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What Does The Surgeon General Do?

Dr. Richard Carmona

Intense debate has broken out across the blogosphere regarding the candidacy of CNN medical correspondent, Sanjay Gupta, for the Office of Surgeon General of the United States. Some argue that he is not qualified for the position, others say that his charisma would be a boon to public health communications. But before we draw conclusions about who’s right for the job, we need to understand what the job entails.

I asked Dr. Richard Carmona, 17th Surgeon General of the United States, to explain the roles and responsibilities of the office. You may listen to our conversation by clicking on the podcast below, or read the summary of our conversation that follows.

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Dr. Val: What is the primary role of the Surgeon General?

Dr. Carmona: It’s the Surgeon General’s responsibility to protect, promote, and advance the health safety and security of the United States. The office of the Surgeon General dates back to 1798, when President Adams passed a law to create the Marine Hospital Service. The lead physician of the service became known as the Surgeon General. The Marine Hospital Service eventually became the US Public Health Service, and the roles and responsibilities of the Surgeon General broadened to include immigration, disaster preparedness (in the case of nuclear and biological warfare), national safety, health prevention, and many complex public health issues that face our nation and the world.

Dr. Val: What sort of experience is appropriate for a candidate of the office of Surgeon General?

Dr. Carmona: A successful candidate for the office of Surgeon General should have deep and broad public health experience, especially as a public health or uniformed military officer.  The Surgeon General is given the rank of Admiral, and as such he or she will interface with other Admirals and Generals, and Army and Navy Surgeon Generals, most of whom are career officers with decades of experience in military matters. The Surgeon General must have the wisdom and experience to take on the position of an Admiral and represent our country internationally.

Dr. Val: What does the Surgeon General do on a daily basis?

Dr. Carmona: The Surgeon General is the commander of the US Public Health Service Commissioned Corps, which consists of thousands of officers in hundreds of locations around the world working anonymously to keep our nation and our world safe. The Surgeon General interfaces on a daily basis with the NIH, CDC, SAMHSA, HRSA, and all of the federally related health agencies as well as global health organizations like the World Health Organization, Pan American Health Association, and the American Public Health Association. The Surgeon General provides in-depth analysis of health policy for every cabinet minister, including the Interior, Commerce, and Homeland Security. It’s a very visible, credible, and iconic position.

Dr. Val: What’s the selection process for the office of Surgeon General?

Dr. Carmona: The Surgeon General is nominated by the President of the United States after much due diligence, and under the recommendation of his staff. The candidate is then introduced to the United States Senate. Then the Senate, if they so choose, extends the candidate the privilege of appearing before them for a Senate confirmation hearing. During the hearing they review the candidate’s credentials and ask him or her questions about anything and everything related to the public health of this nation and the world. You’re essentially put in a hot seat, and rightfully so because the Surgeon General is America’s face of public health to the world.

Dr. Val: What should Americans expect of their Surgeon General?

Dr. Carmona: The Surgeon General of the United States needs to remain a non-partisan physician. He or she should always communicate the honest, scientific truth to the American public so that they can make informed decisions about improving their health. Often, that scientific information is not the same as the policy that the President or Congress come out with, because policy is a very complicated process.

The Surgeon General has the largest medical practice in the nation (300 million), and when he or she issues reports, they actually change behavior in our country and the world. The Surgeon General is the true, honest broker of the best science for the people, offered in an a-political fashion. He or she is a patient advocate at the very highest level of government, and is expected to address the most complex health problems that face our nation. There is no more important or influential office that an American physician can hold.


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2 Responses to “What Does The Surgeon General Do?”

  1. rlbates says:

    Thanks for this interview. I am even more impressed with past/present Surgeon Generals after reading this.

  2. Peter says:

    Gee, I thought I already had a doctor. Since Dr. Carmona considers me in his practice, will he call in a prescription for me?

    Sounds a bit too grandiose!

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

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As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

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