The Occasional Perspective - 11/151/22

Opinions and Reflections 

The Immediate Looming Crisis – The recruitment demand for physicians and advanced practice providers is increasing at an exponential rate according to a recent report from the Association for Advancing Physician and Provider Recruitment. Why? In large measure to replace departing (i.e., retiring) physicians. The placement of such physicians has increased 16% for the period 2018 to 2021. From an overall perspective, the number of clinical searches reached 47% for physicians and 32% for APPs. The shortage is especially acute in the primary care (i.e. frontline) areas of health care with the specialties of family medicine, internal medicine, and hospital medicine represented as the highest need areas. Furthermore, for many health care organizations – the recruitment of clinicians is their #1 problem!! So, why is the turnover occurring? The reasons among the health care systems with 300 to 1000 provides included:

                                                                                           MDs                      APPs

  • Leaving for a similar position                                   74.6%                   91.7%
  • Retirement                                                                67.3%                   12.5%
  • Geography                                                                50.9%                   43.8%
  • Burnout                                                                      34.6%                   33.3%
  • Compensation                                                            30.9%                   68.8%

As a “rural health advocate” it’s also clear that the rural communities are the hardest hit by the problems of clinician shortage. Furthermore, the “thinning” of specialty availability is exacerbating the “burnout” issue. It’s been estimated that 1:5 physicians will retire or leave practice over the next five years or, 20%! And, it could be higher. Some studies show that the number of physicians who will reach retirement age is more than 35% of the workforce over the next five years. That’s huge. In fact, I predict that over the next five – yes FIVE – years, we are going to see a massive shortage of primary care providers due to the retirement and burnout of primary care providers of the Boomer Generation. The overall shortage by some studies is predicted to be over 120,000 physicians not even considering the APPs (for which I do not have any good numbers at this point) But, it’s not just clinicians leaving – it’s also a lack of entry by the next generation of clinical providers into the primary care fold. Finally, one more stake in the heart of primary care is that they are among the lowest compensated of the providers and yet, primary care is one of the most important areas for offering sustained quality with the best outcomes over the longer haul at the lowest overall cost. Hmmm. It’s time for a “rethink.” I personally believe that a move toward “value-based care delivery models” is a major component of the “rethink.”  

But, There’s A Bigger Looming Crisis Needing Our Advocacy Now, while I believe that the shortage of clinicians (physicians and advanced practice providers) is a big issue (SEE above commentary) that requires our attention – I think we also need to be cognizant of the (dare I say) much bigger crisis of climate change. From National Geographic this horrific crisis has been exacerbated by the opening question of “climate injustice”. What’s that? It’s where the least responsible nations for climate change are experiencing the worst burdens at the present time. The results of the recent United Nations Climate Conference or, COP27 held in Egypt point in this direction by offering fair warning from a large contingent of frustrated developing countries on “who” is going to pay for the “loss and damages” due to global emissions. The question is raised because the least developed nations are contributing the leastest of the least amount toward emissions responsible for global climate change. For example, the United States is responsible for 20+% of all historical global emissions of gases (e.g. methane, carbon dioxide) that cause climate change. What’s a world to do? Evidence that “not enough” might be the answer came in the form of plans for resolving the problem. About five years ago the global community of 190+ nations agreed that each country should put together a plan within five years on their intent for helping to solve the problem. The reports from the COP27 meeting revealed that only 25+ reports have been received AND NONE OF THEM were from the leading contributors to the problem = the United States, Europe, China, Russia, etc. It makes the shortage of clinician providers seem like a minor problem…

Readings, Hearings and Quiet Talk To Consider - 10/17/22

Books, Articles and Word-on-the-Street Worth a Second Consideration… 

On Aging – Over the last year one of my favorite web broadcast discoveries has been a video featuring Clint Eastwood – Don’t Let The Old Man In.  It highlights a song written by Toby Keith following a golf match with Eastwood. As the story goes, they were on the 19th T (= “bar” for all of you non-golfers) following a golf match that involved lots of swings and misses when Keith asked Eastwood what he was doing the next day. Eastwood then went into a soliloquy on all the meetings and discussions that were planned as part of a new movie he was going to produce. Keith responded that Eastwood was in his late 80s and asked the question “…How do you do it?” The response from Eastwood: “I don’t let the old man in!” Now comes the story of Ray Ruschel, a 49-year-old business management student at North Dakota State College of Sciencein my home state. As a student at the college, he tried out for the football team as a defensive lineman and managed to beat the younger competition out of the position. He’s a regular on the line in their games. In fact, the competition frequently mistakes him as a coach when he steps on the field. His response? “That always makes me laugh. And then, I play harder.” While I’m way ahead of Ruschel at age 49 I’m slightly behind Eastwood at age 92 on the aging continuum. Regardless, I keep telling myself: Don’t Let The Old Man In.

KitterySlow-Paced Small Towns” In Maine For Leading A Simple Life. I’m pointing with pride to my adopted home in Kittery, Maine!! There are lots of small towns in Maine just like North Dakota where I grew up. But, the advantage is that in Maine, we have “ocean”, “mountains” and “trees”! = Advantage Maine!! Kittery Point was Number 12 on a list of 15 top small towns in Maine, even though I would rank it as #1. Why? Because beyond the three advantages mentioned above, Kittery Point offers great neighbors, a large number of mom-and-pop establishments, and a pace of living that’s very tolerable and culminates in making available all of the basics of life without being a lot of work. With only about a thousand neighbors, it’s easy to get to know one another – the workers at the Post Office, the attendants at the local coffee shop and…and…you get the picture… Besides, if we need more, there’s “Kittery” just next door with over four thousand residents if you need the advantages of the city 😊. 

Back-To-Back Recognitions – Now For The Trifecta! – Just before the start of the September cooling season, we learned that the NASA Webb Telescope had the first clear evidence in identifying an exoplanet with an atmosphere containing carbon dioxide as a planet outside our solar system. The only problem is visitation because the planet is just over 700 light years away from Earth. But even though we (or, at least the current residents of Earth) will never be able to see it, the prospect is still exciting because of the specter of potential life on other planet. Now, to put it context. There are over 3200 stars in our solar system (= the Milky Way) similar to our own Sun. That makes for a fairly large potential number of places just in the neighborhood for “life”. But, then, add to the fact that there are over 2 Billion (with a capital “B”) stars in our galaxy which have the potential for supporting an exoplanet like Earth. Even if the odds stay at 1:3200-to-2,000,000,000 that means there are likely at least 62,500 other Earths someplace in the Universe – that are clearly on the course to discovery so far!! And, the cost of the Webb Telescope development? About $10 Billion or, as Senator Everett Dirksen (R-IL) used to say, “A billion here, a billion there and pretty soon you’ve got real money.” Yes. Real money and real transformation in what this means for our sense of who and what we are as members of the human species.

The Webb discovery was followed a couple of weeks later with an announcement by the Nobel Committee on the 2022 Nobel Prize in Medicine. It went to Svante Pääbo, a Ph.D. researcher who almost singlehandedly developed the field of palaeogenomics over the last two decades. His discovery paved the way for identifying the DNA code for Neanderthals and, a previously unknown hominin, Denisovans. His research laid the groundwork for defining how modern-day humans differ from their historical hominins or, “What makes a human human? I don’t know the cost but as a betting person, I wager it is far, far less than the $10 Billion spent on the Webb telescope initiative.

Now, here’s the clincher. The total USA health care spend in 2021 was $4.3 Trillion (with a “T”) and growing. The projected health care costs in 2025 are anticipated at $5.5 Trillion. If we spent $10 Billion in health care research (the same amount as the Webb Telescope project) towards reducing costs to adopt a more value-based care delivery system in the USA, we would be spending 1:1000th of a percentage point in projected health care costs in a very short 3 years! Seems like a no brainer to me? Yet, we walk away because “the health care conundrum is a tough nut to crack” How many times have you heard this in your career? Yes, it is a tough nut to crack but, it’s not any tougher than finding planets throughout the universe that can potentially support life nor the field of paleogenomics to tell us what we could have become if we didn’t evolve.

In sum, we seem to have a potential Trifecta (i.e. the Webb Telescope, paleogenomics AND solving the health care cost conundrum) on our hands if we will simply invest the time and money into solving the problem. I encourage the younger generation to take this on…after all, I’m working on not letting the old man in 😊.

The Occasional Perspective - 9/20/22

Opinions and Reflections

 Misinformation Derived From Misdirection Causing Misunderstanding – In the last issue of The Fickenscher Files, I regaled you on the difference between “leadership” and “power”. My premise was – AND, is – that much of what we see in the USA today is all about obtaining “power” rather than providing “leadership” – especially in the political sector although the phenomenon is seemingly present throughout all industries. If you’re into power, you’re into making sure that all those around you are totally supportive of you in every way regardless of outcome. Alternatively, if you’re into leadership, you know that there is a segment of the populace that will always be opposed to – or, at least questioning – your ideas, proposed directions or even philosophy despite the fact that you may be making progress in solving problems.

In today’s issue I want to focus on the issue of misunderstandings within the greater community which seems to be a prevalent cause for the intractability for initiating and supporting needed changes in society across the board. I think that most of you would agree that there seems to be a plethora of misinformation, outright lies, and conspiracy theories that are continuously perpetrated on the public on many different fronts. One small example is the nearly half a billion dollars which has evidently been spent by the Russian government in the USA in an effort to dissuade the American public and others from supporting the Ukrainian opposition to the invasion from Russia. It’s just one example. We could no doubt find examples on other issues both large and small for social and economic reasons.

Ironically, the trend seems to be coming from both sides of the equation although (my perspective – where I know I’ll get feedback 😊) more prominent among far-right advocates or autocrats like Mr. Putin. These pieces of mis-information or distortions are propagated by racists, by misogynists, by people with a subversive agendas, by science deniers, by those seeking change at any cost; and, by people who simply hate or are fearful of any type of change on all sides of any aisle. They are exacerbated by governments like China, Russia, the Saudi autocracy, political action committees (PACs), the dark money managers and others with an overt agenda for controlling the direction of decisions, resource allocation, political responses and the like. The same could no doubt be said for some corporations or industrial sectors (e.g. the oil industry).  In recent years, the misinformation has been accelerated through the use of internet trolls or, websites built specifically to draw people in and feed them spurious information; as well as, the posting of derogatory or misleading comments on LinkedIn, Facebook, Instagram, Twitter, YouTube, etc. In other words, you pick your favorite source of information and too often you head down the rabbit hole… 

The second issue relates to misdirection! One of the lessons I’ve learned from one of my high school friends who is a very good performance magician is that the reason for his success is the effective use of misdirection to captivate, direct, arrest, and control the attention of the audience. He’s a master at sleight-of-hand magic. In fact, now that he’s clued me in – I’m more observant of his performance manipulation. Magicians actually use the term misdirection to describe their approach toward understanding the basic laws of human interest. It’s exemplified by the coin magically appearing from the ear of a child or even an adult. Misdirection is rampant across social media and even among network media. Where is Walter Cronkite when we need him?

And, finally – the end result of mis-information coupled with misdirection is misunderstanding! The unsuspecting are pulled down a garden path into an abyss where the cycle of further misinformation and misdirection deepens the well of misunderstanding.

This is what is happening in America on too many fronts. Whether it is the spewing of totally erroneous materials related to immunizations that prevent the spread of Covid amidst the worst pandemic in over a couple of centuries or, the divisive politics (I think on both sides although more prevalent on one – guess which one?) or, the creation of rationales for bringing the world to the precipice of global instability through the unilateral invasion of a sovereign nation – we now face the spreading disease of social instability!!

It’s not clear to me how to stop it but it will require leadership[1] – a capability that I find woefully missing in our current political culture. As a centrist I can find fault on both sides of the aisle but what is coming out of the political right is quite disturbing. Where are the Bob Dole’s, David Durenburger’s, Everett Dirksen’s and the like when we need them? The cauldron seems only to be fed by further mis-information and mis-direction especially by the immediate former President of our country. It’s time for leadership to emerge (aka Rep. Liz Cheney) to help us all move through the evolving morass. And, as we all know, leadership is built on principles. Without clarity on one’s personal set of principles, it’s very difficult to surf the tsunami of misleading tropes and information on all sides of the equation.

I mention all of this because our nation has far larger problems than just those on first base in the political world. We’ve got massive income disparity exemplified by the fact that in 2021, Jeff Bezos earned a stunning $8.56M (yes, that’s a “M”) per hour versus the two parent family with service jobs and two kids barely making ends meet. There are also obvious issues with our nation’s health care system that will NEVER be solved without bi-partisan collaboration. The completion of education after high school is no longer a ticket to success in any nation. I’m not sure that “free” college is the answer but clearly provide a way for “every eligible member of society” to better themselves through college education with low interest support is smart in a global economy. Education is the spark of competitive capability for any nation. In addition, the technology sector is in dire need of better oversight and policy on any number of fronts. Telecom – which has become an essential part of everyone’s life is frequently not available in rural areas and can be out-of-reach for many urban dwellers as well. The investment world needs some retooling according to many advocates although in which direction is up for debate. The list goes on and on…and yet, we dither with mis-information coupled with misdirection and create misunderstanding!

In the upcoming elections, we “the people” need to step up to vote for those who are ardent advocates for the spread of accurate information, for setting a direction that works to bring together the majority of voices so that we can support a foundation of understanding that most of us can get behind to sustain the future of our nation, the global community, the environment and – ultimately – the world. We need to demand a focus on solving problems to create a sustainable future. Now is the time.

We desperately need leadership!! Solving the problems I’ve outlined which is just the beginning of a long list will be and is a tough course to follow. It will require individuals with a set of clearly articulated principles that we can all assess and determine if they meet the needs of society from our perspective. We don’t need mis-information and misdirection. Thanks for letting me ventilate…


[1] See more on this topic in my last Fickenscher Files – sent out on August 23, 2022 – Volume 10, Issue 10.

The Occasional Perspective - 7/6/22

Thoughts in the Moment…

Upending Health Care – Among all of the issues facing health care, the U.S. Supreme Court added to the list by eliminating a 50-year standing policy established in 1973 through the federal right to abortion. The policy was upended by the Supreme Court’s ruling stating that the prior long-standing policy was an error. It’s clear that this historic decision is going to have major consequences across the healthcare community. In case you missed it, here are some of the perspectives issued by various healthcare organizations, companies, and government officials in response the change in law related to abortion access.

  • American Hospital Association: "We expect that today's decision will have practical impacts on hospitals and health systems, including on healthcare provided across state lines, EMTALA obligations, maternal healthcare, the clinician-patient relationship, medical education and access to care for individuals regardless of socioeconomic status. We are committed to helping our member hospitals and health systems navigate the evolving landscape consistent with AHA's mission of advancing the health of all individuals and communities." (news release)
  • American Medical Association: "The American Medical Association is deeply disturbed by the U.S. Supreme Court's decision to overturn nearly a half century of precedent protecting patients' right to critical reproductive healthcare—representing an egregious allowance of government intrusion into the medical examination room, a direct attack on the practice of medicine and the patient-physician relationship, and a brazen violation of patients' rights to evidence-based reproductive health services. States that end legal abortion will not end abortion—they will end safe abortion, risking devastating consequences, including patients' lives. …We will always have physicians' backs and defend the practice of medicine, we will fight to protect the patient-physician relationship, and we will oppose any law or regulation that compromises or criminalizes patient access to safe, evidence-based medical care, including abortion. As the health of millions of patients hangs in the balance, this is a fight we will not give up." (news release) kudos to Jack Resneck, Jr., AMA President
  • American Nurses Association: "Nurses have an ethical obligation to safeguard the right to privacy for individuals, families and communities, allowing for decision making that is based on full information without coercion. As the largest group of healthcare professionals, nurses have for decades assisted their patients with weighing the benefits, burdens and available options, including the choice of no treatment, when discussing sexual health issues and pregnancy. ANA firmly believes that no nurse should be subject to punitive or judicial processes for upholding their ethical obligations to their patients and profession." (news release)
  • Federation of American Hospitals: "FAH members remain committed to providing the best possible care to every patient who comes through our doors, while at the same time complying with state and local laws and regulations." (news release) hmmmmm…
  • America's Essential Hospitals: "This decision could inspire policies that result in an uneven distribution of providers across states, greater disparities in maternal health, and conflicts between state and federal laws. For example, providers might face concerns about how to reconcile state restrictions with their obligations under federal law to stabilize and treat emergency department patients. A chilling effect on physician training and shortages of obstetrician-gynecologists in some states also could follow this ruling. We urge policymakers to carefully consider their actions in the wake of this ruling and reject policies that would restrict healthcare access, undercut medical decision-making, and put patient care and health at risk." (news release) good thoughts for action…
  • American College of Obstetricians and Gynecologists: "Today's decision is a direct blow to bodily autonomy, reproductive health, patient safety and health equity in the United States. Reversing the constitutional protection for safe, legal abortion established by the Supreme Court nearly 50 years ago exposes pregnant people to arbitrary, state-based restrictions, regulations and bans that will leave many people unable to access needed medical care. The restrictions put forth are not based on science nor medicine; they allow unrelated third parties to make decisions that rightfully and ethically should be made only by individuals and their physicians. ACOG condemns this devastating decision, which will allow state governments to prevent women from living with autonomy over their bodies and their decisions." – Dr. Iffath Hoskins, president (news release)
  • National Nurses United: "Registered nurses understand that abortion is a basic healthcare service, and as a union of healthcare providers dedicated to advocating for the best interests of our patients, National Nurses United opposes any efforts to restrict our patients' control and choices over their own healthcare and their own bodies. The basic tenets of ethical medical care dictate that patients should enjoy autonomy, self-determination and dignity over their bodies, their lives, and the healthcare they receive. Singling out this exception, the right to end a pregnancy, that targets only people with reproductive capacity, is not only bad health policy, it is immoral, discriminatory, misogynist, violent, unacceptable and violates the nursing ethics we nurses pledge to uphold." (news release) – if it’s not obvious already, I agree!!
  • National League for Nursing: "With multiple states poised to legislate to eliminate or severely restrict abortion access and potentially hold abortion providers criminally liable, the result will inevitably be a patchwork of laws that will disproportionately negatively impact people of color and those on the economic margins of society, including rural Americans who already travel great distances for medical care." (news release)
  • ServiceEmployees International Union: "As a direct result of this ruling, more women will be forced to choose between paying their rent or traveling long distances to receive safe abortion care. Working women are already struggling in poverty-wage jobs without paid leave and many are also shouldering the caregiving responsibilities for their families, typically unpaid. This radical decision will impact all of us, especially those who already face barriers to accessing healthcare because of structural racism, sexism and corporate greed. Without the ability to determine whether and when to have children, essential workers serving their communities as child care providers, home care workers, healthcare workers, janitors and fast food workers can't hope to join the middle class." (news release)

And, If That Was Not Enough – In a separate – but, equally significant health care issue – the U.S. Supreme Court struck down by a vote of 6 – 3 the century old State of New York limits on who may carry guns in public. The majority opinion was issued by Justice Clarence Thomas which stated that the constitutionality of restrictions is historically “settled” in certain “sensitive places” such as legislatures, courtrooms and polling locations, and that “modern regulations” may “prohibit” the carry of firearms in “new” places. However, an across-the-board prohibition is not an acceptable public policy. Therefore, the states will be required to create a list of “sensitive” places where guns may not be carried. At the same time, the majority opinion did not provide any guidance although during the oral arguments, a number of justices asked questions about areas like public transportationcrowded venuesuniversity campuses or where alcohol is served. Justice Brett Kavanaugh and Chief Justice John Roberts in a concurring opinion noted that states could still enact rigorous requirements for public carry permits such as stringent background, mental health record reviews and requirements for completion of training courses.

The (Unusually Long and) Occasional Perspective - 6/2/22

The Failed Generation – My generation has failed the generations that follow with one of the biggest public health disasters ever. And, unfortunately, we continue to blaze a trail of failure each and every day. We like to think of ourselves as a societal class that exemplified the hallmark for change. After all, there was no Earth Day before we came along. There was little social integration across the spectrum of society. And, while there is still much to do, integration is some better over the last couple of decades. The generation of “peace and love” was going to make a difference but…me thinks we’ve failed. In fact, we failed so miserably that on Tuesday, May 24th I broke down and cried. I sat in my home office and wept for the 19 children and two teachers that will not have a life to lead because we have failed. We’ve failed because of the stupidity of ideas like the proposed “one door” policy. Are we to have one door on churches? On grocery stores? On barber shops? On restaurants? On homes? How senseless…how stupid… And then, since the Uvalde tragedy there have been even more shootings, more senseless murders, more tragic gun violence…When will it end? Only when we decide to do something about it!

Rather than addressing gun violence for what it is, we have stepped aside to the flow of money deposited in the pockets of our generational decision makers. We have allowed reason to be set aside to the libertine polemics of “rights” – as if those who have been killed have no “rights”. What happened to the right articulated in the Declaration of Independence to “life, liberty and the pursuit of happiness”? Does one right weigh more heavily in the “rights panel” than another?

Furthermore, has anyone read recently the Second Amendment to the US Constitution, which states: “A well-regulated militia being necessary to the security of a free state, the right of the people to keep and bear arms shall not be infringed.” Hmmm? A well-regulated militia…not a partially regulated, not an unregulated but a “well-regulated militia”. That is stated first then the secondary right to “bear arms”. Is not “reason” a reasonable pursuit in a civil society? A civil society would allow people to “bear arms” but would use “reason” to offer a “well-regulated” approach.

It would appear that even Antonin Scalia – the icon of conservatism and author of the Supreme Court’s Heller Opinion which laid out the right to bear arms – would agree with me that “regulation” is a component of the right to bear arms. He stated in that opinion:

Like most rights, the right secured by the Second Amendment is not unlimited.” Scalia continued, “…the right was not a right to keep and carry any weapon whatsoever in any manner whatsoever and for whatever purpose.”

Is the requirement for wearing seatbelts an impingement upon my right to incur upon society countless health care costs due to the damage to myself and other that I make during accidents? Is the requirement for having completed one’s childhood vaccinations before entry to school onerous? Are all of the food safety requirements of the Food and Drug Administration (FDA) so noxious that we should ignore them? Are the Environmental Protection Agency (EPA) requirements for destruction of certain noxious gases so onerous as to infringe on my rights to simply throw them in the waste out back? Or, to allow cars to throw carbon monoxide and other noxious gases into the atmosphere for the killing of future generations?

When will we come to a reasonable recognition that certain rights are beyond the pale? Can I go out and purchase a Howitzer for my personal pleasure and destruction? We require a driver’s license to drive cars but do not make the same minimalistic requirement for AR-15 gun ownership! We allow individuals to modify guns such that they automatically dispense death by simply purchasing the supplies over-the-counter. But, I can’t buy certain drugs over-the-counter unless I have a prescription from a designated professional. Life is full of rules and requirements that affect my “life, liberty and pursuit of happiness” – in large measure because we have tests for “reasonability”. These tests are applied across virtually every aspect of our lives – except for one area that has been deemed sacred by a small sector of society. The time has come for the rest of us to step up…

I am NOT advocating that we take away the right to appropriate gun ownership. What society needs to do; however, is to require that your ownership does not impinge upon the rest of us. Go hunt! Have a good time. Take up skeets! Enjoy the afternoon. Protect your home! But do so under the reasonableness test used across all of society for all issues we face – as a society. No, you can’t buy a Howitzer! We’re not going to let you build nuclear weapons at home. Let’s find the line and make it stick for all of society. And, if we are successful, many of us will cry tears of joy instead of regret and disgust at the direction of our country. We owe it to future generations to step up and solve the problem. Are you in?

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