarette. When I finally quit, it was the SITUATIONS that I had to deal with to stay away from cigs.

The most common reason someone who has quit goes back, is that something happens that upsets them, and they say," I need a cigarette." This behavior is not a physical addition, as alcohol or narcotics are, this is a situational addiction. This type of addition cannot be handled with medicines or patches, or hypnosis, or needles. It can only be managed with reasoning and attitude, and understanding.

Simply being aware of this distinction can help the smoker understand and deal with the urge to smoke. Change in one's situation can help relieve the stress and the desire for another smoke.

When I quit, I was nervous for about three days. By then, all the nicotine (the "addictive" substance) is gone from the body. That's when an understanding of the situational part of the "addiction" becomes important. I actually wrote the Attorney General about this about one year ago; he never answered.

Success in quiting smoking is as dependent on being aware of the situational part of this process as it is using a patch or other devices to control the urge. I believe the reason so many of these devices fail is because of a misunderstanding of the causes of this addiction. Good luck.

James P. Weaver, M.D.,FACS

Doctor Ads

Physicians have been advertising ever since 1975, when the successful suit by the FTC against the AMA (Goldfarb v. Virginia State Bar) forced the AMA to remove the prohibition against advertising form its Code of Ethics. Since that time, physicians have used this tool to promote their practices. Unfortunately, physician advertising has placed doctors in the same venue as merchants, and degraded their previous status as one of the "learned professions."


In an article by Tomycz (N.D.Tomybz, Journal of Medical Ethics 2006;32:26-28),he explains that the leaders of the FTC believed that Medicine was mercantile, and needed to be regulated as a business. They believed that regulation would decrease the ever rising tide of medical costs. Didn't work did it!

The original AMA prohibition began in the 1800's, and was generated by the large amount of advertising put out by a multitude of potent makers and charlatans. Not wanting to be identified with this behavior, which was frequently deceptive, this medical organization forbade advertising by its members.

Today, physician's ads are ubiquitous. They are not false, or misleading most of the time. It is not unusual to see one next to a furniture store ad, or a restaurant ad, which places the physician firmly in the arena of the merchant. I have even seen a license plate cover with the name of an orthopedic practice in my town. How about identifying with a car dealership?

The real problem with advertising is that it threatens to dissolve the distinction between what is supposed to be the Profession of medicine, and business. Medicine, in the classical sense, is supposed to be a profession that carries an obligation of self sacrifice and self effacement towards the ultimate good for the patient. This characteristic of the profession is what generates the essential element of TRUST between the patient and the physician.

A merchants might want you to trust them, but they are not going to have any self effacement or sacrifice in their part of the relationship. If physicians are to be regarded as a profession, all of these elements-self sacrifice, self effacement, and trust-must be part of their ethic. By advertising, physicians place themselves in the venue of the merchants, dissolving a significant distinction and jeopardizing a trusting relationship with their patients. Is my doctor in it for the money?

I am aware, that in the current financial environment, doctors believe they must advertise to stay competitive. But they must be aware of the element of "professional suicide" that accompanies the road of self promotion. Medicine should remain a profession that is not interested in selling you anything. Our best advertisement is our reputation and our service.

James P. Weaver, M.D., FACS

Medical Care Oppression

I know most people think physicians have a pleasant professional life, but that is not true. The current atmosphere in the medical world is not a happy world. Most physicians do not advise there children to go into medical fields, and that is a tragedy. A practicing physician, around 40 years of age, should believe that practicing medicine is the best thing to do, and that nothing else would be better.

Doctors today feel oppressed, and Medicare is the major offender. Medicare tells doctors how much time to spend with patients; what they should write in the hospital and in their own private charts; who they can admit to the hospital; how much they will be paid for their labor; and all these directives are done with the constant threat of large fines and imprisonment if these "rules" are not followed. All of these rules apply even though the government promised that there was a "prohibition against any Federal interference" in the first paragraph of the original Medicare law.

Medicare has forced "Professionalism" out of medicine. It cannot pay for all the promises made to the people, and it continues to decrease reimbursement, and increase rules. Fifteen years ago, most doctors believed that they were being paid a reasonable wage for the work they were doing. Today, I and most other doctors believe we are not much more than controlled servants. We work hard for our wages, with difficult patients, taking risks that are not adequately reimbursed. Many services we deliver are "covered" under the "global" coverage of indentured servitude. Global coverage is a method that Medicare uses to force physicians into patient care situations that extract free work from physicians. It is all too common.

I have begun to wonder about the response of people that are forced into a system that they believe has no integrity. I think that doctors believe that Medicare has no integrity or honesty in its dealings with physicians. It continues to unilaterally cheat the providers with its many rules and restrictions. That cannot but encourage behavior in doctors which will not be helpful to patients.

I am searching the business literature for studies on this topic(how people behave in an environment that they believe is unjust), but have not found much yet. I intend to write about it later. How does someone behave when forced to work under a system that one believes has no justice? Why is it the malpractice rates keep going up, but reimbursement keeps decreasing? Are we doing something that is dangerous, but not worth much? I believe this system is not healthy or nurturing to the profession of medicine, and the social consequences have yet to be examined.

More to follow.

Dr. Weaver

The Hospice Threat

They're building another Hospice in my town. I believe that makes about three relatively close to each other. That's the third one on about three years. It scares me. Why are we building these things so fast? Are we getting ready for something? I think we are, but no one's talking about it. I'm not even certain if anyone is thinking about it.

We are heading into a perfect storm in medical care in this country: 65+million baby boomers, general economic decline, and increased demands on our over burdened health care system. It's clear what is coming. We are going to ration much of what we did yesterday, because we don't have enough to spend on the elderly. Who will get the liver transplants in the future? Who will get the coronary bypasses in the future? I even wonder who will get their ruptured abdominal aortic aneurysm repaired tomorrow? The answer is, I believe, more obvious that many are willing to admit.

Residents are trained today to "control costs," and this effects the daily care all hospitalized patients receive. "Don't admit them if you can help it, and if you do, get them out fast!" That is the teaching mantra in today's teaching hospitals, and it is not about to end soon. It is only going to get louder.

Medicare is struggling to keep up with the expenses of the medical promises it has made to the people. It is the biggest entitlement threat to the federal budget. My guess is that the Federal Government will be forced to demand more taxes from every one's pay to support this system. Apparently, 23 percent of Medicare recipients consume 67 percent of Medicare spending, and 30 percent of this spending pays for care in the final year of life.

I have no problem with the idea of the "good death;" that is the idea that Hospice promotes. In many instances that goal is effectively accomplished. The problem is that there should be more concern that Hospice, under the current social conditions can easily become the socially acceptable alternative to appropriate care for the elderly.

Societies cannot always see clearly when individuals begin to act with the herd mentality, and I fear that is a possibility in our future. The picture of an environment with scarce resources, too many patients, and physicians that are too busy with too little of the traditional ethic of the "patient first" is developing before our eyes and we refuse to see it!

Physicians must become aware of this dangerous path, and begin the debate to maintain our obligation to our patients. There is nothing wrong with a bicameral system. In health care, the physicians must stay on the side of the patients. Let the administrators manage the expenses. We must side with the patients. The debate will be fruitful. Once doctors begin to manage the the health care dollar, we will lose the trust which is the glue that holds the physician-patient relationship together.

The patients that come to us are vulnerable, frightened, and in need. Their trust in our public promise to place each patient first, is not negotiable. If physicians forsake this promise their is no professionalism left in medical care, and physicians have become no different than merchants. There is no society that can tolerate this degradation of our professional ethic.

I have no problem with a Hospice system that is used properly. Physicians must remain aware of the danger of a Hospice that becomes the answer to our fiscal constraints. Proper medical care, and the patient first must not deteriorate.

James P. Weaver, M.D.

The Challenger Principle

The Challenger was a disaster that should not have occurred. It was known by the Morton Thiokol company that the "O rings" might not function effectively under cold conditions. On January 28, 1986, the temperature was below 30 degrees Fahrenheit at Cape Kennedy. The company knew there could be a problem with sealing the fuel joints on the rocket, but agreed to the launch anyway. NASA and Morton Thiokol were both pushed into taking a chance because of the cost, the importance of this launch, and constraints of time. The result is too well known.

I have used this incident as a reminder to NEVER BE AFRAID TO CANCEL SURGERY.

In our busy schedules, with multiple operations and multiple patients, it is not unusual to miss some important result that once discovered raises the possibility of danger with the procedure. Discovering something we did not know, prior to an operation initiates an internal debate," Should I cancel this operation? When will I do this case; my schedule is full. The family has come a considerable distance for this patient, and they will have a fit!" When I have this debate,and we all will at some point, I think of the Challenger, and cancel the case.

Going to talk with the family can be difficult, for they have most often taken time off from work, traveled long distances, and waited in anticipation for the surgical result. Talking with the family about the decision to cancel surgery can be acrimonious.

After allowing the family to vent their anger at this situation, I then tell them that I have a specific reason for canceling the surgery, because I discovered something I was uncomfortable with. Then I remind them of the Challenger.

If they don't remamber the Challenger, I briefly reiterate the story of this unfortunate incident. I remind them that a debate occurred for at least three days before the launch, and NASA finally agreed with Morton Thiokol that they would "probably" be alright even though there were questions about the safety of the "O rings." I let them know that I discovered "x" and that I am NEVER AFRAID TO CANCEL AN OPERATION.

All anyone can see when remembering the Challenger is the poof of smoke and the steller cloud slowly sinking back to earth. My experience has been that the family then enthusiastically thanks me for cancelling the surgery.

So, when faced with some new information that brings up doubt about proceeding with surgery, think of the Challenger, and never be afraid to cancel an operation.

James P. Weaver, M.D.

Words Matter: The Operative Request

Surgeons understand the importance of having patients sign a "permit" prior to any procedure. This piece of paper is signed because if you touch someone without their permission, you can be sued for assault. If you have ever had this experience, you want to avoid it ever happening again.
The problem is, however, that the word "permit" is destructive to the relationship between the patient and the physician.

Words matter! They influence our understanding and perception of anything that we describe. Isn't a "previously owned" car much different that a "used" one? "Permit" or "consent" are no exceptions. These words come from the legal arena, and not from medicine. Legal encounters are frequently based on adversarial interactions, and not on relationships of "shared decision making based upon mutual respect and consideration." Medical relationships are a different arena, and we should use appropriate words to describe them.

Surgeons know the law. When we see a patient, we evaluate the patient's history, examine the patient and documentation of tests, and then we suggest a treatment. We describe the risks, benefits, potential complications, and alternative procedures. Once that is done, we ask the patient if she would like to have the suggested procedure. The patient either says "yes" or "no." Either way, we are not getting "permission" to operate, but, if the patient says "yes," the patient is actually "asking" us to do the procedure. There is an important distinction here that places the patient, linguistically, in the appropriate venue. The patient is now out of the adversarial arena of a legal interaction, and in the venue of a "shared decision, based on mutual respect and consideration."

Having the patient sign a "request for surgery" actually implies a greater respect for the patient's rights! The patient is now an active participant is the decision, not just a passive object that we must get permission from to touch. A surgeon is under more obligation to inform completely when the patient must "request" surgery, because the patient in now an active participant in the decision.

This concept was originally started in the VA hospitals in the United States in the late 1970's, by an OB-GYN surgeon named Lindon Lee. He understood these concepts, and spent eight years getting this concept approved in the VA system.

Importantly, there is no legal difference between these terminologies. It accomplishes the same goal in a more "medically" appropriate manner. Lawyers do not, understandably, like it because it does not represent their understanding of the situation.

Surgeons should stand their ground in this battle, and insist that their forms read "Request for Surgery" for it is an important gift to medical students and residents to understand their appropriate relationship with their patients. Give it to your students for their future.

James P. Weaver, M.D.