MEDICAL TUESDAY . NET
Community For Better Health Care
Vol V, No 14, Oct 24, 2006
In This Issue:
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1. Featured Article: The Information Factories by George Gilder, Wired Magazine
The desktop is dead. Welcome to the Internet cloud, where massive facilities across the globe will store all the data you'll ever use. George Gilder on the dawning of the petabyte age.
THE DRIVE UP INTERSTATE 84, through the verdant amphitheatrical sweep of the Columbia River Gorge to the quaint Oregon town of The Dalles, seems a trek into an alluring American past. You pass ancient basalt bluffs riven by luminous waterfalls, glimpsed through a filigree of Douglas firs. You see signs leading to museums of native Americana full of feathery and leathery tribal relics. There are farms and fisheries, vineyards arrayed on hillsides, eagles and ospreys riding the winds. On the horizon, just a half hour's drive away, stands the radiant, snowcapped peak of Mount Hood, site of 11 glaciers, source of half a dozen rivers, and home of four-season skiing. "I could live here," I say to myself with a backward glance down the highway toward urban Portland, a sylvan dream of the billboarded corridor that connects Silicon Valley and San Francisco.
Then, as the road comes to an end, the gray ruin of an abandoned aluminum plant rises from a barren hillside. Its gothic gantries and cavernous smelters stand empty and forlorn, a poignant warning of the evanescence of industrial power.
But industry has returned to The Dalles, albeit industry with a decidedly postindustrial flavor. For it's here that Google has chosen to build its new 30‑acre campus, the base for a server farm of unprecedented proportion.
Although the evergreen mazes, mountain
majesties, and always-on skiing surely play a role, two amenities in particular
make this the perfect site for a next-gen data center. One is a fiber-optic hub
linked to Harbour Pointe, Washington, the coastal landing base of PC-1, a
fiber-optic artery built to handle 640 Gbps that connects Asia to the US. A
glassy extension cord snakes through all the town's major buildings, tapping
into the greater Internet though NoaNet, a node of the experimental Internet2.
The other attraction is The Dalles Dam and its 1.8‑gigawatt power
station. The half-mile-long dam is a crucial source of cheap electrical
power - once essential to aluminum
smelting, now a strategic resource in the next phase in the digital revolution.
Indeed, Google and other Silicon Valley titans are looking to the Columbia
River to supply ceaseless cycles of electricity at about a fifth of what they
would cost in the San Francisco Bay Area. Why? To feed the ravenous appetite of
a new breed of computer.
To read more, please go to www.medicaltuesday.net/feature.asp .
Moore's law has a corollary that bears the name of Gordon Bell, the legendary engineer behind Digital Equipment's VAX line of advanced computers and now a principal researcher at Microsoft. According to Bell's law, every decade a new class of computer emerges from a hundredfold drop in the price of processing power. As we approach a billionth of a cent per byte of storage, and pennies per gigabit per second of bandwidth, what kind of machine labors to be born?
How will we feed it?
How will it be tamed?
And how soon will it, in its inevitable turn, become a dinosaur?
One characteristic of this new machine is clear. It arises from a world measured in the prefix giga, but its operating environment is the petascale. We're all petaphiles now, plugged into a world of petabytes, petaops, petaflops. Mouthing the prefix peta (signifying numbers of the magnitude 10 to the 15th power, a million billion) and the Latin verb petere (to search), we are doubly petacentric in our peregrinations through the hypertrophic network cloud.
Just last century - you remember it well, across the chasm of the crash - the PC was king. The mainframe was deposed and deceased. The desktop was the data center. Larry Page and Sergey Brin were nonprofit googoos babbling about searching their 150-gigabyte index of the Internet. When I wanted to electrify crowds with my uncanny sense of futurity, I would talk terascale (10 to the 12th power), describing a Web with an unimaginably enormous total of 15 terabytes of content.
Yawn. Today Google rules a total database of hundreds of petabytes, swelled every 24 hours by terabytes of Gmails, MySpace pages, and dancing-doggy videos - a relentless march of daily deltas, each larger than the whole Web of a decade ago. To make sense of it all, Page and Brin - with Microsoft, Yahoo, and Barry "QVC" Diller's Ask.com hot on their heels - are frantically taking the computer-on-a-chip and multiplying it, in massively parallel arrays, into a computer-on-a-planet.
The data centers these companies are building began as exercises in making the planet's ever-growing data pile searchable. Now, turbocharged with billions in Madison Avenue mad money for targeted advertisements, they're morphing into general-purpose computing platforms, vastly more powerful than any built before. All those PCs are still there, but they have less and less to do, as Google and the others take on more and more of the duties once delegated to the CPU. Optical networks, which move data over vast distances without degradation, allow computing to migrate to wherever power is cheapest. Thus, the new computing architecture scales across Earth's surface. Ironically, this emerging architecture is interlinked by the very technology that was supposed to be Big Computing's downfall: the Internet.
In the PC era, the winners were companies that dominated the microcosm of the silicon chip. The new age of petacomputing will be ruled by the masters of the remote data center - those who optimally manage processing power, electricity, bandwidth, storage, and location. They will leverage the Net to provide not only search, but also the panoply of applications formerly housed on the desktop. For the moment, at least, the dawning era favors scale in hardware rather than software applications, and centralized operations management rather than operating systems at the network's edge. The burden of playing catch-up in this new game may be what prompted Bill Gates to hand over technical leadership at Microsoft to Craig Mundie, a supercomputer expert, and Ray Ozzie, who made his name in network-based enterprise software with Lotus and Groove Networks.
Having clambered well up the petascale slope, Google has a privileged view of the future it is building - a perspective it's understandably reticent to share. Proud of their front end of public search and advertising algorithms, the G-men hide their hardware coup behind an aw-shucks, bought-it-at-Fry's facade. They resist the notion that their advantage springs chiefly from mastering the intricate dynamics of a newly recentralized computing architecture. This modesty may be disingenuous, of course, but amid the perpetual onrush of technological innovation, it may well be the soul of wisdom. After all, the advantage might turn out to be short-lived. . .
THE FASTEST-GROWING search engine - besides Google - isn't Microsoft or Yahoo or AOL. It's Ask.com, which has seen its total searches grow 20 percent this year. Like Google, Ask.com has built a petascale computer out of commodity CPUs, hard disks, and RAM chips. And while Google doesn't permit outsiders to ogle the hardware inside its data centers, Ask.com is eager for the attention.
The East Coast branch of Ask.com's machine occupies a 500,000-square-foot concrete structure at the end of a long and winding suburban road. The driveway runs a gauntlet of pylons bearing heavy gray power lines and festooned with smaller yellow fiber-optic cables. The windowless facility crouches behind a 10-foot-high chain-link fence in a drab tan camouflage that suggests military-level security. The building holds the central nervous system of not only Ask.com, which occupies more than half the space, but also other well-known information technology companies. Corporate logos are conspicuously absent.
The facility is run by telco giant Verizon. It was designed not for supercomputing but for communications, steering photons through glass threads and mostly copper switches toward their telephonic destinations. MCI, a Verizon acquisition, built it to accommodate UUNet, the premier high-end Internet service provider. . .
Amid the beckoning fantasies of futurism, the purpose of whatever comes next - like that of today's petapede - will be to serve the ultimate, and still the only general-purpose, petascale computer: the human brain. The brain demonstrates the superiority of the edge over the core: It's not agglomerated in a few air-conditioned nodes, but dispersed far and wide and interconnected via myriad sensory and media channels. The test of the new global ganglia of computers and cables, worldwide webs of glass and light and air, is how readily they take advantage of unexpected contributions from free human minds, in all their creativity and diversity. Search and you shall find.
To read the entire article, please go to www.wired.com/wired/archive/14.10/cloudware_pr.html.
George Gilder (firstname.lastname@example.org) is a senior fellow at the Discovery Institute and publishes the Gilder Technology Report.
© Copyright© 1993-2006 The Condι Nast Publications Inc. All rights reserved.
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LONDON -- It would have been more charitable--and certainly a lot
easier--just to give the poor woman the money. But instead, Muhammad Yunus lent
"Charity is not the answer to poverty," Yunus wrote earlier this year. "It only helps poverty to continue. It creates dependency and takes away the individual's initiative to break through the wall of poverty."
The woman and several of her friends used the small loan to start a successful furniture-making business and to escape the bonds of poverty in their rural Bangladeshi village. They repaid the loan in full.
Thirty years and more than $5.7 billion in loans later, Yunus' insight into the nature of poverty and the spirit of entrepreneurship has earned him the Nobel Peace Prize.
On Friday, the Norwegian Nobel committee awarded the $1.4 million prize jointly to Yunus and Grameen Bank, the lending agency he founded in 1983 to pioneer the concept of microcredit--small loans that have helped lift millions out of poverty.
"Muhammad Yunus has shown himself to be a leader who has managed to translate visions into practical action for the benefit of millions of people, not only in Bangladesh but also in many other countries," the Nobel committee said in its citation.
Yunus is the first Nobel laureate from Bangladesh, a wrenchingly poor South Asia country that usually makes headlines for floods and famines.
"I am so, so happy. It's really great news for the whole nation," Yunus told The Associated Press from his home in Dhaka, the Bangladeshi capital.
Yunus, in a 2004 interview with AP, said the idea of using seemingly insignificant loans to help the poor came to him in 1974 while he was doing field work as a rural economist at the University of Chittagong. He met Sufia Begum, a 21-year-old mother of three, who was trying to make ends meet by making bamboo stools.
She explained to him that she had borrowed about 5 taka (9 cents) from a village moneylender for the raw materials to make each stool but collected only 2 cents in profit on the finished product after repaying the interest on her debt.
`She has become a slave'
"I thought to myself: My God, for 5 taka she has become a slave," Yunus said in the interview.
"I couldn't understand how she could be so poor when she was making such beautiful things."
Yunus investigated further and discovered that the female artisans in the village owed the moneylender a total of 856 taka, or $27.
"I couldn't take it anymore. I put the $27 out there and told them they could liberate themselves," he said. By cutting out the moneylender and his exorbitant interest rates, the women quickly earned a decent return on their labor and repaid their loan to Yunus.
Yunus' revolutionary idea was that the poor could be as creditworthy as the rich and that small loans could unleash the entrepreneurial talents of people who had historically been written off as economic basket cases.
He founded Grameen Bank on this principle. Since opening its doors in 1983, the bank has made small loans--usually about $200, but some as little as $20--to more than 6 million borrowers, almost all of them women.
Instead of the usual tests of a borrower's creditworthiness, Grameen's approach was to lend money to small groups of people, with each responsible for the other's debt. The culture of personal shame and honor that prevails in rural Bangladesh served as sufficient collateral.
Grameen Bank boasts of a repayment rate of 98.5 percent. In most developing countries, government-subsidized banks that lend money to businesses and the affluent usually write off about 50 percent of their loans.
"Yunus and Grameen Bank have shown that even the poorest of the poor can work to bring about their own development," the Nobel committee said. . .
In announcing this year's unconventional winner, the Nobel committee recognized that "lasting peace cannot be achieved unless large population groups find ways in which to break out of poverty.
"Microcredit is one such means. Development from below also serves to advance democracy and human rights," it said.
Yunus said he would use part of the $1.4 million prize to start a company that makes low-cost, high-nutrition food for the poor.
To read the entire report, please go to www.chicagotribune.com/news/nationworld/chi-0610140237oct14,1,3952805.story.
Email: email@example.com Copyright © 2006, Chicago Tribune
To receive an update each month on the microcredit, send your e-mail address to firstname.lastname@example.org.
Dr. Yunus has spoken at the last two World Health Care Congresses. For details, please note the lead paragraph on the first MedicalTuesday Newsletter each month. To review, please go to www.medicaltuesday.net/archives/Oct1006.htm.
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3. International Medicine: NHS Centres 'Rationing Consultant Visits' By Beezy Marsh, Health Correspondent, London Telegraph (Filed: 15/10/2006)
New centres that "screen" patient referrals from GPs to hospital consultants are being used by the NHS to ration health care by stealth, say medical professionals.
More than a third of primary care trusts (PCTs) have established "referral management centres" that, critics say, are preventing patients from seeing the doctor of their choice and in some cases are prolonging waiting times in order to save cash.
In one case, GPs found thousands of referral letters stashed in a cupboard for weeks. Patients' groups and doctors' leaders say the referral schemes, which are sanctioned by the Department of Health, are creating another tier of NHS bureaucracy and could actually harm people's health.
GPs say some centres are refusing to let patients see consultants sooner than the Government's outpatient target of 13 weeks. This limits the number of appointments in any one year - saving the PCT money.
In some trusts, people are being sent back to their GPs by doctors employed by referral centres, who decide they are not sick enough to warrant a hospital consultation.
In a survey carried out by the medical magazine Pulse, 10 per cent of all PCTs admitted they had a specific target to cut GP referrals.
When patients in Milton Keynes started complaining of long delays, their GPs investigated. Milton Keynes PCT had set up a referral management centre, which was meant to scrutinise all referrals in order to speed access and ensure patients got the right treatment. But Dr Peter Berkin and colleagues discovered a backlog of more than 2,000 letters locked in a cupboard by the centre's secretaries until just short of the 13-week waiting-time target. . .
Katherine Murphy, of the Patients' Association, said: "These centres are springing up all over the place, but who's monitoring what they're up to? It seems to be another way of rationing patient care by stealth." Dr Hamish Meldrum, chairman of the British Medical Association's GPs' committee, said: "There is considerable concern among doctors. Where clinicians have been involved, things may be working well, but in other places there has been no effective consultation and it seems the main intention is to cut costs. This is potentially harmful to patients' health."
A Department of Health official said referral centres were a "local initiative" by PCTs, but national guidance had been issued on running them. "They must only be set up where they will have clinical benefits and should add value to patient services. They should not conflict with giving patients more choice [and] must not lengthen the patient journey or create 'hidden' waiting times."
To read the entire report, please go to www.telegraph.co.uk/news/main.jhtml;jsessionid=NP5FWX32L1XSTQFIQMFCFGGAVCBQYIV0?xml=/news/2006/10/15/nhs15.xml.
Canadian Medicare does not give timely access to healthcare, it only gives access to a waiting list.
--Canada's Supreme Court
UK NHS also only gives access to a waiting list that can be bureaucratically manipulated.
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CEO's Resignation Reflects Company's Deep Structural Woes By DANIEL MICHAELS, WSJ,
The resignation of Airbus Chief Executive Christian Streiff after just three months on the job underscores the steep hurdles facing the big European aircraft maker as it tries to overcome damaging delays in its largest jet program and overhaul a cumbersome structure beset by politics and bureaucracy.
The major French and German shareholders of Airbus's 80% owner, European Aeronautic Defence & Space Co., quickly named a top EADS official to succeed Mr. Streiff, who resigned after a clash with the EADS board over his demands for greater autonomy as well as over how to quickly implement a planned tip-to-tail restructuring of Airbus announced last week. . .
The structure of Airbus --
created in 1970 by technocrats in
Those tensions are a further example of the troubles arising from European efforts to maintain national balance within multinational companies. Petroleum giant Royal Dutch/Shell, industrial group ABB and consumer-products giant Unilever have all stumbled in recent years in part because of split management that was guided as much by political forces as economic interests.
In Airbus's case the tensions
have been aggravated by the company's recent problems, especially the repeated
delays in its $12 billion program to build the world's largest-ever passenger
jet, the A380, which is now two years behind schedule and about 30% over
budget. The delays have alienated customers and dented profits at Airbus, but
they are benefiting
Today, sales figures clearly show that Boeing is benefiting from its restructuring, as well as from Airbus's troubles. While Airbus is on course to deliver more planes than Boeing this year, thanks to orders placed several years back, it lags badly behind on new sales. For the year through Sept. 30, Airbus logged orders for 226 new planes, of which only 36 were higher-margin widebodies. Boeing, through Oct. 3, posted orders for 723 new planes, including 184 widebodies . . .
The so-called Power8 restructuring plan, which Mr. Gallois will now spearhead, goes beyond getting the A380 program back on track. Managers of both Airbus and EADS indicated last week that they were willing to "break taboos" and tackle politically sensitive issues. When EADS was formed in 2000 from the merger of aerospace companies from France, Germany and Spain, the company said it aimed to run Airbus efficiently, breaking with the aircraft maker's past by keeping a cold eye on the bottom line. That has proved difficult.
EADS's split management -- with dual French and German chairmen and CEOs -- was created to avoid tipping the balance of power inside EADS toward France or Germany. Maintaining that balance has saddled Airbus with a clumsy division of labor between French and German factories. The arrangement has helped preserve jobs in both countries over the years, but has proved costly in building planes. . .
But by yesterday, EADS's board members, on both the German and French sides, had lost confidence in Mr. Streiff's ability to implement his plans successfully, say people familiar with board members' discussions. They felt the executive wasn't diplomatic enough to handle the politically sensitive task of restructuring Airbus -- especially because it is likely to entail job cuts, closing plants and shifting high-profile manufacturing work from one country to another.
--Stephen Power and David Gauthier-Villars contributed to this article.
To read the entire article, please go to http://online.wsj.com/article_print/SB116040215416386840.html.
Write to Daniel Michaels at email@example.com.
Government is not the solution to our problems, government is the problem.
- Ronald Reagan
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Mr Gambezo, a 47-year-old man with late-in-life onset of asthma, required steroids to break his asthma attacks. After being seen and observed closely while medications were adjusted, he was given detailed instructions to reduce the steroid tablets once his asthma was under control. He had been told to do this slowly and if he began wheezing again, to promptly increase the dose to bring the wheezing under control. However, he stopped them suddenly with prompt re-exacerbation of wheezing. He then went to the urgent care center and a number of tests were duplicated, including a chest x-ray. The x-ray was read as pneumonia and he was given antibiotics.
On returning to the office for a follow up to re-check his x-rays to make sure the pneumonia cleared, it was noted that the x-rays were unchanged from his previous ones, with some scarring in the left base. His steroids were again adjusted and the next week he reduced them faster than suggested and experienced another asthma attack and went to the urgent care center. He was again told he had pneumonia (the former pneumonia had not fully cleared) and he was given antibiotics.
Our follow up chest x-ray again was unchanged from our previous one, and it was suspected that the x-rays in the urgent care center were probably also like ours. After acquiring these films, it was determined that there had never been any changes of pneumonia. The isolated chest x-ray, read out of context of his other films, was misread as pneumonia.
This sequence of health-care events points out two corollaries: 1) to switch health-care teams, from your own physician to one unfamiliar with your primary disease, for an exacerbation of a chronic problem is very expensive. This patient exchanged fifty cents worth of steroids, which would have reversed his asthma attack, for a $500 urgent care call with duplicated unnecessary tests, including x-rays. 2) The patient, of course, interprets all these unnecessary tests and treatments as an improvement in the quality of care, when there was no improvement, just reaffirmation of patient non-compliance with recommended treatment.
Sometimes the Most Gluttonous Behavior Will Be Interpreted As an Improvement in Quality
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A recent health insurance brochure pointed out that one percent of its members use 40 percent of their health care dollars. This causes us to reflect on a poorly known fact. The sick already have Medicare, Medicaid or private health insurance. That covers nearly all the major health needs of the American people. Making the other 40 million relatively healthy individuals pay health insurance premiums only increases profits for big insurance. It adds very little to the Nation's Health. In fact, the increased bureaucracy for the 40 million will probably decrease their access to health care.
Health Insurance for All Will Only Improve Big Insurance's Wealth
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Dr Dave: Did you happen to hear Grover Norquist on Fresh Air the other morning?
Dr Ruth: I'm sure he said something that wasn't very welcomed by Fresh Air.
Dr Dave: Fresh Air was on a tirade to tax the Rich. Grover very calmly remarked that to stick it to a small strata of society that was defenseless to resist was basically a holocaust mentality.
Dr Ruth: I can just see Fresh Air come unglued on that one.
Dr Dave: I could almost feel her coming out of her chair as she exclaimed what he meant by that.
Dr. Rosen: And now we have a candidate for Governor of California with the same Holocaust mentality. He wants to tax the rich to pay for a lot of social programs that generally don't work.
Dr Michelle: But they do. The poor need a lot of help.
Dr Rosen: They do. But welfare hasnt helped them.
Dr Dave: We also have a candidate for Lieutenant Governor who has spent his life as insurance commissioner suing big insurance, selling and liquidating big insurance to a French company financed by the French government who paid his asking price, then suing that company when it turned out that our insurance commissioner made a multibillion dollar error in valuation, spending $165 million in legal fees to overturn his own sale, which was only limited by budgetary restraints. Doesn't he have the same Holocaust mentality under the auspices of helping people, only depriving a lot of working people out of their insurance and pensions, and blaming it on the lack of tax revenues? If only he could take more money away from the well-to-do, there would be no limit as to how much good he thinks that he could do. He completely ignores the testimonials in the papers on the people who lost their homes because of him.
Dr Edward: But he's for socialized medicine. Don't you think it's about time we follow the rest of the world?
Dr Dave: No. My grandfather escaped Bismarcks socialized medicine in the 19th century. Where could we escape to if we became like old Europe? America is our sanctuary. It is the last sanctuary for freedom.
Dr Rosen: Didn't you read the article in today's paper on the Nobel Peace Prize? Professor Muhammad Yunus from Bangladesh wrote, "Charity is not the answer to poverty. It only helps poverty to continue. It creates dependency and takes away the individual's initiative to break through the wall of poverty." In addition to his micro-credit, he also helps the poor with health insurance and efficient clinics that can provide cataract and other necessary operations at minimal cost, not handouts. Half of the Nobel Prize went to the Grameen Bank, which distributes the $27 loans. www.grameen.com/
Dr Michelle: I still think it is much easier to help the poor by giving them money rather than make them work for it?
Dr Rosen: I think you should read what Professor Yunus explains are the real answers for helping the poor. Handouts never help. They will again be poor tomorrow. By using micro-credit loans, they will be independent tomorrow and perhaps wealthy in the future.
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Sonoma Medicine, the Magazine of the Sonoma County Medical Association, OUTSIDE THE OFFICE:
A Country Impossible To Understand By Jose Morales, MD
Over the past two years, our
family has visited China three times. This adventure started off as a fun
family trip to explore my wife's country of birth. We wanted to see the city my
in-laws grew up in and show our girls where half their heritage originated.
Our adventure has since evolved into a continuing discovery of what China has been, what it is now, and what it may become. I documented our discovery in a series of photographs, some of which are reproduced here and on pages 23 and 47. These particular images show some of the contrasts we witnessed throughout the country.
Our three trips lasted 10 weeks total and brought us not only to large cities - such as Hong Kong, Beijing, and Shanghai - but also to smaller cities and towns, including Fuzhou, its surrounding villages, and Hanzhou. Our trips differed in many ways from an average vacation in China, particularly since we did not join an organized tour. Instead, we traveled about on our own.
No matter where we went, we were universally met with kindness and curiosity. Our girls were treated like little celebrities and often became the center of attention. Everyone from teens to grandparents wanted to know how old the girls were (6 and 9), if they were twins (don't forget that China is a one-child nation), and most important, could they speak Chinese? (a little).
We saw first-hand how rapidly China is evolving. When we arrived in Fuzhou in 2004, for example, I had to ride on the back of a motorcycle to a distant housing block and use a dial-up modem belonging to a "friend of a friend" for Internet access. The deal was sealed with a large bag of fruit I carried over my shoulder. Fast forward to this past May, when all we needed was to walk downstairs from our apartment and choose between three Internet cafes within two blocks. The cafes were all full of 20-somethings playing video games and sending text messages.
Two other signs of "progress" are much sadder. The first is a rise in the number of overweight kids, and the second is a similar increase in young smokers filling the cafes and restaurants. These unfortunate trends seem to be a byproduct of increasingly Western tastes.
The more we have gotten to know this dynamic country, the more it seems impossible to understand. China is a strange mix of claustrophobic crowds, crazy traffic, ancient customs, modern life, beautiful colors, rudeness, kindness, and politics - all revolving around an incredible dynamic energy of growth.
To read the entire article and view some incredible photos, please go to www.scma.org/magazine/scp/Fall06/morales.html.
Dr. Morales is a Santa Rosa pediatrician.
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9. Book Review: Final Crossing: Learning to Die in Order to Live
I once read a book about Zen which began: "If you
like sweets and easy living, don't read this book." At the age of 19, I liked
sweets and easy living, but I read the book anyway. It was one of the most
influential books I've ever read.
Final Crossing, by Dr. Scott Eberle, is a serious work about a serious subject: death. Indeed, is there any subject more serious? Perhaps, the author himself might argue, there is only one: life. And it appears to be Eberle's intent, by exploring one man's conscious journey through the dying process, to cast light and understanding on the process of how we might more consciously live.
This is not a superficial tourist's guide. For more than 20 years, Eberle has worked with the dying as a physician, teacher, and companion. He writes with an experience and authority that can come only from someone who has done the work. Like the Zen book I read 40 years ago, Eberle's volume entails some hard work and self-reflection. But it is well worth reading, and it leaves lessons in life for years to come. . . .
Eberle forged his physician's skills and temperament literally at the bedside of hundreds of dying patients. What he heard and saw guided the arc of his career toward a nearly singular expertise in end-of-life work. He has directed medical services at Hospice of Petaluma, founded his own Center for Wellness in Medicine, taught courses and workshops for providers and caregivers, conducted wilderness retreats, and become co-director of the School of Lost Borders. He says of his work, "It's not just about death. It's about life, and all life's transitions."
In Final Crossing, Eberle distills his
experience into the form of an intimate case study. The case introduces and
illustrates a model for life's "Great Transition" that, in my
opinion, enlightens even the best work of Elisabeth Kubler-Ross.
The book is structured on four house calls Eberle makes to his patient - who is also a dear friend and his former teacher - during the last six months of the patient's life. Between visits Eberle narrates, educates, and explains his model, a metaphor for the four stages of the classic human journey: severance, threshold, transition, and re-integration. The model is based on ancient Native American ritual and practice, first known among the Mayans in 1500 BC and later modified by tribes among the Northern Cheyenne. It is a familiar hero's journey. Odysseus, Arjuna, Black Elk, Siddhartha, and the "Hero with a Thousand Faces" all come to mind. Eberle brings his own understanding and experience to the interpretation of each stage.
The heart of this book beats loudest in the home visits, where Eberle encounters the dying man. More than anything else, Eberle listens, and he constantly re-invokes himself to be present. It is hard not to relate to these visits as a physician, and there are innumerable lessons to be learned. While I've spent my hours at the bedside of dying patients, both as family and hospice physician, I marvel at the experience and wisdom Eberle brings to the encounter. In the end, Eberle implicitly asks the reader to see him not as a physician, but only "as a fellow human being peering into the great mystery of death."
"Doc, I'm not afraid of death," his patient tells him. "It's the dying that scares me." I was reminded of the line from Woody Allen, whose humor is never just funny: "I'm not afraid of death. I just don't want to be there when it happens." Awareness of death and acknowledgement of our mortality is the first stage of the journey. . .
In the background of Final Crossing is the societal awakening that death is not to be denied or ignored. Since the 1970s - thanks to the work of pioneers like Kubler-Ross and Stephen Foster, and writers like Joseph Campbell and Carlos Casteneda - the cloak of "Forgetting" has been lifting. In 1974, the same year Eberle's patient began his career in life-transition counseling, the first American hospice chapter opened in Marin County. Death is no longer as secret or hidden as it was back then; people are allowed to die at home. In modern medicine, death is not always the enemy. Often the enemy is dying in a sterile and alien environment, surrounded by futile technologies and separated from the ones we love and the surroundings we are "at home" with. What does it mean to die "with dignity"? Thirty years ago we couldn't even ask the question, much less allow patients and families to acknowledge and participate in the greatest of all life's transitions . . .
At one point, Eberle quotes from an elderly
man who faces a potentially life-threatening diagnosis. The man reorganizes his
life. He assesses his values. He reconciles and enriches every one of his
personal relationships and considers what work is most meaningful to him in the
time he has remaining. While his outcome is still in question, he remarks to
his daughter, "You know, whether I live or die, I've still got to make the
Eberle's thesis, based on a career's experience, and illustrated intensely and personally throughout his book, is not easy. But it is simple. There are lessons in the final crossing. Do we have to wait until we die to learn them?
To read the entire review by Dr. Flinders, go to www.scma.org/magazine/scp/Fall06/flinders.html.
Dr. Flinders, director of the Family Medicine Residency Program at Sutter Santa Rosa, serves on the SCMA Editorial Board.
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Relatives have an 'inside track' in lobbying for tax dollars. No laws prevent family members from trying to influence lawmakers or top congressional staffers. Many have succeeded in getting millions for their clients, a USA TODAY investigation shows.
Looks like Congress is a bigger Cesspool than anyone would have thought.
USA TODAY also reports that far too many back surgeries are being performed. After a long debate, they couldn't decide just what can be done about it except chastise doctors.
I had a patient that had five back surgeries. He confided in me that his back pain was far worse than before the first surgery. After the fifth, however, he became paralyzed from his waist down at age 43 and lives his days in a wheelchair. When he has a bowel movement, he uses a hoist to move him over the toilet. When he wants to empty his bladder, he just reaches into his pajamas and pulls out a rubber hose that goes into his bladder and opens the stopcock. He is still looking for that sixth neurosurgeon to fix his back. His search for five years now has not found a neurosurgeon to step forward. A hundred volumes of Medicare and Health Care Laws have not stopped this over utilization.
As long as health care is relatively free, this type of over utilization will continue. It will only stop when the co-payment is a significant percentage of the cost. Then we will have the right amount of surgeries.
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John and Alieta Eck, MDs, for their first-century solution to twenty-first century needs. With 46 million people in this country uninsured, we need an innovative solution apart from the place of employment and apart from the government. To read the rest of the story, go to www.zhcenter.org and check out their history, mission statement, newsletter, and a host of other information. For their article, "Are you really insured?," go to www.healthplanusa.net/AE-AreYouReallyInsured.htm. For the latest on their Antigua Project, please go to www.zhcenter.org/custom.asp?id=188800&page=3. You may be interested in a Medical Timeshare in a resort.
PATMOS EmergiClinic - www.emergiclinic.com - where Robert Berry, MD, an emergency physician and internist practices. Here is his story: Three years ago, I left ER medicine to establish a primary care clinic in a town of about 15,000 in northeast Tennessee - primarily for the uninsured, but also for anyone willing to pay me for my care at the time of service. I named the clinic PATMOS EmergiClinic - for the island where John was exiled and an acronym for "payment at time of service." I have no third party contracts...not commercial, not Medicare, TennCare or worker's compensation. My practice today has over 4,000 patient charts. My patients are typically between 5-50 years old, but I do have a significant number of Medicare patients. A year ago, over 95 percent of the patients I saw had no insurance. Today, that figure may be 75 percent. But even those with insurance learn a simple lesson when they come to me: health insurance does not equal healthcare, at least not at my clinic. I clearly tell my patients how much a visit will cost. Everything is up front and honest. I will prepare a billing claim for my patients with insurance, for a small fee, but I expect them to pay me when I see them. Because I need only one employee in my office, my costs are low. For the same services, I charge about 60 percent of charges made by other local clinics, 40 percent of what the local urgent care clinic charges and less than 20 percent of what the local ER charges. I am the best bargain in town. If I can do it, caring for the uninsured in a small rural town, any doctor can. To read more on Dr Berry, please to go www.medicaltuesday.net/org.asp.
PRIVATE NEUROLOGY is a Third-Party-Free Practice in
Michael J. Harris, MD - www.northernurology.com - an active member in the American Urological Association, Association of American Physicians and Surgeons, Societe' Internationale D'Urologie, has an active cash'n carry practice in urology in Traverse City, Michigan. He has no contracts, no Medicare, Medicaid, no HIPAA, just patient care. Dr Harris is nationally recognized for his medical care system reform initiatives. To understand that Medical Bureaucrats and Administrators are basically Medical Illiterates telling the experts how to practice medicine, be sure to savor his article on "Administrativectomy: The Cure For Toxic Bureaucratosis" at www.northernurology.com/articles/healthcarereform/administrativectomy.html.
Dr Vern Cherewatenko concerning success in restoring private-based medical practice which has grown internationally through the SimpleCare model network. Dr Vern calls his practice PIFATOS - Pay In Full At Time Of Service, the "Cash-Based Revolution." The patient pays in full before leaving. Because doctor charges are anywhere from 25 -50 percent inflated due to administrative costs caused by the health insurance industry, you'll be paying drastically reduced rates for your medical expenses. In conjunction with a regular catastrophic health insurance policy to cover extremely costly procedures, PIFATOS can save the average healthy adult and/or family up to $5000/year! To read the rest of the story, go to www.simplecare.com.
Dr David MacDonald started Liberty Health Group. To compare the traditional health insurance model with the Liberty high-deductible model, go to www.libertyhealthgroup.com/Liberty_Solutions.htm. There is extensive data available for your study. Dr Dave is available to speak to your group on a consultative basis.
Dr. Nimish Gosrani has set up a blend between concierge medicine and a cash-only practice. Patients can pay $600 a year, plus $10 per visit, to see him as many times in a year as they want. Patients may also see him on a simple fee-for-service basis, with fees ranging from $70 for a simple office visit to $300 for a comprehensive physical. Dr. Gosrani reports that he saves two hours per day that he used to spend dealing with insurance company paperwork. To read more, go to http://cgi.photobooks.com/scripts/troll.cgi?dbase=moses&page=2&setsize=10&practice=Nimish+C.+Gosrani%2C+MD&pict_id=2001670.
· Dr. Elizabeth Vaughan is another Greensboro physician who has developed some fame for not accepting any insurance payments, including Medicare and Medicaid. She simply charges by the hour like other professionals do. Dr. Vaughan's web site is at www.VaughanMedical.com, where you can see her march in a miniskirt for Breast Health without a Bra.
· Madeleine Pelner Cosman, JD, PhD, Esq, who has made important efforts in restoring accountability in health care, has died (1937-2006). Her obituary is at www.signonsandiego.com/news/obituaries/20060311-9999-1m11cosman.html. She will be remembered for her important work, Who Owns Your Body, which is reviewed at www.delmeyer.net/bkrev_WhoOwnsYourBody.htm. Please go to www.healthplanusa.net/MPCosman.htm to view some of her articles that highlight the government's efforts in criminalizing medicine. For other OpEd articles that are important to the practice of medicine and health care in general, click on her name at www.healthcarecom.net/OpEd.htm.
David J Gibson, MD, Consulting Partner of Illumination Medical, Inc. has made important contributions to the free Medical MarketPlace in speeches and writings. His series of articles in Sacramento Medicine can be found at www.ssvms.org. To read his "Lessons from the Past," go to www.ssvms.org/articles/0403gibson.asp. For additional articles, such as the cost of Single Payer, go to www.healthplanusa.net/DGSinglePayer.htm; for Health Care Inflation, go to www.healthplanusa.net/DGHealthCareInflation.htm. Read his latest on In Flight Emergencies at www.ssvms.org/articles/0607gibson.asp.
Dr Richard B Willner, President, Center Peer Review Justice Inc, states: We are a group of healthcare doctors -- physicians, podiatrists, dentists, osteopaths -- who have experienced and/or witnessed the tragedy of the perversion of medical peer review by malice and bad faith. We have seen the statutory immunity, which is provided to our "peers" for the purposes of quality assurance and credentialing, used as cover to allow those "peers" to ruin careers and reputations to further their own, usually monetary agenda of destroying the competition. We are dedicated to the exposure, conviction, and sanction of any and all doctors, and affiliated hospitals, HMOs, medical boards, and other such institutions, who would use peer review as a weapon to unfairly destroy other professionals. Read the rest of the story, as well as a wealth of information, at www.peerreview.org.
Semmelweis Society International, Verner S. Waite MD, FACS, Founder; Henry Butler MD, FACS, President; Ralph Bard MD, JD, Vice President; W. Hinnant MD, JD, Secretary-Treasurer; is named after Ignaz Philipp Semmelweis, MD (1818-1865), an obstetrician who has been hailed as the savior of mothers. He noted maternal mortality of 25-30 percent in the obstetrical clinic in Vienna. He also noted that the first division of the clinic run by medical students had a death rate 2-3 times as high as the second division run by midwives. He also noticed that medical students came from the dissecting room to the maternity ward. He ordered the students to wash their hands in a solution of chlorinated lime before each examination. The maternal mortality dropped, and by 1848 no women died in childbirth in his division. He lost his appointment the following year and was unable to obtain a teaching appointment Although ahead of his peers, he was not accepted by them. When Dr Verner Waite received similar treatment from a hospital, he organized the Semmelweis Society with his own funds using Dr Semmelweis as a model: To read the article he wrote at my request for Sacramento Medicine when I was editor in 1994, see www.delmeyer.net/HMCPeerRev.htm. To see Attorney Sharon Kime's response, as well as the California Medical Board response, see www.delmeyer.net/HMCPeerRev.htm. Scroll down to read some very interesting letters to the editor from the Medical Board of California, from a member of the MBC, and from Deane Hillsman, MD.
To view some horror stories of atrocities against physicians and how organized medicine still treats this problem, please go to www.semmelweissociety.net.
Dennis Gabos, MD, President of the Society for the Education of Physicians and Patients (SEPP), is making efforts in Protecting, Preserving, and Promoting the Rights, Freedoms and Responsibilities of Patients and Health Care Professionals. For more information, go to www.sepp.net.
Robert J Cihak, MD, former president of the AAPS, and Michael Arnold Glueck, M.D, write an informative Medicine Men column at NewsMax. Please log on to review the last five weeks' topics or click on archives to see the last two years' topics at www.newsmax.com/pundits/Medicine_Men.shtml. This week's column is on Suicide by Quarterback - Football Players Dying Young. www.newsmax.com/archives/articles/2006/10/3/122610.shtml
The Association of American Physicians & Surgeons (www.AAPSonline.org), The Voice for Private Physicians Since 1943, representing physicians in their struggles against bureaucratic medicine, loss of medical privacy, and intrusion by the government into the personal and confidential relationship between patients and their physicians. Be sure to scroll down on the left to departments and click on News of the Day ... In Perspective or go directly to www.aapsonline.org/nod/newsofday332.php and read about Psychiatry used as a tool against dissent. The "AAPS News," written by Jane Orient, MD, and archived on this site, provides valuable information on a monthly basis. Read the latest newsletters on Evidence Based Medicine at www.aapsonline.org/newsletters/oct06.php. Scroll further to the official organ, the Journal of American Physicians and Surgeons, with Larry Huntoon, MD, PhD, a neurologist in New York, as the Editor-in-Chief. Or go directly to the journal at www.jpands.org/. There are a number of important articles that can be accessed from the Table of Contents page of the current issue at www.jpands.org/jpands1102.htm Don't miss the excellent article on Sham Peer Review or the extensive book review section including Malignant Medical Myths at www.jpands.org/vol11no2/bookreviews.pdf.
The 63rd Annual Meeting of the AAPS, in Phoenix, AZ, September 13-16, was a huge success.
To read this press release, go to www.aapsonline.org/press/nr-09-13-2006.php.
DOCTORS OPPOSE AMA EFFORTS TO HALT MEDICARE PAY CUTS
"It's NOT about the money."
Bookmark www.aapsonline.org/ as your gateway to a vast amount of important information.
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Wisdom and Aphorisms
The basis of the fraternity system is that not all men are brothers. -Anonymous aphorism.
His college fraternity was Gotta Getta Gal. -Anonymous aphorism.
Who was the first person to settle in America? I don't know; undoubtedly some foreigner. -Anonymous anecdotage.
"The trouble with international relations," said the expert, is that we have a whole new group of powers involved." "not at all," said the other expert, "they're the same powers as before - the power of persuasion and the power of superior force." -Anonymous anecdotage.
International relations are as difficult as any other in-laws. -Anonymous aphorism.
Diplomacy is the language of international relations, which can say one thing that has two absolutely opposite meaning for the two parties involved. -Anonymous aphorism.
Some Recent Postings
July HPUSA Issue: www.healthplanusa.net/July06.htm
April HPUSA Issue: www.healthplanusa.net/April06.htm
January HPUSA Issue: www.healthplanusa.net/January06.htm
On This Date in History October 24
On this date in 1945, the United Nations Charter was adopted. The late Adlai Stevenson remarked on this date in 1963 that "The journey of a thousand leagues, we say, begins with a single step. So we must never neglect any work of peace that is within our reach, however small. Our efforts will be erratic, and the world will remain a dangerous place to live."
On this date in 1931, the
Speaker's Lifetime Library, © 1979, Leonard and Thelma Spinrad