Wednesday, June 24, 2015

Do patients really value interaction with radiologists?
To Tell Or Not To Tell?

Dalai's Note: This is compilation of my thoughts as posted to on the topic of  discussing results with patients. It is cross-published as a Front Page article there today! I'm listed under the category of "Imaging Leaders" which tells me the field is in real trouble...
Merriam-Webster defines "value" as follows:
  • The amount of money that something is worth: the price or cost of something
  • Something that can be bought for a low or fair price
  • Usefulness or importance
I find this intuitive, really. The value of something is what it is worth. However, is that something worth the same to me as it is to you? And if I give you something of value, does that make me valuable to you? And what is the value of value?
Under the new healthcare paradigm that's emerging under government-mandated accountable care organizations (ACOs) and the like, healthcare dollars will be divided among member physicians based on the "value" they provide. More accurately, there will be extra money on the table if savings and benchmarks are achieved, and there will be penalties if costs exceed expectations.
As the minority faction at the distribution table, radiologists might just be in trouble. If we try to act as imaging gatekeepers and restrict useless examinations, we'll be told we killed grandma by cutting her access to imaging. Don't laugh -- this is exactly what has been said in the past by those who favor unlimited physician-owned imaging. On the other hand, if we allow unfettered access to imaging, costs skyrocket and the fingers once again point in our direction.
I personally think ACOs and the other "risk" programs are simply clever ways to separate physicians from their hard-earned pay, but not all agree.
A brave new world
To justify and even secure our place in this brave new world, radiologists are being commanded to prove our value, and we are told that our future revenue may depend on this rather nebulous concept. Our leadership has implied that we have to be more visible to patients, that we must make it clear we are "part of the team." Then the patients will finally understand the important role we play, which will somehow translate into a stronger position for us at King ACO's round table.
Having become even more cantankerous in my old age and semiretirement, I view this as little more than a desperate Hail Mary and a naive, knee-jerk response to the coming economic pressures of the (Un)Affordable Care Act. We are being asked to jump up on tables and shout, "We're doctors, too!"
But in its panicky zeal over potential loss of revenue, our illustrious leadership has forgotten something: We are not clinicians. We radiologists are, indeed, doctors, and we are the experts in imaging, but we are not in charge of the patient's care. This is well-illustrated by the concept of reporting our results directly to the patient.
In the June 2015 issue of the Journal of the American College of Radiology, Cabarrus et al presented the results of a patient survey on this topic. They found to no one's surprise that patients preferred to hear the results of imaging exams from the physician who ordered them. I would urge everyone to read the entire report, but in essence, the majority of patients surveyed "appear to prefer the current model of results delivery, in which ordering physicians provide results."
And this makes perfect sense. The usual course of events established decades ago is that results are communicated to the physician who ordered the study, and he or she then discusses them with the patient. There are only two reasons to force this responsibility onto the radiologist, and neither is a good one.
The first excuse is time. Or rather patience. Or rather the lack of patience. You can safely assume that an important, life-threatening result -- a "the patient will die in the next five minutes" type of result -- will be communicated as quickly as possible to the ordering doc. There have been hundreds and thousands of lawsuits on the issue that ensure this will happen.
But a noncritical finding, and even a flat-negative report, generally winds its way to the clinician over a longer time frame. To be fair, in some shops, this could take quite a while: Allow several days for the report to be typed, proofed, and signed, and however long it takes for snail-mail to deliver it to the physician, who then must read it and either call the result or meet with the patient. The entire process could take more than a week, although with our current electronic state of affairs, the nonemergency report should be available to the physician within a few hours of its rendering. Many impatient patients simply don't want to wait. They want the result now. Not next week, not tomorrow, but now.
Patients must remember that I, as a radiologist, cannot pluck them off the street and perform a radiographic examination. In the vast majority of cases, their physician, be it their own internist or an emergency room doc, must order the study. That physician has an established doctor-patient relationship, and knows at least something about the patient and his or her medical history.
When a study comes through on my PACS, I could come running out of the reading room; seek out the patient; act like I'm his or her new best friend, playing a warm, fuzzy Marcus Welby (a TV doc from way back, sort of the opposite of House); and discuss the results of the test. Instant gratification! If you knew me personally, you would realize that I really am a warm, fuzzy, caring kind of guy.
But when those radiographs come though on my PACS screen, I don't know anything about the patient other than the two- or three-word history the physician has lowered himself to give me. If I should happen to have a functioning electronic medical record (a contradiction in terms), I might be able to get some lab values and maybe some additional history. But ... I still don't know the patients like the clinical doctors do. I haven't talked to them, I haven't touched them, and I haven't examined them. So would I be doing them a favor by indulging the itch for an immediate answer?
If I give out instant reports, I place myself between patients and their own physicians. I can tell them what I see, and what they tell me might even enhance my interpretation of the images. But I can't do anything else for them. I am not their doctor. I cannot prescribe drugs to cure the pneumonia I've found, I cannot place a cast on a broken big toe, and I cannot say which surgeon or oncologist to see or what procedure to undergo should I (heaven forbid!) find a cancer.
What happens if in my rush to keep a patient from waiting too long, I miss something on the image, only to discover it later? (Or much later?) And what if a patient is, shall we say, a bit unstable mentally, and he or she totally decompensates in my office after receiving bad news? (I've had this happen to me, by the way.) In the end, my attempt to be kind by humoring a patient's need to know right bloody now may cause more harm than good. And the survey says patients would rather have their own docs do this anyway.
Why the push for 'value'?
So, given that it seems to be a bad idea for radiologists to deliver reports directly to patients, why would our illustrious leadership push us to do so? The answer is value, or rather, the perception (or perversion) of value. Cabarrus and colleagues write:
In an era of value-focused care, some authors have called on radiologists to increase their direct communication with patients in an effort to improve visibility and create value. Improved visibility helps radiologists demonstrate the value they already currently provide. Additional "value" through direct communication could result from a reduced number of intermediary communication errors, decreased delays in patient management, reduced patient stress and anxiety, and improved patient adherence to follow-up recommendations.
Communication errors? Reduced stress and anxiety? How about when the patient hears only every other word I say, and nothing past the word "cancer"? All we've managed to do in that scenario is scare them and then throw them out in the cold until their clinician can see them. The only "value" this practice will create is whatever one might place on the insertion of our faces into the patient's experience. In other words, it is another facet of the pitiful, plaintive cry, "We're doctors, too!"
In discussing this topic with colleagues on the Forums, I have been saddened to find many whose "reality" is that the ACO model is here to stay, and they had better do everything our leadership says to do to secure one's place at the table. What we have here, folks, is a collection of milquetoast millennial physicians who find themselves overwhelmed by the changes around them, changes made by people with no interest in anything other than slashing payments. Changes made by those who think they are smarter than doctors and often have a grudge against them. Changes that pit physician against physician -- and particularly clinician against radiologist.
Many of the mostly younger posters are so frightened of losing their revenue that they are pushing each other out of the way in order to cheer at the front of the crowd when the naked emperor walks by. To be blunt, we all know this "value" thing, this business of pretending to be a clinician, is a crock. But because this is the new "reality," the rubes play along and chastise those who are willing to call it what it is, hoping the new masters notice their loyalty. And even worse, some have declared that they will only talk to patients if they are paid extra to do so. I hope they sleep well at night.
My solution probably comes too late: Avoid joining anything resembling an ACO. You see, we radiologists do add value -- with every single exam. Even a normal chest radiograph adds value, but it isn't "sexy" and doesn't increase our self-aggrandizement.
Most of us do a very good job in the imaging venue. Could we do better? Of course. We could and should have better and tighter communications with our referring clinicians, and we really do try to do this. We could and should do our best to confirm that the patient is receiving the correct exam (even though many ordering clinicians don't want to hear that the exam they ordered won't answer their question, nor do they want to hear that the question is wrong in the first place).
And we can and should talk to the patients, and let them know -- quietly and with dignity -- that we are indeed doctors. We are part of the team whose one and only goal is to make them better.
I, for one, will talk to patients at any time about their exam, provided their clinician is present or at least aware that the conversation will take place and knows what I will say. But I am not going to step in and pretend to be the patient's doctor when that is definitely not my role. That adds absolutely no value at all.
In addition to regular posts in the PACS Community Forums, Dr. Dalai also maintains a blog at His observations and opinions are entirely his own.

Sunday, June 14, 2015

Universal Cobbling

I've received a number of comments about the state of our Universally Disappointing Viewer. Here are some of the best:

As for the UV, thanks for the details on your experience thus far. I assure you that lots of GE customers are watching. As you know, GE has sunset PACS-IW.

The underpinnings of the UV are a Frankenstein PACS -  the UV is a "deconstructed" viewer built on the bones of multiple GE products cobbled together.  The UV can be deconstructed into the following parts - PACS-IW, RA1000, AW Server, IDI (for mammo), Centricity Clinical Archive and streaming from RTI (RealTimeImaging acquired via IDX in 2005). Pieces and parts cobbled together over the past decade largely through separate acquisitions that can be traced back to last century, the earliest from Applicare and Siemens/Loral.

The way GE runs their development, if each piece of the puzzle is not at the exact build of the other, it won't work. Keeping that in synchrony for the life of the product(s) will constantly be an issue.

Outside of the product itself, GE is a shadow of the PACS company they once were, having reorganized so many times and letting go so many expert staff.

This is a GE product and will take a while for it to stabilize. It has been over 2.5 years (I think) since they announced UV. Add on how many years they were working on it prior to launch, and well, that's too long considering the instability you are seeing.

But it's GE.
As it turns out, GE is proud (at least they say they are proud) of this heritage:

Legacy Products

Founded by Thomas Edison in 1878 as the Edison Electric Co., GE is recognized worldwide for excellence, innovation and imagination for numerous products and services spanning a wide breadth of industries. 
GE Healthcare IT is comprised heritage companies including IDX, Marquette Medical Systems, Millbrook, iPath, Innomed, Lockheed Martin Medical/LORAL, MedicaLogic, Dynamic Imaging, Medplexus and many others.
Company NameAcquired DateKey Product Legacy Names and New Names
Lockheed Martin Medical/LORAL1997(now Centricity PACS)
Innomed1997(now Centricity RIS-I - Europe/Asia)
Marquette Medical Systems1998QS (from QMI purchased by Marquette in 1995) (now Centricity Perinatal)
Applicare1999(now Centricity PACS [RA600/CA1000/EA])
Sabri2000(now Centricity EMR - Europe & EOL)
Micro Medical2000(now Centricity CVIS)
Systems Engineering Consultants2000(now Centricity Acute Care - EOL)
Per-Se RIS2001(now Centricity RIS - EOL)
ProAct Medical2001(now Centricity CIS)
CIS HQ2002
iPath2002ORMIS (now Centricity Perioperative Manager)
SEC (now Centricity Perioperative Anesthesia)
BDM2002(now Centricity Pharmacy)
MedicaLogic Logician2002Centricity Physician Office EMR (now Centricity EMR)
Millbrook2002Centricity Physician Office Practice Management (now combined with Centricity EMR as Centricity Practice Solution)
TripleG2003(now Centricity Lab)
IDX Systems Corporation2006IDX Flowcast (now Centricity Business)
IDX Groupcast (now Centricity Group Management)
IDX Carecast (now Centricity Enterprise)
IDX Patient Online (now Centricity Patient Online)
IDX Referring Practice Online (now Centricity Referring Practice Online)
IDX eCommerce Services (now Centricity EDI Services)
IDX Web Framework (now Centricity Web Framework)
IDX Imagecast (now Centricity RIS-IC)
Dynamic Imaging2007IntegradWeb PACS (now Centricity PACS-IW)
Integrad RIS/PACS (now Centricity RIS/PACS-IW)
MedPlexus2010MedPlexus EHR, MedPlexusPractice Management, MedPlexus Revenue Cycle Management and MedPlexus BSP Solution (now Centricity Advance)

Thursday, June 11, 2015

GEe Whiz
...Waiting For Godot Metadata

Two steps forward, one step backward. The story of my life with Universal Viewer. The phrase above is what was displayed when I tried to view the PET images from a comparison PET/CT. I never thought I would appreciate the old Advantage Workstation but like an old Chevy pickup truck, it still does the job when the shiny new Maserati is in the shop, which happens more often than not. (No, I don't have a Mas, but a friend once did, and he always had to have someone follow him in case it broke down.)

We have made some progress, as I alluded to in the last post. It seems that our measurements and markups were being saved after all, but hidden in what I'm going to call a non-standard application of the Presentation State. It seems that they are ONLY saved in a presentation state. Whether this is actually the GSPS (Grayscale Softcopy Presentation State) or something else, I'm not certain.

The key to getting this far was discovered by the chief tech at the GE site, and one of my bosses (former partners) who isn't all that into software. My colleague was subsequently awarded Level Four Status by the techs as he had discovered something Level Four Technical at GE had not, that the measurements were being saved somewhere. I'm not really sure just how he found this but I was able to take it from there.

The secret lies buried in a sub-sub menu, "Done Options", a drop-down from the exit button:

Here, we find several very important check-boxes:

Now, some of these don't seem to work. Clearly, we must be doing something wrong in that we can't designate key images, and so they don't save, check-box or not. For the longest time, we did not have the "Load Presentation State on Startup" checked, and since measurements are saved in the Presentation State, this seems to explain why we weren't seeing them. We've been live with UV for almost two months and no one at GE knew this software well enough to tell us how to make this work. I'll be waiting on my check in the mail.

I'm thinking we are still not configured at all correctly. I cannot believe that measurements and such are ONLY saved in the Presentation State. UV would be the ONLY PACS out there to do so as far as I'm aware. But I guess the developers used their imagination.

But I have only just begun to whine.

So far, I cannot import CD's into the system directly via UV. The mechanism seems to be there, but it doesn't work. To be fair, the Centricity backend spat back or distorted the images of a significant number of outside disks, studies which AMICAS/Merge PACS would handle with aplomb, and even AGFA IMPAX would open nicely. This has made my life miserable, as the outside disks have to be loaded by ME and not preloaded by the staff in downtime. They must be viewed with their native software (although I usually crack them with Merge instead) and I have to compare across different machines. Really poor patient-care, boys and girls. Most every other PACS can do better. We paid extra for this?

Hanging protocols work oddly, but then this is nothing new from Centricity 3.x. Sometimes my standard protocol will display the proper CT series. Sometimes it will show the Smart-Prep single image instead. Sometimes the image will be windowed as I set it, and sometimes not.

The zooming issue seems to relate to field-of-view as saved in the Presentation State, which can be fixed by pressing the "1" key that rezooms all images to the same degree. But we shouldn't have to do that, should we?

I could go on...

I have to take a moment to trash the IDX Centricity RIS-IC. When it works, it works OK. But periodically we get the following set of nag messages when we attempt to sign EVERY SINGLE report:

We have similar problems when using Centricity RIS-IC via Citrix. And every single time we open PACS (via Internet Explorer), we get a nag about its certificate being invalid. It has been said this is due to local site problems rather than something intrinsic, but I'm not sure that is the case and frankly I'm not sure I care whose fault it is at this point.

And one more thing... The Zero Footprint Viewer has some really strange windowing behavior:

This is the most advanced system from the biggest name in the business? Seriously?

Need I say anything about which product suite you should probably avoid if you are in the PACS market?

I'll wait for Godot.

Wednesday, June 10, 2015

Alone In A Conference Call

Today marks my first direct, spoken communication with GE discussing the problems we have had with Universal Viewer. I wish I could report some progress. I wish I could...

As Mrs. Dalai will tell you with great relish and regret (and those aren't easy traits to combine), I am not very good at reproducing conversations. But I'll give you the gist of it.

The call was led by someone most interested in the PET/CT problems. She wanted to understand our workflow, but after a few moments, it became clear that understanding was not likely. Contrary to assumptions on the other end, our older AW workstation does NOT save measurements on the AW server which we don't have. It took 10 minutes to get that across. To be fair, our UV still doesn't save measurements either, and it only took about 1 minute to get that across. Now, we do understand HOW to measure SUV's with UV. (At first, we weren't getting accurate readings, but our new mentor did prompt me to try it again, and SUVmax at least does yield the same number as our AW.) Even though our apps people should have told us how to measure SUV's and make hanging protocols and use the restroom all by ourselves, said our new friend, she would be glad to run us through these things on the WebX once more.

"OK," said I, "that's wonderful. But you do realize we can't read PET/CT on this viewer, yes? Because the fusion pane DOESN'T WORK! A fusion window needs to have an alpha control that varies the contribution of the PET and the CT. We don't have that. The fusion images are unreadable, and unusable, and thus so is the UV itself for PET/CT viewing!"

Oh, yes, we've heard that from other sites. We're working on adding the alpha function. All that IS available in the AW Suite if you didn't know. (We did know...when UV was demo'ed, we were shown AW functionality and I think we somehow thought it was to be included.) In the meantime, what else could we show you about UV?

I pressed on, adding more and more irritation to my voice. I started to wonder if the WebX had disconnected me somehow, as I began to feel quite alone in my own little world where my PACS doesn't work. You would think I could Imagine something better than that.

In my reverie, I reviewed some of our pressing problems beyond having to use the old AW to read PET/CT. Such as images showing up as "0% Loaded" when scrolling through a CT. Such as our annotations not saving. Such as annotations from old studies not showing up. Which is just wonderful for oncologic imaging wherein we measure lesions and determine if they are larger or (hopefully) smaller than they were last time. It helps to actually HAVE those measurements for comparison, otherwise we are doomed to remeasure and remeasure and remeasure. Yes, we are diligent about reporting the slice number and the measurement, but this is a little ridiculous in the 21st Century flagship PACS product of the largest healthcare company in the universe. It teeters on requiring reporting to the FDA. But I'll let someone above my meager pay-grade make that call.

But if I were in the market to buy a PACS, well...

Operator? I think I've been disconnected....


A ray of hope!

We've discovered, somewhat accidentally, on our own, with no help from the mother ship, that the annotations ARE saved...most of the time...within Presentation States. IF you know they're there. Next step: getting the presentation state to present automatically.

That's progress, folks!

Thursday, June 04, 2015

Krauthammer: "Why Doctors Quit"
Hint: EMR's have something to do with it...

I'm a fan of conservative commentator Charles Krauthammer. If you read his column in the Washington Post, you might know that he is a physician by training, although he hasn't practiced in quite a while.

Krauthammer's recent column discusses some of the factors that have driven physicians away from actually practicing medicine. It should come as no surprise that EMR's are near the top of the list of troubles.
In general, my classmates felt fulfilled by family, friends and the considerable achievements of their professional lives. But there was an undercurrent of deep disappointment, almost demoralization, with what medical practice had become.

The complaint was not financial but vocational — an incessant interference with their work, a deep erosion of their autonomy and authority, a transformation from physician to “provider.”

As one of them wrote, “My colleagues who have already left practice all say they still love patient care, being a doctor. They just couldn’t stand everything else.” By which he meant “a never-ending attack on the profession from government, insurance companies, and lawyers . . . progressively intrusive and usually unproductive rules and regulations,” topped by an electronic health records (EHR) mandate that produces nothing more than “billing and legal documents” — and degraded medicine.

How did this happen? I've personally advocated for EHR, RHIO's, Universal ID's, etc., since the early days of this blog. What went wrong?

Krauthammer continues:
And for what? The newly elected Barack Obama told the nation in 2009 that “it just won’t save billions of dollars” — $77 billion a year, promised the administration — “and thousands of jobs, it will save lives.” He then threw a cool $27 billion at going paperless by 2015.

It’s 2015 and what have we achieved? The $27 billion is gone, of course. The $77 billion in savings became a joke. Indeed, reported the Health and Human Services inspector general in 2014, “EHR technology can make it easier to commit fraud,” as in Medicare fraud, the copy-and-paste function allowing the instant filling of vast data fields, facilitating billing inflation.

That’s just the beginning of the losses. Consider the myriad small practices that, facing ruinous transition costs in equipment, software, training and time, have closed shop, gone bankrupt or been swallowed by some larger entity . . . Then there is the toll on doctors’ time and patient care. One study in the American Journal of Emergency Medicine found that emergency-room doctors spend 43 percent of their time entering electronic records information, 28 percent with patients. Another study found that family-practice physicians spend on average 48 minutes a day just entering clinical data.
The devil is in the details, in this case the implementation of the details. EMR should have been a boon to physicians and patients alike. No more duplicated tests or doubly-irradiating patients for a repeat CT. No matter where you go, your information should be easily retrieved, yes? Sadly, no. And all because of good intentions, well, we hope the intentions were good, gone bad:
The geniuses who rammed this through undoubtedly thought they were rationalizing health care. After all, banking went electronic. Why not medicine?

Because banks deal with nothing but data. They don’t listen to your heart or examine your groin. Clicking boxes on an endless electronic form turns the patient into a data machine and cancels out the subtlety of a doctor’s unique feel and judgment.
Yes, I'm from the government and I'm here to help you . . . So why is the federal effort a failure?
Because liberals in a hurry refuse to trust the self-interested wisdom of individual practitioners, who were already adopting EHR on their own, but gradually, organically, as the technology became ripe and the costs tolerable. Instead, Washington picked a date out of a hat and decreed: Digital by 2015.
And so, here we are today:
As with other such arbitrary arrogance, the results are not pretty. EHR is health care’s Solyndra. Many, no doubt, feasted nicely on the $27 billion, but the rest is waste: money squandered, patients neglected, good physicians demoralized.

Like my old classmates who signed up for patient care — which they still love — and now do data entry.
Although I have supported the concept of EMR, and particularly image sharing (ala lifeIMAGE), I have also said at least once a week for the past 10 years on this blog that poor software design is an impediment to actually enacting and using these things, EMR, PACS, RIS, etc. We are reminded on a daily, really an hourly, basis that these programs don't work as they should. They have NEVER worked as they should.

We radiologists tolerated the imperfect software because even a VERY imperfect viewer was a huge advance over film. As the late, great Douglas Adams said of the products of the fictional Sirius Cybernetics Corporation in the Hitchhiker's Guide series:
It is very easy to be blinded to the essential uselessness of them by the sense of achievement you get from getting them to work at all. . .In other words - and this is the rock solid principle on which the whole of the Corporation's Galaxy-wide success is founded - their fundamental design flaws are completely hidden by their superficial design flaws.
I'm sure Mr. Adams wasn't thinking of any Epically LarGE companies when he wrote that piece. But this is where we are. We physicians, radiologists particularly, have accepted utterly unusable software in the name of progress. Programs and equipment that should make our job of promoting the health of our patients easier instead get in the way of doing so. EHR's that should streamline the day-to-day practice of medicine do anything but.




In no small part, it is because the software is spec'ed, designed, created, bought and sold primarily by IT folks. And now, of course, the government is stepping in to "help". Those who actually USE the damn things are left out in the cold. And then these same wretches are blamed when patient care is negatively impacted.

This paradigm has to change. But it won't in my working lifetime. Or that of the hundreds and thousands of physicians who are bailing out.

Progress. Forward. Hope and Change. Just keep saying that to yourself when you have intractable pain and there aren't any doctors left to help you.

Monday, June 01, 2015

The Amoral Revolution In Western Values & Its Impact On Israel

Dalai's Note: The writer of this piece was Commander of the British Forces in Afghanistan. The following text is Col. Kemp’s address delivered at the Begin-Sadat Center for Strategic Studies on May 19, 2015. This version was published on I think this is a VERY important article.
As an officer cadet at Sandhurst in 1977, I studied the wars and campaigns of the Israel-Palestine conflict in great depth, learning lessons in leadership, tactics and strategy from the always victorious operations of the IDF.
Years before that, in my school playground, girls always shopped and boys played war. Normally it was British and Germans or cowboys and Indians. For a time in 1967 it became Israelis and Arabs. After a few weeks, however, it reverted to the usual antagonists because nobody seemed to want to play on the Arab side.
I gather a similar recruitment problem exists today in the playgrounds of England with the Taliban side short of troops.
At 8, I was a little young for the serious study of military science beyond the playground, but later, as a 14-year-old schoolboy, I remember one day during the Yom Kippur War, my form master, a young chap just out of teacher training, came into the classroom with an arm full of newspapers.
He said that normal lessons would stop as there was a ‘real war’ starting and that this was really exciting so we should study it. Every day, we followed the events, wrote stories of our own, and learnt the geography. My father was unamused when all of the articles about the war had been cut out before he could get his hands on his breakfast-time paper. We were quite disappointed when it finished quickly and we had to resume normal lessons.
Why am I telling you all this?
It was all about the good fighting the bad and the good were expected to win. It was very simple even to a 14-year-old.
Even as late as 1973, Israel was still widely seen as the good guys and the Arabs were the bad. Sympathy was with Israel because they were being picked on and bullied. There was little consideration of the ‘legitimacy’ of Israel; it was taken for granted.
In 1967, the capture and occupation of East Jerusalem, which of course we commemorated on Sunday as Jerusalem Day, and of Judea and Samaria were accepted as a legitimate act of self-defense.
This was not true just for those of us still at school and in the fledgling days of a military career. This was the general view of British people, and of many in the West, obviously with plenty of exceptions.
Back then, in the 60s and 70s, young minds were still being shaped by traditional views of good and evil. The Valiant comic, read by most schoolboys, was all about heroic Tommies beating the treacherous Nazis or the fanatical Japanese. War films on the whole told the same stories, and without the graphic violence of today.
We had The Longest Day, The Guns of Navarone and Zulu. The BBC was neutral, and if anything supported the values of the country that paid for it. On the whole, like other UK news services of the day, it sought to convey events from the Middle East and everywhere else free of a political agenda, left or right.
In general, popular culture still reflected the long accepted beliefs and principles of a Christian society. All of this shaped the views of the majority of people.
We live in a very different world today. In 40 years the general opinion of Israelis and their Arab foes has been reversed.
Israel’s stance is unchanged from 1948. A desire for the survival of the Jewish national homeland, at peace with its neighbours.
What has changed? Some say the situation is different. But this is not the case. Fundamentally the situation remains the same. Israel’s stance is unchanged from 1948. A desire for the survival of the Jewish national homeland, at peace with its neighbours.
All that has changed about this has been that Israel has made repeated costly concessions, including giving up land, for peace. Concessions which have not been reciprocated by the Palestinians, but instead exploited at the grave expense of Israel. Concessions which have not been acknowledged or remembered by the international community, who, like the Palestinians, simply and uncompromisingly demand more and more and more and more.
Nor have the Arabs fundamentally changed. We have of course peace treaties with Egypt and Jordan. And the growing threats from Iran and from expanding Sunni jihadism may be leading to some temporary and below the radar mutual cooperation from parts of the Arab world.
But the underlying perspective and agenda, especially among the Palestinians, is the same as it was in the 1920s, 1930s and 1940s. Rejection of Jewish communities in the land of Israel. The destruction of the Jewish State.
Some of the basic dynamics have altered. Before, organized, uniformed and relatively disciplined and conventional Arab armies fought under their national flag. Today the armies have been replaced by terrorist gangsters and black-cloaked jihadists. Conventional war has been replaced by terrorist attacks. Battles fought between tanks and infantry in remote deserts have been replaced by battles fought in densely populated civilian areas and behind the protection of human shields.
In my view if such events as the Gaza conflict last summer were played out in the 1960s and 70s, the support for Israel in the West would have been greater than it was even then. The savage and murderous actions of the Palestinians are far more shocking today.
So I again ask the question, what has changed? And the answer is: The morality and values of the West. They have been transformed almost beyond recognition.
As public opinion in the West in the 60s and 70s was influenced by popular culture, so it is today. Throughout most of the West, certainly in Europe, Judeo-Christian principles, honesty, family values, respect for the state, honour and loyalty have all been eroded, often beyond recognition.
Negative values, such as the acceptance of betrayal, duplicity and deceit, have flourished. Defining values including patriotism and religious faith have been undermined.
We have gone from the heroic Tommies of the Valiant comic to the promotion of the criminal underworld in Grand Theft Auto. From Guns of Navarone to the naked violence of Terminator 3.
The 80s ushered in the insidious campaign of political correctness and moral relativity that has over the last 30 years gripped and taken over so much of our society.
Balanced, level-headed, impartial reporting in our media has been replaced by sensationalism as the purpose of mass media has swung from informing, educating and edifying to making money – and only too often to making the news rather than just reporting it. These negative and destructive values are being promoted constantly in the media.
The values and morality of the average person in the West have changed dramatically since the 70s. The new values often have more in common with Israel’s enemies than with Israel itself.
We all know but rarely have the courage to say, that hypocrisy, duplicity, betrayal and sensationalism are the four cornerstones of violent radical Islam as so often demonstrated to us on our TV screens by Hamas and the Islamic State.
It is impossible to avoid a connection between the shift in public opinion on Israel and the change in Western morality.
How has the new morality impacted on public opinion and perception?
The shift in the way war is presented has complicated the issue. War is no longer the good guy fighting the bad with the good expected to win. Political correctness encourages individuals to say what they think is seen as acceptable and will not offend the majority, rather than what they actually believe. This perpetuates itself and can lead to wholly unacceptable beliefs being outwardly and widely accepted and becoming the received wisdom. The destruction of defining values mean that people will now accept physical acts that would before have been utterly abhorrent to them.
The media destruction and character assassination of strong, outspoken leaders has led to the rise of the ‘grey man’. Political leaders are often seen as weak and gutless and will not stake their reputations on making bold, uncompromising, principled statements or decisions. Instead they frequently take the safer middle ground.  The population tends to take on the mannerisms of their leaders also becoming ‘grey’.
Sensationalism and the graphic depiction of violence has made the population increasingly immune to the horrors of violent atrocities such as public beheadings, massacre, kidnap, execution, torture and forcing your own people to die as human shields. These acts are now less likely to swing public opinion towards the ‘good guys’.
The glorious fight for a noble cause inspired by Judeo-Christian values and beliefs and fought with honor and dignity, the like of which has preoccupied generations of British soldiers before me is now, regrettably, a thing of the past.
So many of these extraordinary changes have been influenced and even driven through by a media, especially broadcast media, especially television, that has to a very large extent been taken over and subverted by those with a moral relativism heightened by an abhorrence for the traditional Judeo-Christian values of the West and a desire to promote as superior the values of other cultures in a form of all-pervading post-Colonial guilt.
The target is Western values themselves; most often represented by the United States, the most powerful country in the world. But Israel has increasingly become a proxy for the United States. For three reasons.
Firstly, the US President and the US Government is at present left wing and liberal and thus harder for left-wing liberals to attack. Second, Israel is smaller and more easily bullied and impacted by corrosive media sniping than is a superpower. Third, Israel can be portrayed as a Western colonial outpost in a rightfully Arab world.
These three things are underpinned by a pervasive and increasing anti-Semitism which intensifies the obsession with Israel and its portrayal as a true evil to be attacked at every possible opportunity.
This contrasts with the post-Colonial guilt I mentioned, combined also with a frequent desire to appease violent Islam and promote its cause and values as being superior to our own and certainly to Israel’s.
Any anti-Islam comment or perspective cannot be tolerated, while anti-Jewish, anti-Zionist and anti-Israel perspectives are all acceptable and encouraged.
In turn these double-standards are reinforced by the grey man syndrome, the corrosive political correctness that I mentioned, under which the majority feel obliged to support Israel’s enemies, and oppose Israel, and feel nervous about not doing so.
History has proven time and again that Arab nations cannot defeat Israel on the field of battle, and this will always be the case. That is of course why the Palestinians have chosen to use terrorist methods to attack the civilian population rather than conventional military forces to attack Israel’s army. It is why Hamas fires missiles at Israel and digs attack tunnels.
These measures, like other terrorist attacks against the Israeli population are not designed to damage or defeat Israel because they cannot and their perpetrators know they cannot.
They are designed for two different purposes. The lesser purpose is to demonstrate to their own population and their supporters that they are fighting for them against an existential threat – the last bankrupt recourse of all troubled regimes.
They use human shields in the hope that Israel will attack and kill their people.
But the far greater purpose is to provoke the inevitable and unavoidable Israeli reaction.  Hamas and the other Palestinian terror groups don’t use human shields in the hope that Israel will refrain from attacking their rocket launchers, weapons dumps, command centers, terrorist bases or tunnel entrances. They use human shields in the hope that Israel will attack and kill their people.
They do this for one purpose: to gain the global condemnation of the State of Israel.
Their particular target is the media, which they know will magnify and intensify their message to the world and force national governments, the UN, human rights groups and other international organizations to bring down unbearable pressure onto Israel.
This can only work of course if the media and these global organizations are willing to be subverted by their message. Willing to see them as the victims and Israel as the demons.
Fatah and the Palestinian Authority have a similar strategy. Their violence is of a different nature. Incentivizing terror by paying terrorists and the families of terrorists killed or imprisoned for attacking Israelis. By inciting anti-Israel hatred through speeches, newspapers, broadcast media, school textbooks and school teachers.
Not only does this entrench anti-Israel feeling that will prevent the acceptance of a two-state solution or any form of peace and future cooperation with Israel, but it also has the effect of inciting violence against Israeli troops and Israeli civilians who live in Judea and Samaria, including rioting, stone-throwing, ramming, battering, stabbing and murder.
Again the aim of this is to provoke an unavoidable reaction in order to attract global condemnation of Israel and bring unbearable pressure onto the Jewish State.
The next stage for the Palestinian leadership of course is to exploit anti-Israel pressure through the United Nations, the International Criminal Court, the European Union, the universities, businesses, trade organizations and now even FIFA.
The goal of all this activity is to undermine the Jewish State but the primary strategy is executed through a conspiracy with a compliant and complicit media. It is the media that brings pressure onto government leaders and heads of international organizations, compelling them to act in their weakness and with their values undermined.
Many of course need little persuasion but even here the media provides them with the excuse, the motive and the cover. It was strongly biased media reports alleging Israeli atrocities against Palestinians that either forced or allowed leaders like the US President, the British Foreign Secretary, the French Prime Minister and the UN Secretary General to demand that Israel did more to protect innocent civilians in Gaza during the fighting last summer.
Never mentioning, suggesting or even hinting at what more they can do. Never acknowledging the context for the action. Never condemning Hamas for the actual war crimes of using civilian locations as military facilities, compelling citizens to remain, and failing in their legal duty to evacuate civilians from a military area.
It is the media, the agents of moral relativism, the tools of the Palestinian leadership that are Israel’s enemies in this conflict today. They can win over not just Western leaders but the public who are imbued with the new morality.
The media should of course get at the truth, and they should fearlessly expose wrongdoing and criminality from wherever it comes. While remaining even-handed, Western media should remain mindful of, and to an extent reflect, the values of the society that supports them, funds them and depends upon them.
And of course it is in the changing nature of these values at much of the problem lies as I have explained. It is not the role of the media, especially publicly-funded media, to undermine the values of their society. It is not the role of the media to turn a blind eye to wrong-doing, corruption, law-breaking and immorality of one side, while exaggerating, falsifying, distorting and over-emphasizing allegations of wrong-doing against the other.
In many cases, the major media organizations have moved from reporting the conflict to being active protagonists.
But in the Israeli-Palestinian conflict this is, with a few exceptions, exactly what they do. In many cases, the major media organizations have moved from reporting the conflict to being active protagonists.
Josef Stalin once famously asked: ‘How many divisions has the Pope?’ The term ‘press corps’ in relation to Israel has assumed a military meaning that was not previously intended. Like Stalin, we might ask: ‘How many corps has the press?’
The answer is that the effectiveness of the press in the Israeli-Palestine conflict, on the side of Israel’s enemies, is immense, probably immeasurable. When the media distort and mislead, when they turn a blind eye, when they paint a false picture, they must be considered culpable for the consequences.
For the violence that is provoked, especially in this region, when they falsely report massacres, intentional targeting of babies, war crimes. For the anti-Semitism, including violent anti-Semitic attacks, and the terrorism around the world that their false prospectus inspires.
They must share culpability for the consequences that follow when political leaders and human rights groups respond to the pressure that their distorted reporting piles on. For the legitimacy that their reports give to political factions around the world that are opposed to Israel. For encouraging terror tactics, war crimes, crimes against humanity and the use of human shields by blaming Israel for the deaths of civilians, rather than the terror groups who are actually responsible.
I am sure most of you could recount many examples of exactly what I am talking about from your own personal knowledge and experiences in some cases. I will give you just a couple of recent examples from my personal experience.
I had just finished an interview on the conflict in Afghanistan in the studios of a major international broadcaster in London. I left the studio and was accosted in the corridor by the network’s prominent Middle East correspondent, who said ‘I want to speak to you about what you say about Israel’.
I said ‘I wasn’t talking about Israel but about Afghanistan’. He said, ‘No but I want to speak to you about what you do say about Israel’. ‘What is it?’ I asked, expecting the worst. ‘I agree with every word you say,’ he said. ‘Then why don’t you say it?’ ‘Because if I did I’d be fired!’ he responded.
I was in Israel for the duration of the conflict last summer. I was probably in a better position to understand what was happening than any other non-Israeli Western military analyst. Yet despite many offers to British, European and American networks I was not asked to do a single interview with the exception of Fox News in the US.
Why? Because I am a regular contributor of analysis to most of these networks on defence, security, terrorism and intelligence. They portray me as a reliable and trusted commentator. But they know that my perspective on Israel is objective and therefore contradicts their own political agendas. They cannot undermine me and therefore they simply do not give me air time on this issue.
I have been accused of supporting genocide and being an apologist for war crimes.  But in reality I have spent much of my life trying to prevent terrorist violence and attacks against innocent civilians and have often risked my own life to do so. I have been involved in peace-keeping operations and have physically intervened in situations where ethnic cleansing has been threatened.
In social media I have been the subject of sustained assaults by particularly virulent anti-Israel networks that I shall not name as I do not wish to give them the benefit of any publicity. I have had my words willfully distorted and falsified in the social media, even as recently as last night.
In universities I have been the subject of demonstrations that have sought to silence me. Most recently in the University of Sydney last month.
I have been subjected to virulent anti-Semitic hatred and threats. I have been placed on a terrorist death list.
I have been publicly accused of corruption and being in the pay of the Zionist entity. I have been deliberately denied business opportunities. I have been subjected to virulent anti-Semitic hatred and threats. I have been placed on a terrorist death list.
Why is this? It is not because I speak out against the moral bankruptcy, corruption, incitement to terrorism or oppression of the Palestinian Authority; or the murder, brutality and terrorist violence of Hamas, Hizballah or the Palestinian Islamic Jihad. I have spoken out at least as much against Al Qaida, the Taliban, the Iranian regime, the IRGC and many other sponsors of terror and terrorist groups without anything like this level of attempted intimidation.
It is for one reason, and that is because I fail to falsely condemn Israel in circumstances where to even be neutral on the subject is itself a crime in the eyes of so many. It is because I have gone further, and used my military experience and my objective view to explain and defend Israel’s legitimate military actions.
Of course in the eyes of many in this region this is already heinous in and of itself. But it is only heinous in the Western world because of the distortions of the media that amplifies the message and helps mobilize a public that it has persuaded to reject traditional values and adopt a new politically-correct moral relativity.
How do we fight this new form of political warfare where so much of the media is the enemy?
As with all battles we must conduct both defensive and offensive operations. The defense in this case of course revolves around doing what we can to ensure that the truth is made known. Both the truth about Israel’s enemies and how they act; and the truth about Israel and how its forces operate.
This must of course be the truth, I am not suggesting false propaganda. I include in this truth, open admissions when errors and wrong-doing take place, including and especially when innocent people die as a consequence.
This is one of the many things that separate us out from our enemies who so often refuse to tell or report the truth.
The offence in this form of political warfare is in exposing the bias, distortions, and untruth of the media. This is much more difficult but it is vital. As in all forms of war, the best form of defense is attack. Without effective offensive action our defensive work will succeed much less and can never produce decisive results.
Some good and vital work is already being done by a range of groups. But their effects remain limited. This campaign has had much tactical success and needs to continue and if possible to intensify. But so far there has been no real strategic impact. Nothing that has forced major media networks to fundamentally re-think their anti-Israel agenda.
Of course strategic effect requires strategic assets. And by strategic assets I mean the combination of significant funds, concerted and sustained will and large-scale, thoroughly planned and carefully-focused effort. The challenge is of course immense, and as with any battle, there is no guarantee of success.
As for myself I have gone through the transmutation from Infantry officer to fighter in this new form of political warfare.
The danger that Israel faces and that the media projects extends far beyond Israel, and threatens us all.
Much of my fight, as was recognized yesterday in the honour graciously and generously bestowed upon me here at Bar-Ilan University, is a fight for Israel. The warm support, encouragement and friendship of this great seat of learning will help to sustain me and to renew my vigor in this fight for Israel and for freedom that I shall never give up.
But to fight for Israel on the international media stage is also to fight for the values of democracy, freedom of speech and expression, and civilized social values everywhere. All of the principles and virtues that once made Britain great.
Make no mistake. This afternoon I have spoken about Israel’s fight. But the danger that Israel faces and that the media projects extends far beyond Israel, and threatens us all.
We should never forget the words of Pastor Martin Niemoller: “When they came for the Jews I did not speak out – because I was not a Jew. Then they came for me – and there was no-one left to speak for me.”
Israel’s fight is the Western world’s fight. Upon Israel’s survival depends the survival of Western civilization.
Do you agree or disagree with Col. Kemp’s analysis? Let us know what you think in the comment section below.
Col. Kemp’s 40 minute address can be viewed here.