Protesting...

I am more than a little fed up with unnecessary wars and deaths. My college days were defined largely by an unnecessary war in Vietnam. I was in the first reactivation of the military draft largely because nobody wanted to go off to Vietnam for no clear reason and fight a war. That first draft was a lottery system by birthday and my lottery number was 215. I was in college at the time and could have received a deferment but I decided to waive it and gamble that my number was high enough to keep me from being drafted. Taking the deferment meant being put in a “second priority group” and continued draft eligibility. I was lucky and 215 was never called. 

On the campuses those days, almost everyone was a war protestor and, in my state, there were some very large protests at the University of Wisconsin. Those protests permanently changed the face of State Street in Madison – where the local drug store was redesigned to look more like a pill box after the windows were repeatedly broken out. The 1960s and 1970s in the US was an era of repeated demonstrations and protests, many of them violent and many resulting in loss of life. On August 24, 1970 - radicals parked a Ford Econoline van packed with explosives next to Sterling Hall at the University of Wisconsin in Madison.  The explosion destroyed the six story building and killed a researcher who was in the building at the time.  The target was the Army Mathematics Research Center.

One unnecessary war in Vietnam, was apparently not enough and the United States went on to prosecute 2 more in Iraq and Afghanistan.  Both of those wars took a tremendous toll in terms of mortality and morbidity to American military personnel and the civilian population and infrastructure of both countries.  Both wars are often rationalized after the fact that Saddam Hussein and the Taliban were not good for the populations of either country, but that is not the reason that either war was initiated. Iraq was invaded on the false premise that it had "weapons of mass destruction".  Afghanistan was invaded because the US military failed to catch Bin Laden as he fled across the country.     

 That brings me to the current era of protests and the expected protests tomorrow at the Democratic National Convention in Chicago. There is a lot of speculation in the press that it may resemble the protests that occurred at the Democratic National Convention in August 1968 – also in Chicago. The 1968 convention followed the assassinations of both Martin Luther King, Jr and Robert F. Kennedy earlier that same year. There were 10,000 demonstrators in Chicago confronted by 23,000 law enforcement and National Guard. The focus of the protests was the war in Vietnam with a secondary issue of lowering the voting age from 21 to 18. Despite violent confrontations between protestors and the police – no deaths or serious injuries were reported. There was subsequent legal action that involved charging 7 of the organizers with conspiracy to riot – and those charges were eventually dropped. In that original protest, many of the organizers had celebrity status and some of the concepts they presented during the protests gained notoriety.  The more radical and violent groups of the 1970s like the Weather Underground did not participate in the protest.

The overall dynamic of the protest was focused on a lengthy and questionable war in Vietnam. The protest made sense because friends and family members were being drafted, killed, and injured in a war that was unnecessary. There was an immediate impact on the American people and political leaders in the United States were accountable. 

Reviewing the dynamics of the protestors who may be present at the DNC tomorrow. The current armed conflict in Palestine is an active war prosecuted against Hamas by Israel. The war was initiated by an attack by Hamas on Israeli citizens on October 6, 2023. That attack consisted of killing, maiming, and raping civilians as well as hostage taking. The specific details can be found here. Hamas is embedded in Gaza and Palestinian noncombatants are essentially hostages to the Hamas war effort.  Since that time, Israel has counterattacked and waged war against Hamas with the resulting destruction of much of the infrastructure in Gaza as well as over 40,000 civilian deaths. The leaders of Hamas and Israel have explicitly stated that their goal is to eliminate the other side completely. In other words – kill everyone on the other side and eliminate any state that they might occupy. These are explicitly stated goals and not my speculation. 

 Along the way, there has been a protest movement in this country that started on campuses. It has characterized the war in Gaza as genocide perpetrated by Israel. The precipitating event by Hamas is either rationalized or ignored. There have been many cases of Jewish students who are US citizens being harassed and threatened. The situation on campuses led to the resignations of University Presidents who had a difficult time determining the boundaries of free speech and antisemitic hate speech. At the same time, the situation in Gaza is a horrific human tragedy in terms of lives lost, war time injuries, families disrupted, starvation, lack of medical care and disease. The Israeli army routinely kills noncombatants – not just civilians but aid workers, and journalists. There have been many cases of deaths where they were no obvious military targets and there is a statement about an investigation of what happened. Spokesmen say that Israel is trying to minimize damage to the civilian population, but there is minimal evidence that is happening. 

 At some point, the protestors in this case decided to put blame on President Biden and Vice President Kamala Harris. I anticipate seeing varying degrees of this at the DNC tomorrow. As a war protestor from the 1970s, these protestors seem to have it all wrong. The current White House staff has been trying to broker an immediate cease fire and peace agreement for several months now. The US government is behind stopping the bloodshed and advocating for peace in an area where there have been decades of senseless wars. There is no more senseless war than one where each side is actively working to completely obliterate the other. That is a mode of thinking from before civilization existed and it may end up threatening to end civilization. 

 If you really want to protest something – protest the primitive thinking of total war promoters in both Israel and Hamas. Hold the leaders with that line of thinking accountable. Their goal of annihilating the other side as a solution is unrealistic and serves only to fuel future terrorism and state sanctioned revenge. It makes no sense at all to protest the peacemakers and call them names.  Protest the real warmakers here - the leaders of Israel and Hamas.

And don't fool yourself into thinking that the leaders of both Israel and Hamas are not looking at the American presidential election and trying to figure out how they can use it to their advantage.  That may include what happens at the DNC protests.

  

George Dawson, MD, DFAPA

Addendum 1:  I heard a protestor interviewed today (August 19) on BBC World News.  Unfortunately I cannot locate a transcript or audio clip so this is my recollection of what he said. He said that both parties in the US were responsible for supplying arms to Israel for a long time and that meant that Biden and Harris were currently responsible.  He had not heard anything new from Harris and therefore he remains hopeful but suggested that people will not vote for her unless she changes positions on Israel.  When the interviewer asked him if he wanted Trump to win he said: "Oh no - I don't want Trump to win but if he does it is because of the policies of Biden and Harris."

Well no it is not. Trump wins if there are insufficient votes for Harris and the situation is more complex than trying to resolve and Arab-Israeli dispute that has been going on for decades in a few months before the election. The protestor is also overestimating the leverage that the US has in this situation as well as the fact the combatants here are sworn to obliterate the other side and at no time have given a hint of becoming more reasonable. 

I am in the process of reading a book on how the US has become a grievance culture. Pick a cause, feel aggrieved, and go on the attack. It has become a cultural norm probably best exhibited by the stolen election meme used by the MAGA Republicans. This protest appears to have humanitarian motives, but it really minimizes the work that the Biden-Harris administration in concert with other countries are doing to secure a cease fire and take steps to end the hostilities.  Either way the additional point is missed that unless the needle is threaded with this agreement - it can easily become an election issue.  The protestor in this case does not want Trump, but he also does not want to do anything to help Harris. That is a conveniently unrealistic viewpoint. Deciding to not vote probably hurts Harris more than Trump because the GOP has the leverage of the electoral college - they have won the presidency with fewer popular votes.

George Dawson, MD, DFAPA

Update (9/2/2024):  The citizens of Israel seem to have no problem placing the accountability for the ongoing war directly on Netanyahu and his refusal to negotiate.  I hope this was noticed by American protestors placing blame on the Biden-Harris administration who are advancing the peace plan. Palestinians and Hamas have no luxury of influencing the leader of Hamas because there is no democratic process.  

https://www.yahoo.com/news/hostage-deaths-pushed-israel-breaking-155646402.html

Graphic Credit:  From WikiMedia Commons per their user agreement and CC license. Click for details.

The Shadow State Hospital System

Up until fairly recently, every psychiatrist at some point in their career was aware of a state hospital system.  The state hospitals were at one point the only available resource for long term care for most residents in a state.  They were also the facilities designated to care for people who were mentally ill and in some cases designated as dangerous to society.  That includes a population  with severe neuropsychiatric illness who have disorders that do not respond well to treatment and always represent some risk in terms of chronic aggressive behavior.  There is a population of people who are adjudicated as mentally ill but criminally culpable - that is they have failed a Not Guilty By Reason of Insanity (NGRI) defense.  This same group can be in a state facility being treated to the point where they are competent to proceed to trial or the minority group of NGRI defendants who have been adjudicated as not guilty but still need treatment before they can be released.  There is an assumption at some nonmedical level that psychopaths and people with antisocial personality disorders associated with aggression can be separated from the mentally ill persons and sent to the correctional system while some of those same definitions result in indefinite stays in specialized state mental hospitals.  The legal systems of some states designate certain forms of psychopathy or other criminal behavior a mental illness in order to allow for indefinite detention of people who are considered to have committed more heinous crimes like violent sexual offenses or sexual offenses against minors.

 At one point there were very large numbers of persons in state mental hospitals.  Two historic movements resulted in large numbers of these patients being released.  The first was the deinstitutionalization movement.  Historian Edward Shorter attributes the start of deinstitutionalization to psychopharmacology - specifically the invention of chlorpromazine that was FDA approved in 1954.  According to Shorter, the total number of patients in state and county mental hospitals declined from a high of 559,000 in 1955 to a low of 107,000 in 1980 or an 80% decrease.  In reality, many of the discharged patients did not take the medication reliably or developed side effects.  Shorter credits the "antipsychiatry movement" with providing continued impetus for state hospital discharges by suggesting that the institutions could be replaced by ""therapeutic communities" - a romanticized version of welcoming friends and neighbors clasping the mentally ill to their bosoms."  He also credits the National Institute of Mental Health with promoting this view.  The movement led to large numbers of mentally ill persons being homeless, not cared for medically or physically,  and  with dwindling resources for outpatient medical care when Community Mental Health Centers started to focus on providing psychotherapy for people without severe mental illnesses.  The Treatment Advocacy Center looks at available bed per 100,000 population as a rate.  They put the minimum acceptable figure at 50 beds/100,000.  In 1955, there were 344 beds per 100,000.  In 2005, that number had dwindled down to an average of 17/100,000 with a range of 7.1 to 50.  According to that same report 42 of 50 states had less than the minimum recommended number.

My copy of Shorter's text was published in 1997 and it says nothing about the managed care era and the effect of managed care on state hospital systems and the community systems of care that were supposed to be there to treat the deinstitutionalized.  There were few of these systems at the outset.  In the 1970s and 1980s there was the beginning of a larger community psychiatry movement and some experts began to develop systems of care to support patients who had been in state hospitals in the community.  Those systems of care were by far the exceptions rather than the rule.  When managed care took over there was no longer an asylum or a containment function in community hospitals.  People with severe mental illnesses could no longer go to short term hospitals because they were no longer able to function or they had numerous problems that were too difficult to be managed in an outpatient setting.  The only reason for hospitalization was the managed care concept of "dangerousness".  Suddenly it no longer mattered if you were manic and squandering your resources, ruining your marriage and losing your job.  Unless "suicidality" was detected or there were threats to kill somebody, a person would be discharged from the emergency department.  Not only that but, anything said in the emergency department was now taken at face value.  A patient could have been tearing up their home, obviously paranoid and threatening a neighbor.   As long as that person said he or she had no intent to harm themselves or anyone else,  they would be discharged even if the family bringing them to the hospital was horrified with that decision.  That is the state of managed care and its impact on psychiatry even to this day.  The reason is quite clear.  Several studies have shown that adequate community treatment of some persons with mental illness may be no less expensive than state hospital treatment.  It is only by providing rationed or no treatment at all that a state or health care company saves money.  That is also referred to as "cost-effective" care by the people who are rationing care.

The other interesting twist is the spin put on deinstitutionalization.  I know one of the leading proponents of this process in the 1970s and had him as an individual supervisor.  I can still recall his presentation about why he became interested in community psychiatry and was one of the leaders.  It was a single black and white photo of a large gymnasium sized room in a state hospital.  There were about a hundred men in the photo and there was room enough to have all of their cots arranged edge-to-edge across the floor.  So never let it be said that state hospitals were luxurious places to begin with.  That fact alone was one of the main reasons that psychiatrists were interested in getting patients out.  

So what is the shadow state hospital system?  At the first level it is an administrative one.  The administrative systems for any state hospital systems have always been fairly intensive.  At some point, there is a predictable scandal and a political reaction to the fact that the many of  these hospitals were mismanaged by the political system in the first place.  It is another case of politicians reinventing themselves by reforming something that they mismanaged  in the first place.  Some clear examples include each of the following:

1.  People with psychiatric illnesses used to pack state hospitals and now they pack jails and emergency departments.  One of the primary goals of the shadow state hospital is to give the public the impression that this is more humane and more effective treatment than real state hospitals run by psychiatrists.  It also effectively removes a large block of people with chronic mental illness from active treatment relationships with psychiatrists.  Any family advocates for these patients and psychiatrists themselves can unite to advocate for these patients but they are neutralized when the system is managed to allow a few 20 minute appointments with the psychiatrist per year.

2.  Rationing to the point of of the absurd is a theme that crops up on a regular basis over time.  That is true, whether you were an asylum psychiatrist seeing 500 patients or a hospital where serious injuries to staff and patients occurs.  Another goal of the shadow state hospital is to give the impression that no matter what, administrators somehow have special knowledge on how to run psychiatric services.  Nothing could be further from the truth.  The psychiatrists themselves end up jumping through a large number of administrative hoops since they are caught in this endless stream of bureaucracy and have less and less time for direct patient contact.  Bureaucrats with no appreciation of clinical medicine lack an appreciation for two critical factors in psychiatry.  Those factors are the quality of all assessments of a patient's problem depends on the time spent in direct contact with that patient.  The quality of any intervention including the prescription of medication also depends on time spent with the patient.  Together that time and relationship with the patient is the best predictor of outcome.  All administrative measures in the shadow state hospital seem to be designed to negatively impact that parameter, including the replacement of psychiatrists by "prescribers."

3.  The shadow state hospital doesn't really need psychiatrists.  Despite the fact that psychiatrists have (by far) the most training of any group of physicians or mental health professionals in hospital care and care of patients with the most serious mental illness, all of the administrative focus is the general elimination of psychiatrists.  I think it makes perfect sense from the administrative side.  If you are an administrator who is accountable to politicians or government bureaucrats - eliminating psychiatrists accomplishes two goals.  The first is taking out any professional opposition to any measures that you decide to implement from the perspective of a person with little to no training in the treatment of mental illness.  The second, is having a group of professional employees to scapegoat.  What better arrangement could there be than hiring people who are overworked to the point that they have little time left to muster any opposition to your plans and that same overworking in a dangerous environment puts them at risk for adverse events that they can ultimately be blamed for?  All of these events are the predictable outcome of people working in a split environment.

4.  Collecting data on citizens for reasons other than their psychiatric care.  To address the ongoing problem of gun violence by some of the mentally ill, many states have adopted legislation that allows a bureaucrat to collect data on people who have been committed for the purpose of putting them on a master list to prevent them from acquiring firearms.  The number of people denied in this manner is very small compared with domestic violence perpetrators or felons, but that doesn't prevent this false solution to the problem of gun violence at the cost of collecting this data.  In many states the only way to get into any existing mental health facilities is by civil commitment.  There is also a process for collecting financial data on the same population for the purpose of collecting money for the cost of hospitalization.  Is it ethically correct to forcibly collect fees from people with few resources who have been court ordered to get treatment?  I don't think so but apparently state and county governments do.

5.  Creating more administrative burdens to adequate treatment.  Some people who were previously treated in state hospitals are in foster care settings.  In Minnesota there was a recent ruling about developmentally disabled patients in a state hospital being secluded and restrained excessively.   That resulted in a long court ruling that applied to that incident and resulted in a financial reward to members of the class action suit, the closing of that hospital, and several administrative procedures that started to affect the providers of adult foster care.  In one case the administration of any "as needed" medication including sedatives for sleep, anti-anxiety medications, and antipsychotic medications - required a foster care provider to go online and complete a 7 page report.  Even a few extra doctor ordered doses of medication per week results in a tremendous paper work burden.  This burden was created for people who have been in stable foster care situations for years and who had been receiving excellent medical and psychiatric care.

6.  The prevention of violence and the care of the violent or aggressive patient in the community is a more bothersome situation.  Several years ago, a friend of mine told me that his son was involved in staffing a small group home that specialized in the treatment and support of violent mentally ill patients in their own adult foster care setting.  If the patient because aggressive, the staff would use pads to hold the patient to the floor until the aggression passed.  I was shocked to hear about this arrangement because there was no onsite supervision or training by anyone specializing in the treatment and containment of a physically aggressive person with mental illness.  Treating this behavior in a hospital setting with a well trained staff and clear support by the administration is difficult enough.  Now it seems that we have mini-facilities trying to provide some level of containment for aggression in residential buildings with a few staff on site.

7.  The use of limited state hospital resources for political purposes continues.  The best example is commitment for psychopathy or sexual offenses, both disorders that have no treatment and are not considered psychiatric disorders in most cases by the legal authorities.  How is it that people committing sexual offenses are hospitalized indefinitely and people with severe mental illnesses are refused admission to hospitals and eventually incarcerated for minor crimes?  Only through a shadow system.

8.  The large population of mentally ill persons who are continuously cycling between the emergency department (ED), very brief and ineffective stays on short term psychiatric units, and jail.  This constant churning is typically covered in the press as a reason for overcrowding of the ED, but the real travesty is that these patients never get their psychiatric and social problems resolved and that keeps them cycling in and out.  Discharging a person with a severe mental illness from a short term psychiatric unit or the ED does not solve anything for that person.  It is nothing more than an expensive time out.

9.  The family as hospital staff has always been with us but it has not been as prevalent since the 1950s or 1960s.  I can recall violent and aggressive patients cared for at home to the point that the entire home was trashed and family members and the patient in question had frequent severe injuries.  Short of that scenario, it is much more common today that a family becomes the default hospital staff in cases where a person with severe mental illness does not meet the managed care "dangerousness criteria" for admission.  That means the patient does not tell an emergency room physician or social worker that they are going to kill themselves or become aggressive.  Family members recognize the person needs supervision and monitoring 24 hours a day/7days a week.  I have really never met a family who could do that for more than a couple of days.  Of course they should never be put in that position, especially with the fees and taxes that every family pays for health care in this country.  Anybody who requires 24/7 supervision should be in the care of professional staff who can offer appropriate therapy and maintain a neutral relationship with the affected person.

10.  It is all about the money.  The war cry of managed care systems, government systems, and government systems managed like they are managed care systems is "cost effectiveness".  It has been known since the Hay Report that psychiatric and mental health systems took a disproportionate hit relative to all other areas medicine.  There has never really been an informed discussion of what  a reasonable budget for the provision of mental health services should be.   The cost of services is often impossible to find.  That is a bureaucratic recipe for transferring money somewhere else.  Even standard bureaucratic solutions like "a 5% budgetary cut across the board" will obviously hit the most marginally funded systems first and the hardest.  Those services are psychiatric services.  The Shadow State Hospital System can function as a funding source for other projects at the cost of providing treatment for persons with severe mental illness.

11.  Let's all pretend that there is a real State Hospital System.  The front end of this illusion usually starts out when a person actually meets managed care "dangerousness criteria" and the hospital case managers cannot discharge them.  In this case, the court usually assists the hospital in getting the patient out.  For example,  there used to be a system to commit patients with substance use problems to treatment.  Those patients are frequently released by courts on the basis that they "no longer do chemical dependency commitments".  In the case of severely disabled patients with mental illness, the court may ignore that standard in a state commitment statutes and release the person for not being imminently dangerous.  In both cases the patient is hospitalized for a few days longer than the 3-5 day managed care length of stay instead of being committed to a system of care.   It appears as though something has occurred but it really has not.  

The Shadow State Hospital System allows the state and its partners in private business to establish covert control over any mental health system of care - to the detriment of the professionals and patients in that system.  The exact number of administrative measures and facilities like the ones I outlined above are unknown.  Shadow systems thrive on a lack of transparency, at least until the next scandal happens.  At that point there seems to be some level of transparency, but it is always incomplete and the real story of what happened and why never seems to surface.

The real state hospitals systems were far from perfect, but it is time for medical accountability to replace government bureaucrats and the very weak standard of accountability of these bureaucrats.  Until the Shadow State Hospital System is recognized as the prime example of mismanaged care we will not be able to address the miscalculations of deinstutionalization or what Shorter called:

"....one of the greatest social debacles of our time."


George Dawson, MD, DFAPA

Ref:

1:  Shorter E, A History of Psychiatry. John Wiley & Sons. New York, 1997.


Supplementary 1:  The image used for this post is of Dexter Asylum attributed to Lawrence E. Tilley [Public domain], via Wikimedia Commons.  The original image was Photoshopped with a graphic pen filter.

Being Honest Won't Save You - Lessons In Medical vs. Business Accountability

Every now and again I flash back to a surgical rotation that I was doing at an old county hospital.  It was quite run down.  We had a large surgical service comprised mostly of people with gunshot wounds, cancer patients, and people who were in long term care hospitals for mental illness who developed acute surgical problems.  Most of the patients who had gunshot wounds had been shot by the police and they had police officers posted outside of their doors.  On some days it seemed like there were a lot of police officers outside of every other door for quite a distance down the hallway. We did two sets of rounds - in the morning after the surgical procedures and another set of rounds at about 6 or 7 PM.  The evening rounds always ended under fluorescent lights in what is probably a long abandoned nurses station.  In this particular case we are rounding with a senior surgeon and a junior surgeon.  The senior surgeon has just demonstrated how much he knew and how little the residents knew about the effects and importance of gastrointestinal tract hormones.  After a few moments of uneasy dead air, the junior staff asks the intern: "What was Mr. X's calcium level this afternoon?"  The labs were typically run at 4PM and in those days we would have started to see results at about 5 or 5:30, but we were all rounding at that time and attempting to answer questions about GI hormones.  The conversations went something like this:

Staff MD:  "What was Mr. X's calcium level this afternoon?"
Intern:  "I don't know."
Staff MD:  "What?  I expect you to run this service.  How can you run this service if you don't know what Mr. X's calcium level is?"

The team got quite nervous in situations like that.  Training in medicine puts you directly in the line of fire or at least it used to.  These days commentary and affect like I witnessed that day might lead to some type of disciplinary procedure for the staff physician.  Something that could be passed down on credentialing forms and haunt a physician for the rest of his or her career.  A type of pseudoaccountability arranged by the bean counters essentially to manipulate physicians.  In this case, it was considered to be a learning experience and culturally appropriate.

In this case the intern in question seemed to recover.  Things went well for another few days.  And then he was gone.  The rumor was he was asked about another lab value, gave an answer that was slightly incorrect as in no physiological difference between the answers. He was fired for making up the answer.  Keep in mind that this incident occurred at a time when there were hundreds of lab values to track and the technology was at a primitive state relative to what is currently available.  The computers were slow and getting results took a lot longer.  Medical students, interns and residents had to write the labs down on cards using whatever shorthand they could devise.  In the process some data was memorized but not all or most of it.  But the difference here is that the integrity of the answer was called into question.  The assumption was that you either know the answer for sure  or you say you don't know.  There are no near misses.  The judgment is that you made something up and that is unacceptable.  In the years since, I have seen quite a few colleagues fall by the wayside as a result of similar incidents or what were considered to be errors in judgment by the senior faculty.

In recent times, I think there is a tendency to lump this behavior in the category of senior faculty being abusive toward physicians in training.  That certainly may be true, but it is also true that it draws a very clear line about what you need to be doing as a physician as opposed to what you may have done in your undergraduate major.  You can no longer make things up like you used to do in your philosophy and English literature classes.  You have to be brutally honest about what you know and what you don't know.  I don't think there is a physician alive who will not tell you that knowing this is one of the most critical aspects of training as a physician.  The ultimate test of whether you are patient centered is whether you will not try to protect yourself - but whether you can be brutally honest even in a situation that may put you at risk professionally.  Can you acknowledge mistakes, lapses in judgment and most importantly a lack of knowledge or expertise?  Patient safety depends on it.  That atmosphere also has the effect that you show up for work.  If you know that you are a target for any faculty who want to criticize you, you tend to want to know everything there is to know about the patients on your service.  In contrast to the events where the question does not get answered I have seen residents give tutorials on ventilator settings or pressure recordings by Swan-Ganz catheters.  They were motivated to some degree by knowing that teaching staff would be asking and their assessment depended on their answers.  

The reason for that introduction is that it frames the backdrop for a discussion from a financial thread with a very interesting title: Will Ebola Vanquish the MBAs Who Run Our Hospitals?  It is a title by a blogger and certainly eye-catching.  I have followed this blogger for a number of years and agree with a lot of what she has to say about the way financial services are managed in this country.  I have disagreed with her about some of her medical opinions, but this post is something that I can agree with.  I was recently e-mailed about my tendency to selectively find research that supports my opinions.  I consider this to be more opinion to support my opinion.  Research on how businesses manage medicine is as scant as research on management in general.  Business people tend to produce papers suggesting there are deficiencies and then say how they will correct those deficiencies.  There is really hardly any research to support business opinion.  The opinion in this case looks at a topic I frequently comment on - how can business people with no medical or scientific training manage physicians and medical facilities?  In my opinion they clearly can't but let's look at what is presented in this article.

The basis for the article is essentially opinion in the press and the opinion of a medical blogger.  The conflict-of-interest here that is usually glossed over is that any journalist, newspaper, or blogger wants the public reading their stuff.  It will be provocative or sensational.  A measured analysis is not typically seen.  For example the comparison of staff infection rates between the staff at Dallas Presbyterian Hospital (DPH) and Doctors Without Borders (DWB) in Liberia seems pointed, but the obvious question is whether the infections rates vary with experience.  For example did the DWB staff in the earliest stages of their involvement have infection rates as high as were portrayed in the DPH staff.  Can a direct comparison be done without that information?  The highlighted emergency department (ED) problems are similarly problematic.  If you pull up the Internet sites for the DPH system of care they are affiliated with a number of inpatient psychiatric units.  Is the wait time a reflection of a large pool of chronically mentally ill or poorly stabilised psychiatric patients being stuck in the ED?  If that is true it would still be consistent with some of the authors concern about the lack of public health concern and the fact that lower socioeconomic classes come face to face with the wealthy in such settings.  It is also an aspect of the mismanagement by rationing that is pervasive with systems of care managed by large businesses.

I have first hand experience with infection prevention in hospitals and attempt to stop widespread outbreaks from respiratory viruses.  Keep in mind that the Ebola virus is not an airborne virus.  All of the remarks in this paragraph are about airborne viruses especially Influenza virus.    For a number of years I was extremely disatissfied with the epidemics of respiratory viruses that swept through the staff where I was working.  Employer rules about paid time off only worsen the situation because the incentive is to work when you are sick to prevent loss of vacation days.  But the most frustrating part of the problem (apart from being sick 3-5 times a year) was that the employer had no real interest in doing anything that might reduce the risk of infections.  The intervention I suggested was just improving air flow in certain buildings.  The standard reply that you get is "wash your hands and cough into your sleeve."  Those are certainly common sense measures but as far as I could tell had no impact on the rate or severity of infections each year.  Hospital administrators everywhere seem to be in denial of the fact that airborne pathogens exist and washing your hands and coughing into your sleeve will not protect you against airborne pathogens.  I was also a member of two different Avian Influenza task forces.  At the time there was much uncertainty about a widespread epidemic that could not be contained.  We were setting up for the worst case scenario of thousands of people (both infected and not infected) coming into EDs and how to triage and treat people.  After years on these task forces it became apparent to me that nobody was really interested in planning for the prevention of mass casualties from an airborne virus.  There was no planning for any additional negative pressure airborne isolation rooms and no planning for any additional bed capacity in the event of a widespread epidemic.  There was planning for what to do with the expected bodies.  In the end it seemed that all of our hopes were pinned on a rapidly disseminated vaccine or antiviral medication.  The specifics of the antiviral medication were murky.  We were shown a picture of a large pallet of oseltamivir sitting in a warehouse somewhere.  From a business administrator's standpoint, planning to use imaginary resources from the government is always preferable to more functional planning because it is free.  My personal experience in this area from volunteer work on respiratory viruses is entirely consistent with the notion that health care businesses are not administered in a way that is consistent with public health needs in the case of infectious epidemics.

The Naked Capitalism article contains analysis from Roy Poses, MD of the Health Care Renewal Blog.  He looks at inconsistencies in the media and concludes that this is another case of health care leaders being untrustworthy.  That appears to be a central theme of his blog and he goes on to criticize them for being inconsistent, suppressing information from employees that may be critical to public health, and having an inflated sense of self importance.  These patterns are easily observed by physician employees of health care organizations.  For at least a decade after passage of The Health Insurance Portability and Accountability Act of 1996 (HIPAA) it was impossible to get necessary information from health care organizations, even in the case of needing to provide emergency care.  I would routinely request information and even send a HIPAA compliant release signed by the patient and I would get a blank form the other hospital saying that my patient had to sign their form and fax it back.  Hospital administrators were a big part of that process.  It is common for the clinical staff to be buffeted by the next big idea from their administrator.  That can range everywhere from high school style pep rallies that are supposed to improve employee morale to a new productivity system that is guaranteed to get even more work from physicians.  In every case, the administrator in charge could be making 2-5 times what the average physician makes for considerable less accountability, practically no "evidence based" methodologies, and no measurable productivity.  As pointed out in the article, public relations is much more of a factor in the CEO's reputation.  From the article:

" On Health Care Renewal we have been connecting the dots among severe problems with cost, quality and access on one hand, and huge problems with concentration and abuse of power, enabled by leadership of health care organizations that is ill-informed, incompetent, unsympathetic or hostile to health care professionals’ values, self-interested, conflicted, dishonest, or even corrupt and governance that fails to foster transparency, accountability, ethics and honesty." 

There are additional lessons from the decimation of mental health care in the United States, especially care delivered at tertiary care and community hospitals.  There is perhaps no better example of low to no value service that is the direct result of non-medical management.  There is no coordinated public health effort either improve the care of psychiatric disorders or specific high risk behaviors like suicide or homicide.  The standard approach is rationing of both care that would result in stabilization but also bed capacity that would alleviate congestion in emergency departments.  There should be no debate on cost, inpatient psychiatric care is without a doubt the low cost leader and is set to match reimbursement from a high turnover low quality model.  Psychiatric services in clinics and hospitals have a lot in common with what Dr. Poses observes on the administrative side of many health care organizations.

Responding to the question of  "Will Ebola Vanquish the MBAs Who Run Our Hospitals?" - my answer would be no.  It is always amazing to consider how so many people in business with so little talent can end up running things and making all of the money essentially through public relations, advertising and lobbying politicians.  There is no shortage of self proclaimed administrator-visionaries.  The author here should know that their power is consolidated around the same strategies that have worked for the financial services industry.  Managed care business strategies based on no science or input from physicians are now in the statutes of many states and in federal law.  They have successfully institutionalized business strategies designed to return profits to corporations as the rules that govern healthcare.  The pro-health care business lobby essentially gets what they want and the professional organizations are weak and ineffective, but continue to browbeat their members for contributions.  Administrators have a lock on running health care and demanding whatever accountability they demand from health care professionals while having no similar standards for themselves.

I can't think of a worse scenario for addressing potential public health problems whether that is an infectious epidemic or the continued mental health debacle.



George Dawson, MD, DFAPA

Supplementary 1:  Kaiser Family Foundation brief PowerPoint and Infographic on the current Ebola out break.

Supplementary 2:  I decided to add the above table comparing the accountability of physicians with business administrators.  Certainly there may be some things I have missed on the business administrator accountability so if I missed anything please let me know and I will include it.  From what I have observed, health organization and hospital CEOs are typically accountable to a Board of Directors that has very little physician or medical representation.  Often the Board is stacked with people who rubber stamp what the CEO wants to do.  Like the web site referred to in the above post there is often an aura that the CEO and the Board have visionary-like qualities that are based on public relations and advertising rather than any academic work or actual results.  I have never really seen an administrator who was a visionary or knew much about medicine - but  you can certainly read their proclamations about how medicine should be reformed on a daily basis in many places on the Internet.  The usual argument for all of the physician accountability is that it is a privilege to practice medicine and therefore regulation of physicians needs to reduce the privacy rights of physicians and subject them to much closer regulation than other professionals.  Why wouldn't that approach apply to the people who actually determine whether a patient gets health care, medications or a specific benefit?  Why wouldn't that same logic apply to the people who really run the health care system?
  

Accountability - The Last Refuge of a Scoundrel

On April 7, 1775, Samuel Johnson said:  "Patriotism is the last refuge of a scoundrel."  His biographer had to clarify that Dr. Johnson was not talking about love of country but "pretend patriotism which so many have made a cloak for self interest".  We see the rhetorical application in American elections where politicians spend more time on discussions of their military records rather than issues relevant to any kind of plan that they have for the nation or solving any real problems.  Nunberg makes the observation that that the term can also mean an irrational bias favoring one's country and that Americans have applied the term indiscriminately at times. He also points out that it can be a word designed to put people on the defensive.  

If I had to pick a word in the medical field that has similar uses - it would be "accountability".  There has probably been no single word more responsible for facilitating managed care and recent government intrusions into the practice of medicine.  If you think about the premise of physicians being "accountable" to politicians and businesses - it is absurd on the face of it.  Taking a professional who has been trained to be accountable to an individual patient and who operates in a professional environment that specifies behavior toward that person and telling them that they are now going to be monitored by businesses with a goal of maximizing profits or politicians with numerous conflicts of interest and a clear interest in getting re-elected - is an ongoing disaster.  So  how has it happened?  I would suggest that most of it has to do with rhetoric.

Before I point out the medical applications of the accountability rhetoric let me say that I don't consider this to be specifically applied to medicine.  Accountability rhetoric is broadly applied by any person or group seeking some kind of political advantage.  An obvious example is education and teaching.  Politicians everywhere get a lot of mileage out of the idea that they are going to hold teachers accountable usually through standardized test scores.  It has become a pat answer to taxpayers concerns about the money being spent on education and low graduation rates.  In some states, the test scores are marched out every year and used to rank schools and teachers.  Never mind the fact that the school system that produces the top international performance scores does not work that way.  In Finland, a professional teaching culture is by far and away the most significant factor in their academic excellence.  In the book written about this the teachers say they would not tolerate the kinds of intrusions that are common in the United States.  These intrusions are all based on accountability rhetoric.  

In preparing for this post, I searched my e-mails from the past three years and found 1800 e-mails containing the word accountability.  Most of those hits were due to the Health Insurance Portability and Accountability Act (HIPAA).  If you read the long title of this act it was clearly doomed out of the box.  The major impetus for the PPACA (Obamacare) was health insurance portability suggesting that HIPPA was already a failure.  That did not deter legislators from including a Privacy Rule under HIPAA to supposedly crack down on privacy violations.  My read of the bill is that is actually broadens the use of anyone's medical information among all "covered entities" affiliated with your health plan.  In the meantime,  the Privacy Rule was so threatening that it almost immediately made it more difficult for the doctors doing the work to get access to data.  Was it necessary for physicians?  Absolutely not - physicians are trained in medical privacy and all broad breaches of medical privacy have been due to either hacking or business people losing computers with significant amounts of data.  Make no mistake about it - politicians will be there to make the most accountable people accountable and greatly decrease their efficiency.   A great example of the title of this post.

I have recently posted a number of examples of accountability rhetoric being used for political leverage against physicians.   It can be used by medical boards, advocacy organizations, state agencies, federal agencies, and specialty boards in addition to politicians.  I am going to focus on a single example and that is Medicare.  All of the information that follows is public and can be accessed through the Medicare link on the American Psychiatric Association's web site.  I picked it up on my Facebook feed but it disappeared and I had to call APA staff to figure out where it went.  I am very familiar with the history of Medicare quality initiatives because I was one of their quality reviewers for inpatient hospitalizations in Minnesota and Wisconsin in the late 1980s and 1990s.  If you look for inpatient psychiatry measures you will find that many of them (polypharmacy, multiple drugs from the same class, discharge planning) are unchanged from that era, despite the fact that the review organization was disbanded because it did not find enough quality or utilization problems to justify its ongoing existence.

The APA points out that Medicare now has a fee scale that takes into account "quality of care measures instead of just paying a standard fee for every procedure (CPT) code".  They have a Physician Quality Reporting System (PQRS) that requires psychiatrists to report on one measure in order to avoid a 1.5% penalty.  For 2013 that report has to be made on one Medicare patient.  This is described as an "incentive" to report on quality performance measures and of course a "penalty" for those who fail to report.   A managed care company would call it a "holdback" in that it is technically work that has been done, but the no cost way to turn it into an "incentive" is just to take it from the people doing the work and make it seem like they are rewarded with it later.

The document goes on to document "measures identified as pertinent to psychiatrists (along with their designated codes)".  If you are a psychiatrist read through these reporting measures and marvel at the morass of initial codes that I am sure are going to grow as this administrative nightmare continues.  The further problem is that Medicare/CMS clearly has the goal of comparing physicians and holding them accountable based on the fantasy that these measures actually mean something in clinical practice or even the world.  And if this list of measures is not enough, there are also 50+ page guidelines online like: "The American Medical Association-convened Physician Consortium for Performance Improvement - Adult Major Depressive Disorder Performance Measurement Set" that describes an additional set of performance measures.  The AMA is involved and if you click the link 2013 PQRS Quality Measures you can search on Major Depressive Disorder and find the following links.  You can download the 50+ page document from the top link.

Most people realize that physicians currently have some of the highest burnout rates of any group of professionals.  Those burnout rates are directly related to micromanagement even before we get to the level I just described in the above paragraphs.  The paradox that every physician is aware of is that these reportable measures are not valid objective markers and they are being promoted by bureaucrats who not only have no accountability but in the case of the mental health system of care are some of the same people who destroyed it in the first place.  Don't forget that Congress skewed insurance coverage of mental illness and addictions so badly that Senators Wellstone and Domenici had to write legislation in an attempt to correct that.  At this time the final form of their legislation is still pending.

So accountability has become the last refuge of scoundrels.  Be very skeptical of any politician or bureaucrat waving that flag.  It has little to do with reality and more to do with promoting their own self interests while creating a tremendous and unnecessary burden for the doctors they regulate.

George Dawson, MD, DFAPA

Nunberg G.  Going Nucular: language, politics, and culture in confrontational times.  Cambridge: MA Perseus Books Group, 2004.

For a complete analysis of political doublespeak as applied to medicine see:

Robert W. Geist:  Hot Air Index: Political/Commercial Double-speak Lexicon for Medicine