1. Featured Article: Cancer: Don't Try to Cure It. Just Focus on Finding It Early, Wired, Jan 2009

Why Early Detection Is the Best Way to Beat Cancer By Thomas Goetz

If we find cancer early, 90 percent survive. If we find cancer late, 10 percent survive.

When the first cell in one of Brenda Rosenthal's ovaries mutated and turned cancerous, she felt no symptoms. The telltale pains or lumps that signal cancer were still months, if not years, away. But there were signs, sparks thrown off by the tumor that had begun to smolder in her belly. As more cells were conscripted from the original task coded in their DNA and assigned a new, malignant mission, they produced proteins that leaked into Rosenthal's bloodstream. Had an effort been made to see these molecules, had there been a strategy for detecting them, the 69-year-old wouldn't face such long odds today.

Certainly, there were statistical red flags, if only Rosenthal had known to look for them. Twenty years before, she had survived a bout of breast cancer, increasing her risk for ovarian cancer in the future. That risk was exacerbated by a mutation in her BRCA2 gene that's been associated with much higher rates of breast and ovarian cancers.

Going purely by the numbers, Rosenthal, a New York City native now living in Delray Beach, Florida, was a prime candidate for ovarian cancer. But even after the link between the BRCA2 gene and breast and ovarian cancer was discovered in 1995, Rosenthal didn't think to get tested. "It didn't even register," she says. "I went on with my life, and I didn't think about cancer." It wasn't until 2005, when she first noticed a physical symptom—"this huge lump in my stomach area"—that Rosenthal learned she was once again a cancer patient.

Ovarian cancer, like most cancers, is measured in four stages. Stage I is early, when the disease is contained in the ovaries. In stage II, it may be present in the fallopian tubes or elsewhere in the pelvis. By stage III, it has migrated into the abdomen or lymph nodes. And by stage IV, the malignancy has spread, or metastasized, into major organs like the liver or uterus. (The first three stages are further subdivided into A, B, and C levels.) For ovarian tumors discovered in stage I or II, the survival rate 10 years after diagnosis is reassuringly high—almost 90 percent—because treatment is straightforward: surgery, perhaps followed by low doses of radiation. But survival rates drop precipitously as the diagnosis shifts to stage III or IV, when the cancer is well established and spreading. Here, the survival rate falls to 20 percent and then to 10 percent. Unfortunately, more than two-thirds of ovarian cancers aren't found until these later stages. That was true in Rosenthal's case: By the time she noticed her lump, the disease had spread and progressed to stage IIIC.

Four years later, after two rounds of chemotherapy, Rosenthal's cancer is in remission. But she remains vigilant. Every three months, her blood is tested for levels of CA125, a protein marker used to monitor ovarian cancer. She tracks clinical drug trials in the hope that she will qualify as a subject. Yet she'll always blame herself, if only a little bit, for missing a way to find the disease earlier. "I could live 10 or 15 years more, but I still won't have the quality of life I would've if we'd found the cancer early," she says. "I don't want anyone else to be in my position."

The survival rate for many cancers is similar to the cliff-like curve that defines ovarian malignancies. Find the disease early, thanks to a stray blob on an x-ray or an early symptom, and the odds of survival approach 90 percent. Treatment—surgery—is typically low risk. But find it late, after the tumor has metastasized, and treatment requires infusions of toxic chemicals and blasts of brutal radiation. And here the prognosis is as miserable as the experience.

This reality would seem to make a plain case for shifting research and resources toward patients with a 90 percent, rather than a 10 or 20 percent, chance of survival. But these are largely hypothetical patients. Cancer may be present, but since it hasn't been detected, as a practical matter these cases don't yet exist. People with full-blown cancer, however, are very real. They are our fathers and mothers, our children and friends. They're right in front of us. These are the 566,000 Americans who will die of cancer this year.

The US spends billions of dollars to save these late-stage patients, trying to devise better drugs and chemotherapies that might kill a cancer at its strongest. This cure-driven approach has dominated the research since Richard Nixon declared war on the disease in 1971. But it has yielded meager results: The overall cancer mortality rate in the US has fallen by a scant 8 percent since 1975. (Heart disease deaths, by comparison, have dropped by nearly 60 percent in that period.) We are so consumed by the quest to save the 566,000 that we overlook the far more staggering statistic at the other side of the survival curve: More than a third of all Americans—some 120 million people—will be diagnosed with cancer sometime in their lives. Their illness may be invisible now, but it's out there. And that presents a great, and largely unexamined, opportunity: Find and treat their cancers early and that 566,000 figure will shrink.

Cancer, in other words, has a perception problem. We lack the ability to see what's going on inside the body, to gaze through our too-solid flesh and glean information on a molecular level. Conventional medical technologies—blood tests, x-rays, MRIs—can serve as proxies for proximity, but the picture they offer is often incomplete and obscured. Without a way to positively identify illness early, to detect that first spark, medicine will continue to be a last resort.

But new technologies for the early detection of cancer are now at hand. Researchers are refining sophisticated protein tests that can pick up molecular whispers in the bloodstream and are testing next-generation imaging techniques that can identify and isolate a tumor within the body. These technologies build on screening methods already proven to reveal cancer—the Pap smear (cervical), the antibody blood test (prostate), the mammogram (breast)—but go further and deeper so that even stubbornly covert cancers might become visible.

This new approach treats diagnosis as an algorithm, a sequence of calculations that can detect or predict cancer years before it betrays symptoms. It starts with a statistical screening to identify people, like Rosenthal, who have a genetically greater risk for disease. A regular blood test follows, one primed to look for telltale proteins, or biomarkers, correlated to specific cancers. A positive result prompts an imaging test to eliminate false positives or isolate a tumor. The process is methodical, mathematical, and much more likely to find cancer than current diagnostic procedures.

This is the potential of early detection: To use data instead of drugs, to reveal a cancer before it reveals itself, and to leave the miracles for the patients who really need them. . .

In fact, much of the meager increase in cancer survival rates over the past 30 years can be attributed not to new chemotherapies or treatments but to early detection. Deaths from skin cancer, which is the most obvious to diagnose and treat, have fallen 10 percent. Since the Pap smear—a simple swab of the cervix for precancerous and cancerous cells—became part of routine care in the US in the 1950s, cancer incidence and mortality rates due to cervical cancer have fallen by 67 percent. Five-year survival rates for breast cancer have likewise improved as mammography and MRI screening have increased. There are tests for these diseases not because they are biologically different from other cancers but because they occur in accessible parts of the body. It's neither difficult nor prohibitively expensive nor dangerous to swab a cervix or perform a mammogram. Other areas of the body, though—the lungs, the pancreas—are less accessible and harder to monitor. Consequently, their malignancies are far more deadly. . .

The typical human body contains something less than 2 gallons of blood. The bloodstream is basically a transport system, a combination of plasma—the fluid itself—and a number of passengers, mostly red and white blood cells, which distribute oxygen and fight infection. Blood also contains thousands of proteins that serve a range of biological purposes, from distributing energy and nutrition to repairing injury and inflammation. The science of proteomics is trying to correlate each of these proteins with its specific metabolic function. . .

For a disease like cancer, so often seen as a death sentence, early detection promises a trade-off. At first, it makes things more complicated. It introduces more doubt and complexity into an already complicated equation. But in return, early detection promises that this doubt can be quantified, that these new variables can be broken down into metrics, analyzed, and factored into our health decisions. Early detection proposes that the result of this calculation—complicated and ambiguous as it is—will yield better results for individuals and for their families. In exchange for a modicum of doubt, it offers a maximum opportunity for hope.

Deputy editor Thomas Goetz (thomas@wired.com) wrote about the Personal Genome Project in issue 16.08. He has a new blog about health and medicine at www.thedecisiontree.com.

To savor and learn more about this cancer frontier research, please proceed to . . .

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2. In the News: Smoking Cessation Clinics Do Not Improve Quit Rates

Targeting Primary Care Referrals to Smoking Cessation Clinics Does Not Improve Quit Rates: Implementing Evidence-Based Interventions into Practice

Elizabeth M. Yano, Lisa V. Rubenstein, Melissa M. Farmer, Bruce A. Chernof, Brian S. Mittman, Andrew B. Lanto, Barbara F. Simon, Martin L. Lee, Scott E. Sherman

Objective. To evaluate the impact of a locally adapted evidence-based quality improvement (EBQI) approach to implementation of smoking cessation guidelines into routine practice.

Data Sources/Study Setting. We used patient questionnaires, practice surveys, and administrative data in Veterans Health Administration (VA) primary care practices across five southwestern states.

Study Design. In a group-randomized trial of 18 VA facilities, matched on size and academic affiliation, we evaluated intervention practices' abilities to implement evidence-based smoking cessation care following structured evidence review, local priority setting, quality improvement plan development, practice facilitation, expert feedback, and monitoring. Control practices received mailed guidelines and VA audit-feedback reports as usual care.

Data Collection. To represent the population of primary care-based smokers, we randomly sampled and screened 36,445 patients to identify and enroll eligible smokers at baseline (n=1,941) and follow-up at 12 months (n=1,080). We used computer-assisted telephone interviewing to collect smoking behavior, nicotine dependence, readiness to change, health status, and patient sociodemographics. We used practice surveys to measure structure and process changes, and administrative data to assess population utilization patterns.

Principal Findings. Intervention practices adopted multifaceted EBQI plans, but had difficulty implementing them, ultimately focusing on smoking cessation clinic referral strategies. While attendance rates increased (p<.0001), we found no intervention effect on smoking cessation.

Conclusions. EBQI stimulated practices to increase smoking cessation clinic referrals and try other less evidence-based interventions that did not translate into improved quit rates at a population level.

To read the abstract, go to www.hsr.org/hsr/abstract.jsp?aid=227

To read the entire scientific data, go to http://findarticles.com/p/articles/mi_m4149/is_/ai_n30985698?tag=artBody;col1

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3. International News: Americans are more charitable than Canadians

Manitoba rated as Canada's most generous province but data shows Americans are far more generous

The report, Generosity in Canada and the United States: The 2008 Generosity Index, shows that Manitoba has the highest percentage of tax-filers among all provinces donating to registered charities (28.1 per cent). The total amount donated is also the highest in Canada at 1.14 per cent of total income earned in the province.

"Since we began tracking charitable donations in 1996, Manitoba has consistently been a leader among Canadian provinces both in the percentage of tax filers who donate to charity and in the percentage of total income donated," said Niels Veldhuis, Fraser Institute director of fiscal studies. . .

Generosity in Canada and the United States: The 2008 Generosity Index measures and compares monetary generosity in Canada's 10 provinces and three territories and in the 50 U.S. states and the District of Columbia using readily available data on the extent and depth of charitable donations as recorded on personal income tax returns.

Newfoundland and Labrador along with Quebec are the least generous among provinces. In Newfoundland and Labrador, 21.6 per cent of tax filers claimed a charitable donation, amounting to 0.49 percent of total income. In Quebec, 22.3 per cent of tax filers donate to charity but donate the least amount of aggregate income earned at just 0.33 per cent – less than one third of that donated in Manitoba.

However, compared to Americans, Canadians are far less generous. When all 64 North American jurisdictions measured are compared, Manitoba, Canada's highest ranked jurisdiction ranks 37th on the generosity index while Ontario is 45th. Canadian provinces and territories occupy 12 of the bottom 20 spots.

Utah is the number one ranked jurisdiction for generosity, with 36.0 per cent of tax filers claiming a charitable donation giving 3.84 per cent of their total income. Maryland is second overall with 43.5 per cent of tax filers giving to charity amounting to 2.11 per cent of total income. The District of Columbia is third overall with 36.1 per cent of tax filers making charitable donations for worth 2.15 per cent of total income.

Additionally, the aggregate income donated in Manitoba was just 1.14 per cent, less than half of that donated in Utah. Overall, the only states giving less than Manitoba are South Dakota, Alaska, North Dakota and West Virginia. . .

"Many Canadians like to believe that we are a more generous and giving nation than the United States. But the data clearly show that in most instances, Americans give more of their income to registered charities than Canadians," Veldhuis said.

In comparing Canada and the United States on a national basis, monetary generosity in the U.S. surpasses that of Canada with 29.7 per cent of U.S tax filers donating to charity compared to 24.7 per cent of Canadian tax filers.

Interestingly, this year's report finds that although the extent of charitable giving fell in almost every Canadian province from 1996 to 2006, the percentage of aggregate personal income donated in Canada has increased.

However, Canadians still have a long way to go to match the amount Americans donate to charity. Americans gave 1.66 per cent of their aggregate personal income to charity, more than double the 0.76 per cent of the total personal income Canadians donated to charity in 2006 (the last year for which data was available).

Canada makes its poorest showing in terms of the average value of charitable donations in local currency. The average U.S. donation was $4,403 US, almost three times more than the average donation in Canada ($1,470 Cdn.). Top-ranked Wyoming recorded an average charitable donation of $10,021 US, almost five times the average in Alberta ($2,057 Cdn.), Canada's top-ranked province. Even in Rhode Island, the lowest ranked U.S. state, the average donation ($2,698 US) is over $600 more than the average donation in Alberta. These differences are more pronounced when currency differences are taken into account.

"If Canadians donated to charities to the same extent as Americans, Canadian charities would have received an extra $9.8 billion in revenue," Veldhuis said.

That's consistent with Canadians wanting to get their health care with other peoples' money (taxes) rather than their own. Probably the same disease.

Canadian Medicare does not give timely access to health care, it only gives access to a waiting list.

--Canadian Supreme Court Decision 2005 SCC 35, [2005] 1 S.C.R. 791

http://scc.lexum.umontreal.ca/en/2005/2005scc35/2005scc35.html

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4. Medicare: Practice Guidelines May Not Be Cost Effective

The big push in going to Managed Care over the past three decades has been cost control. The Managed Care Organizations (MCOs) have hounded doctors into doing fewer tests, fewer x-rays, fewer consultations and fewer office visits. One executive called and asked, "We've noticed that you see most of your patients every three months or four times a year. Wouldn't it be reasonable to see patients every four months or three times a year instead?

This pressure on physicians did reduce health care costs. However, according to the presentation at the CMA leadership conference by business professor Dr. Ewe Reinhardt of Princeton University, costs were only temporarily controlled and now are on the same upward trajectory that they were on before. So it was ineffective for the long term.

Now with increasing government involvement in micromanaging health care, there is a total reversal of emphasis. The push is on quality. Medicare is now reviewing charts to make sure that doctors get diabetic and cholesterol checks, pap smears, mammograms, prostate checks, and colon cancer screenings. They are now considering decreasing reimbursements for what they consider poor care by physicians who do not do everything that Medicare feels is the highest level of health care.

The fact that a greater percentage of patients in the United States receive pap smears, mammograms, prostate and colon screenings than any other country in the world has no effect on this Gestapo attitude by Medicare. Bureaucrats always fail to see the big picture of health care. Thus, these bureaucratic directives will decrease rather than increase the quality of care. It will also increase the costs since Medicare, Medicaid, SCHIP, and other federal programs are headed for bankruptcy and possibly extinction.

It may be best to heed the words of Ronald Reagan (Government is the problem) rather than the words of Barrack Hussein Obama, Jr (Government is the solution).

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

- Ronald Reagan

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5. Medical Gluttony: Can It Reach One Million Percent?

During the past seven years, we have highlighted excessive or gluttonous use of health care resources in this section. Non-medical responses have been rather consistent in their criticism that these are isolated cases. Politicians have made public statements that they are unaware of anyone obtaining unneeded health care. The very idea doesn't compute in their minds. They think unnecessary health care involves fraud. Congress and state assemblies spend considerable time trying to reduce health care costs by five or even ten percent. However, our examples are not about five or ten percent over utilization but 100 percent, or 1000 percent and on occasion even more. An occasional reading of this section causes some people to think this is a radical point of view. One must follow this section on a regular basis to understand the concepts of how this occurs.

How does chest pain, which may be a pulled costal-cartilage that can be diagnosed by a simple exam with palpation of a doctor's hand or even the patient's hand, be realized as only a pulled cartilage far removed from the heart? A pulled cartilage or muscle only requires a couple of extra-strength acetaminophen tablets, rather than an emergency room visit with a full $9,000 diagnostic panorama of tests related to the heart. Can a bureaucrat who is only interested in controlling people by controlling their very health begin to understand that going from 90 cents worth of drugs in a standard medicine cabinet to $9,000 is really a ten thousand (10,000) fold increase or one million (1,000,000) percent increase in health care costs? These are not rare occurrences even though Congress and the state assemblies treat these as unusual and extremely rare.

The question to be answered is how this can be avoided. It cannot be avoided as long as the patient and the public are totally unaware of this happening. The patient, by thinking this is essentially free, has little interest in controlling costs. And if his employer pays his health insurance premium, he has no interest in controlling costs. The public simply fails to believe the extent of the gluttony. My patients that experience this $9000 evaluation with no positive findings are universally elated with this massive attention. Some say hospitals provide accommodations that exceed the Hilton. What a great luxurious stay. Members of Congress and the state assemblies, from their statements in the press, do not believe this is a problem.

MedicalTuesday has always held that there should be no item in health care that is free. We may disagree on how much the deductible and co-payment should be, but there should always be both. We still see ads from insurance companies that boast about various items that their patients get without any deductible or co-payment. Of course, the insurance company is interested in making a sale. And the higher their payout on claims, the higher their premiums and, therefore, profits are higher. There is little motivation for cost control. We must understand that if health care costs would drop by 30 to 50 percent, which is a conservative estimate if it were based on the free market, so would insurance premium costs. At the same percentage of profit, the insurance company profits drop by 30-50 percent also. So they have a vested interest in not using significant deductibles or co-payments which decrease their profits.

Congress and the state assemblies have a similar interest in keeping health care costs high. If health care costs were controlled through this simple mechanism, how could they continue to control our very lives without this harassment? What would they do all year?

Thus, health care reform has to come from outside of government, the insurance industry and the hospital industrial complex. That will be a tough concept to sell. Reagan stated that government is the problem. Our new president states that government is the answer.

Medical Gluttony thrives in Government and Health Insurance Programs.

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

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6. Medical Myths: It Doesn't Cost Me Anything

As doctors try to be judicious with their pen when they order drugs by prescription and x-rays and laboratory tests by requisition, the patients usually try to increase their benefits at no additional costs. They want more medications and ask for prescriptions for OTC medications that don't need prescriptions but are covered by some insurance companies. They ask for more x-rays and tests than are required for diagnosis and treatment. When trying to ask the patient to be reasonable, a common response is that it doesn't cost anything additional so why does the doctor care.

Most doctors are concerned about health care costs. They know that more expensive tests than are needed will increase health care costs even more. So doctors try to educate patients to be concerned about costs. But frequently patients take great exception to this approach. One even said, "You're in cahoots with the insurance plan and, therefore, you're denying me my rightful care."

This changes many doctor-patient relationships, that should be one of trust and confidence of obtaining the best in health care, to one of suspicion, mistrust and even anger. Thus, trying to put the doctor in charge in our current system of managed care destroys one of the more confidential relationships we'll ever have.

What's the answer? The answer may seem like a broken record to many. But there's no alternative. Put the patient in charge by having a significant deductible per year with every service having a significant co-payment. This totally reverses the patient's attitude towards more drugs, more tests, more x-rays and more consultations. Instead of ineffective policing of costs by the health care establishment, control of costs by the patient is more effective. It also improves the doctor-patient relationship, as well as decreasing lawyer involvement in healthcare because patients have determined their own limits and won't be running to attorneys to sue doctors for not doing enough tests and x-rays.

It's a quadruple win situation. Health care costs will become more transparent. Health care costs will decrease and come under control. It will again become more pleasant to interface with doctors who will be treated like professionals should be treated. And it will decrease litigation since patients will be happy and satisfied with their own self-directed, professionally supervised health care. Decreased litigation translates immediately into lower costs for liability insurance - a nationwide problem.

Medical Myths originate when someone else pays the medical bills.

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

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7. Overheard in the Medical Staff Lounge: Can Government Healthcare be as bad as what we currently have?

Dr. Kaleb: I have a hard time getting cancer drugs for my HMO patients. I can't see government medicine being any worse.

Dr. Dave: Don't you read about the patients in the National Health Service who don't have some proven cancer chemotherapy drugs available at all?

Dr. Edwards: In Canadian Medicare, they are restricting more and more drugs as long as they have an inferior drug on their list.

Dr. Rosen: Quality issues are irrelevant in government medicine. It's all about cost and economics of care.

Dr. Kaleb: If patients wouldn't get the care they've come to expect, don't you think they would get their Congress representative to get them approved?

Dr. Sam: What makes you think that if patients in the UK and Canada can't get their government to change, that we would be able to get ours to approve costly items?

Dr. Kaleb: Our representatives want to get re-elected so why wouldn't they try to please?

Dr. Sam: Remember there are less than one million of us. That's only about 0.3 percent of the vote. That is almost totally irrelevant to their future.

Dr. Kaleb: Well, I'm getting sick and tired of spending hours trying to help my patients out at no charge.

Dr. Sam: Well, get use to it. If you had to get government approval for a $2500 cancer drug, we're not talking about hours. We're talking about weeks and months.

Dr. Edwards: With health care costs going skyward, we're probably talking about years.

Dr. Rosen: Or never.

Dr. Paul: Well, in Pediatrics I know I'd be better off with the government paying the tab.

Dr. Sam: In Pediatrics you probably have had little experience with Medicare patients. Better talk to your colleagues over in Geriatrics. Nothing moves without Medicare hassles.

Dr. Paul: Well, I'll take my chances. I've listened to you folks for a long time and I'm beginning not to believe much of what I hear around these tables.

Dr. Sam: You want to take a day off and spend it in my office and gain some first hand experience before you make all of our lives miserable?

Dr. Paul: Not sure that would change my mind.

Dr. Rosen: With many of the major industrial countries trying to privatize their government-run health care, why are so many of us going in the opposite direction? Are we incapable of learning from other's mistakes?

Dr. Yancy: Looks like the answer is around these tables.

Dr. Rosen: Looks like most of us believe that government health care will be far worse than the current mix that people call a non-system. Actually, a non-system is preferable than a poorly functioning government system that most countries have. And we have total access. Any American can go to any Emergency Room and obtain care. This is far better than the waiting lists in all government health plans where many emergencies can't even be triaged but end up on a list.

The Staff Lounge Is Where Unfiltered Opinions Are Heard.

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8. Voices of Medicine: A Review of Local and Regional Medical Journals

Bulletin of the California Society of Anesthesiologists, Winter, 2008

President's Page: The Law of Unintended Consequences By Virgil M. Airola, M.D.

Unintended consequences - probably the best reason for every physician to join one's peers as a member in organized medicine - are the unanticipated results created when someone without a deep understanding of an issue, any issue, begins to micromanage the business where the issue arose. When a physician administers a medication, a narcotic, for example, to a patient and the patient suffers a side effect, nausea possibly, often the side effect has been anticipated and the physician is prepared to manage the nonbeneficial effect of the medication effectively. In my example, the physician had an in-depth understanding of pharmacology and judged that the benefits to the patient outweighed the risks of administering the medication. In our current political environment, organized medicine spends innumerable hours explaining the potential unintended consequences to legislators and bureaucrats who propose to solve a medical issue for their constituents without an in-depth understanding of the medical landscape. Happily, the legislators and bureaucrats usually listen carefully, incorporate the insights of physicians into their understanding of the issue, and make the best informed decisions they can.

As I write this article, the Department of Managed Health Care (DMHC) public hearings on their proposed "balance billing" regulations are ongoing and the written comments deadline has been extended until November 30^th. A number of CSA members and leaders, along with other physicians and other interested parties, have shared their verbal and written comments on these draft regulations with the DMHC. A partial list of CSA members and leaders includes Drs. David Black, Christine Doyle, Wayne Kaufman, Earl Strum, Larry Sullivan, Paul Yost, Mark Zakowski, and me. Individually, we have presented our strong opposition to the DMHC proposals.

Those of us who took a day off work to attend the public hearings had a chance to see and hear the interaction between the DHMC officials and representatives of the public, the health insurance industry, and individual physicians who gave their testimony before the DMHC panel. At times, the testimony was sedate and reasoned, but some individuals became impassioned. What was clear to me from watching the DMHC officials was that the bureaucrats were defensive when the testimony impugned their objectivity or motives in bringing these proposals forward. . .

The proposed regulations include modifications to the Gould criteria that have historically provided the legal foundation for determining what passes for a "reasonable" usual-and-customary physician's fee. The Gould criteria (Gould v. WCAB, 4 Cal.App.4^th 1059, decided in 1992), which legally define the determinants of a reasonable billed fee for medical services rendered by a physician are: (1) the provider's training, qualifications, and length of time in practice, (2) the nature of the services provided, (3) the fees usually charged by the provider, (4) prevailing provider rates charged in the general geographic area in which the services were rendered, (5) other aspect of the economics of the medical provider's practice that are relevant, and (6) any unusual circumstances in the case. The DMHC proposal would add Medicare reimbursement rates and discounted contracted (insurance) rates to the Gould criteria . . .

Read the entire article . . .

VOM Is Where Doctors' Thinking is Crystallized into Writing.

9. Cinematic Review: Why Sister Aloysius "Doubts"

Film asks: Can Faith endure amidst a Modern Sea of Doubt? By James J. Murtagh, M.D.

Warning: spoiler alert. If you have not seen Doubt, do not read further. The film contains a major plot twist, which is discussed in this Op- Ed.

The best (and last) line of the Pulitzer-prize winning play (turned Blockbuster film) Doubt exposes the moral squeeze on its main character Sister Aloysius. In a final and complete reversal of roles, the starch-collar, old school, Catholic nun reveals to her innocent protégé Sister James that she, the hard line absolutist, now has "doubts."

What! Sister Aloysius, the ruler wielding, never-had-a-doubt-in-my-life dogmatic, now a doubting Thomas? To catch a pedophile, Aloysius told a lie. True Catholic dogma (or Kantian dogma, etc) would never allow such a lie, even to defeat evil. In the service of God, the nun finds herself forced into Machiavellian relativism. Does the end really justify the means?

Sr. Aloysius doubt encapsulates the last century of humanity's doubt: "Things fall apart; the centre cannot hold...", "What but design of darkness to appall?-If design govern in a thing so small."

The nun abandons absolutism, violating her vow of obedience to the Church to catch the pedophile. When the hierarchy fails to act, she becomes prosecutor, judge and jury, stepping onto the slippery slope of moral relativism. If even Sister Aloysius cannot defend moral absolutes, can anyone? Then, how will we recognize evil? Can we stop evil without absolutes?

Seemingly, this film examines crisis in the Catholic Church. In reality, it speaks to the crisis in our world.

Doubt is a Rorschach test in the culture wars. What can we know, and when can we know it? Matthew Arnold wrote that faith is gone, and doubt now reigns supreme. Faith once girdled the earth like a sea, and "Sophocles long ago . . . Heard it on the Ægæan" But now "Its melancholy, long, withdrawing roar, Retreating, to the breath"

Are there any boundaries? Aloysius "case" against the pedophile is mainly on intuition. Her "evidence" is more flimsy than the evidence of WMDs in Iraq. She may have gotten the right result, but if so, she was lucky.

History is filled with evildoers acting from fierce conviction: Mullahs, witch-hunters, Inquisitors and suicide-bombers. More often than not, they all act from the conviction that they are protecting children. Aloysius states, "In the service of God, sometimes one must take a step away from God." Aloysius even has the hubris to act before she knows evil has been done. She launches a pre-emptive Jihad based only on suspicion. Such Jihads will be wrong more often than they are right.

Turning and turning in the widening gyre, we are all part of ignorant armies, clashing by night. In the absence of true moral authority, must individuals take matters into their own hands? How do we avoid creating a world of vigilantes, if we apply the principle of Universality? There is no difference in using a lie to stop evil than using a lie to go to war.

When the leaders of moral standards break these standards, the center cannot hold. Mere anarchy is loosed.

The worst villains do not appear. If the bishops had done their job and held evil accountable, it would not have fallen to Sr. Aloysius to launch her one-woman campaign.

Hell's best-kept secret is that we create it for ourselves. Aloysius connived, threatened, and lied to get the pedophile removed from her parish, only to see him promoted. It is nothing but a Dantean existential nightmare.

Job sat surrounded by three friends, wondering why God allows evil. The relativistic devil serves for the amusement of God himself. Job's story contradicts the rest of the Bible, a kind of minority report.

The author of Doubt is doubtless of the company of the devil. Clearly, the author relishes doubt, declaring doubt a part of the "bond" that links all huto man beings. The wisest men in history were those who knew they knew nothing. Universal doubt may have seemed like death to Matthew Arnold and Yeats, yet Socrates and Shakespeare reveled in doubt. The skeptics thought they had the upper hand, at least until Hitler. Then it became clear that relativists would not keep us safe from evil.

One wonders: are the doubters or the faithful more likely to inherit the earth? Possibly, we need both to make the world run.

Dostoevsky believed that punishment was essential to redemption of the human soul. Aloysius knows she is guilty of lying and breaking vows, but is not caught and not punished. Instead, she lives in frozen silence, without that most dear to her, her faith.

Aloysius no longer dwells in a world of precision and grandeur of divine justice. Now, she is in the relativistic company of Nietzsche, Kafka, Orwell and worse. Hamlet, and Aloysius lived in worlds "rotten," full of secrecy, topsy-turvy and despair that they were born to set things aright. To be or not to be? It's a legitimate question when you awake in a dark wood of doubt.

In the film's final ironic twist, the seemingly simple-minded innocent protégé Sister James turns out to have the only durable faith of the characters. Sister James had wished for the certainty and ram-rod faith of Sister Aloysius. But appearance is opposite of reality. It is left to James to comfort Aloysius on a frozen bench, in the winter of Sister Aloysius's doubt and despair.

James J. Murtagh Jr.

jmurtag@mindspring.com

This review is found at www.healthcarecom.net/JM_Doubts.htm

To read more book reviews, go to www.delmeyer.net/PhysicianPatientBookshelf.htm.

To read book reviews topically, go to www.healthcarecom.net/bookrevs.htm.

We welcome submissions of Book and Cinematic Reviews from MedicalTuesday members about books and movies of medical interest or any review by members of the profession.

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10. Hippocrates & His Kin: Paperwork Reduction

My practice received an end-of-year FUTA tax form to be completed. The Paperwork Reduction Act requires government bureaucracies to estimate the time it will take to complete and file the form. It read:

Recordkeeping: 23 hr, 39 minutes
Learning about the law or the form: 1 hr, 23 minutes
Preparing and sending the form to the IRS: 2 hr, 17 minutes

If you have comments concerning the accuracy of these time estimates or suggestions for making Form 940 simpler, we would be happy to hear from you at . . .

A doctor should be able to sit down with his bookkeeper after the last patient and whip this out?

Just a hint of what the new medical regulations will be with the new administration:

A patient medical record must contain an adequate chief complaint, one minute, a full development of this medical problem, 18 minutes, a brief survey of eleven organ systems, 22 minutes, a complete physical examination, 13 minutes, a medical plan for the patient to follow along with requisitions and prescriptions, 8 minutes. Total: 62 minutes.

Since there will be increased utilization of medical services inasmuch as they will be fully covered and free to the patient, physicians will have to see five patients per hour instead of four.

Doctor: If you can't complete the estimated 62 minutes in the required 12-minute appointment, you might just have to work harder.

The Afghan chieftain looked older that his 60-odd years and his bearded face bore the creases of a man burdened with duties as tribal patriarch and husband to four younger women. His visitor, a CIA officer, saw an opportunity and reached in his bag for a small gift - Four blue pills - Viagra. "Take one of these. You'll love it," said the CIA officer. Compliments of Uncle Sam.

It worked. Four days later, the grinning chief returned and offered a bonanza of information about the Taliban movements and supply routes - followed by a request for more Viagra.

"He came up to us beaming. You are a great man." After that, the US intelligence officer could do whatever they wanted to do in his area.

Isn't that how women have always had a great civilizing influence on men?

To read more HHK, go to www.healthcarecom.net/hhkintro.htm.

To read more HMC, go to www.delmeyer.net/HMC.htm.

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

• The National Center for Policy Analysis, John C Goodman, PhD, President, who along with Gerald L. Musgrave, and Devon M. Herrick wrote Lives at Risk, issues a weekly Health Policy Digest, a health summary of the full NCPA daily report. You may log on at www.ncpa.org and register to receive one or more of these reports. This month, read the informative OpEd by Dr. Devon M. Herrick on Health Care Entrepreneurs: The Changing Nature Of Providers.

• Pacific Research Institute, (www.pacificresearch.org) Sally C Pipes, President and CEO, John R Graham, Director of Health Care Studies, publish a monthly Health Policy Prescription newsletter, which is very timely to our current health care situation. You may signup to receive their newsletters via email by clicking on the email tab or directly access their health care blog. Read Mr. Grahams OpEd on Health-Care Rationing is Inevitable? Letters in the Wall Street Journal.

• The Mercatus Center at George Mason University (www.mercatus.org) is a strong advocate for accountability in government. Maurice McTigue, QSO, a Distinguished Visiting Scholar, a former member of Parliament and cabinet minister in New Zealand, is now director of the Mercatus Center's Government Accountability Project. Join the Mercatus Center for Excellence in Government. This month, treat yourself to an article on 21st Century Regulation: Discovering Better Solutions to Enduring Problems.

• The National Association of Health Underwriters, www.NAHU.org. The NAHU's Vision Statement: Every American will have access to private sector solutions for health, financial and retirement security and the services of insurance professionals. There are numerous important issues listed on the opening page. Be sure to scan their professional journal, Health Insurance Underwriters (HIU), for articles of importance in the Health Insurance MarketPlace. The HIU magazine, with Jim Hostetler as the executive editor, covers technology, legislation and product news - everything that affects how health insurance professionals do business.

• The Galen Institute, Grace-Marie Turner President and Founder, has a weekly Health Policy Newsletter sent every Friday to which you may subscribe by logging on at www.galen.org. A study of purchasers of Health Savings Accounts shows that the new health care financing arrangements are appealing to those who previously were shut out of the insurance market, to families, to older Americans, and to workers of all income levels. This month, you might focus on Ms. Turner's OpEd: Congress Hopes to Give Obama Early Victory with SCHIP.

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

• The Heartland Institute, www.heartland.org, Joseph Bast, President, publishes the Health Care News and the Heartlander. You may sign up for their health care email newsletter. Read the late Conrad F Meier on What is Free-Market Health Care?. This month, be sure to read Mr. Scanden's OpEd on Consumer-Driven Health Care Reaches 20 Percent ‘Tipping Point.'

• 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. Be sure to read the current lesson on Economics by Prof William Anderson, an associate professor of economics at Frostburg State University. He writes on Seven Fallacies of Economics. You will want to follow his monthly lectures on the seven fallacies, which we hope to highlight.

• The Council for Affordable Health Insurance, www.cahi.org/index.asp, founded by Greg Scandlen in 1991, where he served as CEO for five years, is an association of insurance companies, actuarial firms, legislative consultants, physicians and insurance agents. Their mission is to develop and promote free-market solutions to America's health-care challenges by enabling a robust and competitive health insurance market that will achieve and maintain access to affordable, high-quality health care for all Americans. "The belief that more medical care means better medical care is deeply entrenched . . . Our study suggests that perhaps a third of medical spending is now devoted to services that don't appear to improve health or the quality of care - and may even make things worse." This month, you'll want to read Should the Government Force You to Buy Health Insurance. Many policymakers seem to believe mandating that everyone purchase health insurance will bring down the cost and lead to less uninsured. However, CAHI explains in this Issues and Answers paper that such an approach treats only the symptom and not the disease.

• The Independence Institute, www.i2i.org, is a free-market think-tank in Golden, Colorado, that has a Health Care Policy Center, with Linda Gorman as Director. Be sure to sign up for the monthly Health Care Policy Center Newsletter. Read her latest OpEd: government health insurance not worth paper it is printed on: Some prominent Colorado health reformers think that everyone will be better off if more people rely on government for their health care. Unfortunately, stories about government inability to meet its current health care promises are increasingly commonplace. They show that health care, like food, housing, communications, and transportation, is far too important to be left in the hands of government.

• 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, in an article entitled "Why Giving Makes You Happy," published late last year in The New York Sun, Arthur Brooks informed us that Americans gave nearly $300 billion to charitable organizations in 2007. One of the explanations for this generosity - in addition to the fact that charitable donations are tax deductible, as they are in Canada - is the simple fact that giving makes you happy. Read GIVING MAKES YOU HAPPY.

• 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. Fraser Forum is a monthly review of public policy in Canada, with articles covering taxation, education, health care policy, and a wide range of other topics. Forum writers are economists, Institute research analysts, and selected authors, including those from other public policy think tanks. To search past issues, go to www.fraserinstitute.org/researchandpublications/publications/search.aspx?Page=1&title=&author=0&keyword=&date=0&topic=0&formatid=94&sort=date.

• The Heritage Foundation, www.heritage.org/, founded in 1973, was a research and educational institute whose mission was to formulate and promote public policies based on the principles of free enterprise, limited government, individual freedom, traditional American values and a strong national defense. -However, since they supported the socialistic health plan instituted by Mitt Romney in Massachusetts, which is replaying the Medicare excessive increases in its first two years, they have lost site of their mission and we will no longer feature them as a freedom loving institution.

• The Ludwig von Mises Institute, Lew Rockwell, President, is a rich source of free-market materials, probably the best daily course in economics we've seen. If you read these essays on a daily basis, it would probably be equivalent to taking Economics 11 and 51 in college. Please log on at www.mises.org to obtain the foundation's daily reports. This month: Remember the credit crunch? Of course you do. We'd never seen anything like it, or so the highest financial authorities and their lapdogs in the news media told us - not in a cool, calm, and collected way, either, but in a breathless delivery that suggested imminent economic doom unless the government immediately undertook to "do something." Which it did, of course, on a scale never before witnessed in US history. Read the entire story at http://mises.org/story/3288. You may also log on to Lew's premier free-market site to read some of his lectures to medical groups. Learn how state medicine subsidizes illness or to find out why anyone would want to be an MD today.

• CATO. The Cato Institute (www.cato.org) was founded in 1977, by Edward H. Crane, with Charles Koch of Koch Industries. It is a nonprofit public policy research foundation headquartered in Washington, D.C. The Institute is named for Cato's Letters, a series of pamphlets that helped lay the philosophical foundation for the American Revolution. The Mission: The Cato Institute seeks to broaden the parameters of public policy debate to allow consideration of the traditional American principles of limited government, individual liberty, free markets and peace. Ed Crane reminds us that the framers of the Constitution designed to protect our liberty through a system of federalism and divided powers so that most of the governance would be at the state level where abuse of power would be limited by the citizens' ability to choose among 13 (and now 50) different systems of state government. Thus, we could all seek our favorite moral turpitude and live in our comfort zone recognizing our differences and still be proud of our unity as Americans. Michael F. Cannon is the Cato Institute's Director of Health Policy Studies. Read his bio, articles and books at www.cato.org/people/cannon.html. This month be sure to understand the association between politics and corruption: Illinois Gov. Rod Blagojevich is the new poster boy for political corruption, but he is really just the most recent reminder of the fundamentally grubby and corrupt nature of politics. In Illinois alone, three recent governors - liberal "reformers" Otto Kerner and Dan Walker and career politician George Ryan - have preceded Blagojevich in making the journey from the statehouse to the big house. Cases like these remind us of the fundamental nature of politics. Blagojevich showed less intelligence and more vulgarity than most politicians, but trading taxpayer money for personal or political gain is the common coin of politicians. In his first post-indictment news conference, Blagojevich himself strongly hinted that he will defend himself with the notion that swapping appointments and favors is merely stock in trade for politicians of the upper echelon. That leads to a virtually inescapable conclusion: The best way to limit such tawdry quid pro quo is to limit the power of politicians and of government.

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

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

• The St. Croix Review, a bimonthly journal of ideas, recognizes that the world is very dangerous. Conservatives are staunch defenders of the homeland. But as Russell Kirk believed, wartime allows the federal government to grow at a frightful pace. We expect government to win the wars we engage, and we expect that our borders be guarded. But St. Croix feels the impulses of the Administration and Congress are often misguided. The politicians of both parties in Washington overreach so that we see with disgust the explosion of earmarks and perpetually increasing spending on programs that have nothing to do with winning the war. There is too much power given to Washington. Even in wartime, we have to push for limited government - while giving the government the necessary tools to win the war. To read a variety of articles in this arena, please go to www.stcroixreview.com. For month's treat, click on Remembering Solzhenitsyn with Dr. Thomas Sutherland

• Hillsdale College, the premier small liberal arts college in southern Michigan with about 1,200 students, was founded in 1844 with the mission of "educating for liberty." It is proud of its principled refusal to accept any federal funds, even in the form of student grants and loans, and of its historic policy of non-discrimination and equal opportunity. The price of freedom is never cheap. While schools throughout the nation are bowing to an unconstitutional federal mandate that schools must adopt a Constitution Day curriculum each September 17^th or lose federal funds, Hillsdale students take a semester-long course on the Constitution restoring civics education and developing a civics textbook, a Constitution Reader. You may log on at www.hillsdale.edu to register for the annual weeklong von Mises Seminars, held every February, or their famous Shavano Institute. Congratulations to Hillsdale for its national rankings in the USNews College rankings. Changes in the Carnegie classifications, along with Hillsdale's continuing rise to national prominence, prompted the Foundation to move the College from the regional to the national liberal arts college classification. Please log on and register to receive Imprimis, their national speech digest that reaches more than one million readers each month. This month, read President Dr. Arnn: THE AUTUMN of 2008 has brought events in politics and economics that touch upon the meaning of our country and how it shall be governed in the future. These events are, as Lincoln said of the results of the Civil War, both "fundamental and astounding." They bring us another step away from the principles and institutions that have made our country both good and great at www.hillsdale.edu/news/imprimis.asp. The last ten years of Imprimis are archived.

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Please note that sections 1-3, 8-9 are entirely attributable quotes and editorial comments are in brackets. Permission to reprint portions has been requested and may be pending with the understanding that the reader is referred back to the author's original site. Please also note: Articles that appear in MedicalTuesday may not reflect the opinion of the editorial staff.

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

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

Del Meyer

Del Meyer, MD, Editor & Founder

DelMeyer@MedicalTuesday.net

www.MedicalTuesday.net

6945 Fair Oaks Blvd, Ste A-2, Carmichael, CA 95608

Words of Wisdom

"Make no little plans. They have no magic to stir men's blood . . . Make big plans; aim high in hope and work . . . Think big." -Daniel Burnham, Chicago architect. (1864-1912)

"The purpose of life is a life of purpose." -Robert Byrne: A leading chess player and newspaper columnist.

"It doesn't matter where you are coming from. All that matters is where you are going." -Brian Tracy: Personal and business development author, lecturer, consultant

Some Recent Postings

A Time for Freedom, by Lynne Cheney: www.delmeyer.net/bkrev_ATimeForFreedom.htm

We The People - The Story of Our Constitution, by Lynne Cheney www.delmeyer.net/bkrev_WeThePeople.htm

Why Sister Aloysius "Doubts" www.healthcarecom.net/JM_Doubts.htm

In Memoriam

Mrs Thatcher's monetarist guru: The death of Sir Alan Walters From The Economist print edition

Jan 8th 2009

His economic advice proved politically costly

ON USHERING visitors into his home Sir Keith Joseph, a punctilious host, would proffer a handshake by way of welcome. On this occasion, however, the senior Tory politician was shocked when his younger guest pointedly refused to take his hand. Instead, he got a volley of abuse about his role in "debauching the currency". Such was the pedagogic style of Sir Alan Walters, who died on January 3rd, aged 82.

At the time of their meeting, in 1974, Joseph was beginning a total re-evaluation of economic policy provoked by Edward Heath's disastrous government, in which he had served. That had ended with a Keynesian public-spending binge, the orthodoxy of the day, to stimulate the economy. But instead of helping, it had caused runaway inflation and a rash of strikes. Surely there was another way?

Joseph had sought out Sir Alan as the leading British exponent of the counter-revolution in economics, led by Milton Friedman at the University of Chicago. Monetarists argued that only by tackling the amount of money circulating in the economy could governments tame inflation, then the scourge of Western economies. This would force them to cut public spending—and in Britain to demolish over mighty trade unions, which extorted wage rises without any increase in productivity.

This, in short, became the essence of Thatcherism. Sir Alan and others hammered this message home to Joseph and his closest political ally, Margaret Thatcher. The politicians were converted, and Sir Alan became Mrs Thatcher's guru on the new policies after she took over as leader of the Conservatives in 1975.

Like his political leaderene, Sir Alan was from a relatively poor background in the unfashionable east Midlands. And like her, he nurtured a lifelong disdain for middle-class intellectual socialists.

As her special adviser in Downing Street, he played a vital role in two of the most important episodes of her premiership. In 1981 he was brought back from academia to stiffen her resolve in pushing though a budget that cut public spending during a recession, the decisive break with the Keynesian past.

And in 1989, even more controversially, he returned to help her in a dispute with her chancellor, Nigel Lawson, who wanted sterling to join the European Exchange Rate Mechanism, a prelude to the euro. Sir Alan, like the prime minister, shared an instinctive distrust of such currency systems; he famously called this a "half-baked" idea. Mr Lawson resigned over what he saw as interference in economic policymaking, and Sir Alan had to go too. But in the long run Sir Alan's view prevailed; the British still seem to prefer their pound, even in its present debauched state, to the euro.

www.economist.com/world/britain/PrinterFriendly.cfm?story_id=12915349

On This Date in History - January 13

On this date in 1898, a man named Emile Zola published in Paris an article entitled "J'accuse" (I accuse). It was a defense of a French soldier named Alfred Dreyfus, who was being railroaded on treason charges. The Zola article aroused France and the world. Before the case was over, not only was Captain Dreyfus vindicated, but also the government of France and the French military establishment were rocked to their heels and drastically changed. This was the power of an idea.

On this same date in 1864, a gentle man died in Bellevue Hospital in New York - a man who rocked no governments, roused no great pangs of science; but a man who wrote songs that have conjured up ever since, for millions upon millions of people, a mind's eye image of America. This is Stephen Foster Memorial Day, in memory of the author of gentle songs that have contributed so much to our picture of ourselves, of the Swanee River, of the old folks at home, of Jeannie with the light brown hair. Times change and some of Stephen Foster's lyrics are no longer sung because their connotations do not fit the times. But the essential spirit that he caught remains as part of the American heritage.

After Leonard and Thelma Spinrad

MOVIE EXPLAINING SOCIALIZED MEDICINE TO COUNTER MICHAEL MOORE's SiCKO

Logan Clements, a pro-liberty filmmaker in Los Angeles, seeks funding for a movie exposing the truth about socialized medicine. Clements is the former publisher of "American Venture" magazine who made news in 2005 for a property rights project against eminent domain called the "Lost Liberty Hotel."
For more information visit www.sickandsickermovie.com or email logan@freestarmovie.com.

MEDICAL TUESDAY . NET	NEWSLETTER
Community For Better Health Care	Vol VII, No 19, Jan 13, 2009