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.

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