John Livingston

Who Do They Serve?

My last duty station on active duty in the Navy was in Keflavik Iceland at the NATO Base Hospital. I held two jobs during those two years. I was a staff General Surgeon and head of the Department of Surgery, and I was The Director of Clinical Affairs. There was an inherent conflict of interest in holding those two positions that I came to appreciate almost immediately. As a surgeon and physician, my first obligation was to my patient(s). As an administrator, my responsibility was to the hospital organization and the Navy Community on the Base.

It is hard to imagine today, but in 1985-86 we were very much isolated in Iceland. I did hold clinical appointments at the University Hospital and the City Hospital in Reykjavik. These were 60 miles away and especially in the winter and spring, these medical assets were out of reach from those on the NATO Base. I also held privileges at St. Joseph Battalion Hospital that was a large Catholic Hospital a little bigger than St. Al’s and Luke’s.

Like all military and many Federal agencies, we were funded by an “OP TAR” funding process. Our funding for the current fiscal year was determined by how much we spent in the past year so there was an incentive to spend all that had been allocated on a per quarter bases. Many times, we had extra money at the end of the quarter that I would want to put in a kind of escrow account to be used in the next quarter. This was illegal. In other quarters we would run out of money because of patients that required expensive care. I had a patient named Davina who had inflammatory breast cancer who needed chemotherapy prior to a mastectomy. The cost of her pre-op care under the hand of a University of Iceland oncologist drained the op tar budget for the entire system for a quarter, and I had to withhold funds for pediatrics and family practice. In addition to making those physicians and patients angry, I was accused of playing favorites to my own patient. That was exactly true. The way I saw it my first responsibility was to my own patient—that is what my patients believed. Lawyers would call this an issue of AGENCY—who do you serve and who and what is your primary responsibility?

Looking back on the Covid-19 pandemic I believe we are seeing this conflict play out many times over. Public Health specialists are absolutely doing their jobs when they recommend a mitigation strategy that is communal in nature. They don’t care for individual patients. Isolating well individuals with the idea that at least some of them are today infectious—5-10% at most, and not prioritizing individual at risk patients in traditional type 3 mitigation strategies is an example of prioritizing the welfare of the group. In the 15,000 years of modern man and our dealing with airborne respiratory viruses, isolating everybody from each other, has never worked. Isolating an entire population except in the initial phases of a pandemic doesn’t work—think the Spanish Flu epidemic after WWI. As Drs. Jay Batchachara, Scott Atlas from Stanford, Marty Mackaray from John’s Hopkins, and Dr. Sunuptra Gupta from Oxford have published, isolating the at-risk group of people is far more important and efficacious than shutting down businesses and isolating everybody.

But here is the rub. Most physicians and nurses are working so hard every day that they don’t have the time or inclination to get involved in politics. And that is exactly what those who head our Federal and State agencies have done. They have politicized the pandemic and information has been disseminated that only serves to propagate a political narrative. The people that have been put in advisory positions aren’t clinicians. Many have dropped out from the practice of clinical medicine and have become ‘administrators” and hold positions with titles like “Director of Clinical or Medical Services” They don’t take care of patients. Why wasn’t an ICU nurse put on the Governor’s Covid advisory panel? The point of view of the administrator has been given more importance than the input of the clinician. In certain academic centers like Eastern Virginia Medical School, The John’s Hopkins, and the Mayo Clinic clinicians like Dr. Paul Marek and Marty Makary have been given a voice in determining not only clinical protocols, but mitigation strategies. The problem of agency becomes even more problematic when a physician is employed by a hospital. If he/she (I still use traditional pronouns thank you) disagrees with either clinical or mitigation policy promulgated by administrators who aren’t taking care of patients, they risk losing their jobs or being reported to the State Board of Medicine. A government bureaucrat, a member of The State Board of Medicine, a hospital administrator serves a different master. What is good for the public may not be necessarily good for an individual patient. That may be why government agencies and hospital administrators have placed mitigation and vaccines over treatment and protecting those most at risk and treatment.

I am disappointed that too many physicians have allowed those who don’t take care of individual patients to have the final say on Covid-19 issues. I am disappointed that doctors and nurses and technicians who are in the fight everyday are looked at with disdain and their opinions are dismissed by government bureaucrats and hospital administrators. It has been 50 years since Dr. Fauci has taken care of a patient. Most people sitting on advisory boards don’t have a license to practice medicine or nursing in Idaho. They are lobbyists and administrators. The doctor patient relationship has suffered during this pandemic. The group is now more important than the individual. In the end that will be the final legacy of the “political pandemic

Recently the CEO of St. Luke’s Chris Roth in an interview with Audrey Dutton in The Capital Sun has stated:

“Sadly, we’ve had individuals who have been used by other groups, or other causes, like the ‘health freedom’ group. We’ve had some of our own people who have been put in front of the camera, and frankly, they’re just getting used for somebody else’s cause”

Is that respect for the people who have been on the front lines for 18 months taking care of Covid patients? I believe it is condescension and disdain. It is dismissive and arrogant. The people who have mismanaged their trust and duty to care for the people of Idaho are now blaming the very people who have placed their own safety at risk.

I respect the job that Dr. Hahn has been asked to do. Same with Dr. Souza, but instead of creating awareness they have created fear. Assessing risk from a position of fear instead of from a position of thoughtfulness and a dispassionate questioning of data leads to bad results. They have been called on to “advise” not to create policy. Only individuals and families have the information available to them about their unique circumstances, that allows for the proper assessment of their own individual risk. Creation of mitigation strategy, the management of scarce resources and the assessment of risk falls first to “We the People”.

I have even more respect for Dr. Ryan Cole who at great personal risk offered a different opinion from today’s political narrative. Of all the “experts” Dr. Cole offers the most impressive academic and scientific credentials. An Air Force Academy graduate and Mayo Clinic residency in Clinical Pathology, and a Special Certification in Virology present “bona fides” to his patients and the people of Idaho more impressive than anyone on any Health Board, The Governor’s Advisory Panel or The State Board of Medicine.

Science is about process and is never settled. The media, the politicians, and the “experts” seem to have forgotten that great truth. Who do they serve? Certainly not patients.

One reply on “Who Do They Serve?”

You are correct Dr. Livingston, professionals who are involved at the closest level of the problem should be making recommendations. But as the world spins out of control we are being taken down the road of technocracy, a society managed by technocrats and supposed experts which is rapidly evolving into a technological world of big data, analysis, and decisions by algorithms.

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