Community For Better Health Care

Vol V, No 4, May 23, 2006


In This Issue:


1.      Featured Article: The Mayo Clinic's new SPARC lab is driving experimentation

A Prescription for Innovation by Chuck Salter, a Fast Company senior writer based in Chicago.

The Mayo Clinic's new SPARC lab is driving experimentation at the frontier of health care. How? By getting physicians to think more like designers. From Fast Company: Issue 104 | April 2006 | Page 83 |

. . .The kiosk was getting there. And that was the idea: Put the earliest version, the rough sketch, in front of patients to see what they thought. Then use the feedback to tweak and retest. Then do the whole thing over again.

The Mayo Clinic in Rochester, Minnesota, is no stranger to innovation. W.W. Mayo and his sons - still known here as Dr. Charlie and Dr. Will - founded their rural group practice in the late 1800s around a new concept at the time: integrated medical care, which involved various specialists working together in the same building, performing comprehensive evaluations, and administering coordinated treatment. Ever since, innovation has been a vital part of the clinic's DNA, traditionally in the research lab.

But the approach with the kiosk - rolling out unfinished ideas to patients - is something new. Last summer, Mayo opened SPARC, a clinical innovation lab that operates like a design shop and that specializes in the "patient experience." Doctors, nurses, and other staffers do what designers do: They interview, shadow, and observe customers (in this case, patients) to uncover their needs, brainstorm with abandon, and engage in rapid prototyping - hence, the paper kiosk.

Despite its status as one of the best known and most respected medical facilities in the world, Mayo is wrestling with the same issues that designers routinely tackle: In an increasingly competitive field, how do you differentiate yourself? How do you generate fresh ideas and implement them in a timely fashion? And how do you make sure those ideas actually benefit customers?

Mayo's program is "definitely unique, and it has enormous implications," says Dr. Samantha Collier, vice president of medical affairs at HealthGrades, which rates the quality of the nation's hospitals. "Medicine has long been embedded in tradition. But just because this is what we've done since the days of Marcus Welby doesn't mean it's still the best way. [Mayo] could find disruptive ways of practicing medicine better. This isn't just about customer service but about quality."

SPARC is not simply a research lab or a medical clinic. It's both. Real patients see real doctors and, in doing so, participate in experiments (they're briefed and asked for permission). Instead of being shunted off-site, the program is based in the Mayo Building like any other clinic; it occupies a corridor that used to house urology. The acronym, which stands for "see, plan, act, refine, and communicate," is meant to remind participants of the design-oriented methodology so they'll continue to employ it when they return to their departments.

The idea grew out of the realization that outpatient care is overdue for fresh ideas. "Medicine has changed, people have changed, technology has changed, but the exam room isn't so different than it was in the 1800s," says Dr. Michael Brennan, an associate chair in the department of medicine, where the program originated. Mayo wants its doctors to apply the same experimental approach to clinical innovation that they apply to scientific innovation.

Ryan Armbruster, SPARC's director of operations and design, researched how other organizations, such as Procter & Gamble and Hewlett-Packard, foster innovation, and was struck by the prominent role of design. Dr. Alan Duncan, SPARC's medical director, had always thought of design as merely about aesthetics, but he quickly recognized the parallels to health care. "Look at how physicians generate a diagnosis," he says. "You do a history, listen, and think about all possibilities. It's purposefully broad to avoid locking into an early diagnosis, just as a designer wants to avoid locking into an early solution."

The inclusion of actual patients is critical. Understanding user needs, after all, is a tenet of smart design, says Armbruster. There are three types of needs: those that are explicit and tacit and can be identified by surveying and interviewing people; those that can't be articulated but become apparent through observation; and latent needs, the hardest to root out. "The only way to identify them is to make something and have people experience it," Armbruster says.

"Just because this is what we've done since the days of Marcus Welby doesn't mean it's still the best way. Mayo could find disruptive ways of practicing medicine better."

Dr. Victor Montori, an endocrinologist, brought doctors and patients to SPARC to experiment with a new way of discussing statins, drugs that lower high cholesterol. Too often, he says, patients get overwhelmed with information and let the doctor choose the treatment. Because they didn't decide for themselves, patients tend to abandon the therapy, which puts them back in the doctor's office.

Montori tested a one-page guide that gives an individual's risk of a heart attack, shows how statins affect those odds, and outlines possible side effects. He's still reviewing the data, which suggests better adherence to medication, but he already knows that the personalized guide got patients' attention. "After the fifth or sixth prototype, we started seeing an emotional and physical response," Montori says. "They were moved." He knows this because SPARC's exam rooms are equipped with small cameras that provide rare glimpses into doctor-patient interactions. "We hear all the time about a clinician being empathetic," Montori says. "Now we're watching empathy at work. The eye contact. The listening. We see the whole dance."

In fact, most everyone can see. With the help of office furniture maker Steelcase, Mayo created a highly transparent environment. The glass walls reveal SPARC's inner offices and show support staff working at the front desk; researchers reviewing project videos; and the SPARC team leading workshops in a central space that functions as an informal lounge and meeting room. SPARC removes the mystery found in a typical closed-off clinic.

The space is also highly flexible. Much of the corridor, including the exam rooms, can be reconfigured to accommodate a variety of experiments. Walls, furniture, and computers can be moved like puzzle pieces. "People come expecting to see the finished product," says Armbruster. "But they experience the opposite. They see prototypes in different stages of evolution."

Mayo's physicians both embrace design principles and integrate them with traditional medical research - in effect slipping the doctor's white coat over all-black designer duds. Doctors or managers propose a problem or a question they want to explore, and the SPARC staff assembles a cross-functional team, which gets a crash course on design methodology. By "the second hour, we were out with cameras, notepads, and tape recorders," says Becky Smith, a manager in patient education. Her team discovered that Mayo's main education center was confusing. It was intended for patients and family members to learn more about diagnoses or treatments. But because the space was open - no walls or doors - patients weren't sure if the computers were for them or the Mayo staff. When they did venture online, it was mainly to check email.

"We hear all the time about a clinician being empathetic. Now we're watching empathy at work. The eye contact. The listening. We see the whole dance."

To read the entire article, please go to

Chuck Salter ( is a Fast Company senior writer based in Chicago.

Have something to say about this story? Email the editor.

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2.      In the News: Selling Generic Drugs by Mail Turns into Lucrative Business

Benefit Managers Say They Save Employers Money, As Their Own Profits Rise -

Off-Patent Bonanza Ahead; By BARBARA MARTINEZ, Wall Street Journal, May 9, 2006


In many industries, middlemen scrape by on small margins. Not so in generic drugs.

Documents from 2001 filed in an Ohio court case show that Medco Health Solutions Inc. paid $90 that year for the pills to fill 114 prescriptions for a generic copy of Valium. Medco sent its client, the State Teachers Retirement System of Ohio, a bill of $1,028 for the drugs, which also reflected its dispensing costs. Medco paid $766 for the pills to fill hundreds of prescriptions for the blood-pressure medicine atenolol. It billed the Ohio teachers $25,628.

Today, Caremark Rx Inc., another middleman, charges the federal government and employees $96.88 for 90 pills of generic Prozac, according to a Caremark Web site. The same pills can be bought wholesale for less than $5.

Medco, Caremark and Express Scripts Inc. are the big three "pharmacy benefit managers," or PBMs. Employers that offer prescription-drug coverage hire PBMs to do the paperwork and keep costs down when an employee needs a prescription filled. More than 100 million Americans carry a card with the logo of one of the big three, using it at the pharmacy to show they're covered.

It's a hugely lucrative place in the food chain. Generic drugs are popular because they save money by offering alternatives to expensive brand-name drugs. But the PBMs have figured out how to use mail order to turn generics into a bonanza. Buying in bulk, the PBMs typically pay a few cents per pill, then turn around and bill employers a quarter, 50 cents or even a dollar a pill. A Medco spokeswoman, Ann Smith, says final profit is much smaller than that spread because of administrative and dispensing costs.

For the employers, the generic prices look like a bargain because they're generally still much lower than those of brand-name drugs. The employers often don't know the spreads enjoyed by the PBMs.

The big three PBMs' perch could grow even more valuable over the next five years as brand-name drugs with $47 billion in annual sales lose patent protection. Copies of top sellers such as the cholesterol drug Zocor and antidepressant Zoloft will take a big bite out of the drug industry's profits, while giving PBMs more chances to sell high-margin generics.

More than half of Medco's net income comes from filling generic-drug prescriptions at its mail-order facilities, although the mail business including brand-name drugs represents just 37% of revenue. Collectively, the big three recorded net income of nearly $2 billion last year.

The business has brought gains for PBM shareholders and made some PBM executives rich, chiefly from valuable stock options, even as many employers and employees struggle to afford health insurance. Caremark's chief executive, Edwin M. "Mac" Crawford, has sold $185 million in stock since November. (See article.) At Express Scripts, Chairman Barrett Toan has sold $64.8 million in stock since last fall.

It helps the PBMs that many employers are unfamiliar with the economics of manufacturing pills. While a brand-name pill such as Lipitor or Prozac may cost employers $2 or more, most of that goes into marketing, research into future drugs and profit for the drug company. The cost of actually producing the pills is usually only a few cents each.

After the patent on a drug expires, brand-name makers lose the monopoly that allowed them to charge a high price. But for customers accustomed to the old prices, it may seem like a bargain to get pills that used to cost $2 for just 50 cents.

The PBMs defend their lofty margins on generics, saying that they need the profits there to make up for overhead costs and losses or slim margins on brand-name drugs. They say employers benefit from their efforts to switch patients to generics. Pharmacies also add huge markups on generic drugs for some customers, such as uninsured people who pay for medicines out of pocket . . .

But for now, the generic mail-order business is booming. It represents the latest evolution of an industry that has played a key behind-the-scenes role in the $250 billion U.S. pharmaceuticals business.

The PBMs started out by promising to liberate employers from the grunt work of offering a prescription-drug benefit for employees. They could handle the paperwork when prescriptions were filled at pharmacies and make sure employers paid only for approved drugs . . .

Today, big facilities like Medco's can fill prescriptions in minutes and put them in the mail with barely a human hand intervening. At its Willingboro, N.J., facility, which Medco calls the world's largest automated pharmacy, trays of bottles get filled from 1,200 bins containing almost every major pill for chronic diseases prescribed in the U.S. Robots cap and seal the bottles after their two-mile journey and drop them into plastic mailing bags. The factory churns out more than a million mail-order prescriptions a week.

When the allergy drug Flonase lost patent protection this March, Medco says it converted 95% of brand prescriptions to generics within two days. A similar conversion in 2001 when Prozac went off-patent took more than six months, it says.

An even bigger opportunity is coming in June, when Merck's cholesterol fighter Zocor goes off-patent. Medco vice president Ken Malley says Medco has a "very overt, very aggressive program" to push generic Zocor. Medco will fax letters to 50,000 doctors urging them to put their patients on the generic pill. The letters say, "Help keep your patients' benefits affordable."

To read the entire article, please go to (Subscription required)

Write to Barbara Martinez at

[The only reason that the Big 3 PBM can charge $25,620 for $766 worth of drugs is that the patient – the primary beneficiary – is completely out of the picture. If patients dealt directly with the Big 3, the PBMs would each have to compete directly for the patient to continue to sell the drugs. There would be a racing frenzy to reduce the price of the drugs to attract the most patients. There is nothing more effective than the free market to reduce health care costs.  –Editor]

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3.      International Medicine: Canadian Medicare Loses in the Canadian Supreme Court

A Seismic Shift: How Canada's Supreme Court Sparked a Patients' Rights Revolution by Dr Jacques Chaoulli

Executive Summary    (

Early efforts by Western democracies to restrict freedom of contract were rationalized on the ground that such restrictions were necessary to prevent the suffering of ordinary citizens. People who oppose the freedom to opt out of state-run health insurance schemes turn that rationale on its head: they oppose freedom of contract even when it is necessary to prevent the suffering of ordinary citizens. A recent ruling by the Canadian Supreme Court has helped to restore that freedom and the right of patients to make their own medical decisions.

On June 9, 2005, to the surprise of many observers, the Canadian Supreme Court struck down two Quebec laws that gave the state-run Medicare system a virtual monopoly. The court ruled that Quebec's ban on private health insurance for services already covered under the Medicare program violated Canadian patients' rights to life, liberty, and security of person.

The ruling in Chaoulli v. Quebec has expanded the right of Canadians to obtain private medical care and opened the door to a parallel, private health care system. Canada's Supreme Court has thus validated freedom of contract as an important component of patients' rights. The ruling also provides a basis for challenging other government activities in health care and could have a significant impact on the U.S. Medicare program, compulsory health care programs in other nations, and certain forms of health care regulation.

Jacques Chaoulli is a physician and a senior fellow at the Montreal Economic Institute. He successfully argued the case Chaoulli v. Quebec before the Supreme Court of Canada, despite no formal legal training.



In advanced nations, the financing of medical care is dominated by state-run insurance schemes. In most cases, governments limit expenditures by limiting the supply of services in the face of heavy demand. As a result, many governments force patients to wait for care - often in pain, and often at the cost of the patient's life.

My adopted home of Canada has historically maintained one of the world's most rigid state-run health care schemes. With funding from the national government, Canada's provincial governments administer a compulsory, monopolistic health care system known as Medicare. All Canadians are compelled to finance Canada's Medicare system through general taxation. All Canadians must enroll in the Medicare program. Until recently, Canadians were forbidden to purchase private health insurance to pay for Medicare-covered services outside the Medicare system. That rigidity has been particularly problematic, given the economics of socialized medicine. Because the state offers "free" health care services, Canadians demand more services than they would if they had to pay. The provincial governments - like many nations - deal with that excess demand by forcing patients to wait for medical care. In Canada, as in other nations, rationing-bywaiting inflicts considerable harm. According to the Fraser Institute, the average wait for treatment in Canada is 17.7 weeks after referral from a general practitioner. That means that if a general practitioner gives a patient a referral to a specialist on January 1, the average patient does not receive treatment from the specialist until May 5. That is an average; some patients do not wait that long, others wait longer. However, the majority of patients generally wait much longer than what physicians consider "clinically reasonable."

The average wait has been increasing since 1993 (though in 2005 it fell slightly), and these delays seem impervious to additional funding. When the state pumps more money into Canada's Medicare system, waiting times often increase.

Those imposed waits can have painful and even fatal consequences. As Canada's Supreme Court noted in Chaoulli v. Quebec:

The evidence shows that, in the case of certain surgical procedures, the delays that are the necessary result of waiting lists increase the patient's risk of mortality or the risk that his or her injuries will become irreparable. The evidence also shows that many patients on nonurgent waiting lists are in pain and cannot fully enjoy any real quality of life . . .



"Social solidarity" was the justification offered by communist leaders from Cuba to Moscow to Beijing for restrictions on private health care and freedom of contract. Today, Russia and China have opened their health care sectors to private enterprise. About Cuba and China, the World Health Organization reported in 2000:

[S]ignificant barriers to market entry have sometimes been created, such as a legal ban on private practice. This is still the case in Cuba . . . China re-legalized private practice in the 1980s. Furthermore, China amended its constitution in 2004 to protect economic rights. With Chaoulli, Canada is moving toward liberalization along with many former communist nations. I hope that my adopted home will soon come to recognize that economic rights - particularly the right to control one's medical decisions - are fundamental. Chaoulli attracted international media attention. Commentators felt that a major event had happened. Still, it will take some time before the far-reaching ramifications of that judgment become apparent. In Canada and around the world, this ruling may help force politicians and courts to reevaluate whether using coercion to pursue absolute equality, or "social solidarity," is in fact compassionate or merely a subtle form of tyranny.  I hope this ruling will be a first step toward a worldwide revolution in patients' rights that reverses the trend toward the expansion of the welfare state in health care.

To read the entire report, please go to

[Medicine, Healthcare, and the peoples of the World will forever be indebted to Dr Jacques Chaoulli.]

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

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4.      Medicare: For All as in Massachusetts - But What's in the Fine Print?


Massachusetts's new universal health coverage law is being hailed as a model for what other states should do. But before you conclude that your state should enact a similar law, you might want to know how it would affect you. A careful reading of the Massachusetts law turns up surprises, says Betsy McCaughey, a former lieutenant governor of New York, who is chairman of the Committee to Reduce Infection Deaths.

Massachusetts aims to achieve universal coverage with a double mandate: All residents must have health coverage (Section 12) and all employers with more than 10 workers must assume ultimate financial responsibility if employees or their immediate family members need expensive medical care and can't pay for it (Sections 32, 44).

What is the impact on individuals?

  • The state will offer subsidies to help low income residents pay for coverage (Section 19), but most of the uninsured earn too much to be eligible.
  • An individual making $29,000 or more would probably have to pay the full cost or find a job that provides health insurance. Individual coverage costs about $3,600 in Massachusetts -- a hefty bill.
  • Moreover, under the new law, individuals purchasing their own insurance must buy HMO policies. Preferred provider plans (PPOs) -- which give you more ability to choose your own doctors and treatments -- are not allowed (Section 65).

It's one thing to criticize, says McCaughey, but there are alternatives to make health insurance more affordable. State legislators have pushed up prices by requiring policies to cover chiropractics, acupuncture and other services that are worthwhile -- if you can afford them. But mandating them is like passing a law that the only car you can buy is a Lexus, when all you can afford is a Ford Focus. People should be allowed to buy basic, high deductible insurance without costly extras.

Source: Betsy McCaughey, "Romneycare's Fine Print," Wall Street Journal, May 5, 2006.

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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: Patient-Driven Health Care Nips Excessive Health Care at the Source

During the recent World Health Care Congress, a senior administrator, who now has high deductible health insurance, relayed her own experience with Patient-Driven Health Care. After she left her gynecologist's office and was about to start her car, she looked at the laboratory tests that her OBG physician had ordered.  She noted that the tests were nearly the same as her internist had obtained the previous month. She returned to the office and explained this to the receptionist. She was told to have the lab results forwarded to the gynecologist's office and that would certainly be acceptable.

She commented that in the past she would not have paid much attention to what was ordered since her previous insurance company paid the bill and increased her insurance premiums every year or so. Now that she had a $2,000 deductible on her policy that she paid out of her own pocket, it became important for her to manage her costs.

It is important to note that, in this instance, consumer- or patient-driven health care cut the laboratory costs by 50 percent, a huge savings not appreciated or accepted by those who want to control individuals by having government control health care costs. It will not be efficiency that will control costs but denial of access and prolonged waiting lists, which have not proven effective in reducing costs in any system of health care. [It just makes the bureaucrats feel that they did some work, even if it was not useful or beneficial to anyone except themselves by providing job security.]

Medical Efficiency: Putting the Patient Financially in Charge Will Eliminate Excessive Health Care Costs Immediately, Without Further Effort on Anyone's Part.

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6.      Medical Myths: Universal Health Care Using EMR will Nip Excessive Costs at the Source

There is a push by the uninformed in government and in our industry that the electronic medical record (EMR) will also eliminate such costs as outlined above. This may not be so since they are unable to integrate this across a variety of practices. The above 50 percent reduction in cost did not occur when the internist and OBG physician were already part of a large managed care system. It occurred only because the patient obtained a Patient-Directed Health Plan.

The EMR eliminates such duplication only in a totally integrated system, such as Kaiser-Permanente and the VA. The Mayo Clinic and other large clinics have EMR, which works inside their clinics across a large number of services and departments. It does not compare to the total national integrations achieved in the Kaiser-Permanente system. The VA system has achieved it for their members that obtain their care exclusively within that system. However, a large number of their patients continue to have one foot in private practice and thus have two medical records, sometimes more, that never interrelate with each other, causing huge duplications. Many of the veterans in my practice find this duplication a source of great comfort.  The usual veteran response is that the VA is free and thus only their private care is a source of health-care costs.

The EMR is making rapid progress in the free-market environment. Government involvement in this process can only slow, diminish and frustrate the progress. We don't need another government bureaucracy to worsen our patient's health care and then blame private physicians and hospitals for a patchwork of disintegrated care. This is being used daily as an argument for the need of a government monopoly such as the disintegrating Canadian system.

Medical Truth: Patient-Driven Health Care, with or Without the EMR, Is the Only Mechanism for Eliminating Excessive Health-Care Costs.

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7.      Overheard in the Medical Staff Lounge: Dr Sam Is Beginning to Dislike Uncle Sam's Medicare

Dr Sam has been having quite an ordeal with Medicare. He reported this week that Medicare has not paid him for the past four weeks. His billing clerk has been hitting a stonewall on all attempts to reach Medicare electronically or by phone. She has been researching the Medicare manuals and has not been able to determine where the glitch is. Dr Sam isn't sure just what he wants to do. Options he's considering include becoming a non-participant in Medicare, firing his billing clerk, leaving the practice of medicine, or drive to the Medicare headquarters and make an issue of it. But then he thought the Medicare employees would have a belly laugh at his expense to think that cutting his income in half could conceivably hurt a doctor. The more heated he became in the lunchtime discussion, the more he thought it best to just eliminate Medicare from his practice.

Dr Dave wasn't much cooler as he came across the article in Opinion Journal about Great Moments in Socialized Medicine, which quoted from Mike Hume in the London's Times: 

Edward Atkinson, a 75-year-old anti-abortion activist, was jailed recently for 28 days for sending photographs of aborted foetuses [sic] to the Queen Elizabeth Hospital in King's Lynn, Norfolk. That draconian sentence was not deemed punishment enough: the hospital has banned Mr Atkinson from receiving the hip replacement operation he was expecting.

Dr Dave was wondering why the same people who don't trust the government to spy on terrorists, lest dissenters get caught up in the web, so often also urge giving government control over our health care?

Dr Rosen pointed out that some six or eight years ago when Medicare electronic billing began, the turn around time from billing to payment was supposed to be one week rather than the three- or four-week delay for paper claims. However, the government (Medicare & Medicaid) stated that the government coffers were unable to pay the past four weeks of claim in one week. They put in an electronic delay - all the claims went into a holding bin for three weeks and then the first week of claims were paid. When doctors complained, the response was rather straightforward. We can't be concerned about your lack of income for three or four weeks when the government does not have the funds to pay one month of the nations health-care cost in one week.

Dr Edwards complained about the frequent loss of claims from Medical, another government program. He actually made a trip to the claims office and was shown an auditorium with hundreds of desks with clerks processing claims. The Medicaid administrator told Dr Edwards that he was sure that every day there were hundreds or more claims lost in that huge auditorium. But there was nothing that could be done about that.

This ability of the government to manipulate electronic claims gave experience and precedent for later abuse and harassment by having data mysteriously disappear, temporarily or permanently. Of course, there was always an administrative explanation. Just as in Dr Sam's case above, which Dr Rosen was also experiencing at the present, Medicare gave the billing clerks an explanation that seemed to satisfy their billing clerk's questions.

Dr Rosen handled the present lack of half of his income for four weeks by borrowing $4,000 to cover the rent and salaries and delaying the payment of other bills. Dr Rosen has made the decision to no longer accept Medicare patients and is holding a decision in abeyance on what to do with his present Medicare patients.

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

A Medical Student's Introduction to the Politics of Medicine, by Brian Boone, Medical Student, FSU School of Medicine, From the Florida Medical Association Quarterly Journal 

I have always had a passion for two things; politics and medicine. On March 15, I ventured to Tallahassee for my first visit to the state capital seeking a chance to combine these interests as part of the Florida Medical Association's Legislative Visitation program. As a first year medical student at the University of South Florida, I spend the majority of my time learning the basic sciences of anatomy, physiology and biochemistry. Very little time is left to monitor the ever changing laws that influence my future profession. Before my trip, I knew that medical malpractice was a huge legislative battle, but I was not aware of the many other proposed laws that threatened the practice of medicine. My visit gave me an appreciation for the complexities of the current issues that affect physicians as well as the political process undertaken to create laws surrounding these issues.

In a single day at the capital, I was exposed to the important issues of tort reform, physician liability, and scope of practice.  I visited multiple committees where bills important to the medical profession were introduced, debated and voted on. I witnessed FMA President-Elect Dr. Patrick Hutton testify before the Senate Committee on Health Care, fighting to preserve physician scope of practice by opposing legislation that would allow pharmacists to give flu shots. I observed the House floor as our representatives debated the tort reform issue of joint and several liability. I was introduced to the complicated process of budget appropriations in the Senate Health and Human Services Appropriations committee. In one day, I witnessed legislative action on numerous bills that will have a dramatic influence on my patients, my ability to practice medicine, and my career. . . .

To read the entire article, please go to

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9.      Book Review: Symptoms of Unknown Origin, by Clifton Meador, MD, 175 pages, Vanderbilt University Press, $15.

Current Books: Biomolecular Misgivings By Colleen Foy-Sterling, MD, In Sonoma Medicine.

A patient is sharing her deepest pain. We sit across from her, slowly sinking into one of the most uncomfortable places for a doctor: being completely unable to empathize and frustratingly unable to offer a cure. As physicians we are sworn to help, to empathize, to care and care for; but it is sometimes altogether impossible.

Symptoms of Unknown Origin, by Clifton Meador, MD, is a compact, folksy remedy for these difficult encounters with a seemingly alien species. Feeling burned out and too pressured to follow the "15-minute hour" so strictly? If so, this delightful little book will be a pleasure to read, providing a slight breeze to your sails.

Meador has been a practicing internist for more than 50 years, and some of his stories are old-fashioned and politically incorrect. In fact, a few tales told by his mentors take place in the 1930s, 40s, and 50s. He seems unconcerned that some of his solutions involve taking a parental or controlling approach to patients. All is acceptable as long as physicians truly listen to patients and work to heal them, or at least to move ahead and get on with life.

Meador's freedom and abandon make his strategies thought-provoking and creative. How many of us would dare to withhold a diagnosis from a patient or to demand that a patient agree to see only you? (In one story, Meador recommends that surgeons not inform a married, male patient of the surgical findings that the patient had the internal organs of a woman.)

Meador graduated from Vanderbilt in 1955 as a true devotee of the biomolecular model of medicine. He confesses that his greatest desire as a newly minted MD was to deduce what was wrong with patients and fix it. He dreamily relates a memory from medical school that profoundly affected him: A female patient is wheeled into a deep, classic amphitheater. She is confined to a wheelchair, barely able to lift her head, and seemingly near death. A white-coated physician brings out a syringe and, with a dramatic injection, brings the patient "to life."

This case, of a patient with myasthenia gravis, is etched in Dr. Meador's mind: "I was amazed. I felt my neck and arms crinkle, as goose bumps rippled across my skin. Awe, in the truest sense of the word, flooded me." The power of the scientific method is demonstrated in all its glory. For years, Meador searches for that rush of amazing, powerful cure bestowed by the kind, intelligent doctor unto the patient.

That search eventually brings Meador to a polar opposite role. He becomes an expert in patients without a cure: those challenging, difficult, and downright annoying patients with "symptoms of unknown origin." Along the way, he discovers the writings of Michael Balint and works with Carl Rogers at the Center for the Study of the Person in La Jolla. There Meador learns how to give patients "full, undiluted, and riveted attention" via participation in "sensitivity sessions" and direct observation of physician-patient interactions.

In 20 cleverly titled chapters, Meador presents intriguing, personal stories of patients who confound their physicians. He explains that, after 50 years of practice, his "overarching thesis … is that the prevailing biomolecular model of disease is too restricted for medical use." Real patients often refuse to fit the biomolecular model. Whether they don't want to be saved, or whether their medical condition is too embedded in a web of psychosocial modifiers, some patients just defy definitive diagnosis and treatment. In fact, many patients come to Meador carrying incorrect diagnoses, invited by their own impossibly long list of symptoms . . .

Dr. Foy-Sterling, a family physician, serves on the SCMA Editorial Board.

To read the entire book review, please go to

Why Johnny Can't Comprehend What He's Reading By DAVID GELERNTER

A review of The Knowledge Deficit by E. D. Hirsch, Jr. (Houghton Mifflin, 169 pages, $22)

American schools are failing to teach our children to read intelligently, and "The Knowledge Deficit" explains why. You cannot be a successful reader, E.D. Hirsch reminds us, unless you understand the context in which the author is working. Competent readers depend on a store of shared knowledge that our children must learn -- but are not being taught.

Our schools are trapped instead in a nightmare of vacuous bullet-points and double-talk; teachers present "comprehension strategies" ("predicting, summarizing, questioning, clarifying") in place of plain, nourishing information. Students are shown again and again how to "classify, draw conclusions, make inferences, predict outcomes." But they still can't read intelligently. No author can possibly spell out the implied context of every sentence he writes. Children must learn to fill in those blanks -- but our schools refuse to teach them.

Imagine trying to read "War and Peace" armed with good "classification skills" instead of basic knowledge. Who was Napoleon? What do czars do for a living? Where is Russia? But those are mere facts and are secondary, according to education-school professionals, to such "metacognitive skills" as "making judgments," "questioning the author" and "looking for the main idea."

To read the entire review of our failing public school system, please go to (Subscription require)

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10.  Hippocrates & His Kin: Just a Notch above Lawyers

In the public opinion polls concerning who inspires the most confidence that people trust, the top has always been doctors, ministers, and Supreme Court justices. Who's on the other end? Well that may be changing. Congress was always considered a "notch above lawyers" until someone figured out that Congress is primarily a bunch of lawyers. Now many respect lawyers more and some have even placed them a "notch above Congress."

But has that really changed what's down in the cellar all that much?

Congress is trying to micro manage every aspect of the practice of medicine: what goes on in the consultation room, how the doctor records the medical history, what diagnosis the doctor is allowed to use, what five digit code the doctor has to use to get paid, have all diagnosis been upgraded every year, how to change the code every year which will confuse most offices and thus there will not be any urgency to pay the claim until after the second or third rejection, what laboratory tests the doctor can order, what procedures are approved by Medicare and Medicaid, who can go to a hospital, who can go to the emergency room, who has to go to a "doc in a box" facility, if the wrong decision is made, it's an excellent reason not to pay that claim, what is recorded in the hospital history and physical examination, what goes into the hospital summary, who can we discharge the patient to, what procedures do we have to follow on discharge, what can we order in a skilled nursing facility, in a custodial facility, in a board and care facility, who can we release the medical records to, how much of the medical record can we release and to whom, HIPAA now demands that we release the records to any governmental agency, but not to a doctor or hospital who are the ones that really need them without full disclosure. What restriction is next? (Censored!)

What other professions or business would allow someone to destroy them and their product?

Where are our professional medical organizations? What are they doing? Are they on our team in protecting us from the harassment and destruction of government? Are they trying to protect the interest of our patients and keep the doctor-patient relationship sacrosanct? Or are they politicians with their own agenda and thus part of the problem? Should we subject our leadership to a "confidence/no confidence" vote? Don't we have enough physician-lawyers that we can start to micromanage the legal profession? Can we tell them how long their appointments are allowed to be, how they have to record their records, whether electronically or be allowed to write, how they have to make them available to any government agency, to any court, to any party in a legal action?

Wouldn't that get Congress and the Bar off of our back?

The Legal Fraternity A BOOK REVIEW, By William Peniston, MD; How our laws have developed ever more largesse for trial attorneys while making the acquisition of truth increasingly difficult.

The Fraternity: Lawyers and Judges in Collusion by John Fitzgerald Molloy, 244 pgs. $22.95, Paragon House, ISBN 1-55778-841-3.

This is a book you must read. You may not enjoy it, but if you have any concerns about our legal system, and you surely must, you will learn there are more problems than you thought.

This is the story of a trial attorney, and the changes he was privy to, during 46 years of private practice that were interrupted by 12 years serving as a judge in various capacities, including the Arizona Supreme Court.

He admits to being a part of this "collusion" for almost all of his professional life. Admittedly, there were times when he mused about his "Daddy's" law practice and that of his own mentor, "Judge Hall." There even were times when he opposed some of the collusion and sometimes wrote minority opinions contesting some of the changes. To read the rest of Dr Peniston's book review, please go to

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11.  Restoring Accountability in HealthCare, 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 To read their latest postings, please go to


•                      PATMOS EmergiClinic - - where Robert Berry, MD, an emergency physician and internist practices. Here is his story: Three years ago, I left ER medicine to establish a primary care clinic in a town of about 15,000 in northeast Tennessee - primarily for the uninsured, but also for anyone willing to pay me for my care at the time of service.  I named the clinic PATMOS EmergiClinic - for the island where John was exiled and an acronym for "payment at time of service."  I have no third party contracts...not commercial, not Medicare, TennCare or worker's compensation. A year ago, over 95 percent of the patients I saw had no insurance.  Today, that figure may be 75 percent.  But even those with insurance learn a simple lesson when they come to me: health insurance does not equal healthcare, at least not at my clinic. I clearly tell my patients how much a visit will cost.  Because I need only one employee in my office, my costs are low.  If I can do it, caring for the uninsured in a small rural town, any doctor can.

•                      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.

•                      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" at

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

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

•                      Madeleine Pelner Cosman, JD, PhD, Esq, who has made important efforts in restoring accountability in health care, has died (1937-2006). Her obituary is at She will be remembered for her important work, Who Owns Your Body, which is reviewed at Please go to to view some of her articles that highlight the government's efforts in criminalizing medicine. For other Op-Ed articles that are important to the practice of medicine and health care in general, click on her name at

•                      David J Gibson, MD, Consulting Partner of Illumination Medical, Inc. has made important contributions to the free Medical MarketPlace in speeches and writings. His series of articles in Sacramento Medicine can be found at To read his "Lessons from the Past," go to For additional articles, such as the cost of Single Payer, go to; for Health Care Inflation, go to To read his latest article on When the Public Loses Faith in Physicians, 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 This week scroll down to read about the doctor that discussed a patient's obesity.

•                      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 click on archives to see the last two years' topics at This week's column is on "Medicare's Looming Crisis" and can be found at  

•                     The Association of American Physicians & Surgeons (, The Voice for Private Physicians Since 1943, representing physicians in their struggles against bureaucratic medicine, loss of medical privacy, and intrusion by the government into the personal and confidential relationship between patients and their physicians.  Be sure to scroll down on the left to departments and click on News of the Day. Be sure to understand how seniors are saving by NOT signing up for Medicare Part D at  The "AAPS News," written by Jane Orient, MD, and archived on this site, provides valuable information on a monthly basis. Scroll further to the official organ, the Journal of American Physicians and Surgeons, with Larry Huntoon, MD, PhD, a neurologist in New York, as the Editor-in-Chief. There are a number of important articles that can be accessed from the Table of Contents page of the current issue.

•                      To Attend the 63d Annual Meeting of the AAPS, in Phoenix, AZ, September 13-16, please go to, your gateway to a vast amount of information. 


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Del Meyer       

Del Meyer, MD, Editor & Founder

6620 Coyle Avenue, Ste 122, Carmichael, CA 95608

Words of Wisdom

Elisabeth Kόbler-Ross (1969): We have to ask ourselves whether medicine is to remain a humanitarian and a respected profession or a new but depersonalized science in the service of prolonging life rather than diminishing human suffering.

F Scott Fitzgerald (1896-1940): No grand idea was ever born in a conference, but a lot of foolish ideas have died there.

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

Some Recent Postings

The Health Insurance Marketplace

Consumer-Driven Health Care: Are Health Savings Accounts the Answer? 

Medicare Reform: Pharmacy Benefit Program - What Must Be Done - A Clinician's Point of View

In Memoriam

Jane Jacobs, anatomiser of cities, died on April 24th, aged 89

. . . This picture formed her distinctive philosophy of cities, and her clarion-call against the 20th-century wreckers. Cities should be densely peopled, since density meant safety; old buildings should rub up against new, and rich against poor; zoning should be disregarded, so that people lived where their jobs were; cars should not be banned, but walking encouraged, on pavements made wide enough for children to play. Streets should be short, so that people were obliged to experiment and explore and have the fun of turning new corners, just as she had done when hunting for jobs and apartments in her first months in New York.

The book in which these thoughts appeared, "The Death and Life of Great American Cities" (1961), was among the most influential and controversial of the 20th century. It stopped America's urban renewal movement in its tracks, to the utter fury of Moses, Felt, Mumford and the rest. Mrs Jacobs, for all her academic-looking fringe and glasses, had no credentials save her high-school diploma. . . .  Read the entire Obituary at

On This Date in History – May 23

On this date in 1785, Benjamin Franklin designed the first bifocal glasses. A man of many talents, in his later years he needed two pairs of glasses: one pair for reading, one pair for seeing at a distance. Old Ben got tired of switching from one pair to another, so he designed a pair of eyeglasses where the upper portion of the lens was for distance and the lower portion for reading. If we aren't sure through what part we're looking, we may see the world in the wrong perspective.

On this date in 1922, the play, Abie's Irish Rose opened on Broadway.  The critics gave it a rather unfriendly reception. As a result, it ran for 2,327 performances and became one of the longest running plays in the history of the theatre. This illustrates that the public has an interesting habit of making up its own mind. Some feel that the age of television and mass media, comments can make or break an artistic offering, or a politician or a product. Others feels that most products, whether plays, movies, speeches, stand or fall on the basis of their own performance.