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.
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!
Focus on the fact that without generalist physicians, the goal of a safe, efficient, effective health care system cannot be achieved.
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.
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.
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.)
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.
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.
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 dinoramzi.com.
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). SavingHealth.com 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.