Earlier this week I attended worship services on the Jewish High Holy Day called Yom Kippur. Falling on the tenth day of the month that begins with Rosh Hashanah, the Jewish New Year, Yom Kippur is the culmination of ten days of penitence and reflection and is called the Day of Atonement. For me it is always a day of deep thinking - about the year past and the year just begun and what I must do to become a better person. But this is also a time of more general reflection.
Often on Yom Kippur I remember how I felt in October, 1973, when a coalition of Arab states led by Egypt and Syria launched a war against Israel on this holiest day of the year. It was a mere six years after the Arabs had been routed by the Israelis in June, 1967. It was the second major event of the Arab-Israeli conflict to occur in my lifetime, and I was just a teenager.
This conflict is a subject that has fascinated me at least as much as any other in history. It goes back to the late 19th century, to the rise of Jewish Zionism and Arab nationalism, the quest to create a Jewish homeland in biblical Israel conflicting with Islamic beliefs about their own religious and historical claims upon the land.
The early Zionists recognized that the Arabs would fiercely resist the creation of a Jewish state in biblical Israel. They believed they must build a military power that would be capable of crushing every Arab effort to thwart the goal of a Jewish homeland. They believed that with such an "iron fist" approach - with each new attempt to destroy their dream beaten back more decisively than the last - they could ultimately convince the Arabs that there must be a lasting, peaceful coexistence.
The wars of 1948, 1956, 1967, and 1973 did not seem to create much progress on the path toward Arab recognition that Israel as a Jewish state was there to stay. Then, in the late '70s, the signal foreign policy accomplishment of the Carter Administration, the Camp David Accords, brought peace between Israel and Egypt, and Jordan soon followed.
During the three-plus decades since, however, there has been little peace. The conflict between Israel and the Palestinian Arabs living in the West Bank and Gaza has waxed and waned. Arab terrorist attacks launched against Israel from Lebanon and Syria, with strong state support from Iran, have been met by Israeli counter-attacks. Ever-lengthening periods of intense bloodshed have been broken up by ever-shortening and increasingly tenuous ceasefires.
Peace has been most elusive. Efforts by the United States and other Western powers to encourage negotiations have met with repeated failure. No American president since Jimmy Carter has had so much as a glimmer of success in advancing the cause of peace. The Israelis face an existential threat from an Arab world that mostly refuses to recognize the Jewish state's right to exist.
Militant Islamic fundamentalists have been especially intransigent on this point. On the flip side of Carter's success at Camp David was the change of regimes in Iran that took place during the late '70s, when the pro-Western ruler Mohammad Reza Shah Pahlavi was overthrown, after nearly four decades in power, and replaced by an Islamic Republic led by Muslim clerics.
Historians will surely long debate whether Carter deserves significant blame for the rise of the movement to establish Islamic religious law in Iran and throughout the region. Surely the Shah himself deserves most of the blame. The oppressive nature of his regime, the growing chasm between rich and poor, and the way in which he approached the modernization and secularization of Iran were all important factors. But the end result was that the success of Camp David was historically paired with events that would prove an ill portent for peace in the region.
It now involved not only the Israelis and the Palestinians and the terrorist movements inflamed by the Palestinian cause. The Iran-Iraq War consumed the 1980s with violence that cost at least half a million lives. But the conflict between Israel and the Arabs continued, with the Intifadas of the late '80s and early '90s, and the first half of the first decade of this century. There have been many battles between Israel and terrorist groups in southern Lebanon. Iran and its surrogate Syria have fueled the incessant war with money and supplies for the terrorists.
Israel has long understood it is in a constant state of war over its very right to be as an independent Jewish homeland. In June 1981 the Israelis launched an air raid that destroyed the Iraqi nuclear reactor at Osirak. The United Nations Security Council passed a resolution condemning the raid. The United States voted in favor of that resolution. The irony of our participation in that condemnation when, a decade later, we launched the First Gulf War, was rich indeed. President George H.W. Bush said Iraq's invasion of its neighbor Kuwait "shall not stand." Would he have been able to say that with any confidence - if at all - had Iraq developed nuclear weapons by then? And would that not certainly have been the case had Israel not destroyed the reactor at Osirak?
It is now Iran that represents the most serious existential threat to Israel. Iranian President Mahmoud Ahmadinejad has repeatedly called for Israel's destruction. He has denied any biblical claim the Jews may have to the land they "occupy." He also denies that the Nazi Holocaust - perhaps the most obvious and tangible reason for the creation and security of a Jewish Homeland - ever occurred.
Now it is Iran that is fervently working to develop nuclear weapons, enriching uranium in an ever-growing number of accelerators. Economic sanctions have proven to be no deterrent. Israeli Prime Minister Benjamin Netanyahu has appeared before the United Nations to urge the entire "international community" to draw a "red line" that Iran must not be allowed to cross.
The United States has drawn no red line. The United Nations will draw no red line. Some in the United States seem to believe that it is none of our business if Iran wishes to acquire nuclear weapons. Others say it will be regrettable, but that a nuclear Iran can be "contained" the way we contained the Soviet Union. But can a doctrine of mutually assured destruction be effective in dealing with an enemy that is surely willing to trade many Iranian lives for success in (literally) wiping Israel off the map of the planet, when there are hundreds of millions more Muslims around the globe?
So it appears that only Israel will draw a red line. When - not if, but when - Iran crosses that line, will Israel have to act alone to prevent the spectre of a nuclear-armed Iran from becoming a reality? And if that happens, will the United Nations Security Council pass another resolution condemning Israel? Will that resolution have U.S. support? Will we ever learn anything history has to teach us?
Saturday, September 29, 2012
Thursday, September 27, 2012
Ask a Nurse - or Do You Really Need a Doctor?
There is a shortage of doctors providing primary care in the United States. No matter how you look at the statistical projections of the growing population and the growing proportion of us who will be older and bear a greater burden of chronic disease, it is clear that we will need more doctors. And, no matter how you look at projections of the supply of doctors, and especially those providing primary care, it is clear that the supply will fall well short of demand.
A colleague of mine recently sent me an article from one of the leading trade publications outlining the many reasons today's physicians find the practice of medicine frustrating and stressful, including ever-increasing and time-consuming government regulations that are seen as mostly inane and useless. The other major stressor is constant worry about being sued any time there is an adverse outcome. We live in a culture of blame, and when a patient experiences an adverse health outcome, the finger of blame will naturally point at his doctor.
So, at just the time when we need more doctors, today's physicians are less satisfied with their work, which means they are deciding to work less, retire earlier, and dissuade their offspring from choosing this profession.
Perhaps, as a society, we should be trying to reverse the trend and make the medical profession more attractive. But wait. There is another possibility. Physicians aren't the only ones who can do this job. There are nurse practitioners. They can do many of the things doctors can do in primary care. They will work for less money. What a deal!
If someone can do a job as well as the last person for less money, that has great appeal as a "value proposition." And the value proposition is important in healthcare when the percentage of our GDP that we spend on it has reached the high teens.
So what about nurse practitioners in primary care? Do they do as good a job for less money?
To answer that question, we need a lot of data. We need data on costs and outcomes. And we need data on outcomes both short-term and long-term. I'll come back to that in a bit.
If you have a cold or a sore throat and go to a retail clinic or urgent care center staffed by nurse practitioners, you will probably get a lower bill than if you went to see a doctor. That suggests a favorable value proposition. But sometimes things are not simple and straightforward, and sometimes you need someone with a deeper understanding of your problem.
Last week a woman sustained a minor head injury and went to an urgent care. The nurse practitioner looked her over and told her she should go to the hospital emergency department. She followed that advice. After waiting several hours - because it was Monday, and emergency departments are often crazy busy on Mondays, which means long waits for those who are not critically ill or injured - she saw a doctor. The doctor took a history and did a proper neurologic examination. Drawing on a deeper understanding of head injuries and a thorough familiarity with what the scientific literature tells us about the proper way to evaluate patients with head injuries, the doctor told the patient she did not need a CAT scan of the head - which was the main reason she had been sent to the ED.
So now the patient has a visit to an urgent care, to which has been added a visit to an ED, where she had to wait a long time, and for which she will get a second bill, higher than the first one. How's the value proposition now?
About now you may be thinking, couldn't we just teach the nurse practitioner how to do a better job evaluating the patient with a minor head injury? Sure we could. We could teach the nurse practitioner how to do a better job at just about anything. That would take some time, though. And the reason doctors are more expensive than nurse practitioners is that it takes longer to train someone to that level. You see where I'm going with this.
Do you have any children still in school? Think about the smartest kid in your child's class. Maybe it's your kid. That kid could go to medical school or law school or choose any other of a number of career paths. Now remember, she's the smartest kid in the class. When you are older and sick, what do you want her to be? Do you want her to be the consultant other doctors call when they are trying to figure out how to keep a perplexing illness from killing or disabling you? Or do you want her to be the lawyer your family calls when things don't go well and they want to find out whether your doctors are to blame?
I believe the bottom line is very simple. If we want excellent medical care in the United States, we need excellent doctors. If we want excellent doctors, we must understand the importance of getting the best and brightest of our nation's youth to choose this profession. Some of my older colleagues believe the "golden age" has passed for the medical profession, and the practice of medicine will never be as enjoyable or rewarding as it once was. I believe we can and must bring back that golden age.
A colleague of mine recently sent me an article from one of the leading trade publications outlining the many reasons today's physicians find the practice of medicine frustrating and stressful, including ever-increasing and time-consuming government regulations that are seen as mostly inane and useless. The other major stressor is constant worry about being sued any time there is an adverse outcome. We live in a culture of blame, and when a patient experiences an adverse health outcome, the finger of blame will naturally point at his doctor.
So, at just the time when we need more doctors, today's physicians are less satisfied with their work, which means they are deciding to work less, retire earlier, and dissuade their offspring from choosing this profession.
Perhaps, as a society, we should be trying to reverse the trend and make the medical profession more attractive. But wait. There is another possibility. Physicians aren't the only ones who can do this job. There are nurse practitioners. They can do many of the things doctors can do in primary care. They will work for less money. What a deal!
If someone can do a job as well as the last person for less money, that has great appeal as a "value proposition." And the value proposition is important in healthcare when the percentage of our GDP that we spend on it has reached the high teens.
So what about nurse practitioners in primary care? Do they do as good a job for less money?
To answer that question, we need a lot of data. We need data on costs and outcomes. And we need data on outcomes both short-term and long-term. I'll come back to that in a bit.
If you have a cold or a sore throat and go to a retail clinic or urgent care center staffed by nurse practitioners, you will probably get a lower bill than if you went to see a doctor. That suggests a favorable value proposition. But sometimes things are not simple and straightforward, and sometimes you need someone with a deeper understanding of your problem.
Last week a woman sustained a minor head injury and went to an urgent care. The nurse practitioner looked her over and told her she should go to the hospital emergency department. She followed that advice. After waiting several hours - because it was Monday, and emergency departments are often crazy busy on Mondays, which means long waits for those who are not critically ill or injured - she saw a doctor. The doctor took a history and did a proper neurologic examination. Drawing on a deeper understanding of head injuries and a thorough familiarity with what the scientific literature tells us about the proper way to evaluate patients with head injuries, the doctor told the patient she did not need a CAT scan of the head - which was the main reason she had been sent to the ED.
So now the patient has a visit to an urgent care, to which has been added a visit to an ED, where she had to wait a long time, and for which she will get a second bill, higher than the first one. How's the value proposition now?
About now you may be thinking, couldn't we just teach the nurse practitioner how to do a better job evaluating the patient with a minor head injury? Sure we could. We could teach the nurse practitioner how to do a better job at just about anything. That would take some time, though. And the reason doctors are more expensive than nurse practitioners is that it takes longer to train someone to that level. You see where I'm going with this.
To the best of my knowledge, there are very limited data on outcomes in primary care - and no long-term outcomes data - comparing physicians with NPs. Such an absence of data leaves me free to answer the question based entirely on my opinions - which, as you know, are invariably carefully considered, unassailable in their logic, brilliant in their exposition, and wise beyond compare. Oh, and they are always correct. *Now extracting tongue from cheek, not without considerable difficulty.*
My internist is a fellow who was several years ahead of me in training. When I go to see him, I know he will follow all guidelines-based recommendations for primary and secondary prevention of chronic diseases. I know a primary care nurse practitioner would do the same thing. I admit to preferring the physician over the nurse, because if I have questions about the science underlying the recommendations, I know which one is more likely to be able to answer them to my satisfaction.
I am also aware that sometimes I need an internist to do more than follow guidelines and recommendations for my healthcare. Sometimes I need him to figure out what is wrong with me.
And there is something else that comes into play here. Sometimes knowing more and having a deeper understanding leads to doing less. (Recall the simple example of the minor head injury.) Very often a smart doctor can figure out what is wrong with you by taking a focused history, asking all the right questions, and doing a careful physical examination for signs of disease. The doctor may be 93% sure about what is wrong with you without doing any tests. Imagine how much money could be saved if you trust his clinical judgment and give him permission to refrain from spending any of your money on tests to raise the diagnostic certainty from 93% to 99%.
I have worked side-by-side with nurse practitioners for nearly three decades, including some I've thought were very capable. I am still waiting to meet a nurse practitioner I might judge to be an astute diagnostician.
This is hardly surprising. One can become a nurse practitioner by starting as an RN/BSN and taking an online master's degree program, while an internist has four years of medical school and three years of residency after the bachelor's degree. To expect the two to have similar abilities in the aspects of practice that rely on a foundation of education in the sciences is quite unreasonable.
Let us begin with the assumption that, among bachelor's-degree RNs, only the best and the brightest decide to go on to earn master's (or doctoral) degrees and become nurse practitioners. Now I'm going to look at that population of students and ask a simple question. How many of them would do well in the year of organic chemistry required of pre-meds and commonly used as a "weeder" course? My daughter Rose is very bright and hard-working. I know this because I lived with her in the same household for nearly two decades. And I saw how hard she had to work to get grades in organic chemistry last year that would meet with the approval of a medical school admissions committee.
Do you have any children still in school? Think about the smartest kid in your child's class. Maybe it's your kid. That kid could go to medical school or law school or choose any other of a number of career paths. Now remember, she's the smartest kid in the class. When you are older and sick, what do you want her to be? Do you want her to be the consultant other doctors call when they are trying to figure out how to keep a perplexing illness from killing or disabling you? Or do you want her to be the lawyer your family calls when things don't go well and they want to find out whether your doctors are to blame?
I believe the bottom line is very simple. If we want excellent medical care in the United States, we need excellent doctors. If we want excellent doctors, we must understand the importance of getting the best and brightest of our nation's youth to choose this profession. Some of my older colleagues believe the "golden age" has passed for the medical profession, and the practice of medicine will never be as enjoyable or rewarding as it once was. I believe we can and must bring back that golden age.
Thursday, September 13, 2012
Of Politics and Facebook
Your repeated status updates, expressing your political views with ever-increasing fervor, have finally brought me around to seeing things your way - said no one, ever.
I have seen postings saying something along these lines several times in recent weeks, from people who have grown weary of the Facebook polemicists. It has gotten me thinking about the style of political expression in this forum.
Never having had any formal education in rhetoric, what I have learned through observation over the years is that the best way to influence the thinking of others is to set forth the various perspectives on an issue and carefully build an argument that demonstrates, in a cogent fashion, why one view is more compelling than others.
It seems there isn't much of that on Facebook. Instead, from Facebook I have learned that Mitt Romney hates dogs. He puts them on the roof of his vehicle and then drives at high speeds in the most extreme weather conditions, frequently passing through tunnels with clearance barely greater than the height of his conveyance.
I have learned that Barack Obama was born not in the United States but rather in Africa, or perhaps a distant galaxy, and his goal is to invite aliens from far away to take over the U.S., if not the entire planet. Oh, and he is a Muslim whose lifelong best friend is an extremist black preacher who hates white America.
If Romney is elected, all of the important social welfare programs enacted in the 1960s will be immediately abolished. Old folks will have no health care and will languish in poverty, eating the cheapest store-brand dog food they can find. The poor will all be living in discarded packing boxes from large appliances, fighting each other for spots above the grates on city sidewalks that bring up warm air from below street level.
If Obama is re-elected, on the other hand, those whose family incomes place them just barely above the middle of the Middle Class will have every penny of income that they don't need for subsistence at a Third World standard of living confiscated. It will then be used to "spread the wealth around," which means giving it to the least deserving of the undeserving poor: those too lazy to lift a finger to earn a living, who will then be able to keep themselves supplied with the latest electronic gadgets - and recreational drugs aplenty.
Romney will ensure that the super-rich get richer by the day, moving all of their money offshore to escape U.S. taxes, just as he himself has always done. Not only will they not pay their fair share; they will pay no taxes at all, and they will receive subsidies so they can hire accountants and lawyers to make it look as though they have given plenty of money to the government and most of the rest of what they have inherited to charity.
Romney intends to shrink government. He speaks with disdain of the Congress that spent a billion dollars in '89-'91. Not 1989, but 1889. That Congress spent money to help the widows and orphans of military veterans. None of that bleeding heart stuff if Romney wins this year.
If Romney is elected, students will be able to go to college only if their parents have the money, but Obama will ensure that it's free for everyone - at least everyone who has always depended on the government to give them other people's money.
In Romney's America, everyone will borrow money from their parents and start small businesses. If their parents have no money, the new generation will just have to find their own bootstraps and pull hard. No such problems under Obama. We won't need any small businesses. The government will build everything. It always does.
Barack wants his daughters to have every opportunity that your sons have. He also wants everyone's daughters to have all the birth control pills that someone else's money can buy. Surely he will also fund a government program to arrange daily text messages to remind women to take their birth control pills. Mitt will let you know exactly what he thinks of this immoral, profligate plan just as soon as he is finished waging his war on women. Oh, and in case you were wondering, Mitt wears magic underwear. Barack goes commando.
Obama will stop global warming and heal the planet. Romney will focus on making life better for you and your family, comforted by the knowledge that people will really like the Atlantic and Pacific oceans much better as vast hot tubs. Never mind those rising sea levels.
Everything the two candidates and their surrogates ever say about the opposition is a lie. The only real question is just how big the lies are, and how loudly and how often they are repeated.
All I can say is, it's a good thing we have fact checkers. These are people we can depend on to ferret out the truth and give us the straight scoop, so we know what to believe and can make up our minds based on facts, not half-truths and innuendo. These fact checkers have no agenda of their own, no political point of view, no bias that might influence their findings. Their only interest is in finding the unvarnished reality and showing it to us.
And that bacon you're eating for breakfast came from pigs that were shot by hunter Paul Ryan as they flew overhead on their way to hear Joe Biden tell us how history will show Barack Obama is the best president the United States has ever had.
I have seen postings saying something along these lines several times in recent weeks, from people who have grown weary of the Facebook polemicists. It has gotten me thinking about the style of political expression in this forum.
Never having had any formal education in rhetoric, what I have learned through observation over the years is that the best way to influence the thinking of others is to set forth the various perspectives on an issue and carefully build an argument that demonstrates, in a cogent fashion, why one view is more compelling than others.
It seems there isn't much of that on Facebook. Instead, from Facebook I have learned that Mitt Romney hates dogs. He puts them on the roof of his vehicle and then drives at high speeds in the most extreme weather conditions, frequently passing through tunnels with clearance barely greater than the height of his conveyance.
I have learned that Barack Obama was born not in the United States but rather in Africa, or perhaps a distant galaxy, and his goal is to invite aliens from far away to take over the U.S., if not the entire planet. Oh, and he is a Muslim whose lifelong best friend is an extremist black preacher who hates white America.
If Romney is elected, all of the important social welfare programs enacted in the 1960s will be immediately abolished. Old folks will have no health care and will languish in poverty, eating the cheapest store-brand dog food they can find. The poor will all be living in discarded packing boxes from large appliances, fighting each other for spots above the grates on city sidewalks that bring up warm air from below street level.
If Obama is re-elected, on the other hand, those whose family incomes place them just barely above the middle of the Middle Class will have every penny of income that they don't need for subsistence at a Third World standard of living confiscated. It will then be used to "spread the wealth around," which means giving it to the least deserving of the undeserving poor: those too lazy to lift a finger to earn a living, who will then be able to keep themselves supplied with the latest electronic gadgets - and recreational drugs aplenty.
Romney will ensure that the super-rich get richer by the day, moving all of their money offshore to escape U.S. taxes, just as he himself has always done. Not only will they not pay their fair share; they will pay no taxes at all, and they will receive subsidies so they can hire accountants and lawyers to make it look as though they have given plenty of money to the government and most of the rest of what they have inherited to charity.
Obama believes that no one has ever built anything by dint of individual effort. He could come upon a five-year-old sitting alone while all her classmates are outside at recess playing, diligently working on a large and complex Lego project, and breezily assert: "You didn't build that. The government built that. Don't expect any credit or recognition for your labor or creativity. The only thing that matters is the collective."
Romney intends to shrink government. He speaks with disdain of the Congress that spent a billion dollars in '89-'91. Not 1989, but 1889. That Congress spent money to help the widows and orphans of military veterans. None of that bleeding heart stuff if Romney wins this year.
If Romney is elected, students will be able to go to college only if their parents have the money, but Obama will ensure that it's free for everyone - at least everyone who has always depended on the government to give them other people's money.
In Romney's America, everyone will borrow money from their parents and start small businesses. If their parents have no money, the new generation will just have to find their own bootstraps and pull hard. No such problems under Obama. We won't need any small businesses. The government will build everything. It always does.
Barack wants his daughters to have every opportunity that your sons have. He also wants everyone's daughters to have all the birth control pills that someone else's money can buy. Surely he will also fund a government program to arrange daily text messages to remind women to take their birth control pills. Mitt will let you know exactly what he thinks of this immoral, profligate plan just as soon as he is finished waging his war on women. Oh, and in case you were wondering, Mitt wears magic underwear. Barack goes commando.
Obama will stop global warming and heal the planet. Romney will focus on making life better for you and your family, comforted by the knowledge that people will really like the Atlantic and Pacific oceans much better as vast hot tubs. Never mind those rising sea levels.
Everything the two candidates and their surrogates ever say about the opposition is a lie. The only real question is just how big the lies are, and how loudly and how often they are repeated.
All I can say is, it's a good thing we have fact checkers. These are people we can depend on to ferret out the truth and give us the straight scoop, so we know what to believe and can make up our minds based on facts, not half-truths and innuendo. These fact checkers have no agenda of their own, no political point of view, no bias that might influence their findings. Their only interest is in finding the unvarnished reality and showing it to us.
And that bacon you're eating for breakfast came from pigs that were shot by hunter Paul Ryan as they flew overhead on their way to hear Joe Biden tell us how history will show Barack Obama is the best president the United States has ever had.
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