Community For Better Health Care

Vol VII, No 6, June 24, 2008


In This Issue:

1.         Featured Article: Do-not-resuscitate: A Revolution Now 30 Years Old

2.         In the News: New Drugs for Rare Diseases

3.         International Medicine: Unequal Health Care Under Canadian Medicare

4.         Medicare: Unequal Health Care Under Medicare

5.         Medical Gluttony: MediGap Insurance

6.         Medical Myths: Congress can control Health Care costs. Shall we start with big OIL?

7.         Overheard in the Medical Staff Lounge: Professionalism in Dress Code

8.         Voices of Medicine: Medical Professionalism: Society's Expectations, Our Expectations

9.         From the Physician Patient Bookshelf: Health Care Co-Ops

10.     Hippocrates & His Kin: Everybody's Practicing Medicine Except Doctors

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

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Logan Clements, a pro-liberty filmmaker in Los Angeles, seeks funding for a movie exposing the truth about socialized medicine. Clements is the former publisher of "American Venture" magazine who made news in 2005 for a property rights project against eminent domain called the "Lost Liberty Hotel."
For more information visit or email

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1.      Featured Article: Do-not-resuscitate: A Revolution Now 30 Years Old by James Murtagh, MD

"Because all the sick do not recover does not mean that there is no art of medicine." - Cicero, 143-06 BCE De Natura Deorum

"And thus it seems a conspiracy of silence has descended . . . We all pretend toward our neighbor that the possibility of his death could never happen."
- Albert Schweitzer

This month marks the 30-year anniversary of a fundamental revolution in America's approach to end of life care. Thirty years ago, it was impossible to issue a legal Do-Not-Resuscitate order. Then, on June 30, 1978, came a legal decision that remains the bedrock of a new legal, ethical and moral consensus that has guides medicine today.

"In the matter of Shirley Dinnerstein" Dinnerstein, 380 NE2d, 134,135 (Mass App 1978) made clear that Do-not-resuscitate (DNR) orders can be issued without court intervention, because the decision to resuscitate or not resuscitate "is a question peculiarly within the competence of the medical profession."

Before Dinnerstein, doctors believed that they had to go to court to stop extraordinary life support. Doctors felt a "technological imperative" to do "everything possible," regardless of whether an intervention could work, and regardless of whether a patient wanted a futile intervention.

Two years previous to Dinnerstein, a New Jersey court in 1976 had ruled in the Karen Ann Quinlan case that all persons had the right to refuse treatment. But the Quinlan court did not make clear how this right could be implemented without court review on a case-by-case basis.

I was a first year medical student at University of Michigan in 1978, and remember the immense relief when Dinnerstein was issued. The hospital attorney, Ed Goldman, and noted philosopher Carl Cohen, hailed the decision as common sense: decisions at the end of life were personal, and had to be made between doctor, patient and family. Courts did not need to involve themselves.

Father Richard McCormack, the theologian from the Quinlan case (and, by coincidence, a friend of my family), wrote in 1978 "The Quality of Life, The Sanctity of Life," reflecting a quote from Martin Luther King that "The quality, not the longevity, of one's life is what is important."

Earlier, Pope Pius XII condemned in 1952 "extraordinary means" to maintain life against the will of patients. All of the major religions remain in agreement. Doctors now work with chaplains and rabbis of all faiths to help patients make these decisions.

Dinnerstein became the basis of the President's commission on Standards for cardiopulmonary resuscitation (CPR) and was adopted by the American Medical Association Report on Standards for Cardiopulmonary Resuscitation, declaring, "The purpose of cardiopulmonary resuscitation is the prevention of sudden, unexpected death. Cardiopulmonary resuscitation is not indicated in certain situations, such as in cases of terminal irreversible illness where death is not unexpected or where prolonged cardiac arrest dictates the futility of resuscitation efforts. Resuscitation in these circumstances may represent a positive violation of an individual's right to die with dignity."

Most medical societies followed suit, and Dinnerstein became embedded into medical standards throughout the country, and in other countries.

It is now realized that doctors should not prolong dying, but instead promote dignity. The physician must weigh the concepts of benefit and burden, and realize that such decisions are value judgments and moral decisions. The physician must always consider the quality of life of his/her patient, to which the patient can hopefully enlighten him/her.

Over the past 30 years, the nation has witnessed debates over Terry Schiavo, and in popular culture in such movies as "Whose Life Is It Anyway?" "Sea of Life," and "Million Dollar Baby." But no one seriously denies that a patient has the right to refuse treatment, and that futile or inhumane treatment should be discouraged. Margaret Edson's Pulitzer prize winning play "Wit" became the basis of new medical school initiatives to discuss the need for end of life dignity. Bill Moyers had a famous series on this topic.

We may take the need for the concept of dignity and for the need for DNR orders almost for granted in 2008. Certainly, grey areas remain, and public discussion remains needed. But we need to remember that today's discussion, and today's law, remains grounded in the 1978 Dinnerstein.

Is this still a "Brave New World?" In reality, questions of our mortality have always been with us, and are "only new to thee." This year, in the wake of Schiavo, and in the turbine of other medical reforms, we need to continue the discussion that was begun 30 years ago, in the case of Dinnerstein.

James Murtagh has spent 20 years as an intensive care unit physician. He was associate professor of internal medicine at Emory University until 2001.

To read other articles by Dr. Murtagh, please go to

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2.      In the News: New Drugs for Rare Diseases

The Orphan Drug Act Has Been a Huge Success, By ED RENSI , WSJ, June 23, 2008; 

In more than 32 years with McDonald's, I worked my way up from grill man to president and CEO by focusing on providing shareholder value while fulfilling a need. In that vein I'd like to recognize the 25th anniversary this year of a groundbreaking piece of legislation that has made it easier for drug companies to do exactly that.

The Orphan Drug Act, signed into law President Ronald Reagan in 1983, made it possible for companies to invest hundreds of millions of dollars in the development of potential treatments for rare diseases. A rare, or orphan, disease is defined as one that affects fewer than 200,000 Americans. By offering tax incentives for clinical trials of these treatments and granting seven years of patent exclusivity once the drug is approved compared to an average of five years with most new drugs the Orphan Drug Act gave hope to the collective millions of Americans living with these horrible diseases.

One of its most notable achievements has been to make the capital markets less risky for biotechnology investors. It has allowed companies to secure financing for research and development, and created opportunities for scientists and entrepreneurs to make important advancements in treating these rare diseases.

Prior to this legislation, it was prohibitively expensive for a company to develop a drug for a disease that affects so few people. In fact, in the decade before the law was passed only 10 new drugs for rare diseases were developed. In the 25 years since, more than 1,100 new treatments for orphan diseases have entered the research pipeline, and over 300 new orphan drugs have been approved by the Food and Drug Administration.

The Orphan Drug Act fosters collaboration between for-profit corporations and nonprofit organizations something I have not only encouraged, but also practiced. As regional vice president of McDonald's USA in Philadelphia, I was approached about the need families of children with cancer had for affordable housing so that parents could be close while their child was undergoing treatment. I decided in 1974 that the Philadelphia market of McDonald's would join in the building of the first Ronald McDonald House, by making it possible for many committed people to take the risk and raise money through our restaurants.

Using nothing but philanthropic funds, we helped to build Ronald McDonald House Charities into what it is today, with 276 Ronald McDonald Houses scattered around the globe. I strongly believe that it is important for a corporation to stand for something and contribute to society in a way in which its employees can be proud.

This isn't always easy for companies to do. The Orphan Drug Act has made it easier for many nonprofit organizations to partner with companies to find treatments for rare diseases. That includes the Scleroderma Foundation, which is celebrating its 10th anniversary this year. . .

I often hear people talk about fighting the terrible diseases that cause Americans pain and suffering, but I rarely hear about real solutions. The visionary leaders who helped to pass the Orphan Drug Act 25 years ago are an exception to the rule. They backed up the talk by creating incentives for companies to innovate and fulfill an unmet need, making it less risky to build a business on treating or curing a rare disease. As we celebrate the anniversaries of the Orphan Drug Act and the Scleroderma Foundation, let's follow their example and move from talk to action by supporting legislation and organizations that make it easier for companies to innovate and solve problems.

Mr. Rensi is the former president and CEO of McDonald's USA and current co-owner of Team Rensi Motorsports.

To read the entire report, go to

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3.      International Medicine: Unequal Health Care Under Canadian Medicare

Waiting for new drugs in Canada: Access to new medicines is delayed or blocked by government policies and drug plans, By Mark Rovere and Brett Skinner

Before a new drug is introduced for sale in the Canadian market, Health Canada must approve it as safe and effective. Thereafter, patients who are dependent on public drug programs1 must wait for the province in which they reside to determine if the cost of the drug will be covered by the public plan.

The recently released second annual edition of the Fraser Institute publication, Access Delayed, Access Denied, measures the length of time patients must wait to access new drugs in Canada. The report reviews the impact that Canadian public policies and institutions have on lengthening the time that patients must wait to have access to newly developed patented prescription drugs. The report also compares consumer access to new drugs under government drug insurance programs relative to access under private sector drug insurance plans. By measuring the impact of government policies and programs on access to new medicines, especially relative to private sector access, the report draws attention to a significant failure of government intervention that could be alleviated by more economically liberal policy approaches.

Access delayed

The total wait time for accessing medicines in Canada is measured in two segments: the national delay - the time spent waiting for Health Canada to certify the safety and effectiveness of a new drug and authorize its use in Canada - and the provincial delay - the time spent waiting for provincial drug insurance programs to approve the public reimbursement of new drugs.

Figure 1 shows the consolidated average wait time for access to new medicines in Canada, broken down by each of the two segments described above. This wait time is measured in days and is presented as an average of wait times for pharmaceutical and biological drugs, 2 including all classes of non-generic new drug approval submissions.

In 2006, the average length of time taken by Health Canada to approve the use of new medicines was 380 days. In the same year, the average subsequent delay resulting from provincial approval of reimbursement for new drugs averaged 323 days (averaged across all provinces and drug submissions). Including both the national delay and the provincial delay, the total average wait time for patients dependent on public drug benefits for insured access to new medicines was 703 days (1.9 years) in 2006.

International comparison

Access Delayed, Access Denied 2008 compares the time spent waiting for government approval of new drugs in Canada, Europe, and the United States.

The data indicate that from 2002 to 2004, Health Canada took longer on average to approve new drugs than the European Medicines Agency (EMEA), its European equivalent. However, in 2005, Health Canada's performance, on average, improved significantly relative to its European counterpart, approving new drugs 67 days quicker than the EMEA. Similarly, Health Canada took 379 days on average to approve new medicines in 2006, compared to 399 days (on average) for the EMEA (Skinner and Rovere, 2008).

When comparing wait times for new drugs in Canada with those in the United States, the data show that the wait times in Canada were shorter than those in the United States in three of the five years studied (2002-2006). In 2006, Health Canada's median approval time significantly decreased from the previous year and was below the US Food and Drug Administration's (FDA) median approval time. The FDA's median approval time in 2006 was 351 days, while Health Canada's median approval time was 328 days. Health Canada took a shorter time than the FDA to approve new drugs in 2002 and 2003, but a longer time in 2004 and 2005.5

These analyses suggest that over the course of the period studied, Health Canada has been improving its drug approval process relative to its international peers. Nevertheless, delays in accessing new medicines caused by Health Canada's approval process currently average more than one year.

Provincial comparisons

In addition to the year-long average delay caused by Health Canada's new drug approval process, the provinces create an additional delay of nearly one year while deciding whether to reimburse the cost of the new drugs certified by Health Canada. Data show that the provinces take 323 days (on average) to declare a new drug eligible for public coverage after it has been approved by Health Canada (figure 1). This means that patients who are dependent on their province's public drug programs must wait almost two years in total before having access to new medicines.

Access denied

To make matters worse, many of the drugs that are approved by Health Canada as safe and effective are not even declared eligible for reimbursement under most provincial drug plans. Averaged across all provinces and public drug plans, only 39% of new drugs that obtained market authorization from Health Canada in 2006 were declared eligible for public reimbursement under provincial drug insurance programs as of October 20, 2007 (table 1).

This means that, in 2006, patients who were dependent on public drug plans were covered for less than half of the drugs that were approved for sale by Health Canada. In contrast, our research indicated that patients who were covered by private insurance plans or could afford to purchase medicine on their own would have had access to virtually all of these drugs as soon as they were approved by Health Canada (with rare exceptions for "lifestyle" drugs). . .

Universal private drug insurance

The evidence suggests that the scope of drug benefits coverage is demonstrably better under private sector insurance plans than it is under government-run drug programs. Policy makers should consider the merits of introducing means-tested, publicly subsidized access to private insurance as a better mechanism for achieving universal access to prescription drugs. Such a policy approach would be expected to reduce or avoid the restrictions on consumer choice associated with central planning.

To read the entire articles and well-designed charts, go to

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: Unequal Health Care Under Medicare


Blacks undergo leg amputations as a complication of diabetes at a far higher rate than whites, according to a study by Dartmouth College out today that also found blacks lag behind whites in breast cancer screening and diabetic tests.

Researchers used data from Medicare to look at amputations, screening rates and other measures of quality care among the 50 states and the District of Columbia.  Other major findings:

         Across the United States, the rate of leg amputation is four times greater among black Medicare recipients than white.

         Black residents of Louisiana, Mississippi and South Carolina had 6 amputations per 1,000 Medicare enrollees, while black residents of Colorado and Nevada had fewer than 2 per 1,000.

         Overall amputation rates for both blacks and whites vary among states; Utah has the lowest rate at .5 amputations per 1,000 Medicare members, and Louisiana has the highest at 1.7 amputations per 1,000.

Blacks also were less likely than whites to get mammograms to check for breast cancer, although the size of the gap varied widely among states:

         In Illinois, for example, 63 percent of white female Medicare beneficiaries were screened for cancer, while only 51 percent of blacks were.

         In Massachusetts, the gap was narrow: 71.9 percent of whites were screened, 71.5 percent of blacks.

With the exception of Arizona and Kentucky, black diabetic patients were less likely to get a recommended annual blood test than whites.  The biggest gap was in Colorado, where 84 percent of whites and only 66 percent of blacks were tested, according to the researchers.

Source: Julie Appleby, "More Blacks Than Whites Must Lose a Leg to Diabetes," USA Today, June 5, 2008.

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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: MediGap Insurance

Recently we have had an influx of Medicare patients. The surprising thing has been the number without MediGap insurance, the policy that Medicare provides through private insurance at a nominal cost to pay for the yearly deductibles, co-payments, and prescription drugs in order to make health care relatively free and unrestrained.

The disparity in attitudes as well as health care costs is striking when compared to the patient with MediGap insurance, usually an HMO policy. The patient with MediGap insurance has a very large appetite for anything with a potential health benefit at the expense of taxpayers, never thinking they are "one of them."

The patient with Medicare as the primary insurance without MediGap is always looking for a cheaper way to obtain the diagnosis and be treated. This brings about a health discussion between the patient and physician concerning the most economical way to get a diagnosis and treatment for an illness. Various avenues in making diagnosis and treatment decisions sharpen the focus not only for the patient, but for everyone on the health care team.

In our experience, Medicare patients without MediGap avoid excessive laboratory testing, reduce the extent of x-ray examinations, and reduce to every other year rather than annually the preventive mammograms and pap smears recommended by many authorities. They do not ask for PSA testing after the age of 75 and reduce their doctor visits to those that are necessary rather than for every ache and pain that is part of the human experience.

Estimates of costs savings might be construed as conjectural, but it appears that there is a reduction in health care costs approaching 30 percent to 50 percent.

Thus, if every Medicare recipient were denied additional insurance, Medicare would be solvent today and remain solvent, since the hospital and outpatient deductible and the outpatient 20 percent co-payment would be self-policing. Medicare micromanaging and controls would not be necessary.

Outlawing MediGap Insurance Would Preserve Medicare.

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6.      Medical Myths: Congress can control Health Care costs. Shall we start with big OIL?

Investigate Big Congress, Not Big Oil, By Alex Epstein 
(Bucks County Courier Times, May 29, 2008; FrontPage Magazine, May 30, 2008)

With gasoline prices exceeding $4 a gallon in some states, politicians are responding as usual: Blame Big Oil First. Several prominent senators have once again summoned industry leaders to Capitol Hill, subjecting them to yet another barrage of rhetorical questions, interruptions, accusations, and sermons. The lawmakers' goal, claims Sen. Patrick Leahy, is to identify "causes of the rising price of oil on which Congress can act." But the foregone conclusion is that "price gouging," "collusion," and "market manipulation" by Big Oil, or speculation by financiers, is responsible.

The simple fact that such Congressional investigations are designed to obscure is that the prices of oil and gasoline are determined by supply and demand--which neither private oil companies nor speculators have any power to dictate in their favor. If they had such market mastery, then why didn't they use it in the 1990s, when gasoline was selling at a barely profitable $1 a gallon? To be sure, speculators can bid up prices--but they only do so when they believe that oil will become even more expensive in the future, and only make money when they are right.

The question Congress should really be asking, then, is: What nonmarket factors are distorting supply and demand? If they sought an honest answer, they would discover that much of the blame lies with Congress itself.

No one disputes that environmentalist laws passed by Congress have cut off some of our most promising and plentiful sources of oil. In the name of safeguarding a tiny portion of caribou habitat in the Alaskan wilderness, drilling is prohibited in the Alaska National Wildlife Refuge--a potential source of 1 million barrels a day, 5 percent of America's daily oil consumption. Also off-limits is 85 percent of America's coastline, which Shell estimates contains some 100 billion recoverable barrels--13 times America's annual oil consumption--and the vast majority of oil shale in Colorado, which Shell estimates at 1.5 trillion barrels. . .

And how about the effects of Congress's open hostility toward the future of oil? Our politicians damn oil as an "addiction" to be eliminated, and seek to cut--by up to 90 percent--the use of oil and other vital fossil fuels that make our standard of living possible. Congress should ask oil executives how this possible forced cut in demand affects their industry. It should ask whether they feel safe to make the billion dollar investments and decades-long plans that oil production requires when Barack Obama, a leading presidential candidate, can uncontroversially proclaim that "the country that faced down the tyranny of fascism and communism is now called to challenge the tyranny of oil." Is it a coincidence that the much-maligned speculators think oil will become even scarcer in the future, and are acting accordingly?

In addition to investigating its own impact on gasoline prices, Congress should investigate how its economic policy partner, the Federal Reserve, has raised our gas prices by lowering the value of the dollars we buy gasoline with. The Fed, along with the Treasury Department, has for years had an inflationary policy that has caused the value of the dollar to plummet relative to other currencies. Were it not for this devaluation of the dollar, oil prices would likely be 40 percent lower--as they are for those on the Euro. Why not call a free-market economist to the stand and ask how much more expensive Alan Greenspan, Ben Bernanke, and Henry Paulson have made our gasoline?

Americans deserve to know the story--in all its gory detail--of what their government has done and is doing to cause high prices at the pump, and to make gasoline--indeed, all energy--more scarce and more expensive in the future. A congressional investigation of Congress would be a great public service. - top

Alex Epstein is an analyst at the Ayn Rand Institute, focusing on business issues. The Institute promotes Objectivism, the philosophy of Ayn Rand--author of Atlas Shrugged and The Fountainhead.

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7.      Overheard in the Medical Staff Lounge: Professionalism in Dress Code

Dr. Dave: A patient returned from a cardiology consultation and asked me to send him to a real doctor.

Dr. Ruth: What was wrong with the consultant?

Dr. Dave: The patient said he didn't look like a doctor. He was not dressed professionally.

Dr. Kaleb: I can understand that. I've been appalled by the dress of many American doctors. No one in my country would have any respect for a doctor who wasn't professionally attired.

Dr. Milton: I don't think we can dictate appropriate dress, but I think many patients have more respect for doctors that look like professionals.

Dr. Dave: I try to avoid sending patients to doctors that don't look professional in my estimation, but this was the only cardiologist available that evening.

Dr. Ruth: Do you think that most patients are more tolerant of after-hours dress?

Dr. Milton: Depends on the hour. Shortly after office hours, I think the daytime professional dress is expected. Making a three a.m. call is somewhat different.

Dr. Rosen: Maybe I'm from the old school. I would wear a coat and tie for a three a.m. call just the same as a three p.m. call.

Dr. Yancy: As a surgeon, if I'm in the office, I would agree. In the hospital, I'll wear greens. I'm not going to change several times a day between operations while on the ward.

Dr. Rosen: I think those of us from the old school would accept that. But dress also reflects respect; both from the physician and the patient.

Dr. Dave: Professionalism creates respect, which in turn improves the Doctor/Patient relationship.

Dr. Patricia: I think always wearing a White Long Coat is important in the Doctor/Patient relationship as well. Since I'm wearing a nice starched coat, I'm more easily recognized as a professional.

Dr. Dave: I think it also decreases many calls after hours. If I get more respect during the day, they treat me with more respect after hours.

Dr. Milton: I think appropriate dress and decorum is extremely important and helps solve many of the problems that plague us. We're being treated more and more like school children.

Dr. Rosen: Even school children on the continent wearing coats and ties to school seem to be getting more respect than doctors being casual.

Dr. Dave: I guess that pretty well tells the story. The first step in improving our image is our dress. We can't afford to dress less than professionally at any time a patient sees us.

Dr. Patricia: Not even at the grocery store?

Dr. Rosen: I think not even in a store, church or a lay meeting.

Dr. Ruth: When I go grocery shopping, I don't think my patients would even recognize me without my face on or hair done.

Dr. Milton: I don't think any of us guys can judge a woman's dress or demeanor.

Dr. Michelle: But I think a patient can judge a woman's dress and her demeanor.

To read more about how doctors think, go to

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

Vital Signs, Official Publication of the Fresno-Madera Medical Society and Kern County Medical Society, March 2008

President's Message: Medical Professionalism: Society's Expectations, Our Expectations, And the Role of FMMS by DAVID SLATER, MD

"There is no reason to doubt the possibility that medicine may fall from the ranks of professions without increased vigilance and a concerted effort to more clearly fulfill society's expectations of us." - William Norcross, MD, Clinical Professor of Family Medicine, UC San Diego, speaking at the FMMS General Membership Meeting on February 6, 2008

Attendees at our February general meeting heard a spirited presentation by Dr. William Norcross. For 33 years he has guided physicians-in-training into professionalism at UC San Diego, and for 12 years he has directed a program there to address lapses in professionalism. (During his presentation, he delivered a sidebar tragicomic lament about how during his two recent hospitalizations at UCSD Medical Center, it became clear how endangered is the art of the physical exam. The story drew nods of agreement in the FMMS audience and went to the point of "competency assured" see below.)

At the heart of Dr. Norcross' presentation was an enumeration of reciprocal expectations that underpin the "contract" between society and its physicians. The idea is that a contract can only remain stable and serve all parties when the expectations underlying it are acknowledged and are met or at least aspired to by all sides.

First the expectations that society has of its physicians (these are based on Cruess SR, Clin Orthop 2006; 449:170):

Service as healer
Competence assured
Morality and integrity
Promotion of the public good

Next, the expectations we physicians have of society:
Health care system is value-driven and adequately funded
Shared responsibility for healthcare
Monopoly if service is adequate to societal needs
Rewards: Commensurate status, respect, money. . .

The admonition at the beginning of this article makes clear Dr. Norcross' opinion that, even at a time when physicians can readily point to ways our expectations of society are not being met, we must still equate society's expectations of us, with our expectations of ourselves. The surest way to de-professionalize physicians - perhaps irreversibly - is to devalue or ignore society's expectations of us as a response to shortfalls in how society is currently meeting our expectations. The best hope we have of society respecting its obligations to physicians, Dr. Norcross maintained, is to meet what we know are society's expectations of us.

This plays into Dr. Norcross' belief that physician organizations - from County Societies like FMMS, to State and National Societies and hospital medical staffs - play a critical role in fostering physician professionalism. Societies like ours offer a framework to achieve much of what the public expects of us. They also offer a way for us to interface with the public in ways that demonstrate our commitment to societal expectations and to be reminded of what they are. This is precisely what the "contract of medicine" needs now, and Dr. Norcross was highly encouraging of our group. This was one of his closing slides:

Promote the Public Good:
Join your county, state, and national medical societies.
Participate in your hospital, professional societies, and the community.
Become involved in the "issues of the day" and work toward solutions that benefit your patients and society.

It has always been FMMS's mission to promote the public good. . . To read the rest of this editorial, please go to

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9.      Book Review: Health Care Co-Ops

HEALTH CARE CO-OPS IN UGANDA Effectively Launching Micro Health Groups in African Villages, by George C. Halvorson, The Permanente Press, Oakland, CA; Portland, OR, 2007, ISBN-13: 978-0-9770463-1-7, 175 pp, $19.95,

Before accepting a position with the Kaiser Foundation Health Plan, George Halvorson was the President and CEO of HealthPartners. Why did HealthPartners, a multi-billion dollar United States health care plan head quartered in Minnesota decide to help set up tiny health care co-ops in Uganda? Because HealthPartners is, itself, a health care co-op - the largest health care co-op in the world.

Land O'Lakes, a sister co-op for dairy farms also headquartered in Minnesota, has a long history of going into developing countries to set up local dairy co-ops. Uganda is one of more than a dozen countries that have benefited from the Land O'Lakes outreach initiative over the past two decades.

Uganda is a poor country full of brave people. Per capita income is a mere $270 per year. AIDS, dysentery, malaria and parasitic infections are common. The infant mortality rates are among the highest in the world. The health care infrastructure is tiny, fragile, unevenly distributed, and functionally uncoordinated. Almost no one is insured through the private sector, and the government simply can't afford to provide care to every person who needs it. The tiny health care co-ops HP set up in Uganda were really the only available form of health coverage in the communities served.

About eight years earlier, members of the Land O'Lakes African dairy co-op were doing well - functioning cooperatively - collecting its milk together, processing it together, protecting the quality together, and selling the milk together at a good price. Farmers working together had better incomes. The local market had better mild. The co-op was also importing carefully selected bull semen from the United States to upgrade the local herds and increase the milk production levels of its cows. Antibiotics were also being made available by the co-op to help ailing members of the tiny cattle herds. The cows in that Ugandan village had never been so healthy or so productive.

One of the farmers at the meeting said to the Land O'Lakes staff, "We now have good veterinary care for our cattle. Is there any way we can also get medical care for our children?"

That question intrigued the Land O'Lakes staff. When they returned to Minnesota, they called HealthPartners and asked that same question. Could it be possible to set up health care co-ops in a third world country, maybe starting with a foundation of small, local dairy co-ops?

HealthPartners decided to explore that possibility. A team from HealthPartners went to Uganda to meet with the co-op leaders. Two doctors and two administrators made that first trip. They met with dozens of rural Ugandan co-op leaders in half a dozen locations, and they concluded that it was worth a try.

Halvorson describes in this volume what the staff from HealthPartners has learned and accomplished since that time. There are now working health care co-ops in Uganda. They are serving thousands of people in a dozen villages and rural communities. People are getting care that they wouldn't have gotten without the co-ops.

It was the cooperative thing to do. Co-ops tend to be a bit evangelical in their approach to the world. People who understand the co-op mentality know that the Land O'Lakes efforts to support developing nations' dairy farmers are very much in keeping with the worldwide tendency of co-ops to help other co-ops get started.

The approach HealthPartners is using in Uganda will not solve Uganda's health care problems. It will make life better for some Ugandans, however. Much better. Women will have prenatal care. Kids will survive dysentery and malaria. Disease will be prevented for some people and cured for others. Some people will be healthier. Not everyone - but some.

Is that enough?

One of Halvorson's favorite stories is of a man walking down a beach early in the morning. As he looked down the shore, he saw another man in the distance walking toward him. The other man was regularly stooping over picking something up, and throwing it into the ocean.

As the men drew closer, the first man saw that the stranger was picking up shellfish and throwing them out to sea.

"What are you doing? He asked. "Why are you throwing those shells into the water?

"Because the tide invariable catches some shellfish and washes them ashore," the stranger replied. "They die on the shore, so I throw them back into the water."

The first man looked down the shore in both directions. There were shells far up and down the coast.

"It's hopeless," the first man said. "There are huge numbers of them. You're just one person. You can't possibly make a difference."

The second man bent over and picked up another shellfish. He held it for a second and then he threw it far out to sea. He looked at the first man and said softly, "Hey, it made a difference for that one."

What's the value of one human life? What's the value on one surviving child? What's the value of one mother being healthy enough to care for her family? What HealthPartners is doing in Uganda won't change the world. But it is making a difference. A real difference in real lives. That's good enough.

Before Halvorson finished writing about what happened, he left HealthPartners to move to Kaiser Permanente, the nation's largest non-profit health maintenance organization (HMO). With other priorities, he put the draft on the shelf. After two years, as more people were asking about the Ugandan co-ops and if there was anything in writing, Halvorson took the draft and wrote this book.

This is more than a story of what happened in Uganda or how co-ops work. It is an excellent study of how health care works in many adverse circumstances, including when budgets are meager. The chapter on trying to reach a ten-cent Target was another illustrative example of "LEAN" as it is now progressing to health care, especially in Non-Profit Health Care, as in Kaiser Permanente, and being attempted in For-Profit HMOs. LEAN having been successful in industry is now involving health care reducing costs without loss of quality.

This review is posted at

To read more reviews, go to

George C. Halvorson
Chairman and CEO
Kaiser Foundation Health Plans and Hospitals

George C. Halvorson is chairman and CEO of Kaiser Foundation Health Plan, Inc. and Kaiser Foundation Hospitals, headquartered in Oakland, California. Kaiser Permanente is the nation's largest integrated health plan, serving more than 8.4 million members in nine states and the District of Columbia. He has more than 30 years of health care management experience. He was formerly President and CEO of HealthPartners, headquartered in Minneapolis. He is the author of "Epidemic of Care" published in April 2003, and "Strong Medicine." He is currently writing two new books, one about racial prejudice around the world, and another about systematic reform of health care in America.

To read more about LEAN, go to,,

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10.  Hippocrates & His Kin: Everybody's Practicing Medicine Except Doctors

Many patients who just turned fifty are bringing in a letter from their insurance company to obtain a colonoscopy. This is not geared to the patient's medical history, the family history, or to any colon symptoms. It is not cost effective but just for publicity to show that the "insurance company really cares." But it will come back to haunt them, and the fall out will be to the doctors because it's their signature that ordered it at the behest of the insurance carriers. Many of the gastroenterologists have been quite leery about doing colonoscopies without a medical indication. They feel they are gouging the patient.

Doctors following HMO directives lower the standard of care and their own standards.

Hemoglobin A1C
The prevailing test to assist in making the diagnosis and then managing the patient with diabetes is for the patient to do finger stick glucose determinations and a glycohemoglobin (HgbA1C) test every 3 to 6 months. Many insurance carriers monitor this since they can see if a charge of HgbA1C has come through as frequently as possible. They put those numbers in the equation to determine how much of the 10 or 20 percent withhold they will return to the physician for obeying their guidelines. Diabetics on diet only may not have any elevations. Thus, the expensive HbgA1C tests are not medically necessary.

Insurance carriers practicing medicine will lower the quality and increase the cost.

Glucose monitoring
Diabetes may be the worst disease that affects humans. As the disease progresses to diabetic nephropathy, diabetic retinopathy, and diabetic neuropathy with progression to leg ulcers, gangrene and amputations, the horrors manifest themselves. Diabetics monitor their blood sugars by doing finger sticks before meals and at bedtime. Medicare doesn't pay for more than one finger stick per day unless the patient's on insulin. However, endocrinologists, the specialists most expert in diabetes and other endocrine diseases, are now having patients with a strong family history of diabetes in first degree relatives monitor their finger stick glucose levels several times a day. If both parents have diabetes, the children are all genetic diabetics from birth. The goal is to never experience clinical diabetes by appropriate diet. One patient noted that his finger stick was 30 points higher in the morning after eating a large baked potato or large bowl of white rice or a large helping of pasta for dinner. Thus, that patient avoided baked potatoes, white rice and pasta so as to never get clinical diabetes. Doctors are very good at modifying care to each individual patient.

Medicare practicing medicine lowers the quality of care and increases the cost of health care.

To read more medical vignettes, please go to

To read HMC, go to

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11.  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

                      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.

                      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.

                      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 2550 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 Read his "Lessons from the Past." For additional articles, such as the cost of Single Payer, go to; for Health Care Inflation, go to

                      Dr Richard B Willner, President, Center Peer Review Justice Inc, states: We are a group of healthcare doctors -- physicians, podiatrists, dentists, osteopaths -- who have experienced and/or witnessed the tragedy of the perversion of medical peer review by malice and bad faith. 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, write an informative Medicine Men column at NewsMax. Please log on to review the last five weeks' topics or go to archives to see the last two years' topics. Have some fun this month and read New Bio-Fuel: Non-polluting, Efficient and Aromatic.

                      The Association of American Physicians & Surgeons (, The Voice for Private Physicians Since 1943, representing physicians in their struggles against bureaucratic medicine, loss of medical privacy, and intrusion by the government into the personal and confidential relationship between patients and their physicians. Be sure to read News of the Day in Perspective: Sabotaging health savings accounts. Don't miss the "AAPS News," written by Jane Orient, MD, and archived on this site. This month, be sure to read DOCTOR NURSE. 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 most current issue. Don't miss the excellent articles and book reviews. Be sure to read Jane Orient's book review of The Criminalization of Medicine: America's War on Doctors by Ronald T. Libby.


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Del Meyer

Del Meyer, MD, Editor & Founder

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Words of Wisdom

When you blame others, you give up your power to change. -Robert Anthony

Find a job you like and you add five days to every week. -H. Jackson Brown, Jr.

"Pain is temporary. It may last a minute, or an hour, or a day, or a year. But eventually it will subside and something else will take its place. If I quit, however, it lasts forever." -Lance Armstrong, Cyclist.

Some Recent or Relevant Postings

James Murtagh, MD:

A Piece of the Pie by Charles B. Clark, MD:

Health Care in the 1930s by Eleanor Rodgerson, MD,

In Memoriam

John Reginald Surdeval Routh, prankster, died on June 4th, aged 80

He could have gone into the army, like his father. His liking for footnotes might have suited him to be an historian. If his lion's mane of hair had been clipped a bit, and his alarmingly shaggy eyebrows had been half disguised by a bowler, he might have cut a figure in the city; for the accent was right, and he always looked dapper with a brolly. But what Jonathan Routh preferred to do was to dress up as a tree, wait at a bus stop and enquire which bus would take him to Sherwood Forest.

That was one of his easier japes. He also attempted to take a grand piano on the London Underground, and persuaded a crowd of tourists that Nelson's Column needed holding up. He set up pyramids of plates to crash when people passed them, and rigged a mirror in a hat shop so that, when each matron posed simperingly before it, the glass cracked from side to side. His notion of a day's work was to ask a passer-by for tuppence for a cup of tea and, having got the money, produce Thermos, milk and sugar for the astonished benefactor and inquire whether they wanted one lump, or two.

Mr Routh played pranks all his life. Uppingham ejected him for hanging a banner reading "Vote Routh, Communist" in the school chapel, and Cambridge parted company with him after he gathered hundreds of signatures to stop an imaginary motorway across Bletchley Park. In 1957 he put an ad in the Times: "Practical joker with wide experience of British public's sad gullibility organises, leads and guarantees success of large-scale hoaxes." He hoped never to do anything else.

His career was made with the appearance in 1960 of the TV series "Candid Camera", in which he starred for seven years. The idea of surreptitiously filming people being tricked had come from Allen Funt in America; but Mr Routh gave it a singularly British twist, and his dark, disturbing features announced the definitive arrival in Britain of the camera as spy. When odd or embarrassing things happened to people after 1960, they would half-expect Mr Routh and his camera to be watching. The modern plague of CCTV devices has grown up in the shadow of his melancholy smile.

He also did much to turn Britons into a nation of voyeurs. On "Candid Camera", they did not merely twitch the lace curtains; they stared boldly, and laughed cruelly, as unsuspecting people had their cars pranged by Mr Routh attempting to park, or were levitated as they made calls from a public kiosk, or jumped as the post box talked to them. Hiding behind the petrol pumps, viewers could watch the astonishment of a mechanic as he discovered that the car Mr Routh had coasted into the garage contained no engine - neither under the bonnet, nor under the chassis, nor in the boot. "How did you drive in here, sir?" "I just came from Basingstoke." From a safe but nosy distance, they could watch as a frantic woman attempted to pack cakes on a conveyor belt that had been made to run three times as fast as usual.

Car-racing nuns

British post-war formality was always useful to him. A prank of serving tea in a cup stuck to the saucer was all the better because people - having tried and failed to lever them apart with spoons or brute strength - still attempted to sip nicely. A trick where a pickpocket removed not only wallet, but also braces, was made wonderful by the indifference of everyone standing by; and Mr Routh's journey as registered "livestock" through the post from Sheepwash in Devon to Fleet Street, accompanied, as required, by a postal official, was deeply enhanced by the official's polite silence all the way. As Britons lost their patient obsequiousness, Mr Routh's pranks played less well. He turned to books: "The Good Loo Guide" (with three-star establishments "worth travelling out of your way to experience"), "The Good Cuppa Guide" and "Leonardo's Kitchen Notebooks", in which every invention was in fact a pasta machine.

Some pundits believed that "Candid Camera" led directly to modern TV reality shows. Certainly Mr Routh, like a demon in a Gothic tale, was after the unexpected, the moment of shock that would reveal the true character of the victim. But his victims were innocent. They had not pushed themselves forward, like the self-promoters of "Big Brother" or "Survivor", and had no thought of seeking fame through humiliation on the screen. They were simply caught in the act of being themselves.

After the show's demise Mr Routh continued to lead a prankish and other-worldly life, shifting from England to Italy and Jamaica as the sun shone, running through various affairs, and bartering bright primitive paintings to settle his restaurant bills. As a painter, he showed a penchant for formal figures suddenly released from all constraints. He painted nuns driving racing cars and flying balloons, the pope windsurfing, Mona Lisa naked or smoking. His favourite subject was the aged Queen Victoria, on an imaginary trip to Jamaica in 1871, doing the hula-hoop or the limbo dance, riding a zebra and driving dodgem cars. He could have found a more prosaic explanation for the missing three months of her reign. But he preferred, as ever, the shock of the absurd, and the sense of the detached voyeur intruding on private space.


On This Date in History - June 24

On this date in 1947, the first reports of the sighting of flying saucers were made. The mysterious objects were supposed to have been sighted above Mount Rainier, Washington. In later years, the reports were much more detailed including little green creatures and later humans inside the space ship. Then the story broke - the Commander of one of the Flying Saucers returned to his own planet and reported that he had landed on earth and visited Times Square. "What did you see there," he was asked. "Well," he said, "there were a lot of little creatures moving about and at every corner there was a big creature with red and green eyes bending over and winking at them. I think the big creatures were making speeches." After that, they no longer came to visit earth.

On this date in 1948, Soviet Russia blockaded West Berlin. It is hard to believe that in 1948, Russia could have thought that by blockading the land and water routes from the West-to-West Berlin they could starve that city or its Western affiliation into submission. As they learned over the next months, they had forgotten all about going by air. Isn't Air one of our best channels of communication, even though much of it is Hot?

After Leonard and Thelma Spinrad