Friday, November 9, 2012
Thursday, November 8, 2012
ER Doc perspective
Emergency Medicine News:
1 November 2012 - Volume 34, - Issue 11A, - p no page #
doi: 10.1097/01.EEM.0000422901.91264.53
Viewpoint
Viewpoint: A Letter to the Country from an Emergency Physician
Jacobson, Michael E. DO
Author Information
Dr. Jacobson is a graduate of Kansas City University of Medicine and Biosciences and the emergency medicine residency at Henry Ford Macomb Hospital in Warren, MI. He lives with his wife and four children in Omaha, NE.
Dear America,
I am an emergency physician with an apolitical message in this rather politically charged, polarized time in our country. I have worked for some time in this profession, and have noticed a disturbing trend about which I must speak out — the growing number of emergency department scenarios in which the selfishness and entitlement of those without real emergencies drown out the quiet suffering of those in real need.
This morning a middle-aged woman came into the emergency room in cardiac arrest. ACLS was performed to keep her alive. Other patients were in the ED before she even arrived, certainly with what they felt were emergencies, but treatments for these individuals were placed on hold as this event took precedence. After 75 minutes of continual heroic measures and life-saving interventions, with her grief-stricken husband crying, holding her hand for the last time, and stroking her face, she died.
This was no movie, no reality TV show. This was as real as it gets. Real life and real death. Family huddled around the bed to say their goodbyes and wished they or we could have done more.
I walked to my office, emotionally drained and exhausted, and from across the emergency department another patient, upset that she had to wait, spoke out brashly in tones that carried to every room in the department. “I know someone's dying and all, but I am in real pain here.”
What most of America don't know is the emergency department staff are graded with a nationally based report card by hospital administration. A survey is sent only to those who are discharged from the ED, not to those who actually needed admission to the hospital for an emergency or to those, like this new widower, whose loved one passed. This survey is a customer service tool used to see if people like coming to our ED and asks whether we did a good job. The ED staff know this survey is skewed because of the population to which it is sent, and certainly it is not the only tool hospital administrators use to evaluate us. That is another topic for another time.
But you must understand, the real emergencies are rarely graded or surveyed; they only go to those vast hoards of folks who were sent home, many of whom did not get their narcotic medication refilled, like Ms. “I'm-in-real-pain-here” who screamed her needs for all to hear, just within earshot of a new widower.
Mitt Romney recently was secretly taped speaking to his party base about the 47 percent of the nation that feels entitled to health care, to homes, to handouts, and to ever-present help from the government. If this lady represents that 47 percent, I have a few things to say.
The widower and his wife were also in need of care and financial aid. They came to the hospital for emergency care and received it. He was gracious about it, even when the scenario ended in a way he did not want. He and his family were thankful for the care. They will not be asked how they felt the care was, but screamer lady will be. It is doubtful that screamer lady would have been happy short a lifetime supply of narcotics, free ambulance rides, meals, and immediate gratification of all perceived needs. In fact, she and her friend raided the refrigerator for food and beverages without asking permission of staff or being cleared for eating or drinking prior to her labs and tests returning.
This widower and his family behaved in a way that acknowledged that there were others in the ED. They realized a limited but adequate number of doctors and staff were available. They were calm in the face of a real emergency, but never acted as though the world should stop for them, even though it ended tragically. They knew how to play fair even though their real emergency was not fair.
We live in a society that David McCullough Jr. describes as rewarding mediocrity because everything fairness and equality. Everyone is special, so nobody is. Everyone should get a prize for participating. And even though Johnny didn't win, we're going to give him a trophy for trying because he is special, too. Competition is bad because there is a winner and loser, and that's not fair. This fundamentally wrong notion breeds false equality and ultimately false fairness and entitlement. We do no one a favor by preaching this. We are lazy parents if we can't find a constructive way to celebrate the winner and help our children be happy for him. Instead, we have chosen an easier road: to make all things fair and equal. If nothing can rise above, be more important, or be first, then all must be mediocre. If all must be fair and equal, all will assume the position of being just as important and just as entitled as everyone else despite the real emergency or the real need.
The government mandates I evaluate and treat everyone who steps foot in our emergency department, regardless of the ability to pay or the acuity of the complaint. The government has passed health care legislation that makes it so everyone must have insurance. Now everyone is equal, everyone is the same — the broken physically, the broken emotionally, the broken spiritually, the broken psychologically, and even the broken culturally. Many have primary care doctors, but they storm the ED at 2 a.m. with the Burger King entitlement of having it their way rather than waiting for their own doctor to see them the following day. They will demand to be treated equally regardless of the acuity of their emergency. And you know what? They will probably get it because we don't want a bad report card from the feel-goods upstairs intent on establishing great PR or the lawyers who will use government mandates to take away your pain and make the other guy pay.
Were I to say something to screamer lady about her behavior, she likely would fall back on the clichéd finger-pointing canard, and say, “You're a doctor. You are well off. You don't understand. You can't relate. And you are the one responsible for the high cost of health care. It's your fault.”
As a young, married medical student, my family and I participated in Medicaid because having insurance was a requirement for my rather expensive medical school. I felt grateful, not entitled, to be able to sign up for the program. I know poverty in America because I lived it for a decade despite help from family. Government programs can help for a time. But know this, I spent my high school years working on grades and homework and at a job. I went to four years of college, working on grades and a job. I went to four years of medical school working on grades and leaning on the government for help, which I am now paying back. Then, I worked four years as a resident on call, on 12- or 36-hour shifts with just enough sleep to go back and start again. Now I work. And I work. Work and making good life decisions result in prosperity. No one — I repeat, no one — becomes prosperous on government programs. Student loans, food stamps, Medicaid, and unemployment benefits are there to help temporarily, but for heaven's sake, government aid is not a right and living your life like you are entitled to eternal government care is not right.
Anyone who wants to can go to school for 12 more years after high school and work, incur student loan debt, drive a 14-year-old car for 12 years, and study (while passing on TV, movies, parties, conversation, family life, sleep, and eating to study some more). They can then make a living that buys a nice home, clothes, insurance for family, and, hey, a new car. Anyone who can work can do this. And I'm all for government help for those who, through no fault of their own (and not their poor choices), can't work.
This woman, however, would reach into my pocket and take my hard-earned money while tapping impatiently on my watch to give her more of my immediate time and attention when others need it more, still claiming I am a cold-blooded heartless rich guy intent on robbing her of all the government assistance that is her due while simultaneously stiffing the hospital for what she considers an unconscionable medical bill. I am not cold-blooded or heartless, just tired and beat from the work I do and proud and gratified that I can do it. The same is possible for anyone here in the land of opportunity.
Are we so far gone as a society, in the name of popular progressivism, that we now don't view work as something to be valued, specifically when the work requirement is removed from the welfare bill? Are we so far gone as a nation that we vilify someone for their hard-earned wealth and elect a national leader who believes in taking that away to pay for those who would act as drains and not aquifers to the national pool of prosperity? Have we developed a national mindset that makes it normal to expect others to take care of us?
I think we develop a self-absorption that is callous in the face of anyone else's need when we rely on the government to handle our every need. No respect. No decency, no restraint, no responsibility, and no apology for it.
Frankly, our government cannot fix this, they cannot mandate a solution to this, and they cannot legislate against this. Nor should they. The solution to selfishness and entitlement can only be fixed with a mother and father (who know how to model character) teaching a child that work is hard and rewarding, that life is not fair and never will be, and that the freedoms you enjoy in this life are because someone else paid the price. Get up and get fixing.
Sincerely,
Michael E. Jacobson, DO
© 2012 Lippincott Williams & Wilkins, Inc.
THE MEANING OF YESTERDAY’S DEFEAT
Yesterday was a comprehensive disaster. Here in Minnesota, to add a local perspective, not only did the state go for Obama–no surprise there–but the Democrats recaptured both houses of the legislature, and voters defeated two ballot initiatives, one on gay marriage and one on voter ID. Similar losses were sustained across the nation, although there were a few bright spots here and there. So yesterday’s defeat was not about a flawed presidential candidate or presidential campaign.
What lessons can we draw? To begin with, conventional political wisdom was upended in a number of ways. When a president runs for re-election, the campaign is a referendum on his performance; undecided voters break against the incumbent; it’s the economy, stupid. These and other familiar maxims can be consigned to the dustbin.
But there is a much more important proposition that, I think, was proved false last night: that America is a center-right country. This belief is one that we conservatives have cherished for a long time, but as of today, I think we have to admit that it is false. America is a deeply divided country with a center-left plurality. This plurality includes a vast number of citizens who describe themselves as moderates, but whose views on the issues are identical or similar to those that have historically been deemed liberal.
Decades ago my father, the least cynical of men, quoted a political scientist who wrote that democracy will survive until people figure out that they can vote themselves money. That appears to be the point at which we have arrived. Put bluntly, the takers outnumber the makers. The polls in this election cycle diverged in a number of ways, but in one respect they were remarkably consistent: every poll I saw, including those that forecast an Obama victory, found that most people believed Mitt Romney would do a better job than Barack Obama on the economy. So with the economy the dominant issue in the campaign, why did that consensus not assure a Romney victory? Because a great many people live outside the real, competitive economy. Over 100 million receive means tested benefits from the federal government, many more from the states. And, of course, a great many more are public employees. To many millions of Americans, the economy is mostly an abstraction.
Then there is the fact that relatively few Americans actually pay for the government they consume. To a greater extent than any other developed nation, we rely on upper-income people to finance our federal government. When that is combined with the fact that around 40% of our federal spending isn’t paid for at all–it is borrowed–it is small wonder that many self-interested voters are happy to vote themselves more government. Mitt Romney proclaimed that Barack Obama was the candidate of “free stuff,” and voters took him at his word.
The question is, can this vicious cycle ever be broken? Once we are governed by a majority that no longer believes in the America of the Founding, is there any path back to freedom and prosperity? The next four years will bring unprecedented levels of spending, borrowing and taxation. The national debt will rise to $20 trillion or more. When interest rates increase, as they inevitably must, interest costs will squeeze out other government spending. That might not be all bad, except that defense will go first. If Obama’s second term turns into a disaster, fiscal or otherwise, voter revulsion may return the Republicans to power. But that doesn’t mean that America will be saved.
To me, the most telling incident of the campaign season was a poll that found that among young Americans, socialism enjoys a higher favorability rating than free enterprise. How can this possibly be, given the catastrophic failure of socialism, and the corresponding success of free enterprise, throughout history? The answer is that conservatives have entirely lost control over the culture. The educational system, the entertainment industry, the news media and every cultural institution that comes to mind are all dedicated to turning out liberals. To an appalling degree, they have succeeded. Historical illiteracy is just one consequence. Unless conservatives somehow succeed in regaining parity or better in the culture, the drift toward statism will inevitably continue, even if Republicans win the occasional election.
This is not primarily the job of politicians, but politicians cannot escape it, either. I have been grumbling for a long time that Ronald Reagan was the last politician who made a real effort to teach the principles of conservatism to the American public. Since the 1980s, we have largely been coasting on his legacy. The prevailing assumption has been that America is a center-right country, and if Republican politicians run a good tactical campaign and get their voters to the polls, they will generally win. That strategy no longer works, and conservative politicians need to try much harder not just to appeal to conservative voters, but to help create new ones.
The stark question posed by the country’s unmistakable drift to the left is, does America have a future? Can we once again become a beacon of freedom, or will talented young Americans be forced to look elsewhere for opportunity? Barack Obama’s budget–the one that was too extreme to garner a single vote in either the House or the Senate–projects that in four years, we will have a $20 trillion debt. That debt will be paid off by a relatively small minority of our young people, the most productive. If you were in that category, and had to make a choice between staying in the United States and inheriting a debt that could well be $1 million or more, and starting fresh in another country, what would you do? And if you were an investor, where would you put your money? In the United States, where hopelessness reigns and where high unemployment and close to zero growth are now accepted as normal, or in a country with limited government and a dynamic, growing economy?
These are dark days, indeed.
Wednesday, May 16, 2012
I Was Wrong About Marriage
Earlier this week, the Washington Post’s David Wiegel (a quite nice and inquisitive guy, by the way)apologized for tweeting that people who defend traditional marriage “anti-gay marriage bigots.” In an extended post, Wiegel explained why he said what he said:
But why was I willing to be so disrespectful to one group of activists? Unlike with most activists, I don’t really see the direct impact on their lives, or on the lives of the people who agree with them, of the cause they oppose. Antitax protesters are threatened by higher taxes. Anti-health-care-bill protesters fear their coverage will get worse. Anti-meat-eating protesters believe animals are being murdered and the environment is being made worse . . . But who’s threatened by legal same-sex marriage? Whose life is made worse?
When I read those words, they reminded me of a strikingly similar sentiment from aJanuary, 2004 op-ed, written shortly after the Massachusetts Supreme Judicial Court legalized same-sex marriage in Massachusetts:
Unfortunately, the conservative argument against gay marriage often reeks of hypocrisy. Our society stopped viewing marriage as a sacred (God-ordained) institution long ago. Since the invention of no-fault divorce laws, divorce rates have skyrocketed. Now, almost half of all marriages end in divorce.Even in the conservative Christian community, divorce is rampant. As the only lawyer in my church . . . I frequently receive telephone calls from fellow church members requesting assistance on child custody matters, property division and other divorce-related questions.I have fielded so many questions about divorce that I am sometimes surprised when I encounter middle-aged congregants who have not been previously married. The gay community could not treat their marriage vows any worse than many Christians treat their own.For those who believe gay marriage is morally wrong for Biblical or other religious reasons, this decision changes nothing. Churches can still speak out against sexual immorality and can still choose not to perform gay weddings. The gay couple down the street in no way makes our own straight marriage more difficult or challenging, nor can any decision of any court of law change the definition of marriage in the eyes of God.
Now, why would I remember an op-ed from 2004, when I sometimes can’t even remember blog posts I read five minutes ago? Because I wrote it. For some time after the Massachusetts decision, I supported legalizing same-sex marriage — or, to be more precise, I did not oppose its legalization.
Why? I can basically sum it up in one sentence. I have a strong libertarian streak and was completely fed up with the cavalier way in which the Christian community treated its own marriage vows. .
But I was wrong. No, I wasn’t wrong that Christians have their own marriage problem. That much is obvious. I was wrong in believing that there was essentially “no harm, no foul” legally or culturally in recognizing “gay marriage.” I was wrong to believe that the proper response to the damage to done to the institution of marriage was to essentially throw our hands up and allow even further damage. And I was definitely wrong to believe that legalizing same-sex marriage — as a practical matter — is a libertarian decision in the real world.
With so many college students jumping on the same-sex marriage bandwagon, often for the very reasons I did, it might be helpful to explain why I was wrong, and why I came to understand that marriage must be defended.
First, it’s important to note that I initially approached the marriage question from a fundamentally incorrect starting position — implicitly adopting the argument that marriage exists for the benefit of adults, for their fulfillment and enjoyment. This is a fundamentally selfish view of marriage (I’m getting married to fulfill me). Instead, marriage is the fundamental building block of the family, the cultural cornerstone of a society, and it exists primarily for the benefit not of adults but of children.
Why does that distinction matter so much? Because we now know — after decades of social experimentation for the benefit of adults (from the disaster of no-fault divorce to the widespread acceptance of out-of-wedlock births often to avoid “stigmatizing” — that’s right — the adult), we now understand that we have made a horrific cultural error:
Children from two-parent families are better off emotionally, socially and economically, according to a review of marriage research released Tuesday in The Future of Children, a journal published jointly by the non-partisan Brookings Institution and Princeton University’s Woodrow Wilson School.. . .“When we were saying it doesn’t matter in the ’60s and ’70s and ’80s, we didn’t have the experience of enough kids in a culture when families were breaking down. It was just our best guess,” says Diane Sollee, a former marriage and family therapist who organizes an annual conference for marriage therapy professionals.
We consented to no-fault divorce and increases in single parenting in part because there was “no proof” that it was bad for us. But now, the proof is in, but it took a while to accumulate. One does not necessarily discern cultural trends instantaneously:
Only in recent years has research shown the benefits of couples staying together; long-term studies on the children of divorce were not available earlier. But Census data show that single-parent families have increased while two-parent families have decreased.
Doesn’t it make sense for us to encourage and support those institutions that leave children “better off emotionally, socially, and economically” rather than institutions that leave children worse off?
I know the typical response to this: There may be proof that other alternatives to the two-parent, mother-father family harm children, but there’s no proof that same-sex parenting harms kids. It’s a recent phenomenon, and the data just isn’t in. Yet weknow that the traditional family is good for kids. We know that every other long-term family permutation has proven bad for kids. How can we logically justify taking yet another risk with our cornerstone cultural institution? So to answer David Wiegels’ question: who’s hurt when we depart from the traditional family structure? The kids.
So, what should we do? To me, the answer is relatively simple. Hold the line on same-sex marriage, try to roll back the pernicious, adult-worshipping institution of no-fault divorce through innovations like covenant marriage, and — crucially — model the right behavior by denying self and serving others in your own life and marriage.
Yet it’s not “just” kids who are hurt when we change the definition of marriage. Ironically enough (considering my initial libertarian impulses), same-sex marriage is leading to a campaign of repression and censorship against religious individuals and institutions. Same-sex marriage is resulting in less liberty, not more. The trend first emerged when the Commonwealth of Massachusetts attempted to force Catholic Charities to match adopted children with same-sex couples. Catholic Charities had to decide between its religious convictions and compliance with state mandates. It chose to follow Catholic teachings and stopped providing adoption services. Since that time, we’ve seen college students punished for refusing to support same-sex parenting, graduate students thrown out of counseling programs for refusing to affirm homosexual sex, denials of tax exemptions for church land when the church refuses to host same-sex ceremonies, photographers punished for refusing to photograph same-sex commitment ceremonies, and social work licenses threatenedmerely because the social worker publicly supported a state marriage amendment.
And this litany doesn’t even begin to recount the avalanche of constitutional litigation surrounding the “sexual orientation” issue. After all, if the Christian Legal Society losesCLS v. Martinez (argued last month before the Supreme Court), then Christian campus ministries in American public universities may be required to open voting membership and even leadership to individuals who engage in homosexual activity. Such a ruling would have massive ramifications off-campus as well, potentially placing at risk the tax exemptions of every biblically orthodox church in America.
For a movement that says its about “love,” this campaign of repression (which has even included widespread threats of violence and personal retribution against marriage amendment supporters) often seems quite hateful and bigoted in its own right.
In 2004 I was both pessimistic and foolish. I did not foresee the conservative community rallying in response to the Massachusetts Supreme Judicial Court’s decision and marriage amendments sweeping the nation. I viewed marriage through the prism of adult rights and adult enjoyment rather than through the (proper) prism of adult responsibilities and cultural foundations. The citizens of each state have the right and responsibility to defend marriage and do what they can to halt a cultural decline that has elevated parents over children. It is not “bigotry” to realize a fundamental truth: “What parents want and what’s good for kids isn’t always the same.” It is not bigotry to oppose legal changes that are leading to a wave of censorship, intimidation, and even threats of violence against religious institutions and individuals.
David Wiegel wrote: “I can empathize with everyone I cover except for the anti-gay marriage bigots. In 20 years no one will admit they were part of that.” But this assumes that the tides of history and opinion are irreversible, that the opinions of our youth are permanent. They are not. And I’m living proof.
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