Physicians, Business, Professional and Information Technology

 Networking to Restore Accountability in HealthCare & Medical Practice

 MedicalTuesday, Vol IV, No 4, May 31, 2005

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In This Issue:
1. Technocrats' Takeover Threatens Patient-Oriented Medicine
2. Now That Chimeras Exist, What if Some Turn Out Too Human?
3. UK's Prime Minister Takes Time out from His Election Campaign to Instruct Doctors How to Make Patients' Appointments. Laughable? No, Tragic
4. An Insider's Critique of the Health Care System
5. Medical Gluttony: If You Don't Mind Doctor, I Would like For You to Just Start over and Do All My Tests Again
6. Medical Myths: Sick Time Represents Medical Illness
7. Overheard in the Medical Staff Lounge - Convalescent Hospital Rounds
8. The MedicalTuesday Recommendations for Restoring Accountability in Medical Practice, HealthCare and Government

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1. Technocrats' Takeover Threatens Patient-Oriented Medicine
Susan Konig, Managing Editor of the Heartland News, discusses the report "How Technocrats Are Taking Over the Practice of Medicine: A Wake-up Call to the American People," written by Twila Brase, president of the Citizens' Council on Health Care (CCHC), that challenges the "increasingly touted theory of evidence-based medicine (EBM)."

Calling evidence-based medicine "managed care masquerading as science" at a special press briefing for the release of the report in December, Brase told reporters in St. Paul, Minnesota, "control over medical decisions is being shifted from doctors to data crunchers; from professionals at the bedside to bureaucrats in big offices."

According to Brase, EBM "has become an ever-present mantra in health care publications. In the last few years, legislators have gotten hold of it and proposed legislation or actually placed the term into law."

For example, EBM guidelines are found in Maine's Dirigo Health Reform Act, signed into law in September 2003, and in the California Workers Compensation Reform of April 2004 (SB 899). EBM provisions have made their way into several health-related laws in Minnesota, and Colorado considered an EBM measure in 2004 but did not pass it.

"If evidence-based medicine is not understood for what it is, managed care [organizations] will use it to solidify [their] control over medical decisions and the practice of medicine. Managed care will become the law of the land," said Brase at her December press briefing.

Term Has Become Euphemism
"Evidence-based medicine has become a euphemism for managed care," Brase told reporters. "It's still care-restricting and physician-controlling, but the term gives leverage to care-restricting decisions. Behind this term, insurers can continue to impose limits on health care.

"But instead of explaining their decision by saying the service is not necessary or not cost-effective, they can say it is not scientifically sound. [That is] a much stronger argument, and much more difficult for the public to fight against. After all, who holds almost all the data? The insurers and the government--those who pay the bills."

Evidence-based medicine is defined as "the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients." (See Evidence-Based Medicine (Churchill Livingstone, 2000) by David L. Sackett.)

However, Brase said, individual patients are not the focus of EBM and its standardized practice guidelines. "The guidelines are created by accessing private medical record data, aggregating the data, and synthesizing it into population-based treatment algorithms for all physicians to use on all patients," said Brase. "EBM is group-think medicine."

Greg Scandlen, director of the Center for Consumer Driven Health Care at the Galen Institute in Washington, DC, described Brase's paper as a "landmark analysis of the attempt to bureaucratize medical practice."

Myriad Concerns Raised
The 22-page, extensively documented report points out not only the rationale espoused by proponents of "evidence-based medicine," but also the myriad concerns of critics of the practice. For instance, supporters say EBM and evidence-based practice guidelines ("best practices") are needed to, among other things, contain health care costs, reduce variation in physician practice, keep physicians up to date with the latest research, and reform medical malpractice. . . .

Brase's report quotes, for example, Dr. Uwe Reinhardt, an economist at Princeton University, from a 1999 published conversation on EBM. Reinhardt said, "My fear is that medicine will slide into the same intellectual morass in which economists now wallow, often with politics practiced in the guise of science. In medicine, it might be profit-maximizing in the guise of science."

Evidence Is Suspect
Besides the failure to view patients as unique individuals, practice guidelines have other problems, the report notes. The guidelines often fail to make explicit how recommendations are devised, and they rapidly become outdated, the study points out.
Brase writes, "In 2000, a group of researchers determined that more than 75 percent of the guidelines developed between 1990 and 1996 needed updating. In addition, they discovered that half the guidelines were outdated in 5.8 years."

. . . Quoting the 2004 Institute of Medicine publication, Patient Safety: Achieving a New Standard for Care, Brase notes the difficulty of determining what is authoritative evidence: "There are gaps and inconsistencies in the medical literature supporting one practice versus another, as well as biases based on the perspective of the authors, who may be specialists, general practitioners, payers, marketers, or public health officials."

Finally, critics have claimed EBM changes what it considers to be science in order to suit the goals of its proponents. Gary Belkin, M.D., Ph.D., author of The Technocratic Wish: Making Sense and Finding Power in the "Managed" Medical Marketplace, argues that different versions of "scientific credibility" can be embraced to change the power structure in health care.

EBM, he told Health Care News, is not just about science but about the destructive industrialization of medicine.

Harm Could Be Huge
Despite these concerns, Brase reports insurers, state governments, employer groups, and the U.S. Congress have begun implementing "pay-for-performance" strategies, including the monitoring of physicians through medical record surveillance and the issuing of compliance reports to pressure physicians to cooperate with EBM "guidelines."

In the process, practice guidelines essentially become practice directives, which puts individual patients at risk, according to Brase and other critics of EBM.

Brase's report quotes Dr. David M. Eddy, M.D., Ph.D., who warns, "If an individual physician and a patient make a wrong decision, that patient will be harmed, but the damage will stop there. In contrast, practice policies are intended to influence thousands, even millions, of decisions. If a policy is wrong, the harm can be huge."

May Hasten Rationing
Brase states that EBM may also hasten rationing of health care. In her study she notes the National Institute for Clinical Excellence was created in England in 1999 to, among other duties, provide guidance on medical "best practices." A 2003 paper by Syrett Keith of the University of Bristol, "A Technocratic Fix to the 'Legitimacy Problem'? The Blair Government and Health Care Rationing in the United Kingdom," in the Journal of Health Politics, Policy, and Law (August 2003: 28(4)), called the effort a "technocratic approach" and a "means for scientifically depoliticizing the rationing debate."

The Brase report provides readers with a brief history of EBM-type medical guideline development and legislative action on guidelines, including the Clinton Health Security Act, state legislative initiatives since the early 1990s, and the Medicare Modernization Act of 2003. The study notes that concerns about rising medical malpractice claims have caused policymakers to consider standardized practice guidelines as a means of protecting physicians against litigation.

Others see the promise of malpractice relief as a "political chip" to use in gaining physician support for the guidelines. . .

Brase's report includes statistics on guideline availability and costs of guideline development. The development cost, the report notes, depends on whether guidelines are developed and updated by the public or the private sector. One documented source reveals guideline production costs to be $80,000 to $100,000 unless the government does it, in which case the cost nears $800,000.

Implementation Costs Are Unknown
The U.S. government currently provides funds for guideline development to 13 designated Evidence-Based Practice Centers. However, no studies have measured the cost of guideline implementation, and some analysts say it is not clear the guidelines save money.

Brase emphasizes her belief that "evidence-based medicine" is not the objective, purely scientific tool its name suggests. Instead, she says, "EBM is an intrusive encroachment on the patient-doctor relationship and the practice of medicine; an encroachment that policy makers are turning into legal requirements."

Brase concludes the study with a strong warning to the American people: "The evidence-based medicine initiative involves a technocratic takeover of the practice of medicine through data collection, guideline creation, clinical surveillance, pay-for-performance strategies, and centralized decision-making. In short, EBM is aimed at stopping the heart of health care--the compassionate, first-do-no-harm, to-my-own-patient-be-true ethics of medicine."

Susan Konig (konig@heartland.org) is managing editor of Health Care News. To read her entire report, go to http://www.heartland.org/Article.cfm?artId=16433. To read the original report by Twila Brase, RN, President of the Citizens’ Council on Health Care, go to  http://www.cchconline.org/pdfreport/index.php.

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2. Now That Chimeras Exist, What if Some Turn Out Too Human?
Sharon Begley asks in her Science Journal column in the Wall Street Journal "If you had just created a mouse with human brain cells, one thing you wouldn't want to hear the little guy say is, 'Hi there, I'm Mickey.' Even worse, of course, would be something like, "Get me out of this &%#!! body!"

"It's been several millennia since Greek mythology dreamed up the chimera, a creature with the head of a lion, the body of a goat and the tail of a serpent. Research on the chimera front was pretty quiet for 2,500 years. But then in 1984 scientists announced that they had merged embryonic goat cells with embryonic sheep cells, producing a "geep." (It's part wooly, part hairy, with a face only a nanny goat could love.) A human-mouse chimera made its debut in 1988: "SCID-hu" is created when human fetal tissue - spleen, liver, thymus, lymph node -- is transplanted into a mouse. These guys are clearly mice, but other chimeras are harder to peg. In the 1980s, scientists took brain-to-be tissue from quail embryos and transplanted it into chicken embryos. Once hatched, the chicks made sounds like baby quails.

"More part-human chimeras are now in the works or already in lab cages. StemCells Inc., of Palo Alto, Calif., has given hundreds of mice human-brain stem cells, for instance. And before human stem cells are ever used to treat human patients, notes biologist Janet Rowley of the University of Chicago, they (or the cells they develop into) will be implanted into mice and other lab animals. "The centaur has left the barn more than people realize," says Stanford University law professor and bioethicist Henry Greely.

"Part-human creatures raise enough ethical concerns that a National Academy of Sciences committee on stem cells veered off into chimeras. It recommended last week that some research be barred, to prevent some of the more monstrous possibilities -- such as a human-sperm-bearing mouse mating with a human-egg-bearing mouse and gestating a human baby. "We're not very concerned about a mouse with a human spleen," says Prof. Greely. "But we get really concerned about our brain and our gonads."

"That's why his Stanford colleague, Irving Weissman, asked Prof. Greely to examine the ethical implications of a mouse-human chimera. StemCells, co-founded by Prof. Weissman, has already transplanted human-brain stem cells into the brains of mice that had no immune system (and hence couldn't attack the foreign cells). The stem cells develop into human neurons, migrate through the mouse brain and mingle with mouse cells. The human cells make up less than 1% of the mouse brain, and are being used by the company to study neurodegenerative diseases.

"But Prof. Weissman had in mind a new sort of chimera. He would start with ill-fated mice whose neurons all die just before or soon after birth. He planned to transplant human-brain stem cells into their brains just before their own neurons died off. Would that lead the human cells to turn into neurons and replace the dead-or-dying mouse neurons, producing a mostly human brain in a mouse?

". . .To reduce the chance that today's chimeras will be as monstrous as the Greeks' were, the U.S. patent office last year rejected an application to patent a human-chimp chimera, or "humanzee." But that, of course, just keeps someone from patenting one - not making one.

To read the entire article, go to http://online.wsj.com/article_print/0,,SB111533777277126366,00.html.

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3. UK's Prime Minister Takes Time Out from His Election Campaign to Instruct Doctors on How to Make Patients' Appointments. Laughable? No, Tragic.
Titled "Not what the doctors ordered," Simon Caulkin reports in The Observer earlier this month that "Medicine for the public services is the same as for the Bank of England: be independent.

"The most surreal episode in the election campaign was the panicked prime ministerial time-out from matters of trust, immigration and war in Iraq to instruct doctors how to make patients' appointments.

“In itself, the incident might seem laughable. But there could hardly be a more telling symbol of Labour's greatest domestic failure: its inability to fathom how its relationship with the public services should be managed.

"Think about it: after decades of privatisation, and the erection of a tentacular regulatory regime (now costing the public sector at least £13 billion a year) with the express aim of distancing government from the day-to-day management of services, ministers are more dedicated interferers than at any time in the past 50 years - perhaps ever.

"This is micromanagement on a gigantic scale (if you see what I mean). But it is more than that. Like the almost daily promises to get rid of MRSA, deliver cleaner hospitals, cut the number of asylum seekers, improve exam results, and shorten hospital waiting lists, the ministerial dictation of doctors' appointment systems is straight out of the Gosplan handbook for central planners, circa 1950.

"Command from the centre didn't work in the Soviet economy, and it doesn't work in the NHS either. The first reason is that the government doesn't know what patients ringing up for an appointment actually want. Since it doesn't know the nature of the demand (how many calls are real emergencies, how many can be handled by a nurse, how many are follow-ups) it follows that it can't know the real capacity of the system to meet it.

"In turn, this means that the famous target of all appointments within 48 hours is entirely arbitrary. Some surgeries may be able to meet it, others not. If enough pressure is brought to bear, those that can't will feel obliged to manipulate the numbers, as the only things under their control, to get the desired result. That's what happened in the appointments case, just as it happens in all other services subject to blanket specifications too.

"It follows also, because it's a government representation of what patients want rather than the thing itself, that the system is not likely to be a good one. It's not patient-friendly. A follow-up appointment a week later may be much more important than a first-time one which has to take place within 48 hours. But as a mass-production system it can't handle this legitimate variety. (see EBM by Konig above)

"Moreover, ministerial prescription subverts any possibility of improvement. As the scientist-philosopher Gregory Bateson put it: 'Learning proceeds from difference.' Difference has the political disadvantage of inequality, since some solutions will be better than others. But it has the advantage of movement: given a degree of choice, a better solution for patients or customers will attract more adherents, to the exclusion of poorer ones.

"The other thing Whitehall still doesn't seem to get is the costs of its interference. These are hidden but enormous. And although where they emerge is unpredictable, their incidence isn't. Tinkering with one part of a system always has costly ramifications somewhere else.

"In the surgeries case, the cost of meeting the 48-hour appointments deadline is that some patients find it harder to see their doctors for a follow-up. The cost of insisting that hospitals treat all accident and emergency patients within four hours is that some infected wards can't be taken out of commission to get rid of MRSA.

"So interference begets more interference, as ministers decree changes and regulators diligently amend and tighten the rules. But if the capacity isn't there - if there simply aren't enough doctors and nurses to attend to all the first-time and follow-up patients that need to be seen - surgeries will either not meet the targets or, if enough jobs depend on it, find new ways round them.

"And so the dance goes on, with more and more invention and effort going into satisfying ministers' demands for the right numbers and less and less into finding better ways of treating the patient.

"There are other casualties, too. Perhaps the most insidious is the degradation of official numbers. Paradoxically, the more the government prods, measures and intervenes, the less the figures it produces to show that the desired ends are being met, are believed.

"There are good reasons for the scepticism. We should know by now that you can't use the same figures for measurement and control: the control function corrupts the measurement.

"Because of the interventions, the figures are constantly being revised, so it's hard to compare like with like. But they're dubious anyway, partly because of the representation problem noted earlier, but also because in every public service they are subject to systematic manipulation. The figures may purport to show that no one has to wait more than two days to see their doctor, but any straw poll says the contrary - a next-day appointment is rare. The figures don't correspond to the reality as people experience it.

"The diagnosis from the doctor's surgery is that, the election over, New Labour needs a new start. Foreign adventures apart, its only hope of a fourth term is to win unambiguous recognition that public services are getting better. But to clean up the figures, it needs to acknowledge an unpalatable truth. The famous efficiency review, now being worked on in every department across Whitehall, has the wrong focus: the major engine of bureaucratic cost inflation is ministers themselves.

"Accordingly, to win back control over the numbers, No 10's Delivery Unit should decree a self-denying ordinance: reform starts with conquering the atavistic urge to command and control.

“That's not as paradoxical as it sounds. Curiously, there's a precedent under its nose. Practically New Labour's first significant act when it took office was to grant the Bank of England independence. Although the move was controversial then, it has come to be ranked as an almost unqualified success. No party wants to turn the clock back. The medicine is the same for any other public service. Set people a clear purpose, give them the keys to the system, hold them accountable - and stand well back.”

simon.caulkin@observer.co.uk    The original article can be found at http://observer.guardian.co.uk/business/story/0,6903,1478866,00.html.

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4. An Insider's Critique of the Health Care System - by Alex Berenson (NYTimes)
Many people think the health care system in the United States needs to be fixed. It may be a surprise that Henry A. McKinnell is among them. Mr. McKinnell is chairman and chief executive of Pfizer, the world's largest drug maker, which made $14 billion in profit last year, more than any other health care company. But in a new book, "A Call to Action" ( McGraw-Hill), he says that the system needs radical changes.

His description of the problems will ring true to anyone who has ever visited a doctor or filled a prescription, though some of his solutions - like higher drug prices for Europe - may strike readers as, well, a bit self-serving. In late May, Mr. McKinnell spoke about his book. Following are excerpts from the conversation:

Q. What prompted you to write the book?

A. I've been concerned for some time, many years, actually, that in the United States and countries abroad, that when it comes to health care, we're on the wrong track, and the problem starts with the definition of the problem, which is the high cost of health care. We know how to solve that problem. It's rationing access to medicine and treatment and it's price controls. And if we do that, my fear has long been that that carried to its logical extreme wouldn't be successful, that people would get frustrated, that they would get angry, and that's exactly what's happened.

Q. Your main prescription seems to be health savings accounts, that you want people to have more accountability and you want them to be more involved in making decisions about their health care.

A. The basic point I make is that we are in a crisis: it's not in health care, it's in sick care, and it's not because of bad people or bad intentions, it's because of the incentives. When you pay for procedures, don't be surprised that you get a lot of procedures. If people think that somebody else is paying for their health care, please don't be surprised that they spend a lot of money. So it's really the incentives I think we need to look hard at, and health savings accounts are only one example of how we can shift the incentives to people having ownership of their own health and therefore health care, as opposed to thinking that some third party pays the bill.

Q. And you mention technology as a major force - you would like to see more technology, you would like to see people with more access to all their records?

A. Oh, clearly. The corner supermarket has more technology than the typical hospital, and the fact that we don't have electronic medical records is a national disgrace. It means files are lost; we don't have any kind of efficiency within the health care system. I've never seen a number I really believe, but the best estimate I've seen is that administration costs in health care are 30 percent. Most businesses run on 4 to 6 percent. There's a lot to be done just on the efficiency side.

But my basic problem is not just the use of technology for cost-saving, but the use of technology for better diagnosis, better patient care, better patient education. So, for example, when you see a doctor today, the first question is always the same. "How are you?" Well, in an information-rich environment, the doctor would know more about you than you do, so he wouldn't have to ask, "How are you?" He would start at a much later place in the process.

Q. There are going to be a lot of people who are skeptical from the very beginning -

A. I do address that -

Q. You do -

A. From the very beginning (laughs).

Q. Can you address why should anyone trust the head of the world's largest drug company?

A. Well, you don't have to trust me, but if you read the book, I think you'll begin to question a lot of things that we are doing within the system that just don't make a lot of sense. You don't have to trust me. But listen to the ideas, reject them if you wish, but if you find yourself agreeing to some of these ideas, let's then start a debate around why it is we do that and how can we do it differently.


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

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5. Medical Gluttony: If You Don't Mind Doctor, I Would like for You to Just Start over and Do All My Tests Again.
As mentioned elsewhere in this newsletter, when you pay for tests and procedures, don't be surprised if you get a lot of tests and procedures. The lack of disincentives may really be perverse incentives to excessive health care costs. Hence, a lot of unnecessary tests and procedures are performed.

In January, one of the major insurance carriers eliminated one of the Sacramento Hospitals and it's medical group from their approved panel. About fifty of these patients migrated to our practice. We encouraged them to have their records transferred in order to give us a head start on their several medical problems. Unfortunately, many patients do not regard their medical record as a major document of their health care investment, which can be very expensive. Although it may represent an investment of tens of thousands of dollars and on occasions hundreds of thousands of dollars, they don't see it as a personal investment because someone else paid for it. Not wanting their medical record transferred is tantamount to abandoning a car or a home.

Last week, one of these patients with several medical problems came to our office and stated she would prefer not have her medical records transferred. She did not want me to have that information. Her contention was that her medical file would prejudice her treatment, thus she would be no better off than with her previous physician. Instead, she requested that I reorder all the tests and procedures to find out what was actually causing her problems. I pointed out that her cardiac and pulmonary problems were indeed real and not insignificant, but were well controlled. Also the results of the previously performed sophisticated and expensive tests would be helpful in our ability to treat her; repeating them would not only be expensive, but unnecessary and would give us identical information.

She obviously felt I was working for her insurance company and not for her. This is another expensive fall out of our current system of insurance companies’ attempt to practice medicine. This is not seen as competing with the doctor's authority, but working as a team against the patient. Thus, the patient never knows which side you are on. In the normal doctor and patient relationship, there is never any doubt in either's mind.

When the patient or consumer is not in charge of his or her health care, there is never an appreciation of the value of health care costs. This is the ultimate tragedy of those misguided individuals, organizations (including medical societies), government and others who want universal coverage or government medicine. Although there is no hard data on the excessive costs of such schemes, the estimates border on a 30 to 50 percent increase in unnecessary health care costs when third parties, whether government, insurance carriers, or any bureaucracies, are in charge. Thus the very people that say single payer will control health care costs are unwittingly producing the single, most expensive cause for further increases in health care costs. If single payer is implemented, it will be too late to control costs other than by denial, rationing and decrease quality of care.

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6. Medical Myths: Sick Time Represents Medical Illness
Unnecessary sick time is a huge employer cost. Unions are always working to increase sick days. It is logical that employees not work when they are really sick. However, utilization of sick days is frequently unrelated to illness. Historically, employees take more sick days around Thanksgiving, Christmas and other holidays when illnesses are actually less prevalent. They take more sick time when friends or relatives are visiting. They get paid for getting reacquainted.

During the last eleven years of solo practice, my sole employee never missed work because she was sick. She knew the patients would not have access to my care if she was not there. Just as on occasion I might be sicker than any patient I evaluated that day, likewise with her. When I picked up on her not feeling well, I would have her go home as soon as the patients were seen.

Last week, a patient had a panic attack on the light rail on the way to work at the State of California. He got off, took his Xanax and started to walk back home. Before he got there he felt well. I asked if he then proceeded to go back to work? He stated he had already called in from his cell phone, took the day off, and went over to the methadone clinic instead. He returned home by noon and relaxed in the sun.

I asked him who did all his work since he calls in sick so frequently. He said he didn't know. That was not his problem. Did he do any useful work on days that he showed up? He wasn't sure. He just did what his supervisor told him to do. In fact, he said, he had a good chance of being promoted to supervisor. He was excited about that. It would put an extra few thousand dollars per year into his retirement three years hence. "But won't you have to know the workings of your department when you supervise?" He said that when he got his promotion, he was sure there would be someone there to tell him what to supervise.

Meanwhile, I'll continue to write an excuse stating that he was seen that day and may return to work the following day. The joys of being an employee of the State of California are sometimes immeasurable. The cost to the taxpayer is huge. This is not to malign the state workers. I once worked at the State also. Almost all of us agreed that there were three or four times as many employees as was necessary on most days.

Also, see state subsidizes illnesses at http://www.lewrockwell.com/rockwell/sickness.html.

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7. Overheard in the Medical Staff Lounge - Convalescent Hospital Rounds
Dr Thom, who has primarily a convalescent hospital practice, makes rounds in the five convalescent hospitals he services. Since he has 40 to 50 patients in each, it takes him nearly all day to finish one. When he doesn't find the patient in the room, he continues his rounds wheeling the chart rack into the day room, the beauty shop, to physical therapy, and to the dining room.

One day, he was examining Mabel's heart and lungs under her loose fitting gown as she was finishing her dessert. He heard Sadie next to her complaining, "The men just don't pay us any mind. Just look at them across this long table. They've pushed their wheelchairs back and half of them are snoring."

Mabel: "So Sadie, what are you going to do about it?"

Sadie: "I think I'll streak right in from of them to get their attention."

Mabel: "Why don't you try it and see what happens."

Dr Thom couldn’t believe his eyes as he was recording his exam notes in Mabel's chart and looked up. There was Sadie at the far end of the table taking her clothes off and then she streaked naked right in front of all those men in their wheelchairs. Dr Thom saw a few raised eyebrows across the table as he overheard:

Al: "Joe, did you see what just went by?"

Joe: "Well, Al, I couldn't rightly make it out, but it sure looked like Sadie."

Al: "Yes Joe, but did you happen to notice what she was wearing?"

Joe: "No Al, not really. But whatever it was, it sure needed ironing."

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8. MedicalTuesday Supports These Efforts of the Medical and Professional Community in Restoring Accountability in Medical Practice, HeathCare and Government

PATMOS EmergiClinic - where Robert Berry, MD, an emergency physician and internist states: "Our point-of-care payment clinic makes acute and chronic primary medical care affordable to the uninsured of our community by refusing to accept any insurance (along with the hassles and crushing overhead that inevitably come with it).  As a result, our average professional fee is about $40, typically half that of surrounding clinics and less than 20 percent of local ER’s.  Even patients with insurance, including those with Medicare and Tenncare (Tennessee’s Medicaid), choose to pay amounts such as these from their own pockets for health care they have been unable to obtain in a timely fashion with their health coverage. Read the rest of the story at www.emergiclinic.com.  To read Dr Berry's testimony in Congress, click on the sidebar. Read Dr Berry’s response to Physician’s Support of Single-Payer Health Care or Socialism at www.delmeyer.net/hmc2004.htm.

• This Month We Welcome Michael J. Harris, MD - www.northernurology.com - 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 served in the U.S. Air Force as the Chief of Urology at Eglin Regional Hospital in Ft. Walton Beach, Florida for two years and as an instructor of surgery and urology at Wilford Hall USAF Medical Center in San Antonio, Texas. Dr Harris pioneered the development of a contemporary and anatomically correct method of radical perineal prostatectomy for prostate cancer while teaching urology in San Antonio. In 1993, he entered the private practice of urology and continue clinical research which has been expanded to other common urologic procedures. His publications reveal some of the most comprehensive analyses of clinical outcomes in the management of prostate cancer. Dr Harris is also nationally recognized for his medical care system reform initiatives. To understand that Medical Bureaucrats and Administrators are basically Medical Illiterates telling the experts how to practice medicine, be sure to savor his article on "Administrativectomy: The Cure For Toxic Bureaucratosis" at www.northernurology.com/articles/healthcarereform/administrativectomy.html.

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 www.simplecare.com.

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

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

Madeleine Pelner Cosman, JD, PhD, Esq, has made important efforts in restoring accountability in health care. She has now published her important work, Who Owns Your Body. To read a review, go to www.delmeyer.net/bkrev_WhoOwnsYourBody.htm. Please go to www.healthplanusa.net/MPCosman.htm 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 www.healthcarecom.net/OpEd.htm.

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 www.ssvms.org. To read his "Lessons from the Past," go to www.ssvms.org/articles/0403gibson.asp. For additional articles, such as the cost of Single Payer, go to www.healthplanusa.net/DGSinglePayer.htm; for Health Care Inflation, go to www.healthplanusa.net/DGHealthCareInflation.htm.

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 www.peerreview.org.

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 www.delmeyer.net/HMCPeerRev.htm.  To see Attorney Sharon Kime’s response, as well as the California Medical Board response, see www.delmeyer.net/HMCPeerRev.htm. 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.

 "There is no federal statute that requires peer review committees to observe due process, which the Supreme Court has defined as (1) giving written notice of the actions contemplated, (2) convening a hearing, (3) allowing both sides to present evidence at the hearing, and (4) having an independent adjudicator. Prior to the Health Care Quality Improvement Act of 1986 (HCQIA), the effects of an adverse peer review finding were restricted to the hospital involved. Because the HCQIA mandates the reporting of disciplinary actions of peer review committees to the National Practitioner Data Bank, such a report could harm a physician's career throughout the nation.” -- Segall & Pearl, Southern Med. J. March, 1993. To view some horror stories of atrocities against physicians and how organized medicine still treats this problem, please go to www.semmelweissociety.net.

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

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 www.newsmax.com/pundits/Medicine_Men.shtml. This week’s column is on "Another HIT on Health Care" asking "Are Americans ready to have their personal medical data online?" and can be read at http://www.newsmax.com/archives/articles/2005/5/18/132325.shtml.

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

Special Offer for Medical Tuesday readers: Receive a free gift subscription to the Newsletter and Journal of the Association of American Physicians and Surgeons (AAPS). “Founded in 1943, AAPS is the greatest voice for private physicians.  Each month we report on our actions promoting free market and ethical medicine.  In the past year AAPS has helped defeat the California medical board, the FDA, the DOJ and currently has briefs pending in multiple federal circuits.  Learn how to opt out of insurance and succeed with a cash practice.  Benefit from our network of thousands of like-minded physicians, and legal support.”

• “Please send an email to jeremy@aapsonline.org or call 800-635-1196 to take advantage of this no-strings offer to new subscribers.  Regular price is $160 (half-year), but it can be yours now for free.  Act now, while supplies last!”

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 Words of Wisdom

Dwight D Eisenhower: There are a number of things wrong with Washington. One of them is that everyone has been too long away from home. May 11, 1955

P. J. O'Rourke: If you think that health care is expensive now, wait until you see what it costs when it's free.

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

Winston Churchill: We contend that for a nation to try to tax itself into prosperity is like a man standing in a bucket and trying to lift himself up by the handle.

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

 Review some recent postings below.

Voices of Medicine: To read a review of the first issue of Sacramento Medicine in 1950, go to http://www.ssvms.org/articles/0403vom.asp remembering that the first 132 years are no longer available. To read this year’s series of my column, the "Voices of Medicine," go to www.healthcarecom.net/vom2005.htm.

Charles B Clark, MD: A Piece of the Pie: What are we going to tell those bright-eyed little boys and girls who are going to be the doctors of tomorrow? When there isn’t anything left for them, are we going to tell them we didn’t fight because the changes were inevitable anyway? What are we going to say when they ask us why we laid down and died when things got a little tough? Are we going to feel good about ourselves when we tell them it’s all right because we got a piece of the pie? Read Dr Clark at www.healthcarecom.net/CBCPieceofPie.htm.

Ada P Kahn, PhD: Foreword to "Encyclopedia of Work-Related Injuries, Illnesses and Health Issues. Dr Kahn came to Sacramento in February and I joined her on a Channel 31 interview about her book. I was privileged to write the foreword which we’ve posted at www.delmeyer.net/MedInfo2004.htm. To purchase the book, go to www.factsonfile.com/ and type in KAHN under search.

Henry Chang, MD: WEIGHT LOST FOREVER - The Five-Second Guide to Permanent Weight Loss, suggests daily weights to stem the weight loss before it becomes a problem and, if it does,  how to take it off and keep it off. Congratulations to Dr Chang for winning the Sacramento Publishers and Authors 2004 award for “Best Health Book of the Year.” Read our review at www.healthcarecom.net/bkrev_WeightLostForever.htm.

Tammy Bruce: The Death of Right and Wrong (Understanding the difference between the right and the left on our culture and values.) www.townhall.com/bookclub/bruce.html. Reviewed by Courtney Rosenbladt

An Alzheimer's Story: To read a touching story by a nurse about her Alzheimer's patient, go to www.delmeyer.net/MedInfo2003.htm.

An Entrepreneur's Story: AriadneCapital (http://www.AriadneCapital.com) provided the initial funding for MedicalTuesday and the Global Trademarking. Julie Meyer, the CEO, has a clear vision in her mind of the world that she wants to live in, and it's considerably different from how it looks now. If you're an entrepreneurial woman, or if you lost hope or are having difficulty envisioning success, (if you'll forgive a little nepotism), the following article may be of interest to you. www.observer.guardian.co.uk/business/story/0,6903,1237363,00.html

 On This Date in History - May 31

On this date in 1962, Adolf Eichmann was hanged by the State of Israel after being hunted down as a Nazi mass murderer of Jews in the Hitler era in Germany.

On this date in 1954, Dwight D Eisenhower made a speech at Columbia University's bicentennial as President of the United States and former President of Columbia. "Here in America we are descended in blood and in spirit from revolutionists and rebels - men and women who dared to dissent from accepted doctrine. As their heirs, we may never confuse honest dissent with disloyal subversion."


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