The Zero Curse

Last month, in the final weeks, and then days, preceding the presidential election, the pundits were talking about how close the race seemed to be.  They were intently focused on the "battleground states."  They worried (or were they really rubbing their hands together in eager anticipation?) that some of the state vote tallies might be so close as to trigger automatic recounts.  And that could lead to legal challenges.  There were echoes of Florida in 2000.  It didn't turn out that way, probably to the disappointment of some journalists (and maybe lawyers) and the relief of everyone else.

But it brought to mind conversations I'd had during the six weeks or so of the contested election of 2000, that period between Election Day and the U.S. Supreme Court's ruling.  Perhaps, I said to the medical students and residents I was supervising in the emergency department, neither Bush nor Gore should want to be the winner, because of the tragic history of presidents elected in years ending in zero.

I noted that the last president elected in a year ending in zero, Ronald Reagan (1980), had been shot soon after taking office and come perilously close to death. Who, I asked them, was the last president before Reagan to be elected in a year ending in zero and not die in office?

I didn't expect anyone to know the answer straight away.  I wanted to see how they would approach the question, what they knew of presidential history, which I would be able to tell if they tried to work their way back through the years that were multiples of 20 - the presidential election years ending in zero.

Nearly all (I was aghast that it was not all) knew that John F. Kennedy was elected in 1960 and assassinated.  But things went downhill quickly from there. Most did not know that Franklin Roosevelt was elected in 1940 (and, of course, also 1932, 1936, and 1944) and died in office (in the spring of 1945, from a cerebral hemorrhage), to be succeeded by Harry Truman.

As I recall, exactly no one knew that Warren Harding was elected in 1920, died in office, and was succeeded by Vice President Calvin Coolidge.  I believe one person knew William McKinley was elected in 1900, assassinated by an anarchist, and succeeded by Teddy Roosevelt.

1880.  James Garfield was shot in 1881 by a psychotic man who believed Garfield should have recognized the work he'd done on behalf of the presidential campaign (which was trivial) and appointed him to an important job. The bullet wound was actually not that bad - nowhere near as serious as the one that almost took the life of Ronald Reagan.  Garfield was more a victim of the terrible medical care he received.  No one knew that.  I can't say I was surprised, but I was disappointed just the same, if only because the medical part of the story was so important.

Truly appalling, however, was that not everyone knew 1860 was the year of Lincoln's first election, although of course everyone knew he'd been assassinated.

1840 offers yet another especially interesting piece of presidential history. William Henry Harrison was elected.  In those days inauguration was on March 4th.  (It didn't move into January until FDR was president.  The nation decided that the wait until nearly spring for Roosevelt's inauguration had been too long, given the urgency of addressing the economic woes of the Great Depression.  So 1933 was the last year it was March 4th, and it was then moved to January 20th). Harrison gave his inaugural address outdoors.  The weather in early March in Washington, D.C. is usually mild, but in 1841 it was not.  Harrison did not wear an overcoat.  A month later he died of pneumonia.  Causality, of course, is open to question, but the result was that Harrison became the first U.S. president to die in office.

No.  That's the answer to your question.  Not a single one of the young medical trainees knew anything about Harrison or his vice president, John Tyler.  What a shame.  Because it's a fascinating story.

Harrison, you see, was not a politician, but a war hero, best remembered for the Battle of Tippecanoe.  (Remember the campaign slogan, "Tippecanoe and Tyler, too?")  He was recruited by the Whig Party, which was desperate to win the White House.  The Whig party was opposed to just about everything Andrew Jackson (Democratic president elected in 1828 and 1832) stood for, but they had learned from dealing with the hero of the Battle of New Orleans (1815) just how popular war heroes can be.  Harrison was perfectly willing to run on the Whig party platform, which was very short on detail, as he had no fixed political principles of his own.  The Whigs then needed a candidate for the #2 spot on the ticket.  Harrison was from Ohio, so they looked south of the Mason-Dixon line for geographic balance and asked John Tyler of Virginia.  Tyler was a Democrat, but apparently not a loyal Democrat, as he agreed to run for VP as a Whig.

Then Harrison died, and Tyler assumed the office.  This had never happened before, and the Constitution was not entirely clear on how it should work.  The Constitution said that in the event of the death of the president, the "powers and duties" of the office "shall devolve on the Vice President."  What wasn't clear, however, was whether the VP actually became president, with all of the accoutrements of the office, or whether he was just the acting president.

It probably wouldn't have been a big deal if Tyler had been a loyal Whig.  But not only was he really, after all, a Virginia Democrat who differed with the Whig party's principles in important ways, but he started doing something earlier presidents had generally not done: vetoing bills passed by Congress because he didn't like them.

[Before Tyler, presidents typically vetoed a bill only if they could plausibly contend it was unconstitutional.  Nowadays we think of it as the Supreme Court's job to address such questions (which it does only if a challenge is brought before it), established very early in the 1800s by Chief Justice John Marshall as the doctrine of judicial review, and presidents routinely veto bills with which they disagree.  But the president is sworn to uphold the constitution and certainly shouldn't sign into law a bill he thinks is unconstitutional.]

Congressional Whigs were livid, and came very close to mustering the votes to impeach Tyler.  They refused to call him the president, referring to him as the acting president - or "His Accidency."

No one I asked knew any of this.  Nor did they know that our fifth president, James Monroe, had been elected in 1816 and 1820 and served his two terms in full, the last president before Reagan to be elected in a year ending in zero and survive to the end of his elected tenure.

So I did not expect anyone to respond to my initial question by saying, "James Monroe!"  I just wanted to see what they knew of presidential history.  Damned little, as it turned out.

Far too few of us show much interest in history in grade school or college, and I'm sure it's at least partly because there are too few history teachers who make the subject interesting, as some of mine did.  This is a terrible shame.  American history is fascinating, and studying presidential history is a wonderful way to approach it.  Thomas Carlyle said, "The history of the world is but the biography of great men."  We've had forty-three presidents (Grover Cleveland, who served two non-continuous terms, is counted twice to get to #44 for Barack Obama). The history of our nation is most certainly the history of these men, especially if you read the sort of expansive biography - the man and his times - that is the kind really worth reading.

I tell residents who train at our institution that there is more to learn in the emergency department than medicine.  A sense of history is something I hope to give each of them, at least a little bit, by the time they've completed the three years I have to influence their lives.

Soak the Rich

On Christmas Day, we are filled with thoughts of charity toward our fellow man. We also think more about all things spiritual, such as the immortality of the soul and the afterlife.  Those who believe in Heaven have all heard that it is easier for a camel to fit through the eye of a needle than for the rich to gain entrance to Heaven.



Pastor Rick Warren was shown, in a video clip I saw several times on CNN yesterday, saying that it is not a sin to be rich, but it is a sin to die rich. That is a fine argument for philanthropy.



And so, when CNBC's Website yesterday ran an article (titled "Majority of Rich Want Themselves Taxed More") about how the well-to-do say they are willing to pay higher taxes, it seemed entirely in keeping with the Christmas spirit.




Sadly, but not surprisingly, however, reading beyond the headline revealed that this was just another example in an unending stream of shoddy journalism.

The article cited a poll done by American Express Publishing and The Harrison Group showing that "67% of the top one percent support higher income taxes."  More specifically, "more than half" support higher taxes on those making more than $500,000 per year.  (In case you're wondering, estimates of what household income places you in the top one percent range from about $400,000 to over $500,000.)

"More than half" of the top one percent?  That's a very interesting breakpoint.  If you do a bit of research, there is a very substantial difference in both income and wealth

between the bottom and top halves of that top one percent.
The bottom half includes professionals like doctors and lawyers who are comfortably upper middle class but not truly wealthy.

The top half of that one percent - and especially the top 0.1% of all taxpayers - is where the real concentration of wealth is found.

An understanding of the big difference between the lower and upper halves of that top one percent makes it easy to understand how half of this group could be supportive of higher taxes on themselves (because they can easily afford it), while the other half are not so keen.  And that explains why more than 60% of the top 1% say they "carry an unfair burden" in the amount of their income they pay in taxes, which doesn't sound as though they would be at all supportive of taxing themselves more.

The CNBC article goes on to tell us that "Other recent surveys show that the wealthy support higher taxes as part of a balanced solution to the government debt problem that includes spending cuts."

A "balanced solution" must include spending cuts?  That's what we've been told. How about some arithmetic?  I know, it's Christmas Day, and you'd like to give your brain a rest, but don't worry, I've done the arithmetic, so all you have to do is read it.

The top one percent represents about 1.4 million taxpayers, with an average taxed income of about $1.3 million.  If we were to add a 4% surcharge (which is what the president has proposed) to the top marginal tax rate on the amount of income taxed at the top rate (which means the income above about $180,000/year), that would generate about $62.72 billion in additional revenue.  The federal budget deficit for the current fiscal year is about $1.372 trillion.  So this surcharge on the top one percent of taxpayers would reduce the budget deficit by about 4.6%.

The House Republicans don't want higher taxes on anyone, but they have suggested they could go for a cut-off of $1 million, while the president is seeking higher taxes on incomes above $250K.

The NCPA needs a reality check itself!

You have to be careful about believing the numbers you read.  The National Center for Policy Analysis, which espouses free-market ideals and doesn't like taxes or government regulation, says the proposed higher taxes on those with incomes over $250K would bring in an additional $42 billion.  That cannot be correct, because that proposal would mean higher taxes on a lot more people, so it would have to raise revenues by more than the $62.72 billion I estimated for the top 1%, and the NCPA does not claim to have taken reduced economic growth (which economists say would result from higher taxes) into account.

Do I claim my numbers are accurate?  Of course not.  First of all, I took only a year of economics in college, and I've been only a casual student of economics in the 35 years since I graduated.  Second, calculations made by even the most erudite economic theorists rest on a set of assumptions, any of which could turn out to be wrong.


The point, however, remains: we cannot tax our way out of these enormous deficits.  We must dramatically reduce government spending.  The "soak the rich" approach may make those of us in the other 99% feel better, and at least some of the wealthy seem to be eager to pay higher taxes.

(If you haven't heard Warren Buffett's preaching about this, you've been hiding under a really big rock.)

We all have different ideas about how to cut spending, from getting out of wars and ceasing to be the world's policeman to cutting off entitlement programs for those who are too lazy to be productive citizens and contribute to society instead of sponging.






The point is that if we don't soon have the kind of political leadership it will take to build national consensus about how to reduce government spending, the drag on our economy created by spectacular annual deficits and mind-boggling national debt will cause the most powerful economic engine in the history of the world to grind to a halt.

A Culture of Violence

Eight days ago a disturbed 20-year-old man visited unimaginable horror upon an idyllic town in New England.  Twenty children and six adults at an elementary school in Newtown, Connecticut fell victim to this violent attack.

Much attention has been focused on the implements used in such mass murders, especially a semiautomatic rifle chambered in a caliber called .223 Remington, also known as 5.56mm NATO.  The latter designation has drawn particular note, and such a rifle is often described in news reports as a "military style assault weapon."  Those who are careful in their use of terminology point out that the rifles used by the military are designed to be fired in fully automatic mode (squeeze and hold the trigger, and bullets are launched from the muzzle in rapid succession until the magazine is empty), and that only such a "machine gun" is accurately described as an "assault rifle."

When the problem brought into relief by such a terrible incident is captured by the phrase "gun violence," it is easy to understand the focus on the gun.  But when we consider that the number of guns in the United States is nearly as large as the number of people, and the overwhelming majority of these guns are never used in acts of violence, it seems logical to suggest that our focus should be on the behavior rather than the implement.

So, while it has been said many times by people on both sides of the debate about the role of firearms in our society that America has a "gun culture" (see, for example, William R. Tonso's 1990 book The Gun Culture and Its Enemies), I believe it may be more helpful to focus on the fact that America has a culture of violence.

Many social scientists have studied and written about the way violence is portrayed in entertainment media.  The word "glorified" is often used, and much attention is directed to violence in movies, television shows, and - especially - video games.

When I was growing up I wondered about Saturday morning cartoons. Characters in those programs routinely did terrible things to each other.  In the Road Runner cartoons, Wile E. Coyote was endlessly getting blown up or having large, heavy objects fall upon him from great heights.  In Tom & Jerry, literally a running cat-and-mouse game, awful things happened to the cat several times per episode.  Vivid in my memory is a scene in which Tom (the cat) is struck a fearsome blow to the head with a frying pan by Jerry (the mouse) while he is sleeping.  I was especially intrigued by the fact that these cartoon characters nearly always appeared in the very next scene as though nothing had happened to them, and I thought this might mislead young children about the consequences of violent acts.  I have since decided that young children are probably a little better than we give them credit for at distinguishing fantasy from reality, and perhaps when the fantasy is a cartoon it is that much easier.

In television shows and cinema, however, it is all about realism.  Directors and cinematographers are very much intent on the goal of making everything that happens look quite real.  Psychologists have worried about how this may desensitize viewers to violence.  I am quite certain it does exactly that.  The only question is how much, and with what consequences.

Video games bring an entirely new dimension to this discussion.  Their realism is ever greater as the technology advances.  Unlike the violence we see on television shows and in the movies, when we play these video games we are not passive spectators.  We are the actors.

A quick overview of some of the titles may lead one to suspect the violent nature of the content.  With names like Assassin's Creed, Mortal Kombat, Call of Duty: Modern Warfare, and Sniper Elite, it is easy to imagine what participants in these games may be doing.  Even the television commercials advertising these games can be more than a bit disturbing, and when the voice-over notes that a game is rated "mature," it is easy to understand why.

Have you ever used Google's specialized search functions?  Mostly I use ordinary "search" or "maps."  (Regular readers know that for some of my essays I use Google Images to find appropriate graphics.  I haven't done that for this one, because the subject is so "graphic" when we just read or talk about it that I didn't think it needed any help.)  I am quite fond of Google Scholar, which has become an excellent way to find out what research has been published on a particular subject.

I could tell you that entering the combined search terms "video games" and "violent behavior" yielded 43,000 "hits."  But it drives me bonkers when speakers at a scientific meeting show a slide that depicts such results, because that doesn't tell you how many of the results might just be researchers endlessly citing their own and others' work.  Most important, it doesn't tell you how much good or important or illuminating research has been published.

So it is necessary to do some careful reading of the stuff we get to by clicking on the links.  And thus I'd like you to know about Craig A. Anderson, Ph.D., Distinguished Professor and Director of the Center for the Study of Violence at Iowa State University.

A 2004 paper by Anderson in the Journal of Adolescence introduces the subject:

For many in the general public, the problem of video game violence first emerged with school shootings by avid players of such games at West Paducah, Kentucky (December, 1997); Jonesboro, Arkansas (March, 1998); Springfield, Oregon (May, 1998), and Littleton, Colorado (April, 1999).  More recent violent crimes that have been linked to violent video games include a school shooting spree in Santee, California (March, 2001); a violent crime spree in Oakland, California (January, 2003); five homicides in Long Prairie and Minneapolis, Minnesota (May, 2003); beating deaths in Medina, Ohio (November, 2002) and Wyoming, Michigan (November, 2002); school shootings in Wellsboro, Pennsylvania (June, 2003) and Red Lion, Pennsylvania (April, 2003); and the Washington, DC.‘‘Beltway’’ sniper shootings (Fall, 2002).Video game related violent crimes have also been reported in several other industrialized countries, including Germany (April, 2002), and Japan (Sakamoto, 2000).

Anderson has devoted many years to this work.  He has published extensively. For those of you who are interested, I strongly recommend that you Google him and visit his home page.  The more you read, the more you will understand one of his salient conclusions:

...as documented in several articles in this special issue as well as in other recent reports, a lot of youths are playing violent video games for many hours per week.  When large numbers of youths (including young adults) are exposed to many hours of media violence (including violent video games), even a small effect can have extremely large societal consequences.

The American Academy of Pediatrics has a longstanding and well-developed interest in the effects of exposure to violence in entertainment on the development of children and their behavioral health.  Noting that medical professionals have been concerned about portrayals of violence in the media since the 1950s and that the U.S. Surgeon General issued a report on the subject in 1972, the AAP issued a policy statement in 2009 that said, "The evidence is now clear and convincing: media violence is one of the causal factors of real-life violence and aggression."

Some of you are probably thinking that many medical professional organizations are also on record as supporting all manner of gun control legislation.  The AAP, for example, has said a home with children is no place for firearms.  But there are important differences.  There is no evidence that access to guns, or learning how to shoot them for sport, makes people prone to use them to commit violent acts. There are abundant data to the contrary.  For example, people who obtain permits to carry concealed handguns for personal protection almost never use their guns in the commission of crimes.  In this instance of the intersection of public policy with health policy, by contrast, there are many studies all supporting the same conclusion that violence in entertainment has a real and causal link to violent acts in real life.

There is another important difference to keep in mind.  We had a ban on the importation and sale of a vast array of semiautomatic rifles, as well as a ban on high-capacity magazines, on the books for ten years.  The statistics kept by the Department of Justice tell us the result in all its simplicity: there was no effect on violent crime committed with firearms.

In case you have forgotten since you started reading, our nation is awash in guns.  Limiting the sales of certain new ones will be like looking at a backyard swimming pool, recognizing the danger it poses to the toddler who cannot swim, and deciding we must not add more water to the pool.  Unless we intend not only to ban the sale of all new guns but also to confiscate all the old ones, we cannot expect to prevent the commission of violent acts with guns by controlling their availability.  For those who may think confiscation is a fine idea, I will note that self defense is a fundamental, natural, human right.  In human societies, armed self defense must be available, else the slow, the weak, and the infirm will ever be at the mercy of the young, the fast, and the strong who just happen to be amoral.

Yesterday the NRA held a press conference in which the organization suggested that placing well-trained, armed security guards in schools might be a valuable and effective short-term solution.  The NRA was promptly scorned by those who thought - contrary to what anyone who knows anything about the Association's history over the last 50 years would have expected - that the NRA was holding a press conference to announce it would embrace new gun control legislation in a spirit of compromise.

We can enact all sorts of new gun control legislation.  We may do exactly that. We will certainly spend a great deal of time talking about the merits of doing so. But the time and effort we devote to this must not detract from the attention directed toward our culture of violence and how we can go about changing that.

The Wrong Hands

In the context of the recent horrors in which deranged persons have shot and killed scores of innocents, we have renewed discussions of gun control legislation in hopes of averting such tragedies in the future.

After the assassinations of Martin Luther King, Jr. and Bobby Kennedy, Congress passed the Gun Control Act of 1968.  Attempts to assassinate American presidents, including one that was very nearly successful in ending Ronald Reagan's life in 1981, continued unabated.

There is a common theme in these tragedies, whether it's John W. Hinckley, Jr. (who shot Reagan), or Seng-Hui Cho, who killed 32 and wounded 17 on the campus of Virginia Tech in 2007, or James Eagan Holmes, who killed 12 and injured 58 in a movie theater in Aurora, Colorado earlier this year ... the list seems endless.  And that common theme is mental illness.

Anyone who could shoot a classroom full of kindergartners is insane beyond our ordinary capacity to fathom madness.  Mental health professionals understand the disconnection from reality that occurs in the minds of the psychotic.  The rest of us can only shake our heads in bewilderment.

On December 7, 1993 (yes, a day that will live in infamy) Colin Ferguson opened fire on passengers on the Long Island Railroad.  Among his victims were Dennis and Kevin McCarthy.  Dennis was killed, and his son Kevin was seriously injured. Dennis's wife, Carolyn, a nurse, was elected to Congress three years later, on a mission to promote gun control legislation.

In the 16 years since her election, Carolyn McCarthy has introduced many gun control bills.  Most have languished in House committees.  But after the Virginia Tech shooting, McCarthy realized the shooter could have been disqualified from purchasing firearms if there had been a more robust database of mental health history to be queried by dealers.  The National Instant Check System (NICS) was created to assure that people with felony records who are prohibited by federal law from purchasing guns cannot obtain firearms from licensed dealers. McCarthy's bill became the NICS Improvement Amendments Act of 2007 and included funding to beef up the system of getting information about disqualifying mental illness into the database.  It was strongly supported by the National Rifle Association and signed into law by President George W. Bush.

Doesn't the NRA oppose all gun control legislation?  Obviously not.  The NRA is just as keen as everyone else on keeping guns out of "the wrong hands."  But McCarthy's bill was opposed by organizations of mental health professionals, including psychologists and psychiatrists, who complained that it would only add to the stigma of mental illness.

Under current federal law, persons who have been hospitalized involuntarily because they are a danger to themselves or others and persons who have been adjudicated mentally incompetent are disqualified from buying guns.  The key element is that this has gone through the legal system, which has due process and safeguards against infringing upon the rights of persons who aren't really crazy.  This is important, because in many states people can be involuntarily admitted to psychiatric facilites on the say-so of just about anyone.  If your spouse thinks you are suicidal and fills out the papers, a constable will take you into custody, and you will be placed in a psychiatric bed somewhere until a judge holds a hearing on the matter within a statutorily specified time, typically 24 hours. Before the hearing, you will be interviewed by a mental health professional.  At the hearing, you will be represented by legal counsel.  If you are not, in fact, dangerously mad, that will be determined at the hearing, and you will be released. If the judge says you are a danger to yourself or others as a consequence of mental illness, you are then disqualified under federal law from owning firearms. Not only are you prohibited from future purchases, but guns in your possession are to be confiscated.

You can see, quite easily I'm sure, that this approach will fail to identify many people who are mentally ill and potentially very dangerous, because most such people are never processed through the legal system and thus never disqualified from gun ownership.

If you are a patient in my emergency department who suffers a loss of consciousness as a result of some medical condition, such as a seizure, or intoxication, or a precipitous drop in your blood sugar, I am required to fill out a form saying whether the Commonwealth of Pennsylvania should initiate a proceeding to determine whether your driving privileges should be restricted. Most states do not have such laws, and where such laws exist they certainly have unintended consequences, such as deterring patients with seizures from seeking medical care when they should.

Why not have a requirement that I fill out a form for every crazy person I see that indicates whether the state should initiate a legal proceeding to determine whether such a person is dangerous and should be disqualified from possessing firearms?

Essential features of such a system would be the involvement of the legal system, with guaranteed due process and rights of appeal, and the entry into the NICS database of determinations that persons have been disqualified.  The role of the legal system is crucial, because a system that disqualified people based on the opinion of a psychiatrist would result in many disqualifications by mental health professionals who simply don't like guns and think people - all people - shouldn't have them.

News reporting and the blogosphere, not to mention innumerable postings on social networking sites, have already made the point that our mental health system is woefully underfunded and inadequate to meet the needs of the population.  Ask any emergency physician or nurse about schizophrenics living under bridges, people who in generations gone by would have been long-term residents of state mental hospitals.  Might some of those who were "deinstitutionalized" really have been much better off living in group homes instead of state institutions?  Absolutely.  But what about the ones who are living in large cardboard boxes, with the occasional stint in a homeless shelter or an acute care psychiatric facility, only to wind up back on the street, seeking shelter under a bridge or the warmth of air rising from a grate over a city subway?  While our mental health system struggles and fails to meet their needs, how many people who are less overtly crazy get no care at all because the resources simply don't exist?

We can pass all the gun control laws we want with no effect whatsoever on the problem.  Until we commit far more resources to our mental health system and devise a mechanism that identifies those too dangerously insane to own firearms, we will have many more tragedies like those in Aurora, Colorado  and Newtown, Connecticut.  

60 Minutes Exposé: Hospital Care for Dollars?

This week the CBS news magazine, "60 Minutes," included a segment on Health Management Associates alleging that HMA pressured doctors to admit more patients to HMA-run hospitals so as to increase revenues.

HMA, according to 60 Minutes, set goals for doctors to admit a certain percentage of patients who visited the emergency department for care. Specifically, the program said HMA set a goal of 20%, according to emergency physicians at some HMA facilities.

The percentage of patients admitted from the ED varies greatly from one hospital to another.  The ED at a tertiary-care hospital in a metropolitan area may see patients with a high likelihood of being seriously ill.  The percentage of patients admitted from such an ED may be well upwards of 30 or even 40.  On the other hand, the ED at a small-town or rural hospital, where the large majority of ED patients have minor illnesses or injuries, may admit fewer than 10% of the patients to the hospital.

The claim in the 60 Minutes segment was that HMA runs mostly smaller, more rural hospitals, especially hospitals that were financially struggling before being taken over by HMA.  Such a hospital would not be expected to admit 20% of its ED patients, and setting that as a goal would put undue pressure on the doctors in the ED to hospitalize patients who don't really need inpatient treatment.

The show's producers found emergency physicians from HMA hospitals who described in detail how they were pressured to admit more patients.  They explained that hospital administrators wanted to fill beds, thereby improving the hospital's revenue stream - and its "margin," which is what you call it if you don't like the word "profit," or if you are running a not-for-profit entity (which doesn't mean you don't need to have revenues exceeding expenses).

This makes HMA look bad.  But there was a lot 60 Minutes didn't explain. Perhaps the most important is that there is a good deal of subjective judgment involved in deciding whether a sick patient should be hospitalized.  It is often not a straightforward matter to figure out whether the evaluation and management of a patient's illness, beyond what has been accomplished during the ED visit, can be carried out at home or requires admission to the hospital.

Medicare, which was a primary focus of the TV report because it pays for so much hospital care, has criteria we can use to judge this, called "severity of illness" (how sick is the patient?) and "intensity of service" (what care does the patient require, and is it best provided in-hospital?) criteria.

HMA was allegedly pressuring doctors to admit patients who met such criteria for hospitalization.  What, you might ask, is wrong with that?  Well, not everyone who meets criteria for admission actually requires admission.  It's just not that simple. And it requires clinical judgment.

And here is where we run into an interesting paradox.  The Centers for Medicare and Medicaid Services (CMS - don't ask me what they did with the extra "M") is perfectly happy to have us use clinical judgment to decide that a patient who meets criteria for admission can, instead, be treated as an outpatient.  Thank you, doctor.  No questions asked.  But flip the coin and try to get the hospital paid for taking care of an admitted patient who didn't meet the criteria used by CMS. Good luck with that.

I find this very frustrating, although I would like to say that in any number of ways that would require impolite language.  I bristle when my clinical judgment is questioned, especially by people who don't practice medicine but like to tell doctors how to apply their science and their art.  We call them bureaucrats, with every bit of the derision and negative connotation that word can carry.

So this is at least partly about clinical judgment.  These are judgments we must make many times a day, every day.  An emergency physician may initiate a conversation with an internist about a patient by saying, "This is a 'soft admission.'"  That means it's a patient the emergency physician feels uncomfortable sending home but that the internist might think doesn't really need to be in the hospital.

During every shift I work, I see patients who might benefit from hospitalization but also might be safely managed as outpatients.  I often discuss the options with the patient, the patient's family, and the patient's regular doctor before arriving at a decision agreeable to all concerned.  It's not always simple and straightforward.

So you can imagine what HMA was saying to the doctors.  You have a patient in the ED and you're considering hospitalizing that patient?  Just do it.  The hospital has empty beds.  We want to fill them.  After all, we need the revenue.  We need the margin.  This hospital exists to serve the health care needs of the community.  That is our mission.  You know the saying: no margin, no mission.

Should HMA tell doctors at a hospital that admits 7% of its ED patients that they have to get that up to 20%, or tell doctors who don't admit 20% of the ED patients they see that their services will no longer be required?  Of course not.  And if HMA did that, I would be the first to criticize that practice.

But I must say that there are many motivations for hospitalizing patients who might be "soft admits."  The further evaluation and treatment the patient requires might be conducted more expeditiously in the hospital.  The likelihood that everything that is envisioned actually gets done is greater.  The chances that something is missed, and an adverse outcome results, are reduced.  (And maybe, correspondingly, the likelihood of a malpractice lawsuit is reduced.)  The satisfaction of the patient and the family with the care provided at the hospital goes up.  And everyone in health care wants satisfied patients.

The 60 Minutes segment didn't tell us any of that.  No, instead, they intimated that HMA might be guilty of "Medicare fraud."  Was HMA providing services to patients that were unnecessary or inappropriate?  No evidence of that was set forth.  Was HMA billing Medicare for services not provided (which would clearly have been fraud)?  That was not even implied.

Far be it from me to say that 60 Minutes, that paragon of investigative journalism, would take a potentially interesting or important story and sensationalize it.  Oh, no.  Why would they do that?  Just for ratings?  To get more people to watch the show?  To make more money?

We certainly expect our providers of health care to be above such motives.  But we have no such expectations of journalists.  Should we?