OP-ED

Us and Them-Ism

Us and Them
And after all we’re only ordinary men

The wanna-be congressman appeared with his neat hair and pressed suit, a competent yet compassionate expression on his face.  ”The first thing I am going to do when I get to congress is to work to repeal Obamacare,” he said, expression growing subtly angry.  ”I will do everything I can to give you back the care you need from those who think big government is the solution to every problem.”

My wife grabbed my arm, restraining me from throwing the nearest object at the television.  I cursed under my breath.

No, it’s not my liberal ideology that made me react this way; I’ve had a similar reaction to ads by democrats who demonize republicans as uncaring religious zealots who want corporations to run society.  I am a “flaming moderate,” which means that I get to sneer at the lunacy on both sides of the political aisle. I grew up surrounded by conservative ideas, and probably still lean a bit more that direction than to the left, but my direction has been away from there to a comfortable place in the middle.

It’s not the ideology that bugs me, it’s the use of the “us and them” approach to problem solving.  If only we could get rid of the bad people, we could make everything work.  If only those people weren’t oppressing us.  If only those people weren’t so lazy.  It’s the radical religious people who are the problem.  It’s the liberal atheists.  It’s the corporations.  It’s the government.  All of this makes the problem into something that isn’t the fault of the person making the accusation, conveniently taking the heat off of them for coming up with solutions to the problems.

Taken to its logical end, the “us and them” mentality leads to concentration camps, the Spanish inquisition, the gulag, or McCarthyism.  The problems this state of mind creates are much bigger than the ones it is trying to avoid in the first place.  Hate crimes are committed against people who aren’t like us, while others are demonized for voicing an opinion that go against the “right” way of thinking.  Both of these reactions are extreme, and both of them push us further from the solutions to any problem.

Us and them-ism is also a prominent feature in medicine.  Drug companies are evil, Medicaid patients are scum, doctors are too busy counting their money to care, and patients don’t listen to what their caring doctors say.  My conservative patients come in to the office assuming that all of the problems in health care are obviously caused by Obama, just as the liberals blamed it all on Bush four years ago.  They worry about me leaving medicine because of the passage of the ACA, not really knowing what kind of impact it actually has on primary care physicians.  Ironically, the one thing both conservatives and liberals agree on is term limits for congress members, as we all see that the “bad” special interest groups are controlling congress.  Maybe that’s more of the us and them-ism, but I can get anyone to laugh at a joke with a congressman at the butt.

“When you don’t have blood going to your head,” I explain, “you pass out so the blood can get to your brain easier.  Getting blood to your brain (and your heart) is pretty much essential…unless you are a member of congress, where having a brain or a heart seems to be a liability.”  I’ve gotten laughs from the right and the left on that one.

We unfortunately are soon to experience the pinnacle of us and them-ism: a presidential election.  Those who govern us leave governance and embrace pure politics. If Obamacare was the best possible law, the republicans would demonize it anyway to avoid giving the president the political upper hand.  The same would happen if there was a republican president; this is bipartisan power lust with no apology.

Yet the problem in my exam rooms remains: care is too expensive, there is more red-tape and less good care, more patients have no insurance than ever before, and doctors are getting really, really tired of dealing with this mess.  Patients die due to poor access to care (far more than most people realize), and many grow rich off of a system which pays more attention to shareholders of device manufacturers than to the patients with the devices in their bodies.

The intersection between health care and politics is the place where I lose my temper.  Politicians playing the power game with the lives of my patients are my arch nemesis.  This is insane.  This has to change.

When I was a medical student I did a cardiology rotation.  I had a patient who had a heart attack and was sent to the floor, seemingly stable.  I met her and her family, getting to know the situation as well as could be understood by a student.  I heard the overhead page for the code on the ward she was in, so I ran to see if it was her who had suddenly crashed.  My heart sank when I came to her room and saw a flurry of activity around her doorway, with her family somberly standing outside while people hurried in and out of the room.  Her husband’s eyes were tearful as I came up to the doorway.

“It’s Maria,” he said to me, “She just stopped breathing.”

I gave a weak smile to try to comfort him. “I’ll go and find out how she’s doing.”

She wasn’t doing well.  Her heart rhythm was nothing I had ever seen before and her face was ashen.  The respiratory therapist was assisting her breathing using a bag-mask and the nurses were attending to her IV.  The cardiology fellows I was working with on the rotation were in a corner, far away from the woman, arguing with each other.

“I think it’s a junctional rhythm with PVC’s,” said one with passion.

“No, it’s clearly a left bundle with a-fib,” argued another, with derision in his voice.

As the argument went on between the doctors, the woman grew more pale.  She was obviously dying.  I thought about her husband, not able to be with his wife as she lay dying in bed, away from him, instead being the subject of an academic debate about heart rhythms.

I felt sick.

The rhetoric on health care seems eerily similar.  The patient is laying on the bed dying while the politicians are vying for the upper hand in the debate.  The patients are ignored, though, serving as a tool with which to smear the other side.  Just like I felt when I was a medical student, I feel powerless to do anything while a tragedy unfolds before my eyes.

With, without
And who’ll deny that’s what the fightings all about
Get out of the way, it’s a busy day
And I’ve got things on my mind
For want of the price of tea and a slice
The old man died

Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at More Musings (of a Distractible Kind) where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player.  He is a primary care physician.

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Judy ByrumSteveHsouthern docsteveMargalit Gur-Arie Recent comment authors
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Judy Byrum
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Judy Byrum

Maggie has just about talked me out of being a Democrat.

Maggie Mahar
Guest

Barry– In theory safe harbor proection is a good idea, but we don’t have a lot of “comparative effectiveness reserach” that would apply to “failure to diagnose.” Failure to diagnose is usually about “not doing something” Most recently,here in NY a little boy went to the ER, and the lab failed to tell the ER doctors that his tests showed a seriious infection.This doesn’t have anything to do with practicing evidence-based medicine. Failure to diagnose has more to do with: failing to take a good patient history; failing to really listen to the patient; jumping to a conclusion. There are… Read more »

Maggie Mahar
Guest

Rob– I completely understand that few people have the time to wade through the legislation and absorb the details. As you say that is what I do for a living. But the main point of your post seemed to be that most politicians– Republicans and Democrats alike–were failing to represent the best interests of patients. You then went on to say that if only Democrats had been more inclined to compromise, it would have been a better bill. Now you’re saying that you really don’t know a great deal about the specifics of the bill. So how can you simultaneously… Read more »

Barry Carol
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Barry Carol

Maggie – The trend toward fewer malpractice suits is all well and good and so is the trend among hospitals to disclose errors and learn from them. However, if we want doctors to follow evidence based guidelines where they exist and even to push back against patients who think more care is better care even when it isn’t, the least we can do is give them safe harbor protection from failure to diagnose lawsuits when they didn’t order the extra test because the evidence based guidelines didn’t call for it. We’re not talking about wrong site surgery here. We’re talking… Read more »

Maggie Mahar
Guest

Rob– I asked if you could give an example of something that the Democrats should have compromised on, and you replied: “I’m not specific here about the bill because I don’t think I need to.” Wel I guess that ends the discussion. Southern Doc– good point! Barry–I’m relieved to know you weren’t talking about a ‘flat tax.” I’m sorry I misread your comment. Since you brought up malpractice: did you know that both the number of malpractice cases, and the size of awards has shrunk significantly each and every year for the past 8 years? It’s become increasingly difficult to… Read more »

Rob
Guest

Maggie: I am not here to argue specifics on the bill, especially with someone who does that sort of thing full-time. My expertise (as I said in other comments) is that of a clinician who has to live with the consequences. Would you care to argue clinical medicine with me? I am disappointed that you ignore the entire point of what I said, which is trying to look at the forest and not debate the trees.

Maggie Mahar
Guest

Margalit_

You wrote:

“Perhaps you should care, because health and health care are inexorably connected to poverty, and poverty is rising at alarming rates….
I don’t see the irony in any of this. I do see tragedy though. ”

Yes, I totally agree.

And you also are right that the majority of Democrat failed to adrress ther rise in poverty.

Barry Carol
Guest
Barry Carol

Margalit – While I don’t have any magic bullet to fix the economy either, there are a few things I wish we could do that wouldn’t raise a huge amount of money but would improve the optics and make most people perceive that the playing field isn’t quite as tilted against them as it appears to be now. Specifically, if it were up to me, I would at least do the following: (1) as an alternative to Obama’s proposed “Buffett Rule,” and until we can get broader tax reform, I would include income from capital gains and qualified dividends as… Read more »

Margalit Gur-Arie
Guest

Barry, I hope you know that I also appreciate and respect your opinions, and I I consider plenty of fiscal conservatives part of my “us”. I know and appreciate that the reasons for the increasing disparities in wealth are many and are very complex. Nevertheless disparities are now higher than ever before in this country and this was never a good thing for either citizens or the economy. Certainly “fixing” the economy should help, but I am not sure we can “fix” the economy without addressing the root causes for disparities first, and even if we could, I am not… Read more »

Barry Carol
Guest
Barry Carol

Margalit – While I know we disagree more often than not, I appreciate and respect your viewpoint. As I noted earlier, a key reason for the increase in inequality over the last 30-40 years is the sharp rise in the stock market as the wealthy own a disproportionate share of stocks. Another stock market crash would reduce that inequality considerably but the consequences wouldn’t be pleasant for the middle class or for many state governments, especially CA, which depend on a small sliver of wealthy taxpayers for a huge percentage of their income tax revenue. You may not be aware… Read more »

Barry Carol
Guest
Barry Carol

Rob – I agree again. One issue Democrats could have tackled was sensible tort reform. Specifically, safe harbor protection from failure to diagnose lawsuits for doctors who follow evidence based guidelines where they exist would have been helpful. Of course, that would have meant taking on the trial lawyers, a key Democratic constituency. That wasn’t going to happen, especially in the Senate where they knew they needed 60 votes to pass anything. I think the biggest problem with the health reform law was its timing coming soon after the late 2008 financial system meltdown and the deepest recession since the… Read more »

Margalit Gur-Arie
Guest

Just a small point here, Barry, about the “ramming through”: If Obama would have stuck to his (our) guns and indeed rammed through a public option, I would understand your frustration. This thing that passed is in my opinion nothing more than corporate welfare and it is largely due to Obama & Co. trying to compromise with the other side of the house, similar to what Rob thinks should be done, I guess (maybe not).

southern doc
Guest
southern doc

Rammed through? I thought they voted on it according to the rules of the House and Senate. My mistake.

SteveH
Guest
SteveH

I’ve heard that the Democrats offered to include tort reform as part of the ACA if Republicans would agree to vote for the bill. They were told by their Republican colleagues that no matter which Republican amendments were included (and there were many that made it into the final bill) there wouldn’t be any Republican votes for the bill.

Maggie Mahar
Guest

Steve H–

This is all true. Many Democrats favored some form of tort reform.
And in order to pass the legislation, Democrats compromised on many
points, and included Republican proposals in the final legislation.

But Republicans were adamant: there would be no Republican votes for the bill. I’m told that what they did to Olympia Snowe and one or two others who seemed inclined to stray was frightening.

Margalit Gur-Arie
Guest

“Regarding the rich and the middle class, which is where all of the irony seems to be located, I don’t care a whole lot.” Perhaps you should care, because health and health care are inexorably connected to poverty, and poverty is rising at alarming rates. I don’t see the irony in any of this. I do see tragedy though. This is not about Democrats and Republicans because both parties are equally at fault for failing to represent the interests of the majority of people who elected them to office. This is not about liberals and conservatives either. This is about… Read more »

Rob
Guest

The irony is there because the rhetoric on the discussion became “us and them” rhetoric. I care about poor people, but the point of this post is not a discussion about poverty, but a comment on how politicians take my patients’ health (both rich and poor patients) and turn it into a political football they use for their advantage. I am an expert on what the patient in the exam room looks like. I am an expert on patients being injured, and even killed because of our system. My expertise comes from my face-to-face encounter with it every day. I… Read more »

Margalit Gur-Arie
Guest

I think our differences stem from different definitions of “us” and “them”. At this point, I regard all politicians from both parties (with few notable exceptions) as “them”.

Barry Carol
Guest
Barry Carol

“Meanwhile, you would have everyone pay the same tax rate on all of their income –whether their household takes in $800,000 a year or $40,000?” Maggie – If you read my comment carefully, you would see that I never said any such thing. I said the top rate in the 1986 Tax Reform Act was 28%. There were rates starting at 15% at the lower end, 25% in the middle and 28% at the top after subtracting personal exemptions, the standard deduction or itemized deductions for the minority of taxpayers who itemize (30% these days as I noted previously). The… Read more »

steve
Guest
steve

I am largely in agreement with you, but I think you miss a few things. CEO/management now makes about 20 times more than it did 30-40 years ago. We have not seen this same disparity in other countries. There is something unique about the US, and it is not that these execs are producing 20 times the results for their companies.

It is also fairly clear that we have decreasing returns on labor. Not all of this is due to globalization. Much of it is also redistribution to management and to the financial sector.

http://www.washingtonpost.com/blogs/ezra-klein/wp/2012/07/27/corporations-are-saving-more-and-paying-less/

http://www.livingstandards.org/wp-content/uploads/2012/02/Decoupling-of-wages-and-productivity.pdf

Steve

Maggie Mahar
Guest

Rob– I’m wondering where liberals could have “gotten better results” if they “moved further to the right”? What should they have given up on? I’m asking this seriously. From a doctor’s perspective, where (on what issue?) do you think they could have benefited patients, and wound up with a better piece of legislation if they went along with Republicans? (In particular, where did you the leadership ( Reid & Pelosi) held out for sometihing where they should have compromised? ) As you say, Republicans simply did not want to hand Obama a huge legilsative victory. As Mitch McConell has said,… Read more »

Rob
Guest

Democrats are not the only ones with good ideas. I would expect that people from both sides looking seriously to fix the system, both willing to give up on issues to get something that was a health care bill, not a political bill, would make something far better than bills that “survive” our political process. In general, creating good through cooperation is a far better way to make something than to make through a nasty game. I am not being specific here on the bill because I don’t think I need to. Surely you don’t think our political process is… Read more »

Barry Carol
Guest
Barry Carol

Rob – I agree with you. The problem with our politics, as I see it, has two parts. First, in the House, computerized gerrymandering has created more safe seats that we’ve had historically which reduces the incentive to compromise from what it once was. Second, it seems to me that way to much of the electorate at election time rewards pandering, demagoguery, and negative campaigning while they penalize honest, straight talk about the difficult choices we face. We wouldn’t see so much negative campaigning if it weren’t rewarded. In short, we’ve met the enemy and it’s us. Separately, one more… Read more »

Maggie Mahar
Guest

Barry– The “middle-class” is, by definition, a band of people clustered around median income. Today, for a household, that is roughlly JOINTincome of $60,000– before taxes. Half of all households earn less; half earn more. So statisticaly speaking , couples with joint income of roughlyl $50,000 to $70,000 constitute the middle class . Sit down and try to calculatet necessary expenses for two adults and just one child (rent or mortgage) food, utilities, transportation to work, since public transportaiton is not available in most of the country, this usually means gasoline, care repair, auto insurance ) medical insurance, childcare while… Read more »