Community For Better Health Care

Vol XI, No 10, Jan 2013

In This Issue:

  1. Featured Article: Women in foxholes

  2. In the News: How can a wife be either a man or a woman in a civil society?

  3. International Medicine: The Metrics of Health System Performance

  4. Medicare: A Digital Shift on Health Data Swells Profits in an Industry

  5. Medical Gluttony: Electronic Prescribing, Automated Refills, and Obamacare.

  6. Medical Myths: Gastric Bypass Obesity Surgery is Cost-Effective Weight Loss

  7. Overheard in the Medical Staff Lounge: Same Song, Same Verse

  8. Voices of Medicine: Medical Weight Loss by Jennifer Hubert,DO

  9. The Bookshelf: The Children Of Men: What to Expect When No One's Expecting

  10. Hippocrates & His Kin: “The new "29ers."

  11. Restoring Accountability in Medicine, Government and Society

  12. Words of Wisdom, Recent Postings, In Memoriam, Today in History . . .

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The Annual World Health Care Congress, a market of ideas, co-sponsored by The Wall Street Journal, is the most prestigious meeting of chief and senior executives from all sectors of health care. Renowned authorities and practitioners assemble to present recent results and to develop innovative strategies that foster the creation of a cost-effective and accountable U.S. health-care system. The extraordinary conference agenda includes compelling keynote panel discussions, authoritative industry speakers, international best practices, and recently released case-study data. The 10th Annual World Health Care Congress will be held April 8-10, 2013 at the Gaylord Convention Center, Washington DC. For more information, visit The future is occurring NOW.

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  1. Featured Article: Women in foxholes


By Maj. Gen. Patrick Brady, U.S. Army (ret.)

Gen. Patrick Brady says putting females in combat poses 'an insane burden on readiness'

For many Americans, it is hard to believe that Secretary of Defense Leon Panetta could top his statement in defense of the administration’s tragic bungling of the terrorists’ massacre in Benghazi: “(The) basic principle is that you don’t deploy forces into harm’s way without knowing what’s going on; without having some real-time information about what’s taking place (The Obama Panetta Doctrine).” But he did top it.

In justification of the administration’s policy to put women in foxholes, he claimed that women in (direct) combat strengthen our military. His statement is a contradiction of every war we have fought and the ethos of every warrior who ever fought in those wars. Read more . . . But it does reflect the attitude of the commander in chief, disastrously over his head in the international arena, a “leader” unable to make tough decision who is fearful of risk and does not know the difference between a corps and a corpse. He is more comfortable around homosexuals and feminists than warriors. Panetta’s statement extolling the readiness multiplier of women leading bayonet charges is beyond the pale.

Neither Obama nor Panetta has ever served in combat, nor has most of Congress. But worse, none of the current military leadership has had any serious combat (in the trenches) experience, and it is beginning to show.

World War II was won by combat veterans from World War I. In Korea we had the veterans of World War II, and in Vietnam the combat veterans of both World War II and Korea. The Vietnam veteran won Desert Storm. All those warriors and their leadership are gone, and we see a military with dismal leadership resulting in unprecedented rates of suicide, PTSD and security breaches. We had one high-ranking officer lament that the terrorist’s massacre at Fort Hood would damage his diversity efforts! Leadership relieved the judge in the trial of the Fort Hood terrorist for enforcing military shaving rules on the terrorist – and after over three years, he is not tried! And they are calling that obvious terrorist massacre “workplace violence,” deliberately depriving those killed and their families of deserved benefits.

Unimaginable in our past, we have leaders who consider awarding medals for not shooting, and now a medal for risking carpal tunnel syndrome that outranks the time-honored Bronze Star for valor. This gaggle actually lost graves of our warriors at Arlington Cemetery and are attacking the benefits of America’s nobility – our veterans. I don’t know where the term girlie men came from, but it perfectly describes many in this administration and their military leaders.

After commanding an all-men medical unit in combat, I commanded a medical battalion, including many women, in peacetime. These units are not direct-combat units but do spend a lot of time on the battlefield and are exposed to enemy fire and casualties. But it is nothing like the exposure of the grunts in the mud and grime for days and weeks at a time.

My rule in the battalion was standards, not gender-governed, except where they were already assigned, i.e., medics and mechanics. This was during the ’70s, a tough time for drugs and discipline in the military. Here is what I found. As a result of competition, my driver and our color guard, highly contested duty, were women. The women had less disciplinary problems than the men. In administrative jobs, they were at least equal to men. But most could not carry their load physically – loading litters in choppers, carrying wounded to safety, even lifting tool chests. As a result the men covered for them, often causing us to use two people when one should have done the job – all of which effected readiness. They were not good in the field and became less functional when issues of hygiene, and feminine hygiene, literally knocked them out and we had to jerry-rig showers, wasting valuable time.

And they got pregnant, which took out key jobs at critical times. Other sexual distractions, favoritisms, fraternization and assault are also readiness disruptions and follow women throughout the military, even in our military academies. I had serious problems with wives whose husbands shared standby shacks with women overnight. This would go on for weeks in direct combat units; think tank crews. Male bonding, immeasurable to success in combat, would be damaged. All in all, the women pose an insane burden on readiness.

My conclusion, which I passed to my division commander at his request, was that I would not want females with me working the battlefield let alone in direct combat. I told him I would not want my daughters in a unit of half women going bayonet to bayonet with an enemy unit 100 percent men. Those comments almost cost me my career because my immediate superior disagreed, which may explain some of the obsequiousness and cowering of military leaders today on this issue and a quad-sexual military.

The move to teach our daughters and mothers to kill is defended using the same criteria I used in my battalion: standards, not sex-govern. It does not work. Most men will not treat women as they do other men – thankfully. And there is no intention to do so despite what we hear. Listen to our top military leader, Gen. Martin Dempsey: “If we decide that a particular standard is so high that a woman couldn’t make it, the burden is now on the service to come back and explain to the secretary, why is it that high? Does it really have to be that high?” Those standards have been set over hundreds of years of combat! We should change them to satisfy the crazes of the president’s feminist supporters? Imagine how Gen. George Patton and all the leaders who founded and secured this country would react to those comments.

I have said, and many men agree with me, that Adam’s rib was the greatest investment in human history. Why? Because God then gave man woman, a different creature, who complemented him. God did it on purpose, and we are privileged to live with the differences. Feminists, et al, get over it. It is not discrimination to accommodate God’s design; it is acknowledging His will – it is wisdom. . .

It is difficult to teach some men to kill, but they have no choice. Imagine a draft and a nation forcing our women into killing units. Visualize what will happen to women POWs, not to mention homosexuals, captured by our most likely enemies. We have heard of the man who sent his wife downstairs to check on a possible burglar (I actually knew such a man). We are becoming a nation like that man, a girlie nation. There will always be burglars, (international thugs), most of whom are male, and they should be confronted by males.

Why these ridiculous changes? No serious person could believe that women in foxholes will do anything but reduce readiness . . .

Read the entire article:

Maj. Gen. Patrick Brady, retired from the U.S. Army, is a recipient of the United States military’s highest decoration, the Medal of Honor.

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  1. In the News: How can a wife be either a man or a woman in a civil society?

Magistrate judge officially sworn in to federal bench

By Denny Walsh

. . . Those who know and have worked with Allison Claire describe her as "super smart," a hard worker and compassionate, and they harbor no doubt it will be an effortless transition for her.

Claire was officially sworn in Friday as Sacramento's seventh U.S. magistrate judge at an installation in the federal courthouse's ceremonial courtroom.

Afterward, her wife and their teenage triplets – two daughters and a son – slipped the black robe on her. . .

Claire, 52, is the first member of the federal judiciary in the nation, at any level, to be in a state-sanctioned same-sex marriage. She and her wife were married during the 4 1/2-month window – June 16 to Nov. 5, 2008 – between the California Supreme Court's validation of same-sex marriage and the passage of Proposition 8, an amendment to the state constitution outlawing it. Read more . . .

Read further:

I recently had a patient who had a man follow him into my office. When asked who this man was that followed him into the exam room, the patient answered, “He’s my wife.”

In the first instance the wife is a female, in the second instance, the wife is a male. Why are we in this quagmire of gender confusion? Can either man or woman be a wife? Isn’t wife no longer gender specific? Being a wife or husband or man or woman should not be a Civil Rights Issue. It’s a Civil Society Issue.

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  1. International Medicine: The Metrics of Health System Performance do not Measure Efficiency

US health care: A reality check on cross-country comparisons

H.E. Frech, Stephen T. Parente, John Hoff

The Organisation for Economic Co-operation and Development (OECD) uses mortality metrics to measure health care system performance, but these data do not adequately indicate health status differences and do not accurately judge health care system efficiency. . .

This Outlook offers a brief critical assessment of international health system performance metrics. We will focus on three statistics that the OECD delves into in its report: infant mortality, life expectancy, and premature death. The strengths and weaknesses of these measures are illuminated through brief examples that ultimately demonstrate that the measures do not reflect the efficiency of any country’s health system. Given that organizations such as the OECD continually try to evaluate countries’ health systems, US policymakers and analysts must understand the limitations of such exercises. We conclude with suggested changes in approach and a road map for improved research.

Before describing the key metrics for international comparison, it is useful to recall the relatively recent origin of international health statistics. The OECD was created in 1948 as the Organisation for European Economic Co-operation (OEEC) to administer funds made available by the US Marshall Plan for the reconstruction of Europe after World War II. Later, the OEEC’s membership was extended beyond Europe. In 1961, it was reformed into the OECD. Today, its members are thirty-four developed countries.[5]. . .

Health Status Metrics

A common misconception is that people value health care in and of itself. In reality, people value the improved health status that they hope to gain from receiving health care. Indeed, using most health care is unpleasant. Health status is not directly measurable; it can only be approximated through related factors that can be measured. Read more . . .

The OECD report focused on observable measures as proxies of health status to provide comparative statistics. A depressing reality is that these observable measures are all some derivative of mortality. The OECD expects all its member states to provide death registers as part of a planned, one-hundred-year public health mission to identify sources of death and time of death to track epidemiological emergencies such as those resulting from infectious diseases. In the service of OECD, mortality metrics are outcome measures that are meant to proxy health status and the output of health care systems, rather than the consumption of health services.

The OECD uses infant mortality, life expectancy, and premature death as measures of mortality in their report.[6] The validity of each one of these measures as proxies for health system performance is examined below.

Infant Mortality. There are three overlapping OECD infant mortality measures: infant, neonatal, and perinatal mortality.[7] Infant mortality is the number of deaths in the first year per one thousand live births. Neonatal mortality is the number of deaths in the first twenty-eight days per one thousand live births. Perinatal mortality is the number of deaths in the first week after birth, plus fetal deaths after twenty-eight weeks of gestation or fetuses that exceed a weight of one thousand grams.

Partly based on an argument by Nixon and Ullmann, the OECD report states that these infant mortality measures are less influenced by factors unrelated to the health care system than are other possible measures.[8] However, we believe that the opposite is true. One major concern is that the basic definitions of infant mortality are not consistent across countries.

For example, babies who are not viable and who die quickly after birth are more likely to be classified as stillbirths in countries outside the United States, especially in Japan, Sweden, Norway, Ireland, the Netherlands, and France. This is especially likely for babies who die before their birth is legally registered.[9] In the United States, however, nonviable births are often recorded as live births, making the US infant mortality rate appear misleadingly high. In a detailed study of medical records and birth and death certificates in Philadelphia, Gibson and colleagues found that infant mortality had been overstated by 40 percent, merely as a result of these nonviable births that were recorded as live births.[10]

There is another problem with using infant mortality to represent health care efficacy. US physicians often go to great efforts—at the prenatal and postnatal stages—to save a baby with poor survival chances. The additional prenatal care an American doctor provides may improve the odds of the live birth of a baby with poor survival chances, who is then likely to require extensive neonatal care. Accordingly, the US uses substantially more neonatal intensive care units (NICU) than other industrialized countries. In this case, the additional health care may actually worsen reported infant mortality rates and misleadingly suggest poor care in the United States. Similarly, US physicians are more likely to resuscitate very small premature babies, many of whom nevertheless die and many others of whom live with serious and expensive medical problems. This practice also raises measured infant mortality rates for the United States.

The combination of higher delivery costs because of greater NICU use and the unique way the United States counts live births could lead one to erroneously conclude that the United States is highly inefficient compared to other industrialized nations. Furthermore, infant mortality is strongly and immediately affected by external influences such as the mother’s age, behavior, and lifestyle (meaning factors such as obesity and use of tobacco, alcohol, and illicit drugs).[11] Infant mortality is strongly linked to birth weight and gestational age, which are highly, but not perfectly, correlated. Indeed, the correlation is high enough that researchers will often use one or the other measure according to conveniences. In any case, both measures are largely a result of parental lifestyles.

Teenage mothers are more likely to have preterm, low-birth-weight babies. The mortality rate for infants born to US teenage mothers is 1.5 to 3.5 times as high as the rate for infants born to mothers ages twenty-five to twenty-nine.[12] The US rate of births for teenage mothers is very high—2.8 times that of Canada and 7.0 times that of Sweden and Japan. If the United States had the same birth weights as Canada, its infant mortality rate—adjusting for this variable alone—would be slightly lower than Canada’s (5.4 versus 5.5 per one thousand births).[13]

Turning to gestational age, MacDorman and Mathews calculate that if the United States had the same distribution of gestational ages as Sweden, its recorded infant mortality rate would drop by 33 percent, tying it with France as the fifth lowest rate out of twenty-one developed countries.[14] Moreover, in the United States, mortality rates for infants born to unwed mothers were about twice as high as for infants born to married women.[15]

Overall, these lifestyle and socioeconomic factors may reflect poorly on some aspects of society in the United States in comparison to other countries. It is inappropriate, however, to conclude that the root cause is the US health care system rather than societal factors in a dynamic heterogeneous society. Infant mortality is a particularly misleading metric by which to grade country-specific health system performance and to make international comparisons. . .

Read more about the other variables, Life Expectancy and Premature Mortality which makes the comparisons even more invalid at

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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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  1. Medicare: A Digital Shift on Health Data Swells Profits in an Industry

It was a tantalizing pitch: come get a piece of a $19 billion government “giveaway.”


But today, as doctors and hospitals struggle to make new records systems work, the clear winners are big companies like Allscripts that lobbied for that legislation and pushed aside smaller competitors.

While proponents say new record-keeping technologies will one day reduce costs and improve care, profits and sales are soaring now across the records industry. At Allscripts, annual sales have more than doubled from $548 million in 2009 to an estimated $1.44 billion last year, partly reflecting daring acquisitions made on the bet that the legislation would be a boon for the industry. At the Cerner Corporation of Kansas City, Mo., sales rose 60 percent during that period. With money pouring in, top executives are enjoying Wall Street-style paydays. Read more . . .

None of that would have happened without the health records legislation that was included in the 2009 economic stimulus bill — and the lobbying that helped produce it. Along the way, the records industry made hundreds of thousands of dollars of political contributions to both Democrats and Republicans. In some cases, the ties went deeper. Glen E. Tullman, until recently the chief executive of Allscripts, was health technology adviser to the 2008 Obama campaign. As C.E.O. of Allscripts, he visited the White House no fewer than seven times after President Obama took office in 2009, according to White House records.

Mr. Tullman, who left Allscripts late last year after a boardroom power struggle, characterized his activities in Washington as an attempt to educate lawmakers and the administration.

We really haven’t done any lobbying,” Mr. Tullman said in an interview. “I think it’s very common with every administration that when they want to talk about the automotive industry, they convene automotive executives, and when they want to talk about the Internet, they convene Internet executives.”

Between 2008 and 2012, a time of intense lobbying in the area around the passage of the legislation and how the rules for government incentives would be shaped, Mr. Tullman personally made $225,000 in political contributions. While tens of thousands of those dollars went to the Democratic Senatorial Campaign Committee, money was also being sprinkled toward Senator Max Baucus, the Democratic senator from Montana who is chairman of the Senate Finance Committee, and Jay D. Rockefeller, the Democrat from West Virginia who heads the Commerce Committee. Mr. Tullman said his recent personal contributions to various politicians had largely been driven by his interest in supporting President Obama and in seeing his re-election.

Cerner’s lobbying dollars doubled to nearly $400,000 between 2006 and last year, according to the Center for Responsive Politics. While its political action committee contributed a little to some Democrats in 2008, including Senator Baucus, its contributions last year went almost entirely to Republicans, with a large amount going to the Mitt Romney campaign.

Current and former industry executives say that big digital records companies like Cerner, Allscripts and Epic Systems of Verona, Wis., have reaped enormous rewards because of the legislation they pushed for. “Nothing that these companies did in my eyes was spectacular,” said John Gomez, the former head of technology at Allscripts. “They grew as a result of government incentives.”

Executives at smaller records companies say the legislation cemented the established companies’ leading positions in the field, making it difficult for others to break into the business and innovate. Until the 2009 legislation, growth at the leading records firms was steady; since then, it has been explosive. Annual sales growth at Cerner, for instance, has doubled to 20 percent from 10 percent.

We called it the Sunny von Bülow bill. These companies that should have been dead were being put on machines and kept alive for another few years,” said Jonathan Bush, co-founder of the cloud-based firm Athena health and a first cousin to former President George W. Bush. “The biggest players drew this incredible huddle around the rule-makers and the rules are ridiculously favorable to these companies and ridiculously unfavorable to society.” See below . . .

Read the entire article at the NY Times . . .

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

- Ronald Reagan

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  1. Medical Gluttony: Electronic Prescribing, Automated Refills, and Obamacare.

Mr. Tullman, who left Allscripts late, last year . . . characterized his activities in Washington as an attempt to educate lawmakers and the administration. “We really haven’t done any lobbying,” Mr. Tullman said in an interview. (See reverence in section 4 above)

Between 2008 and 2012, a time of intense lobbying in the area around the passage of the legislation and how the rules for government incentives would be shaped, Mr. Tullman personally made $225,000 in political contributions Mr. Tullman said his recent personal contributions to various politicians had largely been driven by his interest in supporting President Obama and in seeing his re-election. . .

Industry executives say that big digital records companies like Cerner, Allscripts and Epic Systems of Verona, Wis., have reaped enormous rewards because of the legislation they pushed for. “Nothing that these companies did in my eyes was spectacular,” said John Gomez, the former head of technology at Allscripts. “They grew as a result of government incentives.” . . .

We called it the Sunny von Bülow bill. These companies that should have been dead were being put on machines and kept alive for another few years,” said Jonathan Bush, co-founder of the cloud-based firm Athena health and a first cousin to former President George W. Bush. “The biggest players drew this incredible huddle around the rule-makers and the rules are ridiculously favorable to these companies and ridiculously unfavorable to society.” Read more . . .

The major push for electronic prescriptions was to capture the refill market, usurp the doctor’s responsibility for prescribing by making all prescription essentially freewheeling over riding the doctor’s refill limit which is geared to the needs for re-evaluation of the patient. In other words when a physician evaluates and exams a patient, reviews the lab work, x-rays and other procedures, the physician proceeds to the treatment plans and determines a safe interval after which the patient needs further face-to-face reevaluation. Hence, there should never be a need for the pharmacist to request a refill. For physician to respond to a fax refill request, without reviewing the chart when at the previous office visit the physician has decided on the appropriate interval, would lower the quality of care. To superficially review a chart to see if a premature renewal would jeopardize care would a clerical nightmare, time consuming of about one-half of a follow up unscheduled office visit. If the patient or insurance company paid for that like other professions get paid for the time spent, whether in conference, on phone, or email, this harassment wouldn’t be near as painful or costly.

I was at a health care meeting when the electronic prescribers held forth and bragged about being able to gender refill requests by sending a fax request for refills when the doctors considered opinion was to limit the refill requests to remind the patient that further re-evaluation was needed before the prescription was renewed.

The Allscripts reps couldn’t understand why any doctor would want to eliminated the fax reminders that the prescription had run its course. Doesn’t this just make things run smoother?

The prescription drug executives do not understand the basic nature of health care. To interfere without understanding can be very hazardous in medicine.

I tried to explain that they were sending fax refill requests when the last prescription was picked up and sometimes several times a week adnauseam. What they should be doing is reminding the patient that this was their last refill and they needed to see their doctor for reassessment as to the continuing need of this prescription, a possible change in medications, or a renewal for a safe period of time before the further assessment would be required. If it was a 30 day refill, the patient might be reminded that they have 30 days to see their doctor. If it was a 90 day refill, they would have 90 days to see their doctor.

Recently I was only seeing male patients for three days while my wife and office manager/assistant was visiting her sick father in Florida, I read the faxes that were dropped into my computer each day at 7 PM when I finished my patients. I counted more than a hundred refill requests each day when there should have been none. In the past I would have shredded 100 sheets of paper per day and destroyed at least one tree per day. Now they come into our computer and I could read them and deleted them electronically without such a waste of paper.

In California, controlled substances such as a hypnotic or tranquillizer required a doctor’s re-assessment after four refills. For narcotic controlled substances, a patient reassessment is required after five refills. For a pharmacist to try entice further refills by fax, without the face-to-face reassessment, can precipitate Quality of Care as well as legal issues. There are a few frequently abuse controlled drugs that can’t be refilled at all. These patients require monthly exams to obtain these drugs. To give these patients two prescriptions with different dates so they could come in every other month, instead of monthly, could be interpreted as a major violation and make the physician liable for a felony conviction. These may not be medical limits in some patients, but they are legal limits and thus equally hazardous for the physician if not followed.

In California the medical practice act prohibits treatment without a current medical examination. A current medical examination has generally been interpreted as being examined within a year. If the patient has stable disease, whether arthritis or heart disease, we would generally give refills for the entire year. A faxed refill request may run afoul of the medical practice act which is policed by the California Medical Board (CMB) which monitors our license to practice medicine. To jeopardize our license to practice medicine is a serious threat to our future as well as our family’s future.

A physician who is diligent in writing hypnotic prescription with 4 refills, narcotics with 5 refills, and routine medications with 11 refills, should never hear from the pharmacist to vary this. The pharmacist’s job after the prescription has run its course is to remind the patient to make an appointment to acquire a new prescription from his/her physician.

So with a 100 fax refill request in a single day it would require an extra 300 minutes after hours to review the charts to make sure no medical jeopardy in Quality of Care (QOC) issues were present or legal jeopardy was incurred. If my office manager was present, she would have the same 300 minutes of work with no reimbursement.

Notis Brevis: Before you feel the above is an exaggeration, we have just completed a six-month request to see Medicaid patients that Obamacare had placed into HMOs. We had 600 patients added to our rolls. The very first day they were placed on our list, we have had up to 150 messages on our phone each day of which 100 were refill requests. These came in during each of the 24 hours of day or night. We at once realized that none of these new enrollees had jobs or worked, they all had cell phones which explain the day and night requests since these were men and women essentially at leisure without any time frame.

My wife normally would come to the office and respond to the three or four phone messages, and then get on with the day’s work. During these six-months, she spent three hours every morning to record the messages and another two hours to process the requests. Our HMO felt no obligation to reimburse us for this additional work. Thus my front desk had five additional hours of work each day for no pay. We were promised these patients would be paid on the Medicare fee schedule for the first visit and all subsequent visits would be 10 percent above MediCal rates. It took us a while to figure out why our income had dropped so precipitously. Instead of $18 for a MediCal office call, we were now paid $19.80. We were forced to terminate what we had hoped was our obligation to the poor. But we were getting poor in the process and unable to pay our taxes.

Every single function with this new category of care took immeasurable longer. Doctors that saw referrals for us would not accept this new hybrid of welfare/ HMO patient. After working for hours on one referral, my wife found a consultant in a town 50 miles away. The next time she tried to use the same consultant; his practice was closed to this hybrid. We had one specialty referral that no one of the 4000 physicians in Sacramento, would accept, and the HMO called and said they found someone in San Francisco (100 miles from Sacramento) that would see her. We actually had one patient willing to make this trip before that practice was closed to this hybrid of welfare/HMO.

Thus this monstrosity of Obamacare which was to make health care more accessible has, in our experience, made healthcare less accessible and in several cases, totally inaccessible.

Medicine during the days of the county, city and state hospitals was a two-tiered system. Unfortunately it still is. With the entitlement mindset, it will always be.

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Medical Gluttony thrives in Government and Health Insurance Programs.

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

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  1. Medical Myths: Gastric Bypass Obesity Surgery is Cost-Effective Weight Loss

Study disputes long-term medical savings from bariatric surgery

By MELISSA HEALY Los Angeles Times

In the span of 15 years, the number of bariatric surgeries performed in the United States has grown more than 16-fold to roughly 220,000 per year, gaining cachet as a near-panacea for obesity.

Despite the daunting price tag, mounting research has boosted hopes that the stomach-stapling operations could reduce the nation's health care bill by weaning patients off the costly drugs and frequent doctor visits that come with chronic obesity-related diseases like diabetes and arthritis.

But a new study has found that the surgery does not reduce patients' medical costs over the six years after they are wheeled out of the operating room. Read more . . .

The study, published Wednesday in the journal JAMA Surgery, tracked the expenses of nearly 30,000 Americans who got one of two forms of bariatric surgery, and compared their long-term health costs with those of similar patients who were obese but did not go under the knife to lose weight. Even when the initial $20,000 to $25,000 cost of the procedure was taken out of the equation, the ongoing expenses for the patients who had surgery were roughly the same as for those who did not.

In an editorial accompanying the study, Dr. Edward H. Livingston wrote that "bariatric surgery does not provide an overall societal benefit." Though acknowledging that such surgery has "dramatic short-term results," he added that its longer-term effects - including on longevity - have been disappointing. . .

Kenneth Thorpe, chairman of health policy and management at Emory University's School of Public Health, said there's reason to believe that drug and behavioral therapies are a better investment than surgeries. For patients considered pre-diabetic, studies have shown that a 16-week course called the Diabetes Prevention Program staves off the disease in 58 percent of those under 60 and 71 percent of patients over 60. And the Food and Drug Administration last year approved two new weight-loss medications, Qsymia and Belviq, that could bring similar health benefits.

The costs of these treatments are "a pittance compared with what we're doing with bariatric surgery," Thorpe said.

Read more here:

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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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  1. Overheard in the Medical Staff Lounge: Same song, same verse

There was not much new in the Staff Dining Room this month. Doctors are getting discourage and burned out because of the inability to practice quality medicine like they’ve been trained and dealing with the medically illiterate to justify routine treatments.

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The Staff Lounge Is Where Unfiltered Opinions Are Heard.

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  1. Voices of Medicine: From Sonoma Medicine: Bariatrics

Medical Weight Loss by Jennifer Hubert, DO

Overweight and obesity are complex chronic medical conditions that should be given the same consideration as other chronic diseases. “Overweight” is defined as a body mass index (BMI) of 25-29.9, while “obese” is defined as a BMI of 30 and above. Many comorbid conditions--such as heart disease, type 2 diabetes, hypertension and hyperlipidemia--may be improved or reversed with treatment for obesity and overweight.

Both medical and surgical treatments are available for obesity and overweight. This article focuses on medical treatments, including very low calorie diets (VLCDs) and anorectic medications. Read more . . .


The terms VLCD and PSMF (protein-sparing modified fast) are sometimes used interchangeably, but a VLCD uses liquid meal replacements, whereas a PSMF uses regular food. In the past, VLCDs ranged from 400-800 kcal per day, but now they are commonly set for 800 kcal/day.

Patients with a BMI of 27 and above with comorbid conditions or of 30 and above regardless of comorbid conditions can benefit from a VLCD program. VLCDs can help those who have been unsuccessful on other diets or those that need to lose 30 or more pounds.[1] They can also be used to help the obese lose weight in preparation for surgery, or for patients who cannot or do not want to make food choices.

Patients put on a VLCD should have a complete medical evaluation by a physician trained specifically in the clinical use of VLCDs, such as a bariatrician. VLCD patients need to be closely monitored by the bariatrician or other physician expert. There should be routine lab work and EKG monitoring. A key component of a successful VLCD program is ongoing nutritional and behavioral support and education by trained specialists, such as dieticians and behaviorists.

Women on a VLCD typically lose 3-3.5 pounds per week, and men lose 4-5 pounds per week.[2] The average loss on a VLCD is 2-3 times greater than on a conventional calorie-reducing diet in the same time period.[1] A VLCD can be strenuous on the body and should not be started in patients with a recent myocardial infarction or stroke, or those with pregnancy or a serious illness.

Anorectic Medications

Schedule III and IV anorectic drugs include benzphetamine, diethylpropion, mazindol, phendimetrazine and phentermine. Of these, phentermine is the most widely prescribed. Two Schedule IV anorectics that had been used in combination with phentermine (fenfluramine and dexfenfluramine) were removed from the U.S. market because of heart valve problems. Nonetheless, phentermine was found by the NIH to be useful in weight loss if used for 6-12 months.[3]

Schedule III and IV anorectics have a bad reputation due to their structural similarity to amphetamines and because of inappropriate prescribing. Studies, however, have not shown any tolerance or drug dependence with anorectics. In fact, the Drug Abuse Warning Report of 2006 found that anorectic drugs have one of the lowest drug misuse/abuse rates per 100,000 emergency room visits, even lower than acetaminophen and ibuprofen.[4]

Although most of the published studies of anorectic drugs have run for 12 weeks or less, several studies that have run for longer periods have demonstrated the safety and effectiveness of these medications.[5] With close monitoring and proper starting dose, side effects can be minimized or avoided in most cases.

Non-Approved Treatments

Some weight-loss programs promote the use of human chorionic gonadotropin (HCG), a hormone secreted by the trophoblastic cells of a placenta during pregnancy. However, the use of HCG for weight loss is not approved by the FDA and is not recommended.

In 1954, Dr. Albert Simeons first used HCG for the treatment of obesity in conjunction with a VLCD. He put patients on 500 kcal/day and 125 units of HCG injected 6 days per week for 8 weeks. A few initial studies supported his approach to weight loss, but subsequent studies demonstrated that the HCG part of the diet was ineffective and that the weight loss was solely due to the VLCD portion.[6]

The Future

Several obesity drugs are currently under review by the FDA. In February, for example, the Endocrinologic and Metabolic Drugs Advisory Committee recommended that the FDA approve Qnexa, which combines the appetite suppressant phentermine with topiramate, an anti-seizure medication that may alter hunger hormones, decrease appetite, and adjust glucose and insulin concentrations. The FDA is scheduled to announce its decision on Qnexa in April.

Contrave, another new drug for treating obesity, was rejected by the FDA last year. The FDA stated that a large-scale study of cardiovascular risk from Contrave would be needed before they could consider approval. Guidelines for the study appear to have been clarified, but approval is uncertain.

The FDA has also accepted a re-application for Lorcaserin, an appetite suppressant. The drug may help to eliminate hunger by stimulating parts of the 5-HT2C serotonin receptors located in the hypothalamus, the control center for metabolism and appetite.


Obesity and overweight are chronic conditions and should be treated as such. Unfortunately, treatments for obesity typically require a change in the patient’s lifestyle and behavior. Without this change, the likelihood that the patient will maintain the weight loss is low.

A multidisciplinary team (bariatrician, primary care physician, dietician, behaviorist) can help patients maintain weight loss. Ongoing support by the patient’s primary care physician is one of the most important factors. A little encouragement and reinforcement can go a long way.

VLCDs and anorectic medications can be effective for weight loss, but they should be prescribed by a trained specialist with a comprehensive program. The use of non-FDA approved medications such as HCG is highly discouraged.

More than a decade has passed since a new weight-loss medication was approved by the FDA and released to the market. Perhaps one of the drugs pending approval could help the two-thirds of Americans suffering from obesity and overweight.

Dr. Hubert, an internist, is medical director of the MedLite Weight Loss & Laser Center in Santa Rosa.



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

* * * * *

  1. Book Review: The Children Of Men by WILLIAM MCGURN, WSJ

What to Expect When No One's Expecting

By Jonathan V. Last (Encounter, 320 pages, $23.99)

For decades we've been warned about the dangers of overpopulation.
The real threat to our future, argues Jonathan V. Last, is that we are not having enough babies.

Among the children of progress it is commonly supposed that while liberal policy is guided solely by data, facts and the objectively verifiable, their opponents' minds are darkened by irrational allegiances and authorities (guns and religion, anyone?). Barack Obama gave voice to this conceit in his first inaugural when he vowed to "restore science to its rightful place." Never mind that American liberalism is not without its own pieties, orthodoxies and apocalyptic tropes. Read more . . .

None has been more powerful than the fear of overpopulation. Even before Paul Ehrlich's 1968 best seller, "The Population Bomb," our enlightened classes have been telling us that growing populations are bad—bad for women, bad for the economy, bad for the environment. Now comes Jonathan Last to tell us that they got it all wrong: The real threat to our future, says Mr. Last, is that we are not having enough babies.

His argument in "What to Expect When No One's Expecting" is summed up in three broad propositions. First, that "there is something about modernity itself that tends toward fewer children." Second, that most attempts to reverse this trend have failed. And third, that unless something changes soon, the United States will face what Japan and Europe are already seeing: shrinking, graying populations that will affect everything from armies and real-estate prices to entitlements and entrepreneurship.

From today's vantage point, it is hard to recall the fevered advance of the gospel of overpopulation, or the way it fixed itself in the firmament of institutions like the World Bank. In poor Eastern nations such as China and India, Western pieties about keeping families small became official policy. Only very recently has progressive America even acknowledged the inevitable abuses that came with it (involuntary sterilization and forced abortion, to name but two). . .

Why should we care? For one thing, declining fertility rates threaten entitlements such as Social Security and Medicare as more retirees come to be supported by fewer workers. (Mr. Last tartly notes that these programs were "conceived in an era of high fertility.") An older America would also likely have a harder time projecting military power without the large numbers of young people that such a commitment requires—or the tax base to pay for it. Creativity and innovation could be affected as well. As the Nobel Prize-winning economist Gary Becker put it in The Wall Street Journal in 2006: "The vast majority of important new ideas come from inventors and scientists who are younger than age 50, often far younger." . . .

Read the entire book review at the WSJ . . .

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The Book Review Section Is an Insider’s View of What Doctors are Reading

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  1. Hippocrates & His Kin: “The new "29ers."

Welcome to the strange new world of small-business hiring under ObamaCare. The law requires firms with 50 or more "full-time equivalent workers" to offer health plans to employees who work more than 30 hours a week. (The law says "equivalent" because two 15 hour a week workers equal one full-time worker.) Employers that pass the 50-employee threshold and don't offer insurance face a $2,000 penalty for each uncovered worker beyond 30 employees. So by hiring the 50th worker, the firm pays a penalty on the previous 20 as well.

Because other federal employment regulations also kick in when a firm crosses the 50 worker threshold, employers are starting to cap payrolls at 49 full-time workers. These firms have come to be known as "49ers." Businesses that hire young and lower-skilled workers are also starting to put a ceiling on the work week of below 30 hours. These firms are the new "29ers." Part-time workers don't have to be offered insurance under ObamaCare. WSJ

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Hippocrates and His Kin / Hippocrates Modern Colleagues
The Challenges of Yesteryear, Yesterday, Today & Tomorrow

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  1. Restoring Accountability in Medical Practice, HealthCare, Government and Society:

Bottom line: "We are the best deal Physicians can get from a statewide physician based organization!"

Our motto, "omnia pro aegroto" means "all for the patient."

* * * * *

  1. Words of Wisdom, Recent Postings, In Memoriam, Today in History . . .

Words of Wisdom

"Most of the important things in the world have been accomplished by people who have kept on trying when there seemed to be no hope at all."

Dale Carnegie: American writer, lecturer, and developer of famous courses in self-improvement

"Risk comes from not knowing what you're doing."

Warren Buffett: Investor, billionaire, and philanthropist

"Rather go to bed without dinner than to rise in debt."

Benjamin Franklin: Founding Father of the United States

Some Recent Postings

In The December Issue:

  1. Featured Article: ObamaCare: Who’s Winning, Who’s Losing by David Gibson, MD

  2. In the News: The Underworked Public Employee

  3. International Medicine: How does US Healthcare compare with Rest of the World?

  4. Medicare: Raise the Retirement and Social Security Age to 70?

  5. Medical Gluttony: The Cure

  6. Medical & Other Economic Myths: What Saved the Great Depression?

  7. Overheard in the Medical Staff Lounge: When doctors reach 65?

  8. Voices of Medicine: Dr. Benjamin Carson, Neurosurgeon, at the National Prayer Breakfast

  9. The Bookshelf: Questioning the Obesity Paradigm by Deborah Donlon, MD

  10. Hippocrates & His Kin: How the Donkey learned to Tax & Spend.

  11. Restoring Accountability in Medicine, Government and Society

  12. Words of Wisdom, Recent Postings, In Memoriam, Today in History . . .

In Memoriam

Dave Brubeck, pianist and composer, died on December 5th, aged 91

The Economist | From the print edition | Dec 15th 2012

TO PUT Dave Brubeck in a box was an unwise thing to do. He’d just jump right out again, big, broad and strong, with those horn-rimmed glasses and that crazy, slightly cross-eyed smile. Call him cool, and he’d tell you that many of his jazz arrangements were so hot, they sizzled. Lump him with players of white west-coast jazz, and he’d object that he felt more black than white. Suggest he was influenced by the pelting, intellectual strain of bebop that took over jazz in the 1940s, and he would say nope, he didn’t listen to it; he only ever wanted to do his own thing. Call him the usher of a new jazz age, put him on the cover of Time magazine, where he landed in 1954, and he was crestfallen. Duke Ellington deserved all that, he said, but not him.

His contrarian ways went further. Give him a few bars of Beethoven, and he’d weave a jazz riff through it; but put him in the middle of a jazz set, and he would come up with classic counterpoint as strict as the “Goldberg Variations”. Sing him a tune in C, and his left hand would play it in E flat; give him a jazz line in standard 4/4 time and he would play 5/4, 7/4, even 13/4 against it, relentlessly underpinning the adventure with big fat blocks of chords. He was a jazzman who struggled to read notation and who graduated on a wing and an ear from his college music school; and he was also, in later years, a composer of cantatas and oratorios who was proud to have written a Credo for Mozart’s unfinished “Mass in C minor”.

The musicians he picked for his quartet, which dominated the popular jazz scene from 1951 to 1967, were chosen because they could break out of the box like him: Paul Desmond on feather-light, floating alto sax, Joe Morello razor-sharp and witty on drums, Eugene Wright rock-solid on bass. Their greatest success, an album called “Time Out” (1959) that sold more than 1m copies, was a collection of breezily poly tonal pieces in wild time signatures, centring on a Desmond piece called “Take Five” written in teasing 5/4, and “Blue Rondo à la Turk”, devised by Mr Brubeck after hearing street musicians playing in 9/8 in Istanbul. These two pieces alone consolidated the quartet’s fame on campuses and in clubs all over America; but Columbia Records refused to release the album for a year, just baffled, said Mr Brubeck impatiently, by the fact that it broke so many rules. It did, but hey, it sounded good. . . .

Read the entire obit at The Economist . . .

This Month in History - January

President Birthdays:

January 7, 1800: Millard Fillmore

January 9, 1913: Richard Nixon

January 29, 1843: William McKinley

January 30, 1882: Franklin DD. Roosevelt

After Leonard and Thelma Spinrad

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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, any single payer initiative, Social Security was born for the benefit of the state and of a contemptuous disregard for people’s welfare.

We must also remember that ObamaCare has nothing to do with appropriate healthcare; it was similarly projected to gain loyalty by making American citizens dependent on the government and eliminating their choice and chance to improve their welfare or quality of healthcare. Socialists know that once people are enslaved, freedom seems too risky to pursue.