Compassion for the sick

We Americans have always been at the cutting edge of compassion for the ill. We have compassion for those with cancer, stroke, mental retardation, and heart disease, to name but a few. We also have compassion for whiplash syndrome, fibromyalgia, and sexual addiction syndrome. These are all diseases, from which the victim is the patient.

It is time to spread our wings of compassion to two new medical conditions.

TRS (Tax Revulsion Syndrome, also known as Money Addiction Disease)

• Sufferers of this syndrome have extremely negative reactions to the normally painless task of paying taxes. They get upset at tax time. They tend to make financial errors, fail to report income, fail to pay their taxes or even fail to file their returns. Often they use typical psychological defenses to describe their actions (the government will just waste the money on a $10,000 toilet seat; I don't support the war; I can better stimulate the economy by spending or investing the money; etc). Sometimes, this can lead to conflicts with the IRS. It can even lead to possible job related issues. Who can forget Al Capone, Wesley Snipes and Tim Geitner, to name but a few.
• Those who suffer from this disease should not be punished! It is a disease and we need to treat this seriously. Fining and imprisonment is criminalization of a disease and we are above that! These people need our sympathy. We need to understand why they act as they do and to allow for their differences. First of all, they have a different cultural belief system and who are we to judge them? If we want to change them, then we need to pay for their counseling, rehabilitation, and perhaps their taxes until they feel confident enough to pay it themselves.

Bribomania

• Sufferers from this condition are addicted to easy money. They are willing to sell just about anything for money. We most often see this in the political sphere, selling votes for money, but also see it in those who enforce building codes and throughout society as a whole. There seems to be some attraction to those who suffer from this disease into the public sector.
• Like malaria and leprosy, this condition is more common in poorer, undeveloped nations.
• Like drug addition, these people are addicted to an external substance
• Treatment, as with drug addicition, is the use of counseling in addition to a substitute to ease them off their addiction. As with drug addition, a long acting, slow release substitute is used. Those subject to bribomania should be given, at our expense of course, an amount of money each day to keep them from asking for and taking bribes. As each person is different, the daily amount of maintenance money should be individualized.

Remember, DocBrain IS A DOCTOR, board certified by the American Board of Psychiatry and Neurology. Unless you are a physician, you cannot say these diseases do not exist. Nor, can you deny the need for treatment of medical disorders. And as a proud citizen of the USA, you cannot deny now that it is YOUR responsibility to pay for everyone and anyone's illnesses. We may not be able to cure TRS or Bribomania, but we can certainly help pay for the care of those who suffer from these conditions.

Yes we can!

The devilish details

Any principles that are not part of the world of nature (law of tooth and fang; survival of the fittest; simple self/family/species interest) arise from myths we create about the dignity of God and man. That many of these transcend different cultures indicates a need of humanity for something beyond the primitive existence of the plant or animal. We try to learn about the world to mitigate the sometimes seemingly cruel natural law.

Moral and ethical people make decisions based upon principles. Principled decisions can often impact our individual freedoms and finances. Laws are just codified principles, with structure to interpret and enforce them. So far, not all moral principles are encompassed in laws. Some see this as a shortcoming of society, others see it as a way individuals can still exercise judgement to choose good, enabling individuals to be virtuous in their own eyes.

When it comes to health care, we come to several problematic details.

• Do we decide by individual or group? Since few things can be predicted with 100% certainty, we can never know if our preventive interactions or treatments will be beneficial to any individual, but certainly can make statements about group effects. Is it reasonable to apply group data to individuals, or can we allow individuals to freely opt out, even if their choice statistically is likely to impact us with great financial burden?
• If a disease leads to more suffering than preventing it, is it more noble to prevent it? What if preventing it means interfering with an individual's freedom or finances?
• If adherence to therapy leads to less suffering, is it right to insist on adherence? What if adherence leads to less financial burden on the society as a whole?
• Does suffering indicate a need for society to help? What about one person causing the suffering of others? Impact on others is a slippery slope. Certainly, a person walking the streets with a virulent, highly contagious infection is a health problem for others as well as a potential financial crisis for society as a whole. What about a woman, perhaps depositing upon society the burden for care of a child that is highly deformed or unwanted? What about a man who is homeless and who's behavior, appearance and odor are an affront to others? What about the woman, who sees her life as terrible because of her appearance, and acts miserably to others, who would be a much happier person and a better citizen if she only had plastic surgery?
• If there are two ways to prevent a disease and one is less expensive than the other, should society allow the individual to choose or should society make that choice?

In a world where we feel it is our moral obligation to pay for the care of others, is there a moral obligation of individuals to take care of themselves to help defray the costs to others? In a world where we feel there is a financial obligation to pay for the care of others, should there be a financial penalty for individuals who fail to take care of themselves? Since all laws are backed by force, should equal force be applied to both situations?

We often hear of psychological diseases that make a person unable to adhere to the typical standards of good health. I have no doubt that there are similar health issues that make some people unable to adhere to laws of financial obligation. If we can excuse one, why can't we excuse the other?

The ObamaCare Revolution

You say you want national health care
Well, you know
We all want to change the world
You tell me that it's evolution
Well, you know
We all want to change the world
But when you talk about cutting medicare and sweet deals for votes
Don't you know that you can count me out
Don't you know it's gonna be all right
all right, all right

You say you got a real solution
Well, you know
We'd all love to see the plan (and have time to really read it and understand it)
You ask me for a contribution (barackobama.com has sent me hundreds of requests for money!)
Well, you know
We're doing what we can
But when you want money
for people with minds that hate (to listen to the people)
All I can tell is brother you have to wait
Don't you know it's gonna be all right
all right, all right
Ah

ah, ah, ah, ah, ah...

You say you'll change the constitution
Well, you know
We all want to change your head
You tell me it's the institution
Well, you know
You better free your mind instead
But if you go carrying pictures of chairman Mao (Che, Malcolm X, Rev. Wright, Ayres, Henry Gates Jr, etc)
You ain't going to make it with anyone anyhow
Don't you know it's gonna be all right
all right, all right
all right, all right, all right
all right, all right, all right

All Right! Gone Left too far!!!

Evidence Based Politics

In medicine, it is all about demonstration of truth. Here are a few political hypotheses which are waiting for evidence of truthfulness.

• We can spend our way to prosperity
• To strengthen the weak, we need to weaken the strong
• The best way to help laborers is to place controls and penalties on the employers
• Only by group identification can the poor ever gain an advantage over the rich
• Heavy taxation of the rich will solve the problems of the poor
• Deficit spending will solve our problems
• Only team players have courage and good character
• If you help people enough, they will eventually do what they could have done for themselves all along

Gravy Train

What is the purpose of a census?

• Find out how many people are in a country
• Find out who is available for military service
• For research purposes
• Apportion members of the House of Representatives
• To apportion federal funding for social and economic programs

When you listen to the TV ads for the 2010 census, you get the impression that the only purpose is the last one, to make sure you are getting your fair share of federal gravy.

Could this lead to a change in the way people arrange themselves in a population? Especially in a society that takes big to give big, this places a great value on being where the most are. A person of less than average income would be best served by locating in an area with large population to benefit from the additional public services that will flow from government coffers (and from their rural neighbors).

Once upon a time there was landed gentry and the huddled poor masses. The USA gave the poor the opportunity to own land, to be their own masters. Could the census, as currently portrayed, lead us back to the class system again?

Stark Reality

Rep. Pete Stark, one of the sponsors of the new health care legislation, has nearly single-handedly increased health care costs. How can I say that? Here is a small town example that you can multiply across the country if you so desire.

In the early 1980s, magnetic resonance imaging (MRI or NMR as it was known then) was the hot new diagnostic technology. It appeared to be a revolutionary step in evaluating brain and spine disease and evolutionary in other areas as well. The equipment was expensive and no one had a lock on interpretation of studies, as no physicians in practice, including radiologists, had learned this technology in training.

Medical centers that had been early adopters became the places to obtain training and training was available for any physician who had enough passion and likely patients.

MRI Part 1: It enters the private diagnostic arena Free Market Style

A group of neurologists, neurosurgeons and orthopedists banded together and purchased a MRI scanner. For several years, this one unit supplied the majority of the needs of the neuroscience community for a population of 3 million. How could one scanner satisfy such a large group of physicians and their patients? All studies had to be interpreted by the ordering physician (who had to demonstrate competence before being allowed to interpret studies). This meant that anytime a test was ordered, it would impart a commitment of time to interpret the study. With finite physician time came a careful choosing of appropriate patients. The machine ran 24/7, maximizing the investment and minimizing overhead. Even with continuous operation, there was a limit to the available time slots, no one could be "piggy" and monopolize the unit.

MRI Part 2: A piece of the action

In my small community, the local hospital wanted to get involved in the MRI business. It put together a coalition of local physicians to invest with the hospital, with the images being interpreted by the local radiologists. The plan was for the local physicians to refer their patients to this unit and to make some return on investment, while the radiologists would earn by interpreting studies. Now, those who just wanted to turn a profit were investors and there was no physician time limit on the number of scans that could be ordered, as MRI interpretation was separated from other (evaluation and management) physician services. More studies could be performed per population. But, there still was a control: the desire for profitability. The goal remained to maximize profits by efficient operation.

MRI Part 3: Stark

The Stark law made physician co-ownership (joint venture) illegal. The practicing physicians had to withdraw from the MRI investment which now became totally owned by the hospital and run by the radiologists. The theory was that physicians were sending patients for MRI scans to pad their pockets and that now, under Stark, we would see a reduction in MRI studies and cost savings. What happened? Two nearby hospitals now had no reason not to have their own MRI machines, so each acquired their own. Each hospital had its own independent radiology group. One purchased the original scanner and two others built their own free standing MRIs. Finally, a local university established a local outreach clinic in the area and installed its own MRI. One MRI was now replaced by 6. With so many MRI machines in the area, it became not who should get a MRI, but who should NOT. Supply was essentially unlimited for this small community, leading to increased utilization for even marginal indications. As even marginal indications occasionally produced unexpected findings (and as failure to perform a MRI became a legal issue, especially where access was easy) the demand for scans kept up with the supply. To an extent. The scanners run 1 shift/day. Some only run 5 days/wk. So, we have more scanners run less efficiently and more scans for less concrete reasons.

MRI Part 4
The final step is currently underway in Pennsylvania (DocBrain's home) but is already in effect elsewhere. It is to bar any non-radiologist from interpreting a MRI study. This would finally eliminate any time constraint control on MRI studies. MRIs can be interpreted by telemedicine, eliminating even the minimal friction of local radiologist time constraints.

The well-intended government and Pete Stark have done exactly the opposite of what would have kept health care costs down. They took control of a diagnostic procedure away from those who know how best to use it because of fear of profit. The unintended consequence was to increase number of scanners, number of scans, and the overall cost of health care in my small community by a factor of at least 6.

And what about the entire area that was covered by that first neuroscience scanner? There are now 160 MRI scanners within those physician's practice areas.

And you trust Pete Stark to give you affordable health care?

March Madness

"To provide affordable, quality health care for all Americans and reduce
the growth in health care spending, and for other purposes."

The above is the purpose/mission statement of H.R.3962, the health care bill as it is now in the House of Representatives.

If you don't see something wrong with that statement, you have not been paying attention.

• A health care provider is one who provides care. I am not sure that all the members of Congress even know how to perform CPR, let alone provide health care.
• Will this Bill cover non-Americans (ie, undocumented visitors)? If so, then it flies in the face of its purpose.
• What if the US could be the acme of world health care? What if the US health care system could employ 60% of the US work force and provide care, at a profit, to 60% of the nations of the world? There would be a growth in jobs, profits, and general wealth, but there would also be an increase in spending. This legislation could actually act to stifle growth and progress in one of the areas where the US still has dominance...the frontiers of health care.
• Other purposes? Would you trust John Edwards to hire your daughter to be his secretary and "for other purposes"?

"Mr. DINGELL (for himself, Mr. RANGEL, Mr. WAXMAN, Mr. GEORGE MILLER
of California, Mr. STARK, Mr. PALLONE, and Mr. ANDREWS) introduced
the following bill"

These are the Representatives who introduced this legislation. I will just highlight two names.

Mr. Rangel. Hello???? DocBrain chaired two ethics committees! Exit, stage far left!

Mr. Stark. Anyone remember his claim to fame? Mr. Stark, of the Stark I and Stark II Laws, authored legislation that effectively limited competition in the health care industry and took control out of the hands of physicians, placing it in under the control of big corporations and big insurance. It was his grand schemes that got us into this mess. Costs skyrocketed as the Stark legislations opened the floodgates for middle-men in the health care industry. These individuals neither are providers nor insurers. They add nothing but cost to the system, thanks to Pete Stark. And you trust that a bill sponsored and authored by this gentleman will save you money and provide you with better care?

P.S. There are 1989 more pages in this bill. If you can't trust page 1...

Cheap health care

Here are a few pointers on how to have inexpensive health care:

• Take care of your body. Eat right, exercise, stretch, get enough sleep
• Take care of your mind. Read, learn, exchange ideas with people
• Take care of your psyche. Relax. Identify what you can change (ie, yourself) and what you cannot (ie, others) and focus on what you can do to make your life better.
• Take care of business. Earn your own way in the world.
• Tell it like it is. Don't lie or misrepresent to your health care provider.

Here are a few medical pointers:

• If you are suffering but all your tests are normal, you will probably not die from it. Make your peace with your symptoms and move on. Only focus on it if new things develop
• No treatment is without downside. Before trying something new, accept the downside.
• Generics have their place, but so do brand name products.
• Rely on your physician. If you don't trust your physician, get a different physician. If you can not find any physician to trust, maybe it's you (see above).

Why SGR cut is a bad idea

As of 3/1/10, physician reimbursement by Medicare has been cut by 21%. Clearly, Medicare cannot afford to pay physicians this additional 21%. But what is the consequence of this?

1. The cuts can be passed on to physicians as decreased income. Most physicians are in the 35% tax bracket. This will reduce income tax by 35% of the 21%. City and State income taxes will also be reduced. Physicians are known big spenders. Unlike others who earn in the same category, physicians feel sorry for themselves (long hours, high stress, delayed gratification due to years of schooling). They buy cars and clothes, go out to dinner or shows or travel (yes, play golf). This pretty much accounts for the rest of that 21%. This will spread as a slump in the economy. In addition, it may cause some physicians to fall below the top limit for FICA, leading to more liability on other taxpayers to pay for Social Security for the very physicians whose pay they are cutting.

2. The doctors keep their income up by cutting corners and firing personnel. This will lead to unemployment in the health care sector and support sectors (ie, people who dispense bottled water to doctor's offices).

Even if you believe that physicians "don't deserve the money" can we afford to not give it to them?

Unintended consequences can be expensive.

Means and Ends

In trying to see the difference in approaches to the world, DocBrain thinks he may have discovered a key difference among people. It has to do with means and ends and which one is the most important.

Means are more important than ends. "The means justify the ends." There are core beliefs as to what constitutes "good" or "moral" or "ethical" behavior. As long as you do good, the ends will take care of themselves. If the ends do not turn out as you anticipated that they would, then it really is not your fault, as you have done the right thing. Perhaps not enough "good" was done. Perhaps some who did "bad" foiled the plans. Lets call these people "idealists" since the ideals of behavior trump all else.

Ends are more important than means. "The ends justify the means." You know how you want things to end up. You do whatever it takes to get there, even if it involves deviating from what is considered "good" or "moral" or "ethical". Lets call these people "realists" as the real world outcome is all they care about.

The problem with idealism is that living the ideal life does not guarantee that the ends will be what you want them to be. Part of the reason is that idealists must live with realists. The other problem is that some ideals may be flawed or not poorly understood. The classical example is that one should never lie, but what if you are harboring an innocent fugitive in your basement. Do you lie to authorities and save an innocent life? Usually, this leads to a clarification of "Don't Lie" to something more nuanced. So, idealists wind up getting nuanced and bullied.

The problem with realists is that they can play fast and loose with the social glue that holds us together. You need a pain medication? You are short on money but have a gun? Why not just take it at gunpoint from the druggist? Assuming you cannot be identified, problem solved. Realists must exist with idealists, so they must at least attempt to solve problems through virtuous behavior. The realists wind up getting tsk tsked and policed.

When idealists get too much power, they push for virtuous solutions that fail because they are not nuanced enough (unintended consequences) or are corrupted (graft, political favors).

When realists get too much power, they may harm good people in their attempts to achieve the desired end.

In the end, we are left with the dilemma: do what is virtuous or achieve a desired end. Turning the "or" into an "and" is quite difficult.

The health care debate can be framed in this way. Ideally, everyone gets free health care. If we move ahead, there will be unintended consequences and corruption and we will never get there as we try to make sure that every possible good is maintained or enhanced. On the other hand, if we begin at the end "everyone has affordable, high quality health care" and get there by any means necessary, we would certainly choose a different path than the one currently being discussed. Nothing would be off the table.