Thursday, June 11, 2009

Patients Gone Wild and Healthcare Reform

(I'm blogging from the operating room.  Here's my Saipan Tribune column for this week.)

I recently had the opportunity to read President Barak Obama’s letter on Health Care Reform, dated June 3, 2009.  There is one paragraph in particular that jumped out at me, because it seeks to identify the “root cause” of rising health care costs.  Here it is:

“At this historic juncture, we share the goal of quality, affordable health care for all Americans.  But I want to stress that reform cannot mean focusing on expanded coverage alone.  Indeed, without a serious, sustained effort to reduce the growth rate of health care costs, affordable health care coverage will remain out of reach.  So we must attack the root causes of the inflation in health care.  That means promoting the best practices, not simply the most expensive.… That's how we can achieve reform that preserves and strengthens what's best about our health care system, while fixing what is broken.”

First, let me say, that I agree with the gist of the statement.  Rising health care costs are killing our economy (well, that and a few other things), and medical care can definitely be improved so that it is more cost effective.

But here’s the truth.  The single best way to reduce the cost of healthcare is to reduce the need for healthcare.  We are a sick bunch of people, and for the most part, it’s because of our own behavior – we’re all “patients gone wild.”  The majority of us are sick, not because we’re out doing healthy things and suddenly get struck down by some horrific disease.  No, we’re sick because we eat too much, sit around too much, eat the wrong foods, smoke, consume alcohol, and generally ignore the things that lead to good health.  We’re sick because of the wild and crazy choices we make.  The vast majority of healthcare costs in America and the CNMI are tied to chronic “lifestyle” diseases.  The top ten causes of death in the US include heart disease, stroke, diabetes, and cancer.  And every single one of these has been incontrovertibly linked to how we live our lives – whether it’s what we eat, what we do, what we drink or what we inhale. 

To a large extent, we’re digging our graves with our spoons and forks.  Last year, we spent over $20 billion dollars on cholesterol lowering drugs.  That’s billion, with a “B”.  If you had $20 billion dollars, and decided to burn a million dollars a day, every single day, it would take you 55 years to spend $20 billion!  Why is our cholesterol high and why does it need to be lowered at a tune of $20 billion a year?  High cholesterol is a major risk factor for heart disease and stroke.  Our bodies produce some cholesterol, but most of the problem comes from what we eat.  Only animals have cholesterol in them.  Vegetables have no cholesterol at all.  We’ve known for decades that the most effective way (and the cheapest way) to lower cholesterol is to lower our consumption of animal products – animal flesh, animal milk, animal cheese, animal crackers, etc.  But you know what? We’d rather not make that kind of change.  We’d rather pop a pill and keep eating whatever we want to eat.  And that’s $20 billion dollars we spend so we can do what we want to do, which is to eat lots of animals. 

The same is true for diabetes, which is devastating our community, and growing at an alarming rate.  We know that for most of us, the adult onset variety can be controlled, or at least hugely improved, with diet and exercise.  Yet we choose not to make these difficult changes.  We choose to eat what we want, and take pills and go on dialysis and lose our vision and our feet and our erections.  And we spend untold billions on the cost of care for diabetes and its related problems. 

A diet high in animal fat is also linked to a slew of cancers.  Pass the processed meat that starts with “S” and ends in “M” and rhymes with “PAM”.  Or just pass a burger or wiener or any other chunk of meat.  Alcohol consumption is linked to many cancers.  Pass a Bud (better make that a Bud Lite).  Tobacco is irrefutably linked to cancer.  But we can’t seem to manage to pass legislation to ban smoking in public spaces.  Pass the votes. 

I admire efforts to improve the cost-effectiveness of the healthcare we deliver, but I know that the “root cause” of the mess includes our culture of indiscretion, of consumption, of sitting around.  Any serious effort to fix the healthcare mess must include a change in our culture – what we eat, what we do, what we drink and what we inhale.  These changes won’t solve all the problems, but they’ll make a huge dent in the demand for and the cost of healthcare.  A major portion of the responsibility to “reform” belongs on our shoulders -- those who end up needing healthcare.  Reduce the need, and you reduce the cost.  It’s simple.  But it’s not easy.  We humans typically don’t like change.  Yet failure to change our behavior will result in more and more people needing healthcare every year, rising costs, and eventually, not enough doctors, hospitals or other resources to take care of so many sick people.  We’re experiencing the fallout right now, right here in the CNMI. 

Addressing our behavior needs move to the front and center in the public policy discussion on healthcare reform.  It’s a nut we must crack.


David Khorram, MD is the co-founder and medical director of Marianas Eye Institute.  He is the author of the book, World Peace, a Blind Wife, and Gecko Tails, which is available on and at Marianas Eye Institute.  Dr. Khorram can be emailed by visiting, or by phone at 670-235-9090. © David Khorram, 2009.

Friday, May 1, 2009

What they're not telling you about Swine Flu

Here's a portion of an email I got from one of our public health officials, just to put things in perspective:

I am getting more than 8 Swine Flu "Updates" per hour.  Good grief.  This is a true epidemic, likely soon to be a global pandemic.  My guess is that we'll be in Phase 6 next week.  But the relatively minor human toll (low morbidity and low mortality) does not yet justify the resource allocation, nor the media attention that we have all seen.

We need to insure that we have a "measured response" that is commensurate with the real, not the perceived, threat.  And responding appropriately, in the face of media hype and patient worry and governmental involvement, is a real art.  I am hoping to hear your opinions on this.

In the past six weeks, Swine Flu has killed between 20 and 80 people.  More than 2000 have had clinically significant infections.  In the same time period, more than 40,000 people have died from routine influenza.  Millions were infected.  More than 40,000 died from TB just last week.  40,000 more died from malaria last week.

Friday, March 13, 2009

Jerks Die Younger

The next time some jerk is yelling at you for no good reason, you can smile, knowing that they'll be off the planet sooner than you.

A new study published in the Journal of the American College of Cardiology finds that people who are angry and exhibit hostility have a 19% higher risk of dying from coronary artery disease -- i.e. a heart attack.

The average person hopes that future studies will show an increased risk.

Thursday, March 12, 2009

Sexualization of Young Girls

I was at the Thursday night street market, where every week on Saipan you'll find food vendors and live entertainment.  Tonight, a dance schools performed.  I'll tell you, it was a sad scene.  There were kids, girls, six, seven, eight years old, dressed like teenagers, with short skirts, makeup, and shin-high boots, and dancing suggestively to lyrics like "Let's make love, ooh, baby, let's make love."

When did this happen?  When did parents start looking the other way, and give their assent to the sexualization of their young girls?  It's like they all went out for a walk, let some stranger called  a dance instructor come into their house, and in the name of "developing talent" twist their kids into these vacant performers.  It disgusts me.  What happened to protecting innocence?  What are these parents thinking?  Do they think this is okay?  To have their young daughters thrusting their pelvises while lip-synching these overtly sexual lyrics?  I don't get it.

Saturday, February 28, 2009

Nagoya City University Hospital

A few years ago, I needed some surgery that wasn't available on Saipan, so I was faced with finding a surgeon to undertake my care.  Part of the issue for me was that I wanted to get the care close-by, and being self-insured, I needed it to be cost effective.

My main four choices came down to Australia, Hawaii, Manila and Japan.  I visited one of the top surgeons in Sydney during a trip there, and I wasn't impressed.  I scratched Manila off the list pretty quickly.  I've had a fair bit of experience with patients going to Manila for care, and although one of the surgeons I've worked with there is good, I've found that in general, the delivery was not up to the standards I expect when sending a patient to a major medical referral center.  Sorry guys, but that's the truth.  I wouldn't go to Manila unless it was a last resort.  I'm sure many have had good experiences there, but seeing many of my patients return, I haven't been too happy with the quality of care they received.

Hawaii was an obvious choice because, well, it's US quality medical care.  The problems with US care is that it's expensive.  If I'd had the procedure in Hawaii, it would have cost me $10K.  If I had had insurance, my 20% co-payment would have been $2K, for an outpatient procedure.  So, I just held this option in reserve.

I started to look seriously at Japan.  In the world of medicine, Japan is one of the areas, along with the US and parts of Europe, that lead medical research and publish in medical journals.  I know the quality of care there is top-notch, and that the cost is reasonable.  I ended up finding one of the best surgeons in the world for my condition, and headed there for my surgery.  I was very happy with the quality of the care I received, and the cost was only $2K.  That included the surgery, and five days in the hospital, getting fed and watered.  The system of care in Japan is a little antiquated, and many expatriates in Japan complain about it for this reason, but as someone in the medical field and as someone who has experienced the care first-hand, I think that the care is on par with anyplace in the US, and even better than the US, it's cost effective.

After I returned, I tried to convince the powers that be to start looking at Japan as a place to send our medical referral patients from the CNMI.  It close, it's cheap, and the quality of care is outstanding.  It's taken a while, but finally the CNMI has a relationship with the Nagoya City University Hospital (NCUH), and we have liaison people on the ground to help patients navigate a foreign country.

Nagoya City University Hospital is an 800 bed medical center (CHC has 72 beds).   The first patient from the CNMI that went there was an infant, a few days old, who was on the way to Hawaii for cardiac surgery, decompensated while on the tarmac in Nagoya, and was taken to the NCUH where the pediatric cardiac surgeons did an outstanding job on a very complex surgical procedure.  Since that time, the relationship has deepened, and in the next few weeks, I hope to send the first ophthalmology patients there.  This should provide closer and less expensive care than is available in Hawaii, and  as high a quality of care.   I'm looking forward to using NCUH as a referral center.

Sunday, February 22, 2009

Truth, Death, Unity and Classroom Cataract Surgery

Because of my book, I was invited to give the keynote address to the University of Guam during their faculty development day on Friday.  I just shared some thoughts that were on my mind.  I think in some way, the points I raised had to do with some of the anchoring principles of my life.  It was also an opportunity for me to try out some of the stand-up comedy material I had been working on, and most of the jokes got laughs.  Here were my key points.

1.  "Truthfulness is the foundation of all human virtues.  Without truthfulness, progress and success in all the worlds of God are impossible for any soul."  Before I really started to think about this principle in my own life, I used to "fib" so much to avoid embarrassment or to stay out of trouble.  Being committed to total truthfulness required me to change the way I did a lot of things, but it was a liberating process.  It's a pain, and I feel I sell out pretty easily at times.  But it's still one of the key principles that I think everyone can benefit from.

2.  We're all gonna die.  Really.  Remaining conscious of this truth on a daily basis helps lend clarity to life.  This can be done by bringing oneself to account each day.  "Bring thyself to account each day, ere though art summoned to a reckoning, for death unheralded shall come upon thee and thou shalt be called to give account for thy deeds."

3.  The motto of UOG is "Unity in Diversity."  Unity requires that as individuals we refrain from faultfinding.  The process of higher education gears us toward "critical analysis" which makes faultfinding a natural way of life.  Faultfinding is an intellectual activity that is quarantined to one's mind.  But the real problems arise when we mention the faults of others -- when faultfinding moves to backbiting.  It's endemic in our culture, and there is a need to establish "no backbiting zones" around our mouths, and even our ears, so we don't participate in this corrosive force.

4.  Cataract surgery brings vision.  Teaching brings vision.

The faculty were appreciative of having a speaker who wasn't there with charts and numbers, and as someone said, "we're all human, and it's nice to remember that at times."

Saturday, January 31, 2009

Gory Eye Picture - Dermoid from Hell

This is a weird growth that some people are born with.  It's called a dermoid.  It can enlarge over time, as this one has.  (This guy walked in this week is in his 20's.  Time to remove it, don't ya think?)  You can see it has hair growing on it.  Sometimes there's bone and teeth and cartilage and other Frankensteinian components in them.   Growths like this that consist of tissue not normally found at the site are called "choristomas".   One choristoma made it to the big screen in the movie, "My Big Fat Greek Wedding," where the Aunt is telling the fiance of the lump that was removed from her back that had teeth and hair in it, and that it was the remnants of her twin that was never born.  It was a great scene, and a proud day for choristomas everywhere.

Often, ocular dermoids go deep into the substance of the eye wall, so despite it's "stuck-on" appearance, you can't just slice it off, (or lacking instruments, pluck it off), because you could end up with a hole in the eye.  So you have to have donor tissue available to patch up the hole at the time of surgery.  They occur in about one per 10,000 people.