MEDICAL TUESDAY . NET |
NEWSLETTER |
Community For Better Health Care |
Vol VIII, No 3, May 12, 2009 |
In This Issue:
1.
Featured Article:
The
Case Against the Electronic Medical Record
2.
In
the News: The Ultimate
Result of Cigarette Taxes: Smoke or Be Fined
3.
International Medicine: There is no Accountability in Government Health Care
4.
Medicare: To
Continue to Participate, Join The Electronic Medical Superhighway
5.
Medical Gluttony:
The Ultimate Gluttony - Big Government Medicine
6.
Medical Myths:
Health IT and the Other Myths of Reform
7.
Overheard in the Medical Staff Lounge: Taxes on Everything - Profession Services Next?
8.
Voices of Medicine: Is Medicine now a GO-TO Profession?
9.
The Bookshelf: Homebirth in The
Hospital, by Stacey Kerr,
MD
10.
Hippocrates
& His Kin:
Neighborly Kindness Is So Hard For The World To Understand
11.
Related Organizations: Restoring Accountability in HealthCare, Government and Society
Words of Wisdom,
Recent Postings, In Memoriam . . .
*
* * * *
The Annual World Health Care Congress, a market of ideas, co-sponsored by The Wall
Street Journal, is the most prestigious meeting of chief and senior
executives from all sectors of health care. Renowned authorities and
practitioners assemble to present recent results and to develop innovative
strategies that foster the creation of a cost-effective and accountable U.S.
health-care system. The extraordinary conference agenda includes compelling keynote
panel discussions, authoritative industry speakers, international best
practices, and recently released case-study data. The 3rd annual
conference was held April 17-19, 2006, in Washington, D.C. One of the regular
attendees told me that the first Congress was approximately 90 percent
pro-government medicine. The third year it was about half, indicating open
forums such as these are critically important. The 4th
Annual World Health Congress was held April 22-24, 2007, in
Washington, D.C. That year many of the world leaders in healthcare concluded
that top down reforming of health care, whether by government or insurance
carrier, is not and will not work. We have to get the physicians out of the
trenches because reform will require physician involvement. The
5th Annual World Health Care Congress was held April 21-23, 2008,
in Washington, D.C. Physicians were present on almost all the platforms and
panels. It was the industry leaders that gave the most innovated mechanisms to
bring health care spending under control. The
solution to our health care problems is emerging at this ambitious Congress.
The
6th Annual World Health Care Congress was held April 14-16, 2009,
in Washington, D.C. The
5th Annual World Health Care Congress – Europe 2009, will meet in Brussels, May 23-15, 2009. The 7th Annual
World Health Care Congress will be held April 12-14, 2010 in Washington
D.C. For more information, visit www.worldcongress.com.
The future is occurring NOW.
To read our reports of the
2008 Congress, please go to the archives at www.medicaltuesday.net/archives.asp
and click on June 10, 2008 and July 15, 2008 Newsletters.
*
* * * *
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
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.
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.
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
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 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 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? . . .
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. . .
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.
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. . .
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.
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?
*
* * * *
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 17th
or lose federal funds, Hillsdale students take a semester-long course on the
Constitution restoring civics education and developing a civics textbook, a
Constitution Reader. You may log on at www.hillsdale.edu to register for the annual weeklong von Mises Seminars,
held every February, or their famous Shavano Institute. 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.
* * * * *
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Del Meyer, MD, Editor & Founder
6945 Fair Oaks Blvd, Ste A-2, Carmichael, CA 95608
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.
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.
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.