Community For Better Health Care

Vol VIII, No 22, Feb 23, 2010


In This Issue:

1.                  Featured Article: The Art of Bacterial Warfare

2.                  In the News: Is Federal Pain Control around the corner?

3.                  International Medicine: Newfoundland's Premier to have his heart surgery in the U.S.

4.                  Medicare: Who Really Understands ObamaCare?

5.                  Medical Gluttony: Have X-rays, CTs and MRIs replaced the physician's hands-on exam?

6.                  Medical Myths: With government health care, people get immediate care in emergencies

7.                  Overheard in the Medical Staff Lounge: The "House of Medicine" is in turmoil these days.

8.                  Voices of Medicine: Controversies in Therapeutics

9.                  The Bookshelf: Every Patient Tells a Story

10.              Hippocrates & His Kin: Things to ponder

11.              Related Organizations: Restoring Accountability in Medical Practice and Society

Words of Wisdom, Recent Postings, In Memoriam . . .

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Always remember that Chancellor Otto von Bismarck, the father of socialized medicine in Germany, recognized in 1861 that a government gained loyalty by making its citizens dependent on the state by social insurance. Thus socialized medicine, or any single payer initiative, was born for the benefit of the state and of a contemptuous disregard for people's welfare.

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1.      Featured Article: Stopping Infections: The Art of Bacterial Warfare

New research reveals how bacteria hijack our bodies' cells and outwit our immune systems--and how we can use their own weapons against them

By B. Brett Finlay

Key Concepts

·                     Bacterial pathogens multiply and make toxins inside human hosts, but how the microbes elude our defenses and deliver their poisons have been poorly understood.

·                     Studying host-pathogen inter­actions reveals sophisticated bacterial strategies for co-opting and manipulating host cells to serve a bacterium's needs.

·                     A new understanding of bacterial tools and tactics is leading to novel approaches for battling the microbes


Most bacteria are well-behaved companions. Indeed, if you are ever feeling lonely, remember that the trillions of microbes living in and on the average human body outnumber the human cells by a ratio of 10 to one. Of all the tens of thousands of known bacterial species, only about 100 are renegades that break the rules of peaceful coexistence and make us sick.

Collectively, those pathogens can cause a lot of trouble. Infectious diseases are the second leading cause of death worldwide, and bacteria are well represented among the killers. Tuberculosis alone takes nearly two million lives every year, and Yersinia pestis, infamous for causing bubonic plague, killed approximately one third of Europe's population in the 14th century. Investigators have made considerable progress over the past 100 years in taming some species with antibiotics, but the harmful bacteria have also found ways to resist many of those drugs. It is an arms race that humans have been losing of late, in part because we have not understood our enemy very well. . .

To penetrate diverse organs and tissues and to survive and thrive in our bodies, bacteria become skilled subversives, hijacking cells and cellular communication systems, forcing them to behave in ways that serve the bugs' own purposes. Many microbes take control by wielding specialized tools to inject proteins that reprogram the cellu­lar machinery to do the bugs' bidding. A few are also known to employ tactics that rid the body of benign or beneficial bacteria, to better comman­deer the environment for themselves. As investi­gators have identified the aggressive strategies and ingenious weapons used by pathogenic bac­teria to invade and outwit their hosts, we have wasted no time in trying to devise therapies that turn the microbes' own weapons against them.

Breaking and Entering
The first step in any bacterial assault, for in­stance, is attachment to the host's cells. A dis­ease-causing strain of Escherichia coli, known as enterohemorrhagic E. coli O157, has perhaps what is called the innate arm of the immune sys­tem, such as neutrophils and dendritic cells, nor­mally ingest and destroy ("phagocytose") any invaders. These phagocytes engulf bacteria and sequester them in membrane-bound vacuoles where killing molecules destroy the captives. But Salmonella species penetrate the intestinal lin­ing by passing from epithelial cells to immune cells waiting on the other side. Once inside the phagocytic vacuole, the bacteria deploy a second T3SS, called SPI-2, which releases effector pro­teins that convert the vacuole into a safe haven where Salmonella can multiply. The proteins cause this switch from death chamber to sanctu­ary by altering the vacuole membrane so that the killing molecules cannot get in.

The SPI-2 system is critical to the success of Salmonella typhi, the strain that causes typhoid fever. By allowing the microbes to survive inside the phagocytic cells, which travel within the body via the bloodstream and lymphatic system, SPI-2 enables the organisms to reach and repli­cate in tissues far beyond the intestine, such as the liver and spleen.

An ability to live long term inside a host's cells is a trait common to many bacterial pathogens that cause serious disease, including those re­sponsible for tuberculosis and Legionnaires' dis­ease. Indeed, Legionella pneumophila is partic­ularly intriguing in that it injects at least 80 dif­ferent effectors into phagocytic cells through its T4SS. Although the function of only a handful of these proteins is known, at least some of them serve to convert the phagocytic vacuole into a safe haven.

Dodging the Sentries

The ability of bacteria to set up housekeeping inside immune cellsthe very cells meant to kill themattests to the versatility of the microbes' tool kit for co-opting cellular machinery. The similarity between human immune cells and bac­terial predators outside human hosts may explain the origin of other bacterial survival tactics as well. Some of the most sophisticated mecha­nisms that bacteria are known to deploy are devoted to evading host defenses and even enlist­ing immune cells to help the microbes thrive. . .

It is not only the innate immune system that bacteria dupe. Some have learned to avoid the "acquired" immune response, which consists of T cells and antibody-producing B cells that are trained by innate immune cells to recognize a specific pathogen by its surface features (anti­gens). Microbes may dodge these defenses, either by constantly changing surface proteins to evade antibodies or by secreting enzymes that degrade antibodies. . .

A Competitive Community

To thrive in a body, pathogens need to do more than manipulate cell signaling and outwit immune defenses. They also have to outcompete the body's hordes of normal, friendly bacteriaplayers that were virtually ignored by most microbiologists and immunologists until recent­ly. All the surfaces of the body exposed to the environment, including the lining of the gastro­intestinal tract, contain an enormous population of these "commensal" microbes. Each gram of the large intestine's contents, for example, con­tains approximately 60 billion bacteria10 times the number of people on the planet.

One of the most obvious ways to eliminate competition is to cause diarrhea and thereby flush one's opponents out of the body, at least temporarily. . .

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2.      In the News: Is Federal Pain Control around the corner?

Will The Feds Ban Your Pain Meds? February 16, 2010

What if you were injured and developed severe pain that wouldn't go away? Would your government let you take the kind of pain medication you need? If federal officials follow the recommendation of a Food and Drug Administration panel, many of the most effective prescription painkillers—including Vicodin, Percocet, and countless generics—would be banned.

Scott Gardner says that kind of a move would be "intensely cruel."

"I took Vicodin for three years," says Gardner. "I needed it. It got me through a very tough period of my life." The tough period began after a cycling accident shattered the left side of his body. After eight surgeries and countless hours of physical therapy, Gardner's once active life is now filled with limitations. He suffers from chronic pain that prevents him from sleeping more than a few hours at a time, and yet his pain today is nothing compared to the agonizing days and months following his accident.

"When there's nothing but pain, there's no reason to live," says Gardner. "There were times where the only way I could stay sane and civil was because I could take painkillers."

The fear of addiction and abuse already makes many suspicious of pain medication. Media reports about celebrities like Rush Limbaugh or Matthew Perry suggest that it's common for people to become addicted to medications they once took for legitimate medical conditions. And countless public service announcements remind us of the dangers of prescription drug abuse.

Now the old fear of prescription drug abuse takes a new twist. The FDA panel is targeting drugs like Vicodin and Percocet because they contain acetaminophen, a popular painkiller also found in many over-the-counter drugs. Panel members warn that some Americans ingest too much acetaminophen, and overdoses can lead to liver damage, even death.

But maybe the FDA panel isn't putting this threat into context. After all, mundane threats like falling down stairs claim more lives than acetaminophen overdoses. And it turns out the more common fear—that patients will become addicted to prescription drugs—is also overblown. In fact, the barrage of warnings we hear about prescription drugs obscures an important point—people saddled with severe chronic pain need these painkillers.

Says Gardner, "I think people who haven't dealt with pain don't really know what it's like."

"Don't Get Hurt" is written and produced by Ted Balaker, who also hosts. The director of photography is Alex Manning, the field producer is Paul Detrick and the animation in the piece is from Hawk Jensen.

Approximately five minutes.

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Related video: When Cops Play Doctor: How the Drug War Punishes Pain Patients.

For's coverage of "opiophobia," or overblown fears by the government about prescription painkillers, go here.

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3.      International Medicine: Newfoundland's Premier chooses to have his heart surgery in the U.S.

Why Danny Williams' decision to seek private health care matters by Brett J. Skinner 

Canada is virtually alone in prohibiting people from spending their own money to get quicker or better health care.

Appeared in Amherst Daily News, Truro Daily News, and New Glasgow Daily News - February 10, 2010 

What does it say about the state of Canadian health insurance when Newfoundland Premier Danny Williams chooses to have his heart surgery in the U.S.? Some pundits say it means nothing while others have insisted the premier could have obtained his medical care somewhere in Canada.

But the details of Premier Williams' case are irrelevant to the main question, which is, if it is okay for a Canadian politician to get private medical treatment in America, why is it illegal for regular Canadians to get private medical treatment in Canada? In other words, why do provincial governments make it illegal for Canadians to spend their own money to preserve and improve their own health? Why are ordinary Canadians forced to wait in a government-imposed queue for access to necessary medical care?

Danny Williams' decision is not unique. According to the most recent Fraser Institute estimate in 2009, Williams would be only one of approximately 41,000 Canadians who annually seek non-emergency medical care outside of Canada. Consider how absurd it is that the only way for Canadians to pay privately for better or quicker medical care is to leave their own country.

Our annual international report comparing Canada to other countries with universal health insurance systems shows that Canada is virtually alone in prohibiting people from spending their own money to get quicker or better health care.

Who is to blame for this? Despite commonly held beliefs, the federal Canada Health Act does not prohibit private insurance for medical services—the act only prohibits user charges under public insurance. It is actually the provinces that prevent ordinary Canadians from doing at home what Premier Williams chose to do in the United States. In fact, six provinces (accounting for about 84 per cent of the national population) legally ban direct private payment for necessary medical services, and six provinces (accounting for 90 per cent of the national population) legally ban the purchase of private health insurance for necessary medical services.

Most provinces also prohibit parallel billing by health care providers. In these provinces, hospitals and physicians are not allowed to accept private payment or private insurance reimbursement while accepting public payment from the provincial health insurance system. Health care providers must choose to work either for private payment or public payment, but cannot elect both. Most doctors are not willing to surrender their billing rights in the public system, and therefore do not even make their services available for private payment.

This is how governments effectively ban private health insurance and medical care in Canada. . .

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Canadian Medicare does not give timely access to healthcare, it only gives access to a waiting list.

--Canadian Supreme Court Decision 2005 SCC 35, [2005] 1 S.C.R. 791

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4.      Medicare: Who Really Understands ObamaCare? - Kaiser Health News

Source: John Goodman in Kaiser Health News

From the very moment public opinion started going south on the president's health plan, the White House and Democrat leaders in Congress began sounding a familiar refrain: The public does not understand the bill; they've been lied to, deceived and misled by the opponents; and once they learn how it really works, familiarity will breed...well, something other than contempt.

I have four problems with this point of view:

1. If it is sincere, you would think the Obama Administration would have made a major effort to educate the public about how the bill really works; in fact, they have made no effort whatsoever.

2. Since ObamaCare is modeled after the Massachusetts health plan, voters in that state should be better informed than even Obama himself about how it "really works"; yet Massachusetts voters resoundingly rejected the president's plan in Tuesday's U.S. Senate election.

3. There was a lot of misleading information flying in all directions at last summer's town hall meetings; but on balance, the average protestor appeared to be better informed than the average member of Congress.

4. Among the chattering class - who are paid to express informed opinion - the proponents of ObamaCare are far less knowledgeable than the opponents.

Cognoscenti are in the Dark. Let's take the last point first. How many editorials have you seen where the writer rattles off a laundry list of health care problems and then concludes with "that's why we need health reform"? Each of these editorials makes the same two mistakes: (1) They assume that ObamaCare will solve the problems they are writing about and (2) they assume it's either ObamaCare or nothing. This second mistake is called the fallacy of the excluded middle.

As we have pointed out many times, ObamaCare is not going to solve our most serious problems. It will make costs higher, not lower. It will lower, rather than raise, the quality of care. It will "solve" the problems of pre-existing conditions by substituting problems that are even worse. And it may not even increase access to care.

Then there are the writers who bypass the details altogether and jump straight to wild claims. Here are two:

["ObamaCare] will give Americans what citizens in every other advanced nation already have - guaranteed access to essential care. " (Paul Krugman in The New York Times)

For the first time, we will enshrine the principle that all Americans deserve access to medical care, regardless of their ability to pay." (Eugene Robinson in The Washington Post)

Now you would think that anyone who hasn't been living in a cave in some remote spot would know that access to the care they need is exactly what many Canadians and Britains do not have. And if they do not have the money to buy that care in the private sector or in another country, they are forced to go without because of lack of "ability to pay."

Bay State Folks Know What's Happening in Their State. We don't have to go all the way to Britain or Canada to see where Krugman, Robinson and others have missed the boat, however. Massachusetts will do just fine. Bay Staters are not clamoring to repeal what they have. But they are acutely aware of the problems that haven't been solved. And one of them is lack of access to care for people who lack the ability to pay market prices. As previously noted, the wait to see a new doctor in Boston is more than twice as long as in any other U.S. city. Further, the number of people going to emergency rooms for nonemergency care in Massachusetts is as great today as it was before health reform was enacted.

The White House is Doing Nothing to Educate the Public. It's not just the general public that is being kept in the dark. Obama is the same way with his base. Since June, the president has been sending a weekly e-mail to an estimated 19 million faithful about health care. Strangely, these letters are never truly educational. Instead they are cheerleading messages - the sort of thing you would expect at a pep rally. (By contrast, the NCPA's weekly messages to 1.3 million petition signers tend to be very informative.)

Voters on the Whole are Very Informed. There has probably never been a major piece of legislation before Congress about which voters were better informed. I continue to believe that the average "activist" who opposes the bill knows more about it than his/her congressional representative. Rasmussen found that after an initial poll question, people were just as negative - if not more so - when pollsters described ObamaCare in some detail.

As Lanny Davis said the other day, "It's the substance, stupid."

John Goodman is the President and CEO of the National Center for Policy Analysis

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

- Ronald Reagan

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5.      Medical Gluttony: Example from New York Times Diagnosis Columnist Lisa Sanders

This week we excerpt an example from Lisa Sanders book: Every Patient Tells a Story: Medical Mysteries and the Art of Diagnosis, See Section Nine: Book Review below.

Sanders raises questions about our art and science, and challenges many of the practices we accept routinely. Has technology replaced the physical exam? 

Daily I see evaluation of abdominal pain start with contrast CT of the abdomen. I wrote recently in this magazine about a 14-year-old gymnast with a painful knee who had X-rays, CT and MRI of his joint before actually being examined. During that exam, he was found to have Osgood-Schlatter's disease, a diagnosis that could have been made at the outset with the clinician's thumb on the tibial tuberosity. 

Taking a medical history to define the problem before the shotgun approach to expensive technology would save major medical costs. Or is that too simple?

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Medical Gluttony thrives in Government and Health Insurance Programs.

Gluttony Disappears with Appropriate Deductibles and Co-payments on Every Service.

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6.      Medical Myths: With government health care, people get immediate care in emergencies.

Myth 16. In countries with government-funded health care, people get immediate care in emergencies, though they may have to wait for elective procedures.

The usual response to concerns about the months-long waiting lists for surgery in Canada and Britain is that this is a mere inconvenience, a small price to pay for universal "free" care. If you have a really serious need, you'll get immediate attention—or so Michael Moore and others tell us.

Although one can surely come up with anecdotes about someone who got good emergency care in a Canadian or British hospital—especially if the person is a prominent journalist—this is not the norm.

The average wait in Canadian emergency rooms is 23 hours, stated John Stossel on ABC's 20/20.

Once admitted, a Canadian patient may wait three days in the emergency department for a bed (Michael A. Platokov, "A Temple for Human Sacrifice," Western Standard 12/4/06).

Actress Natasha Richardson suffered an epidural hematoma from head trauma while skiing Mont Tremblant in Quebec. Prompt neurosurgical treatment probably would have saved her—but it took 4 hours to get her to a properly equipped hospital after she started to deteriorate and called 911 from her hotel room. Quebec—unlike the U.S.—has no medical helicopters ( 3/21/09).

But the flip side, advocates for the Canadian system say, is that U.S. helicopters are "way overused." A person with a non-life-threatening injury might get killed in a helicopter crash, as has happened ( 3/27/09).

Because of lack of a single bed in any neonatal intensive care unit in southern Ontario, 10 to 15 babies per year have to be transferred to Buffalo, N.Y. Parents of Ava Isabella Stinson were amazed at the way their daughter was treated—and ended up with a different view of Americans.

"Even the security guards care about how you feel." And the Ronald McDonald House was "like living in a mansion, said Stinson" (Buffalo News 7/2/09).

Cancer might be considered an emergency by the patient—but not by the Canadian or British health bureaucracy. Those who want prompt surgery generally have to come to the U.S., as Stuart Browning shows in the video A Short Course in Brain Surgery, which has been seen by more than 3 million viewers.

In Britain, the National Health Service is supposed to cover necessary treatment, but people are selling their homes to get cancer care (Daily Express 12/22/2008). One British cancer patient waited for an appointment with a specialist, only to have it cancelled—48 times (David Gratzer, "The Ugly Truth about Canadian Health Care," City Journal, summer 2007).

Kidney failure is fatal, if you can't get dialysis. In Britain, you are ineligible for this life-saving treatment once you reach the age of 55. The mother of Beth Ashmore, a past president of the National Association of Health Underwriters, developed kidney failure while visiting England. Treatment was denied because of her mother's age, so Ashmore arranged for a specially equipped jet to bring her home. The hospital, however, had placed her in a back room to die, alone—and could not locate her! Thus, she died while an aircraft that could have saved her waited on a runway in Atlanta to find out its destination.

Mere pain, no matter how severe or disabling, is not considered life-threatening, so orthopedic surgery that could relieve it is usually long delayed. Dr. Brian Day, former president of the Canadian Medical Association, saw his operating room time reduced from 22 hours to only 5 hours per week, 10 hours less than recommended for minimal competence by the Canadian Orthopaedic Association. He had 450 patients waiting for care (National Post 10/23/07).

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Medical Myths Originate When Someone Else Pays The Medical Bills.

Myths Disappear When Patients Pay Appropriate Deductibles and Co-Payments on Every Service.

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7.      Overheard in the Medical Staff Lounge: The "House of Medicine" is also in turmoil these days.

A list around Washington of the medical groups that opposed the Senate bill included 42 organizations representing nearly a half million physicians. Some of these groups are now forming a coalition to stand as an alternative to the AMA. They are supporting the right of physicians to privately contract with their patients, to determine quality in medical care, and to advocate for liability reform.

Dr. Rosen: I received an email to join the coalition and pay $1000 in dues. Did anyone else receive such an email?

Dr. Yancy: No I haven't and I haven't been a member of the AMA or the CMA or the local society ever. I feel they have been a very ineffective voice for physicians.

Dr. Dave: I wish we had Dr. Edward R. Annis running the AMA again. He was truly a voice for private practice during the time the public was being sold the Medicare Bill of Goods.

Dr. Rosen: Annis was quite the character. He never ran for office before and I don't think he has since. He was just the right guy in history. Too bad we didn't have another cheerleader to carry on. Things went down hill again after he left.

Dr. Sam: I quit the AMA a decade ago and I'm about to quit the local society also. It seems that most of the administrators of the local and state societies are socialists. We were able to get rid of the one at the state. But it's rather like changing parties in Washington. The staffers live there and are hired by the newly elected who ruin them also.

Dr. Paul: I'm not a member of the AMA for quite the opposite reason. They are not pro government enough.

Dr. Rosen: I guess you can't please all the people all the time and pleasing some of the people all the time doesn't get anything accomplished. I mentioned the coalition earlier. Is that viable?

Dr. Yancy: If this coalition actually supported the right of contract, I might join them. I've been beat terribly by managed care. Procedures I use to get paid $1500 for, I scarcely get $600 for them now.

Dr. Milton: I'm still a member of Organized Medicine but sometimes I wonder why. I wouldn't be too optimistic about this coalition. I would prefer that we support an organization like the American Association of Physician and Surgeons that already is out there and are committed to free enterprise, private practice of medicine, and a total revision of the insurance game.

Dr. Edwards: Now a revision of the insurance program is a game I could get behind. In fact there is very little health insurance that is really insurance. It's a prepayment scheme and that's why it evolved into HMOs where all payments are screened.

Dr. Rosen: Insurance for outpatient medicine is very costly. We need insurance primarily for the expensive things like surgery, heart attacks, strokes, etc. It should never cover office calls and routine lab. CalPERS tried to implement a high deductible that was suppose to equal the average cost of outpatient care including a yearly exam, but I didn't see it implemented anywhere.

Dr. Yancy: Now that's one thing I could support - insurance for surgery and hospitalizations. That would help all of us surgeons, as well as trim health care costs.

Dr. Edwards: I understand that a policy for hospitalization and surgery would be on the order of $300 a month, instead of the $800 to $1200 a full policy costs.

Dr. Rosen: The $500-a-month savings in premiums would pay for a lot of office calls and prescriptions.

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The Staff Lounge Is Where Unfiltered Medical Opinions Are Heard.

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

Controversies in Therapeutics by Kirk Pappas, MD

In this issue of Sonoma Medicine, we explore—through the eyes and words of practicing clinicians—the therapeutic challenges we face in caring for our patients.

Congress, the public and President Obama seem to believe that only if we physicians adhered to practice guidelines, all would be well in the world. A more standardized approach to care does seem to be in order, and the president has made Dr. Atul Gawande's recent New Yorker article, "The Cost Conundrum," required reading for all in Washington, DC. In the article, Gawande discusses the startlingly different levels of utilization in two Texas towns: El Paso and McAllen. 

Can we all learn from a more "predictable" practice? Can we choose to be El Paso instead of McAllen?

What would Osler say? Does the future hold the promise of quality or the clarity of an algorithm that Bones from Star Trek would be proud of? Or are we products of our training and detailing by Big Pharma and the vast medical-industrial complex?  . . .

Recently, a colleague consulted me to review a case, including an MRI, and ask my opinion regarding conservative care vs. a spine injection. This physician had already reviewed the literature and examined the patient and now asked my thoughts on next steps. We consulted over the phone. . .

We reviewed both sides of the literature together and discussed options. The choice was clear, and the patient agreed. At the end of the day, our experience, our opinions and our review of the clinically relevant literature persuaded us we were doing "the right thing" in the warm comfort of our choice. 

I wonder what our local Congressional representatives, Lynn Woolsey and Mike Thompson, would think about the time spent as we came to our conclusions. Would they want me to spend the time to collaborate on choices, or should I follow a protocol? Will the new and improved system of health care allow (and perhaps even compensate us) for this type of cognitive evaluation? Or will a computer program make the decision?  . . .

Where are our voices—not just with each other, but with our patients—regarding the choices that we make for patient care? How can we collaborate in a better dialogue about the cost of our choices? Who is suffering from the lack of dialogue about controversies in therapeutics?  . . .

As you read this issue, perhaps you can use it as part of a discussion in your exam rooms . . . I will keep in mind the words of F. Scott Fitzgerald: "The test of first-rate intelligence is the ability to hold two opposing ideas in mind at the same time yet still retain the ability to function. One should, for example, be able to see that things are hopeless and yet be determined to make them otherwise."

Read the entire article with references as well as the journal issue . . .

Dr. Pappas, a physiatrist at Kaiser Santa Rosa, is the immediate past president of SCMA.

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

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9.      Book Review: Every Patient Tells a Story: Medical Mysteries and the Art of Diagnosis 
by Lisa Sanders, MD, Broadway Books, 2009, ISBN 978-0767922463

Diagnosis Inside Out By Rick Flinders, MD

Every patient has a story. Physicians already know that. The longer we practice, the more it is true. So why do we need to read this book? Because we forget. Because our brains are frail. Because we're in a hurry. Because we often fail to take the time to listen. There are many more reasons, as many reasons as we have patients. 

Lisa Sanders, MD, is a particularly fine story teller who is willing to take the time to tell us a few stories about her patients. An internist on the faculty of the Yale University School of Medicine, she is also an astute clinician who shares a few of the lessons from the practice of medicine she has learned along the way. Her column "Diagnosis" appears monthly in the New York Times Magazine, and she is the inspiration and medical advisor for the runaway television series "House." Are you listening yet?

Sanders begins with the story of a young woman lying in the ICU for a week while dying of progressive, inscrutable liver failure. She is in a large university hospital at an academic center, where her diagnosis has eluded multiple specialists, until an aging internist called in on the case notices, buried in her chart, overlooked results that suggest mild hemolysis. This combination—liver failure and isolated red blood cell destruction—is an unusual manifestation of an unusual inherited illness that the internist recognizes. He goes to the bedside with his ophthalmoscope and confirms his diagnosis of Wilson's disease. The patient receives an organ transplant the following week and survives.

How was the internist able to make a diagnosis after so many had failed? "I was lucky," he explains. "No one can know everything in medicine. I happened to know this. A bell went off and a connection was made." 

"This book," writes Sanders, "is about that bell. How doctors know what they know is a messy process, filled with red herrings, false leads and dead ends. An important clue can be overlooked in the patient's history or physical exam. An unfamiliar lab finding may obscure rather than reveal." Or the doctor may be too busy or too tired to think through the case. "Even the great William Osler," writes Sanders, "must have had his bad days."

Sanders weaves a handful of medical mysteries throughout her book, dividing it into four parts. Part One is the title track: "Every Patient Tells a Story." Part Two, "High Touch," chronicles the "vanishing art of history-taking and physical diagnosis." In Part Three, "High Tech," Sanders details the enormous power and limitations of our rapidly advancing diagnostic technology. She concludes in Part Four with "The Limits of the Medical Mind."

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10.  Hippocrates & His Kin: Things to ponder


Is it just me, or does anyone else find it amazing that during the mad cow epidemic our government could track a single cow, born in Canada almost three years ago, right to the stall where she slept in the state of Washington?

And, they tracked her calves to their stalls.

But they are unable to locate 11 million illegal aliens wandering around our country.

Maybe we should give each of them a cow.


They keep talking about drafting a Constitution for Iraq. Why don't we just give them ours? It was written by a lot of really smart guys, it has worked for over 150 years, and we haven't used it much for the past 75 years.

Why let a good document we don't use anymore gather dust?


The real reason that we can't have the Ten Commandments posted in a Courthouse or Congress is that you cannot post 'Thou Shall Not Steal,' Thou Shall Not Commit Adultery' and Thou Shall Not Lie' in a building full of Lawyers, Judges and Politicians.

It creates a hostile work environment.


Socialist: Why do you think Socialists can't get into heaven?
Believer: Because they don't believe in God.
Socialist: What makes you think that?
Believer: They believe in government as their God and the source of all good things including their salvation and all things needful. Who needs God, they think?
Socialist: Only conservatives need a God. They aren't charitable. They have to be taxed to be charitable. So we're doing them a favor.
Believer: Taxed charity does not benefit the forced giver or the ungrateful receiver. It only makes Socialists feel good when they see money taken away from Conservatives and given to the poor and make them feel entitled to more and more.

Many are called, but few are chosen.

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The Challenges, Medical or Otherwise, that Modern Day Colleagues of Hippocrates Face.

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11.  Professionals Restoring Accountability in Medical Practice, Government and Society:

                      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

                      Medi-Share Medi-Share is based on the biblical principles of caring for and sharing in one another's burdens (as outlined in Galatians 6:2). And as such, adhering to biblical principles of health and lifestyle are important requirements for membership in Medi-Share. This is not insurance. Read more . . .

                      PATMOS EmergiClinic - where Robert Berry, MD, an emergency physician and internist, practices. To read his story and the background for naming his clinic PATMOS EmergiClinic - the island where John was exiled and an acronym for "payment at time of service," go to To read more on Dr Berry, please click on the various topics at his website. To review How to Start a Third-Party Free Medical Practice . . .

                      PRIVATE NEUROLOGY is a Third-Party-Free Practice in Derby, NY with Larry Huntoon, MD, PhD, FANN. ( Dr Huntoon does not allow any HMO or government interference in your medical care. "Since I am not forced to use CPT codes and ICD-9 codes (coding numbers required on claim forms) in our practice, I have been able to keep our fee structure very simple." I have no interest in "playing games" so as to "run up the bill." My goal is to provide competent, compassionate, ethical care at a price that patients can afford. I also believe in an honest day's pay for an honest day's work. Please Note that PAYMENT IS EXPECTED AT THE TIME OF SERVICE. Private Neurology also guarantees that medical records in our office are kept totally private and confidential - in accordance with the Oath of Hippocrates. Since I am a non-covered entity under HIPAA, your medical records are safe from the increased risk of disclosure under HIPAA law. 

                      FIRM: Freedom and Individual Rights in Medicine, Lin Zinser, JD, Founder,, researches and studies the work of scholars and policy experts in the areas of health care, law, philosophy, and economics to inform and to foster public debate on the causes and potential solutions of rising costs of health care and health insurance. Read Lin Zinser's view on today's health care problem:  In today's proposals for sweeping changes in the field of medicine, the term "socialized medicine" is never used. Instead we hear demands for "universal," "mandatory," "singlepayer," and/or "comprehensive" systems. These demands aim to force one healthcare plan (sometimes with options) onto all Americans; it is a plan under which all medical services are paid for, and thus controlled, by government agencies. Sometimes, proponents call this "nationalized financing" or "nationalized health insurance." In a more honest day, it was called socialized medicine.

                      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 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."

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

                      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.

                      Madeleine Pelner Cosman, JD, PhD, Esq, who has made important efforts in restoring accountability in health care, has died (1937-2006). Her obituary is at She will be remembered for her important work, Who Owns Your Body, which is reviewed at 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

                      ReflectiveMedical Information Systems (RMIS), delivering information that empowers patients, is a new venture by Dr. Gibson, one of our regular contributors, and his research group, which will go far in making health care costs transparent. This site provides access to information related to medical costs as an informational and educational service to users of the website. This site contains general information regarding the historical, estimates, actual and Medicare range of amounts paid to providers and billed by providers to treat the procedures listed. These amounts were calculated based on actual claims paid. These amounts are not estimates of costs that may be incurred in the future. Although national or regional representations and estimates may be displayed, data from certain areas may not be included. You may want to follow this development at During your visit you may wish to enroll your own data to attract patients to your practice. This is truly innovative and has been needed for a long time. Congratulations to Dr. Gibson and staff for being at the cutting edge of healthcare reform with transparency. 

                      Dr Richard B Willner, President, Center Peer Review Justice Inc, states: We are a group of healthcare doctors -- physicians, podiatrists, dentists, osteopaths -- who have experienced and/or witnessed the tragedy of the perversion of medical peer review by malice and bad faith. We have seen the statutory immunity, which is provided to our "peers" for the purposes of quality assurance and credentialing, used as cover to allow those "peers" to ruin careers and reputations to further their own, usually monetary agenda of destroying the competition. We are dedicated to the exposure, conviction, and sanction of any and all doctors, and affiliated hospitals, HMOs, medical boards, and other such institutions, who would use peer review as a weapon to unfairly destroy other professionals. Read the rest of the story, as well as a wealth of information, at

                      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 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. For more information, go to

                      Robert J Cihak, MD, former president of the AAPS, and Michael Arnold Glueck, M.D, who wrote an informative Medicine Men column at NewsMax, have now retired. Please log on to review the archives. He now has a new column with Richard Dolinar, MD, worth reading 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. Read an Open Letter to the Profession. . . Be sure to read News of the Day in Perspective:  Doctors Tell Congress: Just Stop It.  Don't miss the "AAPS News," written by Jane Orient, MD, and archived on this site which provides valuable information on a monthly basis. This month, be sure to read LOOTING MEDICINE. Browse the archives of their 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.

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Words of Wisdom

"You cannot multiply wealth by dividing it." - the late Adrian Rogers

"Early risers are happier, healthier, and more productive at work. They stay in better shape, earn more money, and report that they are more satisfied with their lives. Get up early and seize the day!" - Michael Masterson: Entrepreneur and best-selling business author, 

"In a world where the big things have little difference - it's the little things that make a big difference." - Peter Thomson: U.K. strategist on business and personal growth, 

Some Relevant Postings

Peer Review: Inquisition or Quality Control . . .

The Hunted Physician by Sharon Kime and Robert Sullivan, Attorneys-at-Law . . .

A Medical Tragedy . . .

In Memoriam

Jerome David Salinger, writer, died on January 28th, aged 91

From The Economist print edition | Feb 6th 2010

PEOPLE kept sneaking year after year to the place on the hill in Cornish, New Hampshire, but the Great American Writer was almost never seen. Ageing rebels, second-year master's students with lacquered nails, broad-shouldered phonies in Norfolk jackets, snappers from Newsweek, all approached the cringing, little house where he had lived, or battened down, or holed up—you, general reader, can choose the word you please—ever since a great wave of fame had broken over him in 1953, two years after he happened to write a book called "The Catcher in the Rye". Read more . . . .

They caught a glimpse of him sometimes, with his haughty head, angular and bug-eyed, getting groceries in the village; but he gave them the slip almost always. The truth of it was that though his book might be on all the syllabuses, picked over by the academicians, hailed as the authentic voice of every teenager who had ever squeezed a pimple or tried, drawing himself up tall, to order a Scotch and soda, his life was nobody's godammed business. If his dream was to live in the woods, with a fireplace and a typewriter and sheaves of notes hooked on the wall, almost like a deaf-mute in his dealings with the world, that was his affair.

He was not just away in Cornish, he was also above. (The italics were his own.) From above, Holden Caulfield, the hero of "Catcher", first entered his story to look down on the distant football game between Saxon Hall and Pencey Prep, all those little running figures of whom he was not one, because he was outside and expelled. The writer who truly lived for his art—who made it, as Mr Salinger did, his religion, along with Vedanta and Zen and the Tao—did not descend and did not integrate. He defended until death, or non-publication, the sanctity of his words. A writer asked to discuss his craft ought just to jump up and declaim, de haut en bas, the names of Flaubert, Tolstoy, Blake, Coleridge, Proust, James. And admit that after Melville there had been no really good American writer until—Salinger.

But that—wait—was not necessarily the name he answered to. In his short stories, a scant three dozen of them, rounding off the whole oeuvre, he gradually took the name and voice of Buddy Glass, a fortyish and paunchy short-story writer who had ended up in an English Department. And Glass in turn wrote obsessively, devotedly, as if of some plaster saint, about his elder brother Seymour, his Literary Ideal. Buddy was the working-writer Salinger, the man who had laboured in 1939-43 to get stuff into Esquire and the Saturday Evening Post, while all the time disdaining those slicks and lusting after the New Yorker—which, in 1948, took him into its embrace. But Seymour was "all real things to us: our blue-striped unicorn, our doublelensed burning glass, our consultant genius, our portable conscience…our one full poet." He would open the door, blow "three or four or five unquestionably sweet and expert notes on a cornet"—and then disappear.  .  .

Read the entire obit . . .

On This Date in History - February 23

On this date in 1836, a siege in the city of San Antonio began. Inside was a small band of determined men. Outside was a Mexican Army. The place was the Alamo. The gallantry of the defenders of the Alamo is well remembered.

On this date in 1945, the famous picture was taken of the Marines raising the American Flag at Iwo Jima. The picture, taken by Associated Press photographer Joe Rosenthal at the height of the fighting on that embattled Pacific Island, was the inspiration for the Iwo Jima monument in Washington, outside the Arlington National Cemetery. It represents a spirit of valor that continues as an inspiration to all of us today.

After Leonard and Thelma Spinrad


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