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Is resistance useless?

1/31/2017

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Like many of you, I have been thinking about normal-for-a-Republican and abnormal-for-anyone things that Donald Trump does. Let us bracket the obvious fact that these are on a spectrum; sometimes they overlap (the Iraq War was a huge, avoidable deception which was perpetrated by mainstream Republicans and many Democrats). I agree it is useful to keep the categories separate for the sake of argument. Further for that sake, let’s consider whether it is better to let our guard down so that some sane members of the Cabinet have the chance to do some good. James Mattis has already been confirmed as Secretary of Defense, and has been praised for some public remarks about the importance of international allilances. The name floated for the Secretary of the Veterans Administration, David Shulkin, is by all accounts a respected public servant.

But then there’s a question: given that run-of-the-mill Trumpism is racism and dismantling of the state (and we have no reason to believe the next 4 years will be any different), what does it mean to “do good” in that context? I think it depends on the extent to which different Cabinet departments are their own separate domains, or whether they are infiltrated and dismantled. I am no expert, but I assume that Defense is a much different place than State, which in turn is different from HHS or the EPA. Each could be ruined by Trump, or left untouched. Bannon could ride roughshod over any attempt by Mattis to retain the US’s place in the international order; the VA’s health care system could be crudely privatized even if Shulkin and his team are working on reform of an already well-performing system subject to unfair scrutiny.


Given what we have seen, I am afraid the expectation (in the economic sense) is a large negative: it seems very likely that Trumpism, and Bannonism, will affect the entirety of the Federal government, even if there are good actors here and there.


If I am right, and of course I welcome correction, it is our duty to oppose even the nomination of the relatively inoffensive nominees, and to try and gum up the works as much as possible. The good actors’ attempts will be thwarted by the incompetence and malevolence of the Administration as a whole, and any collaboration will sap strength from a growing movement whose aim should be the restoration of a liberal order.


Some thoughts, perhaps only to buoy myself, but also to consider when deciding who to call, with what demands, and why.

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Primary care doctors ask the AMA: how could you endorse Price? The AMA says, "Mr. Trump gets to pick his team"

1/13/2017

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Doctors and other clinicians around the country reacted with dismay a few weeks ago when the American Medical Association, a generally right-wing group representing less than 15% of physicians, endorsed the fringe Rep. Tom Price as Trump's nominee for secretary of the Department of Health and Human Services. (The American Association of Medical Colleges did so as well - dealing academic medical centers a black mark.) His policies and his affiliation with the American Association of Physicians and Surgeons (like the John Birch Society, but for doctors, noted for anti-vax, racist, and conspiracist thinking) are both red flags.

Among the professional societies speaking out against the nomination is my own, the Society of General Internal Medicine. I am proud that, in separate letters, SGIM reacted with evidence-based, productive, but unstinting language, telling the AMA and AAMC in no uncertain terms why they should reconsider their endorsement.

Now comes the AMA's response to SGIM, which I paste in its entirety below. It is notable for several reasons: its deference to Trump ("America chose Mr. Trump, and he gets to pick his team"); its lack of specificity regarding those policies of Price's with which the AMA does not agree; and its disconcerting air of unreality regarding the contradiction between endorsing Price (or as the AMA distances themselves from it, "supporting the nomination") and a stated goal on the part of the AMA of not denying Americans coverage. 

Thank you for your letter. I am on the AMA trail, so I will respond electronically rather than on letterhead. 
​
I appreciate hearing your opinion about the AMA’s support for Dr. Tom Price, President-elect Trump’s nominee for Secretary of the Department of Health and Human Services. We take seriously the concerns expressed by those who do not support the nomination, and our support for it is not an endorsement of every policy position Dr. Price has advocated.

Here is a link to an article by our board chair, Patrice Harris, explaining our decision.  

https://wire.ama-assn.org/ama-news/why-we-support-dr-price-lead-hhs

There is also an editorial in the Washington Post about why the Dems should not oppose the Price nomination. You might find that interesting as well. http://wpo.st/QWhI2

As a physician, Dr. Price has had a relationship with the AMA, and with organized medicine generally, for decades.  Over these years, there have been important policy issues on which we agreed, and others on which we disagreed.  One thing that has been consistent through the years is his understanding of the many challenges facing patients and physicians, and his willingness to listen directly to concerns expressed by the AMA and other physician organizations. I will paste below a summary of policies where we have found common ground.

If confirmed by the Senate, Dr. Price will be charged with pursuing the policy goals of the President he will serve.  Similarly, as a non-partisan organization committed to improving the health of the nation, the AMA is charged with advancing a robust set of policies established by its House of Delegates, including the healthcare reform principles we circulated to our House following our recent Interim Meeting. I have attached that document to this email.

The AMA continues to be driven by our mission statement, which is “To preserve the art and science of medicine, and the betterment of public health. We remain committed to improving health insurance coverage so that patients receive timely, high quality care, preventive services and other necessary medical treatments.  Moving forward, a core principle for the AMA is that any new reform proposal should not cause individuals currently covered to become uninsured.

Democracy is messy. America chose Mr. Trump, and he gets to pick his team. Our job is to work for the principles we believe in. We look forward to continuing dialogue with Dr. Price, and to our collaboration on health care priorities on which we share common ground.

The AMA has in no way abandoned its principles regarding patients, access, quality or equity. The AMA will continue to engage with the new administration on behalf of those principles. It was those principles, in fact, which led us to support the Affordable Care Act, which engendered equally critical emails from people whose world view is quite different from yours.

Thank you again for reaching out, and best wishes for the new year.

Andy

Andrew W. Gurman, MD

President

American Medical Association

Altoona Hand & Wrist Surgery, LLC

1701 12th Avenue, Suite C-2

Altoona, PA 16601

Dr. Tom Price efforts that align with AMA policy/advocacy

 

Leader on efforts to improve the Meaningful Use (MU) regulations:
Led the bipartisan effort to extend and expand the MU hardship exception for the 2015 reporting year.   Introduced H.R. 3940, the “Meaningful Use Hardship Relief Act.”  This was enacted as a part of S. 2425, the “Patient Access and Medicare Protection Act.”
Led an MU sign-on letter in the House (signed by 113 members) which was sent to the Office of Management and Budget (OMB) and the Department of Health and Human Services (HHS) (9/28/15).
Participated in an AMA/Medical Association of Georgia MU town hall in Atlanta, GA in July 2015.
Led efforts in 2015 and 2016 to have a 90-Day reporting period.
Leader on efforts to reverse Centers for Medicare and Medicaid Services (CMS) regulations to unwind global surgical codes (language was included in the Medicare Access and CHIP Reauthorization Act (MACRA) which accomplished this objective).
Leader on efforts to delay and improve the Comprehensive Joint Replacement (CJR) rule (led a House sign-on letter on the CJR Rule – 9/21/15).
Leader on House efforts to improve the proposed MACRA regulations.  Led numerous stakeholder calls; led a House sign-on letter to CMS and OMB on improvements to the MACRA regulations (10/6/16).
Led House efforts to push back on the proposed Part B Drug Model; led House sign-on letter to CMS (5/2/16); co-introduced H.R. 5122, to prohibit further action on the proposed rule regarding testing of Medicare part B prescription drug models.
Introduced in multiple Congresses the “Medical Freedom of Practice Act” (H.R. 3100 in the 114thCongress) which would  ensure that physicians are not required to participate in any health plan or comply with MU requirements for electronic health records (EHRs) as a condition of licensure in any state.
Led a House sign-on letter opposing a proposed demonstration on prior authorization for home health services (5/25/16).




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Can Cupping Cure Anything?

1/3/2017

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This column was originally published in Yiddish at the Yiddish Forward, and is published here in translation by arrangement with them.

Dear Dr. Berger,

What is your medical opinion of cupping?
Yerachmiel Lopin, New York
​

Dear Mr. Lopin,

Though cupping is not a brand new cure, it got a new moment in the sun in 2016, when a picture of Olympic swimmer Michael Phelps went viral - featuring his back covered in black and blew circles, telltale signs of the practice. Presumably he didn’t do this out of nostalgia for the old country and its traditional healers or for the East Side’s “bankes” parlors frequented by immigrant Jews. Phelps used cupping because of its “alternative” cachet.
How does this so-called cure work and why is it more popular now (if that is the case)?

Cupping has arisen in parallel a number of times in different cultures. The Chinese, Greeks, and Arabs acknowledge the practice, and Jews too, under the name “bankes.” Each culture, or people, has a different explanation why it might work, relevant to its own health beliefs. Chinese explanations of cupping center on “qi,” the bodily energy which flows through the organism along various lines. The Arabs of the Middle Ages, on the other hand, emphasized the balance between liquids (probably under influence of the ancient Greeks’ humors). My favorite, “Dr. Maimonides,” in his Jewish-Arabic treatise on hemorrhoids, suggested cupping as a cure, though second-line.


The ancestors of today’s Ashkenazic Jews, for example, didn’t use cupping on the basis of any theory. They just used it as a treatment, sitting in the hot baths, applying a sort of jar (the meaning of the Yiddish word “bankes” is “jar,” from the Russian). The cup, or jar, creates negative pressure which tugs at the skin. Various kinds of cupping are possible - “hot,” “cold,” “wet,” “dry.” even (so says Dr. Wikipedia) “flaming.” (Don’t ask.) People say that cupping can help pains, heal certain illnesses -- all sorts of claims.


More important than claimed mechanisms are the reasons that people are attracted to a treatment like this. I think that it has to do with the “alternativeness” of it. It’s an old-wives’ treatment in the positive sense, something supposedly natural, from the home, and easily available, like in Grandma’s kitchen, without the costs, unfriendliness, and cold scientism of today’s medicine.


That brings us to the final question. Is cupping any good? In short, the answer is - probably not. Several systematic reviews of the scientific literature on cupping have been carried out in recent years (in particular, in China, where there is an incentive to carry out such studies, often of dubious quality), which show that it might be useful in some cases, but perhaps not (the evidence is weak), and probably no differently than placebo.
​

But if you’re looking for an alternative therapy, a placebo sort of thing, which can calm you and bring comfort, despite the ineffectiveness according to the dry facts, and something which has been popular throughout the generations….well, so what if it isn’t any good? Never mind that. You get bruised, the wallet gets lighter, and at the end of it all it’s unlikely to harm you very much.

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    The author of Talking To Your Doctor and Making Sense of Medicine blogs about the books, shared decision making, doctor-patient communication, and the redeemable imperfections of healthcare.

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