MEDICAL TUESDAY . NET	NEWSLETTER
Community For Better Health Care	Vol VIII, No 2, Apr 28, 2009

In This Issue:

1. Featured Article: Why 'Quality' Care Is Dangerous by MDs Groopman & Hartzband, WSJ

2. In the News: How data monitoring can kill patients - or save them, The Economist

3. International Medicine: The horrors of Stafford Hospital ills of the NHS by Mary Riddell

4. Medicare: When Doctors Opt Out by Marc Siegal, MD, WSJ

5. Medical Gluttony: I have an appointment for a Peripheral Vascular Disease study.

6. Medical Myths: Having everyone insured will decrease health care costs.

7. Overheard in the Medical Staff Lounge: How the doctors voted on the Financial Bailout

8. Voices of Medicine: The Ties That Bind Us - Medical Professionalism

9. The Bookshelf: "State of Play" - A Spy thriller takes a wrong turn By James Murtagh, MD

10. Hippocrates & His Kin: Will Rogers on income tax returns

11. Related Organizations: Restoring Accountability in Medical Practice and Society

Words of Wisdom, Recent Postings, In Memoriam . . .

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The 6th Annual World Health Care Congress

Advancing solutions for business and health care CEOs to implement new models for health care affordability, coverage and quality

Was held on Tuesday, April 14 – Thursday, April 16, 2009
Marriott Wardman Park Hotel
Washington, DC
www.worldhealthcarecongress.com
Toll Free: 800-767-9499

In partnership with MedicalTuesday.net, the 6th Annual World Health Care Congress is the most prestigious meeting of chief and senior executives from all sectors of health care. The 2009 conference convened 1,700 CEOs, senior executives and government officials from the nation's largest employers, hospitals, health systems, health plans, pharmaceutical and biotech companies, and leading government agencies. Many were physicians.

View previews of the Power Point Presentations at www.worldhealthtalks.com/ where they can be purchased for a nominal fee. One sequence that we attended was 21 hours over 2 and ½ days. There were Key Note addresses every morning and ten tracks running concurrently every afternoon. Forty nations of the world were present including Nobel Laureate, Dr. Muhammad Yunus, Professor of Economics, in Bangladesh.

For Patrick Golden's top 10 Keynotes, review at www.worldcongress.com/events/HR09000/PDF/News/WHCC%20-%20Media%20tip%20sheet%20-%20Keynotes.pdf.

The corporate CEOs, such as Steve Burd of Safeway, gave some of the strongest messages on market base employee health with the costs of employer health care remaining flat. We will be reviewing some of the presentations in MedicalTuesday. The major emphases, however, will come from the HealthPlanUSA newsletter that deals with health plans more specifically. This newsletter has been coming as part of your MedicalTuesday free subscription on a quarterly basis and in the future will come from its own new updated website. Please click on www.HealthPlanUSA.net and then on Newsletter on the top bar and enter your email address. Unless you do this, you will no longer receive this HealthPlan related free issue, after the current issue, bringing you the progress in health care in the US as well as throughout the world. This is a rapid and dynamic area with countries going in various directions.

Denmark and other Scandinavian and European countries had delegates at the Congress learning about private based health care since their costs of government health care is no longer sustainable. There were fewer presenters who continue to feel there is still no alternative to government paid Universal Health care. They seemed to be losing the debates on most panels. Despite the fact that Medicare and Medicaid costs will no longer be covered in a few years, the Tax and Spend advocates don't understand limits. Instead of indexing Medicare with Social Security, they think that the Medicare age can be lowered to 55. Reality doesn't compute. The issues are changing weekly if not daily. Stay tuned.

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1. Featured Article: Why 'Quality' Care Is Dangerous

The growing number of rigid protocols meant to guide doctors have perverse consequences.

By JEROME GROOPMAN and PAMELA HARTZBAND, WSJ

The Obama administration is working with Congress to mandate that all Medicare payments be tied to "quality metrics." But an analysis of this drive for better health care reveals a fundamental flaw in how quality is defined and metrics applied. In too many cases, the quality measures have been hastily adopted, only to be proven wrong and even potentially dangerous to patients.

Health-policy planners define quality as clinical practice that conforms to consensus guidelines written by experts. The guidelines present specific metrics for physicians to meet, thus "quality metrics." Since 2003, the federal government has piloted Medicare projects at more than 260 hospitals to reward physicians and institutions that meet quality metrics. The program is called "pay-for-performance." Many private insurers are following suit with similar incentive programs.

In Massachusetts, there are not only carrots but also sticks; physicians who fail to comply with quality guidelines from certain state-based insurers are publicly discredited and their patients required to pay up to three times as much out of pocket to see them. Unfortunately, many states are considering the Massachusetts model for their local insurance.

How did we get here? Initially, the quality improvement initiatives focused on patient safety and public-health measures. The hospital was seen as a large factory where systems needed to be standardized to prevent avoidable errors. A shocking degree of sloppiness existed with respect to hand washing, for example, and this largely has been remedied with implementation of standardized protocols. Similarly, the risk of infection when inserting an intravenous catheter has fallen sharply since doctors and nurses now abide by guidelines. Buoyed by these successes, governmental and private insurance regulators now have overreached. They've turned clinical guidelines for complex diseases into iron-clad rules, to deleterious effect.

One key quality measure in the ICU became the level of blood sugar in critically ill patients. Expert panels reviewed data on whether ICU patients should have insulin therapy adjusted to tightly control their blood sugar, keeping it within the normal range, or whether a more flexible approach, allowing some elevation of sugar, was permissible. Expert consensus endorsed tight control, and this approach was embedded in guidelines from the American Diabetes Association. The Joint Commission on Accreditation of Healthcare Organizations, which generates report cards on hospitals, and governmental and private insurers that pay for care, adopted as a suggested quality metric this tight control of blood sugar.

A colleague who works in an ICU in a medical center in our state told us how his care of the critically ill is closely monitored. If his patients have blood sugars that rise above the metric, he must attend what he calls "re-education sessions" where he is pointedly lectured on the need to adhere to the rule. If he does not strictly comply, his hospital will be downgraded on its quality rating and risks financial loss. His status on the faculty is also at risk should he be seen as delivering low-quality care.

But this coercive approach was turned on its head last month when the New England Journal of Medicine published a randomized study, by the Australian and New Zealand Intensive Care Society Clinical Trials Group and the Canadian Critical Care Trials Group, of more than 6,000 critically ill patients in the ICU. Half of the patients received insulin to tightly maintain their sugar in the normal range, and the other half were on a more flexible protocol, allowing higher sugar levels. More patients died in the tightly regulated group than those cared for with the flexible protocol.

Similarly, maintaining normal blood sugar in ambulatory diabetics with vascular problems has been a key quality metric in assessing physician performance. Yet largely due to two extensive studies published in the June 2008 issue of the New England Journal of Medicine, this is now in serious doubt. Indeed, in one study of more than 10,000 ambulatory diabetics with cardiovascular diseases conducted by a group of Canadian and American researchers (the "ACCORD" study) so many diabetics died in the group where sugar was tightly regulated that the researchers discontinued the trial 17 months before its scheduled end.

And just last month, another clinical trial contradicted the expert consensus guidelines that patients with kidney failure on dialysis should be given statin drugs to prevent heart attack and stroke.

These and other recent examples show why rigid and punitive rules to broadly standardize care for all patients often break down. Human beings are not uniform in their biology. A disease with many effects on multiple organs, like diabetes, acts differently in different people. Medicine is an imperfect science, and its study is also imperfect. Information evolves and changes. Rather than rigidity, flexibility is appropriate in applying evidence from clinical trials. To that end, a good doctor exercises sound clinical judgment by consulting expert guidelines and assessing ongoing research, but then decides what is quality care for the individual patient. And what is best sometimes deviates from the norms. . .

State pay-for-performance programs also provide disturbing data on the unintended consequences of coercive regulation. Another report in the most recent Health Affairs evaluating some 35,000 physicians caring for 6.2 million patients in California revealed that doctors dropped noncompliant patients, or refused to treat people with complicated illnesses involving many organs, since their outcomes would make their statistics look bad. And research by the Brigham and Women's Hospital published last month in the Journal of the American College of Cardiology indicates that report cards may be pushing Massachusetts cardiologists to deny lifesaving procedures on very sick heart patients out of fear of receiving a low grade if the outcome is poor.

Dr. David Sackett, a pioneer of "evidence-based medicine," where results from clinical trials rather than anecdotes are used to guide physician practice, famously said, "Half of what you'll learn in medical school will be shown to be either dead wrong or out of date within five years of your graduation; the trouble is that nobody can tell you which half -- so the most important thing to learn is how to learn on your own." Science depends upon such a sentiment, and honors the doubter and iconoclast who overturns false paradigms.

Before a surgeon begins an operation, he must stop and call a "time-out" to verify that he has all the correct information and instruments to safely proceed. We need a national time-out in the rush to mandate what policy makers term quality care to prevent doing more harm than good.

Dr. Groopman, a staff writer for the New Yorker, and Dr. Hartzband are on the staff of Beth Israel Deaconess Medical Center in Boston and on the faculty of Harvard Medical School.

WSJ, April 8, 2009

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2. In the News: Hospital deaths: Making them count: How data monitoring can kill patients - or save them

An actuary sent us this P4P and EHM results … from the UK Edition of The Economist, print edition, Mar 19th 2009

TOO few nurses, too poorly trained; receptionists rather than medical staff assessing arrivals at A&E; high rates of infection by the superbug Clostridium difficile; at least 400 more patient deaths than expected in just three years. A tale of a single disastrously managed institution, and yet the failings of Stafford Hospital, which were first picked up by the Healthcare Commission in 2007 and made public in a report on March 17th, have triggered apologies right up the political ladder. "On behalf of the government and the NHS I would like to apologise (sic) to the patients and families of patients," said the health secretary, Alan Johnson. The following day the prime minister, Gordon Brown joined in: "We do apologise to all those people who have suffered," he told Parliament, adding the usual bromide that it "should never be allowed to happen again".

This local difficulty has gone national mainly because people suspect that those terrible hospital managers were made worse by the pressure to meet government targets. Both the health secretary and the prime minister deny it, but the commission's report into the scandalous level of care provides support for the view. It found that hospital managers were chasing stringent financial targets in order to achieve "foundation" status, the badge of honour (sic) given to the best hospitals, which comes with more freedom to manage one's affairs. This led them to cut more than 150 posts, including some nursing ones, and left the hospital seriously understaffed. To avoid breaching the national target that almost all patients in A&E should be seen within four hours, those waiting were sometimes moved to a "clinical decision unit" where they were neither monitored nor treated, and doctors were sometimes moved from treating the very ill to looking after those with more minor ailments.

An object lesson, perhaps, in how target-setting and the use of performance indicators can have perverse results. But it is also a shining example of how health-care data can be used to spot problems fast. The Healthcare Commission started its investigation only because in 2007 it began monitoring routine data on hospital admissions, treatments and outcomes. It soon discovered that, after taking account of factors such as the age of patients, the severity of their illnesses and so on, Stafford Hospital had a consistently high death rate for patients admitted as emergencies: at least 127 deaths for every 100 expected. After checking that the findings were not caused by chance or error, the commission asked the hospital to explain. Its inability to do so triggered a full-blown investigation. . .

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3. International Medicine: What the horrors of Stafford Hospital tell us about the ills of the NHS

An isolated disaster, a fatal case of bureaucracy, or a sign of the NHS's future? This scandal could be all three, says Mary Riddell.

By Mary Riddell

The photos pinned to the campaign group's clipboard span all ages. They include a newborn baby dressed in pink, a Burma veteran and a grandmother whose portrait is captioned "81 years young". This disparate group have only one thing in common. All died in the care of Stafford Hospital.

Its record of squalor, indignity and suffering defies belief. Hundreds of lives may have been prematurely extinguished in understaffed wards, where patients were assessed by receptionists, left untended in filthy beds and compelled to slake their thirst with water from flower vases.

Many have described the conditions as "Third World". That is an insult. I spent a day last week in a hospital in a broken town in one of the most desolate countries in Africa. Doctors had not been paid for months by a near-bankrupt state, and post-operative patients lay, two to a bed, in crowded wards. But compared with the Stafford "war zone", this clinic looked like Harley Street. Battle-ravaged lives were being saved in an atmosphere of hope, respect and compassion; qualities absent in a flagship hospital in one of the most medically advanced nations on earth. The Prime Minister, said by a friend to be consumed by "fury and frustration", called Stafford a one-off disaster. Let's hope he's right.

www.telegraph.co.uk/comment/columnists/maryriddell/5012757/What-the-horrors-of-Stafford-Hospital-tell-us-about-the-ills-of-the-NHS.html

The NHS does not give timely access to health care, it only gives access to a waiting list.

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4. Medicare: When Doctors Opt Out

We already know what government-run health care looks like,

By MARC SIEGEL, WSJ

Here's something that has gotten lost in the drive to institute universal health insurance: Health insurance doesn't automatically lead to health care. And with more and more doctors dropping out of one insurance plan or another, especially government plans, there is no guarantee that you will be able to see a physician no matter what coverage you have.

Consider that the Medicare Payment Advisory Commission reported in 2008 that 28% of Medicare beneficiaries looking for a primary care physician had trouble finding one, up from 24% the year before. The reasons are clear: A 2008 survey by the Texas Medical Association, for example, found that only 38% of primary-care doctors in Texas took new Medicare patients. The statistics are similar in New York state, where I practice medicine.

More and more of my fellow doctors are turning away Medicare patients because of the diminished reimbursements and the growing delay in payments. I've had several new Medicare patients come to my office in the last few months with multiple diseases and long lists of medications simply because their longtime provider -- who they liked -- abruptly stopped taking Medicare. One of the top mammographers in New York City works in my office building, but she no longer accepts Medicare and charges patients more than $300 cash for each procedure. I continue to send my elderly women patients downstairs for the test because she is so good, but no one is happy about paying.

The problem is even worse with Medicaid. A 2005 Community Tracking Physician survey showed that only 50% of physicians accept this insurance. I am now one of the ones who doesn't take it. I realized a few years ago that it wasn't worth the money to file the paperwork for the $25 or less that I received for an office visit. HMOs are problematic as well. Recent surveys from New York show a 10% yearly dropout rate from the state's largest HMO, the Health Insurance Plan of New York (HIP), and a 14% drop-out rate from Health Net of New York, another big HMO.

The dropout rate is less at major medical centers such as New York University's Langone Medical Center where I work, or Mount Sinai Medical Center, because larger physician networks have more leverage when choosing health plans. Still, I am frequently hamstrung as I try to find a good surgeon or specialist to refer one of my patients to.

Overall, 11% of the doctors at NYU Langone don't participate in at least two insurance plans -- Aetna or Blue Cross, for instance -- so I end up not being able to refer my patients to some of our top specialists. This problem, in addition to the mass of paperwork and diminishing reimbursements, is enough of a reason for me to consider dropping out as well.

Bottom line: None of the current plans, government or private, provide my patients with the care they need. And the care that is provided is increasingly expensive and requires a big battle for approvals. Of course, we're promised by the Obama administration that universal health insurance will avoid all these problems. But how is that possible when you consider that the medical turnstiles will be the same as they are now, only they will be clogged with more and more patients? The doctors that remain in this expanded system will be even more overwhelmed than we are now.

I wouldn't want to be a patient when that happens.

Dr. Siegel, an internist and associate professor of medicine at the NYU Langone Medical Center, is a Fox News medical contributor.

WSJ, April 17, 2009

Government is not the solution to our problems, government is the problem.

- Ronald Reagan

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5. Medical Gluttony: I have an appointment tomorrow for a Peripheral Vascular Disease study.

We saw a patient last week who sported a requisition for a PVD (Sometimes call Peripheral Arterial Disease - PAD) to be done next week. His doctor told him he thought the circulation to his legs was poor and he may be in danger of gangrene. I asked if he had a blood pressure cuff at home. Since he had one, I asked if he had measured the BP in his ankles. But why would I do that?

When I had finished taking his BP on his arm (Brachial BP), I proceeded to take the pressure around his lower leg. It was the same. So I told him he had no significant PVD (or PAD). Would he let me know how much the charges were?

He called and said the charge was $300 at the lab and since he had the measurements, he didn't want his insurance company to pay that type of excessive charge (Gluttony) since I had done it as part of my physical exam.

Health plans are structured around making everyone happy except maybe the doctor. Doctors are supposed to be seeing patients so fast that they don't have time to do these two- and three-minute tests to save hundreds of dollars. The same goes for most tests that can be done in a doctor's office. Why do insurance companies pay doctors $20 for an $80 electrocardiogram when they pay the hospital several hundred dollars? (1980s data) Or why should they pay doctors $35 for a chest x-ray and pay the x-ray facility $85 and the hospital $145 (1980s data). Or why should they pay doctors $60 for a pulmonary function test and pay the hospital lab $240 (1980s data). How can anyone remotely believe that insurance carriers are interested in controlling health care costs when they pay two to five times as much as the competitive market would support?

The co-payments are directed primarily against the physician. The co-payment should be directed to every provider in the system. If the patient had to make a co-payment at the ECG lab, the X-ray lab and the PFT lab, the evaluation of the charges would occur at the registration desk. We will be publishing our clinical study online on how co-payments on every item in health care would reduce health care costs by 30 to 50 percent with no decrease in quality or placing patients at risk in the near future. The results are astounding. The costs are reduced at the registration desk. Watch this space. Also, enroll at www.healthplanusa.net/newsletter.asp for a relevant newsletter.

Medical Gluttony thrives in Government and Health Insurance Programs.

Gluttony Disappears with Appropriate Deductibles and Co-payments on Every Service.

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6. Medical Myths: Having everyone insured will decrease health care costs.

The prevailing opinions among patients and other citizens is that health care costs will be brought into line when the government takes over the entire system. Patients seem to be demanding relatively routine care whether day or night. We continue to have examples of what happens in government systems as Medicare and Medicaid where the appetite for x-rays and laboratory testing knows no limit. There is also no limit on going to the doctor, the urgent care center or the emergency room. In regards to the latter, some studies suggest that three-fourths of all ER visits are for routine medical care. This is seen daily in most physicians' practice.

Today's example from my practice includes a middle-age woman who felt anxious and somewhat panicky. She has known panic attacks and has medications to control them. However, she was so disorganized that she forgot to take them. So she went to the Emergency Room and with all her complaints overwhelmed the ER physician who did thousands of dollars worth of testing. Everything was normal and she was discharged home eight or ten hours later. They did not give her any medications. The nurse, not the doctor, gave her the parting goodbye.

The next night, she became somewhat panicky again and went to the urgent care center and hundreds of dollars worth of testing was done. Nothing again was found. The urgent care center doctor did give her some anxiety relieving pills and told her to take her anxiety medications at home and double up on them if she felt panicky again. This kept her home until seen several days later.

When seen, she was anxious, but lucid, and the exam was normal again. She was reassured, given new guidelines on her panic pills, and was given one before she left. An experienced physician knows that one-fourth of patients do not follow the doctor's directions and, therefore, keeps a supply of common medications on his shelf to give the first dose which greatly facilitates treatment.

This practice also holds for antibiotics to get the antimicrobial effect working while the patient gets the prescription filled. One patient sent the prescription to his mail order pharmacy, which meant the treatment of the infection would not begin for a week or ten days. Giving the first pill emphasizes the urgency of the matter.

Having fully paid government health care or full health insurance coverage will continue this overutilization of health resources. This can be most effectively controlled by having the patient make a percentage co-payment at every step of the way in obtaining care. This would prevent up to half the unnecessary care when the patient registers at the hospital, ER or urgent care center.

This is not accepted by the Tax & Spend parties who want to control health care and ration it later when the costs are excessive, as the above examples show. But then it will be too late. It takes 50 to 100 years of people's misery and sitting on waiting lists and dying while waiting before the next generation that is use to free health care can begin to understand basic economics. The NHS after nearly sixty years is toying with increasing options for private care. Other countries, after nearly 100 years, are trying to relearn private practice. Many of my UK colleagues can't imagine what private practice would be like having never experienced it before. We must abort this enslavement of physicians and their patients before it becomes a fait accompli. It can only happen outside the heavy hand of government. Stay informed with a free subscription to HPUSA.

Medical Myths Originate When Someone Else Pays The Medical Bills.

Myths Disappear When Patients Pay Appropriate Deductibles and Co-Payments on Every Service.

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7. Overheard in the Medical Staff Lounge: How the doctors voted on the Financial Bailout

The Allergist voted to Scratch It.

The Dermatologists advised not to make any Rash moves.

The Obstetricians felt they were all Laboring under a Misconception.

The Gastroenterologists had sort of a Gut feeling about it.

The Neurologists thought the administration had a lot of Nerve.

The Orthopedists felt that a thorough investigation by a Joint Committee was in order.

The Ophthalmologists considered the idea shortsighted.

The Otorhinolaryngologist picked up a Putrid Smell.

The Neurosurgeons felt a Prefrontal Lobotomy was in order.

The Pathologists yelled, "Over my dead body!"

The Pediatricians said "Oh, Grow Up!"

The Psychiatrists thought the whole idea was Madness.

The Pulmonologists thought it needed some Oxygen.

The Radiologists could see right through it.

The Nuclear Medicine Physician saw the Cancer light up.

The Surgeons decided to Wash their Hands of the whole thing.

The Internists thought it was a Bitter Pill to swallow.

The Plastic Surgeons said, "This puts a whole New Face on the matter."

The Podiatrists thought it was a Step forward.

The Chiropractors thought Congress needed an adjustment.

The Urologists felt the scheme wouldn't hold Water.

The Anesthesiologist thought the whole idea was a Gas.

The Cardiologists didn't have the heart to say "No."

The Nurses felt they could use an Injection.

The Hospital Administrators just got in Line.

The Health Insurance Broker started looking for a New Job.

In the End, the Proctologist left the decision up to the Ciphers at the End of the Anal Canal in Washington.

The Staff Lounge Is Where Unfiltered Medical Opinions Are Heard.

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8. Voices of Medicine: A Review of Local and Regional Medical Journals

VITAL SIGNS - Journal of The Fresno-Madera And Kern Counties Medical Societies

THE TIES THAT BIND US - MEDICAL PROFESSIONALISM

President's Message: DAVID SLATER, MD

It is my honor to represent you as FMMS President in 2008 – the 125^th anniversary of the founding of this Society – and I thank Dr. Arain for his leadership in 2007. Over the 20 years I have practiced here, I have seen increasing divisions in our house of medicine. Our professional environment is a complex mix of things intrinsic to our individual practices and things external to us, but with huge influence upon us. Not much has remained static in either of those domains.

As a group of physicians, we practice in both the smallest of rural hamlets and in the midst of some of the busiest clinics and urban hospitals anywhere. We provide care to some of the poorest, most disadvantaged people in the USA and to the very affluent and privileged among us. While we collectively care for these demographic polar extremes of patients and those in between, the way in which this care sorts out among us – and among these patient groups – is quite nonuniform.

We span the globe in our own origins, our traditions, and our training. We speak many languages at home; we practice many faiths or perhaps no faith. We could put together a fascinating compilation of stories about how each of us came to live and practice here.

Our range of specialization includes classic primary care and sub-specialty care that is exquisitely organ and disease-focused. Our reliance on technology ranges from the reflex hammer and stethoscope to those "…first and only one in the…" wondermachines that warrant large newspaper ads.

Our medical incomes vary hugely, as does the degree to which we as individuals prioritize and derive satisfaction from the entrepreneurial side of medicine. Some of us unlock the office door and open the mail ourselves if our office manager-spouse has not done so. Others hope for a decent parking spot and must scan a badge to enter big facilities with large org charts and large group practices. 325 words

Our ages vary at least 3-fold, and our years in practice vary perhaps 50-fold. The balances we seek in our lives between work and play, between family and career, and between quality and quantity (of you name it) vary widely and will change over time. Some of us are political activists – either red, blue, or beyond –while others have little interest in or energy for matters political. It seems we physicians must look hard to identify our "common ground" these days. But, as a Society of Physicians, we must find that common ground. So, in 2008 and beyond, what is the glue that will hold us together as a Society of Physicians? If some of the historical glue no longer serves us, can we nurture what remains and find new bonds or bonds that are now more critical? Where should our FMMS be focused, in order to engage and show value to regional physicians and insure our ongoing relevance? . . .

To read some of Dr. Slater's ideas, go to www.fmms.org/pdf/Jan08_VS_FINAL.pdf.

A suggestion was made by Dr. Slater: It is clear that both major practical considerations and some deep philosophical issues are at play in this debate. While everyone recognizes a need to reform what we now have, physicians . . . are not of a single mind. FMMS wants to see if there is interest in having an informal, stimulating – and of course strictly collegial –roundtable discussion about health care reform. This could start out being as simple as pizza, salad and wine at FMMS offices some early evening. If you are interested, please let us know.

VOM Is Where Doctors' Thinking is Crystallized into Writing.

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9. Book or Cinema Review: "State of Play" - A spy thriller takes a wrong turn

"State of Play"- Time for Spy Thrillers to Come in from the Cold.

By James J. Murtagh, M.D.

Warning: spoiler alert. If you have not seen this movie, do not read further. The film contains a major plot twist, which is discussed in this Op- Ed.

Once, there was a great divide in the great spy game - espionage stories could be either great dark literature, or they were pure escapism. John Le Carr and Graham Greene were the masters of the gritty literary spy, eschewing the action escapist spies like James Bond or the Man from U.N.C.L. E. There was real spycraft, and then there was just fantasy spydom. The great Roy Marsden spymaster from "The Sandbaggers" summed it up: "If you want James Bond, go to a library." The real spies are for real, with dirty jobs that had to be done, and with high stakes for the world.

But now, a third kind of spy thriller has emerged - the zero spy, with little connection to either the literary spy or the fantasy spy. The zero spy is a fanciful and confused cardboard concoction that exists only to befuddle the audience with an incomprehensible non-plot. Apparently, the zero spy himself has no clue who he is working for or why. There is no effort to actually solve the mystery he is in. The audience leaves the theater wondering why they went to see the movie.

"State of Play" and "Duplicity," are the newest examples of spy netherworld non-thrillers. "Duplicity," the Julia Roberts vehicle, had so many triple- double-agent plot twists that the protagonists are left by themselves sitting in a complete muddle. So does the audience. The writers apparently treated their characters - and their audience - as kind of rag dolls to gleefully buffet back and forth at will. First, the bad guys are the good guys, and vice versa, then versa vice, until no one cares.

What would George Smiley or Sherlock Holmes make of a plot that trivializes the Circus to the point that there is no point? The fictional characters are supposed to put their lives on the line - for nothing?

Similarly, "State of Play" pretends at first to be about the great issues of our times - government, corruption, intrigues and secrecy about to undermine our democracy, and a flailing newspaper-military-industrial complex unable to print the truth. Yet, the movie devolves into just another typical politician tripping over his own zipper. The movie forgets to deal with the big government-military conspiracy that is by no mean resolved or even explained.

It is as if Hamlet never got around to solving who killed his father, and just left the state of Denmark to continue to sink in its rottenness.

Sure, the serious spy does not win all his missions - John Le Carre's spies often look back in disbelief at what control sent them to do. And in the end, the spy might refuse, or defect, or sabotage his own mission. But the spy had conviction, or a crisis of conscience, or at least the will to solve the mystery following a solid plot. There was a reason to see the movie, and a resolution explaining the spy's efforts. More often than not, the spy found something within himself.

We live in a troubled age, with a wealth of issues ripe for movies that matter. Do we really need another movie patterned on the television series "Alias," where agents flip sides at least twice between every commercial? Is this supposed to be a reflection of some kind of everyman that fails to find a connection or loyalty to anything?

Some call the post 9/11 world the decade of spy thrillers. Some great spy thrillers include "Syriana," "The Constant Gardner," "Munich" and "Michael Clayton." The real-life "Insider" was at its core a spy-versus-spy movie. Many of these movies directly trace back to "Three Days of the Condor," the movie that much more effectively asked many of the same questions as "State of Play." Is there a secret CIA inside the CIA? Will newspapers tell the truth?

We live in a serious age with serious problems. There is no shortage of great material for the great spymasters and Hamlets of the world to wrestle with. That is the point and the power of great spy thrillers - to invite audiences to grapple with very real and present dangers, even if in a fictionalized story.

Spy thrillers are not an invention of the modern age. Odysseus was the consummate spy using a spy contraption greater than Q ever dreamed - the Trojan horse. Casablanca, at its core, was a story of double and triple agents, but with a wonderfully unifying plot. The Bible, Homer and Alexandre Dumas used priests and princes as spies.

Spy thriller audiences deserve more respect. It's time for an end to the pretentious non-stories of "State of Play", "Duplicity," and "Alias." The world needs our best spymasters, both fictional and non-fictional, to inspire the best in us, as never before.

James J. Murtagh Jr.

jmurtag@mindspring.com

This Cinematic review is found at www.delmeyer.net/CinematicOpEdReviews.htm.

To read more book reviews, go to www.delmeyer.net/PhysicianPatientBookshelf.htm.

To read book reviews topically, go to www.healthcarecom.net/bookrevs.htm.

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10. Hippocrates & His Kin: Will Rogers on income tax returns

The number of pages in the CCH Standard Federal Tax Reporter, which records tax law, regulations and related material, soared to 70,320 from 26,300 in 1984. . . As Will Rogers once observed about tax forms: "Even when you make one out on the level, you don't know when it's through, if you are a crook or a martyr."

No wonder H & R Block makes out most tax returns. Sounds like too much law even for attorneys.

These days I can cut salaries by 10 percent and people will thank me for not firing them. -Scott Adams.

Looks like GM (Government Motors) has not been reading Dilbert about reducing costs.

Two Kansas City Power & Light executives can look forward to more comfortable retirements, thanks to a doubling of their pension. Each will get a $700,000 bonus check when he retires. The payouts will be covered by KCP&L customers, whose rates are up and expected to rise more, and stock holders who have seen their dividends cut in half.

Is this Enron in a regulated utility?

Need a job?

Now isn't that real opportunity? Two jobs and one paycheck? Or two jobs and no paycheck?

To read more HHK, go to www.healthcarecom.net/hhkintro.htm.

To read more HMC, go to www.delmeyer.net/HMC.htm.

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11. Professionals Restoring Accountability in Medical Practice, Government and Society:

• John and Alieta Eck, MDs, for their first-century solution to twenty-first century needs. With 46 million people in this country uninsured, we need an innovative solution apart from the place of employment and apart from the government. To read the rest of the story, go to www.zhcenter.org and check out their history, mission statement, newsletter, and a host of other information. For their article, "Are you really insured?," go to www.healthplanusa.net/AE-AreYouReallyInsured.htm.

• PATMOS EmergiClinic - where Robert Berry, MD, an emergency physician and internist, practices. To read his story and the background for naming his clinic PATMOS EmergiClinic - the island where John was exiled and an acronym for "payment at time of service," go to www.emergiclinic.com. To read more on Dr Berry, please click on the various topics at his website.

• PRIVATE NEUROLOGY is a Third-Party-Free Practice in Derby, NY with Larry Huntoon, MD, PhD, FANN. (http://home.earthlink.net/~doctorlrhuntoon/) Dr Huntoon does not allow any HMO or government interference in your medical care. "Since I am not forced to use CPT codes and ICD-9 codes (coding numbers required on claim forms) in our practice, I have been able to keep our fee structure very simple." I have no interest in "playing games" so as to "run up the bill." My goal is to provide competent, compassionate, ethical care at a price that patients can afford. I also believe in an honest day's pay for an honest day's work. Please Note that PAYMENT IS EXPECTED AT THE TIME OF SERVICE. Private Neurology also guarantees that medical records in our office are kept totally private and confidential - in accordance with the Oath of Hippocrates. Since I am a non-covered entity under HIPAA, your medical records are safe from the increased risk of disclosure under HIPAA law.

• FIRM: Freedom and Individual Rights in Medicine, Lin Zinser, JD, Founder, www.westandfirm.org, researches and studies the work of scholars and policy experts in the areas of health care, law, philosophy, and economics to inform and to foster public debate on the causes and potential solutions of rising costs of health care and health insurance.

• Michael J. Harris, MD - www.northernurology.com - an active member in the American Urological Association, Association of American Physicians and Surgeons, Societe' Internationale D'Urologie, has an active cash'n carry practice in urology in Traverse City, Michigan. He has no contracts, no Medicare, Medicaid, no HIPAA, just patient care. Dr Harris is nationally recognized for his medical care system reform initiatives. To understand that Medical Bureaucrats and Administrators are basically Medical Illiterates telling the experts how to practice medicine, be sure to savor his article on "Administrativectomy: The Cure For Toxic Bureaucratosis."

• Dr Vern Cherewatenko concerning success in restoring private-based medical practice which has grown internationally through the SimpleCare model network. Dr Vern calls his practice PIFATOS – Pay In Full At Time Of Service, the "Cash-Based Revolution." The patient pays in full before leaving. Because doctor charges are anywhere from 25–50 percent inflated due to administrative costs caused by the health insurance industry, you'll be paying drastically reduced rates for your medical expenses. In conjunction with a regular catastrophic health insurance policy to cover extremely costly procedures, PIFATOS can save the average healthy adult and/or family up to $5000/year! To read the rest of the story, go to www.simplecare.com.

• Dr David MacDonald started Liberty Health Group. To compare the traditional health insurance model with the Liberty high-deductible model, go to www.libertyhealthgroup.com/Liberty_Solutions.htm. There is extensive data available for your study. Dr Dave is available to speak to your group on a consultative basis.

• Madeleine Pelner Cosman, JD, PhD, Esq, who has made important efforts in restoring accountability in health care, has died (1937-2006). Her obituary is at www.signonsandiego.com/news/obituaries/20060311-9999-1m11cosman.html. She will be remembered for her important work, Who Owns Your Body, which is reviewed at www.delmeyer.net/bkrev_WhoOwnsYourBody.htm. Please go to www.healthplanusa.net/MPCosman.htm to view some of her articles that highlight the government's efforts in criminalizing medicine. For other OpEd articles that are important to the practice of medicine and health care in general, click on her name at www.healthcarecom.net/OpEd.htm.

• David J Gibson, MD, Consulting Partner of Illumination Medical, Inc. has made important contributions to the free Medical MarketPlace in speeches and writings. His series of articles in Sacramento Medicine can be found at www.ssvms.org. To read his "Lessons from the Past," go to www.ssvms.org/articles/0403gibson.asp. For additional articles, such as the cost of Single Payer, go to www.healthplanusa.net/DGSinglePayer.htm; for Health Care Inflation, go to www.healthplanusa.net/DGHealthCareInflation.htm.

• Dr Richard B Willner, President, Center Peer Review Justice Inc, states: We are a group of healthcare doctors -- physicians, podiatrists, dentists, osteopaths -- who have experienced and/or witnessed the tragedy of the perversion of medical peer review by malice and bad faith. We have seen the statutory immunity, which is provided to our "peers" for the purposes of quality assurance and credentialing, used as cover to allow those "peers" to ruin careers and reputations to further their own, usually monetary agenda of destroying the competition. We are dedicated to the exposure, conviction, and sanction of any and all doctors, and affiliated hospitals, HMOs, medical boards, and other such institutions, who would use peer review as a weapon to unfairly destroy other professionals. Read the rest of the story, as well as a wealth of information, at www.peerreview.org.

• Semmelweis Society International, Verner S. Waite MD, FACS, Founder; Henry Butler MD, FACS, President; Ralph Bard MD, JD, Vice President; W. Hinnant MD, JD, Secretary-Treasurer; is named after Ignaz Philipp Semmelweis, MD (1818-1865), an obstetrician who has been hailed as the savior of mothers. He noted maternal mortality of 25-30 percent in the obstetrical clinic in Vienna. He also noted that the first division of the clinic run by medical students had a death rate 2-3 times as high as the second division run by midwives. He also noticed that medical students came from the dissecting room to the maternity ward. He ordered the students to wash their hands in a solution of chlorinated lime before each examination. The maternal mortality dropped, and by 1848, no women died in childbirth in his division. He lost his appointment the following year and was unable to obtain a teaching appointment. Although ahead of his peers, he was not accepted by them. When Dr Verner Waite received similar treatment from a hospital, he organized the Semmelweis Society with his own funds using Dr Semmelweis as a model: To read the article he wrote at my request for Sacramento Medicine when I was editor in 1994, see www.delmeyer.net/HMCPeerRev.htm. To see Attorney Sharon Kime's response, as well as the California Medical Board response, see www.delmeyer.net/HMCPeerRev.htm. Scroll down to read some very interesting letters to the editor from the Medical Board of California, from a member of the MBC, and from Deane Hillsman, MD.

To view some horror stories of atrocities against physicians and how organized medicine still treats this problem, please go to www.semmelweissociety.net.

• Dennis Gabos, MD, President of the Society for the Education of Physicians and Patients (SEPP), is making efforts in Protecting, Preserving, and Promoting the Rights, Freedoms and Responsibilities of Patients and Health Care Professionals. For more information, go to www.sepp.net.

• Robert J Cihak, MD, former president of the AAPS, and Michael Arnold Glueck, M.D, who wrote an informative Medicine Men column at NewsMax, have now retired. Please log on to review the archives.

• The Association of American Physicians & Surgeons (www.AAPSonline.org), The Voice for Private Physicians Since 1943, representing physicians in their struggles against bureaucratic medicine, loss of medical privacy, and intrusion by the government into the personal and confidential relationship between patients and their physicians. Be sure to read News of the Day in Perspective: If patients die as a result of health information technology (HIT) defects, the clinicians will be liable—not the vendors. Don't miss the "AAPS News," written by Jane Orient, MD, and archived on this site which provides valuable information on a monthly basis. This month, be sure to read It is possible that the theme song for the current Administration in Washington will be "The Winner Takes It All," and its motto, "I won." Browse the archives of their official organ, the Journal of American Physicians and Surgeons, with Larry Huntoon, MD, PhD, a neurologist in New York, as the Editor-in-Chief. There are a number of important articles that can be accessed from the Table of Contents.

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Words of Wisdom

Government is an endless pursuit of new ways to tax.

They use to say that the only thing the government didn't tax was taxes. Then came Lyndon Baines Johnson who invented the surtax.

The history teacher asked the class, "What caused the American Revolution?" Immediately a little girl raised her hand and said, "Taxation." A little boy then raised his hand at that and the teacher said, "Tommy, do you have anything to add?" "Yes," said Tommy, "why do they teach that we won?"

Some Recent Postings

Why Government Doesn't Work by Harry Browne . . .

PC, MD - How Political Correctness is Corrupting Medicine by Sally Satel, MD . . .

MEDICAL WARRIOR - Fighting Corporate Socialized Medicine by Miguel A Faria, Jr, MD . . .

In Memoriam

Jade Goody, a reality TV star, died on March 22nd, aged 27

From The Economist print edition, Mar 26th 2009

CAMERAS were not kind to Jade Goody. However flattering the angle, they could not disguise the fact that, as she breezily admitted, her lips were too thick and her nose too big. Nor could "50 million" different hairstyles—black wigs, blonde dyes, hair extensions—do much to improve the face that stared at her out of the tabloids. It was "just the way I was born". For much of the time, despite popping slimming pills until it became an addiction, she was fat, too, and the paps captured that unsparingly. By any pool they would be lurking to get the pictures of her "kebab belly" overflowing her too-small bikini, and her DD breasts hanging out.

Her parents were drug addicts. As a toddler in a cot, she watched her father at night injecting himself with heroin, his eyes rolling back in his head. Her mother smoked crack. Jade grew to loathe the smell of ash and spent matches and the sight of aluminium foil, but most of all she hated the lying: the fruitless attempts to hide the paraphernalia, the futile pretence that all was normal, and the denials. . .

Opioid lollipops

Among the dark places she avoided was her own medical condition. The odd faints and bleedings were scary, but appointments for tests were lost or ignored. When she heard that she had advanced cervical cancer (on camera, though not broadcast, on the Indian version of "Big Brother"), she felt at first "as if I was completely starkers, with a big torchlight shining through me". Fairly rapidly, though, she decided to sell her illness to the papers. Again, it wasn't just about the money. She could make other young women aware of the risks. And she could deal with death better, she said, if the cameras were on her.

For seven months she died in public. It was the most extraordinary of modern British deaths, orchestrated by Max Clifford, her publicist, in all the nation's tabloids. On the supermarket shelves, between the beans and the biscuits, Jade was seen with her oxygen tank on her lap, or sucking on opioid lollipops, or with her bald head tied up with yellow ribbon like an Easter egg. . .

British public, never keen to look too long at death, were not invited to go deeper. That mysterious place was illuminated only by Sun and Mirror pieties, where the angels were calling and Jade would be "the brightest star in the sky". She was baptised, but also consulted a white witch. On February 22nd she married her on-again off-again lover, Jack Tweed, on day-release from jail for assault. Rather than planning her funeral, she bravely wore herself out organising parties and cakes. The wedding rights were sold to OK! magazine for £700,000.

One of her last real pleasures was to watch the clips of that day. Death became her: with her £3,500 Mota dress her bald head looked perfect and beautiful. Exploitation, cried some observers. But her first exploiter was herself, and the cameras, for as long as they could, kept her alive.

Read the entire obituary . . .

On This Date in History - April 28

On this date in 1817, the Rush-Bagot Agreement was signed. In less than three short years after the end of the War of 1812 between the U.S. and Great Britain, when the British Minister to the U.S., Charles Bagot, and our acting Secretary of State, Richard Rush, set down on paper an agreement to limit militarization of the border between the U.S. and Canada. The spirit of the agreement ultimately led to the longest demilitarized and unfortified border between nations in the entire world. If you judge treaties by the results, this has to be one of the best.

On this date in 1789, Fletcher Christian led an uprising of the crew of H. M. S. Bounty against the stern Captain Bligh. After that story was transferred from a best selling book to the motion picture screen, the name of Captain Bligh came to mean a sort of sea-going Simon Legree. But that wasn't exactly the way it really was. Captain William Bligh went on, after that mutiny, to become ultimately a vice-admiral in the British Navy. When Fletcher Christian set him adrift with 18 others in the Pacific, he sailed the small boat across thousands of miles of open sea to the East Indies. He was harsh and he was tough but he served his country well.

After Leonard and Thelma Spinrad

MOVIE EXPLAINING SOCIALIZED MEDICINE TO COUNTER MICHAEL MOORE's SiCKO

Logan Clements, a pro-liberty filmmaker in Los Angeles, seeks funding for a movie exposing the truth about socialized medicine. Clements is the former publisher of "American Venture" magazine who made news in 2005 for a property rights project against eminent domain called the "Lost Liberty Hotel."
For more information visit www.sickandsickermovie.com or email logan@freestarmovie.com.

Order your Conference Summary Media Today

Extend the value of this year's WHCC with video of all keynote sessions, audio of all breakout sessions and PDF versions of speaker presentations. These valuable take-aways are now available on a Multimedia Flash Drive, a Multimedia Data DVD or iPod Nano. Please call (925) 426-8230 or click here to order or for more information.

Media Coverage

Impressive Media Coverage! As one of the exciting elements of the event, The WHCC was honored to welcome live on-site coverage from CNBC programs "Squawk on the Street" and "Closing Bell," Reuters Television and Bloomberg's "Taking Stock." CNBC's "Healthy Horizons" program and C-SPAN also joined with cameras rolling. NBC's coverage of the poster session on "Extremely Affordable Health Innovations" was picked up by more than 30 affiliates across the country. Joining the television media were more than 100 other press who interviewed dozens of speakers, posted articles and blogged throughout the conference. Click here to see a list of the publications and outlets in attendance, please visit www.worldcongress.com/news to view the coverage — More articles are being added daily!

2010 World Health Care Congress

Register early for the 2010 World Health Care Congress and receive a free upgrade to a VIP Membership! Please call customer service at 800-767-9499 or visit our website for details.

For additional information on our membership package, visit our website.

The 2010 Congress is scheduled for April 12-14, 2010 at the Gaylord National Resort and Convention Center, National Harbor, MD (Washington, DC area). I hope to see you there!