MEDICAL TUESDAY . NET
Community For Better Health Care
Vol V, No 19, Jan 16, 2007
In This Issue:
The Annual World Health Care Congress, co-sponsored by The Wall Street Journal, is the most prestigious meeting of chief and senior executives from all sectors of health care. Renowned authorities and practitioners assemble to present recent results and to develop innovative strategies that foster the creation of a cost-effective and accountable U.S. health-care system. The extraordinary conference agenda includes compelling keynote panel discussions, authoritative industry speakers, international best practices, and recently released case-study data. The 3rd annual conference was held April 17-19, 2006, in Washington, D.C. One of the regular attendees told me that the first Congress was approximately 90 percent pro-government medicine. This year it was 50 percent, indicating open forums such as these are critically important. The 4th Annual World Health Congress has been scheduled for April 22-24, 2007, also in Washington, D.C. The World Health Care Congress - Asia will be held in Singapore on May 21-23, 2007. The World Health Care Congress - Middle East will be held in Dubai, United Arab Emirates, on November 12-14, 2007. World Health Care Congress - Europe 2007 will meet in Barcelona on March 26-28, 2007. For more information, visit www.worldcongress.com.
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1. Featured Article: The Perfect Human - Your
Mind Is Your Most Important Muscle
Dean Karnazes ran 50 marathons in 50 days. He does 200 miles just for fun. He'll race in 120-degree heat. 12 secrets to his success. By Joshua Davis, Wired Magazine
DEAN KARNAZES WAS SLOBBERING DRUNK. IT WAS HIS 30TH BIRTHDAY, and he'd started with beer and moved on to tequila shots at a bar near his home in San Francisco. Now, after midnight, an attractive young woman - not his wife - was hitting on him. This was not the life he'd imagined for himself. He was a corporate hack desperately running the rat race. The company had just bought him a new Lexus. He wanted to vomit. Karnazes resisted the urge and, instead, slipped out the bar's back door and walked the few blocks to his house. On the back porch, he found an old pair of sneakers. He stripped down to his T-shirt and underwear, laced up the shoes, and started running. It seemed like a good idea at the time.
He sobered up in Daly City, about 15 miles south. It was nearly four in the morning. The air was cool, slightly damp from the fog, and Karnazes was in a residential neighborhood, burping tequila, with no pants on. He felt ridiculous, but it brought a smile to his face. He hadn't had this much fun in a long time. So he decided to keep running.
When the sun came up, Karnazes was trotting south along Route 1, heading toward Santa Cruz. He had covered 30 miles. In the process, he'd had a blinding realization: There were untapped reservoirs within him. It was like a religious conversion. He had been born again as a long-distance runner. More than anything else now, he wanted to find out how far he could go. But at that exact moment, what he really needed to do was stop. He called his wife from a pay phone, and an hour later she found him in the parking lot of a 7-Eleven. He passed out in the car on the way home.
That was August 1992. Over the next 14 years, Karnazes challenged almost every known endurance running limit. He covered 350 miles without sleeping. (It took more than three days.) He ran the first and only marathon to the South Pole (finishing second), and a few months ago, at age 44, he completed 50 marathons in 50 consecutive days, one in each of the 50 states. (The last one was in New York City. After that, he decided to run home to San Francisco.) Karnazes' transformation from a tequila-sodden party animal into an international symbol of human achievement is as educational as it is inspirational. Here's his advice for pushing athletic performance from the unthinkable to the untouchable.
1. BE AUDACIOUS
Finding the right challenge is the first challenge. "Any goal worth achieving involves an element of risk," Karnazes says in his autobiography, Ultramarathon Man: Confessions of an All-Night Runner. Risk, yes, and creativity too. For instance, looking for the ultimate endurance running challenge, in 1995 Karnazes entered a 199-mile relay race - by himself. He competed against eight teams of 12 and finished eighth.
2. GO LACELESS
One of the biggest annoyances in long-distance running is lace management. After banging out 50 miles, it can be hard to squat or even bend over long enough to tie your shoes. . .
3. FLIRT WITH DISASTER
In 1995, Karnazes ran his first Badwater Ultramarathon, a 135-mile trek that starts in Death Valley, California, in the middle of summer and finishes at the Mt. Whitney Portals, 8,360 feet above sea level. After running 72 miles in 120-degree heat, Karnazes collapsed on the side of the road suffering from hallucinations, diarrhea, and nausea. He had pushed himself to the point of death to find out whether he was strong enough to survive. He was. . . "Somewhere along the line, we seem to have confused comfort with happiness," he says.
4. EAT JUNK – LOTS OF IT
You wouldn't believe the stuff Karnazes consumes on a run. He carries a cell phone and regularly orders an extra-large Hawaiian pizza. . . He'll chase the pizza with cheesecake, cinnamon buns, chocolate éclairs, and all-natural cookies. The high-fat pig-out fuels Karnazes' long jaunts, which can burn more than 9,000 calories a day. . . When he's not in the midst of some record-breaking exploit, Karnazes maintains a monkish diet, eating grilled salmon five nights a week. He strictly avoids processed sugars and fried foods - no cookies or doughnuts. He even tries to steer clear of too much fruit because it contains a lot of sugar. . .
5. CUT BACK ON SLEEP
Karnazes has a wife and two kids, and he worked a 9-to-5 job for the first eight years of his quest to transcend his own limits. Finding four hours for a 30-mile run during the day was next to impossible. The solution: sleep less. "Forgoing sleep is the only way I've figured out how to fit it all in," he says, noting that running in the dark can be soothing . . . He now gets about four hours of shut-eye a night. . .
6. SHOW YOUR BODY WHO'S BOSS
"The human body has limitations," Karnazes says. "The human spirit is boundless." Your mind, in other words, is your most important muscle. As a running buddy told him: "Life is not a journey to the grave with the intention to arrive safely in a pretty and well-preserved body, but rather to skid in broadside, thoroughly used up, totally worn out, and loudly proclaiming: Wow!! What a ride!"
7. GET A COOL WATCH
Karnazes wears a souped-up Timex that monitors his speed, distance, calories burned, and elevation, all of which is critical for deciding when to order the next pizza while in the midst of a 200-mile trek. Besides letting him order a pie on the run, his cell phone uses specialized GPS software to broadcast his location to the Internet for all to see. . .
8. LEARN TO LOVE KRAZY GLUE
If something goes wrong - and it inevitably will - it's usually with Karnazes' feet. In races and on training runs, he has battled giant, foot-devouring blisters. A surprisingly effective treatment: Krazy Glue. Pop the blister, slather the wound with the super-adhesive, and voilà - your foot is ready to take a beating again. . .
9. GET USED TO IT
If you're going to explore the boundaries of human endurance, you'll have to learn to adapt to more and more pain. To prepare for the searing heat of the Badwater race, Karnazes went on 30-mile jogs wearing a ski parka over a wool sweater. He trained himself to urinate while running. . . Eventually, when he grew accustomed to the pain, it stopped hurting. "There is magic in misery," he says.
10. PROMOTE THE HELL OUT OF YOURSELF
Before he became Superman, Karnazes was the Clark Kent of the PR world: a humdrum marketing executive at a pharmaceutical company. But in the past three years, he's published a memoir, nabbed a sponsorship from the North Face, appeared on Late Show With David Letterman, and gotten himself on the cover of a handful of magazines. . .
11. BREAK IT DOWN
Fifty-six miles into his first Western States Endurance Run - one of the oldest 100-mile races in the country - Karnazes found himself alone entering a canyon at twilight. It was tough going - the trek boasts a total elevation change of 38,000 feet. With 44 miles to go, his spirit was flagging, but he found a way to make it seem conquerable: He remembered the next checkpoint would leave only a marathon and two 10Ks left to go. He knew he could run each leg, and that helped him achieve the whole.
12. AVOID KRYPTONITE
Forget tequila. Karnazes has given up hard drinking. His big vice these days: chocolate-covered espresso beans.
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Ms. Galvin's Insurer Studies Psychotherapist's Notes; A Dispute Over the Rules Complaint Tally Hits 23,896, By THEO FRANCIS, December 26, 2006
After her fiancé died suddenly, Patricia Galvin left New York for San Francisco in 1996 and took a job as a tax lawyer for a large law firm. A few years later, she began confiding to a psychologist at Stanford Hospital & Clinics about her relationships with family, friends and co-workers.
Then, in 2001, she was rear-ended at a red light. When she later sought disability benefits for chronic back pain, her insurer turned her down, citing information contained in her psychologist's notes. The notes, her insurer maintained, showed she wasn't too injured to work.
Ms. Galvin, 51 years old, was appalled. It wasn't just that she believed her insurer misinterpreted the notes. Her therapist, she says, had assured her the records from her sessions would remain confidential.
As the health-care industry embraces electronic record-keeping, millions of pages of old documents are being scanned into computers across the country. The goal is to make patient records more complete and readily available for diagnosis, treatment and claims-payment purposes. But the move has kindled patient concern about who might gain access to sensitive medical files -- data that now can be transmitted with the click of a computer mouse.
The U.S. Department of Health and Human Services implemented standards in 2003 for guarding patient privacy, supplementing a patchwork of state laws. The federal standards, which grew out of the 1996 Health Insurance Portability and Accountability Act, single out psychotherapy notes for extra protection.
Critics claim that loopholes in the rules have left patient privacy under threat. Ms. Galvin, for example, discovered that when psychotherapy notes are mixed in with general medical records, the federal rules afford them no special protection. That is precisely what happened with her records at Stanford, she says.
"I feel like now I have no privacy," Ms. Galvin says. "My most private thoughts, my personal tragedies, secrets about other people, are mere data of a transaction, like a grocery receipt.". . .
Confidentiality has been integral to the practice of medicine since the Hippocratic oath was drafted some 2,400 years ago. . .
Patients tend to be especially sensitive about medical information they believe could stigmatize them in the workplace or among acquaintances, such as records about AIDS, substance abuse and abortion. "What's sensitive to one person may not be to another," says Deborah Peel, an Austin, Texas, psychiatrist and head of Patient Privacy Rights, a medical-privacy advocacy group. "How many women want somebody to know whether they are or are not on birth control?"
Mental-health records are generally viewed as worthy of the most stringent safeguards. In recent years, courts and state legislatures have afforded psychotherapy records special protections. All 50 states recognize some form of psychotherapist-patient privilege to limit disclosures in legal proceedings, and a similar federal privilege was established in a landmark 1996 Supreme Court ruling.
Because Ms. Galvin learned of the disclosure and filed a lawsuit, unusual in such cases, her experience offers a look at how increasingly complex confidentiality issues are affecting patients and their insurance coverage. . .
In 2000, she sought help for sleeping problems at a sleep-disorder center at Stanford Hospital. She began psychotherapy sessions with clinical psychologist Rachel Manber, director of the center. The sessions, she says, delved into her problems at work, as well as deeply personal matters such as her fiancé's death. "I would never have engaged in psychotherapy with her if she did not promise me those notes were under lock and key," Ms. Galvin says.
On a rainy morning in February 2001, Ms. Galvin was rear-ended at a red light in Palo Alto and suffered four herniated discs. She returned to work, but over time her back problems worsened, she says. Her doctor eventually diagnosed an unusual connective-tissue disorder that made healing difficult, she says. Two years after the accident, she applied for long-term disability leave. "My body just started breaking down," she says.
Her employer's carrier, UnumProvident Corp., asked her to sign a broad release covering her medical records. Without it, the insurer said, it would deny her claim. Ms. Galvin signed, she says, only after receiving assurances from Dr. Manber that the therapy records wouldn't be turned over without additional authorization. Ms. Galvin says she figured the newly adopted federal privacy rules that grew out of the Health Insurance Portability and Accountability Act, or HIPAA, would give her another layer of protection.
HIPAA's principal goal was to ensure that people could change jobs without losing insurance coverage for pre-existing medical conditions. When employers and insurers complained about the added cost, the federal government pledged to make it easier for medical providers, insurers and others to swap medical information electronically, potentially saving as much as $30 billion over a decade.
To assuage concerns of privacy advocates, Congress authorized the Department of Health and Human Services to draft privacy regulations. The final rules allow health insurers and medical providers -- including doctors, pharmacies and hospitals -- to disclose medical information for "treatment, payment and health-care operations," among other situations, without specific patient permission. But they aren't supposed to send any more records than necessary for nontreatment purposes.
Dawn Ross, a 37-year-old Los Angeles hairstylist, says she was startled to discover how much a bill collector knew about her. Federal rules permit the release of medical records in connection with "payment." Soon after Ms. Ross returned home from an uninsured hospital stay, the hospital's collection agency began dunning her for $8,600. When she disputed the bill, she learned that the agency had detailed records about her miscarriage and the treatment she received for it.
The rules also do not require patient permission for the release of records for "health-care operations," a broadly defined category that includes some marketing, data warehouses and fund-raisers. . .
Complaints of privacy violations have been piling up at the Department of Health and Human Services. Between April 2003 and Nov. 30, the agency fielded 23,896 complaints related to medical-privacy rules, but it has not yet taken any enforcement actions against hospitals, doctors, insurers or anyone else for rule violations. A spokesman for the agency says it has closed three-quarters of the complaints, typically because it found no violation or after it provided informal guidance to the parties involved. . .
She continues to worry, she says, that "any time anybody asks for my medical records, my psychotherapy notes are going to be turned over." In therapy, she adds, "all kinds of things come up -- they want you to go into detail about your feelings about your mother and your father and your sister and your brother and your dead fiancé and how all of that affects you."
To read the entire article, (subscription required) please go to http://online.wsj.com/article_print/SB116709136139859229.html.
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3. International Medicine: A Devastating Indictment Of Management in the NHS
BBC show under fire after damning verdict on NHS
Business boss blames weak managers and 'collective inertia' as he attempts to transform a struggling hospital, by Jo Revill, health editor, The Observer, Sunday December 31, 2006
One of Britain's leading business managers, Sir Gerry Robinson, is to deliver a devastating indictment of management in the NHS in a move that will provoke fresh controversy over whether the extra billions of pounds earmarked for healthcare are being squandered.
After spending six months in a Yorkshire hospital in an attempt to 'turn it around' and cut the waiting lists, the former chairman of Granada and Allied Domecq told The Observer he left the hospital feeling upset about the state of the NHS. He said that the 'collective inertia' within the system, combined with weak management, meant that the right decisions were not being taken and that senior managers indulged in too much 'blue skies' thinking and too little time motivating staff.
In Can Gerry Robinson Fix The NHS?, a BBC2 series to be broadcast next week, Robinson is seen attempting to change attitudes at Rotherham General Hospital which has six-month waiting lists and low morale. He ends up asking the doctors to work through their lunch breaks to maximise the use of operating theatre time and addresses the question of why some consultants are so unhappy with the health reforms put in place by the government. By the end of the programme , the waiting lists had fallen and 90 per cent of patients were now getting their operation within three months.
Robinson, a Labour donor who was knighted in 2004 and a former chairman of the Arts Council, is adamant that simple techniques work. 'I came away from the programme feeling very upset, to be honest,' he said, speaking from his home in Ireland. 'We have this really precious thing which is free delivery of healthcare when you are ill. We shouldn't pretend it is a business, because it's not, but, my God, we should be running it well.
'The health service works brilliantly in so many ways, but it is failing in the sense that it is not getting the most out of huge amounts that are now being put into it. Given that there is enormous willingness among the staff, we should be able to get it right.'
Much of the criticism in the programme is reserved for the hospital's chief executive, Brian James. 'Brian comes through in the end, and he's an example of someone who could do it, but he tends to think of grand schemes and spends time looking into the future. Rather than just going from A to B to get things done, he tends to get there via 14 other letters first,' Robinson said. James, who became chief executive of the Rotherham NHS Foundation Trust, which runs the hospital, two years ago, defended his management techniques this weekend, accusing the programme makers of 'concentrating on style rather than substance'.
He said: 'I was disappointed that it wasn't a more intellectual programme and it didn't really convey the complexities of running an NHS organisation. I know it's TV and you have to simplify things, but their great failure is to explain to the public that the NHS isn't like a business where you can hire and fire staff or change your prices. We work under a lot of constraints - both political and historical. I was very unhappy that much of the focus was on a small group of disaffected consultants who don't want to change their ways, when I get on well with 95 per cent of the consultants who want to make progress.
'I get redeemed in Act Three, in the final episode, when I do as Gerry suggests and get out and about a bit more. What disappoints me is that the main message seems to be that the chief executive should walk around a bit more and tell staff what they should be doing, and it isn't like that. It's about finding ways of incentivising staff who are frankly demoralised after years of reform. It's about stopping them being cynical and helping them to do more to look after the people they serve.'
There are now 40,000 managers within the NHS and their numbers have increased in recent years, but spending on management consultants has jumped more than fifteen-fold from £31m to more than £500m in two years.
Robinson believes there is a case for spending more on better, permanent hospital managers. 'If you spend money on really good management, and that would include spending enough to make it attractive for hospital consultants to become managers, then I think it would be worth it. It shouldn't be seen as a luxury.'
The NHS does not give timely access to healthcare, it only gives access to a waiting list.
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Ayn Rand Institute Press Release January 10, 2007, www.aynrand.org/site/News
Irvine, CA--On Monday Gov. Arnold Schwarzenegger proposed a plan to mandate health insurance coverage to nearly all of California's 6.5 million uninsured. Under Schwarzenegger's plan, all Californians would be required to have insurance, including those unwilling or unable to afford it; the poorest would be subsidized.
According to Dr. Yaron Brook, president of the Ayn Rand Institute, "Gov. Schwarzenegger's plan is a moral travesty, and must be rejected.
"The governor's plan is immoral," said Dr. Brook, "because it is based on the premise that the needs or desires of some people give them a claim on the lives and property of others. This vicious double standard turns the providers--doctors, hospitals, businesses--into the serfs of those deemed to be in need. There is no right to health coverage. The governor's scheme, like other socialist healthcare schemes, requires wielding government force to violate the rights of untold individuals."
Government is not the solution to our problems, government is the problem.
- Ronald Reagan
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I recently saw a patient who developed pain in the pit of his stomach with nausea and vomiting associated with gastro-esophageal reflux disease. This began shortly after he entered the service at age 19. A clinic physician prescribed Tagomet, an acid H2 blocker, with refills. He improved while the refills lasted for about a year and then the pain in the pit of his stomach with nausea and vomiting recurred. He had a gastroscopy and was told he had some esophageal scarring but nothing else was found. He was stressed because his wife was pregnant and he was being shipped to Japan. TUMS, an antacid tablet, gave transient relief. A year or so later he was evaluated at a regional Air Force Medical Center and had a second gastroscopy. He was told everything looked good but he had some scarring and should avoid spicy foods to keep that from progressing. On leaving the service, he obtained a truck-driving job. He enjoyed his new job. He did well for years. Then the pain in the pit of his stomach recurred. Some days he couldn’t drive his truck. He was sent to a psychiatrist who placed him on antidepressants. However, he was not depressed; he just hurt. The pills didn’t help. They made him feel worse. He was fired from his truck-driving job because he called in sick too often. Since he couldn't work, he applied for disability benefits and began receiving them. The pain in the pit of his stomach persisted and he had a third gastroscopy at a private regional medical center. He was told that his esophagus was scarred and narrowed and they passed a rubber tube to open it. He undoubtedly was talking about a dilatation. He was given Protonix. It helped relieve the pain until the refills ran out. The pain in the pit of his stomach recurred. His wife changed insurance plans and he came in for a medical evaluation.
When I saw him for the pain in the pit of his stomach, he had been unable to work for about 10 years and was on disability. The heartburns occurred after each meal and he took an occasional TUMS with some relief. He awakened during the night, essentially every night, with the pain. As he was thinking about this, he said that he had been awakening with the this pain nearly every night for at least 10 years and possibly since he went into the service 20 years ago. He had not been asked this question regarding this classic symptom of peptic ulcer or reflux disease. I gave him a Prevacid, which I had readily available, and a Gaviscon chewable antacid pill. By the conclusion of the exam, he was feeling better. I told him to purchase the formerly $5.00 purple pill that was now generic and available at Walmart or Cosco for 50 cents. I advised him to take it at least before breakfast and dinner and at bedtime if he still had heartburns. He was told to buy large bottles of antacids and to take a large swallow of it after each meal and at bedtime and during the night if he had heartburns. He was told that he could return to driving a truck in a month or so and was advised to have a bottle of antacids next to him and to take a large swallow every couple of hours and whenever he had heartburns. He and his wife were incredulous and mentioned their doubts and disbelief. He was disabled and the thought of returning to worked seemed to frighten both of them.
When he came back in a month, he was a different man. He hadn't experienced heartburns or pain in the pit of his stomach, he slept through the night, had no nausea or vomiting, and was looking into driving a truck again. His outside records at this time confirmed that he had a negative H. Pylori titre and thus not a reversible cause of GERD. His gastroscopy reports were rather remote and did not become available.
Here is a patient who had 20 miserable years, ten on disability, and a distraught wife and daughter. It was all reversed by a caring physician simply listening to his story. He stated that most of my questions had not been asked before. Of critical importance was the fact that he received his first dose of an acid inhibitor and acid neutralizer while in the office so he was better by the time he got home. This, of course, gave him the impetus to drive to Walmart or Cosco to obtain the Prilosec and antacids at OTC prices.
Other observations of relevance in our health care milieu are important. This man was seen in three sophisticated medical systems. He had three invasive procedures, all of which he did not need. What he needed was simply a physician or a nurse practitioner who would do a medical interview and a medical examination. Pressing on the pit of his stomach confirmed that it was on fire from all the acids burning his esophagus and pylorus. Hence, it was apparent that the fire could easily be put out with antacids. It was.
In addition to the unnecessary health-care costs, and cost on his family, there was also the unnecessary cost of disability payments and the loss of a job he really missed. Government medicine would not have been better. One of the three medical systems that saw him was the Federal Government. Doctors no longer are given the time to explore the medical history on which three fourths of all diagnosis are based. They immediately proceed to unnecessary procedures and then don’t take the time to explain the findings in terms the patients can understand. This happens in all the systems of health care. But the answers are evolving. Stay tuned to MedicalTuesday to keep posted.
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"Government intervention in medicine
is immoral in principle and . . . disastrous in practice. No man . . has a right to medical care; if he
cannot pay for what he needs, then he must depend on voluntary charity. Government
financing of medical expenses . . . even if it is for only a fraction of the
population, necessarily means eventual enslavement of the doctors and, as a
result, a profound deterioration in the quality of medical care for everyone,
including the aged and the poor."
Leonard Peikoff, "Medicine: The Death
of a Profession," The Voice of Reason.
Government medicine hurts the aged and the poor, the ones for which it was designed to help.
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Dr. Dave: Ed, we faxed a five-page consult to your office when we referred the patient to you and your receptionist tried to tell us we didn't. Can't you get them organized?
Dr. Edward: I've tried to get my staff organized and it seems to be getting worse every month. By the time I saw your patient, I had two copies of everything - maybe even three. I've wondered where all the extra paper came from. We're going through so many extra reams of paper since HIPAA that we fill a 60 gallon black bag with shredded paper almost every week.
Dr. Dave: Why aren't the environmentalists taking our Congress to task for causing the shredding of all these beautiful redwoods and pine?
Dr. Milton: You don't really think that either group can make that connection, now do you Dave? That would require two brain cells making a synapse.
Dr. Sam: Did you see the new Wall Street Journal last Monday? Wasn't it awful? Looked smaller than the Sacramento Bee or the SF Chronicle.
Dr. Rosen: Has anyone seen it here in the staff lounge?
Dr. Michelle: It's over here. Just got lost in the other daily papers. It's no longer distinctive.
Dr. Rosen: You can say that again. I read the WSJ briefly in the morning and then lay it aside. I catch up on the entire week on Friday night or Saturday. So when I couldn't find it yesterday, I asked my wife where was it? She couldn't recall seeing it. She said that she just took the paper to the office like always.
Dr. Michelle: That's funny. The WSJ never misses a home delivery. It even makes my Sacramento BEE on time. They have never missed since the WSJ started using the same delivery service. Gets both papers leaning against my front door every morning.
Dr. Rosen: When I got to the office, I couldn't find it either amongst the papers. Then I started sifting though the individual papers and I couldn't believe what I saw. The WSJ was inside the BEE or the Chronicle as a subsection and it just looked like all the other subsections.
Dr. Sam: Looks like the WSJ did an excellent job of making something extra-ordinary look so ordinary. It lost all its class. What a pity.
Dr. Rosen: Yes, what a shame to see such a class act be mistaken as just another section next to the food section of an ordinary paper.
Dr. Sam: And the world’s most ambitious editorial page looked so unimpressive. And the letters to the editor seem to be floating around the paper with no home yet.
Dr. Rosen: Yes, sometimes you are directed to another section of the paper to read them. The two-page editorial and reader dialogue spread is what I was able to read every morning before going to work. I got so frustrated the first week that I haven’t bothered to read the second week. Unless they return to their previous format, I wouldn’t be surprised if circulation drops within months.
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CSA Bulletin, California Society of Anesthesiologists -
Who Needs Physicians? By Jason Campagna, M.D., Ph.D.
There is a not-so-quiet evolution occurring in medicine. The doctor is slowly, but methodically, being replaced. In an era when politicians promise "more, better, cheaper" health care, the business world, the world of for-profit medicine, is executing its own vision of this promise. With each passing day, more and more hospitals, doctors' offices, imaging centers, and walk-in clinics are being staffed with increasing numbers of nonphysicians. The Target Corporation has opened rapid-treatment clinics in its stores, staffed with physician assistants or nurse practitioners. That MRI your mother is scheduled to get next week? From the time of her arrival at the imaging center to the time the scan is read, chances are she won't see a physician. Never mind that the image might even be read halfway around the world in India. Show up at the clinic to get a surgical consultation on your dad's lung cancer, and nonphysicians will perform much of his history, physical examination and preoperative planning. If your dad goes on to be hospitalized for removal of his tumor, then there is a growing chance, already very likely in many states, that his anesthesia provider will be a person who will not have done a residency in anesthesia or even gone to medical school. This transformation is occurring because nonphysicians are replacing physicians. Medical care in America is no longer about patients. It's about consumers and services. In this world, health care is a commodity, bought and sold like stocks on the NASDAQ or NYSE. The key players in this version of medicine are the consumer (formerly the patient) and the provider (formerly your physician). The services "provided" to the "consumer" are what used to be called medicine.
Although we will crow incessantly about how the business moguls and the insurance titans and politicians are responsible for our marginalization, I offer one more pungent truth: Physicians as a group are as much to blame as anyone for the predicament in which we all find ourselves. A perfect illustration of this complicity can be found in a report issued in 2004 by the American Association of Medical Colleges. The AAMC convened deans from some of America's most prestigious medical schools as a working group on the future of medical education. The following is a summary "action item" from their report:
Medical schools and residency programs should provide clinical learning experiences of an interdisciplinary nature for the purpose of preparing future physicians to function effectively as members of a care team (bold added for emphasis).
Taken at face value, it is concerning. When viewed, however, in the context of the current changes occurring in health care - it is nothing less than a surrender, a gross acquiescence on the part of organized medicine. The "mantra" in the American system of health care delivery (a.k.a. medicine) is that of cost savings while simultaneously improving "quality." There is no denying that cost of health care is a major issue for our society. According to the Congressional Budget Office, we spend more than 15 percent of the GDP on this endeavor. The absolute number is not so alarming to policy people; it's the rate of rise of this number that tends to get people's attention; and it is rising fast. This statistic has been the driving force behind the massive reorganization from traditional fee-for-service medicine to managed care during the past three decades. Now, in the early years of the 21st century, we have found ourselves standing bleary-eyed in the midst of a Kafkaesque landscape where, just as in the 1970s, those rising costs frighten businesses and also, like then, have politicians clamoring for some way to reduce "spiraling health care costs."
A key argument marshaled in the 1970s was that other countries spent a considerably smaller percentage of their GDP on health care. This argument has been slightly modified in our present debate to include not only our enormous expenditures, but also that we deliver care of lesser quality for all that money. Whether this is true is unclear (for example, how can a system that is partially socialized, like that in the U.S., spend more than systems that are fully socialized, like most of the European Union countries?), but this supposed "truth" is now repeated in the media nearly ad nauseam and is used as a bludgeon to cull any opposition to the "improve medical quality" bandwagon. Here again is a quote from the AAMC Ad Hoc Dean's report:
Although it is generally believed that the quality of medical care in the United States exceeds that provided in the rest of the world, there is growing evidence indicating that the care is often less than optimal. The results of a number of well-conducted studies show that doctors fail on occasion to use diagnostic and therapeutic approaches of proven value and to communicate with patients and their families adequately, and do not always recommend health promotion and disease prevention practices of proven benefit. In 2001, the Institute of Medicine called attention to the need to improve the quality of medical care provided in this country.
The ruinous reasoning that follows from this reading results in pundits being able to associate such putative substandard delivery of medical care with the unrelated, often cited but poorly substantiated statistics that the U.S. allegedly has the highest infant mortality rate, and a below-average life expectancy compared to other industrialized nations that spend less on health care.
In sum, the torch for "medical reform" has been lit, and there are strong arguments being marshaled to improve quality and to decrease costs. One thing is abundantly clear: the effort to reform medicine is being co-opted by persons and companies whose primary concern is profit, not people. In an effort to find ways to control rising costs, a culture of "cost-containment" in health care has sprouted, modeling itself on the successful efforts of augmenting efficiency by non-health care sectors. One belief that has been born of these efforts is that - quite simply - physicians are expensive. So, it is reasoned, one way in which to cut costs is to replace physicians with nonphysician labor. This disturbing reasoning is being applied to nursing as well. It is of great concern that these labor shifts are occurring in large part with the cooperation - in some cases, overt goading - of organized medicine.
Medicine "polices" itself through a variety of means. Of increasing importance are "Quality Improvement" or "Quality Assurance" committees. Formal QI in the latter 20th century evolved to include system-based evaluation techniques adapted from non-health care industries. In every JCAHO-certified hospital in the U.S., QI is a mandated activity.
Broadly speaking, there are two types of QI activities. The first is when the QI process seeks to understand how errors occurred and to implement changes such that the risks of similar errors in the future are minimized. A second is when a prospective change in some device or care model is implemented, and the QI folks collect data to determine if the new practice results in a change in "outcome." The goal of these QI activities is to implement a change that ideally saves money and improves outcomes. Andrew Kofke in the Department of Anesthesiology at the University of Pennsylvania and Michael Rie of the University of Kentucky at Lexington have written on this subject. A recent article cites as examples of this type of QI activity:
· Systematically decreasing laboratory tests and radiographs
· Requiring approval to order expensive drugs
· Decreasing nursing or physician staff . . .
I fear it is too late for physicians to reclaim the mantle of "physician" instead of "health care professional." I worry that people have no sense of what a long road we have crawled along to get to the 21st century where cures and miracles seem an almost daily occurrence. I worry about what would happen if physicians really stopped caring and just became opportunists who stopped innovating and instead just showed up and worked: simple labor without regard for what comes next, or what new drugs we need, or what new cures we should have. Maybe the best way to get the general public to think about these things is to remind them what it was like when medicine was little more than prayer and potions and nostrums and, in the end, despair. If the medical superstructure wants to replace physicians and restore the world to pre-20th century medical science, perhaps everyone should be reminded of just what the 15th century was all about.
To read the entire article,
please proceed to the CSA website
below . www.csahq.org/pageserver.cgi?tpl=internal.tpl§ion=publications&name=bulletin_view&idx=14
Dr. Campagna practiced academic anesthesia on the East Coast prior to settling in Santa
Barbara in 2005. Most recently, he has published a review of anesthetic mechanisms of action
in the New England Journal of Medicine, and a historical narrative about the social and
religious controversies surrounding the use of anesthetics in the 19th century. Dr. Campagna, being new to the CSA, contributed this article to the Bulletin in the hopes of stimulating discussion about the trajectory on which our specialty finds itself and where we may be in the near future if that pathway remains unaltered.
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9. Book Review: AMERICA ALONE, The End of the World as we Know It, by Mark Steyn
AMERICA ALONE, The End of the World as we Know It, by Mark Steyn, Regnery Publishing, Inc, an Eagle Publishing Company, Washington, DC, xxx & 224 pages, $27.95; © 2006 by Mark Steyn. ISBN-13 978-0-89526-078-9
"When people see a strong horse and a weak horse, by nature they will like the strong horse." -Osama Bin Laden, Kandahar, November 2001.
"If we know anything, it is that weakness is provocative." -Donald Rumsfeld, Washington DC 1998.
Steyn begins: "Do you worry? You look like you do. Worrying is the way the responsible citizen of an advanced society demonstrates his virtue: he feels good about feeling bad.
But what to worry about? Iranian nukes? . . . worrying about nukes is so eighties."
So what should we be cowering in terror over? Steyn feels the harrowing nightmares of doom didn't start with Chicken Little and won't end with Al Gore. So, should we forget about the end of the world and head for the hills? Steyn says: Don't head for the hills - they're full of Islamist terrorist camps. He describes a much bigger nutshell. The Western world will not survive the twenty-first century. Many, if not most European countries will effectively disappear in our lifetime. Just as in Istanbul there's still a building known as St. Sophia's Cathedral, but it's not a cathedral: It's merely a designation for a piece of real estate. Likewise, Italy and the Netherlands will merely be designations for real estate. Forget the ecochondriacs's obsessions with rising sea levels that might conceivably hypothetically threaten the Maldive Islands circ 2500; contrary to Francis Fukuyama, it's not the end of history; it's the end of the world as we know it. Whether we like what replaces it depends on whether America can summon the will to shape at least part of the emerging world. If not, then it's the dawn of the new Dark Ages (if darkness can dawn): A planet on which much of the map is re-primitized.
Before you think that Steyn is as nuts as the
ecodoom set, he reminds us of Chicken Little's successors in this field:
Scientist Paul Ehrlich declared in his 1968 bestselling book, The
Population Bomb , "In the 1970s the world will undergo famines
- hundreds of millions of people are going to starve to death."
In 1977, Jimmy Carter, president of the United States
(incredible as it may seem), confidently predicted that "we could use up
all of the proven reserves of
None of these things occurred. But according to Steyn, here's what did happen between 1970 and 2000: in that period, the developed world declined from just under 30 percent of the global population to just over 20 percent, and the Muslim nations increased from about 15 percent to 20 percent. Is that fact less significant than the fate of some tree or endangered sloth? In 1970, very few non-Muslims outside the Indian subcontinent gave much though to Islam. Even the Palestinian situation was seen within the framework of a more or less conventional ethnic nationalist problem. Yet today it's Islam a-go-go: almost every geopolitical crises takes place on what Sam Huntington, in The Clash of Civilizations, calls "the boundary looping across Eurasia and Africa that separates Muslims from non-Muslims." That boundary loops from Bali, to southern Thailand, to an obscure resource-rich Muslim republic in the Russian Federation, to Madrid, and London before penetrating into the very heart of the West in a little more than a generation.
September 11, 2001, was not "the day everything changed," but the day that revealed how much had already changed. That Tuesday morning the top of the iceberg bobbed up and toppled the Twin Towers.
Steyn says that his book is about the seven-eighths of the iceberg below the surface - the larger forces at play in the developed world that have left Europe too enfeebled to resist its remorseless transformation into Eurabia and that call into question the future of much of the rest of the world, including the United States, Canada and beyond. . .
So what is a book on America's future doing in a medical newsletter (www.MedicalTuesday.net), to be posted on a medical electronic journal (www.healthcarecom.net/bookrevs.htm), and appear on the Physician/Patient Bookshelf section (www.DelMeyer.net) where we list reviews about what physicians do and what they write about?
It should be apparent by now that Steyn writes about the future of healthcare as part of all government entitlements. He puts government healthcare into a perspective that few who are still pushing for making it an entitlement understand. All entitlements are the same. He has given up on Europe and already calls it Eurabia. Their cradle-to-grave welfare system will totally collapse before 2050, when there won't be enough children to pay for it. Then all healthcare, social security, childcare and all government programs will simply disappear as the beneficiaries will wonder why they are without benefits.
Suffused with Steyn's trademark wit and piercing insights, America Alone calls on us to summon the will to fight this great struggle for Western civilization. Steyn provides an enlightening basis on just how bad things are now and are likely to get. We should take his insight seriously now to ensure that our children and grandchildren live in the bright light of freedom our forefathers fought so hard to win for us. Let's not turn our backs on our heritage.
There is also a critical message on how detrimental state healthcare is for our future. He places it in context that even the most arched advocate of government medicine should be able to understand. It is critical for our doctors' professional organizational leaders, who are still supporting single-payer initiatives, to understand. This book is a must read for all physicians, nurses and health administrators. It is critical for all our patients to comprehend.
To read the entire review, please proceed to www.delmeyer.net/bkrev_AmericaAlone.htm.
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When Ronald Reagan became President in 1981, there were about 1,500 U.S. attorneys. Today, there are more than 7,000, all of whom need high conviction rates to gain promotions and increased pay. The federal prison population in early 1981 stood at about 20,000; today it is more than 170,000. –The Freeman
If they keep on prosecuting doctors at the current rate, they'll have to build more prisons.
Federal Prosecutions Destroy Good People and the American Spirit
These prosecutions destroy not only the lives of their targets, but also are slowly but surely destroying the American spirit. It almost seems in reading the daily newspapers that prominence very nearly guarantees if not prosecution then at least exhaustive investigation. Investigation alone is so draining in so many ways that even without prosecution, the American spirit ebbs with each succeeding case. Then, again, none of these businessmen have any chance of receiving a trial by their peers, in an y but the legal sense; faced with virtually no chance of acquittal, many who are innocent, and many who are, at the very least, not guilty, plead guilty as a strategy. This is extremely bad for morale and makes it far more difficult for those who maintain their innocence despite the effectively bought (remember Singleton) testimony of those who have plea bargained. Such testimony is a corruption that throws the entire prosecutorial enterprise in this country into question.
If America is to remain prosperous, such prosecutions must be brought to a halt, and for that to happen the number of prosecutors must be dramatically reduced. A small band of prosecutors will focus narrowly on those who have truly been corrupt; legions of prosecutors necessarily overreach. –Joseph Fulda
To read more vignettes, please proceed to the website: www.healthcarecom.net/hhkintro.htm.
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• The National Center for Policy Analysis, John C Goodman, PhD, President, who along with Gerald L. Musgrave, and Devon M. Herrick wrote Lives at Risk issues a weekly Health Policy Digest, a health summary of the full NCPA daily report. You may log on at www.ncpa.org and register to receive one or more of these reports. Read Devon Herrick's latest on THE COMING REVOLUTION IN THE MEDICAL MARKETPLACE at www.ncpa.org/sub/dpd/index.php?page=article&Article_ID=14062.
• Pacific Research Institute, (www.pacificresearch.org) Sally C Pipes, President and CEO, John R Graham, Director of Health Care Studies, publish a monthly Health Policy Prescription newsletter, which is very timely to our current health care situation. You may subscribe at www.pacificresearch.org/pub/hpp/index.html or access their health page at www.pacificresearch.org/centers/hcs/index.html. Be sure to read "Towards Universal Choice in 2007" at www.pacificresearch.org/press/rel/2007/pr07-01-03.html.
• 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: Read about California terminating private insurance at www.marginalrevolution.com/marginalrevolution/medicine/index.html.
• The National Association of Health Underwriters, www.NAHU.org. The NAHU's Vision Statement: Every American will have access to private sector solutions for health, financial and retirement security and the services of insurance professionals. There are numerous important issues listed on the opening page. Be sure to scan their professional journal, Health Insurance Underwriters (HIU), for articles of importance in the Health Insurance MarketPlace. www.nahu.org/publications/hiu/index.htm. The HIU magazine, with Jim Hostetler as the executive editor, covers technology, legislation and product news - everything that affects how health insurance professionals do business. Be sure to review the current articles listed on their table of contents at hiu.nahu.org/paper.asp?paper=1. To see my recent column, go to http://hiu.nahu.org/article.asp?article=1328&paper=0&cat=137.
• 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. This week, log into to her editorial:
Medicare drug benefit is fine as is, Madam Speaker, found at www.chron.com/disp/story.mpl/editorial/outlook/4447256.html.
• Greg Scandlen, an expert in Health Savings Accounts (HSAs) has embarked on a new mission: Consumers for Health Care Choices (CHCC). To read the initial series of his newsletter, Consumers Power Reports, go to www.chcchoices.org/publications.html. To read the latest newsletter, be sure to click on No 62.
• The Heartland Institute, www.heartland.org, publishes the Health Care News. Read the late Conrad F Meier on What is Free-Market Health Care? at www.heartland.org/Article.cfm?artId=10333. You may sign up for their health care email newsletter at www.heartland.org/Article.cfm?artId=10478 or access their health care archives at www.heartland.org/IssueSuiteTopic.cfm?issId=9&istId=150.
• 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 editors most recent commentary: The Goal Is Freedom: Pleasing Consumers Isn't Easy at www.fee.org/in_brief/default.asp?id=1038.
• 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." Be sure to check their wealth of health care resources at www.cahi.org/cahi_contents/resources/.
• The Independence Institute, www.i2i.org, is a free-market think-tank in Golden, Colorado, that has a Health Care Policy Center, with Linda Gorman as Director. Be sure to sign up for the monthly Health Care Policy Center Newsletter at www.i2i.org/healthcarecenter.aspx. Read her latest newsletter at http://www.i2i.org/articles/2006-I.doc.
• 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. Be sure to continue the series on Capitalism and Commerce at www.quebecoislibre.org/06/061217-5.htm.
• The Fraser Institute, an independent public policy organization, focuses on the role competitive markets play in providing for the economic and social well being of all Canadians. Canadians celebrated Tax Freedom Day on June 28, the date they stopped paying taxes and started working for themselves. Log on at www.fraserinstitute.ca for an overview of the extensive research articles that are available. You may want to go directly to their health research section at www.fraserinstitute.ca/health/index.asp?snav=he. Be sure to continue with the series on How Good is Canadian Health Care at www.fraserinstitute.ca/shared/readmore.asp?sNav=pb&id=877.
• The Heritage Foundation, www.heritage.org/, founded in 1973, is a research and educational institute whose mission is to formulate and promote public policies based on the principles of free enterprise, limited government, individual freedom, traditional American values and a strong national defense. The Center for Health Policy Studies supports and does extensive research on health care policy that is readily available at their site. This week, be sure to read The Educations of Ronald Reagan at www.heritage.org/press/events/ev011907a.cfm.
• The Ludwig von Mises Institute, Lew Rockwell, President, is a rich source of free-market materials, probably the best daily course in economics we've seen. If you read these essays on a daily basis, it would probably be equivalent to taking Economics 11 and 51 in college. Please log on at www.mises.org to obtain the foundation's daily reports. If you haven’t read Hazlitt’s Economics in One Lesson, and don’t have time to read the entire 234 pages reproduced here, the preface gives an excellent overview by clicking on the book at the opening page. You may also log on to Lew's premier free-market site at www.lewrockwell.com to read some of his lectures to medical groups. To learn how state medicine subsidizes illness, see www.lewrockwell.com/rockwell/sickness.html; or to find out why anyone would want to be an MD today, see www.lewrockwell.com/klassen/klassen46.html.
• CATO. The Cato Institute (www.cato.org) was founded in 1977 by Edward H. Crane, with Charles Koch of Koch Industries. It is a nonprofit public policy research foundation headquartered in Washington, D.C. The Institute is named for Cato's Letters, a series of pamphlets that helped lay the philosophical foundation for the American Revolution. The Mission: The Cato Institute seeks to broaden the parameters of public policy debate to allow consideration of the traditional American principles of limited government, individual liberty, free markets and peace. Ed Crane reminds us that the framers of the Constitution designed to protect our liberty through a system of federalism and divided powers so that most of the governance would be at the state level where abuse of power would be limited by the citizens' ability to choose among 13 (and now 50) different systems of state government. Thus, we could all seek our favorite moral turpitude and live in our comfort zone recognizing our differences and still be proud of our unity as Americans. Michael F. Cannon is the Cato Institute's Director of Health Policy Studies. Read his bio at www.cato.org/people/cannon.html. To read comments on the first 100 hours of our 110th Congress, please go to www.cato.org/homepage_item.php?id=444
• 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.]
• Hillsdale College, the premier small liberal arts college in southern Michigan with about 1,200 students, was founded in 1844 with the mission of "educating for liberty." It is proud of its principled refusal to accept any federal funds, even in the form of student grants and loans, and of its historic policy of non-discrimination and equal opportunity. The price of freedom is never cheap. While schools throughout the nation are bowing to an unconstitutional federal mandate that schools must adopt a Constitution Day curriculum each September 17th or lose federal funds, Hillsdale students take a semester-long course on the Constitution restoring civics education and developing a civics textbook, a Constitution Reader. You may log on at www.hillsdale.edu to register for the annual weeklong von Mises Seminars, held every February, or their famous Shavano Institute. Congratulations to Hillsdale for its national 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 the latest Imprimis, Freedom vs Non-Freedom: a View from Russia at www.hillsdale.edu/imprimis/2007/01/. The last ten years of Imprimis are archived at www.hillsdale.edu/imprimis/archives.htm.
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Words of Wisdom and Understanding
"We are all kept alive by the work of man's mind - the individual minds that still retain the autonomy necessary to think and to judge. In medicine . . . the mind must be left free." -Leonard Peikoff, "Medicine: The Death of a Profession," The Voice of Reason
"The culture of the therapeutic inherited criteria of ‘Good and Bad,' of ‘Right and Wrong' are dissolved into the new culture of ‘Well and Ill,' ‘Interesting and Uninteresting.' There is ‘Psychology' where there used to be 'Religion, Morality, and Custom.'" -Philip Reiff, 1968.
Management has to give direction to the institution it manages. It has to think through the institution's mission, has to set its objectives, and has to organize resources for the results the institution has to contribute. In performing these essential functions, management everywhere faces the same problems. It has to organize work for productivity; it has to lead the worker toward productivity and achievement. It is responsible for the social impact of its enterprise. Above all it is responsible for producing the results - whether economic performance, student learning, or patient care - for the sake of which each institution exists. -Peter Drucker, Insights for Today, January 16.
Some Postings from
Physician Patient Bookshelf: www.delmeyer.net/PhysicianPatientBookshelf.htm
Hippocrates Modern Colleagues: www.delmeyer.net/HMC.htm
Medical Practice Available: www.delmeyer.net/Practice_Valuation.htm
THERE were many times in his long life when Gerald Ford felt he had reached the top of the tree. The moment when, puffing out his teenage chest, he was made an Eagle Scout after earning 21 badges (Cooking, Camping, Civics, Lifesaving, Bird Study, First Aid). The afternoon when, his big bland face still running with sweat under his leather cap, he was named most valuable player for Michigan against Minnesota in the 1934 football season. The day in 1948 when he beat Bartel Jonkman, darling of the powerful Dutch Calvinist community, to win the Republican primary for the Grand Rapids congressional seat by nearly 10,000 votes; and the morning when, wearing one black shoe and one brown one, he walked down the aisle with Betty Warren, the prettiest single woman in the city.
The moment he became vice-president of the United States felt somewhat less portentous. Spiro Agnew had resigned in October 1973 after charges of tax evasion; the leaders of Congress had picked Mr Ford to succeed him. There was a telephone call. Mr Ford, after 13 terms as a congressman, had risen to become a popular minority leader in the House, with no ambitions but to be speaker one day if control swung back to the Republicans. Still, as he told Betty, the vice-presidency would make a "nice conclusion" to his career.
On this date in 1920, the Prohibition Amendment, The Eighteenth, went into effect. Today we mark the anniversary of what was called "the noble experiment." It didn't work, but we like to think it taught us something. It was abandoned in 1933. We learned, among other things, that law depends on the people for its effectiveness in a democracy. But we still haven't learned. We pass laws to force people to purchase car insurance. But nearly as many are without insurance as before. There is a push to pass laws to force employers to pay a larger minimum wage. But this doesn't work either and many lose their jobs as it pushes automation faster. There are still some that think we can pass laws to force people to purchase health insurance. This won't work either. But lawyers and courts will have more business prosecuting our fellow human beings that can't afford it. Can't we have a moratorium on "No New Laws" for a year or so? That would really be healthy.
On this date in 1883, the U. S. Civil Service established a merit system with the Pendleton Act. We thought we had solved the problem of governmental corruption with the Pendleton Act for merit in government employment. We had no idea then of the infinite complications and ingenious devices which would grow up in public employment, and in private attitudes toward the operations of government. Has life become more complicated or is it merely government that has grown more complicated?