MEDICAL TUESDAY . NET
Community For Better Health Care
Vol XIII, No 9, Dec, 2014
In This Issue:
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The Annual World Health Care Congress, a market of ideas, co-sponsored by The Wall Street Journal, is the most prestigious meeting of chief and senior executives from all sectors of health care. Renowned authorities and practitioners assemble to present recent results and to develop innovative strategies that foster the creation of a cost-effective and accountable U.S. health-care system. The extraordinary conference agenda includes compelling keynote panel discussions, authoritative industry speakers, international best practices, and recently released case-study data For more information, visit www.worldcongress.com. The future is occurring NOW.
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1. Featured Article: How bad is Censorship getting?
By Harvey Silverglate, WSJ Nov. 9, 2014 5:59 p.m. ET
On campuses across the country, hostility toward unpopular ideas has become so irrational that many students, and some faculty members, now openly oppose freedom of speech. The hypersensitive consider the mere discussion of the topic of censorship to be potentially traumatic. Those who try to protect academic freedom and the ability of the academy to discuss the world as it is are swimming against the current. In such an atmosphere, liberal-arts education can’t survive. Read more . . .
Consider what happened after Smith College held a panel for alumnae titled “Challenging the Ideological Echo Chamber: Free Speech, Civil Discourse and the Liberal Arts.” Moderated by Smith President Kathleen McCartney in late September, the panel was an apparent effort to address the intolerance of diverse opinions that prevails on many campuses.
One panelist was Smith alumna Wendy Kaminer—an author, lawyer, social critic, feminist, First Amendment near-absolutist and former board member of the American Civil Liberties Union. She delivered precisely the spirited challenge to the echo chamber that the panel’s title seemed to invite. But Ms. Kaminer emerged from the discussion of free speech labeled a racist—for defending free speech.
The panel started innocuously enough with Ms. Kaminer criticizing the proliferation of campus speech codes that restrict supposedly offensive language. She urged the audience to defend the free exchange of ideas over parochial notions of “civility.” In response to a question about teaching materials that contain “hate speech,” she raised the example of Mark Twain’s “The Adventures of Huckleberry Finn,” arguing that students should take it as a whole. The student member of the panel, Jaime Estrada, resisted that notion, saying, “But it has the n-word, and some people are sensitive to that.”
Ms. Kaminer responded: “Well let’s talk about n-words. Let’s talk about the growing lexicon of words that can only be known by their initials. I mean, when I say, ‘n-word’ or when Jaime says ‘n-word,’ what word do you all hear in your head? You hear the word . . .”
And then Ms. Kaminer crossed the Rubicon of political correctness and uttered the forbidden word, observing that having uttered it, “nothing horrible happened.” She then compared the trend of replacing potentially offensive words with an initial to being “characters in a Harry Potter book who are afraid to say the word ‘Voldemort.’ ” There’s an important difference, she pointed out, between hurling an epithet and uttering a forbidden word during an academic discussion of our attitudes toward language and law.
The event—and Ms. Kaminer’s words—prompted blowback from Smith undergraduates, recent alumnae and some faculty members. One member of the audience posted an audio recording and transcript of the discussion, preceded by what has come to be known in the academic world as a “trigger warning”:
“Trigger/Content Warnings: Racism/racial slurs, abelist slurs, anti-Semitic language, anti-Muslim/Islamophobic language, anti-immigrant language, sexist/misogynistic slurs, references to race-based violence.”
One has to have imbibed this culture of hyper-victimization in order even to understand the lingo. “Ableism,” for example, is described at ableism.org as “the practices and dominant attitudes in society that devalue and limit the potential of persons with disabilities” and that “assign inferior value (worth) to persons who have developmental, emotional, physical or psychiatric disabilities.”
The contretemps prompted articles in the newspapers of Smith College and neighboring Mount Holyoke College, condemning Ms. Kaminer’s remarks as examples of institutionalized racism. Smith president Ms. McCartney was criticized for not immediately denouncing Ms. Kaminer. In a Sept. 29 letter responding to the Smith community, she apologized to students and faculty who were “hurt” and made to feel “unsafe” by Ms. Kaminer’s comments in defense of free speech.
A rare academic counter-current to the vast censorial wave came from professor of politics Christopher Pyle at Mount Holyoke. He wrote in the Mount Holyoke News that readers of the paper were misled by a report that “a Smith alumna made racist remarks when speaking at an alumnae panel.” He criticized the condemnation of Ms. Kaminer for her willingness to challenge the tyranny of “sanitary euphemisms.”
Smith is not the epicenter of hostility to free speech. On university campuses nationwide we are witnessing an increasing tide of trigger warnings. They are popping up on syllabi, in discussions of public art, and even finding their way into official school policies.
On Oct. 27, the Massachusetts Institute of Technology circulated a survey questionnaire to its entire student body on the issue of sexual assault—a so-called “climate survey” to try to determine and expose the extent of the problem at the school. Remarkably enough, the survey itself came accompanied by, guess what:
“TRIGGER WARNING: Some of the questions in this survey use explicit language, including anatomical names of body parts and specific behaviors to ask about sexual situations. This survey also asks about sexual assault and other forms of sexual violence which may be upsetting. Resources for support will be available on every page of the survey, should you need them.”
Hypersensitivity to the trauma allegedly inflicted by listening to controversial ideas approaches a strange form of derangement—a disorder whose lethal spread in academia grows by the day. What should be the object of derision, a focus for satire, is instead the subject of serious faux academic discussion and precautionary warnings. For this disorder there is no effective quarantine. A whole generation of students soon will have imbibed the warped notions of justice and entitlement now handed down as dogma in the universities.
Mr. Silverglate, a lawyer and writer, is the co-founder and current chairman of the board of directors of the Foundation for Individual Rights in Education. Wendy Kaminer is a member of FIRE’s board of advisers.
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2. In the News: Doctors will go two weeks without pay next month.
CMS will hold 2015 Medicare payments for 2 weeks
Doctors may have to wait a few extra days to get paid for Medicare services they administer, the Centers for Medicare and Medicaid Services announced.
Claims submitted during the first 14 days of 2015 and dated within that time period will be held to allow for the corrections of errors in the 2015 physician fee schedule. Claims submitted during that time but dated in 2014 will be processed normally. Contractors are expected to process the early 2015 claims beginning Jan. 15. Read more . . .
CMS expects minimal impact to physicians, as it is not required to pay clean electronic claims sooner than 14 days under law.
“I think this will have minimum impact,” American Academy of Family Physicians President Robert Wergin said in an interview. “It does affect your cash flow, but it has happened in the past, particularly around the time with SGR patches.”
With that kind of leadership, it will happen in the future and only get worse.
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3. International Medicine/Medical Affairs: A Swiss Shot Heard 'Round the World
Removing the government cap unleashed free enterprise – hidden value re-appeared
Deutsche Bank suffered about $150 million in losses Thursday after the Swiss National Bank abruptly removed the cap on the Swiss franc's value, sparking a massive franc rally, said a person familiar with the matter. Barclays also racked up tens of millions of dollars in losses, although they totaled less than $100 million, another person said. Read more . . .
Shares in FXCM, the biggest retail foreign-exchange broker in the U.S. and Asia, didn't open Friday for trading on the New York Stock Exchange . . .
A U.K. retail broker entered insolvency, and a New Zealand foreign-exchange trading house collapsed. . .
Can you imagine if the caps on HMO and Medicare medicine were removed, how health care would flourish on the open market? Who would benefit and who would go bankrupt?
Send answers or comments to email@example.com
Canadian Medicare does not give timely access to healthcare, it only gives access to a waiting list.
--Canadian Supreme Court Decision 2005 SCC 35,  1 S.C.R. 791
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4. Medicare: Medicare in Wonderland
THE TWO-MIDNIGHT RULE
Mac Sterling, MD and Melvyn Sterling, MD
“The time has come,”
the Walrus said,
“To talk of many things:
Of hospitals and OPOs
Of Medicare and dings
And why two midnights are the cause
Of patients selling rings.”
—with apologies to Lewis Carroll
Medicare has formulated a new rule—the two-midnight rule—to reduce the money it pays to hospitals for diagnosis-related group (DRG) billing. This Alice in Wonderland gimmick allows the Centers for Medicare & Medical Services (CMS) to shift the cost of hospitalization from Medicare Part A—where the cost of care is almost entirely covered by the federal government—to Medicare Part B, where more of the cost is paid by the patient, unless they have insurance that covers “outpatient care.” Unfortunately, even with the Affordable Care Act, many patients cannot afford such insurance.
CMS currently mandates that patients be designated as “outpatient observation” (OPO) if their anticipated hospital stay is two midnights or less. These OPO patients are admitted to the hospital because they require health care services that are not available outside a hospital. They inhabit a hospital room; sleep in a hospital bed; are usually cared for by hospitalists, hospital nurses and other hospital staff; and are treated with hospital IV fluids and medications from the hospital pharmacy. Read more . . .
If the admitting physician fails to designate the patient as OPO and Medicare’s recovery audit contractor (RAC) decides the patient should have been OPO, the hospital is not paid for the care, and the patient pays the bill. To avoid being “RAC’d,” hospitals are now forced to employ specially trained staff to determine whether the patient is to be admitted as OPO vs. normal hospital status, wasting money that could be spent on patient care.
This absurd situation prompted physicians in the CMA House of Delegates to pass the following resolution in October 2013: “Resolved: That the California Medical Association request that the Centers for Medicare and Medicaid Services eliminate Outpatient Observation status for all patients who require care in hospitals.”
Medicare, we must acknowledge, is terminally underfunded. By 2017, its funding is predicted to be less than its costs. To stanch this hemorrhage of red ink, politicians and bureaucrats are trying to decrease Medicare’s costs before the program fails. Their central challenge is the same as the one articulated by Machiavelli during the Renaissance: “Do the ends justify the means?”
There is near universal agreement that we must maintain Medicare’s viability; but as with achieving any goal, some means are better than others. Simply put, there are two ways of balancing Medicare’s budget: our elected representatives can either increase Medicare taxes or decrease Medicare benefits.
How often has an incumbent politician voted to raise a tax on the working public? Crickets chirp. But is the alternative of decreasing benefits any more politically palatable? Not really. Hence the contortions of Medicare’s decision to reclassify a less than two-midnight stay in the hospital as an “outpatient” benefit, thereby shifting costs to hospitals and to Medicare beneficiaries. Transparency, which begets an honest evaluation of the pros and cons of a change in Medicare policy, suffers when CMS administrators engage in doublespeak by calling nights spent and resources consumed inside a hospital an “outpatient” benefit.
Seen from one perspective, the DRG payment system—which was implemented in 1983 to limit Medicare expenses—is a victim of its own success. Under the system, Medicare pays a set amount for each diagnosis, thereby putting hospitals at risk for the cost of caring for patients whose expenses are greater than anticipated. Now CMS feels that the hospitalization process is “too efficient,” insofar as Medicare is paying a “full DRG” for stays that are shorter than anticipated. In a classic piece of bureaucratic flimflammery, Medicare came up with the idea that a stay in the hospital spanning less than two midnights is actually just “observation,” rather than the provision of efficient inpatient hospital care.
The essential misrepresentation of the two-midnight rule is that a brief stay in a hospital is less resource-intensive than a longer stay. CMS staffers argue, without blushing, that hospital expenses are less per hour when a patient spends less than two midnights in a hospital, compared to hourly costs for a stay of more than two midnights. In fact, the opposite is often true.
Case in point: In the hospital where Dr. Mac Sterling practices as a hospitalist, the administration has created efficient diagnostic and treatment workflows. Several years ago, for example, it was virtually impossible to obtain an MRI on a weekend unless epidural abscess or hemorrhage was suspected. Now the MRI department is staffed to provide services seven days a week. This expanded schedule results in more timely diagnoses for many chief complaints, meaning that the hospital can discharge many patients before two midnights have passed. Doing this, however, is not cheap: the hospital must pay to have the MRI department staffed on weekends. Moreover, under the two-midnight rule, the hospital is penalized financially for providing patients with quicker diagnosis and treatment, as outpatient services are paid at a substantially lower—often dramatically lower—rate than inpatient services. . .
Consider the patient admitted for a transient ischemic attack (TIA). A well-equipped and well-run hospital can expect to complete a workup for this diagnosis before two midnights have passed. According to the two-midnight rule, however, this patient should be admitted OPO. But what happens when the TIA evolves into a cerebral infarct? Now the patient may need to stay in the hospital longer and be converted to inpatient status. Unfortunately for the patient, if they do not spend three midnights in the hospital after being changed to inpatient status, they will not qualify for the Medicare skilled nursing facility (SNF) benefit. Perversely, the result could be a newly hemiplegic patient who does not qualify for SNF benefits for physical, occupational or swallowing therapy. In addition, the patient will have to pay privately for any necessary SNF stay.
The two-midnight rule constitutes an example of political expediency. No Medicare benefits are being cut overtly, but CMS is widening a small stream of “observation stays” into a major river of hospitalized “outpatients.” As noted above, the result is to decrease Medicare A benefits and shift the costs onto hospitals and Medicare beneficiaries.
CMS has a multipronged approach to trimming the ballooning cost of Medicare. The two-midnight rule is one prong. Another is not paying for hospital readmission within 30 days when the patient has the same principal diagnosis as before. When a patient shows up in the emergency department with acute congestive heart failure 29 days after being discharged for a CHF admission, for example, the hospital is incentivized to admit the patient to OPO status, which costs the patient significantly more than an inpatient stay.
The two-midnight rule is a case of the tail of unrestrained health care costs wagging the dog of appropriate Medicare benefits. We submit that CMS should first comprehensively and logically determine the purpose of inpatient hospitalization before altering the definition of inpatient and outpatient. Providing efficient diagnosis and treatment should be among Medicare’s top priorities. Do we really want to disincentivize the hospital system from developing processes for diagnosing and treating more quickly? Care in a hospital is much more expensive than true outpatient care. Making a shorter-than-expected hospital stay a criterion for decreasing a hospital’s reimbursement is a step in the wrong direction. Instead, let us, as a society, incentivize efficiency and quality of care. ::
Dr. Mac Sterling is a hospitalist at Alta Bates
Hospital in Berkeley. Dr. Melvyn Sterling is an internist and palliative care
physician in Orange County.
Emails: Mac Sterling: firstname.lastname@example.org, Melvyn Sterling: email@example.com
MARIN MEDICINE | Fall 2014 | Marin Medical Society
Government is not the solution to our problems, government is the problem.
- Ronald Reagan
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5. Medical Gluttony: Medical Gluttony can be hazardous to your health and well being.
Margaret Mason came in complaining that her fingers were getting numb and she would like to see a neurologist. This was her introductory comment without the courtesy of waiting for her doctor’s diagnosis. Her friend already had given her the diagnosis. She had carpal tunnel syndrome and needed an operation and a neurologist was required to confirm the diagnosis prior to surgery. Read more . . .
Examination revealed loss of sensation in the small finger and one-half of the ring fingers of each hand. This was a typical ulnar neuropathy, caused by pressure on the ulnar notch at the elbow. The usual cause is “elbows on the table or desk” or possibly reading in bed with the elbow supporting shoulder and head for extended periods of time. Her “tunnel” sign was negative. She wouldn’t accept this diagnosis and insisted on seeing a neurologist “just to make sure.”
The neurologist’s consultation was returned stating that the Neuro Conduction Studies revealed some mild conduction loss in her carpal tunnel area as well as in the ulnar notch area bilaterally. The neurologist thought this was non-diagnostic or not severe enough to require surgery. The Neurosurgeon was going to do a nerve transplanting in both elbows and a carpal tunnel release at both wrists. All he wanted from me was an Electrocardiogram to clear Margaret for the neurosurgery on both elbows and both wrists. Margaret could not be persuaded that all four operations were unnecessary.
When seen in routine follow up medical evaluation in six months, an inquiry into her operations revealed no improvement in any symptoms. Her fingers were still numb indicating the ulnar transplantation was not helpful. She had no symptoms or findings at her carpal tunnel site. Her tunnel sign was negative for carpal tunnel syndrome both before and after her surgery. But Margaret was still glad she had the surgery. The neurosurgeon obviously had done a good job of selling her on the need for her unnecessary surgery which this exam confirmed. The absence of a positive result usually is not recognized by the patient.
This is the typical response for unnecessary surgery. It is extremely difficult for any patient to admit that her operation was unnecessary. This makes controlling healthcare costs even more difficult. It will never be controlled as long as there is insurance that covers 100% of all costs. People just cannot say no to something that is free—even if it entails cutting the human body, leaving scars, and decreasing function.
Medical Gluttony thrives in full coverage Government and Health Insurance Programs.
It Disappears with Appropriate Deductibles and Co-payments on Every Service.
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6. Medical Myths: The $64,000,000 Question?
With the President’s Confidence Ratings Sinking to one-third and Congressional ratings slipping to one-tenth, “Why is America putting any confidence in these Medical Illiterates to devise a healthcare program which involves our most personal and confidential lives?”
Send your answers and comments to firstname.lastname@example.org
The $64 Question
Maybe some of you will remember the CBS radio quiz show of the 1940s “Take it or leave it” sometimes called the “Sixty-four-dollar question?” It was very popular in the era of 1941-48. It was so named because $64 was the highest award.
The $64,000 Question
The big-money quiz show that spawned a rash of copycats in the mid-1950s was none other than "The $64,000 Question." The idea for the show came from the 45-year old Louis G. Cowan, who created long-time radio quiz show hits such as "Quiz Kids" and "Stop the Music." Years earlier, Cowan had bought the rights to a popular radio show called "Take It or Leave It," which he hadn’t yet figured out how to repackage. Then he remembered the $64 question—the top prize offered on the show—and had the inspiration to expand that figure to $64,000 for the television version of the program. . . Read more . . .
"The $64,000 Question" was a smash hit from the day of its premiere. One evening during the peak of its popularity, 55 million Americans watched the show, an astronomical viewership. In the first six months of the show, sales for Revlon, the show’s sponsors, increased 54 percent. The following year, Revlon’s sales tripled. Cowan, one of the stars at CBS, was rewarded with a vice presidency of the company.
"The $64,000 Challenge."
A little less than a year later, the station capitalized on the fortunes of the show by launching a spin-off called "The $64,000 Challenge." The show invited winners from "$64,000 Question" to come back and test their knowledge against challengers. Many of the new show’s contestants were celebrities, such as Vincent Price, who tested his knowledge about art against Edward G. Robinson. In July 1956, a little over a year after the first quiz show aired, "$64,000 Question" and "$64,000 Challenge" were rated number one and two on television. These CBS shows were so successful that they drove one of the most respected shows of all time, the "See It Now" with Edward R. Murrow, from the airwaves.
A flurry of imitators followed, including "High Finance," "Giant Step," "Can Do" and "Brains and Brawn." One of the games that jumped on the bandwagon was "Twenty-One," which featured Columbia professor Charles Van Doren in the spring of 1957. Through 1957, interest in "$64,000 Question" and "The $64,000 Challenge" dwindled.
Not long afterwards, "Twenty-One" had a huge winner of its own, as Elfrida Von Nardroff, a 32-year old personnel consultant from Brooklyn Heights won $220,500 during a 16-week run in the field of history.
The quadruple response: $256,000
The producers of "The $64,000 Question" responded by announcing that their show would quadruple its stakes. The first contestant to win big was 10 year old Robert Strom of the Bronx who answered questions in the field of mathematics and went home with $224,000 . . .
The CBS game show: “Dotto”
When the rigging of the CBS game
"Dotto" show was revealed in May 1958, ratings for all the quiz shows
tumbled. More and more former quiz show contestants came forward to reveal how
they had been coached. A contestant from "The $64,000 Challenge," the
Reverend Charles E. "Stony" Jackson, gave details to a grand jury,
saying that he was given answers during his "screening" that enabled
him to win. The same week that Jackson testified, P. Lorillard Tobacco dropped
"The $64,000 Challenge." By October, 1958, both
"Twenty-One" and "The $64,000 Question" were off the air.
Louis Cowan, then president of CBS, defended his innocence. He never appeared before the Congressional committee investigating the shows due an illness many suspected was contrived. Cowan, however, was forced to resign from CBS. Many others connected with the quiz show phenomenon were temporarily blacklisted. The quiz shows disappear temporarily from prime-time television, giving way to the next television phenomenon: westerns.
Read the entire article online . . .
The healthcare conundrum cannot be measure as a $64 million question or challenge. It is also greater than a $64 billion dollar issue. It may become a $64 trillion dollar fiasco if America does not arise to the socialistic takeover of our healthcare system before it is totally destroyed and lost forever. Returning civilization to the dark ages, feudal system, kings, monarchies, dictatorships, requiring the enlightenment and the reformation to reoccur before we re-advance to the civilization we had in the 17th and 18th century that we lost in the 20th and 21st century.
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: ICD 9 is being retired. Are you staying for ICD 10?
Dr. Rosen: The latest word is that the International Classification of Diseases, 9th revision, which was supposed to be retired in Oct 2014, had a one year reprieve to Oct 1, 2015. Has anyone heard anything differently?
Dr. Ruth: I understand that insurance companies were unable to make the changes by Oct 2014 and thus the delay. We’re getting ready to convert in October.
Dr. Edwards: We’re still discussing whether we want to proceed. We’ve gotten so many offers for training with ICD 10. We haven’t bought any of them yet. We thought we’d hang low.
Dr. Michelle: We’ve not gone to any of the training courses. They seem rather expensive.
Dr. Milton: There are always those who will make money on any program shoved down our throats.
Dr. Patricia: Our Practice Fusion Electronic Medical Records is all geared up to substitute the new codes in October. Their training videos are free to users. They also state that they would help us walk through any problems we might have.
Dr. Edwards: We also have Practice Fusion which is now the largest and most popular EMR for Medical Offices. It’s on par with EPIC for hospitals which Kaiser Permanente spent billions on installing. It works very well to interconnect their 20 medical office buildings and three hospitals in Sacramento. What is the down side of using ICD 10?
Dr. Rosen: Remember we had a physician in Sacramento go to jail for 22 months for using the wrong ICD 9 code 20 years ago. But ICD 9 has 16,000 codes. The new ICD 10 has about 68,000 codes. Then there are the Current Procedural Terminology or CPT codes which are also extremely important. In fact one has to have the correct diagnosis that justifies the procedure. The data reflects that 59% of doctors disagree with the Centers of Medicare and Medicaid Services (CMS) as to what are the correct codes. Hence, in any dispute, CMS could put up to 59% of physicians in jail with our present code structure.
Dr. Edwards: I think you have just convinced me that I must eliminate Medicare and Medicaid by October 1, 2015. There are already a dozen different codes for the various cardiac diseases. I see what you mean. With four times as many codes, it may be difficult to make the correct diagnosis in heart disease without a cardiac cath.
Dr. Milton: You’re giving me major trepidations on the ICD 10. I never even considered eliminating Medicare and Medicaid. I understand there are huge risks involved in resigning from Medicare. We had our practice evaluated for a Concierge practice and the numbers didn’t add up. And if you jump through all the hoops of resigning from Medicare, you can’t let covered patients pay you. What to do? Become an employee again?
Dr. Dave: The law doesn’t allow the corporate practice of medicine. The corporation can influence your medical decisions. Hospitals are getting around that by forming Medical Foundations which is only one step removed. One such foundation bought up a large number of medical practices and paid a salary of $180,000 according to some people that should know. The doctors were given a two year contract. They had plush surroundings. Hallways twice as wide as most medical office buildings. Rest rooms twice as large. But expenses caught up with them. When the two year renewals were given, the salaries dropped to $140,000. The local paper last week featured a journeyman plumber who made $120,000 a year. He had On-the-job journeyman training, no college. Physicians generally have 8 to 12 years beyond college of post-graduate and post-doctoral educations and training. How did this de-professionalization occur?
Dr. Rosen: That’s a huge topic for another day. But at this time we all have to make a decision as to what we’re going to do by October 1, 2015. I have made mine. I placed a sign in my office on January 1, 2015, wishing them a Happy New Year and stating that this office would close on June 1, 2015 and we would do no insurance billing after July 1, 2015. That will give me three months to complete all my insurance billing and collections. I’ll put my charges on my Bulletin Board by next month. Those that wish to continue in my practice can do so by paying at time of service with cash, credit card or check. Each patient account will close at the completion of the visit with a super bill in their hand for tax ID purposes. I think this may be the first step in reassuming medicine as a profession. I may not be able to charge $50 for a 1-15 minute phone consultation and $75 for an email consultation like my attorney does. But I will charge $10 for a phone call and $25 for an email all through my Practice Fusion EMR which can record them in HIPAA compliance and charge the patient’s credit card, should they wish this service.
Email any comments to email@example.com (Earthlink.net uses only lower case letter)
The Staff Lounge Is Where Unfiltered Opinions Are Heard.
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8. Voices of Medicine: A Review of Regional Medical Journals : SONOMA MEDICINE
EDITORIAL: Noble Brains, Healthy Lives
Mark Sloan, MD
Humans have long sought to make sense of the brain. Each age has puzzled over this oddly-shaped organ and its role in the complex workings of the body. In times long past, heated debates erupted among scientists and philosophers: Is the brain a cold or a hot organ? Wet or dry? Does the mind exist separate from the brain? Is it the seat of common sense, of memory? Of the soul itself?
Alcmaeon of Croton, a medical writer in the 6th century BCE, was the first to champion the brain as the center of perception, understanding and cognition. He taught that the senses were connected to the brain by “channels,” a theory that originated with his discovery of the optic nerve. Alcmaeon also appreciated the fragility of the brain; if disturbed, he wrote, the “channels” become obstructed and the sensory connections are lost. The brain was something to be handled with care.
Alcmaeon lectured widely on science and philosophy. One of his observations—that “from noble fathers noble children are born,” and that the same was unfortunately true of “baser” parents—resonates today as we consider recent discoveries in brain research. Alcmaeon had unknowingly touched on a fundamental truth of neurodevelopment: early childhood experiences, whether “noble” or “base,” shape not only character but the anatomy and physiology of the brain itself, with lifelong health impacts.
A young child’s brain is a wondrous thing. By age five it contains about one quadrillion neural connections, more than all the links in the entire Internet. But by adulthood one-third of those connections disappear. The pathways used most frequently in childhood are strengthened and streamlined, while those less trafficked simply wither away.
Stress, both physical and emotional, is an inevitable part of life. When buffered by caring and supportive adult relationships, early life stress can be a positive experience, leading to healthy adaptive responses later in life. When stress is chronic and unaddressed, however, it becomes toxic, triggering a cascade of biochemical events that enhance unhealthy neural pathways.
The areas of the brain most affected by toxic stress are the amygdala, the hippocampus and the prefrontal cortex. The amygdala, rich in stress hormone receptors, becomes hypertrophic, while the hippocampus and prefrontal cortex—essential to dampening the body’s stress reactions—lose neurons and neural connections. An overheated, unchecked amygdala can lead to persistent anxiety, impaired memory, learning difficulties and poor executive functioning. Children exposed to toxic stress may overreact to perceived threats, much like combat veterans with post-traumatic stress disorder.
Structural changes in the brain impact other organs as well, through dysregulation of the hypothalamic-pituitary-adrenocortical axis. The overstimulated amygdala spurs the adrenal cortex to secrete excessive cortisol, norepinephrine and adrenaline. An accompanying increase in inflammatory cytokines accelerates wear and tear in the heart, lungs, immune system, and elsewhere throughout the body. Toxic stress in childhood can thus result in lifelong, multi-system disease.
Once a developing brain is altered by toxic stress, setting things right becomes difficult. In their landmark 1998 Adverse Childhood Experiences study, Drs. Vincent Felitti and Robert Anda demonstrated the impact of toxic childhood stress on adult health. They found that adults exposed to multiple stresses in early childhood—such as abuse or neglect, loss of a parent, or maternal depression—were at high risk of cardiovascular disease, depression, substance abuse, and other chronic illnesses, even if the stress resolved before adulthood.
If we are to lessen the burden of chronic illness, we must strengthen the neural pathways that enable children to handle stressful events. This is best accomplished by providing support to families, the people from whom a child will learn (or not) about how to cope with life’s stresses.
As physicians, we have a choice to make. We can accept ever-increasing rates of chronic physical and mental illness as inevitable, or we can attack these problems at their early-life roots. To borrow a phrase from Frederick Douglass, “It is easier to build strong children than to repair broken men.”. . .
You can act on a personal level, too. Talk to your children. Read to your grandchildren. Teach the young people around you how to positively handle life’s stresses. Today’s children—tomorrow’s adults—will be glad that you did. ::
Dr. Sloan is a Santa Rosa pediatrician.
SONOMA MEDICINE | Winter 2015 | Sonoma County Medical Association
VOM Is an Insider's View of What Doctors are Thinking, Saying and Writing about
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9. Book Review: Being Mortal
Being Mortal: Medicine and What Matters in the End, Atul Gawande, MD, Metropolitan, (2014).
Rick Flinders, MD, and Jessica Flinders, FNP
Sonoma Medicine | The Magazine of the Sonoma County Medical Association
Atul Gawande has done it again. With his writer’s craft, he has directed a surgeon’s precision at yet another of the great maladies of his profession. Writing chiefly from The New Yorker since 1988, he has dissected, among other topics, the systemic malady of medical errors (Complications, 2002) and the high cost of medical care (“The Cost Conundrum,” 2009). Now, in Being Mortal, he tackles the burden of owning up to the often delusional stubbornness of our cultural persistence in denying the reality of death. Prolonging, at any cost, life of often dubious and miserable quality has become the modus operandi of a largely undirected and incoherent medical system. At the heart of the discussion is our own mortality. As the contemporary American poet Mary Oliver concludes in her memorable poem “On Blackwater Pond”:
live in this world
you must be able
to do three things:
to love what is mortal;
to hold it
against your bones knowing
your own life depends on it;
and, when the time comes to let it go,
to let it go.
Both of us (Rick and Jessica) practice in settings with considerable experience of the elderly. In addition, we are both old enough to take mortality personally: our patients’, our own, our spouses, our parents, even our children. Gawande writes: “The waning days of our lives are given over to treatments that addle our brains and sap our bodies for a sliver’s chance of benefit. They are spent in institutions—nursing homes and ICUs—where regimented and anonymous routines cut us off from all the things that matter to us in life. Our reluctance to honestly examine the experience of aging has increased the harm we inflict on people and denied them the basic comforts they most need. Lacking a coherent view of how people might live successfully to the very end, we have allowed our fates to be controlled by the imperatives of medicine, technology and strangers.”
In Being Mortal, Gawande carefully and compellingly lays out the case for a more enlightened and compassionate approach to the care of our frail elderly. Like many in our profession, he is appalled by the increasingly excessive treatment of the terminally ill. Who among us has not witnessed our own best efforts to prolong life often succeed only in prolonging dying? We’ve all heard, from more than one patient: “I ain’t afraid of death, Doc. It’s the dying that scares me.”
Gawande is acutely aware of the danger of a physician, sworn to preserve life, writing about the inevitability of decline and death. “Mortality can be a treacherous subject,” he writes, “No matter how carefully you frame it, people are going to accuse you of fostering a society prepared to sacrifice its sick and aging.”
We all remember how the legitimate debate for incorporating the benefits of hospice care into the Affordable Care Act degenerated into the specter of “death panels.” But what if the sick and the aged are already being sacrificed, Gawande asks, “as victims of our collusive refusal to accept the inexorability of our own life cycle?”
A significant portion of Being Mortal examines evidence for better approaches to dying, with better outcomes, that Gawande says are “largely ignored, waiting to be recognized.” As in all his written work, Gawande’s timing and methodology are impeccable. He blends the facts of our aging epidemiology with stories of our elders’ fear of dying and their experience of getting old and sick. In the foreground is the story of his own father, also a physician, written in a direct and delicate voice. Gawande never stoops to melodrama, yet he tells the tale we are all living through as a people and a nation. According to him, the institutional care of our elderly is not only Dickensian in tone, it occurs in settings and inside walls that would fit into the chapters of the coldest and darkest Dickens.
While Gawande’s narrative is informative on the demographics and experience of aging, he also directs us to look past the external circumstances of illness. Listen and learn from the patient. In perhaps the best chapter of Being Mortal, Gawande writes about the “hard conversations” we have with patients. One of these he has come to call the “breakpoint discussion” and urges us to ask these four questions:
• What is your life like right now?
• What are your fears?
• What are your goals?
• What trade-offs are you willing to make in order to achieve your goals?
Gawande’s father, for example, was willing to live as a quadriplegic as long as he could eat chocolate ice cream and watch TV. Closer to home, an acquaintance of ours recently said that he would accept almost any quality of life as long as he was free of severe pain, could sustain his own nutrition, and both recognize and communicate with his loved ones. The answers for each person are unique, personal and unpredictable—and they change with time and experience. While the answers are important in themselves, they also provide a framework for the conversation and process to continue. If death is the last illness we still don’t speak about, the “breakpoint discussion” is a way of opening the conversation.
Rick recently attended his 50th high school reunion. It was sweet and sobering. Sweet to see old friends, but in a sidebar on the invitation was a somber catalog of nearly 80 others who would not be attending the reunion—not because of travel distance, but because of the inconvenient truth of death. Among the old friends who did attend, the topic of conversation was not the prospect of dying, but rather the fear of going bankrupt from medical expenses trying to prevent death—as if the spiritual and existential issues surrounding our mortality weren’t enough.
Just as modern medicine medicalized childbirth a half century ago, it has now medicalized death and dying. These processes have been abducted from the cultural and social context that centuries of civilization developed for family and community.
Dr. Gayle Stephens, the recently deceased founding father of family medicine, feared becoming a patient more than dying. He asked:
“Must death continue to be a tawdry, privatized, sanitized farce played out in institutional settings like so many crucifixions? Cannot we as physicians, who collectively have contributed so much to the horror that makes everybody yearn for a quick and painless death, give some leadership in restoring death to the dignity of its communal roots, and help make it mean something again, not only for the dying but also for the living?”
This is strong language from a medical elder who earned, over a lifetime of practice and teaching, the right and credibility to be heard. At the age of 85, he had to negotiate, vigorously and contentiously, with his university doctors to be released to hospice care and go home to the care of his family.
The Declaration of Independence speaks of the “unalienable rights” of life, liberty and the pursuit of happiness. Given our current circumstances, as so compellingly depicted by Gawande, we may need to add to these the right to be allowed a natural death. ::
Dr. Flinders, who teaches hospital medicine at the Santa Rosa Family Medicine Residency, serves on the SCMA Editorial Board. Ms. Flinders is a family nurse practitioner at Northern California Medical Associates in Petaluma.
The Book Review Section Is an Insider’s View of What Doctors are Reading about.
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10. Hippocrates & His Kin: The High Cost of Stupidity
The exorbitant costs of a tooth ache in the Emergency Department of a hospital.
The local newspaper reports a complaint by a 60-year-old lady of waiting one hour for a bus to take her to the hospital to investigate a toothache. Since hospitals don’t have dentists on duty at night and probably not in the day time either, what are the alternatives? Should her medical insurance pay the average of $600 to $1500 for the emergency visit for tooth ache? If she didn’t take the usual household pain medications which normally blunt a tooth pain, shouldn’t she have to pay for the ER visit? What is the solution to this sort of unnecessary health care cost for stupidity?
Send solutions or comments to firstname.lastname@example.org
Hippocrates and His Kin / Hippocrates Modern
The Challenges of Yesteryear, Yesterday, Today & Tomorrow
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• 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.
AND NOW WE’VE LEARNED THAT THE PERSON THAT DESIGNED ROMNEY’S SOCIALISTIC MEDICAL PROGRAM WAS THE SAME PERSON DESIGNING OBAMACARE. HE THOUGHT PEOPLE WERE TOO STUPID TO RECOGNIZE WHAT IT REALLY WAS. HERITAGE FOUNDATION--YOU CANNOT MAKE SUCH SOCIALISTIC MISTAKES AND SAY THAT YOU PROMOTE PUBLIC POLICIES BASED ON THE PRINCIPLES OF FREE ENTERPRISE, LIMITED GOVERNMENT, INDIVIDUAL FREEDOM, TRADITIONAL AMERICAN VALUES AND A STRONG NATIONAL DEFENSE WHEN YOU SUPPORTED MITT ROMNEY AND OBAMACARE LITE IN MASSACHUSETTES ENSLAVING A ONCE NOBLE PROFESSION. YOU HAVE TO DO DUE DILIGENCE BEFORE MAKING SUCH A DISASTROUS MOVE.
• 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."
• Medical Society affiliating with the AAPS
Recently it has come to our attention that one of the County Medical Societies has requested affiliation with the AAPS. It appears that the AAPS is meeting the needs of physicians better than traditional organized medicine.
Welcome! The door is open.
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Words of Wisdom—Words of Insanity
McLean Hospital is a Bastille for the incarceration of some persons obnoxious to their relatives. –Boston Times Messenger, 1865
Psychiatric hospitals, like prisons, are ‘total institutions,” and share with the Chinese thought-reform centers a marked degree of milieu control and the basic assumption that the inmate is in the hospital because there is something wrong with his thinking and that change, in the direction desired by his attendants, is necessary. –Daniel Blain (1898--?) et. AL. In Silvano Arieti, ed, American Hand book of Psychiatry, 1966
Many evils arise from an indiscriminate intercourse of mad people with visitors, whether members of their own families or strangers. They often complain to them of the managers, officers, and physicians of the Hospital, and at times in so rational a manner as to induce belief that their tales of injustice and oppression are true. –Benjamin Rush (1745-1813)
Mental Hospitals are the POW camps of our undeclared and inarticulate civil wars. –Thomas S. Szasz (1920-)
Mental Hospitals: . . . Cemeteries for the living dead; dormitory beds are the gravesites; psychiatric diagnoses, the gravestones; psychiatrists, the gravediggers; patients, the corpses. –Thomas S Szasz, The Untamed Tongue: A Dissenting Dictionary. 1990
Some Recent Postings
In The November Issue:
11. Restoring Accountability in Medicine, Government and Society
Murder most intricate
Phyllis Dorothy (P.D.) James,
Baroness James of Holland Park, crime writer,
died on November 27th, aged 94
| The ECONOMIST | From the print edition | Dec 4th 2014
As He neared the house, down the quiet autumnal streets of Holland Park in west London, Commander Adam Dalgliesh felt a shiver of apprehension.
To read more, subscribe at . . . http://www.economist.com/news/obituary/21635438-phyllis-dorothy-pd-james-baroness-james-holland-park-crime-writer-died-november
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James was born in Oxford, the daughter of Sidney James, a tax inspector, and educated at the British School in Ludlow and Cambridge High School for Girls. She had to leave school at the age of sixteen to work because her family did not have much money and her father did not believe in higher education for girls. She worked in a tax office for three years and later found a job as an assistant stage manager for a theatre group. In 1941, she married Ernest Connor Bantry White, an army doctor. They had two daughters, Claire and Jane.
When White returned from World War II he was experiencing mental illness and James was forced to provide for the whole family until her husband's death in 1964. With her husband in a psychiatric institution and their daughters being mostly cared for by his parents, James studied hospital administration and from 1949 to 1968 worked for a hospital board in London. She began writing in the mid-1950s. Her first novel, Cover Her Face, featuring the investigator and poet Adam Dalgliesh of New Scotland Yard, named after a teacher at Cambridge High School, was published in 1962. Many of James's mystery novels take place against the backdrop of UK bureaucracies, such as the criminal justice system and the National Health Service, in which she worked for decades starting in the 1940s. Two years after the publication ofCover Her Face, James's husband died and she took a position as a civil servant within the criminal section of the Home Office. She worked in government service until her retirement in 1979.
In 1991, James was created a life peer as Baroness James of Holland Park and sat in the House of Lords as a Conservative. She was an Anglican and a lay patron of the Prayer Book Society. Her 2001 work, Death in Holy Orders, displays her familiarity with the inner workings of church hierarchy. Her later novels were often set in a community closed in some way, such as a publishing house or barristers' chambers, a theological college, an island or a private clinic. Talking About Detective Fiction was published in 2009. Over her writing career, James also wrote many essays and short stories forperiodicals and anthologies, which have yet to be collected. She revealed in 2011 that The Private Patient was the final Dalgliesh novel.
As guest editor of BBC Radio 4's Today programme in December 2009, James conducted an interview with the Director General of the BBC, Mark Thompson, in which she seemed critical of some of his decisions. Regular Today presenter Evan Davis commented that "She shouldn't be guest editing; she should be permanently presenting the programme." In 2008, she was inducted into the International Crime Writing Hall of Fame at the inaugural ITV3 Crime Thriller Awards.
On This Month in History - December
On this date, December 1, 1917, a priest in Omaha, Nebraska, named Father Edward Flanagan founded a unique institution on this day. It was called Boys Town, and its basic concept was centered in Father Flanagan’s firm belief that, in his words, “There is no such thing as a bad boy.” He defined that problem: it wasn’t bad boys; it was the conditions that created their problem. So he tried to put friendless boys into an environment where they could have a chance to grow up as good citizens.
After Leonard and Thelma Spinrad
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Del Meyer, MD, Editor & Founder
6945 Fair Oaks Blvd, Ste A-2, Carmichael, CA 95608
Chancellor Otto von Bismarck, the father of socialized medicine in Germany, recognized in 1861 that a government gained loyalty by making its citizens dependent on the state by social insurance. Thus socialized medicine, any single payer initiative, Social Security was born for the benefit of the state and of a contemptuous disregard for people’s welfare.
We must also remember that ObamaCare has nothing to do with appropriate healthcare; it was similarly projected to gain loyalty by making American citizens dependent on the government and eliminating their choice and chance in improving their welfare or quality of healthcare. Socialists know that once people are enslaved, freedom seems too risky to pursue.