1.
Featured Article: Mirrors in the Mind, Scientific American, November 2006
Mirror neurons, a special class of cells
in the brain, may mediate our ability to mimic, learn and understand the
actions and intentions of others
A special class of brain cells reflects the outside
world, revealing a new avenue for human understanding, connecting and learning By Giacomo Rizzolatti, Leonardo Fogassi and Vittorio
Gallese
John watches Mary, who is grasping a flower. John knows
what Mary is doing - she is picking up the flower - and he also knows why she
is doing it. Mary is smiling at John, and he guesses that she will give him the
flower as a present. The simple scene lasts just moments, and John's grasp of
what is happening is nearly instantaneous. But how exactly does he understand
Mary's action, as well as her intention, so effortlessly?
A
decade ago most neuroscientists and psychologists would have attributed an
individual's understanding of someone else's actions and, especially,
intentions to a rapid reasoning process not unlike that used to solve a logical
problem: some sophisticated cognitive apparatus in John's brain elaborated on
the information his senses took in and compared it with similar previously
stored experiences, allowing John to arrive at a conclusion about what Mary was
up to and why.
Although such complex deductive operations probably do
occur in some situations, particularly when someone's behavior is difficult to
decipher, the ease and speed with which we typically understand simple actions
suggest a much more straightforward explanation. In the early 1990s our
research group at the University of Parma in Italy, which at the time included
Luciano Fadiga, found that answer somewhat accidentally in a surprising class
of neurons in the monkey brain that fire when an individual performs simple
goal-directed motor actions, such as grasping a piece of fruit. The surprising
part was that these same neurons also fire when the individual sees someone
else perform the same act. Because this newly discovered subset of cells seemed
to directly reflect acts performed by another in the observer's brain, we named
them mirror neurons.
Much
as circuits of neurons are believed to store specific memories within the
brain, sets of mirror neurons appear to encode templates for specific actions.
This property may allow an individual not only to perform basic motor
procedures without thinking about them but also to comprehend those acts when
they are observed, without any need for explicit
reasoning about them. John grasps Mary's action because even as it s happening
before his eyes, it is also happening, in effect, inside his head. It is
interesting to note that philosophers in the phenomenological tradition long
ago posited that one had to experience
something within oneself to truly comprehend it. But
for neuroscientists, this finding of a physical basis for that idea in the
mirror neuron system represents a dramatic change in the way we understand the
way we understand.
Instant
Recognition
Our research group was not seeking to support or
refute one philosophical position or another when we first noticed mirror
neurons. We were studying the brain's motor cortex, particularly an area called
F5 associated with hand and mouth movements, to learn how commands to perform
certain actions are encoded by the firing patterns of neurons. For this
purpose, we were recording the activity of individual neurons in the brains of
macaques. Our laboratory contained a rich repertoire of stimuli for the
monkeys, and as they performed various actions, such as grasping for a toy or a
piece of food, we could see that distinct sets of neurons discharged during the
execution of specific motor acts.
Then we began to notice something strange: when one of
us grasped a piece of food, the monkeys' neurons would fire in the same way as
when the monkeys themselves grasped the food. At first we wondered whether this
phenomenon could be the result of some trivial factor, such as the monkey
performing an unnoticed movement while observing our actions. Once we managed
to rule out this possibility and others, including food expectation by the
monkeys, we realized that the pattern of neuron activity associated with the
observed action was a true representation in the brain of the act itself,
regardless of who was performing it.
Often in biological research, the most direct way to
establish the function of a gene, protein or group of cells is simply to
eliminate it and then look for deficits in the organism's health or behavior
afterward. We could not use this technique to determine the role of mirror
neurons, however, because we found them spread across important regions on both
sides of the brain, including the premotor and parietal cortices. Destroying
the entire mirror neuron system would have produced such broad general
cognitive deficits in the monkeys that teasing out specific effects of the
missing cells would have been impossible.
So we adopted a different strategy. To test whether
mirror neurons play a role in understanding an action rather than just visually
registering it, we assessed the neurons' responses when the monkeys could
comprehend the meaning of an action without actually seeing it. If mirror neurons
truly mediate understanding, we reasoned, their activity should reflect the
meaning of the action rather than its visual features. We therefore carried out
two series of experiments.
First we tested whether the F5 mirror neurons could
"recognize" actions merely from their sounds. We recorded the mirror
neurons while a monkey was Observing a hand motor act, such as ripping a sheet
of paper or breaking a peanut shell, that is accompanied by a distinctive
sound. Then we presented the monkey with the sound alone. We found that many F5
mirror neurons that had responded to the visual observation of acts accompanied
by sounds also responded to the sounds alone, and we dubbed these cell subsets
audiovisual mirror neurons.
Next we theorized that if mirror neurons are truly
involved in understanding an action, they should also discharge when the monkey
does not actually see the action but has sufficient clues to create a mental
representation of it. Thus, we first showed a monkey an experimenter reaching
for and grasping a piece of food. Next, a screen was positioned in front of the
monkey so that it could not see the experimenter's hand grasping the food but
could only guess the action's conclusion. Nevertheless, more than half the F5
mirror neurons also discharged when the monkey could just imagine what was
happening behind the screen.
These experiments confirmed, therefore, that the
activity of mirror neurons underpins understanding of motor acts: when
comprehension of an action is possible on a nonvisual basis, such as sound or
mental representation, mirror neurons do still discharge to signal the act's
meaning.
Following these discoveries in the monkey brain, we
naturally wondered whether a mirror neuron system also exists in humans. We
first obtained strong evidence that it does through a series of experiments
that employed various techniques for detecting changes in motor cortex
activity. As volunteers observed an experimenter grasping objects or performing
meaningless arm gestures, for example, increased neural activation in their
hand and arm muscles that would be involved in the same movements suggested a
mirror neuron response in the motor areas of their brains. Further
investigations using different external measures of cortical activity, such as
electroencephalography, also supported the existence of a mirror neuron system
in humans. But none of the technologies we had used up to this point allowed us
to identify the exact brain areas activated when the volunteers observed motor
acts, so we set out to explore this question with direct brain-imaging
techniques.
In those experiments, carried out at San Raffaele
Hospital in Milan, we used positron-emission tomography (PET) to observe
neuronal activity in the brains of human volunteers as they watched grasping actions
performed with different hand grips and then, as a control, looked at
stationary objects. In these situations, seeing actions performed by others
activated three main areas of the brain's cortex. One of these, the superior
temporal sulcus (STS), is known to contain neurons that respond to observations of moving body parts. The other
two - the inferior parietal lobule (IPL) and the inferior frontal gyrus (IFG) -
correspond, respectively, to the monkey IPL and the monkey ventral premotor
cortex, including F5, the areas where we had previously recorded mirror
neurons.
These encouraging results suggested a mirror mechanism
at work in the human brain as well but still did not fully reveal its scope. If
mirror neurons permit an observed act to be directly understood by experiencing
it, for example, we wondered to what extent the ultimate goal of the action is
also a component of that "understanding."
On Purpose
RETURNING to our example of John and Mary,
we said John knows both that Mary is picking up the flower and that she plans
to hand it to him. Her smile gave him a contextual clue to her intention, and
in this situation, John's knowledge of Mary's goal is fundamental to his
understanding of her action, because giving him the flower is the completion of
the movements that make up her act. . .
Connect and Learn
AS WITH ACTIONS, humans undoubtedly understand
emotions in more than one way. Observing another person experiencing emotion
can trigger a cognitive elaboration of that sensory information, which ultimately
results in a logical conclusion about what the other is feeling. It may also,
however, result in direct mapping of that sensory information onto the motor
structures that would produce the experience of that emotion in the observer.
These two means of recognizing emotions are profoundly different: with the
first, the observer deduces the emotion but does not feel it; via the second,
recognition is firsthand because the mirror mechanism elicits the same
emotional state in the observer. Thus, when people use the expression "I
feel your pain" to indicate both comprehension and empathy, they may not
realize just how literally true their statement could be. . .
To read the entire article (subscription required),
please go to www.sciam.com/article.cfm?chanID=sa006&colID=1&articleID=0003617B-DA45-152F-960883414B7F0123
GIACOMO RIZZOLATTI, LEONARDO
FOGASSI and VITTORIO GALLESE work
together at the University of Parma in Italy, where Rizzolatti is director of
the neurosciences department and Fogassi and Gallese are associate professors.
In the early 1990s their studies of motor systems in the brains of monkeys and
humans first revealed the existence of neurons with mirror properties. They
have since continued to investigate those mirror neurons in both species as
well as the role of the motor system in general cognition. They frequently
collaborate with the many other research groups in Europe and the U.S. now also
studying the breadth and functions of the mirror neuron system in humans and
animals.
* * * * *
2.
In the News: Climate Change: WSJ vs Scientific American, The
Final Word?
Jeffrey D Sachs director of the Earth Institute at
Columbia University, in his Scientific American column, Sustainable
Developments, in October discusses "Fiddling while the Planet Burns"
He asks: Will the Wall Street Journal's editorial writers accept a
challenge to learn the truth about the science of global climate change? Sachs
outlines his position at (subscription required) www.sciam.com/print_version.cfm?articleID=000D5C47-C124-1509-805C83414B7FFDB0.
Climate
Non-Conformity, WSJ, November 2, 2006
Two scientific events of note occurred this week, but
only one got any media coverage. Therein lies a story about modern politics and
scientific priorities.
The report that received the headlines was Monday's
700-page jeremiad out of London on fighting climate change. Commissioned by the
British government and overseen by former World Bank chief economist Nicholas
Stern, the report made the intentionally shocking prediction that global warming
could eliminate from 5% to 20% of world economic output "forever."
Meanwhile, doing the supposedly virtuous thing and trying to forestall this
catastrophe would cost merely an estimated 1% of world GDP. Thus we must act
urgently and with new taxes and policies that go well beyond anything in the
failed Kyoto Protocol.
The other event was a meeting at the United Nations
organized by economist Bjorn Lomborg's Copenhagen Consensus Center. Ambassadors
from 24 countries -- including Australia, China, India and the U.S. -- mulled
which problems to address if the world suddenly found an extra $50 billion
lying around. Mr. Lomborg's point is that, in a world with scarce resources,
you need priorities. The consensus was that communicable diseases, sanitation
and water, malnutrition and hunger, and education were all higher priorities
than climate change.
We invited Mr. Lomborg to address the Stern report,
and he takes apart its analysis brick-by-brick in the columns nearby. To our
reading, there isn't much left of this politicized edifice. But we'd stress a
couple of points ourselves. To read these points, please go to (subscription
required) http://online.wsj.com/article_print/SB116243389091610956.html. For Mr Lomborg's analysis, read on.
Stern
Review on the Economics of Climate Change, WSJ, By BJORN LOMBORG November
2, 2006
The report on climate change by Nicholas Stern and the
U.K. government has sparked publicity and scary headlines around the world.
Much attention has been devoted to Mr. Stern's core argument that the price of
inaction would be extraordinary and the cost of action modest.
Unfortunately, this claim falls apart when one
actually reads the 700-page tome. Despite using many good references, the Stern
Review on the Economics of Climate Change is selective and its conclusion
flawed. Its fear-mongering arguments have been sensationalized, which is
ultimately only likely to make the world worse off.
The review correctly points out that climate change is
a real problem, and that it is caused by human greenhouse-gas emissions. Little
else is right, however, and the report seems hastily put-together, with many
sloppy errors. As an example, the cost of hurricanes in the
The review is also one-sided, focusing almost
exclusively on carbon-emission cuts as the solution to the problem of climate
change. Mr. Stern sees increasing hurricane damage in the U.S. as a powerful argument
for carbon controls. However, hurricane damage is increasing predominantly
because there are more people with more goods to be damaged, settling in ever
more risky habitats. Even if global warming does significantly increase the
power of hurricanes, it is estimated that 95% to 98% of the increased damage
will be due to demographics. The review acknowledges that simple initiatives
like bracing and securing roof trusses and walls can cheaply reduce damage by
more than 80%; yet its policy recommendations on expensive carbon reductions
promise to cut the damages by 1% to 2% at best. That is a bad deal.
Mr. Stern is also selective, often seeming to
cherry-pick statistics to fit an argument. This is demonstrated most clearly in
the review's examination of the social damage costs of CO2 -- essentially the
environmental cost of emitting each extra ton of CO2. The most well-recognized
climate economist in the world is probably
Most economists were surprised by Mr. Stern's large
economic estimates of damage from global warming. Mr. Nordhaus's model, for
example, anticipates 3% will be wiped off global GDP if nothing is done over
the coming century, taking into account the risk for catastrophes. The Stern
review purports to show that the cost is "larger than many earlier studies
suggested."
On the face of it, Mr. Stern actually accepts Mr.
Nordhaus's figure: Even including risks of catastrophe and non-market costs, he
agrees that an increase of four degrees Celsius will cost about 3% of GDP. But
he assumes that we will continue to pump out carbon far into the 22nd century
-- a rather unlikely scenario given the falling cost of alternative fuels, and
especially if some of his predictions become clear to us toward the end of this
century. Thus he estimates that the higher temperatures of eight degrees
Celsius in the 2180s will be very damaging, costing 11% to 14% of GDP.
The Stern review then analyzes what the cost would be
if everyone in the present and the future paid equally. Suddenly the cost
estimate is not 0% now and 3% in 2100 -- but 11% of GDP right now and forever.
If this seems like a trick, it is certainly underscored by the fact that the
Stern review picks an extremely low discount rate, which makes the cost look
much more ominous now.
But even 11% is not the last word. Mr. Stern suggests
that there is a risk that the cost of global warming will be higher than the
top end of the U.N. climate panel's estimates, inventing, in effect, a
"worst-case scenario" even worse than any others on the table.
Therefore, the estimated damage to GDP jumps to 15% from 11%. Moreover, Mr.
Stern admonishes that poor people count for less in the economic calculus, so
he then inflates 15% to 20%.
This figure, 20%, was the number that rocketed around
the world, although it is simply a much-massaged reworking of the standard 3%
GDP cost in 2100 -- a figure accepted among most economists to be a reasonable estimate.
. .
The Stern review's cornerstone argument for immediate
and strong action now is based on the suggestion that doing nothing about
climate change costs 20% of GDP now, and doing something only costs 1%.
However, this argument hinges on three very problematic assumptions. . .
Why does all this matter? It matters because, with
clever marketing and sensationalist headlines, the Stern review is about to
edge its way into our collective consciousness. The suggestion that flooding
will overwhelm us has already been picked up by commentators, yet going back to
the background reports properly shows declining costs from flooding and
fewer people at risk. The media is now quoting Mr. Stern's suggestion that
climate change will wreak financial devastation that will wipe 20% off GDP,
explicitly evoking memories of past financial catastrophes such as the Great
Depression or World War II; yet the review clearly tells us that costs will be
0% now and just 3% in 2100.
It matters because Gordon Brown, Tony Blair and
Nicholas Stern all profess that one of the major reasons that they want to do
something about climate change is because it will hit the world's poor the
hardest. Using a worse-than-worst-case scenario, Mr. Stern warns that the
wealth of South Asia and Sub-Saharan Africa will be reduced by 10% to 13% in
2100 and suggests that effect would lead to 145 million more poor people.
Faced with such alarmist suggestions, spending just 1%
of GDP or $450 billion each year to cut carbon emissions seems on the surface
like a sound investment. In fact, it is one of the least attractive options.
Spending just a fraction of this figure -- $75 billion -- the U.N. estimates
that we could solve all the world's major basic problems. We could give
everyone clean drinking water, sanitation, basic health care and education
right now. Is that not better? . .
Last weekend in New York, I asked 24 U.N. ambassadors
-- from nations including China, India and the U.S. -- to prioritize the best
solutions for the world's greatest challenges, in a project known as Copenhagen
Consensus. They looked at what spending money to combat climate change and
other major problems could achieve. They found that the world should prioritize
the need for better health, nutrition, water, sanitation and education, long
before we turn our attention to the costly mitigation of global warning.
We all want a better world. But we must not let
ourselves be swept up in making a bad investment, simply because we have been
scared by sensationalist headlines.
Mr. Lomborg, author of "The Skeptical
Environmentalist" (Cambridge, 2001), teaches at the Copenhagen Business
School and is director of the Copenhagen Consensus Center.
http://online.wsj.com/article_print/SB116243506287110986.html
* * * * *
3.
International Medicine: From The Journal of
Child Psychology and Psychiatry
Research published in The Journal of Child
Psychology and Psychiatry in January has shown that even women without past
mental health problems are at risk of psychological ill-effects after abortion.
Women who had had abortions had twice the level of mental health problems and
three times the risk of major depressive illness as those who had given birth
or never been pregnant.
This research has prompted the American Psychological
Association to withdraw an official statement denying a link between abortion
and psychological harm.
Since women having abortions can no longer be said to
have a low risk of suffering from psychiatric conditions such as depression,
doctors have a duty to advise about long-term adverse psychological
consequences of abortion.
We suggest that the Royal College of Obstetricians and
Gynaecologists and the Royal College of Psychiatrists revise their guidance,
and that future abortion notifications clearly distinguish between physical and
mental health grounds for abortion.
ROBERT BALFOUR
Emeritus Consultant Obstetrician and Gynaecologist, Bridgend
PATRICIA CASEY
Professor of Psychiatry, University College, Dublin
MARJORY FOYLE
Consultant Psychiatrist, London
To review the list of 15 prominent physicians who
asked the Royal College of Obstetricians and Gynaecologists and the Royal
College of Psychiatrists to revise their guidelines, please go to
www.timesonline.co.uk/article/0,,59-2423358.html.
To read about SUE HULBERT, 44, who had an abortion in
May 2000 and is only now recovering from the depression and psychosis that
followed, culminating in an overdose, please go to www.timesonline.co.uk/article/0,,8122-2424033,00.html.
* * * * *
4.
Medicare: Stethoscope socialism By Deroy Murdock, Washington Times, September 5, 2006
A national health-care system may be the Holy Grail of
American liberalism. If only the government managed medicine, the argument
goes, costs could be restrained, quality assured and access extended from the
poshest beach house to the humblest shotgun shack.
On NBC's "Meet the Press" last fall, Rep.
Rahm Emanuel, Illinois Democrat, advocated a "universal health-care system
over the next 10 years." If Sen. Hillary Rodham Clinton, New York
Democrat, reaches the Oval Office, she likely would take another crack at
socialized medicine, as she did so disastrously in 1994.
Amy Ridenour of the National Center for Public Policy
Research sees this model more as a poisoned chalice. Her Washington-based
free-market think tank (with which I am a "distinguished fellow") has
begun educating Americans on the massive belly flop that is state-sponsored health
care. Wherever bureaucrats control medicine, the wise money says: "Don't
get sick."
It would be bad enough if national health care merely
offered patients low-quality treatment. Even worse, Ms. Ridenour finds, it
kills them. Breast cancer is fatal to 25 percent of
its American victims. In Great Britain and New Zealand, both
socialized-medicine havens, breast cancer kills 46 percent of women it strikes.
Prostate cancer proves fatal to 19 percent of its
American sufferers. In single-payer Canada, the National Center for Policy
Analysis reports, this ailment kills 25 percent of such men and eradicates 57
percent of their British counterparts.
After major surgery, a 2003 British study found, 2.5
percent of American patients died in the hospital versus nearly 10 percent of
similar Britons. Seriously ill U.S. hospital patients die at one-seventh the
pace of those in the U.K.
"In usual circumstances, people over age 75
should not be accepted" for treatment of end-state renal failure,
according to New Zealand's official guidelines. Unfortunately, for older Kiwis,
government controls kidney dialysis.
According to a Populus survey, 98 percent of Britons
want to reduce the time between diagnosis and treatment.
Unlike America's imperfect but more market-driven
health-care industry, nationalized systems usually divide patients and
caregivers. In America, patients and doctors often make medical decisions and
thus demand the best-available diagnostic tools, procedures and drugs.
Affordability obviously plays its part, but the fact that most Americans either
pay for themselves or carry various levels of insurance guarantees a market
whose profits reward medical innovators.
Under socialized medicine, public officials administer
a single budget and usually ration care among a population whose sole choice is
to take whatever therapies the state monopoly provides.
Medicrats often distribute resources based on politics
rather than science. Government doctors and nurses frequently are unionized. As
befalls American teachers in government schools, excellence rarely generates
additional compensation - so why excel? Without incentives, such structures
eventually breed mediocrity. Patients in universal-care systems get cheated
even worse than do students in failing public schools. While their pupils
suffer intellectually, politically driven health care jeopardizes patients'
lives.
Emily Morely, 57, of Meath
Park, Saskatchewan, discovered that cancer had invaded her liver, lungs,
pancreas and spine. She also learned she had to wait at least three months to
see an oncologist. In Canada, where private medicine is illegal, this could
have meant death. However, Mrs. Morely saw a doctor after one month - once her
children alerted Canada's legislature and mounted an international publicity
campaign.
James Tyndale, 54, of
Cambridge, England, wanted Velcade to stop his bone-marrow cancer. However, the
government's so-called "postcode lottery" supplied this drug to some
cities, but not Cambridge. The British health service finally relented after
complaints from the Tories' shadow health secretary, MP Andrew Lansley.
Edward Atkinson, 75, of Norfolk, England, was deleted from a government
hospital's hip-replacement-surgery waiting list after he mailed graphic
anti-abortion literature to hospital employees. "We exercised our right to
decline treatment to him for anything other than life-threatening
conditions," said administrator Ruth May. She claimed her employees
objected to Mr. Atkinson's materials. Despite a member of Parliament's pleas,
Mr. Atkinson still awaits surgery.
For all its problems, America's more market-friendly
health system offers patients better care and would deliver greater
advancements if government adopted liability reform, interstate medical
insurance sales, unhindered health savings accounts and other pro-market
improvements. As for importing universal care, author P.J. O'Rourke said it
best: "If you think health care is expensive now, just wait until it's
free."
www.washingtontimes.com/functions/print.php?StoryID=20060904-102551-8847r
Deroy Murdock is a columnist with the Scripps Howard News Service and a
senior fellow with the Atlas Economic Research Foundation in Arlington, Va.
Our thanks to MedicalTuesday member Gretchen Longcore
for bringing this article and others to our attention.
Government
is not the solution to our problems, government is the problem.
- Ronald Reagan
* * * * *
5.
Medical Gluttony
is Increasing System Inefficiency: This is NOT Sustainable.
We were introduced to Jim Womack's Lean Marketing (www.lean.org) concepts by the CEO of Superfactory (www.superfactory.com) and have been following this idea over the past
couple of years. We have been keeping our members informed of their medicinal
application. This month, the editor of Superfactory, in commenting on their
tremendous growth, emphasizes that lean manufacturing and lean enterprise
methods are required to remain competitive in our global economy. So much of
health care is moving in the opposite direction in the pursuit of cost control,
when in fact it is increasing costs and decreasing efficiencies. The only
problem is that the system is unable to measure many of these costs. Many
doctors who weren't in tune to business practices were persuaded in giving up
their formerly small, efficient business units. They were seduced by hospital
PHOs, IPAs, Foundations, and managed care organizations (MCOs) into believing
that the larger unit was required to be efficient. However, efficiency has been
lost.
Let us look at the simple one-minute process of
writing a prescription for the patient. This has created a nightmare of costs
that is not recorded as medical costs. My front-office staff will spend up to
15 minutes on the phone before hand trying to determine which particular drug
is covered by that patient's health plan. In several instances, the same
prescription will generate three separate phone calls before the resolution.
This, in effect, is more time in completing a one-minute prescription than the
initial 20-minute office visit. The more than 100 percent increase in cost to
the physician's office is not noted as a health-care cost.
This is not just an isolated instance. Caremark, Rx
Solutions, Medco, and Express Scripts all have the same problem. My
front-office assistant estimated that her time devoted to this task on two days
last week exceeded three hours each day. (To see what pharmacy benefit
managers' CEO's make, go to www.medicaltuesday.net/archives/May2306.htm#INTHENEWS.)
At a Blue Cross Conference, one of these Pharmacy
Benefit Managers extolled the efficiencies of their system. When the patient
picks up his last refill, they immediately start faxing the doctor's office for
renewals, sometimes daily. We pointed out that all of our patients get refill
renewals on all their prescriptions until their next appointment, PLUS one
month in case they have to reschedule. Hence, we would appreciate not getting
20 to 30 faxed requests for refills a day. My patients probably are already
scheduled for their next visit before the current refill is used up. At that
time, they will get new prescriptions with refills to last one year or until
their next appointment. Unless I happen to get to the office before my staff so
that I can put the 20 or 30 faxes through the shredder, it creates an office
cost in processing all that unnecessary paper work.
Before answering the question, the speakers looked at
each other for a moment and then replied that they had developed this super
efficient system, and they would not consider making it less efficient. What
they perceived as efficiency was not lean healthcare, but was actually
gluttonous health care, which decreases efficiency and increases costs.
Gluttonous health care cannot survive in the free market. It will die - unless
the government takes over health care, in which event it will thrive and
flourish.
The Free and Open Medical Market Place Will Make
Health Care Lean and Affordable.
* * * * *
6.
Medical
Myths: Rising to the Challenge by
Donald W Fisher, PhD, President & CEO
Publisher's
Comment: Group Practice Journal, American Medical Group Association
This issue features highlights from, our recently
published 2006 Medical Group Compensation & financial Survey. According to
findings, most specialties saw modest increases in compensation in 2005.
Declining reimbursements, competition for specialists, the cost of new
technology, and other factors are having a negative effect on revenues in most
parts of the country, a situation that is clearly unsustainable.
The section of the survey that examines financial
operations also found that medical groups were operating at an average loss
of$1,264 s per physician (median performance per physician). It reports
significant variation by region: groups in the Northern Region continue to
operate at a significant loss, $8,111 per physician. Medical groups in the
Eastern and Southern regions continue operating at a loss $3,494 and $1,539 per
physician, respectively). Groups in the Western Region were performing better
at 7,970 per physician.
In the face of the current economic climate, medical
groups are rising to the challenge of delivering the highest quality,
coordinated care to the patients they serve. One of the components contributing
significantly to the trends in financial performance of medical groups is the
current payment model. Most of the groups represented in the survey are large
multispecialty groups that make substantial investments in technology,
operations, and the most innovative care processes to best serve populations
under their care, and are able to achieve remarkable results for their
patients. Our current transaction based reimbursement system is indifferent to
these results and to the efforts of medical groups to elevate the standard of
care in the U.S.
lMGA's Results-Based Payment System (RPS) initiative
seeks to design and implement a reimbursement system that rewards care quality
and results. The RPS initiative seeks to develop a new model for reimbursement,
based on improved healthcare delivery with regard to efficiency, timeliness,
quality, appropriateness, and other factors. Results-based payment moves beyond
today's pay-far-performance (P4P) models, and would promote coordinated care,
technologic innovation, and continuous learning, as well as increase accountability
for all stakeholders in health care. For more information, visit www.amga.org.
* * * * *
7.
Overheard in the
Medical Staff Lounge: The Butcher of Baghdad Meets His Fate
There were three
newspapers on the staff room dining tables: the Sacramento Bee, the SF
Chronicle, and the Wall Street Journal. The WSJ had no
headlines for the Saddam Hussein verdict. The other two highlighted the news in
huge print.
Dr Edwards: Yesterday's papers both said that
the Saddam verdict will further divide Iraq. Today's headlines state that the
Saddam verdict elicits hope. Which is it?
Dr Yancy: There can't be any more
division than there is already. The Shiites and Kurds will be elated that the
Butcher of Baghdad will meet his due reward.
Dr Ruth: But the Sunnis say that Saddam
was a righteous man. They aren't going to take this.
Dr Edwards: But the division can't get any
worse. The verdict should help bring closure.
Dr Ruth: But there has never been a
trial and verdict in the Arab world such as this. What will be the fallout in
the entire region?
Dr Yancy: The people of the mideast have
been fighting and killing each other for thousands of years. Nothing is going
to change that picture.
Dr Ruth: After the elections, there
might be a greater push to leave them alone to let them do their killing in
peace without our presence.
Dr Edwards: But many of our soldiers who
are fighting for the cause are now saying, we can't leave. We need to stay.
Doesn't that say something? Isn't that a bit more insightful than our
congressmen who visit the battlescarred country and come back as experts after
a few days?
Dr Yancy: You can't trust a congressman.
They don't have an opinion until after they read the polls about what their
constituents think.
Dr Rosen: It was Lew Rockwell who said
that they don't have a brain. No one with a brain goes to Washington anymore.
No one with a brain goes to a country and overnight considers himself an expert
in their history and culture.
Dr Yancy: I spent four years of my
training in Israel and know the area well. I'll be watching the hanging on TV
with my family. I hope the cameras will be able to pick up the first Shiite or
Kurd that puts a bullet through Saddam. After the first bullet, I'm sure there
will be hundreds. The Arab world doesn't believe in gun control. There may be thousands firing. That will be
closure for a lot of folks.
* * * * *
8.
Voices of Medicine: A Review of Regional Medical Journals from Rural
California
The Bulletin, Published Monthly by the Humboldt-Del Norte County Medical
Society, Sept 2006
IN
MY OPINION: The Way We Were (And Will Be Again) by GEORGE
INGRAHAM, M.D.
It was 1970: I had finished my residency and settled
in Eureka. There were three hospitals in the city: Humboldt County Medical
Center and the General Hospital, in addition to St Joseph. Each hospital staff
met as a whole once a month. New docs needed to be on all three staffs if they
wanted to build a referral practice. We had no neurologist, plastic surgeon, or
neurosurgeon. Emergency room physicians
were unknown outside academia. We were all, on a rotating basis, on call to the
hospital emergency rooms: ophthalmologists were called to deliver babies and
internists were consulted for corneal abrasions. The hospital ERs were not
staffed until a patient was brought in, at which point the nursing supervisor
would unlock the Emergency Room and telephone the patient's family physician or
whoever was on call for that day.
We had no scanners, much less computers, and no
physician expanding FNP's, PA's, or CRNA's. We had only two female physicians,
women having been felt by our predecessors not to be suited (I had a surgical
mentor who proclaimed to our incredulous group that it was a waste of resources
to let women into medical school at all) to the practice of medicine. More on
this foolishness later.
What we did have; and it made up for many of the
things the community lacked, was a very close-knit county medical society. The
monthly meetings were held at OH's Town House (they still do a pretty good
prime rib!) and with some exceptions every physician was there every month.
Everyone knew the community's problems, which were discussed (not always
dispassionately by those who had begun the evening at the bar) and dealt with
as best we could. The medical society was an integral part of the mechanism of
the community, and willingly accepted responsibility for seeing to it that the
medical care part of the community was adequate and effective. Unfortunately,
it was a men's club: it could get rowdy, and there were some outsize egos on
parade. But by and large, flawed as it was, through the haze of bourbon fumes
and cigarette smoke, angry exchanges, and the occasional abrupt and angry
departures
it worked. Some decades
passed, and with them most of my hair, near vision, and svelte physique. We got
a CAT scanner, Ted Loring bought a computer to do his billing, Russel Pardoe
came to town, FNP's and PA's came on the scene, and ER docs became part of the
herd, over the misgivings of the family practice docs who saw them as a threat
and insisted on reassurances that they wouldn't be allowed to follow up on
cases they had seen. The size and diversity of the medical community increased. Hospital staffs, too large to meet as a
whole, became departmentalized; and the medical community fragmented. You could
actually pass another physician on the street and not recognize him or
good
grief...her! Attendance at the monthly
meeting of the Society declined (largely due to an apathy which still confuses
me) to the point that it was no longer felt to be worthwhile. The sense of
community was largely lost. Fortunately the Medical Society remained
intact. The medical community now faces
major changes in Eureka's one remaining hospital. The recruitment of new docs
falls short of our need to replace the aging physician workforce. Falling
reimbursements and intrusive management of care
but you know the list.
What's heartening is the resurgence of the Medical
Society as the vehicle within which this loose collection of docs, unable to
deal with these problems as individuals, may again become a de facto medical
community with a real connection to the community we live in. With any luck, we
will get back to where we were thirty odd years ago, minus the posturing and
the verbal brawls. OK, most of the verbal brawls. For this we must largely
thank Ellen Mahoney, whose willingness to take her time, that limited and
irreplaceable gift, to organize and lead the troops, and Kate McCaffery, who is
recruiting new members. The conventional wisdom is that psychologically women
are better at finding consensus and organizing groups toward shared goals, and
if so we are very lucky to have women leaders who can grab us by the ears and
tell us "OK: we're going to deal with these problems; now sit down over
there and start cooperating!"
Or
maybe gender has nothing to do with it. After all, they're both Irish. §
www.humboldt1.com/~medsoc/images/bulletins/SEPTEMBER%202006%20BULLETIN%20for%20web.pdf
* * * * *
9.
Book Review: From our Archives: Inside the AARP
TRUST BETRAYED - Inside the AARP by Dale Van Atta. Regenery Publishing, Inc.
Washington, DC: 1998, 208 pp, $25, ISBN 0-89526-485-4.
Dale Van Atta wrote a syndicated column with Jack
Anderson that ran in more than 800 newspapers for over seven years. Today, he
is a freelance author and journalist. He dedicates this volume to his aging
mother, Vera Van Atta. We should alert our aging parents, even those under age
50, about this volume and the highly charged promotional campaign of the AARP.
The AARP is the second-largest organization in the
United States, after the Catholic Church. It has thirty-three million members.
Ethel Percy Andrus, a retired schoolteacher, was its founder. Steeped in the
American ethos of God, country, and self-reliance, she explicitly stated that
the "AARP is not a pressure group, petitioning for special privileges
and exemptions because of age and numbers."
Today, the AARP supports higher taxes, disastrous
health care legislation that threatens seniors, and other political causes such
as attempting to defeat property tax reductions, the very thing that allows
many retired seniors to keep their homes. The AARP has numerous business
enterprises, including insurance and pharmaceuticals, that it claims are
nonprofit services for seniors, but which are revenue engines for AARP causes
and profit its business partners. Colonial Penn derives 80% of its profits from
the AARP monopoly.
The AARP, with an income of more than $400 million a
year, spent $83 million for salaries and benefits in 1994. Nineteen of the
AARP's 1,732 employees earn more than $100,000 a year. The executive director,
Horace Deets, headlined in a 1997 Fortune magazine profile as Washington's
Second Most Powerful Man, making $357,000 a year in salary and benefits
($157,000 more than
To read other reviews, please go to the Physician/Patient Bookshelf at www.delmeyer.net/PhysicianPatientBookshelf.htm.
* * * * *
10. Hippocrates & His Kin: Practice Guidelines can
work in two ways - neither of which are good.
At medical grand rounds this past week, the speaker
addressed the guidelines that will rule medicine. He mentioned that shifting
the guidelines on mammograms minimally could make a difference in saving
billions of dollars in health-care costs. So let's see. If the radiology lobby
gains ascendancy and changes the guidelines for mammograms to earlier than the
current age or to obtain them more frequently, it could add billions of dollars
to the radiologist's income?
Bureaucratic medicine will always favor the ones in
power over the ones practicing good medicine.
It's a Relief to Know the Truth after All Those
Conflicting Medical Studies
On two tables of stone, DIETS & DYING found
on Mt Ararat, a short distance from Mt Sinai, the final word on nutrition and
health were found. (We're researching the validity of the finding.)
The Japanese eat very little fat or red wine and
suffer fewer heart attacks than the British or Americans. The French eat a lot
of fat, drink a lot of red wine, and also suffer fewer heart attacks than the
British or Americans. The Italians drink excessive amounts of red wine and a
lot of cheese and also suffer fewer heart attacks than the British or
Americans.
CONCLUSION: Eat and drink what you like. Speaking
English is apparently what kills you.
During the course of the
election campaigns, a San Franciscan didn't seem too worried that any
Republican could or would get elected. He said San Francisco has the best
politicians that money can buy.
Although some people think that things will be getting
better after the elections, let's remember Yogi Berra: "Predictions are
very difficult, especially about future events."
To read more vignettes, please go to www.healthcarecom.net/hhk2000.htm.
* * * * *
11. Organizations Restoring Accountability in HealthCare,
Government and Society: