1. Featured Article: How does a woman say goodbye to her breasts?

By Jessica Les, MD

Sonoma Medicine, Volume 67, Number 4 - Fall 2011

On the day of surgery, my alarm went off at 4:15 a.m., 20 minutes before my family’s. I showered deliberately, then I stretched my naked arms out in front of me, goose bumpy after the chill of the shower, and photographed my breasts. I reveled in their smooth symmetry, unblemished except for the purplish hole-pokes from the biopsy. Other alarm clocks sounded, and we mobilized to the surgery center as one impenetrable unit, as if traveling this way would guarantee the tumor too would be organized and therefore easily extracted in one smooth trip to the operating room. Read more . . .

That morning was my first time on the waiting-room side of the surgery center, but I already knew the white corridors, operating rooms and recovery area well because I had worked in the surgery center as a third-year medical student one month before. At 5 a.m., I checked in with a kind, caffeinated young woman with such ease that I thought I was leaving my car for an oil change. I gripped the yellow copies of my consent forms and turned to the waiting room. We were supposed to sit down now. . .

I knew too much about the operating room and what happened after they rolled you in. At some point I would be totally naked under those lights in front of everyone, so I had shaved my legs and groomed my pubic hair.

A nurse called my name and led me to the surgical staging area. As I changed into the blue starred patient gown, I rehearsed in my head how I would refuse midazolam nonchalantly. Once the anesthesiologist gives you this relaxant medication, you yap and yap, respond to commands, climb over from the gurney to the operating table when prompted, and then remember nothing of these motions or conversations afterward. I wanted to remember.

I climbed onto the gurney and settled into the pre-surgery area. The sun dragged itself above the horizon. I lay surfing channels and intermittently dispensing encouraging hand pats and smiles to friends and family visiting my curtained nook two by two as permitted. I felt distracted. One month ago, I circulated among these same curtains as a medical student preparing patients for surgery. I had explained to patients what would happen in the operating room, and then I put in their IV. On that anesthesia rotation, I felt like a scout prepared for the worst. But instead of a green Girl Scout sash and first-aid kit, I sported blue surgical scrubs and clutched a mauve banana-shaped basin carrying needles for the IV, alcohol pads, a tourniquet, and a Band-aid for failed attempts.

Before medical school, I could not conceive of subjecting strangers to needles guided by my learning hands. But as medical students, we had practiced on each other once. And once is all you get. See one, do one, teach one was the mantra in medical training.

I thought about all this as I observed the flashing lights of the TV suspended near my gurney. I wondered who would come around to place my IV. I lay there in my hypocritical guilt, wishing that it wouldn’t be a medical student or anesthesia resident. The rings at the top of the curtain shuddered open to the right. A nurse had come to put in my IV. Grateful, I extended my arm to her.

I hadn’t really comprehended what would be in store for me this morning, before surgery. At my last appointment, Dr. Wapnir decided she would need MRI-guided wire localization to mark each end of the tumor. She explained that using intraoperative ultrasound to locate the tumor wasn’t an option as she had hoped. On the ultrasound screen, my tumor looked like just another flurry in the snowstorm image.

During my surgery rotation, I had seen women wheeled into the operating room with antennae protruding from their breasts. Now I would learn how they got there. The name of the procedure sounded clean and straightforward: MRI-guided wire localization. But after lying half pitched over in a magnetic tube, my chest facing a hole through which the radiologist poked long needles, then wires into my breast, I was no longer fooled by the name.

Most of the blood from the needle-pokes dripped to the floor. Using the corner of my right eye, and being careful not to move, I watched it trickle down. But some had dried on my chest. The radiologist tried to clean me up before securing the six-inch antennae with gauze and tape so that I wouldn’t poke myself in the eye or worse, dislodge the wires from their precise location.

The only staff person’s name I remember from the whole day was Marquee, the radiology transport technician. With my sore chest taped up, I lowered myself into the wheelchair he offered. “Hey there, I’ve seen you around,” he said. “Are you a student here?”

I thought for a moment, unsure of the answer. I didn’t feel like a medical student anymore. “Yeah, a med student.”

“Well alright then,” he answered, his voice utterly unhurried and gentle. “We’re going to take you to mammography and make sure these wires are okay.”

He took the long route, through the basement, avoiding other patients, medical students, doctors, nurses, anyone I might know. He slowed before bumps in the hallway where one part of the hospital joined in a ridged seam to another, avoiding any further jostling of my sore chest. In my deflated state after that long morning before surgery, I was suddenly grateful.

After I returned to my curtained pre-surgery cubby, Dr. Wapnir entered and said, “What we’re going to do isn’t nearly as bad as what has been already done.”

Okay, fine, I thought. She was right, I would be asleep. With a hand on my shin, she looked at my parents and then me. She paused, then said, “Jessica, because the tumor is palpable, the cancer is most likely invasive.”

I could feel my parents crumple, though they appeared unchanged from the outside. This was the first time anyone had said invasive to me or my family, or at least the first time we had heard invasive. It’s perplexing how few medical interactions are fully absorbed by patients and their families, no matter how hard everyone tries. Invasive was logical. You can’t feel ductal carcinoma in situ, a more desirable, early form of breast cancer where the cancer cells are still safely bundled within the lining of the milk ducts. Against all reason, we were holding out for that possibility.

Dr. Wapnir could not have realized that her words had pulled the pin on a grenade. She gave my shin another warm pat and left my bedside; she had another operation to perform before mine. My parents and I remained silent and lingered in the bitter, falling ash. My mom left quickly and my dad followed. I knew she was going to the waiting room to cry.

I know it was hard for Dr. Wapnir to speak those words, and I couldn’t fault her. She had to forewarn us about what might be ahead—that she might have to come out of surgery and say that the cancer had spread to my lymph nodes. Or that later, once all the pathology results were in, she might have to sit us all down and say, “I am so sorry Jessica, it doesn’t look good.” I imagine my mom cried for all of those terrible possibilities. . .

As a last resort, my mom started talking about a book, The Power of Positive Thinking. The author claimed that by thinking positively, a person could change their circumstances for the better, leading to greater happiness. My mom suggested that I read the book, that it had benefitted her. I scoffed, “I guess all the Bosnian women were raped because they weren’t thinking positively,” at my gentle mom, a former Texan now bundled in an L.L. Bean parka meant for snowstorms. Just at that moment, we passed through a flooded intersection. Leaf soup splashed up on either side of the car and shuddered against the underbelly, silencing my words. I was grateful she hadn’t heard me.

I never told my mom that whenever I faced a difficult situation since then, I tried to think positively. I also didn’t tell her that until recently, I would get annoyed at myself for thinking that such a ploy worked. But now, more than anything, I wanted to think positively because I believed positive thoughts would make a difference in my outcome. Psychiatrists term this sort of delusion “magical thinking.” I scrambled in my mind for something to put me at ease, to shift my thinking. I needed something absurd. I remembered the ruddy duck.

After my parents were dealt my diagnosis, they dropped everything in Wisconsin and appeared so quickly in California that there were days to spare before my surgery. My parents, my boyfriend Mike and I went up to Foothills Park for a hike. We first heard the ruddy duck’s multisyllabic squawk while distracted by some other waterfowl. Our eyes searched through the reeds for the source of the sound. And there he was, an exuberant duck bobbing his head with each absurd quack, a ruddy duck. His sky-blue beak, auburn body and fanned, upright tail made him look fantastically overdressed for this small pond in the California hills. Before we left the park, Mike perfected his impersonation of the bird, including the accompanying head bob. Over the following otherwise somber week, I laughed whenever he did the ruddy duck squawk.

I asked someone to call Mike from the waiting area. He offered up a perfect ruddy duck call right before the nurse drew the curtain open. She handed me a gauze surgical cap like the Lunch Ladies wear and said, “Okay, Jessica, you know what to do.” The nurse ushered in my family so they could wish me well.

I put on the cap as the anesthesiologist rolled me away from my family and Mike. I waved at them but didn’t look back. I couldn’t bear to see my parents’ faces. When we turned the corner, I started blabbering to the anesthesiologist, his head upside down from my position on the gurney. I tried to be cheerful. A good, brave medical student. He asked me about my year in medical school. Did I know what I was going to specialize in? Would I stay local or go to the East Coast for residency?

The career questions didn’t bother me. I was preoccupied about being naked under the glaring operating room lights. I had worked with most of the operating room staff one month before as a medical student. I would be asleep when they put the urine catheter in and would lie briefly exposed while they swapped my patient gown for a new set of sheets and sterile drapes. I would not remember any of these events. But lying prone on the gurney, I imagined everyone else would remember. Maneuvering anesthetized patients was their job, and I was one of dozens of unremarkable bodies splayed beneath the florescent lights in their operating room this week. Then I realized that today I was not their medical student: I was their patient.

The foot of the gurney pushed open the operating room doors. I recognized Dr. Wapnir across the room—masked, gowned and wearing heels. From her eyes, I could tell she smiled at me behind her mask. She put her surgical gloves on. The operating room felt different lying down. Monitors beeped and plastic packaging crinkled as the scrub nurse unwrapped sterile instruments, the suction wand that would clear my blood, the cauterizing tool that would cut through my breast tissue. I looked around at all the people in the room and at Dr. Wapnir. Everyone was here to take care of me. I did not have to take care of anyone. I didn’t have to know, or do, anything. Just breathe in the mask.

Email: LesJ@sutterhealth.org

Dr. Les is a third-year resident at the Santa Rosa Family Medicine Residency. She is writing a book about her medical education and her breast cancer, which is currently in remission.

Read the entire article in Sonoma Medicine . . .
Feedback . . .
Subscribe MedicalTuesday . . .
Subscribe HealthPlanUSA . . .

* * * * *

2. In the News: OLIVES: UCD’s Rising Industry

Editor’s Note: UCD, which was the second campus of the ten campus University of California system, began as the animal farm and then the agricultural and veterinary schools. Although these are the colleges in which they are world-class leaders, the UCD campus has grown into a major university with essentially all the colleges normally seen in major universities. The School of Medicine and the Medical Center complex is now in Sacramento. However, fields and barns are a significant landscape at the UCD campus. It appears that Olive Orchards will now appear on the horizon in the fields and not just as messy shade trees. Our School of Viticulture has trained a large number of wine makers that have made California wines compete rather well with France. Perhaps we will now also compete with Italy.

Growing olive demand spurs 'liquid gold' rush

By Anne Gonzales, Bee Correspondent

Published: Sunday, Nov. 27, 2011 | Page 1D

Dan Kennedy, a farmer in the north Sacramento Valley, used to gaze out over his swampy rice fields or undulating alfalfa. These days, his property in Artois is more likely to have trellised hedgerows of sage-colored bushes bearing a tiny, lime-green fruit.

There's oil in those hedges, a "liquid gold" that reflects a contemporary California rush.

"They're a perfect fit for marginal soils, and use less water," Kennedy said of his 5-year-old olive orchards. "We're pretty happy with them."

Mechanical harvesting and new California olive oil mills are priming a sluggish olive industry, as growers in the state rapidly plant olive oil tree varieties and break into what's historically been an import market. Read more. . .

Spanish missionaries introduced olive plantings to California in the 1700s, and Spaniards rebooted the business in the late 1990s with technological advances and an infusion of cash.

Already, the California Olive Ranch, which began with initial capital from Spanish investors, has built two mills in the Sacramento Valley, with 60 growers signing contracts with the firm, many of them converting land from thirstier crops, such as nuts or the area's iconic rice, to the hardier and drought-resistant olive tree.

Other smaller mills are sprouting up in the Central Valley, as demand for olive oil grows in general and as consumer interest for a fresh, domestic oil is piqued.

"The olive industry in California is growing very quickly," said Dan Flynn, executive director of the Olive Center at the University of California, Davis. He said olives hold promise to compete as one of the powerhouse crops of the state, much like almonds or wine grapes.

Flynn said California olive acreage for oil hovered at 6,000 in 2004, and now has shot to 35,000 to 36,000 acres. Table olive acreage remained flat at 25,000 to 30,000.

Growers favor the crop because they get long-term contracts and guaranteed prices, taking some volatility out of the risky business of farming. Kennedy has a nine-year contract with California Olive Ranch, with a guaranteed price of $9 a gallon for oil.

Growers are getting $15 a gallon for oil, Flynn said. Last year, olive oil was a $15.3 million California commodity.

Meanwhile, growers and processors are swimming in vats of market potential. While 75 million gallons of olive oil are consumed in the United States annually, California produced about 1.2 million gallons last year, up from 850,000 gallons the previous year. The huge gap is made up in olive oil imports, mainly from Spain.

California, which processes more than 99 percent of the nation's olive oil, now has enough olive trees in the ground to produce 4.5 million gallons, once they start bearing fruit, Flynn said. And many industry observers predict that milling capacity will grow to keep pace with olive production and demand.

The business opportunity in olives came from high-density plantings of varieties made for oil processing, said Gregg Kelley, president of California Olive Ranch, based in Oroville. The company was a pioneer in using a Spanish system for planting olives in bushy rows, allowing for mechanical harvesting.

"It was a fundamental change in production, because we can now produce high quantities of high-quality oils with reduced labor costs," Kelley said.

Three workers and a mechanical harvester can strip an acre of trellised trees of fruit in about 30 minutes, work that used to take a crew of 25 a day to pick by hand, he said.

Olive trees can be grown in poor soils, including rocky ground and clay, and are ideal for water-strapped areas. Kelley said olives require about 15 inches a year of water per acre, as opposed to 4 to 8 acre-feet for other crops, including almonds, walnuts and rice.

"I like to think that, long term, olives will have a role in addressing the state's water issues," Kelley said. "They were developed in drought-stricken regions and a Mediterranean climate. They are survivors."

California Olive Ranch planted the first high-density olive orchard in the United States in 1999, on 500 acres in Oroville. The company opened its first mill in Oroville in 2002, and a second mill in Artois in 2008. In 2005, California Olive Ranch owned or contracted for 1,000 acres of olives, and now has holdings and contracts totaling 15,000 acres.

"Last year, California Olive Ranch alone produced three times as much oil as the entire California industry in 2006," Kelley said.

Kelley said olive oil production is creating local jobs and is an economic engine statewide. The firm employs 65 people in its two Sacramento Valley plants. Kelley said California Olive Ranch has grown its investment in the Artois mill 300 percent since initial construction with the addition of a storage facility and packaging line, and increased processing capacity. . .

While the company still has Spanish backers, it has American investors too, Kelley said. Spanish research and development programs also yielded the specialized harvester, which cannot be widely used in Spain because of its hilly terrain. A nursery in Spain also was home to the oil varieties chosen for their bushy character and success in warm, dry climates, Kelley said.

Brady Whitlow, president of Corto Olive Co. near Lodi, said the high-density plantings and mechanical harvesting drew his family farm into the olive oil business. The company started planting olives in San Joaquin County about eight years ago and built a mill to process oil about five years ago.

Today, Corto owns 3,000 acres of olives and contracts with about 10 other growers.

While traditional olive orchards have about 50 trees to an acre, the high-density plantings have almost 700 trees to an acre, Whitlow said.

In the first year, the Corto mill processed about 5,000 gallons of oil, and Whitlow said it now produces a half-million gallons. With mill capacity at just under a million gallons, there's already talk of expansion, he said.

"Adding capacity is the easy part," Whitlow noted. "We have to demonstrate to consumers how much better our oil is and what a value it is, so we can add acreage and more market opportunities."

Read the entire article in the Sacramento Bee . . .
Feedback . . .
Subscribe MedicalTuesday . . .
Subscribe HealthPlanUSA . . .

* * * * *

3. International Medicine: Health Welfare and Corporate Welfare are both Lawmaker Diseases That infect and affect Human Health as well as Corporate Health.

More than $27 billion spent by Ontario governments on corporate welfare since 1991

By Mark Milke

Ontario governments are addicted to dispensing corporate welfare.

Between 1991 and 2009, Ontario governments of all political stripes spent more than $27.7 billion on direct subsidies to corporations, says a new report released today by the Fraser Institute, Canada’s leading public policy think-tank.

“Subsidies to businesses, whether bailouts, loans that may not be repaid, or straight grants are all forms of corporate welfare and do nothing to benefit Ontario families,” said Mark Milke, Fraser Institute senior fellow and author of Ontario’s Corporate Welfare Bill: $27.7 billion.

“In the most recent year for which data is available, the cost of Ontario corporate welfare was the equivalent of $424 from each person who paid income tax in Ontario, or $848 per working couple.” Read more . . .

Milke points out that the multi-billion-dollar handouts to business have an opportunity cost: other more desirable policies are ignored or not enacted because the money is spent on business subsidies. For example, he calculates that money spent on corporate welfare could have been used to almost eliminate the Ontario Health Premium, estimated to have cost taxpayers $3.1 billion in 2011/12. Other options include reducing personal income taxes, reducing business taxes, or reducing Ontario’s annual deficit by $2.7 billion.

“In light of the Occupy protests that sprang up this fall and the concerns over perceived favours to individual corporations, Ontario politicians should rethink their propensity to spend millions of tax dollars on corporate bailouts and risky business ventures,” Milke said.

“With an Ontario government that faces multi-billion-dollar deficits as far as the eye can see, one easy target for spending reductions should be corporate welfare. Besides, Ontario’s existing policy of lowered business tax rates makes much more sense, as that policy is neutral towards any one business.”

The report points out that virtually all peer-reviewed research on business subsidies concludes that corporate welfare does not have a demonstrable positive impact upon the economy, employment, or tax revenues because of the substitution effect: when employment and tax revenues are merely shifted, no new investment or employment is created on a net basis when the national or international economy is considered. For example, a subsidy meant to “create” manufacturing jobs in Ontario may simply shift intended investment away from Quebec or British Columbia.

“Even though research does not support claims that corporate welfare contributes to widespread economic growth, governments continue to pursue these policies because they want to be seen to be doing something,” Milke said.

“By subsidizing or bailing out failing or risky business ventures, politicians can tell voters they are saving jobs, or they can appeal to voters with interests in specific industries.” . . .

The report found that all three political parties that have formed government in Ontario since 1991 – NDP, Progressive Conservative, and Liberal – have all spent substantial amounts on corporate welfare.

“Ontario’s current corporate welfare policy, which it justifies based on job creation, is backwards. Low corporate tax rates – not high corporate welfare payments – will lead to employment growth and job creation in Ontario,” Milke said.

Read the entire Release at the Fraser . . .
Feedback . . .
Subscribe MedicalTuesday . . .
Subscribe HealthPlanUSA . . .

Canadian Medicare does not give timely access to healthcare, it only gives access to a waiting list.

--Canadian Supreme Court Decision 2005 SCC 35, [2005] 1 S.C.R. 791

http://scc.lexum.umontreal.ca/en/2005/2005scc35/2005scc35.html

* * * * *

4. Medicare: Bundled Payment Experiment

Medicare’s Flawed Bundled Payment Experiment

John C. Goodman

John C. Goodman is president and CEO of the National Center for Policy Analysis.

For several years now, scholars have been calling for a radical change in how Medicare pays doctors and hospitals. Instead of having Medicare set millions of prices for predetermined packages of care, we should allow providers the opportunity to produce better and cheaper care by repackaging and repricing their services. Read more . . .

Everyone on the provider side should be encouraged to make Medicare a better offer. Medicare should accept these offers provided (1) the total cost to government does not increase, (2) quality of care does not decrease, and (3) the provider proposes a reasonable method of assuring that (1) and (2) have been satisfied.

Instead of maximizing against reimbursement formulas, doctors and hospitals would be encouraged to discover more efficient ways of providing care. They would be able to make more money for themselves as long as they save taxpayers money and patients don’t suffer.

Health and Human Services Secretary Kathleen Sebelius recently seemed to indicate she has heard the call. Yet there are flaws in her approach which could very well ruin the experiment.

Bundling Payments

Going forward, providers will be able to offer to perform heart surgery and other procedures for a lump sum (bundled) price covering all aspects of the procedure, and (like Priceline) they can name their own price. Medicare will accept the offer if taxpayers are likely to come out ahead on the deal.

Unfortunately, Medicare will dictate what the bundles will look like. Providers will be able to re-price, but not repackage. Yet, ironically, re-pricing without repackaging could actually make things worse.

Feedback . . .
Subscribe MedicalTuesday . . .
Subscribe HealthPlanUSA . . .

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

- Ronald Reagan

* * * * *

5. Medical Gluttony: Corporate Practice of Medicine

Some states—California, Texas, Ohio, Colorado, Iowa, Illinois, New York and New Jersey—preclude hospitals from employing physicians who provide out-patient services. These states legislate what is known as the corporate practice of medicine doctrine. The rationale for prohibiting employment of physicians by hospitals is derived from the concept that individual physicians should be licensed to practice medicine, not corporations. . . The basic premise is the divided loyalty and impaired confidence between the interests of a corporation and the needs of a patient. In practice, states with corporate practice of medicine laws permit formation and licensure of business corporations established as professional service corporations (but not a non-profit corporation) to practice medicine but only if controlled by physicians. Read more . . .

Many medical practices have been purchased by hospital corporations. This has diluted the ban on the practice of medicine by corporations through arms-length foundations. But the magnitude of the cost to the patient has not been adequately addressed. We touched upon this practice several decades ago when the hospital foundations were beginning the purchasing of physician practices.

Recently, we have been forwarded a number of physician statements as well as new statements that they received after their doctors were controlled by hospital foundations. The doctors' statements were essentially unchanged. But there was a second portion, frequently larger than the first portion, of the hospital charge for providing space, support, billing and other services, all of which were formerly included in their doctor's statement. This caused quite a stir among these patients when they found their co-payment didn’t include these services. The patients were rather upset since they expected their $25 or $50 co-payment to be their entire obligation and then were asked to pay more than a $100 additional for the support charges. A class action lawsuit apparently is in progress. This is sheer gluttony outside of the usual gluttony that is ameliorated when an insurance company does not pass charges through to the patient.

This class action will have an unpredictable effect on health care costs. These costs are always stated in terms of health care reform. Only a socialist would call this progress. What is overlooked is that these charges would never have occurred if physicians were in charge of their practices rather than corporations, even if it’s an arm’s length foundation. Foundations and the corporate practice of medicine will always divide loyalty and impair confidence, not only in the patient’s physician, but also in the quality of care.

It is unethical for a physician to sell a practice to anyone except to another physician.
This should also be prohibited by the Medical Practice Act.

Feedback . . .
Subscribe MedicalTuesday . . .
Subscribe HealthPlanUSA . . .

Medical Gluttony thrives in the corporate practice of medicine.

It Disappears with Physician ownership of their practice.

* * * * *

6. Medical Myths: The National Practitioner Data Bank is Confidential

Editorial: The Debacle of the National Practitioner Data Bank

By Lawrence R. Huntoon, M.D., Ph.D., Editor-in-Chief

Journal of American Physicians and Surgeons Volume 16 Number 4 Winter 2011

The National Practitioner Data Bank (NPDB) was created by the Health Care Quality Improvement Act of 1986 (HCQIA). Its stated purpose was: “…to restrict the ability of incompetent physicians to move from State to State without disclosure or discovery of the physician’s previous damaging or incompetent performance.”²

Information reported to the NPDB is considered confidential. Read more . . .

HCQIA §11137(b)(1) provides, in part: “Information reported under this subchapter is considered confidential and shall not be disclosed (other than to the physician or practitioner involved) except with respect to professional review activity.…” HCQIA also provides for public disclosure of information, provided that the data are in a form that would not permit identification of a specific physician/practitioner or entity. Such de-identified data are considered non-confidential: “Information reported under this subchapter that is in a form that does not permit the identification of any particular health care entity, physician, other health care practitioner, or patient shall not be considered confidential.”³

De-identified Information Identifiable

If the information in the NPDB Public Use File (PUF) is compared with information in publicly available documents, such as court documents, then the information in the databank can be linked to a specific physician. This type of comparison analysis allows journalists, attorneys, and others to discover information which otherwise may not be discoverable.

Malpractice settlements, for example, are reportable to the NPDB. Malpractice settlements may have confidentiality agreements that by definition would not be in public documents. However, through diligent analysis, one may be able to link a single publicly available court document with certain NPDB data, and then the physician’s entire NPDB report can be revealed.

Former NPDB Official Provides Information

In a statement dated Oct 2, 2011, a former NPDB official acknowledged his role in providing extracts from the NPDB PUF to a reporter for the Kansas City Star:

From 1997 until my retirement in 2008, I was Associate Director for Research and Disputes for HRSA’s [Health Resources and Services Administration] Division of Practitioner Data Banks, which operated the National Practitioner Data Bank. I was recruited to the Division in 1993 to establish the Data Bank’s research program. Among other duties, I personally designed the Data Bank’s Public Use File and oversaw its development and quarterly updating…. On a volunteer basis, I have also assisted patient safety advocates, the news media, and others in using the Data Bank’s Public Use File and understanding the Data Bank. For instance, I created extracts containing Public Use File records for the Kansas City Star.

…. I did not assist the Kansas City Star in identifying records for the physician named in the recent story that led to HRSA’s removal of the Public Use File. It should be noted that what I did for the Star was no different from what I and my staff did hundreds of times for researchers, including newspapers and other media, as a HRSA employee.⁴

Indeed, the Association of Health Care Journalists has posted a list of examples in which reporters have used the NPDB PUF to research and write stories concerning individual physicians.⁵

HRSA Threatens Reporter

In a letter dated Aug. 26, 2011, the director of the Division of Practitioner Data Banks, Cynthia Grubbs, R.N., J.D., wrote to health reporter Alan Bavley and threatened civil monetary penalties for any violation of the confidentiality regulations governing the NPDB. The letter stated:

The U.S. Department of Health and Human Services (HHS) has been informed that you may be writing an article for publication in the Kansas City Star which potentially involves the republication of information obtained from the National Practitioner Data Bank (NPDB). Please note that NPDB reports and the information derived from them are protected by Federal law…. [E]ven the existence of NPDB reports regarding specific practitioners is considered confidential information.”⁶

The letter goes on to state: “Any person who violates paragraph (a) shall be subject to a civil money penalty of up to $11,000 for each violation.”

Did HRSA Director Violate Confidentiality?

As the HRSA official’s letter to the reporter contained a “cc” at the end of the letter, naming the specific physician involved, the following question is raised: Did the HRSA director violate the very confidentiality regulations (45 CFR 60.15) which she cited in her threatening letter to the reporter? Her letter to the reporter essentially confirmed the existence of a report on the named physician in the NPDB.

Public Use File Removed from NPDB Website

On Sept 1, 2011, the NPDB Public Use File was removed from the NPDB’s public website. A special notice posted on the website stated:

On September 1, 2011, HRSA removed the Public Use Data File (PUF) from our website. We regret that we had to take this temporary action and are committed to restore the PUF to our site as quickly as is possible. The statute that governs the NPDB clearly states that we are obligated to keep data about individual practitioners housed in the NPDB confidential. We now know that the PUF in its current form can be manipulated to identify individual practitioners, and therefore were compelled to act…. At this time, a researcher must provide a proposal (including table shells) for their need of data. DPDB will review the request and approve or deny the request for data. DPDB will provide only the variables needed to complete the research. Please contact dpdbdatarequests@hrsa.gov for research requests.⁷

Newspaper Publishes Article

Despite the threat from the NPDB official, the Kansas City Star published the article on Sept 4, 2011. Information attached to the article described exactly how the newspaper developed the story:

The Kansas City Star analyzed National Practitioner Data Bank records from1990 through 2010 of physicians who have had payments made on their behalf in Kansas or Missouri for malpractice claims and who have not been disciplined by the state’s medical board…. The methodology used to analyze the data was recommended by Robert Oshel, retired Data Bank associate director who created its public use file…The Star linked [the doctor] to entries in the Data Bank by comparing its public reports to information about [the doctor] contained in court filings.⁸

HRSA took no further action against the reporter.

HRSA Failed to Protect Confidential Information

Although the new procedure for obtaining information from the NPDB has drawn protests from journalists, who have complained that the new more restrictive procedure infringes upon their First Amendment rights, one thing is certain: the agency tasked with keeping information in the NPDB confidential utterly failed to prevent violation of confidentiality as required by law. HRSA now fully admits that the data were vulnerable to manipulation so as to identify individual physicians.

Section 11137(b)(1) of HCQIA clearly states, in part:

Information reported under this subchapter that is in a form that does not permit the identification of any particular health care entity, physician, other health care Practitioner, or patient shall not be considered confidential. The Secretary (or the agency designated under section 11134 (b) of this title), on application by any person, shall prepare such information in such form and shall disclose such information in such form.

The law clearly required HRSA to accept applications for information and to prepare such information, not simply place thousands of files on a public website in reckless disregard of physician confidentiality.

Conclusion

The lesson to be learned is that, despite assurances of politicians and bureaucrats to the contrary, government is not capable of keeping private information private and confidential. Those who still value their medical privacy would do well to keep this fact in mind as electronic health records and linked data bases become more prevalent.

Lawrence R. Huntoon, M.D., Ph.D., is a practicing neurologist and editor-in-chief of the Journal of American Physicians and Surgeons . Contact: editor@jpands.org.

1 42U.S.C. §§11101–11152.

2 42U.S.C. §11101(2).

3 42U.S.C. §11137(b)(1).

4 Oshel RE. Statement of Robert E. Oshel, Ph.D., Concerning HRSA’s Removal of the Data Bank Public Use File and New Requirements for Research Data Requests; Oct 2, 2011. Available at: www.healthjournalism.org/uploads/NPDB-Oshel.pdf.AccessedOct 29, 2011.

5 Reporters Use NPDB’s Public Use File to Expose Gaps in Oversight of Doctors. Available at: www.healthjournalism.org/secondarypage-details.php?id=982. Accessed Oct 29, 2011.

6 Letter from Cynthia Grubbs, R.N., J.D., director, Division of Practitioner Data Banks, to Alan Bavley, health reporter, , Aug 26, 2011. Available at: www.healthjournalism.org/uploads/NPDB-Bavley-letter.pdf. Accessed Oct 29, 2011.

7 U.S. Dept of HHS. Special notice: access to public use data file. Available at:
www.npdb-hipdb.hrsa.gov/resources/publicData.jsp. Accessed Oct 29, 2011.

8 Bavley A. Bad medicine: family wishes they’d known surgeon had been sued repeatedly for malpractice. Oct 6, 2011.
Available at: www.kansascity.com/2011/09/04/3191038/badmedicine-family-wishes-theyd.html. Accessed Oct 29, 2011.

Journal of American Physicians and Surgeons

Kansas City Star

The Data Bank: National Practitioner Healthcare Integrity & Protection

REFERENCES: Journal of American Physicians and Surgeons Volume 16 Number 4 Winter 2011

Read the entire Editorial . . . Used by permission of the author.
Feedback . . .
Subscribe MedicalTuesday . . .
Subscribe HealthPlanUSA . . .

Medical Myths originate when the Government makes promises.

Bureaucrats generally don’t honor promises of prior Congressional Bureaucrats.

* * * * *

7. Overheard in the Medical Staff Lounge: Will GOP choose between two flawed frontrunners?

Dr. Dave: Looks like the GOP problem won’t go away. But it’s getting very sticky. A very unfortunate choice.

Dr. Michelle: I don’t trust Newt Gingrich for the same reasons that Dr. Ruth stated last week. But he had the chance when he was speaker of the House about 15 years ago. He closed down the government when he had a large majority and he backed down within a week or 10 days.

Dr. Edwards: We had great hopes on his disabling Congress and if he had any backbone, he should have kept Congress and the Government closed for at least six months. Look at the money we could have saved. Read more . . .

Dr. Paul: That would have been tragic to do so.

Dr. Dave: That would have been tragic if you think Congress is working on our behalf. The only way that they would be working on our behalf is if they can’t pass any laws. Zero.

Dr. Paul: Who would pass laws then? We’d just have presidential edicts?

Dr. Dave: Isn’t that what we have today? Pelosi and Reid are just Presidential pawns, aren’t they?

Dr. Paul: I think they are individuals in their own rights. Just because they agree with President Obama doesn’t make them pawns, does it?

Dr. Dave: I agree. But then they should have had an original thought, don’t you think?

Dr. Ruth: Or the ideology of the radical left is so set in concrete that they all seem to be made from the same mold.

Dr. Rosen: Newt is so unstable that he can’t think a solution through to its final effect. He stops too many good ideas before they are successful.

Dr. Edwards: Maybe we can explore Mitt Romney’s position on healthcare a bit. He said he saw a problem in Massachusetts and he fixed it. But if you read between the lines, it was a problem in Emergency Coverage that was given him as a problem. He then spent his term solving what he thought was the healthcare problem. He has no ideahttp://www.medicaltuesday.net/BookReviews.aspx how complicated healthcare is. He would put us all in a straitjacket. It’s the story of the six blind men and the elephant all over again. I believe one felt his flank and thought it was very much like a wall; and one felt his leg and thought it was very much like a tree; one felt his tail and felt it was very much like a rope. I don’t recall what the other blind men felt, but Romney feels that all of health care is very much like an emergency room. That’s a very atypical or myopic way of looking at our entire product.

Dr. Dave: Yes, economics defines healthcare much as economics defines about everything else that we do.

Dr. Rosen: The economics of health care is straight forward as we’ve discussed a number of times in this staff lounge. But we can’t get to an economic discussion as long as one party insists it must be totally free. Then it has no value. It has no limit. And health care is the most expensive item in our budget and it should not be freewheeling. If you give every American a free automobile, how many would choose a small car. If a $100,000 car was as free as a $10,000 car, would anyone choose the cheap car? If an MRI at $800 was as free as an $80 x-ray, when the latter would give the diagnosis, who would choose an x-ray? In both examples there is a 10-fold increase in cost but gluttony would prevail. A ten-fold increase is a 1000 percent increase. Isn’t that why health care costs are astronomical?

Dr. Dave: Has any candidate explained this simple math to the uninformed?

Dr. Rosen: Maybe the uninformed are refractory to being informed.

Feedback . . .
Subscribe MedicalTuesday . . .
Subscribe HealthPlanUSA . . .

The Staff Lounge Is Where Unfiltered Opinions Are Heard.

* * * * *

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

GOP must choose between two very flawed front-runners

By Charles Krauthammer, MD
Washington Post Writers Group

. . . barring yet another resurrection, or something of similar improbability, it's Mitt Romney vs. Newt Gingrich. In a match race, here's the scorecard:

Romney has managed to weather the debates unscathed. However, the brittleness he showed when confronted with the kind of informed follow-up questions that Bret Baier tossed his way Tuesday on Fox's "Special Report" – the kind of scrutiny one doesn't get in multiplayer debates – suggests that Romney may become increasingly vulnerable as the field narrows.

Moreover, Romney has profited from the temporary rise and spontaneous combustion of Michele Bachmann, Rick Perry and Herman Cain. It required no exertion on Romney's part. Read more . . .

Enter Gingrich, the current vessel for anti-Romney forces – and likely the final one. Gingrich's obvious weakness is a history of flip-flops, zigzags and mind changes even more extensive than Romney's – on climate change, the health care mandate, cap-and-trade, Libya, the Ryan Medicare plan, etc.

The list is long. But what distinguishes Gingrich from Romney – and mitigates these heresies in the eyes of conservatives – is that he authored a historic conservative triumph: the 1994 Republican takeover of the House after 40 years of Democratic control.

Which means that Gingrich's apostasies are seen as deviations from his conservative core – while Romney's flip-flops are seen as deviations from … nothing. Romney has no signature achievement, legislation or manifesto that identifies him as a core conservative. . .

. . . the party base, ostentatiously pursuing serial suitors-of-the-month, considers him ideologically unreliable. Hence the current ardor for Gingrich.

Gingrich has his own vulnerabilities. The first is often overlooked because it is characterological rather than ideological: his own unreliability. Gingrich has a self-regard so immense that it rivals Obama's – but, unlike Obama's, is untamed by self-discipline.

Take that ad Gingrich did with Nancy Pelosi on global warming advocating urgent government action. He laughs it off today with "that is probably the dumbest single thing I've done in recent years. It is inexplicable."

This will not do. He was obviously thinking something. What was it? Thinking of himself as a grand world-historical figure, attuned to the latest intellectual trend (preferably one with a tinge of futurism and science, like global warming), demonstrating his own incomparable depth and farsightedness. Made even more profound and fundamental – his favorite adjectives – if done in collaboration with a Nancy Pelosi, Patrick Kennedy or even Al Sharpton, offering yet more evidence of transcendent, trans-partisan uniqueness.

Two ideologically problematic finalists: One is a man of center-right temperament who has of late adopted a conservative agenda. The other, more conservative by nature, is possessed of an unbounded need for grand display that has already led him to unconservative places even he is at a loss to explain, and that as president would leave him in constant search of the out-of-box experience – the confoundedly brilliant Nixon-to-China flipperoo regarding his fancy of the day, be it health care, taxes, energy, foreign policy, whatever.

The second, more obvious, Gingrich vulnerability is electability. Given his considerable service to the movement, many conservatives seem quite prepared to overlook his baggage, ideological and otherwise. This is understandable. But the independents and disaffected Democrats upon whom the general election will hinge will not be so forgiving.

They will find it harder to overlook the fact that the man who denounces Freddie Mac to the point of suggesting that those in Congress who aided and abetted it be imprisoned, took $30,000 a month from that very same parasitic federal creation. Nor will independents be so willing to believe that more than $1.5 million was paid for Gingrich's advice as "a historian" rather than for services as an influence peddler.

My own view is that Republicans would have been better served by the candidacies of Mitch Daniels, Paul Ryan or Chris Christie. Unfortunately, none is running. You play the hand you're dealt. This is a weak Republican field with two significantly flawed front-runners contesting an immensely important election. If Obama wins, he will take the country to a place from which it will not be able to return (which is precisely his own objective for a second term).

Every conservative has thus to ask himself two questions: Who is more likely to prevent that second term? And who, if elected, is less likely to unpleasantly surprise?

Read the entire OpEd column in the Sacramento Bee . . .
Feedback . . .
Subscribe MedicalTuesday . . .
Subscribe HealthPlanUSA . . .

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

* * * * *

9. Book Reviews: Robin Cook, MD and Tess Gerritsen, MD

CHROMOSOME 6 by Robin Cook, MD. G P Putnam's Sons, New York, 460 pages, 1997. Berkley Edition, 1998. Putnam Berkley Audio Group, Inc, Tapes, read by Boyd Gaines, 4 cassettes, 6 hours, 1997.

LIFE SUPPORT by Tess Gerritsen, Pocket Books, New York, 1997. Simon & Schuster Audio Books, read by, Megan Gallagher, 2 cassettes, 3 hrs.

Review by Del Meyer, MD

Dr Robin Cook, on leave from the Massachusetts Eye and Ear Infirmary, has had an unbelievable series of medical suspense novels (15 best sellers). Each book has been well-researched and in Chromosome 6, Cook again provides his reference material, giving his work credibility. His scholarship is secondary, though, to the large ethical questions he tackles. The plot in Chromosome 6 centers on genetics. It specifically describes how organs are engineered to grow in primates that can be harvested for use in humans. In Cook's hands, this premise uncoils into a rich and riveting story. Read more . . .

Carlo Franconi, a notorious underworld figure, is gunned down, and his body is stolen from the medical examiner's morgue before the autopsy is completed. The next day a "floater" is brought in from the bay without head or arms. When a recently transplanted liver is found in the body, without immune response or anti-immune drugs in the body, the scene is set for chromosomal analysis. The transplanted liver proves to be from a primate, created by introducing human genes from chromosome 6 into primates. The yield is a reservoir of matched organs for those able to afford them--mafia chieftains, for example, who have a double engineered to cheat the reaper should they meet with a little accident.

The forensic investigation leads you to a research laboratory where chromosome 6 of certain wealthy individuals are crossed with the chromosome 6 of bonobos, a type of chimpanzee. The resultant chimeras have organs that can be transplanted into the human. But such meddling with DNA leads to inevitable disturbances and unexpected fallout. As the experiment plays out, the highly peaceful bonobos morph into a more savagely human-like species. They begin living in caves, making fires. They develop a language, invent weapons and kill each other. If only the bonobos’ original pacific nature could bleed into their human hosts. Cook unravels the tangle with his usual masterful craft.

Dr Tess Gerritsen, an internist who left her practice to write Harvest, (reviewed in Sacramento Medicine, Jan 98) has now published her second novel, Life Support, which measures up to expectation. In Life Support, Dr Gerritsen addresses a number of medical issues--peer review, hospital discipline, doctors as owners of free-standing surgery centers, and just plain ruthless hospital medical/administrative politics. She entertains us with a plot that features an outbreak of Creutzfeldt-Jakob disease that does not turn out to be mad cow disease, and fetal brain multiple pituitary tissue transplantation, with the twist of impregnating call girls in order to harvest fetal products to benefit the wealthy patients of a medical retirement community.

When one batch of pituitaries is contaminated, the CJD outbreak makes the medical business establishment and their doctors cover tracks fast. The doctors have difficulty handling some of the deaths that occur, but when the administrators force the research neurosurgeons to eliminate other doctors (who were simply trying to diagnose their patients as they arrived in the Emergency Rooms), they realize the slight trading on ethics came to a point of no return as they become felons.

We have set up structures such as peer review that prove lethal. In Life Support, Dr Toby Harper leaves a disoriented patient she thinks went to have a CT in x-ray to attend to a CPR secondary to tamponade in the next ER room. The hospital holds her responsible for the disappearance of the disoriented patient transferring hospital responsibility to a doctor in order to remove her privileges. In Chromosome 6, the surgery suite is moved offshore where the hospital administrator more simply disposes of non-compliant doctors.

Cook & Gerritsen both trade on the strong desire and recurring theme that humans want to live forever. Gerritsen explores the research into pituitary growth and, therefore, body rejuvenation through fetal pituitary transplants into the sella turcica while Cook explores organ supply. The drive for immortality is so urgent that ethics become distorted; physicians commit crimes at the fringes of medicine.

Surgical pathology came into being as a quality issue to make sure that organs and specimens removed from bodies have surgical justification. A high autopsy rate similarly kept those of us on the medical side of practice honest, since we knew there would be an accounting. In both novels, it is the autopsy that brings abuse to light and then to justice. Post mortem examinations are the ethical proving ground.

These medical thrillers by physicians are a call to perceptive examination and exposure of some of the questionable, institutionalized practices in modern medicine. Cook and Gerritsen both train their sights on this formidable opponent. Their goal is ambitious and entirely necessary--a return to ethical behavior.

Del Meyer, MD
DelMeyer@MedicalTuesday.net

This book review is found at . . .
To read more book reviews . . .
To read book reviews topically . . .

Feedback . . .
Subscribe MedicalTuesday . . .
Subscribe HealthPlanUSA . . .

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

* * * * *

10. Hippocrates & His Kin: Washington thinks it can do it better.

Washington can do it better.

During a Washington DC rainstorm, the lawn sprinklers in front of the White House suddenly turned on and began operating full force. A passerby turned to his companion and said, “Why do you suppose those sprinklers went on now?” “It’s an old rule in Washington,” said the other. “Whatever nature does, Washington thinks it can do better.”

Can’t anyone tell them the truth?

Read more . . .

Fewer Potheads?

The City of Sacramento has frozen permit applications for existing marijuana dispensaries but has allowed most to stay. Meanwhile, Sacramento County's cracked-down in the unincorporated areas, by contrast, is having a dramatic effect on California’s quickly shrinking medical marijuana industry. Eight marijuana stores—from as many as 99 dispensaries that opened—are left. Dozens have closed in recent weeks amid fears of federal prosecution and aggressive actions by the country, including litigation and fines . . .

With marijuana tablets now available by prescription, no one should be deprived of this treatment.

Americans are worried about their future.

A recent poll by The Hill revealed that 83% of Americans are either very or somewhat worried about the future.

Then why are they following the sheep in the chute to the slaughter?

The National Data Bank

The Tomb for Physicians without an appropriate funeral.

Feedback . . .
Subscribe MedicalTuesday . . .
Subscribe HealthPlanUSA . . .

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

* * * * *

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.

• 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.

• 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.

• 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.

• 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?

• 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.

• 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.

• 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.

• 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.]

• McLauren Institute MacLaurinCSF is a community of students, scholars, and thinkers working together to explore and understand the implications of the Christian faith for every field of study and every aspect of life.* Our Mission: MacLaurinCSF bridges church and university in the Twin Cities metropolitan area, bringing theological resources to the university and academic resources to the church. Our goal is to strengthen Christian intellectual life in this region by creating public space for leaders in the academy and church to address enduring human questions together. MacLaurinCSF is grounded in the Christian tradition as articulated in Scripture and summarized by the Apostles’ and Nicene creeds, and our conversations are open to all.

• 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.

• Chapman University: Chapman University, founded in 1861, is one of the oldest, most prestigious private universities in California. Chapman's picturesque campus is located in the heart of Orange County – one of the nation's most exciting centers of arts, business, science and technology – and draws outstanding students from across the United States and around the world. Known for its blend of liberal arts and professional programs, Chapman University encompasses seven schools and colleges: The university's mission is to provide personalized education of distinction that leads to inquiring, ethical and productive lives as global citizens.

• 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 ? Choose recent issues. The last ten years of Imprimis are archived.

* * * * *

Words of Wisdom

Knowledge is the food of the soul. –Plato

Knowledge which is acquired under compulsion obtains no hold on the mind. –Plato (427?-347 B.C.)

The pursuit of knowledge is, I think, mainly actuated by love of power. –Bertrand Russell (1872-1970)

Those who think they know it all are very annoying to those who do. –Sheetz’s Rumination

When a man’s knowledge is not in order, the more knowledge he has, the greater will be his confusion. –Herbert Spencer (1820-1903)

Some Recent Postings

In The October 28 Issue:

1. Featured Article: Is free transportation, regular toenail trimmings revolutionary?

2. In the News: Rick Perry's jobs-creation plan is a liberal nightmare.

3. International Medicine: UK: National Health Service

4. Medicare: Romney still favors an Obama approach to Healthcare

5. Medical Gluttony: : Transparency in Medical Charges Would Prevent Gluttony

6. Medical Myths: Promises of ObamaCare

7. Overheard in the Medical Staff Lounge: Who will be our next President? Does it matter?

8. Voices of Medicine: Don’t Let Chaos Get You Down

9. The Bookshelf: New American film: Dirty Hoover

10. Hippocrates & His Kin: RomneyCare in America would be a BIG MISTAKE

In Memoriam

Curmudgeonly Commentator Andy Rooney Dies at 92 on NOVEMBER 5, 2011

By STEPHEN MILLER

Andy Rooney was America's bemused uncle, spouting homespun wisdom weekly at the end of "60 Minutes," a soupcon of topical relief after the news magazine's harder-hitting segments.

Peering at viewers through bushy eyebrows across his desk, Mr. Rooney might start out, seemingly at random, "Did you ever notice that…" and he was off, riffing on pencils, pies, parking places, whatever. Then he was done, slightly cranky revelations delivered in a neat three-minute package.

Mr. Rooney, who died Friday night at age 92, was a reporter and writer-producer for television for decades before landing in 1978 on "60 Minutes." To his consternation, the show made him into a celebrity.

He created over 1,000 of his mini-essays for "60 Minutes"—many inviting viewers to look anew at some mundane object. He once proposed National Wastebasket Day in honor of its inventor.

For an irascible man of so many opinions, it was remarkable that Mr. Rooney offended so few viewers. At one point in 1990, he was suspended for some apparently offhand comments about homosexuality and race. By the time he was reinstated a month later (delivering an ardent apology), ratings at "60 Minutes" had declined by 20%.

A native of Albany, N.Y., Mr. Rooney worked briefly in his teens as a copyboy for the Albany Knickerbocker News. He was drafted into the Army while attending Colgate University, and on the strength of his journalistic experience was assigned to work for the GI newspaper Stars and Stripes.

In one early dispatch, "How It Feels to Bomb Germany," he wrote about riding in a Flying Fortress nicknamed the Banshee during an Allied assault on the port city of Wilhelmshaven. German fighter planes raked the bomber with machine-gun fire, but the crew got back safely.

"The Banshee had what the crew called 'a quiet trip,' " Mr. Rooney concluded. "I don't want to go on a noisy one."

After the war, Mr. Rooney wrote books about being an air gunner, a history of Stars and Stripes, and in one of his strongest journalistic reports, an account of U.S. occupying forces in Germany that criticized American servicemen for abusing German citizens.

After struggling to make ends meet as a freelancer, Mr. Rooney took a job writing for Arthur Godfrey's radio and television shows on CBS, and later wrote for the whole stable of CBS stars, including Garry Moore and Victor Borge.

In the 1960s, he wrote and produced TV news specials and topical essays, often narrated by CBS newsman Harry Reasoner. Mr. Rooney left in protest in 1970 when the network refused to broadcast his "Essay on War," moving briefly to Public Broadcasting Service and ABC. He returned to CBS and began narrating his own quirky news specials, including "Mr. Rooney Goes to Washington," which focused on things like the number of buildings the government owns and the fare at the congressional dining room.

Mr. Rooney had occasionally contributed to "60 Minutes" when in 1978 he was called on by the show's executive producer, Don Hewitt, to be a temporary replacement for a segment called "Point Counterpoint." One of his first segments saw him visit Pottstown, Pa., home of Mrs. Smith's Pies. He discovered there was no Mrs. Smith.

Mr. Rooney hunkered down for what turned out to be a 33-year run at "60 Minutes." In addition to his weekly TV spot, he wrote a syndicated newspaper column and collected his columns and scripts in best-selling books.

Read the entire obituary in the WSJ, subscription required . . .

On This Date in History – November 8

On this date in 1923, Adolph Hitler and a group of followers generally regarded as semi-lunatics broke into a Munich beer hall in Germany and proclaimed a new government. They had some thousands of adherents, but they miscalculated the attitude of the government and the people. Not only did the so-called beer hall putsch fail, but a few days later Hitler fled, only to be arrested and sent to prison. Some people thought that was the end of Adolf Hitler. We cannot stop even the worst of ideas by imprisonment. We can only stop ideas with better ideas.

On this date in 1932, Franklin Delano Roosevelt was elected President. He was elected again and again and again—four times in all. Whether liked or disliked, he was universally regarded as the politician par excellence. No American politician was ever more successful than he at convincing the American people that theirs was the generation that, in his words, had “a rendezvous with destiny.” It’s been a long rendezvous and I think it is still going on.

—After Leonard and Thelma Spinrad

Thank you for joining the MedicalTuesday.Network and Have Your Friends Do the Same. If you receive this as an invitation, please go to www.medicaltuesday.net/Newsletter.asp, enter you email address and join the 10,000 members who receive this newsletter. If you are one of the 80,000 guests that surf our web sites, we thank you and invite you to join the email network on a regular basis by subscribing at the website above. To subscribe to our companion publication concerning health plans and our pending national challenges, please go to www.healthplanusa.net/newsletter.asp and enter your email address. Then go to the archives to scan the last several important HPUSA newsletters and current issues in healthcare.

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.

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

Del Meyer

Del Meyer, MD
Editor & Founder

DelMeyer@MedicalTuesday.net

www.MedicalTuesday.net

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

Feedback . . .
Subscribe MedicalTuesday . . .
Subscribe HealthPlanUSA . . .

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, any single payer initiative, Social Security was born for the benefit of the state and of a contemptuous disregard for people’s welfare.

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.

Stalin said. "He who votes does not have power. He who counts the votes has power".

MEDICAL TUESDAY. NET	NEWSLETTER
Community For Better Health Care	Vol X, No 15, Nov 8, 2011

John C. Goodman

In Memoriam

Curmudgeonly Commentator Andy Rooney Dies at 92 on NOVEMBER 5, 2011

By STEPHEN MILLER

Del Meyer

Del Meyer, MD Editor & Founder

Del Meyer, MD
Editor & Founder