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?
Wrong. To
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
cheeseburger."
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.
* * * * *
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
·
California "Pay or Play" Law, February 2004
·
AAPS Membership/Subscription Information http://www.aapsonline.org/nodarch.htm
* * * * *
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.
* * * * *
4.
Medicare: Medicare and
the Market, Washington Post
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.
Consider:
·
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
2003. 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.
www.ncpa.org/sub/dpd/index.php?page=article&Article_ID=14064
Source: Mike Leavitt, "Medicare And The
Market," Washington Post, January 11, 2007.
For text: http://www.washingtonpost.com/wp-dyn/content/article/2007/01/10/AR2007011002020.html
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
* * * * *
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 text: www.investors.com/editorial/editorialcontent.asp?secid=1501&status=article&id=254536378672573
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
* * * * *
6. Medical Myths: Will the Government Pay Me for Not
Being Sick?
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. Keep up the good work.
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?]
* * * * *
7.
Overheard in the
Medical Staff Lounge: Universal Health Care Paid for by Doctors
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.
Dr Yancy:
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.
* * * * *
8. Voices of Medicine: A Review of What Physicians Say in
Local and Regional Medical Journals
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.
* * * * *
10. Hippocrates & His Kin: Just a Notch Above Politicians
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?
* * * * *
11.
Physicians
Restoring Accountability in Medical Practice, Government and Society: