MEDICAL TUESDAY . NET

NEWSLETTER

Community For Better Health Care

Vol VI, No 1, Apr 10, 2007

 

In This Issue:


1.                   Featured Article: The Power of Babble 

2.                  In the News: American Media Ignore Swiss Vote

3.                  International Medicine: See Your GP at the Supermarket

4.                  Medicare: Government-Run Health Care Gets Pessimistic Prognosis

5.                  Medical Gluttony: Coronary Angioplasties

6.                  Medical Myths: Cholesterol Pills Prevent Heart Attacks

7.                  Overheard in the Medical Staff Lounge: Narcotics or Surgery?

8.                  Voices of Medicine: What would impact Medicare far more than any amount of lobbying?

9.                  From the Physician Patient Bookshelf: The Charity Gap, By Sheryl Sandberg

10.              Hippocrates & His Kin: The Most Flagrant Oxymoron: Politically Correct

11.              Related Organizations: Restoring Accountability in HealthCare, Government and Society

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The Annual World Health Care Congress, co-sponsored by The Wall Street Journal, is the most prestigious meeting of chief and senior executives from all sectors of health care. Renowned authorities and practitioners assemble to present recent results and to develop innovative strategies that foster the creation of a cost-effective and accountable U.S. health-care system. The extraordinary conference agenda includes compelling keynote panel discussions, authoritative industry speakers, international best practices, and recently released case-study data. The 3rd annual conference was held April 17-19, 2006, in Washington, D.C. One of the regular attendees told me that the first Congress was approximately 90 percent pro-government medicine. This year it was 50 percent, indicating open forums such as these are critically important. The 4th Annual World Health Congress will be held April 22-24, 2007, also in Washington, D.C. The World Health Care Congress - Asia will be held in Singapore on May 21-23, 2007. The World Health Care Congress - Middle East will be held in Dubai, United Arab Emirates, on November 12-14, 2007. World Health Care Congress - Europe 2007 will meet in Barcelona on March 26-28, 2007. For more information, visit www.worldcongress.com. 

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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.

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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

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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.

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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

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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.

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6.      Medical Myths: Cholesterol Pills Prevent Heart Attacks

Inside Medicine: Chances are, cholesterol pill is of little help By Dr. Michael WilkesSac 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.

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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.

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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 professionalism—mastery of special skills and knowledge, the independence of judgment in providing and charging for a service, and a position of authority in society—are 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 occur—by consent, fear of confrontation, or apathy—risks 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:


 

                      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. This week, be sure to read about Perverse Incentives in Health Care.

                      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 subscribe at www.pacificresearch.org/pub/hpp/index.html or access their health page at www.pacificresearch.org/centers/hcs/index.html. Be sure to read John R Graham on MariaCare or SheilaCare? at www.pacificresearch.org/press/opd/2007/opd_07-03-05jg2.html.

                      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: This week, be sure to read Mr. McTigue's 8th Annual Performance Report Scorecard: Which Federal Agencies Best Inform the Public.

                      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. www.nahu.org/publications/hiu/index.htm. 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. Be sure to review the current articles listed on their table of contents at hiu.nahu.org/paper.asp?paper=1. To see my recent column, go to http://hiu.nahu.org/article.asp?article=1328&paper=0&cat=137.

                      To read the rest of this column, please go to www.medicaltuesday.net/org.asp.

                      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 new 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. This week, read Toward Free-Market Health Care at www.galen.org/hcbasics.asp?DocID=1017.

                      Greg Scandlen, an expert in Health Savings Accounts (HSAs) has embarked on a new mission: Consumers for Health Care Choices (CHCC). To read the initial series of his newsletter, Consumers Power Reports, go to www.chcchoices.org/publications.html. To join, go to www.chcchoices.org/join.html.  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, at www.chcchoices.org/publications/cpr9.pdf.

                      The Heartland Institute, www.heartland.org, publishes the Health Care News. Read the late Conrad F Meier on What is Free-Market Health Care? at www.heartland.org/Article.cfm?artId=10333.   You may sign up for their health care email newsletter at www.heartland.org/Article.cfm?artId=10478. Be sure to read about the Al Gore debate at www.heartland.org/Article.cfm?artId=20891.

                      The Foundation for Economic Education, www.fee.org, has been publishing The Freeman - Ideas On Liberty, Freedom's Magazine, for over 50 years, with Richard M Ebeling, PhD, President, and Sheldon Richman as editor. Having bound copies of this running treatise on free-market economics for over 40 years, I still take pleasure in the relevant articles by Leonard Read and others who have devoted their lives to the cause of liberty. I have a patient who has read this journal since it was a mimeographed newsletter fifty years ago. This week, please read Can the Free Market Provide Public Education? By Sheldon Richman.

                      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 at www.i2i.org/healthcarecenter.aspx. You can also scroll down and read her latest topics of interest.

                      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. This month, read OVER FOUR HUNDRED AND FIFTY AN HOUR? LIFE IS FULL OF RISKS by Ralph Maddocks.

                      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 at www.fraserinstitute.ca/health/index.asp?snav=he. Be sure to read Canadians waiting longer than Europeans and Americans for access to new medicines.

                      The Heritage Foundation, www.heritage.org/, founded in 1973, is a research and educational institute whose mission is 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. The Center for Health Policy Studies supports and does extensive research on health care policy that is readily available at their site.

                      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 at www.lewrockwell.com to read some of his lectures to medical groups. To learn how state medicine subsidizes illness, see www.lewrockwell.com/rockwell/sickness.html; or to find out why anyone would want to be an MD today, see www.lewrockwell.com/klassen/klassen46.html.

                      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 at www.cato.org/people/cannon.html.

                      The Ethan Allen Institute, www.ethanallen.org/index2.html, is one of some 41 similar but independent state organizations associated with the State Policy Network (SPN). The mission is to put into practice the fundamentals of a free society: individual liberty, private property, competitive free enterprise, limited and frugal government, strong local communities, personal responsibility, and expanded opportunity for human endeavor.

                      The Free State Project, with a goal of Liberty in Our Lifetime, http://freestateproject.org/, is an agreement among 20,000 pro-liberty activists to move to New Hampshire, where they will exert the fullest practical effort toward the creation of a society in which the maximum role of government is the protection of life, liberty, and property. The success of the Project would likely entail reductions in taxation and regulation, reforms at all levels of government to expand individual rights and free markets, and a restoration of constitutional federalism, demonstrating the benefits of liberty to the rest of the nation and the world. [It is indeed a tragedy that the burden of government in the U.S., a freedom society for its first 150 years, is so great that people want to escape to a state solely for the purpose of reducing that oppression. We hope this gives each of us an impetus to restore freedom from government intrusion in our own state.]

                      The St. Croix Review, a bimonthly journal of ideas, recognizes that the world is very dangerous. Conservatives are staunch defenders of the homeland. But as Russell Kirk believed, wartime allows the federal government 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 war time we have to push for limited government—while giving the government the necessary tools to win the war. To read a variety of articles in this arena, please go to www.stcroixreview.com.

                      Hillsdale College, the premier small liberal arts college in southern Michigan with about 1,200 students, was founded in 1844 with the mission of "educating for liberty." It is proud of its principled refusal to accept any federal funds, even in the form of student grants and loans, and of its historic policy of non-discrimination and equal opportunity. The price of freedom is never cheap. While schools throughout the nation are bowing to an unconstitutional federal mandate that schools must adopt a Constitution Day curriculum each September 17th or lose federal funds, Hillsdale students take a semester-long course on the Constitution restoring civics education and developing a civics textbook, a Constitution Reader. You may log on at www.hillsdale.edu to register for the annual weeklong von Mises Seminars, held every February, or their famous Shavano Institute. You may join them to explore the Roots of American Republicanism on a British Isles cruise on July 10-21, 2006. 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. Read President Arnn's comments at www.hillsdale.edu/arnn/usnews.asp. Please log on and register to receive Imprimis, their national speech digest that reaches more than one million readers each month. This month, read Victor Davis Hanson on Nuclear Iran.  The last ten years of Imprimis are archived at www.hillsdale.edu/imprimis/archives.htm.

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Editorial comments are in brackets.


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Del Meyer, MD, Editor & Founder

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Words of Wisdom

In war there is no substitute for victory. –Douglas MacArthur, April 19, 1951

Let every nation know, whether it wishes us well or ill, that we shall pay any price, bear any burden, meet any hardship, support any friend, oppose any foe, to assure the survival and the success of liberty. –John F. Kennedy, Jan 20, 1961

Above all, we must realize that no arsenal, or no weapon in the arsenals of the world, is so formidable as the will and moral courage of free men and women.  Ronald Reagan, Jan 20, 1981

Remember, George, this is no time to go wobbly.  –Margaret Thatcher, 1991

Some Recent Postings

America Alone, Mark Steyn: www.stcroixreview.com/. Click on Book Review.

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.  

 

In Memoriam

Robert Taylor, a possible victim of alien abduction, died on March 14th, aged 88, The Economist, March 29, 2007

WHAT was it about Bob Taylor? He was an unassuming man, steady, phlegmatic, with a thick brush of white hair and a craggy outdoorsman's face. He liked a pint, and a dram too, but not when he was working. He smoked, but not too many. In his house at the edge of Dechmont Woods near Livingston in West Lothian, where he had worked all his life as a forester, there were very few books. And certainly there was none that could explain what happened to him on November 9th 1979, and why his trousers, of thick navy serge like a policeman's and with useful pockets in the sides, should have ended up in the archives of the British UFO Research Association.

Mr Taylor set off that morning, with his red setter Lara, to check the woods on Dechmont Law for stray sheep and cattle. It was a damp day and, after he had parked the van and set off down the forest track, even the noise of the Edinburgh-Glasgow motorway was muffled by thick, dark fir trees. The dog ran, and Mr Taylor's trudging wellingtons made the only sound. Then he turned a corner into a clearing filled with light, and saw it.

 

It was a "flying dome", 20 feet wide, hovering above the grass. No sound came from the object, and it did not move. It seemed to be made of grey metal, shiny but rough, like emery paper. About half-way down it had a circular platform, like the brim of a hat, set with small propellers. There were darker areas on it that might have been portholes, but the strangest thing was that the dome would be solid one moment, transparent the next, so that Mr Taylor could see the fir trees through it, as if it was trying to camouflage itself.

Both he and the dog stood stock-still with surprise. But then, suddenly, two smaller spheres dropped out of the dome and came trundling across the grass, one to his right, one to his left. They were covered in long spikes, like navy mines, that made a ghastly sucking sound as they dug in and out of the mud. . .  To read more about this alien abduction, please go to www.economist.com/obituary/displaystory.cfm?story_id=8922229.

On This Date in History - April 10

The first US patent law was approved on this date in 1790. For the first time in history, one could build a better mousetrap and profit from his inventiveness and ingenuity which was important in building this great nation.

On this date in 1866, a new organization call the American Society for Prevention of Cruelty to Animals received a charter. Prior to that mistreatment of cart horses and beasts of burden was so common place that it wasn't even regarded as being particularly cruel.

Three quarters of a century after the ASPC was born, the victorious Allies in WWII came upon the horror and ultimate cruelty to humans on the discovery of the concentration camp at Buchenwald, Germany on this date in 1945, with its corpses, and living skeletons who survived, crematoria, gas chambers, and paraphernalia that made the Middle Ages look like kindergarten. Although we like to think this taught us a lesson, are we witnessing an equal Barbarism in the uncivilized parts of our present world, and whole countries are looking the other way?

After Leonard and Thelma Spinrad


MOVIE EXPLAINING SOCIALIZED MEDICINE TO COUNTER MICHAEL MOORE

Logan Clements, a pro-liberty filmmaker in Los Angeles, seeks funding for a movie exposing the truth about socialized medicine. Clements' strategy is to release the documentary this summer on the same day that Michael Moore's pro-socialized medicine movie "Sicko" is released. This movie can only be made in time if Clements finds 200 doctors willing to make a tax-deductible donation of $5K each by the end of March. Clements is also seeking American doctors willing to perform operations for Canadians on wait lists. 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.