All posts by Dino William Ramzi, MD, MPH

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Disruptive Innovation

This is based on an old post from The Physician Executive when I first started thinking about the place of disruptive innovation in health care delivery.

 

The problem with disruptive innovation in health care is thinking twice about how it applies.

A couple of precepts before we begin, just so we’re all on the same page, or at least the same library:
1) First the technology can exist for a long time before it is adopted, if at all. It is in the application that an innovation potentially becomes disruptive.
2) Adoption is likely to come from smaller players as new technologies are frequently overlooked by the big players.
3) The innovation is not disruptive to the consumer. It is disruptive to other producers. The consumer adopts it because it is simpler and cheaper than the alternative.

In my world, the innovation will come from changes in the way health care is delivered, not about a sexy new scanner or robotic procedure or even a new iPad app for diabetics. And here, observations about how slowly such innovations are taken up become pertinent.

I would argue against big business. Lately, consolidation has caused health care to be delivered out of monolithic medical systems incorporating primary care, specialty, allied health (physical therapy, audiology, optometry among others) and imaging services. This creates a few problems:

1. Like big government, big business generates an entrenched bureaucracy that is resistant to change, difficult to navigate and primarily interested in perpetuating itself.

2. Incentives are skewed to generate more testing and services. Primary care, when properly delivered, reduces downstream costs to the system, meaning less revenue for the organization.

3. There is less choice (see availability of reproductive services in areas dominated by large Catholic health systems) and the cost advantages of scale initially required to reap the benefits of the technology deployed are rarely manifest.

Carving primary care out of the health care delivery system and providing a special place for it with better revenue, greater legal protection (e.g. tort reform, voiding non-competes) and subsidizing an infrastructure to allow small, personal, relationship-based practices would be a tectonic shift on how we think about health care.  Now that would be disruptive; and just as the iPhone disrupted the PC market, it is only primary care that can disrupt the medical tech (specialty/referral/imaging) sector.

Maybe this is why Clayton Christensen believes health care is ripe for disruptive innovation, although the comments confirm to me that he has not yet found the right disruptions. It will be up to people like Dave Chase, Rob Lamberts and Brian Forrest to figure it out. I could include others, but why take sides?

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What the Heck is Cultural Competence?

I stumbled across this old post about Washington trying to pass a bill mandating continuing education for physicians on cultural competence. They just did it again in the legislative session that ended. Again the bill died, but not the one mandating education on suicide prevention.

Suicide prevention is a wonderful thing, but I will be obligated to spend six hours of my valuable time learning about something I bet I do better than 99% of the doctors in this state. I’m not being cocky, it’s just that we have very few psychiatrists around and I have had to upgrade my psychiatric, pharmacology and counselling skills.

The sad part is that it will not help suicide prevention because CME is superbly badly suited to the skill required. So here is the old post.

 

Washington State has chosen to address the cultural competency of their physicians and providers.

While this is laudable in purpose, an effort to assure cultural competence is difficult to implement well. On the face of it, additional training seems the logical response to a deficit in cultural competence. Unfortunately, continuing medical education and training has never been demonstrated to effectively change the practice patterns of physicians, so there is no reason to believe it will work here.

One could try to increase the diversity of the physician supply, but my experience is that whereas this may improve the satisfaction of people with similar ethnic and cultural backgrounds, it does not address the competence of physicians dealing with a diverse group of patients. Foreigners of any given ethnicity are no better able to deal with other ethnicities than a plain vanilla white American boy.

Moreover, the way cultural competence is presented can be dangerous, the way many well-intentioned efforts succumb to the law of unintended consequences. For example I recently received a brochure from The Joint Commission (aka JCAHO) which represents different ethnic groups and their usual beliefs and behaviors about illness.

Many of the ‘facts’ presented are truisms and platitudes that only hold for some people in any given population. Not every Hmong rubs coins on their childrens’ backs and not every Latina mother thinks about cold and hot illnesses. These beliefs are typical of ordinary people and thus much more dramatically influenced by socio-economic status within the culture that by the culture itself. It is tantamount to calling an Asian smart or an African athletic. Whether or not the statement hold true in the aggregate, the seed of prejudice (i.e. pre-judging) lies in assuming that the person in front of you shares those attributes.

Perhaps there is a different way to assure cultural competence, but also to address the underlying issues for poor communication between physicians and patients. Physicians are taught interpersonal and communication skills in medical school and residency, but the training is uneven and inconsistent between programs. To deal with every person on a psychosocial continuum is to see them as a unique collection of ethnic, cultural, social, family personal, biological and genetically determined experiences that need to be peeled away layer by layer without assumption, judgment or bias. Culture rightly become a focus, but only of one of several factors which shape the interaction.

In the cognitive specialties, like the primary care specialties, the ability to provide satisfactory care without excessive investigation is the key to assuring low-cost, high-quality health outcomes.

I would propose we completely and utterly abandon cultural competence (by the way, I am convinced Washington State is using “competency” in a grammatically incorrect way) as the framework for how we approach patients and replace with a broader psychosocially defined “communication competence concept.” These can be taught through the current channels with an IOM-driven effort to influence curricula via ACGME and the AAMC. In other words, use current channels to support a broad communication-skills agenda rather than a narrow-focus of cultural competence.

Some resources can be found at HRSA, Joint Commission (aka JCAHO) and the ANM.

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Immigration and Health Care Costs

Impressions from a cross-country road trip dominates this
Physician Executive post from 2008. The cultural diversity of the country made a big impression on me. It is ironic that while we argue today about Immigration Reform, the pressure from immigration has been dissipated by new economic realities. Net migration from Mexico is now negative. I suspect it is only a matter of time before xenophobia rears its ugly head again in the healthcare debates.

 

In my drive across the country, I encountered many languages. Coming from a polyglot city like DC, it is easy to be jaded about the American heartland and consider fairly white-bread. This is why it struck me that I encountered so many cultures along the way. I could have said that there were more non-English culture Americans along the way, but then I would be grandstanding.

I did run into a family of Greeks from Turkey along the way, an almost vanished cultural subgroup. Mostly I found myself conversing in my broken Spanish. First was a family from Cuba and we met in the St. Louis arch. Of course the dominant group was Mexican-American, who manned convenience stores, restaurants and hotels the entire length of the country, even in the most white bread areas. I even saw a young black man cleaning a hotel room, a truly unaccustomed site in this country over the last decade, but it was at a National Park, where reasonably affluent young adults work hard in exchange for the adventure of their lives.

All these impressions came on the heels of a radio talking-head saying something to the effect that the trouble with this country was the extent of illegal immigration. He was saying that people seemed to think it was OK to break the law or to simply ignore it in such unprecedented numbers.

So, that would mean that all laws must be vigorously enforced at all times. I’m glad this guy isn’t in charge of the highway administration; I would have been in trouble with speeding especially in some abandoned stretches of road in the West. But the level of policing required to eliminate all speeding in the country would be onerous, certainly it would be cost-prohibitive. Before the ACLU lost its way when the real issues gradually disappeared, they would have gently reminded us that not all laws are meant to be enforced severely given the risk that we could begin to look like a police state; a deplorable condition to be avoided at all costs. Indeed the fathers of this country did proclaim their liberty, or their lives!

If a law requires such severe and absurd efforts like building a wall across a natural resource like the Rio Grande, then I would consider the law worthy of re-evaluation. A law of the land is not a natural law. It is not the Law of Evolution, it is not a Law of God handed down to Moses, or elucidated by Mohammed or revealed by Christ. This country’s laws reflect intelligent people’s best bet on how to secure the greater good.

Our immigration laws are not only ineffectual; they are economically and socially counter-productive.

I caught a CSPAN rerun of Chris Matthews plugging his new book and he suggested that he had a problem with providing government documents to people who were not supposed to be here, i.e. making someone look like they had a status or legitimacy they did not have. That, I can understand. His position reflects serious thinking about how to approach the problem of rapid, undocumented immigration. But stopping immigration altogether is a boneheaded concept. Stopping illegal immigration is unlikely, given the strength of the forces behind migration. In fact, it is the complexity of human migration decisions that makes draconian immigration enforcement so stupid.

It is also economically counter-productive since I am convinced that labor is an asset for any country and does not represent a net burden in services. Some services relate to infrastructure that already exists and incremental increases are not necessarily harmful. Other services such as health care have raised some people’s hackles.

Those people who are up in arms over health care costs to immigrants need to come off it! Immigrants, especially illegals are mostly young, fit and hard-working. They do not come with the express purpose of seeking free health care for themselves or their families, although that may play into their needs after several years if their parents fall ill. There are numerous indications that immigrants, and especially illegals, use less health care and are more likely to pay for it than America’s own native poor. (By native, I mean born in the USA.)

The major burden in most areas is a fertility rate that approaches third world levels, but we’re too busy preaching the ineffectual dogma of abstinence to do anything about it (but that’s another post.) If anyone bothered to do a detailed economic accounting of the costs and benefits, I suspect it would quickly become clear that even illegal immigration is of net economic benefit to this country. Issues related to national security are just more fear-mongering to which I have become inured.

In construction and agriculture alone, this work force represents the ultimate in flexible, mobile work force to do labor of a kind no American would accept to do for any wage. To get native born-American to take up the back-breaking toil which is manual farm labor, we would all be looking at $8 tomatoes and a $20 head of cabbage.

If the problem is that there are too many immigrants, then I say it is the same old xenophobia that has affected people since time immemorial; a mean-spirited, deeply-rooted human fear of all that is unfamiliar. If the problem is only that such immigration is illegal, then I say change the laws. They are too impractical and poorly thought out for my liking. There are better and more intelligent ways to deal with a big incentive for economic migration from our southern neighbors.

The fear of health care costs related to immigration is just one more ideological bone from the political demagogues.

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Response to Michael Cannon

More on Cannon and the USA Today article from 2007.

I have had trouble responding to Michael Cannon. I knew when I first read his response to my critique of his USA Today Op-Ed (that’s a mouthful to follow) that more should be said. He spent most of his time defending incorrect referencing in his Op-Ed, but there was something more. The more I read, the more I perceived a purposeful selection of data in support of an existing position. I am more familiar with the scientific method which requires the writer to follow the data, including contradictory evidence. Mr. Cannon comes from an ideological perspective to which I cannot relate. Perhaps no response is required for ideologues. After all, what is the purpose of the Cato Institute but to purvey a particular ideology?

I have a libertarian streak, but I am no libertarian. These ideas serve as a reminder that there are limits to what government can and should do. There are limitations to the financial resources of any society. I do not believe that there should be a single payer or that everyone is entitled to every possible medical intervention. But as I dig deeper, my understanding is growing of the ideology which shares these principles.

First let me direct some comments directly to Michael’s defense of the USA Today Op-Ed:

  1. To minimize the number of uninsured is to miss the point that there are vulnerable people in society who need some assistance. The government has a role in improving the quality of life of its citizens by supporting education, defense, law and order, health care and probably other areas as well. To believe the government has no role whatsoever is false, intellectually on the fringe and historically on the road to revolution.
  2. To suggest that all people covered by Medicaid would be better off with private insurance is as ignorant of the lives of the poor as Mariah Carey talking about poor starving kids and flies and death and stuff. Crowd-out as Michael Cannon describes is another name for cherry-picking. To force low-income individuals who are most likely to cost insurers more money is to keep private insurance more profitable for the insurers.
  3. Most medical care is not cost-effective, as measured by macro-level indicators. Since leaving Canada I have learned that no country ever became great by trying to be cost-effective, but rather by achieving its goals. Therein lies my objection to raising the issue of medical cost-effectiveness. The most important variable in cost-effectiveness is defining the goal, so as to know if you are being effective in achieving the goal. It would be cost-effective to focus efforts on coverage of the most vulnerable. It would be cost-effective to stop treating the elderly, the disabled and the mentally retarded. Sometimes we do things because we feel it is important as a reflection of the quality of our society. Economic reasons alone are not good enough to make decisions about health care policy, something I was taught by a health economist from Harvard.

There are some very valid notions being floated regarding health reform, not the least of which are reducing payments to hospitals (which account for 50% of the country’s health care bill), increasing transparency of pricing and increasing consumer control of their own health care money and benefits. These proposals address many problems in health care today, but not the problems of those who need the greatest assistance. At the risk of sounding like a guild monopolist, physicians are better representatives of patients when they cannot speak for themselves than a policy wonk who’s never walked a day in clinic.

The first step in crafting health care policy is articulating a role for government. If you don’t believe there is any role for government in health care, then we have nothing more to talk about and we must agree to disagree. If the goal is a responsible approach to improving the well-being of the population through expanded health coverage while simultaneously improving accountability of the tax dollar, then there is a possibility of discussing the relative merits of various approaches.

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USA Today Health Reform Editorial

Here is one Michael Cannon would prefer to forget. The problem with the ideologues is that they learn to reference their papers after they’ve written theM. So often, the articles do not say anything about what is being referenced. This is why I do not often use material from think tanks unless it is clear to me they do not have a political agenda and treat facts respectfully, with reason and an absence of rhetoric. From The Physician Executive in September in 2007. I will never delve this deeply into ideological clap-trap ever again! 

 

Dear readers, I need your help.

As you may know, I am a proponent of a non-dogmatic approach to policy debate and would like to see some truly conservative approaches to health care reform. I despise the tools of rhetoric and the use of formal logical fallacies that characterize the current crop of so-called conservatives.

Yesterday (via InsureBlog), USA today published an op-ed by Michael Cannon of the Cato Institute, an organization which I usually find provocative and challenging, but not thoroughly manipulative nor responsible for shoddy scholarship. I reviewed the articles which Mr. Cannon offers as references and have trouble connecting the articles to the point being made. There are also some logical inconsistencies.

Here is a systematic breakdown of what I found:

1. US Census Bureau. Nothing wrong here, the Bureau’s number may very well bear re-examination since all surveys have strengths and weaknesses. There is no such thing as methodological perfection.

2. Agency for Health Research and Quality: “other recent surveys put the number between 19 million and 36 million” for the uninsured. The link takes us to a MEPS survey (Medicare Expenditure Panel Survey is a running survey of medical expenditures using a representative sample of the entire US population) which does not support Mr. Cannon’s statement. The study delves more deeply into the census bureau’s figures by looking at the duration of being uninsured. The census bureau counts people as uninsured if they have been uninsured for any time n the past 12 months. Since the public health concern is identifying a vulnerable population, this is an entirely valid definition. The MEPS survey states “In 2003, 25.4 percent of the population was uninsured at some point during the year, 18.8 percent was uninsured throughout the first half of the year, and 13.6 percent was uninsured for the entire year.” Even math errors on Mr. Cannon’s part does not explain why he is comparing the proportion of American uninsured for the first half, second half and at any time of the year.

3. The next link is used to support the phrase “As many as 20% of the “uninsured” are eligible for government health programs, so in effect they are insured.” This is the most egregious. It comes from data that many who are eligible for Medicaid do not sign up since 20% of those eligible are not signed up for SCHIP. The statement holds true only if all the uninsured are eligible for some kind of government program, which is inconsistent with a seprate implication, presented with no evidence, that so many of the uninsured are illegal. Moreover, it escapes me how someone who is eligible for a program is still covered if they chose not to sign up. How does this address the vulnerability associated with catastrophic health expenditures? Moreover, the study referred to is a sober and numbing methodological comparison of the MEPS and Census surveys, not one of the many studies which have demonstrated repeatedly that under-utilization appears to be the hallmark of programs like SCHIP.

4. Mr. Cannon uses a study by Bundorf and Pauly to support the statement that as many as 75% of the uninsured can afford insurance. The paper is a fascinating and illuminating look at the effect of different definitions of affordability on the population estimate. While 76% is the high end, 31% is the low end of the estimate. Their findings support a statement much different than Mr. Cannon’s, here I quote from Bundorf and Pauly’s conclusion: “Our results demonstrate that lack of “affordability” is an important barrier, but not the only or the major barrier to obtaining coverage for all, or even most, of the uninsured. […]Omitted variables related to health status are potentially of particular importance. If our measures of health status do not capture characteristics of individuals that result in unusually high premiums (potentially due to risk rating of premiums or denials of coverage in the individual market, for example), we may over estimate the affordability of health insurance for high risks. […]Deciding for whom health insurance is affordable is ultimately a normative decision on the part of policymakers and society. We believe that our definitions, however, offer researchers and policymakers a positive empirical framework with which to begin to evaluate this question by basing the definition of affordability on the behavior of other consumers with similar characteristics, rather than an arbitrarily chosen income threshold.” This is very wise, unlike Mr. Cannon’s inexplicable peripatetic diversion.

5. To support the statement that “many economists can find no evidence that it [expanding coverage] is a cost-effective way to improve health” Mr. Cannon uses a non-peer reviewed piece of secondary literature that is actually an interesting review of the literature with respect to causality between insurance and health. The reviewers observe that if the causal chain fails, it may be either health insurance or health care that may not improve the health of the population. That is an established fact, which is not at issue because we are talking about extending health coverage to vulnerable sub-populations. The poor represent the majority of the uninsured unless you believe the prior misinformation. Perhaps the argument against covering the uninsured is being used as an argument against either government run or universal health insurance.

6. A rapid sequence of references asserting that expanding health coverage will not

a. Improve quality: New England Journal article shows that income is more important than race. The study does not address access to which coverage is most relevant.

b. Reduce disparities: Paper argues that reducing poverty is more important to health than improving health care access.

c. Affect life expectancy: A New York Times article about education being related to longevity.

d. Reduce cheating: A Health Affairs analysis of how health care costs for the uninsured are currently distributed. No mention of how not having a program deters cheating on the aforementioned non-existent program, i.e. Mr. Cannon’s argument is nearly circular.

7. The Kaiser Family Foundation says that the average family of four spends $11,000 a year. Individuals are pegged at $4,000. What the average cost per employee is, I just don’t know. Using one number without the other is not an honest presentation of the problem and I may be a little dense here… what was the point? Health care is expensive? We know that.

8. Several correct citations regarding the number of people covered by employer-sponsored insurance, rise in health insurance premiums, a White House press release, Rudy Guliani’s campaign website and a CBO letter.

Please review what you can (not everyone has full text access to Bundorf & Pauly) and let me know if I have mis-read any of Mr. Cannon’s references. Please note the title of the editorial refers to making Americans care about health care. This is a very promising position. I hunger to hear the argument, but am I just dense, or did he completely skirt around the cost, except a passing mention of average family insurance expenditures? I think there are extremely cogent arguments to be made.

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Costco, Fashion and Health

I share a lot with the society in which I live.

Shopping at Costco, you always notice the overstock items run in a small number of sizes. Somebody overestimated the number of items manufactured in a given size. Sometimes it’s easy to find your size, which probably means it was either butt-ugly or mis-priced.

My size is not easy to find. People with 18 inch necks are not usually 34 sleeve. You can find 18/36 and 17/34, but 18/34 just ain’t easy.

I have message for the “shmatta” industry: America is getting fat! I’m not proud of it, but facts is facts and I’m not getting any younger, thinner or hairier on the top of my head. America is getting fat and the population’s obesity no longer looks like a bell curve. Stop making clothes for the ideal of the human form and you will lose less money in unsellable overstock.

One good thing: tomorrow is the day I will start to exercise, knowing I finally found an 18/34 this weekend, just in time for Valentine’s Day.

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State Licensure: Quality Assurance or Trade Barrier?

When I moved to Washington from Maryland, it was a difficult transition. The worst part was getting to my new job earlier than anyone thought I could, but then having to sit around and wait for my license. I worked hard trying to familiarize myself with the organization as best I could. But it made me think … this post was written in 2008.

 

It is hard to believe that The Physician Executive has not yet received his new state license. It has been over six weeks, but physician readers will not be surprised. Fortunately, our insurers have already assured us that the moment the license is verifiable online, they will honor charges in his name.

In Maryland, the Board of Physicians says it takes 120 days to obtain a license (it usually goes faster). The last time I looked into California, it was over six months. States that decide they are over-doctored typically take longer than other states. There may be something to that, since I have heard of some primary care physicians having a hard enough time finding work that they are considering leaving California. But to be fair, I don’t know if a couple of anecdotes are worthy of calling it an established trend; I will be watching.

The reason it takes so long is something known as primary source verification. Licensing boards are diligent in verifying every employment situation, every hospital affiliation and every training site. Sometimes they go so far as to verify every locum situation as well. If a physician has worked for a single weekend covering a rural hospital, someone will want to verify it. Even thirty years later.

This needs to be done.

But it generates an awful lot of paperwork.

Since some of my former employers are closed, it creates challenges in identifying the correct individual to provide important verifications. Unsurprisingly, many Canadian residencies are less concerned with American credentialing than I am. My former internship site is apparently renovating and having trouble finding documents for some guy who left the country ten years ago.

Such is life.

The trail is long and I am a bit of a Donabedian groupie, so I don’t have a problem with primary source verification. However, there is an awful lot of overlap. There is the National Practitioner Database and the AMA, which offer some degree of triangulation, even though they are primarily a method of identifying complaints, lawsuits and other problems. Employers also do their own primary source verification, that way employers do not need to stay familiar with their state board’s processes. In one instance, the state board was able to obtain verification and the employer was not. The employer insisted on a signed affidavit.

Then there are the insurers. One company I am familiar with refuses to begin a credentialing process until everything is in the file. Then it takes them four months to review. Then they do not pay for any services provided during the credentialing process. I understand the importance of credentials verification, but this sounds a little like manipulating a process to their financial advantage. Yes, I am talking about you, Amerigroup. (Gratuitous stock advice: consider buying the stock, but never the insurance.)*

I would never advocate the elimination of licensing requirements (if I hear someone quote Milton Friedman on the subject one more time, I will subject them to the merciless ridicule reserved for followers of cults, star energy, homeopathy and other quackery), but there are certainly some implications for a free market in health care. There isn’t one.

We could streamline licensing procedures and credentials verification across the country. The CAQH already has electronic tools to facilitate the credentialing process. It would open up interstate competition in health care. (In a subsidized environment, heath care is driven by practitioners, so the competition is between jurisdictions and employers to attract them, not between practitioners to attract customers.) The problem of mal-distribution of physician resources would likely continue, but there are a very few examples of regulatory incentives to encourage physicians not to settle in cities or suburbs. Physicians flock to nice places to live until they start going belly-up. Or working for MinuteClinics.

As it stands, as a CMO, I am competing with much wealthier jurisdictions and facilities and then faced with an outsized regulatory burden to verify my practitioner’s credentials and facilitate our payer’s verifications. Moreover, the barriers to interstate movement of the medical labor force is at a level that makes me think of protectionist trade barriers.

I hope to see my first patient next week.

*I suppose there should be a disclaimer about the fact that my comment is meant sarcastically and not intended to represent real stock advice etc etc, but I assume that my readers are intelligent enough to figure that out for themselves. Caveat emptor.

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The Economics of Mid-Levels

Another old post from The Physician Executive with currency in today’s environment. 

 

I was once a family physician delivering babies in an East Coast big city.

No, I am not a masochist, I was a family practice residency faculty.

Given the intense turf wars caused by an oversupply of competing specialists, it was an unpleasant environment to work. The concentration of specialty providers in big cities and urban areas poses some problems when it comes to costs. Frequently, one looks to mid-levels as a way of addressing problems in health care. Indeed Physician Assistants and Nurse Practitioners have a potentially important role to play in health care, but where?

Jason Shafrin at the Health Economist takes a look at midwives (included in the ranks of nurse practitioners for most of the latter part of the past century.)

I like midlevel providers like nurse practitioners and physician assistants because of their ability to bolster the ranks of primary care, the main engine of cost containment in health care. They can be invaluable in rural areas where it is difficult to entice specialists, even where there is a critical mass of demand for their services.

On the other hand, Jason’s post appears to be looking at midwives as a less costly alternative to obstetricians. A commenter on my site reminded me of Milton Friedman’s assertion that licensing leads to higher costs without assuring quality. In medicine, we have established a complicated and lengthy licensing process in the secure belief that the alternative was the chaos of snake-oil salesman that populated the United States at the turn of the last century. In other words, there was a compelling societal reason to limit and license people delivering health care.

I’m not sure what we accomplish by looking at mid levels as alternatives to established specialty providers. Moreover, specialists and midwives are equally maldistributed, being over-represented in metropolitan areas, where competition finds a way of increasing costs. Yes, health care acts strangely and higher concentrations of specialists tends to increase costs rather than reduce prices as one would expect.

On the other hand, finding an incentive to better distribute physicians may be a subtle way of improving physician incomes and health outcomes and reduce costs.

I want to make it clear once again, this is not a tirade against nurses or midwives. Nurses have saved my backside too often not to be collaborative and old school midwives working in labor and delivery taught me everything I know about delivering a baby.

I am questioning how we make policy in the face of a web of data and mess of potential starting points from which to approach the data.

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Christmas and Change

I wrote this 6 years ago. It is oddly suited today, because the more we learn, the more we discover to learn. The better I get, the worse I was.

 

Merry Christmas. Christianity was seen by Bertrand Russel as an excuse for mediocrity. I think this perception can arise from Christianity’s insistence on the potential for change.

Christianity is (or at least should be) about forgiveness and redemption above all. That means no matter how inadequate we are, how erroneous our ways, how mediocre our performance, there is always the opportunity for improvement. This position can sometimes seem to excuse past mediocrity, perhaps even celebrate it and reward it.

I was an awkward child, and a certain social awkwardness has penetrated into my adult life. But I am getting better. I have made many mistakes and continue making them. But I need to be free of the baggage of past errors in order to progress. For this reason perhaps, Christianity seems so ready and willing to forgive everything, in heaven if not on earth.

There can be no redemption without guilt. There can be no change without mediocrity. They are the catalysts for change.

Have a warm and happy day.

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A Splintered House

This is the text of a speech I gave to the Clark County Medical Society’s New Physician Reception in 2013.

Thank you to our sponsors and guests, to the Board of the CCMS and especially to each of you for coming. To all the new physicians; welcome to Clark County and to the medical society. I want to take a few minutes tonight and talk to you about our medical society and its history, my personal spin on what has happened to medicine in the 72 years since CCMS got started and how the House of Medicine became splintered. I would also like to talk a little about what our future might look like under the current and coming reality. Life is changing quickly for physicians these days.

“Clark County Medical Service Corporation” was established in 1941. The articles of incorporation, written under the name “Clark County Medical Society, Inc.”, were signed by Clyde B. Hutt, MD, as President and L.E. Hockett, MD as Secretary/Treasurer and were approved and filed on December 3, 1942. The constitution and by-laws of 1942 were amended on May 6, 1947 and adopted by membership on May 4, 1948. The bylaws have stood unamended since the last review and overhaul accomplished in 1991. They have withstood the test of time.

Medicine was simpler back in 1941. The bulk of CCMS membership knew each other. The largest group in town was the Vancouver Clinic and it had four doctors: a GP, a surgeon, a pediatrician and an OBGYN. If you wanted to hang a shingle, you may have wanted to meet the local docs so they could tell patients about you and maybe put in a good word for you at local merchants and businesses or maybe the bank. The county medical society was a way to let people know what your special interests and skills were and this was the way you got most of your referrals.

No I am not going to wax sentimental about the golden age of medicine. County medical societies had a dark side: they were exclusive and closed old-boys clubs that enforced standards of behavior in a manner that would be frowned upon today. They focused too much on their own interests and not enough on the health of the people they served. Keeping an eye on the money worked well for the US medical societies, and their parent organizations all the way up to the AMA, until the first turf wars erupted. I don’t need to belabor strife within the House of Medicine.

At the turn of the last century, there was a tug of war in the House of Medicine regarding the need for specialization: Some thought that generalism was necessary to understand the whole person, others thought that specialism was the way of increasing the relevance of physicians and to provide the best possible care for individuals. This was all derived from scientific medicine and the notion prevalent in an industrial society that there was more value in specializing.  Sir William Osler, perhaps the largest historical proponent of scientific medicine was ambivalent about the notion: “[Specialization]’” he said and I am quoting here, “must then be associated with large views on the relation of the problem, and a knowledge of its status elsewhere; otherwise it may land him in the slough of a specialism so narrow that it has depth and no breadth, or he may be led to make what he believes to be important discoveries, but which have long been current coin in other lands. It is sad to think that the day of the great polymathic student is at an end; that we may, perhaps, never again see a Scaliger, a Haller, or a Humboldt—men who took the whole field of [human] knowledge for their domain and viewed it as from a pinnacle. “

One of the earliest specialty societies was the American Academy of Pediatrics, hatched about 15 miles from here at an AMA meeting in 1930. In 1933, dermatology, OB-GYN, ophthalmology and ENT were the founding members of the ABMS. 1941 marked the year that the CCMS was founded and that Anesthesia became America’s 15th recognized specialty. Today we have splintered into between 130 and 157 specialties and sub specialties depending on how you count them and nearly as many specialty societies.

I think that is the word that best represents the House of Medicine today: splintered.

But somehow I think that people with an MD or a DO degree after their name may share certain characteristics more than a similar day-to-day existence within their own narrow silos of specialty and employment.

Somehow I think that people whose primary role is to help patients navigate our current morass of regulation, government, insurance, corporations, pharmaceuticals, manufacturers of various gadgets and medical technologies from titanium hips to scribe-friendly keyboard operated EHRs… somehow these people who bear the primary responsibility for trying at least to improve the health of well-being of their patients (and by consequence our community) have more in common than their differences would suggest.

When I first got to Clark County 4 years ago, I set about charting a course to understand how I could personally influence the course of events impacting my life. I have a MPH,  so I was interested in my role as an advocate for patients and how I could impact the epidemiological measures of health. I looked at what my specialty society was doing in the local community. I found the impact was driven by individuals, many of whom were involved with the local residency. The point is that my specialty association’s largest impact was being felt at the national level and had recently hired a lobbyist at the state. At the local level it was not any association, it was the individuals. I think this is probably true for each of our specialty associations. We can do at least as well locally.

So I believe that medicine has a role in improving the health of our communities. It may follow that when we band together and work towards that purpose, we may have better chances of success. It’s a subject for another day, but medicine has a role. It must have a role if the industry is to remain relevant as a social good, otherwise, we might as well all quit and become bankers, because that’s where the real money is.

Don’t get me wrong, I proudly carry the flag of my specialty society, but the fact is that all our specialty societies are somehow vaguely inadequate to the grass roots tasks. Its not just primary care, but all aspects of medicine that are at work in this town, from the anesthesiologist and the gynecological oncologist and the cytogenetic geneticist. We have more impact as a House of Medicine united in this one common mission that we agree on than worrying about turf wars.

And the impact is felt community by community. A truism in epidemiology is that you need large numbers to detect small changes, but it tells you nothing about what happens to individuals. And communities are made up of individuals, states are made up of communities and nations are built on states. It all starts where you live and work and being concerned for the health of your neighbors and the people around you. The health of Clark County depends in a small way on each one of you. The health of Clark County needs you to speak for it and for its concerns.

One aspect that has helped the health of Clark County has been the role of CUP. CCMS has advocated and will continue to advocate on behalf of this local non-profit community-based health plan both because it works for the community’s health and because it is a significant employer. We were concerned with toxic byproducts of a recycling plant and successfully shot it down. At the state, with other medical societies, we helped overturn the rule that emergency rooms wouldn’t be paid if their services were retrospectively judged not to be emergencies. Physicians got involved to work with the DOH and saved them more money than they envisioned by their prior plan. We also fought the B&O tax which no longer applies to physicians in WA. We are now looking at the impact of a coal terminal on our coast as well as the trains have along the route, so we are supporting studies to clarify the impact and publicize our concerns. At the state we have also supported public health nurses working on STD’s and providing the related questions and answers assistance, reproductive equity in the state and pushed for medical staff reviews that are not quite so abusive of physicians.

Only here in Clark County can you speak out about our lack of availability of fresh food in a wasteland of fast food. Only in Clark County can you do something about obesity in your community. Only in Clark County can you set up community forums to counter the vaccine objectors’ propaganda that makes us so vulnerable to epidemics IN THIS COUNTY!

I hope you each continue to support the county medical society, I hope you get involved, speak up, be a light for others to follow, be obnoxious if you want, just speak!!! And tell you colleagues about the society. You need to take responsibility for your own “belonging” to a group you believe in. And if the AMA or WSMA or even CCMS does something you disagree with, remember that your voice counts. Without that voice, it’s not surprising the organizations do things that don’t meet with your approval. You won’t win every battle in a democracy, but you will win some/ You will make a difference.