Maurice A. Ramirez, DO, CNS, CMRO

Our "Sicko" Society

As a regular commentator on the state of Disaster Preparedness and corporate healthcare responsibility in the United States as well as an ardent defender of healthcare professionals, their needs and their very lives, I was both honored and a bit taken back when asked by several medial journals to attend and review Michael Moore’s documentary “Sicko”.  I was the immediate recipient of much ribbing from colleagues, even receiving a prescription, just 32 milligrams of Zofran to be taken immediately before the movie; this from an oncologist who reminded me that Zofran is the drug of choice in preventing chemotherapy related nausea and vomiting, “if it can handle chemo, it can handle Michael Moore.” 

By total coincidence and an ironic twist of fate, I served federal jury duty the day I saw the movie and took an oath to hear all evidence before me without prejudice or preconception.  Having being released from jury service by noon, I girded myself in that oath and drove to the theater. Plopping down my $7.50 for the ticket and $10 for popcorn and a large water bottle, I strode in air conditioned comfort to theater 8.  The theater itself was virtually abandoned, despite the fact that I had chosen to attend the movie at Walt Disney World’s Downtown Disney AMC Theatre at the height of tourist season.  I had expected the theater to not only be full but to be filled with people who are ardent supporters of Mr. Moore and his films.  I must admit I would not be among them.  Quite to the contrary, I had not seen a Michael Moore film in a number of years.  I do enjoy the occasional documentary and own a copy of Super-Size Me which I still recommend to patients, but Mr. Moore’s story telling style is, well let’s say it is not to my taste.

Within the first moments I found myself confronted with an uncomfortable fact, Mr.  Moore’s movie was attacking the same Heavily Mangled-care Organizations (HMO’s) that were in large part the very reason that I had left private to practice.  Everything that Mr. Moore said about such large organizations as Aetna, Cigna, Humana and Kaiser were true.  Of course in invertible Michael Moore fashion he told only one side of the story, paying only passing homage to the fact that five-sixth of the US population do in fact have healthcare coverage and that out of 300 million people in the United States, most of whom have Internet access, he received fewer than 80,000 replies to his solicitation for healthcare horror stories.  Still, Mr. Moore was actually making sense.

Unfortunately, also in an inevitable Michael Moore fashion, he quickly snatched defeat from the jaws of victory.  The totally incomprehensible detour to a cold war era campaign by the American Medical Association to speak specifically against the evils of socialists and communists in medicine was juxtaposed against the Clinton era’s attempt at Universal Health Care.  Mr. Moore seems to have missed the fact that now New York Senator Hillary Rodham Clinton stated emphatically throughout her term as chair of National Healthcare Committee that Universal Health Care was not a socialized healthcare system. 

Mr. Moore also seems to have forgotten the historical context in which the American Medical Association launched its anti-socialist campaign in those early days of the cold war.  Communist fears gripped the nation for over twenty years and every “respectable” professional or fraternal organization “did its part” to combat the so-called Red Menace.  The American Medical Association’s campaign against socialist medicine was a political statement against socialism and communism not against Universal Health Care. 

Although I am a physician I do have the unique perspective of not being a member of the American Medical Association.  In fact, at the same time that the American Medical Association was actively attacking socialists and communists in healthcare; they were also attacking my profession of osteopathic medicine and therefore if anyone would support Mr. Moore’s attack on the American Medical Association it should be me, a member of the American Osteopathic Association.  Just as I swore earlier in the day to objectively hear the case against the defendant in federal court I must now objectively evaluate the arguments made by Mr. Moore and in the case of the American Medical Association Mr. Moore’s arguments fall far short of any form of reality.

Returning to the main theme of the movie (corporate greed as the oppressor of the people) Mr. Moore next attacked the profits and policies of the pharmaceutical industry. The donations to prominent congressional members and others in government were enlightening and even entertaining in their presentation, but there was no new news here. The Food and Drug Administration and even Congress itself has decried these practices for years.

Mr. Moore then took a brief trip around the existing Socialized Medicine Programs in Canada, Great Britain and France.  He went to great lengths to describe their advantages, speaking to Americans who thought that they benefited from a socialized medicine system in which they had no need for insurance and no need to pay copay’s.  He also spoke with fully satisfied individuals living in Canada and Great Britain. 

Mr. Moore’s interview with one British doctor was quite enlightening. On screen I met a physician whose entire education had been paid for by his government and his government was generous enough to pay him a salary equal as a family practitioner equal to what I make as an emergency department physician.  Although, I am board certified in family practice as well as emergency medicine, I never made as much in US dollar equivalents as this young man makes now.  This London doctor lives in a four-bedroom home worth twice as much as my home and drives a car worth four times as much as my car.  He has these benefits not because a socialized medicine system works better or even pays better but because he was the beneficiary of socialized education through graduate school.  I labor under student loan payments that almost equal my mortgage payment and will do so for a thirty-year period of time.  If I had the benefits of free education, I too could live in a home worth over a million dollars, although I would still drive my Saturn because quite frankly I like it.

Mr. Moore’s tour then took an unusual direction clearly designed to draw publicity rather than make any specific point.  Mr. Moore took several 9/11 survivors and delivered them to Cuba in order to receive treatment for 9/11 related injuries and illnesses. Mr. Moore claims he did this because he had found an American “socialized medicine” system at Guantanamo Bay, Cuba and just wanted 9/11 heroes to receive the same medical benefits as Al Qaeda. Why not take these heroes to a state prison in Florida? The almost every state correctional institution in the United States, inmates receive the same or better care than the detainees at Guantanamo Bay. Again Michael Moore missed the mark.

I find it curious that while in Canada, a country that is accustomed to American film makers and quite frankly Americans sneaking across the border to obtain free healthcare, Mr.  Moore and his would be American patient for the Canadian system found it necessary to flee Canadian police at two separate clinics in order to avoid arrest, yet in Cuba, a country well known world-wide to embrace its tourists but to be highly suspicious of those with professional movie making equipment, Mr. Moore appeared to never encounter a police officer. In fact Mr. Moore was allowed to photograph throughout the state-run Havana Hospital, the very same hospital where Cuban leader Fidel Castro received his recent medical care.  Further Mr. Moore was miraculously permitted to photograph in and around a Havana fire station, exchanging gifts and even souvenir badges with fire brigade members.  I find it equally interesting that these badges were conveniently available. 

Mr. Moore, who appears throughout the movie, to this point, to be very upfront with the challenges and special arrangements made in the production of his film seems to leave out the fact that he doubtless had special dispensation from the Cuban government allowing both for his film making and the care of Americans on Cuban soil.

Despite these glaring inconsistencies, I was thrilled when the Cuban doctors began to touch on the issue of the relationship between the system and the healthcare professional. I thought that Mr. Moore was finally going to disclose American Healthcare’s greatest shame, the total annihilation of the nurturing relationship between healthcare professionals and their corporate masters. But alas, Michael Moore again shied away from the issue… why?!

An interesting conversation took place recently between a 45 year nursing veteran and her family. The topic of the day was the nursing shortage and the veteran nurse surprised all by announcing, “There is no nursing shortage, there is a hospital nursing shortage.”

She went on to explain that in the home health and non-institutional nursing fields, there is an adequate supply of nurses willing to work for employers who respect and value their services. According to this nurse who had worked in hospitals for much of her career, the problem today is that hospitals and other institutions see nurses and other professionals as replaceable rather than precious.

“No nurse my age is going to work for some young supervisor who believes that you manage people by threatening them or their license. There are too many jobs out there to deal with that nonsense.”

This veteran nurse struck on the key factor in any employee shortage, the relationship between employer and employee.

Healthcare has become a split marketplace with institutional care (hospitals and nursing homes) separated from non-institutional care. Nurses are gravitating to non-institutional care despite lower pay because of the factors that Intuit and others have come to appreciate. Employees care more about the relationships than the money. Veteran nurses remember being respected and appreciated for long hours and selfless dedication. It was not expected or required, it was given freely and accepted graciously. Even in a “materialistic society” people want to be loved and cared for, respected and valued.

There is no nursing shortage, there is a relationship shortage. This is the true problem with corporate healthcare in America.

All and all I will say that Mr.  Moore’s film was an honest review of the current state of the Heavily Mangled-care in the United States.  Greedy insurance companies take from doctors in the form of Malpractice Coverage.  They take some patients in the form of health coverage; they raise profits through denials of care, restrictive practices, penalties against physicians who place patient care and safety ahead of performance numbers and by seeking to exclude those who most need insurance.

Sadly, the majority of Mr. Moore’s movie missed the point.  American healthcare will not be served by the conversion to a socialized medicine system.  Quite to the contrary most of the equipments seen in background of Mr. Moore’s movie was invented, designed, manufactured, or funded by the America’s private healthcare industry.  American healthcare would be best served by rebuilding relationships with the most valuable resource in healthcare, the healthcare provider. All those Mr. Moore interviewed told stories of having a favorable relationship with a system which they respected and which respected them. Regardless of whether you are a healthcare professional or a healthcare consumer, the basis of the process of healthcare is a relationship based on mutual respect, the system delivering that healthcare must live by that standard as well.

Socialized medical systems certainly have their advantages for citizens of countries willing to live with different freedoms and different lifestyles than we prefer in America. A better system is out there, we need only have the resolve to find it.

Mr. Moore also falls significantly short in failing to make note of the reasons that so many Americans require so much healthcare.  Even a man with only a high school diploma such as Mr. Moore must ask himself if five-sixth of the United States population have health insurance, then why do individuals in other countries live longer than we do.  Perhaps it is because we also have an excess of food, an excess of cars, an excess of conveniences.  United States longevity for it’s citizens and disease rates among its most vulnerable are so high not only because people put off necessary healthcare for fear of incurring debt, but because they chose instead to indulge in fast foods which are too high in salt and fat, drive rather than walk or bicycle for short errands, play video games rather than exercise, and finally watch movies about what others do rather than going out and doing something themselves. 

As I watched the corpulent Michael Moore striding down the streets of London and France being passed by much thinner Europeans, I could not help but be struck by the fact that it is not our healthcare system, but our societal values that are truly “Sicko.” It is time we all put down our popcorn, take our water bottles and go outside to exercise with our children.

007 - Is the Stock Market “Disaster Drop” Really Inevitable?

The newest James Bond movie “Casino Royale” is in part based on the theory that Osama Ben Laden and other terrorist groups profited from the down turn in the stock market following September 11, 2001 and other disasters. The movie suggests that a terrorist organization heavily invested in puts could cause a wholesale sell of stocks in an entire industry and profit from the ensuing options rush.

History certainly support the viability of this approach. The stock market and airline stocks dropped after 9/11. When a private plane strayed over the nation’s capital in 2005, the stock market fell as America held it’s collective breath and the tragic crash of a private plane into an apartment building in New York City was followed by another drop in the market that only reversed when it became clear that the crash was merely an over publicized accident.

While the drop in the stock market after 9/11 was unavoidable, the drops following these non-terrorism events was NOT inevitable. All these events resulted in a business and stock market panic that many "experts" have called both unpredictable and unavoidable.

These "experts" are wrong. To avoid being part of that statistic, you must “Be D.I.S.A.S.T.E.R.  R.E.A.D.Y. & P.L.A.N. Each letter in the mnemonic stands for a key item in your disaster preparation checklist.

Go through each letter and take the necessary action. While this is not something you will complete in an hour, you do need to start now—long before any disaster. When you can check all these items off your list, you will be as prepared as possible for any disaster that may come your way and your business will survive.

Let’s start with D.I.S.A.S.T.E.R.:

D is Detect
Detect your own vulnerabilities and those of your community. You have geographic vulnerabilities and competitive vulnerabilities. You also have emotional vulnerabilities. The stock market dropped after the capital sirens sounded because those making the trades failed to detect their own fear of terrorist attack. If you identify your fear and prepare to respond calmly and effectively, you now have a competitive advantage.

Detect your community’s needs too. Consider how your business can help. If so, you’ve just detected a unique advantage you can offer to the community in the event of an emergency. 

I is In Charge
Every community has one person in command in case of a disaster. That person, the “incident commander,” has a set of responsibilities to delegate that filters down through an established structure. Find out who is in that incident command position now and ask how you could help become a part of that structure. If you wait until disaster strikes, your offers of help may be too late. Do it now. The use of the Incident Command model also helps prevent “panic selling” by filtering all decisions through one person.

S is Safety
Know where your safety vulnerabilities are. Will the potential terrorist attack directly affect you or your place of business? If you were to lose power or cellular phone service, how will that affect your business? Be prepared. If you own stock, you will feel vulnerable. But are you? Ask yourself, would a successful attack really affect the stock price in the long term.

A is Assess
Assess your situation—either your current one or the potential one during a disaster. If keeping your business open is not safe, or if your employees have urgent personal or family needs during a crisis, you need to take responsibility for that and be realistic. Assess whether it is safe to continue to be open and ask yourself if your employees have needs that are outside of the business. If so, make allowances for those. You don’t have to stay open 24/7 or put yourself or your employees at risk. Letting your employees know that their personal needs are important will gain you their trust and loyalty. Track the effect the event has had on your portfolio and the companies in which you invest.

S is Support
Support works both ways. The easiest way to get support during an emergency situation is to give it as part of the support team. All emergency response managers are taught to reach in their community and make pre-arrangements for the resources they need. These are called mutual aid agreements. Approach the emergency response manager and say, “I can provide you the following things. Will that be of help?” You will most likely get a yes, especially if you do this ahead of time. You will be written into the county’s plan. Be prepared to deliver whatever you promise. An advantage to you is that when you have a need, you are already known to the people with the power. And since you’ve already detected what kind of support you’ll need, you can ask for it in advance.

T is Triage
Triage means to do the most good for the most people with limited resources. Even if you’ve been the best person and the most helpful to your community, if your needs are minor you will have to wait longer than someone whose needs are greater. The person with the greatest need will get help first—no matter when they ask. Adopt the same principle with your business resources. If you own stock, see how the businesses they represent have been effect by the completed attack. Once you have made this analysis, repeat your standard due diligence for each stock. Then and only then will you know what to keep, what to buy and what to sell. Even though it may be a hard decision to make, you are really benefiting your portfolio.

E is Exit Strategy
If you are called to evacuate, go. Orders to evacuate usually come in stages. When they tell the group you belong to that it’s time to evacuate, heed the warning—it’s unsafe to stay. Rest assured that businesses that are prepared and forced to evacuate in most cases will reopen when it’s safe to do so.

R is for Recovery
Recovery begins with your disaster planning—long before the event occurs. Deal with your fear, get counseling, do what it takes to recover.

And now for R.E.A.D.Y:

R is for Rely
Now that you’ve been through the disaster plan, you need to be ready within your own business. What do you rely on? What do the companies in your portfolio rely on? Are there key employees or key procedures that only exist in employees’ heads? Write them down now. You and the companies you invest in must keep a copy at business and another off-site at a safe location. Those processes are important. Are you heavily invested in a particular business, geographic area or business sector?

E is for Educate
If you become part of your community response, you will need to know how to access people and how they can access you. How are they going to identify themselves? How do you collect payment? Cash or a trust system? Develop a written procedure. Make sure your staff knows exactly what they should do. They’ll take comfort in knowing what procedures to follow in the event of an emergency. Do the companies in your portfolio have a written plan? Learn what that plan entails.

A is for Appreciate
Appreciate your employees every day. Not only will you experience a more pleasant workplace, but in a time of crisis your employees will pay you back with their loyalty. In the face of a disaster, continue to appreciate your employees—particularly the ones who came back. But still appreciate the ones who couldn’t come back. Some people will have more pressing personal responsibilities than others. Find out if the companies you invest in appreciate their employees’ efforts.

D is for Drill
You have dry runs of your disaster plan. Just as you have a routine procedure for a fire drill, the companies you invest in should perform disaster drills. If they don’t, panic will set in and their mind will shut down and your portfolio will suffer. When the mind shuts down, people revert to what is familiar—the day-to-day routine they’ve always done—not what they should be doing in a disaster. The companies in your portfolio must dedicate themselves to the entire process and drill.

Y is for You
For businesses, it comes down to you—each individual and each employer. Take responsibility for all your actions and your investments. Don’t be part of the selling panic. Plan ahead and be part of the recovery solution.

Finally, let’s P.L.A.N.

P is for People
The first step in making your plan is to take an inventory of who will be participating. If you are making a plan for your family, consider who will be with you and how to prepare each person for the disaster. If you have small children, you may need to talk to them about what is happening, and reassure them that everything will be all right.

Also, what tasks will each person perform? If you’re facing a hurricane, who will board up the windows? Who will make sure the dog gets into the car if you evacuate? Each person should have a function in ensuring the safety and security of everyone else. Even children can participate. A small task might make a child feel more purposeful, like a critical part of the plan, rather than a helpless bystander. So if your children are old enough to take part, put them in charge of the extra batteries or have them fill the water bottles.

Likewise, if you are making a plan for your business, consider who will participate and what role each person will fill. If you plan to close, you need to know who will be involved in the closing decision, and how you will secure the premises. If you decide to stay open, your plan is even more important because you will be responsible for the safety of your employees.

Other people in your plan include contacts outside the disaster zone. You need someone to serve as a message board for communication. Then everyone involved in your plan can call in and let the centralized person know they are safe and their location. If you decide to leave, you need someone out of state whom you can stay with.

Finally, consider what outside facilities you are going to rely on. If you have unanticipated emergencies, who are you going to call? Are they going to be able to get to you? If your entire plan is to call 911 and get assistance, you need to realize that in a disaster situation they probably won’t be able to assist you for seventy-two hours. In this case, you will need to reassess your plan.

L is for Leave
Next, consider leaving the disaster zone. When and how will you leave (evacuate)? Where will you go and how will you get there? Will your family or fellow evacuees meet before you leave or when you arrive at your destination? The decision to leave makes communication and your contacts outside the disaster zone critically important. How will you communicate while you evacuate and after you arrive at your destination? What are you going to do if you get separated? Operate on a buddy system; no one should be left alone. When you and your family or business associates become mobile, make sure everyone knows the plan. Then, if your plan fails, you need an alternative.

If you are not leaving, consider where will you stay and how will you stay safe. Will you all stay together or shelter in the place you are when the disaster strikes? Will you send some of your family to your evacuation destination while others stay? All these factors need careful consideration and planning.

A is for Anticipate / Adapt
Unfortunately, in a disaster situation, nothing always goes as planned. So anticipate plan failures and plan for the “what ifs.” This is a chance to brainstorm. Make a list of all the possible failures. What if the phone lines go down? What if your basement floods? What if you get caught in traffic? No “what if” is too extreme to consider. The only possibility that you can’t plan for is the one you didn’t think of.

Once you’ve brainstormed possible failures, you need to adapt to each one with an alternate plan. If the phone lines go down, can you use your cell phone? If your basement floods, can you seek shelter with a neighbor or in some other nearby location? If you get caught in traffic, will you have enough gas to evacuate successfully?
What if something happens that you didn’t anticipate? If you go through this process enough times and really work on your plan, then you will be able to adapt to the failure. You’re mind will be primed and you’ll be ready to think of alternatives, even if the failure isn’t anticipated beforehand. Anticipate that events will not unfold as planned. Be flexible. Adapt to the unexpected.

Remember: “Sempier Gumby” – “Always Flexible”

N is for Needs
In any disaster situation, you must be ready to go for seventy-two hours without assistance. Those first seventy-two hours are critical because emergency relief will be overwhelmed during that time. Fire departments, police, and medical personnel won’t have the resources to get to everyone.

After hurricane Katrina, many people died simply because they ran out of food and water in those critical three days. However, four days before Rita hit Texas, the community leaders were on the television warning people that if they decided to stay, they needed to be prepared for seventy-two hours because no one would be able to help them.

When working on your plan, make sure you account for all your needs for seventy-two hours. Be prepared to be self-sufficient during this time. Each one of your family members must have personal identification and photos of all others in your plan, two quarts (liters) of drinking water, seventy-two hours of food, seventy-two hours of clothes, two weeks of medications, two weeks of toiletries, a supply of cash (credit/debit cards can’t be verified if phone lines go down), a flashlight, a portable radio, batteries, a signal whistle, white/silver duct tape, a first aid kit, prepaid calling card, and a list of emergency phone numbers.

These needs should be kept in a rolling backpack that stays with the owner. Keep this bag, your Disaster Pack, readily accessible. And if a disaster is imminent, keep the Disaster Pack with you at all times.

Are You Ready?
Once you have taken an inventory of your family, made arrangements for evacuation, anticipated and accommodated failures, and gathered all your needs for seventy-two hours, you need to review and practice your plan each year.

Hurricane situations are timely because of what happened on the gulf coast, but regardless of what disaster situation you face you must have a plan. In a tornado, tsunami, terrorist attack, or whatever, you can use these steps to make your disaster plan and ensure the safety of your family and your business.

Take Action
Nothing you do can prevent a disaster. With proper planning, however, your healthcare facility can become “D.I.S.A.S.T.E.R. R.E.A.D.Y.” and “P.L.A.N.” Identify your strengths and weaknesses. If the worst happens, don’t panic. You already know the drill and what is expected of you. Be ready to do your best and activate your plan at the drop of a hat, ready to help those with the greatest need.