MEDICAL TUESDAY . NET
Community For Better Health Care
Vol VI, No 5, June 12, 2007
In This Issue:
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The Annual World Health Care Congress, co-sponsored by The Wall Street Journal, is the most prestigious meeting of chief and senior executives from all sectors of health care. Renowned authorities and practitioners assemble to present recent results and to develop innovative strategies that foster the creation of a cost-effective and accountable U.S. health-care system. The extraordinary conference agenda includes compelling keynote panel discussions, authoritative industry speakers, international best practices, and recently released case-study data. The 3rd annual conference was held April 17-19, 2006, in Washington, D.C. One of the regular attendees told me that the first Congress was approximately 90 percent pro-government medicine. Last year it was 50 percent, indicating open forums such as these are critically important. The 4th Annual World Health Congress was held April 22-24, 2007 in Washington, D.C. This year many of the world leaders in healthcare concluded that top down reforming of health care, whether by government or insurance carrier, is not and will not work. We have to get the physicians out of the trenches because reform will require physician involvement. The World Health Care Congress - Middle East will be held in Dubai, United Arab Emirates, on November 12-14, 2007. The World Health Care Congress - Asia will be held in Singapore on May 21-23, 2008. The 4th Annual World Health Care Congress - Europe 2008 will meet in Barcelona on March 3-5, 2008. The 5th Annual World Health Care Congress will be held April 21-23, 2008 in Washington, D.C. For more information, visit www.worldcongress.com.
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Some of the most popular issues of our MedicalTuesday newsletters seem to be our report on medical conferences. The interest may be primarily from non-physicians such as medical writers, nurses, administrators and health care executives.
The feedback on the World Health Care Congress, which we reported last month, is the most prestigious meeting of all sectors of the health care industry. We appreciate the $400 discount offered to all MedicalTuesday members. This is an important meeting for all physicians to attend.
In addition, physicians should also attend a physician-oriented practice meeting. Unfortunately, the AMA and the CMA (California Medical Association) no longer hold annual meetings of this nature. They offered physicians an opportunity to be in the same city, to get to know one another, and to select from a large variety of presentations in dozens of specialties. Wouldn't it be great if 100,000 physicians descended on Chicago (or some large city on a relatively neutral weekend such as Columbus Day weekend in October) every other year? And on the alternate years, the state societies could gather on the same weekend. The CMA could have 50,000 physicians from California together at one time? What a message that would send to our critics. At the present time, the only pro-physician meeting is the annual assembly of the American Association of Physicians and Surgeons, which meets on the second weekend of October. Be sure to put that on your calendar.
The third type of meeting physicians should attend on a yearly basis is the major clinical meeting of the various medical specialties. Some are very large, such as the 20,000 oncology or the 35,000 cardiology or large family doctor meetings. Many that attend these meetings are primary or personal physicians with special interests. I attend the International Conference of the American Thoracic Society, which was held in San Francisco this year. Next year it is in Toronto. It generally alternates between the two coasts inasmuch as nearly 40 percent of our 18,000 members are from other countries. This makes travel easier, at least from Europe and Asia where large membership exists. This year we had 16,400 registrants. Essentially all of the countries of the continents of Europe, Asia and Australia were represented. Most of the countries of South America and Africa were also represented. It also seemed like more of the Mid East was represented. The World Health Care Congress recognizes this interest in scheduling a meeting in Dubai, United Arab Emirates this fall.
The specialty of Lung Medicine has had various names during its 100-year history. (We are the second oldest specialty after Eye.) In addition to Lung, we are Pulmonary Physicians, or Respiratory or Chest Physicians. The lung surgeons are generally known as Thoracic Surgeons. Hence, the membership of the ATS is largely composed of the clinical specialties of Pulmonologists, both Internists and Pediatricians, Thoracic Surgeons, Respiratory Nurse Clinical Specialists, Respiratory Therapist, and Pulmonary Function Technologists. The research arms in academia are primarily respiratory physiologists, lung anatomist, pulmonary pathologists, and now respiratory cell biologists and geneticists.
In the early 1900s, tuberculosis or TB was the plague that was the primary interest of our organization, then known as the American Trudeau Society, named after its founder in 1905. With no drugs to fight TB, and with millions dying from it, the Sanatorium movement began to isolate TB and provide "healing" rest in pastoral surroundings. They also sponsored research in why TB reactivated so frequently. In the early days, removing a diseased or destroyed lung was the basis for Thoracic Surgery training. When I trained in Michigan, there was a van of TB patients from the various sanatoriums around the state that arrived at the University of Michigan Medical Center every Monday for lung surgery and returned to the sanatoriums usually by Friday. This trained some of the best Thoracic Surgeons for many years.
The annual meetings enlarged over the years to include many chest diseases and the lay organization was called TB & Health, and later the Lung Association. The medical arm changed its name form Trudeau to the American Thoracic Society.
There was increasing friction between the two organizations over the years, and the doctors felt that lung research was not emphasized enough comprising about 25 percent of the donated income. The local lung associations gave even less to research. About 1999, there was a divorce and the American Thoracic Society had to pay the American Lung Association for the American Thoracic Society name and to acquire ownership of the medical Journal, which was The American Review of Respiratory Disease. This evolved into The American Journal of Respiratory and Critical Care Medicine; the new name incorporated Critical Care medicine since much of critical care in the ICUs was done by pulmonologists. There is now a similar movement to incorporate Sleep Medicine since most of Sleep Medicine, such as Obstructive Sleep Apnea, is done by Pulmonologists. This journal comes out twice a month.
There is a second journal, The American Journal of Respiratory Cell and Molecular Biology, which is published monthly or two volumes a year. A third journal was recently added, The Proceedings of the American Thoracic Society, which publishes Reviews and Symposia.
The ATS is making all the required payments for the 10-year buyout , has greatly enlarged its research funding,
and expanded internationally, more than tripling in size. It has become the Premier organization for all aspects of lung disease. The societies in many of the other continents, such as the European Respiratory Society and Asian Societies, are establishing alliances with the ATS. Joint memberships are being established with a number of them. Joint sponsorship of the World Chest Conferences is beginning to occur. (It was of interest that Google noted my attendance and reportage of the Pan American Chest Conference in Lima, Peru.)
The international conference consisted of sessions from 7 AM to 9 PM. There were twenty concurrent sessions each day and 60 concurrent poster sessions. Frequently, a speaker would mention the time and date that his researchers would be stationed at the posters related to his presentation; one could then speak with these researches in such great detail that an hour could be spent studying with the presenters. It was good to see aggressive Pulmonary Fellows still scheduling themselves 14 hours of sessions daily. This could add up to more than 50 hours of Continued Medical Education credit for attending the conference. (Twenty-five hours per year are required to maintain a medical license in California.) There were some fellows who purchased hundreds of tapes to listen to the other 19 sessions that they couldn't attend. (Will they have time to listen to hundreds of hours of lectures after their normal 80-hour work week? This must truly be a genuine love for excellence in medicine realizing that most of them will never make more than $30 to $50 an hour for their 80-hour work week.)
The concurrent sessions covered every aspect of clinical lung disease. The most popular session every morning was the two-hour review of the latest progress in all aspects of pulmonary medicine. This popular session was held in conference halls that seated three to four thousand attendees with standing room only in all side aisles and the back.
Although daily journal reading is important for all practicing physicians, one would be hard pressed to obtain as much information as is packed into such a four-day conference. In addition, there were two full days of 26 post-graduate courses that include intense training in one particular field such as sleep medicine, respiratory physiology during mechanical ventilation, pharmacogenetics, lung transplantation, and chest imaging to name a few of the 26.
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After the morning review sessions on the first afternoon of the conference, I attended the "Controversies in Interstitial Pulmonary Fibrosis - A Pro/Con Debate." It has always been an interest of my mine how hospitals and experts can rank physicians, who, after following algorithms for managing patients, still can't decide on a unified approach to a disease that has been studied since the first paper published by the Mayo Clinic in 1935 and the second published in 1944. My interest was also peaked since two such patients floated into my practice this past year. I saw the first one shortly after I entered practice and was able to make the pathologic diagnosis with a fiberoptic bronchoscope doing a transbronchial lung biopsy. We introduced this procedure into Sacramento in the early 1970s: the biopsy forceps is pushed through the bronchial wall ideally snaring 50 to 100 alveoli in order to study the alveolar wall under a microscope and view the fibrosis present. I kept this patient alive for more than twenty years, knowing that some of the first patients described in 1935 only lived six months to a year. Now we know that IPF is a multitude of diseases all with different prognosis. And the experts are still debating what should be the treatment of choice for each.
The series of sessions on the "Metabolic Dysfunction in Critical Care Illness," "Emerging issues in Drug Induced and Iatrogenic Lung Disease," and "Life after Critical Care" were all very popular sessions with standing room only. Admission to an ICU or Critical Care Unit carries a very ominous prognosis. Patients become anemic starting on the second day. The generally accepted standard is to give a blood transfusion when the Hemoglobin drops to 10 grams percent from the usual 14-16 Gm%. However, alveolar injury can be demonstrated within six hours of a transfusion and up to 85 percent of ICU patients are transfused. Hence, the large number of complicated "Acute Respiratory Distress Syndromes" (ARDS) in the ICUs which accounts for a significant mortality. One presenter suggested that transfusion should be held off until the Hemoglobin drops to 7 Gm% or half normal. Most patients will survive better if not transfused, thus many transfusions will be eliminated. (Be sure to follow Jerome Groopman's suggestion of asking your doctor the right questions and being aware of your loved one's hemoglobin levels every day in the ICU.) Many patients develop neuropathy and myopathy in the ICU. It is so common that they are now lumped as neuromyopathies. This is a significant barrier for patient's return to work after an ICU admission. Fifty percent are unable to return to work for a year after an ICU admission. Up to 75 percent are able to return to work within five years with appropriate physical therapy. A new and surprising finding is that 43 percent of patients have sexual dysfunction after a critical care admission. There are a number of neuropsychological problems that are just beginning to be recognized.
The highlight of the Annual Membership Meeting was the President's Lecture given this year by Jerome Groopman, MD. Dr. Groopman is the Chief of Experimental Medicine at Beth Israel Deaconess Medical Center, one the world's leading researchers in cancer and AIDS. He is a staff writer for The New Yorker and author of four thoughtful books on healthcare including "The Measure of Our Days," "Second Opinion" and "The Anatomy of Hope." His current best seller is "How Doctors Think" which is available in book and audiodisc and hit the bookstores on the third day of this meeting. We will be reviewing his book over the next month or two to bring you the wisdom of a consummate physician who is comfortable at the research bench, the bedside and the consultation room. This week, we bring you a review of his first book below: The Measure of our Days - New Beginnings at Life's End.
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Patients suffering from head and neck cancer are to be denied a new drug on the National Health Service because it is claimed it is no more effective than existing drugs.
The National Institute for Health and Clinical Excellence (Nice) has rejected Erbitux, also known as cetuximab, for cancer sufferers in England and Wales. The drug is available in Scotland.
Nice said the drug, when used in conjunction with radiotherapy, did not offer "better therapeutic value" than existing treatments for locally advanced head and neck cancer.
However, according to clinical trials carried out by Merck Serono UK, the drug's manufacturer, patients treated with Erbitux plus radiotherapy survive for an average of 49 months, compared with 29 months for those treated with radiotherapy alone.
Campaigners said the move was a blow to patients as the drug is the first licensed in the past 40 years for treating locally advanced head and neck cancer. . .
More than 7,800 people are diagnosed with head and neck cancer in the UK every year.
Dr Vinod Joshi, of the Mouth Cancer Foundation, said: "Nice has effectively denied [head and neck cancer patients] this new treatment option for a chance to live longer.
"There is now a postcode lottery as the Scottish Medicines Consortium has approved not only cetuximab but also docetaxel [another head and neck cancer drug] for Scottish patients."
Christine Piff, the chief executive of the head and neck cancer support group Let's Face It, said: "I am devastated by the news. Head and neck cancer continues to be the Cinderella cancer, receiving little or no attention from the NHS. . .
Dr Nick Slevin, a consultant oncologist at the Christie Hospital in Manchester, added: "The decision from Nice ignores the complexities and pragmatism of clinical practice.
"I have no doubt that cetuximab with radiotherapy is the correct treatment option for some patients.
"Head and neck cancer management is not black and white and I believe this decision is discriminatory against a group of patients who don't carry the same political influence as others."
A Swedish study published earlier this month showed that the UK has one of the worst records over access to new cancer drugs. Experts ranked the UK in the bottom group for its "slow and low" uptake of drugs after analysing sales in 25 countries.
The NHS does not give access to appropriate healthcare, but only access to a waiting or wish list.
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An entire day post-graduate course was devoted to Current Procedural Terminology codes. These are ever-changing codes used by physicians in an attempt to get paid for the practice of medicine. These have gotten more complicate and more extensive by the year. I did not waste eight hours attending this. It would not lead to any professional enhancement or improve quality of care. It only allows one to play the government games. Even though these codes are a requirement for Medicare Billing, they are carefully guarded and copyrighted by the AMA and cannot be acquired without purchase.
Government is not the solution to our problems, government is the problem.
- Ronald Reagan
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The high-tech hospital is extremely important for the complicated and seriously ill patient. However, as this conference repeatedly pointed out from acquired infections to simple blood transfusion, it is an increasingly hazardous environment. The consequences extend far beyond the hospitalization into the ambulatory care arena. As hospitals lose much of their volume from inpatients, they have increasingly resorted to outpatient medicine. However, it has repeatedly been shown that outpatient hospital medicine is far more expensive than similar treatment in a doctor's office - sometimes on the order of two or three-fold. It also depends on the system and reimbursement mechanisms.
In the average hospital, the goal is increasing revenue, which is how they stay in business. But it is increasingly costly and maybe gluttonous. A recent example surfaced.
There is a great emphasis on pulmonary rehabilitation in recent years. Medicare reimburses for this. I had a patient that enrolled at the local hospital and he stated that Medicare was billed about $2500 for the two-week program. There were about 20 COPD patients in his group and he figured that the hospital revenue for providing one respiratory therapist for two hours a day to lead this group netted the hospital well over $50,000 for what he estimated at 25 hours of work.
I also had some Kaiser Permanente patients in my research group that went to pulmonary rehabilitation at KP three days a week for 10 or 15 years. There was no charge in this integrated health care system. I made a visit to the rehab unit and spoke with the respiratory therapist. He stated that KP provides these facilities and saves considerable moneys by preventing hospitalizations. He had the figures to prove that when patients dropped out of the program, they were more likely to go to the emergency room and be admitted.
The key difference is that the private hospitals make money on such programs and also make money on the failure of such programs, which then requires admission to their high-cost center.
KP, being an integrated health care system with the three arms of Kaiser Foundation Hospitals, Kaiser Foundation Health Plans, and The Permanente Medical Group, work in concert with each other to reduce health care costs. They are connected through electronic medical records that allow any Permanente physician to access a patient's medical record from any computer terminal within the system. It appears to be a winning combination. They feel that this is the answer to the insurance dilemma.
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One morning, Bernie woke up with stiff joints in his knees and hands. Thinking he might have pulled some muscles, he took ibuprofen and went about his daily routine. After three of four days of the same pain, he went to the doctor and explained to her that the pain was debilitating and keeping him from doing his ordinary activities.
The doctor asked a series of questions and conducted a careful physical exam.
The doctor said, "Well, the good news is, I've not found any signs of a serious disease like rheumatoid arthritis. I've ordered some blood tests, but I think the results will come back negative. So I think we can assume that you just have a touch of mild ordinary arthritis. Some mild pain relievers are all you need."
So Bernie feels better, right? Well, not exactly. According to a recent study in the British Medical Journal, when doctors try to reassure patients, they may actually cause them more worry. Several studies have shown that after doctors reassure patients that their chest pain is nothing serious -- even after they've been scanned and tested and found to be normal -- they continue to fret and limit their physical activity. The same is true with patients who have headaches: They continue to be concerned even after being told everything is fine.
The problem may be a difference in perspective, communication style, language and understanding of risk.
What did the patient with the arthritis hear?
"I heard the doctor tell me she couldn't find anything -- that my arthritis wasn't very serious. Well, that's easy for her to say. She doesn't see me in the evenings when the pain is worse. I think she thinks I am faking all of this."
The doctor never heard what Bernie thought because she never asked. The doctor thought she did a good job providing reassurance, but we now know that simply saying that everything is all right doesn't seem to comfort very many people. They interpret the doctor's words in the context of their illness and in relationship to their own stories and experiences. . .
By the same token, patients need to understand that "I don't know" doesn't mean "I don't care" or "I am a bad doctor." Most of medicine remains an art -- far too little of medicine is scientific despite our constant talk of "studies" and "research."
To read the entire article, go to www.sacbee.com/107/v-print/story/176177.html.
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Dr. Rosen: The Washington Conference by the Whistleblowers certainly raised the consciousness in this country concerning the hostility to many segments of the health care industry.
Dr. Milton: I certainly hope so. I don't think the public has any concept of how a doctor's efforts to improve care by pointing out inferior care are thwarted by hospitals, whether private, military, VA, or public.
Dr. Michelle: I have a friend who provided care to the military service and did such a good job that she was ultimately subjected to PEER REVIEW and after a Kangaroo trial, lost her job and nearly her medical license.
Dr. Ruth: She must have done something egregious.
Dr. Michelle: Nothing of the sort. Although they tried to take issue with her care, she had outside physicians that supported her clinical decisions in each and every case. Every case withstood scrutiny. But facts don't matter in a Kangaroo Court.
Dr. Dave: Another hostility we face is women alleging sexual misconduct. Goodness, we're in the business of examining human bodies and half of them happen to be female.
Dr. Milton: I overheard some women at a table in a restaurant discuss that when their job was in jeopardy or they just needed money, they could always consider filing a complaint for sexual misconduct because it's so hard for the defense to win and they always settle for a goodly sum, usually it beats several years of earned income.
Dr. Michelle: I've heard women discuss the same. If they ever got pushed against a wall financially, they would always have the option of filing a complaint against an employer or even a physician since that is open sesame.
Dr. Rosen: There was an internist in California who had a patient that made sexual advances to him. He was a devoutly religious man and rebuffed her several attempts. This incensed her and she vowed to get even. She alleged that he took a little longer to do a pelvic exam on her than was necessary and so he was a sexual pervert. She was a medical assistant in another practice and monitored the internist's practice and contacted every female he examined. It took five years for her to find one other patient that agreed that perhaps the doctor took a bit longer to do a pelvic exam than was absolutely necessary. She found the third and fourth much faster and then she had a case and sued.
Dr. Ruth: Didn't he have a chaperone in the room with him?
Dr. Rosen: Yes he did. But the court alleged that since she worked for the doctor, she couldn't be objective for fear of losing her job. And he went to jail for this trumped-up charge.
Dr. Ruth: Was it a short jail sentence?
Dr. Rosen: I think he spent five years in prison before he was paroled. But his medical license was not restored. So the authorities set up a trap. They found a former patient who called him for an urgent medical problem. He responded and gave her some medications and immediately the police came out of his former patient's closet and arrested him for practicing without a license.
Dr. Ruth: So was it back to prison?
Dr. Rosen: Yes, pronto. And he hasn't been paroled in ten years. It was very hard on his family and his son committed suicide.
Dr. Dave: So why is this all happening to us? What can we do about it?
Dr. Yancy: We need to counter sue. In fact, I have a special malpractice policy that requires an additional premium. If I'm every sued for any reason, they will promptly counter sue any patient for any reason - whether it's a misdiagnosis, an alleged therapeutic misadventure, Peer Review, Whistleblower, or even Sexual Misconduct. They just believe that nearly all physicians are basically very honest and probably have the highest standard of any profession and all suits are nuisance suits and should be stopped in their tracks.
Dr. Rosen: The tragedy of all this is that our profession runs scarred and we don't help each other. When one doctor is named in an allegation of Peer Review or sexual misconduct, many are afraid to come to his defense because they know these are trumped up charges and they can turn on anyone interfering with a hospital or medical board's attempt to destroy a physician's license, which then eliminates his livelihood and generally destroys his family.
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Modern Day Paul Revere's Ride to Washington, By James J. Murtagh, M.D.
(James Murtagh spent 20 years as an Intensive Care Unit physician. Dr. Murtagh is the founder of Doctors for Open Government and is a co-chair of Washington Whistleblower Week.)
So through the night rode Paul Revere;
And so through the night went his cry of alarm
To every Middlesex village and farm.
A cry of defiance, and not of fear,
A voice in the darkness, a knock at the door.
Paul Revere is America's most well known whistleblower. Present day patriots who sound the alarm when danger threatens our society rightly believe Paul Revere to be the founding father of whistleblowing. Like modern day patriots, he called on the Sons of Liberty to oppose the grave, immediate dangers posed by redcoat troops sent to impose the will of an unresponsive king and parliament.
Last week, a conference as unique as Paul Revere's ride took place in our nation's capital. Whistleblower's Week in Washington (WWW) alerted the countryside of the grave dangers threatening our nation's security and well being. Modern patriots from a broad spectrum of government and private employers - health, environment, national security, civil rights, veterans, and more - have all banded together in a single meeting. The program was initiated and organized by the whistleblowers themselves. They were joined by more than 50 eminent public interest organizations in Washington to sound the alarm on dangers proven too real to be ignored. Hundreds of citizens took part.
Whistleblower's Week in Washington provided the time, place and voice for whistleblower patriots to band together for the first time to speak out against fraud, waste and corruption. These heroes and heroines represent a broad spectrum of government and private employees - national security, veterans, healthcare, environment, civil rights and justice.
Activities included congressional forums and hearings, an award ceremony for Senator Charles Grassley, rallies, and a film screening and book signings by eminent whistleblowers. Participants visited legislative offices to alert individual members of Congress of grave concerns.
Speakers and participants included both well-known figures and unfamiliar but important whistleblowers such as:
· Republican Senator Charles Grassley who was the keynote speaker. He was given a lifetime achievement award for his fight against waste, fraud and corruption in government. The award, like the conference, is completely bipartisan and has been endorsed by both blue-chip conservatives and liberals.
· Mahatma Gandhi's grandson Dr. Kanubhai R. Gandhi and EPA whistleblower and civil rights activist Dr. Marsha Coleman-Adebayo asked to keep America beautiful and safe from "Sea to Shining Sea.
· Religious leaders, including Rev. Walter E. Fauntroy, stressed the role of speaking the truth and the role of faith based initiatives in America's civil rights heritage.
· Climate Change Whistleblower Rick Piltz who suffered numerous retaliations after reporting that White House officials with no scientific training tampered with critical reports.
· Susan Wood who resigned in protest against the FDA's delaying of a ruling on whether the Plan B pill would be made more accessible to patients. She charged that then-acting FDA Commissioner Lester Crawford interfered in FDA decisions.
· Physicians Dr. Helen Salisbury and Dr. Larry Poliner who put their careers on the line to protect quality patient care. Dr. Janet Chandler battled to protect the humane treatment of her patients, and after more than a decade of legal appeals won a Supreme Court verdict upholding her stand for integrity in medical decisions for patient care.
· Coleen Rowley who blew the whistle on the FBI's negligence preceding the September 11 terrorist attack. Ms. Rowley was named as one of Time Magazine's Person's of the Year, along with conference supporter and Enron whistleblower Sherron Watkins.
Patriotic commitment united this band of whistleblowers who oppose hazardous, illegal and unsafe conditions, waste, fraud and abuse. They unite in order to maintain an open society, and to protect the rights of U.S. citizens to speak without reprisal on matters threatening the general welfare and defense of our nation.
In true Jeffersonian tradition, America's truth-tellers invited the press, Congress, and the American people to take part, to hear their stories, and to judge for themselves. Like Paul Revere, they rode to Washington to be heard throughout the land. New Sons and Daughters of Liberty must rise to defend our safety, our national defense and our honor.
The joint task force of WWW urges you to write your congressman, your senator, the media, and your friends to support the goal of a safer, freer America.
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Our profession has recently focused on pain management and end-of-life care since a law enacted in July 2001, that become effective on January 1, 2002, requires us to take continuing medical education on this topic. What our legislature has reduced to legalese, needs to be seen in a medical perspective. I believe this book does that.
Jerome Groopman, Professor of Immunology at Harvard and Chief of Experiment Medicine at Beth Israel Deaconess, explores life's lessons as he describes eight patients with life-threatening illnesses gazing into the face of death. He is able to transform medical case studies into spiritual journeys to help us understand why some are ennobled by it, others defeated.
During his second year as a medical student at Columbia, he experienced a major confrontation with death. He rushed home from his dormitory to find his father in the final throes of cardiogenic shock. He watched him die. Groopman feels that his father died before his time and before he, his family and friends could prepare for his passing. The family physician offered no medical expertise or emotional comfort. This experience committed Groopman to caring for his patients and their loved ones with compassion and scientific excellence. . .
After discussing the eight patient stories, Groopman gives a final epilogue. While writing this book, his mother developed breast cancer. The death of his father gave him the impetus and strength to do his life's work; looking to the future, he continues to seek lessons from his patients on how he and his mother should live. This is not something that can be learned in a classroom, forced upon us by lawmakers. Or, as Dr Mark Skousen, President of the Foundation for Economic Education says, "The triumph of persuasion over force is the sign of a civilized society." When we arrive in such a society, our lawmakers will have little to do.
To read the entire review, please go to http://healthcarecom.net/bkrev_MeasureOfOurDays.htm.
To read other book reviews, please go to www.delmeyer.net/PhysicianPatientBookshelf.htm.
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A San Francisco supervisor was targeted by the FBI because of a $40,000 cash payment he received from two men who sought his help with city permit problems for fast food restaurants. He immediately received a vote of confidence from supporters who say he is a man of character.
Only in SF does $40K seem to fall under the $25 limit for not having receipts for cash donations.
For the first time in history, the state of California will spend more on incarcerating inmates than on educating students in its public universities.
Just wait until Health Care is in the same budget soup. Will we be third? Or after roads?
Reminds me of when I was a visiting consultant to the San Juan Hospital in Lima, Peru. They had no fiberoptic bronchoscopes to make a diagnosis on a cancer patient they presented to me when every hospital in Sacramento, even an 80-bed hospital, had one. The chief of Thoracic Surgery told me that the anchovy trade to Eastern Europe exceeded the health care priority for the seventh straight year. Romania had no bronchoscopes to use as payment. They only had cardiac monitoring equipment, which he pointed out in his ICU. None of the units were functional.
At least Romania had anchovies while Peruvians died of an unrecognized arrhythmia.
Husband: What is this Environmental mouthwash? Wife: It doesn't kill germs that cause bad breath - it rehabilitates them and releases them into the wild. (after Piraro)
When your teeth fall out, just put them under your pillow for the fairy godmother. Maybe she has magical powers to counteract the environmentalist.
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• The National Center for Policy Analysis, John C Goodman, PhD, President, who along with Gerald L. Musgrave, and Devon M. Herrick wrote Lives at Risk issues a weekly Health Policy Digest, a health summary of the full NCPA daily report. You may log on at www.ncpa.org and register to receive one or more of these reports. This week, be sure to see the latest in the health care fiasco by logging on to HEALTH CARE - MORE SPENDING, NO RESULTS.
• Pacific Research Institute, (www.pacificresearch.org) Sally C Pipes, President and CEO, John R Graham, Director of Health Care Studies, publish a monthly Health Policy Prescription newsletter, which is very timely to our current health care situation. You may subscribe at www.pacificresearch.org/pub/hpp/index.html or access their health page at www.pacificresearch.org/centers/hcs/index.html. Be sure to read John Graham's latest treatise on Should Medicare be Means-Tested Symposium.
• The Mercatus Center at George Mason University (www.mercatus.org) is a strong advocate for accountability in government. Maurice McTigue, QSO, a Distinguished Visiting Scholar, a former member of Parliament and cabinet minister in New Zealand, is now director of the Mercatus Center's Government Accountability Project. Join the Mercatus Center for Excellence in Government: This week, focus on Why Is Income Inequality in America So Pronounced? Consider Education.
• The National Association of Health Underwriters, www.NAHU.org. The NAHU's Vision Statement: Every American will have access to private sector solutions for health, financial and retirement security and the services of insurance professionals. There are numerous important issues listed on the opening page. Be sure to scan their professional journal, Health Insurance Underwriters (HIU), for articles of importance in the Health Insurance MarketPlace. www.nahu.org/publications/hiu/index.htm. The HIU magazine, with Jim Hostetler as the executive editor, covers technology, legislation and product news - everything that affects how health insurance professionals do business. Be sure to review the current articles listed on their table of contents at hiu.nahu.org/paper.asp?paper=1. To see my recent column, go to http://hiu.nahu.org/article.asp?article=1328&paper=0&cat=137. Review the Health Care Coverage Options Database at www.nahu.org/consumer/healthcare/index.cfm.
• The Galen Institute, Grace-Marie Turner President and Founder, has a weekly Health Policy Newsletter sent every Friday to which you may subscribe by logging on at www.galen.org. A new study of purchasers of Health Savings Accounts shows that the new health care financing arrangements are appealing to those who previously were shut out of the insurance market, to families, to older Americans, and to workers of all income levels. This week, review the basics at www.galen.org/hcbasics.asp.
• Greg Scandlen, an expert in Health Savings Accounts (HSAs) has embarked on a new mission: Consumers for Health Care Choices (CHCC). To read the initial series of his newsletter, Consumers Power Reports, go to www.chcchoices.org/publications.html. To join, go to www.chcchoices.org/join.html. Be sure to review Greg's impressions of the month at www.chcchoices.org/publications.html.
• The Heartland Institute, www.heartland.org, publishes the Health Care News. Read the late Conrad F Meier on What is Free-Market Health Care?. You may sign up for their health care email newsletter at www.heartland.org/Article.cfm?artId=10478. This month, read a letter on Walk-In Clinics.
• The Foundation for Economic Education, www.fee.org, has been publishing The Freeman - Ideas On Liberty, Freedom's Magazine, for over 50 years, with Richard M Ebeling, PhD, President, and Sheldon Richman as editor. Having bound copies of this running treatise on free-market economics for over 40 years, I still take pleasure in the relevant articles by Leonard Read and others who have devoted their lives to the cause of liberty. I have a patient who has read this journal since it was a mimeographed newsletter fifty years ago. This month read, The Goal is Freedom: Be Our Guest (Worker).
• The Council for Affordable Health Insurance, www.cahi.org/index.asp, founded by Greg Scandlen in 1991, where he served as CEO for five years, is an association of insurance companies, actuarial firms, legislative consultants, physicians and insurance agents. Their mission is to develop and promote free-market solutions to America's health-care challenges by enabling a robust and competitive health insurance market that will achieve and maintain access to affordable, high-quality health care for all Americans. "The belief that more medical care means better medical care is deeply entrenched . . . Our study suggests that perhaps a third of medical spending is now devoted to services that don't appear to improve health or the quality of care–and may even make things worse." This month, read Clinton Re-Enters the Health Care Fray.
• The Independence Institute, www.i2i.org, is a free-market think-tank in Golden, Colorado, that has a Health Care Policy Center, with Linda Gorman as Director. Be sure to sign up for the monthly Health Care Policy Center Newsletter. Read her latest newsletter at www.i2i.org/files/misc/CBPP2.doc. For other matters, please go to www.i2i.org/main/author.php?author_id=80.
• Martin Masse, Director of Publications at the Montreal Economic Institute, is the publisher of the webzine: Le Quebecois Libre. Please log on at www.quebecoislibre.org/apmasse.htm to review his free-market based articles, some of which will allow you to brush up on your French. You may also register to receive copies of their webzine on a regular basis. This month, read Mencken's AVOID THE RUSH: PREPARE NOW FOR AMERICA'S BANKRUPTCY.
• The Fraser Institute, an independent public policy organization, focuses on the role competitive markets play in providing for the economic and social well being of all Canadians. Canadians celebrated Tax Freedom Day on June 28, the date they stopped paying taxes and started working for themselves. Log on at www.fraserinstitute.ca for an overview of the extensive research articles that are available. You may want to go directly to their health research section at www.fraserinstitute.ca/health/index.asp?snav=he. Be sure to read The Misguided War Against Medicines: Are Drug Expenditures Making Public Health Insurance Financially Unsustainable?
• The Heritage Foundation, www.heritage.org/, founded in 1973, is a research and educational institute whose mission is to formulate and promote public policies based on the principles of free enterprise, limited government, individual freedom, traditional American values and a strong national defense. The Center for Health Policy Studies supports and does extensive research on health care policy that is readily available at their site. This month, be sure to read Children's Health: SCHIP Should Not Become a Welfare Entitlement.
• The Ludwig von Mises Institute, Lew Rockwell, President, is a rich source of free-market materials, probably the best daily course in economics we've seen. If you read these essays on a daily basis, it would probably be equivalent to taking Economics 11 and 51 in college. Please log on at www.mises.org to obtain the foundation's daily reports. Be sure to read The Arithmetic of Environmentalist Devastation. You may also log on to Lew's premier free-market site at www.lewrockwell.com to read some of his lectures to medical groups. To learn how state medicine subsidizes illness, see www.lewrockwell.com/rockwell/sickness.html; or to find out why anyone would want to be an MD today, see www.lewrockwell.com/klassen/klassen46.html.
• CATO. The Cato Institute (www.cato.org) was founded in 1977 by Edward H. Crane, with Charles Koch of Koch Industries. It is a nonprofit public policy research foundation headquartered in Washington, D.C. The Institute is named for Cato's Letters, a series of pamphlets that helped lay the philosophical foundation for the American Revolution. The Mission: The Cato Institute seeks to broaden the parameters of public policy debate to allow consideration of the traditional American principles of limited government, individual liberty, free markets and peace. Ed Crane reminds us that the framers of the Constitution designed to protect our liberty through a system of federalism and divided powers so that most of the governance would be at the state level where abuse of power would be limited by the citizens' ability to choose among 13 (and now 50) different systems of state government. Thus, we could all seek our favorite moral turpitude and live in our comfort zone recognizing our differences and still be proud of our unity as Americans. Michael F. Cannon is the Cato Institute's Director of Health Policy Studies. Read his bio at www.cato.org/people/cannon.html. This month, read How Big Government Corrupts, Cripples, and Compromises American Education.
• The Ethan Allen Institute, www.ethanallen.org/index2.html, is one of some 41 similar but independent state organizations associated with the State Policy Network (SPN). The mission is to put into practice the fundamentals of a free society: individual liberty, private property, competitive free enterprise, limited and frugal government, strong local communities, personal responsibility, and expanded opportunity for human endeavor.
• The Free State Project, with a goal of Liberty in Our Lifetime, http://freestateproject.org/, is an agreement among 20,000 pro-liberty activists to move to New Hampshire, where they will exert the fullest practical effort toward the creation of a society in which the maximum role of government is the protection of life, liberty, and property. The success of the Project would likely entail reductions in taxation and regulation, reforms at all levels of government to expand individual rights and free markets, and a restoration of constitutional federalism, demonstrating the benefits of liberty to the rest of the nation and the world. [It is indeed a tragedy that the burden of government in the U.S., a freedom society for its first 150 years, is so great that people want to escape to a state solely for the purpose of reducing that oppression. We hope this gives each of us an impetus to restore freedom from government intrusion in our own state.]
• The St. Croix Review, a bimonthly journal of ideas, recognizes that the world is very dangerous. Conservatives are staunch defenders of the homeland. But as Russell Kirk believed, war time allows the federal government grow at a frightful pace. We expect government to win the wars we engage, and we expect that our borders be guarded. But St Croix feels the impulses of the Administration and Congress are often misguided. The politicians of both parties in Washington overreach so that we see with disgust the explosion of earmarks and perpetually increasing spending on programs that have nothing to do with winning the war. There is too much power given to Washington. Even in war time we have to push for limited government - while giving the government the necessary tools to win the war. To read a variety of articles in this arena, please go to www.stcroixreview.com. Please read the editorial on The Cost of a College Education by Dr. MacDonald.
• Hillsdale College, the premier small liberal arts college in southern Michigan with about 1,200 students, was founded in 1844 with the mission of "educating for liberty." It is proud of its principled refusal to accept any federal funds, even in the form of student grants and loans, and of its historic policy of non-discrimination and equal opportunity. The price of freedom is never cheap. While schools throughout the nation are bowing to an unconstitutional federal mandate that schools must adopt a Constitution Day curriculum each September 17th or lose federal funds, Hillsdale students take a semester-long course on the Constitution restoring civics education and developing a civics textbook, a Constitution Reader. You may log on at www.hillsdale.edu to register for the annual weeklong von Mises Seminars, held every February, or their famous Shavano Institute. You may join them to explore the Roots of American Republicanism on a British Isles cruise on July 10-21, 2006. Congratulations to Hillsdale for its national rankings in the USNews College rankings. Changes in the Carnegie classifications, along with Hillsdale's continuing rise to national prominence, prompted the Foundation to move the College from the regional to the national liberal arts college classification. Please log on and register to receive Imprimis, their national speech digest that reaches more than one million readers each month. This month, read Robert A. Sirico on Socialism, Free Enterprise, and the Common Good. The last ten years of Imprimis are archived at www.hillsdale.edu/imprimis/archives.htm.
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Words of Wisdom
Peter Drucker's Insights: Management courses for people without a few years of management experience are a waste of time. Action Point: Take executive development courses that pertain to your current position and the position to which you aspire. Apply the concepts directly to your work assignments. www.peter-drucker.com/
Redd Foxx: Health nuts are going to feel stupid someday, lying in hospitals dying of nothing.
Some Recent or Relevant Postings
BARGAINING FOR LIFE - A Social History of Tuberculosis, 1876-1938 by Barbara Bates, MD www.delmeyer.net/bkrev_BargainingForLife.htm
THE FORGOTTEN PLAGUE - How the Battle Against Tuberculosis Was Won and Lost by Frank Ryan, M.D. www.delmeyer.net/bkrev_ForgottenPlague.htm
SNITCH CULTURE - How Citizens are Turned into the Eyes and Ears of the State, by Jim Redden www.healthcarecom.net/bkrev_SnitchCulture.htm
Modern Day Paul Revere's Ride to Washington By James J. Murtagh, M.D. www.healthcarecom.net/JM_PaulReveresRide.htm
Mr Chandler was the dean of American business historians, the man who more or less invented the history of the big corporation. But he was more than an ivory-tower academic. For much of his life he taught at Harvard Business School, where he made business history mainstream. (In 1970, when he arrived, few took the course; in time, hundreds enrolled.) This gave his work a sharp practical edge.
He influenced a generation of consultants with his insistence that structure must follow strategy - that changes of strategy can be successful only if managers are willing to wrench their organizations [sic] into new forms. His fingerprints are all over one of the 20th century's classic business books, "My Years with General Motors" by Alfred Sloan. (Mr Chandler ascribed his habit of drinking sherry every lunchtime to Sloan's influence. Sloan used to hit the martinis at lunch when they were working on the book together. The younger historian thought it more prudent to stick to sherry.)
Mr Chandler could easily have missed his vocation. He was born into a patrician family in Delaware, and remained passionate about patrician sports: some of the best duck-hunting anywhere, he would say, was found round Guantánamo Bay. At the height of the Depression he went with his family on a year-long cruise to the Galápagos. He liked to show visitors a photograph of the Harvard sailing team of 1940, a group of five handsome young men in ties and jackets that included himself and Jack Kennedy.
His teachers thought he should do Greek, but three things pushed him into the vulgar calling of studying how businesses work. The first was his wartime interest in how large outfits like the navy (in which he served) operated. The second was the influence of local legends such as Talcott Parsons and Joseph Schumpeter. The third was his family heritage. Mr Chandler's patrician friends in Delaware included the mighty du Pont family.
Yet his academic career might still not have started without a piece of luck: the discovery, in a storeroom in the house of a recently deceased great-aunt, of the papers of one of his ancestors, Henry Varnum Poor (of the Standard & Poor's Corporation). Poor was the leading analyst of the most important industry of his day, the railways, and his papers provided Mr Chandler with the substance of his PhD and the start of his life's work: the history of big business as an organisational form. . .
To read the entire Obituary, go to www.economist.com/obituary/displaystory.cfm?story_id=9184105.
On This Date in History - June 12
On this date in 1776, the Virginia Declaration of Rights, largely written by George Mason, was adopted by the Virginia Convention almost a month before the Declaration of Independence. "Article 1. All men are by nature equally free and independent and have certain inherent rights . . . the enjoyment of life and liberty . . . and pursuing and obtaining happiness. 2. That all power is . . . derived from the people." It also insisted on freedom of the press and freedom of worship. All in all, a remarkable document, whose influence on the Declaration of Independence, the Constitution and the Bill of Rights was obvious. Our great American tradition of freedom has many roots, but one of the greatest is that which was adopted on this date in 1776 - the American privilege to be able to get up and speak your mind. As seen elsewhere in this Newsletter, physicians no longer have this freedom of speech in many hospital or staff situations. Unfortunately, they don't have the financial resources to file a constitutional lawsuit.
On this date in 1939, the Baseball Hall of Fame opened in Cooperstown, New York. Many may think this is something silly or frivolous, but recognition for accomplishments is something Americans can use more of.
After Leonard and Thelma Spinrad