One of the most frequent questions I have been asked recently is what about the Covid Vaccine?  Here are my thoughts. 

It is amazing we have a Covid Vaccine.  It is nothing short of a miracle that President Trump and his team were able to move the bureaucracy, so that it was possible for companies to develop a vaccine in such a short period of time.  It is a shame that in all of the media hatred towards President Trump, he has not been given the credit he deserves.

Covid is a serious disease.  In the United States alone, millions have been sickened by it, many of these very sick and hundreds of thousands have died from it.  As I write this article, it is clear that we are again having a major increase in cases.  You would have to be blind and deaf to not realize Covid has had a serious impact on the health of our society and it continues to sicken and kill.  We are not going to beat Covid or eliminate Covid.  Covid is now a permanent part of the pathogens which can infect human beings.

In my opinion, the vaccine is the only effective means we have to protect people from getting Covid.  Masks are next to worthless.  Lockdowns may have slowed the transmission of Covid, but I do not believe lockdowns changed the endpoint and in the process have caused incredible harm.  This virus will eventually infect every individual, who is susceptible.

Despite the fact that I am thankful for the vaccines and I believe they are beneficial, I am really struggling with where we are at with the vaccines.  I am so sickened by how our public officials and the media are lying to us and treating people like they are morons.  When the vaccines were first released they were touted as being 94-96% protective against getting Covid.  It didn’t take long for that claim to be proven false, but they never admitted being overly promising.  They simply changed the 94-96% effectiveness to  protective against hospitalization and now critically ill and dying.  How long will that moved goal post last?

The matter of adverse reactions to the vaccine is exceedingly troubling.  There have been many thousands of adverse events in close proximity to people being given the vaccine.  At best, one is miserable for a day or two after the vaccine.  More serious reactions  range from people getting seriously ill to dying.  Granted, some of these adverse events have nothing to do with the vaccine, but there are far too many to pretend, as our science authorities do, that it is ridiculous to be afraid of the adverse reactions caused by the vaccines.

Part of the problem here is under normal conditions, when a pharmaceutical company is developing a drug, the federal government is constantly double checking (most of the time excessively) to make sure the drug produced is safe and effective.  When it comes to the Covid vaccine, the federal government is spending billions to pay the pharmaceutical companies to make these vaccines.  No neutral party is monitoring for safety and efficacy.  

Any other drug that had even a fraction of the adverse reactions the Covid vaccines have had, would have been pulled off the market.  I am not advocating the Covid vaccines be pulled, just for an honest discussion of the risks.  The refusal of the CDC and FDA to admit adverse reactions are occurring, makes one wonder what they are hiding. 

Then there is the totally inconsistent and constantly changing guidance that is flying around.  There is a huge push to get everyone vaccinated with this 95% effective vaccine, but one still has to wear a mask.  This makes no sense.  IF the vaccine works, why do you still have to wear a mask, once vaccinated. Since this position was absurd, they came up with the idea that while the vaccine protected you from getting sick, you can still spread the virus.  This makes even less sense.  If the vaccine protects, why do the vaccinated fear those who are not vaccinated or not wearing a mask.  Does the vaccine work or not?

When I was in training, one of the cornerstones of medical ethics was Informed Consent and Medical Authoritarianism was viewed as a bad thing.  Each individual had the right to review the risks and benefits of a given treatment decision and decide what was best for them.  This has clearly been thrown out the window.  The view today is that the population at large is too stupid to make their own risk/benefit analysis and come to a decision.  Our behavior has to be dictated by the enlightened who hold power and if we do not acquiesce to their viewpoint we will not be able to travel, socialize, shop, go to school, express opinions or even earn a living.  This is really scary stuff, because it is not limited to only a Covid vaccine. 

What is my opinion on getting the vaccine?  I think the Authoritarianism in this once free country is out of control.  I think people should be given ALL of the facts and be allowed to make their own decision.  If the vaccine is effective (as claimed), then the vaccinated have nothing to fear from the unvaccinated and all of these mandates and name calling are nothing more than one group of people forcing their view on another group of people. 

From a purely medical standpoint, I think the vaccines have some risks, but the disease cannot be escaped and the risks to adults from Covid are much greater than the risks of the vaccine.  In those who have had the disease, I think it is much less clear cut.  Clearly having had the disease does impart some protection, but we are definitely starting to see people with their 2^nd go round of Covid and in some, the 2^nd time is worse than the first.  Therefore, on balance it is probably best, even for those who have had Covid, to get the vaccine.  Unfortunately, I am not aware of any literature that is definitive in showing the prior infected have increased protection by getting the vaccine.   I will admit, I am personally having a hard time saying I want to deliberately make myself sick with a vaccine that might or might not give me more protection.  In the case of children, it is even more difficult.  As far as I know, healthy kids, while they can get sick, are not dying from Covid.  This makes it very difficult to recommend children get a vaccine that clearly has risk associated with it, to protect them from something that is not going to kill them. 

Needless to say, Covid has been an extremely difficult time for the world.  My heart goes out to all of the countless number of people who have lost loved ones to this horrible disease.  I ache for all of those sick with Covid, who have had to suffer alone and even die without a last hug and kiss from those they love. 

From prevention to the treatment of Covid, we are all going to have different ideas.  I have put out my thoughts and each of you should be entitled to have and act upon your own conclusions. 

W. Keith Stafford, MD

P.S.  I had written this article and was ready to publish it when the President announced we are all going to need Covid Vaccine boosters at 8 months.  Since then, he has lowered the interval to 5 months.  This means the vaccine is no more effective than getting the disease itself.  If the vaccines are no more effective than what is being said most recently, they had better get back to the drawing board and come up with therapeutics that are far more effective than what is currently being used in our hospitals.  No one, even the strongest advocates for the vaccine, is going to want to run this gauntlet every few months.

There have been two defining  experiences in 2020.  The one is the political situation, which is a huge subject in itself.  The second is the Covid situation.

The end of 2019 saw introduction of a new virus into the world in Wuhan, China.  There are all kinds of theories as to where this came from ranging from a naturally arising new pathogen to something arising from the wet markets in China to a deliberately manufactured bioweapon.  We may never know what the real answer is, but it has been an experience never before seen in World History.

It goes by several names from Wuhan Virus (maybe call this derogatory, but I do not see it any more derogatory than the name Lyme Disease, merely designates where it was first recognized and possibly started) to SARS-COV-2 to Novel Corona Virus to most commonly called Covid-19.  There is obviously a huge science of virology behind this which I know little about.  My interest is in the day to day experience.  

Some people blame China and WHO for not informing the world sooner of the plague overtaking the world.  I do not know any of the politics, but it is believed the virus first entered humans between October and December 2019 (thus the name Covid-19) and was first identified as a new disease February 2020. (On the political side Joe Biden claims President Trump knew all amout Covid in January 2020 and should have acted at that time to stop it – RIDICULOUS) I think about this timeline and am amazed it was recognized so quickly.  Can you imagine if a new disease first showed up in the US, how long it would take to identify it.  First of all it would have to have symptoms that made it look totally different from any currently known illness (Certainly not the case with Covid-19) Then you would have to have enough cases occurring in clusters so that the same doctors would see multiple cases and thus recognize it as a new disease and also occurring in a place that the doctors seeing it would have the ability to make their suspicions known to the public health system. (Apparently in Wuhan, the first doctors to report If something like this happened in my office, there is no way in the world anything would have been made known to the world.  I think it is incredible that it was known so quickly and is one thing that points to a less than random event.

The next thing that was amazing about this disease is how rapidly it spread around the world.  In just a couple months it went from one city in Asia to being in almost every country in the world.  This is both evidence of how interconnected our world is today and also how incredibly contagious is this organism.  I am sorry, but I do not care what any government does, you are not going to stop a less than microscopic sized organism that is this contagious from going wherever biology (and more importantly God) wants it to go.  It is so contagious, it is moving throughout every community like lightening and yet people living in the same house with a very sick person are not getting it.  How does this work?

While all diseases have variations of symptom expressions and severity of symptoms in different people, it seems to me Covid has more than others.  Covid symptoms are ranging from totally asymptomatic to colds to seriously ambulatory sick to death.  Some have primarily respiratory symptoms and others have essentially no respiratory symptoms.  Many lose taste and smell, but many do not.  This makes it exceedingly difficult as a clinician to recognize it.  

I have now had my own experience with it.  Covid has been in our community since probably March of 2020.  I have had contact with numerous cases of Covid since that time.  I have taken no special precautions (reasons to be discussed later) and up until now avoided it.  It is hard to know when I first developed symptoms, but the last week in October and first week of November I lost my appetite (take a few bites of a meal and throw the rest away) and extreme fatigue.  I could barely wait to go to bed.  If I was not working, I was taking a nap.  I assumed it was my diabetes out of control so I did labs on 11/6/20.  To my surprise, my labs had actually improved (A1C of 7.5 and FBS of 141 – not super, but much improved). On 11/7/20 I started feeling weaker and diaphoretic and had body aches, so had a Covid swab done.  It came back positive on 11/9/20.  The weekend of the 7th and 8th I continued to get sicker with fever and weakness and wanting nothing except to sleep.  Carol tried to really push the fluids, but I do not know where they went.  I had very little vomiting and diarrhea and I was drinking, but I kept feeling weaker.  I had no respiratory/pulmonary symptoms, except a minimal intermittent dry cough.  I did run a fever up to 102.5.  Monday and Tuesday night were rough because after sleeping all day I could not sleep at night, but felt very uncomfortable so was constantly turning, my feet were numb and cold and I came close to having panic attacks.  About 6 in the morning on Wednesday 11/11 I knew I was in trouble.  I felt so weak and lightheaded, I thought sure I was going to pass out.  My fever at that point was 103. I had lost 12 pounds since getting sick. 

 Carol had been sleeping on the sofa and I struggled to the door of the bedroom and told her I had to go to the ED.  That was a huge step, because I could not figure out why I would be so sick I had to go to the hospital and yet I knew if something did not change I was going to be in serious trouble.  She put me in the car and drove me to Pelham (less than 10 minutes from our house) They put me in a wheelchair and told Carol to leave.  I told them if they did not get me in a bed, I would end up on the floor.  I do not know how they got my information, because I did not even have my wallet on me.  They put me in a room and except for a very few questions and chest x-ray (showed some pneumonia) they did not do anything except give me two liters of intravenous fluid.  I do not know how to explain it (and have seen it many times from the doctor side), but it was miraculous what those two liters of fluid did.  I felt like a new person.  Not only did I no longer feel like I was going to collapse, but my fever was minimal after that, my body aches diminished and each day after that I felt stronger.  I continued to need extra sleep and I got diaphoretic whenever I got up for the next three to four days.  By the end of the day 9/15, I felt like was almost back to normal.  My appetite and strength had pretty much returned to normal and I felt ready to go back to work.

Now, my perspective on all of these measures being pushed by public health.  Social distancing, mask wearing, lock downs;  these are all measures being promoted as the answer to stopping the spread of Covid-19.  I have taught students for years that patients expect us as practitioners to “do something” to fix whatever is broken.  It does not matter whether what we are recommending will work or not, we have to “do something.”  It is the reason antibiotics will always be inappropriately prescribed and alternative medicine will have a large number of adherents.  It matters not whether the “something” works or not; to do nothing is not an acceptable alternative.  All of the public health measures being advocated fall under this same category.  

The current emphasis is on mask wearing.  It is stated as a matter of fact that by people wearing masks we will stop the spread of Covid.  Yet, in the beginning of the crisis, the infamous authority and CDC expressly said wearing a mask would not stop the spread of Covid.  They now claim the said that then, not because they did not believe masks would not work, but because they did not want the supply of masks to be overwhelmed.  This means they either lied to us at the time or they are lying to us now.  Take your pick, but at one time or the other, we were being lied to and manipulated.  (Personally, I believe it is now.). Secondly, even today, the CDC web site acknowledges mask wearing has almost no objective evidence that they work to reduce the spread of Covid and yet we force people all day long to wear extremely uncomfortable masks just to be doing something and cause people to become hysterical if they “catch” someone without a mask.  Thirdly, how exactly are masks supposed to be stopping the spread of Covid?  Do they stop it by filtering the air we are breathing.  Anyone, who has worn a mask (and now that is all of us) knows that no air goes through the mask itself.  All of the air breathed is moving in and out of your nose and mouth by going around your mask. Therefore, the mask is not filtering out the dreaded virus.  If it somehow was filtering, it would mean your mask would be full of the virus and you should be constantly removing your mask wearing gloves and burning the mask in order to destroy the deadly coronavirus.  Is anyone doing that?  I would bet almost everyone is wearing the same mask for days or weeks at a time.  At best, a mask might prevent you from coughing directly in someone’s face, but it does nothing to reduce the amount of virus you breathe in as you go about your daily activities.  

The media has imbued a mythical protective ability on masks. I have seen a person walk in with a mask on, go apoplectic because they see someone not wearing a mask.  Why exactly? If the masks are so effective, than you wearing your mask would protect YOU and it would not matter what other people are doing.  I certainly believe people have the right to wear a mask themselves, but it is ludicrous to force the entire population to wear masks.  Freedom used to be a principle that was highly valued and each individual was responsible to decide how much risk they were personally willing to undertake.  No more.  Now, the government has the desire and power to determine that we as individuals have NO right to determine how safe we want to be in our daily lives.

Social distancing or the magical 6 feet of separation is supposed to prevent us from getting Covid.  What?  Do these particles magically disappear within 5 feet and 11 inches?  Are there no particles lying on hand rails and counters, etc.  There are no currents stirring up particles that have fallen to the floor.  What about when one cleans, nothing gets sent back into the air?

Then the biggest tragedy of all is the lockdowns?  I am just shocked that with very few exceptions, the entire world decided to destroy their countries’ economies in the hope that by locking everyone in their home, they would stop the Covid virus.  Now that we are 9 months into it, there is no question the lockdowns have been a bust.  Even a casual review of the statistics and your own personal experience tell you that people continued to get sick whether they were locked down or not.  The real tragedy is not just that the lockdowns have been a totally futile effort, but that their cost has been so high.  The isolation from one another leading to all kinds of mental illness.  People suffering illness and even death all alone.  Jobs and businesses lost.  Life’s savings evaporated.  ,The government not only spending trillions of dollars it does not have, but now being given license to routinely spend trillions of dollars any time they declare a need.  Politicians now believe they have the power to throw our freedom out the window and control every one of our actions by declaring an emergency.    As someone said, you don’t save a village by burning it to the ground, but that is just what we have done.  

The latest travesty of this whole situation is the vaccine.  The vaccine is supposed to be the thing which finally rescues us from this mess.  We are being told that having the disease itself does not provide immunity (even though there are very few cases of reinfection).  I am having a hard time understanding how if the disease itself does not provide immunity, this vaccine is going to provide immunity.  Then the pharmaceutical companies announced their vaccines produced a 90-94% efficacy rate.  Stocks jumped and all the faces in front of the cameras cheered.  Again, this made no sense because, because no pharmaceutical is that effective.  This past weekend I finally was able to read the PI (Product Information) on the Pfizer vaccine that was shipped today with much fanfare.  I wrote in this blog that what was being bragged about was the results after only 7 days.  It was pointed out to me that I misread the data, so I went back and studied the data tables more intently and I will admit that I was not accurately portraying their results.  I have been detailed by pharmaceutical reps for so many years, that I have a big prejudice of skepticism towards their claims.  At the time of the PI publication (the PI can be found here https://www.evernote.com/shard/s13/sh/2d29f002-f17c-6346-61ea-d6c7d653196c/8aff2faa209a7095f1bc6849827d357c ) there had been 9 Covid cases in the vaccinated group and 169 cases in the placebo group (approx 20,000 people in each group).  This would indicate a protective effect, but I would still argue that the statement of the efficacy by using a percent is misleading.  I believe we, meaning the public, should be given raw numbers of both cases of Covid and Adverse reactions and not easily manipulated percents so we can make accurate assessments.  These are also very early results, for obvious reasons.  I am not opposed to these vaccines being offered, but the public should be given all the information, not just the sales information.     I have no idea if these vaccines will provide any true lasting protection or not (I hope they do), but at this point they have not provided evidence that they will do so, nor the potential risks.  The really bad part is many of us, in order to keep our jobs, travel, go to school, intermingle in public will be forced to get these vaccines.  That, I believe, is very wrong.

W. Keith Stafford, MD

One does not need to listen to the news very long to realize there is a problem in the United States with people overdosing on controlled substances.   More than 16,000 die every year of prescription drug overdose .  This is more than die annually in motor vehicle accidents.  In addition to overdose deaths, there is also significant other mayhem being caused by controlled substances.  There is no question prescription controlled substances are a major problem in this country.  How did we get here?

Substance abuse has been a problem for all of human history.  The thing that has changed in recent years is the amount that prescription medicines are now one of the major components of the illicit drug scene.  Prescription Controlled substances include narcotic pain medicines  (Lortab, Norco, OxyContin, etc.), benzodiazepines for anxiety (Valium, Xanax, Ativan, Klonopin, etc) and ADHD meds (Ritalin, Concerta, Adderall, Vyvanse, etc.).

In the 1990’s  there was increasing activism that doctors were not adequately treating pain.   As a result, in 2001 “pain” was officially established as the ‘5th vital sign”. Now, not only were medical personnel expected to treat pain more aggressively, but they were mandated to eliminate patient’s pain.  This happened at the same time as options for treating patient’s pain, such as Darvocet and Vioxx were taken off the market.  More recently the use of ibuprofen, Tylenol and codeine have been discouraged.  The result was that the amount of strong narcotic pain medicine prescribed increased dramatically.  For a short period of time, things were good.  Patients felt like their pain was being addressed and treated.  Regulators had something else to measure and with which to cite health care providers.  Physicians felt more comfortable treating pain more aggressively. More potent, long acting pain medicines were subsequently developed, to meet this new need.

Then the inevitable negative consequences of government mandates started occurring.  Stress levels on nursing increased as they tried to meet the unrealistic regulatory requirements. The addictive nature of narcotics (that were ignored in the push to more aggressively treat pain) became increasingly evident.  It started to be realized how short a time it took to become physically and emotionally addicted to these substances.  It was realized that it took an ever increasing amount of medication to provide the same amount of pain relief.

As the number of patients using narcotic pain medicine increased,  prescription medicines started being diverted into the illicit drug use culture.  Even legitimate pain patients began engaging in manipulative behavior in order to obtain adequate pain relief.  Unfortunately, the number of overdoses also began increasing.

When deaths from prescription medications increased, regulators, politicians and organized medicine decided it was their job to fix this problem.  They never admitted, they were the cause of the problem.  Instead, they blamed the doctors prescribing the medicines. They never acknowledged that all of these deaths occurred not when the medications were used as prescribed, but rather when they were misused by the individuals using the medicine.    They argued doctors were prescribing without adequate education on the use of controlled substances. They blamed greedy pharmaceutical companies for developing medications to meet the need the regulators had created.  When patients misused pain medicines or took them in inappropriate settings or diverted them, the doctor was blamed, rather than the patient taking the wrong action.

It was decided the way to fix this problem was to require more documentation and regulation. The various agencies issued “guidelines” that significantly restricted the prescribing of pain medicine.   The enforcement arms of government started raiding doctors offices and auditing charts.  Many physicians, especially solo physicians, were removed from practice.  Various regulations have made the actual prescribing of all medicine, especially pain medicine, more difficult and inconvenient.

Physicians are now required to do yearly education on the treatment of pain.  While learning what is currently known about pain mechanisms and the treatment of pain is helpful, so much of this education is totally disconnected from real everyday practice.  It pretends there is a way to distinguish between legitimate and illegitimate seekers of pain medicine.  It continues the fallacy that the pain medicine problem was caused by physicians and they can control patient’s behavior.  It still promotes the fantasy that it is possible to objectively quantify the totally subjective symptom of pain.  It tells us acute pain only lasts 4-5 days and after this patients no longer need narcotic pain medicine.   It tells us chronic pain should be managed with counseling and physical therapy, instead of narcotics. Then it gives no answers to what we are supposed to do when these modalities do not work or, as in many cases, are not available.  .

These pain education courses never tell us practicing physicians what we are supposed to do with the patient we are sitting with, who is crying and begging for relief from their pain.  What are we to do when we are cursed and threatened because we refuse to treat a patient’s pain.  These courses never acknowledge that every single human being wants relief when they are in pain and that relief of suffering used to be a primary role for physicians.

The results of these efforts to fix this problem from the top down have not been positive.  What has not happened is a reduction in overdose deaths.  Heroin use has gone up as  prescription medications have become less available.  The use of Suboxone is being promoted, which is an insanity.  Suboxone is just an expensive form of the travesty of methadone clinics.  People  in chronic pain are becoming increasingly desperate and deliberate suicides are increasing among them.  Even people with acute pain needs are no longer being given adequate pain relief.

We have gone from a state where the treatment of pain may not have been perfect, but for most it was adequate, to a state where pain medicines were way over prescribed.  Now those same entities that promoted the overprescribing,  have swung the pendulum totally the other way.  I tell patients that the government has declared there is no such thing as chronic pain.  While this is technically not true, in practical terms it is the truth.  Physicians have become afraid to prescribe pain medicine.  Those with chronic pain can find no doctor, not even pain management physicians to treat their pain with medication.  Even for surgery or significant injuries, frequently patients are given inadequate amounts of pain medication, thus increasing the burden of suffering on everyone.

Politicians and regulators have all looked at the overdose problem and concluded that it is the doctors fault we have this problem and it is now the politicians and regulators job to fix this problem.  I contend that politicians and regulators are the ones who created this problem and in the usual fashion of public policy, their response will not fix the problem of drug addiction and overdose, but it will have many casualties in the attempt. Those casualties will include every one of us.

Over the last several years there has been increasing emphasis on “quality” in the field of medicine.  On the surface this sounds good.  After all, who wants poor quality healthcare?   The problem is that the excuse of increasing quality is being used for ever increasing central planning in the area of healthcare.  A long list of countries have tried, central planning in the area of politics and economics.  In every case, they have shown the utopian theories of central planning results not in improved quality, but rather a decline in quality.  It concentrates all power in the hands of a few, very fallible human beings.    Progress stagnates.  It exterminates individuality, free choice and innovation.   (As an aside, even a holy, perfect God did not choose to institute central planning.  He knows man is going to make harmful choices, but still gives man free choice.)

The consequences of central planning are now happening in health care.  Medical facilities are coalescing into ever larger organizations.  Rather than lowering costs, as was promised, it is raising the price of healthcare.  Healthcare is being depersonalized.    Large healthcare mega companies are eliminating options for students, patients and those employed in the health care field.

Medical care is being dictated by one size fits all protocols, rather than the best judgment of the patient and their physician.  The last couple decades emphasis on patient rights and patient centered ethics is being thrown out the window in favor of a single model of health care for the entire population.

This is starkly illustrated by what is currently going on in hospitals with regards to vaccines.  The central planners at the CDC  have decided that a woman should get a TdaP (Tetanus, Diphtheria,  acellular Pertussis) shot every pregnancy.  This is the result of an acknowledgment that the pertussis component of the TdaP is not as effective as we wish.  It has been decided that the solution to this is to give the TdaP more often.  Thus, pregnant women can potentially get multiple TdaPs in a very short period of time.  There have been no studies to show this strategy is effective and causes no harm, but it has been declared as the correct thing to do by those with no responsibility.

Next enters the money.  The real objective for “paying for quality” is not increasing quality, but rather for the payers to pay less for the healthcare delivered to the patients.   In the effort to spend less on healthcare we are moving to pay for “quality” instead of the amount of work done.  One of the items that has been determined to be a part of quality is immunization rates.   The rate of giving new moms a TdaP is being measured.  If the required percentage of women are not given a TdaP, then the reimbursement to the hospital is reduced (the goal of the payers).  The hospital cannot tolerate a reduction in cash flow, so now they are threatening the nurses, if immunization rates are not adequate.  The nurses are being told their salaries will be reduced if immunization rates do not meet the benchmark.  They are made to feel guilty, saying it is their fault their coworkers are paid less because they are not pushing moms to get their TdaP.  It has gotten so bad that moms are no longer being offered a TdaP, but rather the injection is brought in and the mom is told this is a medicine your doctor has ordered for you to get (a falsehood, as it is an automatic order, created by the hospital hierarchy).  They do not even tell them what the injection contains, unless asked.

This is one of the reasons the vast majority of pediatric practices refuse to provide medical care to children who are not following the CDC vaccine schedule.  Their vaccination rates are being audited and their reimbursements reduced if they have too low a vaccine rate.

All patients (and that is all of us) are being pushed to comply with the definition of quality as determined by “expert” organizations.  Those organizations are unaccountable to the patient or even the doctor.  They are not only fallible human organizations, but are also influenced by other factors than just what is the best medical care for the population, much less individuals.

Defining quality is very difficult.  We have this concept that every issue in medicine has a single correct solution.  In reality, we are all different biologically and psychologically.  Therefore what a study indicates is the best solution for a majority of people, does not tell you what the result will be when applied to any given individual.  We need to be able to customize.

We have to remember that science changes constantly.  (Be skeptical of any politician or other leader who defines right and wrong by what “scientists say”). What is defined as the best medical treatment today, may well change in a few years.  However, if “quality” protocols lock us into a given treatment, we will be extremely slow to improve our care.

“Quality” today is defined by things that can be easily counted.  It totally ignores softer, but even more important factors such as  accuracy of diagnosis; your doctor listening to you; ease of access to your doctor; what it costs you to get the care you need; your concerns being taken seriously.

“Quality” is currently defined by process, rather than outcome.  In fact, in today’s world, one can have a good outcome, happy patients, lower cost care provided, but if the doctor did not follow the externally defined protocol  he/she can be in big trouble.  On the other hand, one can have a misdiagnosis, large sums of money spent, unhappy patients, poor outcome and even death; as long as the protocol has been followed, the medical hierarchy says quality health care has been delivered.

We all want to receive high quality health care, but  “quality” is not as easily defined as it sounds.  “Quality” can also be misused to manipulate, stifle innovation and hurt individuals.  We need to be careful about jumping on the “quality” bandwagon.

Greek literature contains the account of Damocles and Dionysius.  Damocles was a courtier who coveted the luxury, influence and power of King Dionysius.  Damocles begged Dionysius to allow him to experience what it was like to be the King.  Dionysius consented and traded places with Damocles.  Damocles gleefully stepped up and sat down in the throne.  He began enjoying all of the privileges of being king.  As Damocles gazes around at his luxurious surroundings, he looked up and suddenly his mouth went dry and all of the pleasure he had been enjoying drained away.  The source of his sudden change of mood was that he saw directly over his head, a large sword was hanging suspended by a single hair.

There are lots of people who are envious of doctors.  Doctors are perceived to have lots of money, status and power.  There is no argument that doctors are paid more than the average individual.  In most communities, doctors are given respect solely on the basis of their profession.  People entrust their lives and thoughts to doctors in ways they would never trust anyone else.

There is no question that physicians are privileged to be able to earn their living in a field that is intellectually stimulating, pays well and allows one to be a tremendous help to lots of people.  At the same time, there is a huge Sword of Damocles hanging over physicians.

The job of being a doctor has always been stressful.  Knowing that the evaluations and decisions you make regarding a patient can have a tremendous impact on that individual is a very heavy burden.  That burden has not gone away, but now is added the burden of fear of being sued or running afoul of the endless regulations.    Imagine what it is like to be a physician knowing that every single interaction with a patient has the potential to result in a law suit or cause you to violate some regulation.  No  matter how conscientious you are, you will be sued at some point during your career.  You are going to be audited and have to defend your actions before some regulatory body.

Today physicians are literally being hunted.  Lawyers advertise, trying to stir people up to sue their doctors.  The government now has whole departments spending millions of dollars, devoted to finding “fraud” being committed by doctors and hospitals.  The average person thinks fraud means the health entity is trying to get paid for services they did not perform.  The government’s definition of fraud is providing a service without doing the paperwork properly or not following all of their endless rules, which are designed to not pay for the services being provided.  They do not have to have probable cause to investigate you.  They just show up, collect records and try to find evidence you have committed “fraud.”

Even if a physician does not experience the major events of being sued or running into regulatory difficulty; just the daily practice of medicine is a struggle.  There is the unending paperwork, the constantly changing and ever more complex rules.  There are patients, who are understandably frustrated with how difficult it is becoming for them to obtain medical care, and they frequently take that frustration out on the doctor or their staff.

Over the last number of years, I have been saying that I still love being a physician, but being a doctor in the United States has become a nightmare.  I can think of nothing I would rather do than work with people to solve their problems.  Unfortunately, the providing of medical care, in the United States, has become very overshadowed by many other factors.  These other factors are having a tremendously negative impact on physicians.  Whenever, I am with a group of physicians, I am struck by the overwhelming amount of gloom that permeates their thinking.  This is how one observer puts it:   “Physicians, almost universally, are caring people.  They’re programmed personality-wise to please others and try as hard as they can to be perfect.  I‘ve seen what happens to physicians when they’ve delivered care out of the goodness of their hearts only to have it turned around in some way and become somebody’s lawsuit.”

You cannot put a human being under the relentless pressure that physicians in the United States are under today and not have serious adverse consequences.  Some of the results patients see are cold and irritable physicians.  Practices become very rigid, unwilling to help patients outside of strict and costly guidelines.  The physicians themselves have much turmoil in their personal life as a result of the stress of practicing medicine.  Male physicians have twice the suicide rate of the general population and female physicians have a rate up to seven times the general population.

The result that has the greatest impact on patients is the early retirement of physicians.  For most physicians, being a doctor is part of what makes them tick.  As a result, in years gone by most physicians practiced until they could physically no longer do it.  That is no longer the case.  Now most physicians are retiring from clinical practice as soon as they can afford to do so.  The result is a major loss of the most experienced clinicians, who are at the peak of their profession.  Today 50% of physicians are over the age of 50.  Imagine the impact on skilled physician availability to patients as these physicians retire at a very high rate, because they are no longer willing to endure the stresses being imposed by an ever more oppressive health care system.

Unfortunately, these pressures on physicians are going to continue to mount and that will have a negative impact on the patients for  whom they care.

I am frequently asked about my opinion regarding Obamacare.  There has been lots and lots of excellent pieces written on the subject by others, but here are some of my thoughts.  

This thing was never going to work.  They took the worst aspects of insurance medicine and the worst aspects of government  paid/controlled medicine, lumped them together and called it a wonderful plan.   Only in government does that make sense.   

The government cannot do anything  efficiently.  It is true that the military kills people and breaks things with excellence (not skills most people look for in their doctor), but anyone who has been in the military knows the military does not do things efficiently, nor economically.  Whether it be the post office, IRS, immigration services, TSA, DMV or myriads of other government agencies, none of them do things with the level of excellence expected of our private health care system and all are incredibly wasteful of money.  We already have a government run health care system in the Veteran’s Administration.  Not a single person will argue that the VA provides services on par with the private health care system.    It is beyond my comprehension,  how anyone thought the government, through the “Affordable Care Act” could create a well functioning health care system, much less make health care cheaper.   

Politicians who voted for the Affordable Care Act, did so because they could not resist the temptation to vote for something that had the hope of giving people something for free.  They assumed giving people “free” health care would buy them votes.  They did not even read the bill, much less think about the long term  implications of the bill.  (Doctors are committing malpractice when they do that type of thing.)   

Hospitals, professional medical organizaitons and insurance companies supported this thing because they could not resist the promise of more money and increased control over the delivery of health care.  Some well-meaning people accepted the false rhetoric of the selling points.  For the few entities that might have resisted getting on board with the government, there was fear that the government would come after them and cause them great harm.  Even though it is becoming increasingly clear this thing was a mistake, you will notice no medical or insurance organization is speaking up.  I suspect that is because they believe that for all of its problems it is going to be maintained in one way or the other and they are afraid of the repercussions from the government if they should speak out against it.  

While it was clear that Obamacare could not work, I was absolutely astounded that the government is so incompetent as to not even be able to get a simple web site correct.  Obviously, these are not actually simple websites, but there are scores of similar commerce websites and in comparison to the complexity of taking care of patients and running an entire health care system, they are child’s play.  If they are having this much difficulty with a web site, what kind of problems are going to arise as the real thing starts?  

It also needs to be pointed out that the claimed reason we had to have the Affordable Care Act is because it was unacceptable that there should be uninsured people in the United States.   The irony is that as a result of the regulations in the Affordable Care Act, we will have more uninsured after the act is implemented, than we had before it was passed.  Only arrogant politicians could rationalize how making health insurance more expensive and then mandating that it be bought is going to make people and employers who already could not afford to buy health insurance now able to buy it.  Of course, they are increasing those covered by Medicaid and throwing a lot of subsidies out as the answer to this question.  The problem is that the subsidies and increased Medicaid will not come close to making up for the increased expense of insurance and the loss of employer provided insurance.  The biggest problem with this approach is that an already bankrupt government is going to take more in taxes and print more monopoly money to cover those increased expenses.  Sooner or later that will have a devastating impact on the economy as a whole.  

January 1st started the use of Obamacare as an insurance policy.  Up until this time all of the focus has been on the dysfunctional web site.  Though still a challenge, it seems over a million people nationwide have been able to sign up for a policy.  Now what happens?   

The government equates having health insurance with receiving health care.  Therefore, they assumed that if people get health insurance they will have health care.  This assumption is very problematic.  Just as their web site was non-functional, so is the very complicated means of administering these health plans.  People have plugged in all of their information and been told they have insurance, but then nothing further happened.  This means when they go to obtain health care they are in a worse position than those who have no insurance in the first place.   

We as a practice have been given zero information on how this system will work.  Blue Cross forced us to sign up with their exchange product by telling us,  if we did not sign up for an exchange our regular Blue Cross fee schedule would be penalized.  Since then nothing else has happened.  We have no way to check eligibility.  We have no idea of the fee schedule.  We have no idea of the process for billing.  All of this means that people will maybe get an insurance card and then have difficulty finding  providers who accept that insurance coverage.   

The fact that neither the government, nor health care organizations, understands is that health care is delivered by individuals to individuals.  It is not delivered by the government or even hospital systems or Accountable Care Organizations.  It all comes down to an interaction between two individuals.  The pressures being added to those providing the health care on top of the pressures already present is going to produce an increasingly dysfunctional health care system for all because individuals on both sides of the stethoscope will be negatively impacted by these pressures.   

What is going to happen now?  Obamacare will muddle on for awhile with the problems piling up.  Those problems will be ever increasing costs to the Amrerican public in insurance premiums and taxes.  The health care itself will become less available and less pleasant when obtained.  There will be all kinds of difficulties and stresses for both patients and health care providers.  The government will blame the problems on the insurance companies, doctors and hospitals (and George Bush).  It may eventually get repealed, but so much damage will have been done to the health care system that the result will be unacceptable and there will be a big push for a single payer system.  There is no question that the health care system prior to Obamacare was very problematic.  Unfortunately, the Affordable Care Act, did nothing to fix those problems, but has compounded them greatly.   

Hold on, it is going to be a very unpleasant ride.

Most individuals who go into medicine do it because they want to earn their living in a field where you can help people and because they find the subject matter interesting.  Once one begins their training, they find reality, especially in the United States, is often very different from the ideals which caused them to pursue a career in medicine.  Here are some examples:

1. A health practitioners primary responsibility is doing the paperwork.  Taking care of the patient is secondary.  One spends far more time on the paperwork than  actually talking to and examining the patient.  Now, with the electronic medical record mandate, this has gotten even worse.  You can take perfect care of the patient, but if you do not complete the mountain of paperwork associated with that care, there will be trouble.  There will be less trouble if the patient does not do well or is dissatisfied with their care, but all the paperwork is good.
2. Most of the piles of paperwork, revolve around money.  The patient completes lots of paperwork, because they want the insurance company to pay for the visit and services.  The doctor has to write enough in the chart to justify the fee he/she is charging for the care they just rendered.  The insurance company does not want to pay for the services, so they do audits and require unending forms and conversations to justify the treatments prescribed.
3. Medicine is the only field where you are expected, in fact required, to offend your customer.  Every other business does everything in their power to give the customer whatever will make them happy, so that they will buy more of their services or products.  While healthcare entities attempt to give good customer service, the regulators and insurance companies demand that physicians assume all of the patients are liars, who are trying to get something to which they are not entitled.  This is the reason for the mountains of paperwork, whenever a service is ordered.  No one goes into medicine, so they can be a police officer.  However, this is the position in which the American system has put physicians.  It starts with school and work excuses and includes the affidavits connected to almost any service today.  I am supposed to discern who is or has been legitimately sick.  In the first place, that is an impossible task.  Then, if I somehow conclude they were not really sick, I am expected to call my customer a liar, but hope they will keep buying my service.  Then, just to add insult to injury, when the patient complains,  the doctor following the insurance company rules, is portrayed  as the one in the wrong.
4. Only field where you are expected and required, to provide a service, even when you are not going to be paid for that service.  If someone wheels their shopping cart out of a grocery store without paying for the items, they are arrested for shoplifting.  On the other hand, many people expect doctors to provide them services and have no intention of paying for that service.  The insurance companies and government have even gotten on this bandwagon. They constantly change the rules, expecting the doctors to do ever more work for the same or less money.  There is also a list of diagnosis which doctors and hospitals are required to treat, but which Medicare and other insurances categorically will not pay for and the patient cannot be billed.  Patients who present to the emergency department for even non-emergent complaints  have to be cared for, even though a large percentage will never pay for that service.
5. For a physician, perfection is not good enough.  Everyone knows human perfection is not possible, but in medicine, not even perfection is good enough.  We are expected to get every diagnosis correct.  We have to choose the correct treatment every time.   What becomes especially difficult is that we are also expected to correctly predict the future.  We are supposed to know,  in advance, who will have an adverse reaction to a medication.  It is expected that we can accurately predict who will benefit from a given treatment or procedure.  How long will someone be sick?  Who is going to have a relapse?    I have often said that when I graduated from medical school I missed the table where they were giving out the crystal balls and that has tremendously  hindered my medical career.  As a patient, I can certainly understand that one wants their doctor to always be correct and doctors certainly strive for perfection as well as to accurately predict the future.  Nevertheless, it is extremely difficult for doctors when they are not only chastised for being incorrect, but run the risk of being sued when things do not turn out as they said they would.
6. The process is more important than the result.  There are now all kinds of rules and regulations controlling how medicine is practiced.  This first creates the practical problem, that it is humanly impossible to keep track of all the rules.  Secondly, the goal is no longer to find the solution that best meets the needs of the individual patient.  The goal is to find the solution that follows all the rules established by the central planners.  A doctor gets in bigger trouble for breaking the rules, than he/she does for providing poor quality medical care.
7. Up until recent times, physicians were taught problem solving, innovative thinking and individualized solutions.  This approach is rapidly being replaced by protocols and population based treatments and central decision making.  It is argued that this approach provides the best outcomes for the most people.  The problem is that human beings are not all the same.  They are complex entities with very individualized needs and require individualized solutions.  Today’s approach to medicine is making individualized treatment impossible.
8. The patient is not the doctor’s customer.  In the traditional sense a patient is a doctor’s customer.  In reality, the patient is not the doctor’s customer.  The real customer is the government agency or insurance company who is paying the bill and the government entities creating the regulations.  The patients are just the widgets which are manipulated between the doctor and the payer and the government.  Everyone wants “free” health care, but the moment someone else is paying the bill, the patient is no longer in control.  Patients routinely get very angry at doctors because they are unable to get that which they think they are entitled, but the doctors are not the ones making the rules.  They are, unfortunately, the messenger.
9. The patient has no personal responsibility for outcomes.  I certainly believe physicians have a responsibility to take care of patients to the best of their ability and to keep up with medical knowledge as it advances.  It is  just as important for patient’s to take responsibility for their own health as well.  The majority of bad outcomes are not a result of poor quality doctors, but rather because patients have unhealthy life styles, do not take the prescribed medicine, fail to follow-up as recommended.  The current emphasis on paying for quality, totally ignores the fact that patients have every bit as much responsibility for their health as do the doctors.
10. Computers are not the fix.  I love using computers and have used electronic medical records since 1998 and computers can be a very useful tool.  Unfortunately, the government is now controlling how medical software operates and the result is inefficient, time consuming software.  The focus of a doctor visit is no longer the patient’s concern, but rather data entry and dealing with the concerns the central planners think are important.

There are also many positive aspects of practicing medicine in the United Medicine, but unfortunately with the ever increasing dominance and control of government and insurance companies, the negatives are rapidly overshadowing the positives.  Anyone want to add to this list, both good and bad?