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.
www.wired.com/wired/archive/15.01/ultraman_pr.html
* * * * *
2. In the News: Medical Dilemma Spread
Of Records Stirs Patient Fears Of Privacy Erosion
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.
* * * * *
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.'
http://media.guardian.co.uk/bbc/story/0,,1980662,00.html
The NHS does not give timely
access to healthcare, it only gives access to a waiting list.
* *
* * *
4.
Medicare:
California Bill Mandating Universal Health Insurance Is Immoral
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
* * * * *
5.
Medical Gluttony:
Medical Tragedy
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.
* * * * *
6.
Medical Myths:
Government Must Help Citizens Obtain Health Care - It Is Their Right
"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.
* * * * *
7. Overheard in the Medical Staff Lounge: Doctors' offices have such
incompetent help.
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.
* * * * *
8. Voices of Medicine: A Review of Local and Regional
Medical Journals
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.
* * * * *
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:
Distinguished
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."
·
Distinguished 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 1976, Lowell Ponte published a huge bestseller
called The Cooling: Has the New Ice Age Already Begun? Can We Survive?
·
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 oil in the entire world by the
end of the next decade."
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.
* * * * *
10. Hippocrates & His Kin: Why Should we Fear the
Federal Government
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.
* * * * *
11. Organizations Restoring Accountability in HealthCare,
Government and Society: