Wednesday, November 18, 2020

Enrolling as a Research Subject

About a year ago, I volunteered for a study at the state university examining cognitive decline as people age.  Appropriately, they recruited subjects from a table set up in the lobby at the Osher Lifelong Learning Institute.  Being always on the prowl for something to do, I offered my contact information, underwent screening and was assigned as a healthy control.  I attended two on-site sessions, getting a university parking ticket at one that I successfully challenged.  I read my own uncontrasted cranial MRI which freaked out the technicians a bit, but never got the formal radiology interpretation.  On exercise testing they measured oxygen consumption but neither I nor my physician ever got results.  They did psychometric testing which my self-interpretation would suggest limitations of spatial orientation and maybe some immediate memory. My honorarium arrived in due time.

OLLI has gone virtual due to Covid-19 but the computerized face pages still recruit us for university studies.  I followed the link, somebody contacted me, and ran a miniscreening.  They performed over the phone a mini-mental status exam, where I had great difficulty repeating the words I had just heard, both immediately and a few minutes later.  All else seemed intact, but the deficit qualified me for the next stage.

My professional research experience, despite an endocrinology fellowship, was quite minimal.  I had written an NIH Training Grant Proposal as a program requirement, did not get selected, and really graduated without understanding stages of clinical studies until I became a subject who had to give consent.  The current project has an honorarium far larger than the last one and is subdivided into two main grants and some lesser offshoots.  While I thought the first screening qualified me, that was not the case.  I underwent a second more detailed screening, including my wife's presence part of the time to provide information about me while I was sent someplace else.  Then the exam, a more detailed mental status exam with a language component, much like we were taught in neurology class in medical school to assess a mixture of dementia and aphasia.  I did a lot better, even the repeating of words.  As I listened to the dozen or so words being presented, I did not think of them as isolated words but as categories: gemstones, animals, and dwellings.  By classifying them, I was able to repeat a lot more of them this time than last, so I may not qualify for a memory impairment study, though had I not categorized the words and just tried to remember them as words, I probably would.  Is it a short term memory deficit that's compensated but still a deficit?  The person administering the questions couldn't tell me.  But it's not a functional deficit.  While the first study kept my scores hidden from me, the consent on this one requires them to disclose them to me.

But if I am demented at all, it's pretty subtle, exposed only by testing for that purpose.

Thursday, November 5, 2020

Price Transparency: Rescuer or Disruptor?

Between being retired and pandemic limitations on personal contact, I have become blood brothers with my computer.  Mostly cyberspace sites that have large access followings, some smaller assemblies of people like my synagoge or Osher Lifelong Learning Institute, though some with just me and what the geniuses of Microsoft enabled without having me connected to the world.  While I jot down in a notebook at 7PM each evening with roller ball pen three favorable experiences of the day, there are many good things that do not isolate to specific days.  My inquisitive mind did not get fully mashed in the latter days of my medical career by the Electronic Record or a level of oversight that tallied my performance score by measuring how much, often to the neglect of how well.  There are daily goals, as there have been for decades, but better completion as the diversions of commuting, committee meetings, or even workday grooming have moved to the background.

One of my more gratifying self-schedulings has been regular viewing of TED talks, to which I was introduced in recent OLLI classes.  Experts in more fields than I can name, most with a Wikipedia entry to establish their expert credentials, archived over about ten years by date and by topic category.  As an introduction, and to encourage consistency on my part, I assigned myself two talks a day, chosen by subject in sequence by letter of  the alphabet.  While many stimulate my frontal cortex and my stored knowledge meticulously accumulated over decades, I particularly wanted to explore more after a talk on price transparency in healthcare.  It was not really a stump speech that any elected official would offer if elected, but a more thoughtful summary of what an expert thought would happen if that politician really did incorporate price transparency of our medical care to parallel what we pay in a department store or a gas station.

This presentation took place about two years ago, given by a journalist who post-retirement pivoted to an agency head that collects data on medical pricing.  It has had more than two million views, though not with the endorsement of the movers & shakers who can make this happen though a preliminary proposal for this came from the Center for Medicare and Medicaid Services (CMS) at the beginning of the Covid-19 pandemic but has proven less newsworthy than more urgent public health concerns.  Indeed, whether it should happen remains an open question.  While most of us of my age have a fondness for that great medical icon, Dr. Geraldine, who taught the world from our home TV's that "what you see is what you get" doing that with the GDP fraction of health care expenditures can create a Pandora's Box of immense negative possibilities and without that gem of HOPE nestled at the bottom.  The TED speaker's site collects actual prices reported by consumers of medical care for the services they either purchased, shopped for, or had somebody else, usually their insurance, pay an outrageous sum on their behalf.  The almost immense spread of reported prices would be viewed by most readers as scandalous, but the insiders who set the prices and the insurers who pay them are well aware of the pricing structure, its extreme variance among providers, and those gentlemen's agreements to pay the final sum total irrespective of the merits or negotiation of the individual items that create the total.

This shielding of itemization,  never done in grocery shopping or similar small purchases, had a previous legacy elsewhere in the consumer economy.  When my father shopped for a new car, he would take us as a family to several local dealers.  At the time, American cars dominated and more people ordered their car to be built at the factory to specification rather than drive one home from the dealer's inventory.  The salesman would show us the car.  Then he would give us a list of options to make the car "nicely loaded."  My father would add a radio and an automatic transmission, consider air conditioning, or some elective safety features, or tinted windows.  The salesman would write this down on his carbonized form.  The front page where he wrote would have entries for adding what we desired, the total added with an adding machine while shielded from our view, and my father would be handed one of the carbons with the total asking price.  The consumer copy had blacked out the itemization prices so you only knew the base price and the total.  If you said AM/FM radio, the savings to be had by giving up FM was withheld, keeping the consumers at a disadvantage.

Japanese manufacturers eventually undid this industrywide performance norm by just including the options that their data showed most consumers wanted and give a price.  It's a two edged sword, forcing that AM/FM radio because that's the only way their cars were built, even if all you use the radio for is the commuting traffic report or forcing power windows on the customers who really didn't mind rolling their window position manually.  The system created more price transparency, virtually eliminating the American car salesman's "bump" that add a $50 item that you didn't know about but he did because you never got the itemized list of what you agreed to purchase.

We have some variants of this today.  In the days when men were the hosts at business or personal restaurant outings, there were "women's menus" that lacked prices.  Recently a good friend took me to lunch at his snooty city club restricted to alumni of his Ivy alma mater who paid a fee to belong.  Nice restroom with university logo paper towels.  At lunch, my menu had no prices.  I did not see his menu.  Maybe it didn't have prices either if the costs of his meals were part of a membership obligation.  But there was a menu in their lobby that did.  Despite my effort to become literate in Hebrew which is read from right to left, they did not want me reading their menu that way, particularly when somebody else is obligated to pay for what I select.

For a short time, during a wage-price freeze in the pre-computer era, the Nixon Administration included a requirement that the 50 most commonly billed items in medical offices be kept in a loose leaf at the front desk for review by patients.

Even though I did not pay for my family cars and I did not offer to go Dutch at my friend's alumnus haven, I resented having information that might guide my selection withheld from me.  There is a reason that those obliterated carbon copies of car dealership price obscurity and "women's menus" are no more.  The rebellion of the consumer, either by preferentially buying price transparent Japanese cars or by a female executive shaming her waiter by telling him that as the one with the company credit card, she gets the menu with the prices, led to the demise of these attempts to deprive consumers of pricing knowledge they were entitled to have.

Health care outside the scope of physician care has made some progress.  At a dental implant, my periodontist had his front desk offer me a pre-procedure itemization, including surcharges for the CT scan and for harvesting my white cells should those be needed.  Unlike a restaurant patron, I did not have the option of declining a portion that he thought needed to be done.  As a Medicare beneficiary, I shop for a supplement each Open Season.  This includes a Part D prescription plan where the quarterly copay for each of my current prescriptions is itemized, though the portion paid by the insurer is not disclosed to me . However, the monthly premium is.  As a Medicare Beneficiary with a good Medigap policy, when I see my doctor a statement is sent with fee submitted by the doctor's office, the amount that Medicare pays, and later from the Medigap carrier telling me what they paid.  This is more the illusion of transparent, at least for Evaluation & Management codes of office visits, along with an understanding that the price submitted by the. office to Medicare was essentially fictitious.  There is no reason to shop as a different provider will not result in a different final price to either me or to my doctor.  It makes no difference if the submitted sum to Medicare far exceeded any fair market value of what the doctor billed, though it might for bills that contain itemization of procedures that Medicare pays for but really could have been safely declined by an informed patient.  

As much as this is accepted customary delivery of medical care for a fee, sometimes the consumer is the payer and some consumers, myself among them, regard ourselves as stewards of our insurer.  If it is despicable to gouge me, it is just as despicable to gouge them, even though they are run by professionals who would spend more company money screening and challenging charges than they would just paying them.  Moreover, many of us now have high deductible plans so are effectively direct consumers for a considerable up-front sum.  But ultimately, there is a premium paid by either consumer or employer for the coverage, so that gentleman's agreement of deep pocket insurers to just pay what is requested returns to either the taxpayers for public programs or to employers or patients subsidizing the lack of transparency indirectly for commercial insurers in a competitive marketplace.

Something like imposing price transparency on a national scale amid a tradition of itemized obscurity would generate a fair amount of disruption.  It is far from apparent whether mandatory compliance achieves pre-determined goals, assuming we know what the goals are.  Enabling individual consumers shop more wisely seems easy to accomplish and very consistent with other consumer initiatives.  The impact on institutions may have a more significant down side.  Moreover, as quality may be better served by value based payment systems, Geraldine's itemized "what you see is what you get" could reinforce fee for service which has created an incentive to do more medical care when less might be better.  

Price shopping for deals means that a purchase is not urgent.  Mammograms, lipid testing, doctors visits et al have some leeway but not unlimited flexibility to acquisition.  So delaying care in a harmful way  could happen.  Some decisions, while not urgent, are more complex. They carry a higher price tag with serious consequences to indefinite delay, such as heart surgery or cancer care. Delays to get the best financial deal might be more unwise.   

Perhaps the most intriguing provision of the CMS transparency proposal involved providers making available the real cash payment they would accept in lieu of the inflated price given to the self-payer, enforced by collection agencies, later amenable to partial payment.  That's the real price.  For one time purchases such as a car or a home, there is some variability with sellers offering different prices to different buyers.  Parts of the world still have souks.  But JC Penney and FW Woolworth made their fortunes by reassuring their customers that all would pay the same stated price for the same item.  Medical care should not be modelled after the bazaar or the car dealership.

Bringing transparency to institutions, less vulnerable than individual patients, that have professionals and attorneys galore to protect their financial and competitive interests may expose a bigger downside.  Despite their bargaining clout and sophistication, payment for a specified service vary widely between hospitals dealing with the same insurer and between multiple insurers paying itemized or bundled fees from an individual hospital.  Confidentiality allows deals to be negotiated on a very large scale.  If everyone knows what everyone else charges and receives, some services will inevitably play out as commodities, items sold in bulk at market rates irrespective of variations of quality.  As competitive forces restrain the prices of the bulk items, the services provided under conditions of urgency would rise to maintain net financial solvency.  Thus ER or services unique to a particular institution would rise.  Hospitals in less populated areas or hospitals serving an underinsured population would have less ability to leverage their geographic exclusivity.  And as prices that institutions are paid by their insurance contracts are known and squeezed, the source of investment revenue would become less secure as well, jeopardizing acquisition of new expensive technology with uncertain profitability.

Finally, once itemization of real payments, not fictitious charges, becomes public knowledge, it becomes more secure to reaffirm fee for service predictability for a less certain value or outcome based payment system which may have an advantage in nudging optimal medical care.  The ability of physicians or our employers to predict individual or cumulative outcomes leave a measure of uncertainty beyond knowing in a predictable way what you will receive for the work you do irrespective of outcome.

What seems to be my expectation is that individual consumers think of their care as a consumer purchase more when they have to present their credit care than their insurance card.  Dr. Geraldine's "what you see is what you get" has considerable appeal.  Once you get past the consumer to institutional haggling which has to include value as well as price, there may still be some advantages to keeping the verifiable payments confidential.  That emptied Pandora's Box may lack the expected gemstone on the bottom.

Tuesday, September 1, 2020

Visiting the New Doctor

 What I Learned When I Tried a Direct Primary Care Practice

Physician tenure is usually longer than manager tenure though increasingly uncertain.  The independent practice model took its toll on me ten years ago and on my own primary doctor this summer.  He could have distributed us among the remaining independent colleagues but opted to parcel us out to the dominant medical center owned practices.  I latched onto one with some effort but completed the initial visit.

I expected to encounter a more robust enterprise.  Two old colleagues, crossed my path, one recognizing me with a hello and brief chat, the other not.  With three physicians on-site the waiting area, marked for social distancing, seemed devoid of patients.  Check-in, also marked for distance only had one other patient, a new one, also a refugee from my doctor's senior partner.  I appeared the sturdier and more independent.  His son toted his record, something I had provided the previous week, his being much bulkier than mine.

My turn came.  Height by stadiometer, weight by digital scale, blood pressure by electronic doo-dad.  All on target, though I've lost a smidgen of height from my peak, though it's never been measured with a stadiometer in the past.  Waited for the doctor and her resident to come by.  Resident didn't say a word.  As a new patient I provided a history while my new doctor checked the template circles.  Currently asymptomatic pretty much except for the planned obsolescence of chronic arthritis, and that had improved greatly from its peak severity.  Family history given.  Heart and lungs auscultated by the attending physician, not by the resident.  Usually don't find much on exam, and the younger doctors have largely lost the skill.  Neither has a lot of experience with paper medical records, commenting more about handwriting than the more important retrieval of content.  An innocuous encounter to be rescheduled for six months.

When I completed residency, that was the type of job at the top of my list.  Instead for convenience, a hospitalist position came my way as the first job out of residency.  The better choice in the long run.  Despite being on Medicare, I am an easy patient with a small list of recordable problems, preventive care up to date, and nothing medically challenging to be pondered.  I require more processing than reasoning, the most challenging decision perhaps how far into the future to schedule the next appointment.  I would bore me if my medical clones occupied that exam room all day long. 

Most surprisingly to me, the office at the centerpiece of the primary care network of the large regional center did not seem a beehive of medical activity.  Covid-19 probably limits occupancy of the office, but it's usually best when the docs on site look reasonably frazzled by not fully overwhelmed.  Maybe some folks with later appointments will challenge them more.

Thursday, August 13, 2020

Pet Peeve Expression

It began with a post on Twitter from a physician inviting colleagues to relate in 140 keyboard taps or less what provokes them professionally.  His post received overwhelming responses, suggesting that a lot of physicians follow things on Twitter and really are pretty disaffected.  To bring this to a more physician focused forum, one of the editors of Medscape imported this to her forum, inviting the same question from Medscape subscribers who include a wide spectrum of health care workers.

There have been about 250 responses to the invitation, including one of mine.  Some are specialty specific, some more general annoyance with the plight of health professionals.  Some wise, some with levity, some with sarcasm.  I'll offer a few of mine.

People who try to deceive me.  This includes patients whose diabetes log numbers all end in 0 or 5, who ask for far more test strips than they actually use, presumably with the intent of selling the rest to the brokers who post yellow signs on telephone poles all over West Philadelphia offering to pay for unused strips.

I intensely dislike being called a provider.  I resent the expectation of parity with others who really do not share my level of skill.  What bothers me more, maybe, is how fluently this has been incorporated into discussions by the levels of managers, from those in an alcove to those with expensive desks.  These are good people who have allowed their insight to falter.

Our Electronic Health Records and the burdens of using them are a public blight.

Measures of my performance that are really the illusions of measures of my performance.

Consults done at my invitation performed by people who know less than me without the real involvement of the expected person whose expertise exceeds mine and was therefore solicited.

Having to send somebody from my exam room who obviously needs to be admitted but is not in any distress to the ER first.

Overscheduling so that the request of the ignoramus resident that a patient seen in the hospital can return in one week when the next meaningful assessment should really be in two months when the newly prescribed medicine has a chance to do what it is supposed to do.

The fellow who brings coffee to the doctors lounge not having a substitute when he takes a day off.

Patients who have been permanent residents of the USA for decades with chronic illnesses who never thought it important enough to acquire enough local language skills to enable their doctors to do the best they can for them.

Copy and Paste as a surrogate for thoughtful analysis expressed in a medical note.

The law that requires me to pay more for a sign language interpreter out of my own funds double the  money that the office visit would bring in.

Fictional Review of Systems documented but never solicited from the patient.  The presence of dyspareunia may protect from psychosis since everyone admitted to the psych floor specifically does not have it.

Documentation of physical exam components that were really never done.

Having to obtain preauthorization from a functionary who knows less than me and cannot discuss reasonable alternatives with the threshold of knowledge needed to advocate for the patient being discussed.

Dietary solutions for people who weigh 400 pounds who really need medicine to address their problem.

Insufficient financial and talent support to go off on a tangent to explore something that catches my interest.

The hospitalist giving my longstanding office patient's consult or office followup to a colleague instead of me, and my own colleague not making the correction.

Not a bad list.  The longer I think, the longer it grows.

Doctor Shortage: We May Need an Additional 90,000 Physicians by 2

Monday, August 10, 2020

Step 1 Goes Generic

USMLE Step 1 (and Other Standardized Exam) Taking Tips! | My USMLE ...

Assessing medical knowledge has been one of those bugaboos of medical education that has multiple purposes.  By the time a person gets to medical school, they have taken high stakes exams, from SATs, in my day College Board Achievement Tests, the Organic Chemistry final, almost certainly an MCAT once or twice.  All have numbers attached to them, designed in part to assess achievement but also to predict future potential, as these scores get submitted to others who don't really care how much math you really know but have to sort through who to select for limited entry slots.  Medical school Admission Committees skim off the success stories and regroup them into a new pool for new high stakes exams that never really end.  

The general sequence of standardized testing, not counting course examinations, includes Step 1 after the preclinical years, which for some schools tacks on the core clinical year, Step 2 during the senior year, Step 3 usually taken after internship, Board Certification after residency or fellowship, and Recertification which occurs typically at ten year intervals for most specialties.  We get pretty adept at taking them.  

Each ordeal has a number assigned to it.  The purpose of the score becomes less clear as the cohort of test takers becomes more exclusive.  Specialty certification exams, the final step, are functionally pass/fail.  Either you achieve certification or you don't, yet there is a score reported and subdivided by subject for the sole benefit of the applicant to know where some future attention to knowledge upgrades are best applied.  By Step 3, admission decisions have already been made so only a pass benefits the new physician, but the institution needs to know the caliber of those accepted into their programs and options for tweaking their curriculums.  By the time Step 2 is reported, residency match applications have been submitted.  There is a specialty score which may help the program rank its applicants but the scores benefit the medical school more than they benefit the student, especially in view of a 97% pass rate among first time takers. .

Step 1 may be the last test with serious ranking potential both for student and for school.  A recent decision to no longer report scores beyond pass/fail has created some controversy.  Good test takers feel cheated.  Program directors looking at hundreds of applicants from scores of schools liked the ease of lopping off the bottom 2/3 from further consideration.  Students whose test taking savvy fell below their grades, which are more a reflection of daily diligence, now have an advantage.  Is this a good thing?  Nobody knows yet.

In my era we had Part I of National Boards.  My school required a passing score to proceed to the clinical year.  Those who did not pass, about a dozen each year, and not necessarily those who struggled most with their courses, were assigned a remedial summer while the rest of us went to our first clinical rotation.  On repeat examination in September, our pass rate approached 100% and nobody's career was seriously impeded as much as their self-esteem was.  Scores went with our residency applications that could decide what to do with the results of preclinical years.  The biggest beneficiary was probably the school which could design its curriculum to maximize pass rates, assess the effectiveness of its pre-clinical faculty, and target students weak in a particular science for remediation in advance of the exam.  Knowing the historical pass rates also helped.  That is no more.  While in my day, we had scores that would be used later, the immediate utility was an overall Pass that punched the ticket into the clinical years.

As it goes pass/fail with no scores to be passed along either for residency screening or self-assessment, something beneficial is likely to be sacrificed.  Since the pass rates are the same as when I took them 40 years ago, there is still that element of anxiety among the test takers but it won't haunt them two years later.  They can focus on their classes.  The schools can focus on their curriculums without concern of their relative standings among schools.  But the residency program directors will need a different screening mechanism.  Likely those of the more prestigious schools will have a selection advantage that a diamond in the rough who squeaked by the competitive admissions process but thrived once on campus can no longer compensate.  Overall, I suspect people other than the program directors will eventually miss those Step 1 scores.

Wednesday, July 22, 2020

Transitioning Doctors

Physician Liaison Referral Marketing - Physician Referral Marketing

In the past year, as I've latched firmly onto Medicare, some asymptomatic numerical data has kept me more in touch with my personal physician than at any time since he served as one of my more distinguished Internal Medicine residents. He called the medicines correctly, and I've assisted him by taking them almost without fail, so numerical data obtained since the Covid-19 pandemic changed the medical care landscape has never been better. My prior quarterly assessment took place over the telephone, his taking my word for hypertensive data obtained mostly by my home kit. A second agent entered my daily pill container, the systolic BP's came down to desired levels, and I had no side effects of medication. Regional infection risks have abated enough for him to see me in the exam room.

As I waited my turn in his socially distanced waiting area, I seemed the sturdiest of the men there, no women waiting to be seen. People exited but I did not notice that none received a followup appointment, only a note from the secretary of a referral to the regional medical center.

My turn arrived, no complaints on my part. As he proceeded with the encounter, he noted that he and his partners opted to close their practice, accounting for the referral of the previous patients in lieu of followup scheduling. The reasons my doctor gave sounded very familiar, as I had done the same ten years earlier. A lease renewal with ruinous rent increase served as the terminal event. But a look around the waiting area told more. Charts, including mine, still came in bulky manila folders. He entered notes on a computer but could not afford to invest in fully electronic record keeping. Reporting data, billing, insurance, tracking hospitalizations which his group until recently had continued to follow in the hospital, and innumerable petty distractions from the more satisfying elements of being the doctor had claimed another four experienced clinicians, two late career, two mid-career . As much as I appreciated his expert guidance over many years, the time to transition had arrived.

He had inherited me from another outstanding resident who I helped train largely for geographic reasons. My office stood in the building next to his. I needed negligible medical care most of the time, some lipid management, a false alarm on a cardiac concern, allergic rhinitis before nasal steroids went OTC, and some annoying prostate symptoms with even more annoying orthostasis on the usual alpha blocker. He never seemed disappointed at tweaking the medically innocuous, unlike me who thrived on the complexity of lab work at the extremes. My blood pressure eventually needed attention and my appendix, of blessed memory, brought me to the OR after I retired, but medical care never reached complexity. An annual review with lab work became quarterly as medicine needed adjustment. I expected this to plod along indefinitely but the lure of a stable salary as part time hospitalist and part time internist for a thriving orthopedic practice replaced the burdens of independent practice management.

I had just retrieved my three month supply of medication from the pharmacy so there was no urgency to secure a replacement personal physician. As I exited the office the secretary handed me their closure letter, suggesting that followup care be arranged through the regional medical center, which had become something of a local monopoly, though a number of independent practices remained, often with concierge enrollment charges. I looked up the web site, which I expected to be the medical center's physician referral service. It was not. Rather it was an unselected list of staff physicians in Internal Medicine which numbered about 1000 individuals. Subspecialists, ICU physicians, hospitalists, education directors all aggregated with primary care physicians but excluded their whole family practice department which would add another few hundred people. The site had locations where the hospital operated satellite centers. I accessed those but none had a list of physicians assigned to those sites, let alone indication of FP or IM. Next option, called the physician referral phone number provided in my doctor's letter. I noted the site and asked her to give me a list of physicians at that site. She couldn't. This was not very helpful.

Next step, looking up a physician on their payroll who I know well, a contemporary, who I know works at one of the sites. Success. That site has seven physicians. I preferred on of the younger ones, somebody I don't know personally, and read the training bios. Interestingly, all five were women. I called the number which got answered on the 13th ring, though the person I finally reached could not have been more helpful. We reviewed the time frames for appointment, she asked when I would run out of medicine, and then we settled on a woman who seemed a contemporary of my own children who are also physicians. Mission accomplished, though I would have expected a dominant medical center to make the task of latching onto one of their employee physicians a little less troublesome than it seemed.

Tuesday, June 9, 2020

Contending with My FB Friends

Relationships and Accountability - Jason Lauritsen

Social media can be rather toxic, giving the full extent of humanity verbal access to you with no restraint on being abusive with no adverse consequences beyond being blocked.  Medical care also brings us into the full realm of humanity, mostly delightful people but a few for whom the most enticing response might be Undoctor.  But they rarely arrive in the hospital bed or the exam room as your perceived equal, keeping a cap on the abusiveness. But unlike patients who have no obligation to me beyond making an appointment, keeping it, and paying the fee but unchallenged acceptance provided their problem falls within my skill.  Social media is a more equal relationship but a more manageable one.  First, I am not required to show up.  Sermo has been dispatched for cause for some time.  After a few misgivings I might have been premature at not wanting to have trolls as my medical colleagues, any urge to reconnect has long since passed.  Twitter gives me access to some of the finest minds and most influential individuals around.  At that level it is not interactive at all.  At least my Congressional delegation sends a computerized thank you note when I comment on an issue, and usually my representative's position on the issue of concern to me.  Over the years, though, I've received my share of personal responses including my wording in their response.  It is really a forum for me to make a statement, though never to make a difference.  I cannot block anyone from hostility to my comments though I'm generally too much of a peasant in a forum where who you are matters more than what you think.

Facebook remains my media of choice, even to quasi-addiction in the absence of formal limitations on my frequency of access.  I know all the people designated friends personally.  I've largely stopped commenting on organizational sites where loons cannot be regulated away.  Most of my cohort comes from high school.  Ironically, few of us were close friends at the time but the exchange of comments has been respectful.  Each of us have developed over those 50 years certain proficiencies and certain predictabilites of response.  I never Unfriended anyone who I knew personally and only unfollow the occasional nudnik who posts ever ten minutes while awake or somebody who bypasses analysis to toss out a slogan.  But for the most part, my high school educated us well.

The situation with police misconduct leaves me a little at odds with my friends.  We vote the same.  We have different experiences.  My medical career has required mostly favorable interaction with constables who keep my hospital secure, officers who identify people on the street as needing medical care, prison guards who maintain a three way banter between me and the fellow handcuffed to the bed rail.  We agree that targeting Black folks for harshness is unprofessional at best, sometimes criminal or lethal at worst.  We analyze the best solution differently.  Hang the wrongdoers just doesn't change the culture.  

Medicine changed its culture in my professional lifetime.  I could not think of people more demeaning of the patient public than officers of the AMA and regional medical societies, who in many ways opposed physician accountability early in my career.  The state societies had to divest themselves of a unification requirement with a more haughty AMA just to maintain their own membership.  And we got accountability big time, but not objectionable accountability.  It came in the form of performance enhancement but without fear of reprisal which too often undermines that goal.  We have guidelines for many conditions with compliance of analyzed best practices by physicians.  Licensure requires some attention to making medical care safer through risk management.  Some of us find analysis of Big Data and institutional reporting requirements objectionable, though nobody objects to the improvement in care these efforts create.

Calls for police defunding or other punitive responses undermine public safety, not enhance it.  I already met hundreds of honorable officers as patients or in the workplace.  Some of the brutality that makes the cell phone camera exposees may very well be successful implementation of their training.  You don't fix that by any measure other than changing the training, establishing best practices, confidential peer reviews, CME appropriate to policing, and public image enhancement because you accomplished things worthy of public image enhancement.

My FB friends are probably no more outraged by events than me.  They are considerably less analytical than me and most experienced physicians in addressing it.  We've been there ourselves and succeeded but it took a generation.