1.
Featured Article: Can Physicians Ever Get a Fair Hearing in a Court of
Law?
2.
In the News: The President of the Texas Medical Board
Resigns
3.
International
Medicine: Canadian Medicare: A Road To Serfdom
4.
Medicare: A Framework for Medicare Reform
5.
Medical Gluttony: Pharmacy Practices are Hazardous and
Costly
6.
Medical
Myths: Doctors Control the Practice of Medicine
7.
Overheard at
the World Health Care Conference: Grameen Bank for the Poor
8.
Voices of
Medicine: Reflections from the History of Medicine By James K. Gude, MD
9.
The
Bookshelf: The Prince, The Spy, and The Biker who Came in from the Cold
10.
Hippocrates
& His Kin: The High Risk of Law Enforcement Next to Marine Airbases
11.
Related Organizations: Restoring Accountability in Medical
Practice and Society
Merry
Christmas 2008
Tomorrow
night, December 24, 1776, marks the anniversary of George Washington leading
his troops across the Delaware to attack the British the next day in New
Jersey. Thus began the greatest experiment in human freedom the world has ever
experienced. The history of governments for millennia has been one of
oppression and servitude. Freedom of this magnitude was never previously
enjoyed by a nation for 150 years. This freedom has been gradually restricting
for the past 75 years. We must be forever on guard that our government does not
repeat history. To that effort, MedicalTuesday is dedicated beginning with
freedom in health care—the only assurance of privacy in our personal health
matters.
1. Featured Article: Can Physicians Ever Get a Fair
Hearing in a Court of Law?
[The Texas Federal District
Court felt that the action of Presbyterian Hospital and their staff doctors
against Dr. Poliner was so egregious that they awarded Dr. Poliner $366 million
for having lost his practice without just cause. Dr. Huntoon has done a major
service to our profession in his analysis of the Fifth Court of Appeals
arguments in the unfortunate reversal of that decision. All physicians need to
study this case report very carefully for the next victim may be you. And the
facts of the case will make no difference. You will go to the National Data
Bank, the tomb for physicians. –Editor]
Editorial:
Sham Peer Review: The Fifth Circuit Poliner Decision by Lawrence R. Huntoon, M.D., Ph.D. www.jpands.org/jpands1304.htm
TO read the entire clinical story, go to www.jpands.org/vol13no4/poliner.pdf.
In a sham
peer review hearing, the truth and the facts do not matter because the outcome
is predetermined and the process is rigged. In a court of law, where hospitals and
peer reviewers are granted absolute immunity, the truth and the facts do not
matter, because the outcome is predetermined and the process is rigged.
On July 23, 2008, the U.S. Court of Appeals for the
Fifth Circuit reversed the judgment of the district court in the Poliner case,
[1] and essentially granted absolute immunity to the defendants. In so doing,
the court destroyed the intent of the Health Care Quality Improvement Act
(HCQIA), which was to provide qualified and limited immunity to peer reviewers,
and it opened the doors wide to further abuse of peer review. Absolute
immunity, like absolute power, corrupts absolutely and invites abuse.
Malice and Bad Faith Motives Are Irrelevant
On Aug 27, 2004, after hearing all of the evidence
presented, a jury rendered a unanimous verdict in favor of Dr. Lawrence R.
Poliner, finding that "…Defendants had acted maliciously and without
justification or privilege." [2] Defendants were found to have violated
medical staff bylaws, and the jury found that defendants failed to comply with
the reasonableness standards of HCQIA. [3] In commenting on the size of the
jury award ($366 million), the court stated: "The jury's attitude and
award was influenced by Defendants' unwillingness to acknowledge their own wrongdoing
and their callous attitude toward Dr. Poliner at the time of the
abeyance/suspension and at trial." [4]
Although the jury made a factual determination that
defendants had not complied with the reasonableness standards of HCQIA, the
Fifth Circuit found that bad-faith motives of peer reviewers are irrelevant.
The court stated:
Poliner's urging of purported
bad motives or evil intent or that some hospital officials did not like him
provides no succor…the inquiry is, as we have explained, an objective one. Our
sister circuits have roundly rejected the argument that such subjective
motivations overcome HCQIA immunity, as do we…[1, pp 18-19] It bears
emphasizing that "the good or bad faith of the reviewers is irrelevant
[internal citation omitted].…" [1, pp 16-17]
Courts that narrowly apply this "objective
test" to the reasonableness standards of HCQIA fail to consider that
biased peer reviewers are likely to present biased or false information and act
in a biased manner in conducting a peer review against the targeted physician.
Instead, courts that apply the "objective test" simply accept a
hospital/peer reviewers' version of the case as truth and as objective
fact—i.e. the judicial doctrine of non-review. The combination of the
"objective test" and the judicial doctrine of non-review creates a
steel-reinforced shield of immunity for hospitals and peer reviewers, which
victims of sham peer review can never overcome.
Truth Does Not Matter
The truth cannot be revealed and justice cannot be
served when courts employ the judicial doctrine of non-review and refuse to
consider the evidence. In its decision, the Fifth Circuit Court stated:
To allow an attack years
later upon the ultimate "truth" of judgments made by peer reviewers
supported by objective evidence would drain all meaning from the statute…as our
sister circuit explains, "the intent of [the HCQIA] was not to disturb,
but to reinforce, the preexisting reluctance of courts to substitute their
judgment on the merits for that of health care professionals and of the
governing bodies of hospitals in an area within their expertise [internal
citation omitted]." [1, p 27]
If this same standard were applied in the criminal
justice system, courts would automatically defer to prosecutors because they
have expertise in the area of criminal law, with no need for either judge or
jury to consider the actual evidence. Motives matter, and the objectivity of
evidence presented by prosecutors and peer reviewers should not be assumed, but
should be subject to fair and impartial consideration of the actual evidence.
Improvement of Quality of Care Does Not
Matter
Although the intent of HCQIA was to improve the
quality of care by encouraging peer review, the Fifth Circuit Court stated:
"[T]he Act does not require
that the professional review result in an actual improvement of the quality of
health care," nor does it require that the conclusions reached by the
reviewers were in fact correct [internal citation omitted]. [1, p 16]
To read the entire Editorial and the references
documenting the positions taken, please go to www.jpands.org/jpands1304.htm.
Conclusions
In summary, the Fifth Circuit decision indicates that
malice and bad-faith of peer reviewers is irrelevant, the truth does not
matter, improvement of quality care does not matter, potential harm to patients
does not matter, compliance with medical staff bylaws is not necessary to
obtain immunity, a hospital/peer reviewers' version of the story should be
accepted as objective truth and fact, and accused physicians are presumed
guilty unless they can prove their innocence, which is a feat not possible
under the judicial doctrine of non-review.
The Fifth
Circuit has thus opened the doors wide to abusive bad-faith peer review, and
the new sign over the doctors' entrance to hospitals reads, "Abandon All
Hope Ye Who Enter Here."
Lawrence R. Huntoon, M.D., Ph.D., is a
practicing neurologist and editor-in-chief of the Journal of American Physicians and Surgeons. Contact: editor@jpands.org.
* * * * *
2.
In the News: SSI
Press Release: The President of the Texas Medical Board Resigns
SEMMELWEIS SOCIETY INTERNATIONAL (SSI) APPLAUDS
THE RESIGNATION OF DR. ROBERTA KALAFUT
Dallas TX, 16 Dec: Semmelweis Society International is pleased to announce that the Texas
Medical Board (TMB) President has resigned.
During her term as President, many Texas
physicians experienced unnecessary, arbitrary, capricious, and punitive
harassment and disciplinary actions at Dr. Roberta
Kalafut's direction.
Many good, competent physicians, including
the current SSI President, were needlessly targeted by Kalafut and cohorts who
include past executive director Dr. Donald Patrick and general counsel Mari
Robinson, who is also expected to resign.
After Texas Governor Rick Perry pushed for
tort reform several years ago, the TMB turned its regulatory responsibilities
agency into an untrained quasi enforcement agency, attacking many solo
practitioners with destructive force and fines on issues like late paperwork,
or incomplete charts while dismissing other doctors with real medical
negligence issues who were either protected by the TMB or larger healthcare
groups that profit from preventable injuries to patients in their care.
The TMB also paid friends of Dr. Patrick to manufacture evidence and cared
little that their testimony was incorrect or unfounded.
Semmelweis Society International requests
that the Texas Legislature form an ad hoc committee to reopen the cases of all
physicians whose medical licenses were suspended or revoked during Dr.
Kalafut.s tenure to ensure that all final orders were properly investigated and
heard. As champions of physicians and patient safety, Senator Jane Nelson,
Rep. Vickie Truitt and Rep. Fred Brown
must take this opportunity to open hearings for physicians and nurses who were
maliciously targeted by the TMB.
For additional information, contact SSI
President Dr. Roland
Chalifoux at 724-678-2648, roland.chalifoux@semmelweis.org, or visit www.semmelweis.org.
(Semmelweis
Society International, Inc., is a registered 501c3 non-profit corporation.
Comprised of physicians, nurses, attorneys and university professors, its
primary mission is to promote patient safety by ending retaliation against
scientists, physicians and nurses who report dangerous conditions, fraud and
corruption within hospitals and the US healthcare industry.)
* * * * *
3.
International Medicine: A Brief History of Canadian
Medicare
Canadian
Medicare: A Road To Serfdom, by William E. Goodman, MD
About the Author: William E. Goodman, MD, is a specialist in
otorhinolaryngology in Toronto, Ontario, Canada. He has been on strike since
1986, when private physicians in Canada were forbidden by law to contract with
their individual patients. Dr. Goodman speaks, writes, and consults extensively
on the effects of government control over medicine.
This article is a slightly
abridged version of a talk given by Dr. Goodman at a regional meeting of the
Association of American Physicians and Surgeons, Toledo, OH, April 20, 1990.
Also by Dr. Goodman: "The Canadian Model: Could It Work Here?" AAPS
pamphlet number 1007, October, 1989.
The Seeds of Authoritarianism
As most of you know, the term "Road to
Serfdom" was coined by the Austrian-born economist Friedrich Hayek. It was
the title for his landmark book, published in wartime Britain in 1944. Some 30
years later, he won the Nobel prize in economics.
I read this work for the first time in the late 1940s.
Now, it is even more apt, more mind-chilling-particularly in the light of the
massive growth of post-war welfare-statism and the advent of national health
insurance, the forced government takeover of medical care in many nations.
The central thesis of Hayek's book was that government
planning on a major scale inevitably leads to a totalitarian approach to
statehood. No matter whether the government believes itself to be socialist,
corporatist, social democratic, communist, or fascist, the tendency is the
same. Such a state must usurp the citizen's basic right to make his own
decisions about where he will live, what sort of work he will do, what wages he
will earn, what sort of food and clothing and medical care he may buy, and so
on. To this end, the state must insist on total powers of compulsion.
This compulsion may take two forms. In the relatively
benevolent state, the citizen either does as he's told by the government, or
his ability to earn a living is threatened by that government's monopolistic
financial controls. To quote the late German Chancellor Otto von Bismarck,
"He who controls the purse has the power.'' In the malevolent state,
exemplified by Germany and Russia in this century, the dissident individual is
simply imprisoned, tortured, hanged, or shot. In other words, depending on its
degree of malevolence, the state imposes its will either by financial
strictures or by physical force. The protesting citizen may die by starvation
or by execution, but professionally and financially if not physically, die he
will. . .
Government Funds, Government Control
In Britain in the 1940s, in Canada in the 1950s and
1960s, and now in the USA, it has been claimed by national health insurance
enthusiasts that the payment of medical bills by the state should not and would
not affect the freedom of physicians and patients or the quality of medical
care. A 1950 report on Lord Beveridge's cradle-to-grave welfare plan, which led
to Britain's National Health Service, said: "The necessary government
controls will not be allowed to interfere with the personal freedom of patients
or the professional freedom of doctors; or the confidential relationship
between the two."
Politicians have repeatedly said that they weren't
interested in controlling health care, only in making public safety-net funding
arrangements. But common sense alone should have persuaded people of the
inevitability of the US court ruling, "what the state funds it has a right
to regulate." Experience has demonstrated only too well the truth of the
German proverb, "Whose bread I eat, his song I must sing." In
Canada, people are beginning to realize that in the long run their apparently
free ride at the taxpayer's expense inevitably ends in survival only at the
pleasure of the wielders of power.
A History of Canadian Medicare
There were four salient events in the development of
Canadian medicare (a total, universal, compulsory, monopolistic,
first-dollar-coverage system, unlike the more limited US Medicare):
1. In 1956, tax funding of all Canadian hospitals
destroyed the independence of their governing boards. ["Die Kunst geht
nach Brot," Martin Luther. Also see AAPS pamphlet 1002.]
2. In the late 1960s, country-wide, tax-funded,
government-mandated medical care was instituted, following the lead of
Saskatchewan, the only province with a socialist government at that time. . .
3. In 1984, passage of the federal Canada Health Act
by the ruling so-called "Conservative" party virtually rendered
medical care a legal government monopoly.
4. In 1986, in my own province of Ontario, the ruling
so-called "Liberal" party pushed through Bill 94, titled "an Act
regulating the amounts that persons may charge for rendering services that are
insured services under the Health Insurance Act." . . . The legislation
also outlawed all competition with the government by doctors, insurers,
hospitals, nursing homes, and so on, and created a total bureaucratic monopoly
that brooks no opposition that might interfere with central planning
initiatives. Nowadays, many doctors feel that they can no longer criticize the
government with impunity. They can no longer act in their traditional role as
patient advocate. . .
"Cost Containment," Canadian Style
Note that both the federal and provincial Canadian
laws achieved their desired ends not by brute force but by financial
compulsion, as befits a relatively democratic state. These are the methods:
1. Cutbacks in hospital funding, leading to chronic
understaffing as well as inability of hospitals to provide the high-tech
expensive machinery needed for state-of-the-art diagnosis and treatment;
2. Resultant rationing of hospital admissions and
hospital procedures, leading to waits of many months or years for cardiac
bypass surgery, cancer radiotherapy, intensive neonatal care, and most of all,
urgent and elective surgery;
3. Government control of permitted types and
frequencies of diagnostic tests, such as mammography, Pap smears, cholesterol
studies, ultrasound, amniocentesis, CT and MRI scans;
4. Government-mandated drug selection;
5. Refusal to permit any Canadian to buy privately
what the government has decided it cannot afford, on the egalitarian theory
that if not everyone can have it at public expense, no one should be allowed to
have it through private payment;
6. Indirect control of medical personnel and medical
institutions, again by financial arm-twisting;
7. Stringent controls on, or outright refusal to
permit privately owned alternatives to hospital ambulatory care or surgical
facilities. (Bureaucrats don't like competition-it makes them look bad);
8. Compulsory "donations" by doctors to
hospitals or universities-just another form of income confiscation or
discriminatory taxation by what are now, in reality, government institutions. . . .
The Status of Serfs
In a previous lecture, at the 46th Annual Meeting of
AAPS in Orlando, FL, I restricted myself to the problems arising from the
financial absurdity of a Canadian-style system. Let's now examine some of the
nonfinancial consequences of total central planning.
1. The Right to Medical Privacy. Confidentiality no longer exists in Canada. In
Ontario, for example, the physician is required by law to submit the details of
every medical visit, every diagnosis, every treatment, every lab test, every
hospitalization, and every operation, to the government's computerized records,
which are accessible to myriads of government clerks. . . .
2. The Patient-Physician Relationship. In order to persuade Canadians that universal, compulsory,
comprehensive, no-limit, first-dollar-coverage, tax-paid, government-mandated
and bureaucratically controlled national health insurance was the ideal, our
politicians used large amounts of the taxpayers' own money to convince them
that:
a) Doctors were overpaid, under disciplined, too
powerful, error prone, and out of control;
b) Only centralized supervision, payment, and fee controls could alter this
situation; and
c) Only total government control and tax funding could provide the medical utopia
presumably lacking in Canada.
The results, so appealing in the short term, have been
nothing short of disastrous in the long run. Our socialist politicians'
response, predictably, has been based on the ``hair of the dog'' hypothesis: if
a little government intervention produces almost insoluble problems, then the
solution is more and more government intervention.
In the preface to chapter 2 of Hayek's book is a
quotation from Hoelderlin: "What has always made the state a hell on earth
has been precisely that man has tried to make it his heaven." . . .
3. The Practice of Medicine as a Subspecialty of
Politics. When politicians arrogated unto themselves the task
of running the hospitals, direct intrusion into medical judgment was only a matter
of time. First, it was justified as a means of cost control: . . . The bureaucratic establishment of mandatory
norms for doctors and hospitals is rapidly leading to a government-directed,
assembly-line, civil-service type of practice. The benefits, if any, are
epidemiological, not individual, the direct antithesis of the Hippocratic
approach to the relations between an individual doctor and his specific
patients. Computers run by nonmedical, politically appointed medical
administrators are progressively replacing medical judgment.
4. The Collapse of Medicine as a Profession. The emigration or early retirement of many of our
best physicians have left large gaps in the medical, hospital, and university
hierarchies. These have been filled, as Hayek predicted, by the rise of many
(often those whose main attribute is political astuteness rather than medical
excellence) who would otherwise have remained in the ranks of the mediocre. . .
5. Liberty: the Doctor's Right to Choose. At least in urban centers, Canadian physicians still
have a right to choose their patients. However, they are rapidly losing their
right of choice as to the location, style, and financial conditions of their
practice. . . .
6. Liberty: the Patient's Right to Choose. At present, Canadian patients can choose to see any
physician they wish, provided he will have them. However, equal and universal
access to what doesn't exist is a mirage, a cruel hoax. If highly qualified
doctors are unavailable because they have emigrated, or had their fees so
reduced by government edict that they have no incentive to exert themselves
beyond the minimum, the theoretical right to access to their services becomes
meaningless. When urgent care must be postponed for months or years because of
government underfunding, then, to paraphrase an old legal maxim, medical care
delayed becomes medical care denied. . . .
The Price of the Search for Utopia
Utopia has been defined as "the best of all
impossible worlds." The search for Utopia, medical and otherwise, is as
old as mankind itself. Unfortunately, it often has hideous consequences:
a) At best, the politicians and bureaucrats use money
made available ostensibly to implement this ideal, either to buy votes and
thereby distort the normal economy of the country, or, worse, to line the
pockets of themselves and their supporters;
b) The Utopian ends come to justify the often unjust,
immoral, and often downright illegal means. To quote Eric Hoffer: "You
cannot build Utopia without terror, and before long terror is all that is
left."
c) Even in the absence of outright terror, governments
have used all kinds of sticks and carrots to force both patients and physicians
into the mold of politician's perceptions of the ideal citizen.
In October, 1977, Prince Philip, the husband of the
Queen, made some revealing observations about the rise of welfare statism in
Britain, which are now equally applicable to Canada. These are directly
analogous to Hayek's arguments on serfdom. "Reduced to extremes,"
Philip wrote, "the choice is between a philosophy which holds that all
individual citizens must serve the general public interest, which means in
effect that the individual becomes a servant of the state; or alternatively, a
philosophy that asserts that the individual is of paramount importance, and
that therefore, the state exists to preserve and protect his human rights to
liberty and integrity....Freedom is indivisible. Once the law ceases to protect
the rights of the individual from the gang-any gang-freedom is lost. Once
a determined government begins the process of eroding human rights and
liberties, - always with the very best possible intentions, - it is very
difficult for individuals or individual groups to stand against it." . . .
To paraphrase American philosopher George Santayana, I
hope you Americans will take the trouble to learn the cruel lessons of the
history of national health insurance systems in other countries, including
Canada, and not have to repeat them.
To read the entire article,
go to www.aapsonline.org/brochures/goodman-serf.htm.
Canadian Medicare does not
give timely access to healthcare, it only gives access to a waiting list.
--Canadian Supreme Court
Decision 2005 SCC 35, [2005] 1 S.C.R. 791
http://scc.lexum.umontreal.ca/en/2005/2005scc35/2005scc35.html
* * * * *
4.
Medicare: A
Framework for Medicare Reform, by John C. Goodman, Ph.D.
The most important domestic policy problem
this country faces is health care. The most important component of that problem
is Medicare. Forecasts by every federal agency that produces such simulations —
the Congressional Budget Office (CBO), the Social Security/Medicare Trustees,
the General Accounting Office (GAO) — show that we are on a dangerous and
unsustainable path. Indeed, the question is not: Will reform take place? The
question is: How painful will reform have to be?
Executive Summary
Health care is the most serious domestic
policy problem we have, and Medicare is the most important component of that
problem. Every federal agency that has examined the issue has affirmed that we
are on a dangerous, unsustainable spending path:
There are three
underlying reasons for this dilemma:
■ Since Medicare beneficiaries are
participating in a use-it-or-lose-it system, patients can realize benefits
only by consuming more care; they receive no personal benefit from consuming
care prudently and they bear no personal cost if they are wasteful.
■ Since Medicare providers are trapped in
a system in which they are paid predetermined fees for prescribed tasks, they
have no financial incentives to improve outcomes, and physicians often receive
less take-home pay if they provide low-cost, high-quality care.
■ Since Medicare is funded on a
pay-as-you-go basis, many of today's taxpayers are not saving and investing to
fund their own post-retirement care; thus, today's young workers will receive
benefits only if future workers are willing to pay exorbitantly high tax rates.
About the Author
John
C. Goodman, Ph.D., is the founder and president of the National Center for
Policy Analysis. The National Journal recently
called him the "Father of Health Savings Accounts," and he has
pioneered research in consumer-driven health care.
Dr.
Goodman is the author of eight books, and is author/co-author of more than 50
published studies on health care policy and other topics. He received a Ph.D.
in economics from Columbia University. He has taught and done research at
several colleges and universities including Columbia University, Stanford
University, Dartmouth University, Southern Methodist University and the
University of Dallas.
To read the entire report, go to www.ncpa.org/pub/st/st315/st315.pdf.
Government
is not the solution to our problems, government is the problem.
- Ronald Reagan
* * * * *
5.
Medical Gluttony:
Pharmacy Practices are Hazardous and Costly
Almost all physicians are getting into the habit of
giving adequate prescription refills and eliminating the need for patients to
call in for prescription refills or having special lines reserved for patients
to call in. They are learning that phone refills are not only hazardous, but poor business practice.
This is accomplished by the physician at the time of
appointment, who, with all the information at hand, determines a safe period
for the patient to take the medicine without further evaluation. Then the
number of refills to that evaluation is given when another prescription will be
written. Thus, if the patient should be evaluated in six months, then the total
refills would equal six and the patient knows to make an appointment when the
sixth refill is filled. The same for a 12-month refill.
At a recent meeting of an insurance company, a
pharmacy service company was expounding on their ability to automatically send
faxes to the doctor when the last prescription is picked up, which will always
be one month before the required appointment. They even bragged that they could
send out daily faxes until the doctor responded. We recommend that a doctor
should not respond to these requests in view of the hazards involved and the
costs of this practice.
They are hazardous
because pharmacists assume that all that is required is a simple yes or no
answer after which they can proceed with refilling a prescription that hasn't
been authorized by the doctor with the patient and his/her chart in front of
him/her. This will assure the pharmacist of return business without the
possibility of patients having a new prescription in their hand, which could be
taken to another pharmacist. But the physician had made a determination that
the patient needed further evaluation when the refills are completed and thus
appropriate health care is subverted. We recommend that a doctor should not
respond to these requests in view of the hazards involved. Faxes can now be
programmed to block such calls from repeat offenders.
Phone refills are an excessive cost to a medical
practice. To refill a prescription, doctors know the risks involved if the
chart is not pulled and reviewed and a new determination is made. Phone refills
are basically an office visit without an exam. Therefore, the actual cost of
this phone request is about half that of an office call. However, there is no
payment for this half-office evaluation. If a doctor sees three patients an
hour, and three refills come in during the same hour, the professional income
is cut in half.
Attorneys have long known that phone calls are
expensive. But they have the mechanism to charge for their time on the phone to
their clients. Most law firms have a minimum time per phone call, such as
one-sixth or one-fourth hour. Thus, if you have a junior attorney in a firm
charging $300 an hour, the phone call is automatically billed at $75 for one to
15 minutes of time, and $150 for 16 to 30 minutes of time. The cost of a senior
attorney at $400 an hour would be $100 for each quarter hour or less. Attorneys
cannot take the risk of possibly giving out legal recommendations without all
the facts in front of them.
The same thing applies to physicians who should not
take the risk of giving out information, recommendations or refills without all
the facts in front of them. Physicians need to establish a fee structure to
take care of this practice much as attorneys do. If they don't, liability
increases and malpractice premiums will rise to cover this liability.
Meanwhile, physicians must ignore all pharmacy requests for new prescriptions
or refills beyond those initially authorized.
* * * * *
6.
Medical Myths:
Doctors Control the Practice of Medicine
A patient called today to schedule an appointment. He
had left the world's largest HMO and was trying private care. He was desperate,
having run out of all of his medications. He had called a physician's office
and was told there were no openings for six weeks. He made the appointment and
showed up. He could not be seen because he did not notify the HMO of his choice
of a new private physician and thus did not have a card with the physicians
name on it. He became very upset and called another doctor on his list. That
office told him that he had to get the HMO to issue another card with the
doctor's name on it. He got upset with the second office stating, "I wish
I could kill all doctors. They are so arrogant." Doctors, however, would
not get paid unless they were authorized to see the patient.
There may be factors of which we are unaware, but here
an HMO patient is blaming his intended doctors for arrogance and wishing them
ill.
This seems to be an attitude with much of the public
blaming doctors for what's wrong with healthcare. I was unable to bend a
hospital rule for the benefit of one of my patients, who wanted to use his own
medications instead of the expensive hospital medications, and got blamed by
the patient who stated rather loudly, "I know doctors run the hospital and
your word is the law. So you could do this if only you wanted to save me
money." What I didn't have the heart to tell him was the charge would be
the same whether the nurse gave him his own medication or the hospital supply.
The cost is the RN administrating the medication.
The same attitude is frequently seen whether doing
Social Security exams, Veteran's exams or employment exams. The doctor is
always at fault if benefits are not received.
The lay people are increasingly blaming physicians for
all the ills of health care. However, the box we're in does not allow much
latitude for appropriate care and patient relationships. Unless doctors assume
charge for private health care, we will go down the route of used car salesmen
and attorneys in the ranking of the respected professions. Some doctors favor
this practice of being simple civil service employees with fixed hours, ten
holidays off and vacations guaranteed. The patients complain whenever their
doctor is not available. When doctors are employees negotiating more and more
time off, patients will be increasingly unhappy due to the loss of continuity
of care. This translates into a lower quality of care.
A Foretaste
of Things to Come with Government Medicine
The critical
answer is for doctors to lower their exposures to third-party medicine, whether
Medicare, Medicaid, any government program and FP-HMOs whenever they can.
* * * * *
7.
Overheard at the World Health Care Conference: A Gift
That Keeps on Giving!
Nobel Laureate Dr. Muhammad Yunus
has spoken to the World Health Care Congress several times over the years,
telling the world health care leaders about micro credit bringing people of
Bangladesh out of poverty into entrepreneurship. Headlines surfaced this past
year of his bringing his micro credit plans to New York and the United States
to help poor people become self-- sustaining. His Grameen Bank has
done remarkable things in this country during its first year. We have just
received this Holiday Message, which we would like to share with you and your
friends. Your contributions here will do far more than either your federal or
state taxes to reduce poverty in America. To learn more, please go to their
website below. Dr. Yunus is speaking at the sixth WHCC on April 14-16, 2009.
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The 6th Annual World Health Care Congress
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* * * * *
8.
Voices of
Medicine: A Review of Local and Regional Medical Journals
SONOMA MEDICINE, the
Magazine of the Sonoma County Medical Association, Fall 2008
Reflections from the History of
Medicine, By James K. Gude, MD
I love the history of medicine! I enjoy rolling among
its pages like my trusty Airedale, Oliver, relishes rolling in new-mown hay. I
cherish what is oldest and distant best. Although I have enjoyed Sonoma County medicine
since I came to Santa Rosa in 1971 to join Dr. George Firestone in his office
(now a parking lot) and teach at the family practice residency at Community
Hospital (now Sutter Medical Center of Santa Rosa), I prefer ancient Egypt,
China, Greece, India, Rome, and the Arabic world. I enjoy talking to Imhotep,
Charaka, Huangdi, Aretaeus and Rhazes. When I pick up a book, it's usually not
on the New York Times bestseller
list. Instead, it's by Rabelais, Locke, Goldsmith, Keats, Schiller, Doyle,
Chekhov, Maugham, Joyce, Cronin, Williams, Percy or Thomas—all of whom were
physicians or at least attended medical school.
When I'm asked for advice, I prefer quoting my
physician mentors. I'll share with you the richest, most memorable nuggets I
know from the history of medicine. My appreciation for 150 years of Sonoma
County medicine begins with my delight in the first named physician, Imhotep,
circa 2700 bce, and what has happened in medicine since then. Here goes:
Imhotep is credited with writing an ancient papyrus
scroll that contains the following clinical presentation: "Should thou
find his countenance is clammy with sweat, the ligaments of his neck are tense,
his face is ruddy, his mouth is bound, and both his eyebrows are drawn, while
his face is as if he wept." This is the first description of risus
sardonicus diagnostic of tetanus, and Imhotep's conclusion is, "An ailment
not to be treated." This wise clinician recognized the ethical principle
of not treating a fatal illness. Here was one of the first No Code orders based
on the concept of futility.
Hippocrates (ca. 400 BCE) wrote, "Life is short,
and the Art is long: the occasion fleeting, experience fallacious, and judgment
difficult." There is no better summary of a physician's fate.
Charaka (ca. 300 BCE), a Hindu physician, wrote,
"Those who for the sake of a living, make merchandise of medicine, bargain
for a dust-heap, letting go a heap of gold." This aphorism sets a high
moral tone for medical practice. . .
Rhazes (ca. 900 CE), a Persian physician, advised,
"Practice what I have preached, and if there be in what I practiced some
deficiency, yet thou canst profit of my theory, and my shortcomings will not
injure thee." Rhazes practiced in Baghdad and wrote prolifically. He was
the most original practitioner of the art of physical diagnosis during the
Islamic Golden Age. . .
John Locke (1632-1704), an English philosopher and physician,
wrote his own epitaph: "Stay, wayfarer, near here lies John Locke. If you
ask what sort of man he was, his answer is that he lived content with his
modest lot. Educated in letters, he accomplished as much as satisfied the
demands solely of truth." Thomas Jefferson borrowed freely from Locke in
writing our Constitution.
Oliver Goldsmith (1728-1774) was an English writer and physician
about whom Samuel Johnson observed, "No man was more foolish when he had
not a pen in his hand—or more wise when he had." Goldsmith's play
"She Stoops to Conquer" shows his strength of loving his fellow man
with a kind acceptance of man's comical situation.
Friedrich Schiller (1759-1805), who began his career as a
physician, is second only to Goethe in German literature. In his plays
"The Robbers" and "Wallenstein," he explores the dimensions
of rebellion and freedom.
John Keats (1795-1821) attended medical school in England but
became a poet. His "Ode on a Grecian Urn" contains the famous lines:
"Beauty is truth, truth beauty,—that is all / Ye know on earth, and all ye
need to know."
Arthur Conan Doyle (1859-1930) fashioned his fictional detective
Sherlock Holmes after Dr. Joseph Bell, Doyle's own professor of medicine at the
University of Edinburgh. Doyle wrote that Bell "would sit in his receiving
room and diagnose people as they came in. He would tell them their symptoms,
and even give them the details of their past life, and hardly ever would he
make a mistake."
Anton Chekhov (1860-1904) worked tirelessly as a physician,
short-story writer and playwright in his native Russia. In his play "Uncle
Vanya," the character Dr. Astrov declares, "I am overworked, nurse.
From morning till night I am always on my legs, not a moment of rest, and at
night one lies under the bedclothes in continual terror of being dragged out to
a patient. All these years that you have known me I have not had one free day.
I may well look old! This life swallows one up completely."
Somerset Maugham (1874-1965) was an English physician and writer
whose novel Of Human Bondage is
a thinly disguised autobiography that portrays the coming-of-age of a doctor
named Philip Carey. Maugham writes, "He had lived always in the future,
and the present always, always had slipped through his fingers. His ideals? He
thought of his desire to make a design, intricate and beautiful, out of the
myriad, meaningless facts of life; had he not seen also that the simplest
pattern, that in which a man was born, worked, married, had children, and died,
was likewise the most perfect?"
James Joyce (1882-1941) studied medicine briefly in Paris
after graduating from University College Dublin. His epic novel Ulysses contains many references to
medicine. Of his famous book, Joyce wrote, "I've put in so many enigmas
and puzzles that it will keep the professors busy for centuries arguing over
what I meant, and that's the only way of ensuring one's immortality."
A.J. Cronin (1896-1981) was a Scottish physician and writer.
In his novel The Citadel, the
main character, Dr. Andrew Manson, seeks the truth despite the medical
establishment's repressive actions. Cronin vividly outlines the ethical
problems in medicine brought about by greed, power and ignorance. . .
Walker Percy (1916-1990), a physician who wrote The Moviegoer and
other novels about the American South, noted, "If the first intellectual
discovery of my life was the beauty of the scientific method, surely the second
was the discovery of the singular predicament of man in the very world which
has been transformed by this science. An extraordinary paradox became clear:
that the more science progressed and even as it benefited man, the less it said
about what it is like to be a man living in the world."
Lewis Thomas (1913-1993), medical-school dean at Yale and NYU, was
a superb essayist. In "The Youngest Science," he wrote about women:
"I am, in short, swept off my feet by women, and I do not think they have
yet been assigned the place in the world's affairs that they are biologically
made for. Somewhere in that other X chromosome are coils of nucleic acid
containing information for a qualitatively different sort of behavior from the
instructions in the average Y chromosome. The difference is there, I think, for
the long-term needs of the species, and it has something to do with spotting
things of great importance."
I have shared with you the richness of our medical
heritage as represented by these physician writers. There were not a fair share
of women, but if you believe Lewis Thomas, that is now changing for the
better.
To read Dr. Gude's entire article, go to www.scma.org/magazine/articles/?articleid=53.
Dr. Gude, a specialist in critical care medicine and pulmonary disease,
lives in Santa Rosa.
E-mail: gudej@sutterhealth.org
* * * * *
The Prince, The Spy, and The Biker who
Came in from the Cold. By James J. Murtagh, M.D.
Biker drama echoes both
Shakespeare and John Le Carré.
Warning: spoiler alert. If you have not seen the
final episode of Sons of Anarchy, do not read further. The episode
contains a major plot twist which is discussed in this Op-Ed.
The season finale of Sons of Anarchy,
the brash new biker-gangster drama, ended this week in the funeral of an
innocent woman mistakenly gunned down in a blood feud. This is not just another
crime story- Sons is even more ambitious than The Shield, The Wire or
The Sopranos. Sons of Anarchy is one of the best counter-espionage stories
in recent memory- worthy of John le Carré, even of Shakespeare.
Sons borrows from the two best spy stories of
all time- The Spy Who Came in from the Cold, and Hamlet. The
Prince, the Spy and the Biker are all totally disillusioned anti-heroes,
acutely aware of gross rottenness. Ghosts haunt all three. His dead father
haunts hamlet the Prince.
Dead secret agents haunt Le Carré's British Spy. The ghost of his
father and other demons haunts Jax the Biker.
The Prince, the Spy and the Biker all use
expendable double agents and triple agents. Do Rosencrantz and Guildenstern
even really know who they work for as they blunder into execution? Does the
British Spy's girl have any idea why she is gunned down on the Berlin wall?
Anarchy explicitly rules all three
stories. How can the body politic be cured of rank and rampant corruption? When
Kings are criminals, no one is safe.
In Sons, bikers are in a kind of
cold war with the FBI. Just as le Carré's spy masters set up their own agents
to deliver lies, the FBI frames a biker to falsely appear as an informant.
Sons baits their dirty lie with detailed artistry to trap their man behind
enemy lines.
The Prince, the spy and the biker all both
contemplate and wreck horrific collateral damage. Hamlet sacrifices a dozen
innocents to bring down Claudius. British Control sacrifices dozens of their own
agents. The Bikers sacrifice their own to protect "The Brotherhood."
Hamlet a real secret agent? True, he
doesn't have a James Bond car, lasers, or a decoder ring. But Hamlet claims to
act for King and country, and has the code of a double 0- he has a license to
kill, or be killed. He kills Polonius by mistake, then expects some lackey like
Felix Lieghter to clean up.
Thinking too much only causes more
carnage. Hamlet hesitates to kill his evil step-father while at prayer,
contrasting the ruthless Laertes who would cut a throat in the church to end a
blood feud. The Spy and the Biker also hesitate, with disastrous results, while
more ruthless Laertes-figures execute without remorse.
All for the greater good. Hamlet, British
control, the FBI (and the Bikers) all see the deaths of innocents as the cost
of doing business. It's all part of the game, as Omar Little might say on
The Wire.
The Prince agreed with Omar, when he
observed that each goes to gain a little patch of ground with no profit in it.
British agent Leamas deeply understands
that the secret service undermine the values of the west. Straddling the Berlin
Wall, Leamas cannot distinguish West and East Leamas. How to know which way to
jump?
The Biker's nemesis, FBI
agent Stahl,
ruefully admits "I guess I'm feeling guilty about making
orphans." She shrugs, and continues the game, despite the lack of
profit for anyone.
To be, or not to be? Ultimately, that is
the question for the Prince, the Spy and the Biker. They all end up take up
arms against a sea of troubles, but ultimately, their fate is clear.
The Prince and the Spy both get their most
fervent wish, and are granted the boon of release in death. Before dying, both
are dipped in bloodbath.
Odds are the Biker will join Prince and
Spy in a not too distant episode.
James J. Murtagh Jr.
jmurtag@mindspring.com
This review can be found at www.healthcarecom.net/JM_SonsOfAnarchy.htm.
To read more book reviews, go to www.delmeyer.net/PhysicianPatientBookshelf.htm.
To read book reviews topically, go to www.healthcarecom.net/bookrevs.htm.
* * * * *
10. Hippocrates & His Kin: Whom are we Praying to Now?
Front page photo in the WSJ showing Bishop Charles H. Ellis III holding a prayer service at
the Greater Grace Temple in Detroit for the auto industry (there were SUVs on the
Altar platform) praying for a bailout from Washington.
What wasn't clear was whether this was a prayer to God
or to Washington, DC.
Have the
Liberals succeeded in making Washington their god?
The
high risk of law enforcement next to Marine Airbases
A California Highway Patrol Officer
was conducting speed enforcement on I-15, North of MCAS Miramar, using a
handheld radar device to nab speeders cresting the hill.
The officer was dumbfounded when the
radar gun issued a 400 mph reading and went dead.
Just then, a deafening roar over the
treetops revealed that the radar had in fact locked onto a USMC F/A-18
Hornet engaged in a low flying exercise.
Back at CHP Headquarters, the Patrol
Captain fired off a complaint to the USMC Base Commander. Back came a
reply in true USMC style:
Thank you for your message as
it allows us to complete the file on this incident. You may be
interested to know that the Hornet's tactical computer had
instantaneously locked onto your hostile radar equipment, sending a
jamming signal back to it. Also, the automatic air to ground
missile systems aboard the Hornet similarly locked onto your equipment,
but fortunately the Marine flying the Hornet recognized the situation
for what it was and quickly overrode the automated defense system before the
target was vaporized.
Thank you for your concerns.
You are welcomed.
The Short
History of Government Ineptitude
"The budget should be balanced, the Treasury
should be refilled, public debt should be reduced, the arrogance of officialdom
should be tempered and controlled, and the assistance to foreign lands should
be curtailed lest Rome become bankrupt. People must again learn to work,
instead of living on public assistance." –Cicero - 55 BC
What have we
learned in two millennia about Governing?
To read more HHK, go to www.healthcarecom.net/hhk2001.htm.
To read more HMC, go to www.delmeyer.net/hmc2005.htm.
* * * * *
11. Professionals Restoring Accountability in Medical
Practice, Government and Society: