Robert F. Kennedy, Jr. Nominated as HHS Secretary: Choices for Senators and Healthcare Providers

President-elect Donald Trump has nominated several controversial figures for cabinet positions. On November 14, Trump announced Robert F. Kennedy Jr. as his choice for Health and Human Services (HHS) secretary (1). Although several of Trump’s nominees are marginal, I could not have imagined a worse choice than Kennedy. As many cringe at the thought of a number of Trump’s nominees, I join many of my fellow healthcare providers and scientists in their abhorrence at Kennedy’s nomination.

Kennedy has long promoted anti-vaccine misinformation and public-health conspiracy theories (2,3). Since the onset of the COVID-19 pandemic, he has emerged as a leading proponent of COVID-19 vaccine misinformation (4). Many of his false public health claims have targeted prominent figures such as Anthony Fauci, Bill Gates, and Joe Biden. He has written books, including The Real Anthony Fauci (5) and A Letter to Liberals (6), perpetuating his lies. Kennedy has insinuated that HIV (human immunodeficiency virus) isn’t the cause of AIDS, that Wi-Fi induces “leaky brain,” that chemicals in the water are responsible for “sexual dysphoria,” and that Anthony Fauci and Bill Gates led a cartel to prolong the COVID pandemic and “amplify its mortal effects in order to promote their mischievous inoculations” (7).

The events in Samoa in 2018 , as summarized in a recent article in the New Yorker, illustrate what might happen with Kennedy in control of the US Health care system (7). “In 2018, two children in Samoa died after receiving measles vaccines, because the nurses who administered them had mistakenly mixed the vaccine with a powerful muscle relaxant (atracurium). Local vaccine skeptics seized on the tragedy, and the government temporarily suspended its immunization program. Children’s Health Defense, an organization chaired by Kennedy, posted about the events on Facebook, where the group was one of the largest purchasers of anti-vaccine advertisements. Although, following an investigation, the Samoan government reinstated the program., immunization rates nevertheless remained perilously low, with less than one-third of infants getting vaccinated. A few months later, the country experienced a devastating measles outbreak. Nearly six thousand people were infected, and more than seventy children died. Kennedy, who had meanwhile visited the island, sent the Prime Minister a letter raising the “regrettable possibility that these children are casualties” of vaccination, rather than a lack thereof. He later called the outbreak “mild” and branded a Samoan vaccine opponent a “medical freedom hero.” (7). In a country with a population of slightly over 200,000 people, most would consider an outbreak of 6,000 measles cases more than mild.

However, not all of Kennedy’s claims are unreasonable. He has also railed against gross conflicts of interest in health care and against the influence of corporations, especially pharmaceutical companies. These companies use dubious tactics to extend patent protections and keep drug prices unconscionably high. He appears deeply concerned about the staggering rates of chronic disease in this country, and correctly condemns the long-standing failure to meaningfully reform the American food system, which is characterized by a glut of ultra-processed products, owing partly to unhealthful agricultural subsidies. The US heavily subsidizes commodity crops, such as corn and soy, which are frequently used as sweeteners and additives. Politicians in both parties receive enormous sums of money from the food, agriculture, and pharmaceutical industries. Kennedy has promised to free regulatory agencies from “the smothering cloud of corporate capture” (7). This is sure to hit a sour note with corporations that deploy legions of lobbyists to shape regulations. He has supported reproductive rights, arguing that abortion should be legal and that mothers are better equipped to decide when to terminate a pregnancy than politicians and judges, a position that likely will offend the pro-life movement. As pointed out in by Dhruv Khullar these opinions might sufficiently offend some right-wing conservatives and ultimately sink his nomination (7). Despite these more reasonable stances Kennedy is hardly the best candidate available.

Trump’s choice of the unqualified Kennedy to lead the world’s largest healthcare system seems to be little more than political payback for a man who, as recently as April, Trump called a “radical left lunatic” (8). At another time the sheer volume of Kennedy’s bizarre and misleading statements would likely have disqualified him from running the world’s largest healthcare system. US Senators now have a choice: vote to confirm Kennedy, with all its dire public health consequences, or block his nomination and risk the vengeance of the President -elect. Blocking Trump appointments on any ground would require an uncommon level of courage from Congressional lawmakers, who have mostly been unwilling to defy even the most brazen whims of the President-elect.

In the interim, let me lend my small voice to the more than 75 Nobel Prize Laureates opposing Kennedy’s confirmation (9). Healthcare providers may also face a choice. If Kennedy is confirmed, it is likely they will be pressured to act in the best interests of those who seek financial or political gain rather than in the best interests of our patients. For example, healthcare providers could be forbidden to discuss vaccination much like some states have prohibited discussions regarding abortion. We need to remember who we serve and act according to our consciences.

Richard A. Robbins MD* 

Editor, SWJPCCS

References

1. McGraw M, Cirruzzo C. Trump to select Robert F. Kennedy Jr. to lead HHS. Politico. November 14, 2024. Available at: https://www.politico.com/news/2024/11/14/robert-f-kennedy-jr-trump-hhs-secretary-pick-00188617 (accessed 12/16/24.
2. Mnookin S. How Robert F. Kennedy, Jr., Distorted Vaccine Science. Sci Am. January 11, 2017. Available at: https://www.scientificamerican.com/article/how-robert-f-kennedy-jr-distorted-vaccine-science1/ (accessed 12/16/24).
3. Huynh A, Rosenbluth T. 7 Noteworthy Falsehoods Robert F. Kennedy Jr. Has Promoted. NY Times. November 22, 2024. Available at: https://www.nytimes.com/article/rfk-conspiracy-theories-fact-check.html (accessed 12/16/24).
4. Jaramillo C, Yandell K. RFK Jr.’s COVID-19 Deceptions. Factcheck. August 11, 2023. Available at: https://www.factcheck.org/2023/08/scicheck-rfk-jr-s-covid-19-deceptions/ (accessed 12/16/24).
5. Kennedy RF Jr. The Real Anthony Fauci. New York: Skyhorse Publishing; 2021.
6. Kennedy RF Jr. A Letter to Liberals. New York: Skyhorse Publishing; 2022.
7. Khullar D. The Fundamental Problem with R.F.K., Jr.,’s Nomination to H.H.S. New Yorker. November 24, 2024. Available at: https://www.newyorker.com/magazine/2024/12/02/the-fundamental-problem-with-rfk-jrs-nomination-to-hhs (accessed 12/16/24).
8. Roush T. RFK Jr. Endorses Trump After Calling Him ‘Sociopath’ — His Reversal, Explained. Forbes. August 23, 2024.
9. Rosenbluth T. Nobel Laureates Urge Senate to Turn Down Kennedy’s Nomination. NY Times. December 9, 2024. Available at: https://www.nytimes.com/2024/12/09/health/kennedy-hhs-nobel-laureates.html (accessed 12/16/24). 

*The opinions expressed in this editorial are those of the author and do not necessarily reflect the position of the California/Arizona Thoracic Society or the American Thoracic Society.

Cite as: Robbins RA. Robert F. Kennedy, Jr. Nominated as HHS Secretary: Choices for Senators and Healthcare Providers. Southwest J Pulm Crit Care Sleep. 2025;30(1):8-10. doi: https://doi.org/10.13175/swjpccs053-24 PDF

If You Want to Publish, Be Part of the Process

Stuart F. Quan, MD¹

Colin Shapiro, BSc (Hon) MBBCh PhD MRCP (Psych ) FRCP(C)²

¹Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital,

Boston, MA, USA

²Department of Psychiatry, University of Toronto, Toronto, ON, Canada

The edifice of academic journals is predicated on the process of peer review. Inevitably it is subject to the vagaries of the individual perspectives and biases of the reviewers. However, there has not been a useful, equitable or viable alternative that would secure a level of quality control in the research domain (1). Given the inevitable human components of range of knowledge, potential biases  and sometimes lazy thinking, it is certainly not a perfect system. Certainly, a worthy paper occasionally is rejected, or a badly flawed paper is accepted. However, in the absence of a better process, it is the gold standard.

Historically, peer review has been an altruistic endeavor. Researchers understood that their reviews contributed to the scientific process by improving the quality of reported information and providing an imprimatur to the reported findings (2); reviewing was an obligation to the scientific community (3). However, there are other benefits to reviewing a paper. These include discovering new insights or approaches to a particular topic, improvement in one’s own writing skills by reading the work of others, and use as a tool for teaching trainees to analyze strengths and weaknesses of a study (4).

Despite the importance of peer review, it is the bane of virtually all scientific journals, and its expeditious functioning is approaching crisis levels. Most journals request that reviews be returned within 2 weeks of acceptance. However, in many cases this is wishful thinking, and reviews often are received far in excess of 2 weeks. This results in long delays in a publication decision;  in our experience, it sometimes can exceed 6 months.  Most delays in review are related to searching for reviewers and constantly reminding them to submit their review on time (5). As current editors for a sleep journal as well as having served as editors for other journals, we have sent up to 50 review invitations for some papers. Other editors confirm that finding reviewers in increasingly difficult for all journals (6).

There are two major factors that have led to this crisis. First is the proliferation of scientific journals. For example, ten years ago there were at least 15 sleep journals which was an increase of 9 over the preceding decade (7). There are even more now, and this does not include journals that only publish some sleep content such as the Southwest Journal of Pulmonary, Critical Care and Sleep, American Journal of Respiratory and Critical Care Medicine, or Neurology. Each of these journals needs reviewers for the papers submitted to them. Second is researchers and academic clinicians over the past several decades have been placed under increasing pressure to generate external funding whether it be grants or clinical income. A few decades ago, being invited to review an important article would have been viewed as a recognition of a degree of competence. Today, it is considered a burden in that there is no time to perform non-remunerative work (3).

Are there any means to alleviate this crisis? We offer the following possibilities:

• An expectation that anyone who publishes in a journal must agree to review a predetermined number of papers in order to submit subsequent manuscripts. This number would likely vary among journals, but we propose that it be a minimum of 3 reviews.
• For journals that charge an article publishing fee, discounts for publishing or other monetary incentive are provided to reviewers who provide expeditious and high-quality reviews. Some journals currently do this, but it is unclear whether these incentives are effective.
•  In addition to a requirement by academic bodies to list publications on one’s vita, there should be a list of reviews submitted including the journal’s name and impact factor and the review date.  
• Academic institutions require a minimum number of manuscript reviews as an essential criterion for promotion or retention. 
• Academic institutions should be encouraged to provide training in the process of writing a scientific article AND the approach to reviewing and evaluating a manuscript.
• Explore the possibility of using generative artificial intelligence to assist in conducting some aspects of peer review (8).

No doubt that there are other novel concepts and journals should adopt policies that will be effective for their own stakeholders. In the meantime, we strongly urge readers of this editorial to be generous with their time and regularly accept requests to review papers. Your efforts will be greatly appreciated by journal editors, and you will be assisting in the dissemination of science as well as fostering your own personal growth as a researcher or academic clinician.

References

1. Smith R. Peer review: a flawed process at the heart of science and journals. J R Soc Med. 2006 Apr;99(4):178-82. [CrossRef] [PubMed]
2. Carrell DT, Rajpert-De Meyts E. Meaningful peer review is integral to quality science and should provide benefits to the authors and reviewers alike. Andrology. 2013 Jul;1(4):531-2. [CrossRef] [PubMed]
3. Fiedorowicz JG, Kleinstäuber M, Lemogne C, Löwe B, Ola B, Sutin A, Wong S, Fabiano N, Tilburg MV, Mikocka-Walus A. Peer review as a measurable responsibility of those who publish: The peer review debt index. J Psychosom Res. 2022 Oct;161:110997. [CrossRef] [PubMed]
4. Quan SF. Expediting peer review: why say yes. J Clin Sleep Med. 2014 Nov 15;10(11):1167. [CrossRef] [PubMed]
5. Quan SF. Expediting peer review: just say no. J Clin Sleep Med. 2014 Sep 15;10(9):941. [CrossRef] [PubMed]
6. Gozal D, Adamantidis A, Stone KL, Pack AI. The current status of the journal SLEEP. Sleep. 2024 Sep 9;47(9):zsae154. [CrossRef] [PubMed]
7. Quan SF. Another Sleep Journal? A Reprise in 2014. J Clin Sleep Med. 2014; 10(7):717. [CrossRef]
8. Chauhan C, Currie G. The Impact of Generative Artificial Intelligence on Research Integrity in Scholarly Publishing. Am J Pathol. 2024 Dec;194(12):2234–8. [CrossRef] [PubMed]

Cite as: Quan SF, Shapiro C. If You Want to Publish, Be Part of the Process. Southwest J Pulm Crit Care Sleep. 2024;29(6):67-68. doi: https://doi.org/10.13175/swjpccs052-24 PDF

A Call for Change in Healthcare Governance

Over the past 30-40 years many healthcare organizations have gradually shifted from a charitable, not-for-profit organization to a not-for-profit in name only business. Accompanying this shift, has been a shift in hospital governance away from a benevolent organization directed by charitable organizations such as religious organizations to businessman focused on revenue and profits. Of course, this does not mean that not-for-profit organizations are for loss. Small or modest profits are necessary to continue to operate.

Accompanying this change in organizational goals from a charitable to a more business focus, has been changes in the hospital board of directors or trustees (1). The mission of a publicly traded corporation is to return economic value to their shareholders and is the primary fiduciary focus of that board. On the other hand, the mission of a not-for-profit, 501c, charitable healthcare system is to provide health services improving the well-being of the community.

The board of directors or trustees of a not-for-profit organization theoretically must be primarily focused on the fulfillment of the charitable mission, not on generating profit for its own sake. Not-for-profit boards tend to be larger. In the 1980s the average size of a not-for-profit hospital board was well over 25, but is declining. By 2023 the average size was around 13 (1). At least 51% of the members of a not-for-profit charitable board must meet the Internal Revenue Service (IRS) definition of independence. This means that these board members must be independent of direct economic relationships with the organization and not have direct family members who work for the organization. This is one way that the IRS tries to ensure that the board is loyal to the charitable mission of the organization.

In the 1980’s new board members were often elected by the board and usually received no or minimal compensation (2). However, today board members are often “nominated” by the administration of the hospital and often receive compensation which can be substantial (2). For example, the 14 board members of Banner Health receive in excess of $95,000/year (3). In addition, hospital CEOs were usually ex officio non-voting board members. Again, using Banner Health as an example, the CEO is a full board member (4). Board composition has also changed. In the past there was often ample physicians and nurses providing medical guidance to the board. Today their numbers have dwindled. Banner has  only 2 physicians on its 14-member board (an internist/emergency room and a family physician). Nursing is not represented.

The role of the chief of staff (COS) has also changed. In the past COSs were usually members of the medical faculty who served one or two years on a part-time basis. They were compensated but that was largely to offset their loss of income as a physician. Now COSs are often full-time serving at the pleasure of the hospital CEO and/or board. They are no longer the doctors’ representative to the hospital administration but rather the hospital administration’s representative to the doctors (5). The concept that the COS can work in a “kumbaya” relationship with hospital administrators is a naive remanent from a bygone era. Although a good working relationship may exist in some healthcare organizations, increasingly the relationship is adversarial.

Physician practice has also changed. In the past physicians were often self-employed independents who practiced within the confines of the hospital or clinic. Now 77% of physicians are employed, a dramatic increase from 26% only 10 years ago (6). The reason most often cited has been declining reimbursement (7). Although cost containment is often cited as a reason for the decline, Medicare physician pay has plummeted by 26% when adjusted for inflation over the past 20 years while hospital reimbursement has surged by 70% (7). The decline in reimbursement has prompted many doctors to abandon independent practice for hospital or corporate employment (7). Some have equated increasing physician employment for decreasing access and quality of care (7).

It seems unlikely that without a change in governance any meaningful change in the businessmen’s stranglehold of medicine with its poor care, high prices and administrative overcompensation will be forthcoming. One simple improvement is election of the COS by an independent medical staff rather than appointment by a hospital director or board.

A second, also simple change is that independent doctors, nurses and technicians need to have their representation increased on the board of directors of the hospital or healthcare organization. They should be elected by the hospital staff and not appointed by the CEO. Rather than just requiring 51% of board members be independent, at least 51% of boards should have doctors, nurses or technicians who practice at the hospital or healthcare organization but are independent. This ensures adequate medical expertise including local knowledge about the operation of the organization.

Changes described above to the COS and board of directors should be required by the Joint Commission, Centers for Medicare and Medicaid, the state department of health and possibly the IRS. These changes could go a long way to resolving the intrusion in medicine by businessmen interested more in their own gain and not the charitable healthcare mission of a 501c hospital or healthcare organization.

References

1. Wagner SE. A Taxonomy of Health Care Boards. Trustee Insights. American Hospital Association. September, 2023. Available at: https://trustees.aha.org/system/files/media/file/2023/09/TI_0923_orlikoff_interview_3.pdf (accessed 6/14/2024).
2. Blodgett MS, Melconian LJ,  Peterson JH. Evolving Corporate Governance Standards for Healthcare Nonprofits: Is Board of Director Compensation a Breach of Fiduciary Duty. Brooklyn Journal of Corporate Financial & Commercial Law. 2013;7(2): 444-474. Available at: https://brooklynworks.brooklaw.edu/cgi/viewcontent.cgi?article=1046&context=bjcfcl (accessed 6/14/2024).
3. ProPublica. Nonprofit Explorer. December 2022 Tax Filing. Available at: https://projects.propublica.org/nonprofits/organizations/450233470 (accessed 6/14/24).
4. Board of Directors. Banner Health. Available at: https://www.bannerhealth.com/about/leadership/board-of-directors (accessed 6/14/24).
5. Robbins RA. The Potential Dangers of Quality Assurance, Physician Credentialing and Solutions for Their Improvement. Southwest J Pulm Crit Care Sleep. 2022;25(4):52-58. [CrossRef]
6. Physicians Advocacy Institute. Updated Report: Hospital and Corporate Acquisition of Physician Practices and Physician Employment 2019-2023. April 2024. Available at: https://www.physiciansadvocacyinstitute.org/Portals/0/assets/docs/PAI-Research/PAI-Avalere%20Physician%20Employment%20Trends%20Study%202019-2023%20Final.pdf?ver=uGHF46u1GSeZgYXMKFyYvw%3d%3d (accessed 6/16/24).
7. G Grossi. Dr David Eagle: CMS Reimbursement Cuts Encourage Trend of Independent Physician Exodus. American Journal of Managed Care. Feb 12, 2024. Available at: https://www.ajmc.com/view/dr-david-eagle-cms-reimbursement-cuts-encourage-trend-of-independent-physician-exodus (accessed 6/16/24).

Cite as: Robbins RA. A Call for Change in Healthcare Governance. Southwest J Pulm Crit Care Sleep. 2024;28(6):91-93. doi: https://doi.org/10.13175/swjpccs028-24 PDF

The Decline in Professional Organization Growth Has Accompanied the Decline of Physician Influence on Healthcare

There is little doubt that most professional organizations are experiencing a failure to grow. For example, in the early 1950’s, about 75% of US physicians were American Medical Association (AMA) members (1). That percentage has steadily decreased over the years. In 2019 there were only 132,133 practicing physicians or about 12.1% of physicians who are AMA members (2). According to Kevin Campbell (2) there are many reasons for this decline including:

• The AMA touts itself as speaking for all of us (physicians) -- but rarely listens to any of us -- they work to fill their own pockets with dollars from big pharma and government.
• The AMA tends to have a narrow-minded political view and works to stifle any dissenting opinions (in an effort to continue to align with the government agencies that line the pockets of AMA executives with taxpayer money).
• The AMA has collaborated with the government to expand irrelevant and unfair payment codes (the hated CPT codes and ICD 10) -- this has significantly contributed to the disparity in pay for different specialties.
• The AMA has spent more (of dues paying member money) than almost any other company on lobbying in the last 20 years -- to a tune of $347 million -- only the U.S. Chamber of Commerce and the National Association of Realtors have spent more.
• The AMA receives nearly twice as much money from the U.S. government as it does from membership dues, and has since the Clinton Administration when the AMA signed on to support price controls for physician services -- in exchange for Washington leaving it to the AMA to decide how the shrinking pot of money for physician payments would be divided up between medical specialties. (Yes, this is all about how the self-serving AMA determines CPT codes.) In 2010 alone, the AMA made 72 million in royalties and credentialing products sold to the U.S. government.

The AMA’s “woes” are typical of many membership-based medical organizations that exist to fulfill a mission. Many professional organizations can be faulted for behavior similar to the AMA’s, particularly ignoring physician members and lining their own pockets at the expense of their members and the patients they serve. However, regardless of size, achieving a mission often comes down to one thing-growth. In a report published by Wild Apricot (3) in 2020, surveyors found 68% of organizations had difficulty growing their organization in 2019 — 11% of those shrunk, and 25% experienced no growth. The remaining 32% grew only 1-5%. 

Not surprisingly, declining membership is associated with declining political clout. At one time AMA approval was critical in moving any healthcare proposal forward through Congress. Now it is at best an afterthought. The present “pay to play” attitude in Congress likely accounts for some of their declining influence. If an organization represents only a small fraction of the electorate, their influence is small.

The decline in professional organization clout can, at least in part, explain many of the onerous tasks that physicians and other healthcare workers must perform. For example, medical notes have become overly long and largely useless (4). Often the point of the note is difficult, if not impossible, to find. These clerical tasks may increase reimbursement but do not appear to contribute to better care or outcomes.

Therefore, combatting membership decline becomes important in improving medicine. Millennials and generation Z are not as likely to join organized groups as their predecessors (4,5). Additionally, not every recruitment strategy may work for a specific association or needs. Therefore, understanding the reasons behind a specific organization’s member churn can help indicate a path to explore. Retaining existing members is low-hanging fruit. It is more cost-effective to keep current members happy than it is to attract new ones. Canceling an unused membership doesn’t require a second thought, so targeting existing members with engagement campaigns showing them how to maximize their membership is important. Declining membership is not a dire situation, but it is a reason to innovate. Organizations should rethink how to engage existing members without neglecting younger audiences.

Richard A. Robbins MD

Editor, SWJPCCS

References

1. Collier R. American Medical Association membership woes continue. CMAJ. 2011 Aug 9;183(11):E713-4. [CrossRef] [PubMed]
2. Campbell K. Don't Believe AMA's Hype, Membership Still Declining. MedPage Today. June 19, 2019. Available at: https://www.medpagetoday.com/opinion/campbells-scoop/80583 (accessed 5/3/24).
3. Wild Apricot. 3 Ways to Grow Your Membership Org. 2020. Available at: https://resources.wildapricot.com/2020-membership-growth-report (accessed 5/3/24).
4. Sax PE. How Did Our Medical Notes Become So Useless? NEJM Journal Watch. January 2, 2019. Available at: https://blogs.jwatch.org/hiv-id-observations/index.php/how-did-our-medical-notes-become-so-useless/2019/01/02/ (accessed 5/3/24).
5. Fry R. Millennials Are the Largest Generation in the U.S. Labor Force. Pew Research Center. 2018. Available at: https://www.pewresearch.org/short-reads/2018/04/11/millennials-largest-generation-us-labor-force/ (accessed 5/3/24).
6. World Economic Forum. Chart: How Gen Z Employment Levels Compare in OECD Countries. 2021. Available at: https://www.weforum.org/agenda/2021/03/gen-z-unemployment-chart-global-comparisons/ (accessed 5/3/24).

Cite as: Robbins RA. The Decline in Professional Organization Growth Has Accompanied the Decline of Physician Influence on Healthcare. Southwest J Pulm Crit Care Sleep. 2024;28(5):72-73. doi: https://doi.org/10.13175/swjpccs022-24 PDF

Hospitals, Aviation and Business

Boeing’s recent troubles remind us that in many ways, healthcare is like aviation:

1. They are both highly technical endeavors, guided by highly educated and trained personnel such as physicians and pilots.
2. Even small mistakes can be devastating.
3. Operating margins (operating income/revenue) are very low.
4. Both are led by businessmen not trained in the industry.
5. Some have put profit ahead of safety.

The cockpit of the typical airliner or the multitude of instruments in the typical intensive care unit demonstrates that aviation and medicine are both highly technical. Airline pilots have a minimum of 1,500 hours of flight time. This includes time spent obtaining a private pilot’s license, commercial license, instrument rating, multiengine rating, and airline transport pilot (ATP) certificate. Pilots often have additional in type ratings for turboprop or jet engines. Many have spent time as flight instructors and normally have at least 5 years of experience. A pilot must be over the age of 23 and be able to pass a 1st class medical exam. The military also trains pilots and brings them along faster, usually requiring some time commitment for the training they receive. In addition, they have recurring requirements to train in simulators to practice emergency procedures or when they begin flying new aircraft.

Physicians have four years of medical school after college. After medical school they become residents, a term from the past when the young physician resided in the hospitals. Residency lasts 3-5 years and is often followed by additional training called fellowship. For example, the typical cardiologist spends 3 years in an internal medicine resident, then an additional 3 years as a cardiology fellow. After fellowship, additional training may occur. For example, in cardiology this could be in interventional cardiology, nuclear cardiology, electrophysiology, etc. which are 1-2 years in length. In many cases additional time is spent doing research to become competitive for grants. Many have PhD’s and some have administrative or business degrees such as master of public health (MPH) or business (MBA). Like pilots, recertification is required. Nurses and physician’s assistants are also highly educated. Some have PhD’s and many have master’s degrees. Like physicians, administrative or business degrees are becoming increasingly common. 

Small mistakes can be devastating. Overshooting or undershooting a runway leading to a crash can kill not only the pilot but passengers on board. Poor handling of an emergency such as an engine failure, a door plug dislodging in flight or poor programming of the complex flight computers, such as occurred with the Boeing 737 Max, can be lethal. Similarly, mistakes in care for a sick patient can be deadly. The popular literature is rife with reports of physicians or nurses overlooking a laboratory or x-ray abnormality, giving the wrong medication, falls, or the wrong surgery on the wrong patient.

Although the high education and need for care are well appreciated, what is not so well known is that profit margins are narrow for both aviation and medicine.  Airlines are expected to have a 2.7% net profit margin in 2024 which is a slight improvement from the 2.6% in 2023 (1). Boeing’s net profit margin as of September 30, 2023 was -2.86%. (2). Hospitals began 2023 with a median operating margin of -0.9% and currently have a margin of -10.6% to 11.1% (3). For the three months ending Sept 30, the Mayo Clinic (Rochester, MN) had a relatively healthy 6.7% profit margin. In contrast, Banner Health was only 1.5%. Hospitals and health systems are estimated to finally break even after several years of losses secondary to the COVID-19 pandemic and higher than expected contract labor costs. The recent median margin data show that essentially half of hospitals and health systems are still operating at a financial loss, with many more just barely covering their costs (3). This means little to no discretionary money. Hospital executives who receive high compensation packages can consume much of this discretionary money. Many would argue that it could be better spent on patient care. 

Both aviation and hospitals are usually led by businessmen. This was not always so. Early airlines and hospitals were usually led by pilots and doctors. Only in the past 50 years have businessmen become involved. The rationale has nearly always been financial. Early aviators cared a great deal about demonstrating that aviation was safe. For example, Boeing Aircraft, founded in 1916 by William Boeing, was considered first and foremost an engineering firm where production of reliable aircraft was most important (4). The emphasis on quality and safety spawned the quote, “If it isn’t Boeing, we aren’t going”. In 1997 Boeing merged with its longtime rival McDonnell Douglas. The new CEO of the merged companies from McDonnell Douglas, Harry Stonecipher, brought a different attitude to the merged companies.

Figure 1. Harry Stonecipher. CEO of Boeing 2001-2, 2003-5.

Stonecipher said, “When people say I changed the culture of Boeing, that was the intent, so that it’s run like a business rather than a great engineering firm. It is a great engineering firm but people invest in a company because they want to make money” (5).  The company became fixated on stock market value and lost sight of the core value of manufacturing reliable, safe airplanes. Boeing is now reaping the decline in quality that was sown by Stonecipher years ago. The Federal Aviation Administration (FAA) which is supposed to  oversee airplane manufactures has also apparently become slack, allowing Boeing to have major declines in quality (6).

In hospitals we have seen a similar progression. Doctors or nurses were replaced as hospital heads in the later part of the twentieth century by businessmen who often did not understand, and in some instances did not care to understand, the core value of quality patient care. Recently, private equity firms have been acquiring hospitals or portions of hospitals such as emergency rooms or radiology practices. Data on the quality of care has been scant but there have been a multitude of complaints from doctors and nurses. Now, a recent systematic review that included 55 studies from 8 countries concluded that not only has private equity ownership increased over time across many health care sectors, but it has also been linked with higher costs to patients or payers (7). Although results for the 27 studies that looked at health care quality were mixed, the researchers found evidence that private equity ownership was tied to worse quality in 21 (7). This suggests a poorer quality of care. The lack of oversight by a variety of healthcare organizations such as the Joint Commission, Centers for Medicare and Medicaid Services (CMS), state departments of health, etc. may be following the FAA example in becoming lax at their jobs.

Hospitals and aviation companies do have one major difference. Hospitals are generally not-for-profit entities that should operate for the public good. Profit is secondary which does not mean that losses can be long tolerated. Aviation companies are for-profit entities where revenue is primary. However, as demonstrated by Boeing, quality is still very important. As more hospitals are acquired by private equity companies, many remain concerned that quality will suffer for the sake of profit. Perhaps in 20 years we will be shaking our heads and lamenting about the decline in the quality of US healthcare the way many are viewing Boeing today.

Richard A. Robbins MD

Editor, SWJPCCS

References

1. https://www.iata.org/en/pressroom/2023-releases/2023-12-06-01/#:~:text=Airline%20industry%20net%20profits%20are,2.6%25%20net%20profit%20margin)
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Cite as: Robbins RA. Hospitals, Aviation and Business. Southwest J Pulm Crit Care Sleep. 2024;28:20-23. doi: https://doi.org/10.13175/swjpccs009-24 PDF