13 April 2011

Dr. Stephen R. Keister : Political Idiots and Economic Dementia

Aldous Huxley: the "dogmatism and proselytizing zeal... of religious or political idiots."

Huxley's 'political idiots' and
public health in America

By Dr. Stephen R. Keister / The Rag Blog / April 13, 2011
"At least two thirds of our miseries spring from human stupidity, human malice and those great motivators and justifiers of malice and stupidity, idealism, dogmatism and proselytizing zeal on behalf of religious or political idiots." -- Aldous Huxley
I begin writing this on a Friday morning, feeling depressed and disillusioned, as the Congress considers a "government shutdown," noting the absurd and idiotic reasons that the Republicans would use to justify such a bizarre act, proposing it in the name of demented economic theory and with the underlying motive of destroying programs currently in place designed to enhance the lives of our elderly and the disadvantaged of this country.

In his Hightower Lowdown column, Jim Hightower recently wrote about a novel called Alpaca,
a remarkably portentous piece of political writing by one of America's first billionaires, Dallas oilman H. L. Hunt. Self-published in 1960, the 191-page book laid out his vision of a libertarian, plutocratic utopia.

Hunt's ideal society was one in which the wealthiest would have a disproportionate say in government. He saw them as the achievers and, as proven by their riches, the most meritorious of citizens. They should get not one vote, he believed, but three, for they could be trusted to protect the volatile masses from the rise of populists.
Hightower sees Hunt’s vision given new life in the current Republican efforts to create a two-class society, a vision financed to the tune of millions of dollars by the U.S. Chamber of Commerce, the American Action Network, Crossroads GPS, and the various enterprises of the Koch Brothers.

This brings me to a point of playing the swami and looking ahead at the future of health care in the United States and the complicity of various physicians in accelerating this crisis.

First let me note a recent CNN poll showing that 75% of Americans want funding levels for Medicare to stay the same or go up. For Social Security, 87% of Americans want funding levels to stay the same or go up. Yet, these same folks have their fate resting in the hands of a Republican Party that exhibits the ideological zeal of the Spanish Inquisition and a Democratic Party and President who look at "compromise" in the same frame as Neville Chamberlain did at Munich.

Currently we who are on Medicare have 75% of our expenses paid for through the Medicare Trust Fund... monies we invested in the fund through our payroll taxes during our working days. These were not payments into the U.S. Treasury, but into a government sponsored "pension fund,” supposedly to be used for no other purposes than paying Social Security and Medicare benefits. Of course this trust was undermined by the Bush administration when the actual funds were used to subsidize warfare throughout the world, and were replaced with government bonds.

Some of us are fortunate enough, having the initial 75% of our medical costs paid by Medicare, to purchase Medicare Supplemental Insurance to cover the 25% not paid by Medicare. Supplements are not to be confused with "Medicare Advantage Plans" which were intended by the Bush administration to be the first step in privatizing Medicare and at the same time hurry the depletion of the Trust Fund. The Republicans have always opposed Medicare as well as Social Security.

The current Republican proposal calls for Medicare -- by the year 2030 -- to pay 32% of medical costs while the individual will pay 68% out of pocket. The GOP plan will gradually increase the eligibility age and give the states more control over the plan. The 32% distributed by the government will be given as "vouchers" in set amounts to purchase private insurance plans.

Of course these plans will cost much more because of the need to pay excessive executive salaries, stockholders, and higher administrative costs. Furthermore, the "doughnut hole" in the Medicare prescription drug benefit will continue at 100% under the Republican suggestions. An excellent review of the thinking behind the Republican plan is addressed by Wendell Potter in CommonDreams.

The Conservative Party, which currently controls the Parliament in the United Kingdom, in the interest of reducing the budget, is attempting to reduce payments to the national health system. This has created a major crisis in British politics -- mass demonstrations in the city streets, strong denunciation of the planned cuts by the British Medical Association ("we do not want quasi-privitization, with a mountain of paperwork, we want time to spend with our patients as we have now"), defections by coalition members in the Parliament, public cries and newspaper editorials regarding decreased help to the disadvantaged, the elderly, undernourished children.

Of course, the British, like most Europeans, are of a different culture than we have in the United States; theirs is a culture of community while ours is based on Ayn Rand's premise of "what is there in it for me?” But let us leave the UK and move on to our state of Vermont where the possibility of a single payer health care system is playing out. This I alluded to in my last Rag Blog submission.

As evolution of single payer care develops in Vermont there is a degree of division among the physicians: the primary care physicians approve of the plan while "certain other" physicians say they will leave the state.

We are at a point that we must take a look at the economics of the practice of medicine. First, I would note that, since I entered medical school in 1942, I have seen an attitude that says we should not increase our medical school graduation rate to a point where we have an excess of doctors in the country.

This is illustrated in recent years by the increased number of foreign graduates practicing in this country, the development of nurse practitioners and physician assistants, and the recent development of non-university affiliated osteopathic physician trade schools.

How are our domestic graduate physicians trained? Just who are these folks? All doctors start out by taking a four-year pre-med course in an undergraduate field of study. Then for the more fortunate we have four years in a university-affiliated medical school. This is followed by three years of residency training for those who wish to be family physicians, while for others, a year of general internship is required, followed by three years of specialty residency in an accredited hospital. Thereafter, one is required to take another year of fellowship in a sub-speciality.

So we see that those in the primary care specialties, internal medicine and its sub-specialities (allergy, endocrinology, rheumatology, neurology for example) have had six years training after medical school. Then we have those in the surgical sub-specialities (cardiac surgery, orthopedics, urology, for example), who have also has six years post-medical school training.

Why then the great income disparity among physicians? Those who work with their hands make some 7-10 times more than the physician who works with his mind. Why does the cardiac surgeon deserve a fee per hour 10 times that of the pediatric endocrinologist who cares for a child in a diabetic coma? Both may be life-saving procedures; the pediatrician is surely saving a life. What is it in the culture of the United States that has created this discrepancy?

Guess which physicians are considering leaving Vermont if single-payer health care passes and becomes law? One would envision in Vermont a physician payment system akin to that of the Mayo Clinic or Cleveland Clinic where the participating physicians are paid a negotiated salary rather than a procedure-based payment. This would explain, as well, why Vermont would be a magnet for the physician who wishes to be an independent contractor again, a professional, free of the dictates of the insurance industry, but by and large a primary care doctor.

There is an excellent new book called "The Hippocratic Myth" by M. Gregg Bloche, M.D. -- who is an attorney as well as a physician. Bloche was involved in the investigation of torture by physicians and psychologists at Guantanamo, and he reviews all violations of the Hippocratic Oath, in medical practice, the insurance industry, government, and the courts.

About reward systems, Bloche says:
More important are the reward systems that today favor technological wizardry over biological breakthroughs -- or time spent with speaking to patients or thinking through their problems. I recall doing some simple math, while a medical student on surgical rotation, and figuring out that my attending made more money per minute for time spent in the operating room than the actress Debra Winger made during her steamy scenes in that year’s hit film, An Officer and A Gentleman.
He took in $7,000 a case from Medicare for coronary bypass surgery, and on some mornings he'd have two cases going at once, in adjacent rooms. He could pull this off because his eager residents and fellows, counting on the same payoffs someday, did almost all of each case, from "cracking" the chest (to open it) to closing up ribs and muscle when work was done.

He put in about 20 minutes on each case, sewing in some of the little leg veins used to bypass blocked arteries. Had he spent this time talking with patients, he'd have taken home perhaps a few hundred dollars.

I fear that we face a broken medical system, as well as a broken political system. I call your attention to two recent publications. One is an extensive book review published in the Scientific American, titled Health Care Myth Busters: Is there a High Degree of Scientific Certainty in Modern Medicine?” The other is from The New York Review of Books: "Drug Companies and Doctors: A Story of Corruption,” by Dr. Marcia Angell.

In the meanwhile the negotiations, the compromises, continue in Washington bring to my mind a statement by Margaret Mead: "It may be necessary temporarily to accept a lesser evil, but one must never label a necessary evil as good."

[Dr. Stephen R. Keister lives in Erie, Pennsylvania. He is a retired physician who is active in health care reform and is a regular contributor to The Rag Blog.]

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