TSA and "Death Panels," What They Have in Common

 In a recent CNN interview, Homeland Security Secretary, Janet Napolitano, inferred that the "pat downs" are not going away soon, and "we better get used to them." We have definitely moved into a new phase in the security business, and I think we need to speculate on the potential effects on basic American culture. Sure, we need more security because it's getting more dangerous to fly with the terrorists making more and different bombs, but I would like to take this problem one step further. In order to reach this level of security, we are having to submit ourselves to invasive personal scrutiny at multiple levels. I must admit, I feel safer when they probe everyone, but I don't like it when it's done to me.

In a sense, they are forcing us to be "dehumanized." We are being forced to become digits, and that is the antithesis of the American way. Americans are supposed to be rugged individualists. We believe in the rights of the individual. Those rights are "endowed by our creator" and therefore can't be taken away. Isn't that what unalienable means?  Americans aren't meant to wait in line, and shut up!  The value of our personal autonomy is rooted deeply in American culture. Unfortunately, that's not what I see in our future, and I worry about changes in that culture.

Being dehumanized, and treated like a number is where we are certainly headed, and the TSA is child's play compared to what lies ahead. Not many columnists are writing about it, but health care is going to be the real changer. Right now we have "patient autonomy" and "patient rights" that pretty much allows each of us to demand all the treatment we can get. That is going to change in the future. No, I'm not talking about "death panels," because there is no such thing.  What I am talking about is the Agency for Health Care Research and Quality.

This agency was funded under H.R. 1 the Recovery and Reinvestment Act: the Stimulus Bill. It gave $1.1 billion dollars to begin this work. It consists of 15 individuals who are highly qualified with PhD, M.D., J.D., M.P.H. and RN degrees (many multiple degrees), who are going to use research to decide what can or will be done if it is efficient and "cost effective."

The genesis of this idea is contained in Tom Daschle's 2008 book, Critical: What We Can Do About the Health Care Crisis.  Among his major ideas was to create an "independent" board which can "exert tremendous influence on every other provider and payer, even those in the private sector." That, I believe, is the intention of this agency. It is going to make determinations about what is "reasonable" and what is "effective" and probably "not too costly."

Now don't misunderstand me. We need something like this. We spend millions on useless procedures and treatments, because, as Americans, we have a right to "life, liberty, and the pursuit of happiness." The tide is turning, and our individual pursuit of life is interfering with others pursuit of happiness because it costs too much. Changing this misappropriation of funds is now a priority.

The connection with TSA is that we will most likely reach a point in our aging that we will be made to feel like a digit. Only this time it will be more a question of life and death. The old thought of American individual rights will be trumped by the welfare of others because they can't afford to pay for our pursuit of life at any price. I hate to say it, but it just seems reasonable.

What concerns me beyond this interference with our medical care freedoms, is will this infringement on our personal autonomy begin to change our views of the "rugged individual American." We just can't have everything, and will we stop striving for "everything" the way we are supposed to as we work towards the elusive "American Dream." I worry that training us to wait in line to be searched, and wait in line for medical care that someone "in charge" might say we are not worthy of, will stifle  our American Spirit and respect for individual rights. If that occurs it is more serious than any conceivable death panel might be.

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

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

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

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