MedicalTuesday

1. Featured Article: Doctors and nurses vs. administrators on patient satisfaction. Who’s right?

DAVID HOWARD | PATIENT | MAY 30, 2015

I’ve been volunteering in an emergency department of a Southern Californian community hospital for five years. I clean gurneys, stock shelves, provide support for RNs and EMTs and translate for Spanish-speaking patients. Since my job requires minimal intellectual effort, I’ve had considerable time to observe the staff and contemplate the inspiring work they do.

I’ve watched them perform heroically with sick babies, agitated psychiatric patients, full cardiac arrests, and everything else from stroke to strep. I love what they do and who they are.

Over time, I’ve also became acutely aware of frustration among ER practitioners with increasing pressure to boost patient satisfaction scores. I began to share their skepticism about the validity, reliability and consequences of satisfaction surveys.

Wasn’t it self-evident that the surveys were bogus? We all knew that a patient might be happier if we order up that MRI his brother-in-law recommended for his backache, if we hand out antibiotics for likely viruses, or write a narcotics prescriptions for malingering addicts, or decline to tell obese problem drinkers that they need to quit the vodka and eat fewer Big Macs. Giving patients exactly what they want will score satisfaction points, but it’s often costly to the system and detrimental to individual and public health.

Then about a year ago, I was asked by our hospital’s quality department to be a patient advisor on the medical-surgery floors. My task was to administer a survey on hospitalist physicians and inquire in general about the quality of the patient and family experience. When I saw questions on the survey like, “Did the doctor sit down when visiting you?” I knew I had entered an alternate universe with values skewed in a way folks in the ER wouldn’t readily comprehend.

I found that although everyone’s priority is quality care for our patients, ER docs and nurses spoke a different language than the quality geeks. Sometimes they talked right past each other. “A hospital isn’t a hotel; patients shouldn’t expect to be pampered,” said the ER nurse. “We should learn from the hospitality industry, and patients should be treated like guests at a four-star hotel,” said the quality administrators.

The disconnect was profound. Even the peer-reviewed studies on outcomes seemed to arrive at contrasting conclusions. One study suggested a negative correlation between patient satisfaction and clinical outcomes. Others claimed the opposite.

Quality experts argue that honing in on tiny measures for improvement bump overall satisfaction scores and cumulatively transform hospital culture to one of overall patient-centered excellence. But nurses’ advocates warn, “Patients can be very satisfied and dead an hour later.” Or they cite the case of an RN who had been disciplined because a patient complained the hospital didn’t have Splenda sweetener.

So who is right? The docs and nurses who practice tough love on recalcitrant patients or the warm and fuzzy hospitality administrators who emulate business class flight attendants and remind us that Medicare reimbursement is inextricably tied to patient satisfaction?

What I’ve learned from both working in the ER and visiting patients on the floors is that real quality is not a zero-sum game. Quality is multidimensional and nuanced; we can’t sacrifice or neglect one dimension for another. Splenda fixation is a surface symptom that alludes to a deeper discontent. When patients are dissatisfied with the minutiae of care, their real message is that their emotional needs are not being met. They may feel disrespected, confined, vulnerable, fearful and lonely. These are all 10s on the scale of painful emotions. Not treating them interferes with healing.

To improve clinical outcomes, we have to pay attention to everything. We can’t supply Splenda on demand, but we can engage in honest conversation about the details of care so that patient and family understand we take them seriously and that the emotional quality of their experience matters. Such conversations foster intimacy; they are empowering for the patient and inspiring for the practitioner; they lead to genuine improvements.

http://www.kevinmd.com/blog/2015/05/doctors-and-nurses-vs-administrators-on-patient-satisfaction-whos-right.html

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2. In the News: 1.5 Million Missing Black Men

By JUSTIN WOLFERS, DAVID LEONHARDT and KEVIN QUEALY APRIL 20, 2015

For every 100 black women not in jail, there are only 83 black men.

The remaining men – 1.5 million of them – are, in a sense, missing.

17 missing black men for every 100 black women. “Missing” menAmong cities with sizable black populations, the largest single gap is in

Ferguson, Mo.

40 missing black men for every 100 black women

North Charleston, S.C., has a gap larger than 75 percent of cities.

25 missing black men for every 100 black women

This gap – driven mostly by incarceration and early deaths – barely exists among whites.

1 missing white man for every 100 white women

Figures are for non-incarcerated adults who are 25 to 54.

In New York, almost 120,000 black men between the ages of 25 and 54 are missing from everyday life. In Chicago, 45,000 are, and more than 30,000 are missing in Philadelphia. Across the South — from North Charleston, S.C., through Georgia, Alabama and Mississippi and up into Ferguson, Mo. — hundreds of thousands more are missing.

They are missing, largely because of early deaths or because they are behind bars. Remarkably, black women who are 25 to 54 and not in jail outnumber black men in that category by 1.5 million, according to an Upshot analysis. For every 100 black women in this age group living outside of jail, there are only 83 black men. Among whites, the equivalent number is 99, nearly parity.

African-American men have long been more likely to be locked up and more likely to die young, but the scale of the combined toll is nonetheless jarring. It is a measure of the deep disparities that continue to afflict black men — disparities being debated after a recent spate of killings by the police — and the gender gap is itself a further cause of social ills, leaving many communities without enough men to be fathers and husbands.

Perhaps the starkest description of the situation is this: More than one out of every six black men who today should be between 25 and 54 years old have disappeared from daily life.

“The numbers are staggering,” said Becky Pettit, a professor of sociology at the University of Texas.

And what is the city with at least 10,000 black residents that has the single largest proportion of missing black men? Ferguson, Mo., where a fatal police shooting last year led to nationwide protests and a Justice Department investigation that found widespread discrimination against black residents. Ferguson has 60 men for every 100 black women in the age group, Stephen Bronars, an economist, has noted.

The distributions of whites and blacks

Most blacks live in places with a significant shortage of black men. But most whites live in places with rough parity between white men and women. . .

Histogram, With Ferguson noted

The gap in North Charleston, site of a police shooting this month, is also considerably more severe than the nationwide average, as is the gap in neighboring Charleston. Nationwide, the largest proportions of missing men generally can be found in the South, although there are also many similar areas across the Midwest and in many big Northeastern cities. The gaps tend to be smallest in the West.

Incarceration and early deaths are the overwhelming drivers of the gap. Of the 1.5 million missing black men from 25 to 54 — which demographers call the prime-age years — higher imprisonment rates account for almost 600,000. Almost 1 in 12 black men in this age group are behind bars, compared with 1 in 60 nonblack men in the age group, 1 in 200 black women and 1 in 500 nonblack women.

Higher mortality is the other main cause. About 900,000 fewer prime-age black men than women live in the United States, according to the census. It’s impossible to know precisely how much of the difference is the result of mortality, but it appears to account for a big part. Homicide, the leading cause of death for young African-American men, plays a large role, and they also die from heart disease, respiratory disease and accidents more often than other demographic groups, including black women. . .

The gender gap does not exist in childhood: There are roughly as many African-American boys as girls. But an imbalance begins to appear among teenagers, continues to widen through the 20s and peaks in the 30s. It persists through adulthood. . .

Age

The disappearance of these men has far-reaching implications. Their absence disrupts family formation, leading both to lower marriage rates and higher rates of childbirth outside marriage, as research by Kerwin Charles, an economist at the University of Chicago, with Ming-Ching Luoh, has shown.

The black women left behind find that potential partners of the same race are scarce, while men, who face an abundant supply of potential mates, don’t need to compete as hard to find one. As a result, Mr. Charles said, “men seem less likely to commit to romantic relationships, or to work hard to maintain them.”

The imbalance has also forced women to rely on themselves — often alone — to support a household. In those states hit hardest by the high incarceration rates, African-American women have become more likely to work and more likely to pursue their education further than they are elsewhere. . .

Since the 1990s, death rates for young black men have dropped more than rates for other groups, notes Robert N. Anderson, the chief of mortality statistics at the Centers for Disease Control and Prevention. Both homicides and H.I.V.-related deaths, which disproportionately afflict black men, have dropped. Yet the prison population has soared since 1980. In many communities, rising numbers of black men spared an early death have been offset by rising numbers behind bars.

It does appear as if the number of missing black men is on the cusp of declining, albeit slowly. Death rates are continuing to fall, while the number of people in prisons — although still vastly higher than in other countries — has also fallen slightly over the last five years.

But the missing-men phenomenon will not disappear anytime soon. There are more missing African-American men nationwide than there are African-American men residing in all of New York City — or more than in Los Angeles, Philadelphia, Detroit, Houston, Washington and Boston, combined.

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3. International Medicine: Canadian Medicare isn’t really free.

Canada’s health care system isn’t really free as there’s monthly premiums or yearly premiums to pay as well as taxes which pay for the entire health care system. There may also be some out of pocket expensed for non-insured services. In Canada there’s access to a waiting list for universal health care regardless of status, income, employment, health, or age. The administration of the heath care is done on a province to province basis.

Most non-emergency surgeries will require wait times. These wait times may put the patient at risk while they wait for a surgery or their condition may deteriorate as they wait. Those that need priority care make the wait times for others very frustrating. Seniors, those with life threatening conditions, and other urgent cases will be looked after first while others can sometimes wait a long time.

http://www.formosapost.com/pros-and-cons-of-universal-health-care-in-canada/

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Canadian Medicare does not give timely access to healthcare, it only gives access to a waiting list.

--Canadian Supreme Court Decision 2005 SCC 35, [2005] 1 S.C.R. 791

http://scc.lexum.umontreal.ca/en/2005/2005scc35/2005scc35.html

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4. Medicare: One-third of Doctors Reject Medicaid

By John Goodman Filed under Medicaid

August 8, 2012

Health Affairs: Although 96 percent of physicians accepted new patients in 2011, rates varied by payment source: 31 percent of physicians were unwilling to accept any new Medicaid patients; 17 percent would not accept new Medicare patients; and 18 percent of physicians would not accept new privately insured patients. Physicians in smaller practices and those in metropolitan areas were less likely than others to accept new Medicaid patients. Remember: one-half of the newly insured under ObamaCare are going into Medicaid.

See more at: http://healthblog.ncpa.org/one-third-of-doctors-reject-medicaid/#sthash.QSpQSM8O.dpuf

Of the 32 million uninsured Americans expected to gain health coverage under the new law, as many as 20 million will be insured by Medicaid… [Yet] several studies have found that Medicaid beneficiaries fare less well than patients with private insurance — for example, that they tend to get cancer diagnoses at a later stage, and die earlier, than do privately insured patients, and that migraine sufferers insured by Medicaid get substandard treatment compared with the privately insured. - See more at: http://healthblog.ncpa.org/under-obamacare-most-of-the-newly-insured-will-be-in-medicaid/#sthash.SwS9gnta.dpuf

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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: Health Insurance without Copayments

We are receiving brochures from a number of Health Insurance companies highlighting the fact that there are no co-payments on a number of procedures; certain types of office calls or certain types of drugs. This is very unfortunate. If any one understands overutilization, it should be the insurance companies.

It’s a well-known fact that when anything is free, there is overutilization. In our experience it is well over 50%. The insurance companies are again expecting doctors to be the gatekeepers, the cops, to parcel out only needed care. It is also a well-known fact that patients are referred to as members now. This makes them feel they are part of a warm and cozy family. It the doctor doesn’t give them every test, procedure or drug they want, they will complain to their insurance carrier which is now an HMO, a mechanism to control costs.

The HMO must now straddle the fence. They will not admit to their “members” that their whole purpose to exist is to control costs by controlling patient’s laboratory, pharmacy, and x-ray appetites which they expect us physicians to control. They will restrict and blame physicians as the disorganized group they control without much concern for retaliation. (Didn’t Alexus de Tocqueville allude to this in the 19^th century?)

Physicians need to wake up to the fact that they are pawns in an encroachment on their integrity. If you cannot trust your doctor, whom do you think you CAN TRUST?

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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: Healthcare is expensive

Intensive or critical care is expensive. That’s why it is important to have high end health care coverage. A car crash, stroke, heart attack, cancer and maybe a dozen other medical or surgical problems and emergencies would cause financial hardship in millionaires, much less us ordinary citizens. But catastrophic health insurance with a $3,500 to $5,000 deductible would take care of these quarter million or half million dollar hospital bills. The cost is sometimes as low as one-fourth standard health insurance. The savings will more than cover the deductible in most cases. And believe it or not, your cash costs, paying your doctor, your laboratory, your x-ray, your electrocardiogram will generally be even less than the deductible.

Unfortunately, most people cannot believe that their health care costs would be less than their mortgage payments or their car payments.

The insurance industry and the government and all single payer proponents, the Bernie’s of the country, have hoodwinked people into believing all health care costs are catastrophic. It’s only the dozen or so mentioned above that may be catastrophic even for the wealthy. But the rest of us should obtain only catastrophic or major medical health care coverage but pay cash for your annual doctor visits and the tests that he may require in taking care of you. For most of us until we’re over 60 or have health care problems, our average yearly costs would, more likely than not, be less than a $1000 a year. And you would have no insurance hassles concerning what is covered or what is not covered. Thus the saving of $20,000 to $40,000 on today’s astronomical insurance premiums could allow you to pay cash for a new car. You would also live longer not having to argue with your insurance company after every expense. Medicare is slowly disappearing as the restrictions get more ominous every day. Will you be ready when Medicare goes to healthcare heaven and leaves you behind?

Why do you think so many of the largest buildings, the skyscrapers in the large cities of the world, are owned by insurance companies?

Think about it. Why let health insurance keep you, the so-called member, poor—while the health insurance companies, and their executives, become rich?

Why not get rid of these Medical Myths of Healthcare and take charge of your life!

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Medical Myths originate when someone else, like insurance companies, pay the medical bills.

Myths disappear when Patients pay Cash and let catastrophic health insurance take the risk.

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7. Overheard in the Medical Staff Lounge: Gender Dysphoria

The condition of feeling one's emotional and psychological identity as male or female to be opposite to one's biological sex.

Dr. Rosen: Is the incidence of Gender Dysphoria prevalent in medical practice to any extent?

Dr. Edwards: I have several male patients that are very effeminate. They don’t practice homoeroticism.

Dr. Milton: I have a number of females who are very masculine. I have never explored their emotional or psychologic leanings or identity, however. I’ve always assumed this was just a variation within the gender.

Dr. Ruth: I think some of these masculine females have homosexual overtones. But the ones I see are married have children and seem to have a normal relationship with their spouses.

Dr. Michelle: In my experience the masculine females are homoerotic but have done a rather remarkable job of suppressing those feelings. They have not asked for hormone therapy which I feel would make their psychological adaption worse by reversing the accommodation they have achieved.

Dr. Yancy: I have several masculine types of women who seem to have feminine type female live in partners who display a husband-wife type of relationship. But they have adapted well and seem to have a variety of friends. I agree with Michelle to leave well-enough alone.

Dr. Sam: I think that masculine females and effeminate males are basically homosexuals

Dr. Rosen: I have a very large muscular lady who does serious workouts. She was bragging at one time of doing 250 pounds bench pressing. When she got to 300 pounds, she tore a biceps tendon and couldn’t find an orthopedic surgeon to put her biceps together again. She was married to a man who was much smaller and at least 50 pounds lighter than she. He accommodated her masculine desires rather well. This seemed like reverse accommodation.

Dr Milton: Then we read about the man who has raised a family, seemed to have a good marital relationship, and all at once he comes out of the proverbial closet he’s been in for maybe 40 years and cohabits with a homosexual.

Dr. Michelle: Can you imagine the effect this would have on the wife and children?

Dr Edwards: Gender dysphoria has been around since creation. It never became a problem until the current century when surgeons learned the skill of revising the genitals to the wishes of the dysphoric person. But we haven’t yet had enough publicity for the public to comprehend the mutilation that’s involved.

Dr. Ruth: That brings up the ultimate misunderstanding. They think after their transformation they can have normal sexual relations. That’s really an illusion.

Dr. Edwards: Ruth, have you ever seen a patient after their transformation express that fact?

Dr. Ruth: Not really. I think after the surgical rearrangement, they begin to see their transformation as mutilation. And that would be hard to admit. They can never go back to their birth gender, either emotionally or physically. How could they ever explain that to their friends? The scarred anatomy cannot be made functional in their previous state.

Dr. Michelle: The body will never be beautiful again. That would be the hardest blow for me.

Dr. Sam: Don’t hold your breath, Ruth. There will always be a surgeon somewhere who will attempt to reverse a transgender patient who regrets his transformation.

Dr. Milton: And that will be one case where a surgeon won’t want to take pictures of the restored genitalia and show his work at a surgical conference.

Dr. Michelle: At least not before the lunch break.

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The Staff Lounge Is Where Unfiltered Opinions Are Expressed.

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8. Voices of Medicine: Sham Peer Review—Infusing Staph in a patient to get rid of the Dr.

Sham Peer Review: the Shocking Story of Raymond A. Long, M.D.

Lawrence R. Huntoon, M.D., Ph.D.

It was a story that rocked the little town of St. Albans, Vermont: “Surgeon Accuses St. Albans Hospital of Deliberately Infecting His Patients.”¹

According to the statewide news website, VTDigger.org, “An orthopedic surgeon is suing Northwestern Medical Center in St. Albans for allegedly infecting his patients with bacteria in an effort to ‘destroy his career and falsely blame him for the infections,’ court records show…. Long says he told hospital doctors in 2002 that he was considering adding an MRI machine to his office. At the time, he alleges, Northwestern was involved in ‘an illegal kickback scheme with respect to X-ray facilities’ and the hospital was planning to have a new MRI machine built for its facilities.”¹

The “Factual Background” contained in a lawsuit, for which an Amended Complaint was filed on Sep 28, 2006, also contained hundreds of numbered paragraphs describing the nightmare of events that Dr. Long claimed he experienced at the hands of the hospital and other physicians on staff.²

Northwestern Medical Center Enters into Settlement Agreement with Government

On Aug 16, 2007, the U.S. Attorney’s Office issued a press release stating: “The United States Attorney’s Office announced today that it has entered into a settlement with Northwestern Medical Center, the hospital in St. Albans, resolving the hospital’s potential liability for violating the federal anti-kickback and related laws.”³ Although the hospital faced a potential liability of having to pay triple the amount collected from federal health programs, the government agreed to settle for a mere $30,000.³ . . .

In 2011, Dr. Long hired a former Centers for Disease Control and Prevention infection investigator, William R. Jarvis, M.D . . . .On Aug 5, 2011, Dr. Jarvis issued his report¹¹ concerning the unusual surgical site infections affecting Dr. Long’s patients. Dr. Jarvis reviewed four of Dr. Long’s cases.

In one case, Dr. Jarvis reported: “A nearly pan-sensitive (especially to penicillin) S. aureus strain like [patient’s] is exceedingly unusual. This is even more true of S. aureus strains causing HAIs [healthcare-associated infections] rather than community acquired infections.”^{11, p 5}. . .

The Jarvis Report also addressed cultures taken from an irrigation solution that was about to be used in a patient surgery on Feb 6, 2004:

Cultures obtained from previously unopened bottle of irrigation fluid (that was about to be hung in the NMC operating room for use in Dr. Long’s surgical patient) by Dr. Long on February 6, 2004 grew 800 colony forming units/ml of S. aureus (two morphologies). Given that this was a bottle of irrigation fluid provided by NMC operating room personnel for use by Dr. Long in that surgical procedure, it is highly suspicious. Intrinsic contamination (i.e., that occurring at the time of manufacture) of such manufactured fluids is < 1 in a million—an exceedingly rare and unlikely event. Since no other clusters of infections or outbreaks associated with this manufacturer’s irrigation fluid were reported at around this time and no FDA recall of these fluids occurred around this time, the likelihood of intrinsic contamination is very, very unlikely. In contrast, given that two different morphologies of S. aureus and 800 CFU/ml were recovered, I believe that the likelihood of extrinsic contamination (i.e., contamination after manufacture and most likely at NMC) is much more likely.^{11,
p 10}

Dr. Jarvis also commented on the hospital peer review related to these highly unusual infections:

Given the circumstances occurring at NMC at around December 2003—February 2004 (i.e., the cluster of very unusual SSIs—both in terms of SSIs occurring in very low-risk arthroscopic joint procedures and the types of organisms involved in Dr. Long’s patients), the likelihood that these SSIs were caused by: a) the patient’s flora; b) contaminated surgical equipment, c) Dr. Long’s surgical technique, d) breaks in sterile technique by other operative room personnel, or e) contamination of Marcaine placed in pain pumps, as hypothesized by Dr. Corsetti in his peer review of these cases is exceedingly unlikely.^{11,
p 12}

A much more likely explanation of how the operating room irrigation fluid became contaminated and how the 3-4 SSIs above occurred is that the patients were intentionally infected through extrinsically and intentionally contaminated irrigation fluid (or other fluids, medications, equipment or materials) provided by NMC personnel and used by Dr. Long in the surgical procedures of these patients.^{11, p 13}

The Jarvis Report goes on to state:

Personnel from NMC have acknowledged that personnel at NMC had purchased ATCC [an organization that provides standard reference micro-organisms to labs] strains of S. aureus, coagulase-negative staphylococci (CNS) and Pseudomonas aeruginosa isolates for quality control purposes for the NMC laboratory. In addition, they testified that they also obtained S. marcescens isolates that were used in the microbiology laboratory for quality control purposes. Therefore, all the bacterial species that caused SSIs [surgical site infections] in Dr. Long’s patients were available in the NMC microbiology laboratory. The S. aureus strain (ATCC #25923) was purchased in November 2003 [see Ref #8], days to weeks before [patients’] surgery. Furthermore, the ATCC #25923 S. aureus strain has an antimicrobial susceptibility to all agents commonly tested, including ampicillin, penicillin, cefazolin, clindamycin, erythromycin, cefoxitin (methicillin), tetracycline, and sulfamethoxazole similar to the susceptibility of the S. aureus isolated from [patient’s] SSI…. In addition, the quality control P. aeruginosa isolate was purchased in August 2003, before [patient’s] surgery on December 23, 2003. Interestingly, the antibiotic susceptibility pattern of the ATCC strain #27853 (P. aeruginosa), which was purchased by NMC, supposedly for laboratory quality control purposes, had the same antibiotic susceptibility pattern (of the agents to which both isolates were tested) as that of the P. aeruginosa strain recovered from the SSI of [the patient].^{11
pp. 9-10}

The Jarvis Report also addressed cultures taken from an irrigation solution that was about to be used in a patient surgery on Feb 6, 2004:

Dr. Jarvis concluded that patients were intentionally infected through the use of deliberately contaminated irrigation solutions:

2005 Lawsuit Settles for $4 Million, Hospital CEO Moves on to Another Hospital

The lawsuit filed by Dr. Long in 2005 eventually settled in 2008 for $4 million, and shortly thereafter NMC CEO Peter A. Hofstetter moved on to a new job as CEO of Holy Cross Hospital in Taos, New Mexico,⁹ and, according to Dr. Long, subsequently to Willamette Valley Medical Center in McMinnville, Oregon. . .

Conclusions

In the words of the 2006 Amended Complaint,^{2,
p 92} Defendants engaged in “extreme and outrageous conduct, which was beyond all possible bounds of decency, and which may be regarded as atrocious and utterly intolerable in a civilized society.”

Lawrence R. Huntoon, M.D., Ph.D., is a practicing neurologist and editor-in-chief of the Journal of American Physicians and Surgeons. Contact: editor@jpands.org. To access the entire article including the 17 supporting bibliographic documents, and to see the entire sordid story of the hospital hiring 19 private investigators, with one following Dr. Long day and night, breaking into his home, a brick through his car window, stealing a laptop from his car, deactivating his remote car door opener, finding his door panel on his car had been removed, that his tires have been slashed with the same instrument that the Muslims used to slash the throats of the American Airline Pilots on Sept 11, 2011, spiking his drinks with mercury and amphetamines, harassing him and his wife when they were driving or walking, requesting him to be seen by a psychiatrist who was a Peer Review Specialist for hospitals, etc., et.al.

Read the entire document . . .

Why is the threat of a surgeon setting up his own Surgicenter so threatening to a hospital’s finances that they will infect, harm and possibly kill his and their patients with serious staph organisms that were purchased, spend such astronomical sums of money to discredit him? Is the cash flow from CMS so lucrative that administrators are willing to take the risk of killing patients to get rid of a doctor that may compete?

How prevalent is Hospital Homicide or Medical Murder?

Is there any data out there?

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VOM Is an Insider's View of What Doctors are Experiencing in Managed Healthcare.

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9. The Theater: Let there be Love

By Kwame Kwei-Armah

April 2015, American Conservatory Theater, San Francisco

Let There Be Love is an intimate and interesting family drama by Kwame Kwei-Armah, one of Britain’s most distinguished contemporary playwrights. Alfred, a cantankerous and aging West Indian immigrant living in London, has managed to alienate all those around him—including his equally headstrong lesbian daughter, with whom he rarely sees eye to eye. When an idealistic young Polish caregiver, new to the country, is assigned to look after him, he experiences a powerful reckoning with his past. Filled with the sumptuous jazz standards that pour forth from Alfred’s beloved gramophone and featuring a tour-de-force performance from stage and screen star Carl Lumbly, Let There Be Love explores the unrelenting grip of memory and regret as the Polish caregiver arranges for him to visit his former wife with their daughter who feels estranged from both and forgiveness that can happen. Visit A.C.T . . .

He was feeling good, was rather vigorous, on his feet, dancing with his caregiver after he drank the suicide potion when he welcomes death visualizing the life beyond. The author treats this as Alfred experiencing new possibilities as he collapses in the chair having died.

This support of the hemlock society is very incongruous. One does not enter eternal life by killing oneself. For believers, this is a direct highway to the furnace. Alfred was quite functional, in body and brain, fully alert, without pain. A man of God would have sung praises, as he ascended to the Pearly Gates to meet his Maker.

Unfortunately, Alfred is sliding down the slippery slope to a much warmer place.

This review is found at http://www.medicaltuesday.net/BookReviews.aspx

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The Book Review Section Is an Insider’s View of What Doctors are Reading or Seeing:.

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10. Hippocrates & His Kin: Uncle Willy’s Willy

Last month we were enlightened by a patient who referred to his phallus by the vernacular for “Richard.” Our family had a different vernacular for a guy’s phallus. As near as I can research our family’s history it started when my father and mother’s brothers were helping each other in the barn, garage and tool shed building business. Since these were all men and we didn’t have indoor plumbing, the men just stepped behind a tree or a shed to decompress their bladders. When Uncle Willy, my mom’s brother was helping with the carpentry, making foundations, setting up the 2 x 4 studs, doing the roofing, setting in the windows and doors, he always seemed to go a little further out to empty his bladder. We boys would always notice that he took two hands to pull out his “Richard.”

Back on the farm, when someone’s fly was un-zipped, we would always tell him his “barn door was open and he better close it before the mare poked his head out.

After Uncle Willy got his “Richard” out of “the barn,” he would always to continue to hold it with both hands to aim it in the appropriate direction. We boys always tried but we never did get a good look at Uncle Willy’s “Richard.”

Now we boys always wondered if Grandma had any problem in showing Uncle Willy how to wash that long “thing” and if she showed him how to retract his foreskin and wash his prepuce? Nobody had seen Uncle Willy’s “Richard” when he emptied his bladder behind the barn. He was always turned to the side away from us. But we all knew it must have been some instrument since Uncle Willy had to use both hands to control it. His son Richard had pre-deceased him and it felt rather odd to use the vernacular for Richard, so we renamed his organ, his “Willy.” That avoided generational confusion. So it was now easier to refer to his voiding manner.

If Uncle Willy’s “Willy” was as phenomenal as we suspected, we understood why he had to use both hands. On the farm it was very important not to pee in your own boots. Because if you did, you would find the other workers would be working farther and farther away from you during the course of the day.

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Hippocrates and His Kin / Hippocrates Modern Colleagues
The Challenges of Yesteryear, Yesterday, Today & Tomorrow

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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.

• 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 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 75 years ago. Be sure to read the current lesson on Economic Education.

• 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 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 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.

• 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.

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• 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 17^th 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. Choose recent issues. The last ten years of Imprimis are archived.

• 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."

• 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."

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12. Words of Wisdom, Recent Postings, In Memoriam, Today in History . . .

Words of Wisdom

“A society that puts equality before freedom will get neither; a society that puts freedom before equality will get a good deal of both.” —Milton Friedman

- See more at: http://healthblog.ncpa.org/under-obamacare-most-of-the-newly-insured-will-be-in-medicaid/#sthash.SwS9gnta.dpuf

This administration today, here and now declares unconditional war on poverty in America. –Lyndon B Johnson, 1964. This is not the only war he lost. Why do we have far more poverty in America now than then?

In your time we have the opportunity to move not only toward the rich society and the powerful society, but upward to the Great Society. –Lyndon B Johnson, 1964.

We are not about to send American boys 9 or 10,000 miles away from home to do what Asian boys ought to be doing for themselves. –Lyndon B Johnson, 1964.

Jerry Ford is so dumb he can’t “pass flatus” and chew gum at the same time. –Lyndon B Johnson, 1964.

It’s probably better to have him [J Edgar Hoover] inside the tent “urinating out,” than outside “urinating in.” –Lyndon B Johnson, 1972.

Editor’s Note: I had to change the verbiage on some of the items for this journal. Looks like Donald Trump may have read the vernacular, but changed a few words, Make the Great Society Great Again.

Some Recent Postings

In The February Issue:

MEDICAL TUESDAY.NET	NEWSLETTER
Community For Better Health Care	Vol XIV, No 4, April, 2015

The distributions of whites and blacks

Histogram, With Ferguson noted

Age

In Memoriam

Obituary: Oliver Rackham

Into the woods

Oliver Rackham, plant pathologist and woodland archaeologist, died on February 12th, aged 75

Del Meyer