SreyRam Kuy on the current situation in Medical Care

This demonstrates the urgent need for physicians all over the U.S. to practice leadership in our individual practices, in our hospitals, in our healthcare organizations and in the political process. Physicians hold a trust to protect the health of our patients. We cannot abdicate this sacred trust.

A 2006 poll by the American College of Physician Executives showed that 60% of physicians are considering leaving medicine due to low morale and lack of autonomy and status. We practice medicine in the context of Medicare reimbursements that don’t keep pace with the rate of inflation, a mountain of medical school debt (over $200,000 for some of my colleagues), the constant threat of litigation, and years of delayed gratification. (In my case, 17 years of higher education: four years of college, four years of medical school, seven years of general surgery training and two years of fellowship.) We’re feeling harried, hassled and harassed, and it can be tempting to fall into survival mode, to start thinking, “I worked hard to get here and therefore my self-interests deserve to come first.” We defend this thinking by saying, “No margin, no mission.” If doctors can’t afford to practice medicine, we argue, how can the patient be helped?

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Posted in * Culture-Watch, Health & Medicine

23 comments on “SreyRam Kuy on the current situation in Medical Care

  1. AnglicanFirst says:

    If the advocates of “universal health care” continue to press for their ‘ideological’ and ‘impractical’ innovations, then we are likely to see the ‘law of unintended consequences’ come into play and all of us will suffer.

    Becoming a medical doctor is more difficult than becoming a nuclear physicist or an astronaut.

    The years of one’s personal life invested in the educational process is a sacrifice that few of us would make when with the same gifts of intelligence and self-application that it requires to study medicine, one can easily just decide to use those talents to make money in the business world.

    Not only has a medical doctor invested his gift of intelligence and his time in becoming prepared to practice medicine, he also has to go into large-scale personal debt in order to finance his education.

    And what about his personal life? What about his wife and children? They also sacrifice.

    Once a person becomes a physiciian, he then has to worry about the greedy and unprincipled vultures who flock around him, some patients and too many low-life lawyers, waiting for an opportunity to turn a non-tort into a tort or an innocent mistake, we all make mistakes, into an expensive and career threatening event.

    Yep, the politicians may be able to force “universal health care” upon us, but they can’t force high-intellect and high-quality people into the health care business.

    If these politicians are successful, standby for a generation or two of ‘low quality’ health care and far fewer life-saving medicines and medical innovations.

  2. Daniel says:

    O.K., so how is an ordinary citizen supposed to get readily understandable, objective information on what ails the U.S. health care system, and how is the ordinary citizen able to objectively assess the various cures offered by politicians. I am a CPA with a graduate business degree and experience in corporate finance, and I have trouble understanding exactly what is going on in health care. In addition to obvious problems with health care, we have some serious problems with how we explain the major issues in our society to the citizens in an understandable way that serves the public good and not the “sound bite,” special interests of corporations, professional associations, politicians, lobbyists, media elites, et al.

  3. Country Doc says:

    Let’s face it. Medicine, like so much else of our society has been taken over by the government and the judicial system. Doctors are out of the loop. Most are burned out and also angry, not so much at the government but at the general public who repeatedly vote for leaders who have destroyed the system. It is true that doctors are bailing out in increasing numbers and their children are not going into medicine, but the fastest growth
    in medical missions is from the over 55 year old doctors who can find a ministry that is appreciated. We get the government we deserve, and when doctors completely work for the government, then we will work like government workers! Enjoy!

  4. Dale Rye says:

    What does the government have to do with any of this? If there were no Medicaid or Medicare, physicians would still be faced with private insurance companies that require so much paperwork that filing it out costs the doctors more than the companies are willing to pay.

    As for the uninsured and medically indigent, instead of being paid inadequately by Medicare/Medicaid, doctors would be paid nothing at all. They would have the choice of treating these folks anyway or watching them die in the streets. Given the cost of healthcare in this country, the medically indigent would constitute an increasingly large share of our population if there were no social safety net.

    Blaming the judicial system is another distraction from the real culprits. In Texas, “tort reform” has made it very nearly impossible to successfully bring a malpractice suit. The total amount of judgments has fallen spectacularly. Malpractice premiums have hardly fallen at all. Good doctors are still paying exorbitant rates, but bad doctors are getting a free ride.

  5. Clueless says:

    If there were no Medicaid or Medicare siphoning off more than 50% of the patients, and paying less than cost, then private insurance would not be necessary. Only hospital insurance would be necessary. Folks seeing their doctor in the office would pay the equivalent of their current co pays. The extra amount that private insurance costs goes to pay for the more than 50% of government insured folks who don’t pay office overhead, let alone physician salaries, and the 30% of uninsured or “self pay” folks that the government forces physicians to see for free in the emergency rooms. When only 20% of patients (those with insurance) are paying not only their costs, but the costs for the government sponsored deadbeats, costs will be high. If one didn’t have to deal with insurance, medicaid, medicare, and the gigantic army of biling people to deal with all of it, costs for a doctors visit would be about 5 times the cost of having your hair cut at the cuttery (about 50 dollars).

    If one had a “loser pays all legal bills” system (as is present in Europe) for malpractice suits, costs would drop to about 3x that of a hair cut (about 30 dollars).

    I do not believe it will be possible to bring costs much lower than 30 dollars total/visit even with the above, because after all plumbers get 50 dollars (though they make house calls), and physicians are more skilled than even plumbers, let alone hair dressers.

    If we had government insurance to pay for hair cuts, hair cuts would cost 150 dollars, hair dressers would need to spend 4 years studying their trade, and would take “fellowships” in coloring and manicure, and would have to undergo multiple licensing examinations. This drives up costs, and thus prices. Malpractice lawyers would be lining up outside every barbershop saying “Gosh you’re ugly! You would look beautiful if you had had a competant hair cut. How can you make it to your next visit, without psychological counseling looking as dreadful as you do? Let me help you be compensated for your pain and suffering!”

  6. robroy says:

    #4’s stream of consciousness ramblings might make a good Faulknerian novel but have no basis in fact. Let us look at the benefits of tort reform in Texas (from [url=http://www… ]here[/url]):
    [b]Freed from the threat of onerous law suits, charity care increased[/b]…
    Charity care rendered by Texas hospitals rose 24 percent in the three years following the passage of Prop. 12. But for the 2003 reforms, this $594 million increase in charity care expenses would have left many Texas hospitals with the stark choice of turning away charity care patients or closing their doors altogether. The state’s non-profit hospitals saw their charity care costs increase 36 percent in this same time frame.

    (I have done hundred of thousands of dollars worth of free care to the uninsured. Can they still sue me? You bet.)
    [b]Despite Dale stating up is down and down is up, we have[/b]…
    * All major physician liability carriers in Texas have cut their rates since the passage of the reforms, most by double-digits. Texas physicians have seen their liability rates cut, on average, 24.3 percent. Two-thirds of Texas doctors have seen their rates slashed a quarter or more.
    * Seventeen rate cuts have occurred in Texas since the passage of the 2003 landmark reforms.
    [b]Access to medical PCPs and specialists skyrocketed after tort reform[/b]…
    * Texas licensed a record 3,324 new doctors this year; 808 more than last year.
    * Since the passage of the 2003 reforms, the state has improved its national standing from 48th to 42nd in the American Medical Association’s measurement of patient-care doctors per capita.
    * The physician growth rate in El Paso is 76 percent greater than pre-reform.
    * The physician growth rate in San Antonio is 55 percent greater than pre-reform.
    * The physician growth rate in Houston is 36 percent greater than pre-reform.
    * [b]After a net loss of 14 obstetricians from 2001 to 2003, Texas experienced a net gain of 186 obstetricians.[/b]
    * Texas experienced a net loss of 9 orthopedic surgeons from 2000 to 2003. Since tort reform, the state experienced a net gain of 156 orthopedic surgeons.
    * Texas has experienced a net gain of 26 neurosurgeons since Prop 12, including one each in the medically underserved communities of Corpus Christi and Beaumont.
    * If the pending applicants are approved, the statewide total of pediatric intensive care, pediatric emergency medicine and pediatric infectious disease specialists will double.

    I have many friends who practice in Texas. If you lived in the Valley, you could forget about finding an Ob-Gyn to deliver your baby and if your wife had a high risk baby and needed a maternal-fetal medicine specialist, really forget that (many hispanic women have poorly controlled gestational diabetes and need this). If you had a head injury in the Valley, you better hope that you survived long enough to get yourself helicoptered to San Antonio to see a neurosurgeon.

  7. Clueless says:

    I would love to work in the local free clinic, however my hospital based malpractice insurance will not permit it. I really don’t want to pay an extra 10,000 dollars for an extra malpractice policy just to see folks for free. Therefore, I volunteer outside the country, where I know I won’t be sued.

  8. Irenaeus says:

    Doctors and other health-care providers are being squeezed from several directions. The two most important squeezes come from managed care and lagging federal reimbursement for Medicare, Medicaid, and the like.

    The managed-care squeeze is unpleasant but, given the perverse incentives created by health insurance, more affordable than the alternatives (such as the old system of paying a certain percentage of each doctor’s self-proclaimed “usual” rates).

    But skinflint federal reimbursements are indefensible. Congress (most notably, the Gingrich Congress) arbitrarily cut physician and hospital reimbursements to free up budget money for other purposes.

    From a strictly economic standpoint, it probably doesn’t make sense for doctors to accept Medicare much less Medicaid. Doctors, to their credit, accept it because they care about their patients. Their labors deserve more than a delinquent pittance.

  9. Sarah1 says:

    Dale Rye, a person whom I normally disagree with on many particulars, is still a smart, nice person.

    However, his post above reveals a breathtaking ignorance of the medical landscape, and I fear that it is the same ignorance that is vividly shown in other audiences within the U.S.

    Just a few notes:

    1) Medicaid and Medicare are far more onerous from a regulatory and legal and — thus — paperwork burden than private insurance.

    2) My father was paid in vegetables and eggs when poor people came to see him. He was *thrilled* to do that — or take care of people for free — prior to becoming the paid, highly regulated, sued, and draconianly-punished-for-cutting-prices [regular fee laws by the government] government worker which he did not set out to become when he endured the medical school, residency, and first years of poverty in setting up a small family medicine practice in a small town with a majority minority population in the deep south.

    Would he rather go back to being paid for his services to the poverty-stricken via eggs and vegetables, as opposed to the mounds of ever-changing codes, regulations, and massive-fine-laws of Medicare and Medicaid? [i]You bet your sweet life he would.[/i] In the twinkling of an eye. And they would receive excellent care.

    RE: “Malpractice premiums have hardly fallen at all.”

    Even had RobRoy not provided the devastating stats that he has concerning prices and the happy consequences of tort reform in Texas, I point out to Dale that one of the big issues is not merely high prices of insurance for doctors . . . but [i]no insurance carriers at all[/i]. Several years ago, the state in which my father lives lost all but one of the carriers for insurance. That’s right — there was [i]only one that would do business in that state[/i] and that one was one managed by a consortium of physicians. The resultant loss of physicians — due to no insurance at all if they were not lucky enough to be accepted by the only carrier there — from that state was devastating and led directly to loss of life and health in the cases of trauma and other specialized services. Not to mention the hours of driving to other towns for services that had been available, like obstetrics.

    Again, Dale Rye is an intelligent, nice person.

    And he simply does not have a clue about the medical arena.

    This scares the dickens out of me.

  10. ann r says:

    Medicaid and Medicare are driving countless small rural hospitals, often the only ER within hours of driving, out of business. Not only do they not reimburse anywhere near cost of service, but at the end of the year they will review the year’s payments, and if in their wisdom they decide they overpaid for some procedure they will bill the hospital and expect to be paid back.

  11. John Wilkins says:

    Perhaps if we opened up schools to everyone who was interested in medical training, we’d see more doctors and lower medical costs. Doctors would then get paid like… teachers. As it is, the system isn’t exactly a “market” system, and lots of talented adults are excluded from the profession. I know several talented college students from top schools who didn’t get into medical school (3.9 GPA, good boards). Unfortunately we don’t see the free market in the physician club. There are lots of govmn’t regulations regarding medical schools, it seems.

    Sarah asserts that “1) Medicaid and Medicare are far more onerous from a regulatory and legal and—thus—paperwork burden than private insurance.” For who? For the consumer? I will say that parishioners I know find private insurers much more difficult than medicaid. Perhaps not doctors. It seems an administration that does not WANT medicaid to work, will sabotage it from within and then say, “look, see! It doesn’t work.”

    I suspect an unintended consequence of universal health care would be a decline in medical malpractice suits. As part of the system, patients would get to choose their doctors. They would choose doctors who were better caregivers – if there is access to information.

    One of the issues how information gets distributed: doctors have asymetrical information, so its hard for a patient to know exactly what kind of care s/he is getting. Perhaps if people knew which doctors were getting sued more, bad doctors would be priced out of the system.

    Ann R does note that hospitals are going out of business. But, are hospitals supposed to make money? How do would they do it when their constituents are poor, sick, rural folk? I mean – it would be a pretty amazing business model if they did. I find it interesting that we assume that hospitals are supposed to make a profit – or even break even – from people’s illness.

  12. robroy says:

    John, that was perhaps the most confused piece I have seen in a long time.

    Competition for medical school slots is now higher than ever. Admissions is pretty much a formulaic for most positions. This GPA and this MCAT score gets you in if you don’t come across as a sociopath in the interview. It does seem that some positions are reserved for “diversity”. What the medical schools don’t do well enough is take into account the difficulty of the school. A C-average at Harvard blows away a 4.0 from San Angelo State, but the Harvard student will be eliminated by the computer.

    Some have argued that we have an oversupply of physicians (need more nurse practioners and physician assistants) and some argue that there is an undersupply. The fact that there is an argument tells me that the number of physician is probably not the problem. Distribution is a huge problem. No one wants to work in rural communities. The lifestyle stinks, and the pay (mostly medicare and medicaid, even with adjustments) is terrible.

    “Medicaid and Medicare are far more onerous from a regulatory and legal and—thus—paperwork burden than private insurance.” For who?” (It should be “For whom?”, by the way.) For the physician, of course. A huge problem with Medicaid is there is no self-investment in the system. My medicaid patients have the highest late or no show rate. They overuse the ER’s because it costs them $2.00. Medicare patients are different because they were raised in a time when you respected people’s time. People talk about Universal coverage as Medicare for all. What it will turn out to be is medicaid for all. You will not like it. In order to deal with all the no-shows, all appointments will be double or triple over-booked. Of course, on the days that you have an appointment, the patients will all show up, too and the clinic will be four hours behind.

    [blockquote]I suspect an unintended consequence of universal health care would be a decline in medical malpractice suits. As part of the system, patients would get to choose their doctors. They would choose doctors who were better caregivers – if there is access to information. [/blockquote]
    This just sad. Patient choice will be decreased, of course. Physician and hospital report cards are already out there, and they help the patient not one whit in most cases.

    One can find out already the number of lawsuits against physicians. It costs $3.25 to query any physician. Of course, an easy to use system that didn’t cost anything would actually increase pressure to practice defensive medicine. It is already crazy the amount of MRI’s order, looking for brain tumors, for patients with simple headaches.

    Lastly, rural hospitals that are struggling are almost all public hospitals.

  13. John Wilkins says:

    Robroy – its competetive to get into medical schools. Why not let more medical schools open? Given the number of people who seem to want to become doctors, I don’t see why the market isn’t responding (perhaps it might be regulation or the guild of doctors…).

    One way to increase the # of doctors in rural areas is to give greater incentives. What is wrong with that? Can medicaid patients get regular, yearly exams? If not, I can understand why they use the ER.

    I’m not sure how I would like universal health care. But I’d have to compare it to England, Sweden, Holland or Canada. It seems that people have longer life spans and better health in those countries, and they pay much less. We have to be clear about our criteria for what constitutes a good health plan. Cost? Lifespan? Doctor’s salaries?

  14. robroy says:

    John, most people think that it is a good idea that it is competitive to get into medical school. You want a country where doctors are paid as much as teachers??? I taught elementary education majors. Arithmetic was pushing their limit. You want them diagnosing and treating your unstable angina??? Wow!

    (And the medicaid patients are going to the ER’s not for yearly exams but rather colds, chronic back pain, headaches, etc.)

    I do think that the one area we could save money in is insurance costs. We are going in the entirely wrong direction. There is much less competition now than five years ago. Here is an [url=http://www… ]amazing excerpt from a study by the AMA[/url]:
    [blockquote]To put this in perspective, in 2000, the two largest health insurers, Aetna and United, had a total membership of 32 million lives. As a result of mergers and acquisitions since 2000, the top two insurers today, WellPoint and United, each have memberships, respectively, of 34 million and 33 million, totaling more than 67 million covered lives. Together, WellPoint and United control 36 percent of the national market for commercial health insurance. In 2004 and 2005, 28 mergers valued at a total of $53.8 billion were
    completed or announced, which exceeded the value of all the deals completed in the previous eight years.[/blockquote]
    So I have a 8 FTE’s and a couple part-timers. I am going to tell United that their prices are too high and coverage exclusions are too onerous? Small business owners need to be able to band together and have some clout. But of course if there is only two games in town, the insurance companies can still say take it or leave.

  15. Clueless says:

    People don’t have longer life spans in England and Europe. What they have is a different way of measuring life. In Europe if a child is born alive prematurely and then dies it counts as a “still birth”. In the United States, the child is considered alive if he has a pulse or can be resucitated at birth, regardless of how premature he/she is. We have the highest rate of premie births in the world, because we bother to try to save them. If they die the next day, or if they die of hydrocephalus or respiratory distress the next year, it greatly affects our mortality, which drops from 76 odd years to 1 day. By contrast, we also have the highest survival of people over the age of 80. This is because we actually take care of folks over the age of 80, instead of euthanizing them (as is done in the Netherlands and Belgium) or simply declining services such as surgery, dialysis etc (as is done in UK. Since the increase in life expectancy from 76 to 81 doesn’t count for much, this does not show up in statistics.

    Whether the US should or can afford to keep doing this, is another question. The entire medicare gap could be solved if we were to treat our elderly the way the British treat theirs. If we were to go to the Netherland model, we not only would close our medicare fiscal gap, but there would be money left over to pay for universal health care.

    I think it will happen eventually. I think I could deal with the British model (as long as the rationing was explicit, and everybody knew that folks over a certain age would not be intubated or recussitated). If the Netherlands model came in, I would need to leave medicine.

  16. John Wilkins says:

    Actually, Robroy, we should be paying teachers as much as doctors.

    Further, I don’t think competent doctors has much to do with competitiveness. It may help somewhat, but as you noted, a Harvard educated person will not get into medical school. In other parts of the world they have different sorts of models for medical education. But after seeing really smart people get turned down for medical school and seeing some doctors who were good technicians, I think that the supply and demand idea might be applied to the medical guild. Keep the tests. But create more medical colleges and universities.

  17. ann r says:

    John, teachers do not have to support an office staff, pay for very expensive insurance, and they get the summer off. It requires far more years of education to become a doctor, and one graduates with a mountain of debt. The challenge of any education degree is laughable compare to the challenge of any medical degree. The responsibility for a human life is enormous. As usual, John, your responses really horrify me. One can survive an incompetent teacher. An incompetent doctor is a nightmare. As for medical care for the over 80 class, Clueless, I see a lot of over 80 folks who are doing far more for the community than a good many 20 to 30 year folks. One of the columnists of our local paper just turned 95. The pope is 80. While it is true that terminal illness is expensive, terminal illness is not necessarily totally age related. I lost about half my friends when they were between late 50s and mid 60s. This country is in a fiscal mess. We owe so much, and keep on spending and spending. The only way we can support the vision of those who want to supply everything for everyone practically free, is to print more and more money, until it takes a wheelbarrow full to buy a loaf of bread. We need to get back to pay as you go, as individuals, states and nation.

  18. Clueless says:

    We do need to get back to “pay as you go”. However unfortunately, the elderly and those in the last 2 years of life are not “profitable”. They never were. They were always cared for by their families who, in this current age they abandoned via the divorce and abortion epidemic, and who now abandon them. Therefore today’s elderly _can’t_ pay as they go. Nor will their families (for the most part) pay for them.

    Europe has already figured this out, which is why they have explicit rationing. The US can’t bear to look at the problem squarely, which is why it prints money instead.

    Yes the elderly are useful citizens. However, the question is not “are they useful citizens” but rather “should younger generations, and the unborn pay huge sums for extending the lives of (even the Pope) an extra year by what used to be called ‘heroic means’ ?” (eg intubation, ventilation and surgery). Should the lives of these elderly be considered more valuble than the lives of young people who have no insurance, who could live several decades? Europe has already answered the question in the negative. We dither, printing money, calling for investigations of “fraud and abuse” and encouraging people to believe that a painless solution can be found. It can’t. We are all going to die eventually, and we will most of us, die slowly over a period of five years or so, once that process begins. That slow dying process, (prolonged from a few months to several years by the marvels of modern medicine) is what makes American medicine so expensive.

    Right now, the working poor and their children who have no insurance pay increasing taxes, and cope with accelerating inflation, with the promise of paying even more in order to insure that our generation gets to hog even more of the resources that we have already consumed so much of.

    At some point intergenerational theft becomes a justice issue. I believe that point was reached around 1987.

  19. ann r says:

    Ah, but Clueless, I think you have embarked on the slippery slope. Once the elderly are considered expendable, then what about the mentally handicapped, the physically handicapped, the non-working young fried on drugs, those in prison for life sentences without parole, etc. Remember, long before the National Socialists went for the Jews, they exterminated all the aforementioned in the country. Once any human is considered expendable, where do you draw the line?

  20. Clueless says:

    I know. That is why I will probably leave medicine when it comes in. However the economics issues are also real. Every European nation has restrictions on care for just those people (not only the elderly, but as you say the mentally handicapped, etc.). I don’t know how one draws the line. However again, I don’t think that sending the bill for elder-care to the working poor and their children and grandchildren is a solution. We need to live within our means. That used to be understood. I remember my grandfather telling me when I asked him why he hadn’t gotten his back fixed saying “Well the doctors said they’re was an operation that might help, but there was your father in university, and anyway I didn’t think so.”

    People make choices. They have always made choices. I remember my folks going without coats in the winter so we could have school clothes. I remember my mother eating the chicken neck so we could eat the breast meat. People make choices. They choose to fast, so their children will eat. They choose to live in pain so their children will go to college.

    Our generation also makes choices. We choose to prolong our lives and retirement leisure at all costs, despite the fact that it means that our children can’t afford college, can’t afford health care, and can’t afford the things we took for granted. (OK they have cheap cell phones made in China. Big deal).

    The choices we make are also a “slippery slope”. Committing a murder is evil. Committing theft is also evil. We are stealing from the poor and the young and the unborn. We should stop. Our parents would have stopped long before they ran their country into bancruptcy.

  21. Clueless says:

    Today I saw one of my usual reruns. He has seizures, dementia and sleep apnea, and when ever he forgets to put on his mask he has status epilepticus, and his caregiver (who is also mildly demented) takes him to the emergency room. He has been admitted every two weeks for the past 3 months. They refuse to go to an assisted living center. He has a vagal nerve stimulator, and his caregiver has always forgotten to use it. He has diastat, and his caregiver refuses to use it. She prefers the ER. They refuse other treatments. They are otherwise reasonably healthy, and I suspect this pattern will continue for the next 5 years and after a stroke a couple of pneumonias etc. one of his events will carry him off.

    The cost for his hospitalizations is probably about 10,000 every two weeks, or about 240,000 a year. This would buy high grade health insurance for 50 families.

    In England, he wouldn’t have lasted this long. In the Netherlands he wouldn’t have gotten to first base.

    I’m his doc, and I’m going to continue to do the best I can for him. That’s my job. It is the job of future generations to pay the bills for this, even though they can’t afford their own bils.

  22. ann r says:

    “Our parents would have stopped long
    before they ran their country into bankruptcy.”
    Yes, and that is all the difference. Once upon a time people were responsible for themselves and their families. Modern thought has replaced responsibility with entitlement. Well meaning idealists, like our friend John Wilkins above, who don’t look down the road very far at cause and effect, have put this country into a terrible crisis. (That should get a rise out of John!)

  23. John Wilkins says:

    ann r, I think you might be talking about the “moral hazard” or the the “unintended consequences” possibility. I think the problem is more complex than you seem to believe. I simply think that we treat health care differently than say, purchasing shoes. There is also the problem of asymmetric information.

    You might mistake me for someone else, Ann r, because I think we are responsible for each other. There will always be the “free-rider” problem, but that happens in a variety of contexts: it can’t be eliminated.

    I’m also intrigued by your easy dismissal of teachers. You used the canard “summers off” as if you knew how hard most teachers work. Especially good teachers. And then you mistake me for someone who thinks an education degree makes a good teacher. Not at all. I think that we get what we deserve when we decide we shouldn’t pay teachers good wages. Further, perhaps good teachers might instill in kids a sense of self-responsibility. I would also say that teachers do have responsibilities, but it is your cynicism that has put this country in a terrible crisis.