West of the Rotunda

Most of us live with chronic pain. For some, it can be crippling.

As a young doctor, I quickly came to realize it was a difficult condition to manage. Whether it was headaches, back pain, fibromyalgia, pelvic pain or joints, the suffering could disrupt people’s lives, lay them low. It could be depressing, isolating, ruining.

When the pharmaceutical industry started claiming to doctors in the 1990’s such pain could be “cured” with their new formulation of timed-release narcotics, I understood the temptation to treat these conditions with such. But our past twenty years of opioid over-prescribing and subsequent sky rocketing accidental overdose deaths should have taught us that easy cures, though tempting, can be fatal. That didn’t satisfy my oath to do no harm.

I did my best to study the research. I attended conferences and listened to experts. But more, I listened to the patients.

I went into medicine thinking my job was to fix what ails the patient, when possible. I remember in residency; our patient interactions would be viewed by a behavioral health specialist who would give us feedback. Toni, the specialist watched me once and commented, “You need to be careful. You want to fix patients.”

I was struck dumb. “That’s my job!” I countered.

“No, it isn’t.” She replied firmly. I pondered that one for a long time.

 It was a hard lesson for me to learn that many ailments aren’t fixed, but managed. When a cure isn’t available, the focus has to move to maximizing function. That adjustment can be hard to accept. It often was for me.

But I worked at learning. I thought that was my job, as a primary care physician, to care for the patient. So, I am troubled now when I see so many patients with chronic pain sent away from their primary care providers to pain specialists. I think some of this is a reaction by my colleagues to our years of excessive prescribing. Doctors got on the opioid bandwagon too easily. So now some won’t even take a short ride. I see signs up at the receptionist: “We do not treat chronic pain”. This too, is I believe, a mistake. Patients need our care.

Don’t get me wrong, pain management specialists are valuable. I have made such referrals. They have much greater depth of experience than I do in their fields. But most primary care providers can manage most chronic pain patients.

In rural Idaho, chronic pain is common and specialists are far apart. We need to help our primary care providers serve their communities. And we are.

I get a quarterly report from the Board of Pharmacy on my patterns of prescribing controlled substances. It lists the number of prescriptions, the daily dose and comparisons to my colleagues. This is helpful.

If I have concerns that a patient might be “doctor shopping” for controlled substances I can access a data base that lists all prescriptions, sorted by prescriber and patient. It even links to most surrounding states. This is a great resource.

But one of the best tools has been developed by the Idaho WWAMI program, the medical school affiliated with the University of Washington School of Medicine. It is Project ECHO. Twice a month any provider can log in to an hour-long conference with specialists. Colleagues from around the state will be on the screen. After a short presentation there is time for questions, case presentations and discussion. Management of these challenging conditions is supported.

Currently, the Idaho legislature is considering whether it should support this program with taxpayer dollars. It would be a worthwhile investment. I wish it had been available when I was starting out.

Separation of powers is a fundamental principle in both our state and federal Constitutions. The framers figured that by splitting up the powers that govern us, we, the governed would be less oppressed by our government (read Federalist 51). But what happens when one branch relinquishes its power or another infringes? Does the loss of separation from this disrupted balance lead to increased oppression of the governed?  We have two examples to consider.

Impeachment is the biggest test of this separation. Our federal Constitution gave Congress the power to remove the President. I’m sure you have heard about our recent civics lesson. The verdict has been given, though it was probably a foregone conclusion. Many trials are. But the failure of the US Senate to hear witnesses, review documents or even stay awake to “impartially” consider the charges doesn’t bode well for the power they are supposed to hold. The majority declared themselves submissive to the executive they were judging.

In fact, the previous administration exulted in and abused Congress’ impotence. When one branch abdicates, the other usurps. Executive orders have become fiat. Budgets are managed by “continuing resolution” from one threatened shutdown to the next. Our debt to GDP ratio is higher than any time except right after World War Two. Only when Congress, the House and the Senate, Republican, Democrat and Independent resolve to put aside differences and govern, can they reassert their separate constitutional power. Meanwhile, the executive sucks up the foregone power.

I believe the wisdom of the electorate desires separation and balance. The first midterm election after a new president is elected has almost always seen Congress swing the other way. Obama lost 63 House seats in the Tea Party wave of 2010; Trump lost 37 at his first midterm. Could this be the electorate pleading with Congress to assert its power?

Here in Idaho, it’s the opposite imbalance. The legislature is leaning on the executive branch. Take the recent Administrative rule dust-up example.

When the Idaho legislature passes a law, the executive branch that enacts that law writes administrative rules to fill in the details. For instance, Idaho code 33-1612 (Courses of Instruction) list in outline the general principles for classroom instruction, then delegates:

The state board shall adopt rules… to establish a thorough system of public schools with uniformity as required by the constitution.

The Idaho legislature reviews and approves or rejects all new administrative rules. They even got this power into the Idaho Constitution. But then, last session, the House and the Senate could not agree on the process for review and ended up not renewing ALL the administrative rules. Governor Little made lemonade out this and put a lot of government employees to work reviewing all 8000 pages of rules. He successfully reduced some, but, by law ALL these new rules needed to be reviewed by the legislature.

Legislative review of executive branch rules can blur the separation of powers that keeps government weak, like it should be.

Last week, the House Education Committee voted to reject the rules for teacher certification standards. They also voted to reject all K12 classroom standards for Math, English and Science.

There can be great temptation to re-legislate when the rules come before you. Imagine being in the position of opposing legislation that gets passed. Or, more often, opposing funding for the department. Now imagine those rules come before you and your job as a legislator is to make sure they conform to the intent of the statute that you opposed. You might be tempted to throw a wrench in the works. The House Ed Committee is acting like a mechanic on meth.

The Idaho legislature has slowly over the years usurped power from the executive branch through rules review.  It’s gotten to the point of micromanagement, wasting our taxpayer dollars. If the Idaho legislature really has so little productive to do, I propose they take January off and shovel snow.

Governor Little has a sense of justice. And he’s acting on it. He’s fighting poverty in Idaho, though he doesn’t freely use the term.

This week we remember Martin Luther King. He fought against racial injustice but more, he knew poverty was a millstone around the neck, preventing young children from developing the content of character by which he famously called for us to judge them. But many rise up out of poverty and grow their character, and indeed, grow their wealth. Justice guards that path from poverty.

In Idaho, as well as nationally poverty is defined based on monthly income; this gives us the measure “Federal Poverty Level”. Many dispute these terms, but if you are going to measure something, you need to be consistent. I’ll use it.

If you look at that national designation, Idaho is actually pretty low, with only 11% below 100% FPL, ranking us near the bottom. Nationally, nearly 14% live below 100% FPL. But if you look a little higher, folks making less than 200% of the FPL, we jump up to the top third, with 34% earning less than $2082/month. Nationally, only about 30% earn less than 200% of FPL.

So, Idaho has poverty, but more, we have many folks working hard and not making a lot. We are a low wage state. That pathway out of poverty, guarded by justice is paved with education. Idaho folks would benefit greatly from the opportunity of education, a free, common, uniform education, as our Idaho Constitution guarantees. Our founders knew it; Brad knows it.

And Governor Little knows, for primary education to be valuable and effective, the ability for students to read at grade level when they reach third grade is a key indicator. Most of those that can’t struggle going on in the grades; many of those that can will thrive. He has committed investment toward early reading capabilities. It is a worthwhile investment. And, as always, there is more to do.

The other move Governor Little has made for justice in Idaho has to do with the recently released criminal offenders. Idaho has one of the highest incarceration rates in the country. Over a third of those in the system are there for crimes involving drugs or alcohol. Furthermore, Idaho has the highest recidivism rate (people released, then returned to prison). So, we incarcerate many with fixed sentences for drug violations, and when they are released, they often go back to jail or prison for parole violations.

Reintegrating offenders takes an investment. The recently passed Medicaid Expansion law will help felons in need of medical care, since, odds are they will be working a pretty low wage job that might not offer health insurance benefits. Brad knows this value and knows the investment is worth it.

But Governor Little knows the path for released offenders from the structured chaos of the prison environment to the goal of productive community members would benefit from sign posts; limited structure. He has put funding to operate a community reintegration center in Twin Falls. Low risk offenders will live there in a supervised setting, continuing programs and working in the community before being released.

Work gives more than a paycheck. It’s a place to build relationships, confidence, skills and value. And people need more than money to climb out of poverty.

I appreciate our governor’s commitment to justice. All people deserve our respect and all, under our Constitution have the right of justice. But making positive steps forward take time. And there is more to do.

To quote Martin Luther King:

 If you can’t fly then run, if you can’t run then walk, if you can’t walk then crawl, but whatever you do you have to keep moving forward.

I owe an apology to Bryan Taylor, Prosecutor for Canyon County. I hope this is good enough for him.

Last week I wrote about Canyon County’s Followers of Christ Church and their strong belief in faith healing over medical treatments and how this has led to many documented preventable deaths of children. I referenced a conversation we had, when I asked him if he thought the law should be changed. He pretty much said, “That’s your job.” Meaning, as a legislator who works to write, repeal or revise the laws, that’s what I should have been working on. And he was right.

What I did not reference, but, thanks to the Canyon County Information Officer for supplying it, was a lengthy and detailed, even directive email to me.

Prosecutor Taylor clearly stated: “As a prosecutor, I feel as though it is my responsibility to protect our children.” Then he went on to outline the steps I should follow to change the law that would make “the cleanest” change.

I had discussions in the statehouse but drafted nothing. Today, I apologize for my inaction. But more I apologize for last week mischaracterizing Mr. Taylor’s position.

In 2017 the Idaho Senate took a run at the law. A bill got to the floor of the Senate where it was killed 11-24. Three out of five Senators with some of Canyon County in their legislative districts voted yes. Not a single Senate Democrat supported it. There were complaints it didn’t go far enough.

It’s hard to build coalitions around passionate issues.

I was also informed last week by the Canyon County Information Officer that Canyon County has in fact been doing child fatality reviews for some ten years or so. I have asked for details about how often, who attended, what were the findings, but those details are pending. But digging through press reports suggests it sounds like there could have been some conflict about how child death investigations were handled in Canyon County.

A LA Times article from 2017 described how the Canyon County Sherriff had formed his own unit to investigate childhood deaths. He had concerns that the then-coroner was not doing an adequate investigation. In 2018 Canyon County elected a new coroner.

It would be my hope that persistent investigation of childhood deaths in Canyon County could help bring clarity to this issue. Further, persistent scrutiny maintains focus.  If clarity for a resolution to this issue, as expressed to me by Canyon County Prosecutor Bryan Taylor is found, I would hope such resolve could be communicated to our state legislature. And then some clear action to change the laws must be taken by the Idaho legislature. It’s long past time.

The “cleanest” solution proposed by Mr. Taylor was simple repeal of Idaho Law 18-1501(4):  The practice of a parent or guardian who chooses for his child treatment by prayer or spiritual means alone shall not for that reason alone be construed to have violated the duty of care to such child.

This is in the criminal statutes that define “injury to children” and carries a punishment of jail or prison. Removing this section which protects parents from prosecution would not prohibit the free exercise of faith healing, prayer, or religious practices, all protected by our Constitution. But it would turn up the pressure on parents to consider the children’s well-being.

Maybe Mr. Taylor said it best in that poorly-remembered, unacted-upon email he sent me when I was a State Senator almost five years ago now:

By changing the statute, it does not force an individual who believes in faith-healing to change their beliefs and I don’t think we should ask for that. The First Amendment protects ones right to have whatever religious beliefs they choose, but that right does not include the right to abuse or neglect a child.

Well said Mr. Taylor. I hope you will accept my apology. I wish I had done more.

For the past eight years, advocates have come to the Idaho legislature requesting repeal of Idaho’s “Religious Shield Laws”. Advocates say children are dying because parents refuse life-saving treatment for their children. Religious Shield laws protect parents from prosecution in these instances. And so far, the legislature has done nothing.

Well, not quite nothing, legislative defenders would counter. They had an interim committee meeting. Okay, one meeting, then nothing.

Governor Otter, to his credit did something. He started a Child Mortality Review Team by executive order in 2013. Their reports are available on line. The reports show that 2-5 children in Idaho die annually from treatable diseases where parents refused to seek treatment for religious reasons.

The report doesn’t locate these deaths, but the religious community famous for this is the Followers of Christ Church in Canyon County in southwest Idaho. One Child Mortality Report estimated the death rate for children in the Followers of Christ community to be ten times the rate for the rest of Idaho.

When I was contacted as a new (but not young) Idaho State Senator by advocates for removing the religious shield laws, I wondered what the local authorities thought. I knew they had some recourse. I don’t like solving local problems in the legislature.

I spoke with the then-coroner of Canyon County. My main question, an allegation made by former church members wanting the shield laws removed, was: are all these child deaths being reported and adequately investigated by the county coroner? The allegation was that some dead children had been buried without a birth certificate, without notifying the coroner of a death. Both of these acts are illegal, and not protected by religious shield laws. But the then-coroner assured me she had a “good relationship” with the church community and she had recorded and investigated all the deaths.

To check this out, I got pictures of all the headstones of children in the Peaceful Valley cemetery, where Followers of Christ inter their dead. There were over fifty. I asked the Idaho Department of Vital Statistics to correlate the headstones with death certificates. They reported “near” 100% correlation. So, it looked like, unless there are unmarked graves somewhere else, the coroner did indeed record the deaths. I did not review the adequacy of her investigation.

I also asked the Canyon County prosecuting attorney if he was aware of instances of child neglect or abuse that he had not prosecuted because of the religious shield laws. His lawyerly answer was, “You guys in the legislature make the laws, not me. I just prosecute the laws you make.”

I’m not sure changing the law is a necessary step. If Canyon County cared about child deaths in their community they could form their own Child Mortality review team. They already have a Multidisciplinary Task Force for the Prevention of Child Abuse. Every county in Idaho has one by law. These task forces get together on a regular basis and review all referrals to the Department of Health and Welfare Child Protection Services (CPS) about abuse and neglect. Members of the task force include law enforcement, CPS, school officials, and others. I was a member of our county task force as a physician and as the county coroner.

I started a Child Mortality Review in our county in the early 2000’s when I became aware Idaho was not reviewing child deaths in a systematic fashion. This was before Governor Otters Executive order. The prosecutor, law enforcement, CPS would attend. I would present the case and my findings and ask for their input. Did I miss something in the investigation? Is there something more I should be doing?

If Canyon County elected officials, but more, if Canyon County voters demanded such work from their elected officials, maybe some helpful discussions would occur. As it is, it just looks like Canyon County doesn’t care about preventing children dying because of their parents’ religious beliefs.

I think I just took my Family Medicine Board Certification test for the last time. They didn’t kick me out for my lousy scores, its just things are changing.

Most people (patients) aren’t aware of the hoops and hurdles of medical education. Most MD’s have a four-year undergraduate degree (Bachelors), then complete four years of medical school (where they receive their MD degree). But that’s just a piece of paper you hang on the office wall.

To legally practice medicine in any state you need a license, granted by the Board of Medicine in that state. The Board of Medicine in Idaho is given the power by the Idaho legislature (thus, the people) to grant or remove licenses by statute (Title 54, Chapter 18).

Each state sets its own requirements for Medical licensure and each state enforces this professional monopoly, through the laws enacted by the legislature.

Most states require US MD graduates have some practical training after medical school, called “residency” to get their state license.  You’ve watched Greys Anatomy. I hated that show. Idaho requires US medical school graduates have 1 year of residency training, Washington 2, Nevada 3. But no state requires board certification as a standard for licensure.

So, what the heck is “Board Certification”? It’s another hoop. After you’ve done all those college hoops, National Board exam hurdles, residency requirement hours and hurdles, then, the specialty you choose to join has some more for you.

Since I decided to be a family doctor I thought I should be “Board Certified” in family medicine. I paid the fee ($1850) and took the test. It was a relief to pass, but then when I saw 95% passed I didn’t feel so special. The day long test came up every 7 years for me. I was also required to complete annual self-training requirements to maintain the certification.

Who cares about Board Certification? Not patients; most folks who walk through our office can’t tell an MD from a DO from an NP from a PA. Most pay attention to the practitioner’s demeanor. Still, when polled, 70% of the public will answer “yes” to the question “Is Board Certification an important criterion for choosing a doctor?” Seems a pretty leading question to me.

Board Certification has been used by some hospitals and health care networks to determine who can be employed or work in their facilities.

Insurance companies have used Board Certification status to adjust payment schedules.

Does it matter that 90% of practicing MDs in the US have some sort of board certification?

Since so many of my practicing colleagues have jumped through this hoop, paid the fees, submitted education credits and taken the tests, (and passed) you would think they all agree on the value of making it through the hoop. But for the last ten years there has been grumbling. Many physicians object to the silliness of the day-long multiple-choice test, where a full third of the questions have been shown to have no relevance to current practice. But most point to the lack of evidence for value. There has never been any correlation between performance on certification and clinical quality, even when studied by the national boards themselves.

Such grumbling might be a sign of change. I hope so. A profession questioning its own methods is healthy reflection. Maybe some resolve will come out of it.

From now on, the Family Medicine Boards will offer the old fashioned every 7-10-year day-long test or a quarterly open book test. In addition, I will need to show regular self-education and self-improvement activities. I’ll do my best, but honestly, hoops, at my age, with these knees?

Instead of the national certification, I would hope my patients, my colleagues would respectfully let me know when I mess up and offer me guidance when I stray. Such cultures, such comrades would do more to promote excellence than thousands of hours of tests. I’ll do my best to be part of that change.

Santa’s sleigh circled the dome and found a safe spot to perch. Santa stretched his legs, swung his big belly out and planted his boots in the crusty Boise snow. He patted Dunder’s and Bitzen’s flanks and circled back for his bag. The starry night showed no light in the east as he called to the team, “Take a break you all. This finishes off Idaho, then we sweep down the West Coast. You know the drill.” Knowing there was no chimney, he took the stairs.

He slipped a little on the marble floor; the bag on his back shifted and a box toppled out and over the rail. He followed it’s fall and listened for breakage. It dropped to the main floor and thudded. Santa harrumphed, “Must be those socks for Speaker Bedke,” he muttered.

He stopped outside the JFAC analysts’ offices up on the fourth floor. He knew from the book they’d all been nice, none naughty, so they were all getting new sharp pencils. He gave the one in charge of the prison budget a red one, just as his little joke.

Down the winding stairs he first dropped the big box of chocolates for the Senate staff. Then in front of the Majority office he had to place his finger by his nose and ponder. He had a couple lumps of coal to give out, and the Treasurer had suggested the Speaker and Pro Tem in her letter to Santa, but he didn’t think he should pick sides, since they had both suggested the coal (or worse) for her. So, he picked his smallest slightly wrinkled Washington apple, left it there and then strolled over to the Minority side. He left them a bright new dog leash.

His bag was half full as he swung east to the House side and he offloaded the bigger box of chocolates for their staff. On Speaker Bedke’s desk he left a note to look downstairs for his present. On the Minority side he left a small bag of peanuts, honey roasted.

The second floor was easier as the bag got lighter. The Secretary of State got boot polish, the Attorney General a new tie (black and gold). The Lieutenant Governor got a small pink purse.

By the time he got to the west Governors wing on the second floor the lumps of coal were banging together in the bottom of his bag. But his book said the governor’s staff had been very good, so they got free Boise parking passes.

Governor Little had also been good, the book said, so the lumps of coal stayed in the bag. It was against his good judgement but he left a Copenhagen can top with the Idaho seal on it for the chief executive.

Just as he was leaving the Governor’s office he heard footsteps behind him. The security guard called, “Hey!” and Santa swung around. He was holding Bedke’s crumpled package. “You drop this?” he asked.

“Why yes son, I did.” Santa reached out and took it from the young man. “Thank you,” he said and twinkled his eyes.

“You about done ‘cause I gotta lock up this wing?” the young man asked.

“Just a couple of lumps of coal to give out.” Santa sighed.

“Let me, I’m doing my rounds, just tell me where.”

Santa flipped through his book. “Well, I guess it will be for two of the Senators or Representatives down in the basement.” He said still counting all the tally marks. As he took out the coal from his bag he fumbled and they fell to the floor, breaking into many pieces.

“Oh dear.” Santa pouted his rosy lips.

“It’s OK. This way I’ll have enough for everybody.” The young security guard smiled as he collected the shards. “And don’t you worry. If I run out I know how to make more. That’s how we do things around here.”

“Merry Christmas son.” Santa smiled. “And Merry Christmas to you.”