1. Featured Article: A Tale Of Two Bridges
The SF Oakland Bay Bridge open in 2013 and is showing water damage and rust its first year.
The old rusty bridge it replaces was built in 1936 and has survived earthquakes.
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As Montreal bridges, however, the Jacques Cartier far outshines the Champlain. Most obviously, the Jacques Cartier was opened to traffic in 1930 and is still in good shape 80 years later. The Champlain was opened to traffic in 1962 and is falling apart only 50 years down the road. Their histories—and today’s proposals for rebuilding the Champlain—are a sad indictment of how some things have changed for the worse in Canada over the last hundred years. Read more . . .
The ground breaking ceremony for the Jacques Cartier Bridge was held on May 26, 1925, according to the website of The Jacques Cartier and Champlain Bridges Incorporated (JCCBI), the crown corporation that has managed and maintained—or failed to maintain—both bridges since 1978. The Jacques Cartier was completed almost a year and a half ahead of schedule, in December 1929 instead of May 1931, as planned. It cost $20 million to build, the equivalent of around $262 million in today’s money, according to the Bank of Canada’s Inflation Calculator |
http://www.quebecoislibre.org/11/110915-9.html
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2. In the News: A Tax-limiting Amendment
What If Congress Raised Taxes And Nobody Cared -- Or Even Noticed?
Joseph Thorndike , Forbes Contributor
Two years ago, Congress raised taxes on almost every working American – and nobody cared. In fact, a lot of people didn’t even notice. That tells us something important about the way Americans view taxes. But it also tells us something important about how we collect them.
In 2011 and 2012, Congress cut the Social Security payroll tax by two points. More specifically, lawmakers reduced the portion of the tax levied on employees from 6.2% of taxable wages to 4.2%. (The portion paid by employers remained at 6.2%; most economists believe that this other half of the tax is also ultimately borne by workers in the form of lower wages.)
The payroll tax cut was explicitly designed to be temporary – a one-year shot in the arm for the struggling economy. After a year, lawmakers agreed to extend the cut for another 12 months. But on January 1, 2013, the payroll cut expired, and workers began paying the full 6.2% again.
And hardly anybody noticed. Read more . . .
Asked in early 2013 whether their payroll taxes had changed, 55.6% of respondents to a Google Consumer Survey said they didn’t know. Only 28.9% had actually noticed the increase. (To round things out, 8.3% said the tax had remained the same and 7.1% thought it had fallen.)
Dean Baker of the Center for Economic and Policy Research, which commissioned the survey, found these results illuminating. “Let’s face it,” he said. “The public cannot be too upset by tax increases if they don’t even notice when they take place.” Baker suggested that the poll results might even point the way toward a long-term fix for the (eventual) shortfall in the Social Security funding:
These survey results suggest that the public may not be especially adverse to a modest increase in the payroll tax, since they may not even notice it. This supports the findings of other polls that indicate that most Americans favor strengthening Social Security through revenue increases, such as raising the payroll tax rate or the cap on taxable wages.
Baker is probably right. As he noted, the 2013 tax increase was especially dramatic, implemented in a single large jump rather than a series of small increases. If that sort of hike didn’t raise hackles, then smaller, phased-in increases would probably be even less controversial.
In addition, the payroll tax has always been relatively well tolerated by Americans. In surveys asking Americans to rank various levies by their desirability, the payroll tax places near the middle of the pack – below “sin taxes” on alcohol and tobacco but above property, sales, and individual income taxes. (For a great roundup of popular opinion on taxes, take a look at the American Enterprise Institute’s “Public Opinion on Taxes: 1937 to Today.”)
The relative popularity of the Social Security tax probably derives from the popularity of Social Security benefits. Unlike most elements of the federal tax system (and especially unlike other big-money revenue raisers), the payroll tax makes a clear connection between taxes paid and benefits received. Indeed, that tight connection leads some people to view the payroll tax (incorrectly, in my view) as a sort of insurance premium.
But there’s another element of the payroll tax that also contributes to its popularity — its invisibility. For most people, the tax is automatically withheld rather than consciously paid. That’s no small thing. Withholding makes taxpaying a lot less painful – as anyone who makes estimated tax payments can readily attest. When you have to sit down and write the government a check every quarter, you start paying attention to the cost of government – and who’s paying for it.
Small-government conservatives are well aware of this. Mark C. Schug, an emeritus professor at the University of Wisconsin-Milwaukee, recently made the case for abolishing withholding entirely (he focuses on individual income taxes, but the argument applies equally well to the Social Security levy).
When people have their taxes withheld from their paychecks, Schug wrote for The Hill, they’re less inclined to get mad about paying them. And that leads to passivity and (eventually) the inexorable growth of government:
Taxpayers are inclined to look at the bottom line and pay little attention to how much of their salary or wages are actually taken by government. It’s like money they never saw. The pain comes in one or two drops at a time – not in a torrent each quarter.
Schug argued for keeping taxpayers on the hot seat. “Once people see how much they actually owe the government each quarter, there will be a tax rebellion that will make the Tea Party look like child’s play,” he predicted.
That’s almost certainly true. But it’s also true that withholding is not going away. It’s a fundamental element of the American state – and a key explanation for its growth. And while that makes it a tempting target for anti-state ideologues, it also makes it entirely secure.
Invisible taxes are the life blood of the Tax – Spend – Regulate members of our society that abhor the liberties enumerated in our Declaration of Independence and Guaranteed by our Constitution.
The
T – S – R’s
more likely than not represent approximately 70-80% of the Democratic Party and
20-30% of the Republican Party and 0% of the Libertarian Party.
What is a fair tax structure? The T-S-Rs have no limit. The Reader’s Digest once published a poll on this. It came back as the total tax structure for a combination of the Federal, State and local taxes should never exceed 25% of your earnings. That was in the ERA of a marginal tax rate of 91%. I asked one of my patients who always felt that the rich should pay more. It looks like you think the rich can pay 100%? He said “absolutely.” I then asked him if he thought the rich should pay 200%? He said “absolutely.” So there will never be a limit that the T-S-Rs will accept. So we have to have a Constitutional Amendment to limit taxes.
How about each level of government having a limit of two taxes? The Feds could have an income tax of 15% and an excise tax on interstate and import commerce of 10%.
How about giving the states a 5% income tax limit and a 5% sales tax limit?
How about giving the city and local government a 1% property tax and 5% sales tax limit?
I know that’s more total than the 25% poll from Reader’s Digest of yesteryear? But wouldn’t that be a good start and maybe a good ending also?
State after state would approve this. It may have to start in the states and thus work back to the Feds which would then have to abide by it.
Any comments? Send to medicaltuesday@earthlink.net
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3. International Medicine: The Republic of Georgia chose to outsource regulation.
How to Make Medicine Safe and Cheap
By Steve H. Hanke, Alexander B. Rose, and Stephen J. K. Walter
Assuring that affordable, high-quality drug therapies are available in poor countries is a priority for policymakers, scholars, and advocacy groups around the world. However, there is little agreement over how to achieve that goal. Some see international arbitrage as a solution. Its proponents would allow firms to buy patented, trademarked, or copyrighted goods in countries where prices are low (perhaps because of local price controls or lower wholesale prices set by manufacturers) and re-sell them in higher-price countries without the permission of the owner of the intellectual property rights attached to the goods.
They argue, among other things, that such behavior enhances competition in international markets and thus improves welfare, especially for lower-income consumers.
This view alarms many scholars, especially when such “parallel trade” (meaning the goods in question sometimes travel a parallel route out of the manufacturing country and then back again) involves pharmaceuticals. They note that developing and obtaining regulatory approval for new drugs frequently involve enormous fixed costs and low marginal costs of production. Read more . . .
Recovering the fixed costs while maximizing the gains from exchange commonly requires not a uniform price across markets and countries but, rather, adept price discrimination. These scholars claim that “Ramsey pricing”—higher prices in affluent countries where demand for pharmaceuticals is inelastic, and much lower prices in poorer countries where demand is more elastic—would maximize welfare and be more likely to recover fixed and marginal costs. They warn that allowing parallel trade would cause prices to fall toward marginal costs everywhere, disrupting the Ramsey pricing scheme and reducing research and development investment and innovation. To avoid that, the scholars say, drug companies likely would stop giving discounts to low-income nations—or leave them unserved altogether.
As befits a topic that is both controversial and important, volumes have been written about the advisability of allowing parallel imports, but much of this work is theoretical. There have been few assessments of the actual effects of this phenomenon, especially in developing countries. In this brief case study, we contribute to this sparse empirical literature by examining the reasons for and consequences of international arbitrage of medicines in the Republic of Georgia, which encouraged the practice via regulatory reforms starting in late 2009.
We find that the regulatory environment and market conditions in a particular country will be key factors in determining whether parallel trade in pharmaceuticals (and presumably other goods for which intellectual property rights issues are important) might be welfare-enhancing. Specifically, Georgia’s experience demonstrates that the nature of institutions in a small, developing nation can lead to noncompetitive pricing in local markets, and that regulatory changes—in this case, outsourcing some key processes—that facilitate arbitrage can deliver major benefits to consumers without, apparently, disturbing manufacturers’ pricing policies or adversely affecting cost recoupment for R&D efforts. . .
Concluding Remarks
Though there are many reasons to be concerned about possible ill side-effects of expanded international arbitrage of pharmaceuticals, the regulatory reforms that enhanced such trade in Georgia must be counted as a success—at least thus far—and should be instructive for other developing countries.
Georgia did not simply jettison regulation and invite unfettered parallel imports of drugs. Rather, the country removed some regulatory barriers to competition that had, by creating and maintaining oligopoly power among its largest pharmaceutical firms, inflated domestic prices. By farming out some regulatory duties to bodies in larger, wealthier states, Georgia’s reforms quickly and significantly reduced prices of essential medicines to consumers by making market entry easier and less costly. Thus, price relief came in this case not because parallel trade disturbed an intricate international price discrimination scheme on which R&D cost recoupment and further innovation depend, but simply by enhancing domestic competition.
Of course, the efficiencies resulting from this reform should not be terribly surprising. As noted earlier, Georgia is about as populous as the Phoenix metropolitan area. If Phoenix officials decided they did not trust the U.S. Food and Drug Administration to regulate drug safety and efficacy, and the city set up its own regulatory apparatus, it would be obvious that such needless duplication would significantly increase costs for local distributors and retailers. The added (fixed) compliance costs would tilt the competitive playing field in favor of large-scale local enterprises.
There would be an immediate hue and cry to “open up the Phoenix market” to parallel trade, and doing so would likely have effects every bit as favorable as those demonstrated here for Georgia, and without adverse effects on the behavior of innovators. . .
Read the entire report at Cato . . . .
Steve H. Hanke is a professor of applied economics and co-director of the Institute for Applied Economics, Global Health, and the Study of Business Enterprise (IAEGHSBE) at the Johns Hopkins University. He is also a senior fellow at the Cato Institute. Alexander B. Rose is a research assistant at IAEGHSBE. Stephen J. K. Walters is a professor of economics at Loyola University Maryland and a fellow at IAEGHSBE
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4. Medicare: The Patient Friendly Medicare Program may Not be so Patient Friendly
- Medicare is essentially compulsory.
People who refuse to join Medicare Part A are not allowed to receive their earned Social Security benefits.1 Brian Hall, et al. v. Kathleen Sebelius, et al, was filed October 9, 2008 and appealed June 14, 2011.
On June 30, 2011, U.S. Sen. Jim DeMint and 12 GOP colleagues introduced the Retirement Freedom Act to decouple Medicare from Social Security.2 On February 7, 2012, the D.C. Circuit Court of Appeals held that “because plaintiffs are entitled to Social Security benefits and are 65 or older, they are automatically entitled to Medicare Part A benefits. The statute offers no path to disclaim their legal entitlement to Medicare Part A benefits.”3
- Medicare patients cannot pay cash for care. Read more . . .
A 1997 law (Balanced Budget Act, section 4507) forbids private contracts between patients and doctors. With few exceptions, Medicare recipients cannot pay cash for a Medicare-covered service that Medicare denies until the doctor has opted out of Medicare.4 Most physicians cannot afford to opt out. Obamacare cut $716 billion from Medicare5 and enacted two administrative panels that are expected to advance rationing: the Independent Payment Advisory Board (IPAB)6 and the Patient-Centered Outcomes Research Institute (PCORI).7
- Initial refusal to enroll in Medicare Part B leads to costly penalties.
Seniors are automatically enrolled in Medicare Part B. Those who refuse and later change their minds will pay a premium for the rest of their lives that is 10 percent higher for each year they were not enrolled.8
- Citizens do not have a right to their Medicare contributions (payroll taxes)
There is no binding contract between the government and citizens for future payment of Medicare benefits.9 Congress can alter or eliminate Medicare benefits at its discretion.
- Medicare comes in four parts.
Part A (hospitalization insurance) is funded through payroll taxes.10 In 2010, Obamacare increased the payroll tax for individuals earning more than $200,000 and couples earning more than $250,000.11
In 2006, Part B (coverage for physician services, diagnostic tests, and other services) was funded approximately 76% by federal income taxes and 21 percent by Medicare recipients.12
Under Part C, the Medicare Advantage HMO managed care plan, insurers receive approximately $800 per month per Medicare enrollee (12-18% more per individual than in traditional Medicare).13
Part D allows senior citizens to pay for and receive subsidized drug coverage.14
6. Medicare dependency is growing. In 2003, there were 42 million Medicare recipients.15 In
2010, there were 46.5 million recipients.16 In 2011, the first of 77 million baby boomers began entering Medicare.17
7. Medicare is heading toward bankruptcy. In 1965, 4.6 workers/taxpayers supported each Medicare recipient.18 In 2005, 3.8 workers supported each recipient.19 In 2010, there were less than three workers per retiree. In 2030, only 2.3 workers/taxpayers are estimated per Medicare recipient.20 Medicare is expected to grow from 3.7% of GDP in 2011 to 5.7% in 2035 to 6.7% of GDP by 2086.21
8. Medicare is not health insurance. Medicare does not pay for hospitalization longer than 150
days, and there is no cap on out-of-pocket expenses.22 “Medigap” insurance is often
purchased to cover out-of-pocket costs, including coinsurance and copays, and to protect
against huge medical bills not covered by Medicare. In 2011, there is a choice of ten
standardized Medigap policies.23
9. Medicare Advantage is HMO coverage. With the 1965 enactment of Medicare, 19 million
seniors received free access to health care without having paid a penny for it. To stem the run
on the U.S. Treasury, the HMO Act of 1973 was enacted, providing $375 million for the
development of HMOs nationwide and the eventual placement of Medicare recipients into
HMOs to limit access to care.24
10. Medicare recipients pay much less in Medicare taxes than they receive in care. An
average-wage, two income couple together earning $89,000 a year that retires in 2011 will
have paid $114,000 in Medicare payroll taxes and can expect to receive services, including
prescriptions, worth $355,000.25
Read all 17 Medicare Facts at http://www.cchfreedom.org/pdf/17%20Medicare%20Facts.pdf
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Government is not the solution to our problems, government is the problem.
- Ronald Reagan
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5. Medical Gluttony: HMOs practicing parallel medicine and interfering with patient care
Health Maintenance Organizations are becoming more aggressive in taking over the health care of the insured. They have unobtrusively sent physicians, who are not the patient’s personal physician, to visit our patients, interview them, examine them, do very detailed personal/social interviews, make various and sundry recommendations about their habits, medications, their diets, drinking, and other behavior. Read more . . .
Our patients are complaining about this intrusion into their lives at home and some have said the “traveling doctor” stated their purpose was to do the annual physical examination recommended by Medicare but not done by their personal physician (Their PCP). Some have shown the “HMO” doctor to the door. Others have been able to intercept and avoid this intrusion on the phone when the HMO calls to make the “Medicare approved” call. One felt this must be a very high level government Medicare supervising physician to check for incompetence. After understanding the interview, as recalled by the patient, it appears that some of the recommendations were inappropriate and actually reduced the level and quality of care. The patient then realized that the incompetency lay with the HMO government Medicare doctor and then wanted to take legal action against Medicare. We were successful in squelching this.
Since HMOs are squeezing doctor reimbursement, this extra HMO money for professional services rightly belongs to the treating physician. What is the real message the is being rendered? HMO’s receive the patient care money and feel free to divvy it up as they see fit? Why is the personal physician being overrun? Splitting the professional portion of the reimbursement from the insurance coverage to a non-treating HMO physician is totally unethical. The HMO is no longer supporting its own physician members. It looks like another reason to get out of HMOs. But where is our exit?
If this is indeed Medicare authorized or induced, Medicare is no longer on the physician side of the health care equation. Then the combination of Medicare advantage which teams Medicare with HMOs with regulatory power, is no longer physician friendly, and physicians should no longer participate. But where is our Exit?
But this whole problem and misunderstanding is primarily on the Regulatory side, whether, Medicare, Medicaid, private insurance, HMO, Congress, the White House, or entities yet unknown.
Healthcare was personal, affordable from antiquity until the 1950s when the government illiterates became involved. Physicians, being a trustworthy and patient oriented group hardly noticed. As our professional organization became more political involved, physicians couldn’t comprehend that our friends were no longer our friends, much less working against us. Many physicians never comprehended that when our representatives stated a big advantage was their advocating for us. Many of us never realized that they were not advocating for the private practice of medicine, but for government medicine, for single payer medicine, for socialized medicine, and more recently for Obamacare.
HMOs, having a second doctor on every patient who makes house calls and a complete medical evaluation, must double the cost of healthcare. House calls, in and of themselves, are more time consuming than office calls, generally two to three times as long, particularly if the second patient is more than 20 minutes away from the first patient. The HMO executives need to attend a conference of the Lean Medicine Institute since they seem to be going in the opposite and more costly direction, not to mention their distrust of their own panel of physicians.
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Medical Gluttony thrives in Government and Health Insurance Programs.
It Disappears with Appropriate Deductibles and Co-payments on Every Service.
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6. Medical Myths: You can keep your insurance and doctor and save money with Obamacare
Medicaid surge triggers cost concerns for states
By Ricardo Alonso-Zaldivar
| Associated Press May 27, 2014
WASHINGTON — From California to Rhode Island, states are confronting new concerns that their Medicaid costs will rise as a result of the federal health care law.
That’s likely to revive the debate about how federal decisions can saddle states with unanticipated expenses.
Before President Obama’s law expanded Medicaid eligibility, millions of people who were already entitled to its safety-net coverage were not enrolled. Those same people are now signing up in unexpectedly high numbers, partly because of publicity about getting insured under the law. Read more . .
. . . the catch is that they must use more of their own money to cover this particular group.
In California, Democratic Governor Jerry Brown’s recent budget projected an additional $1.2 billion spending on Medi-Cal, the state’s version of Medicaid, due in part to surging numbers. State officials say about 300,000 more already-eligible Californians are expected to enroll than was estimated last fall.
‘‘Our policy goal is to get people covered, so in that sense it’s a success,’’ said state legislator Richard Pan, a Democrat who heads the California State Assembly’s health committee. ‘‘We are going to have to deal with how to support the success.’’
Online exchanges that offer subsidized private insurance are just one part of the health care law’s push to expand coverage. The other part is Medicaid, and it has two components.
First, the law allows states to expand Medicaid eligibility to people with incomes up to 138 percent of the federal poverty line, about $16,100 for an individual. Washington pays the entire cost for that group through 2016, gradually phasing down to a 90 percent share. About half the states have accepted the offer to expand coverage in this way.
But whether or not a state expands Medicaid, all states are on the hook for a significantly bigger share of costs when it comes to people who were Medicaid-eligible under previous law. The federal government’s share for this group averages about 60 percent nationally. In California, it’s about a 50-50 split, so for each previously eligible resident who signs up, the state has to pony up half the cost.
There could be many reasons why people didn’t sign up in the past.
They may have simply been unaware. Some may not have needed coverage. Others see a social stigma attached to the program. But now virtually everyone in the country is required to have coverage or risk fines.
Read the full article in the Boston Globe . . .
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Medical Myths originate when someone else pays the medical bills.
Myths disappear when Patients pay Appropriate Deductibles and Co-payments on Every Service.
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7. Overheard in the Medical Staff Lounge: Repeal & Replaced are two dangerous words.
Dr. Rosen: The T-S-R folks are searching for new items to levy taxes on. Obama care has latched on to medical equipment as a new revenue source.
Dr. Edwards: That should be one of the first items that the new congress repeals. That’s an unnecessary cost for health care which in turn is used for other government largess.
Dr. Milton: What about the new taxes on the Internet for interstate commerce items? Catalog items , which is a similar trade, have been free of taxes for a long time if they were sent interstate.
Dr. Rosen: The volume of catalog items has never been increasing at a rate that interstate items have increased in recent years. Government Taxing authorities are seeing internet sales as a gold mine for increasing their revenue and power.
Dr. Dave: And for enlarging the size and inefficiency of government which in turn will also increase our personal income taxes as well as other taxes.
Dr. Rosen: We were in SF last week and it’s always enlightening what the center of the T-S-R folks are doing. Condo owners are complaining that the taxes on their parking space is equal to the taxes on their condo. The owners complained that is not their understanding of the intent of the last SF initiative. The city stated that was the way they understood the law. The condo owners asked how could they appeal? The city said, “There is no appeal. Your parking space has a separate parcel number and therefore is subject to the same taxes as your condo”
Dr. Edwards: What a devious way to double your taxes!
Dr. Dave: How can we stop this runaway government?
Dr. Rosen: That’s not all. They also tax the size of your roof in addition to the size of your house.
Dr. Edwards: I don’t think this can be stopped outside of the political realm. We have make sure to reduce the number of sympathetic T-S-R folks in Congress and the Legislatures.
Dr. Milton: We have to be very careful not to over react. Otherwise the election two years from now could go the other way.
Dr. Rosen: I completely agree. I think the two most dangerous words the conservative use about the new health care fiasco is “Repeal and Replace.” No one has designed the “Replacement” yet that the people will support.
Dr, Edwards: That’s why we have to chip away in increments, like the tax on medical equipment.
Dr. Rosen: Remember President Ronald Reagan. I’m sure he would have like to repeal Social Security and Medicare and Medicaid. But having people on SSD be reexamined saved a lot of money. Most work injuries don’t last a lifetime but generally just a few years. So he was able to remove a large number of people who no longer were disabled from the disability roles. That was a big savings to tax payers.
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The Staff Lounge Is Where Unfiltered Opinions Are Heard.
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8. Voices of Medicine: A Review of Medical Journal Articles: The Dilemma of Speaking Up
Primum Non Tacere: An Ethics of Speaking Up
By Dwyer, James
Academic journal article
The Hastings Center Report , Vol. 24, No. 1 , January-February 1994
PEER-REVIEWED PERIODICAL
Article excerpt
During the last five years I have conducted ethics courses, seminars, and case conferences for medical students. I have also had many informal discussions with students at all stages of their medical training. Yet I am still surprised by how many students know and refer to the Hippocratic maxim to do no harm. Some even cite the Latin version: Primum non nocere. I wish, however, that more medical students would also keep in mind a Socratic maxim: Primum non tacere. First, do not be silent.
When I encourage students to articulate ethical issues that they face as students, they often describe situations where they must decide whether to speak up or keep quiet. The following are cases that students have described and that I have altered somewhat and then formulated from a student's perspective. Read more . . .
1. Spos (acronym for "subhuman piece of shit").[1] Before I entered medical school I read House of God, but I didn't find it very amusing. I was troubled by the attitudes the characters displayed, and I told myself that I would try to be more respectful of patients. I assumed that speaking about patients in derogatory terms was a fad that would be over by the time I began my clerkships at the hospital. That was not the case. During my first rotation my resident presented me with a new admission: "Here's your patient. He's a forty-year-old Hispanic male, a shooter, a real spos."
I wondered whether I should say anything. I didn't like that language and the attitude it displayed, but it wasn't my job to train the house staff. On the other hand, if I didn't say anything, I'd seem to accept the judgments and attitudes I want to avoid.
2. Informed Consent.[2] I always thought that informed consent was integral to the doctor-patient relationship, that it was really one aspect of good communication with patients. Yet some people view it differently, as a bureaucratic hassle imposed by people outside medicine. This difference became painfully clear during my first week in the clerkship. My resident told me to "consent" one of his patients. This was my second day. I had never met the patient and had no idea what the risks of the proposed procedure were. So I politely asked my resident about the risks, but he told me with a slight sense of annoyance that the patient will sign anything. What were my choices? I could say something to the resident I could just get the signature. I could look up the procedure in a textbook. Or I could ask someone who might explain the procedure to me. In fact, I asked another resident who told me a bit about the procedure.
An hour later my resident saw me again and said that the team had decided to include a second procedure. He told me to simply write the second procedure onto the form and to use the same pen. I didn't want to be party to this sham, but I also didn't want to jeopardize my grade.
3. Practice Makes Perfect.[3] I understand that this hospital is a teaching hospital and that students, residents, and fellows are here to learn. The fact that we learn on patients means that some patients are subjected to additional pain, inconvenience, and physical examinations. I guess there's a kind of bargain: we learn medicine on people who are mostly poor, and they get care they might not otherwise have access to. Whether or not this arrangement is fair, I've come to accept it. But I never imagined that people would practice a procedure that wasn't medically indicated.
Late one night I was working with a resident in the labor and delivery room. The patient was in labor, and the resident decided to do a forceps delivery. I didn't see the indication. The woman didn't seem very fatigued, and there were no apparent complications. I didn't know the exact statistics, but I was sure that a forceps delivery involved some risk to die fetus. I didn't know what to do. If I asked what the indications were, the resident was sure to have some rationalization. If I told an attending physician the next day, I'd create a lot of trouble and no good would come of it. …
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VOM Is an Insider's View of What Doctors are Thinking, Saying and Writing
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9. Book Review: Extreme Medicine: by Kevin Fong, MD
CURRENT BOOKS | Miraculous Medical Tales | by Brien A. Seeley, MD
Extreme Medicine: How Exploration
Transformed Medicine in the Twentieth Century,
Kevin Fong, MD, Penguin (2014) | 304 pages,
It’s amazing what a body can stand —Third-year resident
observation
My Father-in-law, the late Dr. Lyle Powell Jr., taught me the axiom that “to best understand something complex, one should examine its extremes.” This examination not only clarifies the thing’s limits; it reveals what inner workings impose those limits. That revelation is precisely the result when this axiom is applied to human physiology by Dr. Kevin Fong in his engaging new book, Extreme Medicine.
Fong’s book provides the reader with a fascinating tour of the emergence of modern medicine from a brutish past in which war, disaster, epidemics and the perils of exploration all pressed pioneering physicians to try new things. Fong is a master storyteller, and his prose delivers a captivating and punchy mix that is part Discovery Channel and part Rod Serling. His writing style bespeaks of British formality, impeccably correct and at times reminding one of a dialogue in Downton Abbey. His medical training in London gives much of the book the tone of a lecture by an emeritus professor. Yet his tales have a dramatic and personalized intimacy, both from his own experiences and those of real historical figures. These stories are thrilling. They put the reader right there, as if personally confronting the acute, life-threatening medical problem and having to make the daring decisions about what should be done. Read more . . .
Extreme Medicine will reward both lay readers and those in the medical profession. For physicians, this book will summon again the awe and “aha” that we felt at the new insights into human physiology that were bestowed upon us during our medical training. When Fong recounts the frantic, midnight rush to respond to a code blue crash-cart experience, he instantly transports the physician reader back to those breathtaking codes that we attended as interns, where some of those insights were etched into us.
Time and again, Fong removes the reader from the immediate crisis to the comfort of a crystal-clear, academic retelling of the underlying physiology that pertains. This technique is quite effective, and it intensifies our appreciation for the importance of the miraculous cellular and molecular workings of human physiology. As such, this book will improve every physician who reads it.
Fong was born and raised in the UK. He has an ideal résumé for writing this book, with degrees in both astrophysics and medicine from University College London (UCL) as well as a degree in astronautics and space engineering from Cranfield University. He worked with NASA at the Johnson Space Center, as well as serving as medical officer for deep-sea diving expeditions. He completed training as an anesthesiologist and now teaches as honorary senior lecturer in physiology at UCL.
Fong begins Extreme Medicine with a thoughtful description of what life really is, deconstructing it as an active, organized storing of potential energy as charged ions are corralled behind a cell membrane, and then the periodic release of that energy when those ions cross the membrane with purposeful effect. This struggle against entropy, this straining to postpone collapse into equilibrium, is what makes us us, he says. Such a fundamental definition of life exemplifies the depth that Fong applies to his other explanations in the book.
Fong vividly sets the scene in each of a series of cases in which the intrepid doctors of yore are forced to solve terrible medical problems by trial and error. What emerges from the ways in which pioneering doctors deal with freezing, drowning, burning, dismemberment, shock and weightlessness are discoveries that make modern medicine the miraculous thing it is today. Each case is told with dramatic detail, such as that of Tom Gleave, an RAF fighter pilot in World War II whose Hawker Hurricane, when struck by machine gun fire from a German bomber, catches fire and inflicts Gleave with severe burns before he can bail out. The following excerpt conveys Fong’s writing talents and the intensity of his subject:
Gleave glanced down. Flames were pushing into the right side of the cockpit from below; the fuel tank buried in the root of his starboard wing was alight. He rocked the Hurricane hard and slipped it sideways in the vain hope that this would somehow quell the fire. But the flames only grew fiercer, wrapping around his feet and climbing to reach his shoulders. Plywood and fabric burst rapidly into flames around him, accelerated by fuel from the breached tanks. In a few short seconds, the center of Gleave’s cockpit had become the head of a blowtorch. The aluminum sheet in which the dials of his control panel were set began to melt. But he was far too high to ditch the aircraft; there was nothing he could do but attempt to bail out.
Fong goes on to describe Gleave’s miraculous survival and arduous recovery after extensive, pioneering plastic surgery, including breakthrough techniques in preserving graft vascularity. He includes other examples of burn therapy and reconstruction that exemplify the enormous medical progress driven by injuries in war and industrial accidents. . .
Extreme Medicine is also available as an audio book, a 6-CD set elegantly narrated by the very British Jonathan Cowley. The audio book can be enjoyed by busy physicians while driving a car.
I highly recommend this book to anyone who wants to better understand the body in which they live. ::
Dr. Seeley, a Santa Rosa ophthalmologist, serves on the SCMA Editorial Board.
Email: cafe400@sonic.net
This book review is found at Sonoma Medicine . . .
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The Book Review Section Is an Insider’s View of What Doctors are Reading.
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10. Hippocrates & His Kin: Doctors Continue to become more irrelevant
Pharmaceutical companies are now bypassing physicians in hospital based practices and are making calls on the hospital administrators instead.
Another incursion on physicians by medical illiterate administrators influencing the freedom to treat.
Insurance companies are now bypassing their own physician panel passing judgment on whether their doctor chose the correct drug, not only to their physician, but also to the patient.
The policing of physicians in their own professional work by non-professionals
Health Maintenance Organizations are now sending their own physician, who is not on the patient’s panel, on a house call to do a duplicate “Health Maintenance Examination” and keeping the reimbursement money.
Isn’t
this an unethical interference with the Doctor/Patient relationship?
Or is this just stealing the physician’s professional fees?
Or is this just plain subterfuge?
|
synonyms: |
deviousness, deceit, deception, dishonesty, cheating, duplicity, guile, cunning, craftiness, chicanery, pretense, fraud, fraudulence |
The only place in the world where women do not have the freedom or right to drive a car!
The
Saudi council pushes for rules to let women over 30 drive from 7 AM to 8 PM on
week days and
from noon to 8 PM on weekends as long as they had permission from a male
relative, wore their head scarves and no makeup.
Why aren’t all the feminist marching up and down the Jordan to protest this enslavement of their sisterhood?
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Hippocrates and His Kin / Hippocrates Modern
Colleagues
The Challenges of Yesteryear, Yesterday, Today & Tomorrow
* * * * *
11. Restoring Accountability in Medical Practice, HealthCare, Government and Society:
• The National Center for Policy Analysis, John C Goodman, PhD, President, who along with Gerald L. Musgrave, and Devon M. Herrick wrote Lives at Risk, issues a weekly Health Policy Digest, a health summary of the full NCPA daily report. You may log on at www.ncpa.org and register to receive one or more of these reports.
• Pacific Research Institute, (www.pacificresearch.org) Sally C Pipes, President and CEO, John R Graham, Director of Health Care Studies, publish a monthly Health Policy Prescription newsletter, which is very timely to our current health care situation. You may signup to receive their newsletters via email by clicking on the email tab or directly access their health care blog.
• The Mercatus Center at George Mason University (www.mercatus.org) is a strong advocate for accountability in government. Maurice McTigue, QSO, a Distinguished Visiting Scholar, a former member of Parliament and cabinet minister in New Zealand, is now director of the Mercatus Center's Government Accountability Project. Join the Mercatus Center for Excellence in Government.
• To read the rest of this column, please go to www.medicaltuesday.net/org.asp.
• The National Association of Health Underwriters, www.NAHU.org. The NAHU's Vision Statement: Every American will have access to private sector solutions for health, financial and retirement security and the services of insurance professionals. There are numerous important issues listed on the opening page. Be sure to scan their professional journal, Health Insurance Underwriters (HIU), for articles of importance in the Health Insurance MarketPlace. The HIU magazine, with Jim Hostetler as the executive editor, covers technology, legislation and product news - everything that affects how health insurance professionals do business.
• The Galen Institute, Grace-Marie Turner President and Founder, has a weekly Health Policy Newsletter sent every Friday to which you may subscribe by logging on at www.galen.org. A study of purchasers of Health Savings Accounts shows that the new health care financing arrangements are appealing to those who previously were shut out of the insurance market, to families, to older Americans, and to workers of all income levels.
• Greg Scandlen, an expert in Health Savings Accounts (HSAs), has embarked on a new mission: Consumers for Health Care Choices (CHCC). Read the initial series of his newsletter, Consumers Power Reports. Become a member of CHCC, The voice of the health care consumer. Be sure to read Prescription for change: Employers, insurers, providers, and the government have all taken their turn at trying to fix American Health Care. Now it's the Consumers turn. Greg has joined the Heartland Institute, where current newsletters can be found.
• The Heartland Institute, www.heartland.org, Joseph Bast, President, publishes the Health Care News and the Heartlander. You may sign up for their health care email newsletter. Read the late Conrad F Meier on What is Free-Market Health Care?.
• The Foundation for Economic Education, www.fee.org, has been publishing The Freeman - Ideas On Liberty, Freedom's Magazine, for over 50 years, with Lawrence W Reed, President, and Sheldon Richman as editor. Having bound copies of this running treatise on free-market economics for over 40 years, I still take pleasure in the relevant articles by Leonard Read and others who have devoted their lives to the cause of liberty. I have a patient who has read this journal since it was a mimeographed newsletter fifty years ago. Be sure to read the current lesson on Economic Education.
• The Council for Affordable Health Insurance, www.cahi.org/index.asp, founded by Greg Scandlen in 1991, where he served as CEO for five years, is an association of insurance companies, actuarial firms, legislative consultants, physicians and insurance agents. Their mission is to develop and promote free-market solutions to America's health-care challenges by enabling a robust and competitive health insurance market that will achieve and maintain access to affordable, high-quality health care for all Americans. "The belief that more medical care means better medical care is deeply entrenched . . . Our study suggests that perhaps a third of medical spending is now devoted to services that don't appear to improve health or the quality of care–and may even make things worse."
• The Independence Institute, www.i2i.org, is a free-market think-tank in Golden, Colorado, that has a Health Care Policy Center, with Linda Gorman as Director. Be sure to sign up for the monthly Health Care Policy Center Newsletter.
• Martin Masse, Director of Publications at the Montreal Economic Institute, is the publisher of the webzine: Le Quebecois Libre. Please log on at www.quebecoislibre.org/apmasse.htm to review his free-market based articles, some of which will allow you to brush up on your French. You may also register to receive copies of their webzine on a regular basis.
• The Fraser Institute, an independent public policy organization, focuses on the role competitive markets play in providing for the economic and social well being of all Canadians. Canadians celebrated Tax Freedom Day on June 28, the date they stopped paying taxes and started working for themselves. Log on at www.fraserinstitute.ca for an overview of the extensive research articles that are available. You may want to go directly to their health research section.
• The Heritage Foundation, www.heritage.org/, founded in 1973, is a research and educational institute whose mission was to formulate and promote public policies based on the principles of free enterprise, limited government, individual freedom, traditional American values and a strong national defense. -- However, since they supported the socialistic health plan instituted by Mitt Romney in Massachusetts, which is replaying the Medicare excessive increases in its first two years, and was used by some as a justification for the Obama plan, they have lost sight of their mission and we will no longer feature them as a freedom loving institution and have canceled our contributions—as have many of our friends.
• The Ludwig von Mises Institute, Lew Rockwell, President, is a rich source of free-market materials, probably the best daily course in economics we've seen. If you read these essays on a daily basis, it would probably be equivalent to taking Economics 11 and 51 in college. Please log on at www.mises.org to obtain the foundation's daily reports. You may also log on to Lew's premier free-market site to read some of his lectures to medical groups. Learn how state medicine subsidizes illness or to find out why anyone would want to be an MD today.
• CATO. The Cato Institute (www.cato.org) was founded in 1977, by Edward H. Crane, with Charles Koch of Koch Industries. It is a nonprofit public policy research foundation headquartered in Washington, D.C. The Institute is named for Cato's Letters, a series of pamphlets that helped lay the philosophical foundation for the American Revolution. The Mission: The Cato Institute seeks to broaden the parameters of public policy debate to allow consideration of the traditional American principles of limited government, individual liberty, free markets and peace. Ed Crane reminds us that the framers of the Constitution designed to protect our liberty through a system of federalism and divided powers so that most of the governance would be at the state level where abuse of power would be limited by the citizens' ability to choose among 13 (and now 50) different systems of state government. Thus, we could all seek our favorite moral turpitude and live in our comfort zone recognizing our differences and still be proud of our unity as Americans. Michael F. Cannon is the Cato Institute's Director of Health Policy Studies. Read his bio, articles and books at www.cato.org/people/cannon.html.
• The Ethan Allen Institute, www.ethanallen.org/index2.html, is one of some 41 similar but independent state organizations associated with the State Policy Network (SPN). The mission is to put into practice the fundamentals of a free society: individual liberty, private property, competitive free enterprise, limited and frugal government, strong local communities, personal responsibility, and expanded opportunity for human endeavor.
• The Free State Project, with a goal of Liberty in Our Lifetime, http://freestateproject.org/, is an agreement among 20,000 pro-liberty activists to move to New Hampshire, where they will exert the fullest practical effort toward the creation of a society in which the maximum role of government is the protection of life, liberty, and property. The success of the Project would likely entail reductions in taxation and regulation, reforms at all levels of government to expand individual rights and free markets, and a restoration of constitutional federalism, demonstrating the benefits of liberty to the rest of the nation and the world. [It is indeed a tragedy that the burden of government in the U.S., a freedom society for its first 150 years, is so great that people want to escape to a state solely for the purpose of reducing that oppression. We hope this gives each of us an impetus to restore freedom from government intrusion in our own state.]
• The St. Croix Review, a bimonthly journal of ideas, recognizes that the world is very dangerous. Conservatives are staunch defenders of the homeland. But as Russell Kirk believed, wartime allows the federal government to grow at a frightful pace. We expect government to win the wars we engage, and we expect that our borders be guarded. But St. Croix feels the impulses of the Administration and Congress are often misguided. The politicians of both parties in Washington overreach so that we see with disgust the explosion of earmarks and perpetually increasing spending on programs that have nothing to do with winning the war. There is too much power given to Washington. Even in wartime, we have to push for limited government - while giving the government the necessary tools to win the war. To read a variety of articles in this arena, please go to www.stcroixreview.com.
• Hillsdale College, the premier small liberal arts college in southern Michigan with about 1,200 students, was founded in 1844 with the mission of "educating for liberty." It is proud of its principled refusal to accept any federal funds, even in the form of student grants and loans, and of its historic policy of non-discrimination and equal opportunity. The price of freedom is never cheap. While schools throughout the nation are bowing to an unconstitutional federal mandate that schools must adopt a Constitution Day curriculum each September 17th or lose federal funds, Hillsdale students take a semester-long course on the Constitution restoring civics education and developing a civics textbook, a Constitution Reader. You may log on at www.hillsdale.edu to register for the annual weeklong von Mises Seminars, held every February, or their famous Shavano Institute. Congratulations to Hillsdale for its national rankings in the USNews College rankings. Changes in the Carnegie classifications, along with Hillsdale's continuing rise to national prominence, prompted the Foundation to move the College from the regional to the national liberal arts college classification. Please log on and register to receive Imprimis, their national speech digest that reaches more than one million readers each month. This month, read ? Choose recent issues. The last ten years of Imprimis are archived.
• John and Alieta Eck, MDs, for their first-century solution to twenty-first century needs. With 46 million people in this country uninsured, we need an innovative solution apart from the place of employment and apart from the government. To read the rest of the story, go to www.zhcenter.org and check out their history, mission statement, newsletter, and a host of other information
• Medi-Share Medi-Share is based on the biblical principles of caring for and sharing in one another's burdens (as outlined in Galatians 6:2). And as such, adhering to biblical principles of health and lifestyle are important requirements for membership in Medi-Share. This is not insurance. Read more . . .
• PATMOS EmergiClinic - where Robert Berry, MD, an emergency physician and internist, practices. To read his story and the background for naming his clinic PATMOS EmergiClinic - the island where John was exiled and an acronym for "payment at time of service," go to www.patmosemergiclinic.com/ To read more on Dr Berry, please click on the various topics at his website. To review How to Start a Third-Party Free Medical Practice . . .
• PRIVATE NEUROLOGY is a Third-Party-Free Practice in Derby, NY with Larry Huntoon, MD, PhD, FANN. (http://home.earthlink.net/~doctorlrhuntoon/) Dr Huntoon does not allow any HMO or government interference in your medical care. "Since I am not forced to use CPT codes and ICD-9 codes (coding numbers required on claim forms) in our practice, I have been able to keep our fee structure very simple." I have no interest in "playing games" so as to "run up the bill." My goal is to provide competent, compassionate, ethical care at a price that patients can afford. Private Neurology also guarantees that medical records in our office are kept totally private and confidential - in accordance with the Oath of Hippocrates. Since I am a non-covered entity under HIPAA, your medical records are safe from the increased risk of disclosure under HIPAA law.
• FIRM: Freedom and Individual Rights in Medicine, Lin Zinser, JD, Founder, www.westandfirm.org, researches and studies the work of scholars and policy experts in the areas of health care, law, philosophy, and economics to inform and to foster public debate on the causes and potential solutions of rising costs of health care and health insurance. Read Lin Zinser’s view on today’s health care problem: In today’s proposals for sweeping changes in the field of medicine, the term “socialized medicine” is never used. Instead we hear demands for “universal,” “mandatory,” “singlepayer,” and/or “comprehensive” systems. These demands aim to force one healthcare plan (sometimes with options) onto all Americans; it is a plan under which all medical services are paid for, and thus controlled, by government agencies. Sometimes, proponents call this “nationalized financing” or “nationalized health insurance.” In a more honest day, it was called socialized medicine.
• Michael J. Harris, MD - www.northernurology.com - an active member in the American Urological Association, Association of American Physicians and Surgeons, Societe' Internationale D'Urologie, has an active cash'n carry practice in urology in Traverse City, Michigan. He has no contracts, no Medicare, Medicaid, no HIPAA, just patient care. Dr Harris is nationally recognized for his medical care system reform initiatives. To understand that Medical Bureaucrats and Administrators are basically Medical Illiterates telling the experts how to practice medicine, be sure to savor his article on "Administrativectomy: The Cure For Toxic Bureaucratosis."
• David J Gibson, MD, Consulting Partner of Illumination Medical, Inc. has made important contributions to the free Medical MarketPlace in speeches and writings. His series of articles in Sacramento Medicine can be found at www.ssvms.org. To read his "Lessons from the Past," go to www.ssvms.org/articles/0403gibson.asp. For additional articles, such as the cost of Single Payer, go to www.healthplanusa.net/DGSinglePayer.htm; for Health Care Inflation, go to www.healthplanusa.net/DGHealthCareInflation.htm.
• Dr Richard B Willner, President, Center Peer Review Justice Inc, states: We are a group of healthcare doctors -- physicians, podiatrists, dentists, osteopaths -- who have experienced and/or witnessed the tragedy of the perversion of medical peer review by malice and bad faith. We have seen the statutory immunity, which is provided to our "peers" for the purposes of quality assurance and credentialing, used as cover to allow those "peers" to ruin careers and reputations to further their own, usually monetary agenda of destroying the competition. We are dedicated to the exposure, conviction, and sanction of any and all doctors, and affiliated hospitals, HMOs, medical boards, and other such institutions, which would use peer review as a weapon to unfairly destroy other professionals. Read the rest of the story, as well as a wealth of information, at www.peerreview.org.
• Semmelweis Society International, Verner S. Waite MD, FACS, Founder; Henry Butler MD, FACS, President; Ralph Bard MD, JD, Vice President; W. Hinnant MD, JD, Secretary-Treasurer; is named after Ignaz Philipp Semmelweis, MD (1818-1865), an obstetrician who has been hailed as the savior of mothers. He noted maternal mortality of 25-30 percent in the obstetrical clinic in Vienna. He also noted that the first division of the clinic run by medical students had a death rate 2-3 times as high as the second division run by midwives. He also noticed that medical students came from the dissecting room to the maternity ward. He ordered the students to wash their hands in a solution of chlorinated lime before each examination. The maternal mortality dropped, and by 1848, no women died in childbirth in his division. He lost his appointment the following year and was unable to obtain a teaching appointment. Although ahead of his peers, he was not accepted by them. When Dr Verner Waite received similar treatment from a hospital, he organized the Semmelweis Society with his own funds using Dr Semmelweis as a model: To read the article he wrote at my request for Sacramento Medicine when I was editor in 1994, see www.delmeyer.net/HMCPeerRev.htm. To see Attorney Sharon Kime's response, as well as the California Medical Board response, see www.delmeyer.net/HMCPeerRev.htm. Scroll down to read some very interesting letters to the editor from the Medical Board of California, from a member of the MBC, and from Deane Hillsman, MD. To view some horror stories of atrocities against physicians and how organized medicine still treats this problem, please go to www.semmelweissociety.net.
• The Association of American Physicians & Surgeons (www.AAPSonline.org), The Voice for Private Physicians Since 1943, representing physicians in their struggles against bureaucratic medicine, loss of medical privacy, and intrusion by the government into the personal and confidential relationship between patients and their physicians. Be sure to read News of the Day in Perspective: Don't miss the "AAPS News," written by Jane Orient, MD, and archived on this site which provides valuable information on a monthly basis. Browse the archives of their official organ, the Journal of American Physicians and Surgeons, with Larry Huntoon, MD, PhD, a neurologist in New York, as the Editor-in-Chief. There are a number of important articles that can be accessed from the Table of Contents.
•
The AAPS California
Chapter is an unincorporated
association made up of members. The Goal of the AAPS California Chapter is to
carry on the activities of the Association of American Physicians and Surgeons
(AAPS) on a statewide basis. This is accomplished by having meetings and
providing communications that support the medical professional needs and
interests of independent physicians in private practice. To join the AAPS
California Chapter, all you need to do is join national AAPS and be a physician
licensed to practice in the State of California. There is no additional cost or
fee to be a member of the AAPS California State Chapter.
Go to California
Chapter Web Page . . .
Bottom line: "We are the best deal Physicians can get from a statewide physician based organization!"
• PA-AAPS is the Pennsylvania Chapter of the Association of American Physicians and Surgeons (AAPS), a non-partisan professional association of physicians in all types of practices and specialties across the country. Since 1943, AAPS has been dedicated to the highest ethical standards of the Oath of Hippocrates and to preserving the sanctity of the patient-physician relationship and the practice of private medicine. We welcome all physicians (M.D. and D.O.) as members. Podiatrists, dentists, chiropractors and other medical professionals are welcome to join as professional associate members. Staff members and the public are welcome as associate members. Medical students are welcome to join free of charge.
Our motto, "omnia pro aegroto" means "all for the patient."
* * * * *
12. Words of Wisdom, Recent Postings, In Memoriam, Today in History . . .
Words of Wisdom-Manners
Deportment-Social Conduct-Civility with Polish
If a man be gracious, and courteous to strangers, it shows he is a citizen of the world. – Francis Bacon
In the days of old/Men made the manners; manners now make men. –Lord Byron 1824
Good manners are, to particular societies, what good morals are to society in general: their cement and their security. –Lord Chesterfield, 1749
Civility costs nothing, and buys everything. –Lady Mary Wortley Montagu, 1756
There are few things that touch us with instinctive revulsion as a breach of decorum. –Thorstein Veblen, 1899
You can learn good manners from the bad manners of others. –Anonymous aphorisms
Man is judged by his manners more than by his looks. –Anonymous aphorisms
Some Recent Postings
In The July Issue:
