Image over substance,
Tech games over serious thought,
Clueless over informed,
Sunglassed shrugs the mainstream.
Obama’s minions control this culture,
This baby boomer-hippy spawn,
Government pawns.

Liberals are a puzzle,
Maybe they like burkas and hijabs.
So myopic they seem about sequelae
Of misdirected jabs.
But at least they stand for something,
And like conservatives have a point of view,
Unlike the significant swathe
Who exist without a clue.

Our government is an abscess,
Which has festered for many years.
Obama & Co., like others, have found this pool
Ideal for swimming and diving
Amid a raft of cheers.
Incision and drainage is required!
Are there any civil servants unwired
With knowledge and courage enough
To slice open this necrotic mire
And completely drain the pus?

Can surgery slice deep enough?
At bottom is the core,
Absent engagement from the gimme generation,
Which splashes clueless,
Bathing in the smoke and mirrors of politicians,
Who’ve promised them everything before.

In the Forward, written by American economist Kenneth J. Arrow, of the text, Health Economics And Financing 3rd Edition (2007, ISBN: 9780471772590), by Professor Thomas Getzen, there is the following statement: “But insurance reduces the incentive of an individual patient or physician to seek the most economical means of treatment. As a result, new institutions and regulations develop to overcome this “moral hazard,” as it has been termed— institutions such as health maintenance organizations (HMOs), managed care by insurance companies, and regulations such as those that govern Medicare expenditures.”

I challenge the validity of the above statement: My view is that insurance doesn’t reduce this incentive because the incentive wasn’t there to begin with and that it’s right and good that this incentive is NOT part of the clinical decision making, which occurs within the context of a sound, ongoing, non-conflicted doctor  patient relationship. Thus, these new institutions developed to deal with a moral hazard of their own creation thereby establishing themselves as another type of insurance carrier within the business of medicine and reaping huge revenues and profits based on the underlying rhetoric that we must have this incentive to deal with a moral hazard emanating from the doctor patient relationship.

Can doctors create a dollar conflict within the doctor  patient relationships which they are part of? Absolutely YES! My view is that this should NOT OCCUR. To prevent it from occurring or to deal with it when it does, there are several approaches including the most important one: An absolute demand that all of our doctors come to the fore with an attitude that the dollar bill is NOT their primary motivation in seeing patients and that their patients can develop a TRUST in them regarding this.

Self-serving 3rd party payer manipulations pressing upon the clinical decision making of the doctor  patient relationship need to be exposed and seen for the garbage that they are! Indeed, 3rd party payers are a moral hazard!

R. Garth Kirkwood, MD  (doctork@equalhealthcare.org)

Recently, the New England Journal of Medicine (NEJM) published the following article: Cents and Sensitivity–Teaching Physicians to Think about Costs.  http://www.nejm.org/doi/full/10.1056/NEJMp1205634 Please take a few minutes to read this article. You may not understand the medical lingo, but the message is clear enough.

I wrote the following letter to the editor regarding this article, which the editor politely declined:

Cents and Sensitivity—Teaching Physicians to Think about Costs by Drs. Rosenbaum and Lamas is Socialized Medicine[1]. Bringing dollars to mind while working up a patient conflicts the work-up. A doctor trying to save money is just as conflicted as a doctor doing procedures solely because he/she profits from them.

Costs are out of control largely because of greed:

1. Multi-billion dollar insurance companies, whose sole function is clerical administration of payment of the bill,
2. Thousands of not-for-profit hospitals, which garner hundreds of millions of dollars in revenue; pay administrators salaries of $500,000 to $1,000,000/year or more; and do not understand their own billing[2], have become independent business fiefdoms,
3. Drug & Technology Companies,
4. Lobbying politicians at state and federal levels,
5. Malpractice lawsuits.

Capitalism and profit making are the essence of American culture. When capitalism becomes unbridled allowing open-ended greed to endanger the doctor—patient relationship, it’s time to bring the business of medicine under control, while concomitantly ensuring its negotiated profitability, not to scapegoat  the doctor—patient relationship.

R. Garth Kirkwood, MD

http://www.equalhealthcare.org

doctork@equalhealthcare.org

 Dear Dr. Kirkwood,

I am sorry that we will not be able to print your recent letter to the editor regarding the Rosenbaum article of 12-Jul-2012.  The space available for correspondence is very limited, and we must use our judgment to present a representative selection of the material received.  Many worthwhile communications must be declined for lack of space.

Thank you for your interest in the Journal. 

I question, Why did they not publish my letter? It is correct information. Surely what they suggest is socialized medicine, not the economic definition of that term but rather the end result of that type of healthcare system: The payer, public or private, interfering with non-conflicted clinical decision making within individual doctor  patient relationships. They would make the doctor a vicarious administrator for 3rd party payers, which results in the following message to the patient: That test or therapy is just too expensive to use for your individual case. The clinical thinking of the doctor becomes conflicted with the dollar bill. This is exactly what formally socialized systems do either directly or indirectly. But here, the doctor becomes a substitute for the payer, which accomplishes that agenda.

The second part of my letter is also correct. For true healthcare reform, it is necessary to challenge all the mechanisms of greed embedded in the business of medicine and to recognize that scapegoating the doctor  patient relationship is not the answer.

So, why didn’t they publish my letter?

In the following paragraphs, I am going to dissect this article a little more to show how these authors use rhetoric, which I think is misleading, to accomplish this new way of operating for the doctor  patient relationship. I will italicize statements from the article and then respond to them in regular text. You should pay close attention to make sure that I have correctly transcribed the authors’ statements and that I have not taken them out of context.

First: Good care, we believe, cannot be codified in dollar signs. But with health care costs threatening to bankrupt our country, the financial implications of medical decision making have become part of the national conversation. This is true. But who is making this part of the national conversation? The answer is the 3rd party payers and their co-opted politicians  from both political parties, under the guise of the noble rhetoric, reducing healthcare spending. These authors suggest that now individual doctor  patient relationships should be co-opted by this business thinking. It is wrong, a thousand times over. When you start this modus operandi, the accumulation of medical information and knowledge for that individual patient becomes obstructed by the dollar bill.

Second: The fact that we can no longer ignore the financial implications of our decisions leaves the medical profession in a quandary. The operative word in this sentence is our. These decisions are not ours in the context that the authors employ this word. They belong to individual doctors and individual patients in the context of that unique, individual relationship. If you really want $$$$ to be part of that decision making, then delete the entire 3rd party payer system and tell individual patients that they will have to be first party payers. That’s the only way that financial considerations can be introduced into the doctor  patient relationship without conflicting the doctors’ clinical decision making. The patients would decide whether the expense is worth it. Why do we need 3rd party payers? This would greatly reduce annual healthcare spending because many patients would have to take out loans to pay the bill or forego the clinical evaluation. Nevertheless, annual healthcare spending would be greatly reduced. Such a noble end!

Third: Can a physician remain a patient advocate while serving as a “steward” of society’s resources? The operative word in this sentence is society’s. The word, society, is a circumlocution, which makes vague the fact that the resources, i.e., dollars, in our healthcare system come from the individuals living in America in the form of health insurance premiums, taxes, and out-of-pocket- spending. The first two of these sources go to 3rd party payers, who are supposed to administer payment of the bill. That’s why individuals send money to the two types of 3rd party payers. What we cannot allow is rhetoric from bioethicists, these authors, and others to regulate our health care by using poisoned language to do so. (See, Hayek, F.A. The Fatal Conceit The Errors of Socialism-Chapter 7 for discussion of our poisoned language). Using the words, society’s resources, gives cover to the underlying agendas of these 3rd party payers, which are not in the interests of the individuals who pay for their existence.

Fourth: There are several other examples of misleading rhetoric, which have been insinuated into our healthcare lexicon and which these authors utilize, such as, evidence-based medicine, cost-effectiveness, value-based purchasing etc. I have discussed these elsewhere in this blog. But the final sentence of this article deserves comment: Protecting our patients from financial ruin is fundamental to doing no harm. If the authors really believe this, then the place to focus their efforts is the greed-driven manipulations of the business of medicine, which I outlined for them in my letter to the editor. The doctor  patient relationship is sacrosanct. And this tradition must be maintained without compromise, not because it is a tradition but rather because it is the origin and ongoing source of accumulation of medical knowledge for individual patients and thus for our healthcare system.

R. Garth Kirkwood, MD

Weasel words are words or statements that are intentionally ambiguous or misleading (The New Oxford Dictionary of English, Oxford University Press 1998) and which can deprive of content any term to which they are prefixed while seemingly leaving them untouched (Hayek, F.A. The Fatal Conceit The Errors of Socialism).

Currently it seems the vogue to say, “High Value, Cost Conscious Care” (Do a Google search of this expression, and you will find a plethora of articles). My view is, when this adjective, high value, cost conscious, modifies the noun, care, it extinguishes thought about the noun’s meaning in the context in which it is being used and focuses attention on the dollar bill, $$$. I believe that is the intent of the people who use this expression.

Some of you may say, “Well, that’s not bad, we have to be focused on dollar expenditure in our healthcare system.” However, the people who foster this thinking want it to be part of the doctor’s thinking when he/she is seeing patients (http://www.nejm.org/doi/full/10.1056/NEJMp1205634 and many of the results from your Google search mentioned above).

Let’s look at the functioning of the doctor  patient relationship:

In the doctor  patient relationship there is an intersection or interchange which occurs and involves an exchange of information via the history, physical examination, laboratory tests, xrays, etc. This is how medicine is practiced and it is where clinical decision making regarding diagnosis, treatment, and follow up occurs. The dollar bill, $$$, is not part of this exchange of information. It cannot be because then the information exchange and clinical thinking & decision making resulting from it is muddied. When this happens, medical care will be suboptimal at best or destructive and/or non-existent at worst. No good outcome can occur from bringing the dollar bill and dollar thinking into this exchange of information. The dollar bill is a non-clinical agenda, whether the dollar thinking is intended to benefit the doctor’s income or that of the 3rd party payer under the guise of the noble sounding rhetoric, reduction in healthcare spending and cost control.

If the American public (not their 3rd party payers and their sycophant politicians and think tanks) insists on dollar thinking as part of their doctor  patient relationship, then they have to bring that dollar thinking themselves and not expect that their doctor should or can do it. Admittedly, they will be conflicting their own medical care, but that is their choice. And, of course, with this we enter Gingrich land, the home of his now bankrupt, Center for Health Transformation (http://www.bizjournals.com/atlanta/news/2012/04/05/newt-gingrich-think-tank-files.html?page=all, http://www.kaiserhealthnews.org/Daily-Reports/2012/April/06/Gingrich-consulting-firm.aspx). You must have heard of this dollar-green quagmire, where the advocates of consumer-focused health care ply their rhetoric. It’s all the same poison: high value care, cost conscious care, cost-effective care, consumer focused care, etc., etc: Bring dollars or lack thereof into play within the doctor  patient relationship so that clinical thinking is disrupted. Why? Because that’s the proximate cause of dollar spending in our healthcare system. If you control that, you control a gold mine, a greater than 2 trillion dollar annual gold mine.

The question arises, Why should patients or the American public in general bring dollar thinking into their interchanges with their doctors, when they are already sending mega dollars, $$$$$, to 3rd party payers via private health insurance policies (individual or employer based; note the latter is not a gift from the employer but a defined part of the employees’ salary) and via taxes to the public payers, such as Medicare & Medicaid. Why should they do this? They can’t gain anything from it. All they can do is conflict their own medical care.

So, if the powers that be (unfortunately, this is not the American public, except for the bogus notion that the voting system gives individuals some sort of say) and their sycophants really desire Cents and Sensitivity (http://www.nejm.org/doi/full/10.1056/NEJMp1205634) as a modus operandi, then simply delete all 3rd party payers from our system and allow the American public to become lone first party payers (Lone, as opposed to this greed-driven mixture of cash-out-of-pocket spending via deductibles, co-pays, account management fees for high deductible insurance policies, pharmacy, and uncovered services all of which benefit the payer and its sycophants and disadvantage individual Americans). With the American public acting as lone first party payers, we would surely have what the purveyors of these weasel words want: Medical care conflicted by the dollar bill yet somehow also carrying the label, high value, cost-conscious care.

R. Garth Kirkwood,MD

doctork@equalhealthcare.org

http://www.equalhealthcare.org

A dichotomy is a division or contrast between two things that are or are represented as being opposed or entirely different (The New Oxford Dictionary of English, 1998). A false dichotomy is a dichotomy, which does not accord with truth or fact.

An economist, Uwe E. Reinhardt, an economics professor at Princeton, defines socialized medicine as a health system in which the government owns and operates both the financing of health care and its delivery.  http://economix.blogs.nytimes.com/2009/05/08/what-is-socialized-medicine-a-taxonomy-of-health-care-systems/ He cites the American V. A. health system as the purest form of socialized medicine. The British NHS, which we saw being touted in the opening ceremonies of the 2012 London Olympic Games, is another example of socialized medicine. What is the counterpart or alternative to socialized medicine? What is its name? Is it private, but non-profit; private, and commercial; some mixture of these two? What do we call it? The above reference from Professor Reinhardt explains the answer and is well worth reading and studying.

For those of us who are not trained economists and who just want a healthcare system, which really works for us, what is the practical (every-day-functional) difference between systems which are labeled or thought of as socialized or non-socialized? The answer depends on the context of the question, i.e., on which end goal of the healthcare system we are talking about. http://equalhealthcare.org/2012/07/the-hierarchy-of-ends-in-our-american-healthcare-system/ If the end goal is your individual health care, i.e., the effected work of a sound, ongoing, non-conflicted, spontaneously functioning doctor  patient relationship, then there is no difference between the two systems at all. If you and your doctor are functioning in a manner consistent with the priorities which I describe http://equalhealthcare.org/2012/07/the-doctor-patient-relationship/ then you will receive good medical care regardless of which type of system operates in your country, as long as all the other parts of your healthcare system operate in dedicated, non-conflicted service to the doctor  patient relationship. If the end goal is $$$$, dollar profit and political gain (under the smokescreen of reducing healthcare spending), being viewed as more important than the non-conflicted functioning of the doctor  patient relationship, then the practical difference between socialized and non-socialized systems depends on the amount of interference which the 3rd party payer and other healthcare businesses press onto that non-conflicted functioning. All 3rd party payers (private or public) and some other healthcare businesses directly interfere with the doctor  patient relationship. What determines the amount of this interference? At least four factors and maybe more:

1. The nature of functioning of the 3rd party payer,
2. The power of the 3rd party payer,
3. The courage of doctors and others to stand up to these payers by working without allowing conflicts of interest to intervene,
4. The cleverness of 3rd party payers’, politicians’, drug companies’, and others’ manipulative rhetoric and how easily we are duped by it.

Your mission people, should you decide to accept it, is to understand a different, individually applicable definition of socialized medicine: Socialized medicine means socialized, controlled, obstructed, conflicted, (and a myriad of other adjectives) doctor  patient relationships. And isn’t this the fear that people feel when they here the expression, socialized medicine: That the hand of the payer will squeeze their health care to accomplish its own ends, the hierarchy of which places the doctor  patient relationship lower than $$$$? American health care is already socialized because it makes no difference which entity functions as the payer as long as that entity is allowed to interfere with the non-conflicted functioning of the doctor  patient relationship.

1. The absolute demand for clear and equal access to sound, ongoing, non-conflicted, spontaneously functioning doctor  patient relationships for everyone at a reasonable price,
2. A central payer, which negotiates transparently and repeatedly with all necessary healthcare businesses regarding payments for their services and products; which is composed of people with extensive experience in the various healthcare business disciplines such that negotiations take place between knowledgeable people from both the payer and the business; whose negotiators have long term appointments and remain free from the influences of the private or public sector (like the Supreme Court); and which has two major goals in the following order of importance for the payments which it administers: First, the existence of doctor  patient relationships as described above; Second, the recognition and absolute support of the Profit Motive for necessary healthcare businesses to a level short of greed.

What are the ENDS of our American healthcare system? Since the word, end, in this context means a goal or result that one seeks to achieve (The New Oxford Dictionary of English, Oxford University Press 1998), I guess it depends on whom you ask. I am going to list three rather obvious and important ends for our system, and I ask you to think about them and decide their relative importance, their rank in a hierarchy of ends:

1. , the doctor  patient relationship, which is an equilibrium of trust developed between two people through which clinical decision making regarding the patient’s illness can occur,
2. $$$$, which indicates a profit motive for the businesses which function within our healthcare system. These businesses include hospitals, health insurance companies, drug & technology companies, nursing homes, and on and on. Note that doctors’ practices are also included,
3. Careers & employment, which includes doctors, nurses, technicians, administrators, malpractice lawyers, lobbyists for the healthcare industry, and many other types of positions, which somehow relate to our system of health care.

How do you rank their importance? What is the hierarchy of these ends? I believe that most doctors and patients would rank them in a certain order, while insurance company, drug & technology company, and hospital business people would rank them differently. And finally, those who are employed by our healthcare system might rank them in yet a different order of importance.

I suggest, since the citizens of the USA and some of the non-citizens provide every penny of the MEANS (money), which is the financial base making possible the existence of this system, that they be the ones who decide the hierarchic ranking of these ends. Then maybe a system, which truly tries to achieve the meaning of patient-centered care, i.e., sound, ongoing, non-conflicted, spontaneously functioning doctor  patient relationships, could be developed, as opposed to the “solutions” offered by the poisoned, agenda-driven, greed-driven rhetoric of ALL of our politicians.

How do you make something like this happen? Once they get elected, the politicians quickly forget who elected them, abandon the glorious rhetoric from their campaign messages, and sit in Washington, DC and in fifty state legislatures sucking off the government teat. Take a look at Jack Abramoff on the TV Show, Sixty Minutes,  http://www.cbsnews.com/video/watch/?id=7387331n.

How can we effect real solutions?

R. Garth Kirkwood, MD

www.equalhealthcare.org

doctork@equalhealthcare.org

Some of you who read these essays may wonder why I place this symbol, a bidirectional arrow, between the words doctor and patient, when I write the phrase, doctor  patient relationship. If you can remember high school chemistry, it is the symbol for equilibrium reactions. And this is how I view the doctor  patient relationship, as an equilibrium of trust between two people. The symbol tells us that the relationship is a two way street allowing the mutual exchange of information, the mutual development of trust, and the delivery of and receipt of medical care. The figure shows the interplay of what I think are prerequisite characteristics of doctors and patients for the development of successful relationships through which good-quality medical care can occur. It is also figure 3 in my book, Equal Health Care For All, published in 2007.

I had received some suggestions for this figure when I was writing Equal Health Care For All. One person suggested that honesty be added to the figure. I believe that I would be on firm ground if I added honesty to both columns. But because I think honesty has to, by definition, permeate an entity called a mutual trust I didn’t write it out. Another person suggested that warmth should be added to the doctor column. Again, I didn’t write this out specifically because it seems to me that if the doctor brings those listed characteristics into play that must mean there is some measure of real underlying warmth.

I am sure other people can come up with a figure or diagram and a list of attributes equal to or even better than my list. The important part of this would be that they are actually thinking about it. Give it a try. Figure out what you want from your doctors and your patients and what you must bring in your effort to develop sound, ongoing, non-conflicted doctor  patient relationships.

The statement which this figure does not make and which seems obvious to me and, I think, to most patients is that this relationship is SACROSANCT, not to be trespassed upon by anyone. A major problem in America is that people, whose careers happen in the business of medicine and in politics, do not seem to understand this. Whether they truly do not comprehend the effect of their machinations for increasing profit and for garnering votes, financial campaign contributions, and other favors on the the non-conflicted functioning of the doctor  patient relationship or have decided that this relationship is a tool for them to achieve their goals is not clear to me. Maybe it’s a combination of both in this arena. But I tell you that if it doesn’t stop, there can be no true healthcare reform because health care ceases to be the objective of that reform.

I suggest that you read a couple of other recent articles about this. I provide the links below. Read these pieces carefully and think about them. It’s your healthcare system, and you pay for it completely regardless of what type of 3rd party payer administers payment of the bill.

1. ObamaCare’s Lost Tribe: Doctors by Daniel Henninger in the Wall Street Journal.   http://online.wsj.com/article/SB10001424052702304708604577505210356532588.html
2. Playing Politics with the Doctor—Patient Relationship by Deborah J. Oyer, MD in the New England Journal of Medicine     http://www.nejm.org/doi/full/10.1056/NEJMc1205009   Here, it’s also worth the time to investigate the two references for their information. Just click on references and links are provided.

Nobody, not even hospital administrators; hospital board members; 3rd party payers; politicians; drug & technology company executives; or doctors, is at liberty to manipulate, obstruct, or interfere with the spontaneous, non-conflicted functioning of individual doctorpatient relationships and then claim patient welfare as their goal!

Sound, ongoing, non-conflicted, spontaneously functioning doctorpatient relationships are inseparable from the practice of medicine. Indeed, they are the origin and essence of it.

Healthcare administrators, politicians, and other functionaries in the business of medicine are qualified to make contact with individual doctorpatient relationships in exact proportion to their willingness to give up the dollar quest of their healthcare businesses: in proportion as their love of the essence of medicine, the source of and reason for their existence in this sphere, is above their rapacity.

These three statements are paraphrases of the three opening statements of Chapter 2, “The Origins of Liberty, Property and Justice” of F. A. Hayek’s book, The Fatal Conceit The Errors of Socialism. I substitute the doctorpatient relationship for several property.

R. Garth Kirkwood, MD

http://www.equalhealthcare.org

doctork@equalhealthcare.org

The business of medicine: hospitals, 3rd party payers, politicians, drug & technology companies, doctors’ practices, and others in our healthcare system are driven by the dollar bill. It is understandable; this is America. However, in my view, the practice of medicine is one arena in which the dollar bill should not be the primary driving force. Rather, sound, ongoing, non-conflicted doctorpatient relationships, supported by not supplanted by the dollar bill, should be the goal, which we pursue. Why? Because that’s where clinical decisions are made. These relationships are the proximal source of the work of health care. Dollar thinking should not be allowed to compromise the thinking that occurs within the mutual trust developed between the doctor and the patient. Is it possible to remove the dollar bill from doctors’ thinking? I think it is and I think this has to occur, if we are to have healthcare reform. Doctors themselves must acquire the discipline to put their own dollar earnings out of their thinking when they see patients. They also must possess the courage to say NO! NO! NO! to administrators of hospitals, 3rd party payers, politicians, and any others, who try to bring the poison of their business rhetoric to bear upon the functioning of the doctorpatient relationship. Let’s look at just one of a myriad of examples of this subtle business pressure which sounds oh so good but which is in reality poison for the trust, which must be developed between doctors and patients if sound, ongoing, non-conflicted health care is to be our norm: Physician Compacts with the medical centers, which hire them and pay their salary.

Here is the link to one of these: The Virginia Mason Medical Center Physician Compact:
https://www.virginiamason.org/workfiles/HR/PhysicianCompact.pdf
Perhaps print a copy of this compact and then focus on the following sections under Physician’s Responsibilities:

1. Collaborate on Care Delivery— Behave in a manner consistent with group goals. NO! The goals are decided within the context of a sound, ongoing, non-conflicted doctorpatient relationship. If the doctor wants/ needs help, it will be available. It’s called Consultation with other doctors, who are specialized in other areas of medical knowledge. Teams of professionals are assembled within medical centers to help bring the medical work, the decision making of the doctorpatient relationship, to fruition but not to assert group goals on this decision making.
2. Listen and Communicate— Request information, resources needed to provide care consistent with VM goals. NO! Doctors listen and communicate within the context of sound, ongoing, non-conflicted doctorpatient relationships. Medical centers exist to enable that communication to occur but not to insert their own goals on top of it.
3. Take Ownership— Focus on the economic aspects of our practice. NO! The doctors are not responsible for the medical center’s economic welfare. When this happens, clinical decision making becomes conflicted by those economics.

Let me ask a commonsense question. When you go to the doctor for a medical problem, do you want the doctor to base his/her decision making on their own dollar earnings, their own economic welfare? Of Course Not! This superimposes dollar conflict on top of clinical decision making. It’s the same conflict if the doctor has the medical center’s economic well being on his/her mind during the course of clinical decision making. And yet doesn’t this business rhetoric in this physician compact sound OH SO GOOD! ( Focus on Patients, Collaborate, Group Goals, Economics etc., etc.)

This business rhetoric is poison. It is one of the techniques socialists use to try to assert their authority and beliefs. (F.A. Hayek: The Fatal Conceit The Errors of Socialism Chapter 7). The business of medicine is socializing our health care by using the techniques of Socialism in partnership with 3rd party payers and politicians for their own end: Efficiency in Spending. That is to say, spend as little as you can to make it look like you’re delivering great medical care to everyone in your community while concomitantly lining the pockets of hospital administrators, helping to maintain the mega-profits of insurance carriers, and, of course, keeping the politicians happy! (R. Garth Kirkwood, MD: Socialized Health Care Reform). If you don’t believe this, try looking up the salary of some non profit medical centers’ CEOs, then decide if you think what I’m saying has any merit. This doesn’t conform to the strict definition of Socialized Medicine only because the government doesn’t own and operate both the financing of health care and its delivery in all of these institutions. http://economix.blogs.nytimes.com/2009/05/08/what-is-socialized-medicine-a-taxonomy-of-health-care-systems/ But the end result is the same as that evolving from the pejorative context of the term, Socialized Medicine, i.e, fear of and fact of clinical decision making within the context of doctorpatient relationships being manipulated and controlled by someone else other than the doctor and patient to accomplish an agenda, which is not part of clinical medicine despite the best efforts of these someone elses to make us believe that it is.

WAKE UP TO THE WONDERFUL WORLD OF SOCIALIZED MEDICINE IN THE LAND OF THE CAPITALISTS!

Is there a solution to this? Yes, of course there is. Perhaps the most important part of the solution is for doctors and patients to just say NO! to the business of medicine. Doctors and their patients need to make it known to hospitals, 3rd party payers–private and public, and to politicians that the patient employs the doctor not them. The doctorpatient relationship is an employee-employer relationship. It is an unusual one, to be sure, because, although the ultimate power in the relationship belongs to the patient, the employer, (the patient has the choice of doing what the doctor recommends or not) this employer (patient) does not tell the doctor (employee) what to do. The doctor, based on his/her medical training and experience coupled with information from the patient, decides what is best to do for that individual circumstance. The patient can accept or reject the proposed plan of diagnosis and treatment but that does not put him/her in the position of guiding the relationship. The patient participates in the relationship, which is guided by the doctor. This is why TRUST is so important. For many reasons, some of which are doctor-generated, this trust has been lost in America. It needs to be resurrected. But I state this clearly and emphatically: Medical centers and others, who pay the doctors’ salaries, imposing their own business rhetoric on the clinical decision making of the doctorpatient relationship will not restore this trust. It will simply conflict the clinical decision making with dollar signs, $$$, and we will eventually wind up drowning in the green swamp called, The Big Dollar Pie. (R. Garth Kirkwood, MD Equal Health Care For All)

One other thought: Don’t let the medical centers’ hiring of physicians fool you. Medical centers have evolved for one reason: To enable the clinical decision making within doctorpatient relationships to occur. And their administrators’ proposals, MDs or not, do not supersede that individual decision making, which occurs within the context of sound, ongoing, non-conflicted doctorpatient relationships. Even though these medical centers pay the doctors’ salaries, patients and the American people in general are the original source of the money within the American health care system. Thus, they are the doctors’ employers.

I believe the following is a good and reasonable ethical position for doctors to follow: Put the needs of the patient above your own needs and above the needs of any group for whom or with whom you work. I believe physician compacts like the one discussed in this essay tear this ethical concept asunder. This business rhetoric is widespread across the USA in many forms and disguises:

• Managed Care
• Cost-Effectiveness
• High Value-Cost Conscious Care
• Evidence-Based Medicine
• Shared Decision Making
• Medical Homes
• Bronze, Silver, Gold, Platinum Insurance
• Consumer-Focused
• Others.

In my previous post Socialism 101 ( http://www.equalhealthcare.org/2012/socialism-101/ ), I left a link to the Virginia Mason Medical Center Blog, on which I tried to post a comment regarding a couple of their blog entries. I cannot find my comment on their blog, so I decided to record it here. First, go to the Virginia Mason Medical Center Blog and read the following two parts:

• Are your leaders, doctors and board members aligned with your organization’s mission?  http://virginiamasonblog.org/2012/06/13/are-your-leaders-doctors-and-board-members-aligned-with-your-organizations-mission/
• Part 1: Would you like to improve your organization’s relationship with your physicians? http://virginiamasonblog.org/2012/05/30/part-1-would-you-like-to-improve-your-organizations-relationship-with-your-physicians/

In the first, you will find the “Virginia Mason Strategic Pyramid” and, in the second, the text, “Being very clear about what it means for a physician to be a citizen of Virginia Mason is really the crux of it,” says Dr. Lammert, to both of which I referred in my comment.

You can also see their stragecic pyramid here:

The following is my comment, which I cannot find on their blog:

Your pyramid is politically correct rhetoric, which conceals the poison of what I believe you are trying to do: Hobble the spontaneous functioning of the doctorpatient relationship. The top of your pyramid is just wrong! Patients are not the top of the pyramid of health care. Rather the doctorpatient relationship functioning in a sound, ongoing, spontaneous, and non-conflicted manner is the top of that pyramid. The work defined by the clinical decision making, which evolves from the mutual trust between the doctor and patient, is what needs to be accomplished.
I note the following words from a previous post on your blog: “Being very clear about what it means for a physician to be a citizen of Virginia Mason is really the crux of it, says” Dr. Lammert. The definition of the word, citizen: a legally recognized subject or national of a state or commonwealth, either native or naturalized (The New Oxford Dictionary of English, 1998). So, doctors are the subjects of the state known as Virginia Mason. It’s a bit grandiose, don’t you think? Sounds like Socialism 101.

I understand now why you have placed Virginia Mason Production System as the base of the pyramid. Instead of recognizing reality, which is that Virginia Mason is just one of thousands of medical centers employing millions of people to help accomplish the work defined by the decision making which occurs within the framework of doctorpatient relationships, you place yourself as the very foundation of health care and view doctors as citizens of your state. It’s a load of crap.

R. Garth Kirkwood, MD

I wonder why they didn’t post my comment. Maybe, they can’t handle criticism, which demonstrates the poison of their rhetoric. Of course, let’s not let the medicine of medicine interfere with the business of medicine in this non profit business fiefdom, which records revenue of more than 804 million dollars in their annual report of 2009 https://www.virginiamason.org/images/internal/communications/web/vmfinancials_lg.gif, and more than 836 million dollars for 2010 https://www.virginiamason.org/workfiles/pdfdocs/press/VMFastFacts.pdf.

R. Garth Kirkwood, MD
doctork@equalhealthcare.org
www.equalhealthcare.org