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12/17/2013

LA GENT DEL RIO (THE RIVER PEOPLE) meet NEBRASKA: END OF LIFE TASK


The 5th annual San Francisco Latino Film Festival, Cine+Mas was held September 12-27, 2013. It was a marvel of the best international and national films I’ve seen in a long while.  I was moved by many of the works but the sensibility of the documentary film LA GENTE DEL RIO was profound as my first watching the birth of neo-realism.

An Argentinean film, LA GENT DEL RIO’s directors are Martin Benchimol and Pablo Aparo. It is the story of the people from an aging declining town as told through the voices of its people who are similarly described.  Situated a hundred kilometers from Buenos Aires, the town’s life was seasonal in the past. People came during the summers to swim in and cross the river.  Over the years these transients, dare say rag-tagged visitors, were accused of bringing vandalism to the town. Much of the towns peoples focus became talking about and understanding of what the river people have to do with the fading of the town’s opulence. Eventually, a private policeman is hired who sets up a sentry booth on the town square and patrols to prevent and monitor the river people. In the process the town’s people, through their own presentations lay bare the plight of aging in small, no longer prosperous, rural communities.

On the heels of being so taken by LA GENT DEL RIO, I saw NEBRASKA, Alexander Payne’s most recent film. Remarkably it is filmed similarly, in the neo-realist homage black and white sensibility.   The bioethical themes match the beneficence and autonomy issues associated with caring for the aging, dying and cognitively impaired people in declining small towns.  Both films are life reviews of individuals and the place where they live. Life review is a way of working through end of life tasks.

NEBRASKA is shot on location in a small town in the state for which it is named, and over the highways of four Midwestern USA regions.  The extras, even those with spoken lines are mostly drawn from the streets and bars of this one small town.  Beside the extras, the stars were also brilliant too; Bruce Dern, Bay Area Local Will Forte, Bob Odenkirk, June Squibb and Stacy Keach.  They share the feeling of The River People depicted at the tip of South America, accentuating the universal process of aging in this century.

In the tradition of the Mill Valley Festival there were two separate opening films for this the 36th Festival. NEBRASKA was opening across from the remake of the 1947 film the SECRET LIFE OF WALTER MITTY.  I chose to see NEBRASKA, instead of MITTY because I studied medicine in that state at Creighton University and cared for people in the region. Further, Alexander Payne previously has made bioethics relevant films, particularly CITIZEN RUTH and THE DESCENDANTS. NEBRASKA did not disappoint; raising concerns about the ecology of aging, relevant to Baby Boomers, their elders and children.


LA GENT DEL RIO. (35mm) directed by Martin Benchimol and Pablo Aparo,  Argentina.  Independent. 2012.

NEBRASKA (35mm) directed by Alexander Payne. USA. Paramount. 2012. 

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This entry was posted in Health Care and tagged . Posted by September Williams, MD. Bookmark the permalink.

12/16/2013

Who Messed Up the Obamacare Website? Maybe Private Industry

The flawed rollout of the Federal insurance exchange website has been a huge embarrassment to the President and seems perfectly designed to reinforce the basic economism narrative that the government can never do anything right and that all matters ought to be left to the so-called free market. It’s therefore instructive to review what has happened to one of the state websites, in Maryland, that also has failed to perform as promised (while other state sites, I gather, have been working well). Instead of being a simple parable about how government always messes things up, the true story is more complicated and lays a huge portion of the blame at the doorstep of the private sector.

The story can be found on the Health Care Renewal blog:
http://hcrenewal.blogspot.com/2013/12/sickness-in-information-technology.html
--which in turn cites the original coverage in the Baltimore Sun by Meredith Cohn and Andrea Walker:
http://www.baltimoresun.com/health/bs-hs-exchange-woes-20131207,0,6559272.story

To get the full picture I need to explain that Dr. Scot Silverstein, who blogs for Health Care Renewal about information technology, is very experienced in IT systems for physicians and hospitals, so has had a lot of opportunity to observe the IT industry at close quarters.
The whole story is quite convoluted and it also appears that we don’t know a lot of the story. The Sun reporters sought government e-mails about what went wrong with the Maryland site, but the state officials refused to release a number of the e-mails. Why? Because the withheld e-mails “involved the decision-making process of high-ranking executive officials.” Now, I would have imagined that that’s exactly why the reporters wanted to see those e-mails, and why the public arguably has a right to know what’s in them. But back to the actual website.

Maryland figured it would need a lot of help to get this website operational, and signed up a firm called Noridian to a $71M contract to construct the website. In doing so state officials bypassed the usual procurement procedures, presumably so they could get to work more quickly.
Noridian, having convinced the state that they knew exactly how to design and launch this website, then decided that they didn’t know how to do it after all, and turned around and subcontracted with another firm, EngagePoint. Apparently Noridian at least initially withheld this bit of news from government officials.

Noridian and EngagePoint between them kept reassuring the state that all was well and everything would work just perfectly and on time, leading several officials to make reassuring promises to the public which later came back to haunt them. The website went live and promptly crashed, and some time later the various parties were still trying to pick up the pieces.
As to why the site was such a flop, Noridian replied with a long list of excuses, as to how the site was such a complicated thing to develop and how many different, disparate functions all had to be coordinated in the same place—much more complex than Amazon selling you a book, for example. Dr. Silverstein’s response to this is telling. When you hire an IT firm that’s competent, he says, you expect them to tell you just how hard the job is going to be, how long it will take, and anything you need to know to make it work properly up front. His suspicion, based on his own sad experience, is that in order to snare the contract, Noridian deliberately put out a grossly overoptimistic schedule and work plan. Then, when everything blew up in their face, they suddenly discovered how hard things were after all.

Dr. Silverstein drew on his medical experience to note that, had a surgeon operated on a patient and encountered really nasty but easily foreseeable complications, and then tried to use the difficulty of the surgery as an excuse for not having anticipated and planned for the complications, we’d have a name for that—malpractice.
All this was bad enough, but it promptly got worse. Noridian and EngagePoint started pointing fingers at each other over the blame for the debacle. Eventually Noridian cancelled its contract with EngagePoint, but tried to keep the EngagePoint staff at their jobs and expected them to fix what was broken. EngagePoint sued and Noridian countersued. While the lawyers slugged it out, nothing got fixed.

I am reminded of stories from the very early days of fire departments in the U.S., when fire companies were private, for-profit firms. They would show up if your house was on fire and offer to put it out for a fee. If two rival companies both got to your burning house at the same time, they’d get into a fistfight out in the street as to who had priority to fight the fire, all while your house was burning down.
Not to suggest that the Maryland state government is blameless in this tale of woe and intrigue. But we eventually decided that if fire protection was going to be done in the public interest, we needed to get the private profit motive out of the picture. Maybe a similar lesson ought to be learned about how best to make an Obamacare website that works.

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This entry was posted in Health Care and tagged . Posted by Howard Brody. Bookmark the permalink.

12/16/2013

Who Messed Up the Obamacare Website? Maybe Private Industry

The flawed rollout of the Federal insurance exchange website has been a huge embarrassment to the President and seems perfectly designed to reinforce the basic economism narrative that the government can never do anything right and that all matters ought to be left to the so-called free market. It’s therefore instructive to review what has happened to one of the state websites, in Maryland, that also has failed to perform as promised (while other state sites, I gather, have been working well). Instead of being a simple parable about how government always messes things up, the true story is more complicated and lays a huge portion of the blame at the doorstep of the private sector.

The story can be found on the Health Care Renewal blog:
http://hcrenewal.blogspot.com/2013/12/sickness-in-information-technology.html
--which in turn cites the original coverage in the Baltimore Sun by Meredith Cohn and Andrea Walker:
http://www.baltimoresun.com/health/bs-hs-exchange-woes-20131207,0,6559272.story

To get the full picture I need to explain that Dr. Scot Silverstein, who blogs for Health Care Renewal about information technology, is very experienced in IT systems for physicians and hospitals, so has had a lot of opportunity to observe the IT industry at close quarters.
The whole story is quite convoluted and it also appears that we don’t know a lot of the story. The Sun reporters sought government e-mails about what went wrong with the Maryland site, but the state officials refused to release a number of the e-mails. Why? Because the withheld e-mails “involved the decision-making process of high-ranking executive officials.” Now, I would have imagined that that’s exactly why the reporters wanted to see those e-mails, and why the public arguably has a right to know what’s in them. But back to the actual website.

Maryland figured it would need a lot of help to get this website operational, and signed up a firm called Noridian to a $71M contract to construct the website. In doing so state officials bypassed the usual procurement procedures, presumably so they could get to work more quickly.
Noridian, having convinced the state that they knew exactly how to design and launch this website, then decided that they didn’t know how to do it after all, and turned around and subcontracted with another firm, EngagePoint. Apparently Noridian at least initially withheld this bit of news from government officials.

Noridian and EngagePoint between them kept reassuring the state that all was well and everything would work just perfectly and on time, leading several officials to make reassuring promises to the public which later came back to haunt them. The website went live and promptly crashed, and some time later the various parties were still trying to pick up the pieces.
As to why the site was such a flop, Noridian replied with a long list of excuses, as to how the site was such a complicated thing to develop and how many different, disparate functions all had to be coordinated in the same place—much more complex than Amazon selling you a book, for example. Dr. Silverstein’s response to this is telling. When you hire an IT firm that’s competent, he says, you expect them to tell you just how hard the job is going to be, how long it will take, and anything you need to know to make it work properly up front. His suspicion, based on his own sad experience, is that in order to snare the contract, Noridian deliberately put out a grossly overoptimistic schedule and work plan. Then, when everything blew up in their face, they suddenly discovered how hard things were after all.

Dr. Silverstein drew on his medical experience to note that, had a surgeon operated on a patient and encountered really nasty but easily foreseeable complications, and then tried to use the difficulty of the surgery as an excuse for not having anticipated and planned for the complications, we’d have a name for that—malpractice.
All this was bad enough, but it promptly got worse. Noridian and EngagePoint started pointing fingers at each other over the blame for the debacle. Eventually Noridian cancelled its contract with EngagePoint, but tried to keep the EngagePoint staff at their jobs and expected them to fix what was broken. EngagePoint sued and Noridian countersued. While the lawyers slugged it out, nothing got fixed.

I am reminded of stories from the very early days of fire departments in the U.S., when fire companies were private, for-profit firms. They would show up if your house was on fire and offer to put it out for a fee. If two rival companies both got to your burning house at the same time, they’d get into a fistfight out in the street as to who had priority to fight the fire, all while your house was burning down.
Not to suggest that the Maryland state government is blameless in this tale of woe and intrigue. But we eventually decided that if fire protection was going to be done in the public interest, we needed to get the private profit motive out of the picture. Maybe a similar lesson ought to be learned about how best to make an Obamacare website that works.

Full Article

This entry was posted in Health Care and tagged . Posted by Howard Brody. Bookmark the permalink.

12/16/2013

Top 10 North American Death Panels

by Thaddeus Pope, JD PhD

The term “death panel” is slippery.  It has been used either to describe or to disparage a rather motley group of initiatives and entities.  Here, I review the top ten North American “death panels.”  While common, applying the term “death panel” in the first two instances is inaccurate and misleading.  Indeed, most popular usage of the term “death panels” remains mere calumny.  But, sometimes, the “death panel” nomenclature is actually befitting.  In the remaining eight cases, the term “death panel” fits reasonably well.

1.  Medicare Voluntary Advance Care Planning

The term “death panel” was famously misapplied to statutory and regulatory attempts to expand Medicare provider payments for voluntary advance care planning discussions. …

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12/15/2013

"See one, Do one, Teach one"









 You must read the satire on the "Glorious Tradition" of the description of medical education as "See one, Do one, Teach one" in the October 1 2012 issueof  the "Daily MedicalExaminer" where a doctor K.R. Thuxston. III, MD writes an essay about the topic, presumably "tongue in cheek" but then who knows.   This concept of a medical student or intern learning a procedure  but in reality actually learning it upon a patient and often the patient unaware of the learning going on was a practice considered acceptable back in the old days of medical professional paternalism.  Ah! But then came the last generation of medical practice and education with an ethical switch from medical professional paternalism to patient autonomy.  "See one and Do one" has become a "no-no" ..well, at least not on a living patient or at least not to "do one" with minimal, if any, supervision unless it is only drawing blood from a vein.  Simulators are all the rage now in medical education.  Simulators characterized by "standardized patient" (actors playing patients)  are used for honing up on interview techniques and general physical examination techniques but particularly female breast and genital exam of both genders.  For surgical practice, the simulators can be divided into organic, a very old technique in education in which animals and fresh human cadavers are utilized and inorganic, the current and future educational tools which comprise  virtual reality simulators and synthetic bench models and who knows what other "gadgets" in the future.  These tools bearing major medical educational investment are said to be of significant educational value but there are still studies going on regarding the validity of that conclusion.   For example even the use of standardized patients to instill the skill for students to later convey satisfactory "end-of-life" communication to real patients is still under investigation (JAMA. 2013;310(21):2257-2258}.

On the other hand, what is wrong with "See one, Do one..."?  Shouldn't patients take an altruistic view of donating their living body to medical education?  And as Dr. Thuxston concluded " Post-op, patients should look down at the ragged, poorly sutured scar on their abdomen and forget about the fact that they can’t wear a swimsuit at the beach anymore.  Instead, they should beam with pride, because the misshapen scar will remind them that their body was once used to teach a budding doctor how to operate."  And you, how about you? A bit of altruism? ..Maurice.

Graphic: Ancient Greek Medicine. Wikipedia via Google Images

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This entry was posted in Health Care and tagged . Posted by Maurice Bernstein, M.D.. Bookmark the permalink.

12/13/2013

Patient Modesty: Volume 61

The question becomes: will changing the medical system's  "bedside manner" be what is necessary to make most of the folks who are writing to this thread more comfortable with regard to their patient modesty issues?  In other words, is it a fi...

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This entry was posted in Health Care and tagged . Posted by Maurice Bernstein, M.D.. Bookmark the permalink.

12/13/2013

Wealth Disparity As A Bioethics Concern

by Craig Klugman, Ph.D.

How much money do you need to live on? $60,000 per year? $40,000 per year? $20,000? Could you live on $11,000 per year? If you made the U.S. Federal minimum wage ($7.25 since 2009) and worked 30 hours per week (the most a large number of employers will permit because anything over and they have to provide health care under the Affordable Care Act) and including no paid vacation or sick time, then you would be earning about $10,875 per year . The U.S. poverty level for a single person is $11,490 and for a family of 4 is $23,550.…

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This entry was posted in Featured Posts, Health Disparities, Politics. Posted by Craig Klugman. Bookmark the permalink.

12/10/2013

An interview with Michael McCarthy, “Exploring the intersection of faith and medicine.”

Michael McCarthy is a PhD candidate at Loyola University Chicago, and has his Master’s in Theological Studies degree from Weston Jesuit School of Theology.  Currently he is the Assistant Director for Clinical and Theological Ethics at the Neiswanger Institute for Bioethics at the Stritch School of Medicine.  Prior to joining the Bioethics Institute this past […]

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This entry was posted in Health Care and tagged , , , , . Posted by Bob Johnson. Bookmark the permalink.

12/10/2013

When Parents Disagree With the Doctor

by Craig Klugman, PhD

“You are considered sane until you disagree with the doctor” is an old adage in clinical ethics circles. We rarely question a patient’s ability to make decisions if the patient’s choice agrees with what the physician wants. I have had several cases where I’ve been asked to look at capacity issues for a patient showing signs of dementia. When I asked who consented for that patient’s procedures to that point, the response was usually, “the patient.” This incongruence seemed to escape notice. When you disagree with the physician, then questions arise about your rationality and capacity to make decisions.…

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This entry was posted in End of Life Care, Featured Posts, Pediatrics. Posted by Craig Klugman. Bookmark the permalink.

12/07/2013

Welcome to the Club, Mr. President—Obama on Economic Mobility

President Obama gave a speech to the Center for American Progress in Washington this past Wednesday on the theme of economic mobility:
http://www.whitehouse.gov/the-press-office/2013/12/04/remarks-president-economic-mobility

Paul Krugman described this speech in his column as important, despite the relatively ho-hum if not actively negative reaction of the press:
http://www.nytimes.com/2013/12/06/opinion/krugman-obama-gets-real.html?partner=rssnyt&emc=rss&_r=0

Looked at from a political point of view, the speech seems to affirm Krugman’s analysis that it’s a sort of coming out of the closet for the President. Obama makes quite clear that he’s speaking as a fellow progressive and that he intends to conduct himself as such for the remainder of his term. Apparently, all pretense (if it ever was pretense) of being a centrist and being above all dedicated to bipartisan solutions, no matter how much he might have to give up to cut a deal with the Republicans (who usually refused to cut a deal anyway), is done with as a failed effort. Just as it is hard to imagine that the Congress could get any more partisan and nasty just because the Democrats changed the Senate rules to limit filibusters, it is hard to imagine that the Republicans could scorn Obama any more because he made this speech.
Our point of view here, however, is related to economism. I have quoted from previous Obama speeches, both in The Golden Calf and in this blog. As a rule, in the past, I was quite happy if I could identify one or two passages in an entire speech that seemed fully expressive of an anti-economism posture. In this speech, on the other hand, I was hard put to find a passage that did not seem to me to call out economism for the flawed ideology and policy that it is.

The main focus, as the title indicates, is the way that income inequality in the U.S. has led to a loss of economic mobility. It is simply no longer true that a poor person, or the poor person’s children, can hope that through hard work, or education, or whatever, they will become reasonably well off.  Obama labels this as a serious challenge to who we are as a nation.
Along the way, the President trots out many of the statistics that people worried about income inequality commonly cite—like the CEO who was content to make20 to 30 times that the average worker made in the 1960s now makes 273 times as much, and that the top few percent of the population are running off with an increasingly disproportionate percentage of wealth and new economic growth. He deals with many of the standard ploys that economism’s defenders use to defend the status quo (like the claim that raising the minimum wage would hurt poor workers) and points out why all of them are misguided or inaccurate. He insists that government policy must play a major role in redressing the problems.

The road back from economism (maybe that’s a good title for the book that refutes the standard reading of Hayek’s The Road to Serfdom) will be long and difficult, but it has to start with the flaws of economism becoming the subject of robust political debate. As I explained in The Golden Calf, for far too long, economism has thrived on the widespread belief that the key portions of its ideology are nothing but common sense and that no rational politician could possibly disagree with them. Just to call them out and to insist that the debate must start is a major step forward.

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This entry was posted in Health Care and tagged . Posted by Howard Brody. Bookmark the permalink.