Voices Of Medicine

Current Issue

An ICD-10 Christmas Tale

My friend and colleague, Dr. Jack Ostrich, who always gives us an enlightening Christmas Story gave us this one. The ICD 9 would have several codes for different types of fracture, for instance, now the ICD 10 has dozens of codes to identify minor differences and what is the type of visit for each type of fracture. Hence, the humor of his parody.

We’ve always enjoy Jack’s Christmas stories. This year he gave us an adaption from an essay by Gerry Wieder, RN of Seattle

`Twas the night before Christmas, when all through the house,

Not a creature was stirring, not even a mouse.

W53.01XA Bitten by mouse, initial encounter

W53.01XD Bitten by mouse, subsequent encounter

W53.09XA Other contact with mouse, initial encounter

W53.09XD Other contact with mouse, subsequent encounter

The stockings were hung by the chimney with care,

In hopes that St. Nicholas soon would be there.

X06.2XXA Exposure to ignition of other clothing and apparel, initial encounter

X06.2XXD Exposure to ignition of other clothing and apparel, subsequent encounter

X06.3XXA Exposure to melting of other clothing and apparel, initial encounter

X06.3XXD Exposure to melting of other clothing and apparel, subsequent encounter

The moon on the breast of the new-fallen snow

Gave the lustre of mid-day to objects below.

X37.2XXA Blizzard (snow)(ice), initial encounter

X37.2XXD Blizzard (snow)(ice), subsequent encounter

When, what to my wondering eyes should appear,

But a miniature sleigh, and eight tiny reindeer.

201.01 Encounter for examination of eyes and vision with abnormal findings

R44.1 Visual hallucinations

With a little old driver, so lively and quick,

I knew in a moment it must be St. Nick.

R54 Age-related physical debility

F22 Delusional disorders

More rapid than eagles his coursers they came,

And he whistled, and shouted, and called them by name:

            R49.8 Other voice and resonance disorders

            R49.9 Unspecified voice and resonance disorder

“Now, Dasher! now, Dancer! now, Prancer and Vixen!

On, Comet! on Cupid! on, Donner and Blitzen!

            W55.39XA Other contact with other hoof stock, initial encounter

            W55.39XD Other contact with other hoof stock, subsequent encounter

To the top of the porch! to the top of the wall!

Now dash away! dash away! dash away all!”

            V97.0 Occupant of aircraft injured in other specified air transport accidents

            W13.0XXA Fall from, out of or through balcony, initial encounter

            W13.0XXD Fall from, out of or through balcony, subsequent encounter

            W22.01XA Walked into wall, initial encounter

            W22.01XD Walked into wall, subsequent encounter

As dry leaves that before the wild hurricane fly,

When they meet with an obstacle, mount to the sky,

            X37.0XXA Hurricane, initial encounter

            X37.0XXD Hurricane, subsequent encounter

So up to the house-top the coursers they flew,

With the sleigh full of toys, and St. Nicholas too.

            Y93.29 Activity, other involving ice and snow

            V96.8XXA Other nonpowered-aircraft accidents injuring occupant, initial encounter

            V96.8XXD Other nonpowered-aircraft accidents injuring occupant, subsequent encounter

And then, in a twinkling, I heard on the roof

The prancing and pawing of each little hoof.

            W13.2XXA Fall from, out of or through roof, initial encounter

            W13.2XXD Fall from, out of or through roof, subsequent encounter

            W55.32XA Struck by other hoof stock, initial encounter

            W55.32XD Struck by other hoof stock, subsequent encounter

            As I drew in my head, and was turning around,

Down the chimney St. Nicholas came with a bound.

            X02.0XXA Exposure to flames in controlled fire in building or structure, initial encounter

            X02.0XXD Exposure to flames in controlled fire in building or structure, subsequent encounter

He was dressed all in fur, from his head to his foot,

And his clothes were all tarnished with ashes and soot.

            Y93.E9 Activity, other interior property and clothing maintenance

A bundle of toys he had hung on his back,

And he looked like a peddler just opening his pack.

            Z59.0 Homelessness

            Z59.1 Inadequate housing . . .

He had a broad face and a little round belly,

That shook, when he laughed like a bowlful of jelly.

            E66.3 Overweight

            Z72.3 Lack of physical exercise . . .

He sprang to his sleigh, to his team gave a whistle,

            V00.221A Fall from sled, initial encounter

            V00.221D Fall from sled, subsequent encounter

            V00.228 Other sled accident

And away they all flew like the down of a thistle.

But I heard him exclaim, ‘ere he drove out of sight,

            W94.23XA Exposure to sudden change in air pressure in aircraft during ascent, initial encounter

            W94.23XD Exposure to sudden change in air pressure in aircraft during ascent, subsequent

            encounter

 “Happy Christmas to all, and to all a good-night.”

Read the RN’s original and complete version at http://gerrywieder.com/an-icd-10-christmas-tale/

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

Voices Of Medicine

Previous Issue

The waste and danger of unnecessary care

ANNALS of HEALTH CARE: OVERKILL

An avalanche of unnecessary medical care is harming patients physically and financially

What can we do about it?

By ATUL GAWANDE, MD | The New Yorker Magazine | June 11, 2015

It was lunchtime before my afternoon surgery clinic, which meant that I was at my desk, eating a ham-and-cheese sandwich and clicking through medical articles. Among those which caught my eye: a British case report on the first 3-D-printed hip implanted in a human being, a Canadian analysis of the rising volume of emergency-room visits by children who have ingested magnets, and a Colorado study finding that the percentage of fatal motor-vehicle accidents involving marijuana had doubled since its commercial distribution became legal. The one that got me thinking, however, was a study of more than a million Medicare patients. It suggested that a huge proportion had received care that was simply a waste.

The researchers called it “low-value care.” But, really, it was no-value care. They studied how often people received one of twenty-six tests or treatments that scientific and professional organizations have consistently determined to have no benefit or to be outright harmful. Their list included doing an EEG for an uncomplicated headache (EEGs are for diagnosing seizure disorders, not headaches), or doing a CT or MRI scan for low-back pain in patients without any signs of a neurological problem (studies consistently show that scanning such patients adds nothing except cost), or putting a coronary-artery stent in patients with stable cardiac disease (the likelihood of a heart attack or death after five years is unaffected by the stent). In just a single year, the researchers reported, twenty-five to forty-two per cent of Medicare patients received at least one of the twenty-six useless tests and treatments.

Could pointless medical care really be that widespread? Six years ago, I wrote an article for this magazine, titled “The Cost Conundrum,” which explored the problem of unnecessary care in McAllen, Texas, a community with some of the highest per-capita costs for Medicare in the nation. But was McAllen an anomaly or did it represent an emerging norm? In 2010, the Institute of Medicine issued a report stating that waste accounted for thirty per cent of health-care spending, or some seven hundred and fifty billion dollars a year, which was more than our nation’s entire budget for K-12 education. The report found that higher prices, administrative expenses, and fraud accounted for almost half of this waste. Bigger than any of those, however, was the amount spent on unnecessary health-care services. Now a far more detailed study confirmed that such waste was pervasive.

I decided to do a crude check. I am a general surgeon with a specialty in tumors of the thyroid and other endocrine organs. In my clinic that afternoon, I saw eight new patients with records complete enough that I could review their past medical history in detail. One saw me about a hernia, one about a fatty lump growing in her arm, one about a hormone-secreting mass in her chest, and five about thyroid cancer.

To my surprise, it appeared that seven of those eight had received unnecessary care. Two of the patients had been given high-cost diagnostic tests of no value. One was sent for an MRI after an ultrasound and a biopsy of a neck lump proved suspicious for thyroid cancer. (An MRI does not image thyroid cancer nearly as well as the ultrasound the patient had already had.) The other received a new, expensive, and, in her circumstances, irrelevant type of genetic testing. A third patient had undergone surgery for a lump that was bothering him, but whatever the surgeon removed it wasn’t the lump—the patient still had it after the operation. Four patients had undergone inappropriate arthroscopic knee surgery for chronic joint damage. (Arthroscopy can repair certain types of acute tears to the cartilage of the knee. But years of research, including randomized trials, have shown that the operation is of no help for chronic arthritis- or age-related damage.)

Virtually every family in the country, the research indicates, has been subject to overtesting and overtreatment in one form or another. The costs appear to take thousands of dollars out of the paychecks of every household each year. Researchers have come to refer to financial as well as physical “toxicities” of inappropriate care—including reduced spending on food, clothing, education, and shelter. Millions of people are receiving drugs that aren’t helping them, operations that aren’t going to make them better, and scans and tests that do nothing beneficial for them, and often cause harm.

Why does this fact barely seem to register publicly? . . .

It is different, however, when I think about my experience as a patient or a family member. I can readily recall a disturbing number of instances of unnecessary care. My mother once fainted in the Kroger’s grocery store in our Ohio home town. Emergency workers transported her to a hospital eighty miles away, in Columbus, where doctors did an ultrasound of her carotid arteries and a cardiac catheterization, too, neither of which is recommended as part of the diagnostic workup for someone who’s had a fainting episode, and neither of which revealed anything significant. Only then did someone sit down with her and take a proper history; it revealed that she’d had dizziness, likely from dehydration and lack of food, which caused her to pass out.

I began asking people if they or their family had been subject to what they thought was unnecessary testing or treatment. Almost everyone had a story to tell. Some were appalling. . .

Read the entire “Voices” and more appalling stories  from Dr. Gawande in The New Yorker Magazine. . .

We have also witnessed exorbitant increases in healthcare costs when our patient is no longer under our control and someone else who is unfamiliar with our patient’s health care writes the medical orders for tests. One of our patients with a calcified granuloma since 1954 which needed no further evaluation was admitted to the hospital and had a full pulmonary nodule evaluation with an unnecessary MRI, and almost a bronchoscopy which she had refused. No one had bothered to take a medical history or she would have told them that she’s had this calcium nodule since 1954.

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

Voices Of Medicine

Past Issue

THE CATRASTROPHE

A Neurologist’s Notebook: THE CATASTROPHE

Spalding Gray’s brain injury

By Oliver Sacks, MD

THE NEW YORKER | April 27, 2015

In July of 2003, my neurological colleague Orrin Devinsky and I were consulted by Spalding Gray, the actor and writer who was famous for his brilliant autobiographical monologues, an art form he had virtually invented. He and his wife, Kathie Russo, had contacted us in regard to a complex situation that had developed after Spalding suffered a head injury, two summers earlier. 

In June of 2001, they had been vacationing in Ireland to celebrate Spalding’s sixtieth birthday. One night, while they were driving on a country road, their car was hit head on by a veterinarian’s van. Kathie was at the wheel; Spalding was in the back seat, with another passenger. He was not wearing a seat belt, and his head crashed against the back of Kathie’s head. Both were knocked unconscious. (Kathie suffered some burns and bruises but no permanent harm.) When Spalding recovered consciousness, he was lying on the ground beside their wrecked car, in great pain from a broken right hip. He was taken to the local rural hospital and then, several days later, to a larger hospital, where his hip was pinned.

His face was bruised and swollen, but the doctors focused on his hip fracture. It was not until another week went by and the swelling subsided that Kathie noticed a “dent” just above Spalding’s right eye. At this point, X-rays showed a compound fracture of the eye socket and the skull, and surgery was recommended.

Spalding and Kathie returned to New York for the surgery, and MRIs showed bone fragments pressed against his right frontal lobe, though his surgeons did not see any gross damage to this area. They removed the fragments, replaced part of his skull with titanium plates, and inserted a shunt to drain away excess fluid.

He was still in some pain from his hip fracture, and could no longer walk normally, even with a braced foot (his sciatic nerve had been injured in the accident). Yet, strangely enough, during these terrible months of surgery, immobility, and pain, Spalding seemed in surprisingly good spirits—indeed, his wife thought he was “incredibly well” and upbeat.

Over Labor Day weekend of 2001, five weeks after his brain surgery, and still on crutches, Spalding gave two performances to huge audiences in Seattle. He was in excellent form.

Then, a week later, there was a sudden, profound change in his mental state, and Spalding fell into a deep, even psychotic, depression.

Now, two years after the accident, on his first visit to us, Spalding entered the consulting room slowly, carefully lifting his braced right foot. Once he was seated, I was struck by his lack of spontaneous movement or speech, his immobility and lack of facial expression. He did not initiate any conversation, and responded to my questions with very brief, often single-word, answers. My first thought, and Orrin’s, was that this was not simply depression, or even a reaction to the stress and the surgeries of the past two years—to my eye, it clearly looked as if Spalding had neurological problems as well.

When I encouraged him to tell me his story in his own way, he began—rather strangely, I thought—by telling me how, a few months before the accident, he had had a sudden “compulsion” to sell his house in Sag Harbor, which he loved and in which he and his family had lived for five years. He and Kathie agreed that the family needed more room, so they bought a house nearby, with more bedrooms and a bigger yard. Nonetheless, Spalding had resisted selling the old house, and they were still living in it when they left for Ireland.

It was while he was in the hospital in Ireland following his hip surgery, he told me, that he finalized a deal to sell the old house. He later came to feel that he was “not himself” at the time, that “witches, ghosts, and voodoo” had “commanded” him to do it.

Even so, despite the accident and the surgeries, Spalding remained in high spirits during the summer of 2001. He felt full of new ideas for his work—the accident, even the surgeries, would be wonderful material—and he could present them in a new performance piece, entitled “Life Interrupted.”

I was struck, and perhaps disquieted a little, by the readiness with which Spalding was prepared to turn the horrifying events of the summer to creative use. Yet I could also understand it, because I had not hesitated, in the past, to use some of my own crises as material in my books.

Indeed, using one’s own life (and sometimes others’ lives) as material is common among artists—and Spalding was a very special sort of artist. . . He wondered sometimes if he did not create crises just for material—an ambiguity that worried him. Had he sold his house as “material”?

One of the special features of Spalding’s monologues was that, onstage at least, he rarely repeated himself; the stories always came out in slightly different ways, with different emphases. He was a gifted inventor of the truth, of whatever seemed true to him at the moment. . .

Ever since, Kathie told me, Spalding had been sunk in depressive, obsessive, angry, guilty rumination about selling the house. Nothing could distract him from it. Scenes and conversations about the house replayed incessantly in his mind. All other matters seemed to him peripheral and insignificant. Previously a voracious reader and a prolific writer, he now felt unable to read or write.

Spalding had had occasional depressions, he said, for more than twenty years, and some of his physicians thought that he had a bipolar disorder. But these depressions, though severe, had yielded to talk therapy, or, sometimes, to treatment with lithium. His current state, he felt, was different. It had unprecedented depth and tenacity. He had to make a supreme effort of will to do things like ride his bicycle, which he had previously done spontaneously and with pleasure. He tried to converse with others, especially his children, but found it difficult. His ten-year-old son and his sixteen-year-old stepdaughter were distressed, feeling that their father had been “transformed” and was “no longer himself.”. . .

In September of 2002, Spalding jumped off his sailboat into the harbor, planning to drown himself (he lost his nerve and clung to the boat). A few days later, he was found pacing on the Sag Harbor bridge, eying the water, until the police intervened and Kathie took him home.

Soon after this, Spalding was admitted to the Payne Whitney Psychiatric Clinic, on the Upper East Side. He spent four months there, and was given more than twenty shock treatments and drugs of all kinds. He responded to none of them, and, indeed, seemed to be getting worse by the day. When he emerged from Payne Whitney, his friends felt that something terrible and perhaps irreversible had happened. Kathie thought that he was “a broken man.”. . .

In July, when Spalding first came to see Orrin and me, I asked him if there were any other themes besides the sale of his house that he ruminated about. He said yes: he often thought about his mother and the first twenty-six years of his life. It was when he was twenty-six that his mother, who had been intermittently psychotic since he was ten, fell into a self-torturing, remorseful state, focused on the selling of her family house. Unable to endure her torment, she had committed suicide.

In an uncanny way, he said, he felt that he was recapitulating what had happened with his mother. He felt the attraction of suicide and thought of it constantly. He said he regretted not having committed suicide at the U.C.L.A. hospital. Why there? I inquired. Because one day, he replied, someone had left a large plastic bag in his room—and it would have been “easy.” But he was pulled back by the thought of his wife and his children. Nevertheless, he said, the idea of suicide rose “like a black sun” every day. He said the past two years had been “gruesome,” and added, “I haven’t smiled since that day.” . . .

There was a brief, dramatic break in Spalding’s rumination just a week before he came to see us, when he had to have surgery because one of the titanium plates in his skull had shifted. The operation took four hours, under general anesthesia. Coming to from the anesthesia and for about twelve hours afterward, Spalding was his old self, talkative and full of ideas. His rumination and hopelessness had vanished—or, rather, he now saw how he could use the events of the past two years creatively in one of his monologues. But by the next day this brief excitement or release had passed. . .

But the frontal lobes also exert an inhibiting or constraining influence on what Pavlov called “the blind force of the subcortex”—the urges and passions that might overwhelm us if left unchecked. (Apes and monkeys, like children, though clearly intelligent and capable of forethought and planning, are relatively lacking in frontal lobes, and tend to do the first thing that occurs to them, rather than pausing to reflect. Such impulsivity can be striking in patients with frontal-lobe damage.) There is normally a beautiful balance, a delicate mutuality, between the frontal lobes and the subcortical parts of the brain that mediate perception and feeling, and this allows a consciousness that is free-ranging, playful, and creative. The loss of this balance through frontal-lobe damage can “release” impulsive behaviors, obsessive ideas, and overwhelming feelings and compulsions. Were Spalding’s symptoms a result of frontal-lobe damage or severe depression, or a malignant coupling of the two?

Frontal-lobe damage can lead to difficulties with attention and problem-solving, and impoverishment of creativity and intellectual activity. Although Spalding felt that he had not had any intellectual deterioration since the accident, Kathie wondered whether his unceasing rumination might not, in part, be a “cover” or “disguise” for an intellectual loss that he did not want to admit. Whatever the case, Spalding felt that he could no longer achieve the high creative level, the playfulness and mastery, of his pre-accident performances—and others felt this, too. . .

January 10, 2004, Spalding took his children to a movie. It was Tim Burton’s “Big Fish,” in which a dying father passes his fantastical stories on to his son before returning to the river, where he dies—and perhaps is reincarnated as his true self, a fish, making one of his tall tales come true.

That evening, Spalding left home, saying he was going to meet a friend. He did not leave a suicide note, as he had so often before. When inquiries were made, one man said he had seen him board the Staten Island Ferry.

Two months later, Spalding’s body was washed up by the East River. He had always wanted his suicide to be high drama, but in the end he said nothing to anyone; he simply disappeared from sight and silently returned to the sea, his mother. 

Read Dr. Oliver Sacks’ entire medical narrative of Spalding Gray’s frontal lobe injury in The New Yorker, April 27, 2015. . .

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

Voices Of Medicine

Past Issue

Sham Peer Review—Infusing Staph in a patient to get rid of the Dr

Sham Peer Review: the Shocking Story of Raymond A. Long, M.D.

Lawrence R. Huntoon, M.D., Ph.D.

 It was a story that rocked the little town of St. Albans, Vermont: “Surgeon Accuses St. Albans Hospital of Deliberately Infecting His Patients.”1

According to the statewide news website, VTDigger.org, “An orthopedic surgeon is suing Northwestern Medical Center in St. Albans for allegedly infecting his patients with bacteria in an effort to ‘destroy his career and falsely blame him for the infections,’ court records show…. Long says he told hospital doctors in 2002 that he was considering adding an MRI machine to his office. At the time, he alleges, Northwestern was involved in ‘an illegal kickback scheme with respect to X-ray facilities’ and the hospital was planning to have a new MRI machine built for its facilities.”1

The “Factual Background” contained in a lawsuit, for which an Amended Complaint was filed on Sep 28, 2006, also contained hundreds of numbered paragraphs describing the nightmare of events that Dr. Long claimed he experienced at the hands of the hospital and other physicians on staff.2 

Northwestern Medical Center Enters into Settlement Agreement with Government

On Aug 16, 2007, the U.S. Attorney’s Office issued a press release stating: “The United States Attorney’s Office announced today that it has entered into a settlement with Northwestern Medical Center, the hospital in St. Albans, resolving the hospital’s potential liability for violating the federal anti-kickback and related laws.”3 Although the hospital faced a potential liability of having to pay triple the amount collected from federal health programs, the government agreed to settle for a mere $30,000.3 . . .

In 2011, Dr. Long hired a former Centers for Disease Control and Prevention infection investigator, William R. Jarvis, M.D . . . .On Aug 5, 2011, Dr. Jarvis issued his report11 concerning the unusual surgical site infections affecting Dr. Long’s patients. Dr. Jarvis reviewed four of Dr. Long’s cases.

In one case, Dr. Jarvis reported: “A nearly pan-sensitive (especially to penicillin) S. aureus strain like [patient’s] is exceedingly unusual. This is even more true of S. aureus strains causing HAIs [healthcare-associated infections] rather than community acquired infections.”11, p 5 . . .

The Jarvis Report also addressed cultures taken from an irrigation solution that was about to be used in a patient surgery on Feb 6, 2004:

Cultures obtained from previously unopened bottle of irrigation fluid (that was about to be hung in the NMC operating room for use in Dr. Long’s surgical patient) by Dr. Long on February 6, 2004 grew 800 colony forming units/ml of S. aureus (two morphologies). Given that this was a bottle of irrigation fluid provided by NMC operating room personnel for use by Dr. Long in that surgical procedure, it is highly suspicious. Intrinsic contamination (i.e., that occurring at the time of manufacture) of such manufactured fluids is < 1 in a million—an exceedingly rare and unlikely event. Since no other clusters of infections or outbreaks associated with this manufacturer’s irrigation fluid were reported at around this time and no FDA recall of these fluids occurred around this time, the likelihood of intrinsic contamination is very, very unlikely. In contrast, given that two different morphologies of S. aureus and 800 CFU/ml were recovered, I believe that the likelihood of extrinsic contamination (i.e., contamination after manufacture and most likely at NMC) is much more likely.11, p 10

Dr. Jarvis also commented on the hospital peer review related to these highly unusual infections:

Given the circumstances occurring at NMC at around December 2003—February 2004 (i.e., the cluster of very unusual SSIs—both in terms of SSIs occurring in very low-risk arthroscopic joint procedures and the types of organisms involved in Dr. Long’s patients), the likelihood that these SSIs were caused by: a) the patient’s flora; b) contaminated surgical equipment, c) Dr. Long’s surgical technique, d) breaks in sterile technique by other operative room personnel, or e) contamination of Marcaine placed in pain pumps, as hypothesized by Dr. Corsetti in his peer review of these cases is exceedingly unlikely.11, p 12

A much more likely explanation of how the operating room irrigation fluid became contaminated and how the 3-4 SSIs above occurred is that the patients were intentionally infected through extrinsically and intentionally contaminated irrigation fluid (or other fluids, medications, equipment or materials) provided by NMC personnel and used by Dr. Long in the surgical procedures of these patients.11, p 13

The Jarvis Report goes on to state:

Personnel from NMC have acknowledged that personnel at NMC had purchased ATCC [an organization that provides standard reference micro-organisms to labs] strains of S. aureus, coagulase-negative staphylococci (CNS) and Pseudomonas aeruginosa isolates for quality control purposes for the NMC laboratory. In addition, they testified that they also obtained S. marcescens isolates that were used in the microbiology laboratory for quality control purposes. Therefore, all the bacterial species that caused SSIs [surgical site infections] in Dr. Long’s patients were available in the NMC microbiology laboratory. The S. aureus strain (ATCC #25923) was purchased in November 2003 [see Ref #8], days to weeks before [patients’] surgery. Furthermore, the ATCC #25923 S. aureus strain has an antimicrobial susceptibility to all agents commonly tested, including ampicillin, penicillin, cefazolin, clindamycin, erythromycin, cefoxitin (methicillin), tetracycline, and sulfamethoxazole similar to the susceptibility of the S. aureus isolated from [patient’s] SSI…. In addition, the quality control P. aeruginosa isolate was purchased in August 2003, before [patient’s] surgery on December 23, 2003. Interestingly, the antibiotic susceptibility pattern of the ATCC strain #27853 (P. aeruginosa), which was purchased by NMC, supposedly for laboratory quality control purposes, had the same antibiotic susceptibility pattern (of the agents to which both isolates were tested) as that of the P. aeruginosa strain recovered from the SSI of [the patient].11 pp. 9-10

The Jarvis Report also addressed cultures taken from an irrigation solution that was about to be used in a patient surgery on Feb 6, 2004:

Cultures obtained from previously unopened bottle of irrigation fluid (that was about to be hung in the NMC operating room for use in Dr. Long’s surgical patient) by Dr. Long on February 6, 2004 grew 800 colony forming units/ml of S. aureus (two morphologies). Given that this was a bottle of irrigation fluid provided by NMC operating room personnel for use by Dr. Long in that surgical procedure, it is highly suspicious.

Dr. Jarvis concluded that patients were intentionally infected through the use of deliberately contaminated irrigation solutions:

2005 Lawsuit Settles for $4 Million, Hospital CEO Moves on to Another Hospital

The lawsuit filed by Dr. Long in 2005 eventually settled in 2008 for $4 million, and shortly thereafter NMC CEO Peter A. Hofstetter moved on to a new job as CEO of Holy Cross Hospital in Taos, New Mexico,9 and, according to Dr. Long, subsequently to Willamette Valley Medical Center in McMinnville, Oregon. . .

Conclusions

In the words of the 2006 Amended Complaint,2,  p 92 Defendants engaged in “extreme and outrageous conduct, which was beyond all possible bounds of decency, and which may be regarded as atrocious and utterly intolerable in a civilized society.”

Lawrence R. Huntoon, M.D., Ph.D., is a practicing neurologist and editor-in-chief of the Journal of American Physicians and Surgeons. Contact: editor@jpands.org. To access the entire article including the 17 supporting bibliographic documents, and to see the entire sordid story of the hospital hiring 19 private investigators, with one following Dr. Long day and night, breaking into his home, a brick through his car window, stealing a laptop from his car, deactivating his remote car door opener, finding his door panel on his car had been removed, that his tires have been slashed with the same instrument that the Muslims used to slash the throats of the American Airline Pilots on Sept 11, 2011, spiking his drinks with mercury and amphetamines, harassing him and his wife when they were driving or walking, requesting him to be seen by a psychiatrist who was a Peer Review Specialist for hospitals, etc., et.al.

Read the entire document . . .

Why is the threat of a surgeon setting up his own Surgicenter so threatening to a hospital’s finances that they will infect, harm and possibly kill his and their patients with serious staph organisms that were purchased, spend such astronomical sums of money to discredit him?  Is the cash flow from CMS so lucrative that administrators are willing to take the risk of killing patients to get rid of a doctor that may compete?

How prevalent is Hospital Homicide or Medical Murder?

Is there any data out there?

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VOM Is an Insider's View of What Doctors are Experiencing in Managed Healthcare.

Voices Of Medicine

Past Issue

Homosexuality: Some Neglected Considerations

Nathaniel S. Lehrman, MD

ABSTRACT

In recent decades, American perceptions of homosexuality have changed significantly, largely because of the questionable concept of the homosexual “orientation”: a genetic or biological, rather than a behavioral, etiology. These newer beliefs greatly influence how its morbidity, mortality, and social impact are seen, often causing us to overlook how the “gay” male lifestyle significantly increases the incidence of infectious disease and shortens life expectancy by about 20 years. 

History

Homosexuality in Ancient Times

Homosexual behavior has always existed, and was accepted throughout the ancient world; Greek kings and Roman emperors all engaged in it. These men were also involved with women, and decisions about sexual partners were seen as entirely a matter of individual choice and responsibility.

Historically, homosexual behavior has been viewed as both criminal and sinful ever since Judaism first defined it as an “abomination” along with incest, adultery, and bestiality and Christianity continued this stance. Judaism and Christianity’s new prohibitions represented an immense moral and legal change that greatly strengthened family life.

Homosexuality in 19th and 20th Century Germany

In 1869, German same-sex devotees created the term “homosexual” seemingly more neutral and “scientific” than pejorative terms like “sodomite.” They claimed they were born with women’s souls inside men’s bodies (“Fems”), which supposedly made them unable either to respond sexually to women or to control their urges toward other men. As Foucault put it, “the sodomite had been a temporary aberration; the homosexual was a species.”

That same year, the first psychiatric study of homosexuality appeared. It advocated the replacement of criminal penalties for homosexual behavior with medical treatment, thus acknowledging that such behavior was undesirable, but indicating that same-sex choices were not completely under an individual’s control. This transformed lawless behavior, for which people are fully responsible, into illness-evoked activity, with reduced or absent responsibility.

Other Germans involved in same-sex relationships rejected the apology implied by this inborn-causation idea. To their Spartan ideology, same-sex relationships, especially between men and boys, were morally superior to heterosexual behavior and traditional marriage. Ironically, these super-masculine men held the homosexual “Fems” in deepest contempt and persecuted them fiercely.

Homosexuality grew rapidly in Germany over the following decades. In 1891, Richard Krafft-Ebbing’s Psychologia Sexualis declared that “sex perversion” in Germany was alarmingly on the increase”. In 1922, a Berlin police commissioner wrote that “homosexualist groups have been steadily on the increase in recent decades, especially in the big cities. . . They are closely banded together and even have their own [news] paper.” In 1933 when Hitler took power, Ernst Roehm, leader of his 300,000-man terrorist storm troopers—the Sturmabteilung, or SA—was a notorious pederast, and his corps commanders were “almost without exception homosexuals.”

Redefining Homosexuality in America Today

In the United States, homosexuality was considered an illness or perversion until 1973, when the American Psychiatric Association decided to remove homosexuality from its list of “mental disorders”. without “morally judging” it as sin or crime. Thus, homosexuality could be seen as an acceptable alternate lifestyle. The definitional change helped to make homosexuality, once a felony, respectable.

“The APA vote to normalize homosexuality was driven by politics, not science. Even sympathizers acknowledge this.” The process began in 1970 with a “systematic effort” by a homosexual faction within the APA “to disrupt its annual meetings.” After several years of intimidation, the efforts finally succeeded. In 1973, when the faction met formally with the APA Committee on Nomenclature to discuss removing homosexuality from the list, “the outcome had already been arranged behind closed doors.”

When the APA membership was then polled on the question, the faction sent a letter to more than 30,000 members—secretly paid for by the National Gay Task Force—urging them to “retain the nomenclature change.” A third of the membership responded to the poll and a majority of them supported the change. “The result was not a conclusion based upon an approximation of the scientific truth as dictated by reason, but was instead an action demanded by the ideological temper of the times.”

If a vote by this professional organization is all that is needed to normalize homosexuality, could the same faction-driven process occur with other behavior now considered aberrant, such as pederasty, once a critical mass of politically active practitioners has been reached?

Changing American Attitudes

A change in the attitude of the medical profession accompanied the change in definition, as seen in the American Medical Association’s Complete Medical Encyclopedia and in its “official statement” on homosexuality. The former says that even though “some religious groups condemn homosexuality as morally perverse,” it is, rather, “a normal sexual orientation, not a disorder or a sign of a disorder.” The latter endorses “the physician’s nonjudgmental recognition of sexual orientation and behavior.”

The attitude of the public has been greatly affected by the major media, in which the homosexual movement has great influence. In April 2000, for example, Richard Berke of The New York Times, then its national political, correspondent told the National Lesbian and Gay Journalists Association, “literally three-quarters of the people deciding what’s on the front page are not-so-closeted homosexuals . . ..a real cry from what it was like not so long ago.” . . .

Read the entire article including these sections by Dr. Lehrman at http://www.jpands.org/jpands1003.htm

Destiny or a Choice?

Sexual Orientation

Who is Currently a Homosexual?

Changes in Sexual Orientation over Time.

Is Homosexuality Inborn?

Morbidity, Mortality, and Morality: The Social Impact of Homosexuality

The AMA’s Position

Conclusion:

American concepts and attitudes about homosexuality have changed significantly in recent decades. Most of society and the medical profession now view it as an acceptable alternate lifestyle: a biologically determined, permanent orientation, rather than a learned, experiential, and often changeable choice. The concept of homosexuality as a permanent orientation is, however, without scientific validation; the notion is entirely politically grounded.

One effect of this new view has been to understate the medical and societal harm produced by the promiscuous sexual practices typically associated with homosexuality.

—Bibliography with 37 references

Nathaniel S. Lehrman, M.D., a retired psychiatrist, is former Clinical Director, Kingsboro Psychiatric Center, Brooklyn, NY

Journal of American Physicians and Surgeons Volume 10 Number 3 Fall 2005

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

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VOM Present Views of What Doctors are Thinking, Saying and Writing about

Voices Of Medicine

Past Issue

A Review of Local and Regional Medical Journals: Sonoma Medicine

 

EDITORIAL: Touching the Patient by Rob Nied, MD

At the 2014 Australian Open, Stan Wawrinka became the first man since 2009 to win a Grand Slam tennis tournament outside the Big Four of Federer, Djokovic, Murray and Nadal. In the championship match, he beat Nadal, who was suffering from a back injury. How much low back pain factored into the loss, only Rafa knows for sure. Certainly the 90% of us who have experienced this type of pain can imagine how limiting it might have been. In fact, low back pain is the number one cause of disability in the United States, with an estimated $100 billion annual cost for lost work and wages. For Nadal, the difference between the winner and first runner-up prize money was $1.3 million. 

Does sports participation cause low back injuries? A recent study reviewing injury data from professional tennis players competing in the US Open from 1994 to 2009 did not find a significant increase in low back injuries, despite increases during those years in game intensity, higher rotational velocity serves, and longer playing seasons.1 In fact, NCAA injury surveillance has found that only 2% of all sports-related injuries in college athletes are to the low back. Some of these are traumatic injuries, such as contusions and spondylolysis, but most often athletes suffer from the same common mechanical low back pain as the rest of us.

Degenerative disc disease may be quite common in athletes. In a study of asymptomatic late adolescent elite tennis players, none of whom had a history of low back pain, 28 of 33 athletes had significant findings on MRI, including pars interarticularis lesions, facet arthropathy and bulging discs.2 Does this mean that sports are particularly hard on the spine or that a “bad back” on imaging does not necessarily correlate with symptoms or athletic limitation? Knowing how common abnormal MRI findings are in the general public, my interpretation is that athletes have the same backs as the rest of us but are better able to control their core forces and motion.

Athletes like a hands-on approach to low back pain. They are very aware of their bodies, and manual therapies tend to work well for them. Deep tissue work and massage have become a standard part of most training regimens. Beyond just “feeling good,” animal research suggests that manual therapy may actually help injured tissues recover faster. In a 2013 Consumer Reports survey, of the 14,000 subscribers who had experienced low back pain in the past year but did not have back surgery, 59% were highly satisfied by the care from their chiropractor, 55% with their physical therapist, and 53% with their acupuncturist.3 Only 34% of respondents were highly satisfied with the treatment offered by their primary care physician. Clearly our patients also appreciate the hands-on healing power of touch—it is better than prescribing a pill. . . 

Dr. Nied, a family and sports medicine physician at Kaiser Permanente Santa Rosa, is the immediate past president of SCMA.

 

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Voices Of Medicine

Past Issue

A Review of Regional Medical Journals : SONOMA MEDICINE

EDITORIAL: Noble Brains, Healthy Lives

Mark Sloan, MD

Humans have long sought to make sense of the brain. Each age has puzzled over this oddly-shaped organ and its role in the complex workings of the body. In times long past, heated debates erupted among scientists and philosophers: Is the brain a cold or a hot organ? Wet or dry? Does the mind exist separate from the brain? Is it the seat of common sense, of memory? Of the soul itself?

Alcmaeon of Croton, a medical writer in the 6th century BCE, was the first to champion the brain as the center of perception, understanding and cognition. He taught that the senses were connected to the brain by “channels,” a theory that originated with his discovery of the optic nerve. Alcmaeon also appreciated the fragility of the brain; if disturbed, he wrote, the “channels” become obstructed and the sensory connections are lost. The brain was something to be handled with care.

Alcmaeon lectured widely on science and philosophy. One of his observations—that “from noble fathers noble children are born,” and that the same was unfortunately true of “baser” parents—resonates today as we consider recent discoveries in brain research. Alcmaeon had unknowingly touched on a fundamental truth of neurodevelopment: early childhood experiences, whether “noble” or “base,” shape not only character but the anatomy and physiology of the brain itself, with lifelong health impacts.

A young child’s brain is a wondrous thing. By age five it contains about one quadrillion neural connections, more than all the links in the entire Internet. But by adulthood one-third of those connections disappear. The pathways used most frequently in childhood are strengthened and streamlined, while those less trafficked simply wither away.

Stress, both physical and emotional, is an inevitable part of life. When buffered by caring and supportive adult relationships, early life stress can be a positive experience, leading to healthy adaptive responses later in life. When stress is chronic and unaddressed, however, it becomes toxic, triggering a cascade of biochemical events that enhance unhealthy neural pathways.

The areas of the brain most affected by toxic stress are the amygdala, the hippocampus and the prefrontal cortex. The amygdala, rich in stress hormone receptors, becomes hypertrophic, while the hippocampus and prefrontal cortex—essential to dampening the body’s stress reactions—lose neurons and neural connections. An overheated, unchecked amygdala can lead to persistent anxiety, impaired memory, learning difficulties and poor executive functioning. Children exposed to toxic stress may overreact to perceived threats, much like combat veterans with post-traumatic stress disorder.

Structural changes in the brain impact other organs as well, through dysregulation of the hypothalamic-pituitary-adrenocortical axis. The overstimulated amygdala spurs the adrenal cortex to secrete excessive cortisol, norepinephrine and adrenaline. An accompanying increase in inflammatory cytokines accelerates wear and tear in the heart, lungs, immune system, and elsewhere throughout the body. Toxic stress in childhood can thus result in lifelong, multi-system disease.

Once a developing brain is altered by toxic stress, setting things right becomes difficult. In their landmark 1998 Adverse Childhood Experiences study, Drs. Vincent Felitti and Robert Anda demonstrated the impact of toxic childhood stress on adult health. They found that adults exposed to multiple stresses in early childhood—such as abuse or neglect, loss of a parent, or maternal depression—were at high risk of cardiovascular disease, depression, substance abuse, and other chronic illnesses, even if the stress resolved before adulthood.

If we are to lessen the burden of chronic illness, we must strengthen the neural pathways that enable children to handle stressful events. This is best accomplished by providing support to families, the people from whom a child will learn (or not) about how to cope with life’s stresses.

As physicians, we have a choice to make. We can accept ever-increasing rates of chronic physical and mental illness as inevitable, or we can attack these problems at their early-life roots. To borrow a phrase from Frederick Douglass, “It is easier to build strong children than to repair broken men.”. . .

You can act on a personal level, too. Talk to your children. Read to your grandchildren. Teach the young people around you how to positively handle life’s stresses. Today’s children—tomorrow’s adults—will be glad that you did. ::

Dr. Sloan is a Santa Rosa pediatrician.

Email: markpsloan@gmail.com

SONOMA MEDICINE |  Winter 2015  |  Sonoma County Medical Association


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Voices Of Medicine

Past Issue

A Review Regional Medical Journals: MARIN MEDICINE | Fall 2014

EDITORIAL: Medicine & Politics

Jeffrey Stevenson, MD

This issue of Marin Medicine focuses on medicine and politics, a theme with many facets. First and foremost is Proposition 46, which would raise the statutory cap on pain-and-suffering awards, thereby increasing malpractice insurance rates. The proposition could cause patients to lose their doctors and restrict access to care across the state. . .

Trial attorneys have generated Prop. 46 as a revenue source from physicians, and it stands to add malpractice costs at a time when physicians are struggling to make adjustments for reduced reimbursements and increased workloads. In the interest of financial survival, many physicians have allied themselves with large groups or medical foundations. The greater challenge is whether doctors can work together politically. We need to stand firm for access to quality care. Both the California Medical Association and the Marin Medical Society provide state and national leverage for physicians. . .

One place where physicians need more leverage is with health care insurance companies, who commonly don’t give doctors a seat at the boardroom table. Physician medical directors at these companies provide advice, but the companies aren’t obligated to follow it. A voting physician “on the board” could probably impact policy at a higher level. . . 

Interested parties are developing a time-of-service treatment authorization portal to expedite this process and allow guidelines to be queried and applied to an individual situation in real time. Key to this revised process is the provider’s ability to upload or enter key information to designated algorithms, along with comments, reports and documentation. Part of the concept evolution is for nurses and on-call specialists to handle more detailed reviews in real time. This ability would allow them to focus on the subset of requests that are complex and warrant the extra review.

Meanwhile, fiber-optic infrastructure and emerging hardware promise to bring faster speed and better access. Emerging fiber-based products can download a fully loaded CD in 8 seconds vs. the 90 seconds required with current business broadband. Applying these fiber technologies within local networks as well as distant file transfers can not only speed things up, but also bring real-time streaming without sacrificing fidelity. Fiber-optic provides a more secure network. On the Internet, anything can be hacked, for a price.

I recently tried out a Google Glass real-time transcription product. It had many positive features but was limited in visual resolution in favor of optimizing audio for the transcriptionist. The limited resolution prevented me from getting a video “screen shot” of a page of information, such as a handwritten chart note with diagrams or a picture to the transcriptionist. These details are being sorted out by the developer.

The interconnectivity of different electronic health record systems, whether city-to-city or state-to-state, continues to evolve. Interconnection requires careful segregation of psychological and psychiatric reports, as well as particular infections, alcohol and drug conditions from the past. There are some records that are just too precious to transmit, despite HIPAA promises of security.

Finally, opioids and other pain medications are receiving considerable attention and are under careful review. Locally, we are bringing together community resources, both private and public, to better understand the situation and what we have to learn. Fortunately, some of the world leaders in pain management are available in our community. The risks of opioids have to be balanced with the important need for pain control and the unique situations that apply with particular patients. They need pain-control resources that will give them adequate support.

In closing, I would like to thank my colleagues for the opportunity to serve you this year as president of MMS.

Dr. Stevenson, a Novato general practitioner, is president of the Marin Medical Society.
Email: jeffreystevensonmd@gmail.com

MARIN MEDICINE | Fall 2014 | Marin Medical Society

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

Voices Of Medicine

Past Issue

A Review of Regional Medical Journals and Articles: Colorado Med Society

Prescription drug abuse

Kate Alfano, Colorado Medical Society, contributing writer

State effort focuses on safe use, storage and disposal

Tuesday, July 01, 2014

Aaron started using prescription opioids when he was in high school. From an upper-middle-class family, his parents described him as a typical teenager; light-hearted and full of energy, he was athletic and loved to wrestle. He went to a so-called “pharming” party where students raid their home medicine cabinets, bring any prescription drugs they can find, mix them up in a bowl, pick one or two, and chase them with a beer. 

“That’s considered fun, a reasonable thing to do and reasonably safe because the kids think, ‘they’re just prescription medications. How dangerous can pills be?’” said Rob Valuck, PhD, president of the Colorado Prescription Drug Abuse Task Force and coordinating center director of the Colorado Consortium for Prescription Drug Abuse Prevention.

Without major incident from that first experience, Aaron continued his nonmedical use: trying one or two of his parents’ Vicodin, then one or two more; getting more from friends; and gradually falling into a downward spiral. Tolerance led to increased use, then to dependence, and ultimately addiction.

As his addiction became stronger, Aaron started to scam doctors for opioid medications. In an interview with authorities, he estimated that he visited between 40 and 50 doctors over an 18-month period and went to about an equal number of pharmacies to stay beneath the radar. He said most doctors would give him at least an initial prescription for Vicodin. When he developed a tolerance he progressed to OxyContin.

Aaron eventually started using Oxy- Contin at very high doses, often mixed it with Xanax and alcohol, and overdosed at age 21. He had a difficult stay in the ICU: two myocardial infarctions, seizures, a staph infection and pneumonia, on top of extreme withdrawal symptoms. Doctors prepared Aaron’s parents for his death, which appeared imminent and very likely. Surprisingly, he regained consciousness and eventually recovered well enough to be discharged home. But the overdose left him paralyzed and unable to speak.

“The worst consequence is death,” his mother said in a video about this real patient case for the Medicine Abuse Project. “Other consequences are, like Aaron, trapped in your own body alive but unable to communicate in the way that you would hope that you could. You also lose all of your hopes and dreams and everything you wanted to accomplish in your life.”

The growing epidemic

Prescription drug abuse and misuse is serious problem in Colorado and around the United States. In 2010, more than 38,000 people died from a drug overdose in the United States – one every 14 minutes, Valuck said. Nearly 60 percent of those deaths involved prescription drugs and, of those, 75 percent were opioid painkillers. In Colorado, the number of drug overdose deaths range from 250-500 per year; in 2010 it was just over 300.

The rates of misuse and overdose death are highest among men, persons ages 20-64, non-Hispanic whites, and those in poor and rural areas. “That said, this cuts across all strata demographically – age group, gender, race, ethnicity, diagnoses; it’s a problem all over the place,” Valuck said.

And while the public typically hears statistics on overdose deaths, Aaron’s story demonstrates that death isn’t the only outcome. In 2011, for every opioid overdose death, there were 10 treatment admissions for abuse, 32 emergency department visits for misuse or abuse, 130 people who met the medical criteria for abuse or dependence, and 825 selfadmitted nonmedical users.

“What’s gotten our attention in Colorado is that we’re high in the ranking in self-reported nonmedical use of prescription pain relievers among anyone age 12 or older,” Valuck said. “It’s nonmedical use that puts people at very high risk for becoming addicted and having those problems. That’s led us to do something about it.”

Taking action

A small percentage of providers prescribe the majority of controlled substances. In Oregon, 8.1 percent prescribed 79 percent of these drugs, which Valuck said is typical, especially considering some specialties’ scope of work. “Many doctors prescribe few; some doctors don’t prescribe them ever. It’s really variable and we know that this isn’t an indictment on doctors or one type of doctor.”

However, providers who do prescribe these medications frequently inherently see more higher risk patients and are more likely to have patients who are doctor shopping for opioids. “It’s not necessarily your fault; it’s just the territory,” Valuck said. “You’re working with highly addictive stuff and people who become addicted. That’s where 63 percent of the overdose deaths come, among the 20 percent of prescribers who prescribe the most.”

One of the answers is to try to develop a coordinated response among the many stakeholders. “We could attack this problem at any place in the distribution chain, from manufacturers to the medical system to pharmacies to insurers and payers to patients and the public. Everyone needs education about this,” Valuck said.

As for physicians, he has six recommendations for what an individual can do to help mitigate the prescription drug abuse epidemic.

1. Take continuing education courses and seek out additional training.

2. Find and follow guidelines for safe opioid prescribing, whichever they are.

3. Be willing to prescribe less, whether that’s smaller quantities or other alternatives, and see patients more often.

4. Check the prescription drug monitoring program (PDMP) more often.

5. Educate patients on the importance of safe storage and disposal of unused medications.

6. Talk with colleagues, family, friends and neighbors about the issue and tell them stories about affected patients. .  .

Read the rest of the article . . . 

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

Voices Of Medicine

Past Issue

A Review of Regional Medical Journals: Sonoma Medicine

The magazine of the Sonoma County Medical Association

EDITORIAL: MEDICINE & POLITICS

Rob Nied, MD

Has the current morass in Washington DC inspired you to run for Congress? According to the New York Times, 26 physicians are running for Congress this year, and Kentucky senator Rand Paul, an ophthalmologist, is considered a likely presidential candidate. Compare that with a total of 25 physicians who served in Congress between 1960 and 2004.

Commoditizing physicians and patient care, declining reimbursement, the Affordable Care Act, and increasing bureaucratic regulation have made the business of medicine increasingly unpalatable, so it is understandable that we physicians want to stand up and fight for our profession. Our country’s founding fathers would be proud—more than 10% of the signers of the Declaration of Independence were physicians. 

A few years ago, The Daily Beast published an entertaining article by Dr. Kent Sepkowitz about physician politicians (“Why physicians make crazy politicians,” May 26, 2010). He postulates that physicians are used to taking charge and have a sense of personal responsibility for the world around them. We also share a sometimes outsized belief in our own ability to “fix things.”

Having more physicians in Congress might seem like a good idea, but the ones who are already there don’t necessarily represent the views of physicians in general . . .

The reality is that physicians across the United States have the same disparate views and biases as any group of 600,000 people. Considering that most of a physician Congressperson’s time is spent advocating and deciding on policy matters far removed from their medical training, it may not be in our collective best interest to elect more of them.

Of course, physicians don’t need to hold political office to influence the most important public policy decisions, even at the national level. Politicians know that one thoughtful letter or call from a constituent represents the views of tens or even hundreds of peers who did not bother to publicize their opinions. Personal relationships between physicians and key legislators, forged over a decade of interaction, ultimately led to the “GPCI fix.” The adjustment in the Medicare Geographic Practice Cost Index—which only happened in California—will increase payments to physicians in 14 California counties by $50 million annually and over $400 million in the next decade. Sonoma County physicians will see a 4–9% increase in payments. For other national policy issues, such as repealing the Medicare SGR, personally lobbying our elected representatives is the single most powerful thing we can do.

Some political issues, however, require a more organized, collective effort, such as the current effort to defeat Proposition 46. Organizing a statewide public-relations campaign is too large of a project for one person, one county medical society, or even the largest medical group. The California Medical Association—the collective voice of almost 40,000 physicians—represents our common interests at the state level. The physicians and medical students standing on the California State Capitol steps in support of universal access formed the most lasting image of this year’s Legislative Leadership Conference, which is organized by CMA. To do that work requires people and money. It is important that each of us contribute our share.

Unfortunately, public opinion of organized medicine is not much higher than public opinion of Congress. Corporate medicine has often been guilty of protectionism and favoring special interests. Most people, however, still have a great deal of admiration for individual physicians. A 2011 poll found that 77% of the respondents trust physicians in general and 93% trust their personal physician, a number that is rare in today’s society.

Ultimately, the most effective advocacy for the issues we hold most dear is the clout and respect we have in our own community. We shouldn’t underestimate that. Sonoma County physicians, almost uniquely in California, are embedded in our community. We live and play here. Simply being present and active in our community influences public opinion, effects change and helps educate.

The real question is not whether you should run for Congress. Instead, it’s what are you passionate about? Over the coming year, SCMA will be launching an effort to better connect our members with organizations in Sonoma County that share our common interest in the health and vibrancy of our community. What inspires you? ::

Read the entire editorial in Sonoma Medicine . . .

Dr. Nied, a Santa Rosa family physician, is president of SCMA.
Email: robert.j.nied@kp.org

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A Review of Medical Journal Articles: The Dilemma of Speaking Up

Primum Non Tacere: An Ethics of Speaking Up

By Dwyer, James
Academic journal article
The Hastings Center Report , Vol. 24, No. 1 , January-February 1994

PEER-REVIEWED PERIODICAL

Article excerpt

During the last five years I have conducted ethics courses, seminars, and case conferences for medical students. I have also had many informal discussions with students at all stages of their medical training. Yet I am still surprised by how many students know and refer to the Hippocratic maxim to do no harm. Some even cite the Latin version: Primum non nocere. I wish, however, that more medical students would also keep in mind a Socratic maxim: Primum non tacere. First, do not be silent.

When I encourage students to articulate ethical issues that they face as students, they often describe situations where they must decide whether to speak up or keep quiet. The following are cases that students have described and that I have altered somewhat and then formulated from a student's perspective.  

1. Spos (acronym for "subhuman piece of shit").[1] Before I entered medical school I read House of God, but I didn't find it very amusing. I was troubled by the attitudes the characters displayed, and I told myself that I would try to be more respectful of patients. I assumed that speaking about patients in derogatory terms was a fad that would be over by the time I began my clerkships at the hospital. That was not the case. During my first rotation my resident presented me with a new admission: "Here's your patient. He's a forty-year-old Hispanic male, a shooter, a real spos."

I wondered whether I should say anything. I didn't like that language and the attitude it displayed, but it wasn't my job to train the house staff. On the other hand, if I didn't say anything, I'd seem to accept the judgments and attitudes I want to avoid.

2. Informed Consent.[2] I always thought that informed consent was integral to the doctor-patient relationship, that it was really one aspect of good communication with patients. Yet some people view it differently, as a bureaucratic hassle imposed by people outside medicine. This difference became painfully clear during my first week in the clerkship. My resident told me to "consent" one of his patients. This was my second day. I had never met the patient and had no idea what the risks of the proposed procedure were. So I politely asked my resident about the risks, but he told me with a slight sense of annoyance that the patient will sign anything. What were my choices? I could say something to the resident I could just get the signature. I could look up the procedure in a textbook. Or I could ask someone who might explain the procedure to me. In fact, I asked another resident who told me a bit about the procedure.

An hour later my resident saw me again and said that the team had decided to include a second procedure. He told me to simply write the second procedure onto the form and to use the same pen. I didn't want to be party to this sham, but I also didn't want to jeopardize my grade.

3. Practice Makes Perfect.[3] I understand that this hospital is a teaching hospital and that students, residents, and fellows are here to learn. The fact that we learn on patients means that some patients are subjected to additional pain, inconvenience, and physical examinations. I guess there's a kind of bargain: we learn medicine on people who are mostly poor, and they get care they might not otherwise have access to. Whether or not this arrangement is fair, I've come to accept it. But I never imagined that people would practice a procedure that wasn't medically indicated.

Late one night I was working with a resident in the labor and delivery room. The patient was in labor, and the resident decided to do a forceps delivery. I didn't see the indication. The woman didn't seem very fatigued, and there were no apparent complications. I didn't know the exact statistics, but I was sure that a forceps delivery involved some risk to die fetus. I didn't know what to do. If I asked what the indications were, the resident was sure to have some rationalization. If I told an attending physician the next day, I'd create a lot of trouble and no good would come of it.

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Voices Of Medicine

Past Issue

A Call from the San Mateo County Medical Association.

We need your help to protect MICRA

Dear Physician Colleagues,

We need your help in protecting California’s Medical Injury Compensation Reform Act (MICRA). On November 4, 2014, voters will go to the ballot to vote on Prop 46. The importance of MICRA to physicians in the state of California is significant. We're not asking you to assemble and march on Sacramento as more than 800 physicians, nurses, lab technicians and hospital personnel did in a grass root effort lead by the California Medical Association on May 13, 1975. 

Trial lawyers have sponsored Prop 46. If Prop 46 passes, the current MICRA cap will quadruple from $250,000 to $1.2 million on non-economic damages in medical malpractice lawsuits. If Prop 46 passes, it will result in higher health care cost for everyone and threaten patient’s access to care with his or her providers. If Prop 46 passes, California will be flooded with new lawsuits and big payouts to trial lawyers.

The California Medical Association and county medical associations across the state have been working tirelessly to defeat this measure, but we still need your help. The next two weeks are crucial if we are to defeat Prop 46.

Please make a voluntary contribution ($25, $50, $100, $500) to help us preserve MICRA.

Please click here to donate by debit card or credit card (Visa, MasterCard, or Discover).

You can also mail your check to:SMCMA – Prop 46, 777 Mariners Island Blvd., #100, San Mateo, CA 94404

When November 4 arrives, we hope we will be able to celebrate the defeat of Prop 46 and return to the practice of medicine without increasing threats of malpractice "pain and suffering" awards to increase to $1.2 million blue sky in addition to all the medical injury without limit.

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

Voices Of Medicine

Past Issue

The Dhar Diet, or D-Diet

Sonoma Medicine
The magazine of the Sonoma County Medical Association

COMMENTARY: The D-Diet

By Sanjay Dhar, MD

There are several hundred different types of diets out there, so I figured why not add one more to the list, the Dhar Diet, or D-Diet. How difficult can it be to come up with a diet? All I need to do is read a few books, adopt some basic ideas, tweak the concept and present it with a new “designer” name.

Diets range from A (Atkins) to Z (Zone), and there is no shortage of advice regarding the different diet plans. You may decide to choose one and stick with it or seamlessly switch from one diet to another. However, with all the diets out there and the endless advice offered, why then are Americans getting heavier at a faster pace than ever before? It seems that it’s a never-ending battle between the food industry pushing processed products that make us gain weight, and the diet industry, which has convinced us that we can never be satisfied with the way we are.

Is the truth somewhere in between? We do know that both these sectors are reaping billions of dollars in profits. Let us also not forget the consumer, who is the most important member in this complex relationship. Ultimately we have to be responsible for our actions, even though we know that we live in a free country where we can eat and drink whatever we want.

As a cardiologist, I have been giving dietary advice to my patients over the last 25 years. Diets come in various shapes and forms, with each having a tailored approach or a certain niche. My focus has been on preventing and hopefully reversing heart disease. I try to evaluate dietary habits rather than just giving a blanket order to “lose weight.”

Patients often have difficulty following guidelines because of poor food labeling. The label on a jar of peanuts may report 200 calories, for example, but you have to read the fine print to realize that the calorie amount mentioned is per serving, and that there are several servings per package. Unless patients take the time to read the label in detail, they often consume many more calories in a single sitting than they think. (A cup of peanuts actually contains 830 calories). The same concept is also true for salt and corn syrup content in processed foods. Unfortunately, we don’t have a fuel-gauge sensor in our body that tells us to stop eating when we have reached sustenance levels in calorie intake.

Why do people diet? Most do so to lose weight, to jumpstart the summer season, or to keep up with their new year’s resolution. Some are forced to lose a lot of weight because they have become morbidly obese and it’s affecting their health. Some diet to help their medical conditions, such as diabetes, hypertension, heart disease, arthritis of lower extremity joints, swelling of legs, reduced aerobic and functional capacity, exertional shortness of breath, easy fatigability, sleep apnea and abnormal cholesterol panels, to name a few. Some people have to change their diet because they have developed food intolerances, whether it’s gluten, dairy, nuts or other food ingredients. Then there are some disease states that demand special attention to food choices, such as chronic kidney disease, gout or other metabolic conditions.

For my patients, I recommend a drawn-up plan, any plan that has a chance of being successful. Ultimately losing weight is simple mathematics: calories in vs. calories out … or is it? We know that under extreme starvation, everyone will lose weight. However, since starvation is not practical or sustainable, weight loss should occur without extreme effort or significant time consumption. A good diet plan should be effortless and simple and yet not boring. . .

Providers and corporations have a financial incentive to treat obesity, and they market this concept everywhere. There are billboards (10 days and 10 pounds or your money back) and TV programs (The Biggest Loser), along with ads of all kinds for gyms, diet plans, weight-loss centers, fat farms and so on. Some of them do present compelling messages, but some sound too good to be true. How can you lose weight by eating more? When all else fails, there is always bariatric surgery. Although complications are rare, mortality is not 0%, and some patients do end up having lifelong morbidities.

In a nutshell, it is for us as physicians to decide what is appropriate, how far to promote weight-loss strategies, and what reasonable goals are. It also is up to patients to find a mandate of their own choice and not be driven by outward pressure to look a certain way.

What we do know is that if you consume fresh fruits and vegetables (Mediterranean diet) and reduce intake of highly processed foods, deep-fried foods, artificial sweeteners, foods high in corn syrup, sodas, and saturated fats, you will most likely reduce the probability of becoming obese and/or developing chronic disease conditions linked to heart disease, diabetes and cancer.

So what is the D-Diet? It is simply an ideal diet (heart healthy), made fresh every day from local ingredients. It’s not a liquid diet and it doesn’t come in small containers, cans or cardboard boxes. It’s effortless to follow, quick and easy to make, and is loaded with all kinds of flavors, colors and textures to take you on a pleasing gastronomic cruise. It doesn’t affect your bodily systems in any way, and there are new food choices every day. There are no worries about how much to eat and when to eat. It doesn’t cost a whole paycheck. And by the way, I am still working on it.

http://www.nbcms.org/AboutUs/SonomaCountyMedicalAssociation/Magazine/tabid/747/language/en-US/pageid/685/spring-2014-medical-controversies-feature-articles-commentarybrthe-d-diet.aspx +

Dr. Dhar is a Santa Rosa cardiologist.        Email: santarosadoc@aol.com

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

Voices Of Medicine

Past Issue

A Review of Local and Regional Medical Journals and Articles

Sonoma Medicine
The magazine of the Sonoma County Medical Association

EDITORIAL: Pain and Suffering

Allan Bernstein, MD

Pain is an essential part of our survival mechanism. It warns us that we stepped on a nail or that the coffee is too hot. It triggers autonomic responses that adjust our blood pressure, heart rate, pupillary reactions, blood sugar and blood cortisol levels. It is a warning to get our hand away from the flame and that our shoe is too tight. Pain is something we learn from. We’d like to avoid it, but we need it.

Pain typically indicates injury or potential injury, starting with tissue damage, releasing cytokines, stimulating peripheral nerves, and progressing proximally through nerve roots, spinal cord and into the brain. Spinal reflexes to pain allow us to pull our hand away from a painful stimulus before it even registers in our brain. A series of on/off switches along the way, particularly in the spinal cord and brainstem, allow us to modulate the pain and interpret the meaning. The endpoint, after multiple connections, is the frontal cortex, where we can localize the pain and decide how significant it is.

There are learned behaviors in our reaction to pain and genetic differences as to how we rate pain. “Big boys don’t cry” and “crybaby” are terms used in some cultures but not others. When I was studying painful neuropathy, using a 100-point pain scale, some subjects rated their pain at 80 while others claimed 20 for what appeared (to me) to be similar pain. After treatment, the 80s went to 70 and the 20s went to 17, a statistically identical percentage of reduction. Did one group feel more pain, or were they culturally sensitive when describing pain?

Anticipating pain will activate pain receptors and the appropriate autonomic responses. In contrast, anticipating pain relief will reduce pain signals, at least transiently. Nocebo responses (expecting something bad to happen) and placebo responses (expecting and getting benefit no matter what the treatment) may confound our research studies, but they can be turned into powerful clinical tools. The 45% placebo response in pain research tells us how much anticipation of relief affects our perception of pain.

The brain can create pain that isn’t there, such as phantom limb pain, and override significant pain when circumstances are appropriate, such as war injuries. Chronic pain--pain that persists in spite of no new tissue damage--represents a failure of the normal system that modulates pain.

Suffering is an individual’s emotional response to pain. It is not related to the intensity of the pain, but rather to fear, frustration and lack of understanding as to the meaning of the pain. If the etiology of the pain is well understood, one can rationalize severe pain as due to a specific injury, with an anticipated endpoint. Comprehension may not reduce pain, but it can moderate suffering for many people. The language we use to describe unpleasant situations often hints at a lack of control. We “suffer in silence,” “suffer the consequences” and “suffer the loss of a loved one.” These situations do not describe physiologic pain, but the emotional part of the pain--suffering--is the prominent feature that appears out of our control.

Both pain and suffering are difficult to measure. Pain fibers can be monitored in experimental animals. We assume pain is present when autonomic features appear in correspondence to the level of electrical impulses along pain pathways. We can measure endorphins and serotonin in spinal fluid. While both increase in response to acute pain, they both go down in chronic pain. As we gradually lose our ability to modulate pain, our suffering rises. Raising the level of endorphins and serotonin--through medications, spinal stimulators, exercise, cognitive therapy and diets--may improve pain control and relieve suffering. Therapies such as music, dance, painting and other pleasurable activities also reduce pain and suffering. Dopamine stimulation appears to be the physiologic pathway . . .

Read the entire article at Sonoma Medicine . . .

Dr. Bernstein, a Sebastopol neurologist, serves on the SCMA Editorial Board.

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

Voices Of Medicine

Past Issue

A Review of Local and Regional Medical Journals: Sonoma Medicine

The magazine of the Sonoma County Medical Association

INTEGRATIVE MEDICINE - Weaning GERD Patients off PPIs

Sarah Murphy, MD, and Hana Grobel, MD

Mary (not her real name) is a 45-year-old woman who originally presented with mild gastroesophageal reflux disease (GERD) and was started on a proton pump inhibitor. When we first saw her three years later, she was still on PPIs.

As family physicians, we see many patients like Mary who are initially prescribed PPIs for mild GERD, continue their medication for a long time, and subsequently suffer various side effects associated with PPIs. The question that arises is how to safely wean these patients off PPIs. One possible answer is to use an integrative medicine approach.

But first, let’s back up and consider the function of the entire gastrointestinal tract and the processes that are involved in maintaining the health of our guts. Taken as a whole, the GI tract is one of the largest organs in our body, and its surface area can expand to the size of a tennis court. In our lifetime, we take in 30-40 tons of food that we break down, process, sort, and then use or eliminate . . . 

In addition to the cells of the GI tract, the gut contains 100 trillion bacteria (400 different species), which is 10 times more than the amount of cells we have in our entire body. These bacteria break down food to make nutrients more available, inhibit pathogenic bacteria, and form a layer on the gut mucosa, which protects the intestinal lining and communicates with the enteric immune system.[1,2]

From the perspective of integrative medicine, when we ingest substances that harm this delicate ecosystem, the gut barrier can break down (known as increased intestinal permeability), the microbial ecology can become imbalanced (called dysbiosis), and we can ultimately get sick.[1] Disease not only shows up in the form of GI disorders (e.g., GERD, IBD, IBS, gastroenteritis), but can also present as systemic problems.[3] When the gut mucosa is disrupted, it can become inflamed. Through the more permeable intestinal walls, improperly digested food substances can cross the GI mucosa and trigger further inflammation.[1]

How do we keep our guts healthy and our immune systems intact? One integrative approach is to use the 5Rs of Functional Medicine, where the goal is to support optimal GI health and address the underlying mechanism of disease. The 5Rs stand for remove, replace, repopulate, repair and rebalance. These methods can be applied to many GI conditions, including GERD.

The problem with GERD is not that there is too much acid, but that the acid is in the esophagus rather than the stomach. PPIs block the secretion of acid, thus eliminating symptoms, but they do not address the underlying problem of regurgitation of the gastric lumen contents into the esophagus. In other words, PPIs don’t cure GERD; they only treat the symptoms.

Over time, the body upregulates acid production to compensate for the lack of acid secretion, so stopping PPIs becomes difficult because of rebound symptoms.[4] Some studies have found that long-term PPI use is associated with hyperplasia from increasing gastrin production, as well as increased gastric atrophy.[5,6] Although long-term PPI use has been associated with an increased incidence of gastric cancer, no direct link has been established.

PPIs are valuable in the short-term treatment of GERD, but long-term use may lead to serious complications, including increased risk for pneumonia and Clostridium difficile, and decreased absorption of vitamin B12, calcium, magnesium and iron.[7-12] In fact, our patient Mary was found to be Vitamin B12 deficient.

Despite these potential complications, PPIs are recommended in many circumstances, such as preventing gastrointestinal bleeding in elderly patients on NSAIDs. As with other medications, physicians need to balance the risks and benefits of PPIs, depending on the condition. They should also bear in mind that many patients are on PPIs with no good indication.

The long-term side effects of PPIs make sense based on the multiple roles of acid in the stomach. Acid functions to kill bacteria in the stomach, and it helps break down food to make nutrients more available. In the duodenum, acid helps stimulate release of pancreatic enzymes, which further aid digestion. Higher acidity in the stomach also increases the tone of the lower esophageal sphincter. Thus, acid production plays an important role in tightening LES tone, getting rid of unwanted bacteria, and providing us with properly digested nutrients.

Our goal with Mary was to wean her off PPIs and help her regain the normal function of her GI system. We used an integrative approach based on the 5Rs, as outlined below. Such an approach should begin at least one week before starting to wean patients off PPIs.

Remove. To stop symptoms and prevent their return, it is important to remove the triggers. Certain foods can be aggravating, including caffeine, spicy foods, alcohol, chocolate, fatty foods, dairy, and acidic foods, such as orange juice and tomatoes.[13,14] To identify triggers, patients can use a food diary to document food intake and symptoms. Alternatively, patients can try an elimination diet where specific foods are eliminated from the diet for 2-4 weeks, and re-introduced one at a time to see if symptoms return.[15] Other triggers may include tobacco use, increased weight, prone position, stomach distention and stress.[14] For some patients, addressing lifestyle factors may be enough to stop their GERD symptoms. Don’t underestimate the power of tobacco cessation, weight loss, propping the head of the bed 4-6 inches, eating meals several hours before lying down, eating smaller meals and stress management.

Replace. Once the main triggers are removed, non-aggravating nutritious foods can take their place. Patients may also benefit from replacing vitamin B12, calcium, magnesium or iron, if low.[10] In addition, one small study found that, instead of suppressing acid, some patients may benefit from supplementing with acid to increase LES tone, break down food and stimulate digestion.[16]

Repopulate. Patients who suffer from small bowel bacterial overgrowth after long-term suppression of stomach acid may benefit from probiotics. We recommend at least 10-14 billion units daily, preferably with several different species present. Some symptoms of bacterial overgrowth include bloating, gas, diarrhea and abdominal cramps.[17]

Repair. Various herbs and supplements may help protect and repair the lining of the gut.[3] Many of them act as demulcents and create mucoprotection of the esophageal mucosa, but they can also decrease absorption of other medications, so medication doses must be monitored.[3] One week prior to weaning off PPIs, patients can start taking one or more of the following herbs:

·     Marshmallow (althea officinalis): can be ingested as tea, up to 5-6 grams daily, or as a tincture, 5 mL after meals.

·     Licorice (glycyrrhiza glabra): best taken as deglycyrrhizinated licorice (DGL) 380 mg tablets, 2-4 tablets taken before meals. Glycyrrhizin acts as a mineralocorticoid and can cause hypertension, hypokalemia and edema with prolonged use, so deglycyrrhizinated licorice is recommended.

·     Slippery elm (ulmus fulva) root bark powder: one to two tablespoons of the powder mixed with water and taken after meals and before bed. To increase palatability, mixture can be sweetened with honey.

·     Chamomile (matricaria recutita): used for inflammation and spasmodic effects. 1-3 grams steeped as tea, 3-4 times a day.

·     Throat Coat tea (Traditional Medicinals): contains all the above herbs (licorice root, slippery elm, marshmallow root), but in smaller amounts. Can be taken with meals.

Rebalance. The enteric nervous system houses more neurotransmitters than the brain and makes up 70% of the entire immune system, so stress can affect gut symptoms.[1,18] Many modalities can be used to help decrease stress and prevent the return of symptoms. Stress-reduction modalities include biofeedback, relaxation techniques, meditation, self-hypnosis and journaling. Some studies have found that acupuncture may be helpful for treating GERD symptoms.[19,20] Regular aerobic exercise is also recommended when tapering off PPIs, but symptoms can be exacerbated if exercise occurs right after meals.[13] High-intensity activities like running or cycling may aggravate symptoms.

When using the 5R approach above, it’s important to taper off the PPI slowly. The higher the dose, the longer the taper; counsel your patient to expect rebound symptoms. Begin by decreasing the current PPI dose by 50% each week until the patient is on the lowest dose once daily. After two weeks on this dosage, change to an H2 blocker. If the patient cannot tolerate going straight to an H2 blocker, you can alternate an H2 blocker every other day with omeprazole. After 2-4 weeks on the H2 blocker, taper or stop altogether. After 2 weeks off the H2 blocker, try tapering off supplements. Your patient will benefit from continued lifestyle modifications. .  .

Read the entire article including the details of the 5Rs, lifestyle modification and references in Sonoma Medicine . . .

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

Voices Of Medicine

Past Issue

A Review of Local and Regional Medical Journals

Sonoma Medicine MEDICAL ARTS

The magazine of the Sonoma County Medical Association

Roll on, Bob

By Rick Flinders, MD

I first saw Willie Mays in 1958, when I was 12 years old. I watched him play for 14 years as a San Francisco Giant, through the prime of his career, the greatest baseball player I ever saw. Maybe Roberto Clemente had a better arm. Maybe Barry Bonds was a better hitter. But no one has ever played the game of baseball better than Willie Mays. He was magnificent.

In 1972, Willie was traded to the New York Mets. I watched him flail at the plate, no longer able to catch up with major league fastballs. In center field he was no longer graceful, even once dropping a ball while attempting his signature basket catch. It was painful to watch. He retired in 1973. 

I first saw Bob Dylan in 1965, when I was 19 years old. I’d been struck between the eyes with songs like “Masters of War,” “Chimes of Freedom,” and “With God on Our Side.” On stage at the Berkeley Community Theater in December 1965, he stood alone with only an acoustic guitar and harmonica, and he mesmerized us. After intermission, he returned with an electric Stratocaster and four musician friends he called “The Band.” He concluded the show with a song he’d just released, “Like a Rolling Stone.” He was magnificent.

In the past half-century, few artists have had more impact on our language and culture than Dylan. He changed popular music the way Einstein changed modern physics: he changed everything that followed. Dylan took the lyrics of popular music away from the hacks of Tin Pan Alley and placed them in the hands of poets. As Bruce Springsteen said of the influence of Dylan’s music on his generation: “Elvis freed our bodies. Dylan freed our minds.” A recent concordance of legal decisions in U.S courtrooms showed Dylan’s words the most frequently cited lyrics in judicial opinions, from local magistrates to the Supreme Court.

In the years since that first show in Berkeley, I’ve seen Dylan in concert 15 times, each performance as unpredictable as the performer himself, but always worth seeing.

Until now.

This October, at the Greek Theater in Berkeley, it was hard to watch Dylan on stage. Listening was even more painful. His band, still composed of world-class musicians, was only loud and lifeless. His voice, over-amplified to compensate for 50 years of vocal cord injury, echoed only harsh syllables from his former eloquence.

His most recent album had promised more. Called Tempest, the same title as Shakespeare’s final play, it was rumored to be perhaps his final work. Two songs in particular provided proof that Dylan can still bring the poetry. The title track is a poetic vision of the night the Titanic sank, with lyrics sufficiently vivid to bring you to tears. Another song, “Roll on, John,” is a touching tribute to his old friend John Lennon:

Shine your light, move it on

You burned so bright, roll on, John

Though the poet still lives, the voice is gone.

Bob Dylan has earned the right to sing forever. It’s what he does. But, for the first and only time in 50 years, I walked out early from a Dylan concert, the last one I’ll ever attend. How does it feel? Like watching Willie Mays about to drop a routine fly ball from a basket catch. And while it breaks my heart to say it, Bob, I say this with nothing but love and with gratitude for all you’ve given us. May you live long and continue to know and speak the truth as few others have. May your heart always be joyful and your song always be sung. But from that stage where you burned so bright and delivered a lifetime of magnificent lines and transcendent songs, it is time to roll on.

Dr. Flinders, who serves on the SCMA Editorial Board, is a lifelong fan of Bob Dylan.

Email: flinder@sutterhealth.org

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

Voices Of Medicine

Past Issue

A Review of Local and Regional Medical Journals

A Doctor Leaving Solo Practice

by Marsha McKay DO

I am one of the docs who decided that medicine is not fun anymore, and more importantly is no longer tolerable with all the documentation, coding, referrals, prior authorizations, begging insurance companies to “let me” prescribe necessary medications and so forth. I can’t practice medicine anymore as an Authentic Doctor so I closed my private solo rural practice five days ago and will now just work 8 hours a week in small county jails. I am tired of spending my days clicking templates on an EMR so that if I get audited I don’t have to go bankrupt paying back Medicare or being accused of fraud when I just forgot to document that someone has a gun in their house or doesn’t wear their seatbelt. I did the EMR incentive program for a year, got my $14,000 and then realized it was a loser financially and time wise and added nothing to good patient care. Ditched the program the next year. Then it was time to cope with ICD 10, ACO’s, patient centered medical home, an electronic health record at the local hospital which is completely unusable and adds hours to hospital work.

I really loved my patients, my little office and wonderful staff but I am completely exhausted and done with the struggle of trying to be a good doctor when the forces out there seem to be determined to wear me down. So now about 1500 people have to find a new doctor and I will retire from active family practice at the age of 59. Pretty stupid waste of my training and compassion to be done so early. I am also tired of being perceived as the rich greedy doctor who only wants to make money and is the source of all the health care problems in this country. I am anything but that. Life is too short to work so hard, sacrifice being with family and friends and spend all my time servicing the insurance industry.

I’m not tired of being a physician, I’m just done with all the unnecessary garbage that comes along with it. I agree that doctors are wimps and in our defense, we are just too busy most of the time to get organized and do something about this mess. Most of us are just trying to do some good in a complicated world. Now I’m going to take care of myself, my family and have a real life. Yahoo!

Read the original in Authentic Medicine. . .

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

Voices Of Medicine

Past Issue

A Physician summarizes Obamacare in just one sentence

Dr. Barbara Bellar

http://www.youtube.com/watch?v=mZbFrAAV3-o&feature=youtu.be

We are gifted with a health care plan we are forced to purchase and fined if we don’t; which purportedly covers at least 10 million more people without adding a single new Doctor; but provides for 16,000 new IRS agents; written by a committee whose chairman says he doesn’t understand it; passed by a Congress that hasn’t read it and signed by a President who smokes; with funding administered by a treasury chief who didn’t pay his taxes; for which we will be taxed for 4 years before any benefits take effect; by a government that has already bankrupted social security and Medicare; all to be overseen by a surgeon general who’s obese; and financed by a country that’s broke.

What on earth could possibly go wrong?

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

Voices Of Medicine

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A Review of Local and Regional Medical Journals and Articles

Retaliation against a Physician Whistleblower

By Lawrence R. Huntoon, M.D., Ph.D. Editor, JAPS

Dr. Michael W. Fitzgibbons, an infectious diseases specialist and former chief of staff at Western Medical Center in Santa Ana, California, is not a man who simply walks away and gives up, even in the face of grave injustices inflicted upon him and his family. But more than demonstrating his integrity, his story shows how far some hospital administrators will take retaliation against a physician whistle blower. We all have a stake in the integrity of our judicial system. Many would choose another course, but though

paying a high professional and personal price, and uncertain of any level of victory, Dr. Fitzgibbons chose to stay on the battlefield.

The battle was which ended on Feb 8, 2013. The details of what was done to Dr. Fitzgibbons are frightening and shocking. His story was detailed in a series of articles published by the , weekly newspaper for Orange County, California, published in Costa Mesa, which covered the story intensely.

In 2004, the financially struggling Tenet Healthcare Corp sought to sell four hospitals in southern California—Western Medical Center of Anaheim, Chapman Hospital in Orange County, Coastal Community Hospital in Santa Ana, and Western Medical Center of Santa Ana, the hospital where Dr. Fitzgibbons practiced.

Some physicians expressed concerns about the proposed purchaser, Dr. Kali P. Chaudhuri and his company, Integrated Healthcare Holdings, Inc. (IHHI).

According to an article published in , “Four years ago, Chaudhuri’s KPC holding company closed 81 Southern California medical clinics it had purchased just a year before. The closures stranded 300,000 patients without care and, in many cases, without medical records. Insurers and doctors scrambled to pick up the pieces. Asked to account for the chain’s assets, a bankruptcy judge said the money trail was too complicated to follow. The resulting charges of mismanagement, fraud, and diversion of assets led to dozens of lawsuits and thousands of creditor claims against Chaudhuri and KPC, most of them unsatisfied to this day.”

According to another article, “So vehemently do they oppose Chaudhuri’s takeover of the four Tenet hospitals that in October Fitzgibbons and fellow physicians took to the streets with picket signs. More than 70 doctors from the targeted hospitals formed their own acquisition group and offered Tenet a competing bid.”

At the urging of Fitzgibbons and other physicians, state Senator Joe Dunn convened hearings in 2004 that resulted in an agreement to limit the involvement of Dr. Chaudhuri in the takeover of the four hospitals.

Michael W. Fitzgibbons, M.D., vs. Integrated Healthcare Holdings, Inc., et al., OCWeekly

Conclusion

While the last chapter in this saga has yet to be written, physicians can learn from it the tremendous power of hospital cartels, and the ruthlessness they may display in retaliating against a physician who opposes them or exposes their wrongdoing.

Lawrence R. Huntoon, M.D., Ph.D. is a practicing neurologist and editor-in-chief

of the Journal of American Physicians and Surgeons. Contact: editor@jpands.org.

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

Voices Of Medicine

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Whistleblowers attempt to change the culture of federal agencies

Advocates Applaud Senate Passage of S. 743

November 14, 2012 by
Filed under CampaignCongress & Courts

November 14, 2012

FOR IMMEDIATE RELEASE

Advocates Applaud Senate Passage of S. 743
After Decade Long Campaign, Federal Whistleblower Bill Sent to President’s Desk

After a decade long campaign by the Make It Safe Coalition to restore federal whistleblower protections, we applaud yesterday’s Senate passage of the Whistleblower Protection Enhancement Act, S. 743 (WPEA), by unanimous consent. The House of Representatives approved this measure in September, also by unanimous consent. Congress’ sweeping endorsement of S. 743 demonstrates the strong bipartisan support for this government accountability legislation to expand protections for federal employees who disclose wrongdoing and protect the public trust.  Longtime whistleblower champion and retiring Senator Daniel Akaka (D-HI) was joined by his cosponsors Susan Collins (R-Maine), Joe Lieberman (I-CT), Senators Charles Grassley (R-Iowa) and Claire McCaskill (D-MO) in advocating for passage of this crucially needed reform legislation. A full list of Senate cosponsors can be viewed here. We cannot thank these champions and their staff enough for their marathon commitment to the WPEA.

Whistleblower advocates from across the ideological spectrum celebrated this government accountability and taxpayer protection measure: 

AFGE is proud to join a bipartisan group of lawmakers and a coalition of worker, good government, and civic advocates in applauding passage of S. 743, the Whistleblower Protection Enhancement Act by the Senate. For far too long managers in the federal workplace have faced little or no accountability when they retaliate against federal workers who blow the whistle on fraud, waste and wrongdoing on the job,” said Beth Moten, Legislative Director for American Federation of Government Employees. “The Whistleblower Protection Enhancement Act marks the beginning of a new day of free speech and due process rights for federal workers such as Transportation Security Officers who protect our nation’s airports, food safety inspectors, government scientists, and others when they speak up on behalf of the public.”

“After a 13 year roller coaster campaign, Congress unanimously has given whistleblowers who defend the public a fighting chance to defend themselves. This is a major victory for taxpayers and public servants, but a major defeat for special interests and bureaucrats. Free speech rights for government employees never have been stronger,” said Tom Devine, Legal Director for the Government Accountability Project. “It would be dishonest to say our work is done, however, or to deny that government whistleblower rights are still second class compared to those in the private sector. House Republicans blocked two cornerstones of the legislation: jury trials to enforce newly-enacted protections, and extension of free speech rights to national security workers making disclosures within agency channels.” 

“A transpartisan impulse expressed through bi-partisan consensus. Good to see the U.S. House and Senate finally do something right for the American people,” said Michael Ostrolenk, National Director of the Liberty Coalition. ”The passage of the Whistleblower Protection Enhancement Act is an important first step in protecting citizens against Federal waste, fraud and abuse of power.”

Congress has just made a major bipartisan stride to stand behind conscientious federal employees who stand up for taxpayers,” said National Taxpayers Union Executive Vice President Pete Sepp.“Whistleblowers are true trailblazers on the path to fiscal responsibility in Washington, and passage of S. 743 is a hopeful sign that more progress and more protections lie straight ahead.”

National President Colleen M. Kelley of the National Treasury Employees Union commented: “This is a vital piece of legislation that expands protections for federal employees who disclose fraud, waste, abuse or illegal activity on behalf of taxpayers and in the best interests of our nation. Notably, it includes specific protection for the scientists who work for our nation, are committed to valid research and who should not be swayed or penalized for their work. NTEU is very pleased to see its passage before the end of this current session of Congress.”

“This opening salvo to the lame duck shows that Congress can put aside partisan posturing and deliver more government accountability to the American public. These hard-fought reforms will substantially improve the status quo for federal whistleblowers and taxpayers,” said Angela Canterbury, Director of Public Policy for Project On Government Oversight. “It has been a long time coming, but the federal workers now will have a better chance at real justice when they suffer from retaliation for exposing waste, corruption, and abuse. These courageous workers deserve no less for their service to us and our country.”

“Reforms such as these create a vehicle for workers to safely call out potential hazards in the workplace without retaliation from the employer,” said Keith Wrightson, worker safety and health advocate for Public Citizen’s Congress Watch division. “By giving federal workers more opportunity and resources to identify hazardous workplace situations, the government will become more efficient.”

“Whistleblowers are critical in making the government more efficient and accountable. This legislation finally gives Whistleblowers the respect and protection they deserve,” said David Williams, President of Taxpayers Protection Alliance. “Congress has shown the American people that they are willing to work together and put partisan differences aside to do the right thing by passing the Whistleblower Protection Enhancement Act.”

“We hope that this law will begin a process to change the culture of federal agencies when it comes to whistleblowers,” said Celia Wexler, Senior Washington Representative, Union of Concerned Scientists Center for Science and Democracy. “People who protect the public from unsafe drugs, tainted food, defective products, and environmental hazards should not fear for their jobs when they speak up for safety and scientific integrity.” 

The WPEA includes critically important upgrades to the broken system for federal whistleblowing to better serve taxpayers. Though it does not include every reform that we have sought and will continue to seek, the bill will restore and modernize government whistleblower rights by ensuring that legitimate disclosures of wrongdoing will be protected, increasing government accountability to taxpayers, and saving billions of taxpayer dollars by helping expose fraud, waste and abuse. Overall, the WPEA’s provisions will restore free speech rights closed through arbitrary loopholes and create new protections for federal scientists and Transportation Security Administration officers. The bill also will strengthen due process rights, such as a two-year experiment in normal access to appeals courts (effectively breaking the Federal Circuit’s monopoly on appellate review); provide compensatory damages; create whistleblower ombudsmen at Inspectors General offices; and strengthen authority by the U.S. Office of Special Counsel to help whistleblowers through disciplinary actions against those who retaliate, and to file briefs in court supportive of whistleblower rights.

The Senate cosponsors and their dedicated staff worked closely with their House colleagues, Oversight and Government Reform Chairman Darrell Issa (R-CA), Ranking Member Elijah Cummings (D-MD), retiring Representative Todd Platts (R-PA), Chris Van Hollen (D-MD),  Paul Gosar (R-AZ), Steve Pearce (R-NM), and their committed staff, to reach a bipartisan compromise that could pass this usually contentious Congress. After a hard-fought campaign, Congress has finally enacted this important reform.

A menu of key reforms can be viewed here: http://bit.ly/PwafFC

The bill can be viewed here: http://bit.ly/UDaepU

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

Voices Of Medicine

Past Issue

Authentic Medicine - Douglas Farrago MD, Editor, Creator & Founder

SPEAKING HONESTLY AND OPENLY ABOUT OUR BROKEN HEALTHCARE SYSTEM SINCE 2002

The mission of Authentic Medicine is to rediscover how much the art of medicine means and allow us to reconnect to our roots once again. It is about fighting back against those things that are taking us away from the direct care of patients while still pointing out the lunacy and hypocrisy of this job. Be part of the movement that will take back the healthcare system from the idiots who are ruining it.

Douglas Farrago MD is a full-time practicing family doc in Auburn, Maine.  He is board certified in the specialty of Family Practice.  He is also the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver, and its knock-offs, are worn by many major league baseball catchers.

From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years.  He was featured in the Washington Post, US News and World Report, the AP, and the NY Times.

Authentic Medicine was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. Only when physicians regain control and connect back to the roots of this profession will we ever have AUTHENTIC MEDICINE again. 

about this site

Authentic Medicine is about connecting us back to the roots of medicine.  This online “magazine” will constantly be updated with informative and challenging opinions and ideas.   The goal is to fight back against those things that are taking us away from the direct care of patients while still pointing out the lunacy and hypocrisy of this job.  It is the evolution of what I was really trying to accomplish by the end with the Placebo Journal.

Physicians and patients need to join together to form the “Authentic Medicine Movement”.  This is not about being Republican or Democrat. It is about opening up a dialogue and keeping that conversation going.  You may hate some of the things I say.  I may hate some of your comments.  It doesn’t matter.  

The wrong people (politicians, businessmen, and administrators) are running and ruining this healthcare system.   We need to speak up and be part of the NEVER ENDING DEBATE.

Issues that I am concerned about:

  • Why we are moving to an era of Industrialized Medicine
  • The Quality Movement and why it is a scam
  • The ever expanding Medical Axis of Evil
  • Medical Dogma and the Alphabet Soup (JC, HIPAA, etc.)
  • Bureaucratic Drag and the distractions from treating patients
  • Burnout and depression amongst healthcare professionals
  • Humor in caring for the patient and the caretaker

I would be honored if you can check out the site and tell me what you like or dislike so far.  Come back regularly as new items are added daily (at least).

Email Dr. Farrago – doug@authenticmedicine.com 

Subscribe at http://authenticmedicine.com/

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

Voices Of Medicine

Past Issue

Dr. Sam Vaknin, Israelis Psychiatrist, says Obama has a Mental Disorder

By Michael A. Haberman, MD, An Israeli M.D.

The Voice of a physician in another part of the world

A Reflection Of What Is Happening To The USA—In The Eyes Of Others!

Israeli doctor says Obama has a mental disorder—
Labels him a pathological narcissist.
No greater insanity than electing one says Dr. Sam Vaknin an Israeli psychologist.
Another view on our president.

Dr. Vaknin states "I must confess I was impressed by Obama from the first time I saw him. At first I was excited to see a black candidate. He looked youthful, spoke well, appeared to be confident, a wholesome presidential package. I was put off soon, not just because of his shallowness but also because there was an air of haughtiness in his demeanor that was unsettling. His posture and his body language were louder than his empty words. Obama's speeches are unlike any political speech we have heard in American history. Never a politician in this land had such quasi "religious" impact on so many people.

The fact that Obama is a total incognito with Zero accomplishment, makes this inexplicable infatuation alarming.  Obama is not an ordinary man. He is not a genius. In fact he is quite ignorant on most important subjects."

Dr. Sam Vaknin, the author of the Malignant Self Love believes "Barack Obama appears to be a narcissist." Vaknin is a world authority on narcissism. He understands narcissism and describes the inner mind of a narcissist like no other person. When he talks about narcissism everyone listens. Vaknin says that Obama's language, posture and demeanor, and the testimonies of his closest, dearest friends suggest that the man is either a narcissist or he may have narcissistic personality disorder (NPD).

Narcissists project a grandiose but false image of themselves. Jim Jones, the charismatic leader of People's  Temple, the man who led over 900 of his followers to cheerfully commit mass suicide and even murder their own children was also a narcissist. David Koresh, Charles Manson, Joseph Koni, Shoko Asahara, Stalin, Saddam, Mao, Kim Jong Ill and Adolph Hitler are a few examples of narcissists of our time. All these men had a tremendous influence over their fanciers. They created a personality cult around themselves and with their blazing speeches elevated their admirers, filled their hearts with enthusiasm and instilled in their minds a new zest for life.  They gave them hope! They promised them the moon, but alas, invariably they brought them to their doom.

When you are a victim of a cult of personality, you don't know it until it is too late. One determining factor in the development of NPD is childhood abuse "Obama's early life was decidedly chaotic and replete with traumatic and mentally bruising dislocations, "says Vaknin. "Mixed-race marriages were even less common then. His parents went through a divorce when he was an infant two years old. Obama saw his father only once again, before he died in a car accident. Then his mother re-married and Obama had to relocate to Indonesia , a foreign land with a radically foreign culture, to be raised by a step-father. At the age of ten, he was whisked off to live with his maternal (white) grandparents.  He saw his mother only intermittently in the following few years and then she vanished from his life in 1979. "She died of cancer in 1995."

One must never underestimate the manipulative genius of pathological narcissists. They project such an imposing personality that it overwhelms those around them.   Charmed by the charisma of the narcissist, people become like clay in his hands. They cheerfully do his bidding and delight to be at his service. 

The narcissist shapes the world around himself and reduces others in his own inverted image. He creates a cult of personality. His admirers become his co-dependents. Narcissists have no interest in things that do not help them to reach their personal objective. They are  focused on one thing alone and that is power. All other issues are meaningless to them and they do not want to waste their precious time on trivialities. Anything that does not help them is beneath them and does not deserve their attention.

If an issue raised in the Senate does not help Obama in one way or another, he has no interest in it. The "present" vote is a safe vote. No one can criticize him if things go wrong. Those issues are unworthy by their very nature because they are not about him.

Obama's election as the first black president of the Harvard Law Review led to a contract and advance to write a book about race relations. The University of Chicago Law School provided him a lot longer than expected and at the end it evolved into, guess what? His own autobiography! Instead of writing a scholarly paper focusing on race relations, for which he had been paid, Obama could not resist writing about his most sublime self. He entitled the book Dreams from My Father.

Not surprisingly, Adolph Hitler also wrote his own autobiography when he was still a nobody. So did Stalin. For a narcissist no subject is as important as his own self. Why would he waste his precious time and genius writing about insignificant things when he can write about such an august being as himself?

Narcissists are often callous and even ruthless. As the norm, they lack conscience. This is evident from Obama's lack of interest in his own brother who lives on only one dollar per month. A man who lives in luxury, who takes a private jet to vacation in Hawaii, and who raised nearly half a billion dollars for his campaign (something unprecedented in history) has no interest in the plight of his own brother. Why?  Because, his brother cannot be used for his ascent to power. A narcissist cares for no one but himself.

This election was like no other in the history of America. The issues were insignificant compared to what is at stake. What can be more dangerous than having a man bereft of conscience, a serial liar, and one who cannot distinguish his fantasies from reality as the leader of the free world?

I hate to sound alarmist, but one is a fool if one is not alarmed. Many politicians are narcissists. They pose no threat to others. They are simply self-serving and selfish. Obama evidences symptoms of pathological narcissism, which is different from the run-of-the-mill narcissism of a Richard Nixon or a Bill Clinton for example. To him reality and fantasy are intertwined.

This is a mental health issue, not just a character flaw.  Pathological narcissists are dangerous because they look normal and even intelligent. It is this disguise that makes them treacherous. Today the Democrats have placed all their hopes in Obama. But this man could put an end to their party. The great majority of blacks voted for Obama. Only a fool does not know that their support for him is racially driven. This is racism, pure and simple.

The downside of this is that if Obama turns out to be the disaster I predict, he will cause widespread resentment among the whites. The blacks are unlikely to give up their support of their man. Cultic mentality is pernicious and unrelenting. They will dig their heads deeper in the sand and blame Obama's detractors of racism. This will cause a backlash among the whites. The white supremacists will take advantage of the discontent and they will receive widespread support. I predict that in less than four years, racial tensions will increase to levels never seen since the turbulent 1960's.

Obama will set the clock back decades.  America is the bastion of freedom. The peace of the world depends on the strength of America, and its weakness translates into the triumph of terrorism and victory of rogue nations. It is no wonder that Ahmadinejad, Hugo Chavez, the Castroists, the Hezbollah, the Hamas, the lawyers of the Guantanamo terrorists, and virtually all sworn enemies of America are so thrilled by the prospect of their man in the White House.

America is on the verge of destruction. There is no insanity greater than electing a pathological narcissist as president.

Michael A. Haberman, MD, An Israeli M.D.

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

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