Forgiveness? Think Michael Vick

When I first heard the news that Michael Vick was running a dog fighting operation in the back of his multimillion dollar house in Virginia, I was disgusted and angry. I was glad they found it, had stopped it, and I hoped he would get all the punishment possible for this egregious behavior. How cruel can he be? Training a dog to attack and injure one of its own kind just might be unforgivable. Reports had it that he had killed a dog if it didn't fight well enough. I can't even imagine how twisted the "emotions" of those unfortunate animals must have been.

I love animals. They are, in many ways, dependent on us as children, and to abuse them is beyond my imagination. Dogs, handled properly, give us unlimited love. Animals depend on us in many ways, and we also depend on them. I am convinced that animals, especially dogs and cats, have a "spirit" much like people. They communicate, have emotion, experience fear and happiness, and have much to teach humans, especially about loyalty.

When I was in medical school, we did terrible things to dogs and cats all in the interest of learning.  I would object to doing that now. I had a cat of my own for twenty years, and as he got older, he used to sit on my lap and stair at me the way cats do. I used to imagine he was thinking how horrible I had been to those cats years ago. I guess I felt guilty.

Because I had a lot of feelings about this episode I followed the news of Michael's goings on, and  was elated when he was suspended from the Atlanta Falcons, went to prison,  became bankrupt, and I wanted even more.  I have to say, that as he neared the end of his prison term, and started to look for a new team to play with, I hoped he wouldn't get a second chance.

Once Philadelphia picked him up and I knew that on some Sunday afternoon I would once again be confronted with his athletic antics again and I was forced to think more deeply about Michael.

When and how does one forgive someone anyway? He did his prison time, began speaking about animal rights, admitted he was wrong and shouldn't have done what he did. He even began working with PETA. Should I forgive him?  I knew it wouldn't make any difference to him, but I began to wonder if it would make a difference to me.

Mr. Vick taught me something. He taught me to reconsider the whole idea of forgiveness. All those who have done something hurtful, or wrong, have repented and try to get back into our good graces? What a useful lesson, not only for Michael to have taught all of us about him, but taking if further to the many others in similar situations who are trying to recover from something they should not have done. Forgiveness is liberating for each of us. It let's us use that energy for more useful projects. It is a burden we do not have to carry.

So in this Christmas season, think about someone who has done something wrong to you, and think about what they may have gone through because of their action. If it is appropriate in your particular circumstance, think about forgiveness. Think about Michael Vick.

 Michael, I forgive you, and I hope you do get that dog for Christmas. I know that dog will surely teach you something about love and loyalty.

Censure? Big Deal for Rangel

So Charlie Rangel was censured. So what. He was embarrassed and had to stand in the well of the House of Representatives and listen to some scolding. "Bad, bad man." Why didn't they make him sit in the corner with a dunce cap on? It would have accomplished about as much.  The least they could do was require him to do community service, or get some type of training: anger management, lying management, who knows. Aren't there all  different types of training now to get you back on the straight and narrow? Standing in the well and being "disgraced" is nothing to him. He is a politician. He has been through this and worse before, and I'll bet he has a thick skin.

 Tiger Woods had  some training after his misbehavior, and how about Lindsay Lohan she's getting some "training."  Then there is this guy in Florida who got on the school bus and chewed out the boys who were bullying his disabled 10 year old daughter. Maybe "anger management" would help Charlie? The fact is that if you don't pay your income taxes, the "training" for most of us is prison. I haven't heard any discussion of that possibility here. It just goes to show you, we don't do that to a Congressman.  Congress is SPECIAL.

Apparently, he didn't pay his income taxes on the income from his rental home in the Dominican Republic for 17 YEARS! Forget trying to influence corporate donors for his Rangel Center at the City College of New York. Is that what they do in Congress? Yes, they are exceptional.

They have their own health care system, and pensions, and parking places and transportation and just about everything. I always have a problem when one group requires another group to do something, and they don't have to do it themselves. Would they pass different laws if they had to get the same treatment as the people? Let's see what happens with ObamaCare.

Either way this episode seems to be another example of how intolerably arrogant our elected representatives have become. If we really knew all that goes on up there it would probably make all of us vomit. The best news is that their shenanigans  are usually are exposed gradually. It only gives us heart burn.

The last election was a good beginning at sending an epistle to them.  I hope all the people will wake up , and throw out the Congressmen and Senators who do not listen to us because their thrones are too lofty for them to hear us. "You work for us, and not for yourselves!"

This last election I did more politicking  at the grass roots   than I ever have: walking the precincts, giving money, and calling voters on the phone. I did it because of one sentence spoken by the soon to be previous speaker of the house, Nancy Pelosi, "Let's pass it first, then we will see what's in it!" There was no greater demonstration of arrogance-forget the multi-million dollar flights home- than I can conceive of. It made me sick.

Keep up the Pressure on Patdowns

My advice with the "pat downs" is keep up the pressure. The actual benefit of this new fiasco is that it is calling into question the entire process our government has chosen to deal with the threat of terrorism in the air. The current approach is expensive, inefficient, and too invasive, and socially destructive. The better approach is obvious, but TSA refuses to discuss it or look into the  possible solution of profiling.

We all profile anyway. It's called, "making a judgment based on appearance." Doesn't "first impressions make a difference" apply anymore? Have mothers stopped teaching that these days?

To get right to the point, so you don't waist too much time reading this article, we need to profile. A recent discussion by the ex-chief of El Al air lines claims that we should know who is suspect before they even arrive at the airport. There is more information available than any of us know about, but narrowing the search to the "right people" would save us billions and make the airways safer. It goes without saying that searching a two year old boy  or an 85 year old grandmother to demonstrate to the world how "fair" we are with all people, is not helping anyone. It is helping our deluded sense of priorities.

Apparently, our TSA is now flirting with the labor unions. What a fiasco that will be. Threatening a strike would shut down the the entire nation, and that is not something we need.  Why not put bids out for private contractors to do the job, it will probably be more efficient, and less expensive in the long run. This entire aspect of air travel has gotten out of control and is heading into more trouble.

Finally, there is the singular idea of the invasive nature of this new development. It is unacceptable to have a total stranger fingering our "junk." In a larger sense it is moving the American public further towards the safety side of the "liberty vs. safety" debate that I discussed in my 4/9/09 blog,  "Liberty versus Safety, Always Competing." This illustrates the  tendency of our government to mold the public into a subservient and pliable mass. That is certainly not the basis of our original constitutional principles which strove to create an independent, creative population. I guess we may need to "accept" government force when the Obama health care law grinds into full gear.

My suggestion is to keep up the pressure by discussion and behavior. Refuse these procedures as much as you can, and we will force enough debate that we may get our government to abandon this intrusive and rapacious procedure.

Be Careful with What You Say

I read in the paper this morning that the athletic director from Cedar Ridge High School was suspended pending the outcome of an investigation. He is accused of making a racial slur to a 15 year old student. As the story goes from the Durham Herald-Sun newspaper, the student was hanging from a bar to stretch out his shoulder and commenting how difficult is seemed, when the athletic director walked by and commented that it would be better to be "hanging from a bar than hanging from a tree." There is some dispute about the "tree" word, and maybe he might have said "noose."

Either way, there is an investigation. Now this teacher has been at the school for nine years. He is the basketball coach, and a physical education teacher. All his activities have been suspended during the investigation. He is accused of violating someone's sensitivities by using a "racial slur."

All of us clearly understand that lynching history in this country is a despicable episode that raises disgusting images and distressing feelings in all of us. That's a given.  But this incident again raises the issue of each of our unique sensitivities, and the grand social effort to protect all of them.

It seems that anyone who offends anyone's sensitivities is at risk of interventions that have the potential to interfere with the freedoms we all deserve. My guess is that this comment was an innocent remark that is now being magnified into a major episode. Granted, the reference was ill used, but did it hurt someone's sensitivities so much to cause all kinds of retaliation? I understand that the father of this young person said, "forget suspension, I want his job."  Now that would hurt someone's sensitivities.

A recent episode in California occurred when a grade school student rode his bicycle to school and placed an American flag on it to honor America. He was told he must take it off because it might cause conflict by hurting someone's sensitivities. (I wonder whose?)

Finally, James Jones in Orlando, entered a school bus and berated some students because they had assaulted his handicapped 10 year old daughter. As far as I can tell from the video on the bus, he did not touch the "offenders" but he was charged with disorderly conduct and required to give  hours of community service, $1000 fine, and to take anger management classes. My guess is that every parent sympathizes with his "attack" of these bullies, and his direct confrontation. I wonder if he hurt the sensitivities of the bullies? I think Mr. Jones managed his anger extremely well. He didn't injure anyone, and he made his point,"don't  fool with my daughter."

We are such a divided nation, and we all seem to have our unique "sensitivities" which no one is allowed to bruise. I believe there is some truth to all this regulation, but I sometimes think we are taking it too far and dividing our nation and inhibiting our freedoms of speech and actions.

What about the American flag incident? It's clear the school over stepped it's bounds. Mr. Jones was, no doubt, given  too much punishment.  Finally, the athletic director, time will tell, but I think they should let him go, and I hope the "investigation" reveals how contrite and kind of a person he really is.

There was an event I attended last night that made me feel very comfortable with this conflict of sensitivities to our racial, ethnic, or religious conflict, because if doesn't apply under these special circumstances. I went to a high school playoff football game.

During the game, the black quarterback gave the ball to the white halfback, without conflict. Then he might have passed it to the black end, or the other Asian end. Maybe the quarterback would hand it off to the Jewish halfback who would pass it to the gay end. The point was they were a team, and they had a common opponent. They were doing a job, and all these differences which are the source of our unique "sensitivities"  didn't matter.

Do we really have time to go after the athletic director for an innocent comment? Probably not, but we are divided now, and that incident magnifies our division. It would be best if we took a step back and reevaluated this one. He didn't mean to hurt anyone, and he feels sorry for it.

Finally, it makes me think about all the ***-American types we are these days. I might try saying I am a "Euro-American" sometime, but that kind of talk only continues to divide us further. We need unity, don't we? E pluribus unum forever!

I hope I didn't offend anyone.

Our New Government. What Shall We Do?

Now that the Republicans (Teaparty) have (has)  won a decisive victory against the Democrats in our last election the question becomes; what directions will we go? Will the winners answer the cries of the plaintiffs in this ideological struggle? Or will it be one and the same of the last two years of bickering and gridlock?

For one thing it's clear  that Obama does not seem to see the problem. In his news conference on Wednesday, he blamed the economy foremost. Does he see it? I'm not certain. Only the weeks ahead will tell. Will he compromise? Not certain?

Our Government was designed to encourage gridlock. Governments can do foolish things that cause ripple effects that effect everyone. That's why the founding fathers made it so difficult to get anything done. Witness the recent infusion of billions of dollars into the economy by the Fed. Will that cause later inflation, and the devaluing of all of our property? Most certainly. Should we buy gold? Not certain.

The Republicans are boasting how they are going to repeal "ObamaCare." Big mistake. As I see it, the public approval rating is about 50% now, and let's face it, we need to do SOMETHING! The best approach would be to modify  it. There are some provisions in this law that look reasonable like stopping insurance companies from denying "preexisting" conditions. Of course, it will cost us something, and we need to pay for that.

The recent comments by the Deficit Reduction Commission were genuinely frightening. Not the report itself, but the public's response to it.  Every suggestion was criticized by the faction being cited for cutbacks. I'm not certain we have the will in this country to face the necessity for fiscal restraint.
If we don't, we are all in for uncontrolled financial misery. Can you imaging paying $15 for a Big Mac? I fear we are headed for inflation.

I think the most important response to this recent election is for the public to try to realize that we need to stay in touch with our Congressmen and women. Don't crawl back into our caves, and watch more TV.  Call them, write them, email them to keep them aware of our thoughts.

Finally, the Congress people must LISTEN! They didn't listen when they passed the "unread" health care law, and that is unacceptable to their constituents.  The electorate won't stand for so much arrogance. I think we all did a splendid job in demonstrating that in the last election.

Return to Gettysburg this Tuesday

Eleven score and seven years ago our fathers brought forth on this continent a new nation, conceived in Liberty and dedicated to the proposition that all men are created equal. In three days we will test that proposition again and determine whether a nation so conceived and so dedicated can long endure.

We have the chance again this Tuesday to vote and determine whether this nation is a nation of, by, and for the people, or a nation of, by, and for the government. This is an opportunity to demonstrate our strength as voters and re-establish our future direction as a nation. We have the opportunity to restate the proposition that the power comes from the people and not from the elite. Do we want the government to be in charge, or do we the people want that power.

If there is any single example that demonstrates our arrival at this critical point in our collective national history, it is the manner in which the "health care bill" was passed. "Let's pass it and then we will find out what is in it." Had they read it prior to passage? No!

We citizens have the opportunity Tuesday to demonstrate that this is a government of, by and for the people by voting out those who patronized us by their arrogance and actions these past two years. They work for us, and we must demonstrate this at the polls. If we don't we will be headed down the road to enslavement by our government.

Finally, this is a nation "under God." It is not a nation under government. I hope we are wise enough not to place our ultimate trust in the creations and laws of man which are always flawed, but in the ideals of a higher source. Even though some would like to remove it, "In God we trust" was chosen as our slogan for a reason. With this motto as our guide we "shall not perish from this earth."

New Era for Blog

Trip of a Lifetime

Anne and I are on our Real Vacation. We are going to China. We left yesterday, and flew to San Francisco for a two day lay over to adjust to the time change, and it's 12 hours difference in China.

The "adventure" involved a 3 hour delay because something was wrong with the plane. Really, I'd rather they get it right before we take off. But we arrived in SF about 11 o,clock our time-EST. Good night rest, and now out on the town. We will go into the city and see the "T bone" itself. Hope there aren't any earth quakes!

There will be a lot of moving around on this trip, so I hope I have time to keep you all up with our adventure. What a great feeling to leave the "shoulds and oughts" at home, and head into the world for observation, investigation, and learning.

I have wanted to go to China for a long time mainly because it is so different than my home town, Chicago. New culture, different ideas, great opportunity. I surmise that it will be similar to other travels I have had in that the people turn out to look different, wear different clothes, have different customs, but the same in their fundamental desires, needs, and aspirations.

More to follow, I hope.
JP

Why Physicians are Depressed

I have wondered for quite a while now why "hope" has been taken away from the practice of medicine. I am getting older, and may retire in a year of two, but I see it in my younger colleagues. They look forward to working fewer hours, complaining about the ever increasing scrutiny of physicians, and the all too common government threats to reduce payments to physicians under Medicare. The milieu for practicing medicine is "not what it used to be."

In reading a recent book, "Outliers:The Story of Success" by Malcolm Gladwell, I think I have found the answer. Mr. Gladwell tells the story of Mr. Borgenicht and his wife who started sewing aprons in their kitchen, and built a very successful business in the garment district of New York City. He describes in the following paragraph why Mr. Borgenicht was successful, and why he had "hope." Examining the field of medicine from the perspective that Mr. Gladwell examines the work of Mr. Borgenicht will help us expose the forces in medicine that taking hope out of our practices.

"When Borgenicht came home at night to his children, he may have been tired and poor and overwhelmed, but he was alive. He was his own boss. He was responsible for his own decisions and direction. His work was complex: it engaged his mind and imagination. And in his work, there was a relationship between effort and reward: the longer he and Regina (his wife) stayed up at night sewing aprons, the more money they made the next day on the streets... (my bold)Those three things-autonomy, complexity, and a connection between effort and reward-are, most people agree, the three qualities that work has to have if it is to be satisfying." Is practicing medicine satisfying these days? I would like to examine these three qualities in the practice of medicine: autonomy, complexity and connection between effort and reward.

How about autonomy. Physicians must pass Board Exams-I don't have a problem with that idea, but the exams are changing-every few years now, and they are now going to require continuous re-certification. I recently re-certified in cardio-thoracic surgery and the examination was effective, educational and enjoyable. I was treated like an adult, a professional. It was a take home exam which showed me a critique of the question after I tried to answer it the first time. After reviewing the critique (which contained the answer), I answered the question a second time. It was an educational process which I enjoyed even though I do not do most of the procedures I was queried about. Now, because of the increasing scrutiny of physicians, the exam will be a closed book exam that younger surgeons will have to travel to some hotel to take. Don't we have enough bureaucrats reviewing and checking on us at multiple levels? Ever hear of the "one hundred lives campaign?"

That's only one type of scrutiny. I haven't mentioned JACHO and its review on new doctors, and doctors private offices, and peer review, and CME requirements, and applications for privileges to hospitals, and even-if you can believe it- applying to be on an insurance company panel of "approved" doctors. If something bad happens in surgery, and it can happen, the review is never ending.

I once was placing a pacemaker in a very sick patient. She ended up doing alright, but during the case, she had a cardiac arrest. It was handled fine, and she survived without consequences. During her cardiac arrest,however, while I was resuscitating her, I actually thought, "I can't believe the bureaucracy I will have to go through if she dies!" What a confining and oppressive atmosphere in which to practice medicine. Autonomy is gone, and with it, any sense of professionalism that used to serve as the basis of a life of personal sacrifice for the patients. Are we going into medicine now as a "lifestyle" choice?

Mr. Gladwell's second requirement for hope in a vocation is complexity. I think all will agree that the physician's job is complex, but even the complexity is being threatened by intrusions of others into the daily work of the physician. Documentation has become so important in the field of medicine, that it is just about becoming medical care. At times, the patients seem to be getting in the way of this medical care, and if they would just go away, we could finish our documentation. Why so much documentation? It is done for legal and reimbursement reasons. It doesn't have anything to do with patient care.

In addition, we are told what to write. We can't say diabetes anymore, it has to be "type II diabetes," and anemia is now "blood loss anemia." Imagine controlling what a real professional must write, and how details must be written. Is that another limit on the ever disappearing reward of professional freedom?

Finally, their is a relationship "between effort and reward." There is none whatsoever. Third parties control this important aspect of any service relationship, and they have created systems that exist to decrease reimbursement to providers rather than fairly compensate the work of physicians. Most physicians don't know the details of the reimbursement, but they keep working harder, because they know that their income continues to drop while the bonuses of the third party administrators continues to increase.

I worry about medical care not so much because there are so many millions uninsured, and that most folks can't afford medical care, but I worry that the physicians and other "providers" are working in a field that does not satisfy Mr. Gladwell's requirements for a satisfying work environment. What does this portend for patients in the future? In a word, trouble. I think the relationship between the patient and the physician is dissolving. I think that in the future, there is a danger that when we are sick and vulnerable, and frightened, there will not be much of a connection with the person who is "in charge" of the decisions that will effect our life and limb. That does not bode well for our quest of "coverage for all."

James P. Weaver, M.D.,FACS

The Physician's Vow of Poverty?

A recent editorial in the New England Journal of Medicine "Medicine's Ethical Responsibility for Health Care Reform" discusses Medicine's ethical obligations in the current battle for health care reform. Dr. Brody, the author, suggests that medical specialties come up with a top five diagnostic tests or treatments that are commonly ordered by members of a specialty that are expensive and show no meaningful benefit for the patient. I can't disagree with that idea for I have seen many tests-meaningful malpractice reform might change this- and procedures that don't seem to do much for the patient.

That is the essence of his paper, but he has slipped in a zinger at the beginning of his argument that deserves much further public debate.

He mentions the reform that health insurance companies and pharmaceutical companies have offered to hold down the cost of medical care, and then opines that physician support "has been made contingent on promises that physicians' income would not be negatively affected by reform."

He goes on to remind us that physicians have "sworn an oath to place the interests of the patient ahead of their own interests-including their financial interests." He also notes that none of the for profit health care industries that have promised cost savings have taken such an oath. Well, true enough, but medicine has not taken a vow of relative poverty either, and this deserves further discussion.

Physicians deserve to earn a good living just as the leaders of the pharmaceutical and insurance industries do. And no, they haven't taken such an oath. The millions they earn each year and the way their customers are manipulated and swindled is indisputable proof of that. Physicians earn more than most of us, so is it wrong for them to want to preserve their incomes?

In most clinical situations today, the financial relationship between the physician and patient is not material. Both parties have fallen into the paradigm that the third party controls this aspect of the relationship. Physicians have little leverage over reimbursement from third parties for the noteworthy work they do. Medicare typically pays about 30% of charges, and Medicaid pays worse. To make matters more inequitable, the "private insurers" tied their payments to Medicare over ten years ago in a exquisitely perceptive move to relentlessly lower their payments to physicians.

Over five years ago, the Annals of Thoracic Surgery published an article that dealt with the question of the "purchasing power of thoracic procedures." Their analysis by noted economists showed that the "purchasing power" from the income of thoracic procedures had decreased 50% over the preceding ten years. It has not gotten any better in the last five years, and it doesn't look like it will improve in the next five either.

Physicians are members of the "learned professions." We all know that the interests of the patients are primary, but physicians have financial obligations like everyone. I recently talked to a family doctor who owed over $200,000 in loans from her education. Don't physicians have families, and homes, and other expenses that we all have? Professional athletes commonly earn in the six figures, and many earn much more, and all they do is entertain us. How much is it worth to us to pay someone who will save our life?

I don't agree with Nancy Polosi about many things, but I do agree that the insurance companies (including Medicare) have strangled the economic rights of providers and patients while maintaining a comfortable margin of profit for themselves. This is why medicine must say that it wants to preserve its income when and if health care is reformed. Physicians believe that an inequitable portion of the proposed "cost saving measures" will come out of their pockets because they do not believe they have any significant leverage or clout in the negotiations. They have not had much influence in the past and the future doesn't seem any brighter.

On a one to one basis, I believe most physicians will treat their patients with understanding and respect when it comes to economic matters of reimbursement. Putting the third party in the middle of that relationship has damaged the basis of medicine's professionalism- our relationship with our patients. Preserving physician's income will help to reinforce the bond of service that physicians have promised by paying providers closer to what they are worth in the delicately intimate and consequential exchange the transpires in health care encounters.

James P. Weaver, M.D., FACS
Durham, N.C.