It Never Gets Any Easier

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It Never Gets Easier

 

You’d think the mowing the grass in your own front yard would be a relatively risk free afternoon activity. Sure you need to be a little careful with a blade spinning at 3500 RPM, but modern dead man clutches make accidental injury unlikely. Sometimes, even the mundane can turn deadly. Last Saturday I was on Trauma call and a page came through for an incoming trauma code, car vs pedestrian incident, intubated in the field, unresponsive. I was expecting the usual combination of head and extremity injuries that we often see when people are hit by moving cars. Instead, my patient was a 60-year-old man with no obvious external signs of trauma, unconscious and intubated with no responses to any stimulation. His pupils were 5mm, not dilated but not normal and fixed, meaning they didn’t contract in response to a bright light. This is a bad sign, usually indicative of severe brain injury, bordering on brain death, unless the patient has gotten paralytic drugs, say for a surgery or intubation.

“Did he get drugs in the field?” I asked hopefully.

“No, doc. He took the tube without bucking or gagging, no drugs needed.” Again a bad sign.

Then we got the whole story. He had been mowing his front yard, near the sidewalk, when two cars got involved in a minor fender bender in front of his house. As one of them tried to avoid the accident, it went up on the sidewalk and as the other car hit it, its rear fender brushed against my patient. It was a low speed impact. The car was almost stopped when it clipped him. But speed is less important than force in this case and since force is dependent on mass, the barely moving car knocked the man down. Had he fallen to the grass, he would have had nothing more than a bruise on his thigh. Instead, his head struck the engine housing of the mower. The engine cut off as soon as his hands left the dead man clutch, but the engine is made of tempered steel and aluminum, both much harder than the human skull.

We hurried him off to CT where the scan confirmed a basilar skull fracture with a massive intracranial hemorrhage. His brain was already starting to herniate. That means that the pressure of the bleeding in his skull was pushing the base of his brain into the opening that allows the spinal cord to exit. Herniation = death. The neurosurgeons rushed him off to surgery to take the top of his skull off and give the brain room to expand upward instead of down.

He’s still not responding and may be brain dead. Now I have to talk to the family about organ donation and eventual withdrawal of care if the flow studies show his brain is indeed dead. They’re obviously in shock. His son keeps saying, “He was only cutting the grass”.

This job never gets easier.

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Don’t Just Do Something, Stand There

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Don’t Just Do Something, Stand There

 

Sometimes inaction may be the best action. Recently the hospital where I do much of my elective surgery noted an increased incidence of infections following colon surgery. This was part of a project undertaken in order to comply with a Joint Commission and CMS requirement to demonstrate ongoing quality improvement activity. That’s bureaucratic doublespeak for looking at what you do anyway, and making up some BS about how you’ll do it better. Unfortunately, this time there may really be a problem. The infection rate that the QA department reported was twice as high as other hospitals in the area. Not a good indicator of quality surgical care if true, and not a good way to advertise your hospital.

A meeting of all surgeons who perform colon surgery was quickly called in order to ‘drill down’ on the infection report and find out what was going wrong. Full panic mode ensued in the Admin Office – ‘Oh my God, the sky is falling! We have to DO SOMETHING!’

There may indeed be a problem, but the initial report is very vague and the raw data isn’t necessarily indicative of something amiss. That’s not to imply that post-operative infections are no big deal. They can be and if indeed patient are twice as likely to get an infection at my hospital, I sure want to know why.

The problem isn’t simple. First, no matter what we do, the colon is not a clean place. Antibiotics and cleansing bowel preparations don’t make it even as clean as the small intestine There’s even good evidence that vigorous mechanical cleansing (enemas, bowel washouts, etc.) preoperatively may actually increase the risk of infection. No matter how careful we are, there will be a certain baseline incidence of infection that is inherent in the procedure.

Second, other factors influence infection risk in any surgery, but particularly in contaminated operations such as those on the colon. These include: the presence of infection before the surgery even starts, such as diverticulitis; obesity, which increases the risk of both wound and deep space (inside the abdomen) infections; diabetes which increases infection risk in any procedure; low body temperature – getting cold in the OR; and smoking. If these comorbidities are not accounted for, any apparent increase in infections may be due to patient diseases and conditions rather than anything the surgeon or OR staff does.

Finally, the criteria for reporting an infection may play a role. By Center for Disease Control guideline, any infection within 90 days of surgery is a surgical site infection, but if it’s been more than seven days since surgery, it’s unlikely that anything done in the OR or in the first few hours after surgery played anything other than a permissive role. Altering our preop and postop routines probably won’t change anything.

All of the surgeons understood the problem. We all were motivated to find out what was really going on. Was this just a run of bad luck? The data only represented six calendar months and may have been an aberration. Were our patients just sicker to begin with? There was no information at all about the other hospital to which we were being compared other than their overall infection rate. Was everybody reporting their infections in the same way? Did individual surgeon differences represent differences in patient selection or were some of us just that much better than others?

The Infection Control Nurse had actually done a very good job of analyzing the information. She presented a three page spread sheet detailing the surgeon’s name, the patient’s name and age, the patients BMI (Body Mass Index, an indicator of obesity), the location of the infection, type of infection, organism responsible and about ten other parameters that could have a bearing on why the infection occurred. Unfortunately, in all that data, neither she nor we could find any common factor, break in technique or best practice guideline to explain the spike in infections. We looked at the data we were given, talked about the possibilities and then shrugged our collective shoulders and told the administration there was little we could conclude from the information we had. The infections both individually and collectively appeared to be a mix of patient and surgeon factors and not a systemic issue.

‘Not good enough’, came the reply from the hospital CEO and the Chief Medical Officer (neither of them surgeons). ‘Don’t you all understand? We’ve got to take action to correct this. We’ve got to DO SOMETHING’. And if we as a department didn’t, then they would.

Nobody said anything after that for a few minutes. I looked to our current department Chairman to speak up and explain the issue, maybe advocate that we try to get more information from other hospitals that would allow us to really evaluate whether there was a problem at our institution. He stared at the table. He’s a hospital employee, one of four hired surgeons the hospital brought in to undercut the independent surgeons like me. Finally, I had the temerity to ask, ‘What would you suggest we do?’

Silence. We waited, and when no one else spoke, everyone stood up and left the room.

I fully expect some new regulations out of the front office in the next few days, likely some requirement that we observe ‘best practice’ guidelines, which we do anyway, coupled with a new batch of spies and overseers to grade us on how well we follow the script. It will be a colossal waste of time and energy and will satisfy no one except the administrators. Meanwhile, a couple of the colon rectal surgeons and I have persuaded the QA nurse manager to let us do a focused review of all the colon cases for the next six months. If there is a real problem, we may be able to find it. Or we may only find that sick old people who have major surgery don’t do as well as healthy young ones. Imagine that. If that is the case, then standing still may be the best action to take.

First Duty – 35 years ago today

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First Duty

It was 1979 and I was sitting in a cold, noisy cargo hold aboard a C-141. Around me were twenty other men, all new transfers to Diego Garcia or to Naval Mobile Construction Battalion 5, my new duty station. We had been airborne for almost 8 hours after leaving Bangkok and before that had flown 5 hours from Clark AFB in the Philippines. According to the garbled voice over the aircraft’s intercom we were on final approach and this particular slice of hell was almost over.

This was my first of many flights on the venerable ‘time tunnel’ as the big cargo planes were called by those unfortunate enough to be passengers. The windowless holds were poorly insulated and indifferently heated. The temperature inside hovered a bit above fifty degrees, better than the outside temperature of minus 30 but still bone chilling after a few hours.

Half an hour later, the cold would have been welcome. Diego Garcia is a tiny atoll in the middle of the Indian Ocean. Eight degrees south of the equator, it is the very epitome of a tropical island. We stepped out of the still cold plane into blazing sun and ninety-degree heat. The humidity was within a soaking 95% and there was no shade for a mile in any direction, the native palms having been clear cut for the construction of one of the longest runways in the world. After a long half hour we were finally picked up by a trio of trucks for the three-mile trip to the Naval Support Facility and my new home.

NMCB-5 was the deployed unit responsible for new construction on the island. They had finished the runway before I arrived and were now involved in several major construction projects. There was the fuel pier, the new barracks and the infrastructure and utilities project. I was joining them as the new battalion medical officer.

Four weeks earlier, I had finished my internship at Bethesda Naval Hospital. I wish I could say it had been a good year, but that would be a lie. I was bitter and disillusioned. My peers and I had been regarded as temporary labor by most of our senior colleagues at Bethesda. We all knew that we’d be leaving for at least a year with an operational unit after the internship year and that only a few of us would be back. The rest would serve out their obligated service time as GMO’s (General Medical Officers) and leave the Navy to train in civilian programs. There was little attempt to encourage us to return and the prevailing attitude seemed to be that the only difference between a surgical intern and a cow pie is that no one went out of their way to step on a cow pie. On top of that, my brief marriage of just eighteen months was over. My ex had emptied the joint bank account, diverted the household goods shipment to an apartment in Chicago and, rumor had it, had moved in with an old boyfriend. I was literally broke and everything I owned was in my seabag and a footlocker.

My intention was to serve my time, four years, and then get a job. I would save my pay and make enough money to buy a sailboat and sail around the world. It wasn’t a practical ambition, but I’d done the proper, conventional thing in order to get through college and medical school. Now, I was going to do what I wanted.

The trip to the battalion headquarters was short, but I was soaked with sweat by the time I reported to the C.O.’s office. The Captain didn’t seem to notice. He shook my hand and heartily welcomed me aboard. We made some small talk about the flight, and about Bethesda, where he had been a facilities engineer in the early sixties. He handed me off to his aid, a bored looking ensign who in turn handed me off to the Chief Petty Officer at the medical facility. Chief Harders was the first indication I had that this was real and I wasn’t in training any more.

“First,” he said. “We need to get you into a proper uniform.” I was in travel khakis and the uniform of the day was green fatigues. “We have a supply meeting with the S4 at 15:00. They’ve been shorting us on paper products and for the last two weeks, we haven’t had an officer to stand up that twit ensign over there and get us our full requisition. Then the Master at Arms has Petty Officer Race in the brig. He’s our only Public Health technician and if you don’t get him out, the reefer inspection won’t get done and you’ll have to shut down the galley until it’s certified.” He smiled at the stunned look on my face. “Don’t sweat the small stuff, Doc. I’ll run the clinic, you take care of the officer stuff. OK?”

Over the next two weeks, I got a crash course in running a battalion medical department. I had a budget of several thousand dollars to account for and responsibility for several hundred thousand dollars worth of equipment and supplies. I had a division of twelve corpsmen to lead, discipline, and supposedly mentor and counsel on everything from medical procedures to financial responsibility.

I quickly realized that the C.O. didn’t want excuses. He didn’t care that I had never done this before. If I didn’t know the answer to a question, the only acceptable answer was “I’ll find out, sir”.

I met the rest of the officers and was put in a berthing hut with three of them, all Lieutenants, like me, and all company commanders in charge of several squads of men. I found out quickly that they were all really smart guys. They had good engineering educations and had been in the Navy for five or six years. They knew their jobs and did them exceptionally well. Excellence wasn’t just a goal to them, it was a standard.

And they treated me as an equal. I was a division officer, technically senior to them in the chain of command even though I was clueless.

About a month after reporting in and just as I thought I was getting a handle on my job, the embassy crisis in Iran geared up. This was just after the Shah had been ousted and a bunch of fundamentalists took over our embassy in Tehran.

The C.O. called an all officers meeting after getting a flash message from CentCom. We were put on Defcon 3 and orders were given to prepare the battalion for mount out. Which meant someone thought we might go to war. After an hour or so of readiness reports from the various line companies, the C.O. turned to me and said, “Doc, what’s our readiness plan for casualty clearing and evacuation.” Fortunately I knew the answer (the Chief had spoon fed it to me just before the meeting. God bless Chief Petty Officers). That’s when I stopped playing officer and really felt that I had become one.

My attitude changed after that meeting. I was determined to do the job to the utmost of my ability, just like the other officers around me were. And I was determined to go back to Bethesda and complete my surgical training. If I was going to be a combat medic, then I needed the best surgical training I could get.

In the end, Command decided not to send us into the Iranian desert to build an airstrip for a rescue mission. The logistics were too daunting and the combat power too uncertain. They did load the battalion onto an LST and float us around the Horn of Africa for two weeks before standing us down.

Although we didn’t see combat in the end, for those two weeks, the prospect was very real and I came away with a new outlook on my job and on life in general. I was serving something greater than myself. People had counted on me to lead them in a situation that might involve life or death decisions. It was heady and humbling at the same time, and the knowledge that I could do it changed the way I looked at problems forever.

Stress is Unhealthy – Maybe

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Stress is Unhealthy – Maybe

 

There is a lot of hype surrounding the unhealthy effects of chronic stress. An entire industry is devoted to ‘stress reduction’ as a way to ensure better health. Now there are reputable claims for scientific evidence and a mechanism of action for the adverse effects of stress on health. A 2008 literature review of 165 studies (http://www.ncbi.nlm.nih.gov/pubmed/18493231) purported to find an association between chronic stress and a higher incidence of cancer, poorer disease free survival with treatment and higher cancer mortality. Other reviews have linked poor would healing to elevated stress levels in both human and animal models. (http://www.ncbi.nlm.nih.gov/pubmed/19686881) (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2780920/) So stress is bad, right?

Well, maybe. Many experts are skeptical of research claiming that our mental health can influence our physical health. James Coyne, PhD, director of the Behavioral Oncology Program, Abramson Cancer Center and professor of psychology in the Department of Psychiatry, University of Pennsylvania School of Medicine, has analyzed a range of studies to refute such claims. For instance, he described the gaping holes in a 2007 study claiming that, on average, less than four hours of psychotherapy was associated with a 10-year survival benefit among patients with gastrointestinal cancer. The major issue was that the study was not blinded, and patients who received psychotherapy also received more medical treatment overall. As Dr. Coyne wrote, “they were twice as likely to receive postoperative chemotherapy, five times as likely to receive radiotherapy, three times more likely to receive alternative treatments, and four times more likely to receive a combination of three treatments in the post-treatment period.”

Part of the problem with studies that focus on psychological stress as opposed to physical stress is there is not a coherent definition of what constitutes ‘stress’. When I’m faced with a critically ill trauma patient and don’t know exactly what his injuries are or how to treat him, I’m under stress. But is that different than the fear response experienced by a patient facing a major surgery? Psychologically yes, but physiologically our responses look similar – increased heart rate and respirations, widened pupils, dry mouth – the typical fight or flight response. And yet the studies that support a stress-illness link emphasize the latter circumstance as being more harmful. So called ‘controlled stress’ such as mine is actually a good response, heightening awareness, sharpening observation and inducing rapid thought associations according to a British study of professionals faced with unusual situations in their fields.

Finally, there is no solid evidence that self-reported stress has actual physical correlates. The physiologic fight or flight response can be measured, but many patients who report high stress levels have no evidence of measureable physiologic response to it. Well-controlled studies that include actual measures of physiologic response to self reported psychological stress are lacking.

I don’t doubt that stress influences a patient’s feeling of well-being and that can have a profound effect on their recovery from surgery. I am also prepared to accept that chronic hyper stimulation of the physiologic stress response affect interleukin and other immune modulators on a cellular level. Actual evidence that this has a measurable clinical effect is sparse.

There is certainly no harm in patients (or anyone) undergoing psychotherapy or counseling to help them deal with the effects of an illness. Learning relaxation techniques and engaging in stress reducing recreation or other pursuits enriches and improves our emotional and interpersonal lives. I relieve stress on the water, swimming and kayaking, and am better able to relate to my patients and family as a result. But I object to alternative medicine practitioners making claims, and worse, profiting from ‘treatments’ to reduce stress under the guise of treating or preventing illness.

 

Doing the Right thing

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Doing the Right Thing

 

People have commented on some of my posts, expressing appreciation for my ‘patient advocacy’. I hate that term. Let’s get something straight. I am not a patient advocate. Patient advocates are nurses and social workers with a Mother Teresa complex who see their mission as protecting the patient from evil uncaring doctors who would subject them to unnecessary pain and indignity. I have little tolerance for such people. If I am anything, I am an honest craftsman.

When a patient comes to my office seeking surgical care, I am making a pact with them, a contract if you will. I pledge my honor as a surgeon, as an honest man, that I will do the right thing for them. The right operation for the right reason at the right time. I will be conscientious in the operating room and will do my utmost to give them a smooth and uneventful recovery. To the extent that I do these things, my patient will do well and recover. If there is a complication, the first question I ask is “What did I do wrong?”

Note that in all of that, the real issue is my personal duty and integrity. If I do all those things right, the patient will recover and do well. But in the end, it’s not about the patient – it’s about the integrity of the WORK. The patient’s recovery is a happy side effect. It is the work that is the real motivation.

My personal integrity is at stake each time I go to the operating room. I have pledged to that patient to do my best. I don’t want to know them as people, I don’t have to like them or understand them. Sometimes it’s better if I don’t. I treat the gangbanger with the gunshot wound to the abdomen with the same attention to detail that I bring to the colon resection on the 70-year-old grandmother who bakes cookies for all the neighborhood kids. In the operating room, NONE OF THAT MATTERS. What matters is the skill I bring to my craft.

The highest complement anyone can pay me isn’t to say, “ He’s a good surgeon.” Or “He looks out for his patients.” The true recognition of what I’m about is, “He does what he says he’ll do.”

Medicare Wonderland

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Medicare Wonderland

 

She is 77 years old, a bit frail, and has a recurrent breast cancer 15 years after lumpectomy and radiation in the same breast. Her only option is a mastectomy. She lives alone and has no family in the area. Most of her friends are snowbirds – they leave Arizona for the summer and return when the weather gets cold up north. She has had a total hip and total knee replacement and isn’t too concerned about the mastectomy, since she recovered reasonably well after those procedures.

The problem is that mastectomy is now considered an outpatient procedure by CMS, the agency that makes the rules for Medicare. That means that in order to admit her to the hospital as an inpatient, I have to document ‘medical necessity’. Being old and frail isn’t considered ‘medical necessity’.

I do her surgery and write orders in the recovery room for Observation Status. This is a loophole that lets me put her in a hospital bed for 23hrs to see if there is a medical reason to require admission. It’s intended for ER patients with things like chest pain of uncertain origin, shortness of breath, fevers, etc. Surgeons have learned that we can use this status to give patients time to recover from anesthesia and regroup before going home. The alternative is to discharge directly from the recovery room within an hour or so of surgery.

I am called almost immediately by a Case Manager wanting to know what my diagnosis is that requires Observation. My stock response is pain control – the patient is receiving intravenous narcotics. It’s a bit of a cheat since they are not awake enough to take pills, but both the hospital and CMS have winked at that for years. Not anymore, apparently. Fortunately, her oxygen saturation is a bit low in the recovery room, giving me another excuse to admit her.

By the next morning, she is taking a diet, her pain is controlled and her oxygen is normal. She is still weak, however, and needs two nurses to get her out of bed. I write to convert her to an inpatient admission, since she clearly can’t go home.

Again the Case Manager calls. Her weakness isn’t considered an admission criterion. I get a little snarky and ask the Case Manager if she is willing to take my patient home and care for her, but that doesn’t really help. Now she’s hostile and tells me I can extend the Observation and get a Physical Therapy evaluation. It’s not what I want, but at least it buys another day. By Friday morning, my patient is still weak, but has managed to walk ‘community distance’ (50ft) with PT and is again ‘ready for discharge’.

I am reluctant to send her home. By objective criteria, she’s ready; but looking at her, I am afraid she’s at risk for falling, she can’t prepare her own meals, and she won’t cooperate with the nurses in learning to manage her drain. None of which buy her an admission. I talk to the Social Worker and we set up a Home Health visit for one drain care visit and a home safety evaluation. She goes home in the early afternoon.

Through this whole process, my hands have been tied by Medicare rules. I can’t do what I consider the right thing and admit the patient for a few days. I can write the orders, but Medicare will refuse payment of the hospital charges. I can lie about her condition, I can falsify or exaggerate her problems, but there are others charting on her record that would reveal the inconsistency and I’d be up on a fraud charge. So I reluctantly send her home.

She lasts 18hrs. Then she falls at home, can’t get up, and pulls her drain out in the process. Fortunately she has one of those Medic Alert pendants and calls an ambulance. I see her in the ER an hour or so later. Other than the drain being out prematurely, she is unhurt. Her wound is fine, she has a small bruise on her knee and her chin, but that’s all. I again write admission orders. Surely she has just demonstrated that she is unsafe to be home alone. I don’t even get to sign the order before the Case Manager is on my back again. Falling without injury isn’t an admission criterion. I can put her in Observation again, but that’s all.

I lose my temper and tell the Case Manager where to put her admission criteria (Hint: the sun doesn’t shine on the place I suggest) and storm out of the ER. Before I get to my car, the hospital’s Medical Officer is paging me. All hospitals have a Medical Officer, a paid lackey who nominally provides a clinical voice to advise the administration on good care and resolve conflict between physicians. In reality, they have sold out and enforce the administration’s line of BS. He first takes me to task for losing my temper with the Case Manager. In this he is right and I promise to apologize to her right away.

Then he starts on a long winded explanation of CMS Medicare rules and admission criteria. I tell him I’m well aware of the documentation needed, but unfortunately, my patient meets none of the criteria. What she really needs is a Skilled Nursing Facility for a few days. But here’s the catch – in order for Medicare to pay any of the cost of a SNF, the patient has to have three continuous days of hospitalization. The Observation days DON’T COUNT! Which is why I have been pushing for admission from day one. The SMO repeats the criteria for admission and then tells me that if I don’t change my admission order I’ll be committing Medicare Fraud. The shouting match that ensues erases any trace of cooperation.

In that, I am at fault. I lost my temper and alienated the SMO and the Case Manager. It wouldn’t have changed anything had I been more polite, but the discussion would have been more pleasant. What my patient needs is irrelevant to the bureaucracy. All I can do is keep finding excuses to keep her in Observation and hope she gets strong enough to be safe at home. In the end, I send her home again with another Home Health referral.

There’s a lesson here for all those who think that a single payer system will solve all of our healthcare problems. Medicare is defacto a single payer system for those over 65. There is no alternative other than paying out of pocket. The rules under which we treat Medicare patient are set by CMS and are often arbitrary and capricious. The emphasis is on cost containment, not clinical effectiveness. This is clear from such stupidity as the three day inpatient rule cited above; from the refusal to pay for screening tests recommended by the American College of Cardiology (due to cost issues); from the SCIP surgical protocol which has been shown in a half dozen studies to be at best irrelevant and yet CMS requires a 98% compliance with it for all surgical patients. The problem is less about who pays as it is about who decides what gets paid for.

But wait, some say, aren’t insurance companies even worse about paying for care? Don’t we hear about that all the time in the media? In fact, insurers are generally much better at covering clinically indicated care than CMS. We hear about the egregious exceptions, about the transplants denied or the experimental but lifesaving therapy that isn’t covered. But Medicare doesn’t cover that stuff either. And in my experience, if there is truly a valid clinical reason for a test or operation, I can talk to the insurance company’s medical advisor and lay out my case to him or her. Most of the time, the service is approved. In CMS, there is no one to talk to, no appeal other than to faceless and nameless bureaucrats who have no responsibility to individual patients, only to their budgets.

Charity and Entitlement

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CHARITY and ENTITLEMENT

I am a believer in charity. I write off about 15% of my gross yearly as free care to patients who have no insurance and no ability to pay a medical bill. My wife and I give almost 10% of our after tax income to various charities, mainly food banks and home building organizations as well as several religious charities.

I believe that charity is good for the soul. I am not a religious man, as I’ve discussed in other posts. But I think that the spirit is enriched by actions that promote life and wellbeing in others and in ourselves. And contrary to what many people seem to believe these days, charity is good for the recipient as well as the giver.

There is a school of thought that seems to believe that charity somehow belittles the recipient; that it is a humiliating experience and that it represents some sort of feel-good power trip for the person giving the charity.

I think the opposite is true. When you give to someone with no expectation of any return you are making an exchange of values. You are recognizing in that person an inherent value that you wish to acknowledge. If I help you out with money or material support, I am in essence saying to you, ‘I believe in you. I believe you have worth and potential and wish to see that developed or continued.’

For the recipient, a charitable assist can be uplifting and affirming. You may be down and out, beset by trouble or overwhelmed by circumstances, but another person has seen your trouble and thinks that you are worthy of help; someone believes in your potential enough to put material backing behind kind words of encouragement. It can be a tremendous boost to hope and morale – an affirmation that you still have worth and someone else believes in that worth.

Gratitude is tied into this exchange. Gratitude is not a demeaning or fawning emotion meant to stroke the feelings of the chartable giver. It is rather a subtle but powerful motivator for the recipient. If someone has acknowledged your value in a material way, there is an implied obligation to do your best to improve as a result. Sometimes it may mean repaying the favor. More commonly it is a ‘pay it forward’ obligation. I am grateful to many key individuals in my life who have helped me through tough times. I can’t repay them in kind, but I can emulate them in my dealings with others.

Contrast that to an entitlement. Those who believe in the big government solution to individual problems affirm that we all are entitled by dint of our birth to a certain level of material support. You don’t have to earn it, you are entitled to it. It is paid free of any obligation to repay or pass on to others. In this system, there is no acknowledgement of value. You are just getting your due. In fact, if you don’t get it, you are being deprived of a right and should feel resentful. You are not a person of value, you are just another citizen collecting what is owed to you.

I believe this sort of entitlement philosophy is damaging to the soul. It robs people of their dignity and their individuality. You become just another case number. Your check arrives anonymously in the mail and you have no obligation to do anything but cash it. There is no mutual recognition of value, no opportunity for gratitude. Just take your check and keep the line moving, next case!

I see this in my practice every day. We see all comers, but expect a token level of payment from everyone. The uninsured or self-pay patient pays a ten dollar ‘down payment’ on their appointment. If surgery is recommended, we work out a payment plan that fits their budget. There is no insistence on a huge amount up front, but we expect regular payment on the balance, or at least regular communication. One of my favorite patients paid off his surgery bill with rolls of quarters from his small vending machine company. Every month he would deliver two rolls of quarters. It took him several years and we offered after a while to write off the rest of his bill, but he insisted on paying in full.

Contrast that to the AHCCCS patients I see. (AHCCCS is Arizona’s form of Medicaid) They regularly fight my staff over paying the token $1 fee the state asks us to collect for each visit. They cancel or miss appointment far more often. They are more demanding of immediate scheduling and complain the loudest if we run late. They are entitled to the best care other peoples money can by and by God they’re going to make sure they get it.

The entitlement culture is not just corrosive to those who are on the dole. It cheapens us all. How many times have you passed a homeless person and wondered why ‘someone’ doesn’t do something to help him. Entitlements have allowed us all to abdicate our responsibilities to each other. Society or the government or some other big nameless organization is expected to help those in need. The problems are too big for individuals. They need big expensive solutions.

But in fact, that is a cop-out. It’s hard to look someone in the eye and offer help. It’s hard to know what sort of help to offer or how much is enough. Better to leave it to ‘experts’. That is the abdication that most of us choose.