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MEDICAL TUESDAY . NET |
NEWSLETTER |
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Community For Better Health Care |
Vol VIII, No
22, Feb 23, 2010 |
In This Issue:
1.
Featured Article:
The Art of Bacterial Warfare
2.
In
the News: Is Federal
Pain Control around the corner?
3.
International Medicine: Newfoundland's Premier to have his heart surgery in
the U.S.
4.
Medicare: Who Really
Understands ObamaCare?
5.
Medical Gluttony:
Have X-rays, CTs and MRIs replaced the physician's hands-on exam?
6.
Medical Myths:
With government health care, people get immediate care in emergencies
7.
Overheard in the Medical Staff Lounge: The "House of Medicine" is in turmoil these
days.
8.
Voices
of Medicine: Controversies
in Therapeutics
9.
The Bookshelf: Every
Patient Tells a Story
10.
Hippocrates
& His Kin: Things to ponder
11.
Related Organizations: Restoring Accountability in Medical Practice and Society
Words of Wisdom,
Recent Postings, In Memoriam . . .
* * * * *
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.
* * * * *
1. Featured Article: Stopping
Infections: The Art of Bacterial Warfare
New research
reveals how bacteria hijack our bodies' cells and outwit our immune
systems--and how we can use their own weapons against them
Key Concepts
·
Bacterial pathogens multiply
and make toxins inside human hosts, but how the microbes elude our defenses and
deliver their poisons have been poorly understood.
·
Studying host-pathogen
interactions reveals sophisticated bacterial strategies for co-opting and
manipulating host cells to serve a bacterium's needs.
·
A new understanding of
bacterial tools and tactics is leading to novel approaches for battling the
microbes
Most bacteria are well-behaved
companions. Indeed, if you are ever feeling lonely, remember that the trillions
of microbes living in and on the average human body outnumber the human cells
by a ratio of 10 to one. Of all the tens of thousands of known bacterial
species, only about 100 are renegades that break the rules of peaceful
coexistence and make us sick.
Collectively,
those pathogens can cause a lot of trouble. Infectious diseases are the second
leading cause of death worldwide, and bacteria are well represented among the
killers. Tuberculosis alone takes nearly two million lives every year, and
Yersinia pestis, infamous for causing bubonic plague, killed approximately one
third of Europe's population in the 14th century. Investigators have made
considerable progress over the past 100 years in taming some species with
antibiotics, but the harmful bacteria have also found ways to resist many of
those drugs. It is an arms race that humans have been losing of late, in part
because we have not understood our enemy very well. . .
To penetrate diverse organs and tissues
and to survive and thrive in our bodies, bacteria become skilled subversives,
hijacking cells and cellular communication systems, forcing them to behave in
ways that serve the bugs' own purposes. Many microbes take control by wielding
specialized tools to inject proteins that reprogram the cellular machinery to
do the bugs' bidding. A few are also known to employ tactics that rid the body
of benign or beneficial bacteria, to better commandeer the environment for
themselves. As investigators have identified the aggressive strategies and
ingenious weapons used by pathogenic bacteria to invade and outwit their
hosts, we have wasted no time in trying to devise therapies that turn the
microbes' own weapons against them.
Breaking and Entering
The first step in any bacterial
assault, for instance, is attachment to the host's cells. A disease-causing
strain of Escherichia coli, known as enterohemorrhagic E. coli O157,
has perhaps what is called the innate arm of the immune system, such as
neutrophils and dendritic cells, normally ingest and destroy ("phagocytose")
any invaders. These phagocytes engulf bacteria and sequester them in
membrane-bound vacuoles where killing molecules destroy the captives. But Salmonella
species penetrate the intestinal lining by passing from epithelial cells
to immune cells waiting on the other side. Once inside the phagocytic vacuole,
the bacteria deploy a second T3SS, called SPI-2, which releases effector proteins
that convert the vacuole into a safe haven where Salmonella can
multiply. The proteins cause this switch from death chamber to sanctuary by
altering the vacuole membrane so that the killing molecules cannot get in.
The SPI-2
system is critical to the success of Salmonella typhi, the strain that causes
typhoid fever. By allowing the microbes to survive inside the phagocytic cells,
which travel within the body via the bloodstream and lymphatic system, SPI-2
enables the organisms to reach and replicate in tissues far beyond the
intestine, such as the liver and spleen.
An ability to live long term inside a host's cells is a trait
common to many bacterial pathogens that cause serious disease, including those
responsible for tuberculosis and Legionnaires' disease. Indeed, Legionella
pneumophila is particularly intriguing in that it injects at least 80 different
effectors into phagocytic cells through its T4SS. Although the function of only
a handful of these proteins is known, at least some of them serve to convert
the phagocytic vacuole into a safe haven.
Dodging the Sentries
The ability of bacteria to set up housekeeping inside immune cells—the very cells meant to
kill them—attests to the
versatility of the microbes' tool kit for co-opting cellular machinery. The
similarity between human immune cells and bacterial predators outside human
hosts may explain the origin of other bacterial survival tactics as well. Some
of the most sophisticated mechanisms that bacteria are known to deploy are
devoted to evading host defenses and even enlisting immune cells to help the
microbes thrive. . .
It is not only the innate immune system that bacteria dupe. Some
have learned to avoid the "acquired" immune response, which consists
of T cells and antibody-producing B cells that are trained by innate immune
cells to recognize a specific pathogen by its surface features (antigens).
Microbes may dodge these defenses, either by constantly changing surface
proteins to evade antibodies or by secreting enzymes that degrade antibodies. .
.
A Competitive Community
To thrive in a body,
pathogens need to do more than manipulate cell signaling and outwit immune
defenses. They also have to outcompete the body's hordes of normal, friendly
bacteria—players that were
virtually ignored by most microbiologists and immunologists until recently.
All the surfaces of the body exposed to the environment, including the lining
of the gastrointestinal tract, contain an enormous population of these
"commensal" microbes. Each gram of the large intestine's contents,
for example, contains approximately 60 billion bacteria—10 times the number of people on the planet.
One of the most obvious ways to eliminate
competition is to cause diarrhea and thereby flush one's opponents out of the
body, at least temporarily. . .
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* * * * *
2. In the News: Is Federal Pain Control around the
corner?
Will The
Feds Ban Your Pain Meds? Reason.tv
February 16, 2010
What if you were injured and developed
severe pain that wouldn't go away? Would your government let you take the kind
of pain medication you need? If federal officials follow the recommendation of
a Food and Drug Administration panel, many of the most effective prescription
painkillers—including Vicodin, Percocet, and countless generics—would be
banned.
Scott Gardner says that kind of a move
would be "intensely cruel."
"I took Vicodin for three
years," says Gardner. "I needed it. It got me through a very tough
period of my life." The tough period began after a cycling accident
shattered the left side of his body. After eight surgeries and countless hours
of physical therapy, Gardner's once active life is now filled with limitations.
He suffers from chronic pain that prevents him from sleeping more than a few
hours at a time, and yet his pain today is nothing compared to the agonizing
days and months following his accident.
"When there's nothing but pain,
there's no reason to live," says Gardner. "There were times where the
only way I could stay sane and civil was because I could take
painkillers."
The fear of addiction and abuse already
makes many suspicious of pain medication. Media reports about celebrities like
Rush Limbaugh or Matthew Perry suggest that it's common for people to become
addicted to medications they once took for legitimate medical conditions. And
countless public service announcements remind us of the dangers of prescription
drug abuse.
Now the old fear of prescription drug
abuse takes a new twist. The FDA panel is
targeting drugs like Vicodin and Percocet because they contain acetaminophen, a
popular painkiller also found in many over-the-counter drugs. Panel members
warn that some Americans ingest too much acetaminophen, and overdoses can lead
to liver damage, even death.
But maybe the FDA panel isn't putting
this threat into context. After all, mundane threats like falling down stairs
claim more lives than acetaminophen overdoses. And it turns out the more common
fear—that patients will become addicted to prescription drugs—is also
overblown. In fact, the barrage of warnings we hear about prescription drugs
obscures an important point—people saddled with severe chronic pain need these
painkillers.
Says Gardner, "I think people
who haven't dealt with pain don't really know what it's like."
"Don't Get Hurt" is written and
produced by Ted Balaker, who also hosts. The director of photography
is Alex Manning, the field producer is Paul Detrick and the animation in
the piece is from Hawk Jensen.
Approximately five minutes.
For iPod, HD, and audio versions of this
and other videos, go to Reason.tv.
To watch this video on Reason.tv's YouTube channel, go here. If you
subscribe to the channel, you can also get automatic notifications when new
videos go live.
Related video: When Cops Play Doctor: How
the Drug War Punishes Pain Patients.
For Reason.com's coverage of
"opiophobia," or overblown fears by the government about
prescription painkillers, go
here.
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* * * * *
3. International Medicine: Newfoundland's Premier chooses to have
his heart surgery in the U.S.
Why Danny Williams'
decision to seek private health care matters by Brett J. Skinner
Canada is virtually alone in prohibiting
people from spending their own money to get quicker or better health care.
Appeared in Amherst Daily News, Truro Daily News,
and New Glasgow Daily News - February 10, 2010
What
does it say about the state of Canadian health insurance when Newfoundland
Premier Danny Williams chooses to have his heart surgery in the U.S.? Some
pundits say it means nothing while others have insisted the premier could have
obtained his medical care somewhere in Canada.
But
the details of Premier Williams' case are irrelevant to the main question,
which is, if it is okay for a Canadian politician to get private medical
treatment in America, why is it illegal for regular Canadians to get private
medical treatment in Canada? In other words, why do provincial governments make
it illegal for Canadians to spend their own money to preserve and improve their
own health? Why are ordinary Canadians forced to wait in a government-imposed
queue for access to necessary medical care?
Danny
Williams' decision is not unique. According to the most recent Fraser Institute
estimate in 2009, Williams would be only one of approximately 41,000 Canadians
who annually seek non-emergency medical care outside of Canada. Consider how
absurd it is that the only way for Canadians to pay privately for better or
quicker medical care is to leave their own country.
Our
annual international report comparing Canada to other countries with universal
health insurance systems shows that Canada is virtually alone in prohibiting
people from spending their own money to get quicker or better health care.
Who
is to blame for this? Despite commonly held beliefs, the federal Canada Health
Act does not prohibit private insurance for medical services—the act only
prohibits user charges under public insurance. It is actually the provinces
that prevent ordinary Canadians from doing at home what Premier Williams chose
to do in the United States. In fact, six provinces (accounting for about 84 per
cent of the national population) legally ban direct private payment for
necessary medical services, and six provinces (accounting for 90 per cent of
the national population) legally ban the purchase of private health insurance
for necessary medical services.
Most
provinces also prohibit parallel billing by health care providers. In these
provinces, hospitals and physicians are not allowed to accept private payment
or private insurance reimbursement while accepting public payment from the
provincial health insurance system. Health care providers must choose to work
either for private payment or public payment, but cannot elect both. Most
doctors are not willing to surrender their billing rights in the public system,
and therefore do not even make their services available for private payment.
This
is how governments effectively ban private health insurance and medical care in
Canada. . .
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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
* * * * *
4. Medicare: Who Really Understands ObamaCare? -
Kaiser Health News
Source: John Goodman in Kaiser
Health News
From the very moment public opinion started going
south on the president's health plan, the White House and Democrat leaders in
Congress began sounding a familiar refrain: The public does not understand the
bill; they've been lied to, deceived and misled by the opponents; and once they
learn how it really works, familiarity will breed...well, something other than
contempt.
I have four problems with this point of view:
1. If it is sincere, you would think the Obama
Administration would have made a major effort to educate the public about how
the bill really works; in fact, they have made no effort whatsoever.
2. Since ObamaCare is modeled after the Massachusetts
health plan, voters in that state should be better informed than even Obama
himself about how it "really works"; yet Massachusetts voters
resoundingly rejected the president's plan in Tuesday's U.S. Senate election.
3. There was a lot of misleading information flying in
all directions at last summer's town hall meetings; but on balance, the average
protestor appeared to be better informed than the average member of Congress.
4. Among the chattering class - who are paid to
express informed opinion - the proponents of ObamaCare are far less
knowledgeable than the opponents.
Cognoscenti are in the Dark. Let's take the last point first. How many editorials
have you seen where the writer rattles off a laundry list of health care
problems and then concludes with "that's why we need health reform"? Each
of these editorials makes the same two mistakes: (1) They assume that ObamaCare
will solve the problems they are writing about and (2) they assume it's either
ObamaCare or nothing. This second mistake is called the fallacy of the excluded
middle.
As we have pointed out many times, ObamaCare is not
going to solve our most serious problems. It will make costs higher, not lower.
It will lower, rather than raise, the quality of care. It will
"solve" the problems of pre-existing conditions by substituting problems
that are even worse. And it may not even increase access to care.
Then there are the writers who bypass the details
altogether and jump straight to wild claims. Here are two:
["ObamaCare] will give Americans what citizens in
every other advanced nation already have - guaranteed access to essential care.
" (Paul Krugman in The New York Times)
For the first time, we will enshrine the principle
that all Americans deserve access to medical care, regardless of their ability
to pay." (Eugene Robinson in The Washington Post)
Now you would think that anyone who hasn't been living
in a cave in some remote spot would know that access to the care they need is
exactly what many Canadians and Britains do not have. And if they do not have
the money to buy that care in the private sector or in another country, they
are forced to go without because of lack of "ability to pay."
Bay State Folks Know What's Happening in Their State. We don't have to go all the way to Britain or Canada
to see where Krugman, Robinson and others have missed the boat, however.
Massachusetts will do just fine. Bay Staters are not clamoring to repeal what
they have. But they are acutely aware of the problems that haven't been solved.
And one of them is lack of access to care for people who lack the ability to
pay market prices. As previously noted, the wait to see a new doctor in Boston
is more than twice as long as in any other U.S. city. Further, the number of
people going to emergency rooms for nonemergency care in Massachusetts is as
great today as it was before health reform was enacted.
The White House is Doing Nothing to Educate the Public. It's not just the general public that is being kept
in the dark. Obama is the same way with his base. Since June, the president has
been sending a weekly e-mail to an estimated 19 million faithful about health
care. Strangely, these letters are never truly educational. Instead they are
cheerleading messages - the sort of thing you would expect at a pep rally. (By
contrast, the NCPA's weekly messages to 1.3 million petition signers tend to be
very informative.)
Voters on the Whole are Very Informed. There has probably never been a major piece of
legislation before Congress about which voters were better informed. I continue
to believe that the average "activist" who opposes the bill knows
more about it than his/her congressional representative. Rasmussen found that
after an initial poll question, people were just as negative - if not more so -
when pollsters described ObamaCare in some detail.
As Lanny Davis said the other day, "It's the
substance, stupid."
John Goodman is the President and CEO of the National
Center for Policy Analysis
http://www.ncpa.org/commentaries/who-really-understands-obamacare-kaiser-health-news
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Government is not the solution
to our problems, government is the problem.
- Ronald Reagan
* * * * *
5. Medical Gluttony: Example from New York Times
Diagnosis Columnist Lisa Sanders
This
week we excerpt an example from Lisa Sanders book: Every Patient Tells a Story:
Medical Mysteries and the Art of Diagnosis, See Section Nine: Book Review
below.
Sanders
raises questions about our art and science, and challenges many of the
practices we accept routinely. Has technology replaced the physical exam?
Daily
I see evaluation of abdominal pain start with contrast CT of the abdomen. I
wrote recently in this magazine about a 14-year-old gymnast with a painful knee
who had X-rays, CT and MRI of his joint before actually being examined. During
that exam, he was found to have Osgood-Schlatter's disease, a diagnosis that
could have been made at the outset with the clinician's thumb on the tibial
tuberosity.
Taking a
medical history to define the problem before the shotgun approach to expensive
technology would save major medical costs. Or is that too simple?
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Medical Gluttony thrives in Government and Health Insurance Programs.
Gluttony Disappears with Appropriate Deductibles and Co-payments on
Every Service.
* * * * *
6. Medical Myths: With government health care, people get
immediate care in emergencies.
Myth 16. In
countries with government-funded health care, people get immediate care in emergencies,
though they may have to wait for elective procedures.
The usual response to concerns about the months-long
waiting lists for surgery in Canada and Britain is that this is a mere
inconvenience, a small price to pay for universal "free" care. If you
have a really serious need, you'll get immediate attention—or so Michael Moore
and others tell us.
Although one can surely come up with anecdotes about
someone who got good emergency care in a Canadian or British
hospital—especially if the person is a prominent journalist—this is not the
norm.
The average wait in Canadian emergency rooms is 23
hours, stated
John Stossel on ABC's 20/20.
Once admitted, a Canadian patient may wait three days
in the emergency department for a bed (Michael A. Platokov, "A Temple for
Human Sacrifice," Western Standard 12/4/06).
Actress Natasha Richardson suffered an epidural
hematoma from head trauma while skiing Mont Tremblant in Quebec. Prompt
neurosurgical treatment probably would have saved her—but it took 4 hours to
get her to a properly equipped hospital after she started to deteriorate and
called 911 from her hotel room. Quebec—unlike the U.S.—has no medical
helicopters (CBSNews.com
3/21/09).
But the flip side, advocates for the Canadian system
say, is that U.S. helicopters are "way overused." A person with a
non-life-threatening injury might get killed in a helicopter crash, as has
happened (Slate.com
3/27/09).
Because of lack of a single bed in any neonatal
intensive care unit in southern Ontario, 10 to 15 babies per year have to be
transferred to Buffalo, N.Y. Parents of Ava Isabella Stinson were amazed at the
way their daughter was treated—and ended up with a different view of Americans.
"Even the security guards care about how you
feel." And the Ronald McDonald House was "like living in a mansion,
said Stinson" (Buffalo
News 7/2/09).
Cancer might be considered an emergency by the
patient—but not by the Canadian or British health bureaucracy. Those who want
prompt surgery generally have to come to the U.S., as Stuart Browning shows in
the video A Short Course in Brain
Surgery, which has been seen by more than 3 million viewers.
In Britain, the National Health Service is supposed to
cover necessary treatment, but people are selling their homes to get cancer
care (Daily
Express 12/22/2008). One British cancer patient waited for an
appointment with a specialist, only to have it cancelled—48 times (David
Gratzer, "The
Ugly Truth about Canadian Health Care," City Journal, summer 2007).
Kidney failure is fatal, if you can't get dialysis. In
Britain, you are ineligible for this life-saving treatment once you reach the
age of 55. The mother of
Beth Ashmore, a past president of the National Association of Health
Underwriters, developed kidney failure while visiting England. Treatment was
denied because of her mother's age, so Ashmore arranged for a specially
equipped jet to bring her home. The hospital, however, had placed her in a back
room to die, alone—and could not locate her! Thus, she died while an aircraft
that could have saved her waited on a runway in Atlanta to find out its
destination.
Mere pain, no matter how severe or disabling, is not
considered life-threatening, so orthopedic surgery that could relieve it is
usually long delayed. Dr. Brian Day, former president of the Canadian Medical
Association, saw his operating room time reduced from 22 hours to only 5 hours
per week, 10 hours less than recommended for minimal competence by the Canadian
Orthopaedic Association. He had 450 patients waiting for care (National
Post 10/23/07).
Additional information:
- "What America Needs
to Learn from Canadian Medicare," by Lee Kurisko, M.D., and Dave
Racer, M.Litt., J Am Phys Surg, summer 2009.
- "Lessons from
Sweden's Universal Health System: Tales from the Crypt," by Sven R.
Larson, Ph.D., J Am Phys Surg, Spring 2008.
- "The
Failure of Socialized Medicine in Canada," presentation by David
Gratzer, M.D., AAPS 64th Annual Meeting, 2007. (MP3 audio file)
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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.
* * * * *
7. Overheard in the Medical Staff Lounge: The "House
of Medicine" is also in turmoil these days.
A list around Washington of the medical
groups that opposed the Senate bill included 42 organizations representing
nearly a half million physicians. Some of these groups are now forming a
coalition to stand as an alternative to the AMA. They are supporting the right
of physicians to privately contract with their patients, to determine quality
in medical care, and to advocate for liability reform.
Dr.
Rosen: I received an email to join
the coalition and pay $1000 in dues. Did anyone else receive such an email?
Dr.
Yancy: No I haven't and I haven't
been a member of the AMA or the CMA or the local society ever. I feel they have
been a very ineffective voice for physicians.
Dr.
Dave: I wish we had Dr. Edward R. Annis
running the AMA again. He was truly a voice for private practice during the
time the public was being sold the Medicare Bill of Goods.
Dr.
Rosen: Annis was quite the character.
He never ran for office before and I don't think he has since. He was just the
right guy in history. Too bad we didn't have another cheerleader to carry on.
Things went down hill again after he left.
Dr.
Sam: I quit the AMA a decade ago and
I'm about to quit the local society also. It seems that most of the
administrators of the local and state societies are socialists. We were able to
get rid of the one at the state. But it's rather like changing parties in
Washington. The staffers live there and are hired by the newly elected who ruin
them also.
Dr.
Paul: I'm not a member of the AMA for
quite the opposite reason. They are not pro government enough.
Dr.
Rosen: I guess you can't please all
the people all the time and pleasing some of the people all the time doesn't
get anything accomplished. I mentioned the coalition earlier. Is that viable?
Dr.
Yancy: If this coalition actually
supported the right of contract, I might join them. I've been beat terribly by
managed care. Procedures I use to get paid $1500 for, I scarcely get $600 for
them now.
Dr.
Milton: I'm still a member of Organized
Medicine but sometimes I wonder why. I wouldn't be too optimistic about this
coalition. I would prefer that we support an organization like the American
Association of Physician and Surgeons that already is out there and are
committed to free enterprise, private practice of medicine, and a total
revision of the insurance game.
Dr.
Edwards: Now a revision of the
insurance program is a game I could get behind. In fact there is very little
health insurance that is really insurance. It's a prepayment scheme and that's
why it evolved into HMOs where all payments are screened.
Dr.
Rosen: Insurance for outpatient
medicine is very costly. We need insurance primarily for the expensive things
like surgery, heart attacks, strokes, etc. It should never cover office calls
and routine lab. CalPERS tried to implement a high deductible that was suppose
to equal the average cost of outpatient care including a yearly exam, but I
didn't see it implemented anywhere.
Dr.
Yancy: Now that's one thing I could
support - insurance for surgery and hospitalizations. That would help all of us
surgeons, as well as trim health care costs.
Dr.
Edwards: I understand that a policy
for hospitalization and surgery would be on the order of $300 a month, instead
of the $800 to $1200 a full policy costs.
Dr.
Rosen: The $500-a-month savings in
premiums would pay for a lot of office calls and prescriptions.
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The Staff Lounge Is Where Unfiltered Medical Opinions Are Heard.
* * * * *
8. Voices of Medicine: A Review of Local and Regional
Medical Journals
Controversies in Therapeutics by Kirk Pappas, MD
In
this issue of Sonoma Medicine, we explore—through the eyes and words of
practicing clinicians—the therapeutic challenges we face in caring for our
patients.
Congress,
the public and President Obama seem to believe that only if we physicians
adhered to practice guidelines, all would be well in the world. A more
standardized approach to care does seem to be in order, and the president has
made Dr. Atul Gawande's recent New Yorker article, "The Cost
Conundrum," required reading for all in Washington, DC. In the article,
Gawande discusses the startlingly different levels of utilization in two Texas
towns: El Paso and McAllen.
Can
we all learn from a more "predictable" practice? Can we choose to be
El Paso instead of McAllen?
What
would Osler say? Does the future hold the promise of quality or the clarity of
an algorithm that Bones from Star Trek would be proud of? Or are we
products of our training and detailing by Big Pharma and the vast
medical-industrial complex? . . .
Recently,
a colleague consulted me to review a case, including an MRI, and ask my opinion
regarding conservative care vs. a spine injection. This physician had already
reviewed the literature and examined the patient and now asked my thoughts on
next steps. We consulted over the phone. . .
We
reviewed both sides of the literature together and discussed options. The
choice was clear, and the patient agreed. At the end of the day, our
experience, our opinions and our review of the clinically relevant literature
persuaded us we were doing "the right thing" in the warm comfort of
our choice.
I
wonder what our local Congressional representatives, Lynn Woolsey and Mike
Thompson, would think about the time spent as we came to our conclusions. Would
they want me to spend the time to collaborate on choices, or should I follow a
protocol? Will the new and improved system of health care allow (and perhaps
even compensate us) for this type of cognitive evaluation? Or will a computer
program make the decision? . . .
Where
are our voices—not just with each other, but with our patients—regarding the
choices that we make for patient care? How can we collaborate in a better
dialogue about the cost of our choices? Who is suffering from the lack of
dialogue about controversies in therapeutics?
. . .
As
you read this issue, perhaps you can use it as part of a discussion in your
exam rooms . . . I will keep in mind the words of F. Scott Fitzgerald:
"The test of first-rate intelligence is the ability to hold two opposing
ideas in mind at the same time yet still retain the ability to function. One
should, for example, be able to see that things are hopeless and yet be
determined to make them otherwise."
Read the
entire article with references as well as the journal issue . . .
Dr. Pappas, a physiatrist at Kaiser Santa Rosa, is the
immediate past president of SCMA.
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VOM
Is an Insider's View of What Doctors are Thinking, Saying and Writing about.
* * * * *
9. Book Review:
Every Patient Tells a Story: Medical Mysteries and the Art of Diagnosis
by Lisa Sanders, MD, Broadway Books,
2009, ISBN 978-0767922463
Diagnosis
Inside Out By Rick Flinders, MD
Every
patient has a story. Physicians already know that. The longer we practice, the
more it is true. So why do we need to read this book? Because we forget.
Because our brains are frail. Because we're in a hurry. Because we often fail
to take the time to listen. There are many more reasons, as many reasons as we
have patients.
Lisa
Sanders, MD, is a particularly fine story teller who is willing to take the
time to tell us a few stories about her patients. An internist on the faculty
of the Yale University School of Medicine, she is also an astute clinician who
shares a few of the lessons from the practice of medicine she has learned along
the way. Her column "Diagnosis" appears monthly in the New York
Times Magazine, and she is the inspiration and medical advisor for the
runaway television series "House." Are you listening yet?
Sanders
begins with the story of a young woman lying in the ICU for a week while dying
of progressive, inscrutable liver failure. She is in a large university
hospital at an academic center, where her diagnosis has eluded multiple
specialists, until an aging internist called in on the case notices, buried in
her chart, overlooked results that suggest mild hemolysis. This
combination—liver failure and isolated red blood cell destruction—is an unusual
manifestation of an unusual inherited illness that the internist recognizes. He
goes to the bedside with his ophthalmoscope and confirms his diagnosis of
Wilson's disease. The patient receives an organ transplant the following week
and survives.
How
was the internist able to make a diagnosis after so many had failed? "I
was lucky," he explains. "No one can know everything in medicine. I
happened to know this. A bell went off and a connection was made."
"This
book," writes Sanders, "is about that bell. How doctors know what
they know is a messy process, filled with red herrings, false leads and dead
ends. An important clue can be overlooked in the patient's history or physical exam.
An unfamiliar lab finding may obscure rather than reveal." Or the doctor
may be too busy or too tired to think through the case. "Even the great
William Osler," writes Sanders, "must have had his bad days."
Sanders weaves a handful of medical mysteries throughout her
book, dividing it into four parts. Part One is the title track: "Every
Patient Tells a Story." Part Two, "High Touch," chronicles the
"vanishing art of history-taking and physical diagnosis." In Part
Three, "High Tech," Sanders details the enormous power and
limitations of our rapidly advancing diagnostic technology. She concludes in
Part Four with "The Limits of the Medical Mind."
Read the entire book review . . .
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reviews . . .
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10. Hippocrates & His Kin: Things to ponder
TRACKING COWS
Is
it just me, or does anyone else find it amazing that during the mad cow
epidemic our government could track a single cow, born in Canada almost three
years ago, right to the stall where she slept in the state of Washington?
And,
they tracked her calves to their stalls.
But they are unable to locate 11 million illegal
aliens wandering around our country.
Maybe we should give each of
them a cow.
THE
CONSTITUTION
They keep talking about drafting a Constitution for
Iraq. Why don't we just give them ours? It was written by a lot of really smart
guys, it has worked for over 150 years, and we haven't used it much for the
past 75 years.
Why let a good document we
don't use anymore gather dust?
THE
10 COMMANDMENTS
The real reason that we can't have the Ten Commandments
posted in a Courthouse or Congress is that you cannot post 'Thou Shall Not
Steal,' Thou Shall Not Commit Adultery' and Thou Shall Not Lie' in a building
full of Lawyers, Judges and Politicians.
It creates a hostile work
environment.
CAN SOCIALISTS GO TO HEAVEN?
Socialist: Why do you think Socialists
can't get into heaven?
Believer: Because they don't believe
in God.
Socialist: What makes you think
that?
Believer: They believe in government
as their God and the source of all good things including their salvation and
all things needful. Who needs God, they think?
Socialist: Only conservatives need a
God. They aren't charitable. They have to be taxed to be charitable. So we're
doing them a favor.
Believer: Taxed charity does not
benefit the forced giver or the ungrateful receiver. It only makes Socialists
feel good when they see money taken away from Conservatives and given to the
poor and make them feel entitled to more and more.
Many are called, but few are chosen.
The
Challenges, Medical or Otherwise, that Modern Day Colleagues of Hippocrates
Face.
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* * * * *
11.
Professionals Restoring Accountability in Medical Practice, Government
and Society:
•
John and Alieta Eck, MDs, for their first-century solution to twenty-first
century needs. With 46 million people in this country uninsured, we need an
innovative solution apart from the place of employment and apart from the
government. To read the rest of the story, go to www.zhcenter.org and check
out their history, mission statement, newsletter, and a host of other
information. For their article, "Are you really insured?," go to www.healthplanusa.net/AE-AreYouReallyInsured.htm.
•
Medi-Share Medi-Share is based on the biblical principles of caring
for and sharing in one another's burdens (as outlined in Galatians 6:2). And as
such, adhering to biblical principles of health and lifestyle are important
requirements for membership in Medi-Share.
This is not insurance. Read more . . .
•
PATMOS EmergiClinic - where Robert Berry, MD, an emergency
physician and internist, practices. To read his story and the background for
naming his clinic PATMOS EmergiClinic - the island where John was exiled and an
acronym for "payment at time of service," go to www.patmosemergiclinic.com/ To
read more on Dr Berry, please click on the various topics at his website. To
review How
to Start a Third-Party Free Medical Practice . . .
•
PRIVATE
NEUROLOGY is a Third-Party-Free
Practice in Derby, NY with
Larry Huntoon, MD, PhD, FANN. (http://home.earthlink.net/~doctorlrhuntoon/)
Dr Huntoon does not allow any HMO or government interference in your medical
care. "Since I am not forced to use CPT codes and ICD-9 codes (coding
numbers required on claim forms) in our practice, I have been able to keep our
fee structure very simple." I have no interest in "playing
games" so as to "run up the bill." My goal is to provide
competent, compassionate, ethical care at a price that patients can afford. I
also believe in an honest day's pay for an honest day's work. Please Note that PAYMENT IS EXPECTED AT
THE TIME OF SERVICE. Private Neurology also guarantees that medical records in our office are kept
totally private and confidential - in accordance with the Oath of Hippocrates.
Since I am a non-covered entity under HIPAA, your medical records are safe from
the increased risk of disclosure under HIPAA law.
•
FIRM: Freedom and
Individual Rights in Medicine, Lin
Zinser, JD, Founder, www.westandfirm.org,
researches and studies the work of scholars and policy experts in the areas
of health care, law, philosophy, and economics to inform and to foster public
debate on the causes and potential solutions of rising costs of health care and
health insurance. Read Lin
Zinser's view on today's health care problem: In today's proposals for sweeping changes in the field of
medicine, the term "socialized medicine" is never used. Instead we
hear demands for "universal," "mandatory,"
"singlepayer," and/or "comprehensive" systems. These
demands aim to force one healthcare plan (sometimes with options) onto all
Americans; it is a plan under which all medical services are paid for, and thus
controlled, by government agencies. Sometimes, proponents call this
"nationalized financing" or "nationalized health
insurance." In a more honest day, it was called socialized medicine.
•
Michael J. Harris, MD - www.northernurology.com - an active member in the
American Urological Association, Association of American Physicians and
Surgeons, Societe' Internationale D'Urologie, has an active cash'n carry
practice in urology in Traverse City, Michigan. He has no contracts, no
Medicare, Medicaid, no HIPAA, just patient care. Dr Harris is nationally
recognized for his medical care system reform initiatives. To understand that
Medical Bureaucrats and Administrators are basically Medical Illiterates
telling the experts how to practice medicine, be sure to savor his article on
"Administrativectomy:
The Cure For Toxic Bureaucratosis."
•
Dr Vern Cherewatenko concerning success in restoring private-based
medical practice which has grown internationally through the SimpleCare model
network. Dr Vern calls his practice PIFATOS – Pay In Full At Time Of Service,
the "Cash-Based Revolution." The patient pays in full before leaving.
Because doctor charges are anywhere from 25–50 percent inflated due to
administrative costs caused by the health insurance industry, you'll be paying
drastically reduced rates for your medical expenses. In conjunction with a
regular catastrophic health insurance policy to cover extremely costly
procedures, PIFATOS can save the average healthy adult and/or family up to
$5000/year! To read the rest of the story, go to www.simplecare.com.
•
Dr David MacDonald started Liberty Health Group. To compare the
traditional health insurance model with the Liberty high-deductible model, go
to www.libertyhealthgroup.com/Liberty_Solutions.htm.
There is extensive data available for your study. Dr Dave is available to speak
to your group on a consultative basis.
•
Madeleine
Pelner Cosman, JD, PhD, Esq, who has made important efforts in restoring accountability in
health care, has died (1937-2006).
Her obituary is at www.signonsandiego.com/news/obituaries/20060311-9999-1m11cosman.html.
She will be remembered for her
important work, Who Owns Your Body, which is reviewed at www.delmeyer.net/bkrev_WhoOwnsYourBody.htm. Please go to www.healthplanusa.net/MPCosman.htm to view some of her articles that highlight the government's
efforts in criminalizing medicine. For other OpEd articles that are important
to the practice of medicine and health care in general, click on her name at www.healthcarecom.net/OpEd.htm.
•
David J
Gibson, MD, Consulting Partner of Illumination Medical, Inc. has made important contributions to the
free Medical MarketPlace in speeches and writings. His series of articles in Sacramento
Medicine can be found at www.ssvms.org. To read his "Lessons from the Past," go to www.ssvms.org/articles/0403gibson.asp. For additional articles, such as the cost of Single
Payer, go to www.healthplanusa.net/DGSinglePayer.htm; for Health Care Inflation, go to www.healthplanusa.net/DGHealthCareInflation.htm.
•
ReflectiveMedical Information Systems
(RMIS), delivering
information that empowers patients, is a new venture by Dr. Gibson, one of our
regular contributors, and his research group, which will go far in making
health care costs transparent. This site
provides access to information related to medical costs as an informational and
educational service to users of the website. This site contains general
information regarding the historical, estimates, actual and Medicare range of
amounts paid to providers and billed by providers to treat the procedures
listed. These amounts were calculated based on actual claims paid. These
amounts are not estimates of costs that may be incurred in the future. Although
national or regional representations and estimates may be displayed, data from
certain areas may not be included. You may want to
follow this development at www.ReflectiveMedical.com.
During your visit you may wish to enroll your own data to attract patients to
your practice. This is truly innovative and has been needed for a long time.
Congratulations to Dr. Gibson and staff for being at the cutting edge of
healthcare reform with transparency.
•
Dr
Richard B Willner,
President, Center Peer Review Justice Inc, states: We are a group of
healthcare doctors -- physicians, podiatrists, dentists, osteopaths -- who have
experienced and/or witnessed the tragedy of the perversion of medical peer
review by malice and bad faith. We have seen the statutory immunity, which is
provided to our "peers" for the purposes of quality assurance and
credentialing, used as cover to allow those "peers" to ruin careers
and reputations to further their own, usually monetary agenda of destroying the
competition. We are dedicated to the exposure, conviction, and sanction of any
and all doctors, and affiliated hospitals, HMOs, medical boards, and other such
institutions, who would use peer review as a weapon to unfairly destroy other
professionals. Read the rest of the story, as well as a wealth of information,
at www.peerreview.org.
•
Semmelweis
Society International, Verner S. Waite MD, FACS, Founder; Henry Butler MD,
FACS, President; Ralph Bard MD, JD, Vice President; W. Hinnant MD, JD,
Secretary-Treasurer; is
named after Ignaz Philipp Semmelweis, MD (1818-1865), an obstetrician
who has been hailed as the savior of mothers. He noted maternal mortality of
25-30 percent in the obstetrical clinic in Vienna. He also noted that the first
division of the clinic run by medical students had a death rate 2-3 times as
high as the second division run by midwives. He also noticed that medical
students came from the dissecting room to the maternity ward. He ordered the
students to wash their hands in a solution of chlorinated lime before each examination.
The maternal mortality dropped, and by 1848, no women died in childbirth in his
division. He lost his appointment the following year and was unable to obtain a
teaching appointment. Although ahead of his peers, he was not accepted by them.
When Dr Verner Waite received similar treatment from a hospital, he organized
the Semmelweis Society with his own funds using Dr Semmelweis as a model: To
read the article he wrote at my request for Sacramento Medicine when I was
editor in 1994, see www.delmeyer.net/HMCPeerRev.htm. To see Attorney Sharon Kime's response, as well as the
California Medical Board response, see www.delmeyer.net/HMCPeerRev.htm. Scroll down to read some
very interesting letters to the editor from the Medical Board of California,
from a member of the MBC, and from Deane Hillsman, MD.
To view
some horror stories of atrocities against physicians and how organized medicine
still treats this problem, please go to www.semmelweissociety.net.
•
Dennis
Gabos, MD, President of
the Society for the Education of Physicians and Patients (SEPP), is making
efforts in Protecting, Preserving, and Promoting the Rights, Freedoms and
Responsibilities of Patients and Health Care Professionals. For more
information, go to www.sepp.net.
•
Robert J
Cihak, MD, former
president of the AAPS, and Michael Arnold Glueck, M.D, who wrote an
informative Medicine Men column at NewsMax, have now retired. Please log
on to review the archives.
He now has a new column with Richard Dolinar, MD, worth reading at www.thenewstribune.com/opinion/othervoices/story/835508.html.
•
The Association of
American Physicians & Surgeons (www.AAPSonline.org),
The Voice for Private Physicians Since 1943, representing physicians in their
struggles against bureaucratic medicine, loss of medical privacy, and intrusion
by the government into the personal and confidential relationship between
patients and their physicians. Read an Open
Letter to the Profession. . . Be sure to read News of the Day in
Perspective: Doctors Tell
Congress: Just Stop It. Don't miss the "AAPS News," written by Jane
Orient, MD, and archived on this site which provides valuable information on a
monthly basis. This month, be sure to read LOOTING MEDICINE. Browse the archives of their official organ, the Journal of American Physicians and
Surgeons, with Larry Huntoon, MD,
PhD, a neurologist in New York, as the Editor-in-Chief. There are a number of
important articles that can be accessed from the Table of Contents.
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"You cannot multiply wealth by
dividing it." - the
late Adrian Rogers
"Early risers are happier, healthier, and more
productive at work. They stay in better shape, earn more money, and report that
they are more satisfied with their lives. Get up early and seize the day!"
- Michael Masterson: Entrepreneur and best-selling business author, www.nightingale.com/
"In a world where the big things have little
difference - it's the little things that make a big difference." - Peter Thomson: U.K. strategist on business and personal growth, www.nightingale.com/
Some Relevant
Postings
Peer Review: Inquisition or Quality Control . . .
The Hunted Physician by Sharon Kime and
Robert Sullivan, Attorneys-at-Law . . .
A Medical Tragedy . . .
In Memoriam
Jerome David Salinger, writer, died on January 28th, aged 91
From The Economist print
edition | Feb 6th 2010
PEOPLE
kept sneaking year after year to the place on the hill in Cornish, New
Hampshire, but the Great American Writer was almost never seen. Ageing rebels,
second-year master's students with lacquered nails, broad-shouldered phonies in
Norfolk jackets, snappers from Newsweek, all approached the cringing,
little house where he had lived, or battened down, or holed up—you, general
reader, can choose the word you please—ever since a great wave of fame had
broken over him in 1953, two years after he happened to write a book called
"The Catcher in the Rye". Read more . . . .
They
caught a glimpse of him sometimes, with his haughty head, angular and bug-eyed,
getting groceries in the village; but he gave them the slip almost always. The
truth of it was that though his book might be on all the syllabuses,
picked over by the academicians, hailed as the authentic voice of every
teenager who had ever squeezed a pimple or tried, drawing himself up tall, to
order a Scotch and soda, his life was nobody's godammed business. If his
dream was to live in the woods, with a fireplace and a typewriter and sheaves
of notes hooked on the wall, almost like a deaf-mute in his dealings with the
world, that was his affair.
He
was not just away in Cornish, he was also above. (The italics
were his own.) From above, Holden Caulfield, the hero of "Catcher",
first entered his story to look down on the distant football game between Saxon
Hall and Pencey Prep, all those little running figures of whom he was not one,
because he was outside and expelled. The writer who truly lived for his art—who
made it, as Mr Salinger did, his religion, along with Vedanta and Zen and the
Tao—did not descend and did not integrate. He defended until death, or
non-publication, the sanctity of his words. A writer asked to discuss his craft
ought just to jump up and declaim, de haut en bas, the names of
Flaubert, Tolstoy, Blake, Coleridge, Proust, James. And admit that after
Melville there had been no really good American writer until—Salinger.
But
that—wait—was not necessarily the name he answered to. In his short stories, a
scant three dozen of them, rounding off the whole oeuvre, he gradually
took the name and voice of Buddy Glass, a fortyish and paunchy short-story
writer who had ended up in an English Department. And Glass in turn wrote
obsessively, devotedly, as if of some plaster saint, about his elder brother
Seymour, his Literary Ideal. Buddy was the working-writer Salinger, the man who
had laboured in 1939-43 to get stuff into Esquire and the Saturday
Evening Post, while all the time disdaining those slicks and lusting after
the New Yorker—which, in 1948, took him into its embrace. But Seymour
was "all real things to us: our blue-striped unicorn, our doublelensed
burning glass, our consultant genius, our portable conscience…our one full
poet." He would open the door, blow "three or four or five
unquestionably sweet and expert notes on a cornet"—and then disappear. . .
On This Date in
History - February 23
On this date in 1836, a siege in the city
of San Antonio began. Inside was a small band of determined men. Outside
was a Mexican Army. The place was the Alamo. The gallantry of the defenders of
the Alamo is well remembered.
On this date in 1945, the famous picture
was taken of the Marines raising the American Flag at Iwo Jima. The picture,
taken by Associated Press photographer Joe Rosenthal at the height of the
fighting on that embattled Pacific Island, was the inspiration for the Iwo Jima
monument in Washington, outside the Arlington National Cemetery. It represents
a spirit of valor that continues as an inspiration to all of us today.
After Leonard and
Thelma Spinrad
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