The MD's Rx by Harold P. DuCloux, Jr. MD
Dr. DuCloux is a retired US Army Medical Officer and currently a practicing physician in the state of Wisconsin. tokenone@mac.com Contact him with questions about your health care and receive a reply.
"Don't Ask, Don't Tell" (DADT), My Perspective
"Opinions are like [colons] everybody has one." Or so the cliche goes. So here is my opinion on the "Don't Ask, Don't Tell" policy for gays and lesbians in the US Armed Services. First a little background. I served 22 years on active duty in the Army, 1972-1997, with time out for medical school. Half of my Army career was as a military "doctor". By that I mean my primary duty was as a physician in a hospital or medical clinic. The latter half of my career I was a commander who happened to be a physician. My primary assignment was in military units designed to go to war. My two career paths in the Army were very different.
In the hospital setting there were "lots" of openly gay and lesbian service members. Their personal lives had nothing to do with their professional lives. They did their jobs and went home just like in civilian life. The hospital staff, the patients, no one cared about your sexual orientation as long as you did your job as a physician, nurse, respiratory therapist or whatever. The only difference between a military hospital or clinic and a civilian one was that in military clinics, all the staff wore military uniforms.
In the "TOE" (go to war) units where I served, everyone was "macho" men as well as women. By macho, I mean excellence in soldier skills. Sexual orientation was not an issue. The important question was could you depend on your fellow soldier to keep you from being killed? The highest compliment one soldier could give another one was; "I would take a bullet for you." Few said that to each other but it was something that you felt. This is not a death wish but an attitude that is almost required in war that you trust your "battle buddy" to take a bullet for you.
In my last unit, my Command Sergeant Major was a female. She was tall with long blonde hair. Not one of my soldiers made a pass at the Sergeant Major. She was not a woman or man...she was the Command Sergeant Major.
I think that the "Don't Ask, Don't Tell" policy is like the old military segregation policy toward African Americans. The difference is that the military could target African Americans based on skin color. Gays and lesbians have to"voluntarily" declare their status to be discriminated against. Drop the "DADT" policy and let's stick with the basic policy for military service...are you "Fit to Fight"?
The Health Care Reform Gamble
The health care reform proposed by the Obama Administration is at an extremely critical point. What seemed an easy layup, if not a slam dunk, now depends on a free throw by Shaq, doubtful. The Democrats have committed some pretty serious errors, unforced turn overs, to continue with my sports analogy. In retrospect they almost seem laughable. First they delayed the process so as not to appear partisan. They had the votes in Congress to force feed a health care reform bill but they would have had to steam roll over the Republicans. As the Democrats and the Administration tried to coerce a Republican or two to vote the Democratic version of health care reform, the Republican party took advantage of the delay to build ground swell opposition. Artful bending of the truth made it appear that the Democratic health care reform would take away choice, dumb down services and promote death squads for the elderly. Then the Democrats went to sleep at the wheel and lost Senator Kennedy's seat, losing their 51 vote majority in the Senate. So here we are today staring into the abyss of uncontrolled health care costs, a large portion of the population uninsured or underinsured and an increasing portion of the population at risk for losing their health care coverage.
The proverbial ball is back in Congress' court. There could be a health care reform bill passed in this session of Congress. However, it will take a large portion of gonadal fortitude for that to happen. Change is always met with skepticism and reticence by the establishment. There is a certain comfort with the familiar even though the familiar is unpleasant or immoral. I don't think there are any black people in America today that would turn the clock back to "Jim Crow" times. Although, during the struggle for civil rights, there were many in the black community who were hesitant about supporting the struggle. Change for the positive was uncertain and not guaranteed. Today, the American people recognize the need for change in health care but they don't want things to get worse. Congress must do what we elected them to do, lead. It will be a gamble for many in Congress to support health care reform written by the Democrats. For some it will be political suicide or at least a self-inflicted wound. But that's what we need to happen. The American people need for our Congressional representatives to lead us out of this health care quagmire. The health care reform bill is a start of a journey not the destination. It will take years to see if this Congress' effort was successful in creating a new paradigm for health care. Who could have predicted in 1965 that the Civil Rights legislation would have resulted in the election of an African-American President in 2008?
Primary Care Physician Crisis
The National Resident Match Program (NRMP) for 2010 was completed last week. It is known as "Match Day". The NRMP is the program that matches graduating medical students to residency training. In other words it is the program where medical students choose their medical specialty or career. Here are some facts I find interesting about the NRMP. There are roughly 23,000 residency positions offered in the 2010 match. While there were 16,000 United States medical graduates applying for positions; there were 30,500 applicants total for the 23,000 positions. Where did these additional 14,000 applicants for US residency come from? 50% were Non-US citizens (Non-US IMG) who attended Medical School outside the US e.g. Russia, India, etc. and 26% US citizens (US-IMG) who attended Medical School outside the US e.g. the Caribbean.
The number of primary care positions offered in the NRMP has decreased from 1998 to present. In 1999 there were 3,265 Family Medicine residency positions offered. In 2010 that number was 2,630. The need for primary care physicians will markedly increase in the future as the new Health Care Reform law goes into effect. The estimated 32 million uninsured people who will need primary care physicians by 2019 may not find them. Can the current medical education system rapidly (less than two years) adjust to produce more primary care physicians? No! Will enough US medical graduates choose primary care training over subspecialty careers in the future? No! The current Health Care law is similar to the "No Child Left Behind" legislation, i.e. an unfunded mandate. It's OK though. There is an easy to adopt solution. Stay tuned.
Some Primary Care Options For The Future
Previously, I outlined how the Health Care Reform legislation could act as an unfinanced mandate based on a projected 40,000 primary care physician shortfall. With millions of uninsured Americans eligible for healthcare, primary care physicians might be viewed as an endangered species. One of the proposed solutions to address this crisis is a concept called the "Medical Home".
The Medical Home involves medical practices re-engineering to include putting into place practices to optimize revenue, then re-investing that revenue into health information technology, improved medical quality and better patient experiences. If it sounds complicated...it is. The challenge, as I see it, is that it requires individual medical practices to re-engineer themselves. There is no incentive to change other than it is the right thing to do.
This Medical Home also requires patients to interact with medical offices in a new paradigm. There might be computer alerts sent to patients. Patients might make appointments by e-mail. True, some of this is done presently but in the medical home it would be pervasive. The health care reform legislation does not depend on the insurance industry to do the right thing, it mandates the reforms. Thus, the Medical Home would have to be mandated to be successful in changing primary care access. Any solution to the primary care physician access challenge has to be mandated. Yes, that means more government involvement in our lives. I believe this is a good thing.
One of the simpler solutions to primary care access would be to permit Mid-level Primary Care Providers to become independent practitioners. A mid-level provider is a nurse practitioner or a physician assistant. Most states require these mid-level providers to work under the supervision of a physician. Permitting them to work independently would make them more efficient and allow them to move into areas where there is a primary care need, e.g. rural areas. These midlevels would not require any more legislative oversight than exist currently. This solution, although simple, will be fought "tooth and nail" by primary care physicians who would see this as a "threat" to their clinical and economic territory. It takes two years to produce a mid-level practitioner and seven years to produce a primary care physician.
The primary care access could very well be on its way to a successful resolution with a change in the way we license midlevels. Solutions to the primary care access shortfall are possible and relatively inexpensive, but they will require change by medical providers, state legislatures and patients. So, again, health care reform is necessary and possible but not without "sacrifice" [change that stings].
The Gate Keeper and Health Care Costs
One of the paradigms of healthcare in the 1980's was the concept of the "gatekeeper". In an attempt to control healthcare costs which meant expensive care from medical specialists, primary care physicians were assigned the role of gatekeepers. Insurance companies would not pay for medical specialty care unless the patient was referred to the specualist from a primary care physician. In theory this was supposed to reduce "unnecessary" or inappropriate expensive medical specialty care when patients self-triaged (self-diagnosed) themselves to medical specialists. Primary care physicians: Family Physicians, Internists, General Pediatricians were involuntary assigned this role of gatekeepers. It didn't work or let's say it didn't work very long.
Fast forward to today. We have new gatekeepers. Physicians are the gatekeepers to whatever patients "desire". X-rays, antibiotics, CT scans are just a few of the "consumables". In my anecdotal experience, patients generally present to medical offices an "agenda". For example, I have a sore throat [therefore] I need an antibiotic. I have to go and see a doctor and "pay the Piper" to get my antibiotic. If I go to the doctor and get my antibiotic then I am "happy" and satisfied. If I got to the doctor and I do not get my antibiotic I am "unhappy" and dissatisfied.
My point is that physicians and other healthcare providers are no longer sources of information and advisors on healthcare issues. We have become gatekeepers or access to healthcare consumables. Ask yourself the last time you went to your physician or a healthcare provider and left the office with only advice to take over-the-counter medications or at home remedies, e.g., increase the fiber in your diet? If you answer in the positive were you happy and satisfied with the visit? Was it worth the $150 for the information?
Physicians and healthcare workers are "graded" on two axes. One is the standard of care, i.e., the medical standard practiced today. The other axis is "patient satisfaction". Was the patient satisfied, very satisfied, etc? As a health care provider who's compensation is dependent on how patients "grade" me based on their satisfaction with my care, am I more or less likely to write that antibiotic prescription for a sore throat? Am I more or less likely to order the x-ray for the sprained ankle from a week previous? Even when I know that the antibiotic is not going to help and the x-ray is inappropriate, what will I do? How does the gatekeeper/access paradigm affect health care costs? This is conjecture. I have no evidence that this paradigm exists. I'm only asking the questions.
Oil Spill in the Gulf of Mexico
There has been an understandable outrage and desire to punish BP for the oil spill in the Gulf of Mexico as a result of the Deep Water Horizon oil rig explosion. Poorly and uncoordinated efforts are being under taken to punish BP by boycotting BP service stations in the United States. While these efforts may eventually get the attention of the Board of Directors of BP, the immediate affect will be that Americans will suffer as they lose jobs from closing stations or as adjustments are made by station owners to compensate for low volume.
If Americans want to punish the oil industry, not just BP, for slip shop safety and prevention technology in order to prevent this in the future, then we should make deep water drilling unprofitable for oil companies. If the price of oil does not support deep water drilling then the oil companies will not drill. It is simple economics, no profit, no expensive (deep water) drilling.
If America is serious about preventing the devastating catastrophe currently spewing in the Gulf of Mexico, then we should not only reduce but eliminate our dependence on fossil fuels. I consciously attempt to not drive my car one day a week. Some weeks I can do multiple days, but my goal is at least one day.
What would happen to the price of oil if Americans decreased their gasoline consumption by 14% (1/7)? This is a stretch, but what would the oil companies do if their profits fell by 14%? Maybe, the oil companies, all of the oil companies would get a clear message from the American people about how we feel about our environment.