MEDICAL TUESDAY . NET                         NEWSLETTER


Community For Better Health Care          Vol IV, No 10, August 23, 2005

In This Issue:


1.      Featured Article: Natural Born Liars By David Livingstone Smith as reported in Scientific American MIND, Volume 16, Number 2, June 2005

[Albert Mehrabian, PhD, UCLA, in his research of the 1960s pioneered the understanding of communications. He established the classic statistic for the effectiveness of spoken communications:

7% of meaning is in the words that are spoken.

38% of meaning is paralinguistic (the way that the words are said).

55% of meaning is in facial expression.

This is why Physicians have to use clinical judgements to sift through the multiple means of communication patients use during the medical interview in making a clinical diagnostic impression for treating them. Agencies that cannot evaluate all types of nonverbal assessments of the patient will never replace the physician. HMOs, Medicare, Government, and other medical bureaucrats would like to reduce the entire practice of medicine into terms that they can understand and then control. Electronic Medical Records will never tell the whole clinical medical story that needs to be addressed in patient care. The patients will be the losers. Eventually they will rebel just as they did against HMOs. It is important that we do not waste another 50 years in trial and error before realizing what can’t be done. David Livingstone Smith in our featured article looks at communications from an entirely different perspective, one that may be very important in health care]

Deception runs like a red thread throughout all of human history. It sustains literature, from Homer's wily Odysseus to the biggest pop novels of today. Go to a movie, and odds are that the plot will revolve around deceit in some shape or form. Perhaps we find such stories so enthralling because lying pervades human life. Lying is a skill that wells up from deep within us, and we use it with abandon. As the great American observer Mark Twain wrote more than a century ago: "Everybody lies ... every day, every hour, awake, asleep, in his dreams, in his joy, in his mourning. If he keeps his tongue still his hands, his feet, his eyes, his attitude will convey deception." Deceit is fundamental to the human condition.

Research supports Twain's conviction. One good example was a study conducted in 2002 by psychologist Robert S. Feldman of the University of Massachusetts Amherst. Feldman secretly videotaped students who were asked to talk with a stranger. He later had the students analyze their tapes and tally the number of lies they had told. A whopping 60 percent admitted to lying at least once during 10 minutes of conversation, and the group averaged 2.9 untruths in that time period. The transgressions ranged from intentional exaggeration to flat-out fibs. Interestingly, men and women lied with equal frequency; however, Feldman found that women were more likely to lie to make the stranger feel good, whereas men lied most often to make themselves look better.

In another study a decade earlier by David Knox and Caroline Schacht, both now at East Carolina University, 92 percent of college students confessed that they had lied to a current or previous sexual partner, which left the husband-and-wife research team wondering whether the remaining 8 percent were lying. And whereas it has long been known that men are prone to lie about the number of their sexual conquests, recent research shows that women tend to underrepresent their degree of sexual experience. When asked to fill out questionnaires on personal sexual behavior and attitudes, women wired to a dummy polygraph machine reported having had twice as many lovers as those who were not, showing that the women who were not wired were less honest. It's all too ironic that the investigators had to deceive subjects to get them to tell the truth about their lies.

These references are just a few of the many examples of lying that pepper the scientific record. And yet research on deception is almost always focused on lying in the narrowest sense-literally saying things that aren't true. But our fetish extends far beyond verbal falsification. We lie by omission and through the subtleties of spin. We engage in myriad forms of nonverbal deception, too: we use makeup, hairpieces, cosmetic surgery, clothing and other forms of adornment to disguise our true appearance, and we apply artificial fragrances to misrepresent our body odors. We cry crocodile tears, fake orgasms and flash phony "have a nice day" smiles. Out-and-out verbal lies are just a small part of the vast tapestry of human deceit.

The obvious question raised by all of this accounting is: Why do we lie so readily? The answer: because it works. The Homo sapiens who are best able to lie have an edge over their counterparts in a relentless struggle for the reproductive success that drives the engine of evolution. As humans, we must fit into a close-knit social system to succeed, yet our primary aim is still to look out for ourselves above all others. Lying helps. And lying to ourselves--a talent built into our brains--helps us accept our fraudulent behavior.

Passport to Success

If this bald truth makes any one of us feel uncomfortable, we can take some solace in knowing we are not the only species to exploit the lie. Plants and animals communicate with one another by sounds, ritualistic displays, colors, airborne chemicals and other methods, and biologists once naively assumed that the sole function of these communication systems was to transmit accurate information. But the more we have learned, the more obvious it has become that nonhuman species put a lot of effort into sending inaccurate messages.

The mirror orchid, for example, displays beautiful blue blossoms that are dead ringers for female wasps. The flower also manufactures a chemical cocktail that simulates the pheromones released by females to attract mates. These visual and olfactory cues keep hapless male wasps on the flower long enough to ensure that a hefty load of pollen is clinging to their bodies by the time they fly off to try their luck with another orchid in disguise. Of course, the orchid does not "intend" to deceive the wasp. Its fakery is built into its physical design, because over the course of history plants that had this capability were more readily able to pass on their genes than those that did not. Other creatures deploy equally deceptive strategies. When approached by an erstwhile predator, the harmless hog-nosed snake flattens its head, spreads out a cobralike hood and, hissing menacingly, pretends to strike with maniacal aggression, all the while keeping its mouth discreetly closed.

These cases and others show that nature favors deception because it provides survival advantages. The tricks become increasingly sophisticated the closer we get to Homo sapiens on the evolutionary chain. Consider an incident between Mel and Paul:

Mel dug furiously with her bare hands to extract the large succulent corm from the rock-hard Ethiopian ground. It was the dry season and food was scarce. Corms are edible bulbs somewhat like onions and are a staple during these long, hard months. Little Paul sat nearby and surreptitiously observed Mel's labors. Paul's mother was out of sight; she had left him to play in the grass, but he knew she would remain within earshot in case he needed her. Just as Mel managed, with a final pull, to yank her prize out of the earth, Paul let out an ear-splitting cry that shattered the peace of the savannah. His mother rushed to him. Heart pounding and adrenaline pumping, she burst upon the scene and quickly sized up the situation: Mel had obviously harassed her darling child. Shrieking, she stormed after the bewildered Mel, who dropped the corm and fled. Paul's scheme was complete. After a furtive glance to make sure nobody was looking, he scurried over to the corm, picked up his prize and began to eat. The trick worked so well that he used it several more times before anyone wised up.

The actors in this real-life drama were not people. They were Chacma baboons, described in a 1987 article by primatologists Richard W. Byrne and Andrew Whiten of the University of St. Andrews in Scotland for i magazine and later recounted in Byrne's 1995 book The Thinking Ape (Oxford University Press). In 1983 Byrne and Whiten began noticing deceptive tactics among the mountain baboons in Drakensberg, South Africa. Catarrhine primates, the group that includes the Old World monkeys, apes and ourselves, are all able to tactically dupe members of their own species. The deceptiveness is not built into their appearance, as with the mirror orchid, nor is it encapsulated in rigid behavioral routines like those of the hog-nosed snake. The primates' repertoires are calculated, flexible and exquisitely sensitive to shifting social contexts. . . .

Fooling Ourselves
Ironically, the primary reasons we are so good at lying to others is that we are good at lying to ourselves. There is a strange asymmetry in how we apportion dishonesty. Although we are often ready to accuse others of deceiving us, we are astonishingly oblivious to our own duplicity. Experiences of being a victim of deception are burned indelibly into our memories, but our own prevarications slip off our tongues so easily that we often do not notice them for what they are.

The strange phenomenon of self-deception has perplexed philosophers and psychologists for more than 2,000 years. On the face of it, the idea that a person can con oneself seems as nonsensical as cheating at solitaire or embezzling money from one's own bank account. But the paradoxical character of self-deception flows from the idea, formalized by French polymath Renéé „escartes in the 17th century, that human minds are transparent to their owners and that introspection yields an accurate understanding of our own mental life. As natural as this perspective is to most of us, it turns out to be deeply misguided.

If we hope to understand self-deception, we need to draw on a more scientifically sound conception of how the mind works. The brain comprises a number of functional systems. The system responsible for cognition--the thinking part of the brain--is somewhat distinct from the system that produces conscious experiences. The relation between the two systems can be thought of as similar to the relation between the processor and monitor of a personal computer. The work takes place in the processor; the monitor does nothing but display information the processor transfers to it. By the same token, the brain's cognitive systems do the thinking, whereas consciousness displays the information that it has received. Consciousness plays a less important role in cognition than previously expected. . . .

Solving the Pinocchio Problem
But why would we filter information? Considered from a biological perspective, this notion presents a problem. The idea that we have an evolved tendency to deprive ourselves of information sounds wildly implausible, self-defeating and biologically disadvantageous. But once again we can find a clue from Mark Twain, who bequeathed to us an amazingly insightful explanation. "When a person cannot deceive himself," he wrote, "the chances are against his being able to deceive other people." Self-deception is advantageous because it helps us lie to others more convincingly. Concealing the truth from ourselves conceals it from others. . . .

This awareness created a brand-new problem. Uncomfortable, jittery liars are bad liars. Like Pinocchio, they give themselves away by involuntary, nonverbal behaviors. A good deal of experimental evidence indicates that humans are remarkably adept at making inferences about one another's mental states on the basis of even minimal exposure to nonverbal information. As Freud once commented, "No mortal can keep a secret. If his lips are silent, he chatters with his fingertips; betrayal oozes out of him at every pore." In an effort to quell our rising anxiety, we may automatically raise the pitch of our voice, blush, break out into the proverbial cold sweat, scratch our nose or make small movements with our feet as though barely squelching an impulse to flee. . . .

Natural selection appears to have cracked the Pinocchio problem by endowing us with the ability to lie to ourselves. Fooling ourselves allows us to selfishly manipulate others around us while remaining conveniently innocent of our own shady agendas.

If this is right, self-deception took root in the human mind as a tool for social manipulation. As Trivers noted, biologists propose that the overriding function of self-deception is the more fluid deception of others. Self-deception helps us ensnare other people more effectively. It enables us to lie sincerely, to lie without knowing that we are lying. There is no longer any need to put on an act, to pretend that we are telling the truth. Indeed, a self-deceived person is actually telling the truth to the best of his or her knowledge, and believing one's own story makes it all the more persuasive.

Although Trivers's thesis is difficult to test, it has gained wide currency as the only biologically realistic explanation of self-deception as an adaptive feature of the human mind. The view also fits very well with a good deal of work on the evolutionary roots of social behavior that has been supported empirically.

Of course, self-deception is not always so absolute. We are sometimes aware that we are willing dupes in our own con game, stubbornly refusing to explicitly articulate to ourselves just what we are up to. We know that the stories we tell ourselves do not jibe with our behavior, or they fail to mesh with physical signs such as a thumping heart or sweaty palms that betray our emotional states. For example, the students described earlier, who admitted their lies when watching themselves on videotape, knew they were lying at times, and most likely they did not stop themselves because they were not disturbed by this behavior.

At other times, however, we are happily unaware that we are pulling the wool over our own eyes. A biological perspective helps us understand why the cognitive gears of self-deception engage so smoothly and silently. They cleverly and imperceptibly embroil us in performances that are so skillfully crafted that the act gives every indication of complete sincerity, even to the actors themselves.

To read the entire report, go to

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2.      In the News: California's Insurance Commissioner Is Having a Problem with Facts

Grace-Marie Turner, President of The Galen Institute, reports that California's insurance commissioner is having a problem with facts:

"California grabbed the spotlight this week with a report by the state's insurance commissioner, John Garamendi, blasting Health Savings Accounts and consumer-directed care and stressing his demand for a universal, government-run health care system.

"But he has a small problem with actual facts:

    * Consumer directed plans "put the entire health system at risk" because they attract the young and healthy into leaner plans, leaving the older and sicker in traditional plans.

      In fact, Assurant Health found that 29% of its HSA policyholders had incomes of less than $50,000, 57% were over age 40, and 73% were families with children. Importantly, America's Health Insurance Plans found that 37% of those purchasing HSAs were previously uninsured.

      Further, eHealthInsurance found that most people with HSAs opt for more comprehensive plans that cover 100% of hospitalization, doctors' visits, lab tests, emergency room visits, and prescription drugs after the deductible. Not so "lean."

    * "[F]inancial disincentives are likely to cause many to forgo necessary treatment at early stages."

      In fact, McKinsey & Co. found that those in consumer-directed plans are more attentive to wellness and prevention and were 30% more likely to get an annual physical. Why? "If I catch an issue early, I will save money in the long run," was the reply. And BTW, HSAs have a built-in incentive to encourage preventive care by allowing it to be part of the insurance contract.

    * "Instead of bringing health care services to more people, we are pricing more people out."

      In fact, Garamendi should check out the latest eHealthInsurance data that shows that nearly two-thirds of HSA purchasers paid $100 a month or less for their plans. And seven of the least expensive cities for health insurance for 30-year-olds (who we want in the insurance pool) were in….California."

The Garamendi report is laden with other outrages, but we will leave it to our colleague Dr. Jim Knight, - TeamLeaders, a mover and shaker in California's consumer-directed health care marketplace, to explain Garamendi's outrage at CDHC: "Once a significant number of Americans with health savings accounts are not only saving money on their health insurance, but fully vested in and in control of their own health care future, it will be an almost impossible sell politically to push these voters into government run health care.

"So, Mr. Garamendi and others who share his vision, quite rightly see the fast approaching tipping point for HSAs as a near and present danger to their plans for the future of healthcare in California and the United States," Dr. Knight explains.

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3.      International News: Europe's Forgotten Youth: Each Will Support One Retiree

NCPA Daily Policy Digest: INTERNATIONAL ISSUES, Thursday, August 11, 2005.

Tomorrow, when the world celebrates International Youth Day, youngsters in Europe should receive special attention. Their continent will soon experience a demographic crisis not seen since the Black Death decimated a large chunk of the population in the Middle Ages, says Ann Mettler, executive director of the Lisbon Council, a Brussels-based think tank.

If current trends continue, a rapidly aging and rapidly declining population will put unprecedented stress on public finances and social security systems:

    * In less than 25 years, one Italian worker will have to carry the burden of supporting one retiree.

    * By 2050, Germany will have as many citizens over the age of 80 as youngsters under the age of 20.

    * Already today, public coffers are squeaking under the burden of rising health care and pension costs.

According to Standard and Poor's, the credit ratings agency:

    * Including the rising pension and health-care costs of aging populations, the ratio of debt to gross domestic product in France and Germany will soon exceed 200 percent and government bonds will be downgraded to junk status by 2030.

    * Already today, the state bestows upon every German inhabitant more than 17,000 euros of government debt -- a total of 1,430 billion euros nationwide.

    * Germany spends a fifth of tax revenues paying down that debt; it's only a matter of time until this fiscal burden will ignite a dangerous generational conflict.

With tax burdens already at astronomical levels, Europe's brain drain will accelerate as a highly mobile intellectual elite will simply escape the vicious cycle of sclerotic labor markets, low growth and an irreversible deficit trap, says Mettler.

Source: Ann Mettler, "Europe's Forgotten Youth," Wall Street Journal, August 11, 2005.

For text (subscription required):,,SB112370645163010090,00.html.

For more on International Welfare:

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4.      Medicare to End Contingency Program but Some Choose to Not Comply with HIPAA

Health Data Management reports that although the Medicare program will not accept non-HIPAA compliant fee-for-service claims beginning October 1, ending a contingency program that began more than two years ago, some choose not to comply with HIPAA

"Many provider and payer organizations still are not compliant with a variety of HIPAA requirements to use standard transactions and secure the privacy and confidentiality of protected health information, according to a new survey.

"Top roadblocks to compliance, survey respondents said, were the lack of public relations or marketing problems anticipated with noncompliance, and no anticipated legal consequences for not complying.

"The Healthcare Information and Management Systems Society and consulting firm Phoenix Health Systems conduct the periodic online survey. In June, 282 invited providers and 71 invited payers participated.

"For the first time in six years, results indicated that many organizations have simply chosen not to implement some, if not all, of HIPAA’s requirements."

"For instance, 18% of provider respondents and 6% of payers said they remain non-compliant with the HIPAA privacy rule more than two years after the deadline. 'Consistent with survey results both in June 2004 and January 2005, these numbers infer little or no progress with a core group of non-compliant covered entities,' according to survey authors.

"In June 2005, 78% of providers and 90% of payers reported compliance with the privacy rule. Fifty-nine percent of providers and 45% of payers reported one or more privacy breaches during the first six months of 2005.

"Only 43% of provider respondents comply with the security rule, which had an April 20 compliance deadline, up from an 18% compliance level in January 2005. Payer compliance rose to 74% from the January 2005 rate of 30%. Nearly 40% of providers and 32% of payers reported data security breaches at their organizations between January and June.

"Eighty percent of provider and payer participants in June reported compliance with HIPAA standards--up from 73% of providers and 70% of payers in January. However, more than half of providers and payers said trading partners still cannot accept or transmit certain HIPAA transactions.

"Responding providers and payers ranked pressure from peers or trading partners as a low driver for compliance. Payers, however, were far more likely than providers to be influenced by the prospect of adverse media coverage."

To read the original and related articles, go to

Government is not the solution to our problems, government is the problem.

Ronald Reagan

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5.      Medical Gluttony By Seniors; Subsidizing Sickness by Lew Rockwell, President of von Mises Institute

The most medically dependent group in the country are seniors, who also happen to be, at once, the most government-addicted and financially well-off members of society. Their medical care is largely paid through public dollars. And yet this group is nearly united in the claim that it is not enough. They demand that their drugs be free or at least as cheap as fruits and vegetables at the grocery store. And the candidates respond not by pointing out the unreality and illegitimacy of their demands, but by competing to see who can provide free drugs more quickly through one or another central plan.

Can anyone doubt that Mises was right, that socialized medicine has led to a sickly frame of mind that has swept and now dominates the culture? The habit of complaining is endemic to this sector of society. Never have so many rich people who have been given so much by government demanded so much more. And the politicians are not pilloried for pandering to them but rewarded to the degree that they can dream up central plans that accommodate the complaining class through ever more freebies.

Now, it is sometimes said that medical care is too important to be left to the market, and that it is immoral to profit from the illnesses of others. I say medical care is too important to be left to the failed central plans of the political class. And as for profiting from providing medical care, we can never be reminded enough that in a free society, a profit is a signal that valuable services are being rendered to people on a voluntary basis. Profits are merely a by-product of a system of private property and freedom of exchange, two conditions which are the foundation of an innovative and responsive medical sector.

In the recent century, however, these institutions have been attacked and subverted at every level. In the medical-care market, the process began in the late 19th century with the policies of Germany's Otto von Bismarck, who sought a third way between the old liberalism and communism. As the originator of national socialism designed to foil international socialism, he claimed credit for being the first to establish a national health care system – thus adopting the very socialism he claimed to be combating.

Politicians ever since have followed this lead, continuing with Emperor Francis Joseph of Austria-Hungary, William II of Germany, Nicholas II of Russia, Lenin, Stalin, Salazar of Portugal, Mussolini of Italy, Franco in Spain, Yoshihito and Hirohito of Japan, Joseph Vargas of Brazil, Juan Peron of Argentina, Hitler, and FDR. What a list! As individuals, most have been discredited and decried as dictators. But their medical care policies are still seen as the very soul of compassionate public policy, to be expanded and mandated, world without end.

In each case, the national leader advertised the importance of centralized medical welfare for the health of the nation. But what was always more important was the fact that such policies reward the politicians and parties in power with additional control over the people, while dragging the medical profession – an important and independent sector that is potentially a great bulwark against state power – into a government system of command and control.

Before coming to power, Hitler's party, for example, made statements condemning socialized medicine and compulsory social insurance as a conspiracy to soften German manhood. But once in power, they saw the advantages of the very programs they condemned. As Melchoir Palyi argued, Hitler saw that the system was actually a great means of political demagoguery, a bastion of bureaucratic power, an instrument of regimentation, and a reservoir from which to draw jobs for political favorites. By 1939, Hitler had extended the system of compulsory insurance to small business and tightened the system in Austria. One of his last acts in 1945 was to include workers from irregular types of employment in the system, socializing medical care even in his last days.

After the war, the Social Democratic Party charged with de-Nazification immediately expanded his system to further centralize the medical sector. On the medical care front, Hitler may yet achieve his 1,000-year Reich.

To read Lew Rockwell's entire column go to; to peruse his other columns, go to his archives at 

Real Needs Are Small - Wants Have No Bounds

Paul of Tarsus to Timothy

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6.      Medical Myths: HMO, Pharmacy, Medicare Overview of Practice Improves Patient Care

Every segment of health care wants to review medical records in order to influence the physician's need to prescribe medications and durable medical equipment and requisitions for laboratory and x -ray testing. When organizations complain about Americans receiving only about half the quantity of health care that the best practices recommend, that may not be an understatement as gleaned from all these requests. It seems that most prescriptions for pharmaceuticals generate a fax or email from Caremark or other pharmaceutical concerns that recommend drug monitoring be done, including levels, and liver or other organ function tests. Once, when I ordered an antibiotic that increases the level of another drug by 30 percent, I had already reduced the dose of that drug by 30 percent and measured the appropriate level two days later to see if the therapeutic levels were appropriate. This generated a lot of paper work from the pharmaceutical houses concerning both of the drugs, with cautions to check the appropriate indices. Once, I even got an urgent call from the chief of medicine indicating that my former associate was questioning my treatment plan. I pointed out to him the above data and assured him of my compliance with best practices. He stated, "So that's how it's done." Even the chief of medicine was not current on procedures and thought you had to check the levels daily. On a ten-day course of treatment, the cost of his misinformation would be a thousand percent increase in unnecessary health care costs.

This past week, an HMO for which I see a number of patients, wanted the records on a number of patients to see why a Pap smear was not done. My next reimbursement check would take a hit if I didn't respond promptly. After researching the charts, all the women had prior hysterectomies, one woman had declined, one 80 year old lady just flatly stated she would not submit to such an exam at her age, with which I couldn't disagree. One 47-year-old single female who had never had sexual intercourse stated that she had never had a Pap smear or a pelvic exam and saw no need for one. The incidence of cervical cancer in Nuns, considered the virginal profession, is essentially zero. The men in the requested group obviously did not have a cervix or uterus. One man was a repeat from a similar request the previous year at which time we also informed them that men did not have cervices or uteri.

When I called the nurse reviewer at this HMO, she mentioned that they had incomplete information since they did not have the entire medical record. It takes awhile, she informed me, for them to get a complete medical profile on each of their patients. I pointed out to her that the medical record and profile is for my treating the patient and their job was with the claims. Why were they interfering? She offered to take my name off of the list, but I informed her that would make me a noncompliant physician and would also reduce my income. She couldn't disagree with that either.

Caremark, the pharmacy chain that services many of my patients, also wanted the record on a number of our patients. Medicare previously came in and obtained a complete faxed copy of 29 records, as I recall. Home care wanted some medical records. Hospice wanted a medical record.

This is a huge drain on a medical practice. An office visit may be discounted 40 to 60 percent by the insurance carrier with a take-it-or-leave-it attitude. Each request to provide an abstract is essentially another office visit to review, forms to complete and copies made of portions of the record. Abstracting the requested information for up to four other organizations is essentially giving five office visits for one-half the fee of one. In this case, it more than quintupled the cost of medical care. None of these costs are reimbursed. None of these instances improved care. Where will it end? One practice now just gives patients a copy of their medical record, no longer responds to requests from insurance carriers, pharmacies, durable equipment companies, and leaves it to the patients to do all the spade work for these harassing organizations. Even with the medical record in front of them, my instincts tell me that these organizations will be no more successful in obtaining the desired information because they don't understand it. They need someone to explain it. Physicians should only have to explain it to their patients and not the other providers of services. They can then return to their rightful role of being the physician. That will happen only when patients deal directly with their physicians instead of all these intermediaries.

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7.      Overheard in the Medical Staff Lounge: The Intricacies of Medical Billing

In 1970, I subscribed to the journal Group Practice since I was going to start a group, and needed direction for my mission. Most groups at that time were multi-specialty groups. However, if all specialties were not within the group, problems occurred when one had to refer outside the group. Group practice reported that the newest type of practice was the single-specialty group, such as an Internal Medicine Group. However, if not all the subspecialties of Internal Medicine (allergy, cardiology, endocrinology, gastroenterology, nephrology, pulmonology, as well as dermatology and neurology which were not strict subspecialties) were represented, this created the same problem as out-of-group referral. We had a couple of such Internal Medicine Groups in Sacramento and most of them disintegrated. I decided to start a straight subspecialty group in Pulmonary Medicine that, after eight years, had eight pulmonologists, the largest in the country. Hence, we were all free to receive and obtain consultations from any specialty or subspecialty, without inappropriate referrals needing to be obtained. This started a trend towards subspecialty groups in each of the subspecialties mentioned above. It also brought a lot of phone consultations as well as physicians requesting to come to Sacramento for a half day to meet with me to discuss how it's done. One topic that always came up was employee salaries, and how to keep the skimming of funds to the minimum.

Many outside of our profession do not understand the intricacies of managing an office, where money comes in for fees, partial fees, copayment, partial payments, private billing, and insurance billing. I remember one colleague, whom I'll call Dr Ben, who noted that the practice income was slowing decreasing. He began wondering about his new billing clerk. One day, he found a few hundred insurance forms behind the office copier and upon confronting his biller, was told she just didn't understand all the intricacies of billing and payments -- billing of primary insurance, billing of secondary insurance, re-billing of insurance after denial of payment, and refiling of secondary insurance. Each step would take a month or two for turn-a-round time. So when a bill got to be six or nine months old, she just didn't know what else to do and so she let the insurance forms accumulate behind the copier next to her desk.

Another doctor in Sacramento, we shall call him Dr David, was embezzled for an amount that he never could determine. After dismissing the employee, we'll call her Sharon, on the advice of his attorney, being careful not to make any accusations for fear of a defamation suit, he found his income was diminishing for a similar reason as Dr Ben – a billing clerk with no major experience in a doctor's office. As he was looking over his decreasing income, he began to realize that when Sharon worked for him, he could always count on having a paycheck twice a month. So against the advice of his counsel, he rehired Sharon, the biller that had embezzled him. His cash flow immediately improved. And presumably, so did Sharon's.

Because of third-party payments, these doctors lost control of their practice and fiscal integrity. Only when patients deal directly with the physicians, hospitals and other providers without the lateral to a third party such as insurance or Medicare, can health care responsibility again prevail. Insurance should be a patient responsibility and not come between the patient and the doctor.

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8.      Voices of Medicine: A Review of Various Local and Regional Medical Journals:

Competition Fuels the Market by Charles B Clark, MD in HealthCareCommunication.Network

Perhaps we are all familiar with the quotation, “competition fuels the market.”  This is certainly true in terms of the business world as we know it.  If one outlet charges more than another, the consumers flock to the outlet where the prices are lower.  If the first outlet wishes to remain competitive, it lowers its prices as well.  Usually this reaches a balance and the prices level out.  

So how does this apply to the world of medicine?  This morning I was reading in the newspaper about a patient who spent two days and one night in the hospital in order to have an operation on his neck.  The bill for the hospital was $61,484.  “Under discounts negotiated with the hospital,” the patient’s insurance company paid $1,788.  The patient paid an additional 10% of that paid by the insurance company which was $178.  If all of this is really true, out of a bill for $61,484, the hospital received $1,966.  That amounts to 3% of the amount billed.

Apparently competition is not only fueling the market, but in this case it may be in the process of destroying the market.  But how does this impact the medical doctor?  If you are a self-employed physician, compare your present reimbursement on a fee-by-fee basis with what you received one year ago, five years ago and ten years ago.  If you can go back further than that, so much the better.  If you are a salaried physician, compare what you are receiving to what the fee schedule allows.  You may find that you are not being reimbursed according to the original intentions.

Look at what is happening in terms of the historical perspective.  We continually hear that the cost of medical care is increasing, but the physicians are receiving less and less.  Competition is certainly fueling the market but who are we competing against?  We are the ones providing medical care and we are competing against each other.  As we continue to accept less and less for our services, we are losing what is precious to us - the right to continue to provide our services effectively with reasonable compensation.  The sad thing about this is that we have so willingly accepted our fate.

These are the declining years of the practice of medicine as we used to know them.  Governmental control is just around the corner and with that comes fixed salaries for government employees.  If that doesn’t sound appealing to us, we should advise our children and anyone else who will listen not to pursue a career in medicine.  Three percent today ...two percent tomorrow...will it be one percent after that? To read Dr Clark's other articles, go to

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9.      Book Review: From the Physician Patient Bookshelf: DOWN FROM TROY: A Doctor Comes of Age by Richard Selzer, MD

DOWN FROM TROY: A Doctor Comes of Age by Richard Selzer, William Morrow and Company, Inc., 1992, $20.

Dr. Richard Selzer, a surgeon from Yale, recounts his childhood memories of Troy, NY, as the son of one of the town's doctors. His mother, an artist, wanted him become a writer. His father, however, continually reminded his mother of the boy's fine surgical hands. Every evening at bedtime, his mother, a self-taught soprano, sang an ecumenical litany to her sons, Dickie, as Richard was called, and his brother Billie. She would sing "Shema Yisroel" alternated with "Ave Maria" and "Keep Me, O Keep Me, King of Kings, Beneath Thine Own Almighty Wings," which was Dickie's favorite. His father accused his mother of religious inconsistency. She defended herself: "With prayers, there is no harm in being especially sure." Mother said she was glad she had an untrained voice and had never learned to read music. This way she wasn't a slave to the rules. It was all done by ear and by instinct. If she heard a song once, it belonged to her ever afterward. Dickie never missed her performances at the Troy Music Hall which had the most perfect acoustics in North America. It still does. No one knows how this accident happened.

Mother was also the "doctor's wife" a position of no small importance in those days. Not a day went by that she wasn't stopped on the street and asked for medical advice, which she ladled out as if it were bounty. She didn't always get it right and a portion of Father's time had to be spent countermanding her suggestions.

Dickie's father was a general practitioner, one of a dozen or so who presided over the physical breakdown of the Trojans. In addition to the usual degenerative diseases, there were rampant alcoholism, VD, malnutrition, and TB. The phlegm on the cobblestones was apt to be red. Father occasionally took the boys on house calls. After the conclusion of each school year, the house calls remained a favorite part of the summer vacation. The office was in their brownstone on Fifth Street. Father took care of the prostitutes on Brothel row, which was Sixth Street. These ladies enjoyed great notoriety due primarily to the reputations of their famous clients. He generally had one or more of the women in his waiting room on most days. Despite Father's repeated assurances that neither syphilis nor gonorrhea could be transmitted by sitting, Mother persisted in washing down the oak chairs with creosote every morning, all the while breathing deep sighs of damnation.

Once Father received two tickets to Havana, Cuba, from a Mame Faye. The prostitute was unable to take a vacation and so gave them to Father "for services rendered." Billie, being an infant at the time, was left behind with friends. On his twenty-first birthday, mother not only explained to Dickie that Havana was the site of his conception, but she took him there.

Father & Mother frequently argued. Mother did not share Father's love for Troy. Born and raised in Montreal, albeit in the ghetto of St. Urbain Street, she considered Troy a geographical come-down. Dickie learned from his parents' marriage that there is no need to clear up misunderstandings. It is mainly by them that one day advances into the next and that people continue to relate to one another. The "discussion" between Dickie's parents concerning his becoming a writer versus a surgeon continued.

"When I was 12, and it appeared to Father that he might be losing, he committed the supreme act of seduction," Dr. Selzer writes. "He died. . . Since I could not find him in the flesh, I would find him through the work he did." He became a surgeon. When he turned 40, however, his mother's wish was fulfilled. He also became a writer.

Dr. Selzer returns to his native Troy after 50 years in this is his seventh book. A town with an extraordinary assortment of hookers, (Dr. Selzer did not find out until he was 50, that many of the prostitutes his father treated in his surgery had had him as a client as well as a physician) merciful nuns, spinster schoolteachers, hard-drinking working men, retired professors, and voraciously hungry fat ladies. His insights, humor, humanity, all come to life in this narrative, an art he states he learned from the Bard of Troy, a one-eyed veteran of World War I, named Duffy.

The book was sent as a promotion to our society library. Its nostalgia is worth experiencing. To read the entire review, go to

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10.  Hippocrates & His Kin: From Our 1993 HHK Archives - as Relevant Today as Then

Peter Moore, sees four levels of bureaucracy between him and his doctors. After a consultation with his doctor came the seven most expensive words in medicine: "But we better run a few tests." When he met his deductible, he "hit pay dirt--100% payback. That's when the dollars ceased to be real. Somebody else was picking up the tab. When I pay for health care in fake dollars, I pay no attention to the charges." About the Canadian system, he says, "Canada, shmanada. The entire country –– 26 millions souls –– could fit on the pinkie toenail of the U.S. health giant. . . How ironic it would be if, at the very moment when individual freedom of choice is sweeping the world, the republic that started it all tried to solve its biggest problem by embracing what could become the world's biggest bureaucracy. . . It costs a lot to feed bureaucracies, which are to American society what ticks are to dogs."


Did you know Americans spend more on their hair than on medical research?


An ENT surgeon asked, as he was pulling out a wax plug, "Do you wash your ears out in the shower and then blow-dry the ear canals?" Well, it works. Dried wax falls out during the course of the day and no plugs recur. Can you believe the multiple uses of this appliance? The hair dresser says to blow-dry your hair. The ENT surgeon says to blow-dry your ears. The proctologist says to blow-dry your hemorrhoids. The urologist says to blow-dry the prepuce. The gynecologist says to blow-dry under the mammary glands. The dermatologist says blow-dry under all skin folds. The foot doctor says to blow-dry between your toes! How did we ever get dressed in the morning before the blow-dryer was invented?


Jerry Pogue, a Los Angeles managed care consultant quoted in the July issue of Northern California Medicine, may have the answer as to why physicians let themselves be completely deprofessionalized by accepting capitation. He calls capitation the "cocaine of managed care," noting three levels of capitation addiction: a capitation revenue of 10-15 percent gives physicians a "rush" twice each month when the capitation payment arrives; a capitation revenue of 20-30 percent is enough of a "hook" to put physicians into a dependency relationship with the payor; a capitation revenue of 45-55 percent is akin to "mainlining" by addicts. At this point, a physician changes his behavior to the required efficiency and control of excess utilization. . . In other words, we are then enslaved agents of the carrier and have minimal responsibility to our patients. They are only the commodity providing us our fix twice a month. . . Anybody out there for moving forward into our previous state as a cottage industry with patients making their decisions based on our explanation of the risk/benefit and cost/benefit analysis?


The former Sacramento Union reported that many Canadians travel to the US for their health care. The same can be said for almost every country in the world. . . Has anyone ever heard of an American journeying to a foreign country for anything other than alternative health care and arcane procedures that would never gain FDA approval?


The Harvard School of Public Health study reports that 84 percent of heart patients who sought a second opinion prior to a coronary artery bypass graft were told they didn't need the surgery. . . . Read about the future in the entire 1993 archive at

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11.  Restoring Accountability in Medical Practice, Health Care and Government


                     PATMOS EmergiClinic - where Robert Berry, MD, an emergency physician and internist states: "Our point-of-care payment clinic makes acute and chronic primary medical care affordable to the uninsured of our community by refusing to accept any insurance (along with the hassles and crushing overhead that inevitably come with it).  Read the rest of the story at To read Dr Berry's testimony in Congress, click on the sidebar. Read Dr Berry’s response to Physician’s Support of Single-Payer Health Care or Socialism at

                     Michael J. Harris, MD - - an active member in the American Urological Association, Association of American Physicians and Surgeons, Societe' Internationale D'Urologie, has an active cash'n carry practice in urology in Traverse City, Michigan. He has no contracts, no Medicare, Medicaid, no HIPAA, just patient care. Dr Harris is also nationally recognized for his medical care system reform initiatives. To understand that Medical Bureaucrats and Administrators are basically Medical Illiterates telling the experts how to practice medicine, be sure to savor his article on "Administrativectomy: The Cure For Toxic Bureaucratosis" at

                     Dr Vern Cherewatenko has success in restoring private-based medical practice, which has grown internationally through the SimpleCare model network. Dr Vern calls his practice PIFATOS – Pay In Full At Time Of Service, the “Cash-Based Revolution.” The patient pays in full before leaving. Because doctor charges are anywhere from 25 – 50 percent inflated due to administrative costs caused by the health insurance industry, you’ll be paying drastically reduced rates for your medical expenses. In conjunction with a regular catastrophic health insurance policy to cover extremely costly procedures, PIFATOS can save the average healthy adult and/or family up to $5000/year! To read the rest of the story, go to

                     Dr David MacDonald started Liberty Health Group. To compare the traditional health insurance model with the Liberty high-deductible model, go to There is extensive data available for your study. Dr Dave is available to speak to your group on a consultative basis.

                     John and Alieta Eck, MDs, for their first-century solution to twenty-first century needs. With 46 million people in this country uninsured, we need an innovative solution apart from the place of employment and apart from the government. To read the rest of the story, go to and check out their history, mission statement, newsletter, and a host of other information. For their article, “Are you really insured?,” go to

                     Madeleine Pelner Cosman, JD, PhD, Esq, has made important efforts in restoring accountability in health care. She has now published her important work, Who Owns Your Body. To read a review, go to Please go to to view some of her articles that highlight the government’s efforts in criminalizing medicine. For other OpEd articles that are important to the practice of medicine and health care in general, click on her name at

                     David J Gibson, MD, Consulting Partner of Illumination Medical, Inc. has made important contributions to the free Medical MarketPlace in speeches and writings. His series of articles in Sacramento Medicine can be found at To read his "Lessons from the Past," go to For additional articles, such as the cost of Single Payer, go to; for Health Care Inflation, go to

                     Dr Richard B Willner, President, Center Peer Review Justice Inc, states:  We are a group of healthcare doctors -- physicians, podiatrists, dentists, osteopaths -- who have experienced and/or witnessed the tragedy of the perversion of medical peer review by malice and bad faith. Congratulations are in order: The Georgians for Open Government gave the Center for Peer Review Justice and Richard Willner the "Golden Stethoscope" Award on March 15, 2005 on the steps of the Capital in Atlanta, Georgia. The event was timed for the Ides of March, the anniversary of the assassination of the Roman Emperor Caesar, to send a signal to powerful politicians that public outrage can have disastrous consequences if ignored. Read the rest of the story as well as a wealth of information at

                     Semmelweis Society International, Verner S. Waite MD, FACS, Founder; Henry Butler MD, FACS, President; Ralph Bard MD, JD, Vice President; W. Hinnant MD, JD, Secretary-Treasurer; is named after Ignaz Philipp Semmelweis, MD (1818-1865), an obstetrician who has been hailed as the savior of mothers. He noted maternal mortality of 25-30 percent in the obstetrical clinic in Vienna. He also noted that the first division of the clinic run by medical students had a death rate 2-3 times as high as the second division run by midwives. He also noticed that medical students came from the dissecting room to the maternity ward. He ordered the students to wash their hands in a solution of chlorinated lime before each examination. The maternal mortality dropped, and by 1848 no women died in childbirth in his division. He lost his appointment the following year and was unable to obtain a teaching appointment. Although ahead of his peers, he was not accepted by them. When Dr Verner Waite received similar treatment from a hospital, he organized the Semmelweis Society with his own funds using Dr Semmelweis as a model: To read the article he wrote at my request for Sacramento Medicine when I was editor in 1994, see Verner Waite and Robert Walker To see Attorney Sharon Kime’s response, as well as the California Medical Board response, see Scroll down to read some very interesting letters to the editor from the Medical Board of California, from a member of the MBC, and from Deane Hillsman, MD.

To view some horror stories of atrocities against physicians and how organized medicine still treats this problem, please go to

                     Dennis Gabos, MD, President of the Society for the Education of Physicians and Patients (SEPP), is making efforts in Protecting, Preserving, and Promoting the Rights, Freedoms and Responsibilities of Patients and Health Care Professionals. Be sure to consider attending their Health Care Summit: "American Medicine in Crisis- A Time for Action" in Pittsburgh on Saturday, October 22, 2005 with an impressive array of speakers. For more information, go to

                     Robert J Cihak, MD, former president of the AAPS, and Michael Arnold Glueck, M.D, write an informative Medicine Men column at NewsMax. Please log on to review the last five weeks’ topics or click on archives to see the last two years’ topics at This week read Dr Cihak's "Prohibition all over again" about how the Harrison Act created a new criminal class, this time about 250,000 patients and their doctors at 

                     The Association of American Physicians & Surgeons (, The Voice for Private Physicians Since 1943, representing physicians in their struggles against bureaucratic medicine, loss of medical privacy, and intrusion by the government into the personal and confidential relationship between patients and their physicians.  Be sure to scroll down on the left to departments and click on News of the Day. The “AAPS News,” written by Jane Orient, MD, and archived on this site, provides valuable information on a monthly basis. Scroll further to the official organ, the Journal of American Physicians and Surgeons, with Larry Huntoon, MD, PhD, a neurologist in New York, as the Editor-in-Chief. There are a number of important articles that can be accessed from the Table of Contents page of the current issue.

Join the AAPS for their 62nd Annual Meeting in Washington, DC. September 21-24, 2005 and receive 15.5 hrs of Category I CME credit. Make your reservations at, and plan to attend in historic Georgetown. Meet an outstanding panel of professors, congressmen, lawyers, and international faculty on how to protect American Medicine from the Government before it’s too late.


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Stay Tuned to the MedicalTuesday.Network and Have Your Friends Do the Same



Del Meyer                                                            


Del Meyer, MD, CEO & Founder

6620 Coyle Avenue, Ste 122, Carmichael, CA 95608

Words of Wisdom

Jacques Chaoulli, M.D.: My dream is to show the world how to get rid of a new and subtle form of tyranny hidden under the cover of a Welfare State's compulsory health care program.

Thomas Jefferson: I have sworn upon the Altar of God eternal hostility against every form of tyranny over the mind of man.

George Washington couldn't tell a lie because it would have had a harmful effect on American mythology.

Edward Langley, Artist 1928-1995: What this country needs are more unemployed politicians.

Aphorisms - Washington, D.C.

Washington, D.C. was named for the only President who didn't have to live there.

When you work in Washington a few years you are apt to stay.

Washington, where the buck starts.

Washington, where the lame ducks are on the pond.

On This Date in History - August 23

On this date in 1938, Mount Holyoke Female Seminary graduated its first students. For today’s women, men bend on their knees to women with degrees.

On this date in 1926, Rudolf Valentino, a great romantic film idol of his time, died at the age of 31 plunging countless females of all ages into an orgy of public grief.