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Tuesday, July 30, 2013

"The F Word" - Family Physician Of The Year Acceptance Speech By D. Stoltze, M.D.


Alan: Friend David Stoltze M.D. served as Professor of Family Medicine at University of New Mexico Medical School. For nearly three decades, David also guided the exemplary public health clinic in Las Vegas, New Mexico which he describes as "America's only socialist medical clinic." David co-founded the public health center on the floor of Mexico's Cañón del Cobre (Copper Canyon), and for 25 years has helped build Nicaragua's national health care system.

In 2011, David moved his medical practice to British Columbia, Canada

***

22 Oct. 2004

To the editor:

I would like to make a point in relation to the upcoming election, and I believe that I can make it without mentioning any present-day American politician or political party…

Our family is German-American. Although we are not old enough to have lived through it ourselves, theabsolutely darkest time in history was the Third Reich (1933-1945). Nazi Germany, as a nation, was responsible for World War II and the Holocaust.

The political stance of Nazi Germany was characterized by fascism. The term "fascism" arose somewhat before the rise of the Nazis in Germany, in Mussolini’s Italy.

What are the defining characteristics of the politics of fascism? Most dictionaries cite a combination of militarism, extreme nationalism (and, by extension, racism) and vicious repression of domestic dissent.
Fascism, however, is more than that. Otherwise, the term could be applied to any government with an extremely aggressive and warlike stance in relation to other nations and to its own domestic opposition.

The other aspect of fascism, which is key to understanding its political meaning and its relevance to contemporary politics was well articulated during World War II by US Vice President Henry Wallace. Vice-President Wallace pointed out that the political-economic configuration that brought about all of the more obviously negative manifestations of fascism was a complete merging of the state (government) apparatus with the most powerful and aggressive corporate interests in the national economy. In Italy in 1938, after a few years under Mussolini, the Italian parliament was dissolved and decision-making was vested in the "Camara di Fascisti e delle Corporazioni", a council of Mussolini’s inner circle and leaders of Italian corporations, whose main concern was the protection and expansion of their profits by themeans mentioned above.

Events took a similar, but even more drastic course in Germany.

Of additional note, after the fascists (Nazis) took power in 1933, there were still many viable opposition forces there.

Unfortunately, they were unable to form a United Front, and were eventually relatively easily crushed.
I am reminded of the well-known phrase "Those who fail to learn the lessons of history are doomed to repeat them". 

Do we want militarism, extreme nationalism and repression of domestic dissent in the interest of maintaining and expanding corporate power to be the guiding principles of the US government? 

David Stoltze, MD
1005 2nd St.
Las Vegas, New Mexico



"The F Word"
Acceptance Speech
On Receiving "Family Physician of the Year" Award
New Mexico Academy of Family Physicians
Annual Statewide Family Medicine Conference
Taos, New Mexico, August 7, 2004
By
David A. Stoltze, MD, MPH

First of all, I would like to thank the Board of the Academy for this award. I am surprised and grateful at having received it.

Although I am not usually in the habit of offering unsolicited advice on the personal level, I am going to make the leap of faith that being chosen for this award gives me a few minutes of "poetic license". I have been in practice in Las Vegas for 22 years now. I am reasonably happy most of the time, perhaps more so than many other practicing physicians my age, and I would like to share some of the things that I do to maintain my own personal happiness, as well as how I think personal happiness relates to the functioning of the health care system as a whole.

On the most personalized level, I have some daily activities that I believe contribute substantially to my day-to-day happiness. How many of you have read The House of God by Samuel Shem? (About half theaudience responds). It’s one of those novels where you probably laughed a lot, but might not have been particularly proud of yourself for doing so. The cardiology attending in the novel is a rather stuffy but nonetheless somewhat insightful character who puts forward to the interns the idea of hobbies: "Do you have a hobby? Everyone needs a hobby. I have two myself: running for exercise, fishing for relaxation".

I actually have two hobbies myself, both of which are rolled into my activities-of-daily-living: bicycling for exercise, meditation for relaxation. Starting with the 2nd of those, I wanted to acknowledge Dr. Bien’s presentation earlier today (Ed. Note: Dr. Tom Bien, a clinical psychologist from Santa Fe, gave a presentation at the scientific assembly of the conference entitled "Mindful Medicine: Finding Peace and Well-Being in Your Life and Practice" which was very well received) .I have started most of my days with 20 minutes of meditation for many years now and have been very well served by it. In addition to being very relaxing and centering, it alters my perception of time in such a way that it is much easier to not be "in a hurry" throughout the day. I recommend it highly. My other "hobby" is bicycling. I live in a small town (Las Vegas, NM, pop. about 20,000) and can get anywhere in town on a bicycle within 5 minutes of how long it would take to drive there. By bicycling instead of driving, I get my daily exercise without committing other "down time" to it, and I avoid over-reliance on the automobile, which, in my opinion, is the source of a great number of problems on a societal level.

On a personal level, I have had one other insight over the years which has been of great value to me: I have a fairly clear "take" on the relative importance of time and money. Many people, including physicians, when asked how much money they think they need, will reply, in effect, "a little bit more." I submit that all of us, as physicians, have "plenty", especially when viewed from the perspective of the world as a whole.

Even the "poorest" among us is quite affluent on a world scale. What we are really in need of, I think, is more time. I have been very well served by this outlook. For several years now, I have only been working 8 months per year, primarily as a family practice hospitalist. When I am working, I am WORKING, just like most of us. During the other 4 months, I have been free to work on a variety of teaching and international health projects, be a husband and father, and, frankly, to just be a "slacker" from time to time (applause). There will be a wide range of individual differences among us at to where the "cut point" between time and money is, but I submit that we all have such a "cut point" somewhere.

As I mentioned a moment ago, the practice of meditation has been very helpful to me in terms of my perception of time. In addition, a few years ago, I made a New Year’s resolution to not be in a hurry. It’s often a difficult trade-off between working a little bit longer hours without being in a hurry vs having slightly more time at home.

The upshot of the life-style choices I have made is that, on the whole I think, I have been relatively happy on a scale of physicians. I can honestly say that I enjoy myself most of the time at work. That is not to say, though, that I am immune to the hyper-endemic hassles of day-to-day American medical reality. When we think of what we find irritating in medicine, it’s usually stuff that distracts our attention or promotes anxiety and is not directly related to medical practice per se.

One of these is certainly the medico-legal element of our work. While I do my best, frankly, to avoid having lawyers on the brain on a day-to-day basis, a certain amount of non-constructive fear-mongering is more or less inevitable. I’m afraid that until meaningful tort reform occurs, we are still going to be making, (and with some justification) poor-taste lawyer jokes (laughter, applause).

The other of these irritants is the endless stream of bureaucratic paperwork and other gratuitous harassment that we have to put up with. Our national health system has by far the largest administrative overhead of any industrialized nation—30% of the total health care budget the last time I checked. A great deal of very poor quality professional time is spent on all of these "prior authorizations", "formulary exemptions", "certificates of medical necessity", and various other arguments with insurance guys about whether a patient’s expenses are going to be covered. To me, these kinds of issues are the most irritating and time-consuming of our day-to-day distractions. And when one stops to consider it, thebottom-line purpose of most of these obstacles is to try to figure out ways to deny care to people! I suspect that most of these denials of care are not ultimately reflected as savings to the system, but as an increased bottom-line to the various profiteers involved in the administration of it.

Which brings us to the Canadian portion of our program…(laughter). First of all, I would like to introduce my wife Rosemarie, a proud Canadian. Rosemarie and I have often visited friends and family in Canada over the years, and we have been acquainted with several Canadian physicians. It would be very unusual for a Canadian physician to have a full-time employee whose only job description was to argue with theinsurance industry all day. In our office (Ed. Note: Health Centers of Northern New Mexico, Las Vegas, NM, part of a large group of Community Health Centers), we have 2 people whose time is almost completely occupied with arguing with the VA all day long, and I-don’t- know-how-many others who spend almost all of their time battling the insurance and pharmaceutical industries. Is this how we want to spend our time? I don’t think so. 

And do we really think that Cimarron Salud or some such agency or combination of agencies can fix this situation? (Ed. Note: Cimarron Salud is one of 3 private HMO’s that administer theNew Mexico Medicaid program) How many of you actually think that Cimarron Salud can fix the current situation? (No hands go up). Right! I didn’t think so.

Although my boss is out there in the audience, and I don’t want to irritate him too much, I can’t resist adding here that there is another benefit to making somewhat less money than one might theoretically "deserve". When I am handed some kind of a large form or other administrative document, I have a pretty short fuse for handing it back with a smile and saying, in effect, "Don’t go away mad, but go away." I don’t feel that I am being paid to do these things. Although I must admit that it makes me feel good for a while when I say things like that, it’s not really the solution to a systemic crisis of the sort we are facing.

I believe that nothing short of a system overhaul will fix our potentially excellent but highly dysfunctional health-care system. I agree with the Physicians for a National Health Plan and its local affiliate, which put forward the idea of a Canadian-style single-payer health care system. Do I think that this will solve all of our problems? No. The Canadian system is definitely not perfect. There is a more or less continuous and acrimonious conflict between the provincial governments and the medical societies which negotiate a standardized fee-scale province-wide. This causes the medical societies to function somewhat like trade unions. But, it gets a lot of the really annoying and time-consuming stuff I’ve just been talking about out of our faces on a day-to-day basis. At the end of the day, your average Canadian doctor takes all of his billing statements, puts them in an envelope, sends them to the provincial government and goes home. Wouldn’t that be easier? (Applause)

I’m sometimes surprised at the extent to which we physicians are unable to recognize our own interests.The issue of a single-payer system is commonly phrased as a struggle against government intervention. This implies that in the absence of intervention, we could still somehow be engaged in a kind of cottage industry, in which individual patients would pay fee-for-service in cash or with an "in-kind" service. Such an idealized system has not existed for a long time. I submit that the real decision to be made is not "government intervention vs no intervention" but "government intervention vs control of the health-care system by powerful for-profit corporate interests".

One of the side effects of a single-payer health-care system is that it places the debate about the health care budget into the realm of a more general political debate about national priorities. It is a variant of theage-old economic question: do we want more guns or more butter? We probably can’t have health care for all, a burgeoning military budget, and a big tax cut at the same time. Although the level of political discourse in this country often does not lend itself well to this type of complex discussion, I still believe it would be a good idea if we, as a nation, were more concretely presented with this decision-making process.

The various permutations of a single-payer system that have been proposed over the last few years have not fared well. This is, I think, partly due to skillful manipulation of public opinion by the insurance industry, partly due to our own misunderstanding of our interests, and partly due to the American political climate as a whole. That climate, unfortunately, has been deteriorating in recent years. It is presently characterized by militarism, extreme nationalism, and repression of domestic dissent. That combination of national priorities is, to me as an American, and more particularly as a German- American, very ominous. We already have a term in the dictionary for that set of priorities, and I'm afraid that I have to use "the f-word" here: fascism (silence). Do we want to go there for a tax-cut? I surely hope not.

In my "15 minutes of fame" I have tried to link the personal and the political, in terms of optimal strategies to maximize my (our) personal and professional happiness. I hope I have succeeded in at least provoking some on-going discussion of these issues. A good one-line summary might be Pete Seeger’s old slogan from the labor and folk-music movements: "Take it easy…but take it."

Thank you very much. (Applause)



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