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MEDICAL
TUESDAY . NET |
NEWSLETTER |
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Community For Better Health Care |
Vol VII, No 16, Nov 25, 2008 |
In This Issue:
1.
Featured Article: New Light on Creativity
2.
In the News: Cancer Drugs Don't Help 75% Of The People Who
Take Them
3.
International
Medicine: Socialized Medicine will Collapse with Information Technology
4.
Medicare: The Stepchild of Social Security
5.
Medical Gluttony: Changing Doctors May Decrease Quality
and Increase Costs
6.
Medical Myths: Ten Myths of the American Health Care System
7.
Overheard in the Medical Staff Lounge: The Election is
Over, Now What's Next?
8.
Voices of
Medicine: The Future Practice of Anesthesiology
9.
From the Physician Patient Bookshelf: The Story of Our Constitution
10.
Hippocrates
& His Kin: Don't Just Stand There, Do Something!
11.
Related Organizations: Restoring Accountability in Medical
Practice and Society
MOVIE EXPLAINING SOCIALIZED
MEDICINE TO COUNTER MICHAEL MOORE's SiCKO
Logan Clements,
a pro-liberty filmmaker in Los Angeles, seeks funding for a movie exposing the
truth about socialized medicine. Clements is the former publisher of
"American Venture" magazine who made news in 2005 for a property
rights project against eminent domain called the "Lost Liberty
Hotel."
For more information visit www.sickandsickermovie.com or email logan@freestarmovie.com.
* * * * *
1.
Featured
Article: New Light on Creativity
Neuroscience
Sheds New Light on Creativity Wired
Magazine, Oct 08, By Gregory Berns
Close your eyes and visualize the sun setting over a beach.
How detailed was your image? Did you envision a bland
orb sinking below calm waters, or did you call up an image filled with activity
-- palm trees swaying gently, waves lapping at your feet, perhaps a loved one
holding your hand?
Now imagine you're standing on the surface of Pluto.
What would a sunset look like from there? Notice how hard you had to work to
imagine this scene. Did you picture a featureless ball of ice with the sun a
speck of light barely brighter than a star along the horizon? Did you envision
frozen lakes of exotic chemicals or icy fjords glimmering in the starlight?
What you conjured illuminates how our brains work, why
it can be so hard to come up with new ideas -- and how you can rewire your mind
to open up the holy grail of creativity. Recent advances in neuroscience,
driven by functional magnetic resonance imaging (fMRI) that lets scientists
watch brain activity as never before, have changed what we know about key
attributes of creativity. These advances, for example, have swept away the idea
that there is a pleasure center in the brain that somehow acts as an
accelerator to the engine of human behavior. Rather, chemicals such as dopamine
shuttle between neurons in ways that look remarkably like the calculations
modern robots perform.
Creativity and imagination begin with perception.
Neuroscientists have come to realize that how you perceive something isn't
simply a product of what your eyes and ears transmit to your brain. It's a
product of your brain itself. And iconoclasts, a class of people I define as
those who do something that others say can't be done -- think Walt Disney,
Steve Jobs, or Florence Nightingale -- see things differently. Literally. Some
iconoclasts are born that way, but we all can learn how to see things not for
what they are, but for what they might be.
Perception and imagination are linked because the
brain uses the same neural circuits for both functions. Imagination is like
running perception in reverse. The reason it's so difficult to imagine truly
novel ideas has to do with how the brain interprets signals from your eyes. The
images that strike your retina do not, by themselves, tell you with certainty
what you are seeing. Visual perception is largely a result of statistical
expectations, the brain's way of explaining ambiguous visual signals in the
most likely way. And the likelihood of these explanations is a direct result of
past experience.
Entire books have been written about learning, but the
important elements for creative thinkers can be boiled down to this: Experience
modifies the connections between neurons so that they become more efficient at
processing information. Neuroscientists have observed that while an entire
network of neurons might process a stimulus initially, by about the sixth
presentation, the heavy lifting is performed by only a subset of neurons.
Because fewer neurons are being used, the network becomes more efficient in
carrying out its function.
The brain is fundamentally a lazy piece of meat. It
doesn't want to waste energy. That's why there is a striking lack of
imagination in most people's visualization of a beach sunset. It's an iconic
image, so your brain simply takes the path of least resistance and reactivates
neurons that have been optimized to process this sort of scene. If you imagine
something that you have never actually seen, like a Pluto sunset, the
possibilities for creative thinking become much greater because the brain can
no longer rely on connections shaped by past experience.
In order to think creatively, you must develop new
neural pathways and break out of the cycle of experience-dependent
categorization. As Mark Twain said, "Education consists mainly in what we
have unlearned." For most people, this does not come naturally. Often, the
harder you try to think differently, the more rigid the categories become.
Most corporate off-sites, for example, are ineffective
idea generators, because they're scheduled rather than organic; the brain has
time to predict the future, which means the potential novelty will be
diminished. . . Transplanting the same mix of people to a different location,
even an exotic one, then dropping them into a conference room much like the one
back home doesn't create an environment that leads to new insights. No, new
insights come from new people and new environments -- any circumstance in which
the brain has a hard time predicting what will happen next.
Fortunately, the networks that govern both perception
and imagination can be reprogrammed. By deploying your attention differently,
the frontal cortex, which contains rules for decision making, can reconfigure
neural networks so that you can see things that you didn't see before. You need
a novel stimulus -- either a new piece of information or an unfamiliar
environment -- to jolt attentional systems awake. The more radical the change,
the greater the likelihood of fresh insights.
Some of the most startling breakthroughs have had
their origins in exactly these types of novel circumstances. . . Walt Disney was a decent illustrator, but
he didn't imagine the possibilities of animation until he saw his advertising
illustrations projected onto the screen in a movie theater. In an extreme
example, the preeminent glass artist Dale Chihuly didn't discover his
sculptural genius until a car accident led to the loss of an eye and literally
forced him to see the world differently. Only when the brain is confronted with
stimuli that it has not encountered before does it start to reorganize
perception. The surest way to provoke the imagination, then, is to seek out
environments you have no experience with. They may have nothing to do with your
area of expertise. It doesn't matter. Because the same systems in the brain
carry out both perception and imagination, there will be cross talk. . . To read the entire article, go to www.fastcompany.com/magazine/129/rewiring-the-creative-mind.html
Adapted from the book Iconoclast, by Gregory Berns, by permission of
Harvard Business Press. Copyright 2008 Harvard Business School Publishing Corp.
All Rights Reserved.
* * * * *
2. In the News: Revolutionaries: Merck's Free Radical, Forbes, by
Cancer drugs don't help 75% of the people who take
them. Stephen Friend says he can use science to end the crapshoot
In the downtrodden drug industry, Merck cancer guru
Stephen Friend may be one of the last great dreamers. His latest idea is one
that would completely change the secretive and siloed way the pharmaceutical
business fights cancer: create a giant, open-to-the-public database that will
include every cancer drug and every patient and how that patient is doing.
Track everything and over time we might be able to raise the abysmal success
rate of treatment.
Friend, 54, has been a doctor who treated kids with
cancer, an academic, an entrepreneur and a biotech chief executive. He helped
develop a diagnostic test that predicts whether breast cancer will return after
surgery. For five years he has been in charge of getting cancer drugs invented
at Merck. Now 8 are in clinical trials, up from one, with 15 more preparing to
enter trials. Friend is still unsatisfied. Why is it that, on average, three
out of every four people who take a cancer medicine get lots of side effects
but no benefit?
Researchers have been too willing to bet on hunches,
he says, yet the technology to understand the complex biology of cancer is at
hand. Spurred by Friend, Merck has spent billions on an arsenal of technologies
for understanding how genes work. The resulting data stream is sent through the
fastest supercomputer in the drug industry, a beast that consumes 64 kilowatts
of power and is capable of 16 trillion calculations a second. Friend thinks he
can accurately predict how groups of proteins in tumors work together and use
that information to kill the cancer. He's trying to drag the secretive world of
drug-discovery chemistry into the computer age.
The Friend way would take all the data collected each
year from the thousands of cancer patients entered in trials, make it anonymous
and put it into one database, preferably held by the government but definitely
accessible to any physician or scientist. Right now those data are lost to the
wind once the trial is over. But by keeping track of patients' genes, the genes
in their tumors and what drugs they take, scientists will be able to discern patterns.
Instead of trying drugs in order, from the ones that work most often to those
that work least often, doctors will be able to pick the medicine that is most
likely to help a particular patient. New medicines will get to market faster,
along with diagnostic tests that will predict what will work. Friend predicts,
somewhat optimistically, that prescribing decisions won't be based on "a
promotional campaign." The database will decide.
"That future world is coming," says Friend.
"And pharmaceutical companies can live in that world. If you develop the
best drug and develop it for the right patient, all this does is get it to that
right patient."
Merck has not done much so far to open its trial data
to the world, nor have its rivals, but Merck has less to lose here and more to
gain. It has fewer cancer drugs in human tests than Pfizer or AstraZeneca, and
its shares have dropped by half this year. Friend is powering ahead, building a
first stab at the big database with the H. Lee Moffitt Cancer Center in Tampa,
Fla. Over the next five years every patient who walks through Moffitt's door
will be asked to put genes and tumor samples in a database that will number
100,000 patients; 5,000 are already in. The database will provide information
to the doctors doing research there and, eventually, to patients. If it turns
out you have a gene that tells researchers what drug will work for you, Merck
and Moffitt plan to let you know. Experiments that would have required weeks of
thawing tumor samples now take a matter of hours.
"Right now most of medicine is based on a bunch
of gray-haired guys who say, 'This is the way I do it and it seems to
work,'" says Moffitt Director Bill S. Dalton. "We need to determine
over time what is useful and what isn't. The only way to do that is to study
100,000 patients." . . .
A megadatabase "could save me months or years of
trying to collect patient information," says Oregon Health & Science
University oncologist Brian Druker, who helped get Novartis' potent
tumor-fighter Gleevec to the market. But he questions whether researchers
understand cancer biology well enough for Friend's highly computational
approach to pay off in the short term. "Over the long term the Merck
strategy will be the winning strategy," says Druker. "But right now I
don't think we're quite there."
Merck has spent the past few years trying to dig out
of one of the toughest periods of its 120-year history. In 2003 several
experimental drugs for various diseases failed, all at once. In 2004 the
blockbuster painkiller Vioxx was yanked because it caused heart problems. Merck
settled its Vioxx liability claims last year for $5 billion. . .
Merck hopes fighting cancer is one way out of this
funk. Friend was put in charge of Merck's cancer research efforts in 2003, two
years after Merck bought the company he was running, Rosetta Inpharmatics.
Friend had cofounded Rosetta in 1996 with Leland Hartwell, now director of the
Fred Hutchinson Cancer Research Center in Seattle, and Leroy Hood, now
president of the nearby Institute for Systems Biology. Like rival Affymetrix,
Rosetta began selling tiny DNA chips that could be used to figure out how often
cells were accessing their genes. . .
The first fruits of Rosetta's technology began to
emerge with a 2002 article in the New England Journal of Medicine. Dutch
researchers using Rosetta's software found a particular pattern of genetic
signals within breast cancer tumors that could predict whether or not the
cancer would return after surgery. The test is not a significant product for
Merck but was approved by the FDA in 2007. It and a similar test made by a
rival, Genomic Health of Redwood City, Calif., are widely used to guide post-op
treatment strategy. . .
All of these bets are based on what Friend's giant
computer tells him. "This is going to have to be the path taken by pharma
in the future," says Hood of Friend's current work. "It's a gamble,
but I think it's one that if Merck sticks with it, they'll win big."
Recently Friend took a detour on his way to a research
conference in Chicago. He flew to Florida, rented a 1972 Chevy Chevelle and
drove to Cape Canaveral to watch the space shuttle launch. He says it wasn't
just that he wanted to recapture the feeling of the space race, when scientists
were treated like heroes, but that he wanted to get a sense of a project that
massive and complex. Creating a cancer drug is not that different.
"The puzzle's gotten big," he says of the
cancer drug hunt. "But I think there is only one way to solve it."
To read the entire article, go to www.forbes.com/healthcare/forbes/2008/1110/090.html
www.forbes.com/forbes/2008/1110/090_print.html.
* * * * *
LIBERATION BY INTERNET by Gennady Stolyarov II
In The Constitution of Liberty, Friedrich Hayek gave a dire prognosis for the future
of technology: "[W]e are probably only at the threshold of an age in which
the technological possibilities of mind control are likely to grow rapidly and
what may appear at first as innocuous or beneficial powers over the personality
of the individual will be at the disposal of government. The greatest threats
to human freedom probably still lie in the future."
Hayek, like most of the leading intellectuals of his time, did not foresee the
emergence of the Internet - the quintessential Hayekian spontaneous order. As a
decentralized communication system facilitating the sending and receiving of
messages by billions of people, the Internet has greatly shifted the balance of
power away from governments and toward sovereign individuals. Even in its early
days, the Internet played a vital role in bringing about the downfall of the
Soviet Union's government. Since then, it has catalyzed tremendous economic,
social, and political liberation in countries ranging from Cuba to the United
States.
While governments have
tried to use modern communication technologies to monitor and regulate private
individuals, their efforts are doomed to failure stemming from a much more
powerful and competent market response.
Hayek
Did Not Know the Internet
When Friedrich Hayek's The Constitution of Liberty was first published
in 1960, the Internet did not exist; nor did its military predecessor, ARPANET,
which was initiated in 1969. Fifteen years after the horrors of World War II,
the means by which the totalitarian regimes of Nazi Germany and the Soviet
Union used mass broadcasting technology to indoctrinate their people were still
recent memories. During the Nuremberg Trials, Albert Speer himself expressed
the Nazi regime's effectiveness at using technology to spread propaganda:
"Through technical devices like the radio and the loudspeaker, eighty
million people were deprived of independent thought. It was thereby possible to
subject them to the will of one man." Faced with such facts, Hayek
understandably feared future uses of mass broadcasting technology.
Indeed, in a world where the only mass communication technologies were radio
and films, the scales of power were shifted toward totalitarian governments and
away from sovereign individuals. According to Christopher Kedzie, "Since
traditional broadcast media are located closest to the dictator's optimum they
are almost certain to be employed as a powerful political weapon." . . .
Totalitarian states with the resources to control the small number of radio
broadcasts and films in existence during the 1930s and 1940s could influence
their subjects without major competition from their nonstate opponents.
Hayek was not alone in fearing the combination of technology and government. In
1984,
published in 1949, George Orwell portrayed an all-encompassing surveillance
state that completely controlled not only the present flow of information but
also the historical record. But Orwell also lacked the benefit of seeing
subsequent technological developments and the cost reductions they entailed for
ordinary private individuals. In the words of Richard Muller, "Orwell's
error was remarkably simple: he assumed that only the state would be able to
afford high-tech - an assumption shared by virtually every prophet, science-fiction
writer, and futurist. But it has proven to be wrong."
We do not live in an Orwellian world today, in large part because of Moore's Law:
"In 1965, Gordon Moore, the co-founder of Intel Corp., predicted that,
every 18 months, the processing power of a silicon chip would double as
transistor density increased, a forecast that has proven uncannily
accurate." This exponential growth in processing power has enabled
cutting-edge technology to spread beyond the purview of governments and into
the hands of over a billion individuals around the world.
. . .
The story of the Internet is one of piecewise relinquishment of
government control and empowerment of private individuals and organizations.
Unlike early radio and television, technologies with many possible message
originators - such as the telephone and especially the Internet - are highly
damaging to powerful governments, because they introduce competition into the
market of ideas.
The telephone has its weaknesses; the recipients of any given message are few,
and it is possible to wiretap telephone lines and restrict their number - as
the Soviet government tried to do prior to Mikhail Gorbachev's policy of Glasnost
(openness).
The Internet, however, is far more resilient. Unlike earlier broadcasting
technologies, the Internet has no central nexus from which it can be
effectively controlled and restricted. Tim Swanson notes that the Internet
"is an amalgamation, an assortment of heterogeneous computer systems with
varying capabilities linked together by various protocols." It is
impossible to silence the Internet by seizing pieces of Internet hardware -
even in a concerted effort to do so within any given country. In Kedzie's
words, "Neither the autonomy nor the influence of electronic networks is
constrained by national boundaries." It is entirely possible for a
political dissident in one country to have his website hosted in a different
part of the world - far from the reach of the authorities against whom he
writes and speaks . . .
Some
governments seeking to restrict the free flow of ideas have attempted to
extensively limit their subjects' access to the Internet. But blocking online
content is like using a sieve to stop the flow of water. China's government
requires search engines such as Google to block content critical of the
Communist Party. However, such censorship is ineffectual and fails to
substantively restrict access to even the most "threatening" ideas.
James Glassman notes with amusement that the Chinese government "blocks
access to certain websites, including that of the Washington Post but not of my
own far more subversive free-market technology site, www.TechCentralStation.com."
Even restricting access to virtually every major Western media source would not
address the millions of online articles, political blogs, small magazines,
videos, and audio recordings that Chinese and other government officials do not
know and cannot know about.
Search engines that filter out combinations of provocative keywords still
cannot detect metaphors, allegories, subtle allusions, satires, and even
unusual turns of phrase. Moreover, they cannot stop individuals from using the
local knowledge of their friends and associates in order to find websites
without the aid of major search engines.
Throughout his work, Hayek emphasizes the importance of particular knowledge of
time and place in shaping individual decisions - as well as a centralized
bureaucracy's inability to access such knowledge. Much of individuals'
awareness of content on the Internet arises from their possession of such local
knowledge. A Hayekian analysis would suggest that governments are powerless to
even know the nature of this knowledge, much less to interfere with its
transmission.
The
Early Internet and the Downfall of the Soviet Union
To merely say that the Internet has made the effective large-scale censorship
of ideas impossible would understate the case for the Internet as a tool of
unprecedented individual liberation. The Internet has the power to bring
down oppressive governments - a power that was manifested even in its
early days. For instance, the Internet played an indispensable role in
destroying the Union of Soviet Socialist Republics.
The USSR was destroyed not by the conventional means of invasion or violent
revolution, but by the flow of information. In the words of Shimon Peres, Communism
fell without the participation of the Russian army, for or against; it fell
without having a new political party against the Communists - if at all, it was
done by the Communists; it fell without the intervention of the United States,
Europe, China or anybody else
. . . Authoritarian
governments became weak the minute they could no longer blind their people or
control information. . .
Government
Threats and Market Solutions
Of course, governments can and do attempt to use even contemporary
decentralized technologies in order to increase their ability to monitor,
regulate, and restrict individuals. But they cannot succeed in the long run.
After all, the most advanced technologies accessible to governments today are
fundamentally market driven, meaning that they are driven by the choices of
individual consumers, who do not wish to be monitored, regulated, and
restricted.
Whether a particular technology is adopted or rejected is no longer subject to
the decisions of government officials or even firms in partnership with
governments. Rather, according to Glassman, "technology emerges from a
process, undirected by the state or any other central authority, that
encourages variety, spontaneity and discovery through trial and error. The incentives
that motivate this process depend on free minds operating within free
markets."
Businesses cannot force technologies that consumers do not want onto those
consumers; if they tried, they would quickly lose market share. Timothy Terrell
notes a trend common throughout history: "Technologies that do not present
the consumer with any significant cost or quality advantage will quickly
disappear."
The only way
a government can impose controls on consumers through technology is by sneaking
around the market and establishing covert surveillance and regulation. But if
such a threat exists, the market will respond to it - and will do so more
competently than the government. Glassman observes that technology also
provides countervailing power. While government may now have the power to
eavesdrop on conversations a mile away, the speakers themselves now have the
power to block the reception. Government can intercept Internet messages, but
the senders of those messages can encrypt them in a way they could never
encrypt written messages.
Read the entire article at www.quebecoislibre.org/08/081115-5.htm.
[Socialized control of medicine is similar to a
dictator's control of political freedom. As people in other countries see the
advances in Medicine we enjoy in America, they will eventually break down the
walls that restrict their access to care. We must always be on guard so that we
don't succumb to government control of our medical freedom under the
euphemistic term of single payer medicine - the socialized system from which
the rest of world is trying to extract itself.]
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: The Stepchild of Social Security
Making Social Security
More Harmful By J.
R. Clark and Dwight R. Lee
J. R. Clark holds the Probasco Chair of Free Enterprise at the
University of Tennessee at Chattanooga. Dwight Lee holds the William J. O'Neil Chair of Global Markets
and Freedom in the Cox School of Business at Southern Methodist University.
Social Security is a fundamentally flawed system. If a
private firm offered such a retirement system and made the same claims for it
that the federal government makes for Social Security, that firm would quickly
become a poster child for corporate fraud, and its managers would soon be
convicted of criminal charges.
There are two fraudulent claims the federal government
makes about Social Security that deserve special attention. By considering how
these two claims interact with each other, it becomes clear that the
politicians and pundits who defend Social Security are increasing the harm it
is imposing on American workers.
Two Fraudulent Claims
Consider first that ever since Social Security was
enacted in 1935 Americans have been told that their "contributions"
are being deposited into their own account to pay for their retirement
benefits. This claim has become more implicitly suggested than explicitly
stated in recent Social Security brochures, but not in the statements of
politicians when opposing any attempt to partially privatize the program. Al
Gore, in his 2000 presidential campaign, assured the public that if he were
elected our Social Security "contributions" would remain secure in a
"lockbox" until our retirements. It was never made entirely clear
whether we each had our very own lockbox or all the money was in one big
lockbox.
We cannot find any serious study that estimates how
many people really believe that the taxes they pay to Social Security are being
saved and invested to finance their retirement, instead of being spent
immediately by politicians, as is actually the case. But it is clear that many
do believe that they have a personal Social Security account containing the
money to fund their retirement benefits. Alan Greenspan recounts in his recent
book, The Age of Turbulence, a story told by former House leader Tom Foley.
When Foley tried to inform his mother that there were no lockboxes containing
the money to pay for Social Security, she told him, "I hope you will not
be offended at how surprised and shocked I am to find that the majority leader
of the House of Representatives knows nothing about Social Security."
The other fraudulent claim made about Social Security
(again, from the very beginning of the program) is that employees pay only half
the cost, with employers paying the other half. This claim is widely seen as
plausible because the legislation authorizing Social Security clearly
stipulates that the required payments are to be split evenly between employees
and employers. If this were true, then employees would now be paying 6.2
percent of their before-tax income up to $102,000 a year; employers would match
that amount.
As any good student in an economic-principles course
should learn, however, the amount of a payroll tax actually paid by employees
and employers has absolutely nothing to do with what politicians mandate in
legislation. It is true that each worker has 6.2 percent of his after-tax
income deducted from his paycheck and sent to the Social Security
Administration (SSA) and his employer sends in the same amount. But by altering
the wages employers pay and workers receive, these payments change the supply
and demand schedules for labor - at a given nominal wage, different amounts of
labor will be supplied and demanded than before. (In the lingo of economics,
the supply and demand curves shift.) Until we know how wages and salaries
change in response to these shifts, we cannot tell how much of the Social
Security cost is paid by the employees and how much is paid by employers. For
example, if a worker's salary is reduced by exactly the same amount that the
employer sends to the SSA for her, then the cost to the employer is nothing
(what he pays for the worker's Social Security is offset by the lower salary)
and the worker ends up paying the entire cost. . .
The employer requirement to send a check to the SSA
for each worker equal to 6.2 percent of salary revises downward the firm's
demand schedule for labor according to the amount of this check. This reduction
in demand, considered by itself, obviously reduces the salary the firm is
willing to pay each worker. Similarly, the Social Security deduction from each
worker's paycheck reduces the labor supply by revising upward the supply
schedule by the amount of this deduction, assuming that there is no expected
benefit from Social Security. . .
. . . In fact,
as we show in our Economic Inquiry article, workers are made worse off by
Social Security unless the benefits they expect and actually receive are at
least equal to the total amount paid for Social Security by both the workers
and their employers.
Defrauding Workers
We are now able to nail down our main point - that
advocates of Social Security are defrauding American workers in two ways.
First, claims which leave the impression that money paid into Social Security
is being saved for our retirements lead workers to believe their benefits are
more secure than they are.
Second, persistent claims that workers pay only half
the Social Security tax lead them to believe their benefits cost them less than
they really do.
These fraudulent claims clearly increase the political
viability of Social Security by misleading workers into expecting larger
benefits than they will receive. But it is worse than this. By generating
exaggerated expectations of Social Security benefits, the two claims are
actually reducing the net benefits workers receive by increasing the amount
they are paying for them with lower wages.
It is ironic that those pundits and politicians who
oppose even the most timid moves to privatize Social Security by downplaying,
or denying outright, its Ponzi-scheme nature are widely seen as protectors of
American workers.
To read the entire article, go to www.fee.org/publications/the-freeman/article.asp?aid=8342.
Government is not the solution to our problems,
government is the problem.
- Ronald Reagan
* * * * *
5.
Medical Gluttony:
Changing Doctors May Increase Cost and Decrease Quality
Marjorie had pleural and parenchymal tuberculosis as
an adolescent. Hence she had parenchymal (Lung) nodules in the apex of her lung
and thickened pleura in the lung base on one side. She had been appropriately
treated with antituberculous drugs. She then followed the prescribed regimen of
follow up x-rays every three months for two years, every six months for three
years and then yearly. If the new
x-ray, when compared to the old x-ray, was essentially identical, one could safely
say there was no recurrent activity.
She went to the emergency room for a minor trauma and
cut to her hand on Friday evening. This was treated and a chest x-ray was
obtained for reasons unclear. No medical indication was recorded on the
requisition. The x-ray was very abnormal. Since her previous x-rays were done
elsewhere, there were none to compare. Hence, the radiologist appropriately
listed all the findings, suggesting multiple etiologies, and suggested studies
to rule out tuberculosis, cancer, or multinodular disease. The hospitalist on
duty in the evening admitted the patient and ordered a sputum culture for TB,
isolated the patient against her wishes and demands, and ordered a CT of her
chest. The hospitalist on duty the next day, proceeded with the same direction
of testing, and started antituberculous treatment. The family became very
anxious when their wife and mother was thought to have reactivated her tuberculosis.
The patient subsequently stated that neither hospitalist doctor that admitted
her or the one that saw her the next two days on the weekend asked her about
her known tuberculosis, the treatment in a sanatorium, drugs for two years and
numerous follow up x-rays.
On Monday, she saw a third hospitalist who sat down
and spoke with her and obtained the first real medical history. He made a phone
call to the pulmonologist who faxed him Marjorie's medical history and x-ray
reports. The decision was made in a matter of minutes that the only problem was
a minor laceration that was sutured in the Emergency Room and was clean and
healing well. There had been no medical reason for the hospitalization and no
reason to suspect tuberculosis reactivation. He promptly discharged her with
directions to have her sutures removed in one week.
This is not an isolated case. It is a frequent
occurrence in practice because the patient's personal physician is excluded
from taking care of her in the hospital, thus interrupting the efficient
continuity of care. Although many studies and reports continue to show the
efficiency of having a fulltime hospital physician who is in the hospital
continuously, this is frequently not the case. It may be the case in an acute
care situation where the treatment changes from hour to hour, but in a large
percentage of cases, the patient only needs physician supervision once or
possibly twice daily. This has been the usual standard of care for many decades
and still is.
There needs to be further study on the new so-called
specialty of "hospitalist" - not primarily directed to hospital
efficiency, but to cost effective efficiency. This is a very difficult study to
do since many of the hospital charts no longer reference the prehospital care.
Hence, the study would show cost-effective care when looking at the entire
spectrum of care; it may not be cost effective to the patient or improve the
quality of care.
* * * * *
SAN FRANCISCO The Pacific Research Institute has just released The
Top Ten Myths of American Health Care: A Citizen's Guide. This is the
latest book from health care scholar, and PRI President and CEO Sally C. Pipes.
The book's foreword is by Steve Forbes: "For
anyone interested in getting to the core of America's health care troubles,
this is the perfect book," he writes. "And for health care policy
makers, it should be required reading."
In her 182-page book, Ms. Pipes takes on ten popular
myths about the state of health care in America. The final chapter lays out
several patient-centered prescriptions for reform.
"I wrote this short book as a citizen's guide.
Each chapter tackles a complex issue in straight-forward, easy-to-understand
language," said Ms. Pipes.
The book challenges the conventional belief that only
government can fix our health care system. In fact, says Ms. Pipes,
"government overreach has put the system in a state of crisis."
A complete list of chapters can be found below.
In her conclusion, Ms. Pipes offers some ways to fix
the country's biggest health care problems. "If we want to bring costs
down and extend coverage to more Americans, we have to open the health care
marketplace to competition -- by abolishing costly government regulations and
reforming the tax code to make insurance more affordable."
"We can solve the health care problems that
plague the United States," concluded Ms. Pipes. "But we won't solve
them if we continue to believe the many myths that plague the health care
debate."
Myth One: Government Health Care Is More Efficient
Myth Two: We're Spending Too Much on Health Care
Myth Three: Forty-Six Million Americans Can't Get Health Care
Myth Four: High Drug Prices Drive Up Health Care Costs
Myth Five: Importing Drugs Would Reduce Health Care Costs
Myth Six: Universal Coverage Can Be Achieved by Forcing
Everyone to Buy Insurance
Myth Seven: Government Prevention Programs Reduce Health Care
Costs
Myth Eight: We Need More Government to Insure Poor Americans
Myth Nine: Health Information Technology Is a Silver Bullet
for Reducing Costs
Myth Ten: Government-Run Health Care Systems in Other
Countries are Better and Cheaper than America's
Solutions: Markets, Consumer Choice, and Innovation
Read PDF Study | Purchase Book
http://liberty.pacificresearch.org/docLib/20081020_Top_Ten_Myths.pdf
* * * * *
7.
Overheard in the
Medical Staff Lounge: The Election is Over, Now What?
Dr. Rosen: Well,
the elections are over. What happened? What's next?
Dr. Dave: Well,
I'm bracing myself for the tax and spend programs coming down the pike.
Dr. Edwards: If
Obama really spends an extra $Trillion as promised, he has to get it from the
citizens and that will precipitate a depression just like when Hoover increased
taxes to pay for his bailout.
Dr. Dave: And
then FDR came to the White House and encouraged farmers to destroy crops and
livestock in order to raise prices.
Dr. Michelle: I'd
forgotten that. How gruesome. I'm sure Barrack Obama won't do anything that
foolish.
Dr. Yancy: Or
more foolish like raising taxes on struggling people.
Dr. Michelle: But
Mr Obama says he'll lower taxes for 95% of us. That's got to include me.
Dr. Dave:
Don't count on it. He's changing his tune dramatically. He's asking us not to
expect all his promises during his first term.
Dr. Rosen: He
won't be able to deliver all his promises during his second term either.
Dr. Ruth: How
do you figure?
Dr. Rosen: The
1929 crash and the depression of 1933 was just a warmup for the one coming in
2009.
Dr. Paul: I'm a
new pediatrician on the staff. Like the American Academy of Pediatrics, we're
all for single-payer medicine which will solve all our problems.
Dr. Edwards:
There won't be any money to come close to that fiasco.
Dr. Paul:
People just can't afford health care. I see babies going without shots because
their parents can't afford it.
Dr. Edwards:
Don't your patients have insurance?
Dr. Paul: Most
of them have Medicaid.
Dr. Edwards:
Medicaid pays for immunizations.
Dr. Paul: But
Medicaid is really squeezing my income.
Dr. Edwards: What
makes you think when the government covers us all with Medicaid, you'll have
more money?
Dr. Paul: It
can't get worse. It's only going to get better.
Dr. Yancy:
That's totally irrational. Have you had your serology checked lately?
Dr. Paul: I see
this is a hotbed of Republicans here.
Dr. Edwards: Not
necessarily. Physicians have traditionally been conservative and I did vote for
the veteran. But I'm glad that he lost.
Dr. Paul: Well,
I voted for Obama and I'm glad he won.
Dr. Edwards: If
the war hero had won, with the looming depression, he would have had a
declining approval rate starting in February. It wouldn't have gotten as low as
Congress' ratings, which I understand has now sunk to less than 10 percent, but
a negative rating would have a terrible effect on getting on with the
program.
Dr. Paul: Obama
will get us through this ordeal just fine.
Dr. Rosen: I
just read last week's article in the New Yorker on Obama. He's a very shrewd
man. Most people interpreted his "Change" slogan in regards to the
economy. He even broadsided Jesse Jackson and others that have been down in the
mouth about the future of race. Obama didn't make it an issue and his
"Change" brought about a change to a new race in the White House. We
should be thankful for that great accomplishment which probably no other black
man, except perhaps Colin Powell, could have brought about. He's a smooth
operator and we'll see very shortly what he can do. Nobody has any idea what
that really is.
To read the NewYorker on The Joshua Generation by
David Remnick, go to www.newyorker.com/reporting/2008/11/17/081117fa_fact_remnick.
* * * * *
8. Voices of Medicine: A Review of Local and Regional
Medical Journals
CSA Bulletins: Summer 2008 -
Volume 57, Number 3
The Future Practice of Anesthesiology By Patricia A. Kapur, M.D.
Predicting the future is risky at best; however, some
general trends can be anticipated, even if not known specifically when they
will become manifest. An example would be the evolution from desktop to laptop
to handheld computer devices. A tipping point is reached when the next device
becomes dominant, although all three technologies coexist for some time. Models of medical care delivery that have
technological and human components, such as anesthesiology, are similarly on an
evolutionary continuum and are propelled forward with each new technological
advance.
Examples of some of the technological advances which
are propelling changes in anesthesiology care delivery include such items as
better methods for determining the state of patients' comorbidities, for
example, advanced noninvasive cardiovascular testing which allows for better anesthesia
risk assessments; genetic profiling of patients for drug tailoring;
computer-controlled infusion pumps for physiologic feedback-controlled drug
administration; rapid advances in noninvasive intraoperative monitoring
devices; technology for remote viewing of intraoperative monitor screens, lab
results; real-time remote camera and voice contact with ORs; and so on. The
question that anesthesiology decision makers need to face in preparing
physicians in practice and physicians in training for such a future is not
"How long can we make the current situation last?" but, rather,
"How can we prepare anesthesiologists appropriately for the career
opportunities that anesthesiologists of 2015 or 2025 will face in their
professional practice?"
Although classic literature tells us that we see the
future "
through a glass darkly
," it is not all murky, and we can
make some extrapolations. We do know that advances in home health
infrastructure and home care technology means that hospitals will focus on the
acutely and severely ill with increased numbers of critical care units compared
to ward-level care. There will be safer drugs with minimal side effects, while
pharmacogenetics will allow drug and dose tailoring to improve safety and
reduce therapeutic misadventures. Noninvasive monitoring and transdermal- or
transmucosal-based "lab" tests may obviate the need for extensive
experience with invasive monitor placement and interpretation, and/or for
skills for arterial/venous blood or other body fluid sampling. Remote robotics
will replace a certain number of in-OR surgeons.
Remote physicians with telemedicine-inspired, two-way
video techniques already have replaced on-site physicians in ICUs for
hard-to-serve hospitals and on ICU night-shifts in the United States. Already
in the U.S., remote reading of specialty monitors in the ORs, such as EEGs,
SSEPs, and TEEs, commonly is done by neurologists or cardiologists, similar to
online radiology image interpretation from continents away. Why not have an
anesthesiologist remotely overseeing numerous ORs, by way of electronic access
to automated anesthesia records, an intranet connection to intraoperative
physiologic monitor screens, two-way video/voice communication to each OR,
access to instantaneous output from intra-op lab tests machines, among other
things. . .
Opportunities in the broader areas encompassed by the
anesthesiology knowledge and skill set remain tremendous. The opportunities may
continue to evolve even further in the coming years, but they will still
include the need for talented providers in all areas of acute, sophisticated,
and critical care of patients presenting for interventional care, if that is
interpreted in the broadest sense with a focus on the most severely ill
patients. All anesthesiologists need to remain broadly capable, willing to
transform to incorporate new technology and supervisory/management skills, and
ready to move aggressively into the new opportunities to contribute their
unique knowledge and skills for the optimization of care of the acute patients
presenting across the illness continuum.
To read the rest of a detailed specialty projection,
go to www.csahq.org/pdf/bulletin/future_57_3.pdf.
* * * * *
9.
Book Review: The
Story of Our Constitution
We The People The Story of Our Constitution, by Lynne Cheney, Simon & Schuster Books for
Young Readers, New York, © 2008, ISBN: 13-978-1-4169-5418-7, 30 pp, $17.99, $21
Can.
"The happy union of these states is a wonder;
their Constitution a miracle; their example the hope of liberty throughout the
world." -James Madison
Cheney observes that in 1787, our young country was in
turmoil. The central government was unable to pay off debts, there was armed
insurrection in Massachusetts, and foreign governments were taking advantage of
our weakness. The question of the hour, James Madison wrote, was "whether
the American experiment was to be a blessing to the world or to blast forever
the hopes which the republican cause had inspired."
The story of our founding document is a tale of
persistence, as delegates kept on despite obstacles that at times made their
task seem impossible. It is a tale of creativity, with the delegates providing
a framework for a government entirely new. History might have gone otherwise
but for the framers' genius, and we should be grateful for James Madison,
George Washington, Benjamin Franklin, and the others gathered in Philadelphia.
"The citizens of America . . . are from this
period to be considered as the actors on a most conspicuous theater, which
seems to be peculiarly designated by Providence for the display of human
greatness and felicity." -George Washington
Astride his favorite horse, Nelson, on October 19,
1781, General George Washington looked on as thousands of British soldiers
marched out of Yorktown, Virginia, to lay down their arms. Americans, with help
from France, had just won the battle that would end the Revolutionary War. For the British, this loss was a shock.
Theirs was the mightiest army in the world, and they had thought it impossible
that the Americans would defeat them.
For the citizens of our country, living on a vast and
bountiful continent, it seemed like a new age was dawning. A free and
independent America would surely prosper and become a great and mighty nation.
"I am mortified beyond expression when I view the
clouds which have spread over the brightest morn that ever dawned upon any
country." -George Washington
America had adopted rules for governing called the
Articles of Confederation. They didn't work very well and trouble became
apparent over the next several years. The states printed their own money. They
refused to pay off the debts from the Revolutionary War. Other countries were
taking advantage of the weakness of the United States. The British refused to
move out of military posts they were supposed to give up after the
Revolutionary War. Massachusetts' farmers couldn't pay their debts, rose up
against the government and tried to seize a building in Springfield where guns
and ammunition were kept. The militia fired upon them. Americans were killing
Americans.
"The great fabric to be raised would be more
stable and durable if it should rest on the solid foundation of the people
themselves." -James Madison
In 1787, delegates from twelve states traveled to a
convention in Philadelphia to figure out a better plan for governing the
country. Madison, the first to arrive, believed the current government was near
collapse. In his room at a Philadelphia boardinghouse, Madison, a small man of
great learning, labored over a plan to present to the convention. His boldest
idea was that the nation's government start with the people. Rather than have
the state legislatures choose the members of Congress, Madison proposed that
the people have a direct say in who represented them.
George Washington hated to leave his beloved home at
Mount Vernon, but was worried with thirteen states all pulling in different
directions, which he felt could bring ruin upon America. The people of
Philadelphia remembered how this tall, dignified man had persisted in the
darkest hours of the Revolution, when it had seemed impossible that America
would win her war for independence. They remembered how he had given up power
after the war when some had wanted to make him a king. All across America he
was loved and respected. When he arrived in Philadelphia on May 13, the bells
rang out to celebrate his arrival and joyful crowds gathered to greet him. With
him at the convention, Americans were more likely to look favorably upon what
the delegates decided.
"To the man who unites all hearts." -A
popular toast of the time, offered to honor George Washington.
James Madison was presenting his ideas to his fellow
Virginians while waiting for a quorum of 29 men to arrive eleven days after the
proposed starting date. On May 29, one of the Virginia representatives proposed
Madison's plan to the assembled delegates. Governor Edmund Randolph described a
government of three branches: Legislative or the Congress; Judicial or the
courts; and a national executive. The legislative branch would have two parts
or houses, with the people of each state electing the members of the first
house. Although some delegates felt the people couldn't be trusted to choose
their representatives, most disagreed. They thought that the place for
government to begin was with the people.
"The national legislative powers ought to flow
immediately from the people." -James Wilson, Delegate from Pennsylvania
The Articles of Confederation gave each state one
vote. The Virginia Plan gave more representatives and more votes to states with
more people. The small states believed that their interests would be trampled
upon.
"We would soon submit to a foreign power than
submit to be deprived of an equality of suffrage." -John Dickinson,
Delegate from Delaware
The oldest delegate was inventor and statesman
Benjamin Franklin. At 81, he was carried in a sedan chair from his home to the
convention. Although he commanded great respect, he could not get the
quarreling delegates to put their anger aside as they fought through the
sweltering month of June. Roger Sherman of Connecticut proposed that in one
house of the legislature, states be represented according to size and in the
other, the Senate, each state have an equal number of votes. But the idea went nowhere. Dr. Franklin
suggested that the delegates send for a chaplain to lead them in prayer. The
leaders of the Revolution had sought God's help, he said, and so should those
who were trying to build a new nation.
"How has it happened . . . that we have not
hitherto once thought of humbly applying to the Father of lights to illuminate
our understandings?" -Benjamin Franklin, Delegate from Pennsylvania
The delegates did not call for a chaplain. But as
the Fourth of July neared, they stopped arguing long enough to choose a
committee that came up with a compromise similar to the one Sherman proposed.
While the members of the committee were at work, other delegates took a break.
George Washington went fishing.
"
went
up to one Jane Moore's in the vicinity of Valley Forge to get trout."
George Washington
On September 17, after the final draft of the Constitution
was read aloud, Benjamin Franklin addressed the convention. He told the
delegates that there were parts of the document with which he did not agree,
but that over a long life he had learned he was not always right. On the whole,
he said, the Constitution was astonishingly good, and he hoped that other
delegates who had doubts would join him in signing it. Several refused. George
Washington, as president of the convention, was the first to put his name to
the Constitution, then thirty-seven others followed, state by state. As the
last delegate signed the document, Dr. Franklin looked at the sun painted on
the back of George Washington's chair and saw in it a sign of a new beginning
for America.
"
at length I have the happiness to know that
it is a rising and not a setting sun." Benjamin Franklin
By July 4, 1788, the people of ten states, the
required three-fourths majority, had, after sometimes fierce debate, ratified
the Constitution which made it the supreme law of the country. It was time for
celebration. In Philadelphia, after early morning bells and a cannon salute,
crowds lined the streets to watch high-stepping horses lead a parade of flags,
bands and floats. Citizens of every occupation marched, weavers followed by
chair makers, bricklayers, and gilders; book binders by coppersmiths and
clergymen. At the end of the parade came feasting and an oration. "Happy
country!" proclaimed convention delegate James Wilson. "May thy
happiness be perpetual!"
" Tis done! We have become a nation."
Benjamin Rush, Citizen of Pennsylvania - and of the United States of America
The delegates recognized that no document is
perfect and so they included ways of amending it. The first ten amendments,
called the Bill of Rights, were passed by two thirds of the Congress in 1789,
and ratified by three fourths of the states in 1791, which safeguarded the
freedoms of speech, religion and the press. Amendments after the Civil War did
away with slavery and provided that the right to vote will not be restricted on
account of race. In 1920, the Constitution was amended to recognize the right
of women to vote.
Lynne Cheney, an educator and senior fellow of the
American Enterprise Institute, provides a history lesson for parents and their
children. This book puts the struggles and the founding of our nation and
constitution in perspective. She recognizes that there were Americans who
looked at the Constitution and did not see themselves. Today, "We The
People" includes all of us working together, to make our great country greater
still.
To read the rest of the review, go to www.delmeyer.net/bkrev_WeThePeople.htm.
To read more book reviews,
go to www.delmeyer.net/PhysicianPatientBookshelf.htm.
To read book reviews topically, go to www.healthcarecom.net/bookrevs.htm.
* * * * *
10. Hippocrates & His Kin: The "Don't just stand
there" paradox.
Don't just stand there, Do Something!
At a postgraduate course on Pulmonary Physiology in
Boston, a Harvard Professor was quizzing the class on a problem in the ER. The
responses were a little too timid for him. The patient was in dire straights
but the physiologic abnormalities were not apparent as the lab tests were being
processed. Some of the class felt there should be watchful waiting. The
professor stated that they graded interns on "Don't just stand there, Do
Something." He further clarified this, "even if it is wrong."
The residents and fellows in the class were very polite and didn't take up the
issue of "Do no harm."
Sometimes the higher quality of care is standing there
with watchful observation and waiting.
Don't do something, just
stand there.
At the Medical Grand Rounds
at the University of California at Davis on Thursday morning, Professor
Margaret Beliveau, MD, from the Mayo Clinic College of Medicine, was the guest.
The title of her presentation was "Perioperative Care of Elderly Patients."
She did an excellent job of discussing the caution required in the care of the
elderly fragile patients in getting them ready for required surgery. Sometimes
correcting some physiologic abnormality too aggressively can be dangerous. The
subtitle of her talk, "Don't do something, just stand there,"
was her catch phrase for caution.
Sometimes the higher quality
of care is just standing there before you do something and then doing it
cautiously.
Don't Just Do
Something. Stand There.
So the above
headline in the WSJ on October 31, 2008,
by Russell Roberts caught my eye. It was an important commentary on our
times. What will Obama do?
People ask me
if the current mess feels like 1929. But the right comparison is 1932, when
Herbert Hoover was desperately trying anything, anything at all, to get the
economy going. The stock market had crashed. The economy was starting to follow
it down. So what did Hoover and his fellow policy makers do?
In 1930,
Congress passed a massive tariff increase, in hopes of protecting American
jobs. Hoover signed it. But it simply accelerated the economy's slide. The
Federal Reserve contracted the money supply, taking a recession and making it
into a depression. By 1932, real GDP was 25% lower than three years earlier.
Hoover
increased federal spending steadily, including an increase in real terms of
about 40% in 1932. At the same time, fearful that deficits were harmful, Hoover
raised income taxes.
Nothing
worked. So Franklin Roosevelt came into office pledging stronger medicine.
Enter even bigger increases in government spending. Government nationalization.
Bigger deficits. Destruction of crops and livestock in the name of raising
prices. Government-organized cartels. A greater empowerment of unions. It was a
whirlwind of activity without any real plan.
It worked for
a while, but then, in 1938, the economy turned sour again. Unemployment, which
had been falling, spiked again, reaching 19%. Consumption didn't recover to its
prewar levels until 1945.
To read the rest of
this article and what happened then and what is happening now, go to http://online.wsj.com/article/SB122541582835686689.html?mod=todays_us_opinion#.
Mr.
Roberts is a professor of economics at George Mason University and a research
fellow at Stanford University's Hoover Institution. His latest book is
"The Price of Everything: A Parable of Possibility and Prosperity"
(Princeton University Press, 2008).
Fallout from Proposition 8
The artistic director for
the California Musical Theatre resigned because a growing number of artists
threatened to boycott the organization because of his donation to Proposition
8, the initiative to preserve marriage. After his campaign contribution popped
up on the entertainment websites, other blogs showed up from artists and
writers withdrawing their permission for the California Musical Theatre to
produce any of their works.
Well, so much for free
speech and tolerance in the entertainment industry.
To read more HHK, go to www.healthcarecom.net/hhkintro.htm.
To read more HMC, go to www.delmeyer.net/hmc2005.htm.
* * * * *
11. Professionals Restoring Accountability in Medical
Practice, Government and Society: