MEDICAL TUESDAY . NET
Community For Better Health Care
Vol VI, No 17, Dec 11, 2007
In This Issue:
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. Last year it was 50 percent, indicating open forums such as these are critically important. The 4th Annual World Health Congress was held April 22-24, 2007 in Washington, D.C. This year many of the world leaders in healthcare concluded that top down reforming of health care, whether by government or insurance carrier, is not and will not work. We have to get the physicians out of the trenches because reform will require physician involvement. The World Health Care Congress - Asia will be held in Singapore on May 21-23, 2008. The 4th Annual World Health Care Congress - Europe 2008 will meet in Berlin on March 10-12, 2008. The 5th Annual World Health Care Congress will be held April 21-23, 2008 in Washington, D.C. NEW: The 6th Annual World Health Care Congress will be held April 16-19, 2009 also in Washington, D.C. For more information, visit www.worldcongress.com.
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Please Note: Sears is voluntarily paying the difference in salaries and
maintaining all benefits, including medical insurance and bonus programs, for
all called up reservist employees for up to two years. Confirmed by Bill Thorn, Sears Customer
Care, firstname.lastname@example.org, 1-800-349-4358.
It's Also Verified By Snopes.com at: www.snopes.com/politics/military/sears.asp (shows the entire article). You may want to do some of your Holiday Shopping at Sears this year and tell a manager why you're there to give positive feedback.
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Overstating the Evidence for Lung Cancer Screening by multiple authors, see below.
The International Early Lung Cancer Action Program (I-ELCAP) Study
Arch Intern Med. 2007;167(21):2289-2295.
Last year, the New England Journal of Medicine ran a lead article reporting that patients with lung cancer had a 10-year survival approaching 90% if detected by screening spiral computed tomography. The publication garnered considerable media attention, and some felt that its findings provided a persuasive case for the immediate initiation of lung cancer screening. We strongly disagree. In this article, we highlight 4 reasons why the publication does not make a persuasive case for screening:
The study had no control group, it lacked an unbiased outcome measure, it did not consider what is already known about this topic from previous studies, and it did not address the harms of screening. We conclude with 2 fundamental principles that physicians should remember when thinking about screening: (1) survival is always prolonged by early detection, even when deaths are not delayed nor any lives saved, and (2) randomized trials are the only way to reliably determine whether screening does more good than harm.
To read the authors or disclosures, go to http://archinte.ama-assn.org/cgi/content/abstract/167/21/2289.
To read the full article, sign in at http://archinte.ama-assn.org/cgi/content/full/167/21/2289.
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[Some years ago, the public school teachers in some districts were forbidden to give the children a hug. Some teachers actually stepped back when a child came to close for fear of charges of impropriety. Meanwhile, parochial and private schools knew that kids needed to be touched and caressed and paid no attention to these restrictions. Similar restrictions occurred in medicine. Inappropriate touching had sexual connotations and could cause a loss of licensure. We saw many physicians step back when a patient came to close. So, it was very refreshing to read Doctor Wilkes column last week and the reaction from some of the younger staff. Shouldn't you get a signed consent before you hug a patient?]
A young mother found her 3-year-old son unconscious in their backyard swimming pool. Over the next five horrible days, every minute was spent in the ICU, surrounded by new faces, new beeps and bells, unfamiliar smells, a profound sense of guilt and remorse, and many discussions with nurses, social workers and doctors.
Several consultants, including neurologists,
determined that the boy was brain dead
– he had no high-level
brain functions. For Mom, this hard-to-digest fact flew in the face of what she
was seeing – her son had good skin color and only looked
to be sleeping as he lay hooked up to intravenous lines and a breathing tube.
It was time for the primary care team to hold a meeting to tell the parents they would need to remove their son from life support. Clearly, this is one of the hardest conversations in all of medicine.
As the pediatrician walked into the room, he stopped and hugged the mother. She seemed to welcome the hug, but the simple embrace generated intense discussions among my medical students. Is a hug from a doctor of the opposite sex in this emotional setting appropriate? Is it crossing the line of professionalism? It is taking advantage of a vulnerable woman as the doctor attempts to meet his own emotional need for a hug?
In the proper setting, there is nothing in the human
experience that can be as comforting, can communicate feelings more powerfully
or can connect two people better than a gentle hug. Presidents and other
politicians often use the hug to send a powerful message
– that they care.
President Bush has publicly hugged hundreds of people: firefighters, police
officers, jockeys, families from Virginia Tech and victims of all sorts of
Some people find hugging another person
– especially a stranger
– awkward. And for some
men, hugging an unrelated man is simply unthinkable, as it violates all their
rules of male behavior – it implies excessive emotion and involves
close physical contact. . .
I'd be hard-pressed to offer any scientific evidence that the hug actually works, but neither could I find any evidence that it doesn't. It's just my experience that suggests the hug is often of great benefit. . .
Some of my colleagues would feel far more comfortable
about this discussion if they could first get a signed consent permitting
hugging if deemed medically indicated. For me, it's a natural part of the art
of medicine and it's what I need to do in certain circumstances to connect with
people. Sometimes the words just don't flow
– or if they do, they
don't come out right.
In the case of the young mother, the doctor's hug lasted several minutes and was likely of far greater benefit than a Valium or a sleeping pill. From my perspective, the only harm was that the doctor didn't also feel comfortable hugging the father.
Michael Wilkes, M.D., is a professor of medicine at the University of California, Davis. Identifying characteristics of patients mentioned in his column are changed to protect their confidentiality. Reach him at email@example.com.
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Death toll from third superbug soars: by Denis Campbell, health correspondent, The Observer
Pseudomonas infection is resistant to hospital cleaning - and antibiotics are proving ineffective
Health workers are struggling to control a surge in an 'untreatable' hospital-acquired infection that is estimated to be killing hundreds of patients a year. The number of cases of Pseudomonas rose by 41 per cent from 2,605 in 2002 to 3,663 last year, according to Health Protection Agency figures.
Cleaning agents that hospitals rely on to kill bacteria are proving inadequate, while most antibiotics that usually help patients repel infections are ineffective. It often contaminates water and moisture, so is a particular problem in breathing equipment, intravenous lines and catheters. One child cancer patient caught it when his lips were sprinkled with holy water at a Leeds hospital.
The bug is similar to the potentially fatal MRSA and C difficile infections. MRSA was cited as a cause of death in 1,629 people in England and Wales in 2005, up from 734 in 2001. C difficile was given as the reason for the death of 3,807 people in 2005, compared with 1,214 people in 2001.
There are no official statistics on the number of deaths from Pseudomonas, but Professor Mark Enright, an expert on healthcare-acquired infections at Imperial College London, estimates that it kills 'at least hundreds a year', especially those who get blood poisoning as a result. Previous studies have shown that those who develop septicaemia related to Pseudomonas have only a 20 per cent chance of survival.
People who have had surgery, who are on a ventilator in an intensive care unit or who have a condition such as cancer or HIV that reduces their body's immunity, are especially vulnerable. Some who have had it but survived have lost a limb, gone blind in one eye or suffered some other lasting damage to their body.
Alfred Nell almost died during an outbreak of Pseudomonas at Guy's Hospital in London in late 2005 that killed one woman and infected him and 17 other patients when they were receiving treatment in the urological surgery department. He has now asked Edwina Rawson, a medical negligence solicitor at London lawyers Charles Russell, to investigate if he can sue for damages.
A senior doctor at the hospital has told Nell, a 40-year-old plumber from Luton, that the near-fatal blood poisoning that he developed had been started by Pseudomonas carried on a microscope that doctors put inside him in November 2005 when they were removing a stent inserted during an earlier kidney stones operation. He ended up in hospital for seven weeks undergoing treatment.
'I believe that Guy's hospital nearly killed me because of them not cleaning their instruments properly', said Nell. 'The microscope was shoved into people before me, was shoved into me and was then shoved into other people after me. They should clean it every time.' He has received no letter of apology.
Nell added that he was 'angry because the hospital has taken away my passions, like my ability to play sport and do certain recreations with my son and daughter. And I feel quite frustrated because they haven't admitted to their liability.' He says that he has suffered long-term damage to his left kidney as a result of getting Pseudomonas which means he can only drive short distances and not stand for more than 20 minutes without suffering pain.
'The letters the hospital sent me about my Pseudomonas referred to it as "a urine infection". I would call it a near-death experience. I remember the doctors buzzing around my bed talking about how I was going to lose limbs and they also told my wife, Veronica, at one point that I was going to die,' said Nell.
A spokeswoman for Guy's said: 'An urgent investigation identified the most likely cause to be a faulty washer which was immediately removed from service and subsequently renovated and upgraded prior to the operating theatre reopening.' The trust says it continues to review its decontamination processes. . .
To read more, go to http://observer.guardian.co.uk/uk_news/story/0,,2212762,00.html.
The NHS does not give timely access to Health Care, it only gives access to a waiting list.
The waiting list gives access to a NHS in deep trouble, mired in scandal and incompetence.
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Health Care: Don't want to be part of John Edwards' universal system? Too bad. As he told a group of reporters Monday, under the Edwards regime, "You don't get that choice."
Got that? In John Edwards' America, the people will be forced to be a part of the collective. There's no way out.
Walk into the library and check out a book, you'll get "signed up" for socialist health care. Pay taxes, get signed up. Send the kids to school, get signed up.
"Basically every time they come into contact with either the health care system or the government," Edwards said, ". . . they will be signed up."
The former senator has modified his position somewhat. While campaigning in Iowa over the summer, the mandate only went as far as to require Americans to seek preventive care.
"If you're going to be in the system, you can't choose not to go to the doctor for 20 years," he said. "You have to go in and be checked and make sure that you are OK."
His "if" indicated that on some level, choice was still possible. But Monday's statement cleanly stripped away all pretense.
It seems clear to us that the penalty for not "joining" the system - for failing to obey our keepers - would be imprisonment. But, hey, prisons are government institutions, so they'll probably sign you up there, too. There is nowhere to escape the long arm of John Edwards' nanny-state plan.
We agree with the North Carolina trial lawyer that a government mandate is "the only way to have real universal health care." But we disagree on the necessity for compelling Americans to turn over their medical care - and their rights as Americans - to another bureaucracy.
Besides, if mandates really worked, the government simply could mandate that no one gets sick or injured and be done with it.
There is no shortage of people who will agree with Edwards, though. The country is rife with agitators who want the government to seize the health care sector, which makes up about 17% of the economy.
Some know the effect that will have on our freedoms and are fine with that; they like the idea of a coercive society where the government micromanages lives.
The rest are kidding themselves.
Under forced care, physician choice will not exist. Americans will be assigned a doctor, or allowed to choose from a small group, much like those who are part of the managed care systems - the same ones that are so derided by those who support nationalized health care.
This is not a fevered right-wing fantasy. There is a real-world example: the British system, held up as a model for the U.S. to follow. It does not let patients see the doctor of their choice. Britons who use the National Health Service can visit only designated family physician, whose practice is located near their homes.
Yes, the British can see doctors outside of the NHS. But, remember, under the Edwards plan, there will be no more private-practice doctors in the U.S. They'll all be working for the government - which should frighten anyone who worries about the quality of care.
Canadians and those who support that system think they have physician choice, but the reality is a bit different. Long waiting times there, which are well-documented, make a joke of choice. So does the growing exodus of doctors from that supposed health care haven.
Government interference as proposed by Edwards, Sen. Hillary Clinton or any of the Democratic candidates will never produce the quality of care nor the medical advances that have been generated by a system that rewards excellence. The problems of our current arrangement - both the real and the many imagined - cannot be cured by instituting a state monopoly.
Destroying private medicine in this country is not the way we're going to save health care. The best path is to enact public policy that increases competition.
History shows that has worked in every other sector. There's no reason it can't work in health care.
Related Topics: Health Care
Government is not the solution to our problems, government is the problem.
- Ronald Reagan
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This has been a very popular section with international responses. Some have asked that the articles be collected in a book form to repeatedly emphasize the excessive use and abuse in health care. Week after week, we point out instances of excessive cost, excessive utilization with no benefit in health outcomes. When we started some six years ago, we estimated, along with NAHU, that about a third of heath care costs were of no health benefit. As we point out instance after instance of 100 percent to 1000 percent of over utilization and excessive costs, we can safely say, that if health care was placed in a free-market environment, we would save one half of health care costs. Thus in a free-market environment, the tax benefits of health deduction would pale in comparison to the real reductions in health care costs.
Why don't more people believe these figures? Probably for the same reason that a large number of people don't believe that tax cuts increase government revenues. Each tax cut has produced greater revenue for the government. You would think that the Tax & Spend people would like the increase revenue to spend. However, they want to increase taxes again, which will give them less revenue to restrict freedom and regiment our lives.
Increasing government control with the obvious increased regimentation of our health care will also bring about the opposite result than the purported purpose. It will decrease access, increase cost, and decrease quality of care. Now we have some physicians who believe that they should be restricted and accept bureaucrats making medical decision. Maybe that will be the final chapter in eliminating gluttony. Everyone will be on a waiting list and doctors will go home at 4:30. Just like VA and other government doctors. And patients will no longer be able to double the costs just for curiosities sake.
Doctors could get use to the lack of care of socialize medicine. All that time off and call in sick when you have a tummy ache. But it will be the ruination of the profession.
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Health Alert: Does Socialism Work? Debunking the Myths, by John Goodman, PhD.
David Himmelstein and his wife Steffie Woolhandler are associate professors at Harvard Medical School. Together they are a one-couple team, promoting Canadian national health insurance in the Unites States. They provide the intellectual leadership for the Physicians for a National Health Program. They are about the only academics around whose scholarship routinely gives aid and comfort to the advocates of socialized medicine, unless you count the Commonwealth Fund. They are pleasant (at least to me); they are dedicated; and they are wrong.
I first debated David on a college campus about 15 years ago. My most recent debate with them is reprinted in Annals of Thoracic Surgery. In between the two debates I had an epiphany. I discovered that the worst features of the Canadian system are not the differences with our own system, but the similarities.
But first things first. Since our last debate, new information has become available that helps debunk three widely touted myths.
The Myth of Low Administrative Costs. In a series of articles, all published in medical journals, Himmelstein and Woolhandler (H&W) claim that the administrative costs of the Canadian system are much lower than our own - so much so that we could insure the uninsured through administrative savings alone. However, H&W are not economists. They count the cost of private insurance premium collection (e.g. advertising, agents' fees, etc.) but they ignore the cost of tax collection to pay for public insurance.
Economic studies show the social cost of collecting taxes is very high. Using the most conservative of these estimates, Ben Zycher has shown that the excess burden of a universal Medicare program would be twice as high as the administrative costs of universal private coverage.
The Myth of High Quality. H&W say that Canadian life expectancy is two years longer than ours, implying that the health care systems of the two countries have something to do with that result. Yet as pointed out in a previous Alert, doctors don't control our overeating, overdrinking, etc. Where doctors do make a difference, the comparison does not favor Canada. In an NBER study, David and June O'Neill draw on a large US/Canadian patient survey to show that:
• The percent of middle-aged Canadian women who have never had a mammogram is double the US rate.
• The percent of Canadian women who have never had a pap smear is triple the US rate.
• More than 8 in 10 Canadian males have never had a PSA test, compared with less than half of US males.
• More than 9 in 10 Canadians have never had a colonoscopy, compared with 7 in 10 in the US.
These differences in screening may explain why US cancer patients do better than their Canadian counterparts. For example:
• The mortality rate for breast cancer is 25% higher in Canada.
• The mortality rate for prostate cancer is 18% higher in Canada.
• The mortality rate for colorectal cancer among Canadian men and women is about 13% higher than in the US.
Amazingly, there are quite a few people in both countries who are not being treated for conditions that clearly require a doctor's attention. However:
• Among senior citizens, the fraction of Canadians with asthma, hypertension, and diabetes who are not getting care is twice the rate in the US.
• The fraction of Canadian seniors with coronary heart disease who are not being treated is nearly three times the US rate.
Apparently, putting everyone in (Canadian) Medicare leads to worse results than having only some people in (US) Medicare - ensconced in an otherwise private system.
The Myth of Equal Access. The most common argument for national health insurance is that it will give rich and poor alike the same access to health care. Surprisingly, there is no evidence of that outcome. Indeed, national health insurance in Canada may have created more inequality than otherwise would have existed.
(Similar results have been reported for Britain.) The O'Neill's study shows that:
• Both in Canada and in the US health outcomes correlate with income; low-income people are more likely to be in poor health and less likely to be in good health than those with higher incomes.
• However, there is apparently more inequality in Canada; among the nonelderly white population of both countries, low-income Canadians are 22% more likely to be in poor health than their American counterparts.
References are listed below.
Read them and weep.
John Goodman, PhD, President, National Center for Policy Analysis
12770 Coit Rd., Suite 800, Dallas, Texas 75251
For my debate with David Himmelstein and Steffie Woolhandler, go to
For Ben Zycher's study of administrative costs, go to
For June and David O'Neill's study, go to
Even though it's several years old, the best overall critique of national health insurance is still my own Lives at Risk, written with Gerry Musgrave and Devon Herrick. Go to
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Dr. Sam: The HMO was in my office all day yesterday copying 52 charts.
Dr. Ruth: Could you see patients while they worked? We could only see a half schedule when they were at our office.
Dr. Sam: We just gave them one of our two exam rooms and they spread their work on the doctor's desk, the exam table, the patient's chair, and the extra family member chair. I guess we were also working at half schedule.
Dr. Dave: Seems like that is a lot of time and expense?
Dr. Milton: Yes, time is money and that has not entered the HMO equation. They think nothing of having us spend an extra six or eight hours in busy work just to help them monitor our work.
Dr. Yancy: How many other professions would spend hours without pay to police themselves? And see half as many patients while they are in the office. It is also a 50 percent loss of income.
Dr. Milton: That makes it a huge expense that never shows up in any accounting journal.
Dr. Rosen: The doctors have just given up. They no longer have any will to either fight or resist.
Dr. Edwards: Yes, doctors seem to think the ball game is over and the other team won.
Dr. Sam: The other team is the government and all the agents of the government. HMOs were a decree of the government.
Dr. Rosen: And anything the government does, will never die. They can never admit making a mistake. So they just add more mistakes on top of the original ones.
Dr. Yancy: And the Health Insurance Portability and Accountability Act (HIPAA) was part of the other team to allow the government and their cohorts access to our charts without any authorization from the patient.
Dr. Michelle: Isn't it interesting how the letter reads? "We have this right and the patient need not be informed."
Dr. Rosen: It seems the patients have also given up.
Dr. Edwards: I think they don't really understand what is happening to them.
Dr. Rosen: I think you're right, Ed. When they were copying in our office, a couple of the patients came in and we had to borrow, can you believe, borrow our own charts back from the HMO copiers to see the patient. So we thought we'd point this out to the patient. Several got very upset. One wanted to march into exam room one. I had to physically stand in the way so he wouldn't make a scene.
Dr. Michelle: That would also be a rather touchy situation. Maybe the copier would tell the HMO that Dr. Rosen told the patient her chart was being copied and the HMO would eliminate part of your incentive for informing the patient.
Dr. Sam: You don't ever know who your friends or enemies are anymore. Sometimes I get the feeling that the friendliest are the worst enemies.
Dr. Edwards: Sometimes even in this room I get rather paranoid. Some doctors are very pro HMO and government medicine and just sit quietly taking it all in. You wonder where that might surface some day.
Dr. Sam: (quietly) Is that Dr. Brutus in the corner over there? Doesn't he have a lean and hungry look? Me thinks he thinks too much. Such doctors are dangerous.
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Orange County Medical Association Bulletin: Viewpoints - Debunking American Medical Care Myths, By Lytton W. Smith, MD, 8/1/2007
The debate surrounding American medical care prattles with many unworkable myths. Join me as I examine four of the myths.
Responding to the financial problem in medical care by creating a new tax system defies history.
When the French commemorate the French Revolution with Bastille Day on July 14, and we acknowledge the American Revolution with Independence Day on July 4, the celebrations represent different ideals. The slogans that drove the two revolutions were also different: "Liberty, Equality, Fraternity" in France and "No Taxation Without Representation" in the United States.
Through two centuries of repetition, these slogans achieved mythical status. Detailed analysis of the revolutions reveals the complex situations that created the environment igniting each country. French society evolved differently than American society, and it reflects different attitudes toward health and medical care. The French, until recently, seemed to prefer a nationalized, socialized medical system. After the recent election is that a myth?
Similarly, the debate surrounding American medical care prattles with many unworkable myths. Join me as I examine four of the myths.
Myth 1: Healthcare equates to medical care.
When individuals assess their body functions and conclude they are performing adequately, they presume they are healthy. The maintenance of our bodies in health remains our choice. Public health systems are societal measures that enable us to maintain our health.
When a person's body systems fail from any cause, he seeks the assistance of another to restore the perception of health. That person is seeking medical care.
Maintenance of an individual's health is generally a personal financial choice and responsibility. Why do many people think that that responsibility stops when the individual seeks medical care? Many believe the myth that one's personal choice to seek medical care in any form absolves him of any financial responsibility for that medical care.
Myth 2: Medical care should be equal.
Many demand that access and delivery of medical care be equal for all--that the medical care in Santa Ana equal the care in Beverly Hills. In reality, inequality exists across the world due to different needs, including rural location vs. urban location, pediatric care vs. geriatric care, and urban setting vs. suburban setting.
Achieving equal access to medical care evades all Western nations. Even in Canada, the prime minister receives different care than the average citizen. The diversity of American society requires unequal and different medical solutions for similar medical problems.
Myth 3: Medical care should not be profit-motivated.
When I hear this, I reflect on Winston Churchill's statement, "Capitalism is the unequal sharing of plenty and communism is the equal sharing of little." The profit motive created the business success of this country. Competition within medicine and healthcare abounds as all parties strive to offer profitable services and products . . .
Myth 4: America suffers from a "healthcare
That's the contention in Michael Moore's movie "SiCKO." However, in reality, Americans enjoy access to the best possible medical care. American medical care suffers from a financial crisis.
Most Americans, including me, demand the best care possible, but want someone else to pay for that care. Consequently, third-party payers created unrealistic expectations in their clients. Similarly, artificial charges for hospital care ($20,000/day) and simple office charges ($250) bare little reality to an individual's ability or willingness to pay for these services.
Market corrections, though painful for some, are the best method of achieving resolution to the financial crisis in medical care. Responding to the problem by creating a new taxation system (a single-payer national health system) defies the American Revolution ideal. . .
Mythological stories shed light on our human condition . . . However, they rarely offer solutions to problems. The French Revolution myths cannot compare with the American Revolution myths. Each revolution charted a different course. The American cry to stop oppressive taxes led to a divergent solution compared with where the French cry of equality led. When it comes to our current medical care environment, we must avoid creating solutions to mythological stories.
Lytton W. Smith, MD, editor for the OCMA, is a physician practicing family medicine with the St. Jude Heritage Medical Group in Yorba Linda. Dr. Smith welcomes feedback on his articles and can be reached at firstname.lastname@example.org.
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Final Exam: A Surgeon's Reflections on Mortality, By Pauline W. Chen, MD, KNOPF; 288 PAGES; $23.95
Reviewed by John Vaughn, MD:
During my internship, I cared for a young woman admitted to the ICU after suffering a catastrophic brain injury during a routine medical procedure. Her family hovered by her bedside, but communication was difficult because her son was the only one who spoke a limited, broken English.
One day a lawyer showed up, taking pictures of her room and asking for copies of charts as her family stood by wordlessly. Suddenly, her room became a barren no-man's-land. Daily rounds were terse and as quick as possible; everyone did his best to avoid nursing calls about her for fear of having his name on the chart.
When she finally went into cardiac arrest, the attending physician had the nurse call the entire family into the room so that they would see that we did everything possible to save her life. I'll never forget the look on her mother's face as we jolted the lifeless body with chest compressions and electrical shocks for more than an hour, knowing the whole time that it was completely useless. It looked like an exhilarating set-piece from "ER"; it felt like an assault.
Scenes like this are played out in hospitals across the country every day. Patients in denial without advance directives, families racked with guilt about losing their loved ones, physicians petrified of being sued for missing something and everyone feeling an overwhelming need to do something during a crisis have made many people's last days a needlessly traumatic, often atrocious experience.
Pauline Chen has written "Final Exam: A Surgeon's Reflections on Mortality" to explore how modern medicine has come to such a state.
All physicians deal with death to some degree, but few face it as directly as Chen. As a liver transplant surgeon, she works at the grim intersection of young people who've died too soon and nearly dead people waiting for the donated organs that can save their lives.
That there is an institutional aversion to death in a profession dedicated to fighting disease seems obvious, even necessary. But Chen believes that physicians have sublimated this natural aversion to the point where it expresses itself in an unhealthy "hidden curriculum" in medical training. Through her experiences and the work of social scientists, she demonstrates that this curriculum is what causes physicians to fail patients so miserably at the end of their lives.
Chen covers all the seminal moments in medical training: dissecting a human cadaver; resuscitating a patient during a "code"; performing a postmortem examination of someone who dies in the hospital, talking to the family of the recently deceased. Despite the occasional lapse into mawkishness -- surgeons "caress patients as no lover ever could" and terminal young patients are surrounded by a "halo-like glow" -- her descriptions of these events and their intentionally desensitizing effects on young physicians are accurate. . .
Our culture is rooted in a tradition of rugged individualism and unwavering faith in the power of technology to improve our lives. This deeply ingrained conviction in never giving up, no matter how long the odds are, makes it a lot easier -- for patient and physician alike -- to keep a body alive with powerful medications, ventilators and heart pumps than to look a person in the eye and tell him enough is enough.
"Final Exam" is ultimately about a single question: How do you want to die? It is a truly awful question, one that produces an instinctive, practically visceral need to ignore it. But if we're lucky, it is also a question that each one of us will eventually have a chance to weigh in on. Pauline Chen has given us her answer. We would all do well to listen to what she has to say.
John Vaughn is a writer and physician in Columbus,
Ohio. To read the entire review, go to
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Anne Campbell reports in the UK Metro about a father who drives to the Maternity Hospital and find no one in attendance and delivers his daughter in the back seat of his Renault. The mother was able to assist in unwrapping the umbilical cord from around the baby's neck. After mother and daughter were safely admitted, they praised the excellent care at Women and Children's Hospital. The director apologized to the couple. www.metro.co.uk/news/article.html?in_article_id=76719&in_page_id=34
I wonder what else the director gave the couple to make them think this total absence of care was so good? Maybe a Eurocard with disappearing balances for life?
The next phase of this disease in this patient is dying. What's so unnatural about that?
During my longtime pulmonary practice, I felt very comfortable in frank discussions with the family that the next step in their loved ones' illness would be dying. In those cases, I recommended that we forgo the family torture of CPR and let their loved ones pass on in peace. The suggestion was almost always accepted. However, it was only accomplished if I was actually in attendance during those final moments since this was the era before an order for "No CPR" could be written. This was time consuming on my part, but I felt I restored the dignity of dying in patients who had been with me for a long time. When I was in attendance, there was usually an array of RNs, nursing staff, and respiratory therapist with needles, IV lines, resuscitation masks, and ventilators at the doorway ready to charge in and take over. I felt my presence on one side of the bed and the family on the other essentially blocked access by the vultures. One time, as I was turned to speak with a family member behind me, a respiratory therapist actually got between me and the patient and I had to reach around and place my hand on the patient to re-establish my being in charge. But it was the other charge that I was missing for a long time until a respiratory therapist asked me if I would at least allow the ventilator inside the ICU curtains so that they could at least get that first $500 charge for CPR. I later found out that if the entire team could be established, the hospital was able to charge more than two thousand dollars for the CPR, even if it only lasted for 15 minutes. There was a time charge. One therapist told me he thought it was about $500 for each additional 15 minutes.
With patients and families
being unaware of the economics of dying because of third party payments, it's
no wonder there wasn't a patient-sensitive way of dying for so many years.
The torture chamber seemed to be a hospital gold mining shaft.
To read more HHK vignettes, go to www.healthcarecom.net/hhk1998.htm.
To read more HMC vignettes, go to www.delmeyer.net/hmc2001.htm.
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• 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. To read an overview of Telemedicine, go to www.ncpa.org/pub/st/st305/#. To read how GOVERNMENT, INSURERS KEEP MEDICINE IN STONE AGE, go to www.ncpa.org/prs/rel/2007/20071128.html
• 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 http://health.pacificresearch.org/. Be sure to read the latest article by John Graham, California Dreamin': More Doctors Bail Out of Insurance. The reason? Too much paperwork. Gynecologist Felice Girsh submitted a $110 claim to a health plan that would not process the claim until she sent in 5-years worth of patient records. Read more at http://liberty.pacificresearch.org/blog/id.256/blog_detail.asp.
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. Mercatus Center research seeks to
understand the consequences - both intended and unintended
– of public sector
management processes, such as funding and management decisions by state and
federal governments, and improve the state of knowledge to which these
processes refer, thereby fostering solutions that promote a freer, more
prosperous, and civil society. Research focus includes: tax and fiscal
policy, government accountability, the contracting process, government reform,
and congressional oversight. For the economics of social policy, go to www.mercatus.org/research_area/cfilter.4/researcharea_list.asp.
• 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 one of my columns, go hiu.nahu.org/article.asp?article=1328&paper=0&cat=137.
• 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. See one of Ms Turner's PPT presentations at www.galen.org/printfriendly.asp?DocID=1064&DocType=8.
• 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 a report on Consumer Driven Health Care is Working as Intended.
• The Heartland Institute, www.heartland.org, publishes the Health Care News. Read the late Conrad F Meier on What is Free-Market Health Care?. You may sign up for their health care email newsletter at www.heartland.org/Article.cfm?artId=10478.
• 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. With the current debate on government bailing out people who made bad choices in Mortgages, it's time to re-read Leonard Reed's treatise on Price Controls.
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
–and may even make
things worse." Be sure to read Executive Director Merrill Matthew's recent
editorial in the Wall Street Journal.
• 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. Read her latest OpEd article: Health care "reform" in Colorado: Go home and die; it's cheaper.
• 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 Martin Masse's editorial. Also read OUR DUTY TO SAVE THE PLANET... by Sean Gabb.
• 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. Read the news release, Government policies cause Canadian seniors to pay more for generic drugs than American seniors.
• 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. Read the 2007 Edition of the Index of Economic Freedom.
• 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. Read a report on The Betrayal of the American Right by Murray Rothbard. 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. Read the section on Health, Welfare, and Entitlements.
• 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 to grow at a frightful pace. We expect government to win the wars we engage, and we expect that our borders be guarded. But St Croix feels the impulses of the Administration and Congress are often misguided. The politicians of both parties in Washington overreach so that we see with disgust the explosion of earmarks and perpetually increasing spending on programs that have nothing to do with winning the war. There is too much power given to Washington. Even in wartime, we have to push for limited government - while giving the government the necessary tools to win the war. To read a variety of articles in this arena, please go to www.stcroixreview.com.
• Hillsdale College, the premier small liberal arts college in southern Michigan with about 1,200 students, was founded in 1844 with the mission of "educating for liberty." It is proud of its principled refusal to accept any federal funds, even in the form of student grants and loans, and of its historic policy of non-discrimination and equal opportunity. The price of freedom is never cheap. While schools throughout the nation are bowing to an unconstitutional federal mandate that schools must adopt a Constitution Day curriculum each September 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. Congratulations to Hillsdale for its national rankings in the USNews College rankings. Changes in the Carnegie classifications, along with Hillsdale's continuing rise to national prominence, prompted the Foundation to move the College from the regional to the national liberal arts college classification. Please log on and register to receive Imprimis, their national speech digest that reaches more than one million readers each month. This month, read Paul Johnson at www.hillsdale.edu/news/imprimis.asp. The last ten years of Imprimis are archived www.hillsdale.edu/hctools/imprimis_archive/
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Del Meyer, MD, Editor & Founder
6945 Fair Oaks Blvd, Ste A-2, Carmichael, CA 95608
Words of Wisdom
You can give without loving, but you can't love unless you give. -Bill Keane
The victory of success is half won when one gains the habit of setting goals and achieving them. Even the most tedious chore will become endurable as you parade through each day convinced that every task, no matter how menial or boring, brings you closer to fulfilling your dreams." -Og Mandino: Author, The Greatest Salesman in the World.
"Many of us spend our lives searching for success when it is usually so close that we can reach out and touch it." Russell H. Conwell: Was a writer, minister, and orator.
Some Recent Postings
SHOOT HIM IF HE RUNS by Stuart Woods. www.delmeyer.net/bkrev_ShootHimIfHeRuns.htm
ASHLEY AND THE DOLLMAKER
– by Jared James
Grantham, MD www.delmeyer.net/bkrev_Ashley&Dollmaker.htm
ASHLEY AND THE MOONCORN PEOPLE by Jared James Grantham, MD www.delmeyer.net/bkrev_AshleyMooncorn.htm
Robert Craig (Evel) Knievel, stuntman, died on November 30th, aged 69
THE question was why. Why-as the motor bike soared into the air, hurtled down, crashed into the tarmac and careered onwards, dragging with it a tumbly, bending human figure whose bones were almost audibly snapping - would any sane man want to do such a thing? Where was the point in trying to treat a motorbike like an aeroplane, and landing yourself in casts and a coma for the next few weeks?
Of course, Evel Knievel did not always crash. He sailed over 19 side-by-side cars in Ontario, California, and a pile of 52 wrecked motors at the Los Angeles Memorial Coliseum. In Canada in 1974 he cleared 13 Mack trucks, and in Kings Island, Ohio, in 1975 he soared over 14 Greyhound buses. Statistically, most of his 300-odd jumps were successes. But he was famous for the number of times he miscalculated the distance, or his speed, or mistimed things, thereby meeting the asphalt with more than enough force to kill himself.
His two most-watched jumps were both disasters. In 1967 he smashed a hip, femur, wrist and both ankles attempting to clear the fountains at Caesars Palace, in Las Vegas. Seven years later he almost drowned while failing to jump the Snake River Canyon, a quarter-of-a-mile wide, in Idaho. On that occasion he had strapped two rocket engines onto the sides of his Harley Davidson. Over his career, his 35 broken bones made the Guinness Book of Records; his body rattled with pins and plates, and it seemed preposterous that he should have died in his bed, of pulmonary fibrosis. Each catastrophe increased the likelihood that he would give up his weird stunts; but as soon as he could he would limp back and try again. To read the rest of the story, go to
On This Date in History - December 11
On this date in 1918, Alexander Solzhenitsyn was born in Rostov, Russia. Solzhenitsyn grew up to become the most eloquent protester against the inhumanity of the Soviet system. He proved that one voice, raised in protest and in truth, can start a chorus, and that words can be a mighty weapon.
On this date in 1929, the sponsors of the Empire State Building, when it was a long way from completion, announced that because it seemed likely that there would be regular worldwide Zeppelin service in a short time, a dirigible mooring tower would be built at the top. It is believed that one blimp did actually tie up briefly, but the major effect of the mooring tower was that it gave the building a good deal more height, and another observation deck.
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 email@example.com.
TODAY: EAT SOCIALISM FOR LUNCH (Washington D.C. area movie preview)
12 noon to 1pm, 2nd showing 1pm to 2pm (later screenings and Thursday screening by request) Sorry about short notice-room came available late. Food: bring your own or order from bar on ground level.
Location: Hyatt Crystal City, bottom level, Cinema Auditorium, 2799 Jefferson Davis Highway Arlington, VA 22202
What: You'll see 40 minutes of material taped so far.
Why: We need additional financing to complete the movie. When you see the footage we've got so far you'll see the importance of helping us finish the movie and counter socialized medicine. Ask about the two ways you can support the movie (one offers a tax write-off, the other offers a percent of the profits).
How: Please RSVP by e-mail to firstname.lastname@example.org. If you miss this date but might be interested in seeing the clips I can arrange a private viewing for DC area movie supporters. Only opponents of socialized medicine will be admitted as determined by affiliation or other means.