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The Leg.UpLocal, state and national news of interest to thephysician community

February 7, 2018

Docs Rock Economy Even as the stock market seems to have caught a badcase of the flu, this new report from the AMA is areminder of just how much physicians contribute to thenation's overall economic health. Click here for national and state economic impact,including Virginia's (see p. 13). And click here for aninteractive map showing the Old Dominion has 17,758 physicianswho generate $37.2 billion in annual economic output. This in turncreates 207,525 jobs that bring $18.3 billion in wages and benefits,and $1.14 billion in taxes in Virginia. Remember that the next time you talk toyour legislators or write a letter to the editor! As the AMA's synopsis of 2016 data put it:"Physicians generated a greater total outputthan the higher education, nursing andcommunity care facilities, legal services andhome health industries in each state."

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On the one hand... Gov. Northamseeks Medicaid deal compromise

Cost of Medicaid Expansion in Va.? How much would it cost to expand Virginia's Medicaid program? This question is driving thecurrent debate over Medicaidexpansion betweenRepublicans and Democrats inthe General Assembly, andwith the idea's chief advocate,Democratic Gov. RalphNortham. His administration says thecost of implementing a newwork-study-volunteer-basedMedicaid program couldapproach $100 million in state and local money in the second-year ofthe two-year budget, reports the Times-Dispatch. This "didn't sit well with House Speaker Kirk Cox, R-ColonialHeights, who said last week that the original analysis, with anestimated cost of $10.5 million in the first year and almost $26million in the second, 'doesn't pass the smell test,'" the TD reports. The question stems from a lack of clear guidance on how "civicengagement" would be monitored as part of the new Medicaid planbeing bandied about, "so we're flying blind and developing this as wego," said Deputy Secretary of Finance Joe Flores. In another development, the Senate committee that killed legislationto expand Medicaid has adopted an alternative plan for redesigningthe program to extend health coverage and services, but for fewer

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Sen. Dunnavant seeking support.

people with less federal funding to match state spending thanexpansion under the Affordable Care Act, reports the TD.

The GOP-majority Educationand Health Committeeapproved Senate Bill 915,proposed by Sen. SiobhanDunnavant, R-Henrico, on an8-7, party-line vote lastThursday. It was referred tothe Finance Committee.

Her bill would create a"priority needs accessprogram" by redesigningexisting Medicaid waivers thatoffer limited services to peoplewith mental health and substance use disorders. Dunnavant, anobstetrician and RAM member, proposes to expand both the servicesoffered and the number of people who would receive them, using anew tax on hospital profits to help pay for them.

Chairman Steve Newman, R-Lynchburg, who also serves onFinance, said the bill is one of several legislative vehicles for adebate that he hopes extends beyond Medicaid to ways of loweringthe cost of health insurance in the private market.

"It is unstable, unsustainable and it is killing our constituents,"Newman said.

While Republicans voted in a bloc in favor of Dunnavant's bill, somesaid they are withholding judgment about its merits.

"I'm not sure how much of your bill I support, but I think we need tocontinue the discussion," Sen. Mark Peake, R-Lynchburg, toldDunnavant.

Gov. Northam's administration opposed the bill as an inadequatealternative to Medicaid expansion, but said it's willing to discussDunnavant's goals and ideas for achieving them.

"We see this is an ongoing discussion and continuing dialogue acrossthe aisle in both houses to try to reach common goals," saidSecretary of Health and Human Resources Daniel Carey, acardiologist and former president of the Medical Society of Virginia.

Democrats want to expand Medicaid to a much broader populationunder the Affordable Care Act, the TD reports. They say Dunnavant'sproposal does not add up because it would leverage far fewer federaldollars to serve fewer people, while imposing a similar tax onhospitals as proposed by then-Gov. Terry McAuliffe to pay the state's

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share of costs for fully expanding the program.

"I love you, senator, but I'd hate to see you running one of mybusinesses," Minority Leader Dick Saslaw told Dunnavant.

Virginia's hospitals also opposed the bill. Dunnavant introduced itwith an extensive budget amendment that would include a promiseto raise the reimbursement rate the state pays health providers fortreating Medicaid patients.

"The math simply does not work for the industry being asked tocontribute resources," said Chris Bailey, executive vice president ofthe Virginia Hospital and Healthcare Association, which says it wouldsupport a provider assessment to expand Medicaid only if the stateincludes safeguards in the law over how the money would be used.

Dunnavant and hospital officials do not even agree how many peoplewould be served under the program. She estimates 75,000 to100,000 people could receive treatment for mental health, substanceuse and chronic medical conditions, while Bailey suggested thenumber would be between 20,000 and 30,000, according to the TD.

Sen. Amanda Chase, R-Chesterfield, lauded the bill as "a goodsolution" for many of the health care challenges faced by Virginianswho cannot afford medical treatment.

Jill Hanken, senior attorney at the Virginia Poverty Law Center, saidthere is no comparison between Dunnavant's plan and the pendingproposal to use $3.2 billion in federal funds to expand Medicaidcoverage to 400,000 uninsured Virginians.

"We are really talking about apples and oranges," Hanken said.

Click here for a Washington Post editorial that compares Virginia'sspending for public services to other states. Click here for the studycited. While Virginia hovers around the middle compared to other states inmost categories, the Post says:"But by one glaring metric, Virginia is close to the bottom: per capitaMedicaid spending on the poor, the disabled and others, includingchildren, who are unable to afford health insurance.

"By that standard, Virginia is a laggard - 47th and 46th in the nationin the 2016 and 2017 reports, respectively - and a disgrace. Theaverage per capita Medicaid spending among the 50 states is$1,575; Virginia spends just $967 - and refuses to cover most singleadults no matter how poor they are."

Click here to read more about the Post's criticism of the state GOPfor blocking Medicaid expansion that would cover 300,000 to

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400,000 uninsured Virginians.

If a compromise can be reached, the Post comments, "It wouldn'tbe a Democratic victory or a Republican loss. It would be a triumphfor the neediest Virginians. "

Another Successful Day at the General Assembly

On Monday, February 5th, Academy members met with Richmond-area legislators for our second of a series of 2018 lobby days. RAMmembers continued to discuss keeping adequate clinical experienceas a licensure requirement for nurse practitioners, COPN reform andstep therapy. We'd like to thank the following RAM members whoshared their special talents and energy with us at the GeneralAssembly this week!

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Drs. Sam Bartle, Mark Malkin, Irene Foley, and Karsten Konerding with Senator Rosalyn Dance

Delegate Chris Peace with RAM Members Drs. Karsten Konerding, Owen Brodie and Mark Malkin

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Drs. Sam Bartle, Karsten Konerding, Irene Foley, Walter Lawrenceand Harry Gewanter with new delegate Dawn Adams

Interested in lobbying with us this year? Consider joining uson Thursday, February 15th or Monday, February 19th.

Join your colleagues for breakfast and a legislative briefingbefore meeting with local legislators and sharing yourvaluable input and perspective with them. Please commit tojoining your fellow RAM members from 8:00 to 11:30 a.m.on one of these days!

Contact Lara Knowles at lknowles@ramdocs.org

or call her at 804-622-8137 to register.

Should NPs Fly Solo? New requirements ground bill A bill that would allow nurse practitioners to practice independentlywithout the supervision of a physician edged through its firstcommittee hearing last week, but only after the measure wasstrengthened to require much more training, reports the Times-Dispatch.

"The House Health, Welfare and Institutions Subcommittee wasstanding-room-only as nurse practitioners and physicians - manywearing white medical coats - showed their support or opposition forHouse Bill 793, sponsored by Del. Roxann Robinson, R-Chesterfield," the TD reports.

(see above for more White Coat Days for RAM members!)

"The bill, which would give nurse practitioners full practice authority,

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MSV President Elward

Calling All Artsy/Crafty Members! Are you a physician with a hobby

in arts or crafts? Are you an artist,

woodworker, photographer,

jewelry maker? If so, we'd like

your work represented to benefit

Access Now!

has been met with skepticism from some doctors, who are currentlyrequired to supervise the nurses' work," the TD reports.

"Proponents argue that allowing nurse practitioners autonomy wouldvastly increase access to care, a growing need as almost all parts ofthe country, especially rural areas, are grappling with health careprovider shortages."

During the hearing, two substitutes were suggested for the bill - oneproposed by Robinson, the other by the subcommittee's chairman,Del. Scott Garrett, R-Lynchburg, who is a physician.

After the committee heard various proposals for training - from thebill's original 1,040 hours up to 3,000 hours - the committee backedGarrett's amendment to considerably raise the training requirementto 10,000 hours.

This amendment was backed by the Medical Society of Virginia,which issued a member alert about the pending legislation. Somespoke of the extensive time and money medical students pour intotheir education to become qualified physicians, the TD reports.

"With the capabilities of telemedicine andcommunication today, it is easier than everto collaborate and ensure that proper clinicalsupervision has been obtained," said Dr.Kurtis Elward, the MSV president. "Nursepractitioners in areas where they areproviding needed access have all the supportthey need."

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On Saturday, May 12, theRAM Alliance Foundation will hold its annual fundraiser,Physicians Got Fashion. This fun-filled event featuring Richmondphysicians as models, will include a silent auction of physician-madearts and crafts. Proceeds from both the fashion show and auction goto Access Now, RAM's unique program to improve access tohealthcare for those in need in the greater Richmond area. So if thearts or craftwork is your hobby, or if you know of someonewhose talents you would like to recommend, call or email anyone of our committee members listed below to find out moreabout participating in this worthy event! (NOTE: confirmationof your participation is needed by March 1.) Interested? Then please contact Lyons Burke (804-514-6627,lyonshburke@gmail.com), Vicky Lewkow (804-338-5194,vlewkow@aol.com), or Cecilia Elliott (804-562-8366,dcnelliott@gmail.com).

Nine Ways Docs Have It Worse Than Anyone Else

What if fire departments hadto deal with priorauthorizations? Or CPAs hadto take continuing ed classesin art and French? What if pilots had to deal withthe equivalent of changingformularies, and heard thisfrom the control tower: "Yes, I know you were scheduled to land in Chicago, but Chicago isno longer on our formulary. You will now have to land in St. Louis,even though Chicago always worked really well for people whowanted to actually go to Chicago. You can appeal if you like and we'llhave an answer for you in six weeks, if you want to stay in the airthat long." These scenarios may be exaggerated, but they illustrate some ofthe struggles many RAM members endure every day. Click here toread more from Medical Economics about the many obstaclesphysicians face "in their quest to provide quality care to patients.Imagine if other professions had to deal with some of the samechallenges."

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Here's no. 5, which asks, "What if meteorologists were subject tomalpractice suits for errors? "The man on the stand has been wrong 80% of the time, yet he stillpractices every day, ruining one family outing after another. You, thejury, must put a stop to this heinous, out-of-control malpractice ofmeteorology and send a message to other forecasters that they needto be right 100% of the time or they shouldn't be practicingweather!" And no. 3, which asks, "What if employers denied pay to employeesthe same way doctors get stiffed by insurance companies? "I'm sorry, but I can't pay you for last week because you did notproperly document that you attended the staff meeting. Yes, I sawyou there, but unless you fill out the form correctly, we refuse to payyou... Make sure you use the proper codes from this 1,500-pagebook - the process should only take about four hours to complete." And (no. 9): "What if fire departments had to deal with priorauthorizations? "Is there smoke coming out of the building? OK, but can you actuallysee the flames? Well, we are only going to give approval for one firetruck, but you can appeal if you think you need more than that. CanI put you on hold for half an hour?" Click here for the rest! Speaking of prior auths, click here for a recent report on how theAMA and other groups have offered some constructive ideas to cleanup the mess.

Black Lung Breaking Bad in Southwest Virginia For RAM members who'vevolunteered at the summerRemote Area Clinic in Wise,Va., this week's NPR reportmay be of interest as"epidemiologists at theNational Institute forOccupational Safety andHealth say they've identifiedthe largest cluster of advancedblack lung disease everreported" in Virginia'smountains, reports NPR.

In a research letter published in the Journal of the AmericanMedical Association, NIOSH confirms 416 cases of progressive

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Remote Area Clinic in Wise, Va.(courtesy of Dr. Ken Olshansky)

massive fibrosis or complicated black lung in three clinics in centralAppalachia from 2013 to 2017.

"This is the largest cluster of progressive massive fibrosis everreported in the scientific literature," says Scott Laney, a NIOSHepidemiologist involved in the study.

"We've gone from having nearly eradicated PMF in the mid-1990s tothe highest concentration of cases that anyone has ever seen," hesaid.

The clinics are operated by Stone Mountain Health Services andassess and treat coal miners mostly from Virginia, Kentucky andWest Virginia, a region that includes what have historically beensome of the most productive coalfields in the country.

"When I first implemented this clinic back in 1990, you would see ...five [to] seven ... PMF cases" a year, says Ron Carson, who directsStone Mountain's black lung program.

The clinics now see that many cases every two weeks and have had154 new diagnoses of PMF since the fieldwork for the NIOSH studyconcluded a year ago.

"That's an indication that it's not slowing down," Carson says.

PMF, or complicated black lung, encompasses the worst stages of thedisease, which is caused by inhalation of coal and silica dust at bothunderground and surface coal mines. Miners gradually lose theability to breathe, as they wheeze and gasp for air.

Click here to learn more andlook for an article about theRemote Area Clinic and theexperiences last summer oftwo RAM members - Dr.Christine Rausch and Dr.Ken Olshansky -- comingsoon in the Winter 2018edition of Ramifications.

Is Trump Correct that U.K.'s National Health Service is "NotWorking"? On Monday, PresidentTrump claimed that

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London protest sparks president'scomment

thousands of people weremarching in London lastweekend because theircountry's National HealthService was "going broke andnot working," and thatDemocrats in the U.S. pushingfor universal health care werepursuing a similar failedmodel. Click here for a New YorkTimes "Fact Check," whichincludes some of the long waits and crowded waiting rooms in theUK's NHS. But it also includes the fact that the march drew people"there not to criticize the health service, but to urge the governmentto support it and give it greater funding to cope with the wintercrisis" brought on by the outbreak of the flu and a shortage of skilledhealth workers that's been exacerbated by plans to leave theEuropean Union ("Brexit"). "Created in 1948, during a bleak period after World War II, theNational Health Service is seen as one of Britain's most cherishedinstitutions - a greater source of pride, according to some polls, thaneven the monarchy." Click here to find out why.

Kratom Kills, FDA Warns & Looming Fentanyl Shortage

The FDA intensified itswarnings about the herbalsupplement kratom thisweek, saying new researchprovides strong evidence thatthe unregulated botanicalsubstance has "opioidproperties" and is associatedwith 44 deaths. Click here formore.

"We feel confident in callingcompounds found in kratom, opioids," FDA Commissioner ScottGottlieb said. The agency's conclusion is based on recentcomputational modeling and on scientific literature and reports ofadverse effects in people, he said. The new data reinforced agencyconcerns about kratom's "potential for abuse, addiction and serioushealth consequences, including death."

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The substance, which is imported from Southeast Asia and marketedas a supplement, has become increasingly popular amongconsumers looking for relief from pain, anxiety and depression aswell as opioid-withdrawal symptoms. Kratom, which is sometimesused for recreation, can produce a feeling of euphoria.

Advocates call it a safe way to deal with chronic pain and otherconditions, and some researchers are exploring whether it helpspeople overcome addictions. But other researchers warn that theherb, taken in capsules or by drinking tea, is too risky to use.

Click here for more from CNN, which notes that the herb is native toMalaysia, with leaves that "are traditionally crushed and made intotea to treat pain as well as heroin or morphine dependence andpossibly reduce withdrawal cravings. According to the American Kratom Association, there are 3 million to5 million users in the US. The supplement can be found in headshops and gas stations sold as powders, pills, capsules or evenenergy drinks. It is very loosely regulated by the FDA, CNN reports.

And check out this blog on KevinMD about widespread shortages offentanyl due to its sale on the lucrative black market.

"After I complete my paperwork on the previously mentionedoverdose patient in the ED, I head back to the OR to prepare for mynext patient, who will be receiving general anesthesia for a routinelaparoscopic appendectomy," writes Dr. Asha Padmanabhan, ananesthesiologist and member of the American Society ofAnesthesiologists.

"As I remove the medications from the dispensing machine, I amcareful to ration the minimum amount of fentanyl possible becausewe have a limited quantity available in my hospital. This is becausewe are also in the midst of a nationwide opioid shortage and myhospital, like many others in the country, is severely restricting theuse of intravenous fentanyl.

"How is this possible? On one hand, this drug is rampant on thestreets in its illegally produced forms. On the other hand, there is areal shortage in the hospitals where it is so desperately neededduring surgery. The answer lies in a long and tortuous history."

Click here for the rest!

Can Jeff Bezos, Warren Buffett and Jamie Dimon Fix Health Care?

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Warren Buffett (right) pressing theflesh.

In a mega-deal that combinesthe nation's largest onlineshopping network with one ofits savviest investors andAmerica's largest bank,Amazon is partnering withWarren Buffett's BerkshireHathaway and JPMorganChase to get into the healthinsurance business, reportsCNN.

The three companies unveiled an as yet unnamed company to offertheir U.S. workers and families a better deal on health care. Thestatement said the new company will be "free from profit-makingincentives and constraints."

Berkshire Hathaway owns newspapers across the country, includingthe Richmond Times-Dispatch, the Free-Lance Star inFredericksburg, the Daily Progress in Charlottesville and theRoanoke Times.

All told, the three companies have about 840,000 employeesworldwide. Initially, they plan to focus solely on their employees, butobservers expect their initiatives to spark other innovations.

"The ballooning costs of health care act as a hungry tapeworm onthe American economy," said Buffett. "We share the belief thatputting our collective resources behind the country's best talent can,in time, check the rise in health costs while concurrently enhancingpatient satisfaction and outcomes."

CNN notes that Buffett, Amazon founder Jeff Bezos and Jamie Dimonof JP Morgan Chase are old friends who've talked for years about theproblem of rising healthcare costs.

"It wasn't they saw each other one place and a light bulb went off,"one unnamed executive said. "It's the result of a lot of talk they'vehad both formally and informally over the years, saying in effect, 'Noone has to deal with buying a product like this other than healthcare.'"

Dr. Wenzel "Dreams of Troy"

Longtime RAM member Dr.Richard P. Wenzel recentlyshared excerpts from his newnovel, "Dreams of Troy." Thisbook follows "Stalking

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Microbes," a nonfictionexploration of the interactionof people and microbes, and"Labyrinth of Terror," his firstnovel which serves as aprequel to "Dreams of Troy."

In his unrelenting tale,"Dreams of Troy," Wenzelexplores the epic themes ofloyalty and passion, deceptionand vendettas, truth andsecrecy.

Click here to read more!

Wenzel is a VCU professoremeritus and formerchairman of the Departmentof Internal Medicine, wherehe still teaches. During histenure as chairman, he edited"Between Rounds," an annualvolume of poetry, short storiesand photography. Aninternationally recognizedexpert in infectious diseases and epidemiology, he has been editor-at-large of The New England Journal of Medicine since 2001.

When a Patient Charges "Sexual Harassment" What happens when a female patient accuses a male doctor ofsexual harassment after a routine orthopedic exam?

Click here for a doctor's thoughts on practicing medicine inthe current workplace environment. It was written by Dr.Thomas D. Guastavino and posted on KevinMD.com.

Here are excerpts:

"It was a typical weekend on call. The usual number of surgeries, ERcalls and consults. I was called to consult on 47-year-old female whohad been admitted with four days of left shoulder pain. She hadgone through a cardiac workup and was cleared by her internist. Sonow, a consult was called to see if there was an orthopedic cause forthe patient's pain - not an uncommon scenario. "It was the middle of the day, and the patient was awake as I walkedinto the hospital room. The other bed was empty, so we were alonein the room. My first mistake. I introduced myself, explained why Iwas there and that her heart workup was normal. As is my custom I

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drew the curtain around us and proceeded with the history andphysical examination. My second mistake. "When examining a patient with shoulder pain I also examine theneck and both shoulders, laying hands on and putting each througha series of maneuvers looking for signs of conditions I expect. Themost common diagnosis in this scenario is a simple shoulder bursitisthat was the case here. "I reassured the patient it was nothing serious and discussed thevarious treatments including medication, physical therapy, andinjections. She asked if she would need surgery, and I said only if allthe other treatments failed. She asked when she would bedischarged, and I said probably soon because her heart was OK - butthat was up to her internist. She agreed to try the PT and to returnto my office as an outpatient. I did the note and left. Easy-peasy!" Click here to read what happened two weeks later when Dr.Guastvanio was summoned to the hospital administrators' office. "Inside was the CEO, the head of nursing, the chief of staff andsomeone who I found out later was a hospital attorney ... It wasthen I was informed that charges of sexual harassment had beenfiled against me. After getting over the initial shock and anger, Iasked who it was and when had it allegedly happened. They saidthey were not going to tell me, but they were investigating. I askedhow they could investigate without asking my side, and they said itdid not matter." Only by keeping his cool and careful records did the good doctoravoid getting suspended. His blog ends: "Salem witch trials, McCarthy hearings, kangaroo court, drumheadtrial. Just when we think we are beyond these things another highlyemotional issue comes up like sexual harassment, and it starts allover again. Unfortunately for many, they do not have the means orthe wherewithal to do what I did. The timeless genius and innatefairness of innocent until proven guilty and the right to face one'saccuser must be respected."

The High Cost of Litigation

For doctors, it's a question of when - not if - they will face a medicalliability lawsuit. That's one conclusion to be drawn from a new AMAseries of reports on this troubling problem for physicians and theprice all Americans pay for what the AMA calls our "broken" medicalliability system.

Click here for coverage by FierceHealthcare.com.

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America's litigiousness continues to exact a huge toll on the entirehealthcare system, according to the AMA.

The reports paint "a bleak picture ofphysicians' experiences with medicalliability claims and the associated costburdens on the health system," saidAMA President David O. Barbe, M.D.

"The reports validate the fact thatpreserving quality and access inmedicine, while reducing cost, requiresfairness in the civil justice system. Everydollar spent on the broken medicalliability system is a dollar that cannot beused to improve patient care," Barbe noted.

More than a third of physicians (34%) have had a liability claim filedagainst them at some point in their careers, according to the AMAreport. Click here to read the report.

"A survey released last year painted an even more dire picture withover half of U.S. doctors saying they have faced a malpracticelawsuit," noted FierceHealthcare.

Since older physicians have been in practice longer, they have morelegal exposure, with nearly half of physicians age 55 and over sayingthey've been sued. That compares to 8.2 percent of physicians underage 40, AMA reports.

General surgeons and OB/GYNSs have the greatest risk of beingsued - about 3-4 times greater than pediatricians and psychiatrists,who have the lowest risk.

Click here on the frequency of claims by specialties; here onpayments; and here on premiums.

"You've Been Served: Lawsuit Survival Tips for Physicians"

The Doctors Company offersuseful tips and data on dealingwith litigation. Click here forthe article that begins:

A physician incurs nearly$200,000 in medical studentloan debt, graduates in the top10 percent of her class, and

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dedicates the past 14 years toproviding care to patients.One day, out of the blue, thelocal sheriff's office serves herwith a lawsuit. Perhaps it isregarding a familiar patient, ormaybe a patient the doctorcannot recall. Either way, hermind immediately leaps to:"What did I do wrong?

After the initial shock, thephysician is flooded withemotions -fear, anger, betrayal, frustration, anxiety, humiliation,embarrassment. Even shame.

Citing a RAND study based on information from The DoctorsCompany, the writer suggests that (as shown in the article above),it's not a matter of if you'll be sued, but when.

The Doctors Company is the nation's largest physician-ownedmalpractice insurance company. Your RAM membership gets youa 5% discount in premiums in addition to receiving financialrewards for practicing good medicine upon your retirement. To learnmore, or for a price quote, contact the Academy's endorsedinsurance partner - the Medical Society of Virginia Insurance(MSVIA) - at (804) 422-3100.

Health Hush Ups Nothing New in Oval Office In light of the coverage of President Trump's recent annualphysical, Monica Hesse's recent piece - "A History of Hush AboutHealth" - shows that there's nothing new under the Washington sun.Click here to read it. "The relationship between a president and his physician hashistorically been complicated. And it would hardly be the first timethat we didn't know what we thought we knew about the Americanpresidency - which has been, essentially, a 230-year parade ofunwell men." Here are a few juicy tidbits about the long history of covering up forailing presidents of both political parties: "The nation spent 12 years looking at photos ofFranklin Delano Roosevelt and never knew the mancould barely walk." Even after Grover Cleveland's "celebrity surgeon" -W.W. Keen - determined the lesion in the president's

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mouth was cancerous, the nation was told he had atoothache. Over the 4th of July weekend in 1893, "Thepresident boarded a yacht in New York bound for CapeCod, where a surgical team - in a procedure that wouldhave been complicated even in a hospital - removedfive teeth, part of his jaw, and the upper left part of hispalate, all while afloat." A decade before Cleveland's offshore surgery, "President ChesterArthur suffered from Bright's Disease, a kidney ailment that killedhim a few years after he left office." Going back to Founding Father George Washington, mostAmericans didn't know he "nearly died of influenza, and that amassive boil, excised by Samuel Bard, had been located not on histhigh, as the public heard, but on his butt. (The reason for the fib,Dr. Bard explained, was "presidential dignity.")

From Washington's butt to Trump's gut, thispiece provides a sort of medical road map ofAmerican history - from President WoodrowWilson's stroke (his physician, Cary Grayson,said he was suffering from "exhaustion," but itwas "not alarming") to PresidentEisenhower's major heart attack (firstreported as indigestion) to President Kennedy's litany of ailments(Addison's disease, crippling back pain, colitis - not to mention aphysician named "Dr. Feelgood" who prescribed amphetamines toJFK). Throughout history, the White House doctor (a position that wasn'tmade official until 1928) has practiced in a gray area betweenprivate and public medicine. As historian H.W. Brands said,"Presidential physicians find themselves in a very difficult position.They have taken a vow, as physicians, to protect the privacy of theirpatients, and to ask a physician to break that bond would feel verystrange." Click here to read more!

#MeToo's "Chilling Effect" in Health Care  Click here for a fascinatingarticle about shifting normsaround the nation in the wakeof mounting concerns oversexual harassment raised bythe #MeToo movement.

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The Washington Post articleincludes interviews from theCarilion Clinic in Roanoke. "As Sandy Sayre, a nurse inRoanoke, discussed the sexualmisconduct allegations againstMatt Lauer... with a surgeoncolleague, he told her he couldno longer give her the friendlyhugs they'd shared over a 10-year friendship." Sayre, 50, is the senior director at Carilion's cardiovascular surgeryclinic. She recalls telling the surgeon: "Don't blow things too far outof proportion," adding, "It's very sad that we've gotten to this levelwhere he's afraid to give me a friendly hug because of what otherpeople have done." Saying she feels for the victims of harassment, "But noweverybody's afraid to do anything... We've got to make sure that wedon't as a society lose our ability to connect with each other safely." Click here to read more about this topic across a variety of industriesand professions - a "new normal," as one male firefighter put it.

To Err is Human... We draw from awide range ofprint, online andmedical journalsto bring youinformation wehope is relevantto your practiceof medicine. But as a formerreporter, editorand author, Irecognize that

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mistakes dohappen. Soplease contactme if you haveany concerns,complaints, orideas/articlesyou'd like toshare by clickinghere or calling622-8136.

Click here ifyou'd like to seesome of mybooks. THANKYOU for beingpart of theAcademy and its continuing conversation about the best practice ofmedicine.

Click here for past editions of The Leg.Up!

Chip Jones RAM Communications & Marketing Diector

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