The New England Journal of Medicine and Its Editors: What Is Their Agenda?

Recently, the New England Journal of Medicine (NEJM) published the following article: Cents and Sensitivity–Teaching Physicians to Think about Costs. 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




[1] R. Garth Kirkwood, Socialized Health Care Reform, 2010

[2] Uwe E. Reinhardt, “The Pricing of U.S. Hospital Services: Chaos Behind a Veil of Secrecy,” Health Affairs, 25, no.1 (2006): 57-69

The editor’s response to my letter:

 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


High Value, Cost-Conscious: Weasel Words of 3rd Party Payers and Their Sycophants

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 ( 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 ( 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 ( 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

Socialized Medicine and Its Counterpart: A False Dichotomy

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. 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. 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 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.
Make no mistake, the American healthcare system is compromised by 3rd party payers and others regardless of the economic terminology, which we use to describe our system. The practical difference between calling our system non-socialized or socialized falls by the wayside, and this economic terminology is a false dichotomy. But it is a dichotomy which the politicians and the businesses of medicine want you to stay preoccupied with. Why? Because then you are arguing about which form of compromise of your individual health care best suits you or you agree with. And you are not thinking about the dollar games which benefit them and for which, we supply all the dollars. This is what these healthcare administrative business people and politicians, irrespective of party, do: Serve you rhetoric, which poisons your thinking with false concepts, weasel words, and other manipulations.
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.
The other part of your most difficult mission is to force, by using the ballot box, your elected politicians to grasp this and act on it with your health care and access to it at reasonable out of pocket cost as their primary focus as opposed to kowtowing to lobby groups and political ideologies. These politicians are supposed to be civil servants. They do not function this way. Moreover, when it comes to themselves or a member of their family, they will be on the phone immediately obtaining the most advanced specialist to come tend to their needs.
What can we do about our healthcare system, we who pay for the entire government and the entire healthcare system? The answer is that WE MUST CHANGE OUR SYSTEM OF HEALTH CARE because the current system (with or without the farce of Obamacare) is not serving us, and the politicians are too inept, too unconcerned, too compromised to do anything about it to help us.
The question then becomes, How do we change it? Two basic concepts must form the foundation of true healthcare reform in America:
  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.
I have developed this type of thinking in my two books, Equal Health Care For All and Socialized Health Care Reform and in various essays on this website. In future posts, I will relate some previously recorded and some new ideas for the financing and the functioning of this central payer to include clear explanations of why, if structured properly, it will alleviate all of us from the socialized medicine which currently plagues us. You should note that I believe an individual mandate for everyone living in America is absolutely necessary, even though Obamacare is awful on its best day.
R. Garth Kirkwood, MD