Category: Essays

Pain Pays the Income of Each Precious Thing

Of all the rotations I had to do as a resident, my least favorite was Pain Management. I never enjoyed that specialty. Pain being a rather subjective sensation, it is almost impossible to measure. What a patient says must be taken at face value unless there are circumstances and clinical signs that contradict his or her story. No matter how much empathy one has, there is always the feeling that some patients are not being truthful and that pain was being used as a bargaining chip. A chip to obtain narcotics and not work. Don’t get me wrong – there were patients who were truly in chronic pain but more often than not, those patients found a way to lead a life that was not totally ruled by their suffering.
It was during that rotation that I learnt the term, “Pain pays” and came to realize how true it is.
For the patient, pain brings attention, an excuse from working, doting on by a loved one and pain medications that often lend a high.
For the physician, it is cash from perform pain-alleviating procedures on these patients and the lure of a “pill mill”.
For the drug companies, selling all those pain pills spells profits.

Pain pays!
Shakespeare uses the term in his 1594 narrative poem, “The Rape of Lucrece”.
The poem tells the story of Tarquin, the son Lucius Tarquinius, King of Rome. Tarquin was a soldier in his father’s army besieging Ardea. One night, all the men bragged about how chaste and virtuous their wives were. To prove their claims, they all secretly retuned to Rome to see if each other’s wife was as described. The only wife who proved chaste, virtuous and was incredibly beautiful was Lucerne, wife of the soldier, Collatinus, a friend of Tarquinius’. Her chastity and virtue sparked something in Tarquinius. When they all retuned to Ardea, he stole back to Rome and went to Collatinus’s home.
Lucrece, seeing her husband friend and the king’s son, welcomed him and allowed him to spend the night. In the middle of the night, he entered her room, raped her and fled.
Prior to the act, he debated with himself whether he should commit the dastardly act. As he comes to the door of her bedroom he says to himself:

“Pain pays the income of each precious thing;
Huge rocks, high winds, strong pirates, shelves and sands,
The merchant fears, ere rich at home he lands.”

Lucrece summoned her father and husband the next day back to their home in Rome. She asked them to avenge what had happened to her, told them the story and then stabbed herself to death. Her husband and father carried her body to the public square and told the people of Rome what had happened. The Tarquinius family was chased out of Rome, ending the monarchy.

Did pain really pay?
For a while, Tarquinius may have enjoyed the bitter fruits of his act but his win led to death and misery for all involved.

Before the 1990s, doctors used opioids rather sparingly. One can say that pain was under-treated. Narcotics were mainly given to cancer patients. Then in 1980, Hershel Jick published a study claiming that the use of narcotics in 11,882 in-patients led to only 4 cases of addiction. Six years later, Portenoy published his study looking at the use of narcotics in non-cancer patients. He claimed there were no adverse effects. He studied 38 patients on which he based his claims!
Even though both studies were highly flawed, they dramatically changed medical thinking and then practice. Portenoy formed the American Pain Society and preached that the risk for opioid addiction was less than 1% – a number he would later confess that he grabbed out of thin air!
The society came up with “Pain as a 5th vital sign” slogan and it caught on.
Into this fray was dropped the drug Oxtcontin by Purdue Pharma in 1996. With aggressive marketing, they promoted this new drug.
The Joint Commission got behind pain the 5th vital sign. By 2004, doctors who under treated pain faced sanctions. Opioids were being prescribed to all, even outpatients. Later Endo Pharma and Johnson & Johnson would join the opioid party with their own portfolio of synthetic opioids.
Purdue Pharma claimed that oxycontin was a slow-release formulation and would never lead to addiction. Well, we know better now. They had to pay $635 million in fines in 2007 for misbranding and reformulate the dug but by then it was too late.
By 2012, sales of opioids were more than $9 billion a year and in 2013, opioid overdose surpassed car accidents as the number one cause of accidental death.
These patients are now not just sticking to prescribed narcotics but using heroin, cocaine as well as illegally made fentanyl and karfentanyl of unknown potency!

Like Tarquinius, pain did pay the income of each precious thing. The drug companies got rich. Doctors ran “pill mills” where they prescribes opioids like candy… and got rich. Whatever misgivings these players may have had was only like “ the merchant who fears, ere rich at home he lands”.
Like Tarquinius, doctors and the pharma companies took from these patients something really valuable. Almost as valuable as what was taken from Lucrece. They took away their will to not fall prey to opioid addiction. They took away their independence and sense of worth. They made them dependent. All those years of easy narcotics made all these patients highly susceptible to addiction to heroin and cocaine.
Lucrece killed herself shortly after her defilement. These patients are however dying slowly albeit in large numbers. However the misery their fading lives cause is as profound as that which Lucreces’ father and husband felt.

How his all this going to end?
Are the drug companies and doctors going to get banned from our cities?
Already, states like Ohio are suing the drug companies to force them to finance the care of all these addicts. Will doctors be held liable too?
Whatever happens, I hope we all learn that pain is not a means to amass wealth but rather a sign that the sufferer needs help.

The Scavenger

In 1993, Sudan was in the throes of a second civil war and famine racked the south. The UN and other relief organizations had set up camps and feeding centers to try and alleviate the plight of the South Sudanese.

It’s into this misery that the South African photojournalist, Kevin Carter, flew in March of 1993. He wanted to capture images of the crisis. One day, after photographing all day in a camp and feeding center in the village of Ayod, he headed out into the surrounding bush to take his mind off the misery. He hadn’t gone very far when he saw an emaciated, little girl on the ground ahead of him. It was apparent she was attempting to crawl to the feeding center.
He had been advised not to touch the refugees for fear of contracting whatever disease they carried so all he could do was take out his camera and take pictures. Suddenly, a vulture landed right behind the child.
For 20 harrowing minutes, Carter watched as the vulture stalked the girl. As he took pictures, he hoped the vulture would fly away but it didn’t. Finally, he managed to shoo the vulture away, smoke a cigarette and leave.
Carter later sold the image of the vulture stalking the little child to the New York Times. The Times published it on 26 March 1993 as a “metaphor of Africa’s despair”. In 1994, Carter was awarded the Pulitzer prize for that image.
Two months after winning the prize, he committed suicide. He was haunted by questions of why he didn’t help the child. Even though he didn’t help the child, she made it to the feeding center and died 14 years later from malaria.

I have been thinking of that image of the child and the vulture a lot since the issue of the proposed towing levy in Ghana came up. It may sound a bit far-fetched that I would see a link but there is an underlying theme in all of this that weaves around the issues of hopelessness, scavenging and greed.

The issue of a towing levy in Ghana came up because of a problem. The problem is that drivers often abandon their broken-down vehicles on the sides of our already narrow and unlit roads. These become dangerous obstacles at night and have led to many vehicle accidents and deaths.
Most of these vehicles are not really road-worthy to start with, but people drive them anyway. They have to because in a country where jobs are scarce and prospects are hopeless due to corruption, greed, avarice and bad governance, one has to make a living one way or the other. So people drive these jalopies, eking out a living transporting goods and passengers till they break down, at which point most drivers just walk away.
Enter a man who believes he can fix the problem. He would tow away all these deserted jalopies away for a fee that would be paid through a levy that all Ghanaian vehicle owners would pay.

Now let’s compare this scenario to Sudan in 1993.
The country had a problem. Whereas the Ghanaian problem is that of abandoned vehicles on roadsides that lead to deaths, theirs was a famine that also led to deaths.
The Ghanaian is forced by corruption, avarice and bad governance to drive these death traps so as to eke out a living. The Sudanese was starving because of war.
While the Ghanaian had to drive these jalopies to a destination (the feeding center) in order to make money to feed themselves and their families, the Sudanese had to make it to a literal feeding center to get food.
Sometimes, the mode of transportation broke down and one could not reach the “feeding center”. For the Ghanaian it was that road-unworthy truck, for the Sudanese, the human body.
In both scenarios, leaving the “bodies” on the streets led to deaths. In Sudan through disease, in Ghana through accidents.
When the breakdown occurred and the mode of transport was abandoned, that is when they would appear.
The Scavengers.
In Sudan, it was the vultures. In Ghana, well!

However, scavengers like vultures are not always bad. They are part of Nature’s plan. Theirs is to remove the remains of the “vehicles”. This way, they do not cause disease in the Sudan or accidents in Ghana.
The problem arises when the scavengers stalk the living like in the Kevin Carter photo or the Jospong Group plotting to scavenge the wallets of Ghanaians, even those not “crawling towards feeding centers”.
It is such situations that if a Kevin Carter does not appear or a public outcry does not ensue, the scavengers stalk and finally pounce on their helpless prey, draining them of any life they may have had.
That is why it is incumbent on all Ghanaians to stay vigilant and voice their opposition to this towing levy. It is nothing more than a scavenger preying on the living. Ghanaians as a people need to fight the avarice, greed and bad governance that enable these scavengers to thrive and prey on the living. Like a war that brings about a famine, these vices are ravaging our society and making us seem like carcasses to vultures and hyenas.

Even if victory is apparent, the public should never fall asleep then a vulture is known to be very patient and has amazing situational awareness. It does not hunt but seizes the resources available to it. In a country racked by corruption, avarice, greed and bad governance, the vulture welcomes each day with wings wide open, facing the morning sun. It knows that each day brings new prey then the bodies will forever lie along the roadsides that stay narrow, dark and unlit.

Carrying the Economy Around

Recently, I drove from Accra to Elmina. I took my camera and a 300mm lens with me. My plan was to capture portraits of Ghanaian traders who carried their wares atop their heads.
There was no shortage of them. We set off from East Legon. By the time we hit Weija, I had over 20 headshots already. Had it not been for the rain, I could easily have filled my 8 gb card with images by the time we got to Kasoa (I shoot in RAW).

A large section of the Ghanaian economy is carried around on the heads of traders, keeping it mobile and accessible to many.
Another observation is how many Ghanaians are involved in trading. That sector alone must employ close to 60% of all able-bodied Ghanaians. There is also a great number of children who work as traders.
The whole of this trading economy seems to be situated along our roads. Traveling through the country enables one to sense the level of economic activity in the country.
With the large number of Ghanaians stuck trading, are the other sectors of the economy neglected? Are too many people chasing just a small section of the pie?
Isn’t it the case then that foreigners who emigrate to our country, like the Chinese, Indians and Arabs find all the other sectors untapped and are able to exploit them unhindered?
Why is trading the main economic activity in our land?
Can it be due to how expensive credit is in Ghana? With high interest rates and short lending times, any one who borrows money in Ghana is under pressure to turn the principal over as quickly as possible in order to be able to make payments to the lender. No other sector allows this as much trading. Foreign businessmen often have access to cheaper loans with longer lending times. They are thus able to invest in other sectors of the economy where time is kinder.
Can this also be due to an inherent Ghanaian inability to delay gratification? We know what we want and we want it now. There is no patience for the long-term. It is even seen in how we drive. Trading is the sector that corresponds more to this impatience.
Then is an educational system that honors “What you know” more than “What you can do”. This onus on “What you know” breeds a populace that does not make things. Those sectors that cater to those who make things is starved.
Instead we all trade with a distinctive portion carrying their wares atop their heads in a bid to get them everywhere – our own version of mobile trading.
The head contains the brain, the most important organ in the human body. Harnessing it allows one to do the most with life. Not harnessing it dooms one to a life stuck in just a small section of what is possible in this life, like the Ghanaian economy. It is almost metaphorical.
Is it any wonder an educator once claimed that “the head is used for carrying”?
This inability to “make things” that feed our needs is a glaring sign of a lack of creativity. An almost pathologic inability to innovate. This brings me to a story the great Warren Buffet once told.
Warren Buffet did an interview in 2008 in the aftermath of the financial crash with Charlie Rose of PBS.
Rose asked him, why in spite of so many seemingly smart people, the crash occurred.
Buffet attributed it to the 3 “I”s.
The Initiators, Imitators and Idiots.
A business cycle or idea is started by the Initiators.
The Imitators see a chance to make money and jump on board.
Lastly come the Idiots who never bother to really learn the ropes well and end up messing everything up.
So let’s take Ghana into consideration. The nation abounds with Imitators and Idiots. Where are the Initiators? Without them, we’ll forever go round in circles.
So maybe one day, we’ll set that load of merchandise down and instead use what in in that head to think up ways to diversify Ghana’s economy into other sectors.
Until then, we’ll carry our economy around.

Those Miracles

When one looks at US Health Care from a global perspective, the numbers are not pretty. Compared to other industrialized nations, the US spends way too much money on healthcare but has some of the worst outcomes. Where the US shines though is in cancer care, where only Japan and Sweden do better.
The mortality from ischemic heart disease is especially galling. Looking at 2013 figures, the US mortality is about 128/100000 (0.128%) versus 35/100000 (0.035%) for Japan. Out of 12 nations looked at, the US did only better than New Zealand. This is however easy to explain when one looks at the lifestyle choices of most Americans versus the Japanese as well as access to primary health care in both nations.
In spite of these discrepancies, those of us who work in the system see the effort that most healthcare workers put in daily to achieve good outcomes. Every now and then, some of these outcomes makes one think of a miracle. Someone may even wonder if a Deity has a hand in these miraculous outcomes. Yet if one sits back and analyzes what it took to achieve some of these really amazing outcomes, one sees the expenditure of something more than just faith and prayers.
Now imagine a 60-year-old man, who is a smoker, obese, with uncontrolled diabetes and high blood pressure. He shows up in an ER with an ST-elevation myocardial infarction and is looking rather bad. In less than an hour, a top-rate cardiologist has him in the cardiac catheterization unit and diagnoses severe 3-vessel disease and congestive heart failure that needs surgery. In no time, the cardiac team is ready and the poor fellow is the operating room getting prepped for coronary artery bypass surgery. He has the best cardiac surgeon in the hospital, an excellent cardiac-trained anesthesiologist, a tip-top perfusionist and just amazing nurses and scrub techs. Surgery goes well but his left ventricle has taken a hit so he ends up needing an Intaraortic Ballon Pump (IABP) and then a Left Ventricular Assist Device (LVAD) to make it out of the operating room. The team is worried about his prognosis.
In the intensive care unit, he is cared for by a cardiac nurse with awesome experience and nursed around the clock. A well-trained lntensivist hovers over it all.
The patient stabilizes. The LVAD and IABP are taken out a few days later. About a week later, he is out of his induced coma, has no other complications and is extubated. On post-operative day 8, he is in a chair, looking like nothing happened. His family, expecting the worst now look at him like he is Lazarus walking out of the tomb. He is a miracle!
Which brings me to that something other than faith – Money! This poor man was saved because there were resources to save him and those resources were bought with and paid for by money. He lives in a society that can buy him a miracle! Sure, the prayers of his family may have improved his outcome but those same prayers will be of no use if he had this myocardial infarction in a Third World country!
Now let’s look at the cost of this miracle (these are averages):
The ER visit cost about $2000.
Diagnostic Cardiac Catheterization cost about $2600.
Cost of coronary bypass surgery is about $70,000 to $200,00 (with his complications and assist devices, more like the upper end).
ICU stay cost about $10,000 a day for the ventilated patient, so about $80,000 in his case. I have not even added the cost of the LVAD and IABP.
The above charges are mainly hospital charges. Drugs are not included. Neither are some personnel and ancillary charges.
This was one expensive miracle, only possible in the developed nations of the world. Even in these countries, one has to ask if it is really feasible to spend so much resources on one person. Most people would want such care for themselves and family members if ever in such a situation. Who wouldn’t? is it feasible though in the long term? Can any nation afford this, even the mighty USA?
A British economist, Lionel Robbins, once gave the classic definition of economics. He stated that “it was the study of the use of scarce resources which have alternative uses.
I borrow that definition as I ask the question:
“Can we continue to use the resources we have, which may not be scarce but could have alternative uses, to achieve these medical miracles without any consequences?”
Most patients do not really care but I think we as providers should. Even in the US, nothing last forever.

The Curse of Cassandra

“Yet, mad with zeal, and blinded with our fate,
We haul along the horse in solemn state;
Then place the dire portent within the tow’r.
Cassandra cried, and curs’d th’ unhappy hour;
Foretold our fate; but, by the god’s decree,
All heard, and none believ’d the prophecy.”
– From Virgil’s The Aeneid 2.323.

In Greek mythology, Cassandra was the daughter of King Priam and Queen Hecuba of Troy. Her brother was Paris, the man whose abduction of Helen, wife of Menelaus of Sparta, started the Trojan war. Her other brother was the brave Hector, a hero of said war.
She was described as beautiful, elegant, intelligent, charming, insane, and cursed.
Legend has it that Apollo, the Greek God of Healing, Light and the Truth fell in love with the young Cassandra. She promised to be his lover so he blessed her with the gift of prophecy. Well, when the time came for her to keep her promise, she spurned Apollo. Well, hell hath no fury than a Greek God spurned and so Apollo cursed her that even though she would prophecy, no one would ever believe her.
So no one believed her when she warned that Paris’ abduction of Helen would lead to war and the destruction of Troy. Neither did they believe her when she warned the Trojans not to drag the horse they found outside the city walls into the city.
After Troy fell, she was assaulted by Ajax, one of the Greek heroes and then given to King Agamemnon as a concubine. He took her back with him to Mycenae. Even though she prophesied that they would be killed on their return to Mycenae, Agamemnon did not believe her. Well on their arrival in Mycenae, both of them were murdered by Agamemnon’s queen, Clytemnestra and her lover.
With her constantly prophesying and no one believing her, it is any wonder she was seem as bring insane?

Cassandra has come to stand for those whose words of warning are never heeded. Those who see foresee the misfortunes that await, but are laughed off as “Chicken Littles”.
It could also stand for those who are blessed with gifts that they cannot harness or can harness but just seem unable to make any personal, societal or financial impact with those gifts.
How frustrating it is to be blessed with a gift that seems to go to waste! These feelings of helplessness, uselessness and futility are enough to drive one mad. They are powerful enough to make one wish to end it all. One wonders if the Gods have conspired to play a cruel joke on these poor souls. It is as if the Gods have colluded to destroy these gifted ones by driving them mad. It almost confirms the saying, “Those whom the gods wish to destroy, they first make mad.”

So it begs the question, “Why?”
Why are some gifted ones never heeded? Why are some talented ones cursed into utter oblivion and nonfulfillment?
Could it be that like Cassandra, they reneged on a promise to the Gods? That these gifted men and women spurned the Gods? Could it be that their condition is just a price they are paying for betrayal?

In promising to be with Apollo and then later spurning him, Cassandra exhibited a lack of trustworthiness, a lack of character. This is what brought the curse on her.
Could it be that these gifted but unheeded, these talented but unfulfilled people are in this position because of the lack of character? That it may not be a curse at all but a case of deficient moral rectitude that breeds distrust in them? Maybe the curse of Cassandra is not a curse at all but a lesson in how important character is in life. That irrespective of gifts or talents, character may be the most important of all traits, gifts and talents. Maybe Heraclitus was right after all when he wrote that a man’s character is his fate.

Or maybe I am full of hot air and really, only the Gods know!

From that Cave to the Cave

World Poetry Day!

To commemorate the day, I present:

From that Cave to the Cave

I was pulled out of a cave,
Screaming my head off
An unknown future to brave
Seemed to me quite tough.
I crawled into the bright light
Till I finally found my own path.
Sometimes all seemed right
Until one faced it’s deep wrath.

A dear, loved one I found
Other loved ones we made.
To the top I was bound
My star would never fade.
Then the body began to crumble
As Time it’s ugly head reared
Quietly into another cave to tumble
As Life from me finally veered.

The Physiology of Anger

“You will not be punished for your anger, you will be punished by your anger.”
– Buddha

Anger is a strong emotional response to a perceived slight, threat and hurt. It impacts the whole body and mind.
Emotions are controlled by the limbic and autonomic nervous systems. Whereas the limbic system seems to be the engine of emotions, the autonomic nervous system carries out the effects of our emotions eg. fight or flight.
The complex set of structures called the limbic system are situated on both sides of the thalamus, just under the cerebrum. It includes the hypothalamus, the hippocampus, the amygdala, and several other nearby areas. The amygdala are two almond-shaped structures that are responsible for our emotions.
They identify threats or hurts and send out a warning sign to the autonomic nervous system. The efficiency of the system is such that it can get us to act before the cortex can modify it’s commands. Why is that important? Well, if we react to emotions as directed by the limbic and autonomic nervous systems, our actions are without thought and judgement. Our actions are without consideration of consequences. It is the cortex that gets us to consider our actions.
Thus an angry person runs the risk of action without thought and judgement.
As one gets angry, the muscles tense up. Epinephrine (adrenaline) is released giving one a burst of energy and the desire to take immediate action. The focus narrows, the heart rate and blood pressure increase, blood flow to the arms and legs go up. More neurotransmitters are released putting the angry person in a state of very high arousal. One is ready for a fight.
It is at this point that the cortex is supposed to step in and get one to asses the reasonableness of the planned reaction and consequences. The ability to step back from this angry state and look at things sanely takes some training. It can come from our upbringing, our belief systems or techniques one has learnt (breathing exercises).
If one is able to step back, reassess the situation and take control of the emotion, the cool down phase starts. Now this phase takes a while to get one to the resting, calm state of affairs. It can take days. The problem is, if the cause of the anger re-emerges in this phase, the threshold for getting angry is much lower. The intensity is higher and the chances of acting on the emotion increases.
Beside getting one to act without reason and judgement, anger also makes people think in more negative and prejudiced terms about outsiders. It makes one deal more in stereotypes and hinders analytical thinking, unlike sadness or fear. There is the tendency to place blame on another person for one’s misery. Angry people also tend to find causes for issues that are charged with anger. So an angry person is wont to listen to the pundit who preaches anger-illiciting reasons for societal ills.
Anger is however not wholly a negative emotion. When harnessed well, it can lead to positive action due to arousal. Arousal is a very important human condition. Human action of any sort is preceded by arousal. Every athlete will tell you that a certain level of arousal is needed prior to competition. Moderate arousal levels help the brain to learn and enhance memory, concentration, and performance. So controlling one’s anger stems the hasty action but leaves a level of arousal that can be harnessed to effect real change, create or even learn. When arousal is excessive as in the angry state, it limits our ability to concentrate, learn and remember. Any surprise most do not remember an angry outburst?
Also, anger can be feigned as a strategy to manipulate or even affect the outcome of a negotiation.
The powerful emotion that is anger is meant really to be a force for good. This force can only be realized if we can tame it through the right coping strategies like behavioral therapy and meditation. Then one angry person may have minimal effects socially, but an angry populace can have massive detrimental societal ramifications.

To Diss or Not To Diss

The man wrote beautiful lines like:

“When forty winters shall besiege thy brow,
And dig deep trenches in thy beauty’s field,
Thy youth’s proud livery so gazed on now,
Will be a tattered weed of small worth held”

He also wrote some of the most wordy and flowery put-downs ever. A certain trauma surgeon I know has nothing on the Bard of Avon, William Shakespeare. He wrote 154 sonnets, 54 plays and some of the coolest disses ever.

Check this one out from All’s Well That Ends Well (Act 3, Scene 6):
“A most notable coward, an infinite and endless liar, an hourly promise breaker, the owner of no one good quality.”
Reminds me of someone famous..😳
Or this one from As You Like It (Act 2, Scene 7):
“Your brain is as dry as the remainder biscuit after voyage.”
Ouch!
Or my personal favorite from The Taming of the Shrew (Act 3, Scene 3):
“Away, you three-inch fool! “😂
I keep wondering, “what is three inches?”
Or this one from Timon of Athens (Act 4, Scene 3):
“I’ll beat thee, but I would infect my hands.”
Now that’s mean.
Now this one is special; from Troilus and Cressida (Act 2, Scene 1):
“Thou sodden-witted lord! Thou hast no more brain than I have in mine elbows “
Jeez, elbows?
To round it off, from Henry IV Part 1 (Act 2, Scene 4):
“You starvelling, you eel-skin, you dried neat’s-tongue, you bull’s-pizzle, you stock-fish–O for breath to utter what is like thee!-you tailor’s-yard, you sheath, you bow-case, you vile standing tuck!”
Now that is dissing.

Words! Aren’t they awesome?

This Healthcare Thing

“Nobody knew health care could be so complicated.”
– President Donald Trump, February 27, 2017

Outside the military and veterans, our congressmen and senators and recipients of Medicare, all other Americans fall into one of three classes where health insurance is concerned:
Those who receive employer-sponsored plans, the freelancers who need to buy their own and the poor who cannot afford it.
Under Obamacare, each of these groups saw significant changes.
Depending on whether the changes were predominantly positive or negative depended on factors like political affiliation, profession, socio-economic class and age.
Those under the employer-sponsored plans saw plans that added on things like pediatric dental and vision care, mental-health care and inclusion of children up to age 26.
For the freelancers, the exchanges suddenly allowed the purchasing of affordable plans plus the benefit of getting coverage for pre-exiting conditions.
The biggest boon was felt by the fraction that was too poor to afford insurance yet ineligible for Medicaid. This was done through expansion of Medicaid. The poster child of that is Kentucky.
In 2013, about 13 % of the non-Medicare population had no form of health insurance. By 2015, that fraction had fallen to less than 7%. The estimate is about 300,000 to 500,000 have benefitted from Medicaid expansion in the state.
As with everything, the devil is in the details and in this case, that devil is twofold – money and politics.
Paying for the Medicaid expansion is a bone of contention between the states and the federal government.
Also, there were significant tax increases on those who make more than $250,000 a year to pay for subsidies for those who couldn’t afford to buy insurance on the exchanges.
Then is the fact that companies with 50 or more full-time employees are compelled under the law to insure all employees, a condition that deterred a lot of companies from hiring.
Politically, the desire to annihilate all things Obama is also driving the desire to repeal and replace.
Trumpcare might lead to less tax increases, be less onerous on employers and remove the Medicaid burden BUT will it maintain the same level of insured Americans?
From what is out there, I doubt it but since it is just a framework, the devil will be in play again – in the details.

It’s All About The Product

“Take care of your people and they will take care of your customers.” – JW Marriott

Every busines offers a product. Offering the best version of that product is the main aim of any business..
A hospital is no different. It offers a product. It’s called “Patient Care”
Every hospital aims to offer the best patient care versus all the other hospital competing with it for business.
The most immediate face of patient care in any hospital aren’t the doctors, administrators or janitors. They are the nurses. They are the most immediate parameter used by patients to rate care in any hospital. The care they give will make or break a hospital.
So a hospital that aims to win business and be seen as great cannot afford to skimp on nurses. That hospital will aim to get the best and most experienced nurses. They will also get younger nurses who hopefully can take the place of the older nurses one day but they will not be the dominating group in the nursing pool. The older and more experienced nurses should be.
Then you come to the doctors. You want the best. If you have good ones, you strive to keep them. If they threaten to leave, you try to meet them halfway. If they are surgeons, you stroke their ego – you may need both hands! Then remember the product you offer is patient care and you need good nurses and doctors to achieve that.

Interestingly, there is a trend in the US that boggles the mind. Hospital administrators seem to have forgotten what the product is. They’ve forgotten what really matters. They are bogged down by the numbers so much that they have lost sight of what their product is – Patient Care!
So some lay off nurses, get rid of good doctors, seeing personnel cost as a liability instead of an asset and in the process, worsen patient care. They nickel-and-dime the quality of their product to death – no pun intended.Personnel costs may be a problem when one is dealing with the Post Office but in a hospital, that is the key for a great product.
Now this happens because a lot of hospital administrators honestly do not know and understand the ins-and outs of patient care. Running a hospital is not the same as running, say, UPS or Walmart. They are both businesses but one deals with people – sick people – and there is a high degree of unpredictability that the numbers do not always reflect. That is the problem classically-trained business minds have. It is no accident that physician-owned-and-ran hospitals do better than non-physician-owned ones. It is also interesting that the longer an administrator has been at a position in a hospital, they better the decision-making gets. This is because they are forced to develop relationships with the doctors and nurses and thus acquire a feel for that unpredictability.

Which brings me to my point – that hospitals should be run by physicians and nurses, supported by a finance team. This should be a physician who does clinical work not a desk-hugger. It is the only way that the product, patient care, will always come first and not some arcane numbers. Having a finance team will reduce any excesses that physicians are sometimes prone to when new medical technology or drugs are available. The vision of a hospital will also be more in line with the real needs of patients in a community and the future of medicine not the numbers. The other doctors and nurses in the hospital are more apt to find a listening ear in a physician CEO than a classic MBA daydreaming about numbers and spreadsheets.

Sure, not every physician can be a good administrator but honestly, looking at what is out there now and how physicians and nurses see being treated all over, what do we have to lose?