1. Featured Article: Can we lower medical costs by giving the neediest patients better care?

The New Yorker | January 24, 2011 | Medical Report | The Hot Spotters

by Atul Gawande MD

If Camden, New Jersey, becomes the first American community to lower its medical costs, it will have a murder to thank. At nine-fifty on a February night in 2001, a twenty-two-year-old black man was shot while driving his Ford Taurus station wagon through a neighborhood on the edge of the Rutgers University campus. The victim lay motionless in the street beside the open door on the driver's side, as if the car had ejected him. A neighborhood couple, a physical therapist and a volunteer firefighter, approached to see if they could help, but police waved them back.

"He's not going to make it," an officer reportedly told the physical therapist. "He's pretty much dead." She called a physician, Jeffrey Brenner, who lived a few doors up the street, and he ran to the scene with a stethoscope and a pocket ventilation mask. After some discussion, the police let him enter the crime scene and attend to the victim. Witnesses told the local newspaper that he was the first person to lay hands on the man.

"He was slightly overweight, turned on his side," Brenner recalls. There was glass everywhere. Although the victim had been shot several times and many minutes had passed, his body felt warm. Brenner checked his neck for a carotid pulse. The man was alive. Brenner began the chest compressions and rescue breathing that should have been started long before. But the young man, who turned out to be a Rutgers student, died soon afterward.

The incident became a local scandal. The student's injuries may not have been survivable, but the police couldn't have known that. After the ambulance came, Brenner confronted one of the officers to ask why they hadn't tried to rescue him.

"We didn't want to dislodge the bullet," he recalls the policeman saying. It was a ridiculous answer, a brushoff, and Brenner couldn't let it go.

He was thirty-one years old at the time, a skinny, thick-bearded, soft-spoken family physician who had grown up in a bedroom suburb of Philadelphia. As a medical student at Robert Wood Johnson Medical School, in Piscataway, he had planned to become a neuroscientist. But he volunteered once a week in a free primary-care clinic for poor immigrants, and he found the work there more challenging than anything he was doing in the laboratory. The guy studying neuronal stem cells soon became the guy studying Spanish and training to become one of the few family physicians in his class. Once he completed his residency, in 1998, he joined the staff of a family-medicine practice in Camden. It was in a cheaply constructed, boxlike, one-story building on a desolate street of bars, car-repair shops, and empty lots. But he was young and eager to recapture the sense of purpose he'd felt volunteering at the clinic during medical school.

Few people shared his sense of possibility. Camden was in civic free fall, on its way to becoming one of the poorest, most crime-ridden cities in the nation. The local school system had gone into receivership. Corruption and mismanagement soon prompted a state takeover of the entire city. Just getting the sewage system to work could be a problem. The neglect of this anonymous shooting victim on Brenner's street was another instance of a city that had given up, and Brenner was tired of wondering why it had to be that way.

Around that time, a police reform commission was created, and Brenner was asked to serve as one of its two citizen members. He agreed and, to his surprise, became completely absorbed. The experts they called in explained the basic principles of effective community policing. He learned about George Kelling and James Q. Wilson's "broken-windows" theory, which argued that minor, visible neighborhood disorder breeds major crime. He learned about the former New York City police commissioner William Bratton and the Compstat approach to policing that he had championed in the nineties, which centered on mapping crime and focussing resources on the hot spots. The reform panel pushed the Camden Police Department to create computerized crime maps, and to change police beats and shifts to focus on the worst areas and times.

When the police wouldn't make the crime maps, Brenner made his own. He persuaded Camden's three main hospitals to let him have access to their medical billing records. He transferred the reams of data files onto a desktop computer, spent weeks figuring out how to pull the chaos of information into a searchable database, and then started tabulating the emergency-room visits of victims of serious assault. He created maps showing where the crime victims lived. He pushed for policies that would let the Camden police chief assign shifts based on the crime statistics—only to find himself in a showdown with the police unions.

"He has no clue," the president of the city police superiors' union said to the Philadelphia Inquirer. "I just think that his comments about what kind of schedule we should be on, how we should be deployed, are laughable."

The unions kept the provisions out of the contract. The reform commission disbanded; Brenner withdrew from the cause, beaten. But he continued to dig into the database on his computer, now mostly out of idle interest.

Besides looking at assault patterns, he began studying patterns in the way patients flowed into and out of Camden's hospitals. "I'd just sit there and play with the data for hours," he says, and the more he played the more he found. For instance, he ran the data on the locations where ambulances picked up patients with fall injuries, and discovered that a single building in central Camden sent more people to the hospital with serious falls—fifty-seven elderly in two years—than any other in the city, resulting in almost three million dollars in health-care bills. "It was just this amazing window into the health-care delivery system," he says.

So he took what he learned from police reform and tried a Compstat approach to the city's health-care performance—a Healthstat, so to speak. He made block-by-block maps of the city, color-coded by the hospital costs of its residents, and looked for the hot spots. The two most expensive city blocks were in north Camden, one that had a large nursing home called Abigail House and one that had a low-income housing tower called Northgate II. He found that between January of 2002 and June of 2008 some nine hundred people in the two buildings accounted for more than four thousand hospital visits and about two hundred million dollars in health-care bills. One patient had three hundred and twenty-four admissions in five years. The most expensive patient cost insurers $3.5 million.

Brenner wasn't all that interested in costs; he was more interested in helping people who received bad health care. But in his experience the people with the highest medical costs—the people cycling in and out of the hospital—were usually the people receiving the worst care. "Emergency-room visits and hospital admissions should be considered failures of the health-care system until proven otherwise," he told me—failures of prevention and of timely, effective care.

If he could find the people whose use of medical care was highest, he figured, he could do something to help them. If he helped them, he would also be lowering their health-care costs. And, if the stats approach to crime was right, targeting those with the highest health-care costs would help lower the entire city's health-care costs. His calculations revealed that just one per cent of the hundred thousand people who made use of Camden's medical facilities accounted for thirty per cent of its costs. That's only a thousand people—about half the size of a typical family physician's panel of patients.

Things, of course, got complicated. It would have taken months to get the approvals needed to pull names out of the data and approach people, and he was impatient to get started. So, in the spring of 2007, he held a meeting with a few social workers and emergency-room doctors from hospitals around the city. He showed them the cost statistics and use patterns of the most expensive one per cent. "These are the people I want to help you with," he said. He asked for assistance reaching them. "Introduce me to your worst-of-the-worst patients," he said.

They did. Then he got permission to look up the patients' data to confirm where they were on his cost map. "For all the stupid, expensive, predictive-modelling software that the big venders sell," he says, "you just ask the doctors, ‘Who are your most difficult patients?,' and they can identify them."

The first person they found for him was a man in his mid-forties whom I'll call Frank Hendricks. Hendricks had severe congestive heart failure, chronic asthma, uncontrolled diabetes, hypothyroidism, gout, and a history of smoking and alcohol abuse. He weighed five hundred and sixty pounds. In the previous three years, he had spent as much time in hospitals as out. When Brenner met him, he was in intensive care with a tracheotomy and a feeding tube, having developed septic shock from a gallbladder infection.

Brenner visited him daily. "I just basically sat in his room like I was a third-year med student, hanging out with him for an hour, hour and a half every day, trying to figure out what makes the guy tick," he recalled. He learned that Hendricks used to be an auto detailer and a cook. He had a longtime girlfriend and two children, now grown. A toxic combination of poor health, Johnnie Walker Red, and, it emerged, cocaine addiction had left him unreliably employed, uninsured, and living in a welfare motel. He had no consistent set of doctors, and almost no prospects for turning his situation around.

After several months, he had recovered enough to be discharged. But, out in the world, his life was simply another hospitalization waiting to happen. By then, however, Brenner had figured out a few things he could do to help. Some of it was simple doctor stuff. He made sure he followed Hendricks closely enough to recognize when serious problems were emerging. He double-checked that the plans and prescriptions the specialists had made for Hendricks's many problems actually fit together—and, when they didn't, he got on the phone to sort things out. He teamed up with a nurse practitioner who could make home visits to check blood-sugar levels and blood pressure, teach Hendricks about what he could do to stay healthy, and make sure he was getting his medications.

A lot of what Brenner had to do, though, went beyond the usual doctor stuff. Brenner got a social worker to help Hendricks apply for disability insurance, so that he could leave the chaos of welfare motels, and have access to a consistent set of physicians. The team also pushed him to find sources of stability and value in his life. They got him to return to Alcoholics Anonymous, and, when Brenner found out that he was a devout Christian, he urged him to return to church. He told Hendricks that he needed to cook his own food once in a while, so he could get back in the habit of doing it. The main thing he was up against was Hendricks's hopelessness. He'd given up. "Can you imagine being in the hospital that long, what that does to you?" Brenner asked.

I spoke to Hendricks recently. He has gone without alcohol for a year, cocaine for two years, and smoking for three years. He lives with his girlfriend in a safer neighborhood, goes to church, and weathers family crises. He cooks his own meals now. His diabetes and congestive heart failure are under much better control. He's lost two hundred and twenty pounds, which means, among other things, that if he falls he can pick himself up, rather than having to call for an ambulance. . .

Read the entire report in the New Yorker, January 24, 2011, Issue . . .
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2. In the News: Chastity before marriage may have its uses after all.

The Waiting game | Premarital sex | Jan 20th 2011 | from The Economist | PRINT EDITION

WHEN is it the right time to do the deed? If priests had their way, it would be shortly after the wedding ceremony—but recent studies show such advice is rarely heeded. Roughly 85% of the American population, for example, approves of premarital sex. Faced with numbers like that, what hope do the Vatican and its ilk really have?

More than they did a week ago. Until now, the argument that couples should wait until they are married before they have sex has rested on mere assertion and anecdote. Dean Busby and his colleagues at Brigham Young University, in Utah, however, have gathered some data which support delay.

Fabian tactics

Little is known about the influence of sexual timing on how relationships develop. Even so, opinions abound. Some argue that the sexual organs, both physical and mental (for, as the old saw has it, the most powerful erotic organ is the mind) need a test drive to make sure the chemistry between a couple means they will stay together both in sickness and in health. Others suggest that couples who delay or abstain from sexual intimacy early on allow communication to become the foundation of their attraction, and that this helps to ensure that companionship and partnership keep them together when the initial flames of lust die down.

To examine these suggestions more closely, Dr Busby and his colleagues recruited 2,035 married people ranging in age from 19 to 71, and in length of marriage from less than six months to more than 20 years. Their religious affiliations varied widely; many had none.

All were asked to complete an online questionnaire normally used to help couples understand their strengths and weaknesses. Among the nearly 300 questions, participants were asked when they first had sex with their partners, whether their sex lives were currently good, how they resolved conflicts, and how often they thought of ending their relationship. In addition, the questionnaire had 14 items that evaluated how good participants were at expressing empathy and understanding to their partners and how prone they were to be critical or defensive. All questions, apart from those about frequency of sex, were answered on a five-point scale, with one indicating strong disagreement and five indicating strong agreement.

Because religiosity delays sexual activity, Dr Busby and his colleagues also asked participants how often they attended church, how often they prayed and whether they felt spirituality was an important part of their lives. They used the answers to control for religiosity. They also controlled for income, education, race and length of relationship.

Their report, just published in the Journal of Family Psychology, suggests that people who delay having sex do indeed have better relationships, on four different measures (see table). That result applies to both men and women. . .

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3. International Medicine: Canadian Medicare - GETTING OUR MONEY'S WORTH

SUMMARY: REPORT OF THE TASK FORCE ON THE FUNDING OF THE HEALTH SYSTEM

The Québec government set up the Task Force on the Funding of the Health Care System at the time of the 2007-2008 Budget Speech of May 24, 2007, to make recommendations on how best to adequately fund the health care system.

The Task Force was chaired by Claude Castonguay. Two vice-chairs, Joanne Marcotte and Michel Venne, were appointed after consulting with the opposition parties.

To respond adequately to its mandate, the Task Force dealt with the question of funding the health care system in its broadest sense: the Task Force is convinced that to secure such funding and by the same token the survival of the system, action needs to be taken on both the revenue and the spending sides, clear objectives must be set regarding public coverage and the system's managers, health care professionals, sector workers and the general public must be made aware of the issues at stake.

A Central Objective

From the outset, the Task Force sought to define a central objective to its task, illustrating its priorities and its vision of things: the Task Force considers that Québec must secure the long-term viability of the public health care system by increasing its productivity and adjusting the growth in public health spending to the growth rate of Québec's economy, while improving access to care and quality of services.

The Vision: A New Social Contract

This objective could form the core of a new "social contract" that would be acknowledged as such by Quebecers as a whole. The Task Force believes that the time has come for Quebecers to agree on what could constitute a new social contract designed to ensure the long-term viability of a system we are all strongly attached to, but which cannot be maintained without rigorous effort and a collective awareness of the issues at stake. [Goodness, what naiveté after decades of planning and experience?]

Appealing To Quebecers' Sense of Responsibility

This social contract is first of all an appeal to Quebecers' sense of responsibility. Of all our public programs, the health system is the most significant expression of the solidarity that unites all citizens to respond collectively to the basic needs of every human being. Created during the Quiet Revolution, it quickly became the largest service organization in Québec. However, forty years on, the health system is suffering from a crisis of confidence: our system is costly compared to our collective wealth, and is not as productive as it could be.

Everyone is aware of the difficulties of the health system, yet the situation is not changing quickly enough. The reason is simple: no-one dares call into question the particular interests at play. [Politically incorrect?] There is another reason for this failure to act: we have transformed certain features of our system into dogma, features that other countries have questioned long ago. [Any college student knows that dogma is not subject to reason.]

In recent years, we thought we could resolve the system's problems by rationing services or injecting massive amounts of new money into it. It soon became apparent that these reactions were inadequate. . . [If rationing and major funding increases are inadequate, do we need armed guards in every clinic?]

Values and Principles

This new social contract is based on a number of values and principles that should be familiar to all. The Task Force has identified six, namely universality, solidarity, fairness, efficiency, responsibility and freedom. [Aren't some of these principles inconsistent with each other?]

Specific Obligations for Each Player

The social contract proposed by the Task Force is embodied in a set of obligations that are incumbent on the primary players of the system. The social contract proposed by the Task Force notes that each player in the system enjoys rights and must also satisfy obligations.

For the citizen, the first commitment should be to accept his share of responsibility regarding his own health. The citizen must also contribute to the system's funding according to his means, and in accordance with his consumption of care. [Is this directly from the Communist Manifesto? | Class conflict between the bourgeoisie and proletariat leading to a revolution!]

The primary responsibility of health professionals, physicians in particular, is to provide the right service to the right person at the right time. Health professionals are the chief guarantors of quality of services. Health professionals also have a duty to ensure continuity of care and good cooperation among various categories of professionals. [Who will be the judge to oversee this obligation - the bourgeoisie or the proletariat?]

Managers Ensure The System Runs Efficiently. In return for greater recognition of their local autonomy and fair remuneration, they are responsible for offering efficient services at the lowest possible cost. [That can never happen under a socialistic program – it can only happen in a capitalist program where everyone will be the most efficient at the lowest possible cost to survive.]

The System Cannot Evolve If the Various Interest Groups Fail To Agree To Make Concessions and cooperate on essential reforms. The changes that are needed have all the more chance of succeeding if they are implemented with the support, influence and cooperation of the players involved. Lack of cooperation would therefore put the system itself at risk. The groups concerned must be aware of this. The Task Force invites them to work together. Goodwill is necessary to secure the system's long-term viability. [That's like asking Unions and Management to cooperate rather than be adversaries.]

The Government's First Duty Is To Be Consistent. After setting the limits of the public system's commitment, the government must do what is necessary to keep its promises. . . [Only possible in a Totalitarian state.]

We must thank the CANADIAN TASK FORCE ON THE FUNDING OF THE HEALTH SYSTEM
to analyze the logic of why SOCIALIZED HEALTH CARE can never work with human beings.

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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

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4. Medicare: On the 100^th birthday anniversary of the President who told the Truth about Evil

We give tribute to President Reagan, whom we've used as a byline for this section since August 2005, who was able to call a spade a spade and shovel the evils of socialism off the Washington streets.

Who is this Neanderthal, sniffed the journalistic elite.

On Jan. 29, 1981, barely a week into Ronald Reagan's presidency, the world got a no-nonsense education on how Reagan's America would differ from that of his predecessor. During the first press conference, ABC's Sam Donaldson asked the new president about Moscow's aims and intentions. Throwing diplomatic double-speak to the wind, Reagan calmly explained that the Soviet leadership had "openly and publicly declared that the only morality they recognize is what will further their cause, meaning they reserve unto themselves the right to commit any crime, to lie, to cheat."

Reagan continued, explaining that the Soviets considered their relativistic behavior "moral, not immoral." This was something that the United States needed to "keep . . . in mind" when doing "business" with Moscow. The assembled Washington press corps responded with what National Security Adviser Richard V. Allen described as "an audible gasp."

Reagan's rejoinder was deemed a crass outrage. The journalistic elite sniffed, Who is this Neanderthal? A Washington Post editorial lamented the "indiscriminate quality of some of the things being said." This sudden "good-vs.-evil approach risks missing what legitimate opportunity for honorable accommodation there may be."

In the ensuing weeks, America's leading journalists—perplexed, offended—repeatedly pressed the new president for clarification. And so Reagan would clarify, again and again, saying of the Soviet leadership: "They don't subscribe to our sense of morality. They don't believe in an afterlife; they don't believe in a God or a religion. And the only morality they recognize, therefore, is what will advance the cause of socialism."

All this was too much for CBS Evening News. CBS's grand old anchor, Walter Cronkite, got the opportunity to confront Reagan during a March 3 interview. Cronkite told Reagan that the president's views seemed too "hard line toward the Soviet Union." He noted that "there are some who . . . feel that you might have overdone the rhetoric a little bit in laying into the Soviet leadership as being liars and thieves, et cetera."

Reagan did not back down. He noted that he had merely responded truthfully to a question from a reporter about "Soviet aims." On that, said Reagan, "I don't have to offer my opinion. They [the Soviets] have told us where they're going again and again. They have told us their goal is the Marxian philosophy of world revolution and a single, one-world communist state, and that they're dedicated to that." The president harkened back to the Soviet version of morality: "Remember their ideology is without God, without our idea of morality in a religious sense."

Cronkite seemed befuddled and bothered. He described Reagan's words as "name-calling," and he expressed concern that this would make "it more difficult" to sit down with Leonid Brezhnev and the Soviet leadership.

Yet Lenin declared in 1920: "We repudiate all morality that proceeds from supernatural ideas that are outside class conceptions. Morality is entirely subordinate to the interests of class war. Everything is moral that is necessary for the annihilation of the old exploiting social order and for uniting the proletariat."

Reagan had it right, and he took that insight, and self-assurance, into a two-term presidency where his goal was to win the Cold War and defeat that evil system.

Alas, there was a golden moment at the end of that first press conference, unseen by the public or cameras. It was shared years later by Richard Allen. When the press conference was finished, Reagan, who recognized the weight of what had happened and was unfazed, called over to Mr. Allen and asked, with a grin: "But Dick, the Soviets do lie and steal and cheat, don't they?"

"Yes sir, they do," Mr. Allen replied. Reagan smiled and said, "I thought so."

In January 1981, the world needed a leader who indeed thought so, who dared to say so, and who was willing to do something about it.

Mr. Kengor, professor of political science at Grove City College, is author of "The Crusader: Ronald Reagan and the Fall of Communism" (Harper Perennial, 2007) and "Dupes: How America's Adversaries Have Manipulated Progressives for a Century" (Intercollegiate Studies Institute, 2010) .

When Reagan Spoke Truth to Soviet Power, WSJ, BY PAUL KENGOR, Subscription required.

We need another "neanderthal" in the White House that understands good vs evil.

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

- Ronald Reagan

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5. Medical Gluttony: Health care without physician direction

In the Air Force, I once had a patient who came in with a request for a very specific lab test. When he came back for the answer, I asked him what else he wished. He thought awhile, and then said he'd have to do some more considering as to what else he might need. Since there were no insurance forms to transfer financial responsibility, I thought I'd let him play his diagnostic game.

Sure enough, about a week later, he returned and wanted an electrocardiogram. I obtained it, interpreted it, and gave him a copy of the tracing and report. He thanked me, shook his head as I asked what else he would like. Again he wasn't sure and said he'd be back.

About a week later, he returned and wanted a chest x-ray. Since this again was reasonable, and no costs would be shifted to any insurance company, I ordered a CXR and he went off to obtain it. He returned in an hour with the CXR in hand and I interpreted it for him in detail. On his next visit, I gave him a copy of the official interpretation that was stamped with a credit card type of roller imprint saying, "No Active Disease."

This went on for several months and when he ran out of tests to request, I asked him if I could help. He then stated for the first time he had this tightness in his chest at times and he was worried about having a coronary or lung cancer. Neither are possible at age 19.

I then did a pulmonary function test and diagnosed asthma. He responded well to an albuterol inhaler. I never saw him again.

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Medical Gluttony thrives in Government and Health Insurance Programs.

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

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6. Medical Myths: Medical care costs too much because private corporations make a profit.

In his address to Congress on health care reform, Barack Obama cited Alabama as a state in which almost 90% of health insurance is controlled by one company. "[A]n additional step we can take to keep insurance companies honest is by making a not-for-profit public option available in the insurance exchanges."

The "People Before Profits" slogan also reflects the belief that it is not only inefficient and costly, but morally wrong to make a profit from providing health insurance or medical care. (Also see Myth 22.)

A reality check on health insurers and profit:

§ By far, the dominant players in the health insurance market are nonprofits, especially Blue Cross and Blue Shield. The largest insurer in virtually every state is a nonprofit (John Lott, FOXNews.com 9/16/09).

§ About 55% of insured employees receive coverage through their employer's "self-insured" plan. For Alabama, the correct percentage insured by one company is 36%, not 90%, when the employees of self-insured companies are in the denominator.

§ Getting rid of profits would not reduce costs, Lott writes. Costs would go up because without profits there would not be the same incentives to hold them down. Profits are the reward for figuring out what consumers want. "Profit maximization combined with competition is the only reliable way we know to keep costs down," states Baylor economics professor Earl Grinols (ibid.). . .

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Medical Myths originate when someone else pays the medical bills.

Myths disappear when Patients pay Appropriate Deductibles and Co-payments on Every Service.

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7. Overheard in the Medical Staff Lounge: The Salvos against Socialized Medicine

Dr. Dave: We got our first salvo against ObamaCare socialized medicine.

Dr. Edwards: And it won't be our last.

Dr. Sam: There's going to have to be a lot of salvos before socialized medicine is dead for another generation of Americans.

Dr. Milton: Wouldn't it be great if we could kill it forever?

Dr. Rosen: But our forefathers predicted: We have given you freedom if you are able to keep it.

Dr. Edwards: I guess they knew the forces of evil would always be around.

Dr. Sam: Always waiting to rear their ugly heads.

Dr. Dave: Just like any viper.

Dr. Rosen: It's hard for any civilization to fully inform their next generation. It takes hard-nosed instruction and education.

Dr. Edwards: It's hard for the youth of today to appreciate what we and our forebears experienced. And it will be difficult for us to try to make it so they don't have to experience socialism's failures.

Dr. Rosen: Wasn't it amazing to read in the memoir's of President Reagan how he single-handedly transformed not only our country but the world?

Dr. Edwards: Even Margaret Thatcher couldn't initially believe Reagan when he confronted Russia on its evil intention.

Dr. Rosen: Nor could she initially believe his transformation of world politics from mutual destruction to mutual defense against missiles.

Dr. Edwards: The socialist in this country couldn't believe the Star Wars initiative either. Remember Ted Kennedy even called his counter part in Soviet Russia for guidance on how to handle our president who seemed to him to be "out of control."

Dr. Rosen: The Wall Street Journal commented in their Eulogy of Ted Kennedy that on the most important initiative of his life, "He got it all wrong."

Dr. Milton: But even then the Socialists didn't believe that their favorite Socialistic senator got it all wrong. It's just that Reagan lucked out not understanding the real issues.

Dr. Edwards: But it was only Reagan who understood the real issues and he got it right.

Dr. Dave: Oh, if we just had another candidate like Reagan on the horizon.

Dr. Edwards: I think we have several sprouting their wings. It will be interesting to see what the next two years will bring.

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The Staff Lounge Is Where Unfiltered Opinions Are Heard.

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8. Voices of Medicine: A Review of Articles Written by Physicians

There is More to the Story of The Tucson Shootings

by Jane Orient, MD, JAPS, Jan 11, 2011

A Tucson, Arizona Physician's Commentary

Tucsonans are grieved by the loss of family, friends, and neighbors, and shaken by the reminder of mortality. Standing in line to greet their congresswoman, or just going to the grocery store, they could be killed by a malcontent. They are not immune from the violence that is rampant in the world, bringing sudden death from bombs, incendiary devices, missiles, gunfire, or other means.

If the incident involves a gun, it will of course be used as another crisis to justify limiting Americans' right to self defense or free speech. Those who seek to disarm or gag Americans could try to recruit provocateurs to incite violence and trigger a government reaction. Or they could just wait for an incident.

Two of Tucson's victims were important public officials: a congresswoman and a judge. Many people know them and will immediately feel the effects of their loss, so unsurprisingly the press will focus attention on them. But the most truly newsworthy features of the story are what did not happen here.

There was no riot. There were, to be sure, some 20 victims and 6 deaths, but not dozens. No one bled to death while people cowered and waited for a SWAT team from the sky. The agony did not go on for hours or days, but was ended quickly.

Aside from the names of the fallen, the names that should be remembered are those of the citizens who acted as Americans should, to protect and help themselves and their neighbors in the event of danger. Roger Salzgeber and 74-year-old retired Army National Guard Colonel Bill Badger, who was slightly injured, tackled the shooter. Joe Zamudio helped pin him to the ground. A 61-year old woman, Patricia Maisch, grabbed the magazine the shooter had dropped while trying to reload, and then knelt on his ankles. Daniel Hernandez, Jr., rushed to the side of his new boss, Congresswoman Giffords, applying pressure to her wound, and keeping her from choking on her own blood. Let us commend and thank all of them, and resolve to act as they did if we are ever in such a situation. Let us remember their names, and black out the shooter's.

Zamudio told MSNBC that he sprinted from a store toward the scene when he heard the shots. He has a concealed carry permit, and had his hand on his pistol, prepared to down the shooter if necessary. He said he was very glad that it proved to be unnecessary.

The actual shooting was over quickly, but the artillery of blame seems to be just beginning. Targets include the Tea Party, which didn't even exist when the shooter first became angry at Congresswoman Giffords; the "right wing," though Tucson is actually a very liberal town, and the shooter apparently a leftist; "vitriol," which to some means any criticism of the policies they prefer, disregarding the nastiness from their own side; and of course talk radio. . .

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VOM Is an Insider's View of What Doctors are Thinking, Saying and Writing about

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9. Book Review: How Political Correctness is Corrupting Medicine

PC, MD - How Political Correctness is Corrupting Medicine by Sally Satel, MD,
Basic Books, New York, 82000, x & 285 pp, $27, ISBN: 0-465-07182-1

Review by Del Meyer, MD

What makes us sick? According to Dr Satel, a practicing psychiatrist and lecturer at Yale University School of Medicine, more often than ever social activists, scholars and even health professionals are telling us that the culture of medicine is to blame for many illnesses. They are not talking about health insurance woes, fifteen-minute office visits or medical mistakes, but something more sinister. The New England Journal of Medicine claims that white men get the best treatment for heart disease. Discrimination is a cause of differences in health between blacks and whites. Women's health advocates assert that the patriarchal medical establishment has kept women from participating as research subjects, depriving them of the benefits of medical breakthroughs. (Women actually comprise 62% of the six million participants in NIH-funded research.) Former psychiatric patients, calling themselves "consumer-survivors," condemn the health care system for violating their human rights. They are on a crusade to "limit the powers of psychiatry by making consumers full partners in diagnosis and treatment."

Brown University's Sally Zierler says, "The practice of public health is the process of redesigning society." On the assumption that social conditions are the primary reason for ill health, she and her colleagues urge the redistribution of wealth to ensure the even distribution of health. Sally Satel agrees that the relationship between health and social status is not a trivial one, but taking responsibility for one's own health is now virtually ignored. After all, if AIDS is a "biological expression of inequality," as Sally Zierler has put it, we can't hold people accountable if they place themselves at risk for contracting HIV. We must understand that using a condom is hardly a priority for those who are "seeking sanctuary from racial hatred through sexual connection," as Zierler claims. Doctors like Sally Satel who expect their addicted patients to stop using drugs and to start using condoms--and if all else fails, to use clean needles--are accused of blaming the victim.

PC medicine puts ideology before patients. But it is critical to understand that injecting social justice into the mission of medicine diverts attention and resources from the efforts to find ways of making everyone better off, regardless of race or sex. Satel calls these activist "indoctrinologists" since their prescription for cure is ideology and social reform. Their chief pathogens are capitalism, meritocracy, and even the scientific method. PC medicine has flourished because too few people have been paying attention. The preoccupation of the nation with headline-grabbing subjects such as HMOs, Medicare and uninsured Americans--all pressing issues indeed--has allowed the indoctrinologists to swoop in under the radar and thus gain momentum. in the medical schools, post-graduate programs, editorial boards of prestigious medical journals, directors of academic and professional societies, and their editors.

Satel describes how in South Carolina where a viable fetus is considered a person, child abuse could occur if crack-addicted women had succeeded in their crusade for freedom to use cocaine even during the third trimester of pregnancy. This is not unlike David Horowitz pointing out that gay people, who were responsible for 95% of the AIDS in the 1980s, maintained that testing their blood for HIV violated their civil rights to donate blood. This introduced HIV into the heterosexual drug using and hospitalized blood requiring communities such as hemophiliacs and cardiac surgery patients, of which Paul Gann in our community was one.

As Sally Satel says, the PC prescriptions will be hazardous to our health.

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The Book Review Section Is an Insider's View of What Doctors are Reading about.

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10. Hippocrates & His Kin: Medical Opinions from the real world

A martini and a cigar a day keeps the doctor away.

Regarding Stanton Peele's "A Toast to Your Health" (op-ed, Feb. 2) on the Agriculture Department's recent dietary guidelines suggesting that moderate alcohol consumption may have beneficial effects: I suffered a mild heart attack in 1994. During my recovery, my cardiologist interviewed me to discover any possible cause for the attack. When I related that I had stopped drinking but I smoke a cigar every day, he encouraged me to resume moderate drinking and continue with the cigar. I welcomed his suggestions but questioned the wisdom of such.

He replied that the stress relief from these recommendations far outweighed the benefit of doing without them.

John J. McCormack, Titusville, N.J. - Letter to the Editor, WSJ

Yes, Taking a Martini A Day Could Help Keep Ill Health Away - WSJ

Do Physician Assistants have the training, experience and maturity of judgment of MDs?

Dr. Jim Bowman's assertion that physician assistants and nurse practitioners can perform "many" of the duties of family physicians equally well sounds like the folly of a specialist who does not know what the practice of primary medical care entails (Letters, Jan. 25). I practiced and taught family medicine for 10 years and have been a plaintiff's malpractice attorney for 20 more. The most foolish mistake we have made is to delude ourselves that these nonphysicians (with six years of post high-school education) are even close to the level of family physicians (11 to 12 years of post high-school education). I have sadly watched these nonphysicians take over and lower the level of primary-care medicine.

The most important step this country can take to improve medical care is to close most PA schools and replace them with medical schools that offer incentives to medical graduates to train and work in family practice or other primary fields of medicine.

James Brown, M.D., J.D. , Omaha, Neb. - Letter to the Editor, WSJ

Train More M.D.s, Not NPs and PAs - WSJ

Submitted by a doctor who just got off the phone with a friend of his who lives in Minnesota.

He said that since early this morning the snow has been nearly waist high and is still falling. The temperature is dropping below zero and the north wind is increasing. His wife has done nothing but look through the kitchen window all day. He says that if it gets much worse, he may have to let her in.

Can you believe those cold Minnesota winters? Pets and wives inside?

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Hippocrates and His Kin / Hippocrates Modern Colleagues
The Challenges of Yesteryear, Today & Tomorrow

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

• The National Center for Policy Analysis, John C Goodman, PhD, President, who along with Gerald L. Musgrave, and Devon M. Herrick wrote Lives at Risk, issues a weekly Health Policy Digest, a health summary of the full NCPA daily report. You may log on at www.ncpa.org and register to receive one or more of these reports. This month, read the informative: The rising cost forecast for Medicaid in the coming years has some Texas legislators questioning whether their state would be better off opting out of the system entirely.

• 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 signup to receive their newsletters via email by clicking on the email tab or directly access their health care blog. In an op-ed in the Wall Street Journal, Indiana governor Mitch Daniels offers up a dilemma to U.S. Secretary of Health & Human Services Kathleen Sebelius: If she wants his co-operation (and that of 20 other governors), she'll need to twist and turn Obamacare inside out to get it.

• The Mercatus Center at George Mason University (www.mercatus.org) is a strong advocate for accountability in government. Maurice McTigue, QSO, a Distinguished Visiting Scholar, a former member of Parliament and cabinet minister in New Zealand, is now director of the Mercatus Center's Government Accountability Project. Join the Mercatus Center for Excellence in Government. This month, treat yourself to an article: The Poor Getting Poorer is a Myth. The bottom fifth of households in 1975 earned $28,000 more in 1991.

Top of Form

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• 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. 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.

• 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 study of purchasers of Health Savings Accounts shows that the new health care financing arrangements are appealing to those who previously were shut out of the insurance market, to families, to older Americans, and to workers of all income levels. This month, you might focus on Florida Decision on ObamaCare is Likely to Accelerate Higher Court Rulings.

• Greg Scandlen, an expert in Health Savings Accounts (HSAs), has embarked on a new mission: Consumers for Health Care Choices (CHCC). Read the initial series of his newsletter, Consumers Power Reports. Become a member of CHCC, The voice of the health care consumer. Be sure to read Prescription for change: Employers, insurers, providers, and the government have all taken their turn at trying to fix American Health Care. Now it's the Consumers turn. Greg has joined the Heartland Institute, where current newsletters can be found.

• The Heartland Institute, www.heartland.org, Joseph Bast, President, publishes the Health Care News and the Heartlander. You may sign up for their health care email newsletter. Read the late Conrad F Meier on What is Free-Market Health Care?. This month, be sure to read The February issue of Health Care News reports on federal Judge Henry Hudson's ruling that the individual mandate in President Barack Obama's health care law is unconstitutional. In Commonwealth of Virginia v. Kathleen Sebelius, one of several state cases against the health care law, Hudson determined the mandate "exceeds the constitutional boundaries of congressional power."

• The Foundation for Economic Education, www.fee.org, has been publishing The Freeman - Ideas On Liberty, Freedom's Magazine, for over 50 years, with Lawrence W Reed, 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. Be sure to read the current lesson on Economic Education: Ideas versus Interests.

• The Council for Affordable Health Insurance, www.cahi.org/index.asp, founded by Greg Scandlen in 1991, where he served as CEO for five years, is an association of insurance companies, actuarial firms, legislative consultants, physicians and insurance agents. Their mission is to develop and promote free-market solutions to America's health-care challenges by enabling a robust and competitive health insurance market that will achieve and maintain access to affordable, high-quality health care for all Americans. "The belief that more medical care means better medical care is deeply entrenched . . . Our study suggests that perhaps a third of medical spending is now devoted to services that don't appear to improve health or the quality of care–and may even make things worse."

• The Independence Institute, www.i2i.org, is a free-market think-tank in Golden, Colorado, that has a Health Care Policy Center, with Linda Gorman as Director. Be sure to sign up for the monthly Health Care Policy Center Newsletter. Read the latest: What in the Constitution Gives Authority to Congress to Spend Our Money? part 1.

• 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 about The unfortunate recent shooting in Arizona has revived the gun law debate. While we feel for the friends and families of the victims, and many people think bans are the right thing to do, they simply do not produce the desired effects.

• 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.

• The Heritage Foundation, www.heritage.org/, founded in 1973, is a research and educational institute whose mission was 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. -- However, since they supported the socialistic health plan instituted by Mitt Romney in Massachusetts, which is replaying the Medicare excessive increases in its first two years, and was used by some as a justification for the Obama plan, they have lost sight of their mission and we will no longer feature them as a freedom loving institution and have canceled our contributions. We would also caution that should Mitt Romney ever run for National office again, he would be dangerous in the cause of freedom in health care. The WSJ paints him as being to the left of Barrack Hussein Obama. We would also advise Steve Forbes to disassociate himself from this institution.

• The Ludwig von Mises Institute, Lew Rockwell, President, is a rich source of free-market materials, probably the best daily course in economics we've seen. If you read these essays on a daily basis, it would probably be equivalent to taking Economics 11 and 51 in college. Please log on at www.mises.org to obtain the foundation's daily reports. You may also log on to Lew's premier free-market site to read some of his lectures to medical groups. Learn how state medicine subsidizes illness or to find out why anyone would want to be an MD today.

• 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, articles and books at www.cato.org/people/cannon.html.

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

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

• The St. Croix Review, a bimonthly journal of ideas, recognizes that the world is very dangerous. Conservatives are staunch defenders of the homeland. But as Russell Kirk believed, wartime allows the federal government 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 17^th 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 Brian T. Kennedy, President, The Claremont Institute: It's Never Just the Economy, Stupid at www.hillsdale.edu/news/imprimis.asp. The last ten years of Imprimis are archived.

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Words of Wisdom

"You may believe that you are responsible for what you do, but not for what you think. The truth is that you are responsible for what you think, because it is only at this level that you can exercise choice. What you do comes from what you think." - Quote from A Course in Miracles

"Ask yourself 'Where can I win?'" - Stephen Pierce: Internet marketer and author

"When it comes to eating right and exercising, there is no 'I'll start tomorrow.' Tomorrow is disease." - Terri Guillemets: Quote anthologist

Some Recent Postings

MedicalTuesday In The Last Issue:

1.Featured Article: How the new sciences of human nature can help make sense of a life.

2.In the News: Nice Call There Bamo by BILL WADDELL

3.International Medicine: Our health care delusion

4.Medicare: Repeal and Replace: 10 Necessary Changes

5.Medical Gluttony: Emergency Room Visits for Non Emergent Medical Problems

6.Medical Myths: The health care reform will improve health care in the US

7.Overheard in the Medical Staff Lounge: The repeal of ObamaCare

8.Voices of Medicine: Fulfilling Our Duty as Muslim-Americans

9.The Bookshelf: The Slippery Slope From Assisted Suicide to Legalized Murder

10.Hippocrates & His Kin: Doctor's scales can make you cry

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

Subscribe to MedicalTuesday Newsletter: www.medicaltuesday.net/Newsletter.asp

October HPUSA Newsletter: www.HealthPlanUSA.net

1. Featured Article: The Forgotten Man of Socialized Medicine

2. In the News: Discontinuing Failed Drug Research is Expensive

3. International Healthcare: The Stockholm Network

4. Government Healthcare: A Growth Agenda for the New Congress

5. Lean HealthCare: Healthcare is going ‘lean'

6. Misdirection in Healthcare: What Motivated ObamaCare?

7. Overheard on Capital Hill: Benign Dictatorship and the Progressive Mind.

8. Innovations in Healthcare: Health Plan from the National Center for Policy Analysis

9. The Health Plan for the USA: How technology reduces health care costs

10. Restoring Accountability in Medical Practice by Moving from a Vertical to a Horizontal Industry:

Subscribe to the HPUSA Newsletter: www.healthplanusa.net/newsletter.asp

In Memoriam

Sargent Shriver's passing

The Economist | Jan 20th 2011 | from PRINT EDITION

Civility, altruism, public service, all publicly pined for since the Tucson shootings, seemed summed up in Sargent Shriver, who died on January 18th. In a world split between heavily armed East and West, Mr Shriver's Peace Corps, set up in 1961 under his direction, sent students abroad to foster friendship and be useful. In America itself, riven by race and Vietnam, he led programmes - Head Start, VISTA, Community Action - that looked beyond colour and ideology to improve the lives and chances of ordinary people. And not least, Mr Shriver regularly put his own ambitions aside to help his thrusting in-laws, the Kennedys, grab and hold on to power. Too idealistic for the political rat-run, perhaps; too naive to be president, even if he had wanted it and voters had wanted him; just too darn nice, it seems, ever to have flourished in the present climate. But by no means ineffective, for all that.

On This Date in History - February 8

On this date in 1915, in Los Angeles, was the world premier of the motion picture, The Birth of a Nation. It was like no picture ever made before, using camera and editing techniques that revolutionized the whole business of picture making.

On this date in 1828, fact caught up with fiction with the birth of Jules Verne, king of science fiction in his time. He practically invented the form. He wrote about ships that traveled in the depths of the sea, voyages to the moon and to the center of the earth and other fantasies - some of which have turned out to be fact.

After Leonard and Thelma Spinrad

Thank you for joining the MedicalTuesday.Network and Have Your Friends Do the Same. If you receive this as an invitation, please go to www.medicaltuesday.net/Newsletter.asp, enter you email address and join the 10,000 members who receive this newsletter. If you are one of the 80,000 guests that surf our web sites, we thank you and invite you to join the email network on a regular basis by subscribing at the website above. To subscribe to our companion publication concerning health plans and our pending national challenges, please go to www.healthplanusa.net/newsletter.asp and enter your email address. Then go to the archives to scan the last several important HPUSA newsletters and current issues in healthcare.

Please note that sections 1-4, 6, 8-9 are entirely attributable quotes and editorial comments are in brackets. Permission to reprint portions has been requested and may be pending with the understanding that the reader is referred back to the author's original site. We respect copyright as exemplified by George Helprin who is the author, most recently, of "Digital Barbarism," just published by HarperCollins. We hope our highlighting articles leads to greater exposure of their work and brings more viewers to their page. Please also note: Articles that appear in MedicalTuesday may not reflect the opinion of the editorial staff.

ALSO NOTE: MedicalTuesday receives no government, foundation, or private funds. The entire cost of the website URLs, website posting, distribution, managing editor, email editor, and the research and writing is solely paid for and donated by the Founding Editor, while continuing his Pulmonary Practice, as a service to his patients, his profession, and in the public interest for his country.

Spammator Note: MedicalTuesday uses many standard medical terms considered forbidden by many spammators. We are not always able to avoid appropriate medical terminology in the abbreviated edition sent by e-newsletter. (The Web Edition is always complete.) As readers use new spammators with an increasing rejection rate, we are not always able to navigate around these palace guards. If you miss some editions of MedicalTuesday, you may want to check your spammator settings and make appropriate adjustments. To assure uninterrupted delivery, subscribe directly from the website rather than personal communication: www.medicaltuesday.net/newsletter.asp. Also subscribe to our companion newsletter concerning current and future health care plans: www.healthplanusa.net/newsletter.asp

Del Meyer

Del Meyer, MD, Editor & Founder

DelMeyer@MedicalTuesday.net

www.MedicalTuesday.net

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Always remember that Chancellor Otto von Bismarck, the father of socialized medicine in Germany, recognized in 1861 that a government gained loyalty by making its citizens dependent on the state by social insurance. Thus socialized medicine, or any single payer initiative, was born for the benefit of the state and of a contemptuous disregard for people's welfare.

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Community For Better Health Care	Vol IX, No 21, Feb 8, 2011