1.
Featured Article: Most Sung-About Body Part?
2.
In the News: In Sickness and in Health
3.
International
Medicine: Starving Hospitalized Patients in the UK National Health Service
4.
Medicare: Isn't Social Security Past the Retirement Age?
5.
Medical Gluttony: Visiting Hospital Emergency Rooms for Routine
Medical Problems
6.
Medical Myths: Technology Manage Health Care?
7.
Overheard in the Medical Staff Lounge: I'm Not Paying Cash
Even If It's Less
8.
Voices of Medicine:
The standards related to medical staff governance created havoc.
9.
From the Physician Patient Bookshelf: Code Blue: Health Care in Crisis
10.
Hippocrates
& His Kin: Best Practice is a Doctor's Middle Name
11.
Related Organizations: Restoring Accountability in Medical
Practice and Society
MOVIE EXPLAINING SOCIALIZED
MEDICINE TO COUNTER MICHAEL MOORE's SiCKO
Logan Clements,
a pro-liberty filmmaker in Los Angeles, seeks funding for a movie exposing the
truth about socialized medicine. Clements is the former publisher of
"American Venture" magazine who made news in 2005 for a property
rights project against eminent domain called the "Lost Liberty
Hotel."
For more information visit www.sickandsickermovie.com or email logan@freestarmovie.com.
* * * * *
1.
Featured Article: Most Sung-About
Body Part?
Most Sung-About Body
Part? The Eyes Have It By Eliot Van Buskirk, mailto:eliotvb@gmail.com
August 25, 2008, Music
News
Visual artists Fernanda Viégas and Martin Wattenberg analyzed over
10,000 songs to find out which parts of the human body were mentioned the most
and broke down the resulting data by genre. The result: An interactive graphic
work called "Listen" that correlates musical genres with
the body parts they mention the most, as part of their ongoing Fleshmap project. Clicking on each genre brings up
a more detailed representation of its chief bodily concerns.
"Listen investigates the relationship between language and
the body," reads one sentence of the project's manifesto. "Verbal
manifestations of human physicality in music, poetry and religion are distilled
to their basic elements." By presenting those elements in such an
intuitive way, Viégas and Wattenberg bring data to life graphically, so that it
can be grasped in seconds.
So, what do the results tell us? Across all of the categories, the
eyes are most frequently mentioned body part (Hall & Oates, "Private Eyes"), with the exceptions of hip hop, which
places a firm emphasis on the posterior (Sir Mix a Lot, "Baby Got Back") and blues (Louisiana Red, "Keep Your Hands Off My Woman") and gospel music (The Gospel, "Put Your Hands Together"), which are respectively focused on the
keeping off of one's hands and the clapping or raising of one's hands.
As for the genre that talks about body parts the most, hip hop
takes the honors with more references than any other genre. Meanwhile, gospel
refers to the body the least. There are plenty of other data points to peruse.
It's nice to know that 23.64 percent of hip hop songs refer to the behind,
while 11.83 percent of rock songs talk about eyes.
Viégas and Wattenberg's work has been displayed at the New York
Museum of Modern Art, the London Institute of Contemporary Arts, and the
Whitney Museum of American Art. The "Listen" project can be
viewed free online, or you can order a print of this or any other piece from the Fleshmap series.
http://blog.wired.com/music/2008/08/most-sung-about.html
* * * * *
2.
In the News: In
Sickness and in Health
In Sickness and in Health: The Kyoto Protocol versus
Global Warming, By Thomas Gale Moore, The Hoover
Institution.
In promoting the Kyoto
Protocol, which would require a major cut in greenhouse gas emissions, the
White House claims that "scientists agree that global warming and
resulting climate disruptions could seriously harm human health (projections
include 50 million more cases of malaria per year)" (www.studyweb.com/ ). President Clinton
has asserted: "Disruptive weather events are increasing. Disease-bearing
insects are moving to areas that used to be too cold for them. Average
temperatures are rising. Glacial formations are receding" (address at the
National Geographic Society, October 22, 1997).
In his 1997 exhortation to the environmental ministers
at Kyoto, Vice President Al Gore warned that "disease and pests [are, will
be?] spreading to new areas." The White House's home page continues that
theme: Americans better watch out; global warming will make them sick.
The Sierra Club has also weighed in, asserting that
"doctors and scientists around the world are becoming increasingly alarmed
over global warming's impact on human health. Abnormal and extreme weather,
which scientists have long predicted would be an early effect of global
warming, have claimed hundreds of lives across the US in recent years. Our
warming climate is also creating the ideal conditions for the spread of
infectious disease, putting millions of people at risk" (www.sierraclub.org/global-warming/factsheets/health.html).
The Public Interest Research Group, a left-leaning
environmental organization, fears "Health Threats—Climate change is
projected to have wide-spread impacts on human health resulting in significant
loss of life. The projected impacts range from increased incidence of illness
and death due to heat stress and deteriorating air quality, to the rise in
transmission rates of deadly infectious diseases such as malaria, dengue fever,
and hanta virus" (www.pirg.org/environ/). Other environmentalists and health experts have
also forecast that global warming would bring death and disease (Danzig 1995;
IPCC 1996a; Jackson 1995; Epstein and Gelbspan 1995; Cromie 1995; Stone 1995;
Monastersky 1994; Patz et al. 1996; Kalkstein 1991, 1992; Kalkstein and Davis
1989; Epstein et al. 1998).
This analysis will explore whether Americans do indeed
confront a health crisis. If global warming were to occur, would the United
States face an epidemic of tropical diseases, malaria being the prime suspect;
would Americans face increased heatstroke and summers that brought a surge of
deaths; would global warming bring more frequent and more violent hurricanes
wreaking havoc on our citizens? Is it true that warmer climates are less
healthy than colder ones? Would cutting greenhouse gas emissions, as the Kyoto
Protocol requires, improve the health of Americans? This essay will show that
the answer to all those questions is a resounding no.
Not only does my own research demonstrate that the
claims of imminent doom are unwarranted, but other studies have found little
cause for alarm (WHO 1990; Committee on Science, Engineering, and Public Policy
1991; Taubes 1997; White and Hertz-Picciotto 1995; Shindell and Raso 1997;
Cross 1995; Singer 1997; Moore 1998a, 1998b; Murray 1996; Michaels and Balling
2000; Reiter 2000). Knowledgeable organizations, such as the World Health
Organization (WHO 1997, 1998, 1999) and the American Medical Association
(Council on Scientific Affairs 1996) have ignored the subject, suggesting that,
in their eyes, it is unimportant.
After examining the potential impact of global warming
on poor countries, the American Council on Science and Health (ACSH) took a
realistic view and reported that
Nearly all of the potential adverse health effects of
projected climate change are significant, real-life problems that have long
persisted under stable climatic conditions. Bolstering efforts to eliminate or
alleviate such problems would both decrease the current incidence of premature
death and facilitate dealing with the health risks of any climate change that
might occur.
Policies that weaken economies tend to weaken public
health programs. Thus, it is likely that implementation of such policies would
(a) increase the risk of premature death and (b) exacerbate any adverse health
effects of future climate change. (Shindell and Raso 1997)
As the ACHS concludes:
From the standpoint of public health, stringently
limiting such emissions [greenhouse gases] at present would not be prudent.
Fossil-fuel combustion, the main source of human induced greenhouse-gas
emissions, is vital to high-yield agriculture and other practices that are
fundamental to the well-being of the human population. A significant short-term
decline in such actions could have adverse health repercussions.
The optimal approach to dealing with [the] prospect of
climate change would (a) include improvement of health infrastructures
(especially in developing countries) and (b) exclude any measures that would impair
economies and limit public health resources.
The World Health Organization's World Health Report
1998: Life in the 21st Century, gave the globe an A for progress. The WHO
showed that remarkable advances have been made in increasing life spans, decreasing
disease and suffering, and improving health for virtually all age groups and
that the future looks even rosier (see chart 1). To quote the Executive
Summary: "As the new millennium approaches, the global population has
never had a healthier outlook." How can this be? After all, the White
House tells us the next century promises to be one of rising temperatures,
spreading disease, and increasing mortality. Somehow, the WHO didn't get the
word. The World Health Report 1999: Making a Difference again fails to
address this problem that the White House believes is so worrisome.
According to the WHO, the only significant and growing
threat to human health is HIV/AIDS, a disease that has nothing to do with
climate. Indeed, we have made substantial progress in controlling many major
infectious diseases. By 1980, for example, smallpox had been eradicated; yaws
had virtually disappeared (except to medical students, even the name of this
tropical skin disease is unfamiliar). As a result of antibiotics and insecticides,
the threat of plague has declined; improvements in sanitation and hygiene have
made outbreaks of relapsing fever rare. Unbelievably, for those who remember
summers of fear and polio insurance, poliomyelitis is scheduled for eradication
this year.
A LOOK TO THE FUTURE
Looking to the future, the WHO report identifies three
global trends affecting health—none is global warming. One is economic: the WHO
reports (1998) on the "unparalleled prosperity" between 1950 and
1973, which resulted in marked improvements in health and life expectancies.
The organization identifies the years since 1993 as another era of economic
"recovery," which has once again contributed to reduced mortality.
The other trends singled out as having significant health effects are population
growth and social developments, particularly urbanization.
Over the last forty years, the growth in the world's
economy has brought about a doubling of the world's food supply, while the
number of human mouths has grown much more slowly. This has led to a decline in
the proportion of people who are undernourished. Since 1970, literacy rates
have increased by more than 50 percent. Physical well-being has also grown
apace. More people have access to clean water, sanitation facilities, and
minimum health care than ever before. Like the 1999 review, prior World Health
Reports largely ignored global warming as a significant threat to the health
and well-being of the globe's population. And rightly so.
Of the 50 million plus deaths in 1997, about one-third
stemmed from infectious and parasitic diseases, most of which have nothing to
do with climate. The remaining deaths were from such killers as cancer,
circulatory diseases, and prenatal conditions, none of which would be
aggravated by a warmer world. Most infectious and parasitic diseases are
unrelated to climate.
The WHO has identified AIDS, one of the most
devastating afflictions, as a growing menace in Africa, but it bears no
relationship to temperature or rainfall. Only insect-spread diseases, such as
malaria and dengue fever, and diseases like cholera and typhoid that are spread
through contaminated water, could be worsened by climate change (and then only
if swampy polluted areas were allowed to expand without thought to sanitation,
window screens, and other precautions that have all but eradicated those
diseases in the northern latitudes).
But bear these statistics in mind: In the developed
world, as recently as 1985, infectious and parasitic diseases accounted for 5
percent of all deaths; in 1997, they caused only 1 percent of all deaths. In
short, even for such insect-borne diseases as malaria, climate is much less
important than affluence. Singapore, located two degrees from the equator, is
free of that dreadful malady, while the mosquito-carried scourge is endemic in
rural areas of Malaysia, only a few hundred miles away. Singapore's healthy
state stems from good sanitary practices that reduce exposure. The wealth of
the island-state allows it to maintain an effective public health program.
Nor should we be overly concerned with the diseases
spread by mosquitoes in tropical areas. If climate change were to occur,
according to the global warming models, the poles would warm more than the
equator while temperatures would increase more in the winter and at night than
during the day. In consequence, the tropics, including Africa, would warm less
than the United States or Europe. Any increased burden on health in Africa or
southern Asia would, therefore, be small.
With or without climate change, public sanitation
should be emphasized as the most effective means of attacking water- and
insect-borne diseases everywhere. A warmer world will not add significantly to
morbidity in Third World countries. A poorer world most certainly will.
Both the scientific community and the medical
establishment assert that the frightful forecasts of an upsurge in disease and
early mortality stemming from climate change are unfounded, exaggerated, or
misleading and do not require reducing greenhouse gas emissions. Science magazine
reported that "predictions that global warming will spark epidemics have
little basis, say infectious-disease specialists, who argue that public health
measures will inevitably outweigh effects of climate" (Taubes 1997). The
article added: "Many of the researchers behind the dire predictions
concede that the scenarios are speculative."
Global warming as currently forecast by the
International Panel on Climate Change (IPCC) would not bring tropical diseases
to Americans or shorten their lives or inflict more violent storms bringing
death and destruction to the United States. Moreover, the warmer climate
predicted for the next century is unlikely to induce a rise in heat-related
deaths. As the article in Science magazine points out, "people
adapt. . . . One doesn't see large numbers of cases of heat stroke in New
Orleans or Phoenix, even though they are much warmer than Chicago."
TROPICAL DISEASES . . .
DEATHS IN WINTER VERSUS SUMMER
Deaths from Cold versus Heat
Recent summers have sizzled. Newspapers have reported
the tragic deaths of the poor and the aged on days when the mercury reached
torrid levels. Prophets of doom forecast that rising temperatures in the next
century portend a future of calamitous mortality. Scenes of men, women, and children
collapsing on hot streets haunt our imaginations.
Heat stress does increase mortality, but it affects
typically only the old and the infirm, whose lives may be shortened by a few
days or perhaps a week. There is no evidence, however, that mortality rates
rise significantly. The numbers of heat stress–related deaths are very small;
in the United States; the number of deaths due to weather-related cold exceeds
them. During a recent ten-year period, which includes the very hot summer of
1988, the average number of weather-connected heat deaths was 132, compared
with 385 who died from cold (see chart 5). Even during 1988, more than double
the number of Americans died from the cold rather than from the heat of summer.
A somewhat warmer climate would clearly reduce more deaths in the winter than
it would add in the summer. . . .
To read the
rest of this treatise, go to www.hoover.org/publications/epp/2834641.html?show=essay.
* * * * *
3. International Medicine: Starving Hospitalized Patients
in the UK National Health Service
Number of elderly
patients starving in NHS wards doubles to 30,000 in two years, By Daniel Martin, July 2008
At least 30,000 patients were left starving on NHS
wards last year, despite ministers' pledges to make proper nutrition in
hospitals a priority.
Last year, Health Minister Ivan Lewis admitted that
some patients were given a single scoop of mash as a meal.
Others were ‘tortured' with trays of food placed just
beyond their reach while nurses said they were too busy to help them eat.
Suffering: Cases of poor nutrition jumped 88% between
2005 and 2007
And now, official figures show that between 2005 and
2007, there was an 88 per cent rise in reported cases of poor nutrition leading
to a serious deterioration in a patient's health.
Last year, NHS whistleblowers reported 29,138 such
errors to the National Patient Safety Agency – up from 15,473 in 2005. . .
As the figures only represent reported cases, actual
numbers are likely to be even greater.
Conservative health spokesman Stephen O'Brien said:
‘People go to hospital expecting to get better, yet in 2007, 29,000 people
suffered unnecessarily and completely avoidable harm from poor nutritional
care.
‘Ministers have presided over this growing scandal,
which I have been highlighting for over two years, and yet this Labour
Government have failed to use this 60th anniversary of the NHS to address it.
‘Nutrition is central to health and dignity – how many
more patients must suffer at the hands
of this inept Government?' The Mail has highlighted the
lack of help given to frail patients to eat hospital food as part of its
Dignity For The Elderly campaign.
And last year, a survey by the Healthcare Commission
found that one in five frail and elderly patients complained they did not have
enough help when eating.
Half of nurses said there were not enough staff to
help those who needed it to eat and drink.
Age Concern says 60 per cent of older patients, who
occupy two-thirds of general hospital beds, are at risk of worsening health or
becoming malnourished. The over-80s are particularly at risk.
Patrick Smith, from the charity, said: ‘A missed meal
in hospital is just as much of a risk to patient safety as missing medication
for a patient's recovery. . .
‘Not only do a significant number of older people
arrive in hospital already malnourished, but six out of ten are at risk of
becoming malnourished, or their situation getting worse, while they are there.
. .
The Government last year launched a bid to improve
hospital food, after Mr Lewis admitted many elderly patients were effectively
being starved in hospitals.
Dr Kevin Cleary, medical director of the NPSA, an NHS
agency, said a ‘growth in incident reporting' helps prevent similar
occurrences.
‘We recognise that good nutrition and hydration is
essential for the recovery of patients. And we support clinicians with guidance
to ensure that learning from reported incidents is provided.' To read the
entire report, and get a glance on what we may see in the USA should government
medicine come to pass, go to
www.dailymail.co.uk/health/article-1039562/Number-elderly-patients-starving-NHS-wards-doubles-30-000-years.html#.
The NHS does not give timely
access to health care; it only gives access to a starvation ward.
* * * * *
4.
Medicare &
Social Security: Isn't Social Security Past the Retirement Age?
Social Security Is Morally Bankrupt By Alex Epstein
August 14 marks Social Security's
73rd birthday—placing it eight years past standard retirement age. But,
despite the program's $10-trillion-plus dollar shortfall, no politician dares
to suggest that this disastrous program be phased out and retired; all agree on
one absolute: Social Security must be saved. While the program
may have financial problems, virtually everyone believes that some form
of mandatory government-run retirement program is morally necessary.
But is it?
Social Security is commonly portrayed as benefiting
most, if not all, Americans by providing them "risk-free" financial
security in old age.
This is a fraud.
Under Social Security, lower- and middle-class
individuals are forced to pay a significant portion of their gross
income—approximately 12 percent—for the alleged purpose of securing their
retirement. That money is not saved or invested, but transferred directly to
the program's current beneficiaries—with the "promise" that when
current taxpayers get old, the income of future taxpayers will be transferred
to them. Since this scheme creates no wealth, any benefits one person receives
in excess of his payments necessarily come at the expense of others.
Under Social Security, every aspect of the
government's "promise" to provide financial security is at the mercy
of political whim. The government can change how much of an individual's money
it takes—it has increased the payroll tax 17 times since 1935. The government
can spend his money on anything it wants—observe the long-time practice of
spending any annual Social Security surplus on other entitlement programs. The
government can change when (and therefore if) it chooses to pay him benefits
and how much they consist of—witness the current proposals to raise the age cutoff
or lower future benefits. Under Social Security, whether an individual gets
twice as much from others as was taken from him, or half as much, or nothing at
all, is entirely at the discretion of politicians. He cannot count on Social
Security for anything—except a massive drain on his income.
If Social Security did not exist—if the individual
were free to use that 12 percent of his income as he chose—his ability to
better his future would be incomparably greater. He could save for his
retirement with a diversified, long-term, productive investment in stocks or
bonds. Or he could reasonably choose not to devote all 12 percent to
retirement. He might plan to work far past the age of 65. He might plan to live
more comfortably when he is young and more modestly in old age. He might choose
to invest in his own productivity through additional education or starting a
business.
How much, when, and in what form one should provide
for retirement is highly individual—and is properly left to the individual's
free judgment and action. Social Security deprives the young of this freedom,
and thus makes them less able to plan for the future, less able to provide for
their retirement, less able to buy homes, less able to enjoy their most vital
years, less able to invest in themselves. And yet Social Security's advocates
continue to push it as moral. Why?
The answer lies in the program's ideal of
"universal coverage"—the idea that, as a New York Times editorial
preached, "all old people must have the dignity of financial security"—regardless
of how irresponsibly they have acted. On this premise, since some would not
save adequately on their own, everyone must be forced into some sort of
"guaranteed" collective plan—no matter how irrational. Observe that
Social Security's wholesale harm to those who would use their income
responsibly is justified in the name of those who would not. The rational and
responsible are shackled and throttled for the sake of the irrational and
irresponsible. . .
Social Security in any form is morally irredeemable.
We should be debating, not how to save Social Security, but how to end it—how
to phase it out so as to best protect both the rights of those who have paid
into it, and those who are forced to pay for it today. This will be a painful
task. But it will make possible a world in which Americans enjoy far greater
freedom to secure their own futures.
To read the entire analyses, and a more secure
retirement than Social Security can give, go to www.aynrand.org/site/News2?page=NewsArticle&id=21009&news_iv_ctrl=1021.
Alex Epstein is an analyst at the
Ayn Rand Institute, focusing on business issues. The Institute promotes
Objectivism, the philosophy of Ayn Rand—author of "Atlas Shrugged"
and "The Fountainhead." Contact the writer at media@aynrand.org.
Government
is not the solution to our problems, government is the problem.
--Ronald Reagan
* * * * *
5.
Medical Gluttony:
Visiting Hospital Emergency Rooms for Routine Medical Problems
A friend told my wife last week that her mother was
having urinary burning, had spent 6 hours in the Emergency Room and was given
medications for a urinary tract infection. She was so sick and nauseated in
church that she had to go home. Her daughter called my wife on Sunday afternoon
reporting that her mother was still sick. I interjected that she didn't seem to
need an emergency room visit because they were not envisioning that she might
need to be hospitalized or require surgery. She just needed an after-hours and
weekend doctor. There are "Doc-in-a-box" Urgent Care Centers
scattered all over Sacramento that provide after-hours physician services. The
average wait time is one hour or less.
She, however, decided to return to the Emergency Room
rather than an Urgent Care Center because "they" had already seen
her. "They?" Physicians and the staff change every 12 hours. It would
be extremely unlikely that anyone on duty the previous day would be working
that day to give any continuity of care. My wife received a phone call while
they were still at the ER. They had been waiting for quite a while and did not
appear to be any closer to seeing a doctor than when they arrived. She said her
mother was too sick to stay any longer and they were going to take her home.
The only advice they received from the nurse as they left the ER was to take
the medication that was prescribed even though it made her sick.
Forgetting about duty and obligations, because any one
of us would spend whatever time was necessary for a loved one's benefit, what
are the hidden costs? Because she is elderly and frail, there are two family
members with her each day. Use any hourly rate you're comfortable with for the
24 hours involved to estimate the hidden costs. And still no medical attention.
Add the overhead of a large institution such as a
hospital, that runs into hundreds of dollars per minute, and the basic cost is
extremely high. That's why the equivalent of an office visit to the ER is
closer to $600 plus the tests.
The Urgent Care Centers are usually private
institutions or practices. Hence, their business and practice is dependent on
prompt and efficient service to the people that walk in. That's why the cost to
an Urgent Care Center may be as low as $60 plus the cost of any laboratory
work.
The hospital emergency rooms are socialistic centers
mandated by government to provide services to all comers. Some statistics
suggest that 75 to 85 percent of all comers are not emergencies. Hence, they
must be placed at the bottom of the wait list. As emergencies keep coming into
the emergency room, they go immediately to the top of the list and the
non-emergent urinary infections go further down the list. Is there an
alternative?
Most third-party payers, such as insurance companies,
cover emergency services. Because this makes their costs so insignificant,
people who don't consider their time valuable will spend six hours in an
emergency room even if they don't have a life threatening emergency.
Take away the government mandates and third-party
insurance maneuvering and watch the hospitals provide efficient care.
* * * * *
6.
Medical Myths:
Naiveté? Or Can't Technology Manage Health Care?
Can Technology Better Manage Healthcare? Joe Marion
Last week, while on vacation, I had the opportunity to
experience an example of healthcare up close and personal, as they say.
Let me qualify what I am about to address by saying that this may have been an
isolated incident. My fear is that it is not, and that is why I chose to
write about it.
I should like to describe what happened, and then
highlight where I think the system broke down.
While in Florida visiting a 90-year old family member,
she managed to slip and fall the first night of our visit. She has
difficulty walking and was using a walker at the time. The walker caught
on something, and down she went! She complained of soreness but was able
to get back up with assistance.
The next morning, she was no better, and she opted to
be taken to the emergency department of a nearby hospital – by ambulance, as we
were unable to move her. Upon arrival, she was placed in an emergency
room bay and attached to vital sign monitors. At some point a nurse came
in to take her history, draw blood, and insert additional lines. She was
given a pain pill, after initially being told she could not have anything to
eat or drink, as she might require surgery. . .
After another two hours, she was finally taken to MR
for an exam, and then taken up to a patient ward, where she was kept
overnight. All told, over seven hours in the ER!
We were met the next day by a case worker who was to
assist us with her disposition. We quickly learned that in Florida (and
as I have come to find out, is also true in many other states), as long as the
patient is in control of their facilities, they make the final call on their
course of action. We had felt the best thing for her would have been a
continuous care facility, but when confronted, she indicated she wanted to go
home – no surprise there! The case worker indicated that she would take
care of making all the arrangements with the proper agencies, and she would be
released later in the day. At some point we learned that she could not be
released without these arrangements for in-home care. . .
Now, for the issues with the process:
1. The hospital was extremely
up-to-date, having an automated ER tracking and documentation system, CR and PACS
in Radiology, and mobile documentation carts on the nursing floors (can you
tell I was meddling!).
2. A key element
of patient history was missed by the nurse when taking a history – she has
IBS . . .
3. There was no
known reason for spending seven hours in the ER, other than delays in the CT
and MRI scheduling, and supposedly, availability of a bed . . .
4. At no time in
the ER was she ever examined by a physician. . . .
5. When it came
time for discharge, no one from the hospital followed up to insure that a home
care person was available to accompany her. . .
My key issue? Despite all the technology
available to this facility, it played little in the overall quality and
timeliness of care that this patient received! I could write it
off to staff indifference. After all, there did not appear to be any
incentive for the ER to see that she was informed or expedited to a
room. Similarly, the caseworker seemed more intent on getting her
discharged than on any care that she might receive. It was not the
hospital's fault that she refused the CT exam, although, had the staff spent
any time explaining it to her, perhaps she might not have refused it when they
were about to do the exam!
Instead, I have concluded that the root of the problem
is a breakdown in communication, and "departmentalization," and that
no amount of technology could fix the problem. Perhaps it was the way
technology was deployed at this facility on a departmental level, or the lack
of either an information system application or personnel to oversee the
process. This has me wondering if other facilities mange patients from an
institutional level? . . .
So, I ask myself:
·
How could technology
have been better employed to track and alert staff throughout the entire length
of stay?
·
Is this a reasonable
thing to ask for?
·
Has technology been
"pigeonholed" (in this facility and in general) to
departmentalization, or are there mechanisms that could have better managed the
patient from an institutional level?
·
Was this just a poorly
managed random case?
I'd be interested in your perspective - isolated
example, or a real issue? Please feel free to comment. I'm
particularly interested in whether technology is too departmental, or whether
it can be institutionalized to better manage the patient. I look forward
to your response.
Response left by
Del Meyer, MD:
Satish, Joe and Anthony have
each describe a blind man's impression of the elephant, and each is correct.
But a seven-hour Emergency Room visit appears to be normal for Sacramento. But
what technology are we talking about? Isn't the real issue economic?
Each of the four hospital
systems in Sacramento has a $100+ million expansion program. Despite the
emphasis on outpatient medicine, the hospitals are betting they can alter the
landscape. The ER appears to fund the expansion.
I see patients with chest pain
who have been to the ER and obtained every cardiac evaluation possible. After
six to ten hours they are then told, "We are happy to inform you that you
have no serious heart disease." They are asked to see their personal
physician the next day to transfer liability away from the hospital. When I see
this patient, my hand goes immediately to the chest where the patient states
the pain is and as I press on the costochondral junction (rib-breast bone
junction). They say, "Now that's the pain I went to the ER to have
evaluated."
Costochondritis,
inflammation where the ribs articulate with the sternum, is a very common
musculo-skeletal problem. I see at least several every week and several every
month that have gone to the ER with a full cardiac workup and no diagnosis, one
that I make in the first 30 seconds. An ER doctor told me that they couldn't
make any money if they diagnosed something in the first few minutes. They and
the hospital work by hours and shifts.
A clerk who works in the ER
of one of these hospitals is a patient in my office. She told me that they are
told not to play doctor but to treat every chest pain equally. She states that
the average hospital charge for chest pain complaint is $9,000. How else would
they pay for the $100 million hospital addition? But the insurance company is
able to negotiate their portion down to perhaps one-third; the patient still
pays the full 20 percent on the total charge.
The whole issue could be
solved in the free enterprise market. In our research, studying 5, 10, 20, 30,
40, and 50 percent co-pays, we've found that a 20% co-payment for ER
evaluations reduces all ER visits to the minimum without limiting access or
reducing the quality of care.
This was recently
demonstrated by a patient who went to the hospital ER for breathlessness
without chest pain. She had Medicare and was responsible for the first 20%. She
was in mild cardiac failure, which resolved on the first dose of IV Lasix. She
already had a cardiac ECHO and had good heart function. As they were about to
wheel her out for more tests, she asked about the cost. When she found out that
it was a few thousand dollars more testing, she told them to hold on. She felt
better and desired to go home since they had assured her that she did not have
a coronary. She said she would be back if she got worse. She was doing very
well the next day. She stated that the ER staff seemed very upset over her
early departure. She was wondering if perhaps she cut off the cash flow. She
was still doing very well when seen a month later.
She said she got out of the
ER with a charge of 20% of $3500 or $700. She found out that the tests would
have gone over $8,000 and she was so thankful that she cut if off at the $700
copay, rather than $1600 copay if she had stayed longer.
A percentage copay will
bring health care costs under control and make it efficient. Patients who pay
20% will not visit a hospital again that averages thousands of unnecessary
dollars a visit and instead will seek out the best ER with the most efficient
care at the most reasonable costs. Any one can make one costly mistake. But no
one will make a second costly mistake. Health care cost control occurs with the
second if not the first visit. Government cost control occurs after months and
years of congressional hearings, debates, political maneuvering, and
legislation, which more often than not increases the cost.
And patients will no longer
brag to their friends, relatives and neighbors that they went to the ER and had
$10,000 worth of tests and all was normal and it only cost a $50 co-payment.
That beats Mayo Clinic and all the rest for efficiency. Nobody even thinks of
the $10,000 additional premium that has to be collected downstream for each
visit. Such a raw deal.
Instead, they will go to
their friends, relatives and neighbors stating that they had chest pain, which
they thought surely was a coronary. After an ECG, ECHO, and several blood tests
they were assured that they had no heart disease and the total charge was only
$1200, of which they only had to pay $240. Such a good deal for this kind of
re-assurance.
The former will only lead to
rationing and the ones that need life-saving care will be rationed out of care
and may die.
The latter is the landscape,
the responsible one that will save American Medicine, the world's finest and
most sophisticated.
To read other cases that
continue to make this point, you might sign up at www.MedicalTuesday.net/ (click on Newsletter tab).
Sorry, Joe, technology is
important but not the answer without the economic answer. Third-party health
care will never make this more efficient. Just read MedicalTuesday for a few weeks to see that 25 to 40 percent of
health care costs would vanish overnight with a percentage co-payment for every
item in the CPT.
Del Meyer, MD
Pulmonary Internist
* * * * *
7.
Overheard in the
Medical Staff Lounge: I'm Not Paying Cash Even If It's Less
Dr. Dave: I'm
just amazed at the lack of economic understanding among patients.
Dr. Ruth: How
so?
Dr. Dave: I
had a patient with Rhino-sinus symptoms who needed some antihistamines and decongestants.
I told him these drugs are essentially generic and OTC at a reasonable costs.
Dr. Ruth: He
didn't appreciate your trying to save him money?
Dr. Dave:
Actually he became upset at the very idea of paying cash. He would run it
through his insurance company. He paid them enough that they should be happy
he's getting a generic..
Dr. Ruth: Did
you actually explain the pricing structure so he could understand?
Dr. Dave: My
staff thinks I waste too much of my expensive time because it isn't appreciated.
Dr. Yancy: It's
been shown that patients change insurance plans and doctors for as little as a
$6 change in premium.
Dr. Dave: I
explained that some of these antihistamines were $4 a pill or $120 for a
month's supply when they were proprietary and now they are not only generic,
but over the counter with as much as a 10-month supply for only $12.
Dr. Ruth:
Didn't he think that was a bargain?
Dr. Dave: No.
He said that he didn't have $12. That's why he had insurance to pay for this.
Dr. Ruth: But
what was his co-pay?
Dr. Dave: He
said $5. I pointed out that $5 for a month supply was far more than $12 for a
10 month's supply.
Dr. Ruth: He
could certainly understand that, couldn't he?
Dr. Dave: Well,
his response was simply, "You doctors all work for the insurance company
trying to save them money."
Dr. Edwards: I've
recently had a number of Kaiser Permanente patients enter my practice because
they thought the KP premiums were too high.
Dr. Michelle: I
understand there was a significant increase last year.
Dr. Edwards: But
they were dismayed when the co-payments started to add up because they wanted
to see the same number of consultants that they saw at KP.
Dr. Michelle: And
the inconvenience of driving to several different offices to see these
consultants when they previously had everything so conveniently located.
Dr. Dave: Then
to drive to pharmacies, laboratories and x-ray facilities instead of just going
downstairs to these ancillary services, which is also a wrinkle they didn't
expect.
Dr. Rosen: Their
lack of understanding of all the other variances in health plans frequently add
up to more costs.
Dr. Edwards: I
saw one patient who went from KP to another HMO plan that had shorter office
visits than he was used to at KP. I believe it was 15 minutes instead of 20
minutes.
Dr. Michelle:
Well, did you keep him happy?
Dr. Edwards: My
appointments are very flexible. I may get one patient seen in 15 minutes and
another one may take 25 minutes. But over the course of the day, I'm able to
see my 5 PM appointment by 6 PM. I schedule every 20 minutes, with new patients
every 40 minutes. But many new patients may take an hour. I feel in this
business one can't be more punctual. My patients who are seen an hour late
thank me for waiting for them. Most administrators think of this in the reverse
- the patient is waiting too long. The backward thinking of socialized
medicine.
Dr. Rosen: It's
this economic naiveté that's going to bring about socialized medicine. People
will think it means getting even with doctors. Even when they have to wait six
to twelve months to get a consult that they could have previously gotten the
following week. After the cancer may have spread while waiting, they still
won't understand. They don't believe the rationing all other countries with
socialized medicine are experiencing. But they'll be happier blaming government
doctors who will be totally impotent.
Dr. Michelle: By
that time, I'll be out of this rat race.
Dr. Yancy: And
if I'm not, I'll find something else to do.
Dr. Rosen: I
wonder how long it will take Americans to realize that a six to twelve month
wait to see the specialist they need to cure a suffering life-threatening
disease is really more expensive than the $6 monthly premium saved?
Dr. Yancy: They won't
realize it until it's too late.
Dr. Rosen: Then
the politicians will have a political football that will end the real football
game. Only politicians can change the rules, move the goal posts, lengthen the
playing field, or even stop the clock by a vote of Congress or a filibuster. It
no longer is a real game - just a playing field. Or a crapshoot - heads they
win, tails you lose. And we, the patients and their doctors and nurses, are too
desperate to quit playing the subterfuge. The noble professions have become the
despised profession. The ultimate losers are our patients. But we didn't change
the course of the game while there was still time. Doesn't that make us the
real losers in the eyes of History?
* * * * *
8.
Voices of
Medicine: A Review of Local and Regional Medical Journals
Orange County Medical
Association: What's the Fuss About? By Lytton W. Smith, MD
www.socalphys.com/article/articles/747/1/Whats-the-Fuss-About/Page1.html 6/1/2008
The Joint Commission recently produced its annual
standards for hospital accreditation for 2008.
The standards related to medical staff governance
created havoc for some hospital organizations.
The Joint Commission, formerly the Joint Commission
for the Accreditation of Hospital Organizations, produced its annual standards
for hospital accreditation for 2008. The Hospital Accreditation Procedure
manual gives a full description of the expected standards for hospital compliance.
The standards related to medical staff governance created havoc for some
hospital organizations. After learning of the issues, we at the California
Medical Association's Organized Medical Staff Section chose to reread
Shakespeare's Much Ado About Nothing in preparation for our discussion!
In order to participate in the Medicare program,
hospitals must receive oversight from the Centers for Medicare and Medicaid
Services. The CMS developed a series of standards for participation in the
Medicare program. The Joint Commission, which was established prior to CMS, had
a system of hospital inspections. The CMS contracts with the Joint Commission
to certify that hospitals comply with the standards of participation. This
contract elevates the importance of being certified by the Joint Commission.
The Joint Commission also establishes its own standards to push for improvement
in the delivery of patient care in hospitals.
On a regular basis, the Joint Commission's Standards
Committee reviews and changes the standards based upon input from many sources.
Major changes to the HAP occur every five to 10 years, so you should expect
some major changes in 2009. The change that excited the American Hospital
Association, however, occurred subtly in 2008: the infamous MS. 1.2!
Hidden in the Medical Staff Section, MS. 1.2 sought to
destroy the relationship between hospitals and medical staffs. Yes, a plot by
the American Medical Association--caught just in time by the AHA--surfaced,
threatening the viability of the Joint Commission's survey program. Stop the
presses!
From the Comprehensive Accreditation Manual for
Hospitals: the Official Handbook:
Standard MS.1.20
Medical staff bylaws address self governance and accountability to the
governing board.
Element of Performance
A description of the medical executive's function, size and composition, and of
the methods for selecting and removing its members and the organized
medical staff officers.
Aye, there's the plot: to remove members of the Medical Executive Committee. Imagine
after all the effort to stack the MEC with administration-friendly physicians,
the medical staff might actually remove them. You mean, once all the paid
medical directors take their assigned places on the MEC, the medical staff
could actually vote to remove them? What was the Joint Commission thinking? You
mean the medical staff bylaws need adjustment to allow this element of
performance? Most AMA-recognized attorneys estimated less than $2,000.
Thank California for this mess. Those darn doctors in
Ventura did this! The administration in that small community's hospital decided
to stack the MEC with their chosen few. The doctors of the medical staff
objected and voted to remove the MEC members, replacing them with their own
elected medical staff members. Then the Board of Trustees unilaterally changed
the bylaws, forcing a legal battle heard around the country. In California,
this battle set the stage for the passage of California Senate Bill 1325, which
defined in statute the rights of medical staff members to self governance.
So now the battle over the right of the medical staff
to remove the MEC surfaces on a national level. The CMA OMSS and AMA OMSS
conference calls abound with this issue. Will the Joint Commission capitulate
and remove this innocuous standard? Will the AHA win a concession? Will removal
of "and removing" satisfy the AHA? If removed, will the medical staff
be truly self-governing?
Please stay tuned and, if you have time, reread
Shakespeare's Much Ado About Nothing!
www.socalphys.com/article/articles/747/1/Whats-the-Fuss-About/Page1.html/print/747
To read more VOM, please go to www.healthcarecom.net/voicemed.htm.
To read HMC, please go to www.delmeyer.net/HMC.htm.
* * * * *
Code Blue: Health Care in Crisis by Edward
R. Annis, MD, Regnery Gateway Press, Washington, D.C. 1993, 278 pages.
Review by Del Meyer, MD
Doctor Annis opens his introduction describing the two
worlds that physicians live in: The
wonderland of modern medicine, a gratifying and challenging world of
achievement in research, education, and clinical practice; and the faltering
American health care world, which is on the verge of collapse. Not unlike
Charles Dickens in the opening to this Tale
of Two Cities: "It was the
best of times. It was the worst of times."
Annis gives us many anecdotal insights into the
history of American medicine: Fleming's
discovery of penicillin in England in 1928, that sat on the shelf until
American drug companies developed methods of production in 1943, making it available
to patients; sick England in the postwar era to healthy America; the high death
rate of Europe to increased life expectancy to 68 years in America in 1949. The
high cost of living is only exceeded by the higher cost of dying. His chapter
on health insurance ("Call the Plumber, We're Insured!") is a parody
on why health insurance is not insurance and, therefore, cannot work in its
current format.
Edward Annis, who never chaired a meeting or held an
organized medicine office, was elected president of the AMA at a young age in
an attempt to counter a cunning band of political sophists in Washington, D.C.
He champions the fight to head off government intrusion between doctor and
patient and dispels the myth that a "managed" health care system
would solve America's problems. He feels the problems in health care have a
"Made in Washington" label. Health care already is the most regulated
industry in America, strangling doctors and hospitals by senseless paper work,
counterproductive bureaucracy, an abusive civil court system, and price
controls that are actually driving prices up. He feels it should be labeled a
crisis in government that can only be solved by less government interference.
In his final chapter, "What's the Solution?"
Annis gives us his analysis of why third-party systems aren't working. Clinton's health plan; and two
well-thought-out plans which he feels put the patient back in the driver's seat
– in charge of his or her own money. He favors "An Agenda for Solving
America's Health Care Crisis," by the National Center for Policy Analysis,
which can be reached at 214-386-6272. The other plan "A National Health
System for America," is by the Heritage Foundation and can be obtained by
calling 202-546-4400.
Dr. Annis quotes Tom Paine's 1976 Revolutionary Era
treatise, Common Sense, decrying
excessive government, Time makes more
converts than reason.
This review is found at www.delmeyer.net/bkrev_CodeBlue.htm.
To read more book
reviews, go to www.delmeyer.net/PhysicianPatientBookshelf.htm.
To read book reviews
topically, go to www.healthcarecom.net/bookrevs.htm.
* * * * *
10. Hippocrates & His Kin: Best Practice is a Doctor's
Middle Name
Medical Bureaucrat
(administrator): We are going to be adopting the best practices in our hospital
and enforcing it rigidly.
Doctor: If we all do it, won't best practices be the same as
mediocre?
Medical Bureaucrat:
(administrator) Stop making mediocrity sound bad. [After Scott Adams]
Best
Practice is a Doctor's Middle Name. What don't the bureaucrats understand?
Unnecessary Complexity
Elsewhere in this week's
newsletter, we report on visits to the ER for chest pain that takes hours to
evaluate at high costs. Sometimes it's just a tender rib cartilage called
costochondritis that requires an OTC pain pill, not even an ECG. The writer
couldn't understand why modern technology wasn't more efficient.
Sometimes it is more cost
effective and time efficient to resort to the old standbys of a medical history
and physical examination than to use thousands of dollars worth of technology,
which in this case missed the diagnosis.
Diagnoses are hard to make
without a doctor's examination.
To read more HHK, go to www.healthcarecom.net/hhk2001.htm.
To read more HMC, go to www.delmeyer.net/hmc2005.htm.
* * * * *
11. Professionals Restoring Accountability in Medical
Practice, Government and Society: