1.
Featured Article:
The Power of Babble
MIT researcher Deb Roy is videotaping every waking
minute of his infant son's first 3 years of life. His ultimate goal: teach a
robot to talk. By Jonathan Keats, Wired
Magazine
The time is late morning. The place, a home in the Boston suburbs. Wriggling
around on the living room floor with his baby boy, Deb Roy invents a game.
One-year-old Dwayne watches him, then joins in. Fingers wiggle and arms waver.
Rules change, morphing with their moving limbs. After a while, Dwayne tires.
Roy picks him up and, cradling the child in a hug, lays him gently in his crib.
Fast-forward several weeks. In a laboratory at MIT, a
grad student named Rony Kubat is editing a videoclip on a PC monitor. Onscreen,
there's Dwayne (a name used for this article only), resting just as his father
left him in the crib that morning. Roy watches as Kubat punches keys to scroll
through the footage. Other grad students sit at computers nearby. A 6-foot-tall
robot slouches, deactivated, in the corner. Arms crossed, Roy scrutinizes the
images, which are overlaid with spectrograms and Kubat's annotations.
Almost every new dad breaks out a videocam to record
his kid's early years. But Roy is working on a much more ambitious scale.
Eleven cameras and 14 microphones are embedded in the ceilings of the Roy
household and connected by some 3,000 feet of cable to a terabyte disk array in
the basement. Roy has already captured more than 120,000 hours of footage. Data
from the disks gets backed up to an automated tape library, and every 40 days
Roy shows up at work with a rolling suitcase to download his new haul of data
onto a dedicated 250-terabyte array in the air-conditioned machine room of the
MIT Media Lab.
Roy, 38, directs the Media Lab's Cognitive Machines
Group, known for teaching remedial English to a robot named Ripley. By
recording the early stages of his boy's life, Roy is seeking to supplement his
steel-and-silicon investigations: His three-year-long study will document
practically every utterance his young son makes, from the first gurglings of
infancy through the ad hoc eloquence of toddlerdom, in an unprecedented effort
to chart uninterrupted the entire course of early language acquisition. The
goal of the Human Speechome Project, as he boldly calls his program, is to
amass a huge and intricate database on a fundamental human phenomenon. Roy
believes the Speechome Project will, in turn, unlock the secrets of teaching
robots to understand and manipulate language. To read more,
please go to www.medicaltuesday.net/index.asp.
Disarmingly convincing with a
calm manner and understated black attire, Roy goes on to explain how the
project will ultimately let him combine human observation and robotic
experimentation to address some of the most basic questions about how words
work and what language reveals about cognition. There's a practical side to
this: the motivation of an engineer who wants to make machines talk and think.
There's also a speculative side: the motivation of a scientist who wants to
explore language as a means of investigating the brain. . .
Child psychology has always lacked a killer app.
The first significant use of technology was the language lab, outfitted with
one-way mirrors and video cameras to provide researchers with a window into the
relationship between babies and their mothers. By the early '80s, though, the
laboratory setup was under attack by educational psychologists like Jerome
Bruner. To get a realistic picture of parent-child interaction, Bruner claimed,
you need to "study language acquisition at home, in vivo, not in the lab,
in vitro." His point was well taken but not easily addressed. . .
Deb Roy's recall of his own childhood in
Winnipeg, Manitoba, in the '70s is less than total, reaching clarity only after
his sixth birthday, when he started building robots. "At first they were
just cosmetic," he says. "Then I got interested in building the robot
brain, not just the body, and I realized that I didn't have very good ideas
about how to design controllers. So I started to think, how do people
work?" He went to the library, where he found more questions than answers,
too many unknowns. Humans were a complicated species. Psychology was vague. By
the time Roy finished high school, he had decided to pursue a degree in
engineering.
At the University of Waterloo, he
learned about computer engineering and programming, and he found those
disciplines as unsatisfying as the idle speculations about human nature at the
local library. "Given a set of specs, a traditional engineer tries to work
out the optimal design," he says. "I was more interested in
questioning the specs." So, after four years of applying his engineering
skills to engineering school figuring out how to pass classes with the
minimum possible effort he had a pretty good sense of the environment he
needed to satisfy his particular blend of curiosity and pragmatism. He found it
as a grad student at MIT's famously iconoclastic Media Lab. . .
As robots go, Roy's camera on a
stick was Paleolithic, but it was the start of the research that led him to the
Speechome Project. As part of his doctoral work, Roy built Toco to find out how
boundaries between words are discovered, sifted from the slurry of everyday
speech. To do so, he would allow the robot to learn by doing.
In other words, there wasn't
going to be any fancy artificial intelligence poured into Toco's empty vessel
of silicon. Roy would just utter simple phrases like "Look at the red
ball" to find out whether, using basic pattern- recognition software, Toco
could figure out that red was one word and ball was another
and that they belonged to different grammatical categories. . .
Toco took well to having eyes and
ears, learning with startling alacrity how to talk about the properties of
simple objects. "What color is the ball?" Roy might ask, to which the
robot might reply, studiously ignoring a yellow cube and a blue cone, "Red
ball." A toddler could have had a stimulating discussion with Toco,
perhaps even have learned a thing or two about basic geometry.
Does this mean that Toco the robotic toucan
might help us understand how children learn language? To address this question,
Roy uses an appropriately avian analogy, comparing birds and planes. "They
don't look alike," he says, "yet both share the property of flight.
We learn most of our aerodynamics by building aircraft. We learn about drag and
lift, which are also principles used by birds." In other words,
experiments with gliders and biplanes gave us the physics to understand how
eagles and hawks stay aloft, a template for specialized investigation of wings
and feathers. Likewise, the thinking went, a robot capable of humanlike behavior
will provide a rough model for the study of lobes and neurons.
Back in the late '90s, Roy was a
bit more brash, at least when talking to his soon-to-be fiance. "My robot
is learning," he bragged. "It's learning the way kids learn. I bet
that if we gave it the sort of input that kids get, the robot could learn from
it."
Patel took one look at him, a guy
who could read resistors based on their bands of color but wouldn't know a
binkie from a blankie, and said, "Prove it."
It was no idle challenge. Patel
was working toward her PhD in speech pathology at the University of Toronto,
and she had access to an infant lab. So Roy bought a box of toys and flew to
Canada, where Patel instructed a gathering of mothers to play with their babies
while she videotaped their interactions. For an entire weekend, in hour-long
sessions, the mothers babbled happily about balls and doggies and choo-choo
trains. Then Roy gathered up the toys and caught a plane back to Cambridge.
"After watching a few hours of video, I realized that I hadn't structured
my learning algorithm correctly," Roy says. "Every parent knows that
when you're talking to an 11-month-old, you stay on a very tight subject. If
you're talking about a cup, you stick to the cup and you interact with the cup
until the baby gets bored, and then the cup goes away." Roy needed to give
his algorithm an attention span. . . .
Baby Dwayne is already
negotiating the twin forces of nature and nurture, though he's hardly in a
position to talk about it. So far, the only word he's uttered is bath,
and Roy isn't sure whether he means it as a description or a command, or
whether he even understands the difference.
When he grows up, Dwayne Roy will
be able to retrace his well-documented babyhood watching himself wriggle
around on the floor with his dad, playing made-up games, hearing his own first
words. Like anyone's childhood, it will be a one-time event. But the robots
trained by his father might live a thousand versions of Dwayne's life, babbling
tirelessly, until one of them finally learns to talk.
Jonathon Keats (jonathon_keats@yahoo.com) writes the Jargon Watch
column and is the author of Control + Alt + Delete: A Dictionary of
Cyberslang.
To read the entire article, go to
www.wired.com/wired/archive/15.04/truman.html.
* * * * *
2.
In the News:
American Media Ignore Swiss Vote
Single Payer Rejected by 71% of Voters, Hagerstown, MD, March 15, 2007
CHCC President Greg Scandlen issued the following
statement today
"On Sunday the Swiss people voted overwhelmingly
to reject a Single Payer system. But there has been not a word about it in the
American press other than a single paragraph in the trade publication Business
Insurance (www.businessinsurance.com/cgi-bin/news.pl?newsId=9723http://).
"The vote was on whether to replace Switzerland's
current system of mandatory health insurance coverage provided by 87 private
health plans with a single payer system based on income-related premiums. It
was rejected by 71% of the voters. To read more,
please go to http://www.medicaltuesday.net/news.asp.
"If the vote had gone the other way if the Swiss
had embraced Single Payer it would have been front page news in every
newspaper in the United States, it would have been a lead story in every
broadcast. Reporters would have booked flights to Geneva to interview citizens
and political leaders.≈
"This provides a sobering example of why public
policy goes so wrong in the United States. The public is informed of only one
side of the story. Reporters and editors are biased in favor of government
intervention and against free markets. They are part of a privileged elite who
think consumers are incapable of making sound decisions and intelligent
choices.
"But the people of Switzerland made the same
choice as the American people make every time they have had an opportunity.
Voters in Oregon rejected Single Payer by a vote of 79% to 21% in 2002. People
do not want to be herded into a government-run cattle car. We want and demand
freedom of choice in health care as in every other aspect of our lives."
About Consumers for Health Care Choices
Consumers for Health Care Choices is a national
membership organization of citizens devoted to putting the consumer in the
driver's seat of the health care system. It was organized just over one year
ago and is growing quickly as more people realize the future of health care
rests with empowered consumers. The Board Chair is Daniel (Stormy) Johnson,
Jr., MD, a radiologist in Metairie, Louisiana, and former president of the
American Medical Association.
Consumers for Health Care Choices, Greg Scandlen, President, Website: www.chcchoices.org.
email: greg@chcchoices.org phone: 301-606-7364
* * * * *
3. International Medicine: See your GP at
the supermarket
Retail
Giants Set To Run GP Clinics From The Sunday
Times, London, March
18, 2007 By David Cracknell and Sarah-Kate Templeton
TONY BLAIR is to invite
retail chains including Tesco, Virgin and Boots to bid to run GP surgeries on
behalf of the NHS with contracts worth £225m over five years. GPs will be
encouraged to run clinics at breakfast time and in the early evening in poor
areas where conventional family doctors have been reluctant to practise. To read more, please go to www.medicaltuesday.net/intlnews.asp.
Blair's announcement,
. . . is intended to ensure Gordon
Brown carries on his reforms of the NHS after Blair leaves Downing Street.
The prime minister
will respond to Tory claims that he has left the NHS in "crisis" by
publishing his ideas for "progressive" reform of public services. He
will allow GPs to link up with pharmacies and supermarket drug counters by
sharing electronic patient records.
In an indication that
he is signed up to the scheme, the chancellor will announce measures to expand
the use of "community pharmacies" for routine treatments and tests.
Tomorrow Blair will
publish the first of six policy review papers, on public services, in an effort
to shift the emphasis away from producers to consumers.
Patricia Hewitt, the
health secretary, will name the first towns to take part in the new programme.
Extra family practices, walk-in centres and minor injuries units will be opened
in Har-tlepool, Durham, Mansfield and Great Yarmouth. Other areas will join the
programme in the coming months.
Contracts for the new
services will run for an initial five years, with the possibility of extension.
Although there is no
national shortage of GPs, there are many "underdoctored" areas in
England and Wales. The four areas involved in the first wave have significantly
fewer GPs per person than the national average of 57.9 GPs per 100,000 people.
The programme aims to
attract a broad range of providers, from existing entrepreneurial GPs to social
enterprises and FTSE-100 companies. Some extra GPs and nurses will be recruited
for up to 30 health blackspots to tackle local shortages of doctors.
David Cameron will
also focus on the NHS in a speech to the Conservative party's spring forum in
Nottingham today. He is expected to say: "It used to be said that Labour
were the party of the NHS. Not any more. Labour are the party that is undermining
the health service.
"There's a
simple reason why. It's not because they don't care. But it is because of their
values and philosophy: Labour's mania for controlling and directing things from
the centre; Labour's pessimism about human nature; Labour's belief that if
people aren't told what to do, they'll do the wrong thing. Labour just don't
trust people." nThousands of doctors staged marches
in London and Glas-gow yesterday to protest at reforms
to the system of medical training.
They accuse the government of trying
to "disempower and degrade" the profession.
To read a very active
blog on this subject, please go to www.timesonline.co.uk/tol/news/uk/article1530567.ece.
The NHS does not give timely
access to healthcare, it only gives access to a waiting list.
* * * * *
4. Medicare: Government-run health care gets pessimistic
prognosis, Home News
Tribune 03/30/07
Three scenarios are before us:
·
The
recent troubles at Walter Reed Army Medical Center in Washington, D.C., are
putting the shortcomings of government-run health care on display.
·
Former
Gov. Mitt Romney is finding that his not-yet-implemented plan for universal health
care in Massachusetts is plagued by rising cost estimates, almost doubling the
initial predicted premiums.
·
And
David Walker of the Government Accountability Office has issued a dire warning
about the future of our nation, destined to be sunk by the sheer weight of the
behemoth Medicare system. Medicare responds by lowering its fees to the actual
providers of health care. To read
more, please go to www.medicaltuesday.net/medicare.asp.
These are three striking examples that should make us
pause before handing all of our health care over to big government. The common
thread in all of these scenarios can be summed up in one word bureaucracy.
Bureaucracy is a rigid system of human organization government by fixed rules
and tending to exclude individual initiative. Dr. Max Gammon, a British
economist who sees much to dislike in the British health-care system, has
described what is now known as "Gammon's Law of Bureaucratic Displacement."
This describes the progressive displacement of productive activity by
nonproductive and often counterproductive economic activity.
Walter Reed demonstrates Gammon's Law perfectly. The
system has evolved whereby a soldier is required to file 22 documents with
eight different commands, most off-post, to enter and exit the medical
processing world. Sixteen different information systems are used to process the
forms. The Army has amassed three different personnel databases that cannot
communicate with each other. People with "safe" government jobs run
the outpatient center, a rat- and roach-infested, filthy, moldy deteriorated
building. Since "free" care is provided, the veterans are expected to
shut up, hold their noses, and wait. One cannot blame the VA employees, most of
whom are eager to do a good job, but are helpless to change the
"system."
Britain's National Health Service is another example
of Gammon's Law. In 1948, there were 480,000 beds, now down to 186,000. In the
same period, the staff of the NHS has gone from 350,000 to 882,000, most in
newly formed administrative positions. As the number of bureaucrats rise, so do
costs, and productive activity falls.
The only way to combat this is to get the government
out of health care. Government provides a protected environment for bureaucracy
and shields it from competition. It provides a black hole for resources to be
devoured. Things cannot possibly improve unless innovation is allowed to see
the light of day.
Private enterprise avoids bureaucratic displacement,
and innovation causes positive changes. Wherever there is free enterprise,
progress leads to lower costs, as we have seen in agriculture, telephones,
computers and the Internet. Government involvement in 1965, when Medicare and
Medicaid began, initiated the exponential rise in health-care costs for all.
The simple answer is for the government to abandon the
impossibly unrealistic promise of free health care for all, and back off
meddling in the greatest health-care system in the world, created because the
free market has been allowed to innovate. Equalize the tax treatment of health
care for all citizens and allow American ingenuity to do what it does best.
Aside from serving as a true safety net for the
disabled, the federal government ought to get out of health care. It should
allow us to handle our own health care, using health savings accounts and
free-market insurance for catastrophic medical events. And allow communities to
develop local charities, with individuals not bureaucrats providing the poor
with the charity care they need.
Alieta Eck, M.D., PISCATAWAY, NJ
www.thnt.com/apps/pbcs.dll/article?AID=/20070330/OPINION02/703300363/1004/OPINION
Government
is not the solution to our problems, government is the problem.
- Ronald Reagan
* * * * *
5.
Medical Gluttony:
Coronary Angioplasties
Medicine Enough for Pain in Chest? By Steve Sternberg, USA Today, March 27,
2007
NEW ORLEANS -- Thousands of people with
crushing chest pain who once opted for angioplasty as a quick fix may change
their minds based on a landmark study out Monday showing that medication costs
less, poses fewer risks and works just as well.
"I think this will change the
discussion between the patient and doctor," says Raymond Gibbons of the
Mayo Clinic and president of the American Heart Association. "In some
cases, it will lead to a decision not to use angioplasty and a stent."
The study of 2,287 heart patients with
chronic but stable chest pain is the first to show that taking medication alone
is as effective as coupling medicines with angioplasty, in which a tiny balloon
is threaded into arteries supplying the heart, for preventing deaths, heart attacks
and hospitalization.
The researchers found no significant
differences after five years between the two groups in deaths, heart attacks or
strokes. . . To read
more, please go to www.medicaltuesday.net/gluttony.asp.
Researcher William Boden of Western New
York VA Healthcare Network in Buffalo called the trial "good news"
for patients, because the study shows many can avoid or defer angioplasty. . .
But angioplasty is costly. About 1.2
million angioplasties are done a year. More than half are done to patients with
chronic chest pain, such as those in the study.
The initial cost per patient is about
$8,000, said William Weintraub of Christiana Hospital in Newark, Del. The cost
of each quality year of life gained by angioplasty tops $200,000, four times
the average considered reasonable for medical technology, according to his
research.
Since each angioplasty costs $5,295 more
than drug therapy, eliminating 350,000 could save as much as $10 billion a
year, Weintraub says. . .
After an average of five years, 211 deaths
and heart attacks occurred in the angioplasty group and 202 in the drug group,
researchers told the American College of Cardiology. The findings also appear
online in The New England Journal of Medicine.
Researchers also found drugs alone eased
pain almost as well as angioplasty. By five years, 74% of those in the
angioplasty group said they were pain free, compared with 72% of those
who took drugs alone. (c) Copyright 2005 USA TODAY, a division of Gannett Co.
Inc.
www.redorbit.com/news/health/882221/medicine_enough_for_pain_inchest/index.html?source=r_health#
Read the original article that
appeared in the New England Journal of Medicine.
* * * * *
6. Medical Myths: Cholesterol Pills Prevent Heart Attacks
Inside Medicine:
Chances are, cholesterol pill is of little help By
Dr. Michael Wilkes Sac Bee,
Saturday, March 31, 2007
Heart disease is a major killer in the United States.
Let's say I could give you a pill to prevent a heart attack. You would need to
take the pill every day for five years at a cost of $3,000. Would you take it?
Most would.
But now, let's say that the pill actually prevented a
heart attack in one of every 67 people who took the pill for five years. That
is, 66 people would take the pill and get no benefit -- only one would benefit,
and we can't predict which person that would be. Would you take the pill? This
time, you need to think carefully and weigh the pros and cons. To read more, please go to www.medicaltuesday.net/myths.asp.
Well, this is exactly the type of information you need
to know when choosing any treatment, but particularly when thinking about
taking a medicine to reduce cholesterol.
Jenny is a healthy 50-year-old with no history of
heart disease in her family. But when she went to her doctor for a checkup, he
did the exam and took some blood for cholesterol, which came back elevated. In
a follow-up phone conversation, the doctor recommended to Jenny that she start
taking a drug to lower her cholesterol. There was no discussion of the expected
benefit from the drug (which is probably much less than 1 in 67 over five
years).
In the United States, 36 million Americans take a pill
each day to lower their cholesterol. For those with a history of heart attack
or symptoms of heart disease, the benefits of lowering cholesterol are
substantial and well documented.
However, it is not good science to assume that if
something helps people after heart attacks, it might also help people who have
not had a heart attack. Antibiotics are life-saving for those with pneumonia,
but we don't give antibiotics to healthy people as a precaution.
Most of the 36 million people who take cholesterol
pills do not have heart disease. Their doctors prescribe pills as a form of
preventive medicine -- hoping that lower cholesterol might prevent heart
disease in the future.
In some cases, there is no data to support these
assumptions at all. In other cases, the data suggest only a very small benefit.
Given the small benefit, some reasonable people might decide to not take the
pills when they consider the expense and the daily reminder that their bodies
are abnormal. . .
As a recent article in the journal Tthe
Lancet points out, if people understood the small magnitude of benefit from
taking cholesterol medicine, some might choose a more healthy alternative --
using diet and exercise instead of taking a daily pill. This personal choice
might lead to far fewer people taking medications to lower cholesterol.
My point is twofold. First, given the lack of
scientific data proving a sizable benefit in otherwise healthy, low-risk
people, we might be pushing cholesterol reduction a bit too hard. And second,
people should be told, in simple language, the expected benefits of taking a
drug so they can decide for themselves whether to take a pill for the rest of their
lives.
To read the entire article by Professor Wilkes, go to www.sacbee.com/107/v-print/story/146331.html.
* * * * *
7.
Overheard in the
Medical Staff Lounge: Narcotics or Surgery?
Dr. Milton: It
seems that I'm seeing a lot more requests for narcotics these days. And it's
not just for 20 or 30 tablets any more.
Dr. Michelle: Boy,
you got that right. The other day I had a patient requesting 90 hydrocodones a
month. After 25 years of practice, my limit has been a maximum of 30.
Dr. Rosen: This
past year I had a patient request 720 hydrocodones for a three-month mail
order. He was taking 8 a day, which for 90 days equals 720. To read more,
please go to www.medicaltuesday.net/lounge.asp
Dr. Michelle: I
hope you didn't give him that many. You know the street value of hydrocodone is
$10 a pill. That would be $7,200 if the patient turned around and sold it.
Maybe that's why the BNDD (Bureau of Narcotics and Dangerous Drugs) has been
arresting doctors. They just assume at least a 100-pill kick back.
Dr. Rosen: I told
him that my limit was 30 a month, which would be 90 for three months. He said
that he would have to find another doctor. So, I compromised at 180 for three
months to give him time to find another doctor.
Dr. Michelle: Did
he then leave your practice?
Dr. Rosen: He
had no choice. But the interesting thing that our legislators don't understand
about pain management, is the large variability in people's reactions to pain.
I asked this patient as we were parting, if any other doctor had ever refused
his request for 8 tablets a day, or 240 a month or 720 for three months? He
said yes, and that doctor had not given him any.
Dr. Michelle: Then
what happened until he found another doctor?
Dr. Rosen: I
asked him the same question. If you went without pain pills for three months,
how was your pain? He said that it was about the same. So why did you go back
to pain pills? I needed them, he responded.
Dr Sam: And
the legislator that passed the law demanding doctors relieve pain or be
prosecuted is a total ignoramus about medical pain practice. How do we get the
lawmakers out of the practice of medicine?
Dr. Milton: I
don't think that is going to be possible. They are so jealous of the power of
the physician's pen that they want to position themselves between the physician
and his pen.
Dr. Michelle: I'm
seeing a lot of postop pain. It seems like shoulders and backs are big
culprits.
Dr. Rosen: This
past month I also saw one of each. One lady had a rotator cuff repair and had a
bad result and was talked into a second operation and fared no better. On her
third operation, she had metal inserted into the joint. She said her pain was
far worse now after three operations than before the first.
Dr. Yancy: But
the incidence of such bad results must be on the order of a fraction of one
percent.
Dr. Rosen: But as a medical specialist, I see all the bad
results. I have one patient who had five back operations before he became
paraplegic (paralyzed from the waist down). At age 43, he lives in a
wheelchair, has a rubber catheter through his abdominal wall, and when he has
to urinate, he just pulls the rubber hose out, turns the stop cock, and drains
his bladder into the jar he carries with him. When he has to have a bowel
movement, he rides his wheelchair into the bathroom, slides into a hoist, and
lets himself down over the toilet. When he's done, he hoists himself up again
to his wheelchair and rides off.
Dr. Michelle:
That's an awful story.
Dr. Rosen: Even
more amazing or tragic, he says his back pain is worse than before the first
surgery. And what's more, he's still looking for that sixth neurosurgeon.
* * * * *
8. Voices of Medicine: A Review of Local and Regional
Medical Journals
Mark A. Singleton, M.D., President, California Society of Anesthesiologists discusses what would impact Medicare far
more than any amount of lobbying in his President's Page Message in
the Winter 2007 issue of the Bulletin of the CSA.
"Now is the winter of our discontent."
Richard III, Act 1, scene 1,William Shakespeare.
I doubt that there has been a period of greater
frustration, anger and outrage among American physicians over the continuing
loss of economic autonomy and mounting regulation of medical practice than we
are enduring currently. Our hallmarks of professionalismmastery of special
skills and knowledge, the independence of judgment in providing and charging
for a service, and a position of authority in societyare being eroded with
alarming constancy. As anesthesiologists, the providers of essential and
uncompromising services, we are targeted especially by forces outside our
profession that seek to constrain our ability to provide quality care. To allow
this to occurby consent, fear of confrontation, or apathyrisks the vitality,
and perhaps even the continuing existence, of our specialty. This sentiment has
been expressed by many of our most respected leaders. But what can we do? I
believe we must exercise our only true power: take back our proper authority;
act with dignity; behave professionally; and, when something is misguided,
inequitable and wrong, refuse to be a part of it. To read more,
please go to www.medicaltuesday.net/voicesofmedicine.asp.
Medicare
has treated anesthesiologists unfairly for over a decade, ignoring our pleas
for parity with other specialties and reform of the "teaching rule"
that cuts in half payments to academic anesthesiologists who supervise two
residents. The excellent three-part
essay by Dr. Kenneth Pauker, published in the most recent issues of the Bulletin,
has given a clear history and analysis of how these conditions came to be and
the role ASA played in the process. We hope that, because CMS repeatedly has
ignored us and failed to remedy these inequities, Congress will do it
legislatively. Several bills that have been introduced during this session
would revoke the teaching rule. The American Association of Nurse Anesthetists
has worked actively against our efforts, undoubtedly fearing redirection of
some of their Medicare dollars. I was pleased recently to hear from my own
congressman that he, along with many others, was co-sponsoring one of these
bills. It is a tremendous accomplishment by our ASA Washington office, those of
you who have donated to ASAPAC, and our own Ken Pauker, Chair of our
Legislative and Practice Affairs Division, who publicly challenged Pete Stark
during his address to ASA last spring, to support ASA's effort.
Medicare
payments to physicians are determined by a complicated formula called the
Sustainable Growth Rate, which was originally designed to restrain the Medicare
budget in the face of increasing numbers of Medicare beneficiaries. The predictable result (even without the
math) is that payment to physicians decreases every year while other parts of
the Medicare budget increase. Congress
has failed to abolish the SGR, despite the fact that it is widely recognized as
a disastrous mechanism, and even Congress's own advisory body has, for years,
urged its replacement with an index of medical practice expenses. In the final months of 2006, physician
organizations and individuals across the nation have been imploring their
legislators to at least act as they have every previous year, namely,
temporarily block the SGR-evoked 5 percent decrease due to go into effect
automatically January 1, 2007. The lack of action by the CMS is a clear
indication that our government does not consider payment to physicians in the
Medicare program a problem. The effect on anesthesiologists is compounded by
practice expense methodology and work value adjustments, and, by combining all
of these factors, it results in a 12 percent to 13 percent decrease. We must
each ask ourselves, "Is this unacceptable, and, if so, what am I willing
to do about it?"
In one
of his last weekly reports before leaving the CMA, recently departed (though
alive and well) CEO Dr. Jack Lewin commented on his dismay and disappointment
with congressional inaction on Medicare, after spending a week in Washington
with CMA physician leaders, pleading the case for fair payments to California
physicians. Far more telling was his comment that the only "silver
lining" might be that perhaps this latest insult would drive physicians
out of the Medicare program in numbers big enough for the government to realize
that it is unacceptable and a failure as it currently exists. The CMA has just
reminded its members in an e-mail alert that December 31, 2006, is the deadline
to become a nonparticipant in Medicare for the coming calendar year. It appears
that few alternatives are left for many practitioners. If enough Medicare
patients were told that the anesthesiologist will be happy to care for them,
but the patient will have to pay since Medicare is not paying its fair share,
this would have far more impact than any amount of lobbying.
The entire article including a detailed analysis of
the RBRVS Conversion factors is found at www.csahq.org/pdf/bulletin/issue_15/president_064.pdf.
To read more about what physicians write about and
understand how they think, please go to www.healthcarecom.net/voicemed.htm.
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9.
Book Review: The
Charity Gap, By Sheryl Sandberg, WSJ,
April 4, 2007
[We recently published a
review on WHO REALLY CARES America's Charity Divide Who Gives,
Who Doesn't, and Why It Matters by Arthur C. Brooks, www.delmeyer.net/bkrev_WhoReallyCares.htm. We now present
Sheryl Sandberg's article for further insight. When some twenty years ago, as
president of a charity, I pointed out that less than 25% of our gifts were
going toward purposes for which the organization was founded and how
contributors intended their gifts to be used, I found myself defendant in a defamation
law
suitlawsuit.
The financial costs were immeasurable from which I still haven't recovered.
Hence, no disclosures. I was told that the cost of the building, the RN on the
staff, the program directors, the executive directors salary, which took up
half of the heart felt contributions, were all benefit programs and, therefore,
a benefit for patients with the disease in question even though only 7% was
allocated to fight the disease in question. We present The Charity Gap
to continue the dialogue.]
As Americans prepare their tax returns, many will be
toting up their tax-deductible donations. Whether it is support for a church or
hospital or their alma mater, they have every reason to feel good about what
they're doing.
But there is a surprising disconnect between
Americans' philanthropic aspirations and their charitable giving. The vast
majority of givers believe the bulk of their donations help those less
fortunate than themselves. In fact, less than one-third of the money
individuals gave to nonprofits in 2005 went to help the economically
disadvantaged, according to a new study commissioned by Google.org, the
philanthropic arm of Google. Of the $250 billion in donations, less than $78
billion explicitly targeted those in need. To read more,
please go to www.medicaltuesday.net/bookreviews.asp.
The analysis, carried out by the Center on
Philanthropy at Indiana University, concluded that only 8% of donations provide
food, shelter or other basic necessities. At most, an additional 23% is
directed to the poor -- either providing other direct benefits (such as medical
treatment and scholarships) or through initiatives creating opportunity and
empowerment (such as literacy and job training programs). It's just not true,
in other words, that the major beneficiaries of charity and philanthropy are
the disadvantaged.
The "charity gap" is even wider among the
affluent. Wealthy individuals claim, according to a Bank of America Study, that
their giving is driven by a "feeling that those who have more should give
to those with less." But people who earn more than $1 million per year
give only 4% of their donations for basic needs and an additional 19% to other
programs geared toward the poor.
These numbers matter. Overall donations by individuals
are more than four times that of foundation and corporate philanthropic efforts
combined. And they matter most among the wealthiest, since fewer than 10,000
families contribute more than 20% of all donations. . .
A second reason may be that donors do not fully
understand where their contributions go. For people with annual incomes below
$100,000, religious giving dominates, comprising two-thirds of all donations.
While the church food drive may be in donors' minds as they reach into their
pockets, less than 20 cents of every dollar given to religious organizations
funds programs for the economically disadvantaged. For the wealthiest
Americans, education and health care comprise the majority of donations. Yet in
education, fewer than nine cents per dollar pays for scholarships; in health,
only 10 cents per dollar funds programs targeted to the needy. . .
As Americans consider their 1040s this year, they need
to ask if there is a disconnect between their desires and their actions. Many
will find, perhaps to their surprise, that what they want to do is not, in
deed, what they're doing. If so, they should start looking deeper into how
their donations benefit those whose economic fortunes are dramatically
different from their own.
Ms. Sandberg is vice president of global online sales
& operations at Google Inc. and a board member of Google.org.
To read the entire article (subscription required), go
to http://online.wsj.com/article_print/SB117565580732059314.html.
To read more book reviews, please go to www.healthcarecom.net/bookrevs.htm.
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10. Hippocrates & His Kin: The Most Flagrant Oxymoron.
Live & Die: What's the most flagrant oxymoron
you've ever heard? Politically correct.
After Johnny Hart.
Live & Sue: Sign on the
door of a law office: Hire an attorney. Get a second one free. (You suppose the
third one is half price?)
To read more,
please go to www.medicaltuesday.net/hhk.asp.
Live & Learn: Last week
I saw a patient in pulmonary consultation who spoke no English. He handed us a
card from an interpreter agency and motioned to us to call them for him. About
two weeks later we received a bill from the agency for an interpretation fee,
for which the two-hour minimum was $130 and the mileage charge $11, for a total
of $141. Expected reimbursement for the consultation is about $96. Such a deal.
Spend $50 more than you get paid to see a patient and for helping him with his
asthma. He was from the Ukraine, where I understand such deals are the norm.
Live & Sleep: A
72-year-old patient was brought in by his wife because he was sleeping his life
way. He went to bed at 11 PM after the news and slept until 11 AM. He would
then have his coffee, breakfast, read the paper and take a three-hour nap. He
then took his shower, got dressed, in time for supper. She was asking for help
in giving her husband of four years some ambition. Would a psychiatrist help
what she thought was depression. The patient's response was that they had two
social security checks coming in, he had his government pension, and so why
shouldn't he be able to sleep through his retirement. He loved to sleep. He
enjoyed sleeping ever since he was a little boy. But no longer seem rested.
Suppose we should ask
Congress to increase the taxpayer funded Social Security Benefits to age 55 so
this gentleman could have a much longer restful retirement?
Live & Think
(like a lawyer): A reflex answer: Last month a surgeon was bemoaning the
fact that he had provided outpatient care for a fracture, and a week later the
patient's mother called to tell him her son had died of a massive pulmonary
embolus. She demanded to know why he didn't warn her son of this possible
complication. The surgeon couldn't remember if he had warned the patient of
that specific complication and seemed apologetic. The reflex answer should
always be, "He was told." It is impossible for a patient to get
through the hospital permit and informed consent process without being
adequately warned. We are so concerned about our patients and we feel so
guilty, that we forget that we have to answer like a lawyer when the other side
has already retained one.
To read more vignettes, please go to www.healthcarecom.net/hhkintro.htm.
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11. Organizations Restoring Accountability in HealthCare, Government
and Society: