1. Featured Article: The Case Against the Electronic Medical Record

By David J. Gibson, MD and Jennifer Shaw Gibson

PRESIDENT BARACK OBAMA convened a healthcare summit in Washington on March 5 to identify programs that would improve quality and restrain burgeoning costs.

His flagship proposal was national adoption of the electronic medical record (EMR). This, he said, would save some $80 billion a year, safeguard against medical errors, reduce malpractice lawsuits, and greatly facilitate both preventive care and ongoing therapy of the chronically ill.

The point of this article is to discuss the value of the EMR itself. But it must be pointed out that none of the President's assertions is true.

Obama has based his proposal on a now discredited 2005 RAND study on EHRs.¹ From the time of its publication to the present, there has been no compelling evidence to support the study's theoretical benefits. Read more . . .

If, as RAND asserts, the EMR improves efficiency, enhances productivity, decreases overhead cost and improves the quality of health care, why are only 4 percent of doctors using functional electronic records that can provide any kind of clinical recommendations,² and why are only 1.5 percent of nearly 3,000 hospitals currently equipped with comprehensive electronic records? ³

As a group, health care professionals have been on the forefront in embracing information technology, including beepers, fax machines, cellular phones, desk top computing, data mining and the use of the Internet for both personal and business use.

Yet there is a gap between information technology's deployments in health care as opposed to most other industries. There are several reasons for this.

The Technology Issue.
EMR systems are difficult to maintain in the small practice setting. Furthermore, most studies document a reduction in physician productivity following installation of EMRs. These systems generally add a half-hour or more to a physician's day for tasks such as electronic ordering, and responding to the false alerts that all of these EMR systems generate.⁴

Physicians need an EMR that does not yet exist. They need a mobile, voice-activated, heuristic, architecture-based system rather than a keyboard and mouse-based interface with the EMR. A friend of ours once made the observation that "information technology does not require subsidization unless it is not ready for deployment."

The Business Model Issue.
For hospitals, declining revenues and deteriorating investment returns, coupled with accelerating capital costs, make investing in EMRs problematic.

The Sutter Health System expects to spend a billion dollars to implement EMRs in its Northern California hospitals. The UC Davis health care system began digitizing its medical records about six years ago - at a cost of $90 million. Kaiser Permanente and Veterans Administration Hospitals have invested billions of dollars to bring their EMR systems online.⁵ Small hospitals spend at least $20 million to go paperless while larger academic institutions generally spend as much as $200 million. . .

A new report⁷ by Avalere Health, an information company serving government and the health care industry, found it would cost about $124,000 for a single doctor or small practice to upgrade to electronic health records over the five-year period (2011-2015) during which the stimulus bill offers incentive payments of up to $44,000.

In 2015, Medicare penalties start to kick in for doctors who haven't switched to electronic record-keeping. The projected starting penalty will be $5,100 a year - far less than the cost, less the incentive, to install and maintain an electronic health system

EMR Veracity is Compromised.
The secret generally unknown outside the health care industry is that the only real business model case that resonates for the EMR in medical practices is the support for documenting (and occasionally up-coding) billed charges. Interest in the EMR was generated by the threat from the Centers for Medicare & Medicaid Services (CMS) that physicians needed to adequately document patient visits.

Remember the Evaluation & Management (E&M) Code controversy that arose with the 1996 passage of the Kassebaum-Kennedy Bill? The purpose of the bill, which criminalizes any miscoding of medical services, was to control fraud and abuse in the Medicare program. To no one's surprise, the documentation to satisfy E&M coding requirements fit neatly into a computer coding system - the EMR was born.

A decade later, another reason for adopting electronic recording of clinical information developed. In 2005, "Pay for Performance" (P4P) was introduced by the health insurance industry. These P4P plans - which pay doctors, hospitals and other providers more meet certain goals - were seen as a way of boosting health quality. Recent evidence is that P4P plans are ineffective in achieving any of their original goals.

Researchers at the RAND Corporation studied a P4P program started in 2003, involving seven major California health plans and 225 physician groups caring for 6.2 million people.⁸ The study found that the programs appear to be speeding adoption of information technology such as electronic medical records, but these changes have not improved quality.

There are now rather unpleasant consequences emerging as a direct result of E&M codes, P4P and the evolving deployment of EMRs: The veracity of the medical record is being compromised.

An associate who teaches at a medical school told us that he observed frequent EMR chart entries using macros (one or two key strokes that perform a series of actions) for components of the physical exam that have not been performed.

"Mary, it says here you did a neurological exam and it was normal. I was there with you and didn't see you do a neuro-exam."

The student's response, "I inserted a macro for my physical exam."

Another associate who practices in a large medical group relates that padding of the chart with superfluous, macro-based information is rendering the chart irrelevant.

As this checklist, cut-and-paste, or macro-insertion behavior spreads, the veracity of the medical chart becomes profoundly compromised. How can an attending physician finding neurological deficits ever rely on the recorded clinical findings six months before if there is a possibility the reported data are compromised or, worse, "dry-labbed"?

The answer is they cannot. So the only believable data in these EMRs will be derived from the lab and the objectively recorded diagnostic studies.

Quality of Care.
There is also no evidence that the EMRs improve the quality of health care. A 2008 study published in Circulation⁹ assessed the influence of electronic medical records on the quality of care of more than 15,000 patients with heart failure. It concluded that "current use of electronic health records results in little improvement in the quality of heart failure care compared with paper-based systems."

Similarly, researchers from Brigham and Women's Hospital and Harvard Medical School, with colleagues from Stanford University, published an analysis in 2007 of some 1.8 billion ambulatory care visits. They concluded, "As implemented, electronic health records were not associated with better quality ambulatory care."¹⁰ . . .

One of the oldest of computer problems - "garbage in, garbage out" - exacerbates liability exposure. Once a misdiagnosis enters into the electronic record, it is rapidly and virally propagated. A study of orthopedic surgeons, comparing handheld PDA electronic records to paper records, showed an increase in wrong and redundant diagnoses using the computer - 48 compared to seven in the paper-based cohort.¹²

Propagation of mistakes is not limited to misdiagnoses. Once data are keyed in, they are rarely rechecked for accuracy. Entering a patient's weight incorrectly will result in a drug dose that is too low or too high, and the computer has no way to correct such human error.

Recent studies suggest that adopting computerized systems has not helped but harmed patients. After the Children's Hospital of Pittsburgh added automated prescribing recommendations to a commercial electronic records system, it documented more than a threefold increase in the death rate of child patients.¹³ Another leading system contributed to more than 20 different types of medical errors.¹⁴

Individual Privacy
Once the medical record is in digital form, a couple of mouse clicks on a computer that is connected to the internet can propagate the most private of information to a worldwide audience.

Furthermore, not every health care professional with access to the EMR system should have access to every record within the system. Once cleared for record access, not every professional should have access to every part of the record. This conundrum of layered security level setting has not been resolved.

Current concern over confidentiality of data is not spurious for providers. The liability relating to disclosing personal health Information (PHI) now stands at up to $1,500,000 per occurrence.¹⁵

A Tool for Rationing.
A new concern has arisen with the administration's EMR initiative. Some have speculated that patient data collected in national electronic health records will be mined to assess cost effectiveness of different treatments.

This analysis could then be used to dictate which drugs and devices doctors can provide to patients in federal programs like Medicare. Private insurers often follow the lead of the government in such payments.

Conclusion.
The fact is there is no objective peer reviewed and published evidence that EMRs improve quality or reduce costs.

What lessons can we learn from all of the above? One is that public policy should not drive market development before thorough pre-deployment testing has determined effectiveness and detected unintended consequences.

It should be noted that though we are critical, we are not opposed to the EMR - in fact, we recognize clear benefits from deploying an EMR in the clinical setting. Today, patients are frequently seen without physicians having access to the patient's paper records.

With EMR, health professionals can readily access all information on their patients from a single site. Particularly helpful are alerts in the system that warn of potential toxicity in prescribing certain drugs for a patient already on other therapies.

Rather, our objection is to the opportunistic and abusive use of discredited data and bogus projections for political purposes. The cynical presentation of unsubstantiated or, worse, known inaccurate cost savings and improved quality of care data being used to justify breathtaking increases in taxpayer funding for increased health care spending by the government is patently disingenuous.

To read the entire OpEd article including all the references, go to . . .

Jennifer Gibson traded energy commodity futures on the Chicago Mercantile Exchange. She is also an economist who trained at the London School of Economics and now specializes in evolving health care markets. David Gibson is the C.E.O. of Reflective Medical Information Systems, a software development and consulting firm.

* * * * *

2. In the News: The Ultimate Result of Cigarette Taxes: Smoke or be Fined

China has 350 million smokers, of whom a million die of smoking-related diseases every year.

BEIJING - OFFICIALS in a county in central China have been told to smoke nearly a quarter million packs of locally made cigarettes annually or risk being fined, state media reported on Monday.

The Gong'an county government in Hubei province has ordered its staff to puff their way through 230,000 packs of Hubei-produced cigarette brands a year, the Global Times said.

Departments that fail to meet their targets will be fined, according to the report. Read more . . .

'The regulation will boost the local economy via the cigarette tax,' said Chen Nianzu, a member of the Gong'an cigarette market supervision team, according to the paper.

The measure could also be a ploy to aid local cigarette brands such as Huanghelou, which are under severe pressure from competitors in neighbouring Hunan province, according to the paper.

China has 350 million smokers, of whom a million die of smoking-related diseases every year.

More than half of all male doctors in China smoke, but the government is now trying harder to get them to kick the habit in order to set an example for others, state media reported recently. -- AFP

www.straitstimes.com/Breaking%2BNews/Asia/Story/STIStory_372199.html

* * * * *

3. International Medicine: There is no Accountability in Government Health Care

The NHS fails again, and again it seems nobody is to blame By Jemima Lewis, 18 Apr 2009

Whistleblowers like Margaret Haywood have exposed a system in which accountability slips from one person to the next, and eventually disappears, says Jemima Lewis.

It's a thankless business, blowing the whistle, as Margaret Haywood has just discovered. The 58-year-old nurse has been struck off for secretly filming the neglect of elderly patients at a Brighton hospital.

The Nursing and Midwifery Council (NMC) ruled that she was guilty of misconduct because she had breached patient confidentiality and neglected her nursing obligations in order to make an undercover documentary for Panorama in 2005. Ms Haywood, a nurse for 20 years, insists she only acted in the public interest, having tried in vain to register her concerns about patient care with the hospital authorities. It may be small consolation, but she does at least have the support of her fellow nurses – hundreds of whom have emailed or rung the NMC to register their outrage – and of the public, to whom, after all, the health service belongs.

Anyone who has been on the receiving end of NHS mismanagement will know how difficult it is to establish any kind of accountability. The sheer scale of the system means that responsibility for failings simply slips from one person to the next, trickling through labyrinthine layers of management until, miraculously, it disappears altogether.

If this situation is frustrating for staff, it can be disastrous for patients. Six months ago, my sister and her baby both nearly died in childbirth, because of a hundred small but unforgivable inadequacies in the system. Read more . . .

The staff at my sister's local maternity hospital, an NHS "flagship", failed to notice that her baby had stopped growing in the last month of pregnancy because her placenta was failing. When she went into labour they refused to admit her for three days, despite the fact that she was bleeding copiously. They then refused to believe her tearful insistence that her waters had already broken, and kept scratching around inside her with a glorified knitting needle.

Not surprisingly, both she and the baby developed galloping infections, which the midwives, again, failed to spot. My sister, by this time extremely ill and frightened, begged for a caesarean, but was told – as if she were making a fuss about a perfectly normal labour – "You'd only regret it later."

It was a busy night on the labour ward, and the staff attending her changed continually, each new arrival flicking cursorily through her notes before dashing off to the next delivery room. The midwife who stayed with her longest spoke almost no English and did not know how to work the foetal monitor, which meant she failed to notice that the baby's heartbeat was crashing. It was a passing obstetrician who spotted the catastrophe in the making.

My nephew was pulled out so abruptly that his skull was fractured. He was born blue, and took 20 minutes to breathe on his own. He had suffered a brain injury because of oxygen deprivation, and was rushed straight to intensive care, where he spent the next six weeks.

My sister, meanwhile, was left in the delivery room, half-naked, covered in blood and shaking from shock and fever. No one even offered her a cup of tea, let alone any pastoral care. Four hours later, in desperation, she and her husband simply sat down in front of the reception desk and refused to budge until they were pointed in the direction of a shower and a bed.

Needless to say, shortage of space meant that my distraught sister was put on the main maternity ward, surrounded by new mothers and their healthily squealing babies. Except in intensive care – a high-tech oasis of cleanliness and calm – the standard of care my sister received would have embarrassed many a developing nation. The hospital knows it screwed up, and has apologised repeatedly; yet in all its internal investigations, it cannot seem to find a place to pin the blame.

The staff were overstretched and exhausted; my sister was supposed to be "low-risk"; it was inevitably a "failure of the system". And how do you hold a system devised and run by 39,000 faceless managers (more than there are NHS doctors) to account? It's a Sisyphean task; but I, at least, am thankful that there are still whistleblowers prepared to try.

www.telegraph.co.uk/comment/columnists/jemima-lewis/5178670/The-NHS-fails-again-and-again-it-seems-nobody-is-to-blame.html

The NHS does not give timely access to healthcare, and when you do arrive, there's no one there.

* * * * *

4. Medicare: To Continue to Participate, You Have to Join The Electronic Medical Superhighway

The Electronic Medical Superhighway By Ian Hoffman, MD, MPH Sonoma Medicine, Spring 2009

Late in the evening on Feb. 13, Congress passed the sweeping American Recovery and Reinvestment Act of 2009, commonly known as the stimulus bill. The bill includes more than $787 billion in spending, tax cuts and incentives that are meant to turn the economy around and rebuild for the future. Buried within more than 400 pages of legislation is what will likely be Obama's first-term health care legacy: $21 billion in incentives for physicians and other providers to adopt electronic medical records (EMRs).

The stimulus bill provides $19 billion for general promotion of EMRs, with another $2 billion specifically available to Federally Qualified Health Centers, such as the Southwest center in Santa Rosa and the Alliance center in Healdsburg. The bill defines payment structures starting in 2011 through Medicaid and Medicare, with up to $41,000 per qualified practitioner using an EMR system, amortized over five years. For health centers, the total is up to $60,000 over 6 years. Policy analysts hope the funding will encourage nearly 90% of physicians to adopt EMRs by 2016. According to a February 2009 Commonwealth Fund report, The Path to a High Performance U.S. Health System, adoption of EMRs would result in a projected savings of $895 billion by 2020. Read more . . .

Putting more money into health care infrastructure may sound outrageous when the economy is in crisis, health care spending is out of control, and physicians are struggling to meet community demands with Medicaid's meager payments and cutbacks. Yet the attacks against the health care aspects of the stimulus package were surprisingly minimal. Unlike other reforms, health information technology has broad bipartisan support because of its expected savings and improved efficiency.

In the early days of EMRs, everyone used their own platforms and standards, meaning that every EMR spoke a different language. Early attempts to share information, even locally, were hampered by poor compatibility. In 2004, President Bush, sold on the idea that EMRs could save billions of dollars, proposed to make all American health records electronic by 2014, and to get all systems speaking the same language. One year after Bush's proposal, the Department of Health and Human Services (HHS) began a pilot project to create a national health information exchange–an electronic interface of important health data.

In February 2009, HHS went live with the product of this trial: the Nationwide Health Information Network (NHIN). The new network uses common standards to share patient information across a broad network of EMRs, from solo and group practices to large hospital systems. . .

To read the entire article, go to www.scma.org/magazine/articles/?articleid=397.

Dr. Hoffman is a third-year resident in the Santa Rosa Family Medicine Residency.

E-mail: hoffmaip@sutterhealth.org

Government is not the solution to our problems, government is the problem.

- Ronald Reagan

* * * * *

5. Medical Gluttony: The Ultimate Gluttony - Big Government Medicine

We have had a number of experiences in the United States with Big Government Medicine. In each case, it has resulted in a Gluttonous behavior among its recipients. Unfortunately, this gluttony has been seen by the recipients as unusually excellent medicine.

When Medicare came on the horizon in 1965, the projections of costs were very reasonable. In each case, the actual costs have been four to eight times as expensive (as gluttonous). That's not hard to understand. People's appetite for things medical knows no bounds. Read more . . .

In most practices, it is a common experience that patients go to the emergency rooms. The data from ERs indicate that the vast majority do not have emergencies but need routine care at a time more convenient than when offices are opened. When the worker comes home at five, and someone is not feeling well, it is very easy to take them to the emergency room and have it taken care of then so as not to miss work.

When they go to the emergency room, they are seeing a new doctor who is totally unfamiliar with their health problems. Since the ERs are generally so busy, which precludes taking a 15- to 30-minute medical history, the physician orders a slew of tests that lets the laboratory and x-ray departments make the diagnosis. This also avoids malpractice since the physician is relatively uninvolved. People are very impressed with the array of tests that can be done these days. A CT of the chest or abdomen is now as easy to obtain as a CXR or a KUB of the abdomen. Only it costs about ten times as much.

Rather than take the time to obtain a cardiac history, the doctor will order an Electrocardiogram. If there is a trace of abnormality, order an ECHO Cardiogram. A negative diagnosis will be more readily accepted than a physician spending an exhausting amount of time on the cardiac history to justify the test. Before he's done, the patient will ask, "But can you really be sure I don't have a heart problem?" Patients don't believe a doctor's clinical diagnosis. They want "a test" which they will believe. But an ECHO may cost ten times as much as an ECG.

Rather than take a headache history with the same result, ER doctors have found it expedient to order a CT of the brain while they see another patient or two. This will do more to convince a patient that he doesn't have a brain tumor than a detailed neuro exam which would do the same. The neuro exam is just a detailed part of the physical examination and comes with the price of the ER. The CT Scan of the Brain may costs hundreds of dollars.

Before long, it is easy to understand why many ER visits cost up to $9,000 in the hospital. Patients come back and say their stay there beats any Hilton Hotel in which they have ever stayed. The big difference is that Hilton is cheap compared to a hospital ER.

Why are ERs so expensive? This is really Big Government Medicine. The patients have Medicare, a government program, Medicaid, a government program, an HMO, a government mandated program, or private health insurance, which sometimes prides itself on having no, or minimal, co-payment or deductible which gives incentives to a huge health care appetite and unnecessary costs.

Who are the uninsured? The structure of health care in this country includes Medicaid, which covers the poorest 12 to 15 percent of Americans. We have Medicare, which covers all the elderly over 65 and all the disabled of any age. We have the Veterans service, which covers the veterans in need. The only people in America that are uncovered are the large middle class. Why are they uninsured? Is there an insurance solution for them?

Yes. There is an insurance solution for them. Stay tuned in the coming weeks to learn more.

Medical Gluttony thrives in Government and Health Insurance Programs.

It Disappears with Appropriate Deductibles and Co-payments on Every Service.

* * * * *

6. Medical Myths: Health IT and the Other Myths of Reform

VITAL SIGNS - Journal of The Fresno-Madera And Kern Counties Medical Societies, Feb Issue

Health IT Adoption and the Other Myths of Health Care Reform by Robert Laszewski, columnist, iHealthBeat Newsletter

The arguments that the widespread use of health IT, (Information Technology) improving health status, expanding outcomes research, implementing pay-for-performance systems, and covering everyone will make it possible for us to afford comprehensive health care reform are commonly cited by people on both sides of the political aisle. It's all a myth.

Undoubtedly, these ideas will be at the core of any number of health care reform proposals as we begin the 2009 health care reform effort.

There is nothing wrong with any of these things and all can make a positive contribution toward improving both the cost of and especially the quality in our health care system. All should be part of a reform proposal.

The problem is that none of them would make more than a modest dent in what a reformed system would cost us and not come anywhere near close to accomplishing the objective of stabilizing our health care costs, much less reducing them. Therefore, any responsible reform effort would not count on any, or the sum, of these things by themselves to make it possible for a reformed American health care system to become sustainable.

Simply put, let's stop kidding ourselves that these commonly cited improvements can pay for health care reform. To read more . . .

HEALTH IT AND PREVENTION

Health IT is important and can probably do more to improve the quality of our health care system than save us money.

Prevention and wellness will also help and would certainly improve the quality and length of life for people who deal with preventable health problems.

But the research on both counts always comes up way short of what politicians argue it can do to save money. In this month's groundbreaking Congressional Budget Office report on health care reform options, the authors said, "Approaches – such as the wider adoption of health IT or greater use of preventive medical care – could improve people's health but would probably generate either modest reductions in the overall costs of health care or increases in such spending within a 10-year budgetary window." In his comprehensive review of the literature on health care costs in October, Paul Ginsburg found, "Obesity is a significant factor driving health spending, accounting for an estimated 12% of the growth in recent years." However, any gains from reducing obesity would be concentrated in the short and intermediate period "because some of the savings will be offset by increased longevity and the cost of disease that are most prevalent during old age."

Both the report and Ginsburg's review come to the same conclusion – modest gains, worth doing, but nowhere near blockbuster results.

OUTCOMES RESEARCH

Outcomes research has been going on for decades. Let me make it clear I do buy into the Dartmouth arguments that we could improve our costs by 30% if all health care providers followed the course of the most efficient. As Ginsburg pointed out in his literature review, the inefficient use of technology is the key driver in health care spending, accounting for an estimated 38% to 65% of spending growth.

The problem I have with the suggestions that more outcomes research will save us money is that more than 20 years of outstanding outcomes research, Dartmouth for example, has not kept our health care costs under control. Why would a dramatic expansion of what we already know do any more? . . .

PAY-FOR-PERFORMANCE

There isn't anything in this health care debate that I can be more cynical about than "pay-for-performance." As a concept I can't disagree with it. That it sounds good is likely the most important reason it is at the top of so many reformers' lists. But we haven't agreed on what quality is or how to measure it. In my mind, "pay-for-performance" is just a means of politically rationalizing a way to avoid the upcoming Medicare physician fee cuts and paying the politically powerful providers more. To work, pay-for-performance has to be something better than a sum zero game – it has to be budget negative. The providers, as a group, have to get less than they would have. There must be losers. . .

UNIVERSAL COVERAGE

Politicians on both sides of the aisle have argued for years that getting everyone covered will save us money because it will be cheaper to have them receive proper care early on rather than wait for them to be really sick and then cost us more. That logic is correct. But the savings really aren't anywhere the size promised.

WILL COVERING EVERYONE SAVE US MONEY?

As Ginsburg found, if we insure more people, our health care system will cost more, not less. "The increase in the percentage of people with health insurance accounted for approximately 10% to 13% of the historical growth in spending." The uninsured have not contributed to the recent growth in health spending in the aggregate and will not be a driver in the future unless we find a way to insure more people. . .

WHERE ARE THE SAVINGS?

I will suggest that successful health care reform will deal with the real villains in our system:

· The inefficient and wasteful use of technology.

· Our prices for drugs, devices and services that are dramatically higher than in other industrialized nations.

· Administrative overhead. . .

I accept the premise that our health care prices and overall costs will not likely ever be as low as other industrialized nations because of our higher GDP. But the GDP gap explains only part of it.

Let me also reiterate that including these five things in any reformed health care system will be important – probably more from a quality perspective than a cost-saving effort. But, if we want to just keep kidding ourselves we can count on the myths that these five things will give us the savings we need to reform our system. All we will accomplish is making matters even worse when costs continue to explode and the new promises we have made become unaffordable in ways that will make our current health care system look like a bargain.

If we want to get real, it will take a head-on assault on these more problematic villains. That will likely require us to deal more directly with the demand side as well as the supply side.

Robert Laszeski is president of Health Policy and Strategy Associates, LLC, a policy and marketplace consulting firm specializing in health care issues. Article reprinted with permission from iHealthBeat, a publication of the California Healthcare Foundation.

Read the entire excellent article at www.fmms.org/pdf/Feb09_VS.FINAL.pdf

Medical Myths originate when someone else pays the medical bills.

Myths disappear when Patients pay Appropriate Deductibles and Co-payments on Every Service.

* * * * *

7. Overheard in the Medical Staff Lounge: Taxes on Everything - Profession Services Next?

Dr. Dave: I see in China that people were trying to avoid cigarette taxes.

Dr. Edwards: Don't we all?

Dr. Sam: When an eastern state increased taxes on cigarettes, people went across the state line and loaded up.

Dr. Dave: But in China, they just demanded that income from cigarette taxes achieve a certain level or the public would be fined. Read more . . .

Dr. Paul: But the government needs more money. Where do you suggest they get it from? Milk?

Dr. Dave: The government needs more and more money because they spend it all. They're like a high school kid - irresponsible.

Dr. Paul: What government program would you abolish?

Dr. Dave: Where do you want me to start? From the bottom or from the top?

Dr. Sam: Both.

Dr. Dave: Well, you can't start at the bottom or your name is mud. So let's start with everyone else.

Dr. Paul: Well, our governor has not taken any salary since he was elected. Surely he's done his part?

Dr. Sam: But isn't he the cause of our $18 BB deficit? Didn't he win the Governor Davis recall because of an unfunded $6 BB? Now his is three times as high.

Dr. Edwards: Today I heard that Loma Linda can't maintain their Psychiatry Department. They are losing the faculty to the State Prison System where they are making $300,000 for a 40-hour week?

Dr. Rosen: It's hard to work a 60-hour week, or 3,000-hour year for $150,000 when you can cut your hours, shed most of your responsibilities and make twice that much.

Dr. Ruth: Does the state have any openings for internists?

Dr. Edwards: I think they do, but internists only make $125,000 according to a friend of mine that works at Folsom State Prison here in town.

Dr. Dave: Well, all the state employees could take at least a 20 percent pay cut and not be hurting.

Dr. Rosen: That is happening some places in industry where the senior management is taking a 20 percent hit while the employees take a 10 percent hit.

Dr. Milton: That's where General Motors made a big mistake. They should have told the United Auto Workers that we're closing 40 percent of our factories unless the workers take a 40 percent pay cut and eliminate the salary guarantee for not working.

Dr. Rosen: That would have kept GM viable before they became Government Motors. GM was a global company before we even had a global economy. GuvMot will essentially be no more. Just like our electronic industry all fled because of government interference, it looks like our auto industry will be devastated by the current government program.

Dr. Dave: These have really been a devastating 100 days, haven't they?

Dr. Rosen: It will take us longer to recover than it did during Roosevelt's 100 days. It will take decades to reverse all the harm that's being done now.

The Staff Lounge Is Where Unfiltered Opinions Are Heard.

* * * * *

8. Voices of Medicine: A Review of Local and Regional Medical Journals and Articles

San Mateo County Medical Association Bulletin February 2009

Society Needs to Start Understanding that Death is Inevitable By David Goldschmid, M.D.

All governments have discovered one universal truth: medical costs sustained by any society is directly related to the number of practicing physicians.

Is Medicine now a GO-TO Profession?
When we speak about a physician shortage, we must first define terms. In my view, the number of physicians per capita does not define a physician shortage. In fact that number is expected to rise and remain very high by world standards. In my view, there is a shortage when access to physicians becomes difficult. Thus, one must account for productivity as well as numbers of physicians when trying to define adequate supply. Productivity is measured by the amount of work done, or patients seen, and is related to hours worked and longevity of practice. I will not attempt to discuss the issue of demand for services as it relates access and to the definition of a shortage. The aging of our population, the effect of boomers growing older, and the effect of possible universal coverage will work to make access more difficult.

Measuring Productivity

There is little question that physician productivity is going down. First we can start at the end: retirement.

The data is very suggestive that overall, physicians are retiring at an earlier age. There are no obvious or simple causes, but there are some trends that may help to explain this. Female physicians are more likely to retire from medicine earlier than male physicians (median retirement age: 61 vs. 65) and there are more female physicians now than before. "Furthermore, the impact of physician retirement will be bolstered further by the rapidly growing proportion of employee physicians, who have higher probabilities of retirement than selfemployed physicians in either solo or group practices." Finally, many have elected to retire rather than struggle with overregulation, falling reimbursement, and a hostile legal environment. Read more . . .

Changing Expectations

Next, there is the issue of the expectations of new graduates. Local large and very large groups report that it now takes 2-3 physicians to fill one FTE. This is because many have very specific work hour requirements due to increased family commitments. Physicians moving into the area are having families earlier than before and are usually married to a spouse who must also work (often another physician). Residency directors will explain that there is a greater reluctance to work long hours, weekends, see hospital patients, or be on call than in the past. Small groups and solo practitioners report they can no longer recruit.

There are market forces.

Physicians are the only professionals who have experienced a real drop in income over the past few years. They simply cannot sustain a high level of living in areas where expenses are high.

Medicine has become a "go to" profession. Unlike the past, people now frequently go to Medical school with the expectation that they will never practice but use the degree to "go to" another place such as consulting for IT companies, working for pharmaceutical companies, working at venture capital companies, etc. Lawyers have always done this (often becoming politicians) but this is a new trend in medicine. Here is a quote from a Wall Street Journal blog on "Why More Med Students Won't Mean More Doctors." "A salary of 150K per annum for someone with 12 yrs education/training after high school, 200K of debt, expected to work 60-70 hr weeks, consistently second guessed by Insurance companies and panned in the public as greedy and overpaid, with a feeling that the future income trajectory is down, just will not make attract the brightest amongst our youth." Once medical students figure all this out, they leave the profession before they start. . .

A Complicated Convergence of Forces
I believe that what we are witnessing here are multiple forces, working independently, determined to reduce costs by eliminating our desire to practice while at the same time professing to care about access, but knowing reducing access must happen. The hostile governmental environment and over-regulation physicians have experienced are designed to make reimbursement difficult and low, and to make medical practice undesirable. These forces result in reducing the number of practicing physicians or at least their productivity, to reduce access to reduce costs. Overregulation, bad press against physicians, lowering reimbursement, proliferating HMO principles where profit is tied to reduced productivity, trying to punish us for virtually anything that can go wrong, artificial constraints on marketplace forces such as constraints on balance billing, and Orwellian systems set up to pay us for doing our jobs well instead of simple systems, are not accidents. The intent is to reduce access and it is working. There are lots of people responsible for policy. This is not a conspiracy by a single powerful source. These actions are taken by different people who have come to the same conclusions and are operating independently, but their policies all have a similar desired effect. We are beginning to experience a physician shortage that policy makers hope will reduce costs. Until someone somewhere discovers a better way to reduce the overwhelming burden to society that medical costs will soon become, the physician shortage-defined as access to physicians-will continue and be allowed to get worse. Although physician numbers may continue to rise over the next few years, access to physicians will be reduced.

When society finally understands that death is inevitable and that lawyers cannot manage medical care, we will be able to devise rational cost containment. Then government will act to make the physician shortage improve. Ω

www.smcma.org/Bulletin/BulletinIssues/Feb09.pdf

VOM Is Where Doctors' Thinking is Crystallized into Writing.

* * * * *

9. Book Review: Homebirth in The Hospital, by Stacey Kerr, MD, 176 pp, Sentient Publications, $17

Precious Stories of Birth By Colleen Foy Sterling, MD

In Homebirth in the Hospital: Integrating Natural Childbirth with Modern Medicine, Stacey Marie Kerr, MD, a well-known local family physician and newspaper columnist (and former member of this magazine's editorial board), offers a window into the not-so-new trend of making labor and delivery in the hospital cozy and family friendly. Read more . . .

Homebirth in the Hospital appeared at the end of 2008, but Dr. Kerr has been practicing her own style of natural-birth attending for many years. She was already an advocate of integrative birthing when I interviewed for the family practice residency at what was then called Community Hospital (now Sutter Medical Center of Santa Rosa) in the early 1990s.

A few things about Community Hospital made an instant impression on my already hardened heart, the most outstanding being the way labor and delivery were conceptualized. The "integrative birth experience" at Community was the norm rather than the exception.

I had come from an urban medical school, its tertiary-care hospital large, uninviting, and situated on the edge of a ghetto. Sirens, sliding automatic doors, guards with guns, and an emergency room overflowing into the halls were the order of the day. My obstetrics rotation was filled with memories of mostly surgical deliveries, and to a lesser degree, lectures on research opportunities on the biochemistry and endocrinology of labor.

By the time of my interviewing trip, I had somehow clung to my dream of becoming a family physician, but I was doubtful of ever having much to do with the birthing process. I was actually regretting my decision to become a doctor instead of a midwife. Touring Community Hospital changed all that. The nurses greeted me with smiles and conversation, and the labor "ward" did not look anything like the one in the tertiary-care hospital. There were several tiny labor rooms, along with birthing rooms that looked soothingly homey. There was art on the walls, and the equipment and supplies were hidden behind true closet doors. The delivery bed not only had a birth bar, but also home-style bedding.

The on-call sleep room was even more revealing. It was rarely used for sleeping. The bookshelf was lined with books about natural childbirth and midwifery, which, although worn and well read, stood proudly next to a large obstetrics text.

Stacey, along with several other third-year residents, was one of my mentors. She was an advocate of natural and integrative birthing, an approach that was so much a part of the Community Hospital experience that it was more of a culture than a philosophy alone. I was immediately and happily swept along.

Readers of Homebirth in the Hospital can come along as well. In the book, various mothers and families tell their birth stories, as compiled and edited by Stacey. Many of these families experienced a traditional hospital birth with their first child and then sought out a better way. At least three of the stories are from physicians who trained at Community. Given their background and knowledge, their decision to seek a natural birth experience in a hospital setting makes perfect sense.

As the stories reveal, an integrative experience in birthing depends greatly on the entire team, a fact that Stacey acknowledges by dedicating her book to nurses. The nurses who greeted me so warmly at Community were an important part of my learning, not only on labor and delivery, but on every rotation. I spent hours watching them and absorbing their knowledge and art. I watched them reassure panicked mothers and model labor coaching to pale and reluctant partners. They cajoled laughs from preoccupied grandmothers and reinforced resolve during the pushing. . .

Birth stories are precious, and Stacey has collected an engaging set that will help anyone preparing for labor and delivery. Patients, doctors, midwives, nursing staff and students would all benefit from this little gem of a book. It would be a welcome treasure tucked into a baby shower gift basket or mailed in a care package to an aspiring medical or nursing student. Homebirth in the Hospital will draw you in and open your eyes. . .

The culture at large has it wrong. We spend months and thousands of dollars on planning and carrying out our wedding and commitment ceremonies, but we place our birth stories in the hands of people and organizations we hardly know. If you really want a homebirth in the hospital, take the time to read Stacey's book.

Read the entire book review at www.scma.org/magazine/articles/?articleid=403.

To read more book reviews, go to www.delmeyer.net/PhysicianPatientBookshelf.htm.

To read book reviews topically, go to www.healthcarecom.net/bookrevs.htm.

* * * * *

10. Hippocrates & His Kin: Neighborly Kindness Is So Hard For The World To Understand

At a Conference in England, Colin Powell was asked by the Archbishop of Canterbury if "our plans for Iraq were just an example of empire building" by George Bush. He answered by saying, "Over the years, the United States has sent many of its fine young men and women into great peril to fight for freedom beyond our borders. The only amount of land we have ever asked for in return is enough to bury those that could not return."

The obvious is difficult for those too prejudiced to comprehend.

Printout of an Electronic Medical Record

Yesterday, I had a patient who was somewhat disoriented and unable to give a cohesive progression of his illness from the time he acquired it to the present. I did have a 95-page printout of his EMR. After reading through the entire 95 pages, the laboratory and drug lists were repeated more than a dozen times. However, I was unable to fine one reasonable medical history and physical examination on which to base my continuing care.

Ten doctors reprinting incomplete medical information does not make a Medical History.

Read more . . .

Dumb Aircraft Carriers

At a conference in France where a number of international engineers were taking part, participants included French and American. During a break, one of the French engineers came back into the room saying "Have you heard the latest dumb stunt Bush has done? He has sent an aircraft carrier to Indonesia to help the tsunami victims. What does he intended to do, bomb them?"

A Boeing engineer stood up and replied quietly: "Our carriers have three hospitals on board that can treat several hundred people; they are nuclear powered and can supply emergency electrical power to shore facilities; they have three cafeterias with the capacity to feed 23,000 people three meals a day; they can produce several thousand gallons of fresh water from sea water each day; and they carry half a dozen helicopters for use in transporting victims and injured to and from the flight deck.

   We have eleven such ships; how many does France have?"

Jealousy knows no bounds.

Why is English the International Language?

A U.S. Navy Admiral was attending a naval conference that included Admirals from the U.S., English, Canadian, Australian, and French Navies.

At a cocktail reception, he found himself standing with a large group of Officers that included personnel from most of those countries. Everyone was chatting away in English as they sipped their drinks. A French admiral complained that, whereas Europeans learn many languages, Americans learn only English. He then asked, "Why is it that we always have to speak English at these Conferences rather than French?"

Without hesitating, the American Admiral replied, "Maybe it's because the Brits, Canadians, Aussies and Americans arranged it so that YOU wouldn't have to speak German."

Maybe having the French speak German would have been a good idea?

To read more HHK . . .

To read more HMC . . .

* * * * *

11. Organizations Restoring Accountability in HealthCare, Government and Society:

• 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 month, read Health Care Spending Forecasts.

• 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 signup to receive their newsletters via email by clicking on the email tab or directly access their health care blog. Be sure to read Massachusetts "Universal" Health Care Spends $820 Million to Save $250 Million.

• 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 month, treat yourself to the Tenth Annual Government Performance Report.

• To read the rest of this column, please go to www.medicaltuesday.net/org.asp.

• 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. 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.

• 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 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 month, you might focus on Obama lacks Candor and Courage on Health Reform.

• Greg Scandlen, an expert in Health Savings Accounts (HSAs), has embarked on a new mission: Consumers for Health Care Choices (CHCC). Read the initial series of his newsletter, Consumers Power Reports. Become a member of CHCC, The voice of the health care consumer. Be sure to read Prescription for change: Employers, insurers, providers, and the government have all taken their turn at trying to fix American Health Care. Now it's the Consumers turn. Greg has joined the Heartland Institute, where current newsletters can be found.

• The Heartland Institute, www.heartland.org, Joseph Bast, President, publishes the Health Care News and the Heartlander. You may sign up for their health care email newsletter. Read the late Conrad F Meier on What is Free-Market Health Care?. This month, be sure to read and browse Overview: Health Care Policy and Freedom.

• 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. Be sure to read the current lesson on Economic Education: Government Motors: Redux.

• 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."

• 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 . . .

• 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, be sure to read GOVERNMENT STIMULUS PACKAGES ARE ATTEMPTS TO DENY REALITY.

• 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.

• The Heritage Foundation, www.heritage.org/, founded in 1973, is a research and educational institute whose mission was 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. However, since they supported the socialistic health plan instituted by Mitt Romney in Massachusetts, which is replaying the Medicare excessive increases in its first two years, they have lost site of their mission and we will no longer feature them as a freedom loving institution.

• 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. You may also log on to Lew's premier free-market site to read some of his lectures to medical groups. Learn how state medicine subsidizes illness or to find out why anyone would want to be an MD today.

• 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, articles and books at www.cato.org/people/cannon.html. Consider joining CATO University's summer program: "Economic Crisis, War, and the Rise of the State" will be held at the charming Rancho Bernardo Inn located just north of San Diego, from July 26-31. This summer, Cato University offers a one-of-a-kind opportunity to explore how the state has expanded during times of crises; the threats to liberty, privacy, and independence that have arisen as a result; and what can be done to restrain - or reverse - its growth.

• 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, wartime allows the federal government to 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 wartime, 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.

• 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 17^th 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. 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 Mark Steyn on Live Free or Die at www.hillsdale.edu/news/imprimis.asp. The last ten years of Imprimis are archived.

* * * * *

Thank you for joining the MedicalTuesday.Network and Have Your Friends Do the Same. If you receive this as an invitation, please go to www.medicaltuesday.net/Newsletter.asp, enter you email address and join the 10,000 members who receive this newsletter. If you are one of the 80,000 guests that surf our web sites, we thank you and invite you to join the email network on a regular basis by subscribing at the website above.

Please note that sections 1-4, 6, 8-9 are entirely attributable quotes and editorial comments are in brackets. Permission to reprint portions has been requested and may be pending with the understanding that the reader is referred back to the author's original site. Please also note: Articles that appear in MedicalTuesday may not reflect the opinion of the editorial staff.

ALSO NOTE: MedicalTuesday receives no government, foundation, or private funds. The entire cost of the website URLs, website posting, distribution, managing editor, email editor, and the research and writing is solely paid for and donated by the Founding Editor, while continuing his Pulmonary Practice, as a service to his patients, his profession, and in the public interest for his country.

Spammator Note: MedicalTuesday uses many standard medical terms considered forbidden by many spammators. We are not always able to avoid appropriate medical terminology in the abbreviated edition sent by e-newsletter. (The Web Edition is always complete.) As readers use new spammators with an increasing rejection rate, we are not always able to navigate around these palace guards. If you miss some editions of MedicalTuesday, you may want to check your spammator settings and make appropriate adjustments. To assure uninterrupted delivery, subscribe directly from the website rather than personal communication: www.medicaltuesday.net/newsletter.asp

Del Meyer

Del Meyer, MD, Editor & Founder

DelMeyer@MedicalTuesday.net

www.MedicalTuesday.net

6945 Fair Oaks Blvd, Ste A-2, Carmichael, CA 95608

Words of Wisdom

I don't think we can outsource to government the problem or joy of helping our fellow man. -Julie Meyer, CEO, Ariadne.

"There is no trick to being a humorist when you have the whole government working for you." -Will Rogers.

The bigger the State grows, the weaker the people become - big government creates dependency. -Julie Meyer, CEO, Ariadne.

"I don't make jokes. I just watch the government and report the facts." -Will Rogers.

Some Recent Postings

HOW DOCTORS THINK by Jerome Groopman, MD

WHY GOVERNMENT DOESN'T WORK by Harry Browne

DIETS DON'T WORK by Bob Schwartz, PhD

DOCTORING - The Nature of Primary Care Medicine by Eric J Cassell, MD.

In Memoriam

Sir John Maddox: The nature of Nature, Apr 23rd 2009 From The Economist print edition

The man who reinvented science journalism

WRITING any serious tribute to the science journalist and editor, Sir John Maddox, can only really start a long time after deadline, with the assistance of a cigarette and a glass of wine. Thus he famously began work on his editorials. Some were delivered so late that their first lines were being typeset before the last had been composed. But Sir John, who died on April 12th, was more than a hack with a little deadline difficulty. He was also a pioneer of modern science journalism.

In the course of transforming a parochial and withering publication called Nature into a globally influential scientific giant his instinct for publicity pushed science into British newspapers in a way that had not happened before. He also popularised [sic] the subject as a broadcaster on the BBC. And, perhaps most importantly, he trained a generation of writers who were seekers of scientific rationalism, but who never lost a sense of whimsy—and of whom several have sat in the science and technology office of The Economist. Scroll down to read more . . .

When Sir John (as he then wasn't) arrived at Nature in 1966, having worked for a decade at the Guardian, the doyen of British science journals was in the doldrums. Its offices were piled with several thousand yellowing manuscripts. That was quickly sorted out. He introduced a system of peer review (asking outside experts to assess a paper's scientific worth), as well as the stamping on each manuscript of the date of its submission. He wanted Nature to be more like a newspaper and to be judged, among other things, by how fast it published scientific news. Manuscripts were also edited—shock!—for style and comprehensibility, as well as accuracy.

Anxious to put in something newsy, he started writing leaders—introducing opinion among the facts. He also hired a real reporter to sit alongside the manuscript editors, a beginner called Nigel Hawkes, who would go on to become science editor of the Times. Mr Hawkes was the first, but not the last, of the Maddox protégés.

Think global. Act local

One reason for all this activity was that it was clear to him when he arrived that Nature was losing ground to its competitor—an American publication called Science. During the 1950s and 1960s a shift in scientific power from Europe to America was benefiting Science. According to Alun Anderson, a Maddox protégé who went on to edit New Scientist, Sir John responded by globalising the magazine, opening offices in America, Japan and, in due course, many other parts of the world.

Globalisation, of course, requires global news. But Sir John was equal to that. Henry Gee, another protégé, recalls a trick that Sir John called the "Afghanistan Effect". "You write a little news story that says that nothing much has happened in Afghanistan, and people think ‘Goodness! Nature has coverage of Afghanistan'."

He was also keen on embargoes, by which newspapers are given advance warning of the publication of a piece of research if they agree to delay writing about it until a given date, and make sure they mention the journal in which it is published. John Gribbin, a popular science author and yet another Maddox protégé, remembers the editor was particularly fierce about the embargo if he had an exciting paper. Sir John wanted Nature to make a splash with the story, and this caused friction with Fleet Street editors who wanted the scoop for themselves.

But he raised Nature's profile, and was not afraid to get his hands dirty with public relations. He also beat a path to the laboratory door in search of good material, a practice that continues to this day with Science, Nature, Cell and other top-rank journals competing to acquire papers from the world's leading researchers. . .

The result is that Nature today is an outlet for the world's best scientific news and gossip, and offers strident leadership on public issues. However, the craziest person in the building is no longer the editor, and staff need no longer feel obliged to restrain him, says Alun Anderson.

Although Nature is a more organised and professional place these days, there is still a trace of Maddox present. When your correspondent was a junior reporter at Nature several years after he had departed, she was advised that her first editorial was best written late in the evening with a glass of whisky to hand. Sir John may have left the building, but his spirit lingers on.

To read the rest of the story, go to www.economist.com/science/displaystory.cfm?story_id=13525812

On This Date in History - May 12

On this date in 1926, Roald Amundsen reached the North Pole in a dirigible.

On this date in 1949, the Soviet land blockade of West Berlin ended.

On this date in 1969, General Motors announced the end of the rear-engine Corvair.

On this date in 1978, the Commerce Department announced that hurricanes would no longer be named exclusively after women.

On this date in 1980, the first nonstop crossing of North America in a hot air balloon was made.

After Leonard and Thelma Spinrad

MOVIE EXPLAINING SOCIALIZED MEDICINE TO COUNTER MICHAEL MOORE's SiCKO

Logan Clements, a pro-liberty filmmaker in Los Angeles, seeks funding for a movie exposing the truth about socialized medicine. Clements is the former publisher of "American Venture" magazine who made news in 2005 for a property rights project against eminent domain called the "Lost Liberty Hotel."
For more information visit www.sickandsickermovie.com or email logan@freestarmovie.com.

MEDICAL TUESDAY . NET	NEWSLETTER
Community For Better Health Care	Vol VIII, No 3, May 12, 2009