Saturday, July 14, 2007

If I Were Surgeon General

What follows are questions distinguished NYT contributors would ask James W. Holsinger, Jr, MD, in his appearance before the Senate Committee on Health, Education, Law, and Pensions.

Below are the answers I would give if I were being considered for Surgeon General. Dr. Holsinger, of course, had his own set of answers. Among these answers were these.

-- On his attitude towards gays, “I can only say that I have a deep appreciation for the essential human dignity of all people, regardless of background or sexual orientation, Should I be confirmed as surgeon general, I pledge to you to continue that commitment.”

--On what he would do if asked to yield to political principles, “If I were faced with a situation that I felt I could not in good conscience do, I think I have a clear response to that. I would resign.”

--On universal coverage, “We need to have every American covered for health care.”

Here are the NYT’s Op-Ed contributors’ questions, and how I would answer them.

What Patients Need – from Abraham Verghesse , a professor of medicine and director of the Center for Medical Humanities and Ethics at the University of Texas

1. “Many Americans cannot afford preventive care in a doctor’s office, and therefore get acute care in emergency rooms for preventable conditions. What role does the surgeon general play in bringing about affordable health care for all — the key to practicing preventive medicine?”

My role is use my position as a public pulpit to preach the gospel to teach the benefits of good diet, good exercise, good weight control, good self-care, good management of disease, and avoidance of destructive habits and behaviors. I believe, of course, in affordable care for all, and I would say so.

2. “Americans often find that health care is so fragmented and technology-driven that no one person seems to be in charge as they shuttle from office to office, suite to suite. What can the surgeon general do to bring the pieces together and give patients the security of knowing that the system is paying attention to their needs?”

My role is to encourage Americans to keep a personal health record and to choose a primary care physician whom they trust. Beyond that, there’s little I can do personally. I have no power to integrate or coordinate the system. That task requires collaboration between America’s 5200 hospitals and its 900,000 physicians.

3. “Effective preventive health campaigns by previous surgeons general are partly responsible for Americans’ increased longevity. But now, older Americans carry an increased burden of illness and a greater need for custodial care. And death too often comes in a hospital’s intensive care unit — at great expense to the family and to the taxpayer. What is the surgeon general’s role in improving end-of-life care? “

My role is to encourage patients to investigate hospice services, to seek out disease management services that offer home care, and to encourage older patients to practice self-reliance and demand care that preserves dignity and independence.

The Care Gap – from Harriet A. Washington, the author of “Medical Apartheid.”

1.. “The surgeon general’s office, with a small budget and no specific mandate, makes its impact primarily as a bully pulpit that others have used to take courageous stands. Dr. Thomas Parran, surgeon general from 1936 to 1948, shocked the nation by urging nationwide syphilis education and treatment; Dr. David Satcher, who served from 1998 to 2002, vowed to end racial health-care disparities; Dr. Jocelyn Elders (1993-94) took on the tobacco companies; and Dr. C. Everett Koop (1982-89) dared to make AIDS a household word. What bold initiative would you make your personal mission? “

My “bold mission” would be to announce we’re all in this thing called health care together, including patients, and the best thing to improve outcomes is for patients to watch their blood pressure, their weight, their blood sugar and blood lipids; and to think of their doctors as partners in health.

2. “The black infant mortality rate remains twice that of whites; the black adult mortality rate is 1.5 that of whites and the black maternal death rate is four times that of white women. What action would you take to give racial inequities in health care more prominence on the national agenda? “

I would bring these gaps to the attention of the black community through their national leaders and through community-based organizations, like hair dressing establishments and churches. I would give black leaders a prominent place on my bully pulpit.

3. “Lesbians suffer a higher risk of a variety of health problems from cancer and heart disease to depression, and they are also less likely than other Americans to seek care from a medical system that they perceive to be judgmental, intolerant and even hostile. How will you assuage fears that your beliefs concerning the “unnaturalness” of gay behavior would hamper your ability to effectively address the medical needs of gay Americans?”

I would simply express tolerance and sympathy for gays and publicly support gay unions. That should help to begin to overcome negative perceptions about gays. The surgeon general can shape culture attitudes but he or she cannot overcome them.

4. “Dr. Koop pledged to abandon anti-abortion activities while in office, saying, “I’ve always been able to separate my personal beliefs from my responsibilities as surgeon general.” Will you pledge to the nation that you would not allow your personal beliefs about homosexuality to inform your official actions pertaining to AIDS, medical enfranchisement for gays or stem cell research?”

Sure, I can “personally” do that, but I would point out some belief “personal beliefs” are regarded by some as “personal principles” and “and “social responsibilities” there may be a fine line between them.

Faith in Medicine – From Richard P. Sloan, a professor at Columbia University Medical Center and the author of “Blind Faith: The Unholy Alliance of Religion and Medicine.

1. “According to a recent report in The New England Journal of Medicine, more than 40 million Americans are cared for by doctors who believe that their religious convictions supersede their obligation to provide patients with legal treatments. Are doctors’ primary obligations to their patients or their religious convictions?”

To their patients.

2. “The Christian Medical and Dental Association, a professional society with more than 17,000 members, publishes a handbook that instructs doctors to use their practices to evangelize, explicitly encouraging them to take advantage of patients’ vulnerability. As both a doctor and a high-ranking layman in the United Methodist Church with a master’s degree in biblical studies, how will you balance your religious and medical views? “

Carefully-- and with balance. The tone of your question reflects an underlying hostility and a secular point of view – a view to which you are entitled but is far from universal. I would point out there are 902,000 practicing doctors, and only 17,000, less than 2%, belong to the association you mention.

3. “Former Surgeon General Richard Carmona has disclosed that Bush administration officials pressured him to censure medical information inconsistent with the administration’s ideological positions. If you experience similar pressure, will you resign in protest? “

I would resign if I thought the editing represented censure. The Bush Administration editing of speeches doesn’t necessarily represent censure. I may represent political consistency. In political and academic settings, most speeches are reviewed before presentation so the employing institution can send out a consistent message.

Dr. Advertiser – From Paul Offit, chief of the infectious diseases section of the Children’s Hospital of Philadelphia and the author of “Vaccinated: One Man’s Quest to Defeat the World’s Deadliest Diseases

1. “Cutbacks in state health programs mean that in several states new vaccines to prevent meningococcal, pneumococcal and papillomavirus infections may not be available to all children. Do you have any plans to address this crisis in providing vaccines? “

I will do my best to make sure these vaccines are available, but I would point out that many States have severe budgetary problems, new vaccines are expensive to produce and take time, and it may beyond my power to influence decisions at the state level.

2. “The surgeon general plays an important role in educating doctors and the public about health. Probably the most common way in which patients learn about medical products is advertising. But such advertising often inflates the benefits of drugs or medical devices while minimizing the risks. What role, if any, do you think advertising should play in educating the public about diseases and medical treatments?”

Advertising plays a powerful role in our capitalistic society in which drug and device manufacturers are trying to recoup the cost of their investment. In our society, people are free to make choices, and to believe or disbelieve the advertising message. If the advertising is incorrect, false, or misleading, it should be withdrawn. Mention of risks accompanies most advertising. It is up to the FDA to police medical advertising.

Guns and Needles – From Sally Satel, a psychiatrist and resident scholar at the American Enterprise Institute

1. “If confirmed, you will be working in the city with the highest rate of AIDS cases in the country. Intravenous drug users are estimated to make up about one-third of Washington’s new AIDS cases. The House recently lifted a ban preventing the District from using municipal money to set up a needle exchange program. However, the Bush administration remains opposed to the use of federal funds for needle exchange.”

“If asked to advise the president about changing this stance, using the epidemiological data on the effect of needle exchange on H.I.V. transmission, what would you tell him? And how would you, as a physician and former health administrator, weigh the pros and cons of needle exchange?”

I would weigh the evidence, and if the evidence was overwhelming that needle exchange prevented AIDS, I would advise the President to change his position.

2. “In the wake of the Virginia Tech shootings there was much discussion about re-examining the range of state laws on involuntary treatment of the severely mentally ill. In Virginia, the standard is so narrowly defined that a patient has to be on the verge of harming himself or someone else before the courts can act. What can the federal government do to bring needed change to reduce the chances of another Virginia Tech?”

The federal government can lobby for more consistency in State Laws regarding gun control. But gun control is an emotional and divisive issue in many states, particularly states in which hunting is an integral part of the culture. Short of changing the Constitution of the right to bear arms, I don’t think the federal government can do much but to argue for sane gun control laws

3. “As you know, we are experiencing a dire shortage of organs for transplantation. Close to 100,000 people are waiting for kidneys, livers, hearts and lungs. Last year barely one-third of those on the lists received an organ, and 17 died each day. (Disclosure: I am one of the fortunate few who have received a kidney.) How would you remedy the shortage? “

I would encourage States to include a clause in the driving license process giving drivers permission to donate organs. Also one could encourage lawyers to include such a clause when drawing up “living wills.”

“Also, even if every usable cadaver kidney were transplanted, there would remain a vast demand for kidneys. This is why a growing number of transplant surgeons, legal scholars and ethicists believe we should conduct pilot programs in which living kidney donors can receive some form of compensation to give one up. Is it time to try this?”

It is time to try.

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