Vol. 151 July 15, 2016 Heroin Users Don’t Need To Lie Down To Kick The Habit.

July 15, 2016

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“It is how you act, not what you take, that defines you as an addict.”



Much is being said and written about our current “opioid use/abuse epidemic”, “heroin addiction epidemic”, “opioid dependency problem”, “opioid crisis”, or other politically-correct term that catches your fancy. Speculation, and some good data, is abundant about causes, prevention, treatments, and consequences. Today’s blog will restrict itself just to treatment, Medication Assisted Treatment, or MAT. Outpatient MAT using Suboxone (1) has proved to be effective  treatment for the disease of opioid dependency. Opioid addiction is a disease that we can treat, just like we can treat diabetes with insulin.

Many popular press articles and consultant’s reports are calling for “more opioid treatment beds”, BUT you don’t need a bed to detox from heroin dependency. In fact, most heroin dependent patients don’t even need to “detox”, in the traditional sense of abstaining from a substance for days, going through withdrawal symptoms for days, and coming out “clean” at the other end.

This cry to “increase beds” as the answer to opioid dependency sounds to me a bit like the cry to increase hospital beds in the 70’s and 80’s. In hindsight that urge looks misguided at best as we marvel today at replacing heart valves without surgery with 2 days in the hospital rather than 2 weeks, delivering high potency intravenous medications from the ICU formulary to patients in their homes, and the sprouting up of numerous networks of hospital-run ambulatory diagnostic, treatment, surgical, and urgi-centers. It is getting to the point where they barely let us lie down for some procedures before we are out the door.

Most substance abuse detox centers are based on the alcohol detox model with a bed in a protected residence, help with alcohol withdrawal symptoms by IV or IM or oral medications, IV hydration if necessary, and behavioral support. That model is NOT relevant to heroin dependency treatment, and, as we now know, it does not work very well.

Heroin or opioid detox centers could be described as “revolving doors” as revealed in numerous studies and as depicted in a recent HBO film. Studies have shown that people with substance addiction undergo an average of 3-4 detox stays over a median of 9 years before staying free of substance abuse for 12 months. Each stay may be as long as 3 weeks and cost about $550 a day. Heroin detox stays may, in fact, increase the chance of a fatal overdose for a patient since their tolerance of heroin decreases, and their “usual dose” before detox, if they relapse and take it, may be too much for them. “Recent abstinence is a major risk factor for fatal opioid overdose.” (2)

Today a heroin or opioid user seeking treatment for his disease can walk into a health care provider’s office and receive his first dose of Suboxone in as little as 12-24 hours after his last dose of heroin. That is how fast heroin “washes out” of the body. (Unlike alcohol withdrawal symptoms, like the DTs, which may not start until 2-3 days after the last drink.) Most heroin users starting on Suboxone experience only mild withdrawal symptoms like jitteriness or changes in bowel movements which can be treated with numerous oral medications “on the hoof”. They do not have to lie down. Their behavioral support system, required by all high quality MAT programs, can be initiated and nurtured “on the hoof.”  After the first week or 10 days the Suboxone prescriptions (filled at the local pharmacy and covered by most insurance plans) are issued on a monthly basis while the outpatient mental health visits and behavioral support groups continue. A patient on Suboxone can be treated both medically and behaviorally for a year for about the same total charge as a 3-week detox center stay.

“Treatment of drug use does not require lying down.
Stand up for yourself!”

Our current thinking about the urgent need for more opioid treatment beds may be part of an outdated, knee-jerk response by legislators and policy makers to “do something” about the opioid crisis. Policy changes and public funds might be better focussed on effective, ambulatory Medication Assisted Treatment (MAT) rather than “more beds”.

1. Suboxone is taken daily in tablet or sub-lingual form and contains two drugs: Buprenorphine relieves pain like opioids but does not produce euphoria plus Naloxone which causes immediate withdrawal symptoms if taken intravenously or intramuscularly.
2. New England Jour of Medicine 373;22, November 26, pg. 2015, 2095-7;  an excellent brief history of a century of Federal drug control.

Vol. 147 May 1, 2016 Why UnitedHealth Group Is The Poster Child For What’s Wrong With Our Health Care

May 1, 2016

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UnitedHealth Group, the nation’s largest health insurer, said Tuesday
that in 2017 it will exit most of the 34 states where
it offers plans on the Affordable Care Act insurance exchanges.

                                                          –Washington Post, April 16, 2016


The creation of state health insurance exchanges were incentivized by the Affordable Care Act (ACA) in order to encourage the offering of health insurance policies at competitive prices to individuals not covered by employer plans. Individuals that earned just enough to be ineligible for Medicaid coverage (aka “the working poor”)  could apply for federal subsidies to help pay for exchange health insurance policies. Health insurance companies anticipated that many uninsured people would become premium-paying people resulting in a significant revenue increase to the health insurance companies.  Like any insurance scheme, all the companies had to do was to set “competitive rates” (based on their actuarial estimates) that would bring in more revenue than the expense of what they would pay out for claims.

UnitedHealth Group (UHG) is withdrawing from 34 state health insurance exchanges because the company lost $650-720 million on their exchange policies (aka “marketplace polices”);i.e. claims for medical care received exceeded the premium revenue. Speculations about the reasons for this include:  the companies priced their policy premiums too low in response to the competitive nature of the exchanges (“They screwed up”);  the people who took out these policies were inherently “high-users” of medical services; or the higher than estimated use of medical care represented a backlog of unmet need for medical care.

The fact that the ACA has decreased the uninsured and underinsured in America by 36 million is uncontested.  About 12 million or 33%  of these people gained access to medical services from policies available from the health insurance exchanges.  Close to 87% of those were eligible for and received partial subsidies for the cost of premiums. Most of the rest of the increased access came from expanded state Medicaid insurance subsidized by the federal government under ACA. But 11 million individuals remain uninsured,

“…Depicting the Affordable Health Care Act as a “slippery slope” to single payer is bizarre, given that it relies on private insurance.” (1) Health insurance policies have tremendous influence on medical care delivery by determining who is eligible for what medical service and where. Differential rates, deductibles, and co-pays can favor one type of delivery site (hospital bed, ER, ambulatory center,  provider’s office, home care, or nursing home) and even the type of provider (MD, NP, or PA). Specific coverage for selected medical services (named and unnamed when you buy the policy) can be denied. Coverage of prescribed drugs and even procedures can be unilaterally changed annually by the insurance company simply by mailing to policy owners a fine-print booklet that lists what will be available and at what price for the coming year. In a more positive vein, one study showed that in states that expanded their Medicaid programs under ACA the number of newly diagnosed cases of diabetes increased by 23% as opposed to less than 1% in states not choosing to expand Medicaid. Early diagnosis can be life-saving and cost-effective in a chronic disease with effective treatments like diabetes .

The effect of UHG’s withdrawal will have little real effect on the insurance offered by the exchanges. Premiums for policies from the remaining companies may only increase by 1% or $4 a month. But the UHG withdrawal brilliantly spotlights the profit motive as the basic driver of our health insurance system. Private health insurance has a place in any medical care system, and does exist in most, if not all, of the state-based universal health insurance programs in other developed countries, but only in the U.S. do the profit-motivated health insurance companies have such profound influence on to whom and how medical services are delivered.

Despite what some members of my Monday night pool group may say of me,  I think capitalism is great. It has produced multiple “wonder drugs”, nurtured the widespread distribution of fantastic medical technologies, and can provide the best medical care in the world… for many… but not all.   I also think that is silly to think that profit-motived health insurance will ever be able to provide universal access to medical care, a universal access that could enhance the continued physical and economic good health of our country.

1. The Virtues and Vices of Single Payer Health Care, NEJM 374;15, April 14, 2016; 1401; J. Oberlander, Ph.D.




Vol. 140 January 15, 2016 A Review of 2015 Hubslist Blogs

January 15, 2016

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Click on the date to see the full blog


January 1 – 5 out of 10 of my resolutions were “kept”. You guess which ones.

January 15 – 6 reasons why patients are non-compliant , excuse me, “non-adherent”- the new PC term, with their medications.

February 1 – incidence of sudden death while watching the Super Bowl (Patriot fans probably don’t have to worry about that THIS year.)

February 15 – some myths revealed about cholesterol in your diet, global warming, measles vaccination rates, herbal supplements, and Dr. Oz, vendor of snake oil(s).

March 1 – 8 new causes of death caused by cigarette smoking added to the previously identified 12; a total of 20.

April 1 – Athena Health purchases MySpace which raises more concerns about privacy of health care data (April Fools edition).

April 15 – what does a “board certified physician” mean, and what does it have to do with Presidential candidates (Rand Paul)?

May 1 – physicians’ prognoses are often too optimistic for the same reasons patients’ are.

May 15 – E-cigarettes open new avenues for adolescent use of marijuana and synthetic cannabinoids (“bath salts”).

June 1 – annual review of sunscreens and bug repellents plus less universities providing student access to tanning booths.

June 15 – new forensic techniques of identifying individuals by bacterial, viral, and DNA “fingerprints”.

July 1 – 6 positive access outcomes and 4 positive health care delivery outcomes of Obamacare at 5 years of age.

July 15 – dangers of synthetic cannabinoids (attn: Chandler Jones?) and the minimal (“pending”) review of sunscreens by FDA.

August 1 – two websites with the best “symptom diagnosis” track record for helpfulness, and the one that is the worst.

August 15 – [ family vacation in a lighthouse without electricity or running water]

September 1 – why new drugs cost so much, no “gay gene” identified yet, and the myths of low testosterone, chronic Lyme, and  8 glasses of water a day.

September 15 – The health benefits of our “microbiome” and the “microbiome” of the New York City subway.

October 1 – the misleading, untruthful attacks on Planned Parenthood.

October 15 – the scope and magnitude of adverse effects of dietary supplements.

November 1 – transgender, transsexual, transvestite, and hermaphrodite, oh my!

November 15 – toddlers shooting people and other “norms” of gun deaths – “By Degrees“.

December 1 – changing advice about what NOT to eat during the holidays.

December 15 – the benefits of research using fetal tissue, short history of political attacks on Planned Parenthood, and why if you are NOT fat and live a long life you should thank your parents.


Vol.138 December 15, 2015 Who Buys Baby Parts?

December 15, 2015

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The Colorado gunman who shot and killed three people at a Planned Parenthood clinic in Colorado Springs is reported to have said “no more baby parts.”


The distorted flap about Planned Parenthood “selling baby parts” continues. On December 3 the Senate ( Republican-led) voted to strip Planned Parenthood (PP) of government funding. President Obama (a Democrat) will veto it if it reaches his desk. (I’m not suggesting that this is a political issue, of course) Planned Parenthood received $528 million from the U.S. government in 2014 to help support 700 clinics providing health services to mostly poor women. Why so much money? Basically because PP is providing subsidized women’s health services that in every other developed country except ours is provided by the government. The Congressional Budget Office estimates that if Congress were to succeed in blocking Medicaid patients from obtaining care at PP health centers 390,000 women would lose access to preventative health care in the first year alone. (1)

Who wants “baby parts”?

In 2014 NIH funded 164 research projects using fetal tissue with about 0.27% of its total grant money. (2) These projects were researching HIV/AIDS (39%) , eye development and disease (32%), Hepatitis C and other infections, (13%), diabetes (8%), and miscellaneous others including Alzeihmer’s and Parkinson’s. “Fetal tissue is a flexible, less-differentiated tissue … and it is a tool for research that can’t be replicated with adult tissue.” (3) It is different from stem cells, a medical tissue that came under attack back in W. Bush’s administration.

Use of fetal tissue has been legal since 1993 when Congress passed the NIH Revitalization Act which permits the tissue from any type of abortion to be used for fetal tissue research. The law requires complete and detailed informed consent from the woman to donate tissue from the abortion after she has made the decision to have an abortion. The law allows clinics to recover “reasonable payments” ($45-60 per specimen at PP) for providing the tissue to biological-research supply companies. The companies process the tissue and provide it to the researcher for about $800 per specimen. (I wonder if any Republicans have stock in some of those companies).

An estimated 5.8 Billion (yes, a “B”) people have received vaccines made with the two cell lines derived from fetal tissue. (Oh, NO, another red flag! “VACCINES”, “Guns”, “abortions” – all mentioned in the same blog! It’s almost enough to make you believe that there is a government conspiracy to enslave us all.)

“People are talking about fetal tissue, but really what the discussion is about is abortion.” (4) ( Duh!!)   3% of PP services are abortions, done in 1% of the clinics, and in just 2 states. (5) Planned Parenthood leaders have now instructed any PP clinic providing fetal tissue NOT to accept the measly 60 bucks.

Planned Parenthood has experienced 15 smear campaigns in 10 years according to its medical director (5). The current campaign has included:
1) six votes in Congress to restrict woman’s health care,
2) five Congressional committees currently investigating PP,
3) submission of 25,000 pages of documents by PP, and
4) 5 hours of testimony to one committee by its president.

Abortion politics appear to be as complex and almost as emotionally provocative as Presidential election politics, but the outcome of election politics will immediately affect only two women, not hundreds of thousands.

Another learned cardiologist has reaffirmed the Hubslist axiom: “Just pick your parents right .” Dr. Lee Goldman, Dean of Columbia School of Medicine, explains that obesity is due to our genes in his new book, “Too Much of a Good Thing: How Four Key Survival Traits Are Now Killing Us.” He thinks that our overreaction to stress and our cravings for sweet, fatty, and salty foods all served us well in the cave man years when we had a life-span of 30 years, but that these “survivor genes” are now mismatched with our environment as we live into the 80’s. Of course, being a modern scientist he knows it is too late to “pick your parents”, so he is placing his hopes on future drug therapies that will turn off or block specific genes. Dr. Goldman says, “Gaining weight doesn’t mean that you are a terrible, non-virtuous person. This is the way you were built.” (6)

So, my holiday (includes New Year’s eve, of course) mantra for me and you is:
“Merry Christmas. Don’t beat yourself up. YOU are NOT in control.”

1. CBO cost estimate on H.R. 3134, Defunding Planned Parenthood, September 16, 2015
2. Nature Magazine, Dec. 9, 2015, Meredith Wadman
3. Carrie Wolinetz, Associate Director for Science Policy, NIH
4. Shari Gelbar, MD. Weill-Cornell Medical College
5. Tearing Down the Fetal Tissue Smokescreen, NEJM, December 10, 2015, p.2376, Reagan McDonald-Mosley, M.D., M.P.H.
6. Boston Globe December 14, 2015 , B11

Vol. 133 October 1, 2015 What Year Is This? 1984??

October 1, 2015


“Have you seen the video? You must see the video?” -Carly Fiorina on CNN


I must admit that the Republican Presidential debates have been occasionally entertaining as the non-Trumps gradually reveal a little of their own personalities in trying to counter his H-U-G-E one. But sometimes the posturing for a sound bite or a differentiating headline has so grossly distorted the facts that alarm bells go off in my head. Wait, you say, isn’t that normal for a political campaign? Of course it is, but as a physician I can’t help but cringe watching rabid political attacks based on distorted, misleading, and even deliberately misstated “medical information”.

“Planned Parenthood is profiting from selling baby parts obtained from abortions”.

  1. The 1988 Fetal Tissue Transplantation Panel, appointed by President Reagan, after reviewing decades of research stated that there was no evidence that the possible use of fetal tissue for medical research had ever helped persuade a woman to have an abortion.
  2. Only a few Planned Parenthood affiliates in three Western states have arrangements to provide fetal tissue from abortions to researchers.
  3. Permission for donation of fetal tissue cannot be sought from a woman until after she has decided to end the pregnancy.
  4. By law, the fetal tissue can not be sold for profit. A sum of $30 to $100 may be reimbursed to the health care providers/facility (not to Planned Parenthood, not to the patient) to cover costs of tissue recovery.
  5. By law, there is no federal reimbursement for the abortion procedure itself.
  6. Use of the unique characteristics of fetal tissue has allowed successful research for decades in the development of life-saving , disease-preventing vaccines. “Virtually every person in the country has benefitted from research using fetal tissue.” (1)

“Use of fetal tissue is unethical.”

  1. Just today the pediatric neurosurgeon running for President answered a question in New Hampshire about Planned Parenthood with, “Tearing babies apart? Is that what you mean? The medical ethics of selling body parts and manipulating babies in order to preserve certain body parts? It’s illegal.” Besides mixing “legal’ in with “ethical’, two different concepts, Dr. Carson has also apparently forgotten that he participated in a 1992 medical research study using tissue from aborted fetuses. (2)
  2. “The research use of fetal remains is ethical.” said Reagan’s 1988 panel.
  3. The Committee on Pro-Life Activities of the National Conference of Bishops has written “it may not be wrong in principle for someone unconnected with an abortion to make use of fetal organ from an unborn child who died as a result of an abortion.” (3)

“Planned Parenthood is in the abortion business.”

  1. Three per cent (3%) of the 10.6 million services delivered annually by Planned Parenthood were related to abortion procedures in 2014. That does represent over 320,000 abortions, so I can understand why believers in “zero abortions” might be upset, but Planned Parenthood services are much broader:
    42% for sexually transmitted disease tests (including HIV tests),
    34% for contraception services,
    11% for pregnancy tests,
    and 9% for cancer screening and prevention.
  2. “The inconsistent or incorrect use of contraception accounts for nearly half of unintended pregnancies and half of those end in abortion.” (4)
  3.  78% of the people served lived at or below the 150% federal poverty level.
  4. “We strongly support Planned Parenthood not only for its efforts to channel fetal tissue into important medical research but also for its other work as one of the country’s largest providers of healthcare for women, especially poor women.” (5)

“Have you seen the video? You must see the video?” -Carly Fiorina on CNN

  1. The Video” of Planned Parenthood physicians describing how they obtained fetal tissue is a heavily and deceptively edited compilation of 30 months of taping obtained by actors who misrepresented themselves and asked leading questions.
  2. “The Other Video” and pictures of a bucket of dead baby parts being sorted out by a technician has nothing to do with Planned Parenthood and is from “stock footage” from an anti-abortion organization.

I have no association with Planned Parenthood, and I am not an advocate of abortion as “a means of contraception”.
I am dismayed when information about a major health care provider and a valuable medical research resource is so distorted in such a believable fashion for political means.

In New Hampshire Dr. Carson decried political correctness and likened it to “group-think in Nazi Germany”.  In our present state of political polarization, demand for political correctness, a discouraged middle-class, growing fear of foreigners and scapegoating of immigrants, and even a popular, narcissistic candidate with a distinctive hair style, could “It” happen here?

1.  NEJM 373:10, September 3, 2015 , p.890
2.  Boston Globe, Oct. 1, 2015, B4
3.  Biomedical Politics 1991
4.  Guttmacher Institute 2014
5.  Editors of the NEJM, Sept. 3, 2015



Vol. 128 July 1, 2015 Obamacare is Five Years Old. Can It Walk and Talk?

July 1, 2015


“From a historical perspective,
5 years is a very short time.
Many of the key insurance provisions have been
in effect only since October 2013.” (1)

Now that the Supreme Court has decided that a key provision in the Affordable Care Act of 2010, the federal subsidy of health insurance for eligible citizens, is legal, the infancy of Obamacare is over. It looks like it is here to stay. How is the toddler doing? What has it done? Luckily, The Commonwealth Fund just published a summary of ACA effects so far. (1)

The Commonwealth Fund is a private foundation formed in 1918 with Harkness family money made from the early oil business, (Shell Oil).

“The Commonwealth Fund has sought to be a catalyst for change by identifying promising practices and contributing to solutions that could help the United States achieve a high-performance health system. The Fund’s role has been to establish a base of scientific evidence on what works, mobilize talented people to transform health care organizations, and collaborate with organizations that share its concerns. The Fund’s work has always focused particularly on the challenges vulnerable populations face in receiving high-quality, safe, compassionate, coordinated, and efficiently delivered care.”

This health-care-focussed fund and think tank reports that it is too early to see many benefits of the ACA, but lists some of its immediate, observable effects.

Access to care:

  • 7.0 to 16.4 million young adults from chronically uncovered populations ( hispanics, blacks, and those with low incomes) have gained health insurance coverage since 2010 (different survey methods and timing cause the difference in results).
  • 11.7 million Americans selected a health plan through the health insurance marketplaces established by the ACA. 87% of those people were eligible for federal subsidies of premiums.
  • 10.8 million additional Americans have enrolled in Medicaid since the ACA was passed.
  • 3 million previously uninsured young Americans have gained coverage through the ACA extension of dependent coverage to age 26.
  • 8-12 million Americans have benefitted from the ACA’s regulation that prevents insurers from discriminating against people with preexisting conditions.
  • 75% of those newly insured seeking appointments with primary care or specialist physicians have secured one within 4 weeks or less.

Delivery-System Reform:
“ The law constitutes one of the most aggressive efforts in the history of the nation to address the problems of the health care delivery system through funding many divergent experiments though lacking a coherent strategy.” (1)  The Commonwealth Fund report lumped the efforts into four categories.

1. Changes in Payments:
Reduce readmissions – There are 150,000 per year fewer Medicare hospital readmissions within 30 days of discharge partly attributed to ACA financial penalties to hospitals with higher than expected readmission rates.
Reduce hospital-acquired conditions – ACA financial penalties to hospitals in the highest quarter of avoidable hospital-acquired conditions may have helped the composite rates for those to drop by 17% from 2010 to 2013.
Pay for Performance – ACA payment incentives to hospitals and physicians to improve their performance on various cost and quality measures: “too early to tell”.
Bundled payments – This departure from fee-for-service reimbursement pays the hospital, the physician, and post-hospital services with a single payment for a procedure or condition. 7000 providers have signed up for it, but it is “too early to tell”.

2. Changes in the Organization of Health Care Delivery:
Accountable Care Organizations (ACOs) – An ACO is an organization of physicians and hospitals formed to improve the integration and coordination of ambulatory, inpatient, and post-acute services for a defined population of Medicare beneficiaries. 405 ACOs are participating in a program that allows them to keep a portion of any cost savings they can generate without degrading quality. Although the pilot program of about a dozen Pioneer ACOs “saved” $385 million in the first two years, it is “too early to tell” if the others will have a postive effect.
Primary Care Transformation – A pilot program to reduce costs and improve quality in primary care has shown a $14 per month cost reduction per Medicare enrollee and less emergency room visits and hospitalizations in the 2.5 million patients participating in its first year, but it is “too early to tell”.

3. Changes in Workforce Policy:
The effects of increased primary care reimbursement for Medicaid patient services, increased National Health Service Crops scholarships for practicing in underserved areas, and establishment of a National Health Care Workforce Commission (but remains to be funded by Congress) are all “too early to tell”.

4. Increase Innovation in Health Care Delivery:
The Center for Medicare and Medicaid Innovation (CMMI) was funded at $1 billion a year for 10 years to undertake a wide variety of experiments in improving quality for patients and reducing the 43% share of national health costs now paid by the government.

  • Commonwealth Fund says: CMMI is perhaps the most promising of the ACA efforts, but “way too early to tell”.
  • The CMMI itself reports it has launched 26 “demonstration models” of cost reduction and quality improvement. The Pioneer ACOs mentioned above is the first model “to meet the statutory criteria for expansion”.(2)
  • A separate report from Weil Cornell Medical College Department of Healthcare Policy and Research states that to date the CMMI has spent only one-third of its $10 billion, that it seems to be slow in distributing data from its experiments to participating organizations, and that it is hampered, as most quality improvement efforts are, by the lack of consensus on what constitutes “ improved quality”. So it is “too early to tell” (2)

Wow, that is definitely more than you may have ever wanted to know about the ACA so far!
It is certainly more than I can remember.
It is clear that Obamacare does have a lifetime before it.
As that lifetime unfolds one can only hope that responsible adults will guide it through its future developmental stages.

Bottom line: carry a small laminated copy of this blog in your pocket or purse to pull out when engaged … embroiled, …immersed, …or even entangled in any discussion about Obamacare, which will continue, even if Hilary renames it.

Remember, Medicare was just as controversial when first passed. One governor that opposed Medicare actually mobilized his state’s National Guard the day Medicare was passed in fear of the hordes of newly insured people that he expected to overwhelm emergency room departments.

1. NEJM June 18, 2015;  The Affordable Care Act at Five Years
2. NEJM May 21, 2015;  Assessing the CMS Innovation Center

Vol. 123 April 15, 2015 What Does “Board Certified Physician” Mean? What Does It Have To Do With The 2016 Presidential Candidates?

April 15, 2015


 “Nowadays, medicine is an open-resource team approach. I get all this information in the room with a patient in seconds, and then I use my experience and my knowledge to pull together a plan”

– Dr. Jonathan Weiss, a triple-board-certified physician explaining why he is against a test every ten years to maintain board certification;
NY Times, April 14, 2015, D3

A “board-certified physician” is one who has voluntarily applied for and passed a test of medical knowledge in one of 24 general specialities or over 30 subspecialties.. A non-profit American Board of Medical Specialties (ABMS) composed of physicians was established in 1933 to administer the tests to physicians who apply for the certification after completing their residency training. Each approved specialty board issues a certificate to successful candidates (It hangs on the wall in your physician’s office). Unlike the bar exam for lawyers, physicians are expected to pass the test the first time, though a second attempt is sometimes necessary in some specialties. Most hospitals and many health insurance companies require board certification as a sign of competence as part of their credentialing. States do NOT require board certification for licensure.

One of the founding specialty boards in 1933 was the American Board of Ophthalmology (ABO), which brings us to the 2016 Presidential candidates.

Rand Paul, MD, a recently announced Republican candidate for President, took and passed his ophthalmology boards in 1995.  In 1997 he and 20 other practicing eye doctors protested the ABO’s changing of its certification from “lifetime” to “must be renewed every 10 years.” They argued that this Maintenance of Certification (MOC) test every ten years was “time-consuming for the practitioner, expensive ($1,500-$3,000), and irrelevant to patient care”. They formed a new board, the National Board of Ophthalmology (NBO), that would issue life-time certification for $500. Rand Paul was the lead organizer. He, his non-physician wife Kelley, and his non-physician father-in-law became members of its Board of Directors. NBO was never recognized by the ABMS, was dissolved by the State of Kentucky in 2000, was recreated in 2005 ( that just happened to be 10 years after Rand Paul was initially certified by ABO), and finally was dissolved again in 2011. It certified about 60 physicians in its lifetime.

Rand Paul is not the only critic of the ABMS and the Maintenance Of Certification (MOC) concept. Others have questioned the ABMS certification exams’ ability to evaluate actual clinical decision-making and clinical competence. Others have suggested that the exams’ heavy emphasis on memorized medical facts and pharmaceutical details is irrelevant, when nowadays such details are just a click or two away from the doctor in the exam room via electronic device. In 2013 a prestigious-sounding organization, the Association of American Physicians and Surgeons (AAPS) brought a “restraint of trade” suit against the ABMS for its MOC requirement.

I was impressed by that name, until I Googled it. The AAPS is an ultra-conservative organization established to fend off  “the evils of socialized medicine”. Its positions include “HIV is not the cause of AIDS”, “abortions are associated with breast cancer”, and “childhood vaccinations cause autism”. Rand Paul and his father Ron, also a physician and a past presidential candidate himself, are both members of the AAPS.

“So what” you might think at this point.
Rand Paul’s beliefs and actions indicate to me that he has an excellent ability to create, maintain, and operate within his own reality, one which ignores accepted evidence. Perhaps one could say that very same thing about any politician with whom you disagree, but I don’t disagree with every thing that Rand Paul says.  Physicians are trained to make decisions often using inadequate data. I am surprised that Rand Paul, as a trained physician, can successfully maintain a belief construct that is so at odds with established facts.  Also, he tried, and failed, to develop an alternative governing body of his profession when he disagreed with its policies. It was NOT about trying for better patient care.

These are undesirable attributes in a President of the United States. It also makes Hilary’s real estate shenanigans in Arkansas, her use of more than one email address as Secretary of State, Jeb Bush’s claim to being Hispanic, and Elizabeth Warren’s claim to being Native American look pretty penny ante by comparison.

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