MEDICAL TUESDAY . NET
Community For Better Health Care
Vol V, No 20, Jan 30, 2007
In This Issue:
1. Featured Article: Mending Broken Hearts, By Jennifer Kahn, National Geographic, 2-07
As heart disease reaches epidemic proportions worldwide, researchers are moving away from the old "clogged-pipes" model to search for triggers lurking in our genes.
Cheeseburgers, smoking, stress, the
rise of the couch potato: These are the usual suspects on the list of risk
factors for heart disease, a malady reaching global epidemic proportions. Now
discoveries about genetic triggers may help us spot trouble before it starts.
Gloria Stevens is lying on her back, sedated but alert, staring at an image of her own beating heart. Metaphorically, Gloria's heart is the very core of her emotional self - not to be worn on the sleeve, much less displayed on an overhead monitor. More literally, it is a blood-filled pump about the size of a clenched fist whose rhythmic contractions have kept Gloria alive for 62 years, and with a little tinkering will keep her going for an indeterminate number more.
At this moment, her doctor is threading a thin catheter up through her femoral artery from an incision in her groin, on into the aorta, and from there into one of the arteries encircling Gloria's heart. At the tip of the catheter is a small balloon. The doctor gently navigates the tip to a spot where plaque has narrowed the artery's channel by 90 percent. With a quick, practiced movement he inflates the balloon to push back the artery wall, deflates the balloon, then inserts an expandable stent - it looks like a tiny tube of chicken wire - that will keep the passage open. As Gloria watches on the monitor, the crimp in her artery disappears, and a wide laminar flow gushes through the vessel, like a river in flood.
The procedure is over. It has lasted only half an hour. In all likelihood, Gloria will be able to go home the next day. So will a few thousand other patients in the United States undergoing such routine angioplasty - more than a million of them a year. Pipe fixed, patient cured, right?
read more, please go to www.medicaltuesday.net/feature.asp .
Because of her treatment, Gloria's quality of life will likely improve. She'll breathe easier and maybe live longer. But she is hardly cured. Her coronary atherosclerosis - a hardening and narrowing of the arteries that supply the heart with oxygen-rich blood - still leaves her vulnerable to future blockages and coronary heart disease.
Although hearts suffer many maladies - valves leak, membranes become inflamed - coronary heart disease, which can lead to heart attack and ultimately to heart failure, is the number one killer of both men and women in the United States, where 500,000 die annually. Worldwide, it kills 7.2 million people every year. Exacerbated by the export of Western lifestyle - motorized transport, abundant meat and cheese, workdays conducted from the comfort of a well-padded chair - incidence of the disease is soaring.
To help stem this lethal tide, cardiologists can prescribe such cholesterol-lowering drugs as statins to help keep arteries clear. They can advise patients to change their habits, or they can operate to fix an immediate problem. Angioplasty is one procedure, and surgery to bypass the diseased arteries is another - each year more than 400,000 bypasses are performed in the U.S. Transplants can replace severely damaged hearts, and artificial ones can keep people alive while they wait for a donor heart. But in the face of an impending global epidemic, none of these stopgap measures addresses the essential question: Who gets heart attacks and why?
The human heart beats 100,000 times a day, propelling six quarts of blood through 60,000 miles (97,000 kilometers) of vessels - 20 times the distance across the U.S. from coast to coast. The blood flows briskly, surging out of a ten-ounce (0.3 kilograms) heart so forcefully that large arteries, when severed, can send a jet of blood several feet into the air. Normally the relentless current helps keep blood vessels clean. But where an artery bends, tiny eddies form, as in a bend in a river. This is where bits of sticky, waxy cholesterol and fat can seep into the artery wall and oxidize, like butter going rancid. Other matter piles up too. Eventually, the whole mass calcifies into a kind of arterial stucco, or plaque.
Until recently, cardiologists approached heart disease as a plumbing problem. Just as mineral deposits restrict the flow of water through a pipe, an accretion of plaque impedes the flow of blood through an arterial channel. The more crud in the system, the greater likelihood that a dammed artery will trigger a heart attack. Doctors now dismiss this "clogged-pipes model" as an idea whose time has passed. It's just not that simple.
Most heart attacks are caused by plaque embedded within the artery wall that ruptures, cracking the wall and triggering the formation of a blood clot. The clot blocks the flow of blood to the heart muscle, which can die from lack of oxygen and nutrients. Suddenly, the pump stops pumping.
Contrary to the clogged pipes model, heart attacks generally occur in arteries that have minimal or moderate blockage, and their occurrence depends more on the kind of plaque than on the quantity. Scientists have been struggling to figure out what type is most responsible. Paradoxically, findings suggest that immature, softer plaques rich in cholesterol are more unstable and likely to rupture than the hard, calcified, dense plaques that extensively narrow the artery channel. But understanding the root cause of the disease will require much more research. For one thing, human hearts, unlike plumbing fixtures, are not stamped from a mold. Like the rest of our body parts, they are products of our genes. . .
"Heart disease is not a one- or two-gene problem,"
says Steven Ellis, a Cleveland Clinic cardiologist who oversees a 10,000-person
genetic study known as GeneBank that collects DNA samples from patients who
enter hospitals with atherosclerosis. Ellis, like most cardiac researchers,
suspects that dozens of genes end up contributing to a predisposition: Some
affect arterial integrity, others inflammation (which both causes and
exacerbates arterial cracks), and still others the processing of lipids (the
fats and cholesterol that turn into plaques). Of the several dozen genes, each
may contribute just one percent to a person's total risk - an amount that may
be compounded, or offset, by outside factors like diet. As one doctor told me,
any person's heart attack risk is "50 percent genetic and 50 percent
The point of tracking down all these small mutations, Ellis explains, is to create a comprehensive blood test - one that could calculate a person's genetic susceptibility by adding up the number of risky (and, eventually, beneficial) variables. Combined with other important factors, such as smoking, weight, blood pressure, and cholesterol levels, doctors could decide which patients need aggressive treatment, such as high-dose statins, and which ones are likely to benefit from exercise or other lifestyle changes. Some genes already can predict whose cholesterol level will respond strongly to dietary changes and whose won't. Assessing risk is crucial, Ellis says, because heart disease is often invisible. In fact, 50 percent of men and 64 percent of women who die of heart disease die suddenly, without experiencing any previous symptoms. . .
But statins, like any drug, carry the risk of side effects: Muscle aches are a well-known effect, and periodic blood tests to check liver function are recommended. The fact is, many of us just like to eat cheeseburgers, watch television, and get around in cars. And it's hard, says Leslie Cho, director of the Cleveland Clinic's Women's Cardiovascular Center, for a person to worry about a disease that hits ten years down the road - particularly since heart patients, unlike cancer patients, can't easily observe the progress of their disease. "You've done damage over years, and it will take years to undo that damage," she says. "That's a very hard thing to sell to Americans. We do what we can, but then people go home."
The good news is that genetic research continues to thrive. Should we want to, we will soon be able to know the state of our hearts - and our genes - in ever growing detail. That knowledge, and what we do with it, could make the difference between dying at 65 and living until 80. The choice, increasingly, will be ours.
To read the entire article, go to www7.nationalgeographic.com/ngm/0702/feature1/#topLink.
To subscribe, go to National Geographic magazine.
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2. In the News: News of the Day ... In Perspective, The AAPS, January 2007
Schwarzenegger wants doctors, hospitals, and New Yorkers to finance "universal care" for Californians.
Gov. Schwarzenegger, who campaigned on opposing a far less onerous measure proposed by former Gov. Gray Davis, wants to drive toward "universal coverage," perhaps garnering media plaudits such as those that heralded Gov. Mitt Romney's Massachusetts plan.
The proposed California plan would have individual mandates enforced by measures such as garnishing wages. Businesses with more than 10 employees that did not provide insurance would be forced to pay 4 percent of Social Security wages into a fund to subsidize insurance for the working uninsured. And hospitals would have to pay 4 percent of gross revenues, and doctors 2 percent - even if operating at or near a loss. Paying patients will probably see their costs increased in an effort to offset this loss.
California's state and local tax burden ($4,451 per capita) is already the 15th highest in the nation, and its business climate ranks 45th. Tens of thousands of Californians flee the state every year to escape the high taxes, writes Michael Tanner of the Cato Institute.
The Schwarzenegger plan would recruit taxpayers from
other states to help. By increasing payments to providers, he would trigger
increases in federal matching funds. He would then tax doctors and hospitals to
"recoup" the extra payments, even from those who did not receive any
of the money, bringing in enough to finance the rest of the plan. Through this
"old Medicaid trick," out-of-state taxpayers could contribute up to
$4.3 billion, more than three times as much as Californians, writes Michael Cannon of the Cato Institute.
To read more,
please go to www.medicaltuesday.net/news.asp .
Cannon recalls the tagline from Commando: "Somewhere…somehow…someone's going to pay!"
Californians will pay in other ways. The new mandates for community rating and guaranteed issue will drive up the cost of insurance. A single 35-yeaar-old man in Beverly Hills, who can now get decent coverage for $69/mon could end up paying New York rates of $416/mon to get any coverage at all ("Schwarzenkennedy," Wall Street Journal 1/13/07).
Then there's the 50 percent "crowding out effect": For every two persons newly enrolled in Medicaid, one drops a private policy and becomes a ward of the state. Schwarzenegger's plan would expand Medi-Cal to adults earning as much as 100% above the poverty line and to children, even those here illegally, in middle-income families (David Henderson, "TerminatorCare," Wall Street Journal 1/10/07).
Would the Schwarzenegger plan at least achieve the Holy Grail of universal coverage to offset the damage to the state's economy? Auto insurance is mandatory, but more Californians drive without coverage (25 percent) than go without health insurance (20 percent). And many of the state's uninsured - the unemployed, the mentally ill, transients, and illegal aliens - are beyond the reach of any mandate, Tanner writes. The plan thus might not make too much of a dent in the 3 percent of total spending attributed to "free riders" in the emergency room.
Additional information: www.aapsonline.org/nod/newsofday389.php
· "Massachusetts-Style Coverage Would Cost California about $9.4 Billion," News of the Day 4/28/06
· "White Paper on Medical Financing" by Andrew Schlafly and Jane Orient, J Am Phys Surg, Fall 2006
· "California HMOs Sending Enrollees to Mexico," News of the Day 11/9/05
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3. International Medicine: UK's Battle to Beat MRSA, The Telegraph
As a new and deadly strain of the superbug is identified, Victoria Lambert examines Britain's track record.
All across Europe, virulent bacteria are on the march, constantly mutating to resist the means that we invent to destroy them. Ironically, the better we get at creating antibiotic drugs that can wipe them out, the more inventive and resistant the bacteria must become to survive and multiply.
. . . Now a report has
revealed that a vicious new strain of lung-eating methicillin-resistant
Staphylococcus aureus or MRSA is spreading rapidly through our hospitals,
augmenting the 8,000-plus cases in the UK last year.
To read more,
please go to www.medicaltuesday.net/intlnews.asp .
This will mean a further headache for those trying to hit the Government's target of a 50 per cent reduction in cases by 2008.
Community-acquired infections are becoming increasingly common, too, affecting not just the elderly and infirm, but healthy children and young adults, too.
Last month, eight hospitalised [sic] patients developed infections from "community-acquired MRSA", or CA-MRSA, which throws out a toxin called Panton-Valentine leukocidin (PVL) that effectively destroys the white blood cells the body uses to defend itself. Two of the patients died.
In Texas, bacteria with the PVL gene have affected 10 per cent of all children in three years, with symptoms including the deadly necrotising pneumonia.
What effect this community-acquired MRSA will have on the overall statistics is hard to say. According to Professor Curtis Gemmell, of the University of Glasgow's Division of Immunology, Infection and Inflammation, our rates of hospital-acquired infections are so high that they mask the numbers picked up in parks and playgrounds – so we may never know how serious this part of the problem is.
And then, when you examine how Britain is coping with the superbug problem compared with its neighbours [sic], the news just gets worse. Most of Europe is managing MRSA levels better than us. . .
It feels very much like the Eurovision Song Contest results all over again – with us getting depressingly closer to the bottom every year. . .
How on earth did we get to this? In 1990, the rate of infection in the UK was just 5 per cent - and a strict policy of search (screening) and destroy (isolate and contain) was keeping it low. This "search and destroy" idea is the very one now so popular in northern Europe.
Yet over the next decade, things went badly awry. As the disease became endemic in our hospitals, medical journals debated whether there was any point in trying to screen for the superbug, and our rate shot up to 42 per cent in 2000. . .
Dr Duckworth agrees that we don't look very good compared with our neighbours. There may be several reasons for this, she says. "First we are not comparing like with like. Surveillance is compulsory here, which it is not in other countries, including France. . .
Prof Gemmell believes we must be prepared to increase our spending on health care if we are to emulate our successful neighbours. "We need to have lower bed-occupancy rates, a higher ratio of staff to patients, and more continuity of care." . . .
"Your problem with MRSA only took off in the mid-1990s," he says. "There weren't enough single rooms to isolate cases, and the NHS couldn't cope. It was due to chronic underfunding for the previous 30 years. Your ability to cope was over-run."
Prof Grundmann doesn't think our hospitals have a particular problem with cleanliness - "although some do seem more dusty and dirty. . .
Secondly, there is the encouraging whip of malpractice fines. Every doctor is required to follow stringent guidelines. So, if there is an outbreak at a hospital, doctors could be charged with malpractice and hospitals punished and fined. It seems to concentrate their minds beautifully. . .
He also suggests we build more single rooms for isolation. And that we get ready to spend even more money on our health service. . .
To read the entire article, go to www.telegraph.co.uk/health/main.jhtml?xml=/health/2007/01/22/hmrsa22.xml.
NHS does not give timely access to healthcare. It only gives access to MRSA.
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4. Medicare: Medicare and the Market
The success of the Medicare prescription drug benefit provides strong evidence that competition among private drug plans is favorable to introducing government intervention to negotiate prescription drug prices, says Mike Leavitt, secretary of health and human services.
· The average monthly premium has dropped by 42 percent, from an estimated $38 to $22 -- and there is a plan available for less than $20 a month in every state.
The net cost of the
Medicare drug program has fallen by close to $200 billion since its passage in
To read more, please go to www.medicaltuesday.net/medicare.asp .
Despite the achievement, some believe government can do a better job. Often cited are the successes of the Department of Veterans Affairs (VA) prescription drug benefit program -- which negotiates prices -- and the government's massive buying power, as reasons for intervention. But the reasoning may not hold up in the larger Medicare market, says Leavitt.
The VA formulary excludes a number of new drugs covered by the Medicare prescription benefit. Even Lipitor, the world's best-selling drug, isn't on the VA formulary -- that may be one reason more than a million veterans are also getting drug coverage through Medicare.
Also, the federal government has nowhere near the market power of the private sector, says Leavitt:
· Private-sector insurance plans and pharmacy benefit managers, who negotiate prices between drug companies and pharmacies, cover about 241 million people, or 80 percent of the population.
· At most, Medicare could cover 43 million.
If the federal government begins picking drugs and setting prices for all Medicare beneficiaries, administrative costs would add a new burden to taxpayers, says Leavitt.
There is a proper role for government in health care, but it should not be in the business of setting drug prices or controlling access to drugs.
Source: Mike Leavitt, "Medicare And The Market," Washington Post, January 11, 2007.
For more on Health Issues: http://www.ncpa.org/sub/dpd/index.php?Article_Category=16
Government is not the solution to our problems, government is the problem.
- Ronald Reagan
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5. Medical Gluttony: Health Care Gluttons? Investor's Business Daily
Just because spending on health care is going up at a fast pace in the United States isn't necessarily a sign that something is wrong. More likely it is a sign that we are a wealthy nation that, by and large, has taken care of the essentials of life. As a result, we can afford to spend a bigger chunk of each extra dollar we make on former luxuries, like better vacations, a new laptop and gold-plated health care, says Investor's Business Daily (IBD).
· According to the Organization for Economic Co-operation and Development (OECD), the top spenders on health care on a per capita basis are the United States, Luxembourg, Switzerland and Norway.
· The top countries in terms of per capita income are Luxembourg, the United States, Norway and Switzerland.
Clearly there's a relationship between economic health
and spending on health care. And to the extent that the United States
spends too much on health care, the government isn't the answer. It's the
problem, says IBD.
To read more, please go to www.medicaltuesday.net/gluttony.asp .
At every level, government has for decades imposed incentives, rules and regulations, mandates, and subsidies that have pushed up the cost of care. Government tax and spending policy alone has fueled health care spending by encouraging the rise of "third party" payments in health care:
· California alone has 48 mandates on state insurance companies, requiring coverage for such things as speech therapists, chiropractors, acupuncturists, contraceptives and infertility treatments, according to the Council for Affordable Health Insurance (CAHI); Massachusetts has 40.
· Insurance costs are far higher in those states than in states with fewer mandates; the CAHI study found that these coverage mandates boosted the cost of insurance by as much as 20 percent to 50 percent.
To read the NCPA summary, go to www.ncpa.org/sub/dpd/index.php?page=article&Article_ID=14113.
Source: Editorial, "Health Care Gluttons?" Investor's Business Daily, January 24, 2007.
For CAHI study: www.cahi.org/cahi_contents/resources/pdf/StateIndex.pdf
For more on Health Issues: www.ncpa.org/sub/dpd/index.php?Article_Category=16
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With all the noise about health-care costs, can the department of Health and Human Services take a lesson from the Department of Agriculture and pay people for not being sick? We received a copy of a letter that my farmer patient sent to the Secretary of Agriculture. We report it just as he wrote it.
Dear Secretary of Agriculture:
My friend, Larry Weever, over at Boulder, Colorado received a check for $1000 from the government for not raising hogs. So I want to go into the "not raising hogs" business next year.
What I want to know is, in your opinion, what is the best kind of farm not to raise hogs on, and what is the best breed of hogs not to raise? I want to be sure that I approach this endeavor in keeping with all governmental policies. I would prefer not to raise Razorbacks, but if that is not a good breed not to raise, then I will just as gladly not raise Yorkshires or Durocs.
As I see it, the hardest part of this program will be
in keeping an accurate inventory of how many hogs I haven't raised. My friend
Larry is very joyful about the future of the business. He has been raising hogs
for 20 years or so, and the best he ever made on them was $422 in 1968 until
this year when he got your check for $1,000 for not raising hogs.
To read more, please go to www.medicaltuesday.net/myths.asp .
If I get $1,000 for not raising 50 hogs, will I get $2,000 for not raising 100 hogs? I plan to operate on a small scale at first, holding myself down to about 4,000 hogs not to raise, which will mean about $80,000 the first year. Then I can afford an airplane.
Now another thing. These hogs I will not raise will not eat 100,000 bushels of corn. I understand that you also pay farmers for not raising corn. Will I qualify for payments for not raising corn not to feed the 4,000 hogs I am not going to raise?
Also I'm considering the "not milking cows" business, so please send me any information you have on that too.
In view of these circumstances, you understand that I will be totally unemployed and plan to file for unemployment and food stamps. Are there any other programs you have that I may be missing out on?
Will I qualify for the minimum wage for not working? And since I'm use to working 60 hours a week, will I qualify for the minimum wage for 60 hours? And since my family will also be in the not raising hogs business, and will also be unemployed, will they also qualify for the minimum wage for not working? My wife also works 60 hours a week. My children work 20 hours a week before and after school by milking cows and doing chores. I want to partner with them in the "not milking cows" business.
I see great opportunities for all hard working American in your programs.
Patriotically yours, John Namath
The art of government consists of taking as much money as possible from one party of citizens to give to another. Voltaire (1764)
[Looks like things haven't changed much in 3½ centuries. But didn't our grandparents try to get away from all this by coming to the new world in 1776 and since? Why are we emulating the old world?]
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Dr. Edwards: What do you think of Governor's Schwarzenegger's plan to tax Doctors for Universal Health Care?
Dr. Yancy: He's getting worse that Gray Davis, the governor he helped impeach for an even less ominous plan.
Dr. Sam: Wasn't it interesting that Warren Beatty in his remarks after receiving his Golden Globe Award about the people he had influenced, said, "I told Arnold he should become a Democrat - and he did."
Dr Yancy: You guys take the politician's words too seriously. They're all a bunch of crooks. They are populist trying to win the popular vote.
Dr Edwards: But we have to take their words seriously. People don't change all that much and what they say at one time, is usually how they really feel. Changing their opinion should make us all run in the other direction.
Dr. Michelle: Well, I believe Hillary. She's learned her lesson and will now be our patient's friend.
Dr. Sam: Not on your life. She tried to bamboozle the most ruthless, anti-patient, anti-American, economically unsound national health plan ever devised down our throats. I wouldn't trust her collecting my garbage.
What's the matter Sam? Don't you have a big enough shredder?
To read more, please go to www.medicaltuesday.net/lounge.asp .
Dr. Michelle: But she's a very bright lady.
Dr. Sam: And ruthless. Why do you think her husband had sex with an intern? Isn't that like having sex with a student? Having relations with someone that answers to you is normally prosecuted, whether a student, or patient, or parishioner. The only exception that I know is attorneys and clients. The Bar has not even yet made that unethical.
Dr Yancy: See, there you have it. Any respectable woman would have shed her husband at that point. But a ruthless, conniving, power-seeking women, simply calculates the advantages of remaining in the public eye for her own ulterior motives vs doing a run for the presidency on her own credentials.
Dr. Sam: Has anyone seen the Wall Street Journal this noon?
Dr. Michelle: I have it here. Here's the Market Place section. I'm working on the Personal Journal.
Dr. Sam: Looked to me like you were reading the Chron.
Dr. Michelle: They do look so similar now. Real sad.
Dr. Rosen: A week after our previous comments about the WSJ, I begin receiving a copy of the Financial Times. The label read Jan 14, 2008. Looks like I got a year's subscription as a promotional item. Maybe they're capitalizing on the unfortunate tabloid sizing of the WSJ. I laid the three papers next to each other. The Sacramento Bee and the SF Chronicle were the same size. The WSJ was about a half inch narrower. And guess what? The FT, which was also downsized, was one-half inch wider than the local papers and a full inch wider than the WSJ. And what's more, the smaller size had seven columns of news.
Dr. Sam: Should we ask the Hospital Administrator to switch to the FT for the doctors' staff room?
Dr Edwards: Certainly a more efficient use of a busy practitioner's time.
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THE SAN JOAQUIN PHYSICIAN, The San Joaquin Medical Society Magazine Déjà vu, by Marvin A. Singleton, MD, President
As 2006 winds down as a rather contentious political season, I thought it might be well to review some of the past goals in the legislative session that we have accomplished. Legislative advocacy is one of the cornerstones of organized medicine and is the defense for our profession and patients. Furthermore, the provisions of health care passed in Congress and the state legislatures are paramount for our communities.
I'm struck with how we
continue to have difficulties in the areas of health care policies. I can
remember, as many of you can, the Health Care Financing Administration (HCFA)
that is now the Centers for Medicare and Medicaid Services (CMS), under the
Bush administration. This did not improve or streamline the health care policy
decision-making; it has simply readjusted the name.
To read more,
please go to www.medicaltuesday.net/voicesofmedicine.asp .
For the last several years we have been dealing with a reduction in Medicare payments promoted by the current administration and Congress. We have been dealing with two specific areas within health care policy. One is called the Geographic Practice Cost Indices (GPCI) which raises or lowers Medicare fees in an area depending on whether the area physician's practice costs are above or below the national average. There are three components to the Medicare fee: physician's work, practice experience and malpractice expense. This certainly hits those of us in Locality 99 including those rural physicians of Alpine, Amador, and Calaveras counties. And our fees are lower than areas where the costs are below the national average. This does not take into account a number of other issues including patient mix, housing costs and other problems in the state. Although our reimbursement rate is different and we have been asking for a resolution and a national solution to this problem, we continue to have difficulty and disparities in the Locality 99 counties. This issue continues to be a problem with Congress and after a year of discussion on this matter there has still been no solution presented. . .
Currently an average private practice neurosurgeon has a case mix which is around 20 percent brain surgery, the rest being almost all spine. We are now also seeing the advent of neurosurgeons renouncing brain surgery privileges and becoming pure spine surgeons, another phenomenon unimaginable in the '80s when I went to medical school. In fact it would have been considered outrageous and repugnant. But nowadays it is understood. It is not just the reimbursement factor that's driving this phenomenon; it is also a reaction to the ER coverage crisis, and especially to the malpractice crisis that continues to afflict certain states in the Union. And so it goes. Yesterday's abomination becomes today's routine.
Mass migration towards Sleep Medicine, mostly by pulmonologists and neurologists, is yet another modern change. Sleep Medicine is a field that did not exist as a clinical entity when I was in school. According to a pulmonologist friend with whom I inquired, the factors driving a remarkable rise in this specialty are similar to the spine surgery issues I mentioned above; new understanding in sleep pathology, a massive increase in sleep disorders in relationship to our obesity epidemic and new diagnostic capabilities. On the economic side, Sleep Medicine provides equal pay for less work; most certainly equal pay with less call. An average pulmonologist/intensivist burns out within approximately a decade or so. What better alternative than Sleep? For those who are more durable, they can have the best of both worlds simultaneously practicing pulmonology and Sleep.
Where does it all end? Nowhere of course. Evolution never stops.
We evolved from shamans and barber surgeons into science-based enlightenment healers. We face one certainty in our future: medicine will continue morphing indefinitely and unpredictably as it has in the past leaving the inattentive or unaware as casualties in its wake. Eventually the future generations will view us as crude and primitive, as we ourselves view our predecessors.
I recall a memorable scene from a Star Trek movie ("Star Trek the Voyage Home," Paramount Pictures, 1986). The spaceship, caught in a time warp had somehow found itself in the late 20th century (what a coincidence!). When Mr. Chekov, one of the crew, suffered a head injury and epidural hematoma, he was taken to a "modern" neurosurgical operating room where they started prepping him for a craniotomy. In a dramatic rescue attempt Captain Kirk and Dr. McCoy infiltrated the hospital where he was kept. As they strolled the hallways and elevators looking for him, Dr. McCoy was totally outraged with what he saw and heard: "dialysis" and "chemotherapy" were being offered to patients. This was to him as much Stone Age medicine, as pneumoencephalography is to me. As the drama peaked they stormed the "modern" operating room and found Chekov on the table.
The space doctor, horrified and disgusted with what was about to be done exclaimed, "Put away your butcher tools man!" While Captain Kirk shuffled the O.R. crew aside, Dr. McCoy placed a pager like device on the unfortunate patient's forehead, which emitted a characteristically stellar sound. With the feckless neurosurgeon and his team looking on in astonishment, Chekov miraculously awoke within seconds and was oriented to all except his rank (he claimed he was Admiral). It was now time to whisk him off this horrific "medieval" establishment before the savages came after them.
Great fantasy? I don't know about you, but I'd rather be here with my scalpel and drill, doing what I was well-trained to do, than in the imaginary future, which is likely to hold unimaginable challenges. As for those caught in the vortex of change right now, I wish them all the very best.
To read the entire article, please click on Fall Quarter 2006 at www.sjcms.org/magazine/.
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9. Book Review: America's "Illiteracy Cartel"
CLONING OF THE AMERICAN MIND - Eradicating Morality Through Education, by B. K. Eakman; Review by Del Meyer, MD
"The educational system should be a sieve, through which all the children of the country are passed. . . It is very desirable that no child escape inspection. . ." Paul Popenoe, behavioral eugenicist, American Eugenics Society; Editor, 1926
With this quotation, B K Eakman, educator, speech and technical writer, and researcher, sets the tone and the caution of a well-researched "call to alarms." She previously wrote the first publication to warn of individually identifiable psychological assessments being given under cover of academic (achievement) testing. That 1991 book, Educating for the "New World Order," was a surprise hit. It revealed that "corrective" curricula were being brought into classrooms under the umbrella of remediation. Youngsters' beliefs and viewpoints were being remediated, not their skills in academic disciplines.
Eakman does a masterful job chronicling three parallel
efforts dating over a century--information gathering methodologies, behavioral
science, and legislation--and places these in context to provide insight, not
only into the times and circumstances surrounding each event, but the
ramifications for our present era.
To read more,
please go to www.medicaltuesday.net/bookreviews.asp .
Cloning of the American Mind centers on America's "illiteracy cartel," a term Eakman coined to describe an out-of-control psychographic consulting industry. Psychographics is a relatively new field that combines elements of demographic and marketing research, where personal, student, and family records assume a commodity that with recent advances in computer technology can be acquired by almost anyone. Psychographics means "the study of social class based upon the demographics . . . income, race, color, religion, and personality traits. . . which can be measured to predict behavior." Their use in persons in captive, compulsory settings like elementary and secondary schools is of serious ethical and civil rights concerns.
This book explores today's behemoth psychographic consulting/information brokerage industry, focusing in particular on state-of-the-art computer technologies and advertising strategies to illustrate how behavioral scientists are combining these with psychiatry to reform education. In the process, Eakman shows us two factions of behavioral science as they evolve, clash, and then come together to accomplish what no extremist group or power elite has been able to do in the history of the world: hold an entire population hostage to a set of quasi-political, psychological criteria by predicating children's job prospects on whether they hold "acceptable" worldviews and opinions. These social engineers, by obtaining personal information about youngsters and their families, also get into the belief system of the students and correct any viewpoints they find distasteful.
As a society we are getting desensitized to divulging personal information. We're no longer sure what "personal" means. Certainly our children don't know. When they're asked questions about the family's medicine cabinet, mental problems, drinking habits, sexual practices, they are only too eager to impress, divulge and exaggerate information to please the teacher, and sound impressive misinterpreting what they see and hear. False information is thereby interspersed with accuracy being of little or no concern to those collecting information. The media, of course, has no stake whatsoever in other people's privacy.
The critical point is that there is a computer model available to predict behavior, simply by deriving a pattern of one's past activities. These activities can include anything from long-distance telephone usage to spending, recreation, and health. These are increasingly available, not only as part of any security background check, but also can now be added to a routine background check. If this is not enough, there is the ever-lurking "information underground' to which even government officials turn when they cannot get their data on us through legitimate channels.
Eakman points out that Jeffrey Rothfeder in his 1992 volume, Privacy For Sale, decided to show just how much information he could obtain about a prominent public figure. He selected former Vice-President Dan Quayle, someone he held in mild contempt. By using his personal computer and telephone, Rothfeder found he could easily gain access to information he wasn't supposed to be able to get. He found more than he bargained for and started sounding alarms. However, Rothfeder was blissfully unaware that techniques identical to those he was describing were being used in the nation's elementary and secondary schools. A database exists that not only has the capability to track and cross-reference generic information about people, their beliefs, family ties, friends' and associates' names, addresses, phone numbers and aliases; political/civic clubs and associations joined; magazine subscriptions; frequent shopping places; political campaigns and causes contributed to; how important a person is by region, state, or city; what potentially embarrassing information one may harbor; but can also predict a person's future action. . .
The epitaph of the 20th century should be: "Here lie the victims of open-mindedness." --Joseph Sobran, syndicated columnist.
To read the rest of this review, click on www/healthcarecom.net/bkrev_CloningOfTheAmericanMind.htm.
To read more book reviews, go to www.delmeyer.net/PhysicianPatientBookshelf.htm.
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Warren Beatty, upon receiving a Golden Globe Award recently, stated that after he had told Arnold he should be come a democrat, he did.
Looks like he's becoming more leftist than the leftist Governor Davis whom he helped impeach.
The National Health Service is encouraging the whip of malpractice fines for doctors that don't follow stringent guidelines. If there is an outbreak of MSRA infections at a hospital, doctors could be charged with malpractice and hospitals punished and fined. The NHS states that this threat "seems to concentrate their minds beautifully."
Has the NHS thought about simply buying some cattle
prods to mold doctors' minds?
To read more,
please go to www.medicaltuesday.net/hhk.asp .
In Victoria Lambert's report in the Telegraph, she had spoken to a microbiologist in Romania about their infection rate. The microbiologist could not be named for political reasons, but admits the situation in Romania is not good.
Oh the joys of practicing medicine in an environment where health is less important than politics.
Professor Giuseppe Ippolito in Rome believes the hospitals in Italy are excellent. One of their key areas in management of a patient with MRSA is the immediate removal and isolation of a patient who has this condition.
Why is this "standard of care" universally practiced in America so unusual in socialized countries?
Professor Alkiviadis Vatopoulos of Athens said that Greek hospitals are not dirty. "But they are so busy and understaffed that nurses don't have time to wash their hands between patients, and rooms that are designed to hold three beds often hold four."
Maybe we should avoid Greece on our medical tours if nurses have to go from bedpans to IVs.
Dr Alexander Friedrich, says, it feels like it is "raining MRSA." He feels they are lucky in Munster which is near the Dutch border. The pressure brought by the Dutch ("They won't take patients from our hospitals," he confides.) is forcing his regional government to spend more money on health care.
Maybe our hospitals should "rain MRSA" until Medicare comes across with more funding.
Dr Friedrich is implementing search and destroy programmes [sic], but points out that you need to create regional networks of hospitals, GPs, nursing homes and public health officials so that everywhere an MRSA carrier goes, they can be tracked and treated.
So saving lives should come after we set up a police health-tracking network?
The governor denies that he's becoming a Democrat or Independent, but is he without a party?
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• John and Alieta Eck, MDs, for their first-century solution to twenty-first century needs. With 46 million people in this country uninsured, we need an innovative solution apart from the place of employment and apart from the government. To read the rest of the story, go to www.zhcenter.org and check out their history, mission statement, newsletter, and a host of other information. For their article, "Are you really insured?," go to www.healthplanusa.net/AE-AreYouReallyInsured.htm.
- www.emergiclinic.com Here is his story: Three
years ago, I left ER medicine to establish a primary care clinic in a town of
about 15,000 in northeast Tennessee - primarily for the uninsured, but also for
anyone willing to pay me for my care at the time of service. I named the clinic
PATMOS EmergiClinic - for the island where John was exiled and an acronym for
"payment at time of service." I have no third party contracts...not
commercial, not Medicare, TennCare or worker's compensation. My practice today
has over 4,000 patient charts. My patients are typically between 5-50 years
old, but I do have a significant number of Medicare patients. A year ago, over
95 percent of the patients I saw had no insurance. Today, that figure may be 75
percent. But even those with insurance learn a simple lesson when they come to
me: health insurance does not equal healthcare, at least not at my clinic. I
clearly tell my patients how much a visit will cost. Everything is up front and
honest. I will prepare a billing claim for my patients with insurance, for a
small fee, but I expect them to pay me when I see them. Because I need only one
employee in my office, my costs are low. For the same services, I charge about
60 percent of charges made by other local clinics, 40 percent of what the local
urgent care clinic charges and less than 20 percent of what the local ER
charges. I am the best bargain in town. If I can do it, caring for the
uninsured in a small rural town, any doctor can. To read more on Dr Berry,
please click on the various topics at his website above.
• PRIVATE NEUROLOGY is a Third-Party-Free Practice in Derby, NY with Larry Huntoon, MD, PhD, FANN. http://home.earthlink.net/~doctorlrhuntoon/. Dr Huntoon does not allow any HMO or government interference in your medical care. "Since I am not forced to use CPT codes and ICD-9 codes (coding numbers required on claim forms) in our practice, I have been able to keep our fee structure very simple." I have no interest in "playing games" so as to "run up the bill." My goal is to provide competent, compassionate, ethical care at a price that patients can afford. I also believe in an honest day's pay for an honest day's work. Please Note that PAYMENT IS EXPECTED AT THE TIME OF SERVICE. Private Neurology also guarantees that medical records in our office are kept totally private and confidential - in accordance with the Oath of Hippocrates. Since I am a non-covered entity under HIPAA, your medical records are safe from the increased risk of disclosure under HIPAA law.
J. Harris, MD - www.northernurology.com
- an active member in the American Urological Association, Association of
American Physicians and Surgeons, Societe' Internationale D'Urologie, has an
active cash'n carry practice in urology in Traverse City, Michigan. He has no
contracts, no Medicare, Medicaid, no HIPAA, just patient care. Dr Harris is
nationally recognized for his medical care system reform initiatives. To
understand that Medical Bureaucrats and Administrators are basically Medical
Illiterates telling the experts how to practice medicine, be sure to savor his
article on "Administrativectomy: The Cure For Toxic Bureaucratosis"
To read the
rest of this section, please go to www.medicaltuesday.net/org.asp .
• Dr Vern Cherewatenko concerning success in restoring private-based medical practice which has grown internationally through the SimpleCare model network. Dr Vern calls his practice PIFATOS – Pay In Full At Time Of Service, the "Cash-Based Revolution." The patient pays in full before leaving. Because doctor charges are anywhere from 25–50 percent inflated due to administrative costs caused by the health insurance industry, you'll be paying drastically reduced rates for your medical expenses. In conjunction with a regular catastrophic health insurance policy to cover extremely costly procedures, PIFATOS can save the average healthy adult and/or family up to $5000/year! To read the rest of the story, go to www.simplecare.com.
• Dr David MacDonald started Liberty Health Group. To compare the traditional health insurance model with the Liberty high-deductible model, go to http://www.libertyhealthgroup.com/. There is extensive data available for your study. Dr Dave is available to speak to your group on a consultative basis.
· Dr. Elizabeth Vaughan is another Greensboro physician who has developed some fame for not accepting any insurance payments, including Medicare and Medicaid. She simply charges by the hour like other professionals do. Dr. Vaughan's website is at www.VaughanMedical.com.
· Madeleine Pelner Cosman, JD, PhD, Esq, who has made important efforts in restoring accountability in health care, has died (1937-2006). Her obituary is at www.signonsandiego.com/news/obituaries/20060311-9999-1m11cosman.html. She will be remembered for her important work, Who Owns Your Body, which is reviewed at www.delmeyer.net/bkrev_WhoOwnsYourBody.htm. Please go to www.healthplanusa.net/MPCosman.htm to view some of her articles that highlight the government's efforts in criminalizing medicine. For other OpEd articles that are important to the practice of medicine and health care in general, click on her name at www.healthcarecom.net/OpEd.htm.
• David J Gibson, MD, Consulting Partner of Illumination Medical, Inc. has made important contributions to the free Medical MarketPlace in speeches and writings. His series of articles in Sacramento Medicine can be found at www.ssvms.org. To read his "Lessons from the Past," go to www.ssvms.org/articles/0403gibson.asp. For additional articles, such as the cost of Single Payer, go to www.healthplanusa.net/DGSinglePayer.htm; for Health Care Inflation, go to www.healthplanusa.net/DGHealthCareInflation.htm.
• Dr Richard B Willner, President, Center Peer Review Justice Inc, states: We are a group of healthcare doctors -- physicians, podiatrists, dentists, osteopaths -- who have experienced and/or witnessed the tragedy of the perversion of medical peer review by malice and bad faith. We have seen the statutory immunity, which is provided to our "peers" for the purposes of quality assurance and credentialing, used as cover to allow those "peers" to ruin careers and reputations to further their own, usually monetary agenda of destroying the competition. We are dedicated to the exposure, conviction, and sanction of any and all doctors, and affiliated hospitals, HMOs, medical boards, and other such institutions, which would use peer review as a weapon to unfairly destroy other professionals. Read the rest of the story, as well as a wealth of information, at www.peerreview.org.
• Semmelweis Society International, Verner S. Waite MD, FACS, Founder; Henry Butler MD, FACS, President; Ralph Bard MD, JD, Vice President; W. Hinnant MD, JD, Secretary-Treasurer; is named after Ignaz Philipp Semmelweis, MD (1818-1865), an obstetrician who has been hailed as the savior of mothers. He noted maternal mortality of 25-30 percent in the obstetrical clinic in Vienna. He also noted that the first division of the clinic run by medical students had a death rate 2-3 times as high as the second division run by midwives. He also noticed that medical students came from the dissecting room to the maternity ward. He ordered the students to wash their hands in a solution of chlorinated lime before each examination. The maternal mortality dropped, and by 1848, no women died in childbirth in his division. He lost his appointment the following year and was unable to obtain a teaching appointment. Although ahead of his peers, he was not accepted by them. When Dr Verner Waite received similar treatment from a hospital, he organized the Semmelweis Society with his own funds using Dr Semmelweis as a model. To read the article he wrote at my request for Sacramento Medicine when I was editor in 1994, see www.delmeyer.net/HMCPeerRev.htm. To see Attorney Sharon Kime's response, as well as the California Medical Board response, see www.delmeyer.net/HMCPeerRev.htm. Scroll down to read some very interesting letters to the editor from the Medical Board of California, from a member of the MBC, and from Deane Hillsman, MD.
To view some horror stories of atrocities against physicians and how organized medicine still treats this problem, please go to www.semmelweissociety.net.
• Dennis Gabos, MD, President of the Society for the Education of Physicians and Patients (SEPP), is making efforts in Protecting, Preserving, and Promoting the Rights, Freedoms and Responsibilities of Patients and Health Care Professionals. For more information, go to www.sepp.net.
• Robert J Cihak, MD, former president of the AAPS, and Michael Arnold Glueck, M.D, write an informative Medicine Men column at NewsMax. Please log on to review the last five weeks' topics or click on archives to see the last two years' topics at www.newsmax.com/pundits/Medicine_Men.shtml. This week's column is on how Universal Health Care Spreads to Far East. Get an overview of the unending problems of UHC in every country where it has been tried. www.newsmax.com/archives/articles/2007/1/22/123737.shtml
• The Association of American Physicians & Surgeons (www.AAPSonline.org), The Voice for Private Physicians Since 1943, representing physicians in their struggles against bureaucratic medicine, loss of medical privacy, and intrusion by the government into the personal and confidential relationship between patients and their physicians. Be sure to scroll down on the left to departments and click on News of the Day in Perspective: Congress moves toward price controls on drugs or go directly to www.aapsonline.org/nod/newsofday388.php. Don't miss the "AAPS News," written by Jane Orient, MD, and archived on this site which provides valuable information on a monthly basis. This month, be sure to read LINKAGE: EBM, EMR, P4P at www.aapsonline.org/newsletters/jan07.php. Scroll further to the official organ, the Journal of American Physicians and Surgeons, with Larry Huntoon, MD, PhD, a neurologist in New York, as the Editor-in-Chief - www.jpands.org/. There are a number of important articles that can be accessed from the Table of Contents page of the current issue: www.jpands.org/jpands1104.htm. Don't miss the excellent articles on Confessions of a Corporate Insider or the extensive book review section that covers ten great books this month.
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Del Meyer, MD, Editor & Founder
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Words of Wisdom
What this country needs are more unemployed politicians. -Edward Langley, Artist 1928-1995
Management of an institution - whether a business, a university, a hospital - has to be grounded in basic predictable trends that persist regardless of today's headlines. It has to exploit these trends as opportunities. And these basic trends are the emergence of the Next Society and its now and unprecedented characteristics. -Peter Drucker, Managing in the Next Society, from The Daily Drucker
Some Recent or Relevant Postings
America Alone, www.delmeyer.net/bkrev_AmericaAlone.htm
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
Milton Friedman died on Nov. 16, 2006, age 94. There is a memorial for him today at Stanford University.
In July last year, the late Milton Friedman, Nobel laureate in economics in 1976, granted an interview to The Wall Street Journal. Today we publish material from a question-and-answer exchange he had by email -- shortly after their meeting -- with his interviewer, Tunku Varadarajan, the Journal's editorial features editor.
To read this exchange, go to http://online.wsj.com/article_print/SB116942792191783271.html.
With all the accolades given to this great Nobel Laureate over the past several months, it may be appropriate to point out some serious errors in his thinking. On many occasions he proposed education vouchers even though he was opposed to government handouts. His logic was that this would be a temporary maneuver to improve education and then it would be abandoned.
As an economist, he must have realized that the when the Federal Personal Income Tax Amendment 16 was passed, there was such a rush by Congress for additional money to spend, that they implemented a temporary corporate income tax until the personal income tax would be fully implemented. But as P. J. O'Rourke once stated: "Giving money and power to government is like giving whiskey and car keys to teenage boys." As we all know, the greedy government never gives up a source of tax revenue and so corporate income is taxed twice, once as a corporation and once again as the proceeds go to its owners as personal income where it is taxed again.
Milton Freedman should have known better than to propose school vouchers. It would never have been given up any more than the corporate income tax. It would have destroyed education indefinitely through increasing governmental regulation, just like everything else the government regulates to the detriment of society, the regulated industry and free men and women.
On This Date in History - January 30
On this date in 1882, Franklin Delano Roosevelt was born in Hyde Park, NY. His greatest triumph was not in becoming President in 1933, but in overcoming a great physical handicap after he was stricken with polio.
On this date in 1948, Mahatma Gandhi was assassinated in New Delhi. He was one of the greatest apostles of non-violence and father of civil disobedience in modern times. Life is not all what we make it; it is what other people make it for us.
On this date in 1933, a real black-letter day, Adolf Hitler became Chancellor of Germany, launching the nation on a suicidal path of hate and war. Any day is a good day in comparison.
Have a Great MedicalTuesday