Monday, December 28, 2015

Learning From Your Patients

Some of my best learning moments as a clinician came when a patient left me.  They liked me enough, and respected my trying to meet their needs, to let me know personally why they were leaving me.  Early on, one patient listed my faults (which were many!), including not washing my hands before I examined their child.  Another one, later on, told me I was ineffective in dealing with her troublesome child, and had me read "The Difficult Child" by Henry Turecki, which is a great book that I have recommended to all my patients ever since.  It was painful, but I learned.
And then there was the patient I had with repeated bouts of acute abdominal pain.  I had them come into the office, against their will since they thought I should be able to do it over the phone for free.  I looked at the kid, I thought about it, I walked around the room, and I said, "Does he chew sugarless gum?" 

"Why, yes, he does!" they said. 

"It could be the sorbitol," I said. 

They cut out the sugarless gum and no more stomach aches!  One of my best diagnoses.  I had been studiously reading my newsletters in pediatrics, and it paid off.
The next thing I heard from them was a notice requesting that their records be transferred to a doctor nearer their house.  So I called them up to ask why they were transferring.  They said something about the distance.
I said, "What about that diagnosis that cured the abdominal pain?"
They said, "We expect that!"
What a world.  
Budd Shenkin

Tuesday, December 15, 2015

Ta-Nehisi Coates: Between The World And Me

I just read another book I wouldn't have read except for my book club, Norm's Bookies, having assigned it. In a close vote we chose the widely acclaimed Between the World and Me, by Ta-Nehisi Coates.

The last two years have been filled with evidence of the pervasiveness of police terrorism towards African-Americans. It's incontrovertible – Baltimore, Staten Island, Ferguson, Cleveland, Chicago. All together, the picture is of police terrorism toward African-Americans.

What we have seen in these killings is the outside view. What Coates presents us with is the inside view, what terror lurks in the heart of the oppressed. He, and other African-Americans, need constantly to be on the alert, not at the wrong place at the wrong time, not pissing off the wrong cop, staying under the radar. His friend from Howard, Prince, didn't do that. He wasn't offensive, but he probably was obvious and true to his name, princely. An off-duty Maryland cop stalked him into Virginia and killed him and got away with it. That's not an aberrance, that's the standard, there are many like him, this was just the case closest to Ta-Nehisi.

Stay alert, keep your head down, know where you are. That's really no way to live. He looks at the carefree suburbanites and is irritated. Why do they get to live like that, when Ta-Nehisi has to keep his head down? He's right.

He is on less solid ground, I think, when he talks about his body and relates it to history. It's not just in his mind, they can actually kill him, get to his physical self. In slavery, bodies were captured and ruled. Well, yes, it isn't just mind control, that's true. But that is just history, and it isn't just African-Americans, it's everyone in the world. People didn't just assemble and reason together, after all. Gangs got together, ruled the unorganized and fought the other gangs until finally one gang ruled everything. That's the way states began. The treaties came later, within countries and among countries. The Magna Carta was a treaty between the royal gang and the aristocrat gang. In political theory, the sine qua non for a government that works is having a monopoly on violence.

So, yes, it was a brutal world for slaves and a brutal world still for many. But at least now we have regular ways of negotiating differences, and overall, law is a wonderful thing. Perverted in the case of cops and African-Americans, yes, but better than it was, and it will be better still. Not to say that African-Americans need to be patient. Patience is frequently not a virtue, and this is one such place.

But objectivity isn't the strength of the book; the heart of it is Ta-Nehisi's subjectivity. What he remembers so vividly is that his father had a belt up on the mantlepiece, and he lived in fear of that belt. His father used it frequently, saying “better me than the police.” He made sure by stark physical means that his son would not die at the hands of the police by not showing respect, by mouthing off, by not being aware. Ta-Nehisi accepts the explanation of the father he reveres. He gets beaten for his own good.

I hear this with the ears of a pediatrician. And what I hear is, child abuse. When I hear the alert and watchful adult story, I hear in addition to the reality of police abuse, a certain amount of PTSD from child abuse. Maybe it is functional PTSD; maybe it keeps him out of trouble. But it seems all too reminiscent of scars of child abuse.

I am reminded of the sad case of Adrian Peterson, suspended for a year from the NFL for beating his little son. Charles Barkley objected to the league's view, saying they “They don't understand the South.” Maybe it is necessary; maybe it is. It doesn't sound like it's identifying with the oppressor, man kicks boy and boy kicks dog. It might be one way of dealing with police terrorism. But in any case, it leaves a scar.

It is not just a rhetorical device, then, that the book is written as a letter to his son. We serious people take our parenting seriously. We look at our parents, and we look at ourselves as children. We think, how can I do what I need to do with this most important job of my life?

Our parenting has three major influences. Our default is to replicate our own experience; we can't help but do a lot of that. Our major conditioner is our own personalities. We can only do so much, based on who we are. But then the third influence is what we choose to concentrate on, the things that we want to change. We might have to think about it constantly, because it doesn't come automatically. We might make lots of mistakes, and suspect ourselves of not doing it well enough, or constantly enough. But there are things we think we had better do for the good of the child, things we need to correct in our own upbringing, things in which the clay has hardened in ourselves but not yet in our children.

What Ta-Nehisi has decided to do differently is not to beat his son. And he's trying to tell him, look, I'm not beating you, but you still have to be careful, you hear? They are still out there waiting for you. You hear? I don't want you winding up on a slab like Prince, that magnificent presence at Howard. You can excel, I want you to excel, but you be careful. You hear? You hear?

And now in publishing this book, the rest of America – you hear?

Budd Shenkin

Friday, December 11, 2015

Is It Politically Correct To Be Smart?

I had lunch today with a good friend who takes pride in not being politically correct. I always enjoy it.

He told me about a discussion he had with a younger colleague at the University. My friend Bruce was discussing an issue that had come up on constructing a website for a Departmental project. I think it was on a governmental contract. The problem was this: the staff had constructed the website directory and placed the files in a way that a visitor would have trouble finding what he or she wanted. They had divided up the files according to how they had divided them among themselves as they created them, but that didn't accord with the logic of a visitor. No matter the titles they made up for the sections, It's as though one folder could be called “Mindy's files,” another one “Janet's files,” etc. The path to relevant files was impenetrable.

Bruce said to his friend, “The staff just isn't smart enough to do that job. You need the professors to do it.”

His friend replied, “The staff just doesn't have enough experience in the field.”

No,” said Bruce, “they're just not smart enough. Don't be politically correct. They're staff, not professors.”

His friend couldn't bring himself to agree. For him, it had to be a question of experience. Apparently, under the current rules of political correctness, calling one group “smarter” than another is a no-no.

Well, I could agree with Bruce! Love to be politically incorrect, of course, love being a shit-kicker, but also, like to call a spade a spade.

I told Bruce about my experience when I was a two-year doc in the US Public Health Service in the later 60's. Each year a bunch of us came in as commissioned USPHS officers, Lieutenant Commanders we were, for two years not spent in Vietnam. We did bureaucratic staff work, we worked hard, and in my case it was a high point of my life. We worked side by side with the bureaucracy. We weren't seeing patients, we weren't wearing uniforms, we were doing paper work mostly, looking at the medical stuff that came through Health, Education, and Welfare. It was an eyeopener that gave me knowledge of the ordinary that I have used the rest of my life.

In my experience, the top governmental administrators are pretty smart. They have hard jobs. Imagine trying to get meaningful work out of thousands of employees who are GS-9s or 10s or 12s, who chose government work; that's who you have.

So what would sometimes happen is that a problem would come up that the staff couldn't solve. It would be technical, perhaps, it would be involved, but it wasn't at the level that the administrator him or herself could work on personally. But it had to be solved.

So here is what the savvy administrators would do. They would say, “Get a two-year officer on it!”

But this isn't medical,” the staff would say. “A two-year guy won't know anything about it!”

Doesn't matter,” the administrator would reply. “They'll figure it out.”

And they would. It was a selection issue. Doctors are smart. Some are jerks, some are smug, some are whatever people generally are. But they are smart. They had passed the tests. And they would inevitably solve the problems that the career staff couldn't solve. Because they were smart.

And so are professors. Sure, it's nice to say we're all equal. Just doesn't happen to be true. You could explain to the staff what kind of organization you wanted in the website, you could give examples maybe, but at the end, the professors might as well do it themselves. Incredibly enough, some people are just smarter than some others.

Hope that doesn't constitute a micro-aggression.

Budd Shenkin

Thursday, December 10, 2015

The Obamacare 2014 California Report Card

A couple of years ago I made a bet with my friend Herschel Lessin, a skeptical Republican pediatrician of Poughkeepsie, NY, a graduate of Stanford Medical School and Yale pediatrics residency, and no dummy. Obamacare (otherwise known as the ACA) was just starting, and Herschel believed that the health plans would fail, and that insurance rates would rise significantly the second year.

I didn't think so. I thought that insurance companies would be cautious, since their main lines of business would continue to be non-Obamacare policies, and that they would probably make their rates on the higher side to be safer and not lose money out of the gate, figuring they could gain market share later on when the risks were more knowable.

Herschel won. I don't remember if I have yet ponied up the ten bucks, but still, he won. Rates rose the second year. I supposed that companies had gone for market share after all.

But an article in today's LA Times makes me wonder if the actual culprit for rising rates lies elsewhere. Even though Herschel won (and I will pay up!), I think his win might be tainted.

It turns out that three of California's big four health insurance companies made significant amounts of money last year selling individual policies on the ACA California marketplace. Blue Shield was number one in the country, Kaiser number two, and Blue Cross number seven. So there must be something special about California.

It turns out there is. California mandated that the insurance companies terminate their existing individual policies. According to the article:

Amid a national uproar, Covered California defied the Obama administration and required participating insurers to cancel existing individual policies at the end of 2013.
That move created a healthier, more diverse mix of old and new policyholders at the start of the exchange. About 35 other states allowed consumers to stay longer on health plans that didn't comply fully with the new law.
That decision left many states with a smaller and sicker population signing up for Obamacare. Many new enrollees had been denied coverage previously because of pre-existing conditions.
So that's the story. The problem with the other states is that they didn't really adopt the full ACA as a program; they waffled. As a result it looks like the ACA is a failure, with all those companies losing money, and half the Coop plans going out of business. But in fact, their decisions to let people keep their old policies made the ACA plans victims of adverse selection.

But that's not all there is to the story. In the area of health insurance, it's bound to be complicated. Remember, the biggest wager of the ACA was that insurance companies would reform their sharp practices and compete on quality and price rather than aggressive underwriting and policy denials, that old dogs would find new tricks. Did California health insurance companies learn new tricks?

Well, it seems not. Blue Shield – a chronic offender of sharp practices, according to those of us in the field – benefited by the fact that

consumers had difficulty finding a doctor or getting care during 2014. That could have reduced medical claims, boosting the bottom line for companies.

In fact,

Michael Johnson, a former Blue Shield official and now a company critic, said the San Francisco insurer should issue more refunds to customers. "Blue Shield made this huge profit because they hindered access to care."

And in addition, both BS and BC had inaccurate provider directories, which means that when patients went to sign up and they checked to see if their doctors were in the plan they were signing up for, and they saw that they were indeed on the plan, that information was frequently inaccurate, and after they signed up, they had to switch doctors.

And why were the doctors not on the plan? That's because of the infamous “narrow networks.”

The insurance companies would have us believe that the new plan selected superior clinicians who were most economical in the use of resources, the best and smartest doctors. In fact, however, what happened on the ground was, they circulated a rate schedule to the doctors and said to them, will you take these horrible rates for our new plan? Those that said yes were then christened by the insurance companies as the best of the best.

And meanwhile, let's add one more observation about the insurance companies. There was a ballot initiative last year in California to allow the state Insurance Commissioner to negotiate rates with health insurance companies, as most other states allow their IC to do. It lost with huge insurance company (and organized medicine) advertising campaigns against it. But part of the success of the California ACA state plan is that

Unlike most other states, California negotiates premiums with health plans and doesn't allow every insurer into its exchange.

So in summary, it looks like the ACA looks worse nationally than it should because of the adverse selection problem – too high a proportion of the new policyholders represent people who couldn't get insurance before because of preexisting conditions, probably. And in California, it looks like Covered California is a go, although it could do better with regulating the insurance companies and their practices and narrow networks. And it looks like the old dog insurance companies are continuing with their old tricks.

Stupid insurance companies.

Budd Shenkin