1.
Featured Article: Why Do Some People Sleepwalk? Why do we
get "brain freeze?"
2.
In the News: Virginia Supreme Court Declared the State's
Anti-Spam Law Unconstitutional
3.
International
Medicine: Socialized Medicine Compensation from the NHS.
4.
Medicare: Medicare Is Bad for Your Health
5.
Medical Gluttony: The Hospital Can't Afford to Listen to
Patients
6.
Medical Myths: Is Mandatory Health Insurance Really a Good Idea?
7.
Overheard in the Medical Staff Lounge: What are you doing about
the obesity epidemic?
8.
Voices of
Medicine: Above and Beyond the Call of Duty
9.
From the Physician Patient Bookshelf: AMA ESSENTIAL GUIDES
10.
Hippocrates
& His Kin: HMO Patients Try to Get Three Office Visits on One Copay?
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 logam@freestarmovie.com.
* * * * *
1.
Featured
Article: Why Do Some People Sleepwalk? Why do we get "brain freeze?"
Why Do Some People Sleepwalk?—Carlos Navarro, via e-mail
Neurologist Antonio Oliviero of the National
Hospital for Paraplegics in Toledo, Spain, explains:
Sleep disorders such as sleepwalking arise
when normal physiological systems are active at inappropriate times. We do not
yet understand why the brain issues commands to the muscles during certain
phases of sleep, but we do know that these commands are usually suppressed by
other neurological mechanisms. At times this suppression can be
incomplete—because of genetic or environmental factors or physical
immaturity—and actions that normally occur during wakefulness emerge in sleep.
People can perform a variety of activities
while asleep, from simply sitting up in bed to more complex behavior such as
housecleaning or driving a car. Individuals in this trancelike state are
difficult to rouse, and if awoken they are often confused and unaware of the
events that have taken place. Sleepwalking most often occurs during childhood,
perhaps because children spend more time in the "deep sleep" phase of
slumber. Physical activity only happens during the non–rapid eye movement
(NREM) cycle of deep sleep, which precedes the dreaming state of REM sleep.
Recently my team proposed a possible
physiological mechanism underlying sleepwalking. During normal sleep the
chemical messenger gamma-aminobutyric acid (GABA) acts as an inhibitor that
stifles the activity of the brain's motor system. In children the neurons that
release this neurotransmitter are still developing and have not yet fully
established a network of connections to keep motor activity under control. As a
result, many kids have insufficient amounts of GABA, leaving their motor
neurons capable of commanding the body to move even during sleep. In some, this
inhibitory system may remain underdeveloped—or be rendered less effective by
environmental factors—and sleepwalking can persist into adulthood.
Sleepwalking runs in families, indicating
that there is a genetic component. The identical twin of a person who
sleepwalks often, for example, typically shares this nocturnal habit. Studies
have also shown that frequent sleepwalking is associated with sleep
deprivation, fever, stress and intake of drugs, especially sedatives,
hypnotics, antipsychotics, stimulants and antihistamines. . .
Why do we get "brain freeze"
when we eat something cold?
-Christina Zuniga, via e-mail
Mark A. W. Andrews, professor of
physiology and director of the Independent Study Pathway at the Lake Erie
College of Osteopathic Medicine, replies:
This commonly experienced pain, also known
as an ice cream headache, results from quickly eating or drinking very cold
substances. Officially termed sphenopalatine ganglioneuralgia (talk about a
painful mouthful!), it is the direct result of the rapid cooling and rewarming
of the blood vessels in the palate, or the roof of the mouth. A similar but
painless blood vessel response causes the face to appear "flushed"
after being outside on a cold day. In both instances, the cold temperature
causes blood vessels to constrict and then experience extreme rebound dilation
as they warm up again.
In the palate, this dilation is sensed by
nearby pain receptors, which then send signals back to the brain via the
trigeminal nerve, one of the major nerves of the facial area. This nerve also
senses facial pain, so as the signals are conducted the brain interprets the pain
as coming from the forehead—the same "referred pain" phenomenon seen
in heart attacks. Brain-freeze pain may last from a few seconds to a few
minutes, which is blissfully short as compared with the duration of its cousin,
the migraine headache. Research suggests that the same vascular mechanism and
nerve implicated in brain freeze cause the aura (sensory disturbance) and
pulsatile (throbbing pain) phases of migraines. Interestingly, it is impossible
to give yourself an ice cream headache in cold weather—only in a warm ambient
temperature will it hurt to wolf down a banana split.
Fortunately, abstaining from ice cream is
not necessary. Placing the tongue hard against the palate may help, as will
eating cold foods more slowly or warming food in the front of your mouth before
swallowing.
www.sciam.com/article.cfm?id=why-do-some-people-sleepwalk&print=true
* * * * *
2.
In the News: Virginia Supreme Court declared the state's anti-spam law
unconstitutional
VA. court strikes down anti-spam law, By LARRY O'DELL, Associated Press Writer
The Virginia Supreme Court declared the
state's anti-spam law unconstitutional Friday and reversed the conviction of a
man once considered one of the world's most prolific spammers.
The court unanimously agreed with
Jeremy Jaynes' argument that the law violates the free-speech protections of
the First Amendment because it does not just restrict commercial e-mails — it
restricts other unsolicited messages as well. Most other states also have
anti-spam laws, and there is a federal CAN-SPAM Act as well, but those laws
apply only to commercial e-mail pitches.
The Virginia law "is
unconstitutionally overbroad on its face because it prohibits the anonymous
transmission of all unsolicited bulk e-mails, including those containing
political, religious or other speech protected by the First Amendment to the
U.S. Constitution," Justice G. Steven Agee wrote.
Agee wrote that "were the
Federalist Papers just being published today via e-mail, that transmission by
Publius would violate the statute." Publius was the pseudonym used by
Alexander Hamilton, James Madison and John Jay in essays urging ratification of
the Constitution.
"In my view, the case was never
about Jeremy Jaynes — it was about the First Amendment," said Jaynes'
attorney, Thomas M. Wolf. "The argument was never that there's a
constitutional right to send commercial spam. It was that the government cannot
criminalize the sending of noncommercial e-mail for political and religious
purposes, and that is what this statute did."
Lawyers for the state had argued
that the First Amendment doesn't apply because the Virginia law bars
trespassing on privately owned e-mail servers through phony e-mail routing and
transmission information. The court rejected that characterization of the law.
. .
The Virginia Supreme Court last
February affirmed Jaynes' conviction on several grounds but later agreed,
without explanation, to reconsider the First Amendment issue. Jaynes was
allowed to argue that the law unconstitutionally infringed on political and
religious speech even though all his spam was commercial.
Wolf said sending commercial spam is
still illegal in Virginia under the federal CAN-SPAM Act. However, he said the
federal law does not apply to Jaynes because it was adopted after he sent the
e-mails that were the basis for the state charges. To read the entire article,
please go to http://license.icopyright.net/user/viewFreeUse.act?fuid=MTUzMDIyOQ%3D%3D.
* * * * *
3.
International
Medicine: Socialized Medicine Compensation from the NHS
Is the law bleeding the
NHS to death? By Richard Girling From
The Sunday Times, August 3, 2008
Coming out of hospital with
an injured finger could earn you £75,000. The NHS may have to cough up £9 billion
in lawsuits. Is compensation culture killing our health service?
For Dr Spencer
at his Norfolk surgery, the whoops-a-daisy moment came when he dosed a woman
with bismuth. Startled by her dyspeptic response, and eager to reassure her
increasingly agitated husband, he swallowed a spoonful of the stuff himself.
"See? Perfectly safe!"
Two things then
happened: Dr Spencer vomited, fell down and lay writhing on the floor. His
patient died.
The explanation
was simple. As the doctor explained to the coroner, bismuth and strychnine look
remarkably similar in the bottle and, well, mistakes do happen. At the
subsequent trial for manslaughter, Mr Justice Willes agreed. A simple blunder,
he said, was not in itself a criminal act. To secure a conviction, the crown
would have to prove that the doctor's medicines were in such chaotic disorder
that it was impossible for him to know which was which. Not guilty, said the
jury.
That was in
1867. Legal actions against clinical killers then were exceedingly rare, and would
remain so. By 1989 only six more doctors had been fingered for manslaughter –
an average of one every 20 years. Then something changed. In the 1990s, 17 were
prosecuted, and since 2000 there have been 11 more. One or two of them, like
the Spencer case, were tales of startling improbability. A woman under
anaesthetic was connected to an oxygen cylinder instead of to a ventilator and
inflated like a balloon (the anaesthetist got six months' jail, suspended for
18 months). Mostly, however, they were mundane tragedies of misread notes,
wrong drugs or lethal doses administered by exhausted, inexperienced or
occasionally negligent practitioners who failed in the most basic of their
responsibilities.
This relatively
small number of headline cases, however, was only the tiny tip of a legal
iceberg. It wasn't just the police and Crown Prosecution Service who were
taking a more critical look at wards and clinics – it was the patients
themselves. In England between 1990 and 1998, the rate of civil negligence claims
against hospitals doubled, reaching a peak in 1998-9 of 6,168. If we didn't
know them to be true, the numbers would strain credibility. The cost to the NHS
of claims settled in 2006-7 was £579.3m. In the same year it was hit by 5,426
new cases. The NHS Litigation Authority (NHSLA) estimates that the combined
cost of settling all outstanding claims, including incidents so far unreported,
will be £9.09 billion.
Paralysing
tentacles of fear are now putting the squeeze on medical practice, and changing
the way we are treated. Type the words "clinical negligence" or
"no win, no fee" into Google and you'll see why – a clamorous pack of
legal agencies and law firms who trade on the idea that every accident must be
someone's fault. Some websites even provide interactive body maps showing the
value of everything from an injured finger (£1,000 to £75,000) to serious brain
damage (millions). The come-on to patients is the promise of "no win, no
fee". If the lawyer wins your case for you, he collects his fee in costs from
the other side and you walk away with your damages in full. If he loses, he
charges nothing. So, come on! What are you waiting for? Sue the doc! . . .
As so often
with the NHS, vice is the bastard child of virtue. "No win, no fee"
deals, known in law as conditional-fee arrangements, were introduced by an
amendment to the Courts and Legal Services Act in 1995. It was meant to be a
double benefit. The courts would be opened up to those in the income trap who
were ineligible for legal aid but unable to afford lawyers. The government
itself would save money by effectively privatising legal aid. On the surface it
looked like the long-overdue democratisation of civil justice.
But law firms
are not charities. Working for nothing – pro bono – is not unknown, but it
hardly stands as an ideal business model. If lawyers were to drop their fees
when they lost, then they would need a bonus when they won. Recognising this,
the law allows a "success fee" of up to double the normal scale. In
clinical- negligence cases, when judgment favours the patient, this must be
paid by the NHS, otherwise known as the taxpayer. . .
Once upon a
time, family doctors were revered members of communities that knew how to
respect their betters. They tended to tweediness and avuncularity, and knew
each patient from the moment of conception. Their status was impregnable. Like
magistrates (which they also often were), they dwelt upon a high moral plateau
where errors and injustices were as rare as club-footed Martians with syphilis.
They cut your umbilical cord, signed your passport photograph and came to your
funeral. You would no more think of suing them than you would of denying God or
insulting the king. Doctors for their part were sworn by Hippocrates to guard
the sick against harm and injustice. From this grew the modern ideal of
"preventive medicine" – the inoculations, health checks, dietary
advice and so forth that cure illnesses before they happen.
All this now is
changing. Vulture culture, compensation culture, blame culture. Call it what
you will, the effect is the same. As the British Medical Journal pointed out,
the rise in prosecutions in the late 20th century was not likely to have been
caused by a sudden epidemic of clinical malpractice. An entire profession does
not go rotten overnight. "More plausible explanations," it suggested,
were "a greater readiness to call the police or to prosecute, perhaps
because the Crown Prosecution Service perceives that juries are readier to
convict nowadays."
The old notion
of a lifelong relationship between patient and practitioner was also under
assault. Large group practices and the increasing influence of professional
managers made the NHS seem more remote and bureaucratic.
Suing it seemed
less like attacking a friend than asserting your rights against an impersonal
monolith that knew you only as a computer file. Instead of grumbling about our
grievances, we went to law, and doctors went on the defensive. Out went the
bedside manner; in came proceedings that, in the words of the government's
chief medical officer, Sir Liam Donaldson, "frequently progress in an
atmosphere of confrontation, acrimony, misunderstanding and bitterness".
This is the
real cost of the compensation culture. Preventive medicine (protecting the
patient) is being superseded by defensive medicine (protecting the doctor from
litigation). What it means is that GPs behave more like trampolines than
physicians, bouncing their patients on to consultants rather than taking
responsibility themselves. It means a plethora of clinically unnecessary,
just-in-case blood tests, x-rays, endoscopic examinations, CT and MRI scans,
avoidance of tricky procedures, shunning of awkward patients and reluctance to
try new treatments. As birth defects account for the majority of new claims each
year, it results in a huge increase in the number of caesareans. . .
Because of
rapacious lawyers, he says, GPs now prescribe more freely, refer patients to
consultants and order laboratory tests much earlier than they would have done
in the past. "It's dumbing down what we do. It requires experience and
judgment to do nothing. If there was a diagnostic test for everything, then why
would you need a doctor? Now I can spend a whole surgery writing out test
request forms. It's a hell of a long way from preventive medicine."
Because GPs, like consultants in private practice, are self-employed, they are
not covered by the NHSLA's Clinical Negligence Scheme for Trusts – effectively
a government-run insurance scheme into which local NHS trusts pay annual premiums
of up to £5m each. GPs and private practitioners instead have to use specialist
insurance companies whose payouts are not included by the NHS but still siphon
money away from medicine and into law. The Medical Defence Union, which
indemnifies just over half the UK's GPs and private consultants, primly
declines to reveal the figures. . .
The other thing
that bacteria love is filth, and the ideal place to look for it is in an NHS
hospital. The result is that there are now law firms claiming to specialise in
hospital "superbug" cases, and the number of claims is multiplying
like bacteria on a Petri dish. One of the most notorious cases involved the
three hospitals administered by the Maidstone and Tunbridge Wells NHS Trust
where, between April 2004 and September 2006, more than 1,170 patients were
infected with Clostridium difficile. According to the Healthcare Commission's
official report, about 90 people "definitely or probably died as a result
of the infection". The commission's inspectors found that the hospitals
were epidemics waiting to happen. Supposedly clean bedpans were contaminated
with excrement. Nurses were not washing their hands, emptying commodes,
cleaning mattresses and equipment, or wearing aprons and gloves. If there was a
parlour game called "pass the bacteria", this is how you'd play it.
The health secretary, Alan Johnson, described the episode as
"scandalous", and Kent police are still weighing the possibility of
prosecution. . .
The nurses
might not be washing their hands, but the lawyers sure as hell are rubbing
theirs.
To read the
entire lengthy article, go to http://business.timesonline.co.uk/tol/business/law/article4428686.ece.
The NHS does not give timely
access to health care, but it may give access to legal compensation.
* * * * *
4.
Medicare:
Medicare Is Bad for Your Health
Medicare Is Bad for Your Health By Philip R. Alper, MD
Hoover fellow Philip R. Alper explains how
Medicare's convoluted regulations put the nation's health care system at
risk. Hoover Digest, 1998. (As relevant
today as ten years ago.)
Last summer Columbia/HCA
teetered on the brink of disaster after the Health Care Financing
Administration (HCFA), which administers Medicare, accused the company of
massive fraud. On the other side of that continuing fight, HCFA head Bruce
Vladek recently resigned, saying he was exhausted by trying to control fraud in
the $300 billion Medicare and Medicaid programs.
This battle is really over differing answers to
the question "How many CPAs can dance on the head of a syringe?"
What's lost in all the bureaucratic and legal mumbo jumbo is a fact that's far
more damaging to our nation's health care system: It's too difficult for
doctors to do their jobs well while at the same time coping with a
proliferating web of fraud-fighting regulations.
Bewildering Regulations
The predicament is a lonely one. My patients don't
know that new laws subject physicians to criminal fraud prosecution whenever
they disagree with Medicare about when to order a lab test or how to
characterize a diagnosis. As an internist specializing in geriatrics, I can't
ignore the increasing risk to my own well-being and my family's simply from
remaining in practice. But Washington doesn't care that doctors like me do our
best to play by the rules and have never had any regulatory problems.
This is surely hard to believe. So here's a test
question: If a doctor orders a stool specimen to test for occult blood--which
might indicate early colon cancer--is he engaging in good medical practice or
criminal behavior?
Answer: It all depends. If the patient doesn't
have symptoms and the bill is sent to Medicare, it's a criminal offense because
these "preventive services" aren't covered benefits. Thus, billing
them to Medicare is considered fraud. The absence of intent to cheat Medicare
doesn't matter. Fines of up to $10,000 per "incident" of such
"fraud" may be levied on the physician who simply orders the test
from a lab at no personal profit.
In contrast, tests are legal when they are used
to confirm a suspected diagnosis. But many cases are borderline. And there's a
difference between the screening tests that Medicare covers and what's
recommended by medical authorities. Sometimes the authorities don't even agree
among themselves. For instance, the American Association of Clinical
Endocrinologists strongly recommends thyroid screening for elderly patients,
but the American College of Physicians doesn't endorse it. That's why the
personal physician treating George Bush--who's had access to first-rate health
care his entire life--failed to check his thyroid and why Mr. Bush's heart
complications were the first clue that something was awry.
I've tried explaining Medicare's rules to
patients. Most are bewildered. One patient left me when I asked that she pay
for some screening tests herself. Since mammograms, Pap smears, and flu shots
are covered and since her friends hadn't been asked to pay for any tests, she
figured I must have been up to something funny.
Other doctors concur that ordering a lab test
for Medicare patients can be as complicated as obtaining an informed consent
for surgery. That's just crazy. In this Alice-in-Wonderland system, patients
and doctors are both in trouble. Nobody knows what to do and everyone is afraid
to ask.
One regulatory time bomb is now ticking loudly:
The HCFA advises labs that don't get a "correct" diagnosis code from
the ordering physician to bill either the patient or the doctor for the
test--or just do it free. Instead of a bill, patients receive three-page,
single-spaced letters advising them of Medicare's action in terms that would
take a team of lawyers to decipher. That leaves doctors, patients, and
hospitals to fight it out among themselves. And if anything goes wrong,
patients may be liable for bills for lab tests and some diagnostic procedures
at up to ten times what Medicare will pay.
Given its concern over rising costs, it's
extremely odd that Medicare has never attempted to educate doctors on how to
order lab tests in cost-effective ways. Instead, in its accelerated anti-fraud
mode, HCFA is now instructing labs to "voluntarily" set up their own
programs to spy on physicians and to report "suspicious"
test-ordering patterns. Labs that cooperate with this spying are told they can
expect the HCFA to go easier on them when it is their turn to be audited. A
Russian friend told me this reminds him of the Soviet Union.
Poisoned Relationships
Even in the best of worlds, medical care is a
complex business. But the HCFA is poisoning doctor-patient relationships. When
an elderly patient of mine demanded unnecessary home health visits because her
neighbor got them, I followed the rules and refused. The patient soon found
someone else who was less concerned with the rules--and with the criminal
penalties for breaking them. Since I became a doctor in order to care for
patients, such cases are hard to forget.
Controlling Medicare fraud requires cooperation
between doctors and the HCFA. Over the years, I've kept many patients out of
the hospital, avoided unnecessary operations, and reassured people who
incorrectly thought they needed expensive tests. I don't expect a commendation
for saving a bundle of money for Medicare because that's part of my job. But I
must say that when I see problems and solutions that Medicare ought to know
more about than it apparently does, I feel more like a character in a Kafka
novel than a partner in the program.
Philip R. Alper, M.D., is a
clinical professor of medicine at the University of California, San Francisco,
and the Robert Wesson Fellow in Scientific Philosophy and Public Policy at the
Hoover Institution.
Government is not the solution to our problems,
government is the problem.
- Ronald Reagan
* * * * *
5.
Medical Gluttony:
The Hospital Can't Afford to Listen to Patients
Mrs. Platnick, a five-foot 300-pound rotund female with
severe COPD had some low chest discomfort. Her boyfriend insisted on having her
brought to the emergency room for evaluation. He was concerned about a
coronary; she felt it more like her ulcer acting up.
In the emergency room when her friend mentioned chest
pain, the antennas went up and she received the full cardiac press. After the
first round of tests, she tried to tell an RN and the MD that she felt she was
having severe heartburn and could she have some antacids. She was told it was
much more serious than that. Instead, they rolled her out to the imaging
department for another series of tests. She asked the technician if he had some
antacids in his pocket or available in the department. He told her he didn't
have any and there was none in the department, which had tons of white chalky
material to be infused into stomachs and rectums for diagnostic purposes but
not for treatment.
When she returned to the emergency department an hour
or two later, she asked the nurse for some antacids and she gave her an ounce.
Within minutes, she not only felt better, but also felt quite well and wanted
to go home. After some wrangling, she was allowed to go home, where she
immediately took a few swallows of antacids and an acid reducing pill and slept
well for the remainder of the night. Her boyfriend felt better, even though he
had to wait in the ER for about five hours. He felt it was worth the
inconvenience of waiting to put his mind at ease. There was no cost - they were
MediCal patients.
This is a frequent occurrence in the practice of
medicine. The patient frequently knows what's wrong with her but the friends
and relatives are having an acute anxiety attack over emotionally sensitive
terms such as "chest pain." If she would have just said, George, could
you get my antacids and acid reducers (she was too heavy to walk to the
bathroom or the medicine cabinet on her own steam), she would have gotten well
in the same few minutes, like after the five-hour ER ordeal when she finally
got the antacids.
Unfortunately, much of health care cost is determined
by well meaning relatives and friends when the patients have lost control.
The health care costs of treating anxieties in the
Emergency Rooms are out of control.
* * * * *
6.
Medical Myths: Is
Mandatory Health Insurance Really a Good
Idea?
The Truth About
Mandatory Health Insurance By BETSY MCCAUGHEY, WSJ
Imposing a federal
mandate is a hot issue on the campaign trail. It's also a burning issue in Congress,
where Democratic Sen. Ron Wyden and Republican Sen. Bob Bennett are pushing the
Healthy Americans Act, which would require everyone not in Medicaid or another
government program to buy health insurance.
But is mandatory
health insurance really a good idea? Requiring catastrophic coverage (our
parents called it major medical) probably is smart. This would ensure that a
person who is hurt in a car accident or diagnosed with a costly illness can pay
his own medical bills, instead of being a burden on society.
But catastrophic
coverage is not what the mandate advocates want. They would require that
everyone have comprehensive health insurance, covering preventive and routine
care.
The rationale for
this mandate is not personal responsibility but "shared
responsibility," a polite way of saying shared costs. Requiring
comprehensive coverage, the argument goes, will make it affordable for the
sick, by pulling the young and the healthy -- neither of whom use these health
services very much -- into the insurance pool. Advocates also argue that
requiring this type of coverage will cure overcrowded emergency rooms and help
tame skyrocketing health costs.
These arguments are
based on myths, not facts.
The first myth is
that it's fair to make everyone pay the same price for health insurance. It is
not: For young people who rarely use health services, this is a rip-off. If
people in their 20s paid attention to politics and voted, politicians wouldn't
dare try this.
According to the
latest Census data, 56% of the uninsured are adults aged 18-34. True enough,
forcing them to be a part of a same-price-for-everyone insurance pool will
likely bring down premiums. These young people generally need minimal health
care ($1,500 a year, on average, according to a Commonwealth Fund study).
In most states, (but
not New York and Vermont), young adults who buy health insurance are charged
premiums that reflect their low medical needs. A 25-year-old man can buy a
$1,000 deductible policy for a quarter to a third of what a 55-year-old man has
to pay. (In Manchester, N.H., a 25-year-old man pays $156 per month, while a
55-year-old pays $542 for the same policy, according to ehealthinsurance.com).
Both the Clinton
proposal and the bipartisan congressional proposal prohibit insurers from
giving such price breaks to the young. Their mandates would force the young to
subsidize the heath tab for the middle-aged generation. This subsidy would come
on top of the payroll tax younger people already pay to support today's
Medicare recipients. This is contrary to a fundamental American principle. This
nation has always believed in making life better for its children, not
exploiting them. . .
The second myth
behind federal mandate proposals is this: Lack of insurance forces people into
the emergency room for routine health care. "It's a hidden tax, the high
cost of emergency room visits that could have been prevented by a much less
expensive doctor's appointment," Mrs. Clinton said recently. The truth is
that the uninsured do not use emergency rooms more than other people.
Federal data (the
Medical Expenditure Panel Survey provided by the Agency for Healthcare Research
and Quality) show that the elderly are most inclined to go to the emergency
room, though they are universally covered by Medicare.
Other repeat users,
according to an Institute of Medicine study, are the "frequent
flyers" who are in the ER repeatedly because of mental illness or
substance abuse. Enacting a mandate isn't going to eradicate the behavioral
problems that land them in the ER.
The third myth, in
the words of Mr. Edwards, is that a "system that leaves 47 million
Americans without health care is a moral disgrace." The remedy he has in
mind is a mandate.
The rise in the
number of uninsured people (up from 42 million in 2002) is not due to a sudden
moral failure of the country or a broken health system. Instead, a major cause
is immigration and cultural differences that make recent arrivals especially
likely to be uninsured.
Immigration over the
past seven years has been the largest for any seven-year period in American
history. Over 10 million immigrants entered the country, more than half of them
illegally, according to a report by the Center for Immigration Studies in
Washington, D.C. Nearly 75% of the increase in the number of uninsured people
since 1990 consists of newcomers and their U.S. born children, according to the
study.
In the most recent
Census report, the lion's share of the increase in the uninsured occurred in
five border states: Arizona, California, Florida, New Mexico and Texas. In San
Francisco, public health authorities estimate that 61% of the city's uninsured
are not citizens. . .
Not only are
newcomers from Central and South America uninsured when they enter the U.S., but
a cultural unfamiliarity with health insurance means that many continue to go
without coverage even when they can afford to buy it. One third of all people
who identify themselves as Hispanic on the 2006 Census are uninsured, including
Hispanics with high incomes.
These facts should
point the presidential candidates and Congress toward a sounder policy on
health insurance.
According to the
Census Bureau, of the 47 million uninsured, nearly 10 million have household
incomes of at least $75,000. They probably can afford coverage but have chosen
not to buy it. Another 14 million of the uninsured are already eligible for
government programs such as Medicaid (for low income adults) and the State
Children's Health Insurance Program (for children) and simply need to sign up.
That leaves about
23.7 million people -- some citizens, others newcomers -- who cannot afford
coverage. It's up to the nation to decide what to do about that. One thing is
clear: Mandating that everyone, including young adults, buy insurance, and then
hiding a hefty, cost sharing tax inside their premium, is an unfair solution.
Ms.
McCaughey, a former lieutenant governor of New York, is an adjunct senior
fellow at the Hudson Institute.
To read the entire
article, go to http://online.wsj.com/article/SB119941501118966929.html.
[Some have said that the 10
million Americans making $75,000 a year are effectively self-insured and
shouldn't be counted.]
* * * * *
7.
Overheard in the
Medical Staff Lounge: What are you doing about the obesity epidemic?
[Editor's note: In 2007, of the 200 million Americans
overweight, 100 million are considered obese. Of the ones obese, 15 million are
considered morbidly obese. Of the 20 percent complication risk, it is estimated
that up to 40,000 complications arose. With a one percent death risk, it is
estimated that about 2,000 deaths occurred.]
Dr. Edwards: Wasn't that a great lecture on treatment
of Morbid Obesity by
our liability insurance carrier at Grand Rounds last month?
Dr. Yancy: He was trying to scare all you internists
in order to prevent referrals for Bariatric Surgery.
Dr. Michelle: I think he did that.
Dr. Yancy: You mean you're no longer going to refer
your morbidly obese patients to me?
Dr. Michelle: I will. But it will take longer to get
them to you. I'll give them the complication list to get them motivated to lose
weight by eating less.
Dr. Rosen: Every obese patient I know does not believe
that eating causes obesity. They say it's glandular.
Dr. Michelle: I recorded the complication list into my
PDA: Infections, Bleeding, Incisional and internal hernias, Bowel obstruction,
Stricture, Erosions, Ulcers, Adhesions, Fascial dehiscence, Gallbladder disease,
Re-hospitalization and additional surgeries.
Dr. Rosen: That's quite a list. That should put the
Fear of God in them.
Dr. Michelle: That gets the patient in tuned to try
medical weight loss first.
Dr. Edwards: For medical weight loss, I give them the
information that it takes 3500 calories above their maintenance to gain a
pound. An extra cookie or a coke with 100 calories equals 35,000 per year or 10
pounds of weight gain per year.
Dr. Rosen: Well, does it work?
Dr. Edwards: Then I translate their weight into
calories eaten.
Dr. Ruth: Is that so they can count calories? Two
dieticians can't agree on what my patients eat.
Dr. Edwards: That's the point. We want the patient to
understand just how many calories he or she eats. If the patient went to Weight
Watchers, they multiply the patient's weight by 10.
Dr. Michelle: So a 150-pound person eats 1500
calories.
Dr. Edwards: Precisely. So if the person takes 100
calories off his plate a day, such as a cookie or drink, then he or she will
lose 10 pounds over a year.
Dr. Ruth: Does that compute for the average patient?
If I told a 150-pound woman that she eats 1500 calories a day, she wouldn't
believe me.
Dr. Rosen: But that's a discussion you can't enter.
When a 300-pound lady tells you she doesn't eat more than a bowl of peaches a
day, just say, "Start eating a half bowl," and continue the next
discussion. Otherwise, you won't make it home at night.
Dr. Edwards: Weight watchers use an average. It is
more accurate to use 8-10 calories per pound for women and 10-12 calories per
pound for men. So I use 9 as an average for women and 11 as an average for men
to calculate their current caloric intake.
Dr. Ruth: Isn't that making it more complicated?
Dr. Edwards: It's not the math I leave. It's the
quantity visualization that I leave with the patient. So, if I have a man, I
multiply his weight by 11 and tell him that's what he's eating. We're just
trying to quantify his portions. So, if a 250-pound man is eating 2750 calories
per day, then we can talk about taking one-fifth of his food off the plate.
Dr. Michelle: I see now where you're going. So, by
taking 500 calories off his plate a day, he's removing 3500 calories per week,
which is one pound per week.
Dr. Edwards: Precisely. Then he should lose 8 pounds
in two months, 16 pounds in four months and 24 pounds in six months?
Dr. Ruth: Have you ever seen anyone do that?
Dr. Rosen: Yes, I have experienced it. When my doctor
told me I had to lose 30 pounds if I want to live, since my mother had
diabetes, I removed what I thought was one-fourth my plate or 500 calories. I
must have taken off about 625 calories since in two months I lost 10 pounds, in
four months I lost 20 pounds, and in six months I lost the entire 30 pounds.
Dr. Edwards: Have you had any success in getting
patients to see the light?
Dr. Rosen: After the Grand Rounds presentation, I've
made a renewed effort because of the patients that are suing after Bariatric
surgery. They are not only suing the surgeons, they're suing their personal
physician, surgical assistants and anybody whose name they can read on the
records they acquire.
Dr. Yancy: You guys are making me upset. I spent and
lot of time and money learning laparoscopic Bariatric surgery.
Dr. Michelle: I'll still refer, but there will
certainly be less because I think I will have more success with the medical
treatment of obesity. Many of my patients with Bariatric surgery may lose 150
pounds, but they all seem to regain 50-75 pounds and get back to their old
eating habits.
Dr. Rosen: Maybe less patients, Yancy, but they will
be much better prepared and knowledgeable and thus lawsuits will be less
likely.
* * * * *
8.
Voices of
Medicine: A Review of Local and Regional Medical Journals
The Bulletin of the Humboldt-Del Norte
Country Medical Society, April 2008
PRESIDENT'S MESSAGE Above and Beyond the Call of Duty by KATE MCCAFFREY, D.O.
I made a
trip last week to Humboldt and Del Norte Counties to recruit preceptors for
medical students. What struck me most were the increase in work load and the
decrease in morale of the physicians and the offices I visited.
Depending on their specialty field, some physicians
are seeing up to 45 patients per day on top of doing procedures. Practices are
absorbing patients from physicians who are leaving the area or retiring and
closing their practices.
The average age of primary care and specialty
physicians in Humboldt and Del Norte Counties is over fifty. The area's
recruitment efforts so far have been enough to stem the dam of physicians
leaving but not enough to re-build the area's surplus of physicians for the
future.
For instance, in Del Norte County they will be losing
their only otolaryngologist this year and there likely will not be a
replacement. That will mean that the
primary care physicians in Del Norte will have to refer elsewhere such as
Southern Oregon, Humboldt County and the Bay Area.
We all know the barriers to physician recruitment and
retention in Humboldt. Developing a teaching program and eventually a residency
in our counties is part of the solution. Introducing medical students to the
area will expose them to rural medicine which is a different set of skills than
practicing medicine in the bigger cities.
Rural physicians are usually well rounded in their skills and
resourceful. We know when to treat and when to transport. We also see more
progressed pathology in our patients than our counter arts in the cities due to
a unique rural set of barriers to health care access.
The other thing that struck me on my trip and in
talking to dozens of physicians was the recognition that as physicians in a
small community, we are all interconnected.
When someone leaves or retires, we all feel the effects and have to
shift our practices to compensate. Fortuna has a delicate balance but they are
stable. Arcata is going through changes in several specialties. Eureka is ever
growing and expanding but the doctors are looking at retirement in the next ten
years. Del Norte County is on empty and things are getting worse if that is
possible. If we can get volunteers to
house the Touro medical students, we will be able to place them in practices in
Del Norte County.
I recently received an award from the students at
Touro University entitled, "Above and Beyond the Call of Duty". I
would like to pass this award on to my colleagues in Humboldt and Del Norte
Counties for hanging in there during these difficult times in medicine and also
for practicing in a rural county. I am proud to call you colleagues as well as
friends.
www.humboldt1.com/~medsoc/images/bulletins/MAY%202008%20BULLETIN_for%20web.pdf
What Dr. McCaffrey failed to mention is that, physician
recruitment is only necessary because physicians are paid less than Market
Value by the current bureaucratic system. If physicians were paid what they are
worth, they would flock to the best deal in the state and there would be no
underserved areas.
* * * * *
9.
Book Review: AMA
ESSENTIAL GUIDES and OTHER COMPENDIUMS
THE AMA ESSENTIAL GUIDE TO . . . ASTHMA; HYPERTENSION;
DEPRESSION; MENOPAUSE. Pocket Books, New York, 1998, $14 each
Pocket Books sent these four "Guides"
subtitled "Clear, authoritative health information for your family"
for my review. The editorial staff at the AMA, with Angela Perry, MD, as the
overall Medical Editor produces these books, each with its own science writer
and medical advisor. This system has produced a number of excellent patient
reference books. The previous Pocket Guides, which are about 250 pages, include
Emergency First Aid, Sports First Aid, and Back Pain.
Large coffee table compendiums have included the AMA Family Medical Guide,
AMA Encyclopedia of Medicine, and AMA's Seven Weeks to Better Sex.
While attending an AMA Science Reporters Conference in San Francisco, I was
given the 750 page AMA Complete Guide to WOMEN'S HEALTH, which Dr
Eleanor Rodgerson of our editorial board reviewed in September 1997. She felt it
was the most comprehensive of the numerous volumes available.
Christopher Winslow, MD, is the pulmonologist who
edited the AMA Essential Guide to Asthma. This is a well written, easily
readable, patient friendly book that gives numerous examples of asthma
patients, their environment and infectious triggers for an attack, what may and
should be done in order to facilitate a prompt understanding of the medical
chain of events, and how best to handle the struggle for breath. Today asthma
affects more than 5% of our population--14 million people in the US, up from 10
million in 1990, with one-third under age 18. This useful self-help includes a
list of commonly asked questions about asthma, a glossary of terms, and a list
of asthma organizations that can give further help and support. . . To read the rest of the review, please go to
www.delmeyer.net/bkrv1a99.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: Tell me why HMO patients try
for three visits per co-pay?
Private patients, frequently from the
business/professional world, who pay me $125 for an office visit, never call me
between office visits. If they have an intervening problem, they try to handle it
to the best of their ability or make an appointment and face me directly to
discuss the problem.
However, most of my HMO patients pay a $10 co-payment
to see me, and their HMO pays me an additional $65 about which the patient is
uninformed. These folks have no problem calling at any time about any subject
and try to get three or four office calls for their one $10 co-payment. Their
HMO does not reimburse for office calls, like attorneys do.
Third party medicine totally distorts the
Doctor-Patient relationship.
The Cost of Creating Jobs
The social cost of collecting $1.00 in taxes is $1.24,
notes Linda Gorman of The Independence Institute.
For every four jobs created by spending, about five jobs or their equivalent
will be lost because of taxes.
If you rob Peter to pay Paul, you can always be
assured of Paul's vote to help you rob more Peters.
The Cost of Bail Outs
The federal government
bailed out the American Insurance Group, Inc. for $85 billion. That's stealing
about $500 from every couple in the United States. It seems the rational for
this grand theft could also apply to the auto industry, which seems to be in
severe straights. I think the newspaper industry is nearly there also. The
surgeons tell me they are already there.
Will the Feds feel they are
justified in stealing all of our money and say it's in the public interest?
I don't think the public's interest is the same as the interest of
Congress trying to get re-elected.
We don't argue with people
with whom we disagree. We just shoot them.
An Iranian patient came in
last week having visited his country where a large number of his family still
live. Although he enjoyed seeing them, he stated the leaders are lunatics. They
have so much oil money, that individuals who don't serve their purpose have no
value to them and are totally dispensable. There is no two-way discussion with
them. While he was there, he said there was one group of 99 people that were
summarily shot.
We have a presidential
candidate who wants to go over to Iran and have a two-way discussion to reason
with them in an effort to produce world peace. Reminds me of a miner who said
they would send a canary into a mine and if the bird came back alive, it was
safe to proceed.
A Republican suggested we send the Democratic candidate into Iran
before the elections to test this. He said this would hi-light two problems and
solve one. I wonder what the other problem was.
To read more HHK, go to www.healthcarecom.net/hhk2001.htm.
To read more
HMC, go to www.delmeyer.net/hmc2005.htm.
* * * * *
11. Professionals Restoring Accountability in Medical
Practice, Government and Society: