Tuesday, February 27, 2018

Dander Gathering Again: Terzo

It's hard these days to rid oneself of the rising dander. Dander Omnium Gatherum Patch Numero Terzo. To put it more simply, here are more tales from the DOG Patch. And a smattering of actual good (how's this possible?) news.

Double Back on Politics at the VA. There's a guy now installed under Secretary David Shulkin by the name of Darin Selnick. He carries the title of Senior Advisor, and also works (with the same title) in the White House. Selnick was a California consultant when he fell in with the Koch Brothers and their deep pockets. Together they fostered an organization called Concerned Veterans for America. Check out its Website. Slanted to a remarkable degree toward finding wrongdoing within the VA. Cherry-picking the worst behaviors of VA staff (allegedly including Shulkin) as examples of its systemic inadequacy. And then privatizing it. Right in line with Ronald Reagan's "government is the problem," but in this case creating a huge power struggle within the agency itself. Who'll win is an interesting question. Right now it appears both the President and his Chief of Staff are betting on the popular Shulkin. We wish him well.

Again with the "Idaho Rebellion." Lame duck governor Butch Otter (yep, tha's aptly his nickname) is sticking to his guns with what WaPo calls an "alternative insurance universe." Can the Affordable Care Act be flouted by an individual state within legal bounds. Looks like this will get tested in weeks and months to come. Reverting to "shoddy [and] unfair practices" on the state level might give Butch a dopamine rush on his way out the door. (And perhaps into some cushy lobbying, consulting or law firm?) Well, secretary Alex Azar may have something to say about this, and it'll sure be an interesting litmus test of how he balances the interests of patients against his bosses' ideological leanings. Will Butch go a'ridin' out the door on a horse named Sassy? Oh, no, wait, sorry, that was in Alabama.

Some Good News: Zeke Emanuel on Hospitals' Future. For a change, something to be hopeful about. "Hospitals are disappearing," avers oncologist-ethicist Dr. Ezekiel Emanuel in his latest NY Times op-ed. Hospital CEOs, of whom we've heard here often and eloquently mainly from Chief Blogger Dr. Poses, have garnered (in every sense) an outsized share of the medical care dollar through their late stage capitalism muscle. But today they're sliding down a new razor blade of anachronism. Emanuel, in an unusually candid assessment, notes that after generations of hospital-based progress, "in a throwback to the 19th century, hospitals now seem less therapeutic and more life-threatening." And meanwhile the admission levels of patients into inpatient settings actually maxed out over a quarter of a century ago, in 1981. That dollars didn't max out at the same time is actually a source of pressure, we could add, in the same direction. Not just complex procedures, but also admissions criteria, now more and more they all often point to use of out-patient facilities. Having experienced both, we can only ratify this conclusion. For every risk of "not enough coverage" in clinics and surgical centers, there are many more risks of exposing people unnecessarily to tertiary care facilities. Worth a read.

"96 YOWM With Pneumonia." Another Times op-ed does a deep dive into the life and times of Harvard's Dr. Bernie Lown. Brigham & Women's resident Rich Joseph describes his burgeoning relationship with the remarkable cardiology pioneer who went on to found IPPNW. I feel sure this blog's readers all know this acronym. Physicians against nuclear war. Now that we have a new circus in Washington, the clock-hands have moved closer to midnight. Dr. Lown's work is ever more relevant. Interesting thing about Dr. Joseph's piece (aside from the fact that he's an MBA) is that it was kicked off when he found himself caring for the nonagenarian--none other than the "96 YOWM with pneumonia" himself--on the wards of his own fabled institution. And despite the perceived tertiary care career emphasis of both author and subject, the piece concludes, much as Dr. Emanuel did above, with a plea for more community-based development. Those interested in Lown's career would do well to download and read the PDF of an interview with him conducted some six or seven years ago by Dr. Peter Tishler of the same institution. It's a lengthy and even-handed examination of mid-twentieth century medical innovation, institutional development, and career contingency. But it's not a triumphalist whitewash. “During my professional life," Lown states, "I have seen medicine rise to an apogee of respect, sometimes amounting to adulation and then watched in distress as it began a rapid downward slide." Near the end, Lown provides a telling anecdote of a patient receiving model care: somewhere well removed from the Boston mandarinate in which he in part participated. Only through careful listening to the patient and his family did the physician reach a correct diagnosis and therapeutic plan. "That will rile up a lot of Brigham folks, some Mass General folks, and they'll picket this joint," said Lown. "I hope they do."

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