Saturday, December 26, 2009

Inadequate Coverage

The End of Print Media?

To the Editor,
I am writing to you to register a complaint regarding your newspaper, The Houston Chronicle. I’ve noticed that recently the coverage provided by your publication has been inadequate. The exposure in recent months has been unacceptable and has left glaring gaps that are intolerable. Actually, I’ve noticed this deficiency since the fall of 2008.
During the most recent Presidential Campaign I have to say that your newspaper met my needs in a most efficient manner. I rarely found any significant areas left uncovered and nothing of importance ever was missed by your pages. However, starting around the time of the 2008 election I began to notice glaring deficiencies. At first I tried to ignore the obvious lack of coverage, but after a while I found it impossible to overlook.
So, I decided to change. After looking at all the possible substitutes I settled upon The Wall Street Journal. Admittedly, this paper also may be lacking in some departments compared to the Chronicle, but no other paper surpasses the quality of its coverage. Since I’ve made the change there are no more gaps and my time utilization efficiency is greatly improved.
Now, every Saturday, when I change the paper at the bottom of Isaac and Rebecca’s cage I am thankful for The Journal. The paper overlaps perfectly, so that when one layer is removed the layer underneath is pristine and ready to receive whatever may fall its way. I am also using fifty percent less paper each week and, thus, am helping to preserve one of our most precious natural resources.
As an added benefit Isaac and Rebecca, two Eclectus parrots native to the Solomon Islands, are speaking in much clearer tones and their words seem to make more sense. Of course they have been clamoring for more luxurious accommodations ever since I left the “Homefront” page staring up at them.
And so, dear Editor, it is with a heavy heart that I am cancelling my subscription to the Chronicle. The reduction in the size of your pages was the final straw. I may miss “Dear Abby” and “Blondie”, but I believe that the benefits to our planet and to the aching in my back far outweigh any potential negative effects.
I thank you for your consideration.


David Gelber MD

Sunday, December 20, 2009

Christmas Carols

Christmas Carols
A Message for the Season

This Christmas season brings memories of growing up in the quiet village of Scotia New York. The winter holiday season was always highlighted by the Lincoln Elementary School carol sing. This was a mandatory school event which featured all the students of the school assembling in bone chilling cold to offer heartfelt renditions of a variety of Christmas classics.
The songs were always Christmas songs, some with religious themes and some with wintertime and seasonal themes. There was never any apology made to non-believers and there was no such thing as political correctness and, as far as I know, no student was ever excused because “we don’t believe in that.” So, we took turns lining up in front of our freezing parents, singing our little hearts out and, afterwards, we were treated to Christmas cookies and other delights.
Thoughts of this annual event came to me the other day as I posed the question to the operating room crew: “What is your favorite Christmas carol?”
My assistant across the table offered up “O Christmas Tree”, a wonderful song that speaks of the steadfast, faithful and unchanging nature of God. The others in the room were stumped and did not give an immediate response. Years ago while I was reading the autobiography of Harpo Marx there was one anecdote recounted where he and some of the very literate people of his day asked a very similar question; only their question was “name the best song of all time”. Their collective answer was “Silent Night”.
I really believe that “Silent Night” is a beautiful song that captures the holy nature of the newly born Jesus, but it really does not do justice to the events surrounding that wonderful Christmas Eve.
Christmas Eve started as thousands of other nights had begun, quiet, cold, mundane. But, all of a sudden, for no obvious reason, the shepherds in the field have this quiet solitude rudely interrupted. An angel comes to announce a birth, the birth of a Savior. Then, the night sky suddenly becomes bright and is filled with all the Heavenly host announcing the birth of a new King, but not just any old earthly king. This is the King of the universe, a baby, God’s own Son, sent to save the world. This is an event that was anything but silent. It was and is, rather, a reason for shouting; shouting with joy as the angels announce a new order for our world, one that promises Peace and Goodwill.
The shepherds leave their flocks and investigate and what do they find? The baby, lying in a manger. Perhaps at this moment there is silence as they, along with Mary and Joseph, ponder the cosmic implications of this singular event. The silence is brief, however, as the shepherds leave and spread the news to everyone that can hear, all the while singing praises to God. Definitely, the Christmas story is not one of silence.
My response to the question, “What is your favorite Christmas carol?” results in a tie. My first favorite is “Hark the Herald Angels Sing”. This song brings all the joy and exaltation of Christmas, while also summarizing all the hopes for mankind that Jesus brings. It is best sung with all the power and force one can muster; a true celebration of the true meaning of Christmas.
My other favorite carol is “The Little Drummer Boy”. It is a relatively modern song, written in 1958, but it carries a message that I think we all should heed. Christmas is about giving. God gave this world the greatest gift imaginable, his only Son. But he didn’t just send his son to live among us. Jesus came for one purpose: to reconcile a wayward, sinful people to their Holy God. It is this great spirit of giving all that you have that “The Little Drummer Boy” presents. This spirit of giving and hope is the true message of Christmas, a message for the Christmas season and all the year.

Hark! The Herald Angels Sing

Hark! the herald angels sing
Glory to the new-born King!
Peace on earth and mercy mild,
God and sinners reconciled!
Joyful, all ye nations, rise,
Join the triumph of the skies;
With th' angelic host proclaim
Christ is born in Bethlehem!
Hark! the herald angels sing
Glory to the new-born King!

Christ, by highest heaven adored;
Christ, the everlasting Lord;
Late in time behold Him come,
Offspring of the Virgin's womb.
Veiled in flesh the Godhead see;
Hail, the incarnate Deity,
Pleased as man with man to dwell;
Jesus, our Emmanuel!
Hark! the herald angels sing
Glory to the new-born King!

Mild He lays His glory by,
Born that man no more may die,
Born to raise the sons of earth,
Born to give them second birth.
Risen with healing in His wings,
Light and life to all He brings,
Hail, the Son of Righteousness!
Hail, the heaven-born Prince of Peace!
Hark! the herald angels sing
Glory to the new-born King!

Come, Desire of nations come,
Fix in us Thy humble home;
Rise, the Woman's conquering Seed,
Bruise in us the Serpent's head.
Adam's likeness now efface:
Stamp Thine image in its place;
Second Adam, from above,
Reinstate us in Thy love.
Hark! the herald angels sing
Glory to the new-born King!

Little Drummer Boy
Come they told me, pa rum pum pum pum
A new born King to see, pa rum pum pum pum
Our finest gifts we bring, pa rum pum pum pum
To lay before the King, pa rum pum pum pum,
rum pum pum pum, rum pum pum pum,

So to honor Him, pa rum pum pum pum,
When we come.

Little Baby, pa rum pum pum pum
I am a poor boy too, pa rum pum pum pum
I have no gift to bring, pa rum pum pum pum
That's fit to give the King, pa rum pum pum pum,
rum pum pum pum, rum pum pum pum,

Shall I play for you, pa rum pum pum pum,
On my drum?

Mary nodded, pa rum pum pum pum
The ox and lamb kept time, pa rum pum pum pum
I played my drum for Him, pa rum pum pum pum
I played my best for Him, pa rum pum pum pum,
rum pum pum pum, rum pum pum pum,

Then He smiled at me, pa rum pum pum pum
Me and my drum.

Wednesday, December 9, 2009

On Surgery

One Surgeon's perspective

This blog is called Heard in the OR, a place I spend many hours most days, rummaging around inside people’s bodies. I hope that you will get a glimpse into what can be the bizarre thoughts of one surgeon and I hope you enjoy what I have to say. I welcome any and all comments.
For more than twenty years I have made my living as a general surgeon. This is more than a job, perhaps even more than a profession; it is best described as a passion. The surgeon is called to be passionate about what some would call the unthinkable, the extraordinary, the epitome of arrogance. “Arrogance”, one may say, “how can that be?”
What a surgeon does can only be called arrogant. The surgeon takes an incredibly sharp instrument, slices through living human tissue, and in the course of the operation decides what organ is offensive and is to be removed and what is innocuous or important and is to remain. Or, the surgeon may rearrange our tissues, taking what was once God’s perfect creation and altering it for a, presumably, nobler purposes. Man nobler than God? “Impossible”. Such is the arrogance of the surgeon.
Of course, I don’t in any way imagine any man, surgeon, priest, baker or used car salesman to be nobler than God. It is one of the consequences of living in this fallen world that we need surgeons. Diseases and the specter of Death having been released with the first taste of the forbidden fruit create a need for physicians and surgeons to help keep these evils at bay.
What is it that makes anyone do such a thing? How is it that out of a typical class of one hundred medical students some will choose to pursue a career in surgery. And, after years of rigorous training, of getting out of bed at three in the morning to attend to an anonymous individual who had the misfortune to be hit by a bus, shot, stabbed, suffered a perforated intestine or any number of maladies that can’t tell time, this endeavor remains a passion, something done for the reward of seeing the sick and injured walk out of the hospital alive and whole.
I’ve often considered that what surgeons do for a living would be reason for incarceration if it was done away from the operating theater. In general, cutting people open with sharp objects is considered socially inappropriate and frowned upon by legal authorities. To avoid this hazard the operating theater was developed and we surgeons try to limit such endeavors to that location. Theater is an appropriate description; surgery used to be performed in just such a way. Students and professors would observe the operation from seats in an amphitheater; sterility not a prime concern in those days. Even after the research of Joseph Lister introduced the concept of asepsis to surgery, thus eliminating the open spectacle, the operating room still had observation decks, frequently seen in old movies, but rare today.
So, we surgeons, haughty actors of the medical world, ply our trade before a smaller, but captive audience: anesthesiologist, circulating nurse, surgical technician, surgical assistant and the occasional student. But, the star and center of any operation is not the surgeon; rather it is the patient. Above all, the patient is given the most attention, loving care with every detail of the procedure geared towards carrying this individual to a successful outcome.
Before any operation time is spent evaluating, examining and explaining the operation to the patient. A very common question I hear is something like this: “This is routine isn’t it?” Most of the time the answer is that a particular operation is common, hopefully straightforward, but I never consider it routine. Every operation requires proper planning, attention to detail and the utmost care. And, with every procedure surgeons have a single goal; to perform the right operation, at the right time, with proper technique so that our patient returns to their normal life as expeditiously as possible.
A general surgeon spends 5-6 years in residency after medical school studying and practicing every aspect of the profession so that at the end of his time he believes he is fully and properly trained. This residency provides the necessary basics; how to evaluate a patient, plan surgery, carry out the operation and provide post-operative care. All those years certainly seems to be enough time to learn all that needs to be learned. But, in reality, the practice of surgery is a lifetime of learning. Every day brings the potential for something new, an unexpected anomaly, a new presentation of an old disease, a situation never previously encountered; one that may only echo a vague memory of an article read in an old journal.
So, in our arrogance, we are humbled. It is this humility that separates the good and very good surgeons from the great surgeons. Because, every person that picks up a scalpel has to have the arrogance, the confidence that says I can do this better than anyone. If this belief is missing and the surgeon believes that another surgeon can do the job better, then it is in that patient’s best interest to be referred to that other surgeon. If humility is lacking, the patient may suffer.
What about humility? Physicians quickly learn that, despite our best therapeutic efforts, the human body can be a frustrating and unforgiving subject. Invasion by micro-organisms, tumors, external forces and foreign objects or even by the body attacking itself can rapidly overcome all our good intentions. We do all we can to give our patients the greatest chance for complete recovery and, happily, we are successful in the vast majority of cases. But, every individual is unique and every individual demands our unflagging attention. It is something I am reminded of everyday. The truly great surgeon is never so arrogant as to believe that something can’t be wrong. It is an unfortunate truth that patients sometimes become sick after surgery; that our best efforts may not have been good enough. When this happens we start to look for a reason; all our searching usually leads back to the original operation; something bleeding or not healing as expected, an infection or a wide variety of other potential complications. And so, it is the surgeon’s humility that allows him or her to say, “something’s not right, I need to figure this out and solve this dilemma.” It is this attribute that comes with experience and is the single, most difficult thing for the young surgeon to learn.
Arrogance and humility, truly an oxymoron, but no two words give a better description of what we surgeons are made of. It takes a truly unusual, dedicated person to follow the trail that at the ends bestows the title “Surgeon”. I have followed this path for twenty years and have always enjoyed the challenge. I hope you are informed and entertained by my words as I record them in the months and, hopefully, years to come.

Friday, October 30, 2009

It's Alimentary

Praise to our Intestines

My recent work has taken me to weaving my way in and around people’s bowels, something that is a common task for any general surgeon. However, I’ve had more than my usual share over the last few weeks. While making my way around a particularly difficult colon today those of us in the operating room discussed the relative merits of what has been named the alimentary tract, our intestines, the gastrointestinal tract, bowel , guts or “chitlins”.
If one considers all our various organs one would have to agree that our GI tract is, by far, the most intelligent. Think about it; our brain stands isolated within its protective cage, so snobby and aloof, only allowing certain special materials to enter its domain, always giving orders, but out of touch with its co-organs. The heart is a tireless worker, but mindlessly does the same thing over and over, day in and day out, blood comes in, blood goes out. Ditto for the lungs, a monotonous pastime of breath in, breath out, inhale, exhale, occasionally fending off noxious fumes and fighting invaders.
Kidneys are efficient cleaners and bones are glorified coat racks. Muscle is a little smarter, only working when called upon, but always the same thing, relax, then contract, hold this up, push that down. No wonder they get stiff and sore.
But our bowels do remarkable things. When not needed they rest, blood flow is shut down and our guts essentially go to sleep. Yet, when called upon, they spring into action, sorting out a variety of nutrients, directing them to the liver through the bloodstream or bypassing the liver sending fats through our lymphatic system.
This long tunnel through the middle of our body is constantly fending off invaders, be they micro-organisms, noxious chemicals or a variety of foreign bodies. The GI tract lives in symbiosis with huge numbers of bacteria, using these microscopic invaders for its (and our) own purpose. Yet if one of these foreigners behaves badly they are expelled, one way or another, causing us a brief period of discomfort, but also keeping us well. No other organ has to deal with such insults on so massive a scale, yet our bowels handle them with aplomb. Perhaps, our skin, the body’s largest organ, comes close, but on a much smaller scale.
So, I say, let us praise our bowels. When they are working properly they keep us happy, healthy and whole. But, when they go bad; when they are blocked or punctured or dying nothing can make us so incredibly ill. I say there should be a take your bowel to lunch day. But, come to think of it, everyday is take your bowel to lunch day.

Thursday, October 22, 2009

The Obesity Problem

The Obesity Problem

Today I read an article that tried to shed light on a medical condition endemic to modern society. Obesity plagues our post modern world, particularly in the United States and more particularly in Houston, Texas; my hometown. Houston carries the dubious distinction of having been named the least physically fit, most obese city in the US several years ago. In my general surgery practice I face this reality every day.
There is no question that obesity contributes to the rising costs of health care. Overweight patients can turn straightforward surgical conditions into complex operations that may require significant adjustment or compromise to have a successful outcome.
There is a huge industry catering to the desire of the obese individual to go from size 20 to size 8 or 48 waist to 36. Fad diets, diet pills, lap bands and gastric bypass surgery ads fill our airways, magazines and internet pages promising a svelte and youthful body in thirty (or sixty or ninety) days or your money back.
Today in surgery, while creating a colostomy (always a mind stimulating endeavor), we proposed a powerful solution to this pervasive problem. As background let me say that human beings originally were foragers, searching for their food. Later they became hunters and eventually farmers. The scarcity of food was the driving force in ancient society and wealth was measured in sheep and cattle, rather than dollars.
Of course, times have changed and scarcity of food has become a thing of the past in our developed nations. A casual stroll down the aisle of the neighborhood megasupermarket will result in a cart laden with all the necessities of life. As a matter of fact one need not even make the short drive to the grocery. With a few clicks of your trusty mouse it is possible to select and have delivered to your front door everything you need to keep your pantry and your stomach full.
So, today those of us in surgery decided it is time to return to our ancestral roots. The supermarket should become a place to hunt and forage for food. No longer should the shopper be allowed a leisurely stroll down capacious aisles. No, it is time to work for our food. And, to battle obesity, food that is high in fat and calories should require the greatest work. Fresh fruits and vegetables could require only a short stroll through the “Produce Patch.” However, high fat steaks would need to be hunted, perhaps in a way akin to laser tag, requiring shooting a moving freezer to claim the elusive porterhouse. A craving for donuts would necessitate rock climbing a forty foot wall and Twinkies would oblige the shopper to face a fire breathing mechanical dragon armed only with a sword and a shield.
This very modest plan would fight obesity in several ways. The effort expended to successfully reach the desired food would burn off a considerable number of calories. Those individuals that are unable to put forth the necessary effort would have to forego their fried pork rinds or Ben and Jerry’s and be forced to diet or eat healthy, easily obtainable food.
This plan could solve not only the problem of obesity, but also food shortages in some countries as extra food would probably become available and could be shipped to those in need. A major healthcare issue also would be addressed and in the long term health care costs would go down. Such a modest change could reap benefits for decades.

Friday, October 9, 2009

Global Warming

New Data on Global Warming

An announcement issued today from the Environmental Protection Agency warned of a sudden spike in global warming. This phenomenon has been followed since January of this year. Intense research by the EPA in conjunction with the environmental studies dept at Wassa Matta U. has traced the source of this CO2 spike to Washington DC.
Apparently, increased emissions of carbon dioxide have been measured in the areas around the District of Columbia, southern Maryland and northern Virginia. The economic crisis, coupled with the US Congress’ attempts to reform health care along with cap and trade have led to unprecedented CO2 release from members of Congress and the Executive Branch. The excessive CO2 emissions have also coincided with a three hundred percent increase in hot air emanating from this region of the country.
An executive order was immediately issued from the Obama administration aimed at attacking this environmental hazard at its source. Starting November 1, 2009 there will be strict controls instituted to curb this CO2 release. The order states that Democrats will only be allowed to exhale on Mondays, Wednesdays and Fridays. Republicans will have exhalation rights on Tuesdays, Thursdays and Saturdays. Sundays have been deemed a day of rest and no exhalation will be allowed by members of congress from either party on this day.
An unnamed White House spokesman issued this statement, “The President realizes that this is a drastic step to take. However, the EPA has declared a state of emergency. There estimates are that these new regulations will not only slow the growth of global warming, but actually may allow the planet to cool by several degrees.” When questioned about the Executive Branch reducing its own release of greenhouse gasses the spokesman replied that steps had already been taken in this area. He reported “Although the President firmly believes that CO2 emissions from the Executive Branch have been within appropriate limits he still wants to show that he is doing all that he can. Consequently, he has taken steps to eliminate all carbon dioxide and hot air emissions from the Vice President.”
The newly released order was met with cheers from Wall Street where the Dow Jones immediately rose over 350 points. There was also loud applause heard in northern Alaska where large numbers of polar bears had gathered.
Reaction from Congress was swift. Both Democrats and Republicans condemned the order, calling it an end run around the constitution. A few thoughtful senators, however, stated that it was a wise decision and that they would make every effort to comply. They even went farther, stating that if the newly imposed regulations were effective they would consider drafting legislation that would apply to the many cable news and talk radio sources of excessive CO2 release. FOX News reacted by calling it a violation of the First Amendment. Stay tuned.

Sunday, October 4, 2009

The Health Care Debate Part 2

The Healthcare Debate
The View from the Trenches, part 2

The last article I posted cast light upon the virtues of a single payer system for the delivery of health care to the people of our country. In the time since I wrote that article I’ve had the opportunity to discuss the matter further with many of my colleagues. Responses ranged from enthusiastic agreement to belligerent argument, with several variations in between.

The most commonly voiced objection to a single payer system is that “the government can’t manage anything.” I think there is evidence to the contrary, but the objection raises a very valid point. Reports out of Washington are daily reminders of the incredibly dysfunctional apparatus that is our federal government. An article written by a medical doctor who has been serving in our nation’s capital for the past year casts a bright light on this fact. Our representatives are bogged down in a quagmire of lobbyists, special interests, bloated staffs and insulation from their true employers, namely us.

Politics and perception overshadow careful analysis, scientific study and simple truth. It seems that few congressmen have the time or desire to study this issue from a truly objective vantage point. They glean their information from a bevy of special interests bent on preserving their own slice of the $2.4 trillion healthcare pie and ignore most of the facts that would allow a truly educated decision. In my last article many of these facts were presented.

But, assume for the moment that it is true that the government is not capable of properly administering a Medicare for all system. What is the answer? It seems to me that policy could start at the federal level and then be administered by private insurers. Certain minimum requirements would be mandated, including what and what is not covered, establish appropriate reimbursement for providers and set insurance premiums at a reasonable level. That sounds like a step towards rationing you might say; correctly. But it is no different than what occurs now everyday.

For example, a teenage boy comes to see me with a condition called gynecomastia. This means enlarged breasts in a male. The abnormality may be minor, barely noticeable or it may be a gross abnormality. Either way the unfortunate boy suffers terrible ridicule from his peers. The condition is easily remedied by a surgical procedure, subcutaneous mastectomy. Despite the potential psychological damage the boy may have to endure if the condition remains uncorrected, this procedure is almost never approved by insurance companies; they consider it cosmetic. The patient, his parents and I are left with a dilemma, how do we provide appropriate treatment for this teenager? If the family has resources they can pay out of pocket, probably $4-5000 for the outpatient surgery. I could lie to the insurance company and give them a diagnosis that they will cover, but I really don’t want to commit fraud. What I almost always do is take photos and send them to the insurance company, argue with the medical director at the insurance company, have the parents call the insurance company and after all this, once in a while, the surgery will be approved. In many instances I can find a way to take care of this patient, but sometimes the patient remains untreated.

Denials by health insurers are a daily occurrence and are the current form of rationing health care. It seems to me that any health care reform will have to draw the line somewhere. There certainly is no argument from anyone that a facelift or breast implants (except for reconstruction after cancer surgery) are cosmetic and should not be covered by insurance, just as no one would argue that removal of a cancerous portion of colon should not be covered. There are, however, numerous conditions like the one cited above that are in a gray zone. How they will be dealt with is one of the central issues to any reform proposal.

Having raised these points, what, then, is the answer? The answer lies in spending the healthcare dollar on healthcare. The previous article cited the very high administrative costs for private insurance under the current system. These costs would need to be eliminated and the savings redirected to actually providing care. A government sponsored health plan, one that people could purchase at true cost, should be developed. Health savings accounts coupled with high deductible insurance should be offered. These entities put the power of choice directly in the hands of the consumer and direct the healthcare dollar to patient care, not to administration. A plan such as this is what I have for myself and my family. I have a deductible of $5200, a heath savings account which can be accessed for smaller or uncovered incidents, but catastrophic insurance that pays 100% of costs after the deductible. This allows me to save money each year, but protects me at the same time.
A few other points need to be made. I see the health insurance industry licking their collective chops at the prospect of health care reform as it is currently being proposed. A mandate that 50 million individuals who currently do not have health insurance all of a sudden be covered presents an unexpected bonanza to all the Aetnas and United Healthcares out there in insurance land. Many of the uninsured are that way by choice, foregoing health insurance and playing Russian roulette with their health; many are healthy and rarely use the health care system. Adding these people to the rolls of the insured will put a large amount of money into the insurer’s pockets. I think policy should be that this money be used for health care and not for insurer’s profit. In particular, this windfall should be earmarked to help defray the costs of providing health care to the indigent and those for whom requiring health care coverage would be a great burden.

Health care reform should include relief for providers from frivolous malpractice claims. I am lucky to live in Texas where recently passed reforms have made our state one of the more attractive places to practice medicine. The reforms do not prevent meritorious suits from being filed, but have drastically reduced frivolous claims.

Finally, any reform should be a change in health insurance, not health care. Doctors, nurses, therapists and technicians all receive very thorough training and the overwhelming majority wants only the opportunity to take proper care of our patients and to return them to good health. We all work together towards this goal. Those doctors whose only motivation is earning money soon find themselves in trouble and out of work. There is talk of legislating “clinical, best practice guidelines” with the suggestion that providers that do not adhere to such guidelines face some penalties. However, good medical care cannot be legislated. It is taught in our medical and nursing schools, during internships and residencies and through years of hard work and experience. Every patient is a unique individual and most do not fit into the classic illustrations presented in our textbooks. Despite what one may read, doctors and all allied health professional do a pretty good job of policing themselves and this should be allowed to continue.

In conclusion, I think that any reform of health care insurance should allow the providers to continue to provide high quality care. Money earmarked for healthcare should be spent on the delivery of such care, not on administrative costs or profits. A properly and efficiently administered single payer plan is the most cost effective and efficient system, but any private company that can provide health care coverage within legislated guidelines should be allowed.

Let’s hope that our representatives in Congress can suddenly find the wisdom and fortitude to give us such a system.

Sunday, September 13, 2009

The View from the Trenches
David Gelber MD

So much of the news these days centers around the great health care debate. The sorry fact of about forty five million uninsured Americans coupled with millions more that are under insured has kicked off this great discussion; something that is long overdue. It is unacceptable that citizens of the supposedly greatest nation on this planet have to worry about the consequences of an unexpected illness. Although there are frequent comments about access to care and quality of care, the truth is that any debate on health care insurance and spending comes down to one thing: money. How much is spent and who gets to profit from the health care dollar is the real center of the debate.

I am a very busy general surgeon practicing in a seven surgeon single specialty group. From my perspective I have had to look at health insurance as a provider and consumer. It is a daily occurrence to find myself caring for a patient without resources. Those that have insurance always require assistance negotiating the maze of regulations, restrictions, copays, exclusions and everything else that encumbers most private insurance. And, yearly my partners and I sit down and review the options available for health insurance for our thirty employees, ourselves and our families.

I have watched politicians offer their comments and opinions with regard to the solution to this crisis and have occasionally laughed out loud at either the ignorance or the duplicity that they present to the public. The great scare phrases: socialized medicine, government controlled medicine and other similar buzzwords ignore the simple truth that we already have a health care system that is essentially run by the government. Not one policy maker in government acknowledges this reality, a reality that my colleagues and I live with every day. They talk about solutions such as computerized medical records and expanded preventive care. I agree that both are important and should be a part of any health care package. It is ingenuous, however, to tout either of these as the only solution to the crisis that exists.
Preventive medicine is already being practiced on a wide scale. It is true that some alteration in destructive behaviors is possible if an individual is given proper incentive. But, unfortunately, our patients are still human beings; humans who will still eat the wrong food, forget to wear their seatbelt, smoke a cigarette or have an extra drink. And, even if all the unhealthy behavior can be modified, people will still get sick. They may be a little older or it may be a different disease, but they will still catch a cold, fall and break a hip, or step on nail and develop an infection. A fantasy world where everyone is perfectly healthy until they suddenly die at age one hundred twenty is many years away.
The computerization of the healthcare industry is something that is necessary, but will require some investment to achieve. One of the major frustrations we face in our office practice is obtaining old records on our patients. The simplest solution to this problem is a web-based or individual based system of medical data collection. Every test result, operative note, lab test, X-ray report and any other bit of medical information should go into a database for that individual and be made available to any entity that is properly authorized to access it. In addition, the individual could carry it with them on a card or something as simple as a USB flash drive. Such a database would be no different than the credit databases currently maintained by the major credit reporting bureaus.

Still, the big issue in the health care debate is money. What I get paid is, in fact, determined by the government, not only for Medicare, the national health plan for the elderly and disabled, but for every health plan, private or public. Every insurance company bases their payments on what Medicare allows. Most of them pay at Medicare rates or slightly above and this reimbursement has steadily fallen over the years. When I started in practice in the Houston, Texas area eighteen years ago, I was paid about $1600 to perform an open cholecystectomy, at that time the most common surgical procedure I performed. Laparoscopic surgery was in its infancy and payment for this new technique to remove a diseased gallbladder was about $2500. These were typical payments from private insurers. Medicare was somewhat less at that time. Today I can expect to receive about $700 for a laparoscopic cholecystectomy, be it a patient with Medicare or with private insurance. Open cholecystectomy actually pays a little bit more, which is appropriate as open surgery (that is a regular, larger incision) is usually a more difficult operation performed on a sicker patient. These dollar amounts are in real dollars and do not account for inflation. I recently read an article, written by a professor of healthcare economics, that talked about cost shifting that is done by physicians to compensate for the poor reimbursement from Medicare and Medicaid. This was the reality twenty years ago, but the days of such a practice have long passed. Oh, I can bill Aetna or United Healthcare $3000, $10,000 or $50,000 for a Laparoscopic Cholecystectomy; I will still get paid about $700. Truly, the days of private insurers making up for poor government reimbursement are long gone.
The burgeoning population of uninsured patients is creating a huge burden on the nation’s healthcare providers. In 1991, as a group, we did about eight per cent of our work on Medicaid and uninsured patients, mostly emergencies that came to us while on call for various emergency rooms. In 2009, our group as a whole now sees about 22% of our work being done on uninsured patients only, still mostly admitted through hospital emergency rooms. If Medicaid patients are included, the number goes up to about 27%. Medicaid is the government sponsored healthcare program for the indigent and reimburses at a rate that is below Medicare.
A simple truth that I rarely see mentioned is that almost every uninsured person in this country could receive adequate healthcare coverage without spending a single dollar more on healthcare than we presently spend. Administrative costs for privately insured healthcare in the United States are around thirty one per cent, based on a study published in the New England Journal of Medicine in 2003. Every other developed nation has administrative costs around seventeen per cent. The other fact that is rarely cited is that overhead costs for Medicare run about three percent. The highest number cited for Medicare overhead cost is around nine per cent, still far below costs for private insurers..

Medicare pays our practice reliably within two weeks of submission of a claim. The money is directly deposited into our group’s bank account. Scheduling surgery on a patient with Medicare does not require a person in my office to call someone at the Medicare office to get approval. Years ago we did have to deal with the Texas Medical Foundation (TMF), which was the agency Medicare required us to contact for precertification of certain procedures, but it was found that this was not cost effective. It was determined that nearly one hundred per cent of the proposed surgeries had the proper indications and the TMF was a colossal waste of the taxpayer’s money. A patient with Medicare also has the luxury of choosing almost any facility or provider, something that is not true of most of the private insurers, these being an amalgam of PPO’s, HMO’s etc.
Nine out of ten physicians that I speak with about this issue agree that Medicare or a Medicare-like system for everyone would be the best solution to the health care crisis. Such a system need not be completely administered by the government, but any private insurer should be required to offer equivalent benefits, reimbursement and comply completely with all Medicare guidelines.
Why do our political leaders ignore these facts? There is no question that the health insurance industry is directly responsible. The huge dollars involved create a strong incentive for the insurance industry to maintain the status quo. If one examines the numbers closely it is plainly seen that there is enough money in the system to more than adequately care for everyone in the US. In 2007 total healthcare spending was $2.4 trillion. This amounts to about $8000 per person, more than enough to provide adequate coverage for everyone.
Of this $2.4 trillion spent on healthcare about 60% comes from private insurers while the other 40% is from government programs, Medicare and Medicaid. Studies suggest that administrative costs for these private insurers are around 31% or $446 billion. If these administrative costs were reduced to 10%, then the savings would be more than adequate to cover all the uninsured in the nation.

There is one other point I think needs to be made. The media frequently cites a statistic that goes something like this: A vast sum of money is spent caring for patients in the last six months or year of their life. I would love to have the luxury of knowing ahead of time which octogenarian that presents to the emergency room at 2:00 a.m. with a perforated colon is going to die shortly after surgery, which one is going to develop multi organ failure, but linger for two months and then die, which one will be ill for two months and then recover and which one will sail through surgery and leave the hospital within seven days. Unfortunately, only the powers above are privy to such information. Until physicians develop such clairvoyance we are limited to using our skill and judgment to treat each patient as an individual, on a case by case basis.

Years ago, when I first started in private practice I made several predictions. The first was that within ten years we (physicians), would all be working for Medicare rates. This has essentially come true. The second was that eventually a single payer system would replace the current hodgepodge of insurers we have now. At the time most of my colleagues were aghast and strongly against such a system. In fact, several of our local physicians left Canada to avoid such a system and it is true that the Canadian system is plagued by long waiting times for necessary care. However, the US has a vast medical infrastructure in place and proper and fair implementation of a Medicare for all system seems to be the simplest, least expensive and fairest solution to our health care crisis.

As part of my research for this article I made an informal poll of my brothers as to the type of health insurance they provide their employees. Of note is that I have eight brothers, two of whom are also physicians and the rest are owners of businesses with from three to two hundred employees. Only one of my brothers did not provide health insurance to his employees. He said he recently had to drop it, because it was too expensive. He added that for his own family he had “a crummy HMO with the closest in network hospital forty miles away.” He then added that his health care plan for his family was “don’t get sick.” Unfortunately, such a plan is the norm for far too many families these days.