GP Versus Specialist

In the recent discussion about reforming health care much has been discussed about the lack of primary care physicians and the plethora of specialists. It seems that the specialist is being demonized as the source of waste and overspending in medicine while the GP is praised as the saviour. I would like to dispel this myth by describing two recent cases.

The first case is that of a 54 year old male who came to see me complaining of a sore throat. He had been to his primary doctor several times over the previous 4 months complaining of a sore throat and was given an antibiotic each time. This time he decided to see a specialist. His examination revealed a large advanced malignant tumor in his throat.

The second case is a 33 year old female who came to see me for a wax buildup in her ears. I asked her if she had seen her primary care physician to deal with this problem. She answered that her doctor told her he doesn't clean out people's ears and anyway she preferred to see the specialist.

These cases demonstrate the critical and indispensable role of the specialist in today's health care and three forces that ensure this trend continues. The first is simply patient preference. A significant portion of the population want to see a specialist who has greater expertise in a specific disease or region of the body than a GP. The public believes they will receive better and more up to date care from a specialist who deals specifically with their problem. The woman preferred to see me to clean her ears because this is a regular part of my practice and the assumption is that leads to greater skill.

The second force is that in this era of major advancement in medicine the GP is unable to be fully knowledgeable in all disciplines of medicine. He or she will have a cursory knowledge in many subjects areas but cannot attain the depth of knowledge a specialist would have who just deals with one specific area. Therefore, the GP refers his/her patients to the specialist because they are unable to deal satisfactorily with all their patients complaints and ailments.

Thirdly, the GP refers his/her patients to the specialist because they do not want to take the risk of missing a diagnosis as was done in the gentleman I described. They are covering their behinds because they know if they miss a diagnosis they will be sued for a delay in diagnosis.

So what should be the role of the GP? He/she should coordinate the care for the patients by referring them to the appropriate specialist and then oversee and integrate the recommendations of the varied specialists. The other main role of the GP is to be the disease preventer. Instead of being called a GP he should be the DP (disease preventer). All preventive care (obesity, cigarette cessation, immunizations, etc.) and screenings (mammograms, blood pressure, blood test screening, etc.) should be the responsibility of the DP. The role of the specialist is to treat disease as they have greater expertise in the treatment of ailments effecting their specialty than the DP. And this is often preferred by the patient.

So specialty care often translates into better care and this is likely to continue as the patients and the primary care doctor demand it. Yes it is more expensive care but higher quality often comes at a cost. It is similar to the situation where a transmission breaks. Who would be the preferred person to repair it. A general repair shop or a shop that exclusively fixes transmissions. Or a situation where a pipe bursts. Do you call a general handyman or a plumber. The plumber may be more expensive but the outcome is likely more reliable.

Instead of demonizing the specialists they should be recognized as a product of the incredible complexity of modern medicine. They serve a critical role in delivering state of the art care. Both the primary care and specialist need to work together, in their appropriate roles, for the benefit of their patients. The patient must be seen as a series of complex parts (treated by the appropriate specialists) and also as a whole unit (managed by the DP). Specialty care without the oversight of the DP or primary care without the expertise of specialists is substandard care.

Self Definition

So my mother has been reading this blog and I recently asked her what she thought. She answered, somewhat critically, that she was hoping I would write something more from the heart. To which my wife responded that I have no heart. She was kidding. I think. Well, I thought I would try to write about something less dry than politics.

I was watching 60 minutes last week and there was a segment about the repercussions of the Madoff scandal. They interviewed an elderly man who supposedly lost his entire fortune, which was reported to be in the seven figures. Surprisingly, he didn't appear despondent. His main disappointment wasn't about the money he had lost but the money which friends and relatives had lost who invested with Madoff based on his recommendation. The impact of the potential loss of his relationships with others were more important than his own actual financial loss.

Naturally, it made me think how I would feel if I were to lose everything and then started pondering what defines a person. Or better yet how do we define ourselves. Do we define ourselves based on how others define us or how we think others are defining us. Is a person defined by his/her wealth, by the car they drive or by the house they live in. Do we define ourselves based on the clothes we wear or other external manifestations of materialism.

Or do we define ourselves based on our relationships with others. How we relate to our spouses and children. How we relate to our friends and coworkers. Some defined themselves by their relationship with god. Does one define themselves by the amount of money they have or by how good they are as a son/daughter or mother/father. I suspect that most of us get caught up in the rat race and the pursuit of more and more stuff but the truth is that like the old man it is the relationships we build that has a greater impact on us than the stuff we accumulate. And at the end of the day if we were to all lose our stuff it wouldn't matter nearly as much as losing the relationships we build with others. For some reason it is difficult to live our lives with this knowledge as we concern ourselves with accumulating more and more.

All of us are imperfect and have flaws but we should always try to find the positive attributes of those around us and acknowledge their impact on our lives. It is especially appropriate on this father's day weekend to appreciate the sacrifices our parents have made for us. This day gives us an opportunity to give gratitude to our fathers and we should all tell our fathers thank you.
So Dad thanks a lot for all you have done for me and I hope my kids appreciate what I do for them. Okay Mom?

Upside Down World

I once asked a friend of mine who is Korean how many Jews he thought existed in this world. I prefaced my question by telling him there were 1.3 billion Chinese and 1.2 billion Muslims. I don't remember the exact number he guessed but it was much higher than the actual number which is approximately 12 million. He was astonished by that fact, and I am astonished by the impact this minuscule percentage of mankind has had, is having, and likely will have on human events. If you look at where Judaism ranks in terms of population, it is behind Juche (19 million), Spiritism (15 million), and Sikhism (23 million). When was the last time you saw these religions and there adherents referenced in the media?
The disproportionate impact of the Jews is demonstrated by the countless contributions made in so many areas. Not the least of which is the basis of all monotheistic religions ie. the belief in a single god. There is a hardly a field in the arts, sciences or any other human endeavor that hasn't been advanced by contributions from Jews. They have improved the lives of so many Jews and non-Jews alike, but this advancement has come at a great cost. It has engendered tremendous hatred and suffering towards the Jews throughout history and continues today. The world is truly upside down when you contrast the positive contributions of the Jews to the entire world versus the suffering inflicted upon them and the hatred and blame directed at them by the same world.
Just look at three examples that are occurring currently, the holocaust museum shooting, the Wright statements, and the Iranian situation. The shooter was an old man who probably never even met a Jew who blamed his shortcomings and the country's ills on the Jews. Wright blames the Jews/Zionists for controlling what the president does and who he talks to. Ahmadinejad consistently blames the Jews and Israel and would like nothing more than their destruction. The common theme that underlies all three is that the Jews are responsible for all the ills of society. It is the age old scapegoating against the Jews, when things go bad blame the Jews.
It seems that this is as bad as it has been in a long while. Any positive feeling that the Jews had garnered from the holocaust, which was actually just pity for what they experienced, has ended. It is now back in fashion to openly express one's hatred towards the Jews. The hatred was never gone, it just became politically incorrect, but now that veil has been lifted and the truth revealed. That this tiny percentage of the world population, the Jews, is the recipient of so much hatred amongst so many people and disparate cultures ( Middle America, Black Americans, Muslims) is a stain on humanity.
What have these 12 million people (0.2% of the world population) done to generate such hatred? Discovered medical treatments to prolong and enhance people's lives? Won more than 130 nobel prizes (out of approx 720 awarded)? Advocated for the persecuted, the poor, and the discriminated? All they want is to live peacefully, to practice their religion, to contribute to society, and to live in their ancestral homeland. It is precisely their disproportionately positive impact that has created such jealousy amongst the nations. For only a truly chosen people could accomplish what they have accomplished and this is too much for some non-Jews to bear.
We really live in an upside down world and we should all fear how it is trending.

Rich Kid Poor Kid

Regarding the Sotomayor nomination, a lot is being made of her story being compelling. I suppose this is the typical rags to riches story and how we are supposed to be so impressed by her ability to have achieved from such humble beginnings to where she is today, a nominee to the supreme court. Yes, this is impressive, but is it any more impressive than someone who came from a more privileged upbringing. I believe that in some ways it is equally or more difficult for the child who has it all to grow up to be successful.

When I was a surgical resident I had the opportunity to be involved in the selection process for applicants in my field. The chairman of the department was very impressed by an applicant who had come from humble beginnings and was given an edge over other equally or more qualified applicants. Although this is anecdotal, I believe that if you come from an advantaged background you are penalized at best or at worst discriminated against. Hard to believe I am proposing bias against the children of the wealthy but I believe the thinking is that since you're parents are rich you don't really need the position. Thus the position is given to the one who supposedly scraped and struggled to get to the same level.

The truth is the poor kid may have received significant advantages along the way to have reached the same level as the rich kid. Affirmative action by definition helps a certain group but this is always at the expense of another group. As fair and noble as it may seem to help a disadvantaged child/person it must always be remembered that it comes at the cost of discriminating against the person who has equal or better credentials but the wrong parents. Yes it is true that the wealthy have connections/money that can and do open doors but this is only reserved for the super wealthy. Most moderately wealthy people do not have this advantage.

The poor child who strives for a better life knows the difficulty and hardship of living with limited means . He/She has a hunger to achieve to attain a better life and rid themselves of that poor lifestyle. The rich kid, on the other hand, has been given everything his entire life and lacks the fire in his stomach. The drive is greater for the poor child.

Similarly, the expectations are lower for the poor child and failing in his/her achievement will result in no change in their standard of living. The pressure on them is low. For the rich kid the pressure is much greater to achieve just to maintain the same living standard. The poor kid hasn't much to lose but the rich kid has alot more pressure on him just to stay even with his parents. Thus the rich kid starts out with less drive and more pressure while the poor kid has a strong driving force with little pressure. In other words, the poor kid has nothing to lose as compared to the rich kid who has much to lose.

Ultimately, a persons upbringing should have no effect on whether he/she is selected for a certain position or job. It is not in one's control to effect this genetic fact. Similarly, selecting someone on the basis of his/her race, sex, religion, age etc. is not fair as it is based on factors that a person cannot control. Proponents of selection based on genes or upbringing will say it provides diversity which is advantageous, but lets be honest about what it really is. It is by definition discriminating against someone or a group that does not possess the correct physical appearance or background.

Somewhere out there is an equally qualified or more qualified white middle aged male judge that was passed over for this nomination because he was neither a Hispanic nor a female. The supreme court has filled its quota for middle aged white men. He was discriminated against due to his genetic makeup and his qualifications were secondary. The country ultimately suffers when it is not the most qualified person who gets the job but the individual who wins the genetic jackpot.

Obama Regrets

A few months into the Obama/Pelosi reign there are two demographic groups that should have significant regrets about their votes. The first group is the 18-30 year old voters. Obama won the under 30 vote by 34 points. The young voters that I spoke to during the campaign were completely enamored by Barrack and were totally brainwashed by the media that Bush was a failed president. The vast majority had no clue about his policies and fewer about how his policies would negatively effect their futures.
It is clear that with Obama/Pelosi administration spending is reaching a level never before seen. Trillions of dollars are being spent and commitments being made. This is even before including health care reform which is guaranteed to be a major source of spending. The money to pay for this spending spree can only come from two sources, either raising taxes or borrowing the funds. By borrowing , bonds are being sold predominantly to the Chinese which will have to be paid back over decades. By spending now what will need to be paid for by future generations is basically robbing from our children and grandchildren. The 18-30 crowd will be paying off Obama's debts for almost their entire working career. I wonder if they knew or now know that Obama/Pelosi are spending their future earnings.
Otherwise, taxes can be raised to pay for this historic spending spree. Obama has already indicated his intention to raise taxes on those making over 200k. He says he will only raise taxes to the level they were during the Clinton years but to pay for this degree of spending, taxes will have to be raised substantially more. This degree of confiscatory taxation will significantly inhibit people from trying to exceed 200k of income. Why would someone take unnecessary risks, endure long periods of training, or work extra hard if the government will penalize you by excessive taxation over 200k of income. Young people will be facing a future where their upside is limited. They will be essentially capped at a certain level and any dream to reach above that level will be deemed not to be worth the effort. A very sad prognostication for our youth and for the future of this country. But regretfully, this is what they voted for.
The other demographic group that should be or will be regretting their support of Obama is the Jews. It is astonishing to me that after the Bush administration was such an unwavering backer of Israel, that the Jews overwhelmingly backed Obama. 78% went to Obama versus 21% for Mccain. This is not understandable to me. Why will my coreligionists, the Jews, not support the republicans who have demonstrated such tremendous loyalty. Instead they support the dems who fail to use the words Islamic terrorism. The leftists dems are filled with the blame Israel first crowd. They believe Israel is the obstacle and the Pals just want their independence and are willing to live in peace and harmony. Truly enigmatic.
As time passes, it seems clearer that Obama is going to try to pressure Israel into unilateral concessions. He views Israel as the obstacle to peace and makes no demands on the Pals. He demands a halt to all Jewish construction in the West bank, including natural growth, in the naive opinion that this is what is preventing peace. Obama and Netanyahu do not share the same vision of the middle east and this will continue to fray the relationship between the U.S. and Israel. Regretfully, support of Israel will diminish.
Hopefully, these two demographic groups realize they made some serious mistakes. Hopefully, they will try to correct these mistakes in the midterm elections. Hopefully, these corrections will happen before its too late.

Hooray for California!

They say that California is ungovernable. The blame is falsely placed on the people due to the referenda which the people voted down as they did this past week when they voted no on five measures. The truth is that there hasn't been a government in place which can effectively govern the state and govern in a way that the people want. It is a problem of the government, not of the people. They just don't get it.
Sitting here across the country, I see two main issues which would frustrate me to no end if I lived in California. I see the identical issues here in New Jersey. The people want the budgetary issue solved with smaller government, not tax increases. We are enraged that as private sector jobs are being eliminated due to the economy, the public sector only shows signs of expanding. As we apply for unemployment benefits, you with your government job and your gold plated benefits package are immune to downsizing. What makes this most unfair is we in the private sector are paying for your salary and package. You work for us but you have better job security, salary, and benefits than we do. We the tax payer want this to end.
The people know what we want. We just need the right person to campaign on this platform and implement it . Politicians are desperately needed that will stand up to the unions that twist their arms and renegotiate these ridiculous contracts (that includes the teachers union). We need to be able to vote on a referendum that would correct this imbalance between the public and private sector. And by the way, don't try and scare us that this will reduce services. Get by with less like we are forced to.
The second issue that is infuriating is the illegal immigration issue. California is being buried underneath the weight of the services being given to illegals. Health care, education, costs of incarceration are too much for any state to endure. It is bankrupting the state and needs to change. I strongly believe in the benefits of legal immigration and the its contribution to our economy but California's share of illegal immigration is contributing to its current crisis.
So kudos to the California voter for rejecting these recent referenda and not settling for bad policy. Keep the politicians feet to the fire until they deliver what is needed. California is not ungovernable, it just requires the right government to make the right choices and the people will line up behind it.

Pelosi and/is Torture

First Nancy Pelosi never knew about waterboarding. Then she admitted she was briefed but that it wasn't used and then it came out that she was briefed about the use of the technique that had already been used. It sounds like a Jackie Mason routine. If it weren't so sad it would be comical. As she digs a deeper and deeper hole for herself hopefully the sides will start caving in.
Her behavior and comments are all too typical of modern day politicians. They try to finesse their language in a way that doesn't commit them to a specific viewpoint. Just in case they want to backtrack in the future they have an out. We never know what they truly believe in as they change their opinion based on the current prevailing winds and polls. Pelosi should have said that in 2002 the situation was such that those techniques were appropriate and now in retrospect it was either a good or bad decision. Stick with what you believe in and tell us the truth. If you made a mistake own up to it. Don't treat us like idiots.
In any event, the decision of whether waterboarding is torture is essentially someones opinion. There is no black and white concerning what constitutes torture. Some may feel that yelling loudly at a prisoner is torture. On the other hand, some may feel that the end justifies the means. That is, if life saving information is obtained, that would justify any method to obtain it. So to ask a judge or lawyer or politician whether enhanced interrogation techniques was legal or illegal makes no sense because it depends who is asked. It could be legal during Bush's administration (his legal opinions supported the use of those techniques) and then when a new administration takes over could be deemed illegal.
To look to prosecute individuals based on a new legal opinion is ridiculous. This is a gray area of law that is best left to the discretion of the commander in chief not to a group of politically appointed lawyers. The president has the responsibility to keep the country safe and should not be second guessed by these Monday morning quarterbacks with law degrees.
As much as I despise Nancy Pelosi, I must say she was right in not objecting to the use of these techniques in 2002. This was the right decision at the time and likely saved many American lives. She should be seeking accolades for her decision and not be trying to weasel her way out of it. By trying to rewrite history she demonstrates that she has no ability to stand up for her decisions, no core beliefs, and will change her position based on the prevailing polls. We should demand more from our elected officials.