MEDICAL TUESDAY . NET
Community For Better Health Care
Vol VIII, No 6, June 23, 2009
In This Issue:
1. Featured Article: A Prescription for American Health Care
2. In the News: "Thought Crimes" Bill Advances to the Senate
3. International Medicine: Zambian economist who challenges the liberal aid establishment
4. Medicare: Please take a lesson from Government Sewage and Water Care.
5. Medical Gluttony: Much of patient Gluttony is seen as expected service.
6. Medical Myths: Hospitals Judge Physicians Appropriately, Just as a U. S. Court
7. Overheard in the Medical Staff Lounge: Abusive Peer Review - The Medical Mafia
8. Voices of Medicine: Autism: "Let's wait and see" is not an option!
9. The Bookshelf: Why America's Quest for Perfect Health Is a Recipe for Failure
10. Hippocrates & His Kin: If Government has difficulty treating water, how will they treat patients?
11. Related Organizations: Restoring Accountability in Medical Practice and Society
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HealthPlanUSA was formerly a quarterly addition to your free MedicalTuesday Newsletter subscription that deals with Medical Practice issues in the United States and World Wide.
HealthPlanUSA is now a separate free Newsletter, currently quarterly, which deals with HealthPlan, Insurance, Government and Reform Issues in the United States and Internationally.
Time is running out to restore freedom in health care in the last bastion of freedom in the world. Join now before big brother tells you when you can receive needed medical attention while he reads your electronic medical records to make an impersonal decision on your life and health.
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By John C. Goodman, President, National Center for Policy Analysis
The following is adapted from a speech delivered in Naples, Florida, on February 18, 2009, at a Hillsdale College National Leadership Seminar.
I'll start with the bad news: When we get through the economic time that we're in right now, we're going to be confronted with an even bigger problem. The first of the Baby Boomers started signing up for early retirement under Social Security last year. Two years from now they will start signing up for Medicare. All told, 78 million people are going to stop working, stop paying taxes, stop paying into retirement programs, and start drawing benefits. The problem is, neither Social Security nor Medicare is ready for them. The federal government has made explicit and implicit promises to millions of people, but has put no money aside in order to keep those promises. Some of you may wonder where Bernie Madoff got the idea for his Ponzi scheme. Clearly he was studying federal entitlement policy.
Meanwhile, in the private sector, many employer-sponsored pension plans are not fully funded. Nor is the federal government insurance scheme behind those plans. We have a potential taxpayer liability of between 500 billion and one trillion dollars for those private pension plans, depending on the markets. And on top of that, roughly one-third of all Baby Boomers work for an employer who has promised post-retirement health care. As with the auto companies, almost none of that is funded either. Nor are most state and local post-retirement health benefit plans. Some California localities have already declared bankruptcy because of their employee retirement plans and the first of the Baby Boomers is still only 63 years old.
What all this means is that we're looking at a huge gap between what an entire generation thinks is going to happen during its retirement years and the funds that are there—or, more accurately, are not there—to make good on all those promises. Somebody is going to be really disappointed. Either the Baby Boomers are not going to have the retirement life that they expect or taxpayers are going to be hit with a tremendously huge bill. Or both.
The Mess We're In
How did this crisis come about? After all, the need to deal with risk is not a new human problem. From the beginning of time, people have faced the risks of growing old and outliving their assets, dying young without having provided for their dependents, becoming disabled and not being able to support themselves and their families, becoming ill and needing health care and not being able to afford it, or discovering that their skills are no longer needed in the job market. These risks are not new. What is new is how we deal with them.
Prior to the 20th century, we handled risks with the help of family and extended family. In the 19th century, by the time a child was nine years old, he was usually paying his own way in the household. In effect, children were their parents' retirement plan. But during the 20th century, families became smaller and more dispersed—thus less useful as insurance against risk. So people turned to government for help. In fact, the main reason why governments throughout the developed world have undergone such tremendous growth has been to insure middle class families against risks that they could not easily insure against on their own. This is why our government today is a major player in retirement, health care, disability and unemployment.
Government, however, has performed abysmally. It has spent money it doesn't have and made promises it can't keep, all on the backs of future taxpayers. The Trustees of Social Security estimate a current unfunded liability in excess of $100 trillion in 2009 dollars. This means that the federal government has promised more than $100 trillion over and above any taxes or premiums it expects to receive. In other words, for Social Security to be financially sound, the federal government should have $100 trillion—a sum of money six-and-a-half times the size of our entire economy—in the bank and earning interest right now. But it doesn't. And while many believe that Social Security represents our greatest entitlement problem, Medicare is six times larger in terms of unfunded obligations. These numbers are admittedly based on future projections. But consider the situation in this light: What if we asked the federal government to account for its obligations the same way the private sector is forced to account for its pensions? In other words, if the federal government suddenly closed down Social Security and Medicare, how much would be owed in terms of benefits already earned? The answer is $52 trillion, an amount several times the size of the U.S. economy. . .
Cleaning Up the Mess
The only sensible alternative to relying on a welfare state to solve our health care needs is a renewed reliance on private sector institutions that utilize individual choice and free markets to insure against unforeseen contingencies. In the case of Medicare, our single largest health care problem, such a solution would need to do three things: liberate the patients, liberate the doctors, and pre-fund the system as we move through time. . .
In summary, if health care consumers are allowed to save and spend their own money, and if doctors are allowed to act like entrepreneurs—in other words, if we allow the market to work—there is every reason to believe that health care costs can be prevented from rising faster than our incomes.
The Market in Action
Let me offer a few examples of how the free market is already working on the fringes of health care. Cosmetic surgery is a market that acts like a real market—by which I mean that it is not covered by insurance, consumers can compare prices and services, and doctors can act as entrepreneurs. As a result, over the last 15 years, the real price of cosmetic surgery has gone down while that of almost every other kind of surgery has been rising faster than the Consumer Price Index—and even though the number of people getting cosmetic surgery has increased by five- or six-fold.
In Dallas there is an entrepreneurial health care provider with two million customers who pay a small fee each month for the ability to talk to a doctor on the telephone. Patients must have an electronic medical record, so that whichever doctor answers the phone can view the patient's electronic medical record and talk to the patient. This company is growing in large part because it provides a service that the traditional health care system can't provide . . .
Finally, consider the international market for what has become known as medical tourism. Hospitals in India, Singapore and Thailand are competing worldwide for patients. Of course, no one is going to get on a plane without some assurances of low cost and high quality—which means that, in order to attract patients, these hospitals have to publicize their error rates, their mortality rates for certain kinds of surgery, their infection rates, and so on. Their doctors are all board-certified in the United States, and they compete for patients in the same way producers and suppliers compete for clients in any other market. Most of their patients come from Europe, but the long-term threat to the American hospital system can't be denied. Leaving the country means leaving bureaucratic red tape behind and dealing instead with entrepreneurs who provide high-quality, low-cost medicine.
As these examples suggest, liberating the medical market by freeing doctors and patients is the only way to bring health care costs under control without sacrificing quality. Continuing on our current path—allowing health care costs to rise at twice the rate of income under the aegis of an unworkable government Ponzi scheme—is by comparison unreasonable.
JOHN C. GOODMAN is the president, CEO, and Kellye Wright Fellow at the National Center for Policy Analysis. He received his Ph.D. in economics from Columbia University, and has taught and done research at Columbia University, Stanford University, Dartmouth College, Southern Methodist University and the University of Dallas. He writes regularly for such newspapers as the Wall Street Journal, USA Today, Investor's Business Daily and the Los Angeles Times, and is the author of nine books, including Patient Power: Solving America's Health Care Crisis and Lives at Risk: Single-Payer National Health Insurance Around the World.
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"A government powerful enough to pick and choose which thoughts to prosecute is a government too powerful."
Why is the press remaining mostly silent about the so-called "hate crimes law" that passed in the House on April 29? The Local Law Enforcement Hate Crimes Prevention Act passed in a 249-175 vote (17 Republicans joined with 231 Democrats). These Democrats should have been tested on their knowledge of the First Amendment, equal protection of the laws (14th Amendment), and the prohibition of double jeopardy (no American can be prosecuted twice for the same crime or offense). If they had been, they would have known that this proposal, now headed for a Senate vote, violates all these constitutional provisions, says Nat Hentoff, a senior fellow with the Cato Institute.
· This bill would make it a federal crime to willfully cause bodily injury (or try to) because of the victim's actual or perceived "race, color, religion, national origin, gender, sexual orientation, gender identity or disability" -- as explained on the White House Web site, signaling the president's approval.
· A defendant convicted on these grounds would be charged with a "hate crime" in addition to the original crime, and would get extra prison time.
The extra punishment applies only to these "protected classes," says Hentoff. As Denver criminal defense lawyer Robert J Corry Jr. asked (Denver Post April 28): "Isn't every criminal act that harms another person a 'hate crime'?" Then, regarding a Colorado "hate crime" law, one of 45 such state laws, Corry wrote: "When a Colorado gang engaged in an initiation ritual of specifically seeking out a "white woman" to rape, the Boulder prosecutor declined to pursue 'hate crime' charges." She was not enough of one of its protected classes. . .
Whether you're a Republican or Democrat, think hard about what Corry adds, says Hentoff: "A government powerful enough to pick and choose which thoughts to prosecute is a government too powerful."
Source: Nat Hentoff, "'Thought Crimes' Bill Advances," Cato Institute, May 13, 2009.
For text: www.cato.org/pub_display.php?pub_id=10188.
For more on Legal Issues: www.ncpa.org/sub/dpd/index.php?Article_Category=35.
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Ms Moyo argues that [Aid] has fostered dependency and perpetuated poor governance.
A swell of opposition is building in the aid world to a new protagonist who has thrown down a strident challenge to the rock stars and liberal economists who have long dominated debate over foreign assistance to developing countries.
Galled by the ease with which Dambisa Moyo, the Zambian economist and former investment banker, has suddenly risen to prominence this year, activists are circulating detailed critiques of her ideas and mass mailing African non-government organisations to mobilise support against her.
Yet it is proving hard to suppress the hyper-active graduate of Oxford and Harvard, who pops up weekly in a new capital to promote her book Dead Aid - the title itself an affront to rock star Bob Geldof's Live Aid campaigns.
The former Goldman Sachs strategist has become something of a phenomenon. In April, she hit the New York Times bestseller list, this month she was named on Time Magazine's list of the 100 most influential people, and she has been appointed to the board of brewer SAB Miller.
Within days of reading about her, Paul Kagame, Rwanda's president, flew Ms Moyo out to address his government. This month, Col Muammar Gadaffi, the Libyan leader, invited her to Tripoli.
Broadly, Ms Moyo argues that official development assistance has fostered dependency and perpetuated poor governance. She proposes a blend of commercial debt, microfinance, fairer trade and investment in its place. . .
"It is ludicrous because we now have leaders like President Kagame supporting the anti-aid campaign. . . despite the clear successes of aid in promoting Rwanda's growth," he told the Financial Times. But Ms Moyo has struck a chord in Africa.
"The aid establishment is scared to death of the public relations disaster that a growing movement of independent critical African professionals would be," said William Easterly, the US academic.
Aid does not Improve Growth or Innovation, it only Fosters Dependency and Destroys hope.
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About 82 percent of Americans receive drinking water via publicly-owned water systems, according to the Environmental Protection Agency (EPA). Many of these municipal and regional systems operate at a loss, meaning users' fees don't cover the cost of treating and delivering the water. Many water authorities are critically behind on maintenance. They lack the capital to update their water purification and wastewater treatment plants, or to secure additional water supplies to meet expected growth in demand.
Experience in other countries shows that privatization could solve these water supply problems.
Problem: Funding Infrastructure. The majority of drinking water supply and treatment facilities and wastewater treatment plants in the United States are owned and operated by the government. According to the EPA, many need to be upgraded or replaced, at an estimated cost of nearly $350 billion over the next two decades. . .
Problem: Public Health. The U.S. population is expected to grow to 325 million by 2020. This increase will create new demand for clean water services. Existing water systems must be renovated, and new infrastructure must be built.
In a 2007 congressional hearing, the EPA warned that "numerous treatment facilities that process water and wastewater are in need of upgrading [in order to protect] public health." . . .
Solution: Private Financing. Local governments often contract with private firms to replace infrastructure and provide financing. . . .
Solution: Increased Efficiency. According to the Rio Grande Foundation, a research institute in New Mexico, private systems are more efficient than government-run systems:
· Operating expenses are 21 percent lower for privately run systems than comparable government-run water systems.
· Maintenance costs for privately run water suppliers are on average half that of public water systems.
· Private water companies require less than half as many employees as public water systems and spend one-third less of water sales revenue on employee salaries.
The public officials who manage water systems often receive especially large salaries. For example, the superintendent of the Great Neck Water Authority outside New York City earns more money than the governor of New York. The manager of the Jericho, N.Y., water district receives such additional benefits as a car and a residence. . .
Solution: Private Water Companies. In contrast to the United States, private companies dominate the market for water delivery and wastewater treatment in Europe. Private water delivery has long existed in France. In 1782, around the time of the first French Revolution, the Perrier brothers' company began providing clean, running tap water in Paris. In London, private water companies operated for more than 200 years until a nationalization movement in 1903. England reprivatized water delivery in 1989.
Today, private companies provide drinking water and wastewater services to more than 70 percent of the people in France, England and Chile. Other countries also depend on private water suppliers to treat and deliver water for large percentages of their populations [see the figure]:
· Private companies provide water for residential use for 30 percent to 50 percent of Greeks, Italians and Spaniards.
· And 50 percent to 70 percent of the people in the Czech Republic, Argentina, Hong Kong and Malaysia get water from private systems.
Conclusion. In order to ensure safe, sufficient and relatively inexpensive water supplies in the future, the U.S. water delivery system must change. Historically, municipal water authorities have been underfunded and many have been unable to keep water delivery systems operating safely and efficiently. The gap between needed resources and investments could grow due to the recession. Accordingly, the move to private financing and private water suppliers already taking place should be encouraged and expedited.
H. Sterling Burnett is a senior fellow and Ross Wingo is a research assistant with the National Center for Policy Analysis.
Government is not the solution to our problems, government is the problem.
- Ronald Reagan
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Physicians have been ineffective in pointing out the significant costs of health care that are submerged into medical practices. Patients expect health care as their right. However, where does the right come from and where does it proceed? Patients today receive mostly free care. They pay a small fraction of the cost of being seen, almost none of the cost of the laboratory and x-rays they demand; and this seems to expand the appetite for "more 'n more" courtesies that are not understood as costs. For physicians to even mention them as costs is considered greed on the part of the physician. What are the unappreciated and unrecognized subtleties of excessive health care consumption?
For their own convenience, patients make demands such as having the doctor phone their prescriptions to the pharmacist in order to have ready when they arrived at the pharmacy. Seemingly an obvious small service rendered for their convenience. Any amount of explanation or comment would only be interpreted as insensitive or uncaring. Most patients do not understand the cost of time since they no longer pay for the physician's time. To make the point in terms the patient could most likely understand, after one such request when I was several minutes into the appointment, I placed the call to his pharmacy on the speaker telephone so the patient could hear the menus and the time taken to navigate those menus. While waiting to be transferred to the pharmacist, I completed my examination and explained the diagnosis and the treatment plan. At the conclusion of the 20-minute appointment and also the writing of the prescriptions, I pressed the speaker button to disconnect the phone from the pharmacist waiting list since I knew that 20 minutes is frequently not enough time to phone in a prescription (I was still on hold with the automated voice saying there was only one other customer ahead of me). I got up, gave him the written prescriptions, and led him out the door explaining we were already 10 minutes into the next patient's appointment. As I shook his hand, I pointed out that his HMO pays about half the office call charge; now he could obviously see that to ask for a personalized call-in prescription (as patients frequently do) was like requesting a second full office visit time for half the value of one office visit. Therefore, we would no longer be able to honor phone-in prescription requests; he would have to use the paper prescriptions or the electronic prescriptions available at the time of service. I'm still not sure if the doubling of costs for half the revenue was understood. But it certainly was not appreciated.
In another instance, a patient presented himself at our window during a busy schedule wanting all his prescriptions of the previous week re-written for a mail order pharmacy that allows three-months supply rather than one month at the local pharmacy. So, standing at my counter, after pulling his chart, I rewrote all his prescriptions that had been for a 30-day supply with eleven refills to a 90-day supply and 9 months of refills. I had tried to talk him into using the mail order pharmacy the previous week. This patient again did not comprehend that taking ten minutes or half an appointment was an inordinate cost expected as a courtesy and an affront to the other patients having to wait longer. When unions are rebelling to a 10 percent cut in wages during the current recession, these patients have no realization of the 50 percent cut in the doctor's wages for their 20-minute appointments, now up to 30 minutes.
Last week, a patient wanted his prescriptions on a "fax in" form that others normally bring with them from their mail order pharmacies in order to expedite faxing in their prescriptions. Only this patient did not have the forms. He reminded my front desk manager that she could call his mail order drug plan and request the forms and then I could complete them. It took my office manager 20 minutes to navigate the mail order pharmacy phone menus to finally get the appropriate forms that the patient had left at his home. I had to rewrite the prescriptions on the requested form and my office then faxed them along with his credit card number to his mail order pharmacy. He occupied the check-in/check-out counter at my front desk for about 35 minutes in addition to about 5 minutes of my duplicated work.
Would government medicine be more efficient in the practice situations? Experience to date would not support such a view. Physicians were the most efficient and cost effective when they did their own x-rays, lab work, and other procedures in their offices. These have slowly been driven out by mandates, some of which have actually prevented physicians from doing their own laboratory work and basic x-rays. Most of the arguments have centered on the premise that the physician is incentivised to excessive utilization when in fact they are more efficient in their utilization. Studies have shown that doctors who send their patients to the Lab, X-ray or ECG facility order far more Lab tests, ECGs and CXRs than the internist, cardiologist or the chest physician who do their own Lab, ECG and CXR. Furthermore, the Lab, ECG and X-Ray facilities charge at least twice what a private office charges.
More industries are going through the "lean" revolution these days, some by force of bankruptcy and some by having a culture of "lean manufacturing" or "lean marketing" that are being put through greater challenges during our economic downturn. The most cost-efficient hospitals of the mid-twentieth century were the physician-owned hospitals. During my medical student preceptorship in a rural community where the three physicians owned their own hospital, surgical unit, pharmacy, and office building, they were considerably cheaper than the surrounding community hospitals. When they did their yearly cost analysis, they seldom found a reason to increase any hospital charges to the level of the surrounding community since, in their estimation, they were making adequate profit.
Today, physicians have very little control over hospital, x-ray, lab or pharmaceutical charges. However, in their practice they have little choice but to utilize hospitals, labs, x-ray facilities and pharmacies. Patients still tell me that the physicians control the hospitals. No amount of data will convince most patients otherwise. The only answer will be an integrated health plan outside the arena of government medicine in the open medical market place, which doesn't exist today. If health care could be restored to the open market place, this would be the most ruthless way to reduce charges and all costs. That would also put the patient and his physician in full control. This would require a very disruptive innovation. Almost all of the current players, whether hospitals, physicians, or health insurance plans, would resist and even fight such a change. Stay tuned.
Medical Gluttony thrives in Government and Health Insurance Programs.
Gluttony Disappears with Appropriate Deductibles and Co-payments on Every Service.
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Medical Truth: Hospital tribunals are
a Military tribunal.
They are not the same as U.S. Courts.
Military tribunals not the same as U.S. courts by Bob Egelko, Chronicle Staff Writer, Saturday, May 23, 2009. This article appeared on page A – 1 (Read the similarities in italics . . .)
President Obama says his proposed reforms to the military commissions his predecessor established to try suspected terrorists will bring the tribunals "in line with the rule of law." But it isn't the same law that applies in U.S. courts.
Pentagon officials appoint the judges and can remove them. Military commanders choose the jurors, who can convict defendants by non-unanimous votes, except in death penalty cases. The military can monitor defense lawyers' conversations with their clients.
When a doctor is accused of medical error, hospital officials appoint
the judges and can remove them. Hospital administrators choose the jurors
who can convict defendants by non-unanimous votes. The hospitals can have their
expert witnesses hear the defense of the doctors witnesses, but the doctor's witnesses ca n 's witnesses testimony.
Prosecutors can also present evidence that would never pass muster in civilian courts. Confessions made under physical or mental pressure could be admissible, despite Obama's disavowal of torture and coercion. There's no ban on evidence from illegal searches. And defendants may be convicted on the basis of hearsay - a second hand report of an out-of-court accusation by another person, perhaps a fellow suspect, whom the defense never gets to see or question.
Hospital Medical Executive Committees (MEC) can also present evidence
that would never pass muster in civilian courts. Confessions made under
physical or mental pressure could be admissible, despite disavowal of coercion.
There's no ban on evidence from illegal searches of doctors offices and records
via oblique information from the doctor's employees or hospital employees. And
defendants may be convicted on the basis of hearsay - a second hand report of
an out-of-MEC accusation by another person, perhaps a fellow colleague or
defendant, whom the defense never gets to see or question.
"The system is designed to ensure the outcome they want ... convictions in every case," said Ben Wizner, an American Civil Liberties Union attorney who has attended proceedings for prisoners at the U.S. naval base at Guantánamo Bay, Cuba. "This suggests that the much-heralded improvements to the Bush military commission system are largely cosmetic."
"The hospital hearing system is designed to ensure the outcome
they want . . . convictions in every case," say Medical Defense Attorney
who have attended proceedings for Doctors at many US Hospitals. This suggests that the
much-heralded improvements in Peer Review of Doctors are largely cosmetic . . .
In his speech . . . at the National Archives, Obama promised to charge terrorism suspects with crimes in federal courts "whenever feasible." But he said military commissions, with proper safeguards, are a proper forum for war-crimes trials.
"They allow for the safety and security of participants, and for the presentation of evidence gathered from the battlefield that cannot always be effectively presented in federal courts," Obama said. . .
A judge in a doctor's superior court appeal states that the hospital commission
has proper safeguards to assure the doctor a fair hearing, and since
"Hospitals are Bastions for Mercy" he would not interfere with the
hospital's stripping a doctor of his hospital privileges, despite
that being the
source of his livelihood.
Some conservatives said Obama's words vindicated Bush, who won congressional approval for the current military commissions in 2006 over the opposition of then-Sen. Obama.
"Critics can no longer dismiss this by saying (the commissions) were peculiar obsessions of Dick Cheney and George Bush," said David Rivkin, an attorney who served in the administrations of Ronald Reagan and George H.W. Bush.
Military commissions are
essential to try enemy combatants, Rivkin said, because incriminating evidence
often won't meet standards established by civilian courts. "If you have
virtually no chance of obtaining a conviction, that's not a viable justice
system," he said. . .
Hospital hearings are essential to try enemy (to the hospital's business) doctors because incriminating evidence often won't meet standards established by civilian courts. "If you have virtually no chance of obtaining a conviction of a doctor, you have no chance of pruning your medical staff of unwanted doctors."
Like courts-martial, military commissions employ officers as judges, lawyers and jurors and allow convictions in non-capital cases by non-unanimous verdicts.
Like courts-martial, hospitals employ MEC officers as judges, lawyers and jurors and allow convictions by non-unanimous verdicts.
But unlike courts-martial, governed by laws that protect judges' independence and mirror civilian courts' rules for trials, military commissions operate under a law that leaves the proceedings largely in the hands of the Defense Department. One illustration came a year ago, when the Pentagon-appointed chief judge at Guantanamo removed a judge who had criticized prosecutors' handling of evidence in a case.
But unlike courts-martial, governed bylaws that protect judges' independence and mirror civilian courts' rules for trials, hospitals operate under a law that leaves the proceedings largely in the hands of the Hospital's MEC. One illustration comes to mind, when the Hospital-appointed judge removed an expert witness whose testimony would have vindicated the doctor.
Military officials also pick the appellate tribunal that reviews convictions. A defendant can then take the case to a federal appeals court, but its review is mostly limited to whether the trial followed Pentagon rules.
Hospital officials also pick the appellate tribunal (the hospital Board of Directors) that reviews convictions appealed by the doctor. A defendant can then take the case to an appeals court, but its review is mostly limited to whether the trial followed hospital bylaws.
Evidence standards are much more permissive than in . . . civilian courts, which ban most types of hearsay testimony. Military commissions allow hearsay if the judge decides it is reliable.
Evidence standards are much more permissive in hospital hearings than
in civilian courts, which ban most types of hearsay testimony. Hospital
proceedings allow hearsay if the judge decides it is reliable . . .
Obama also wants to eliminate a rule that allows jurors to consider a defendant's refusal to testify as possible evidence of guilt, and to exclude all confessions extracted by "cruel" interrogations, regardless of whether they involved torture.
But the commissions might hear statements produced by tactics that would be barred in court - for example, the technique known as the "frequent flier" program, in which prisoners are awakened and moved to new cells every few hours for questioning.
Defenders of the commissions say courtroom rules shouldn't be applied to battlefield conditions.
Defenders of the hospital kangaroo commissions say courtroom rules
should not be applied to the important mission of removing doctors that may
have made mistakes in the battlefield of healthcare even though the doctor's
experts from leading medical centers have testified no mistakes were made
. . .
Doctors are not terrorists and should be afforded direct access to civilian courts and attorneys. Doctors are not dangerous. Doctors should not be occupying prison cells when we're releasing prisoners who have committed serious crimes. Peer review trials are primarily doctors and hospitals eliminating unwanted competition from good physicians. Peer review should be handed back to the civilian courts and attorneys who are much more effective in eliminating bad doctors.
* * * * *
Dr. Edwards: Roland, I see you no longer have Dr. Green in your group.
Dr. Roland: Dr. Green was a bad apple and we had to get rid of him.
Dr. Dave: How so?
Dr. Roland: He was always hogging all the patients and increasing his bookings.
Dr. Dave: Aren't new patients distributed to your doctor on call and the others on a rotating basis?
Dr. Roland: Yes it's supposed to act that way. But Dr. Green was always the first one in the office, picked up the new consults for the day, and saw his quota by mid afternoon. So I always got the 4:30 consult and had to work until six.
Dr. Dave: But doesn't the workload rotate and so different doctors work late?
Dr. Roland: That would be the case. So there were several in our group that were getting annoyed. Every time they were on, they also felt they got the shaft. So we just moved to get rid of him.
Dr. Edwards: But what kind of mistakes did Dr. Green make that you could hang on him to remove him?
Dr. Roland: He was mixing up some of his total parenteral nutrition orders a bit differently than the rest of us and we wanted him to fall in line.
Dr. Dave: That's no reason to set him up for a Peer Review trial to find him guilty. Guilty of what? You know any infusion can vary a lot between doctors. That's not a kind thing to do.
Dr. Roland: Who said anything about being kind? The group no longer likes him and wants him out. But he won't leave. So we'll force the issue.
Dr. Edwards: You think you can talk the Medical Executive Committee into doing this trial?
Dr. Roland: Yes we can and we have. One member of our group is on the MEC and we have several friends on the MEC who will support the allegation of bad medical practice.
Dr. Edwards: There is a lot being written about Abusive Peer Review and your hanging of Dr. Green professionally certainly fits that definition.
Dr. Dave: Who would testify for you?
Dr. Roland: We have several that would agree with us and will testify against Dr. Green. In fact, one of them would like to move here and take Dr. Green's place in our group.
Dr. Yancy: Maybe I'll testify for Dr. Green. He's got friends also.
Dr. Roland: You have had two surgical complications in the last three months Yancy. I don't think I would if I were you.
Dr. Yancy: You're getting real nasty. Remember what goes around will come around.
Dr. Roland: I think we have all of the bases covered. Once Dr. Green is served, his friends will all disappear into the tall grass. We won't see them again until he's off the staff and moved someplace else.
Dr. Rosen: But he can't move any place else and practice. He will be reported to the medical board and may lose his medical license. He will then be reported to the Practitioner's Data Bank. Once he's there, he's in a tomb - never to be heard of again.
Dr. Edwards: Don't you think that's rather cruel and inhumane?
Dr. Roland: Well, someone has to do the dirty work. Blame the medical society for setting up Peer Review, which allows us to do this legally and above board.
Dr. Edwards: He may lose his wife, his family, his home, and suffer severe financial straits and may even have to go on welfare since he can never practice again.
Dr. Rosen: That's the unintended consequence that all this favoritism costs us. Doctors felt they were privileged and shouldn't have professional matters decided by courts of law and should be able to set up their own courts made up of Peers rather than have attorneys prosecute them. Now it's back firing. We should have let attorneys clean out bad doctors. And many of the doctors the Peer Reviewers are cleaning out are not bad. Dr. Green is not a bad doctor. In fact, he's a very good physician. One of the best on our staff. Peer Review has allowed economic credentialing. Doctors are being removed for economic reasons, not bad medical practice reasons.
Dr. Edwards: It's getting more frequent that Peer Review is not eliminating bad doctors but good ones. I know a doctor who did a liver biopsy on a patient on a ventilator and didn't have his assistant hold the breathing while the needle went in and out. He ripped the liver and the patient died promptly. The doctor later changed the cause of death so a finger couldn't be pointed at him. He was on and protected by the Medical Executive Committee.
Dr. Roland: How did you find out about that?
Dr. Edwards: I was in the Medical Records room completing my charts when the head of the department asked me if I would take a look at a chart. She felt very uncomfortable with the change in the final death note. I told her that she was correct, but I could not jeopardize my future as a physician by being the teller of truth.
Dr. Rosen: That's a good example, Edwards, where Peer Review protects bad doctors and a malpractice lawyer would be very effective in getting a verdict against that doctor, stringing him up for millions. I think there were fewer bad doctors during the Malpractice heydays than now with Peer Review.
Dr. Edwards: Of course, you will have to agree Rosen, that the Medical Societies did a great thing in controlling economic damages for pain and suffering which were the extra millions that malpractice attorneys always collected on top of the real damages. Attorneys are real good at exploiting pain and suffering.
Dr. Rosen: I wish you would reconsider your plans, Roland. There's no point in soiling your character with abusive Peer Review. Those things will come back to haunt our profession. And if you proceed against Dr. Green, it will come back to haunt you. You might find yourself in the Data Bank.
Dr. Roland: I think you lost a young patient during a cardiac arrest last week, didn't you Rosen? As I said, I think all the bases are covered for a smooth sail through the Medical Executive Committee.
Dr. Edwards: Looks like it's Good-Bye, Dr. Green. Or it will be good-bye to one of us.
Dr. Roland: I think you are beginning to understand Medical Politics rather well, Edwards.
Dr. Rosen: Looks like the Sicilian Mafia has nothing on the Medical Mafia.
The Staff Lounge Is Where Unfiltered Medical Opinions Are Heard.
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SONOMA MEDICINE, the Magazine of the Sonoma County Medical Association, Winter 2009
Autism: "Let's wait and see" is not an option! By Cathryn Ross, MD
Autistic spectrum disorders are common (1:150), chronic, biologically based neurodevelopmental disorders that are highly heritable. Recognition of early behavioral signs of autistic spectrum disorders (ASD) by physicians, followed by immediate referral to early intervention programs, benefits autistic children, their families, their future schools and society. The old "wait and see" approach is no longer an option!
The cause of autism is being actively researched but remains elusive because so many factors are involved. Several genes have been identified that probably have to occur in multiples in the same person. Researchers also believe that some environmental stressors may enhance the penetrance of mutations conferring susceptibility to autism. The immune system may be involved as well, because many cases of autism involve other organ systems and not just the brain; reduced levels of immunoglobulin in children with autism correlates with behavioral symptoms. There is also often increased prevalence of maternal autoantibodies against the fetal brain in autism.
The American Academy of Pediatrics recommends surveillance for ASD at all well-child visits and formal screening of all children with a standardized test at 18- and 24-month visits, and whenever concern is raised. An ASD toolkit from the pediatric academy contains screening tools and fact sheets (for both physicians and parents) that address major issues associated with ASDs.
Diagnosing ASD is challenging because there are no objective laboratory tests or pathognomonic clinical signs. The physician must rely on subjective guidelines provided by the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM IV-TR) and use informed clinical judgment, which requires training, supervision and feedback from experts, as well as experience with many children of different functioning levels and ages. Compounding the challenge is the variability in the expression of the three core features of ASD:
· Impaired social reciprocity
· Communication deficits
· Restricted, repetitive and stereotypic behaviors
ASDs include three subtypes: autistic disorder (AD), Asperger syndrome, and pervasive developmental disorder—not otherwise specified (PDD-NOS), a threshold term used when a child meets some but not all criteria necessary for a diagnosis of either AD or Asperger syndrome. Since this article focuses on ASDs before 2 years old and the average age for diagnosing Asperger syndrome is 8-11 years old, Asperger will not be discussed. When the word autism or ASD is used in this article, it represents both AD and its milder form, PDD-NOS . . .
The earlier the ASD diagnosis is made, the better the outcome; and yet many of the criteria address developmental skills that are not applicable to children younger than 2 years developmental age. Therefore, many severely autistic children may not meet full criteria. For example, the criteria "failure to form age-appropriate peer relationships," "stereotypic or repetitive use of language" or "impairment in initiating or sustaining a conversation with others" is not relevant to a 2-year-old who may be preverbal. Also many children who are later diagnosed with ASD don't develop ritualistic behaviors or a need for routines until after 3 years of age. Taking these issues under consideration, some researchers have suggested applying only four of the possible twelve DSM-IV-TR criteria for children under 3 years of age:
· Lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., lack of showing, bringing, or pointing out objects of interest)
· Lack of social and emotional reciprocity
· Marked impairment in the use of multiple nonverbal behaviors, such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction
· Delay in or total lack of the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime)
The researchers propose that if all four of the above criteria are met, then a provisional diagnosis of autism should be made. After the third birthday, the child should be reevaluated using the full DSM IV-TR criteria. . .
Read the entire article: http://scma.org/magazine/articles/?articleid=314.
Dr. Ross is a developmental-behavioral pediatrician in private practice in Santa Rosa.
VOM Is Where Doctors' Thinking is Crystallized into Writing.
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There is no clear correlation between population health and medical care.
Daniel Callahan, cofounder of the Hastings Center and the Director of its International Programs, takes on the entire medical establishment--doctors, nurses, hospital administrators, medical researchers, and pharmaceutical and medical technology companies--all of whom he believes are united in a relentless pursuit of unlimited medical progress, stopping at nothing short of the conquest of all disease and the indefinite extension of life spans (see last month's review of Schwartz' Life Without Disease - The Pursuit of Medical Utopia).
The Hastings Center is an avant-garde institution where any idea can be explored (see "Duty to Die" in the HHK column). Callahan, as the president of the Hastings Center from 1969 to 1996, must be taken seriously. In the preface, he presents his political leanings, aligning himself with the Clintons in their quest for healthcare reform. He bemoans the fact that no plan made it through Congress--not one bill, not a single reform. Callahan is even more appalled that at the next presidential election, both candidates all but ignored the issue.
Initially, the reason he takes this stance is not clear. However, he soon points out that the universal, if poorly financed and often corrupt, healthcare systems in China, Southeast Asia, and in much of Latin America, are turning to the marketplace and accepting privatization as their new gospel. He finds it most unsettling that the popular, well-managed, equitable health care systems of Western Europe have begun to unravel in the post WW II welfare state. These systems, beset with rising costs, are high on the budgetary hit lists of political leaders who are looking to the marketplace to reduce public benefits, thus securing their own future.
Callahan realizes that if everyone is having a problem, and all are looking for answers, there must be an underlying basic issue. Almost all healthcare reform efforts assume that the solution lies in better organization and financing. Callahan then observes that no matter how much money is spent and no matter what the health gains may be, they never seem to be enough. Conventional solutions do not address the real problem. No matter how much progress, they always seem insufficient to meet the "needs" of the day.
The most cherished and celebrated aims, commitments, and values of modern medicine are beginning to give us trouble. But challenging these ideas, Callahan reflects, is not new. Rene Dubois in his 1954 book Mirage of Health questioned the then imminently anticipated total conquest of disease and stated this would not happen, not soon, not ever. In the 1970s, theologian Ivan Illich, British physician John Powles, American physician Rick Carlson, and British professor of social medicine, Thomas McKeown, each showed in a systematic way that there is no clear correlation between population health and medical care. Carson boldly predicted the diminishing impact of physicians and hospitals on health by the year 2000.
Callahan emphasizes that "A serious transformation will require taking money away from the acute-care sector, including research into the cure of many lethal diseases, and using it instead on prevention research and massive educational efforts designed to change health-related behavior." Callahan asserts that sustainable medicine will do the following: give priority to preventing and treating diseases that afflict the many rather than finding cures for diseases that effect the few, improve the quality of life for the elderly rather than extend life indefinitely, and focus on primary care and public health measures that benefit society as a whole rather than satisfying the health needs of individuals. . .
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Operating expenses are 21 percent lower for privately run systems than comparable government-run water systems. Maintenance costs for privately run water suppliers are on average half that of public water systems. Private water companies require less than half as many employees as public water systems and spend one-third less of water sales revenue on employee salaries.
Single Payer is a Dying Issue. If Resuscitated, then Patients will be Dying. Better that SP dies.
Taxpayers are on the hook for an extra $55,000 a household to cover rising federal commitments made just in the past year for retirement benefits, the national debt and other government promises...
Have you tried asking your employer for a raise to cover that?
Director Mike Judge's new animated television series "The Goode Family" is a send-up of a clan of environmentalists who live by the words "What would Al Gore do?" Gerald and Helen Goode want nothing more than to minimize their carbon footprint. They feed their dog, Che, only veggies (much to the pet's dismay) and Mr. Goode dutifully separates sheets of toilet paper when his wife accidentally buys two-ply. And, of course, the family drives a hybrid. The creator of 'Beavis and Butt-Head' and 'King of the Hill' has a new target: environmentalists.
That's one message you can only expose with humor.
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• John and Alieta Eck, MDs, for their first-century solution to twenty-first century needs. With 46 million people in this country uninsured, we need an innovative solution apart from the place of employment and apart from the government. To read the rest of the story, go to www.zhcenter.org and check out their history, mission statement, newsletter, and a host of other information. For their article, "Are you really insured?," go to www.healthplanusa.net/AE-AreYouReallyInsured.htm.
• PATMOS EmergiClinic - where Robert Berry, MD, an emergency physician and internist, practices. To read his story and the background for naming his clinic PATMOS EmergiClinic - the island where John was exiled and an acronym for "payment at time of service," go to www.patmosemergiclinic.com To read more on Dr Berry, please click on the various topics at his website.
• PRIVATE NEUROLOGY is a Third-Party-Free Practice in Derby, NY with Larry Huntoon, MD, PhD, FANN. (http://home.earthlink.net/~doctorlrhuntoon/) Dr Huntoon does not allow any HMO or government interference in your medical care. "Since I am not forced to use CPT codes and ICD-9 codes (coding numbers required on claim forms) in our practice, I have been able to keep our fee structure very simple." I have no interest in "playing games" so as to "run up the bill." My goal is to provide competent, compassionate, ethical care at a price that patients can afford. I also believe in an honest day's pay for an honest day's work. Please Note that PAYMENT IS EXPECTED AT THE TIME OF SERVICE. Private Neurology also guarantees that medical records in our office are kept totally private and confidential - in accordance with the Oath of Hippocrates. Since I am a non-covered entity under HIPAA, your medical records are safe from the increased risk of disclosure under HIPAA law.
• FIRM: Freedom and Individual Rights in Medicine, Lin Zinser, JD, Founder, www.westandfirm.org, researches and studies the work of scholars and policy experts in the areas of health care, law, philosophy, and economics to inform and to foster public debate on the causes and potential solutions of rising costs of health care and health insurance. There are a number of excellent articles on the website.
• Michael J. Harris, MD - www.northernurology.com - an active member in the American Urological Association, Association of American Physicians and Surgeons, Societe' Internationale D'Urologie, has an active cash'n carry practice in urology in Traverse City, Michigan. He has no contracts, no Medicare, Medicaid, no HIPAA, just patient care. Dr Harris is nationally recognized for his medical care system reform initiatives. To understand that Medical Bureaucrats and Administrators are basically Medical Illiterates telling the experts how to practice medicine, be sure to savor his article on "Administrativectomy: The Cure For Toxic Bureaucratosis."
• Dr Vern Cherewatenko concerning success in restoring private-based medical practice which has grown internationally through the SimpleCare model network. Dr Vern calls his practice PIFATOS – Pay In Full At Time Of Service, the "Cash-Based Revolution." The patient pays in full before leaving. Because doctor charges are anywhere from 25–50 percent inflated due to administrative costs caused by the health insurance industry, you'll be paying drastically reduced rates for your medical expenses. In conjunction with a regular catastrophic health insurance policy to cover extremely costly procedures, PIFATOS can save the average healthy adult and/or family up to $5000/year! To read the rest of the story, go to www.simplecare.com.
• Dr David MacDonald started Liberty Health Group. To compare the traditional health insurance model with the Liberty high-deductible model, go to www.libertyhealthgroup.com/Liberty_Solutions.htm. There is extensive data available for your study. Dr Dave is available to speak to your group on a consultative basis.
• Madeleine Pelner Cosman, JD, PhD, Esq, (1937-2006), is no longer with us. She made important contributions in restoring accountability in health care. Her obituary is at www.signonsandiego.com/news/obituaries/20060311-9999-1m11cosman.html. She will be remembered for her important work, Who Owns Your Body, which is reviewed at www.delmeyer.net/bkrev_WhoOwnsYourBody.htm. Please go to www.healthplanusa.net/MPCosman.htm to view some of her articles that highlight the government's efforts in criminalizing medicine. For other OpEd articles that are important to the practice of medicine and health care in general, click on her name at www.healthcarecom.net/OpEd.htm.
• David J Gibson, MD, Consulting Partner of Illumination Medical, Inc. has made important contributions to the free Medical MarketPlace in speeches and writings. His series of articles in Sacramento Medicine can be found at www.ssvms.org. To read his "Lessons from the Past," go to www.ssvms.org/articles/0403gibson.asp. For additional articles, such as the cost of Single Payer, go to www.healthplanusa.net/DGSinglePayer.htm; for Health Care Inflation, go to www.healthplanusa.net/DGHealthCareInflation.htm. View the Recession and its effect on Health Care, also Terrorists could stay home, yet launch a devastating attack on an unprepared and vulnerable healthcare system.
• Dr Richard B Willner, President, Center Peer Review Justice Inc, states: We are a group of healthcare doctors -- physicians, podiatrists, dentists, osteopaths -- who have experienced and/or witnessed the tragedy of the perversion of medical peer review by malice and bad faith. We have seen the statutory immunity, which is provided to our "peers" for the purposes of quality assurance and credentialing, used as cover to allow those "peers" to ruin careers and reputations to further their own, usually monetary agenda of destroying the competition. We are dedicated to the exposure, conviction, and sanction of any and all doctors, and affiliated hospitals, HMOs, medical boards, and other such institutions, who would use peer review as a weapon to unfairly destroy other professionals. Read the rest of the story, as well as a wealth of information, at www.peerreview.org. Don't miss section seven above on Abusive Peer Review.
• Semmelweis Society International, Verner S. Waite MD, FACS, Founder; Henry Butler MD, FACS, President; Ralph Bard MD, JD, Vice President; W. Hinnant MD, JD, Secretary-Treasurer; is named after Ignaz Philipp Semmelweis, MD (1818-1865), an obstetrician who has been hailed as the savior of mothers. He noted maternal mortality of 25-30 percent in the obstetrical clinic in Vienna. He also noted that the first division of the clinic run by medical students had a death rate 2-3 times as high as the second division run by midwives. He also noticed that medical students came from the dissecting room to the maternity ward. He ordered the students to wash their hands in a solution of chlorinated lime before each examination. The maternal mortality dropped, and by 1848, no women died in childbirth in his division. He lost his appointment the following year and was unable to obtain a teaching appointment. Although ahead of his peers, he was not accepted by them. When Dr Verner Waite received similar treatment from a hospital, he organized the Semmelweis Society with his own funds using Dr Semmelweis as a model: To read the article he wrote at my request for Sacramento Medicine when I was editor in 1994, see www.delmeyer.net/HMCPeerRev.htm. To see Attorney Sharon Kime's response, as well as the California Medical Board response, see www.delmeyer.net/HMCPeerRev.htm. Scroll down to read some very interesting letters to the editor from the Medical Board of California, from a member of the MBC, and from Deane Hillsman, MD.
To view some horror stories of atrocities against physicians and how organized medicine still treats this problem, please go to www.semmelweissociety.net. To review a discussion on a Peer Review Case in progress, go to section six above.
• Dennis Gabos, MD, President of the Society for the Education of Physicians and Patients (SEPP), is making efforts in Protecting, Preserving, and Promoting the Rights, Freedoms and Responsibilities of Patients and Health Care Professionals. For more information, go to www.sepp.net.
• Robert J Cihak, MD, former president of the AAPS, and Michael Arnold Glueck, M.D, who wrote an informative Medicine Men column at NewsMax, have now retired. Please log on to review the archives.
• The Association of American Physicians & Surgeons (www.AAPSonline.org), The Voice for Private Physicians Since 1943, representing physicians in their struggles against bureaucratic medicine, loss of medical privacy, and intrusion by the government into the personal and confidential relationship between patients and their physicians. Follow the list of Third Party Free Practices. Be sure to read News of the Day in Perspective: Kennedy releases draft "health care reform" proposal. Don't miss the "AAPS News," Doctors Are The Key, written by Jane Orient, MD, and archived on this site, which provides valuable information on a monthly basis. Browse the archives of their official organ, the Journal of American Physicians and Surgeons, with Larry Huntoon, MD, PhD, a neurologist in New York, as the Editor-in-Chief. There are a number of important articles that can be accessed from the Table of Contents. Note some timely articles: An Invasion of Medicine by the Information Technology Industry? What America Needs to Learn from Canadian Medicare; Epidemiologic and Economic Research, and the Question of Smoking Bans. The Book Review Section has four important topics.
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"Is life so dear, or peace so sweet, as to be purchased at the price of chains and slavery? Forbid it, Almighty God! I know not what course others may take; but as for me, give me liberty or give me death!" -Patrick Henry.
"He that has sense knows that learning is not knowledge, but rather the art of using it." -Richard Steele: 17th-18th century English playwright and essayist
"If you change the way you look at things, the things you look at change." -Dr. Wayne Dyer: Self-development author and speaker.
Some Recent Postings
By Hudson Sangree firstname.lastname@example.org, May 22, 2009
Steve Larsen, a world-class cyclist and triathlete who grew up in Davis [CA] and owned a bike shop there, died during a workout Tuesday at the age of 39 . . .
Larsen collapsed during a training run at a middle-school track in Bend, Ore., the city he moved to when he left Davis in 2003. Dr. Steve Cross, the Decschutes County medical examiner, said there was no obvious explanation for what happened to Larsen, who was in peak physical condition.
When the elite athlete collapsed Tuesday evening, he was given immediate CPR and arrived at the hospital quickly with two experienced heart surgeons attending him but could not be revived, Cross said.
Larsen, who once owned Steve Larsen's Wheelworks bicycle shop in Davis, twice competed in the Giro d'Italia and rode during his amateur and early professional career as a teammate to superstar cyclist Lance Armstrong.
His penchant for cycling began as a child when he would ride several miles from his family's home on the outskirts of Davis to town, friends said. Famed for his fierce drive, he completed the 200-mile Davis Double-Century bike race when he was 11 years old.
"I was burned out on cycling for two years after that," he told The Bee. "It took me 15 hours; I was practically falling asleep on my bike. I couldn't walk for days."
But he recovered, and begin riding seriously again in the eighth grade. After a stint as a professional road cyclist, Larsen eventually switched to mountain biking and won several national titles.
His mountain biking career ended when he quit as the reigning cross country national titlist in 2000.
Ever the athlete, Larsen in 2000 entered a triathlon and won. He told cycling writer James Raia in a 2003 Bee story that not competing in the Olympics or the Tour de France was a big disappointment: . . .
For more information, go to www.rememberstevelarsen.com.
On This Date in History - June 23
On this date in 963, the principality of Luxembourg was founded. Luxembourg has survived occupations and invasions by more powerful neighbors - and every other country is more powerful than Luxembourg, except in its ability to survive.
On this date in 1961, an international treaty for scientific cooperation and peaceful use of the Antarctic was signed. It will be a cold day in Antarctica when that treaty ends.
-After Leonard and Thelma Spinrad