WE ARE WITHOUT SANCTUARY.


I am happy to be living in a country that affords me the opportunity to succeed. As a parent I am happy that my children will have more opportunities open to them than I did. My job is to guide them into success. As I look around America I am worried for my children in spite of all the opportunity that exists. The recent string of killings of men and women of color has helped to refocus my attention on the details. I, like many people of color in this great country have been lolled into a false sense of achievement. Worst is that we have allowed the wider society to accept the fallacy that racial justice as arrived. We have failed in teaching our children the important details.

As a parent of girls of color I have focused on making sure they are confident and well-educated, that is not enough. Over the last few months I have had to re-evaluate everything I have come to believe about equity in America. The history of people of color in this country is one of brutality and subjugation. There has not been enough change in our situation. In the last several month several studies have shown the depth and pervasiveness of our disenfranchisement. Our girls are 6 times more likely to be harshly punished in school compared to white girls. Americans of African heritage with master degrees are paid the same as whites with bachelors degrees and even doctors of African heritage are paid about 10 % less than similarly educated white doctors. Why is this so? I have come a conclusion, that question is not relevant. It is not relevant because those in power do not care to fix the problem. I have given up on the idea of equity in my country. The continued inequity makes me angry and concerns me for the future of my girls. I am angry but I will not be deceived into violence. Protesting does no good. Voting does almost as little.

So, in my quest to find a better answer I have looked around and think I have found the only viable route in the Jewish experience of World War 2. No one is allowed to forget the Jewish Holocaust and so too no one should be allowed to forget American Slavery and Jim Crow. The end of the Jewish Holocaust is celebrated but the brutality of it is what is referenced most often. This is what we all are reminded of daily. As people of color we need to teach our children about the brutality of the American enslavement of out ancestors and the continued brutality of Jim Crow America and the current discrimination. We need to have them understand that the current celebration of Martin Luther King Jr is fake and serves only to assuage the guilty. It is not a sign of contrition, it is hollow and designed to distract from the ever-present and pervasive discrimination against people of color. Our children need to know about the Martin Luther King Jr struggle before they can appreciated his success. They need to know and see the pictures of America brutality to their ancestors. They need to know the name Emmet Louis TIll along with Martin Luther King Jr. The goal is not anger, it is empowerment. Our children need to understand that things have changed and that we have many opportunities, but they also need to understand that they need to succeed in spite of the many race based road blocks. They need to succeed to honor their ancestors.

Violence is not the answer, it is only a way to continue to enslave us in the prison complex which is designed to strip us of the rights our ancestor died to attain. Our children need to understand the context of their lives in this land of opportunity. We need them to take the opportunities and make progress while making sure no one forgets the brutal treatment of our ancestors. We should honor our ancestors for their willingness to stand up for their rights and we should build on their success by taking the opportunities available and making the most of them. We know that we will not be treated fairly nor paid equitably because this is the current state of America. There is no real hope of progress beyond the eventual death of the merchants of death. As parents of children of color we need to prepare them to survive and thrive until that day of Martin Luther King Jr’s dream arrives. Don’t get violent, get angry and achieve.

NO VITAMINS PLEASE.


The encouragement to take a daily multivitamin continues to be strong. However, the accumulation of data suggests strongly that daily supplementation is not necessary. The reasons for fortification of specific foods with specific nutrients starting in the early twentieth century was deliberate and with good reason. The indications for Folic acid, VItamin D, Iron and Iodine were clear and scientifically proven interventions using prevention as treatment for neural tube defects, Ricketts, iron deficiency and goiter. For these diseases the scientific connection was clear and proven. Forward to today and vitamin and micronutrient fortification is touted as a panacea and treatment for all that ails. The evidence for the addition of most supplements is weak at best. Frankly, it is without merit and almost totally baseless.

The extrapolation that since we need small quantities larger quantities will be better is short-sighted and potentially dangerous. The evidence does not support that view. The industrial production and addition of vitamins to every conceivable food item is primarily a marketing tool. It is a waste of money for consumers. If we look at nature we can see a better paradigm to extrapolate from. The concentration of vitamins and micronutrients are small and very large quantities of whole foods would need to be consumed to approach the quantities in many of the marketed items. If there is not a proven deficiency there is no need to add to our foods. The proven need is for small quantities that is more than adequately supplied by a balanced diet. The evidence for benefit beyond that is none existent.

Although, the evidence for potential harm is small we must ask the question. Will super sizing the quantities we ingest be harmful in the long run? Like with the craze for copious quantities of bottled water we have been marketed a hook and we have bitten and are drowning in a sea of misrepresentation. Improve your diet. Make fruits and vegetables the base of all meals and stop wasting your money on bottles of urine coloring.

DO NOT GIVE THEM AN EXCUSE TO KILL YOU.


Once more our country is focused on the aftermath of the death of a young black man. The frequency with which this scenario occurs is alarming, disgraceful and is not likely to change in my life time. I am a 40-year-old physician without a criminal record. I have a brother who is a Veterinarian and another an Airline pilot. Neither has a criminal record, but we all have experienced the brutality of American racism. We do not often talk about it. We live it and pray that our children will have a better experience. We want them to get a good education and not be killed by the police. That is our American dream.

The truth of what happened in Ferguson is irreverent to us because we live the brutally of knowing that at any moment we could be killed for no reason. As black Americans we have come a far way, but the fundamental problem for us has changed very little. We are not seen as humans, we are seen as murderers waiting for an opportunity. We are determined to survive so we try standing up for ourselves. However, standing up for yourself as a black man is seen as threatening. Success for us is about surviving the constant attempt to institutional us. If that can be avoided material success is possible, but only if you are not convinced to give up before you have had a chance to try. Material success is about picking your battles.

As a Physician I see the contempt patients show towards me at times, I swallow and still provide them the best care possible. I love taking care of patients and that care is not about anything but my pride in doing the best job I can. Because I provide you with care supported by the best evidence I am comfortable. In spite of providing excellent care I am challenged but nurses and patients. I often wonder what I am doing wrong, but it does not matter. I am of the wrong completion, so my care is subject to review. I need to justify my decisions with evidence, while others provide poor care and are not challenged. This is my life as a black physician.

I am strong enough because I was brought up in a culture that expected me to succeed. My early years in Jamaica has given me a belief in myself that is difficult to shake. It has been shaken, but I have recovered. Unfortunately my girls are growing up in a society that does not expect them to succeed. I will push them hard because their mistakes, no matter how insignificant, will be judged and punished harshly. I need to build in them confidence that is based on competence because our country will not give them the chances they deserve. I will teach them about how not to get killed.

The sad story is that my girls and my nieces and nephews will be at risk from violence from all sides. There is more violence in black communities both from cops and criminals alike. There is nowhere to hide, there is only learning how to manage the risk. Our treatment as black Americans is dependent on the complexion of our company. While out with my brothers and nephews we are treated like predators and undesirables. The excuses for treating us like monsters are varied but none are credible. In spite of the despicable treatment I often experience, I will still treat you well. I will still give you the best health care, although I will not be given the same treatment.

Rioting will not help nor will talking. Sorry Martin, I no longer have a dream, just a reality, ” Do Not Give Them an Excuse To Kill You”.

Be safe America.

DOCTOR, TAKE A STAND.


The debate around health care in our fair country as heated up again. The strange thing about the process is that the majority of the people commenting already have great insurance. They can afford to pay for great health care. The ACA is flawed and all should admit it, but it is not the cause of the chronic underperformance of our system. We have a closed unresponsive system that is constrained by an ill-informed electorate.

We need to exposed the entire system, both strengths and flaws, to the public. Doctors need to be in charge of care decisions and also need to be cognizant of the economic realities. Patients need to have realistic expectations, which should be set by their doctors.

Doctors need to stop listening to the ill-informed lobbyists. Those lobbyists are not working on our behalf, they are working for other economic interests. Doctors need to stand up and start voting our economic interests because the lobbyist are voting for their own. The interests of the lobbyist only rarely intersect with our own.

Let us take a stand together. Let us take a stand firstly for our patients and secondly for our own self interests.

GIVE ME ONE HOSPITAL BILL PLEASE.


A funny thing happened on my way to pay a medical bill. I have paid the same medical bill twice and as such have decided to not pay any bill until I get the second notice. So a few day ago I decided to pay the latest bill in the hospital instead of mailing a check to the billing company out-of-state. After much effort I found the correct billing office and presented my bill. I them got what I thought at first was a pleasant surprise. The clerk told me that she did not see a balance owed in the system. She repeated “You do not owe anything on this account”. I was perplexed since the bill I had in hand clearly stated that I owed a significant outstanding balance. As I left the office I began to wonder how many times this situation occurs. What would have happened if I had mailed a check to the out-of-State billing company? How many bills have I paid that were in a similar situation?

This experience has allowed me to revisit an idea that I have expressed to others in the medical community before. I would like to see the morass of medical bills be corralled and only one bill be sent to the patient. Broadly this is how I see it working:
a. all bills are processed by each provider or facility within 20 days of discharge of services,
b. all bills are presented to central biller within 30 days of discharge of patient,
c. one bill presented to patient within 60 days of discharge,
d. all patients have 30 days from receipt of bill to arrange payment.

 

IT IS OUR MORAL DUTY.


The curious nature of the American electorate once again fascinates me. The ongoing discussion of health care coverage and delivery is schizophrenic at best. The most recent pools show a population in need of health care coverage but the same group most highly skeptical of the most recent attempt to improve their ability to access coverage. Furthermore those who are most in need, and treated the most poorly by the current system are still willing to hold onto the failed system. It is unfortunate but the same the tactics developed and used by the cigarette industry to convince us that cigarettes are safe are being used to undermine the ACA. Many are against the ACA without investigating the potential benefits.

The cable talking heads have succeeded beyond their wildest dreams. They have so muddled the facts that it seems no one has a grasp of the services that will be improved. The problem with that assumption is that it is far from being a fact. The data are there if we as consumers would only look beyond the imbeciles on cable T.V. The problem is that our attention is firmly planted on the imperfections and not the goals. We are not being true to the fundamentals of American cultural strength, the belief that we can do it if we want to. I can only suggest that the opponents do not want Americans to succeed. The success of American Corporates is not the same as the success of Americans.

The intellectual dishonesty of the talking heads and those in charge of the news media is disheartening. They have no regard for the uninsured. The consequence is that the people who need help the most have been convinced that there is no help to be had. The truth is not deceptive nor is it hidden. The ACA is good for Americans. The ACA aka Obama Care is good for American business and will be a success. Success will not be achieved overnight, but will be a long hard fight. The fight is against those who do not believe that government has any part to play in the delivery of services and those who do. The battle is against the deceitful. The battle is against the business lobby. The battle is primarily against the ignorance that parades in fine suits on 24 hour cable T.V.

Those of us objectively looking on need to not only look but need to shout down the liars and the dishonest. How do we inform those that need the information the most? I would suggest a grassroots election style campaign. We need to start by informing ourselves. Each of us needs to study the benefits and pitfalls of the law. Without in dept knowledge we cannot be effective advocates. Go advocate, it is our moral duty.

WE ARE ALL ADDICTS.


As a society we have and continue to be beset by many addictions. Some of these are more problematic than others. The essential question is what constitutes a tolerable addiction. I suggest that we have a highly immortal relationship with addicts and addiction in general. I further suggest that if we truly examine the definition of addiction we would quickly reconsider our methods. I hope you will at least consider a re-examination of our cultural stand.
The essential addiction of affluent societies is affluence itself and the indulgences that are attendant. The most problematic of which is our addiction to poor food choices. We all know what best food practice is but we have not organized our cultures to make those choices palatable or convenient.
The  road to affluence is paved by a brisk market of buyers and sellers that provides goods and services at optimal times, place and cost. The pressure to succeed in the marketplace can led to dubious choices, both from the point of view of the producer and consumer. Market pressure has not so far encouraged the easy and convenient availability of healthy choices. The problem here is that the market is about maximum profit, not healthy choices. Furthermore, the consumer does not know how to influence the availability of better options. This juxtaposition of circumstances has led to the situation we are in today.

We are indulgent to the death of us. We eat poorly and excessively. These choices are not accidental. We continue to consume excessively in spite of the consequences of obesity and poor health. This is the definition of addiction. I suggest that out most problematic addiction is to food. Let’s start addressing this addiction by closing our mouth and using our dollars more prudently.

OBAMACARE


There is a time and place for everything and I think it is time for us to all look in the mirror. Our government has impaled herself on her own sword. The truth is that there is only one person to blame. No, it is not the President nor is it members of congress. You and I are to blame. We are the idiots that believe the garbage spewing from the despicable talking heads on radio and TV.

The continued pretense that there is always two sides to a story belies the continued mass delusion we live under. There is not two sides to every story. The imbeciles that continue to repeat that lie are in my view the worst thing that has every happened to our country. This pretense is used to confuse and demoralize the masses. This pretense allows the well dressed liars to continue to manipulate the low information voter. We all need to stop buying what the snake oil man is selling.

The current big lie is that Obamacare or the Affordable Care Act is going to bankrupt the country. The system as we have known it was doing that already. The honest among us will acknowledge that health care inflation was already running rampant. Obamacare has nothing to do with it. The honest among us will admit that there was always a problem and that Obamacare is an attempt to solve it. The most insidious lie of this whole fiasco is the that Obamacare is proposing something new. It is not. If we were paying attention to the health care debate of the mid to late 90’s we would recognize that this is exactly what was recommended by the right-wing think tanks. But the liars among us continue to deny and obfuscate.

The level of dishonesty is mind-blowing and disgusting. The people we expect to know more continue to disappoint. The dishonest continue to lie to the low information voter and said voter continues to send dishonest representatives to Washington. The deeper problem with our country is that the majority of the population lacks the willingness to do what is necessary to be considered a ‘informed citizenry’. Help us all.

TIMELINESS


All of us have our quirks. The question is, can the people around you live with them. On most days I think the people around me can survive. Mine is my drive for efficiency. I once was told that the fastest way to get a task done is to do it the right way the first time. If you work with me you have heard that before and you know that my way is the only correct way. Thanks for the indulgence. What motivates me is accomplishing a task in as few steps as possible. In health care that can be a challenge.

In the world of rising cost and decreasing reimbursement the imperative in healthcare is keeping cost to a minimum. My take is that patient safety is the first goal followed closely by efficiency. Some may wonder about that combination but I posit that they are one and the same. If your question is how so, let me expand by looking at one of the most frequent complaints in healthcare. Timeliness. What is timeliness and do you respect it?

The most offensive ‌thing to me is inefficiency. Inefficient use of time is the highest form of disrespect. The fundamental question is do you respect others. As importantly, do you respect your reputation. You first have to show respect for yourself before you can respect others. Respect motivates and challenges. It creates internal expectations that demand attention. The expectation that you must be the best at each task demands attention to the details of the task. Attention to the small details of the task shows others your commitment to success and will reinforce your reputation for succeeding at your goals. We all want the successful and self motivated on our team. Respect for one’s reputation means always doing ones best, including being on time. Respect for time, I posit carries over into ones preparation for treating patients and will result in better care being delivered.

Unfortunately many in our society have come to equate the cost of their time to value. Value is not defined by cost equations, but by the totality of benefit provided to others. Your time is not more valuable than that of others. As a physician I try to respect my patient’s time. However that attribute is not universally acknowledged and  that  leads to delivery of less than optimal care. The lack of preparation for our patients is reflected in lack of respect for the time of patients and results in us going for the easy fixes instead of the optimal. The easy fix is destroying the reputation of the Medical Profession. “ObamaCare” and Government regulation is just the latest scapegoat for the total lack of respect that physicians have for time and timeliness and by extension our patients. This directly affects our reputations, but too many don’t see the connection. Patients have become a number not because of the business of medicine but because physicians have not shown enough respect for our patient’s time. Too many physicians see patients as a captive audience. Even if our patients do not have many options we should still treat them with the respect they deserve. All of natures children deserve respect and humans no less than our cats or dogs. If we do not reverse this trend, one day we will wake up and find that we are not the only ones taking care of patients. Truth be told that reality is already here. Welcome to the evolving world order.

I AM IMPATIENT AND STUBBORN.


I am impatient and stubborn and I am working on it. Well, not really. I like being stubborn more that I like being impatient. In spite of that, I like being both. Both traits may seem to be negatives, but they are only negative if the full breath of human endeavor is not evaluated. My primary impatience is with how little respect many of us have for other people’s time. I hate waiting so I stopped using bank tellers in the late 90’s. Internet banking then was slow but still better than standing in a line.
I always opt to do it myself. It has to be done right the first time so no time is lost. I am not a master of all. I know when to call for help.
The people who work closely with me know I have an opinion on most topics and that I am sure that my way is correct. Truth is I am not always correct, but I am willing to do the work to ensure I am correct. I am accepting the stubbornness label because I have been labeled as such. I don’t really think that I am stubborn. I just know that I am right and I will defend my stance even if I am the only person that holds that position. I have done the work, have you. That’s my view, take it or leave.
One of the weaknesses of these two traits is that I don’t delegate well. I chose to become an Anesthesiologist so I would not have to delegate. I am a doer. The general direction of medicine makes delegation a larger and larger part of the practice. I am not sure what are the benefits, except for potential financial rewards. I would love to think it provides improved quality of care. However, that is questionable. Superior quality of care is provided by better trained providers. I am going to keep on being impatient and stubborn because it’s the only way to deliver a high level of care. Do you have a different answer?