Illegal Use of Tax Dollars to Cover Insurance Company Shortfalls: Obama Bails Out Insurers

Recently, a Federal audit found that the Obama administration has illegally redirected funds related to collections from the Affordable Care Act that, by law, should have been deposited in the US Treasury. The President, under the guise of executive order, used these tax dollars to bail out insurance companies that have experienced hundreds of millions of dollars in losses due to their participation the Affordable Care Act (ACA) exchanges. In their report auditors state that the Obama administration “ignored the statutory requirement to collect funds for the Treasury,” As you might expect, President Obama defended his actions by arguing that it was necessary to direct these funds to insurers in order to offset the increasing costs (and rising premiums) of the Affordable Care Act. Unfortunately for taxpayers, the Government Accountability Office—who was responsible for this audit—has no legal authority to enforce its findings or legal opinions.

This latest report is just another example of how the President’s devotion to a failed policy continues to hurt the American people. Even with the diversion of tax dollars to insurance companies by Mr. Obama, premiums continue to rise an average of 25% with some states reporting nearly 50% increases for some plans. As these premiums rise, covered services and access to care have begin to dwindle.  Competition in the exchanges is nearly non-existent in some states—patients are beginning to realize that they have very little choice in insurance companies. Many shoppers are unable to compare prices due to the fact that only one company is represented in the exchange marketplace in their State.

This week, the New York Times FINALLY admits that unless changes are made, the ACA is unlikely to be sustainable unless changes are made. While neither candidate has spent very much time on discussing healthcare (no mention in the first debate), healthcare and the ACA will definitely change based on who becomes the next President. As mentioned before, Hillary Clinton wants to expand government involvement in healthcare—ultimately resulting in a single-payer system—Medicare for All. Mr Trump, by contrast suggests that less government involvement will be the answer. Mr Trump advocates for more free market competition—essentially allowing insurance companies to compete for subscribers across state lines.

When the marketplace opens for its fourth year of enrollment in November, consumers will be greeted with higher premiums and fewer choices. Major players such as United, Aetna and Humana have significantly limited their participation in the exchanges due to mounting financial losses. Many non-profit cooperatives have closed down. The basic premise of the ACA is that young and healthy enrollees would help pay for older, sicker enrollees who would require more care and more healthcare dollars. Unfortunately, for the President and his legacy, two things (that I and others predicted) happened:

  1. Older patients with multiple medical problems enrolled in the exchanges in record numbers. This has placed an enormous financial burden on the Federal government and the insurers that participated in the ACA.
  2. Fewer young healthy patients have enrolled in the ACA than originally expected. This has resulted in a premium shortfall in many cases—Many insurers are “upside down” in the ACA and are pulling out.

Ultimately, the ACA is a bad law. While insurance for all is a noble goal, it must be accomplished in a way that is fiscally responsible and in a way that allows doctors to practice responsible evidence based medicine. It is disturbing that our President has manipulated tax dollars (redirected them outside the law) in order to buffer his signature legislation rather than work with Congress to actively overhaul a broken law.


We are the “Kings of Pain” Pills: Addressing The Opioid Epidemic In the United States

Opioids are common pain medications that are used for the treatment for mild to moderate pain. These medications are highly addictive and bind to particular receptors in the brain and spinal column that produce a feeling of euphoria along with the relief of chronic pain. However, in the US they are becoming a leading cause of death due to overdoses. Opioids—such as oxydocodone, Percocet and others—are now gateway drugs to heroin and other narcotics. They are also becoming a drug of choice for those who have not abused drugs in the past. Now they are gaining increased in popularity due to ease of access– and their street value continues to grow. The sad fact is that in the last year, drug overdoses killed more people in the US than car crashes.

While some physicians are very diligent in the way in which they prescribe opioid type pain killers–others are not. Drug companies that make these compounds for profit have misled physicians with small studies touting opioid safety and many physicians have not done their due diligence in evaluating the addictive nature of pain medications. All of these factors have led to a practice of indiscriminate and irresponsible prescribing practices.

What are the Facts Regarding the Abuse of Opioids?

As a society, we are quick to accept a pharmacologic approach to treating any ailment. As a people we demand an immediate fix for any medical problem and often do not consider any other alternatives. Drugs are much cheaper way to treat chronic pain as opposed to a more comprehensive multi-disciplinary approach. Time with therapists, treatment plans involving meditation, yoga and exercise are not widely supported—it is simply easier to take a pill. Currently, the US accounts for over 75% of the world’s total opioid prescriptions. In the last year, over 260 million opioid prescriptions were written in the US alone according to the American Society of Addiction Medicine. Currently, drug overdose is the leading cause of accidental death in the US today. Of the nearly 50 thousand overdose related deaths in 2014, opioid overdoses accounted for over 18 thousand—only 10 thousand were due to heroin.   In the last decade, opioid overdose rates have risen more than six fold. Women tend to be more at risk than men with overdose rates from prescription pain relievers up 400% over the last decade (as compared to 230% for men).

What Role to Doctors Play?

Obviously, physicians and other healthcare professionals are the source of opioid prescriptions. Don’t get me wrong—opioids do in fact have an important role to play in medicine in the short term treatment of acute pain related to accident, injury, surgery or the like. However, chronic opioid use must be avoided. These medications have numerous side effects and can be highly addictive in some patients. As a physician, it is incumbent upon me and my prescribing colleagues to choose the best treatment for a particular patient. It is never OK to enable abuse through writing recurrent, long term narcotic prescriptions. Unfortunately, financial pressures in medicine have created situations in which physicians feel as though they MUST write prescriptions of this type or fear losing patients to another provider who will. In addition, many patients with chronic pain require a great deal of time and effort during the course of a busy office day. Rather than spend the necessary time to create a more holistic and multi-disciplinary treatment plan, many physicians find it easier to simply write a prescription and move on the the next patient—thus enabling addiction.

What Is Our Government Doing to Address Opioid Addiction?

In March 2016, President Obama announced a new initiative (and new funding ) to combat opioid abuse and addiction. Currently, the FDA and DEA is considering regulations that will require “retraining” of doctors who prescribe opioid medications. Healthcare providers may be required to undergo re education in order to maintain a particular DEA prescribing certification. Many state medical boards already track opioid prescribing patterns and will often reach out to physicians who have unusual prescribing practices or prescribe higher numbers than their peers. Many of these physicians may be subject to disciplinary action.

Research dollars are being spent to investigate new types of pain relievers with less abuse potential and greater efficacy. Other studies are being conducted that will help better understand this type of addiction and how best to treat it. In addition, government dollars will be allocated to improve access to addiction treatment programs and the FDA will require new labeling of opioid prescriptions that will make their abuse potential much more clear.

Finally, drugs that reverse narcotics overdoses, such as naloxone (also called Narcan), are making their ways to city streets. It is imperative that we provide first responders as well as others in areas of high abuse rates with easy access to this life saving antidote during an overdoes. IF we do not, many more will die before we can change the course of the opioid epidemic in the US today.

What’s Next?

While these proposed government sponsored initiatives do have some promise, it is unlikely that any of them will have an immediate impact. It is important that we continue to educate the public as well as healthcare providers to the risks associated with taking opioids. In addition, we must make it easier for physicians to develop a more comprehensive and multi-disciplinary approach to pain management. Those physicians who do not carefully prescribe narcotics and instead do so indiscriminately, must be sanctioned and must no longer be allowed to prescribe these medications. We must also address the behaviors of those who are addicted to these drugs—we must identify sources of these drugs in the community and eliminate them from circulation. We cannot wait for government to act FOR us and fix the problem through bureaucracy and legislation—as physicians and as citizens we must act on our own. While ultimately research into better ways to treat chronic pain and the management of addiction will produce new ways to treat our patients, we must all work together NOW in order to halt the alarmingly high rise in opioid use in our country today. Ask your physician for alternative ways to treat pain. If you are concerned you or your friends and loved ones are suffering from addiction—say something—get involved and help.


Doctors Glued to Computers—And Patients Left Out : The Impact of Electronic Medical Records (EMR)

In 2009 the Health Information Technology for Economic and Clinical Health Act (HITECH) was signed into law by President Obama and this law quickly changed the way medicine in the United Sates is practiced. The law was a first step in requiring all physicians to utilize electronic records. The President promised that creating and electronic record mandate for physicians would result in a national, universal electronic medical record system and improve care and communication. Ultimately, the legislation that required EMR implementation in 2009 began the process of penalizing physicians who do not use them and started a lucrative business for healthcare IT vendors such as Allscripts, EPIC, Cerner and many others. The requirements to implement EMR resulted in thousands of physician practices having to make harsh financially motivated decisions—either close the doors or sell out to larger healthcare systems.

What are the Benefits of EMR? What are the Practical Drawbacks?

Certainly, EMR systems do have their benefits—standardized documentation and portability all improve care. When a patient travels and has an illness care is improved when another hospital and provider can easily access long-term medical records. Communication between physicians of different specialties and organizations is significantly improved. However, EMR vendors have not yet created exchangeable, universal systems as Mr Obama promised they would. Each vendor creates their own platform and continues to compete with other EMR makers by creating different interfaces—Each EMR platform has its own idiosyncrasies and none is perfect. The Obama administration failed to put any mandates on EMR vendors—they were allowed to produce whatever they liked. The burden of integration has been dumped squarely in the laps of healthcare providers. In addition, EMR systems have been designed as billing tools and NOT for clinical documentation. Hospital systems are able to reduce billing and coding staff and now force physicians and other healthcare workers to perform this role as well. Because of the design focus of EMRs to capture maximal billing they are often clinically irrelevant and woefully inefficient in the clinical setting.

There is a significant learning curve for physicians and other healthcare workers when changing from one system to another. These transitions often bring operations to a crawl as productivity and efficiency decline for several weeks to months—ultimately negatively impacting patients.

How Has The EMR Requirement Affected Physicians and Patients in the Last decade?

This past week, a study published in the Annals of Internal Medicine found that physicians are spending twice as much time logging data into electronic medical patients as they are actually spending time interacting with patients. In the study, investigators observed nearly 480 hours of clinical time from the practice of 57 physicians across multiple specialties—including family medicine, internal medicine, cardiology and orthopedics. Investigators found that during a day in the office, physicians spent 27% of their time seeing patients and 49.2% of their time on the EMR or doing deskwork. In addition, these physicians also did 1-2 hours of EMR time at home during family time every single night. Ultimately the study found that for every hour physicians spend providing direct face to face patient care, they then spend TWO hours working on the EMR. Obviously, this type of scenario is unlikely to be sustainable. Physician burn-out and dissatisfaction with their job is at an all time high—more younger doctors are retiring early and looking for employment in other industries. More importantly, many patients are beginning to feel isolated and unable to develop any type of meaningful relationship with their physician.

What’s Next?

We must get back to a patient centered focus for the US healthcare system. We cannot allow a computer screen and government mandates to separate docrom patient. We must demand that physicians be given the time and space to interact with patients in a meaningful way that allows for a human connection. While documentation and EMR technology is an important part of clinical medicine, we must not allow the computer to be the focus of the clinical visit.

Here’s what I think needs to be done:

  1. Keep laptops out of a physicians hands in the exam room
  2. Require universal connectivity and easy interaction between different EMR platforms/vendors
  3. Reward physicians for quality CARE, not for quality EMR notes
  4. Make EMR interfaces more clinically relevant, easier to use, and more efficient (NOT AS BILLING TOOLS)

These are not easy goals to achieve. However, we must work diligently to make changes or patients will become more isolated and medicine will no longer be a human interaction between doctor and patient. These changes will only be possible if all of us work together—patients and doctors–to demand legislative reform.


{This blog was originally published in my column on Bold.Global on Monday September 12, 2016}

Major Insurers Bail on the ACA—Limited Choices and Patient Struggles Ahead

(This blog was originally published on September 5, 2016 on Bold.Global)

In the last several months three major players in the Obamacare exchanges have publicly  reported millions of dollars in losses and have made plans to either pull out completely (or significantly decrease participation) in the ACA insurance exchanges. Humana, United and Aetna account for the majority of the policies written under the affordable care act and will no longer be participating in open enrollment in 2017. All three insurers have cited overwhelming losses and a responsibility to their shareholders at the motivation for the change. The mass exodus of larger insurers has created a situation where nearly 1/3 of the individual counties in the United States will have only ONE choice in the exchange—effectively creating monopolies for these insurers. The insurers that remain are already asking for substantial premium increases—in some areas premiums may rise nearly 40%. In an effort to cut costs even further, those insurers that remain are negotiating contracts with healthcare systems that will accept rock bottom reimbursements. Many major healthcare systems are not able to participate in the exchanges. This has left many Obamacare participants with very narrow “in network” choices and some areas are faced with only ONE healthcare system and its affiliated physicians.   By limiting the network choices, the insurers are able to better control costs due to the fact that more expensive physicians and hospitals can be left out. When an insurer contracts with a particular hospital system and affiliated physicians, they are able to require referrals for specialists and the often offer incentives to primary care doctors for limiting costs (with no measure of quality).

What is the obvious Fallout from NO competition??

  1. Diminished Choice

As mentioned above, the remaining insurers must cut costs. The ACA exchanges have been flooded with older, sicker patients that require more care and create a higher cost burden. In order to manage these costs, insurers are negotiating contracts with single healthcare organizations in an effort to limit costs. These contracts will eliminate choice for most of those insured through the ACA. There is a shift towards HMO style plans and there are now fewer PPO (Preferred Provider Organization) options. PPOs allow patients to make choices in providers and HMOs typically have far fewer choices. In many states, there are no PPO choices—overall 15% of customers will have NO PPO to choose from. As you may expect, the profit margins for HMOs tend to be much higher for the insurers.   In 2016, HMOs represented 65% of all ACA plan choices. Non HMO plans tend to have higher premiums and are subject to more frequent and more significant premium increases as these insurers accumulate sicker, more expensive customers.

  1. Less Quality

Whenever there is a lack of competition, quality tends to suffer—no matter what the industry—and Medicine is not immune. Cost cutting measures and incentives for physicians to “do less” can result in a lower quality of care. For the most part, insurance companies are not concerned with the health of the insured—they are focused on the cost and the risk. In an ideal world, medicine would focus on prevention rather than treatment. However, many insurers do not cover important preventative tests and prescription drugs that are designed to modify risk.

  1. Increased Cost

Insurance companies are “for profit” businesses with shareholders to which they must answer. The job of the insurance executives is to maximize profits and minimize risk—Do not be fooled, insurance companies do not care about the well being of their customers. When insurance companies such as those who are taking losses in the exchanges find that their bottom line is negatively affected, they quickly raise rates, increase co-pays and raise deductibles.

  1. Less Access

As insurers limit their networks, patients will find that they have less access. When exchanges only offer one choice of hospital system and affiliated physician groups, patients will have difficulty finding a primary care doctor or may experience waiting lists to see specialists. Ultimately, patients will be separated from their long time physicians (unless they are lucky enough to find that they remain in network). Many physicians will ultimately retire or choose not to participate in the exchanges due to lower reimbursement rates—in some cases the exchanges reimburse at rates lower than Medicare and Medicaid—which are already 30% lower than private insurance rates. Major academic medical centers—such as UCLA and Northwestern for example—and countless others, are not participating in the exchanges due to reimbursement concerns. Academic centers often have cutting edge therapies and experimental protocols for cancer and other devastating diseases. Because of network and cost containment issues, those insured by the ACA will not have access to this type of care.

WHAT needs to be done?

It is clear that the ACA is NOT working. While we have millions of newly insured Americans, many of these newly insured remain effectively “uninsured” due to the inability to meet deductibles, and the limited access to care. It is vital that we insure all Americans—but we must do so in a way that preserves patient choice and helps improve quality of care—all while being fiscally responsible. We must work to better regulate insurers and make sure that the focus of care pivots to PREVENTION in the next decade. Physicians should be measured on how well they PREVENT disease as well as how well they TREAT disease with the highest quality care. We must also require individual accountability for patients. Those that make healthy lifestyle choices should be rewarded with lower premiums. Those that choose to continue high risk behaviors—smoking, poor diet, etc—should pay more.

Ultimately, Congress will have a choice in 2017. They can either bail out a broken ACA by pouring more good money after bad—OR—they can actually legislate and reform the law, making it more effective for all parties—insurers, patients and physicians.


Greed and Pharma: What is Behind the Rise in Prescription Drug Prices?



This blog was originally authored by me and published on and @BoldGlobalNews on Tuesday August 30, 2016 and is reposted here today…

Recently we have all heard about the significant price hike of the Epi Pen made by Mylan pharmaceuticals. While Mylan and CEO Heather Bresch are dominating the headlines now, other drugs are also increasing in cost. While we see a 500% increase in the cost of the Epi Pen, Ms Bresch has seen a nearly 700% increase in salary over the last few years. Mylan is definitely not alone in its greed. Last year the CEO of Turing, Martin Shkreli increased the price of an important (and relatively cheap) drug in the treatment of HIV related illness nearly 5000 percent. Price gouging is not limited to newly developed drugs–even the price of insulin has gone up nearly 300 percent. Healthcare reform has provided more Americans with access to insurance but many still cannot afford the drugs and care that they need.

So exactly why is this occurring and what can we, as healthcare consumers, do?

A new study published in the Journal of the American Medical Association this past week has shown that the average price of a drug has increased by nearly 165% in the last seven years. Buy why? Harvard researchers postulate that the most likely reason for inflated prices is the fact that government regulation allows for drug makers to have exclusivity and near monopolies over certain drugs.   Drug makers are able to do this because Medicare and Medicaid are not allowed to negotiate prices. Even though 1 in 3 Americans are insured by these two entities, federal law allows drug makers to charge (and Medicare and Medicaid) to pay whatever is asked. There is no negotiation. No other business in the world operates in this manner. If they did, they would not exist for long. Almost every other developed nation allows (and requires) their government- sponsored health care programs to negotiate drug prices as they would any other contract for goods and services. In the US we spend more money per person as a percentage of GDP than any other country in the world. Many drugs and procedures cost much more here than abroad.

The bottom line is that Americans pay more because their ability to push back is limited by an inept government and poorly organized government sponsored healthcare programs. In addition There is little or no transparency in pharma—drug makers pay each other to delay generic production and re-file for patent protection when the end of their exclusivity comes to an end—often using “new indications” as a way to continue to avoid generic competition. In addition, the pharmaceutical lobby is quite powerful and often works to stall any meaningful legislative reform in Congress.

The Pharma Response: What about Research and Development Dollars?

 When pushed, pharmaceutical companies will claim that the prices are necessary in order to fund research and development of new drugs. However, the United States seems to fund most of the R and D that happens throughout the world. In addition, many scientific breakthroughs occur at academic institutions where much of the research is funded through government dollars in the form of National Institute of Health (NIH) grants. In fact nearly half of the most important drugs that have been developed in the last 25 years have been created through publicly funded research in academic institutions. In reality, pharmaceutical companies on average reinvest only around 20% of their profits into R and D—the rest lines the pockets of their C level executives. In the case of Mylan, the technology that is utilized to create the injector of the Epi Pen was developed by the US military in 1970 when it was created in order to inject Atropine into battlefield soldiers during a chemical attack. Mylan simply acquired the technology from another player in the market.

So What Next?

The Epi Pen controversy should serve as a wake up call to us all. Over the last 10 years, the number of children with serious allergies has risen nearly 50%. Many of these children will have a dangerous life threatening reaction known as anaphylaxis and the Epi Pen may be the difference between life and death. All children should have access to these drugs—not just those whose parents have the means to provide them at an inflated cost. As healthcare consumers we must demand that our lawmakers act to prevent the greedy and despicable acts of CEOs such as Bresch, . Shkreli and others. Both Presidential candidates have vowed to allow Medicare and Medicaid to negotiate drug prices. Both have also suggested free trade of pharmaceuticals with Canada and other foreign suppliers. In addition, we must also work to reform the FDA and its expensive, tedious and incredibly lengthy regulatory process for drug approval. The answer to inflated drug prices is simple—competition and free market—we must abolish long-standing policies that allow for exclusivity and patent protection for pharma. We must promote the development of cheaper generic alternatives earlier in the life a of new drug or therapy. While name brand drugs only account for 10 percent of prescriptions in the US today, they account for nearly 75% of the cost. Something must be done in order to protect the healthcare consumer—the Patients that depend on drugs every single day—should have the ability to receive therapy without entering bankruptcy.

Mylan Follow up…

Mylan, in and effort to respond to the public outcry has reacted by developing a new patient assistance program—this too still falls far short. Those who can pay are still paying exorbitant prices. Today, Mylan has announced plans to make a generic version—albeit at a price of 300 Dollars. (remember their cost is approximately 6 dollars per unit)   While these concessions are certainly helpful they do not address the bigger issues—increasing deductibles and skyrocketing health insurance costs will not be able to continue to pay these types of inflated prices. Ultimately, the patient will suffer.





Big Brother is “Watching” the Watchman Device—More Government Intrusion into The Practice of Medicine

Note: Let me preface this blog post and remove potential bias by making it clear that I am not an Implanter of the Watchman device.

Atrial fibrillation (AF), the most common heart rhythm disorder in the world, can be complicated by stroke and many patients must take blood thinners for life. A new device, called Watchman, is an alternative treatment for patients who do not want to take blood thinners to prevent stroke.

The Watchman, recently approved by the FDA for the prevention of stroke in AF, has entered the market and is now being implanted by very highly specialized physicians (called Electrophysiolgists). Rigorous clinical trials were performed prior to FDA approval in order to evaluate the safety and efficacy of the Watchman. The Centers for Medicare and Medicaid Services (CMS) has also ruled on the device for use in Medicare patients—but with a caveat. Before being allowed to have the device implanted, patients will be required to have a second opinion—by a physician who may or may not be trained in the implantation and management of these new devices. If the patient does not get the second opinion, Medicare will not cover the cost of the device and procedure.

CMS argues that this requirement is part of a new “shared decision making” initiative—a way to ensure that a patient’s own opinions and values are taken into consideration when discussing the risks and benefits of a procedure. The government contends that the requirement is NOT about a second opinion at all….it is more about making sure that a patient makes clear informed decisions about a particular treatment.



I have always thought that a physician must develop a relationship with their patient over time in order to create a clinical “partnership.” By working with patients and engaging patients in the treatment of their own disease, a doctor can really to get to know patients, their families and their particular values. This is certainly the way I have practiced over my15 year career. So, why then, does CMS want to involve another physician, who may have no relationship with a particular patient, in the decision making process?

In my opinion, the answer is simple—money and regulation.   Increasing pre certification requirements for patients who need procedures will ultimately reduce the numbers of procedures that are performed—ultimately resulting in fewer healthcare payments from Medicare. Many patients will decide not to go through the hassle of getting a “second opinion” from a non expert and many physicians may decide to no longer pursue these treatment options due to increased administrative paperwork burden.

The Federal government continues to inappropriately insert itself into the practice of Medicine. Increasing regulation threatens to undermine the ability of doctor and patient to engage and partner in care of chronic disease. Other recent examples of government encroachment into the doctor patient relationship include requiring physicians to discuss gun ownership during an office visit—I have written on this subject extensively in the last month.

IS The ART of Medicine being Put at Risk by Washington Politicians?

When I have discussions with my patients about treatment options, I always discuss the risks of each option, the benefits, and the data that supports each approach. I try to provide every patient and family with the information that they need in order to make a good decision—a decision that fits in with their goals, their values and their stage of life. I must admit that I resent it when CMS and our government violates the sanctity of the doctor patient relationship. As a physician it is my duty to develop a relationship with my patients. Having “Big Brother” decide that I am incapable of having a meaningful discussion with my long time patients (and friends) erodes at the very fabric of the Art of Medicine. I worry that these recurrent intrusions into the exam room will only serve to further undermine my ability to care for my patients. Throughout my career—from medical school through Fellowship–my mentors have always taught me the importance of developing meaningful relationships with patients. Why now, does the government think they need to “Watch the Watchman”?



Doctors and Gun Control: Get Politics OUT of my Exam Room


Let me preface this blog by stating that I write this to stimulate discussion and debate, NOT to sway opinions…..

Today, doctors are required to spend more and more time doing administrative work—including checking off electronic boxes in the Electronic Medical Record (EMR)—the result is less quality time with patients. Now, those that are in Washington, DC think that requiring physicians to ask about guns in the home may somehow reduce gun violence and gun related deaths in the US today. For me, the answer is simply NO. Physicians should focus on the prevention, diagnosis and treatment of disease—we should advocate for our patients BUT we should not be government agents (unless we all collectively become employed by the state. In an article published this week in the Atlantic, author Olga Khazan argues that doctors have a responsibility in preventing gun related deaths. When I read the article, I was simply struck by how much controversy surrounds this issue—How do we protect patient’s privacy rights? How do we preserve our relationships with patients? Certainly, as physicians we may ask many uncomfortable questions of our patients—Sexual history, drug and alcohol use, and other sensitive subjects—BUT should we really be asking about guns? The legal implications alone of these discussions are enough to make even the most steadfast physician a little weak in the knees….

For far too long, the government has attempted to insert itself into the sacred (and privileged “Doctor-Patient” relationship. The bond between doctor and patient is like no other-honesty, confidentiality and trust are paramount to all other concerns. There is already a debate on the role physicians should play in gun control/gun safety. Our own US Surgeon General has proclaimed in the past (prior to his appointment by a Democratic President) that gun control was a top priority for his office. In Florida, there is a law that does not allow Physicians to ask about guns except is certain circumstances. Others want to require physicians to ask and document the patients answers in the EMR. I fear that allowing discussions on guns to enter an exam room may completely undermine a physicians’ relationship with his or her patient. Patients may feel uneasy about answering the questions and may also be suspicious of why they are being asked in the first place. Patients may be less likely to TRUST their physician (for fear of some repercussion) and my also be less likely to discuss other medical issues with honesty. Lack of honest dialogue between doctor and patient can result in a lack of patient engagement and, ultimately, negative clinical outcomes.

Don’t get me wrong, we MUST educate the public about the proper use and storage of firearms. Guns should never be accessible to children and any person who owns a firearm must be trained in its safety and proper use. However, the role of the physician should remain, first and foremost, as healer—We should not be required to become firearm educators, nor should we be required to document firearm possession to the government. While I do concede that there is likely a role for the discussion of guns in a Pediatrician’s office (with the parents) in order to ensure that guns are stored properly in the home, I do not think that there should be any type of discussion in Adult medicine. There has been much research in this area and much controversy remains. This past week in the Annals of Internal Medicine, researchers from Colorado found that there is a vast array of opinions among patients when it comes to physicians asking them about guns. Only 25% of patients surveyed thought that it was ALWAYS appropriate for a physician to have a discussion about guns. 34% of those studied in stated that it was NEVER appropriate for a physician to ask about gun possession or gun use. While study authors spin the data to say that nearly 2/3rds of respondents think that it is SOMETIMES ok to ask about guns, the reality is that many Americans feel that this type of interaction is not appropriate.

Sadly, there are far too many gun related deaths in the US today. We must do more to prevent criminals, those with mental illness, and others who would do us harm to possess guns. This should be the work of the community and the local, state and Federal government—NOT the work of the physician. I fear that if we begin to mandate data collection of this sort by physicians and other healthcare providers we will undermine the trust that our patients place in us every single day.