Changing Conditions for Hospital Admissions (My Baptist Courier column for August.)

For subscribers to the Courier, here’s the link. For others, the text of the column follows.   (Link won’t open without subscription information!)

When we take our sick or injured loved-ones to the hospital, we often hope that they will be admitted. In many instances this is a very reasonable request. When heart or lung disease are at work, when severe infections, dehydration, fractures or strokes occur, admission may well be the only option. However, sometimes our desire to admit our family members is a throwback to a simpler time in medicine; particularly where the elderly are concerned. I don’t know how many times I have heard this, or some variation: ‘Doc, I know you say she’s fine, and all the tests are normal, but if you could just put mama in for a few days so she could get some rest, I think it would work wonders!’

When I was a younger doctor, without reading glasses and a gray streaked beard, we called them ‘social admissions,’ but we all knew that they were often necessary for pain control, or simply because the patient’s home life was so horrific. In the days when people were generally admitted by their own physicians, it was simple stuff.

‘Hey Billy, Mr. Mason is feeling very weak. We can’t find anything wrong, but he just doesn’t walk well.’

‘Wow, Ed, that’s odd. He’s never like that! Let’s just watch him overnight.’

And it was a done deal!

Alas, it’s not that way anymore, and for a number of reasons. First, insurance companies, along with Medicare, are imposing much stricter controls on what they will pay for, both in and out of the hospital. Honestly, many things we used to do as inpatients can be done much more cheaply as outpatients (and without risk).

Second, health care costs are rising. As we live longer, as we learn to treat more severe illnesses and injuries and simultaneously extend health insurance coverage for more people, look for a lot fewer admissions to the hospital as insurers cut costs wherever they can.

Third, admissions are increasingly done by ‘hospitalists,’ who do only inpatient care. They do excellent work, but they are under enormous pressure to admit only what is necessary and to discharge patients as quickly as possible. Otherwise they (and their hospitals) have to answer to chart reviews and face denial of payment by insurance companies.

Finally, (and perhaps most important) we have less admissions because most of us in medicine have figured out that being in the hospital isn’t inherently safer. You see, in hospitals, mistakes are sometimes made. Medication mistakes, transfusion mistakes, surgical mistakes. Falls and other accidents happen. The modern hospital is a chaotic environment, and for all the heroic efforts of the staff, they are entirely human and their patients are remarkably complex, both adding to the risk of error. In addition, even the best hospitals harbor terrible viruses and bacteria which patients can contract from one another. One is well advised to avoid them whenever possible.

It would be nice if we could keep everyone who wanted to stay. Wait, no it wouldn’t. It would be terrible and crowded and unsafe! So the next time you or a loved one has a condition that might lead to admission, take a step back and ask, ‘is there any way to do this as an outpatient?’ The results might be just as good. Or even better.

The Nativity Scene is the Perfect Balance

Here’s my Christmas column for the Greenville News.  Merry Christmas to all!

When I was a child, one of my favorite things about Christmas was the nativity set. We had a toy shed, made of wood and moss. And we had the characters of the nativity, all porcelain and paint. It was pretty complete, actually. There were angels, three wise men (each of different races), various young and old shepherds, sheep, toy animals I added as the years went by, and of course, Mary, Joseph and the Holy Child in the manger.

I would kneel by the creche and rearrange the characters. In my child’s imagination, putting my face close to the tableau was a way of entering into the story. As if, by participating in the thing, I would be transported back 2000 years to Bethlehem of Judea; or could at least see it first hand through some special lens.

So I changed it from time to time, to be a part. I had Wise Men coming from the East and West, shepherds in front and back. I herded sheep, cattle and camels in among the scenes, and repositioned the blessed family in a variety of ways in the little stable. I seem to remember that I always wanted an angel on top, watching over everything.

Thinking back on this, it occurred to me how formative that was. I learned, from the Gospels, and therefore from my play, that the event was wide-open to mankind. It’s a remarkable story, you see. At the birth of Jesus we have a nexus, where the powerful, like Herod, are frustrated by the powerless, like Jesus’ family (and for the time, Jesus himself). We have a meeting place where poor, uneducated rural shepherds are not only welcomed, but personally invited by the shining angelic emissaries of the King. And we have a prophecy fulfilled, which drew the metropolitan, rich, educated elite we know as Magi, who learned from their ancient texts the magnificent thing that was unfolding. God the father apparently sent unique, specially prepared birth announcements to both groups; both the gilded and the simple.

Near the shed and manger, the chaos of mankind, its commerce, its laws and government, lies upon crowded hotels and packed roads, but nearby is also the emptiness of the desert, lit by the bright stars of the night instead of lamps.

In and about the blessed shed are cattle and sheep, goats and rats, and probably cats. Horses and donkeys are feeding. And yet above it, also part of the created order, are ‘a multitude of the heavenly hosts.’ Below, the dirt from which mankind was made; above, the heavens he longs for. All in perfect balance.

And there, in swaddling clothes, the child and his awestruck, dumbfounded, gloriously happy and moderately confused human parents; all safely ensconced in the will of the God who ordained it all, and in profound mystery also lies stretching and crying before them.

The perfect balance remains today. Buy your own nativity, or simply imagine it in a ‘thought experiment.’ Insert who you will into the scene. A business man and a peasant, a soldier and a peace activist. Insert a criminal and a victim, a politician and a struggling mother. Imagine yourself as a Magi, or as an angel! Pretend you are the parents of the child. See, kneeling, your bitterest ideological enemy; and see yourself, also someone’s foe. Come to the manger as a homeless man or a grieving widower. Place your dog there, if you will, or your horse. Pretend, if you find it all ridiculous, that you are Herod, searching in anger. At least you are searching.

Locate the scene in your old storage shed, your grandparents’ barn, in a homeless tent city or outside a warm hotel. Place it in Greenville, or in New York, in Pakistan or Syria, in the past or the future. Imagine it welcoming, a light in the darkness. But do not make it shiny or comfortable, rich or exclusive.

In time, you will see that the creche is the cross. The meeting place of horizontal earth and vertical heaven, of time and eternity, poverty and riches, loss and hope, fear and joy, cruelty and justice, lies and truth. All of it, right there, in the Nativity Set of my childhood. All of it, right there, at the birth of Jesus.

Where we all have a place in the story, if we only desire it.


How are we supposed to deal with Obamacare?


This is my column in GJWHG for this week.  Dealing with Obamacare.

The Affordable Care Act, aka Obamacare, is law.  And its implementation is moving along slowly, but steadily. (Except when the President decides to personally amend the legislation from week to week.)

You have to give credit to the folks who believed in it, whether grass-roots supporters or highly placed politicians.  They rammed it down the American gullet like a lead ball down the muzzle of a Hawken Rifle.  The problem is, once it goes off, the whole thing is going to explode.

The reasons are many, but from my perspective in emergency medicine, there are some very important issues that the crafters and supporters of the law either failed to notice or (more likely) intentionally ignored.  While I’m not a medical economist, or a politician for that matter, I am a physician. And as a physician, I pretty darn good observer of humanity.

As the cost of insurance rises, people with limited incomes are simply going to pay the fine and go without insurance.  Rather than pay $900/month for their families, they’ll pay the $695 yearly fine…unless of course the qualify for various exemptions.  For some young people, this will be fine.  But many will still be ill and will still show up in emergency rooms, as they have for decades, in the full knowledge that they’ll receive good care and simply be billed later.  But not to worry!  They can still apply for insurance as soon as they need it and not be denied.  Problem is, the concept of insurance then fails. They won’t have put any money into the system, which could have been making money for the company until they became ill or injured.

Of course, many won’t bother with the fine either.  And it’s the height of lunacy to believe that the government (which simply can’t imagine imposing voter ID) will actually track down and prosecute those who don’t pay.  If it did, they would just call a reporter and talk about how they have no money for insurance and the fine would be dropped.

I take care of a lot of folks in this demographic.  Some genuinely have financial struggles and try their best. I love them.  But a not-insignificant group of patients will continue to find ways to move from ER to ER, from narcotic prescription to narcotic prescription, state Medicaid to state Medicaid.  They will still find money for a smart-phone, cigarettes and Methamphetamine.  They will continue to drive large, late model trucks and fish whenever possible.  They will not give accurate addresses, either to the government or to the hospitals who treat them.  And they will not abide by the rules of the Affordable Care Act.  That is, they’ll find a way to have money. But they aren’t foolish enough to use it for insurance.

Added to the problem with the ACA is the issue of pre-existing conditions.  I’m sympathetic here. I have a son with type-I diabetes and a wife who is a cancer survivor. Insurance will be tough for them to obtain without some government mandate.  On the other hand, what about the patient who intentionally does things, or has habits, which make him or her a costly investment?  For instance, the recreational cocaine user?  The heroin addict who has no interest in rehab, only in treatment when things go wrong? The gang-banger whose hobby is shooting others and being shot? It may seem compassionate to offer them help; but it’s cruel to those who will be ultimately paying the costs for those who refuse. It’s a huge drain on a system when people do nothing to care for themselves.

Finally (well not really, but I’m almost out of space), what does the President intend to do about the fact that physicians are retiring early, and moving into practices that don’t take insurance?  What about the fact that there aren’t nearly enough physicians in primary care, nor will there be for at least the next 20 years or more? What about the fact that patients who are difficult are often dismissed from practices?  What do we do with the angry, the addicted, the dangerous, the non-compliant?  Even with insurance, nobody will take care of them for long.

I’ll try to be generous here. The ACA exists in part because of compassion for the sick and needy.  I’ve known patients who simply put off necessary care for lack of insurance.  But the ACA is far too large, far too expensive and ignores simple issues of human nature and behavior like those I listed above.  It also ignores other ‘inconvenient truths;’ like employers changing employees to part-time because they can’t afford insurance, or the impending explosion of patients who haven’t paid into any plan, private or public, because they were illegal immigrants.

Frankly, I’m worried. When government, so far out of touch with reality, imposes its social philosophy on people who do live in reality, only tragedy can result.  What a pity that when it happens, the political class (left and right) will only wring their hands, say ‘tsk, tsk, we didn’t think that would happen,’ and slip off to their private physicians, with their Cadillac, tax-dollar insurance plans, and get more pills for anxiety.

And the masses be damned, or fined, or ignored.


Mandatory flu vaccination for medical staff: a physician's objection

Dear readers,

Below is a letter from one of my dearest friends to his hospital administration.  This year, the administration has mandated Influenza vaccination.  Short of a few accepted exemptions, it is a requirement for continued medical staff participation by physicians or employment by other staff.

Those who do not receive it must wear a mask while working for the entire duration of the flu season, as well as a badge stating that they did not receive the vaccination.

It has become an issue of great contention among staff, but has been largely dismissed as of insufficient concern to the administrative staff.  Another facility near his has excused its staff from this requirement on moral grounds.  Most others are requiring the vaccine.

Whatever you believe, or do not believe, about vaccines in general or Influenza vaccine in particular, My friend, emergency physician Dr.Doug McGuff, makes a reasoned, sound and scientific argument against the requirement.

Hardly the rant of an uninformed individual, Dr. McGuff is without question one of the most intelligent and articulate people I am honored to call friend.  In addition, he is an author and nationally recognized fitness expert.

His websites are, as follows, with links to his recent McGraw Hill publication, Body by Science:

As physicians are slowly, but surely, edged into employment positions, as we find ourselves forced by government and various regulatory bodies to do whatever we are told, as we move from professional to commodity, it would be wise for us to ask, ‘how much more?’  First a flu vaccine, easy enough.  But at what point will our freedom, our judgment, be compromised past the breaking point?

Read Dr. McGuff’s outstanding response to his hospital administration and consider the situation for yourself.  And pass it on.  He gives you permission to do so.


To hospital administration,

I am writing this letter to inform you that when I take my mandated influenza vaccine I will be doing so under protest and with the understanding that failure to do so could result in loss of my ability to earn income for myself and my family.  Unfortunately, I do not qualify for any of the exemptions allowed by our facility.  Since I am not religious, I have no religious objections, I am not allergic, and I have never had Guillane-Barre as a result of a flu vaccine.  My objection to the vaccine is based on rational evidence and moral indignation.

From the standpoint of rational evidence, I was amused that Dr. Eric Kasowski (of the CDC’s influenza division) in his  position paper “Healthcare Workers Must Be Vaccinated Against Influenza” cited no research papers.  This is very unusual given that this is a document directed at health care professionals.  No papers were cited to support this statement because there are no such papers.  The gold standard for evidence-based decision making in health care comes from The Cochrane Collaboration.  This group of experts makes recommendations on all aspects of medicine and science based on a pooling of the best research studies and with a strict avoidance of all commercial or coercive interests.

In their paper titled “Vaccines to prevent influenza in healthy adults” the Cochrane group concluded “In average conditions 100 people need to be vaccinated to avoid one set of influenza symptoms. Vaccine use did not affect the number of people hospitalized or working days lost but caused one case of Guillane-Barre syndrome for every one million vaccinations.  Fifteen of the 36 trials were funded by vaccine companies and four had no funding declaration.  Our results may be an optimistic estimate because company-sponsored influenza vaccine trials tend to produce results favorable to their products and some of the evidence comes from trials carried out in ideal viral circulation and matching conditions and because the harms evidence base is limited.”  This is hardly compelling evidence.

In the Cochrane paper “Influenza vaccination for healthcare workers who work with the elderly” found “that vaccinating healthcare workers who look after the elderly in long-term care facilities did not show any effect on the specific outcomes of interest, namely laboratory-proven influenza, pneumonia or deaths from pneumonia.”  Thus, even in the most high-risk health care population and scenario, there is NO evidence that influenza vaccination protects patients.  In fact, vaccination may actually increase risk because the health care provider, feeling that they are protected by the vaccine, may be less likely to carry out the behaviors that do protect patients.  In their paper “Physical interventions to interrupt or reduce the spread of respiratory viruses” The Cochrane group reviewed 67 studies and found that simple measures such as hand washing, and simple masks were effective in reducing viral (including influenza) transmission.  Further , they “found no evidence that the more expensive, irritating and uncomfortable N95 respirators were superior to simple surgical masks”.   Thus there is NO evidence that not taking a vaccine poses any risks to patients and thus the requirements to wear an arm band (similar to a Star of David or Scarlet Letter) is exposed for what it really is…a way of shaming non-compliers.  In fact, evidence would suggest that it is the vaccinated that are less likely to carry out the behaviors that do work, and it is perhaps they who should wear the arm band.  Furthermore, individuals who are coerced to take a treatment are more likely to experience adverse reactions due to the nocebo effect, which is like a placebo effect but with negative effects.  Such nocebo reactions would likely result in more days lost than days lost due to influenza contracted because of a lack of vaccination.

I would now like to address my moral objections to this requirement.  Let me preface my statement by saying that if the organization had simply been honest and stated that they were requesting employees be vaccinated because less than 90% compliance would be met by a financial penalty from our government payers at a time when the hospital was already under financial stress, I would have been first in line to get my vaccine.  Every day I make personal sacrifices in order to support the financial interests of the hospital in which I work.  I continue to work in an ER that is severely understaffed relative to its workload.  Every shift I arrange for serial ER visits and rechecks of non-paying patients with pyelonephritis, PID, cellulitis, MRSA abscesses, pneumonia, etc rather than having them admitted where they would cost the hospital even greater lost revenues.  This is done at great personal expense (and medico-legal risk) to myself and my group.  I say this to demonstrate that I would do almost anything to help the hospital’s bottom line, and I believe that is true of almost anyone in the organization.  But rather than banking on this goodwill from the employees and staff, the institution chose to frame this as a patient care issue.  Worst of all, it portrayed the providers of healthcare as some sort of danger to the patients that the hospital cares for, as if we were potential vectors of disease should we not comply with this mandate; essentially painting as a threat those that provide care under a real threat of contagion, violence, stress, litigation, government fines and circadian disruption.  This was all done with overwhelming evidence to the contrary.

But even if it were true that healthcare workers were transmitting flu to patients and that vaccination could prevent this from happening, forcing a professional to do even that which is beneficial is profoundly immoral.  Values can only exist when there is freedom of choice.  As philosopher Harry Binswanger recently observed; “You cannot achieve anyone’s good by force, because values are objective.  Values only exist if they are judged by the acting party as beneficial to him.  No one can be forced to make a rational judgement.  The only effect of the force is the destruction of the alleged beneficiary (and everyone else).”  This was probably expressed best by the philosopher Ayn Rand who stated: “A value which one is forced to accept at the price of surrendering one’s mind, is not a value to anyone; the forcibly mindless can neither judge nor choose nor value.  An attempt to achieve the good by force is like an attempt to provide a man with a picture gallery at the price of cutting out his eyes.”  So even if there were a benefit to be had from flu vaccination, it would be wrong to force us to have it.  It is even worse when it is done with evidence to the contrary.

I will therefore submit for flu vaccination on or before November 1, 2012; but please be aware that I am doing so under compulsion and the threat of losing my means of earning a living.


Doug McGuff, MD, FACEP


Atlas endures…for now

This is my column in this month’s Emergency Medicine News.  In Medicine, Atlas endures.  For now…

Most modern American are familiar with the classic political novel, Atlas Shrugged.  Love or hate it, the novel had a great impact on political thinking in the West.  If you haven’t read it, or aren’t familiar, one of the fundamental questions author Ayn Rand asks is this:  what if the producers and innovators of society simply stopped trying?  What if they became tired of contributing and being abused, demonized and taxed for their efforts, and simply withdrew their contributions?

Atlas is straining in medicine as the weight of contemporary healthcare continues to fall upon  emergency departments and as increasing numbers of physicians in other fields either retire or escape from call duties.  I don’t necessarily say this by way of critique.  I understand the perspective of those who have, quite reasonably, made tactical withdrawals from the losing battle.

We face fewer available specialists.  Drug shortages are rampant.  Psychiatric beds are a rarity as state budgets plummet.  Committees and professional societies heap volumes and volumes of new rules on the practitioners of medicine, as if it weren’t difficult enough.  And yet, at the end of the day, the answer is typically:  go to the emergency room; they’ll sort it all out.  And we are full, overwhelmed, understaffed, underfunded and overextended.

So what if we took a cue from Atlas Shrugged?  What if, in one grand, unified effort, emergency physicians decided to stop doing their work, if only for a day?  Or what if we all found another permanent way to earn our incomes?  What if we said ‘no’ to further satisfaction surveys, endless psych holds, innumerable Medicare regulations and pointless JCAHO visits?  If we refused to be fined for not washing our hands every five seconds, if we said ’15 minutes to a doctor’ is ridiculous.  If we explained that blood cultures didn’t matter for most patients and that we were finished giving thrombolytics for stroke when we felt it was the wrong thing to do? What if rule-makers and fine-givers and policy-writers were stuck, for just one day, sorting through the madness that was born of unfunded mandates and unintended consequences?  What if we just said NO!

Well, like that game we all play called ‘what if I won the lottery.’  It’s all academic.  That is, an Atlas Shrugged moment would be a very unlikely event.   For one thing, we aren’t organized enough.  For another, we couldn’t replace our incomes (and therefore pay our debts and bills), that easily…or that quickly.  In addition, we generally dislike change and we have a wonderful, awful habit of following orders and doing ‘the right thing.’  It’s what got us into medicine.  But it’s also what will keep us there far beyond reasonable levels of endurance.

However, another reason emerges.  We feel a sense of duty, a sense of obligation, to the patients who come through our doors.  No matter how bizarre or difficult the work, we press on and do it.  At all hours of the day and night, we station ourselves between patients and death, between patients and disability (no matter how much some of them want it!) and between patients and suffering.

I realized the dedication of my partners and staff recently, as I watched a drunk ‘patron’ pick up his walking stick and pull it back to hit our security officer, even as a deputy politely said, ‘excuse me,’ pushed his way past everyone and fired a Taser into the stick-wielding gentleman.  He dropped fast and was hauled away to the law enforcement center in handcuffs.

I realized it a few months ago when an angry psychiatric patient, who had a ‘sitter’ while he awaited placement, picked up the sitter’s laptop and smashed it through the clear plastic window around the nurses’ station.

My stories are mild compared with some of yours.  You face violent gang members while I more often face obnoxious drunk Southerners.  Many of you face illegals with drug resistant Tb while I am scalpel wielding warrior facing MRSA abscesses by the bucket.  I sort through rattlesnake venom and Xanax overdoses while some of you face designer drugs of no known origin, composition or effect.

Of course, we do it all professionally.  We do it the best way we know how, with fewer and fewer resources.  We do it with falling reimbursement and increasing regulatory burdens.  We do it day and night, holidays and weekends.  It lacks the glamor and gloss of sexy doctors on television shows. It falls short of the moral clarity actors, and politicians, seem to bring to modern medicine.  It is murky and difficult, even on the best days.

Our ‘office’ is the place of chaos.  An administrator once told me, on a day of terrible crowding and dangerous volume, that he couldn’t move patients upstairs to the hallway.  His reason was this:  ‘Dr. Leap, when people leave the ER, they expect to go to a better place.’  I walked away, unable to speak.

Outside of law enforcement, EMS or the military, what work-places are like this?  And who would face such things with regularity even as their reimbursement was cut, their threat of lawsuit ever-present and their every move regulated and watched as if living on parole?

Atlas, at least in medicine, isn’t likely to shrug off his duty.  Oddly, we love what we do even as there are days we despise it.  But that’s a pretty frightening ‘what if.’  All of the senators and congressmen could walk out tomorrow and we’d experience little more than a sudden burst in economic activity.  Most of the attorneys could do the same and our litigation would remain gridlocked…like much of it is already.  But some things matter every day of the year.  Gas has to be refined and pumped.  Cars, buses and airplanes have to move people and material.  Electricity, along with water and food, has to be available.  And disease and injury need to be treated.  And even Atlas needs some relief; needs to make a living, needs to pay his bills.  For Atlas, at least in our profession, the ‘honor and glory’ of carrying everything is wearing off.  And yet, Atlas endures.

What am I trying to say today?  Well, it’s Thanksgivings this month, so here’s a reason for thanks.  America should be thankful that emergency departments are open, and that they are staffed around the clock by well educated, dedicated professionals who don’t shirk their duties.

And thankful that they so far haven’t shrugged off the enormous weight that daily rests upon their broad shoulders.  America should pray that they never do.

If Atlas shrugs off healthcare, it will be a dark day indeed.

Make college relevant, not a resort vacation (my column in the Greenville News)

A big thanks to Glenn Reynolds of Instapundit for the link!

This is my column in today’s Greenville News.  A topic I’m passionate about, in no small part thanks to hearing Glenn Reynolds, of, speak on it at Clemson University.  Visit his website:

Here’s a link to Glenn’s book:

Here’s the link to my column, with text to follow.|newswell|text|Opinion|s

My oldest son is now a high school senior.  Therefore, we have been looking at college options in South Carolina.  He is a born and bred South Carolinian who doesn’t really want to leave his home state.  He has a sense of family, and a sense of place.

I have made several observations while reading brochures, comparing prices and traveling to different locales in the search for the right school for him to attend . First, this is a beautiful state with some magnificent centers of learning.  I had no idea how many majors there are now, how many opportunities to study abroad, how many honors colleges and possible career paths!  When I was in school it was, you know, wheel making and Mammoth studies.  But I digress.

Whenever we have toured a center of learning (and I won’t name them specifically) my wife and I have heard great things about the way our son will mature, will be exposed to opportunities, will ‘develop as a human being.’  (Which I thought was kind of a given, being a human and all.)

We’ve been assured that kids who attend those schools make great progress, and become fully actualized, able to impact the world in a diverse, cutting edge, technologically savvy, multi-cultural, sustainable, tolerant and environmentally friendly manner that would be the envy of anyone in the world.

I had no idea that college was all of that!  You see, silly old person that I am, I thought that our colleges and universities were supposed to help students learn to think clearly, accumulate knowledge and enter useful graduate programs or find meaningful, gainful employment in the world.  I didn’t know it was all about ‘development.’

But since it is, let me tell you what I’ve developed.  I’ve developed a little bit of cynicism about the four-year university.  Why is that, with such magnificent institutions?   Well, a couple of things come to mind.  First, marketing.  My son is constantly introduced to images of lovely dorms and cable television embedded in every treadmill in the shiny gym. He is told about how the sushi bar is a great place to use some of his meal program money and how certain dorms allow opposite sex sleepovers during the week. He learns about the fun of the Greek system and the delights of the town.

And what his bitter, cynical, sometimes wise father knows is this:  college graduates currently have a 50-53% unemployment rate, and nationwide, the college drop-out rate is around 40%.  That student loan defaults are rising and retirees are having their Social Security checks docked for old student loans.  (Which cannot be erased in bankruptcy, by the way). What I know is that across the country, administrative burden is killing education (much as it is in medicine), that all too many fascinating majors lead to low-paying work in the food service industry and that the whole experience generally comes to around $20,000/year for a state run four-year university in SC.

What I have to ask our state educators is this:  have you read about the plight of students?  Are you concerned that many students can’t find work related to their degree, if they find work at all?  Are you at all troubled that without serious scholarships they may enter life with tremendous debt, or that their families will bear the debt?  (And that the ones going to graduate school or professional school will be hundreds of thousands of dollars in debt?)

I challenge the higher education officials of South Carolina to do what Texas did and develop a 4 year degree for $10,000.  I want them to encourage more college-bound students to use technical and community colleges for part (or all) of their educations. And I dare the educators of this state to be honest about the realistic job prospects associated with some of their fascinating, but fiscally shaky, programs of study.

I love South Carolina.  My son does too.  He wants to go to school here.  And so do many of his friends with less material blessings than my family.  But our state, indeed our nation, had better pay attention to the plight of its students. We need to stop marketing college as a four year resort vacation and start having compassion for the kids we send off in the tired old belief that college guarantees a good future.

Because it doesn’t anymore. And educators have to either admit the truth, or make college relevant, and affordable, once again.

Press on even when life brings pain and failure

So, here’s my column in today’s Greenville News.  It’s titled ‘Press on even when life brings pain and failure.’  That’s sort of the point, but more to the point, it’s about how there’s joy in risk, and a nation of citizens who cannot sense that is a nation in danger.  Read it for yourself, and see what you think.


PS  Column text follows link.

I recently treated two young men, both injured in the same football game.  On the way out, one passed the other in the hall, injuries treated and dressed. ‘See you next game!’ they said.  They laughed and looked forward to the struggle.

My wife and I have tried to raise our kids that way.  To enjoy life, to move through difficulty and injury. They suffer from having a physician father, so visits to the ER (for them and their cousins) often equate to visits to the dining room table or the pantry pharmacy for whatever over the counter drug will do the trick.  ‘You’ll be fine,’ is a commonly spoken phrase at Leap General, where mama and papa are the only staff available for consultation or second opinions.

We’ve seen bicycle wrecks (from my sons inexplicably ‘playing chicken with a tree’), scorpion stings and briar cuts from running through the woods in sandals.  We’ve had burnt fingers from working in our very hot coal-fired smithy and various episodes of cough, cold, fever, ear-ache and vomiting.  The kids have had wounds from arrows (covered wisely with foam balls on the tip). Bruises from heavy plastic training swords are not uncommon.

The lesson we hope to instill is simply this:  Get on with it.  Get back in the game of life. Get a bad test score?  Try harder.  Feel afraid to stand in front of people?  Give it a shot anyway.  Fall off the bike?  Get back on. (We don’t have horses.) Life is like that.

The thing is, life is a battle, whether you like that bellicose image or not.  In our brief sweep of years we will struggle with health, education and work.  We will struggle to protect our families,  practice our faith and ensure the future of the Republic.

Sometimes illness will win. Friendships may falter.  Education may not be enough.  Careers may wax and wane.  Our beliefs will be challenged.  Things won’t go our way.  Nations will fall.

To which we must say, ‘press on.’ We have to move past excuses and pain, past the fear of uncertainty or risk.  We have to step out and once again create a nation where failure and struggle are sources of motivation and inspiration, not excuses to surrender.

Much has been written about the age of exploration and colonization.  About the terrible things  done in the name of nation, wealth or progress.  Some are true.  But we would certainly be better if we could only recover that love of danger, discovery and uncertainty.  It was the thing that opened continents and took us to the moon.  It was the spirit that defeated tyrants, diseases, injustices and ignorance with the same passionate joy.

We have become timid and fearful.  We act as if failure must be rescued, that all risk must be mitigated by the herd, that greatness is the same as arrogance, or progress the same as regress.  We turn things upside down by blaming everyone else for our inadequacies and expecting legislators or executives or courts to sooth our hurt feelings by mandating equality of all outcomes, by stretching a net across the chasm of public life so that we can only fall so far…and only climb so high.

What am I saying?  A nation that foments and grows weakness and incapacity, that shields its populace from every risk, criticism, pain or uncomfortable truth is a nation that will not endure.  A nation that scoffs at success built on struggle and rewards bad decisions with bribes from the public coffers is a nation doomed.  And a nation of people for whom even the slightest discomfort requires anesthesia is a nation drifting off to an endless sleep of irrelevance.

Much has been written by wise men down the years about this, by men like Kipling and Edgar Guest.  But my favorite comes from Edgar Lee Masters, in his Spoon River Anthology, a series of poems in which the dead look back on life.  Lucinda Matlock, a pioneer woman, describes her joys and sorrows with no regret and condemns her descendents.  ‘Degenerate sons and daughters, life is too strong for you.  It takes life to love life.’

I couldn’t agree more.  Neither could the two boys I saw in the ER that night.  Because in the battle of life, win or lose, live or die, there is secret joy that only the ferocious can ever comprehend.

Customer satisfaction surveys have their limits

This is my column in last Sunday’s Greenville News, about the peril of customer satisfaction surveys.|newswell|text|Opinion|s&nclick_check=1

Customer satisfaction is quite the rage these days. Many stores and restaurants, many professional offices, hand out surveys, or ask customers to log onto their survey site on the Internet. As a reward, one may win everything from a free sandwich to an i-Pad.

I’d be interested to know how ‘customer satisfaction’ played out in my home. ‘Kids, now you’ve had a week of school-work. Please fill out the attached survey and give your mom and me an idea how we’re doing. Frankly, if you’re not satisfied, your mom is out as teacher!’

How about politics? That would be interesting, wouldn’t it? I know, we vote. But our current system makes it difficult to remove politicians by vote, and even if it’s possible (and between money and media, it can be a stretch), we’re still stuck with them for two to four years. A ‘citizen satisfaction survey’ would be a lot of fun. Unlike a poll, we could give it some real teeth. ‘Senator, it turns out your constituent surveys are really low. So, we’re cutting your salary by half until you bring it up by making people happier!’

Obviously, that technique has problems too, doesn’t it? Politicians can’t always please, or satisfy, everyone. And to do so would be perilous indeed. In the same way that we don’t drop ‘enemy satisfaction’ surveys along with smart bombs. ‘Did you feel that the destruction of your compound was done in a professional and timely manner? Would you be willing to be bombed by the same pilot again in the future?’

Customer satisfaction has also been around in medicine for a long while, and seems to gain traction every year. Hospitals, struggling for market share, love patient satisfaction surveys and scores. For better or worse, these things often determine funding, raises, even continuation of contracts in the healthcare world. And negative scores can cause significant reprimands. It has some merit here as well. Physicians, and nurses, can’t go around being incompetent, or unprofessional. It makes for a very bad experience. And when we’re sick, or our family members are suffering, that’s the last thing we want.

However, the science isn’t always so good. For one thing, the sample sizes from which the surveys are drawn are often very small. A friend of mine worked in a hospital where the data might be drawn from one survey for a given month. If you made that one patient mad, then it was going to be a tough time!

Next, as in so many settings, happy people tend not to fill out surveys. If you like a product, you tell your friends. You go back and get another. But if you’re upset? Out comes the pen, and the boxes are checked in frustration or anger.

But lately, some physicians have been asking ‘is this really a good idea?’ A study from the journal ‘Archives of Internal Medicine,’ published in February, suggested that physicians with very good scores may have patients who do poorly. It’s only one study, but more will likely follow. And it makes sense.

Patient has illness or injury, and desires specific test or drug. Physician feels drug or test aren’t indicated and does not provide them. Patient complains to administrator who pressures physician. Physician begins to do tests and give drugs (especially narcotics) that aren’t appropriate in order to comply with employer. I suspect this is one reason, though certainly not the only one, for the epidemic of narcotic abuse, addiction and narcotic-related deaths in America today.

I believe we should be attentive to ‘customer service.’ But we have to be careful. In settings in which a high degree of expertise is necessary to make decisions, or in which grave dangers underlie poor decisions, customer service has to be balanced against knowledge and experience.

And more relevant, we often hear citizens and watch-dog groups rail against corporate interests and inappropriate influences. If a business, particularly a hospital, asks professionals to do the wrong thing in order to secure payment from the ‘customer,’ it sure sounds like inappropriate influence to me. Likewise, the companies that push the surveys are, themselves, businesses with financial interests.

We all want to be ‘satisfied customers.’ But when satisfaction has the appearance of corruption, or results in danger, maybe a little dissatisfaction would be better, and safer, in the end.



Practice model and economic perspective…thoughts?

I am an emergency physician in private practice.  My partners and I are a corporation, and we contract ourselves to one facility.  As such, we are small business owners. 

In the current economic and politicical climate, my views on Obamacare and entitlement are rathe conservative.  The arrangement of my business is such that I pay my own salary, family insurance, malpractice, retirement etc. out of what I collect.  Vast numbers of physicians in America do the same thing.

On the other hand, many physicians feel otherwise.  They feel that entitlement is very appropriate, that we should not be upset at uncompensated care, that we shouldn’t worry so  much about money. 

As I’ve contemplated this divide, I’ve wondered:  why such a disparity in thought?

So I ask, and not with venom but genuine curiosity, do you fellow Sermoans think that it’s possible that those with  more politically progressive viewpoints simply tend to be employed in academia, or other settings more than the more conservative?

Many academic physicians may be paid salary, and may have all of their benefits paid out of the greater institution.  This  might lead such a physician to wonder why private physicians fuss so much over income and etitlement, over uncompensated care and mandates.

I’m not trying to say one group is more caring or less, even necessarily right or wrong.  But that our opinions may be at variance just because of personal practice settings and reimbursement methods.

Do you have any thoughts?