1. Featured Article: The YouTube Cure: How Social Media Shapes Medical Practice

Popular demand for an unproved surgical treatment for multiple sclerosis shows the growing power of social media to shape medical practice—for good and ill

By Katie Moisse | Scientific American | February 8, 2011 | 23

When vascular surgeon Paolo Zamboni reported in December 2009 that inflating a tiny balloon inside twisted veins in the neck provided relief from multiple sclerosis, he created quite a stir. The idea that surgically straightening crooked veins could somehow benefit a degenerative nerve problem was astounding. Physicians were skeptical. Zamboni himself concluded that his findings should be subjected to more rigorous testing. Regardless, many people with MS, which affects at least 250,000 people in the U.S., immediately began clamoring for the unproved treatment. Their demands, amplified through a wide range of social-networking platforms, soon proved impossible to resist. In the past year, for instance, hospitals in California, New York, Italy and Poland have offered the Zamboni treatment—at a cost of $10,000 or more because it is not covered by insurance.

Doctors found themselves playing catch-up every step of the way. Even before Zamboni published his results in the Journal of Vascular Surgery, a post on PatientsLikeMe.com (an online patient community) boasted news of his research, useful links and a dedicated Facebook URL. Community networks traded contact information detailing who would offer the procedure and where. Before-and-after videos were posted on YouTube. Like AIDS activists of 30 years ago but armed with much more powerful communications tools, patients challenged researchers and medical centers to explain why it was taking so long to offer Zamboni’s approach. Yet most MS experts believe that undergoing the procedure at the moment is a very risky proposition. . .

A Dangerous Game
In the case of Zamboni’s work, it is easy to see how patients might be tempted to jump the gun and seek a treatment that initially sounds exciting. After all, the study findings came from a reputable surgeon (though not an MS researcher) publishing in a respected journal. As Daniel Simon, an interventional radiologist in Edison, N.J., says of the work: “It wasn’t Bob’s Journal of MS and Autobody Repair; it was the premier journal of vascular surgery.” . . .

In the case of MS, as with some other disorders, the difficulty of knowing whether a treatment that seemed to work really did have an effect in a study is compounded by the erratic nature of the disease. The most common form—relapse-remitting MS—has a variable course marked by flare-ups amid symptom-free periods. So it is difficult to know if a certain treatment actually works or was simply taken during a naturally occurring remission. Patients taking placebo have often reported substantial improvements, according to Mount Sinai’s Miller. . .

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2. In the News: The Costly Bureaucracy of Medical Board Certification

Mature Physicians May Quit Rather than Recertify , JAPS, June 7, 2011

While most physicians are genuinely dedicated to constantly improving their skills, increasingly costly bureaucratic demands for recertification may cause many to say “Enough!” just as baby boomers retire and a physician shortage looms.

In the past, board certification was for life, after years of intensive training. For younger physicians, however, the certificate comes with an expiration date. Self-appointed expert committees of specialty organizations are now prescribing more and more requirements that force physicians to spend thousands of dollars and take big chunks of time away from their families and their practices.

In the era of “evidence-based medicine,” these exercises are exempt from any requirement to show that they improve medical care in any way.

Orthopaedic surgeon Lee Hieb, M.D., current president of the Association of American Physicians and Surgeons (AAPS), writes that she had to spend time studying theory of joint replacements, which she never does, instead of focusing on spine surgery, her specialty. Then she needed to hire a lawyer because bureaucrats were refusing to allow her to sit for the examination—for lack of a signature sheet on her application.

“Recertification has become a cottage industry of bureaucrats and testing agencies, dragging with them a few university physicians,” she writes, in the summer 2011 issue of the Journal of American Physicians and Surgeons. www.jpands.org/vol16no2/hieb.pdf

While hospitals all over the country can’t find orthopaedic surgeons to take trauma call, the time of practicing surgeons is being wasted. “Growing numbers of physicians are planning to choose retirement a year or two early rather than recertify,” Hieb observes.

In the same issue of the Journal, Martin Dubravec, M.D., calls board certification/recertification/maintenance of certification “a malignant growth.” www.jpands.org/vol16no2/dubravec.pdf It has become a multi-million dollar industry with no proven benefit to patients. . .

Many physicians are choosing not to recertify. According to the American Board of Internal Medicine, 23 percent of general internists and 40 percent of subspecialists are not renewing their internal medicine certification. “This number will most likely increase as these processes become more expensive and more time-consuming, and continue not to reflect clinical practice,” Dubravec writes.

Some of these bureaucratic agencies are working toward the goal of forcing physicians to recertify to maintain their medical licenses.

A 2009 survey of AAPS members, www.jpands.org/vol14no1/orient.pdf, showed that only 30 percent thought the process of recertification had improved their performance as physicians, and only 22 percent would voluntarily do it again.

“We cannot afford to drive our most seasoned, experienced physicians into early retirement,” stated AAPS executive director Jane M. Orient, M.D. “They simply cannot be replaced.”

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3. International Medicine:

Americans are assuming reform that Russia has already abandoned.

Soviet Economist Warns of Age Discrimination, Quality Lost in “Healthcare Reform”

AAPS, June 10, 2011

The incentives that are an essential part of recently passed healthcare reform have been tried many times before, always with the same result, warns economist Yuri Maltsev, Ph.D., in the summer 2011 issue of the Journal of American Physicians and Surgeons (www.jpands.org/vol16no2/maltsev.pdf) and in a presentation to AAPS members in Omaha last month.

Before defecting to the West, Maltsev was a member of a senior Soviet economics team that worked on President Gorbachev's reform package under perestroika.

The Soviet system looked good on paper, employing plan indicators to indicate hospital performance, Maltsev observes. Statistics such as infant mortality were misleading, however, and actual quality was appalling. In Russia, patients over the age of 60 were considered worthless parasites, and those over 70 were often denied even routine care unless they were members of the elite class.

"Age discrimination is very apparent in all government-run or heavily regulated medical systems," Maltsev writes. It has not yet taken hold in the U.S. because the elderly vote in large numbers. But Americans are insidiously being prepared for it by the architects of Obama's plan, he notes.

In Russia, the trend is toward privatization, while "Obama suggested a system that we can rightly define as communist or socialist," states Maltsev, quoting Oleg Kulikov, a member of the Russian Duma (parliament). Kulikov also remarked that "they [Americans] are assuming positions that we've abandoned."

While Marxist ideas perpetuate hatred and envy, blaming those who are better off for societal miseries, the real problem is socialist ideology. Socialists "ignored the fact that nobody puts forth effort without reward," Maltsev states. Apathy resulting from lack of any incentive to excel resulted in widespread corruption and extensive loss of life.

The crisis of the socialist welfare state throughout Europe is triggering calls for privatization as a critical feature of a more efficient and more humane system.

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Government does not give timely access to quality healthcare, it only gives access to corruption.

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4. Medicare: America has changed its course, perhaps forever

Welcome to Europe - Commentary by Pete du Pont - The Wall Street Journal, March 25, 2010

Late Sunday night America made its largest public-policy course change since the 1930s: Congress moved 17% of our national economy from the market place to full regulation and control by the federal government. The vote in the House was close, 219-212, but our country's health care system will now be organized, operated and regulated by the federal government.

Tens of thousands of new employees, supervisors and investigators will be in charge of our health-care system's day-to-day operations. And the Heritage Foundation estimates the original Senate bill will retard economic growth to the tune of 620,000 lost jobs.

Add to that the new income-tax increases that will soon be with us. The Bush tax-rate reductions expire at the end of this year, so that the top personal income tax rate will go from 35% to 39.6% and the dividend and capital gains tax rates will rise from 15% to 20%.

Then will come the ObamaCare tax increases. There will be a new 3.8% Medicare tax increase on investment incomes--interest, dividends, capital gains, annuities, royalties and rents--for individuals with annual adjusted gross incomes over $200,000. Those increased rates are estimated to reduce disposable income by $17.3 billion a year. A second Medicare tax increase will take 0.9% of upper-income workers' earnings.

Soon the government will fully regulate health care. As The Wall Street Journal pointed out last weekend, "ObamaCare is really about who commands the country's medical resources. It vastly accelerates the march towards a totally state driven system . . . [and] government rationing will become inevitable [while] . . . doctors, hospitals, and insurance companies will over time become public utilities." Even worse, the government will begin to decide "what kind of treatment options patients are allowed to receive."

And a Republican House Ways and Means Committee report estimated that 16,500 IRS agents will be employed to make sure that people sign up--and pay for--the health insurance they will be forced to purchase.

Consider the impact these policies will have on our country and all of us.

First, tax rates will continue to increase for most everyone as the federal government needs more revenue to cover ever-expanding expenditures. . .

Second, our national debt will continue to mount. From about 1970 to 2008, the U.S. government debt was between 33% and 69% of GDP. The Obama administration projects the national debt will increase to 100% by 2012 . . .

Third, the federal government's massive interventions, from the General Motors bailout to a prospective cap-and-trade policy, command and control of national health care, and the large increases in the size and scope of government, will slow our growth and depress our economy even more.

Finally there comes the growing loss of trust in America's government. We have seen the national disbelief in the huge government expansions, spending and control over our society.

As a result . . . the Europeanization of America is coming to pass, for individual choice and opportunity are being replaced by statism.

Contrast this new American policy direction with our country's history, and it leads to an even worse conclusion. We held our country together in the Civil War, fought two wars in Europe to keep its nations free, won the Cold War, survived the social upheavals of the 1960s and the economic challenges of the '70s, and built a greatly expanded American economy and opportunities in the 1980s.

But now, for the first time in our history, we are becoming just another European nation, with bigger government, higher taxes, more regulation of almost everything, and the basic public-policy preference that the government, not we the people, should be in charge of the nation's choices.

So America has indeed changed, perhaps forever, as the White House and brazen congressional leadership nationalized 17% of our economy, replacing individual choices with governmental regulation. The sunset of the American belief in economic growth and individual choice and responsibility is now with us. If we do not change our course, that will be a shame.

www.ncpa.org/commentaries/welcome-to-europe-the-wall-street-journal
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Government is not the solution to our problems, government is the problem.

- Ronald Reagan

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5. Medical Gluttony: The Private vs Public Welfare System

Our pulmonary practice has always accepted a ten percent welfare or Medicaid load. These patients have accommodated well with private patients who keep appointments, follow up with recommended laboratory tests and x-rays and return afterwards to discuss the laboratory or test data. They are pleasure to work with and fit in well with our combined private and managed care practice.

Now the Obama administration is trying to phase out fee for service (FFS) Medicaid and place them into the Medicaid HMO scheme of things. We were assigned about 50 of these patients, which we thought was reasonable with our established 1,000 patient population. However, out costs have skyrocketed. This new generation of welfare patients does not work, yet all have cell phones and call our office day and night. Even if no one is there, they leave lengthy messages with some even trying to give their long medical history. Whereas, we formerly had zero to three messages on the phone in the morning, we now have as many as 45. It is no longer a five-minute chore to process these messages but a three-hour process. At a staffing rate of $25 an hour, this adds up to an extra $300 a week or could add up to $15,000 a year in extra expenses for patients that don’t pay and for which the state pays about 20¢ on a dollar.

These patients are very demanding. Most have had a number of doctors, numerous tests, and can’t remember the doctor’s names, so previous records are essentially unavailable. On occasion we have researched their past medical history and acquired their prior records only to find a large number of tests and x-rays have already been done. The patient frequently denies this or brushes it off and says, “My doctor never told me about these tests, or x-rays.” Occasionally we have tried to point out that these are large cost procedures. These patients do not recognize costs if it doesn’t affect their personal pocketbook. Hence, even the mention of their gluttony will bring about an administrative review that assumes patients should not have to worry about costs and it is against their civil rights to bring this up.

The taking of a medical history is also a struggle. Perhaps they have never had a medical history taken before. A simple exploration of their childhood diseases may take ten minutes instead of ten seconds to just say Chicken Pox and Measles. The same can be said about their surgical history. It’s amazing how many of these patients can’t remember what operations they have had. The same can be said about their medications. In this era of large numbers of medication interactions, an accurate list of medications is critical. Not to obtain this could in some instances be considered malpractice if a serious adverse reaction should occur. Private patients generally bring in a list of their medications, the diseases and operations they’ve had.

Another problem is the large number of these new welfare patients that are on narcotics. Many cannot describe any injury to their back or neck but state it came on suddenly while in bed or in a chair. Life may be painful, but there are no double blind studies to confirm that narcotics make it less painful. One patient requested eight narcotic pills a day or 720 for a three-months supply. When I mentioned that 90 was my maximum a month, I asked if he had any other physician that did not fill that many. He stated that he had. It took him three months one time to find another physician. When asked, “How was your pain during those three months without any pain or narcotic pills?” He replied, “About the same.” The California Legislature passed a law that physicians can be prosecuted for not relieving pain. But these medical illiterates are unable to understand that there are many pains not conducted through pain fibers, and there is not a medication that will relieve such a pain.

What’s the answer to this Medical Gluttony?

I trained in a county hospital where the poor people gathered every day or night. Much of this was social on their part. But there was one medical record for all the welfare patients in the county or city. This record contained all their medications, there past medical history, their operations, and high quality care could be administered in a standard brief office visit. A new doctor at the next visit could not be manipulated into excessive tests or x-rays because the last reports were in front of the doctor in the only chart the patient had. The patient always received superior but lean efficient care without Medicare, Medicaid or other insurance company’s expensive overview. Government intrusion is always expensive and less effective.

When Congress decided that all people should be covered through Medicare and Medicaid, the state, county and city hospitals all evolved into private or university structures. Wayne County General Hospital in Michigan, a 500-bed hospital in which I was the first class of interns in 1962, was demolished for lack of a new function in the 1980s. The building was in excellent shape and still looking like new. In 1966, with the advent of Medicare and Medicaid, the 6800-bed ambulatory, infirmary and psychiatric patients were all transferred into private facilities to remove the stigma of second class care. This was unfortunate. There are a number of attempts today to move many of these patients back into such care centers to improve their level of care. Their social-economic standing just never fit in with private first class care. In retrospect, it appears that the city and county hospitals provided the best care for them. The medical staff was first rate consisting primarily of university faculty with their residents and interns providing university level care as well as private practice volunteers. Now that’s a price hard to beat.

This was another example of the medical illiterate in Congress determining what the best care is for a group of patients.

Now we not only have the Medical Illiterate in Congress projecting the care in the US for the next century, we have a Medically Illiterate president who is leading healthcare in a downward spiral. It is not likely that anyone writing history fifty or a hundred years from now will really understand what happened in the first two decades of the century.

The Private Welfare System didn’t work out so well.
Maybe we should move forward to the place we’ve been:
The City and County Hospital Public Welfare System.

The university hospital, along with the affiliated city-county and VA hospitals,
provided the best combination of patient with which to train the next generation of doctors.

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Medical Gluttony thrives in the Private Welfare Systems.

It Disappears with the City-County Hospital Public Welfare System.

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6. Medical Myths: Missed Appointments Save Money

With the new onslaught of Private Welfare patients, the office has taken on new characteristics. Although we always had about a ten percent volume of Medicaid patients, the recent push to put FFS Medicaid patients into private managed care has changed the structure of our office significantly. We were given fifty such patients to mesh in with our private and managed care patients. Before, we had a rather sophisticated private practice where patients showed up for appointments, followed directions, took their medications, and obtained the requested x-rays and lab work. Now, we have a 30 percent volume of missed appointments, and non compliance in obtaining their x-rays or related lab work to continue an appropriate discussion of their medical problems.

These welfare patients who have been shoved into the private world of healthcare do not see missed appointments as anything more than saving health care dollars. No show = no cost, or so they reason.

Discussions of the cost of paying staff, rent and utilities without an income is not understood as anything serious. At least not something about which they are concerned.

On a few occasions when the subject is raised, it is met with hostility that the patient should not be made aware of any shortcomings. It’s becoming a civil rights issue—legally hazardous to even mention.

When health care becomes a civil right, it will no longer be beneficial healthcare.

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Medical Myths originate when someone else pays the medical bills.

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

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7. Overheard in the Medical Staff Lounge: The High Cost of Health Care

Dr. Rosen: What do you think is the primary cost of health care inflation?

Dr. Sam: Government bureaucracy increases costs.

Dr. Ruth: How’s that?

Dr. Sam: I must spend six or eight hours a week just doing forms and letters to traverse the system.

Dr. Dave: Government Mandates increase the costs.

Dr. Paul: How do you figure? Government mandates just tell you how you must proceed. There are no reports.

Dr. Dave: But telling you how you must proceed is not efficient and takes extra time. Isn’t time, money?

Dr. Edwards: Patients and their unrealistic demands increase health care costs.

Dr. Michelle: I can see that. I have a hard time not giving in to patient demands. It damages my HMO Profile.

Dr. Edwards: Maybe you’re too afraid of losing them as patients.

Dr. Michelle: Yes, sometimes it hurts when a patient leaves. It makes me feel like I’m a failure.

Dr. Milton: Peer review increases costs. If you lose your license you lose the money that paid for eight to twelve years of medical training. And you’re left with no career to pay your mortgage and your children’s education. I was called up once and nearly lost my hospital privileges. If I didn’t have major friends around the country that reviewed every chart and found that I provided excellent care, I might not be practicing today. So I spend an extra 30 minutes on every new patient typing up an excellent medical record. It far exceeds what I see out there from other doctor’s offices. I’m so afraid that if I get caught with less than the best medical history and physical write up, I might get called down again. It messes up my day off and Saturdays to get caught up. In addition every Peer Review letter costs about $5,000 in lost time, legal fees, and harassment to clean up the threats to my license. The Japanese call this MUDDA, interference with efficient services.

Dr. Rosen: I think the studies have well established that it frequently is the best doctors that get reviewed and are forced out of the system. The government provided an easy way to eliminate competition in the medical staff. This is another unintended consequence or unfortunate outcome of government interference in Medical Practice.

Dr. Joseph: Every time I come here for lunch, I’m so thankful I retired from my surgical practice. I don’t see how or even why you folks tolerate this hostility and threats to survival? I don’t see how I could do surgery today with this hostile environment. To keep looking behind me all the time is how surgeons nick the aorta. One has to keep their eye on the surgical field, not their colleagues.

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The Staff Lounge Is Where Unfiltered Opinions Are Heard.

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8. Voices of Medicine: A Review of Regional Medical Journals: Drug Expiration Dates

Bulletin of the Humboldt-Del Norte County Medical Society, February 2011

IN MY OPINION BY SCOTT SATTLER, MD

The Drug Expiration Date: A Costly Illusion

Recently I noticed that the label on my prescription carried a new warning. Somewhere along the way the old “Good Until” had been replaced by the much more ominous words “Do Not Use After”, and it set me thinking. What’s with this drug expiration business anyway? Who determines the magic moment when a medication goes from being perfectly fine and dependable to being so potentially dangerous or useless that it needs to be discarded for reasons of health and safety? How are such determinations made? What does the phrase “drug expiration date” really signify?

I decided to call my friendly local pharmaceutical rep for more information. He referred me to a fellow rep who gave me his company’s physician access line for such queries. I called and asked them these questions, and they told me that someone higher-up would get back to me. A while later I got a call from a woman who quickly informed me that our conversation would be recorded and asked if that were OK with me. When I assured her it was, she told me (as best as I can recall, for I didn’t record the conversation) that each pharmaceutical company is responsible for setting the date for each batch of medicine it produces, by order of the FDA. I asked about the process involved in determining the date, and was told that the process involved proving that the drug would still be good on the date stamped on the batch. I asked whether it was good after that date as well, and she repeated that it was good on the date indicated. I asked if this date actually defined the time when the drug had been shown to become unstable and/or unsafe, and she again affirmed that the drug was safe up to the time of its expiration date. At some point the conversation became more circuitous than I could follow, and I asked if she would kindly fax or email me the information I sought. To my surprise, she told me that she had been instructed very clearly by her supervisors that she was to send nothing to me in writing pertinent to this conversation. Our information exchange was to be absolutely verbal only. Since this was a pretty good conversation stopper, it was clear that I needed to look elsewhere. Thank God for Google.

The FDA Regulations

In 1979 the FDA passed a law requiring that drug products bear an “expiration date” which was to be supported by appropriate stability data. But despite the use of the word “expire,” as in “die,” the FDA did not actually require drug manufacturers to determine how long a given medication remained safe and effective.

Instead it allowed and continues to allow companies to choose an arbitrary date and to perform tests demonstrating the drug’s safety and efficacy as of that selected date. Interestingly, the 1985 federal regulations recommended that “stability testing be performed initially, than every three months for the first year, then every six months for the second year, and then annually thereafter. However, more frequent testing near the end of the anticipated expiration date is often likely to give better information about the actual stability of the finished product. Nonetheless, testing at least annually is considered minimal for compliance with CGMPs [Current Good Manufacturing Practices].” ¹ I find it fascinating that this specific requirement for prolonged ongoing stability testing to determine a drug’s true expiration date no longer exists.² Clearly the term “drug expiration date” has become a misrepresentation of reality, an obfuscating misnomer. What the FDA currently allows to pass for an “expiration” date is, in truth, a “good at least until” date.

The Wall Street Journal Weighs In

Let us jump to March 28, 2000. On this date Laurie P. Cohen, a Pulitzer Prize winning investigative journalist working for the WSJ published a feature story on just this subject.³ Much of the following information is taken from that article. She reported that in 1985 the Air Force had become very concerned about the costs needed to destroy and replace their worldwide multimillion-dollar stockpile of medications every two to three years. They asked the FDA to check 58 different pharmaceuticals to determine which, if any, might be safely used beyond their expiration date. After testing, the FDA extended more than 80% of the 137 expired lots, by an average of 33 months. More than half of the drugs studied in 1985 were still safe and potent when they were retested yet again in 1992. Some remained stable for 15 years post-expiration. They reportedly saved 59 times the cost of the drug testing in this first year alone by avoiding destruction of perfectly good medications.

The DOD-FDA Shelf Life Extension Program (SLEP)

The Department of Defense was so interested in these findings (it was holding over $1 billion in medication reserves) that it invested nearly $3.9 Million from 1993 through 1998 to do further stability testing on an expanded group of over 100 pharmaceuticals. During this five year period they found that 88% of tested medications were clearly safe and effective far past their original expiration date and the DOD saved more than $263Million on drug replacement expenses. They named this program SLEP, the Shelf Life Extension Program⁴, and it continues to this day. The FDA administers it for the Army, Navy, Air Force, Marines and Coast Guard. It probably contains the most extensive source of pharmaceutical stability data in the world. Unfortunately, full access to this huge database appears to be restricted to the military branches listed above. My research to date indicates that this restriction specifically excludes sharing data with the US Public Health Service and, as you can see, the general public.

Francis Flaherty, pharmacist and former director of this FDA testing program, concluded that expiration dates have essentially no bearing on whether or not a drug is usable for a longer period, and that the stated expiration date does not mean or even imply that a given drug will stop being effective or become harmful after that date. He went on to share his perception that, “Manufacturers put expiration dates on for marketing, rather than scientific, reasons.” Flaherty retired from the FDA in 1999. . .

This topic will be continued in next month’s In My Opinion editorial that will hopefully present more information as to specific drug stabilities and instabilities found through the SLEP research and posit thoughts as to how the SLEP database might be used to significantly reduce the overall cost of healthcare, if Congress wishes to do so.

1. Title 21 Code of Federal Regulations: (21CFR 211.166) 10/18/85 Stability Testing: Number 41, Section B-3: Test intervals

2. Title 21 Code of Federal Regulations: (21CFR 211.166) 04/2010 Stability Testing: Chapter I, Subchapter C

3. Cohen LP. “Many medicines prove potent for years past their expiration dates.” Wall Street Journal. March 28, 2000. http://www.terrierman.com/antibiotics-WSJ.htm

4. Garamone J. “Program extends drug shelf-life.” American Forces Press Service. March 29, 2000

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VOM Is an Insider's View of What Doctors are Thinking, Saying and Writing about

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9. Book Review: Sonoma Medicine, Spring 2011

CURRENT BOOKS: An Interest in the Future, By Bob Schultz, MD

The Story of Dr. Sidney R. Garfield
by Tom Debley and Jon Stewart,
148 pages, Permanente Press, $20.

Churchill, Lincoln, Shackleton—all [are] people who accomplished great things under incredibly difficult circumstances. I am drawn to stories like these, and that is why I was delighted to find that Tom Debley and Jon Stewart have written a book focusing on the life and accomplishments of Dr. Sidney Garfield. Debley is director of Heritage Resources for Kaiser Permanente, and Stewart is a director of communications.

Garfield worked in partnership with Henry Kaiser, the noted industrialist, to provide health care for employees (and their families) working on three of Kaiser’s major construction projects during the 1930s and 40s: the California Aqueduct, the Grand Coulee Dam, and the Richmond Shipyards. During these projects, Garfield developed a system for delivering health care that was to become Kaiser Permanente, the largest nonprofit health care delivery system in the world.

Henry Kaiser was a larger-than-life figure who frequently overshadows his physician partner. Debley and Stewart try to rectify this situation by focusing on the contributions of Garfield, a true visionary who deserves recognition in his own right. . .

Garfield got his bachelor’s degree from the University of Southern California in 1924 and his MD from the University of Iowa in 1928. After an internship at Michael Reese Hospital in Chicago, he returned to USC, where he completed his surgery residency in 1933.

The situation was bleak at that time, and opportunities for new physicians were rare. Garfield learned that 5,000 men were working on the California Aqueduct in the Mojave Desert. With a loan from his father, he built a small but fully equipped hospital—Contractors General Hospital—near the town of Desert Center to care for any injured workers.

Garfield received fee-for-service payments from insurance companies for work-related injuries. Two problems quickly arose. First, the insurance companies were slow to pay and frequently discounted the amount paid. Second, Garfield treated workers for a wide variety of non-work-related illnesses, and most of the workers were unable to pay for these services. These two factors combined to drive Garfield near bankruptcy.

At this point, insurance executives involved with the aqueduct realized they would have a serious problem if Garfield was not there to provide services for the workers. They approached him and offered a novel idea: prepayment. They would pay Garfield a nickel a day to take care of industrial injuries. Garfield made a few calculations and agreed to try it. With a steady income, he was able to meet payroll and make ends meet.

Garfield subsequently realized that for another nickel a day he could provide complete health care to the workers. When offered this choice, 95% signed up, creating the first pillar of Kaiser Permanente: prepayment.

If workers stayed healthy, Garfield further reasoned, they would be better off, and he would make more money. This relationship fostered an alignment between doctor and patient. Thus, the second pillar of Kaiser Permanente came into being: intense focus on keeping patients healthy. . .

After the aqueduct was finished, Garfield planned to go into private practice in Los Angeles—but Henry Kaiser had other plans for him. Henry was building the Grand Coulee Dam in Washington state and needed medical care for his workers and their families. Garfield reluctantly agreed to visit the construction site.

Once there, Garfield saw a larger hospital and realized he could implement the third pillar of Kaiser Permanente: group practice. As a surgery resident, he had enjoyed the environment in the LA County Hospital. All the colleagues he needed for consultation and help were under one roof. Garfield decided to duplicate that environment at Grand Coulee. He recruited colleagues and successfully delivered medical care to the workers and their families using the three pillars of Permanente medicine: prepayment, prevention and group practice. . .

To read the rest of this book review, go to Sonoma Medicine . . .

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The Book Review Section Is an Insider’s View of What Doctors are Reading about.

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10. Hippocrates & His Kin: Public Pensions are a Black Hole for taxpayers

Dale Kasler reports in the Sacramento Bee that California’s two statewide retirement systems earned a combined $66 billion on their investments in the past year – but still can’t shake criticism that public pensions are a black hole for taxpayers. . . Both are underfunded and are only able to pay 70% of their retirement obligations.

Why worry if you have access to the taxpayers’ purse and bank accounts?

Is the Higher Education Bubble About to Burst?

Between 1975 and 2008 the number of faculty in the California State University system rose by 3 percent; during those same years the number of administrators rose 221 percent.

Subsidies create incentives for what economists call rent-seeking behavior.

Providers of supposedly beneficial goods or services try to sop up as much of the subsidy money as they can. . .

After all, their customers are paying with money supplied by the government—bubble money, as it turns out. And sooner or later bubbles burst. –Washington Examiner

Let’s Hope So

Managing Hypertension without measuring the BP?

One of my patients was transferred from a nursing facility to a memory facility. On making a visit, I was informed that the facility had no BP cuffs or thermometers because it was against California State Law. But my patient had hypertension and was taking medications. I was asked to just renew her BP medications and they would inform me of anything adverse.

I received a call from the facility the following week that she refused to take her BP medications and could I give them a verbal order to hold them every time she declined. But how do we determine if her BP rises, I asked?

The nurse suggested that every time I needed to know the BP, they would have the hospital home care nurse do a visit and measure it. The last time I saw the charges for a home health care nurse to make a visit, Medicare paid the hospital twice what they paid me “because the hospital had to pay for the nurse’s car mileage.”

Ever wonder why it’s so costly to work around government mandates?

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Hippocrates and His Kin / Hippocrates Modern Colleagues
The Challenges of Yesteryear, Yesterday, Today & Tomorrow

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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 their suggestions for the number one domestic policy of our time: Health care. The three biggest problems in health care are rising costs, inadequate qualeity and incomplete access to care. To address these problems, the NCPA has developed private sector, free enterprise solutions to empower patients, liberate doctors and encourage competition in the medical marketplace.

• 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. July 31, 2011 would have been Milton Friedman’s 99th birthday. Now, more than ever, we need his vision. To honor the impact he has had on our society, and to help clarify his moral framework for freedom and free enterprise, we will celebrate the Friedman Legacy for Freedom in partnership with the Foundation for Educational Choice.

• 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, and 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, to understand the real issues on taxes, explore their research on taxes and revenue: As Congress and the administration debate the need for tax increases in the debt deal, economist and Mercatus scholar Antony Davies shows that historically, altering the top marginal income tax rate has had no effect on tax revenue as a fraction of GDP. The same is true for the average marginal tax rate, Social Security and Medicare tax rates, the effective corporate tax rate, and the capital gains tax rate. The following series of charts ilustrates these relationships:

• 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 her new book:

• Why ObamaCare Is Wrong for America.

• 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 Consumers for Health Care Choices, a project of The Heartland Institute, seeks to preserve individual freedom, improve the quality of health care, and improve the efficiency of America’s health care system. The best way to do this is by empowering individuals by giving them more control over the dollars spent on their behalf. We believe Obamacare moves the nation in just the opposite direction, and therefore ought to be repealed and replaced. Read more . . .

• The Foundation for Economic Education, www.fee.org, has been publishing The Freeman - Ideas On Liberty, Freedom's Magazine, for over 50 years, with Lawrence W Reed, 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 from Freedom University which offers an introductory, interdisciplinary, comprehensive overview of the workings of a free society. The Austrian approach to economic theory, including Mises and Hayek, will be emphasized. Topics range from the history of money and inflation to the current economic climate and healthcare. Read more . . .

• 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: Some are advancing the idea that President Obama can raise the debt ceiling all by himself. Professor Rob Natelson does not agree. Here he presents the constitutional case against the President's power to pull the purse strings. Read more . . .

• Martin Masse, Director of Publications at the Montreal Economic Institute, is the publisher of the webzine: Le Quebecois Libre. Please log on at www.quebecoislibre.org/apmasse.htm to review his free-market based articles, some of which will allow you to brush up on your French. You may also register to receive copies of their webzine on a regular basis. This month, read: Private capital is the key to economic growth and new jobs. But we cannot create jobs if we demonize profits, punish risk-taking capitalists, and stay hostile to foreign investment. Read more . . .

• 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. -- 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, and was used by some as a justification for the Obama plan, they have lost sight of their mission and we will no longer feature them as a freedom loving institution and have canceled our contributions. We would also caution that should Mitt Romney ever run for National office again, he would be dangerous in the cause of freedom in health care. The WSJ paints him as being to the left of Barrack Hussein Obama. We would also advise Steve Forbes to disassociate himself from this 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.

• 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 The Crisis of the European Union: Causes and Significance at www.hillsdale.edu/news/imprimis.asp. The last ten years of Imprimis are archived.

• The Kirby Center: Welcome from Dr. Larry Arnn

The Allan P. Kirby, Jr. Center for Constitutional Studies and Citizenship is a project of Hillsdale College. The purpose of the Kirby Center is to teach the Constitution, the debate that brought it to life, and the principles that give it meaning. As such, the Kirby Center does in Washington, D.C., and throughout the nation, what the College has been doing without fail since its 1844 founding.

Through the study of original source documents from American history and the history of Western thought, the Kirby Center seeks to inspire a generation of men and women who place the Constitution at the heart of their careers and their policies, and whose work is grounded in real knowledge of that document and its ways.

This is a large task. It is a task particularly suited to the purposes and abilities of Hillsdale College. From its founding before the Civil War, it has taught all of its students and also multitudes of its fellow citizens the principles and ideas upon which the Constitution is built and according to which it must operate.

The worth of the Kirby Center project can be discovered both in the example of the Founding Fathers and in the example of those who have sought most effectively to undo their work. Both of them began in learning. Both of them spread their message by teaching. Both of them looked to education, and the kind of statesmanship it inspires, to make their gains long lasting.

The American Founders emphasized an education for citizens. It was one of self-government, about the knowledge of and ability to defend the principles of the Declaration of Independence and the Constitution.

The Progressives, now in ascendance in Washington, emphasized an education for experts. It began with the work of a few academics. Studying German historicism, Woodrow Wilson and other Progressive leaders came to believe that the Declaration of Independence was "obsolete." Through three generations of teaching, they have built a now-powerful movement whose goals are at odds with the purpose of the Founders.

For this reason, unfamiliarity with the Constitution and its initial claims is now a problem, especially among those who lead our nation. The urgent task is simply to recover knowledge that is lost. Both the Founders and the Progressives advanced propositions that are testable by reason and can be compared with real facts in the world. This is an exciting task that must be undertaken fairly and openly.

Abraham Lincoln called for a "return to the fountain whose waters spring close by the blood of the Revolution." Hillsdale College was very much enrolled in the cause of Lincoln in his day. It continues in that cause today.

Larry P. Arnn

President, Hillsdale College

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Words of Wisdom

The basic ideas of the American Creed—equality, liberty, individualism, constitutionalism, democracy—clearly do not constitute a systematic ideology, and they do not necessarily have any logical consistency. At some point, liberty and equality may clash, individualism may run counter to constitutionalism, and democracy or majority rule may infringe on both. Precisely because it is not an intellectualized ideology, the American Creed can live with such inconsistencies. –Samuel Phillips Huntington, American Politics, 1981.

The objective of the liberals is to destroy this country." - Herman Cain

"I refer to the debt — the new red menace. This time consisting of ink." - Mitch Daniels.

"[Obama's reelection] would subject the country to what might be a fatal last dose of statism." - Mitch Daniels.

"Our fiscal ruin and resulting loss of world leadership will, in [liberals'] eyes, be not a tragic event but a desirable one." - Mitch Daniels.

"Our liberties, which have made us great, are now destroying us." - Rev. Michel Faulkner, at the CPAC "Traditional Marriage and Society" panel.

"Maybe conservatives need to start thinking about forming other institutions, and new types of universities that will be able to create our own Harvard’s and our own Yale’s and our own Princeton’s." - Dr. Richard Brake, Intercollegiate Studies Institute, at the same panel.

"Conservatives tend to be happy because they tend to like freedom. You are happy people, you are here today, because like Reagan you have intellectualized conservatism and have rejected liberalism as anti-intellectual." - Craig Shirley, author of Rendezvous with Destiny, at the CPAC "Reagan at 100: Role Model for the Next Generation" panel.

"Now that [Reagan's] place in history is secure, [liberals] are trying to remake him. A pernicious myth is that Reagan and Tip O'Neill were great friends." - Craig Shirley.

"The movies television and music we used to produce created an image of America that the world envied… now the millions around the world call us the Great Satan — and with good cause." - Pat Boone.

"Leftist, socialist, former and current communist czars." -Pat Boone, on the Obama administration.

"It's gonna be a big heart-breaker
Gramma needs a new pacemaker
And the doctor says, "I realize she's ill
But there's talk of legislation
On all our medication
And maybe all we can do is put her on a pain pill.
Aw me! Hey Congress!
You vote ObamaCare, and we'll vote you outta there
We the People have wakened to your tricks
You vote to let this pass, you're gonna be out on your [the noise of flatus instead of the vernacular for anus"]
We the People have awakened…" - Ray Stevens, in song.

Some Recent Postings

In The May 24 Issue:

1. Featured Article: The History of Memorial Day

2. In the News: How Brains Bounce Back from Physical Damage

3. International Medicine: Cancer survival rates in Europe and the United States

4. Medicare: Robbing Peter to pay Paul doesn’t help Peter or Medicare!

5. Medical Gluttony: “It Didn’t Cost Me Anything. I’m on MediCal!”

6. Medical Myths: It Didn’t Cost Anything!”

7. Overheard in the Medical Staff Lounge: Is Texas Governor Perry Presidential?

8. Voices of Medicine: Concierge Medicine Practice

9. The Bookshelf: The Rising Tide: The danger in failing to recognize the storms

10. Hippocrates & His Kin: A Short History of Political Suicide

11. Related Organizations: Restoring Accountability in Medical Practice and Society

Words of Wisdom, Recent Postings, In Memoriam . . .

In Memoriam: Huguette Clark

Society Girl Who Spent 8 Decades In Seclusion

By STEPHEN MILLER, WSJ

After a society debut at age 20 and a brief marriage at 22, Huguette Clark, one of America's wealthiest and most prominent debutantes, divorced and spent the next eight decades in virtual seclusion.

Ms. Clark died Tuesday at 104 in a New York City hospital where, despite good health, she had taken up residence more than 20 years ago. At the hospital she pursued a passion for antique dolls but rarely saw visitors.

Her early life was a whirl of private schools, dance lessons in Paris, and a childhood spent in "Clark's Folly," the 121-room mansion her father built on New York's ritzy Fifth Avenue.

But after her brief encounter with high society, Ms. Clark retreated into isolation, living for decades with her mother in 42 art-festooned rooms overlooking Central Park.

The apartment—said to be the biggest on Fifth Avenue—was kept in good order, but she never lived there after choosing to enter the hospital. Nor did she spend time at her two other properties, a California mansion valued at $100 million and a Connecticut estate that is on the market for $24 million.

Instead, Ms. Clark became a recluse, unnoticed until a report last year by msnbc.com raised questions about how her fortune was being handled by her lawyer and accountant. The Manhattan district attorney is investigating concerns raised by Ms. Clark's family, whom she refused to see.

It was a solitary ending to the most privileged of lives. Ms. Clark's father, William Clark, was one of the 19th century "copper kings" of Montana, and his United Verde Mining Co. helped vault his fortune alongside those of the Rockefellers and Carnegies. The city of Las Vegas was first established as a maintenance stop for one of his railroads.

By the time Ms. Clark came along, her father was 67 and a U.S. senator. Ms. Clark was his sixth and last child, born in Paris, where Mr. Clark liked to go to buy art. He died in 1925, leaving Ms. Clark with a fortune of at least $9 million and an allowance that newspapers liked to point out came to $333 per day.

Educated at Miss Spence's School for Girls in New York, Ms. Clark was married in 1928 to William Gower, a Princeton-educated son of a socially prominent family. But the marriage didn't last. Gossip columnists observed that she was worth millions and he was a $30-a-week Wall Street clerk.

In 1930, Ms. Clark managed to scandalize Reno, Nev., known then as the "divorce colony," when she arrived with a retinue of servants and rented an entire floor of a hotel for the duration of the divorce proceedings.

Ms. Clark dropped out of society from then on. She was linked to an English duke, but nothing came of the rumors.

She leaves a fortune estimated at $500 million, and no descendents. Her lawyer, Wallace Bock, said last September she had signed a will.

She once told friends that wealth is a "menace to happiness."

Read the entire obituary in the Wall Street Journal, Subscription required . . .

It is unfortunate that she didn’t ask me to remove her menace for her. I’d have had several suggestions.

On This Date in History – June 14

On this date in 1777, the Continental Congress officially adopted the Stars and Stripes. June 14 is commemorated as Flag Day. The star spangled banner still waves over the land of the free and the home of the brave. It is a comforting and very inspiring symbol that lends itself to graphic representation for what we still stand for, what is worth preserving, free speech so that speakers can speak their mind.

On this date in 1811, Harriet Beecher Stowe was born in Litchfield, Connecticut. She wrote a book whose alternate title was Life Among the Lowly. The full title was Uncle Tom’s Cabin or, Life Among the Lowly. It first appeared in 1852, and it helped greatly in whipping up abolitionist sentiment in the North before the Civil War. Its influence lasted long after the war. Uncle Tom doesn’t mean today what it did to Mrs. Stowe’s time, but it is still drawn from her book. Not too many authors or speakers can make that much of an impact.

After Leonard and Thelma Spinrad

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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. We respect copyright as exemplified by George Helprin who is the author, most recently, of “Digital Barbarism,” just published by HarperCollins. We hope our highlighting articles leads to greater exposure of their work and brings more viewers to their page. 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.

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Del Meyer, MD, Editor & Founder

DelMeyer@MedicalTuesday.net

www.MedicalTuesday.net

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Always remember that Chancellor Otto von Bismarck, the father of socialized medicine in Germany, recognized in 1861 that a government gained loyalty by making its citizens dependent on the state by social insurance. Thus socialized medicine, or any single payer initiative, was born for the benefit of the state and of a contemptuous disregard for people’s welfare.

Thus we must also remember that ObamaCare has nothing to do with appropriate healthcare; it was similarly projected to gain loyalty by making American citizens dependent on the government and eliminating their choice and chance in improving their welfare or quality of healthcare. Socialists know that once people are enslaved, freedom seems too risky to pursue.

MEDICAL TUESDAY . NET	NEWSLETTER
Community For Better Health Care	Vol X, No 5, June 14, 2011