MEDICAL TUESDAY . NET
Community For Better Health Care
Vol V, No 21, Feb 13, 2007
In This Issue:
The Annual World Health Care Congress, co-sponsored by The Wall Street Journal, is the most prestigious meeting of chief and senior executives from all sectors of health care. Renowned authorities and practitioners assemble to present recent results and to develop innovative strategies that foster the creation of a cost-effective and accountable U.S. health-care system. The extraordinary conference agenda includes compelling keynote panel discussions, authoritative industry speakers, international best practices, and recently released case-study data. The 3rd annual conference was held April 17-19, 2006, in Washington, D.C. One of the regular attendees told me that the first Congress was approximately 90 percent pro-government medicine. This year it was 50 percent, indicating open forums such as these are critically important. The 4th Annual World Health Congress has been scheduled for April 22-24, 2007, also in Washington, D.C. The World Health Care Congress - Asia will be held in Singapore on May 21-23, 2007. The World Health Care Congress - Middle East will be held in Dubai, United Arab Emirates, on November 12-14, 2007. World Health Care Congress - Europe 2007 will meet in Barcelona on March 26-28, 2007. For more information, visit www.worldcongress.com.
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As a connoisseur of strategy -- student, practitioner (in business) and teacher -- I have long been intrigued with the relationship between strategic principles applied to nations and strategies pursued by businesses. Strategy had its origin in military use, but over time it migrated into the business setting. The linkage is still there: Most contemporary business students, for example, will have read Sun Tzu's "Art of War" in their Business Strategy course. But it is a different relationship that preoccupies me.
Just as medical research tests biological processes in large populations of fruit flies or rodents before human application, I am intrigued by the prospect of applying -- to nations -- the strategic practices that have been formulated and evaluated in the "laboratory" of the world's businesses. As in medical applications, we must be careful in extrapolating from one to the other. Nevertheless, I believe there are benefits to such comparative analysis.
The first question that needs to be examined is this: If business's task is to generate revenue and profits for its owners, what is the equivalent task for a nation and its government? The principal measure is the Gross Domestic Product of the country. Changes in this number are commonly used yardsticks of economic health. Moreover, when one compares two national economies, say the economies of the U.S. and China, the first measure we use in this comparison is GDP. But when we talk of GDP, we must consider not just the GDP of today, but the long-term stability of the productive capacity of our economy. This is how factors like national security enter into the objectives of a government.
What about governance? Corporations are run by senior management, with power concentrated in the hands of the chief executive. The equivalent to this in our country is the institution of the executive branch headed by the president. It is important to stress that even as individual presidents come and go, we expect the institution to be durable, with a view and a constancy of purpose that is appropriately long-range.
A successful business strategist must understand cognitively and instinctively the structure of the industry in which the business operates, and must know that as the structure changes, so must the winning strategy. By way of historical example, IBM, a huge, vertically integrated company, dominated the computer industry before the advent of the personal computer. All computer companies had to be cognizant of IBM's influence on the entire industry, and had to construct strategies which allowed them to prosper in coexistence with this monolith. The arrival of the personal computer changed all this. New rules replaced old ones governing vertical integration, development of standards, and many other factors.
After the Cold War, a similar change took place in the world of nations. Monolithic and vertically integrated military powers gave way to numerous sources of power, each following independent strategies, sometimes in partnership, sometimes embroiled in friction. That changed the rules governing international relations. If national strategy in the days of the Cold War was dominated by the presence and size of nuclear weapons capabilities, what are the critical dominant factors today, when these weapons are increasingly widespread? What takes their place? Religious beliefs? Historical relationships or enmities? How does one set strategies when these factors are unknown? As in the case of the computer industry, it takes many years to figure out how the new rules work. . .
In a well-publicized study of a large number of corporations, Jim Collins has found that longevity of success in the marketplace is associated with a certain leadership style. I was particularly impressed by the finding that successful leaders are able to face what Mr. Collins calls the "brutal facts" of the competitive positions of their companies. As I observe our political leaders today, I have a hard time finding many examples of a willingness to do this. In fact, I find an alarming tendency to skirt the critical issues by not even pronouncing the words that describe them, rendering them "non-words." Examples: Who among our national leaders spells out that the likely consequence of the heightened global competition is to suppress domestic wage rates? Or addresses the need to allocate the increasingly complex and expensive medical procedures being developed today? Or admits that our emergency medical system is heading toward catastrophe as it becomes the last-resort access to medical care for the growing millions of uninsured? Non-words lead to non-solutions, in energy dependence and in other key issues.
Our nation's corporations have been under severe criticism for a variety of shortcomings. Even so, the capitalist/free-market system of corporations consistently produces results. When corporations do not produce, they become irrelevant and often perish. In other words, if the brutal facts are not faced by the leaders, the brutal reality sets in. By contrast, our national strategy-setting and -execution machinery often seem broken. Consider this: Could we pull off the Manhattan Project today? With its complexities of planning and execution, under extreme time pressure? I doubt it.
Fruit flies can teach us how to cure diseases in human beings. Why not study how businesses set strategies and execute them, and adopt the best methods to address the overwhelmingly important issues facing our society?
Mr. Grove is retired chairman of Intel Corp.
To read the entire article, please go to (subscription required) http://online.wsj.com/article_print/SB116942729333183265.html.
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A host of new products are arriving in stores and online to help people "exercise" their brains. But what are you getting for your time and money?
At least a dozen companies are promoting software, Web sites and gizmos that promise a daily dose of mental stimulation. The products are the vanguard of what scientists expect will be a flood of tools for a ready market: baby boomers who are anxious to stave off Alzheimer's disease and related ills.
The thinking -- and advertising -- behind most of the products is simple: If 30 minutes on the treadmill each day is good for your body, 30 minutes (or so) of playing computer games and similar activities must be good for your noodle.
Scientists don't universally accept the use-it-or-lose-it mantra. Some say there's little evidence that engaging in mentally stimulating activities actually slows mental aging. Other researchers argue that training can improve mental performance -- meaning mental exercise can help your brain function at a higher level than it would otherwise.
For the moment, definitive answers to the question -- Will brain exercise help me? -- will have to wait for additional testing. That said, if you wish to hedge your bets, as many consumers are doing, what follows is a look at a half-dozen of the most widely available "workouts."
We asked a panel of nine experts, who deal with brain-aging issues in different ways as part of their day jobs, to try these tools at home and in the office. How do they work? What science, if any, is involved? And are these products more about "fun" than about health?
The answers indicate that no one has cornered the market on a tool that's scientifically proven, easy to use -- and entertaining. What is clear, the panel notes, is that the 50-plus crowd is already thinking about mental health and how best to maintain it.
"Boomers are looking at this remarkably increased longevity and, for the first time, are very seriously wondering: Are their minds going to keep up with their bodies?" says Gene Cohen, director of George Washington University's Center on Aging, Health and Humanities in Washington, D.C.
To read about these products, please go to
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3. International Medicine: UK's Continuing Struggles with the NHS
If 2006 was the "best year ever" for the NHS, according to Patricia Hewitt a statement that made millions of us wonder if we inhabited the same universe, let alone planet, as the Health Secretary then the start of 2007 hints at this being one of the grimmest.
A week into the new year and hospitals are being told to delay surgery for as long as possible to ease budget problems; a leaked government report is predicting 37,000 health service jobs will be lost as hospitals battle to manage deficits, while also warning of a drastic shortage of doctors and nurses by 2010.
Health unions are already muttering about industrial action. And another report, from the Right-wing think tank Reform, claims that despite record levels of investment since 1997, quality of service is poorer than it was two years ago.
There is a growing sense that the NHS is beyond help, that no political party is prepared to introduce the reforms necessary to make it work, yet neither politicians nor civil servants can manage it in its existing state. Well, one of Britain's leading businessmen, Gerry Robinson, disagrees.
Sir Gerry, the former chairman of Granada, Allied Domecq, and the Arts Council, management guru and New Labour donor, conducted his own six-month investigation into the problems involved in running the NHS. He set himself the task of reducing waiting lists at a Yorkshire hospital and the results are revealed in Can Gerry Robinson Fix the NHS?, which begins on Monday on BBC2.
It was, says Sir Gerry, a fascinating, frustrating and ultimately fulfilling exercise that Ms Hewitt and her team should take note of.
He discovered the NHS to be riddled with practices that, in his words, "defied belief", and his solutions which range from finding a "million-dollar" man or woman to run it, to banning hospital car-parking charges are rooted in the common sense and good business practice that seem to have escaped the thousands of management consultants employed at great cost by the Department of Health to advise it.
Sir Gerry, 59, who lives with wife, Heather, and two children in a beautiful Georgian house in County Donegal, exudes warmth and good humour, [sic] but there is no doubt that this is allied to a fierce sense of discipline and resolve that forms the core of his management technique.
Yet one of the first lessons Sir Gerry learnt when he began his experiment at Rotherham General Hospital early last year was that a combination of charm and his reputation as a manager par excellence had absolutely no impact on surgeons, who, frankly, weren't that keen to work on a Friday afternoon.
"Without a doubt," he says now, leaning back in a plump leather chair in his study and smiling incredulously at the memory, "the biggest single surprise for me was seeing how under-utilised [sic] the operating theatres were. Theatres are the engine rooms of a hospital most procedures have some connection to them. Orthopaedic work, ophthalmic, routine stuff, elective stuff it all goes through theatre.
I thought they'd be packed and that this was the reason there was a problem with waiting lists. But it really wasn't like that. The theatres simply weren't being managed in any way that I would recognise as being appropriate for an important and expensive resource.
"There was a schedule worked out, and kept to, by and large. But if somebody cancelled an operation, no one used that slot for something else. And then there were Fridays the operating theatres were empty on a Friday afternoon."
Sir Gerry was assured by Rotheram's chief executive, Brian James, that this was acceptable, that the doctors worked their full complement of hours, but that they preferred not to operate when only weekend cover would be available as back-up after operations. There was, he says, also a sense of "this is the way we always do it here we don't need to operate then".
"I said 'Hang on' " Sir Gerry still sounds as shocked now as he did on camera confronting Mr James " 'What do you mean we don't need it?' If you have waiting lists, surely the best thing any hospital can do is to utilise any available time and space to bring those numbers down.
"Not having them running on Friday afternoons was effectively cutting out 10 per cent of the hospital's work time. Not only was it wasteful in itself, but as the NHS system now means that money follows a patient so the trust hospital where a patient is diagnosed as needing surgery must pay for that procedure even if it is carried out elsewhere you are not earning the money you could be. It didn't make any sense." . . .
'Can Gerry Robinson Fix the NHS?' starts on BBC2 on Monday at 9pm. Here's his formula:
1. Hire a chief executive a businessman or woman with a proven track record, not a civil servant or politician to run the NHS and pay whatever it takes
2. Depoliticise theNHS; Whitehall should be left to formulate strategies, not implement it.
3. Sack all management consultants
4. End contracting out of staff
5. Improve moral listen to the staff
6. Make doctors choose between working in the NHS or in private practice
7. Cut red tape
8. Ensure every operating theatre is in use every weekday.
9. Focus on cutting waiting lists.
10. Ban penny pinching; car park charges, vending cards for bedside telephones and TVs, etc.
Signed: Sr Gerry, Jan 6, 2007
If you'll forgive a little nepotism, here is another view point of how Europe must also change.
A novel approach to ensure Europe prospers, By Julie Meyer, Financial Times, January 16, 2007
On my way to learn Spanish, almost a decade ago, I picked up Atlas Shrugged by Ayn Rand in Barcelona airport. I read the first sentence - "Who is John Galt?" - and hardly put down the 1,100-page book till I read the last. I missed the opening day of my courses, read through the night, missed dinner and slept in my clothes. Nothing has affected me more than that book (unlike Charles Pretzlik's critical view of it on this page on January 6/7). . .
In 2007, the 50th anniversary of Atlas Shrugged, you may well be asked: "Who is John Galt?" The answer is to get the book and read it. Let me know if you find him. I have been looking for him all my life.
The writer is chief executive of Ariadne Capital, a London-based investment and advisory firm. She is the co-founder of First Tuesday, an international network of entrepreneurs.
The NHS does not give timely access to healthcare, it only gives access to a waiting list.
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Health Care in Three Acts By Eric Cohen and Yuval Levin, February 2007
Americans say they are very worried about health care: on generic lists of voter
concerns, health issues regularly rank just behind terrorism and the Iraq war.
And politicians are eager to do something about it. To empower consumers, the
White House has advanced the idea of Health Savings Accounts; to help the
uninsured, it has explored using Medicaid more creatively. Senator Edward
Kennedy of Massachusetts, the Democrats' leader on this issue, has backed
"Medicare for all." The American Medical Association has called for
tax credits to put private coverage within reach of more Americans. A number of
recent books have proposed solutions to our health-care problems ranging from
socialized medicine on the Left to laissez-faire schemes of cost containment on
the Right. In Washington and in the state capitals, pressure is building for
But what exactly are Americans worried about? Untangling that question is harder than it looks. In a 2006 poll, the Kaiser Family Foundation found that while a majority proclaimed themselves dissatisfied with both the quality and the cost of health care in general, fully 89 percent said they were satisfied with the quality of care they themselves receive. Eighty-eight percent of those with health insurance rated their coverage good or excellent - the highest approval rating since the survey began 15 years ago. A modest majority, 57 percent, were satisfied even with its cost.
Evidently, though, this widespread contentment with one's own lot coexists with concern on two other fronts. Thus, in the very same Kaiser poll, nearly 90 percent considered the number of Americans without health insurance to be a serious or critical national problem. Similarly, a majority of those with insurance of their own fear that they will lose their coverage if they change jobs, or that, "in the next few years," they will no longer be able to afford the coverage they have. At least as troubling is what the public does not seem terribly bothered about - namely, the dilemmas of end-of-life care in a rapidly aging society and the exploding costs of Medicare as the baby-boom generation hits age sixty-five.
All of this makes it difficult to speak of health care as a single coherent challenge, let alone to propose a single workable solution. In fact, America faces three fairly distinct predicaments, affecting three fairly distinct portions of the population - the poor, the middle class, and the elderly - and each of them calls for a distinct approach.
For the poor, the problem is affording coverage. Forty-six million
Americans were uninsured in 2005, according to the Census Bureau. This is about
15.9 percent of the population, which has been the general range now for more
than a decade, peaking at 16.3 percent in 1998.
But that stark figure fails to convey the shifting face and varied make-up of the uninsured. On average, a family that loses its coverage will become insured again in about five months, and only one-sixth of the uninsured lack coverage for two years or more. In addition, about a fifth of the uninsured are not American citizens, and therefore could not readily benefit from most proposed reforms. Roughly a third of the uninsured are eligible for public-assistance programs (especially Medicaid) but have not signed up, while another fifth (many of them young adults, under thirty-five) earn more than $50,000 a year but choose not to buy coverage.
It is also crucial to distinguish between a lack of insurance coverage and a lack of health care. American hospitals cannot refuse patients in need who are without insurance; roughly $100 billion is spent annually on care for such patients, above and beyond state and federal spending on Medicaid. The trouble is that most of this is emergency care, which includes both acute situations that might have been prevented and minor problems that could have been treated in a doctor's office for considerably less money. The real problem of the uninsured poor, then, is not that they are going without care, but that their lack of regular and reliable coverage works greatly to the detriment of their family stability and physical well-being, and is also costly to government.
For the middle class, the problem is different: the uncertainty caused in part by the rigid link between insurance and employment and in part by the vicissitudes of health itself. America's employment-based insurance system is unique in the world, a product of historical circumstances and incremental reforms that have made health care an element of compensation for work rather than either a simple marketplace commodity or a government entitlement. This system now covers roughly 180 million Americans. It works well for the vast majority of them, but the link it creates between one's job and one's health coverage, and the peculiar economic inefficiencies it yields, result in ever-mounting costs for employers and, in an age of high job mobility, leave many families anxious about future coverage even in good times.
The old, finally, face yet another set of problems: the steep cost of increasingly advanced care (which threatens to paralyze the government) and the painful decisions that come at the limits of medicine and the end of life. Every American over sixty-five is eligible for at least some coverage by the federal Medicare program, which pays much of the cost of most hospital stays, physician visits, laboratory services, diagnostic tests, outpatient services, and, as of 2006, prescription drugs. Established in 1965, Medicare is funded in part by a flat payroll tax of 2.9 percent on nearly every American worker and, beyond that, by general federal revenue. Most recipients pay only a monthly premium that now stands at $88.50, plus co-payments on many procedures and hospital stays.
But precisely because Medicare is largely funded by a payroll tax, it suffers acutely from the problems of an aging society. In 1950, just over 8 percent of Americans were over sixty-five. Today that figure stands at nearly 15 percent, and by 2030 it is expected to reach over 20 percent, or 71 million Americans. Moreover, the oldest of the old, those above the age of eighty-five, who require the most intense and costly care, are now the fastest growing segment of the population; their number is expected to quadruple in the next half-century.
For Medicare, therefore, just as for Social Security, the number of recipients is increasing while the number of younger workers to pay the bills is declining. But Medicare faces a greater danger still. Its costs are a function not only of the number of eligible recipients but of the price of the services they use. Over the past few years, health-care spending in America has increased by about 8 percent each year, most steeply for older Americans who have the most serious health problems. As these costs continue to rise much faster than the wages on which Medicare's funding is based, the program's fiscal decline will be drastic, with commensurately drastic consequences for the federal budget.
Three different "crises," then, each of a different weight and character. The crisis of the uninsured, while surely a serious challenge, has often been overstated, especially on the Left, in an effort to promote more radical reforms than are necessary. The crisis of insured middle-class families has been misdiagnosed both by the Right, which sees it purely as a function of economic inefficiency, and by the Left, which sees it as an indictment of free-market medicine. And the crisis of Medicare has been vastly understated by everyone, in an effort to avoid taking the painful measures necessary to prevent catastrophe. In each case, a clearer understanding may help point the way to more reasonable reforms .
No less odd is the character of what we call health insurance.
Insurance usually means coverage for extreme emergencies or losses. We expect
auto insurance to kick in when our car is badly damaged in an accident, not
when we need a routine oil change; homeowner's insurance covers us after a
fire, flood, or break-in, not when we need to repair the deck or unclog the
gutters. But when it comes to health, we expect some element of virtually every
expense to be covered, including routine doctor checkups and regular care.
America's insurance system is largely a historical accident. During World War II, the federal government imposed wage controls on American employers. No longer able to raise salaries to compete for employees, companies turned instead to offering the lure of fringe benefits, and the era of employer-based health care was born. Thanks to a 1943 IRS ruling allowing an exemption for money spent by employers on health insurance, an enormous tax incentive was created as well. Rather than giving a portion of every dollar to the government, employees could get a full dollar's worth of insurance through their company. . . .
Even as we pursue practical options for reform, however, it behooves us to remember that health itself will always remain out of our ultimate control. Medicine works at the boundaries of life, and its limits remind us of our own. While our health-care system can be improved, our unease about health can never truly be quieted. And while reform will require hard decisions, solutions that would balance the books by treating the disabled and debilitated as unworthy of care are no solutions at all. In no small measure, America's future vitality and character will depend upon our ability to rise to this challenge with the right mix of creativity and sobriety.
To read the entire treatise, please go to www.commentarymagazine.com/cm/main/printArticle.aip?article=com.commentarymagazine.content.Article::10826
Government is not the solution to our problems, government is the problem.
- Ronald Reagan
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Recently a patient fell out of bed and couldn't get back into the bed. He was a little heavy and he couldn't make his legs work. He assessed his body and saw that he was able to raise both arms and legs individually and thus determined he didn't have a stroke so just lay on the carpet beside his bed and took a nap. When he awakened a couple of hours later, he got up and sat on the side of the bed. Not remembering if he took his blood pressure medications, he reached into the bedside table and took his blood pressure. He found that it was 90/50. He reasoned that he not only had taken his blood pressure medication, but may have taken an extra dose. Since it was now perfect, he retired for the night. Health care costs: Zero. Loss of sleep: none.
It just so happened that on the same day, a second patient had fallen by his bed on the way from the bath room. Even though he felt fine, he was too weak, and his wife just couldn't lift him. She called 911 and had the emergency squad come out. They checked him over, decided that he was fine, and the EMT ambulance driver placed him in his own bed for the night. Estimated cost: between $450 and $600. Loss of sleep: about an hour.
A third patient on a different day experienced a similar problem. He had gotten dizzy getting up and slid to the carpeted floor. Between his weight, weakness and dizziness, neither he nor his wife could get him into bed. She called the resuscitation squad and he was transported to the hospital. In the hospital, his blood pressure was 80/40 which explained his weakness and dizziness, and he was given several glasses of water and several cans of juice that he drank over several hours. His blood pressure increased to 90/60 during that time and he was sent home. Estimated health care costs: The ambulance charge was the same as in patient no 2 plus a $1500 emergency room charge or about $1950 to $2100. Loss of sleep: about 6 hours.
The above is a very frequent problem seen in practice. We can blame obesity or treatment for hypertension and they do share some of the blame. But the variations are primarily determined by who pays the bill. The higher the deductible, the more responsible the patient becomes. With universal government coverage, the higher the health care costs become, the more irresponsible the patient becomes and the lower is the quality of health care.
When you fall out of bed, there are alternatives depending on who pays the bill.
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At long last, both the U.S. Senate and the House of Representatives have passed a version of ethics legislation limiting payola and conflicts of interest. It is high time that those working in medical research do the same.
At stake is our national health, our confidence in both science and government, and huge amounts of public money.
Here is just one very recent example. The National Institutes of Health, the world's leader in medical research, is scheduled to hold a national conference on neonatal herpes infections. The goal of the meeting is to develop recommendations on how to manage a pregnancy in which the mother has a herpes infection. While herpes infections in pregnant women are rare, the medical community is divided on whether all pregnant women should be screened for the disease. The cost of such a screening program would be enormous, and it is unclear what impact the screening would have on the unborn baby.
Not surprisingly, at least for those of us who follow conflicts of interest in medicine, the push to screen all women is not being fought on an even scientific playing field, nor is it being moderated fairly.
GlaxoSmithKline is leading the charge for screening (guess who manufactures the drug used to prevent herpes from being passed from mother to infant) and is using some effective approaches to push its cause. The pharmaceutical industry has heavily influenced the selection of the expert speakers and panel members at the NIH herpes meeting.
Of the five "experts" who have been asked to speak on neonatal herpes transmission, four received substantial gifts or funding from Glaxo. The drug company is also paying for classes to "teach" doctors the importance of testing for herpes.
As health-care costs increase, doctors all over America are being asked to follow scientifically based practice guidelines intended to improve the quality of medical care. These guidelines are the result of experts distilling scientific evidence into specific suggestions on how physicians should manage diseases.
Recently, we've discovered that many of these guidelines are heavily corrupted by industry influence -- to the point at which patients have been injured and colossal amounts of money wasted on drugs and procedures that just don't work.
The marketing power of drug companies is astoundingly effective at persuading physicians to follow expensive medical practices, which maximize company profits but often turn out worse health outcomes than cheaper alternatives.
How can insurers and hospitals insist doctors follow practice guidelines when the guidelines, even those from our own government, are not scientific and unbiased?
By no means is the herpes conference an isolated case or an administrative oversight. For example, nine of the 11 physicians on the NIH committee developing guidelines on the control of high blood pressure had industry ties to manufacturers of medicines for high blood pressure. The same was true for cholesterol-reduction guidelines. The NIH recommendations on treating high cholesterol were written by a committee on which eight out of nine doctors had ties to the companies that make cholesterol-lowering drugs. . .
The solution is simple: No one with a conflict of interest should serve on NIH expert panels. I'd even go one step further and say that no one with a financial conflict of interest should be working at the NIH.
I recently testified at a House hearing at which a top Food and Drug Administration expert claimed he just couldn't find experts with no industry ties. This is hogwash and only reflects where government officials are looking for their "experts." If you're looking for guards to protect the henhouse and you look only for candidates in fox holes, I guess you'll only find foxes.
Medical Practice Guidelines may be the most prejudicial way to treat a suffering patient.
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Dr. Edwards: How long do you think it took for Governor Schwarzenegger to be become corrupt?
Dr. Yancy: When he thought he could have a special election to implement logical reform.
Dr. Edwards: Wasn't that about half way into his first term?
Dr. Rosen: Is about a half-term the usual time for a politician to lose all his principles?
Dr. Edwards: How many days did it take President Clinton to place his wife Hillary in charge of socializing health care?
Dr. Milton: How long do you think it will take Hillary to become corrupt if she gets elected?
Dr.Yancy: Since she's already corrupt, in her case it preceded election.
Dr. Edwards: Why do you think politicians corrupt so easily?
Dr. Rosen: Remember the congressman from the Northeast who was such an honest man that he was really going to straighten out this country? He even was going to end pork barrel legislation.
Dr. Milton: Well, did it take him half way through his term?
Dr. Rosen: The interesting, and tragic circumstance in this case was that the Congress placed him in charge of the pork barrel. He was beginning to wonder about the cost of getting re-elected when he became so enamored with the ease of getting taxpayers' money into his district, that he became the pork champ. This was a very shrewd maneuver on the part of those that live off of pork - a little temptation is a dangerous thing.
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You've Been Subpoenaed, What Can You Do? By Alberto Bolanos, M.D.
Imagine being in your office one day and being served with a subpoena to appear at a nearby hospital a week later to provide a deposition on your patient's injury and prognosis. Because of the short notice, you have to cancel surgery or office hours or your vacation. This is onerous, but you have to appear because it's been ordered by the Superior Court in the name of The People of the State of California. If you don't appear, "you may be punished for contempt of the court and will be liable for up to five hundred dollars and all damages resulting from your failure to obey." So you have no choice but to succumb to this mandatory burden, right? Wrong!
An understanding of subpoenas and court proceedings reveals that you actually have recourse and many options to the demands placed on you by a surprise subpoena.
First, you should be aware that a deposition is an elective legal proceeding that can be scheduled at any time and place convenient for the parties involved. A good attorney would be considerate of your schedule and call you in advance to obtain convenient times for your deposition. This approach is less likely to cause the physician to be resentful, combative, or otherwise taint proceedings and possible outcomes of the lawsuit. Lawyers who serve you with a subpoena without the courtesy of contacting you first are hoping that you are so ignorant about legal matters that you will simply show up at the time and place that is convenient for them and will be so scared of possible penalties that you will just answer all questions posed to the best of your abilities.
Are there really any penalties if you don't comply with the subpoena? Only if you don't respond! If you do nothing and don't appear, the attorney will report you to the Superior Court judge who will then issue sanctions for a lack of response. Instead, simply notify the attorney that you have other commitments that preclude your appearance. Don't make the phone call yourself; have your office staff contact the attorney's staff so that you have witnesses in case the attorney claims you did not respond to the subpoena. You don't have to provide an explanation to the attorney, only to the judge if the attorney unwisely decides to report you. If the attorney reports you, a typical response from the judge would be "you subpoenaed the doctor for a deposition with no notice and then learned of a schedule conflict? I presume you rescheduled the deposition for a time convenient to the doctor, correct?" If you are reported at this point, simply provide a reasonable explanation to the judge, who would then reprimand the attorney for abusing subpoena powers. To read the entire article, please go to www.smcma.org/Bulletin/BulletinIssues/Sept06issue/Subpoenaed.html.
Dr. Bolanos practices orthopaedic surgery in San Mateo.
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WHO REALLY CARES America's Charity Divide Who Gives, Who Doesn't, and Why It Matters by Arthur C. Brooks, Basic Books, New York, 250 pp, $26 © 2006, by Arthur Brooks, ISBN-13: 978-0-465-00821-6
"Now abideth faith, hope, charity, these three;" said the Apostle Paul, "but the greatest of these is charity."
When I served on the stewardship committee of my parish, which was responsible for obtaining every member's pledge, I noted that there were large differences in pledges. It also seemed that the giving percentages were higher for the poorer members of our parish. Although the congregation thrive on the large givers, we remember the widow's mite in Jerusalem that was looked on with favor by our Lord since it was all she had.
The expressed opinion in many political circles is that the conservatives are not compassionate. The pre-elections income tax filings by our wealthy lawmakers were also very enlightening. The charitable giving of some of our rich senators seem to calculate out at about one or two percent of their listed income. But they seemed to be generous in raising taxes to make everyone "charitable." Thus, only liberals view themselves as truly compassionate.
Reader's Digest published a poll several years ago on what Americans thought would be an appropriate maximum tax rate. The consensus, as I recall, was that all taxes should never add up to more than 25 percent of their income. Meanwhile the marginal tax rate is approaching 50 percent and the rich senators and representatives want to further increase it - to make America more compassionate.
Now comes Arthur C Brooks with the documented truth about liberals and conservatives and his detailed analysis of the charity divide. He found the reverse was actually the truth. Being a liberal, he had difficulty accepting the results of his own research. America's working poor are, relative to their income, far more generous than their liberal counterparts including the middle class and rich. Not so surprising, the nonworking poor - those on public assistance instead of earning low wages - give at lower levels than any other group. In other words, poverty does not discourage charity in America, but welfare does.
In 2004, former president Jimmy Carter claimed that Americans are indifferent to suffering around the world - we don't really care. Brooks cites a foreign businessman who comes to this country to become better informed about giving and volunteering because many foreigners admire the philanthropic zeal of Americans and consider it the secret of our success.
Another famous foreign visitor to America some 170 years ago was Alexis de Tocqueville. When he came to the United States in 1835, he found a spirit of voluntarism and charity unlike anything he had encountered before. In his classic book Democracy in America, Tocqueville marveled at America's many civic associations, which were supported through voluntary gifts of time and money: "Americans of all ages, all conditions, and all dispositions constantly form associations," Tocqueville reported. "The Americans make associations to give entertainments, to found seminaries, to build inns, to construct churches, to diffuse books, to send missionaries to the antipodes; in this many found hospitals, prisons, and schools."
Who is correct about American charity - Alexis de Tocqueville or Jimmy Carter? To a certain extent, they're both right, according to Brooks. When it comes to charity, America is two nations - one charitable, and the other uncharitable. Most Americans are generous, compassionate people. However, there is also an identifiable slice of the population that does not donate to people in need, does not volunteer, does not give in formal ways, and does not even feel compassion toward others.
Brooks states his book is about these two Americas and the reason they behave so differently. In the process of investigating the forces of charity and selfishness, he uncovered some hard truths about American culture, politics and economics. But the stakes are higher than showing a few surprising truths. It matters a lot that we are two nations. Charity, he feels, is essential to our health and happiness, community vitality, national prosperity, and even to our ability to govern ourselves as a free people. America's greatest glory lies ahead - if we become more charitable. But just as America, the Charitable spills abundance onto the rest of us, America the Selfish threatens our prosperity as a nation through the policies it supports and the culture it encourages. It is important to understand what makes people charitable and what makes them uncharitable. Our strength as a nation is affected by our ability to bring more people into the ranks of the generous - for their good and for ours.
Fortunately, Tocqueville's America is bigger than Jimmy Carter's. There are far more charitable Americans than uncharitable ones. Approximately three out of four families make charitable donations each year. The average amount given by these families is $1800 or about 3.5 percent of household income. About a third goes to religious activities and the rest goes to education, health and social welfare. Charitable donations in the United States add up to about quarter trillion dollars per year. To read the entire review, please go to www.delmeyer.net/bkrev_WhoReallyCares.htm.
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I'm so concerned about environmentalism, so as Miss Universe, my first official act will be to find another suitable planet for us to live on. -Dan Piraro
Now who said you can't have both beauty and brains.
The British NHS: Sir Gerry Robinson recommends that hospital car parking lots should be free. "Car-park fees are fine if you want to ration space. But to make money from patient parking fees, patient telephones and patient vending machines? I hate it.
But Sir Gerry, when the
HNS can't charge patients, is
bankrupt, mismanaged, don't you have to make your money where you can?
Gerry Robinson, a Labour donor who was knighted in 2004 and a former chairman of the Arts Council, is adamant that simple techniques work. 'We have this really precious thing which is free delivery of healthcare when you are ill. We shouldn't pretend it is a business, because it's not, but, my God, we should be running it well.
But isn't it interesting that all his remedies are based on good business principles?
There are now 40,000 managers within the NHS and their numbers have increased in recent years, but spending on management consultants has jumped more than fifteen-fold from £31m to more than £500m in two years.
Incompetence only breeds incompetence in any bureaucracy. That's why government medicine will never work. Every government says it just hasn't been done right. But our memory is so short.
To read more vignettes, visit the archives at www.healthcarecom.net/hhk2001.htm.
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The National Center for Policy Analysis, John C Goodman, PhD, President, who along with Gerald L. Musgrave, and Devon M. Herrick wrote Lives at Risk issues a weekly Health Policy Digest, a health summary of the full NCPA daily report. You may log on at www.ncpa.org and register to receive one or more of these reports. This month, be sure to read what happened to New Jersey when lawmakers handed out benefits (legalized stealing of taxpayers' money to give to their supporters) to teachers and employees without fiscal responsibility: an extra $8700 per citizen, at www.ncpa.org/sub/dpd/index.php?page=article&Article_ID=14166.
Pacific Research Institute, (www.pacificresearch.org) Sally C Pipes, President and CEO, John R Graham, Director of Health Care Studies, publish a monthly Health Policy Prescription newsletter, which is very timely to our current health care situation. You may subscribe at www.pacificresearch.org/pub/hpp/index.html or access their health page at www.pacificresearch.org/centers/hcs/index.html. New study finds more than $1 billion in public funds to improve schools yielded little academic improvement: www.pacificresearch.org/press/rel/2007/pr07-01-14.html. [Government funding does not improve education and cannot improve healthcare. How can we stop Government funding?]
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, read about Africa's Enterprise-Based Poverty Solutions by clicking on the topic.
The National Association of Health Underwriters, www.NAHU.org. The NAHU's Vision Statement: Every American will have access to private sector solutions for health, financial and retirement security and the services of insurance professionals. There are numerous important issues listed on the opening page. Be sure to scan their professional journal, Health Insurance Underwriters (HIU), for articles of importance in the Health Insurance MarketPlace. www.nahu.org/publications/hiu/index.htm. The HIU magazine, with Jim Hostetler as the executive editor, covers technology, legislation and product news - everything that affects how health insurance professionals do business. Be sure to review the current articles listed on their table of contents at hiu.nahu.org/paper.asp?paper=1. Also read about HSA updates at www.nahu.org/legislative/hsa2007.cfm.
The Galen Institute, Grace-Marie Turner President and Founder, has a weekly Health Policy Newsletter sent every Friday to which you may subscribe by logging on at www.galen.org. A new study of purchasers of Health Savings Accounts shows that the new health care financing arrangements are appealing to those who previously were shut out of the insurance market, to families, to older Americans, and to workers of all income levels.
Greg Scandlen, an expert in Health Savings Accounts (HSAs) has embarked on a new mission: Consumers for Health Care Choices (CHCC). To read the initial series of his newsletter, Consumers Power Reports, go to www.chcchoices.org/publications.html. To join, go to www.chcchoices.org/join.html. Be sure to read Prescription for change: Employers, insurers, providers, and the government have all taken their turn at trying to fix American Health Care. Now it's the Consumers turn. www.chcchoices.org/publications/cpr9.pdf
The Heartland Institute, www.heartland.org, publishes the Health Care News. Read the late Conrad F Meier on What is Free-Market Health Care? at www.heartland.org/Article.cfm?artId=10333. You may sign up for their health care email newsletter at www.heartland.org/Article.cfm?artId=10478. Be sure to read how the president plans to reform the tax treatment of health insurance at www.heartland.org/Article.cfm?artId=20565.
The Foundation for Economic Education, www.fee.org, has been publishing The Freeman - Ideas On Liberty, Freedom's Magazine, for over 50 years, with Richard M Ebeling, PhD, President, and Sheldon Richman as editor. Having bound copies of this running treatise on free-market economics for over 40 years, I still take pleasure in the relevant articles by Leonard Read and others who have devoted their lives to the cause of liberty. I have a patient who has read this journal since it was a mimeographed newsletter fifty years ago. This month, be sure to read Richard Ebeling on Milton Friedman and the Chicago School of Economics at www.fee.org/publications/the-freeman/article.asp?aid=6214.
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 careand may even make things worse." This month, read what needs to be done to achieve their goals at www.cahi.org/cahi_contents/issues/.
The Independence Institute, www.i2i.org, is a free-market think-tank in Golden, Colorado, that has a Health Care Policy Center, with Linda Gorman as Director. Be sure to sign up for the monthly Health Care Policy Center Newsletter at www.i2i.org/healthcarecenter.aspx. Read her latest newsletter at www.i2i.org/hcpcjune2004.aspx, which includes a section on PC Medicine and Euthanasia. Be sure to read Defining School Quality: Government or the Marketplace? at www.i2i.org/main/event.php?event_id=15.
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 CLIMATE CHANGE AND GLOBAL WARMING POLICIES: ON OR OFF THE BANDWAGON? at www.quebecoislibre.org/07/070128-5.htm.
The Fraser Institute, an independent public policy organization, focuses on the role competitive markets play in providing for the economic and social well being of all Canadians. Canadians celebrated Tax Freedom Day on June 28, the date they stopped paying taxes and started working for themselves. Log on at www.fraserinstitute.ca for an overview of the extensive research articles that are available. You may want to go directly to their health research section at www.fraserinstitute.ca/health/index.asp?snav=he. This month, read about The Misguided War Against Medicines at www.fraserinstitute.ca/shared/readmore.asp?sNav=pb&id=885.
The Heritage Foundation, www.heritage.org/, founded in 1973, is a research and educational institute whose mission is to formulate and promote public policies based on the principles of free enterprise, limited government, individual freedom, traditional American values and a strong national defense. The Center for Health Policy Studies supports and does extensive research on health care policy that is readily available at their site. Be sure to peruse their health care required reading lists at www.heritage.org/research/healthcare/RequiredReading.cfm.
The Ludwig von Mises Institute, Lew Rockwell, President, is a rich source of free-market materials, probably the best daily course in economics we've seen. If you read these essays on a daily basis, it would probably be equivalent to taking Economics 11 and 51 in college. Please log on at www.mises.org to obtain the foundation's daily reports. Read this week's report on Murder and Inflation: the Kentucky Tragedy By Clifford F. Thies at www.mises.org/story/2467. You may also log on to Lew's premier free-market site at www.lewrockwell.com to read some of his lectures to medical groups. To learn how state medicine subsidizes illness, see www.lewrockwell.com/rockwell/sickness.html; or to find out why anyone would want to be an MD today, see www.lewrockwell.com/klassen/klassen46.html.
CATO. The Cato Institute (www.cato.org) was founded in 1977 by Edward H. Crane, with Charles Koch of Koch Industries. It is a nonprofit public policy research foundation headquartered in Washington, D.C. The Institute is named for Cato's Letters, a series of pamphlets that helped lay the philosophical foundation for the American Revolution. The Mission: The Cato Institute seeks to broaden the parameters of public policy debate to allow consideration of the traditional American principles of limited government, individual liberty, free markets and peace. Ed Crane reminds us that the framers of the Constitution designed to protect our liberty through a system of federalism and divided powers so that most of the governance would be at the state level where abuse of power would be limited by the citizens' ability to choose among 13 (and now 50) different systems of state government. Thus, we could all seek our favorite moral turpitude and live in our comfort zone recognizing our differences and still be proud of our unity as Americans. Michael F. Cannon is the Cato Institute's Director of Health Policy Studies. Read his bio at www.cato.org/people/cannon.html. Read The REGULATION journal at www.cato.org/pubs/regulation/index.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.] Read about the first 1000 committed to move at http://mmdnewswire.com/content/view/1175/.
The St. Croix Review, a bimonthly journal of ideas, recognizes that the world is very dangerous. Conservatives are staunch defenders of the homeland. But as Russell Kirk believed, wartime allows the federal government to grow at a frightful pace. We expect government to win the wars we engage, and we expect that our borders be guarded. But St Croix feels the impulses of the Administration and Congress are often misguided. The politicians of both parties in Washington overreach so that we see with disgust the explosion of earmarks and perpetually increasing spending on programs that have nothing to do with winning the war. There is too much power given to Washington. Even in wartime we have to push for limited government - while giving the government the necessary tools to win the war. To read a variety of articles in this arena, please go to www.stcroixreview.com.
Hillsdale College, the premier small liberal arts college in southern Michigan with about 1,200 students, was founded in 1844 with the mission of "educating for liberty." It is proud of its principled refusal to accept any federal funds, even in the form of student grants and loans, and of its historic policy of non-discrimination and equal opportunity. The price of freedom is never cheap. While schools throughout the nation are bowing to an unconstitutional federal mandate that schools must adopt a Constitution Day curriculum each September 17th or lose federal funds, Hillsdale students take a semester-long course on the Constitution restoring civics education and developing a civics textbook, a Constitution Reader. You may log on at www.hillsdale.edu to register for the annual weeklong von Mises Seminars, held every February, or their famous Shavano Institute. Congratulations to Hillsdale for its national standing 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 the latest Imprimis "Let them at least have heard of brave knights and heroic courage" at http://www.hillsdale.edu/imprimis/2007/02/. The last ten years of Imprimis are archived at www.hillsdale.edu/imprimis/archives.htm.
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Del Meyer, MD, Editor & Founder
6620 Coyle Ave, Ste 122, Carmichael, CA 95608
Words of Wisdom
No crisis is beyond the capacity of our people to solve; no challenge too great. -Ronald Reagan
Civilizations die from suicide, not murder. -Arnold Toynbee
A thankful heart is not only the greatest of virtues, but the parent of all the others. -Cicero
There are two ways to live your life. One is as though nothing is a miracle. The other is as though everything is a miracle. -Albert Einstein
Do not wait for leaders; do it alone, person to person. -Mother Teresa
Some Postings from our Archives
Physician Patient Bookshelf: www.delmeyer.net/PhysicianPatientBookshelf.htm
Hippocrates Modern Colleagues: www.delmeyer.net/HMC.htm
Medical Practice Available: www.delmeyer.net/Practice_Valuation.htm
Henry Grouθs ("Abbι Pierre"), champion of the homeless, died on January 22nd, aged 94
TRADITIONALLY most saints are gentle creatures. Those enshrined in French homes, or on prayer-cards stuffed into the missals of elderly churchgoers, are usually St Anthony carrying the child Jesus, or smiling St Thιrθse of Lisieux with a bouquet of flesh-tinted roses. Odd, then, that the nearest modern France has come to a saint was a man fuelled and driven by unceasing anger: anger that the poor should suffer and that the rich did not care. . .
To read the obit, please go to www.economist.com/obituary/PrinterFriendly.cfm?story_id=8625572.
On This Date in History - February 13
On this date in 1635, the oldest American public school, the Boston Latin School, began. After nearly 400 years of free public education, there is still so much room for improvement, that the private schools are seeing their greatest growth.
On this date in 1795, the first state university in the United States opened - the University of North Carolina at Chapel Hill. This continues the trend of concerned citizens looking into the relationship between government and education.
After Leonard and Thelma Spinrad