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Breast Feeding: Froelich & CDC

This is another old post from The Physician Executive that I expect is still relevant because old habits like supplemental feeding in hospital nurseries die a hard death when they are the path of least resistance. It was originally published on June 16, 2018

Edwina Froelich, founder of La Leche League, passed away last week. La Leche League used to state that the three main obstacles to successful breast-feeding were doctors, hospitals and social pressure.

My experience has been one of utter frustration with maternity nurses, who should know better, but frequently feed their wards sugar water for no reason. Some kids can get hypoglycemic, but certainly not three quarters of the nursery. Some kids may lose weight, but that is a normal phenomenon, with the natural history of birth being a decline in weight and return to birth weight by day 10. It is not abnormal to lose weight, but it is abnormal to get formula or D5 on day 1.

These practices appear to me (on an anecdotal basis) to be widespread in places I have worked in the US, but they would be unacceptable in other places of which I have some knowledge: Montreal, England, or France. I understand from a cousin in Dubai that at least one hospital reflects the US’s breastfeeding dysfunctions, so I am sure there is tremendous variation from country to country, especially by socio-economic class.

The harm done is that by allowing alternatives to breast feeding, we don’t give a woman a reasonable chance of establishing her breast milk in the first place. To establish breast feeding, you need an infant sucking on a nipple, which provides the hormonal stimulus to produce milk in the first place. The more concerned you are that the breast milk may “not be enough”, the more you assure the fact.

The problem with personal observations is the tendency to generalize. Finally, the CDC surveyed hospital infant feeding practices, as reported in MMWR. American hospitals persist in providing alternatives to breast feeding to infants, such as sugar water and formula. I am sure that most well-meaning maternity ward nurses will explain that they are trying to make sure babies gain weight or not become hypoglycemic. Unfortunately, entire wards of infants are not likely to suffer from the risk factors for hypoglycemia and weight loss in the first three days is a natural phenomenon that does not get babies in trouble if skilled observation and timely intervention is available.

So breast feeding suffers for entire populations as we chase the shadows of unusual and uncommon poor outcomes that rattle us to the point that it is easier to just chuck formula into every crying newborn’s mouth.

Hopefully there will be more Edwinas around to take up the cause.

Are You At The Table?

In case you’re wondering, this is my piece for the Clark County Medical Society newsletter, summer 2013.

There are just under 900,000 licensed physicians in the U.S. Current AMA membership numbers about 224,500, rising up to levels not seen since 2009 when the AMA’s endorsement of Obamacare apparently precipitated a 5% drop in membership. Local Medical Societies are often loosely affiliated with the state and national medical association and can compare themselves to the national benchmark. Clark County has a better percentage than the national average, but barely. Nearly a quarter of the county’s physicians belonging to the medical society.  
In my few months as President of the CCMS I have watched with interest as some counties struggle without any physician cohesion as others have active and dynamic medical societies that contribute much to their communities’ well being.  It would be enlightening to understand what accounts for low membership in the AMA and local county societies.
The most significant drivers of membership seems to be related to the employment status of a growing number of physicians.  In the much storied  past of American Medicine it was necessary to belong to a local medical society as a source of referrals and recognition within that local medical community. As more and more physicians find themselves employed by large multispecialty groups, the relevance of a medical society diminishes. In addition most specialists seem to believe that their interests are better represented by their societies.
Perhaps at some point in the past couple of decades, the House of Medicine lost its ability to extract growing concessions from the rest of society and thus external conflicts became intra-professional conflicts. Despite the larger world relying on progressively greater degrees of specialization, it seems unwise to perpetuate internal conflicts. We each have a role to play in the larger system, including the generalist role in primary care and care coordination.
What seems self-evident is that a fragmented medical profession is easier to control and manipulate than a united one.  There was a time when a nationwide group of educated, professional healers were felt to be the best hope for advising on the population’s health. Some social theorists have suggested that the medical profession squandered its social capital on protecting its economic welfare. I would argue that a small minority of narrow-minded and short-sighted physicians temporarily hijacked an organization whose role has always been nobler than its own economic welfare.
We all have colleagues who will not join the AMA because of positions it had taken in the past. Well, the trouble with that is that no one has a voice who is not at the table. There should be no illusions about how political organizations work and how advocacy comes about; we may lose the occasional internal battles but still fight for common goals. A medical society works for the interests of its members but it would be a mistake to take a shortsighted view of what that means. Medicine based on scientific proof still safeguards the public’s health. Thus, there is no way of continuing to safeguard the public’s health, either by prevention or treatment  without a highly trained, professional force working to create a health system that is both effective and efficient improving the health of the entire population.
Health care has a knack of exposing the weaknesses of a free market system but I have also worked in a socialized health system that shared different weaknesses, but of equal magnitude.  It seems the US medical system is evolving into some sort of hybrid system midway between different ideologies. Anxiety comes with any change and we are being presented with a major change in the environment of medical practice.
Whatever your politics and personal philosophical structure, much of this change has happened with nominal input from organized physicians groups. It is important for the House of Medicine to speak with one voice whenever it can come to a consensus. My thoughts and opinions have been well-received at the state level where they have differed from the official position of the WSMA. Clark County has been particularly active at the state level, especially when it comes to advocating for the health of the Medicaid population. We have been involved in discussions regarding CUP, physician wellness programs, Prescription Monitoring Program funding (in the future, it will no longer be from your license fees), exempting physicians from the state B&O tax, the role of physicians in the state disciplinary body MQAC, and disseminating information about the upcoming state health insurance exchange.
We need to focus on what is best for the health of our population and not just what is best for ourselves. However, we must also stand up for ourselves because without a professional workforce, the population will suffer. We must face the fact that the industry of which we are an integral part extracts $2.7 Trillion from the general economy and we are being held accountable for the value we return in exchange for our share.  

One thing is sure. This is no longer your father’s AMA! It is YOUR AMA! And its actions depend on your participation at the local level in your County Medical Society.

Vaccine Objector Backlash

In March, a version of the following article appeared in Lacamas Magazine, a local lifestyle publication. It was very well received, and attracted an enormous number of hits. I need to rework something for the local daily paper, The Columbian. Until then, I offer you an opportunity to review and comment; it is a controversial topic but I believe science is the benchmark, not conspiracy theories. We are one epidemic away from the ostracization of people who object to vaccines. This is why my original title is somewhat inflammatory. It was softened for the actual publication.  

Many of the digital back-issues are online, but not the one containing this article. I will link to it if it comes back live.

Vaccines are the most effective tool of medical science to decreasing the burden of human disease since Edward Jenner in 1798 described a method of inoculating healthy people with cowpox to prevent smallpox. Countless lives have been saved worldwide with a record of remarkable safety and a miniscule degree of adverse reactions given the magnitude of the benefit. Despite the incontrovertible weight of the evidence, there remains an anti-vaccine movement and a persistent fear of immunizations of all sorts.[1]

Opposition to vaccines can be found as far back as 1905 when the case of Jacobson v Massachusets went to the Supreme Court. In that case, a father refused to be forced by the state to vaccinate his daughter in the midst of a smallpox epidemic. The Supreme Court found that despite a legitimate libertarian argument, there was a compelling reason to over-ride the rights of the individual when fighting an epidemic because there was direct link between the number of people who were immunized and the total spread of the epidemic. It turns out that interrupting transmission was a function of reducing the number of people who could transmit the virus. The benefit to the person was magnified when the effect on the community was examined.

More recently opposition started with Andrew Wakefield, an English surgeon, who became interested in vaccines and published a study that claimed to show a link between MMR (measles, mumps and rubella) and autism in 1996. Understandably, this captured the imagination of parents everywhere. Can anyone imagine causing brain damage to their children by accepting an injection which was supposed to protect them against a deadly disease? Emotions run high with autism; parents wonder if they did something wrong and grasp at any potential cause to explain he unexplainable.

There were problems with the hypothesis from the start. First, the assertion of a link between immunizations and autism rested on the observation that the increase in the occurrence of autism ran parallel to the increase in vaccinations. Of course many other things also increased in the same interval; there was also an increase in the number of doctors available who could diagnose autism and better diagnostic criteria to distinguish autism from other forms of developmental problems. One can make an argument that anything else that increased over the prior several decades was linked, but a link is not a cause. The number of cars on the road has also increased parallel to the increase in autism, and the lead in automobile emissions is actually biologically active when ingested in the form of dust by an infant. It is more plausible than mercury as a cause, but nobody would take the idea seriously.

The vaccine link was supposed to be thimerosal, a mercury-containing preservative in the MMR vaccine. Mercury is indeed neurotoxic, but not all forms of mercury are active when absorbed into the body. For example, it is the fumes that are the best absorbed and the most active. Inorganic mercury is found almost universally in the soil and water in nature and poses no hazard. Theoretically, someone could swallow elemental mercury and not suffer any effects, because it cannot be absorbed that way (of course fumes may be released before, during or after digestion, so no one will say swallowing mercury is safe.) The mercury in thimerosal is very tightly bound and probably inert. The same way, mercury in the soil behind dams cannot be released into the food chain until bacteria convert it into a form that can be absorbed by eating fish. But mercury in fish is a well-recognized problem and there is no connection between autism and ingesting mercury-containing fish. It is difficult to think about how a relatively inert form of mercury can have any biological activity when injected. In fact, it was found that babies excrete thimerosal much faster than would be expected from our knowledge of how the body handles the toxic forms of mercury. This is one more small piece of evidence suggesting that mercury in thimerosal does not have time to interact with tissue. Nonetheless fear and controversy won out and vaccine manufacturers responded to the concerns. Thimerosal was never universally present in all vaccines and has since been removed in most every vaccine available today, except where it is impossible to use something else for technical reasons. Rates of autism continue to increase.

Then Wakefield’s study blew up! The co-authors smelled something fishy in the results especially when information emerged that proper methods in conducting the study were not followed. Eventually, it became clear that the data had been falsified, Wakefield was accused of fraud and he lost his license to practice medicine. It is believed that he falsified data so that he could profit from being a consultant on all the lawsuits that would follow. He currently lives in Texas.

The damage he caused was in stirring up a controversy that was not based in any sort of fact, in spreading false information and fear leading people to refuse vaccination and suffer the burden of increased vaccine-preventable disease making a come-back, in intense efforts to remediate a problem that did not exist and untold research dollars that would have been better spent seeking the real cause of autism. We can see the traces of his misinformation when someone like Congresswoman Michelle Bachman says that she knows people who got autism from the HPV vaccine. The statement is appallingly ignorant, brutally stupid and horribly violent for the children who would benefit from the vaccine.

Some people seem to feel that the number of vaccines is an overwhelming assault on the immune system. The problem with this notion is that in each vaccine there are a handful of highly purified proteins designed to arouse a strong immune response. Purification may always introduce trace chemicals, but at levels less than the neighborhood pool. A bowl of chicken soup probably contains an order of magnitude greater number of proteins that the entire set of childhood vaccines from birth to the teen years. It seems much more likely that prematurely feeding an infant adult food would be more harmful.

The number of needles required frequently comes up with parents. It is easy to understand how five injections at one time can be heartbreaking, especially as the child begins to wail. Older doctors however remember the days that circumcisions were done on infants without anesthesia. Without condoning what seems like a barbaric procedure to some, there is some dissonance between insisting on a circumcision on one hand and worrying about an extra needle on the other. The pain is limited. The benefit is huge.

The immunization regimens are constantly being revised and changed as circumstances permit, including the increasing availability of combination vaccines to reduce the number of individual injections. We must also remember that vaccines have become victims of their own success. When polio is fresh in people’s memory — the paralysis, death and suffering wrought by a horrible disease — it is easy to convince parents that the vaccine is necessary. When the disease has become rare because of the widespread use of a vaccine, the benefit does not seem as significant. Until the disease starts coming back, that is.

Other accusations thrown around about vaccines are that they represent a conspiracy on the part of pharmaceutical companies. This is laughable to people who have been interested in vaccines since the decades that research had stalled. In the 80’s, fear of litigation led most manufacturers to withdraw from vaccine research and development and shortages were looming. In 1986 Congress created the National Vaccine Injury Compensation Fund so that people who were injured by vaccines could be compensated publicly  After all, there is a societal good to vaccination that makes even the rarest adverse reaction doubly tragic. Two things happened after establishing the fund; first vaccine manufacturers reinvested in developing vaccines and lawsuits plummeted. It seems the new fund was more rigorous in making awards, not subject to the vagaries of the “jury lottery” of super-sized awards and nuisance claims. In other words, vaccines do not have a history of being particularly profitable, at least until the past couple of years when prices have started to sky-rocket. In the mean-time the compensation fund is one government program that is significantly over-funded because there have been so few claims made.

Incidentally, the body that makes vaccine recommendations is the American Committee on Immunization Practices, set up by the CDC at arm’s length. It has representation from numerous medical, public health and consumer groups and has remained stubbornly independent. It accepts no money from industry, works only peripherally with the FDA, limiting its recommendations to FDA approved parameters and constantly weighs the risks and benefits of any immunization. All their deliberations are public, transparent and available online. With the National Science Foundation and The Institute of Medicine, the ACIP is one organization that is least likely to be swayed by the big pharma’s financial interests.

Clark County’s Public Health Officer Alan Melnick is fond of saying that “vaccines prevent diseases that kill kids.” This is also true for adults. The ACIP makes recommendations based on the best science and evidence available with the aim of saving as many lives as possible with the lowest risk of any adverse events. The science and the evidence demonstrate that there is a community benefit that exceeds just the individual protection. Diseases like whooping cough and measles can still occur in an immunized population if enough people remain uncovered. It is not enough to immunize your own kids if neighbors and schoolmates refuse their immunizations; your kids can still get sick. The risk is small but probably greater than the risk of a serious reaction to a vaccine. It is an inflammatory statement that may yet prove true; that not immunizing your own kids can allow diseases to spread that potentially can kill other kids as well as your own. Vaccine objectors have not yet faced this backlash, but it remains that human beings living in communities have a responsibility first to themselves and their families, but then also to the communities which sustain them.

[1] An immunization is an intervention designed to increase an immune response to a specific agent. Vaccines have come mean the same thing although historically the word vaccine refers to vaccinia, the cowpox virus used to prevent smallpox.

EBM Assesment in the Real World; or Critical Assessment on the Internet

A little discussion on Twitter led me to elaborate on red flags. Back in the days when I taught at a residency program, the Internet was exploding and it was important to apply the principles of critical assessment in order to evaluate the credibility of such vast access to new information. These are the same skills and principles we use in evidence-based medicine (EBM). The whole thing begins by not believing what you hear or read and being systematic and rigorously in analyzing the reasons not.

This Twitter interchange pretty much followed the same pattern. Shelley Petersen is a London based journalist and social networking marketer who focuses on innovative medical technologies and maintains an active twitter feed chock full of medical science articles. One of her articles raised a lot of red flags for me and when she asked me what those flags were I thought it was too much for 140 characters. It was time to tramp back over the article and provide a detailed analysis of what struck me as improbable and unreliable about the information.
The article was from a Pittsburgh paper and was fairly balanced, presenting some contrary perspectives, so the red flags were about what the principal was saying. In brief, the CEO of a private company was discussing how a long recognized function of telomere shortening and how it explained aging and all the diseases associated with aging.
1. Everyone has an inherent bias, mine is to be skeptical. The CEO of a company is to sell something. In this case, I suspect it is to sell a narrative to investors. I am dubious at the get-go, so red flag number 1.
2. Most research happens at universities. Scientists know that some of the best research happens at smaller universities, but when the only experts cited in any article are from Harvard and MD Anderson, I begin to suspect spin. Certainly I would expect some degree of balance between “name” institutions and other excellent university departments which are less of household names. Over-citing can raise flags.
3. Telomeres are not new. Telomere shortening is not new. When one individual claims he has insights that nobody else has been smart enough to figure out over decades, it is wise to be suspicious. Moreover telomere shortening is an epigenetic phenomenon. Nobody believes that epigenetic phenomena occur at the same pace everywhere in all tissues at the same time. Telomere shortening in fibroblasts does not predict telomere shortening in ovaries, or any other tissue. So wildly expansive claims should leave the reader incredulous that decoding this one phenomenon will end aging, cure all cancer (where telomere shortening may eventually pan out to a mechanism in one or another subtype of cancer), get rid of heart disease, cure wrinkles and fix your stiff knees..
4. Activating the immune system is a phrase that is a throw-away for naturopaths and quacks. Ask anyone with allergies or rheumatoid arthritis. An active immune system is not a good thing and depending on your definition, may well lead to a cancer, like say… lymphoma, a cancer of the immune system. Let’s face it, we all need a well-regulated immune system, but “activation” is meaningless in any scientific context.
5. Anyone who tries to market an innovative pharmaceutical product as a supplement is selling snake oil, plain and simple. The FDA evaluates specific therapeutic claims for specific pathological entities. They do not even evaluate absolute efficacy, drugs only need to demonstrate superiority over placebo. No such regulation exists for supplements, so many companies that do not have the ability to go through a rigorous review and demonstrate scientific merit will circumvent the process and come to market as a supplement. With the notable exception of nutritional deficiencies, there is usually no merit to claims that vitamins, supplements or minerals cure cancer, heart disease or any other disease, except maybe obesity and weight loss issues supplemented by means of ECA stack, etc. The idea that taking something as simple as a supplement may be appealing but has no basis in fact, since it is still an exogenous product, natural or otherwise. 
The principles of critical assessment are to assess date, author, quality of the publication and citations. Biological plausibility is important in assessing a scientific article, along with the link between the data and the claims made. This can be applied to journalistic information as well and when claims are expansive or vague, skepticism should take over. Any attempt to circumvent well-established processes to verify and certify scientific findings completely invalidates the speaker’s credibility in my mind. Being skeptical means you will believe only a small fraction of what you read, but this is not necessarily a bad thing. There is very little truth in much of what you come across on a daily basis, but there is plenty of hype and plenty of reasons for people to try and attract your attention.
Shelley’s work exposes me to a wide variety of information, which I find useful. The article itself was well-balanced and prudently presented, but the company and the spokesman were presenting snake oil under the guise of science.

Family Medicine in the New Healthcare Landscape

A couple of weeks ago, I was invited to our local residency graduation party to give a few words on behalf of the Clark County Medical Society. It was more of a party than anything else, but there was so much I wanted to say. It was supposed to be about the residents, they had a keynote speaker, and I had five minutes to promote the society. I also kept getting ideas right up to the time of the speech. I cannot tell you how many rules of public speaking I broke. I read most of the speech, way too fast, couldn’t keep eye contact with the audience and improvised on the fly… not really sure if the main points came through. It was probably more of an essay, probably more multi-layered than it should be for a simple five minute talk.
So here it is in blog format.

You are graduating into the single most exciting period in the past century of medicine. Sweeping changes to how healthcare is delivered is being contemplated and actually being enacted.
The last time this much change was going on at the same time was.. well, it was when I was graduating. They told me the same thing. From my  In the late 1980’s and early 90’s, a pharmaceutical revolution had reduced hospital stays and the technological revolution of minimally invasive surgery was about to threaten the need for beds across the country. HIV had been isolated and drugs were emerging that could potentially provide hope for a treatment. The practice of medicine was coming to be viewed more and more as a business and restrictions on physician advertising were being rolled back, along with the introduction of pharmaceutical direct-to-consumer advertising that was just starting at the time. Managed care was growing, HMO’s were felt to be the inevitable wave of the future and the first wave of integrated health systems was about to begin, with physicians selling their practices to hospitals that were reaching out blindly to won as many practices as they could.
Since then, we saw the boom of primary care in the HMO era, the consumer backlash that followed, and the unwinding of integrated health systems. It was painfully apparent by then that FP’s did not always have a good business sense and many lost money taking on capitated patients with exposure to too much risk. The hospitals realized they needed to pay attention to what they were buying when they bought a practice and for more than a decade, they were very cautious in such enterprises. The pharmaceutical industry seems to have split in two: the “me-too” drug manufacturers and the biotechs. The success of specialty drugs is perhaps nowhere felt more than in oncology where survival started increasing in the most stubborn of cancers like lung and pancreas. Indeed breast cancer is now more of a chronic disease than an acute illness and this may yet occur with other conditions. In fact, think of HIV/AIDs which is a persistent, annoying and important public health problem, now also best managed as a chronic disease. Some of our internal medicine colleagues, not known for being well remunerated have entered a golden age of their own, think of rheumatologists and the spread of biologicals in lupus and RA.
So maybe I’m wrong, maybe every age is the most exciting age in the history of medicine and the pace of change is merely accelerating. That means you will have to be accustomed to constant change throughout your careers. Such a thought can be a little sobering, because we all need some constants in our life. Living with constant change sometimes feels like living in the eye of a hurricane.
On the other hand, consider the following… no matter how much the content and context of medical care changes around you and your patients, some things do not change… a physician and a patient behind a closed door discussing their health. The generalist physician, in particular, is the one who does the troubleshooting. This never changes. Family medicine defined this way, is an integral part of the health care system. Worldwide, many experiments are under way in horizontal care with nurse practitioners, physician extenders, community health workers and the like… At the center of any program is a generalist physician who encourages, fosters and actively participates in caring professional relationships with people who may or may not know what kind of healthcare they need.
A mature specialty does not ask for the respect of its colleagues; it merely acts knowing that it is contributing to the well-being of everyone it touches by the individual acts of its practitioners.
A mature specialty does not criticize its colleagues for acting according to their immediate pecuniary interests. It recognizes its inherent power to guide and direct patients to where they will get the greatest value for their money. It also recognizes that much of its credibility in the eyes of the populace rests in the network of specialists to which they have access. People see value in getting to the right specialist quickly.
Primary care will be at the center of the future healthcare system and the fact that family physicians alone see all patients along the age spectrum provides a huge market advantage. I speak as an employer now. I have asked family physicians to step aside if they were uncomfortable with caring for certain age groups to step aside. I’d rather have an internist.
So how about some free advice to be valued as such from a doc who is now old enough to be looking downfield for a Hail Mary pass:
Family Medicine will be fine as long as you focus on certain things:
  1. Focus on the health of the population. In so doing, you will always be able to see the amount of value you are contributing to the communities where you work, no matter how little you actually get paid!
  2. Focus on the fact that without generalist physicians, the goal of a safe, efficient, effective health care system cannot be achieved.
  3. Focus on the fact that you need to work well with everyone in the allied health fields: PA’s, NP’s, pharmacists, home health aides, radiology technicians, lab porters… Medicine was never supposed to be a turf war and what you do depends on the contributions of so many, it is best to remember them in everything you do.
  4. Remember that nothing makes competition irrelevant than a change in the landscape. Your competition is not against PA’s, NP’s, specialists and the like… it is with them you must work to improve the health of populations.
  5. It is OK to say no to working more for less. There are settings where you can deliver better care with less effort and mean more to people. (And maybe make more money.)
  6. Stay involved.
    Medical and specialty societies are both important. In this county the WAFP is not as strong as the WSMA, but there are other counties where the opposite is true. Get involved in both. It’s not about how they represent you, but rather that when you get involved, you start driving how it represents you. There is nothing more important to understanding how a new relationship between family medicine and the rest of medicine will work until you see how family physicians are getting involved all the way up to the AMA.
I would like to leave you with this one final thought on how important your contribution is
“Family physicians are the guardians of the House of Medicine; the last credible proponents of sensible care.”

Egypt and Democracy

It was not my plan to start off a blog by a physician, medical director and policy “wonkabe” with a commentary on international geopolitics, but I have been recently obsessed with my father’s ancestral land and had some interesting online interactions.

When Mohamed Morsi was deposed by a military intervention following a popular uprising, the question became if the military’s action represented a coup. More to the point, the question was which party was behaving undemocratically.

First let me get some disrespect out of the way; it is easy to make fun of the USC graduate who worked for NASA and yet appears to be unable to speak English on a televised interview. He is wooden in front of the camera, tentative and sometimes speaks in confused and inarticulate manner. Even those for whom Arabic is a fluent and native tongue find him confusing. He spoke about inclusive and democratic dialogue but shut people out when they disagreed with him.

Nonetheless, were demonstrations, mobs and civil unrest an appropriate democratic response to an apparent political incompetence to govern? Usually a coup involves a small group of people installing themselves over a large majority of the population and enforcing their power through terror and a police state. This may not have fully occurred in Egypt this week, but even trivial human rights violations give a bad taste. Given the Muslim Brotherhood’s decades of persecution and professed patient non-violent path to power, the apparent failure of democracy has deep and profound implications about effecting change though political action rather than the point of a gun.

My  early experience in Canada was with governments that folded under popular opposition and pressure. Sometimes it occurred when it looked like political capital was tapped out. Frequently the popular dissatisfaction with a particular political figure played out along party lines. Pierre Trudeau was forced to resign in 1980, but when his successor was defeated in a general election, he managed to return and regain the post. Brian Mulroney was forced to resign as his popularity plummeted. Canada’s first prime minister John A McDonald was forced to resign due to a scandal. A crisis in 1896 involving numerous cabinet resignations and chaos in Ottawa forced the resignation of McKenzie Bowell two years after taking office and never having won an election.

In England, I doubt that Gordon Brown would have been able to usurp Tony Blair’s position had it not been for scathing criticism, popular disaffection with his leadership and plummeting poll numbers. The 1970’s brought a time of great unrest in strike-bound Britain, with at least one government collapsing and a snap election being called (Edward Heath 1974). Some would argue that Neville Chamberlain had to resign after losing face in a campaign of appeasement towards Hitler’s Germany.

In 1979, Indian PM Morarji Desai was forced to resign in the face of tumultuous internal party strife accompanied by numerous manifestations. More recently internal party strife has led to Australia’s Julia Gillard and Kevin Rudd flipping the post and they are even on the same side, belonging to the same party.

But all these are parliamentary democracies and things may not work the same in republican democracies. What happens in the US? We have the example of Richard Nixon leaving office for an unelected, quickly appointed vice president due to overwhelming public opposition and popular resistance to his rule. We also have a militia culture in some parts of the country that view themselves as the final arbiter of what the federal government can and cannot do. If recent attempts to pass gun control legislation had been judged too obtrusive by some segments of our society, civil disobedience would have been a real possibility. Even though I support this type of legislation, it is probably just as well we were unable to pass it because it was divisive. Much to the surprise and dismay of those in other democratic settings, the existence of a potentially violent resistance in the US is omnipresent but has not been a factor thanks to the structural and constitutional checks and balances that prevent any branch of government from accumulating too much power.

It has struck me in the past that the function of democracy is not to get things done, but to prevent any large group from doing something stupid. Democracy is the anti-accomplishment method of running a government.

But this has not been the purpose of the Muslim Brotherhood and the style of political Islam which appears to have only succeeded in Turkey. Islam in political terms is much like American “Fox News Conservatism” which seeks to remake society in ideological terms. The question posed by Deena Adel (@deena_adel) and Yamine El Rashidi (@yasminerashidi) in a recent twitter exchange is how a democratic system can be inclusive of a group bent on violence. The question I responded with is how can you integrate a group whose goal is the establishment of a totalitarian theocratic state.

The fundamental failure of Morsi, The Freedom and Justice Party and the Muslim Brotherhood was attempting to govern as though winning the election was a mandate for them to act as they wished. The fundamental platform, based on faith that their actions are always just as long as they further the interests of Islam, is that good people representing Islam are above the law and the constitution. This seems to me the assumption behind the constitutional slight of hand of late 2012. Understandably the Islamist statists do not see these actions as justification for military action or even having their candidate succumb to popular pressure to step down. “It is not fair, I was elected, ” Mr. Morsi said in one of his prolonged speeches. The manifestations of democracy begin and end with the election.

Of course the last sentence is not true. Democracy is a messy give and take between majority and minority power centers reflecting the balance of power in a society at any given point in time with the given understanding that it is a constantly shifting power base anyway. Civil society is based on the presence of stable institutions reflecting vested interests, whether the Cato Institute or the local chapter of the Soroptimists. Plural societies can organize around groups that even embody conflicting values within limits. Democracy requires constant cajoling, realingnment, arm twisting, threatening and rewarding. It requires the recognition that fundamental freedoms are never abrogated by the democratic process itself.

In an article by the Brookings, Hadi Shamid reflects on how 2013 will fall into the pantheon of Islamist betrayals like 1992 in Algeria, among others. But as I recall, the problem in 1992 was that the election was allowed to proceed in the first place with he Islamic Salvation front. It was a party that specifically and freely acknowledged a goal of introducing an Islamic totalitarianism. The failure of secular forces was to expect them to be defeated, so that when they won there was no choice but to forcibly shut them down like the anti-societal totalitarians they were.

The Islamists proper grievance is that the rules seem to change once they get in power. Attempts by liberals to demonstrate their openness to any and all opposition groups leads them to extend courtesies where consideration will bear no fruit. It is inadvisable and unwise not to be clear from the beginning: that any action which undermines a pluralistic, diverse and civil society will result in exclusion from the political process. This is what happened to Mr. Morsi and we are now left in the awkward position of trying to explain why the military in Egypt is the entity to forcibly enact principles of democracy.

The fact that David Brooks’ Defense of the Coup is so insulting in reference to “lacking the most basic mental ingredients” for a democratic transition reflects this basic dynamic. We explain democracy as we understand it, using Western terms with our education and a half millennium of enlightenment thinking. The messages are being received by a group whose intellectual heritage missed the enlightenment altogether and whose logic remains in a theocratic constraint where logic does not need to be rooted in any verifiable empirical evidence. Mr. Brooks makes the correct observations, but comes to the wrong conclusions. The problem is not DNA, it is intellectual heritage. The problem may be an elitist perspective bred by education and an inability to reach out to the less instructed.

I am cautious to point out that the US must play its cards right in order to secure the entire world’s future stability. The fault for the terrorist attacks on 9/11 rests only with the terrorists themselves, but the sequence of events that unleashed our current Islamist nightmare may well be traced back to Western goofs over the past century. They may also even include Nasser’s 1954 crackdown on the Brotherhood as Hadi Shamid suggests.

I am equally cautious to point out that the root of Islamist excess today rests in Christian excess of the past. I remember reading an account from Turkey a century and a half ago, where a Muslim trader expressed resentment that every time he wanted to develop a business, he had to go through Christian middle men. The Copts in Egypt were in the majority a little over a century ago, but their [our] concern for the poorer Egyptian and mostly Muslim brethren’s social and economic well-being was perhaps at times less than admirable. The milk of Christian love must first look at oneself, not for fault but for root cause.

Today Coptic communities are poorer than ever, escaping Egypt for economic and physical security, and struggling to help create a better Egypt for all. I am personally a half-century removed from basking in Egypt’s summer sun, but I have drunk from the Nile and my thoughts ever go back. We all need to find a better way to communicate the meaning of democracy and our intolerance to attitudes that will not support a civil society. Islamist disappointment is quite justified, but this is because Islamist ideology is simply not compatible with democratic institutions and processes.

I hope this article leads to a respectful discussion of the role of political Islam in democratic Arab states. I hope it is not offensive to any parties.

First Post

I used to write a blog several years ago under a pen-name. I became disillusioned around that time; not with blogging as much as with my job. I stopped writing as my anger was leaking into my writing. I was supposed to be “The Physician Executive” but found myself unable to hold a job, buffeted by my own ego and surrounded by some more than disingenuous people. Nothing in my career as a physician, teacher, manager or self-described policy commenter had prepared me for the foulness of the human struggle.

Yes, I got involved in a political battle at work and found myself oddly unprepared for the interpersonal and political battles which presented themselves. The blow to my confidence was such that my next job, accepted mostly because I needed a job, went just as badly. Well, ’nuff said.

I have since gotten back on my feet.I worked my way into a private practice, where I am now a principal and am working on developing a medical home and honing our quality performance. During my Master’s, I particularly honed interests in Outcomes and Management with a view to quality management. I feel reasonably well-integrated in the community; I get along with most people, but am already aware of some people who stand in opposition to my ideas, attitudes and practices. That’s OK, nobody in the world only makes friends without being a little obtuse.

Over time, I have regained confidence in my insights and my ability to communicate them. I no longer intend to write just about health care, management and policy items, or be in search of ideas for persuasive essays. This is not a blog with its own brand identity. Writing for a local magazine, I requested republication rights. Everything I publish should eventually come under the umbrella of

My wife and I have started two companies, one was a consulting company that took in some revenue between jobs, and is now a small holding company with investments in several healthcare (and non-healthcare) fields. SanZoe Health is in pursuit of ideas that can improve the delivery of primary care, because it is the best way to improve the health of populations (at least as far as health services are concerned). is a web site that will deliver evidence-based medicine (EBM) insights from the perspective of a practicing physician. There was a time I would perform reviews for the teaching program when I was involved in teaching at Emory. I have published an evidence-based review in a large circulation continuing education journal. Now that I am in practice, I find I still use the skills. These skills may be scarce, but they are definitely not unique but nobody is actively blogging them. So we’ll get this one up when we get the time… between patients, you know.

We also started PanZoe, which should begin accepting donations within a month or two to help deliver innovative primary care to uninsured or underinsured Americans. We will begin locally, in the Camas/Washougal area, suburbs of Portland Oregon. This is our status as of June 2013 and I do not intend to update this first entry.

At this time I am also the President of the Clark County Medical Association, an alternate delegate to the Washington State Medical Association, and an active member and delegate to the Washington Academy of Family Physicians.

Politically, I am conservative, but you might not recognize my ideas as conservative given that the current crop of right-wingers are merely radicals to my eye. Many of them would call me a liberal. At the end of the day, I am an Independent who supports No Labels and the Congressional Problem-Solvers. Being a bit of a gadfly and calling out inconsistencies on both sides, I could be regarded as uniter of the parties; both sides can always rally behind the idea of throwing me out of the room!

The simple and effective communication of complex ideas is not at easy thing to do. It is a skill that requires a great deal of practice. I have not invested enough time in doing this, but have become aware that my head is exploding with innumerable multi-step ideas. There is no way to describe the role direct-primary care combined with reinsurance and a disappearing deductible for employers to avoid the Obamacare tax and improve the health of the population without building ideas one by one. I need this venue to develop the articulation of these ideas.

The greatest paradox and struggle of my life is that an intellectual path eventually takes you to a place of uncertainty, unknowing and doubt, which inevitably leads to either a sort of intellectual nihilism or on the other hand, to a succumbing to faith. I came backwards to the faith of my ancestors, to the world of Eastern Orthodoxy, mostly as a cradle Greek Orthodox. I accepted this world because of its inherent mysticism; although there is dogma in this church, there is much we acknowledge as unknown. All revelation is short of the blinding reality of God. I find echoes of Orthodox Christianity in the non-religious methodology of mindfulness meditation and most recently in “happiness” research and the concepts of “flow” and “social altruism.” My old professors are guffawing as I write, but this too is something by which I stand.

If by way of advocating for the things I am most passionate about, I run into something offensive, please forgive me in advance. It is not my primary purpose to advocate for any single entity; not for primary care or family medicine, not for the Clark County Medical Society, the AMA, the AFP or its state affiliates, my wife’s for-profit holding company or my non-profit foundation, EBM, mindfulness meditation or the Orthodox Church. But these things are reflections of who I am and what I care about.

I hope you will enjoy the blog and follow its evolution.

Why Should Physician Rankings Impact Quality of Care?

Dr. Stanley Feld at Repairing the Healthcare System has been writing his blog for over a year and most would agree that he is a very thoughtful physician. Even without an MBA or an advanced management degree (that I can tell), he presents the kind of insights that non-MD executives and business people would do well to carefully heed.

His most recent series has been on physician ratings, especially the ratings produced by the insurance industry. He follows up on an article in the Washington Post that reported physicians’ reputations beings harmed by the inaccuracies of insurance company data.

Dr Feld writes,

“In our dysfunctional healthcare system tensions are building to great heights between the insurance industry, patients and physicians. The appearance of this article makes me think that the insurance industry subconsciously has a death wish to completely destroy the Healthcare system. The insurance industry is totally insensitive to patients and physicians. Its only concern is its bottom line and seducing employers to buy its product.”

Right on the money!

Of course, one could ask what a for-profit entity should try to accomplish if not increase profits? [Full disclosure: I currently own 100 shares of United Healthcare, a company that was raked over in the Post article.]

It is doubtful that United or the insurance industry is trying to destroy the healthcare system; it is much more likely that the corporations that run health plans are pandering to one or more of their stakeholders, especially Wall Street. Employer groups, who are much more vocal than individual patients, have been clamoring for more physician ratings and greater transparency in health care. They have nothing to lose publishing imperfect physician ratings:

  1. If the data are accepted they get kudos for being proactive and their efforts are appreciated by wall-streeters who judge it a positive development for the company. Investors be sold on the idea that it is a worthy attempt to reduce costs (meaning payments to providers). One of Dr. Feld’s point that deserves high-lighting is that the insurance company’s real customers are human resource directors and benefits managers. These people make their CEO’s happy when they take care of their employees at the lowest cost with the fewest complaints. After all most consumers don’t get to chose an insurance company unless it’s on their employer’s menu.
  2. If the data are rejected, the insurance companies can simply blame physicians. They can tell the world physicians are impairing transparency in healthcare. This effectively deflects that the lack of transparency is mostly a by-product of the insurance industry working with hospitals. Be clear about this: it is not in the insurance industry’s interest to promote transparency.

I happen to believe in data and performance improvement. Collecting data is never a bad thing, as long as you keep away individuals who do not understand the limitations of numbers! The only ‘bad’ data is the data are the data that policy-makers take inappropriate action with.

One of the major objections on the part of physicians is that they do not directly control patient behavior and they can’t be accountable for the health outcomes of their patients, most of whom do not follow physician direction, no matter how meticulously it is presented. These are valid arguments against pay-for-performance, which in turn, is the logical extension of physician ratings. Our understanding of what constitutes quality in healthcare is incomplete, definitions are not really operational except in defining negative incidents, the data is imperfect and the the measures would not meet the most superficial test for validity. Despite all this, there are forces afoot that would move the process forward because that is how systems learn. Systems make mistakes, adjust, refine and correct themselves.

Another counter-argument to physicians who feel they are being held accountable for outcomes that are beyond their ability to influence is the variation in outcomes. Some doctors simply do better at changing people’s behavior and achieving certain results.

For example, it is a reasonable argument that low-income patients with poorer health status and greater health literacy needs and enormous racial and ethnic disparities would have poor health outcomes. However, data from the Health Disparities Collaboratives would suggest that Federally Qualified Health Centers can blow away the competition in most measures of health outcomes according to the chronic conditions measures. [Full disclosure: the facility I help manage participates in the Collaboratives and I have only seen data on diabetes.]

Bottom-line: some physicians appear to get better outcomes from their patients, no matter the initial health and socio-economic status. I know one doc who has spent considerable time learning about motivational interviewing and even before this training had an uncanny connection with some patients. She was capable of getting patients to do things most physicians had enormous trouble with. She could get people to quit smoking and exercise and collect body fluids for 24-hour urine tests and stool collections where most patients produced contaminated or incomplete specimens. They would get their mammograms and even come back for repeat Paps when they were unspeakably scared of what they might find. They would take their pills and could be seen walking to the mall!

Health outcomes and health behaviors are multifactorial and -make no mistake – physicians can have a huge impact. This should be reflected in pay for performance, physician evaluations, ratings etc. However, it needs to be a relatively small component of the overall rating to reflect the fact that patient behavior is not entirely determined by the physician. The patient remains part of the picture. The bulk of the rating should reflect the process: i.e. on the referral for mammography, not how many patients actually followed through. (Process measures not outcome measures.)

There are quality measures that look at processes (did you do the test?), and quality measures that look at biological outcomes (did the patient’s test result improve?). These two categories are at opposite ends of what is directly in the physician’s control and what is not. Behavioral outcomes are probably somewhere in the middle. Each of the three should have different weight in a physician rating. For example, 75% on the referral and 20% on if the patient went and 5% on the actual outcomes, but that’s pretty arbitrary.

The conundrum is that all quality measures are really proxies for quality. Nobody really knows that the definitions of quality truly represent the notion of quality. Half a physician’s value, at least in non-procedural specialties, is due to intangibles. The practice of medicine is all about relationships: if a patient has a good relationship with their doc, they’ll do better. No performance measures can capture that. We also know that patient satisfaction measures are subject to the halo effect, affected as much by the age of waiting room magazines are and the attractiveness of the staff. These are not direct measures of how good the physician is! I suspect the main reasons physicians resist and are disengaged from the process of performance improvement is the intuitive understanding that both patient satisfaction and performance improvement activities have serious limitations. Data are good, but physicians question if the data is good enough to be actionable. Experience has taught them that such efforts are not often based on good science, but can be reflection of societal pressures and the political struggles behind them. It has progressively made their lives miserable. Data is intended to be used to make policy, but rarely does data drive the policy!

Unfortunately, physicians have not had much reason to embrace quality and performance improvement. The us wastes and incredible amount of resources on healthcare and gets very little outcome on a population basis. Physicians should engage; they are a better source of solutions than we have now. Physicians can point out the strengths and limitations of data on their own practices.

If physicians are disengaged because they are skeptical, outcomes are less likely to improve. My advice is get involved and back a single horse to smooth out the standards. (There are currently over 10 organizations and agencies in the US that encourage the use of one or another standard for measuring quality of care. The National Quality Forum is my fave. The Post article points out that there are subtle differences in the wording and cutoffs of the standards, which leads to confusion.)

Moreover, once the data are part of a performance improvement project, the are often used to reward high-performing physicians and punish another. One of the primary principles put forward by Donabedian in the 1960’s was not to use such data punitively or you’ll never be able to collect valid data again! The goal isn’t to make people look good or bad, it is to improve care overall. Everyone who is working to collect data knows the data isn’t perfect and that it doesn’t need to be perfect to be useful. But it better be accurate enough to be actionable.

Socialized Medicine – Business Medicine

There is a lot of buzz lately over government’s role in health care. As usual, it seems to me that the arguments align predictably with ideology. Some feel health care is a right, others that it is a business and any effort for government intervention is tantamount to socialized medicine.

Physician executives and other health care executives are caught in the classic “Catch-22” of an obligation to provide care where it is necessary (morally, legally and ethically) while struggling to justify the radical expectation that they should actually be paid for services provided.

The conclusions are a natural consequence of the assumptions with which people approach the argument. The arguments are always logical and internally consistent, but logic is useless without constant attention to assumptions, so I’d like to see how they stand up. The first two statements below are polar opposites of the next two and are among assumptions that are typical of the right and the left.

  1. Health care is not a right
  2. Medicine is not a calling
  3. Health care is not a business
  4. Medicine is not about improving one’s own living status

I suspect most readers would either agree or disagree with each of these four statements, some will even react violently. The reader might also wonder why they are written in the negative. My point is that’s the only way for all four statements to be true… read on.

Health care and medicine are an unusual sector of the ECONOMY where a social good coexists with a business activity.

The health care sector is responsible for one seventh of the country’s economic output but recipients of health care may see other economic consequences. I believe there are economic benefits of access to good health care, including future economic production. However, the closest I ever got to seeing the proof was a reference to an ancient pilot study that purported to show an improvement in income following the introduction of improved Medicaid services. Well, I never found the original study and I bet it was fraught with problems. I suspect economic benefits of health care access is an extremely difficult point to prove, which is why it is simply not part of the debate.

The relationship between economic productivity, health status and poverty are clear, but the effects of intervention (i.e. improved access to health care) are certainly not adequately fleshed out. Moreover, is there any reason to believe that the researchers would not bring their ideological biases to any such investigation?

Other social activities bear a similar burden of dual roles (social good and economic engine), like road construction and education. Free markets and competition sometimes exist in these sectors, but only by virtue of the type of regulation that levels the playing field and defines areas of potential abuse and profiteering. The same can occur in health care.

Medicine IS a business AND a calling. Health care is a right AND an economic engine. Only after acknowledging this will the rhetoric cool and pragmatic intelligence drive a pragmatic capitalist solution to social needs.

Michael Moore, Fair and Balanced

I came across this post from hippocrates, which is one of the most fair and balanced assessments I have read about SiCKO. Brilliant really, as much as the film was entertaining.

The whole SiCKO phenomenon underlies much of my fascination with the health care debate. Both the right and the left come to the issue with predictable preconceptions. Michael Moore manipulates facts beautifully… nearly as effectively as Fox News and the pop culture caricatures of conservative thought. In SiCKO, Moore strikes me as much more honest and less the propagandist than in his prior films. No solutions here, but this film has brought the debate to the fore. Only time will tell if it will galvanize anything.

After all neither Upton Sinclair nor Michael Moore are to be taken seriously as policy makers; this is not the Flexner report that forever changed the face of medical education. Michael Moore is an entertainer and a darn good one at that.