MCN | Medical Consultants Network

The Power of a Second Look

Should Sperm Donors Have to Pay Child Support?

When should the biological father be held financially accountable for a child born from his sperm?

A recent Kansas case demonstrates the collision of the imposition of a medical standard on a decidedly non-medical act.

A number of issues arise in reproduction — individual rights to control their own bodies and reproduce as they see fit, society’s right to ensure financial accountability for children when the custodial parent can’t or won’t provide adequately, the child’s right to adequate care, and the mother’s right to seek child support from the “father” of her child.

There is nothing high tech about sperm donation, but we do face many complex scenarios in cases of assisted reproduction via In Vitro Fertilization using donor eggs and other variations on the old fashioned way of getting pregnant.

Sometimes the situation flows from a simple belief on the part of man and woman who procreate with no intention of having an ongoing relationship who make a verbal agreement that the father will not be responsible for the resulting child, believing the agreement will hold.

I am not aware of a situation where the mother gives up the child to the father with a similar understanding of lack of subsequent responsibility, but could see it happening. People can and do change their minds, especially when the economic burden of raising a child is no longer an abstraction.

Legal adoption appears to be the only situation where one can reasonably and consistently assume that one’s responsibility as father or mother for their child given up, is safe, across all jurisdictions.

In other situations, as the case above, it appears to be “donor beware.” Mothers and the state routinely may seek child support from a father regardless of any prior understanding and, apparently, even with a written contract.

To the degree that the interests of the child, who is not a party to such contracts, bear weight, this may be understandable, if not wise.

Any man asked to help a woman get pregnant who does not want to be psychologically or economically responsible for his offspring would do well to either say no, or seek legal advice in his state.

The father in this case may pay dearly for his ignorance, despite his good intentions.

Nurses Fired for Refusing Flu Vaccine

An Indiana hospital fired eight nurses last month after they refused to meet the deadline for receiving a mandatory flu vaccination themselves.

The ABC News article, “Nurses Fired for Refusing Flu Shot,” speaks for itself.

MCNTalk would like to hear from you, our readers, what you think about this topic and this particular case. Vaccination refusal is a hot button issue that pits individual beliefs against the public interest.

— Note that we are not stating that the beliefs are accurate or the public interest well-founded (though be assured we do have our own view on both).

Thank you, Doris McCroskey!

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Doris McCroskey has spent 24 years with MCN. We thank her for her hard work and wish her the best in Texas!

At MCNTalk our focus tends to be on the world of medicine, from the very specific field of independent medical assessments to broader discussions of the practice of medicine.

Occasionally, we post on contemporary issues which affect both, such as health care insurance policy, the opioid epidemic, obesity, and our more recent post on War Tourism.

Sometimes, however, we like take the time to make note of events more personal to us. To that end, we bid a fond farewell — as an MCN employee —to Doris McCroskey.

She has spent 24 years with MCN, most recently as our Spokane office manager. She leaves us for a new chapter of her life in Texas. We have many warm memories of her two plus decades with us and wish her the best.

We also congratulate and welcome to the manager’s chair in Spokane, Dana Townsend. Dana has been with MCN 17 years, serving as a Customer Service Representative.

Inexcusable Sloppiness of Thinking: Blaming Mental Illness or Autism for the Recent Tragedy

By Brian L. Grant MD

The pain of recent events bring out the best and the worst in people’s responses. It also brings out ignorance, and in the case of some advocates for avoiding looking at the downside of our gun policies, malevolent efforts to shift blame and distract us from core causes and solutions.

These recent New York Times articles lend perspective the data to the debate on the relationship between violence and mental illness in one. The other addresses autism and Asperger Syndrome. It is clear in the latter that if anything, such individuals suffer from too much empathy and caring, not sociopathic disregard. It should also be noted that the diagnosis of autism is fraught with imprecision and some controversy as to whether one being a bit strange or awkward in the case of the milder variants, warrants a diagnosis at all. 

The closing paragraph in the first article referenced above, the debate on violence, states:

“All the focus on the small number of people with mental illness who are violent serves to make us feel safer by displacing and limiting the threat of violence to a small, well-defined group. But the sad and frightening truth is that the vast majority of homicides are carried out by outwardly normal people in the grip of all too ordinary human aggression to whom we provide nearly unfettered access to deadly force.”

 We can’t predict human nature, or predict and prevent the dark side of individuals emerging in unpredictable ways. We can and should do what we can to make those who act out due to callous disregard for the lives of others—as well as those who would turn on themselves—less lethal.

Connecticut Shooting Differs in Newsworthiness and Degree, Not Substance

By Brian L. Grant MD

Many of us were in a sad mood on December 14, the day of the Connecticut shootings. But further reflection lead me to the unfortunate conclusion that beyond the fact that the carnage in one spot was mainly children and the number in this single incident was high, this was a typical day in America.

According to the Center for Disease Control and Prevention (CDC), we had 31,347 (10.2 per 100,000) deaths by firearm in the U.S. in 2009. That is an average of 86 per day. Of these about 64% are actually suicide, and a small number are accidental.

In the same year, motor vehicle accidents took the lives of 34,485 (11.2 per 100,000 or about 94 per day). Only a few more than were killed with guns. Cars serve a vital purpose and there is unfortunately collateral damage when they collide. Guns are for killing.

Related statistics from Wikipedia describe firearm deaths across many countries in the world.

Our rate per population of gun deaths in the U.S. is roughly 40 times that of the UK and twice that of Canada. Both countries, along with much of Europe, have significant limits on guns. We can’t identify who might engage in slaughter ahead of time without locking up all of us. What we can do is make those predisposed to harm others less lethal by making it a lot tougher to get a gun and limit the types of guns available. This might include limiting access to military and police only on guns capable of shooting many shots rapidly.

As a non-expert on the technical aspects of firearms, I would defer details to those better informed regarding guns and ammunition that ought not be in civilian hands. No hunter or person protecting their home will be meaningfully limited in their purpose by such restrictions. But it might change our landscape regarding gun violence.

We have attempted in this blog to address irrational behavior in a number of areas including the obesity epidemic and our dysfunctional health care system. The recent tragedy may have the positive outcome of shocking society and political leaders into a careful review of the status quo, based upon data and not rhetoric, and hopefully without “shooting” the messengers, as is the habit by those who don’t like what they see or hear.

In the aftermath of the shooting, outspoken gun opponents such as Mayor Bloomberg of New York are being attacked for their opinions, at least as much as their opinions are being challenged.

The political force represented by gun proponents, embodied by the National Rifle Association (NRA), is formidable. Politicians are scared of being on their bad side. Perhaps now more than a few of us, including politicians, will finally say enough and make rational decisions based upon careful analysis. This should include reviewing laws and gun cultures of other countries where freedom seems to coexist with safety and more restrictive gun laws. How many might have the courage to publicly take on the extreme positions of the NRA? Could their political dominance come to an end? Can caring and decent gun owners take it upon themselves to move beyond rhetoric to consider that change may be in order?

It is truly hoped that responsible gun owners will separate themselves from the extremists who see limits on guns at virtually any level as impingement on their freedom and our nation’s values.

One person’s freedom is another person’s burden, or even death, when an innocent is shot with a gun that should not have been available. Competing interests deserve to be heard. We should not be proud of our national record of gun deaths.

For every person who defends themself with firearms reasonably, how many have abused their power and taken a life that could have been preserved? How many murders are the result of open and basically unrestricted commerce in guns? How many suicides would have not taken place if limits were in place? How many people would be served in a positive way by a change, including lives saved?

Indeed, how many actual additional deaths of innocent victims of criminals with guns, as claimed by proponents, would take place? Do international comparisons have relevance, or are we Americans so special and unique that we have nothing to learn from countries like Australia, France, Canada, and Chile, among others? Should we instead emulate Brazil and El Salvador? Even the Mexican drug cartels get their weapons to commit mayhem from north of the border.

We require cars to have all sorts of safety features that have reduced mortality. We license drivers and cars. We have police watching our driving and enforcing driving laws daily. What reasonable limits on access and types of guns and ammunition would balance safety with ownership?

Our constitution has been amended many times including establishing the right to bear arms, allow women to vote, and  abolish slavery. What would our founding fathers say about modern weaponry including semi-automatic rifles and their place in the hands of ordinary citizens? Can the constitution stand as it is with respect to guns while allowing meaningful laws to be imposed? The constitution is silent on types of weapons and the government should be allowed to regulate as they already do, and are hired by us to do.

Let me briefly put to rest the concept that we can prevent many firearm deaths by better mental health assessment. The majority of mentally ill are not violent and unless one chooses to define violence as mental illness, the majority of those who shoot others are not mentally ill. The proximate cause of gun deaths are bullets and guns, not mental illness. Other countries with their share of troubled people and criminals have fewer deaths because violence is enacted in less lethal ways, such as with knives or fists.

We had a sad day. Let us hope that we will honor the memory of all victims of violence in the U.S. with meaningful change consistent with both our respect for liberty and for human life.

MCNTalk Readers Paying It Forward

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After another successful year, MCN is delighted  to announce five non-profits that will benefit from year-end donations!

Thanks to the growing loyalty of our readers,  we sponsored a contest wherein MCNTalk subscribers could select a non-profit organization of their choice to receive a $200 donation in their honor.  We’ve listed the organizations below and provided a bit of information about each

At MCNTalk we frequently write about the issues we face in today’s world: the rising cost of medical care, the number of uninsured Americans, and medical challenges faced by everyone. When viewed as a whole, the magnitude of the situation is daunting, perhaps overwhelming, so it is good to have the opportunity to provide some support.

As an organization, MCN and our employees are privileged to provide financial support to umbrella social services organizations such as United Way and to the thriving arts community in Seattle as well.

1. Shane’s Heart: The Shane McCusker Foundation for Pediatric Cardiology

The specific purpose of The Shane McCusker Foundation for Pediatric Cardiology includes educating the public about congenital heart conditions and providing funding in the field of pediatric cardiology at UCLA’s Medical Center Mattel Children’s Hospital for the goal of servicing and saving children born with heart defects.

2. Hogan Cedars Elementary PTSO

The mission of the Hogan Cedars Elementary School Parent, Teacher, and Student Organization is to promote the continued welfare of our children and the improvement of our school.  They feel this goal can be most readily achieved by expanding the channels of the communication between parents, students, and the faculty through the establishment and the organization of on-going projects.

3. 826 Seattle

A non-profit writing and tutoring center dedicated to helping youth, ages 6 to 18, improve their creative and expository writing skills and to helping teachers inspire students to write.

4. THON

Is a student-run charity at Penn State University provideing support to families of children with pediatric cancer and for cancer research.

5. Harrisburg Humane Society

The mission of the Humane Society of Harrisburg Area, Inc. is to build a better community for pets and people through compassion, protection, education, and collaboration.

Thank you to everyone who participated in the recent contest by subscribing to MCNtalk, and thank you to the contest winners for their choices. We hope you have safe and happy holidays!

For Holiday Cheer, We Made MCN Beer!

By Erik Madrid

As the popularity of craft beer amongst drinkers everywhere continues to rise, so does the popularity of an age-old hobby: homebrewing beer.

In a report earlier this year, the American Homebrewers Association estimated there are approximately 1 million Americans currently brewing beer at home.

Homebrewing beer has many benefits:

  • It is a fun and affordable hobby
  • It allows beer enthusiasts to learn much more about beer
  • One can be much more creative in making the beer they want to drink
  • It’s a good way to make sure there’s always a supply of fresh quality beer on hand

At the MCN Corporate Office in Seattle, three of the company’s employees collaborated on homebrew recipes this past year – Erik Madrid (Physician Recruiting Manager), Erik Halse (Peer Review Product Manager), and Aaron Schultz (Accounts Receivable Coordinator).

Team Rainwater Brewing (as they’ve dubbed themselves) collaborated on two batches of homemade beer served at the company holiday party. On tap at the corporate office were seasonal Gingerbread Ale and an IPA (India Pale Ale).

The basic ingredients used in Gingerbread Ale and IPA.

Both the crafting of a recipe and the process of brewing beer can be as simple or as complicated as the brewer decides to make it. The four core ingredients making up any beer recipe are: water, malted grains, hops, and yeast. Simple enough, right? Not so much.

There are hundreds of unique types of grains and hops and several different strands of yeast to choose from. Mixed and matched in different quantities, and brewed using a wide variety of methods is what allows for such a diverse mix of beer styles; and is why within any one style, two beers can have incredibly different flavor profiles.

Factor in optional ingredients like fruit or spices and the possibilities are truly endless. Some extreme brewers craft delicious recipes using outlandish ingredients like jalapenos, bacon, and oysters (yes, oysters!).

The basic steps of homebrewing beer: 

Erik Halse (left), and Aaron Schultz, (right) check the H2O Temperature for the Mash.

The Mash: The grains are mixed with hot water (typically between 148-155 degrees) and allowed to soak/steep for one hour. This process is called the mash, and is done in a mash tun. During the mash, the grains are broken down and the fermentable sugars are extracted from the grain.

Homebrewers often use converted water coolers with false bottoms to easily maintain the temperature for the duration of the mash and then strain the liquid off.  After the initial mash is drained, additional hot water is added to the mash tun to rinse off any residual sugars – a process called sparging. The mix of malted grains make up the backbone of the beers flavor profile and contribute the color to the beer.

The Boil: All of the sugary liquid (referred to as wort: unfermented beer) from the mash and the sparge are collected in a kettle and brought to a boil. The wort is boiled for at least 1 hour, which allows for any of the naturally occurring micro-organisms and bacteria living in your water or the grains to be boiled off.

Erik Madrid, a homebrewer for a year and a half, has already brewed over 25 batched of beer.

The other big part of the boil stage is the addition of your hops, spices, or other adjunct ingredients (honey, fruit, etc) and getting all those flavors to come together just like a good soup.

The frothy wort of the Gingerbread Ale.

Hops contribute 3 key elements to beer: bitterness, aroma, and their natural preserving qualities. Hops added at the beginning of the boil contribute more towards bitterness and flavor; while hops added to the end of the boil contribute mostly towards aroma.  You can take 1 variety of hop and get a totally different flavor and/or aroma in your beer depending on exactly when and how much you add during the 60 minute boiling period.

 

 

Pitching the yeast: Yeast is a living organism whose role in making beer is to eat all the fermentable sugars, poop out alcohol, and fart out CO2. The 210 degree temperature of boiling wort would kill the yeast. Most strands of yeast used to make ales prefer temperatures closer to room temperature. Once the boil is finished the temperature of the wort is quickly brought down to a range ideal for the yeast being used. anitization of all equipment becomes crucial at this point and for every stage from here on out. The chilled wort is transferred from the boil kettle into the fermentation vessel, at which point the yeast is added (pitched).

Fermentation: A restaurant grade bucket or a glass carboy are the most popular fermentation vessels used by homebrewers. Once filled the fermentation vessel is sealed off with a plug and an airlock that allows some C02 to escape while the yeast is actively eating through all the fermentable sugars, but prevents any bacteria from entering the fermenter. For most standard alcohol content ales, your typical fermentation takes about 2 weeks.

While optional, most brewers prefer to transfer their beer from the first vessel to a secondary fermenter. In doing so, spent yeast that settles to the bottom of the fermenter is left behind, preventing the dead yeast cells from imparting any unwanted flavors in the beer.

Gingerbread Ale bottled for secondary fermentation.

Getting the beer off his sediment also improves the clarity in appearance. These stages are referred to as primary fermentation and secondary fermentation.

Bottling or Kegging: Once fermentation is complete, the beer is siphoned into either individual bottles or a keg to be carbonated and then served. Carbonation will occur naturally in bottles, as there is still a small amount of yeast eating the last of the sugar content in the beer, but now the C02 created is no longer allowed to escape.

Using the bottling method takes between 2 and 4 weeks for the beer to properly carbonate and prime. Alternatively, the beer can be transferred into a keg and hooked up to a C02 tank for force carbonation. A high amount of C02 pressure is infused into the keg for a couple days until the desired carbonation level is reached.

MCN Holiday Beer Ready to be served!

Drinking: If you can’t figure this part out for yourself, we’re in trouble! Now, if you’ve gotten this far and haven’t become thirsty enough to grab a beer, then you must be at work.

Seriously though, give any beer you’re drinking the justice it deserves and pour it into a glass before consumption. The aroma and the color are part of the experience, and you just can’t get that from the bottle.

If you’re drinking a homebrew, remember to leave the last little bit behind in the bottle – the residual sugars and yeast that have settled after carbonation is complete are not the last thing you want to remember about the beer.

 

For the MCN Holiday Party, Aaron and the Eriks have brewed up a Gingerbread Ale and an IPA. The Gingerbread Ale is a Brown Ale with nutmeg, cinnamon sticks, cloves and candied ginger added throughout the boil to create a flavor and aroma profile very similar to gingerbread. The IPA was brewed with a mixture of a variety of hops to create a nice crisp and bitter flavor profile typically associated with a good Northwest IPA.

Interested in homebrewing? Ask Team Rainwater about equipment, recipes, tips, and more at MCNTalk@mcn.com or comment below.

 

 

Great News for the US: Evidence of Trending Down in Childhood Obesity

While still early, recent studies show evidence that childhood obesity is reversing in some cities.

This is tremendous news for all. The small percentage suggests a reversal of a longstanding trend.

If true, it demonstrates that awareness, education, and intervention helps. The culprits include ignorance, indifference, and the pushing on society of empty calories, especially those in sugary beverages.

Nationally, about 17 percent of children under 20 are obese, or about 12.5 million people, according to the Centers for Disease Control and Prevention, which defines childhood obesity as a body mass index at or above the 95th percentile for children of the same age and sex. That rate, which has tripled since 1980, has leveled off in recent years but has remained at historical highs, and public health experts warn that it could bring long-term health risks. Read More…

Eliminating destructive food options in schools, providing healthier snacks in stores, and reducing intake overall can make a difference.

Just because something is tough does not make it undoable. These statistics mean that some kids are doing a lot better and likely feel great about it, not only physically, but emotionally.

Let’s hope this is not a fluke as we have a long ways to go as a society.

Concierge Medicine: Elite Care or Creative Innovation?

Concierge medicine is a growing trend among primary care. For a basic fee that can be a modest several hundred dollars annually, or a hefty many thousands, patients can be part of a small practice, with quick access to their physician.

The payoff for the doctor is the ability to provide quality care to fewer patients while maintaining income and avoiding the hassle and expense of dealing with insurance carriers.

The Business Week article, “Is Concierge Medicine the Future of Health Care?” describes the trends, along with critiques and benefits. The article also warns of a growing deficit of providers and concerns about a two-class system that may be emerging; one for those who can pay extra and another for those who can’t or won’t.

As a recent MCNTalk posting described, this is one more area where outside investors appear interested and are investing, which I see as a red-flag. From a business standpoint, I can’t quite figure out why significant capital is required to design a concierge practice and thus, the interest of outside investors.

There would appear to be no barrier to entry for a physician wanting to start a concierge practice, just a decision to hang up one’s shingle and do a bit of marketing. Yet some groups, like Qliance have attracted millions of dollars of investments. How will these investors generate their payback on limited size practices with high costs to run?

Setting aside the financial structure, concierge practices offer value to practitioners frustrated with high patient loads, high hassle factor and declining professional satisfaction.

Patients like it because they get to engage meaningfully with a physician who is able to commit time and attention to their medical concerns and is quickly accessible. The trend can’t be ignored nor should it be. It is a creative approach to a problem and invites further study.

War Tourism

By Brian L. Grant, M.D.

I write this during a quick trip to the sun of Hawaii, island of Oahu.

We took a drive up scenic Tantalus Drive, to catch an aerial view of Honolulu. At the turnout there was another car. Two young men and a woman. One of the men was in a wheelchair. He had no legs and wore a prosthesis for his left arm – a triple amputee.

We three exchanged pleasantries and I commented on his T-shirt that said “Team X-T.R.E.M.E”. He told me it has to do with veterans doing some extraordinary physical activities. I asked him how he was injured and he said Afghanistan in August 2010. His name is Todd Love. Todd is 22.

Our visit was brief and I did my research upon returning to the hotel. There were no shortages of articles about Todd. I contained myself until getting back in the car. This was an unplanned visit that served to accent our next planned stop.

Minutes later, we turned into the Punchbowl Cemetery, known as Arlington of the Pacific. This beautiful cemetery houses remains of approximately 53,000 veterans from World War I through Vietnam Era veterans, along with stunning memorials with graphic histories of these conflicts. Beautifully landscaped, it is a special, solemn and sacred place.

The next day we took in the most popular tourist spot in Hawaii, the USS Arizona Memorial at Pearl Harbor.

A well-organized place, one gets tickets for a time slot to see an instructive film about the Pearl Harbor Attack of December 7, 1941 before boarding a small boat that takes you to the memorial building constructed in the water, above the sunken ship where 1,102 of the  1,177 sailors and marines killed on that vessel lie. All told, the 353 Japanese planes sunk four battle ships and damaged an additional four. 188 U.S. aircraft were destroyed as well as several other vessels. 2,402 Americans were killed and 1,282 wounded. The attack lasted slightly less than two hours.

I make a point of visiting war memorials and related sites during travels. Around 1984, I visited the Piskariovskoye Memorial Cemetery in Leningrad (now Saint Petersburg), Russia. This cemetery contains the remains of about a half a million victims of the 900 day Siege of Leningrad during World War II. Most of these were civilians. It was a somber visit with the laying of a wreath by our group. Marshall music played over speakers. The Russians knew war first hand on their soil and paid dearly in the past century at a level we Americans have fortunately been spared.

In 1994 during a trip to France, we visited the Normandy Beaches and the adjacent cemetery containing the remains of almost 10,000 Americans who died in and around the D-Day landings. You may recall the site from the film “Saving Private Ryan”.

As far as one could see were fields of crosses and the occasional Star of David. A short walk brings one to the cliffs overlooking the landing beaches, with remains of German bunkers intact high above the water.

Seeing the geography of the site first hand, I could imagine the terror of those soldiers as they came ashore, under fire from above. To the Germans, it was like shooting ducks in a barrel. Our soldiers knew that living or dying was a matter of a perverse lottery  of where the bullets and their bodies happened to be at any given moment. I understood sacrifice and heroism in new terms.

Our French hosts from Normandy treated us young Americans, born after the war, with thanks and respect for what our parent’s and grandparent’s generations did to liberate their country. How strange. I could not accept the credit but enjoy their friendship and hospitality to this day.

Prior to this visit, my exposure to war was from the tortured Vietnam era, during which I came of age as a teenager. It was a time of ambivalence to not only the war, but the men and women who served there. Thankfully, we have embraced the service of our soldiers, while that war remains a matter of ongoing debate, as have those that followed, including the Afghanistan conflict that claimed the limbs of Todd Love.

 

Since then I have visited the breathtaking memorials to Viet Nam, Korean War and World War II several times in Washington, D.C. I recall my first encounter with the Korean War Memorial one night during a jog along the Capitol Mall. I encountered the lifesize statues of soldiers in the dark, but with a spotlight on their faces, alert and on patrol. It was breathtaking, aligning the power of war with that of the artist.

I have visited several holocaust museums and the concentration camp at Theresienstadt in the Czech Republic.

I have driven along roads in beautiful Croatia, where from 1992-1995, citizens were being subject to genocide. And where today there are still signs warning of remaining mines in adjacent fields.

There are unfortunately no shortages of war memorials and battle sites that, could if one chose, become the primary travel destination rather than an interlude during restful vacations or business visits.

I imagine that to the degree that I travel, where war or memory of war is, I will visit. The reasons are complex. These sites, especially memorials, are generally places of somber beauty and often great artistry.

One shares the experience with fellow citizens and tourists from around the world in the U.S., or as a tourist abroad sharing it with the locals whose own people suffered or bore witness. I think about the sacrifices of war and how I would have fared if given the obligation or opportunity to serve. In most cases ordinary men were forced by circumstance and history into extraordinary situations. Some fought and some supported the fighters. Some died, some were wounded and some survived. In many cases civilians were slaughtered or starved.

The visits combine historic curiosity with honor and respect. These sites reduce the abstraction of war. Some glorify it with heroic murals and grand quotes, while others put stark numbers and names to the dead.

They cause one to wonder how it is that the wars start, how one side is seen as enemy to the other, while both generally view their cause as the right and just one. I think about the alternative of going to war or doing nothing in the face of evil and death of innocents. I wonder but doubt that such evil will ever end.