Community For Better Health Care

Vol X, Dec 13 & 27, 2011


In This Issue:

1.                  Featured Article: Social media in the 16th Century

2.                  In the News: Michigan has become the latest to repudiate Obamacare:

3.                  International Medicine: Santa Claus Governments

4.                  Medicare: Medical Entitlements can never be controlled by Medical overview.

5.                  Medical Gluttony: No preparation for the medical appointment.

6.                  Medical Myths: Why are Humans so impressionable, emotional, and irrational?

7.                  Overheard in the School Lounge: What do you do for Christmas?

8.                  Voices of Medicine: Secrets of the Operating Room

9.                  The Bookshelf: Dandy Dames

10.              Hippocrates & His Kin: Not a Ringing Endorsement

11.              Related Organizations: Restoring Accountability in HealthCare, Government and Society

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

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                  Merry Christmas 2011                  

Saturday night, December 24, 1776, marks the anniversary of George Washington leading his troops across the Delaware to attack the British the next day in New Jersey. Thus began the greatest experiment in human freedom the world has ever experienced. The history of governments for millennia has been one of oppression and servitude. Freedom of this magnitude was never previously sought nor enjoyed by a nation. This freedom lasted for 150 years. It has been gradually restricting for the past 75 years. We must be forever on guard that our government does not repeat history. Government has found a new access to our most personal and private lives - our medical records. This last invasion now makes control over our very lives absolute. Let's make our final stand in our battle of Appomattox, which on April 9, 1865, preserved our nation in the Civil War. To that end, MedicalTuesday is dedicated to restoring freedom in health care - the only assurance of privacy in our personal health matters and in our lives. After this battle is won, we will continue the battle for the Freedom we won in 1776, began losing in 1933, and nearly completed in 2011, to eliminate the intrusion of government into our personal and private lives.  

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1.      Featured Article: Social media in the 16th Century                                                                   

Five centuries before Facebook and the Arab spring, social media helped bring about the Reformation

How Luther went viral: The Economist | from the print edition | Christmas Specials | Dec 17th 2011

IT is a familiar-sounding tale: after decades of simmering discontent a new form of media gives opponents of an authoritarian regime a way to express their views, register their solidarity and co-ordinate their actions. The protesters’ message spreads virally through social networks, making it impossible to suppress and highlighting the extent of public support for revolution. The combination of improved publishing technology and social networks is a catalyst for social change where previous efforts had failed.

That’s what happened in the Arab spring. It’s also what happened during the Reformation, nearly 500 years ago, when Martin Luther and his allies took the new media of their day—pamphlets, ballads and woodcuts—and circulated them through social networks to promote their message of religious reform. Read more . . .

Scholars have long debated the relative importance of printed media, oral transmission and images in rallying popular support for the Reformation. Some have championed the central role of printing, a relatively new technology at the time. Opponents of this view emphasize the importance of preaching and other forms of oral transmission. More recently historians have highlighted the role of media as a means of social signaling and coordinating public opinion in the Reformation.

Now the internet offers a new perspective on this long-running debate, namely that the important factor was not the printing press itself (which had been around since the 1450s), but the wider system of media sharing along social networks—what is called “social media” today. Luther, like the Arab revolutionaries, grasped the dynamics of this new media environment very quickly, and saw how it could spread his message.

New post from Martin Luther

The start of the Reformation is usually dated to Luther’s nailing of his “95 Theses on the Power and Efficacy of Indulgences” to the church door in Wittenberg on October 31st 1517. The “95 Theses” were propositions written in Latin that he wished to discuss, in the academic custom of the day, in an open debate at the university. Luther, then an obscure theologian and minister, was outraged by the behaviour of Johann Tetzel, a Dominican friar who was selling indulgences to raise money to fund the pet project of his boss, Pope Leo X: the reconstruction of St Peter’s Basilica in Rome. Hand over your money, went Tetzel’s sales pitch, and you can ensure that your dead relatives are not stuck in purgatory. This crude commercialisation of the doctrine of indulgences, encapsulated in Tetzel’s slogan—“As soon as the coin in the coffer rings, so the soul from purgatory springs”—was, to Luther, “the pious defrauding of the faithful” and a glaring symptom of the need for broad reform. Pinning a list of propositions to the church door, which doubled as the university notice board, was a standard way to announce a public debate.

Although they were written in Latin, the “95 Theses” caused an immediate stir, first within academic circles in Wittenberg and then farther afield. In December 1517 printed editions of the theses, in the form of pamphlets and broadsheets, appeared simultaneously in Leipzig, Nuremberg and Basel, paid for by Luther’s friends to whom he had sent copies. German translations, which could be read by a wider public than Latin-speaking academics and clergy, soon followed and quickly spread throughout the German-speaking lands. Luther’s friend Friedrich Myconius later wrote that “hardly 14 days had passed when these propositions were known throughout Germany and within four weeks almost all of Christendom was familiar with them.”

The unintentional but rapid spread of the “95 Theses” alerted Luther to the way in which media passed from one person to another could quickly reach a wide audience. “They are printed and circulated far beyond my expectation,” he wrote in March 1518 to a publisher in Nuremberg who had published a German translation of the theses. But writing in scholarly Latin and then translating it into German was not the best way to address the wider public. Luther wrote that he “should have spoken far differently and more distinctly had I known what was going to happen.” For the publication later that month of his “Sermon on Indulgences and Grace”, he switched to German, avoiding regional vocabulary to ensure that his words were intelligible from the Rhineland to Saxony. The pamphlet, an instant hit, is regarded by many as the true starting point of the Reformation.

The media environment that Luther had shown himself so adept at managing had much in common with today’s online ecosystem of blogs, social networks and discussion threads. It was a decentralised system whose participants took care of distribution, deciding collectively which messages to amplify through sharing and recommendation. Modern media theorists refer to participants in such systems as a “networked public”, rather than an “audience”, since they do more than just consume information. Luther would pass the text of a new pamphlet to a friendly printer (no money changed hands) and then wait for it to ripple through the network of printing centres across Germany. . .

As with “Likes” and retweets today, the number of reprints serves as an indicator of a given item’s popularity. Luther’s pamphlets were the most sought after; a contemporary remarked that they “were not so much sold as seized”. His first pamphlet written in German, the “Sermon on Indulgences and Grace”, was reprinted 14 times in 1518 alone, in print runs of at least 1,000 copies each time. Of the 6,000 different pamphlets that were published in German-speaking lands between 1520 and 1526, some 1,700 were editions of a few dozen works by Luther. In all, some 6m-7m pamphlets were printed in the first decade of the Reformation, more than a quarter of them Luther’s. . .

Both reformers and Catholics used this new form to spread information and attack their enemies. “We are Starting to Sing a New Song”, Luther’s first venture into the news-ballad genre, told the story of two monks who had been executed in Brussels in 1523 after refusing to recant their Lutheran beliefs. Luther’s enemies denounced him as the Antichrist in song, while his supporters did the same for the pope and insulted Catholic theologians. . .

Luther’s enemies likened the spread of his ideas to a sickness. The papal bull threatening Luther with excommunication in 1520 said its aim was “to cut off the advance of this plague and cancerous disease so it will not spread any further”. The Edict of Worms in 1521 warned that the spread of Luther’s message had to be prevented, otherwise “the whole German nation, and later all other nations, will be infected by this same disorder.” But it was too late—the infection had taken hold in Germany and beyond. To use the modern idiom, Luther’s message had gone viral. . .

Modern society tends to regard itself as somehow better than previous ones, and technological advance reinforces that sense of superiority. But history teaches us that there is nothing new under the sun. Robert Darnton, an historian at Harvard University, who has studied information-sharing networks in pre-revolutionary France, argues that “the marvels of communication technology in the present have produced a false consciousness about the past—even a sense that communication has no history, or had nothing of importance to consider before the days of television and the internet.” Social media are not unprecedented: rather, they are the continuation of a long tradition. Modern digital networks may be able to do it more quickly, but even 500 years ago the sharing of media could play a supporting role in precipitating a revolution. Today’s social-media systems do not just connect us to each other: they also link us to the past.

Read the entire article in The Economist (Print edition) Christmas Specials (subscription required) . . . .
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2.      In the News: Michigan has become the latest to repudiate Obamacare:

In an action with major implications for health reform in Michigan, the state House has voted to turn down—at least for now—nearly $10 million in federal funds to create a statewide health exchange by 2014 to sell more affordable, standardized health insurance to consumers and small businesses. Read more . . .

Jack McHugh of the Mackinac Center for Public Policy writes:

Under the Michigan Constitution, no money can be spent by the state—including federal grant money—unless the Legislature passes an appropriation bill authorizing the spending…

House Republicans have shown no eagerness [to create a state Obamacare exchange], and that reluctance extended to this appropriation bill. In the colorful words of House Appropriations Chair Chuck Moss, R-Birmingham, to MIRS News, “They’d rather be caught sacrificing to Satan than voting for Obamacare .  .  . ”

Time does help us gain perspective

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3.      International Medicine: Health Care can no longer be separated from Government. It is a branch of government and therefore we have to understand Politics to reform healthcare.

Santa Claus Governments by Mark Milke

Appeared in the Calgary Herald

For those who look back on 2011 and wonder how European and American governments dug themselves into such a deep debt hole, consider this image as an explanation: Santa Claus.

Over the decades, governments have promised benefits to current voters at the expense of future generations. They borrowed massively; that created debt, which future families must pay back with interest through their taxes. Government played this promise-now, pay-back-later game in both high-tax countries (Greece) and in more moderately-taxed countries (the United States), so a lack of tax revenue was never the problem, just the chronic Santa-induced spending binges. Read more . . .  

Even in Canada, where we pat ourselves on the back for having (partially) dealt with government deficits in the 1990s, the federal government ran deficits in 37 of the last 50 years, including in every year since 2009. Most of the provinces are also deeply in the red again.

Governments have played Santa Claus in another fashion and this added to the borrowing binge: by spending billions annually on subsidies to business (corporate welfare), this on the justification that such spending creates jobs.

Almost every government in the country—be it Alberta, B.C., Quebec, other provinces and the federal government—engages in corporate welfare. They do so even though all are running large deficits.

As a specific example, consider Canada’s most populous province, Ontario, which forecasts a $16.3 billion deficit this year. From 1991/92 to 2008/09, Ontario governments of every political stripe—NDP, Progressive Conservative and Liberal—have transferred $27.7 billion in total in tax dollars to businesses. . .
Ontario’s Minister of Economic Development and Innovation, Brad Duguid, argued recently that such spending is a necessity. He asserted that without it, Ontario would be “completely unarmed” in competition with the rest of the world.

Nonsense. Ontario has been lowering corporate taxes rates and that helps make it competitive with other jurisdictions. That’s not the only factor that matters in attracting business—regulation, power costs and other factors also count—but lower rates are preferable to picking corporate winners and losers with scarce tax dollars.

Besides, Canada’s politicians should keep in mind Canada can easily be “outgunned” in subsidy battles given our relatively small 34-million population base and thus how much any one government can spend in tax dollars vis-à-vis larger jurisdictions. The European Union has 500-million people and the United States has 312 million people. If they attempt to bribe companies and outbid Canada (and they do), it’s relatively easy to do. That imbalance is why free trade agreements between countries that cut down on corporate subsidies are useful and ought to be pursued with vigour.  .  .

Economist Terry Buss found that governments, in their corporate welfare and jobs justifications, routinely ignore what’s called the “substitution effect”. That’s where tax dollars and jobs are merely transferred from healthier businesses to those in pursuit of taxpayer cash. Buss concluded that no new economic activity or jobs were created from corporate welfare, not when the wider geographic area was considered.

A perfect illustration of this happened years ago in Quebec. There, in the 1980s, the federal government funnelled tax dollars to pay for the construction of a new fish processing plant at a cost of $2.2 million with the justification of 250 new jobs. However, in a later review, the federal Auditor General noted how the nearby existing fish-processing facility soon shut down. The job losses at the old facility were equivalent to those “created” at the newly subsidized plant.  .  .

As we enter 2012, governments will need to stop playing Santa Claus. They will need to end the practice of borrowing money which future families must repay with interest. So here’s one easy “gift” governments can stop giving: corporate welfare.

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Corporate welfare doesn’t create new jobs. It just destroys old and stable nearby jobs.

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

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

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4.      Medicare: Medical Entitlements can never be controlled by Medical overview.

Mrs. Atkinson, an RN, brought her elderly mother who uses a walker into the office to obtain a number of items for her through Medicare. Mrs. Atkinson complained that her mother was just too worn out from walking from the car to the store and back. She needed a wheelchair.

The daughter was refractory to any discussion of the walk from the car to the store being good therapeutic physical therapy. We finally acquiesced, being tired of playing the medically responsible police officer. It’s always a lose—lose proposition. It finally comes down to the time spent for health care responsibility and being the bad guy versus the time spent to complete all the Medicare requirements for durable medical equipment. When Medicare makes the decision, we are no longer the ogres. Read more . . .

After getting all the forms for medical necessity for the equipment completed; and my staff time making the arrangements with the home care supplier; faxing all the required justifications to the home medical supplier; the patient was called to pick up her wheel chair. 

When the patient went to pick up all her supposedly needed durable medical equipment at taxpayer’s cost, she found out that Medicare required a 20% co-payment. She refused to pick up the items stating she wasn’t that sick, didn’t need to be pushed around in a wheel chair and went home walking.

When her daughter went to see her later in the day, she became very upset. The daughter tried to convince her mother that she needed the wheel chair. The patient insisted that she could manage her shopping very well using the walker. She didn’t want to depend on another person every time she went out or went shopping.

There are two very important observations: First, the original Medicare 20% copayment; if it were still universally required, it would be a very effective guard against unnecessary health care costs. The 20% copayment probably is more effective than the HMO or Medi-Gap coverage instituted after Medicare was founded which tries to control costs by medical review and denial. In this case medical review allowed the purchase of the wheel chair, but it was the patient copayment that deemed it was an unnecessary health care cost.

The second equally important cost savings is poorly understood and totally disregarded by Medicare and other insurance companies. The total time over three days spent to obtain the approval of the wheel chair is born by the physician, his staff, and the durable medical equipment company. Our office spent about 80 minutes on the medical justification time, talking with the patient, reviewing the arguments of the RN daughter, documentation of what the family felt was an important need, completing the several documents and forms, faxing them to the carrier and the home care company. Later the patient ruled it was unnecessary.

Our office is paid by Medicare about one-half of our usual fee for a 20 minute office call. The non-reimbursed cost for the time spent after the office visit was more than three times the office visit billable costs.  How long can the system bear this drag and justification costs that are hidden and really may be several times what should be a lean health care cost?

We should just return to the 20% Medicare copayment system which would eliminate the drag of justification costs, reduce Medicare expenses by 30% to 40% by some actuarial estimates, and save Medicare for all seniors.

How can this be accomplished? Just by eliminating the entire Medi-Gap insurance system which eliminates patient responsibility.

Patient responsibility will always control costs—even if only a 20 percent copayment.

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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: No preparation for the medical appointment.

Margie, a 29 year-old-white married female came in for a complete examination on referral from her insurance carrier and Medicaid. Three months earlier she had a Cesarean section. She developed diabetes during her pregnancy. She was on pills for her diabetes but didn’t know the name of the medication she took with breakfast and dinner. Mentioning several diabetic medications didn’t cause any recollections to surface. Furthermore, she was a little put out that it would make any difference. What her new doctor prescribed was all that mattered. If I thought her previous medications were important, why didn’t I just call the pharmacy? But then she couldn’t remember which pharmacy she got them from. Read more . . .

After a 10-15 minute unpleasant delay, we just prescribed Metformin and asked her to bring her medications with her the next time. We asked her to measure her finger stick glucose levels before meals and at bedtime.

When she returned, she not only forgot to bring in her glucose records, she hadn’t been able to find her prior medications. Why was I so nosey to check up on her prior doctor?

With the current crop of welfare patients being forced into HMOs, we see very little appreciation for the doctor—patient relationship or any semblance of a shared responsibility for health. We have not seen this since the old County Hospital days. With hospitals building palaces and acquiring huge accounts receivables which are rapidly declining in value, and high deductible plans increasing in popularity as hospitals bargain for their cash payments, we may find ourselves returning to the County or City or States or Public hospitals again.

The unfortunate tragedy is that physicians and surgeons who thought that being part of a hospital medical  group represented security, will become unemployed as one hospital in every community declares bankruptcy as they find their hundreds of millions of dollars of accounts receivable are essentially worthless. It’s not too early to speculate which one it shall be in a community with four major hospital systems, each with more than a hundred million dollar expansion program. The university hospital which can write checks on the taxpayers state bank accounts? The large Kaiser multiple regional hospital system with their 20 Permanente Medical Offices with an enviably tight contractual interrelation? The large Catholic multi-state Healthcare System representing a world-wide membership of over one billion members? Or the free standing regional hospital systems which can’t maintain any continuity with patients in various insurance systems? Maybe they did the radiology group they fired a great big favor.

When over half our population receives food stamps indicating that half of America can no longer feed themselves, the “Dollar” losing value, with taxes going up to the Pre-Reagan era, realizing that a 100 percent income tax soon won’t be able to pay the interest on the National Debt that Obama has foisted on the American People in just three years, we are headed to a crises out country has never previously experienced. When the Dollar no longer is the world’s currency, whose currency will we use to purchase goods internationally?

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Medical Gluttony thrives in Government and Health Insurance Programs.

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

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6.      Medical Myths: Why are Humans so impressionable, emotional and irrational?

How Ernest Dichter, an acolyte of Sigmund Freud, revolutionised marketing

From The Economist | print edition | Dec 17th 2011

THESE are thrilling days for behavioural research. Every week seems to yield a new discovery about how bad people are at making decisions. Humans, it turns out, are impressionable, emotional and irrational. We buy things we don’t need, often at arbitrary prices and for silly reasons. Studies show that when a store plays soothing music, shoppers will linger for longer and often spend more. If customers are in a good mood, they are more susceptible to persuasion. We believe price tends to indicate the value of things, not the other way around. And many people will squander valuable time to get something free. Read more . . .

The sudden ubiquity of this research has rendered Homo economicus a straw man. Yet such observations are not new. Analysts have been studying modern man’s dumb instincts for ages. Sigmund Freud argued that people are governed by irrational, unconscious urges over a century ago. And in America in the 1930s another Viennese psychologist named Ernest Dichter spun this insight into a million-dollar business. His genius was in seeing the opportunity that irrational buying offered for smart selling.

 “You would be amazed to find how often we mislead ourselves, regardless of how smart we think we are, when we attempt to explain why we are behaving the way we do,” Dichter observed in 1960, in his book “The Strategy of Desire”. He held that marketplace decisions are driven by emotions and subconscious whims and fears, and often have little to do with the product itself. Trained as a psychoanalyst, Dichter saw human motivation as an “iceberg”, with two-thirds hidden from view, even to the decision-maker. “What people actually spend their money on in most instances are psychological differences, illusory brand images,” he explained.

At a time when national companies were aggressively jockeying for position among Americans—a suddenly cash-happy and acquisitive bunch—Dichter promised a way to influence consumers’ brains. If shopping was an emotional minefield, then strategic marketing could be a gold mine for companies.

Between the late 1930s and 1960s Dichter became famous for transforming the fates of businesses such as Procter & Gamble, Exxon, Chrysler, General Mills and DuPont. His insight changed the way hundreds of products were sold, from cars to cake mix. He pioneered research techniques such as the focus group, understood the power of word-of-mouth persuasion and earned startling fees for his theories. By the late 1950s his global business reached an annual turnover of $1m ($8m today), and he enjoyed a reputation as the Freud of the supermarket age.

Dichter’s radical approach to goading shoppers, called “motivational research”, was considered so successful that he was even accused of threatening America’s national well-being. Americans have become “the most manipulated people outside the Iron Curtain,” complained Vance Packard, a sociologist and virulent critic, in his 1957 book “The Hidden Persuaders”. Even so, Dichter’s fame waned long before he died in 1991. He spent his later years as a discarded guru in Peekskill, New York, scribbling the occasional book about management or motivation. Media research moved on; his name has largely been forgotten. Yet many of his ideas about the role of the unconscious in sales are now back in fashion. . .

. . . . Asking shoppers why they bought particular products was like “asking people why they thought they were neurotic,” quipped Dichter.

In fact, he believed, most people have no idea why they buy things. They might answer questions in an effort to be helpful (particularly in the early 20th century, when consumers were chuffed to be asked to share their thoughts). But these were attempts to make sense of decisions retrospectively. To understand what truly motivated people, Dichter said, it was necessary to get them to talk at length about their everyday habits. Instead of subjecting many people to quick questionnaires, he preferred a deep, psychoanalytical approach with fewer participants: “If you let somebody talk long enough, you can read between the lines to find out what he really means.”  . . . 

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Medical Myths originate when someone else pays the medical bills.

Myths disappear when Patients pay Appropriate Deductibles and Co-payments on Every Service.

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7.      Overheard in the School: What do you do for Christmas?

The teacher asked young Patrick Murphy:  "What do you do at Christmas time?

Patrick addressed the class: "Well, Miss Jones, my brothers and sisters and I go to midnight mass and we sing hymns; then we come home very late and we put mince pies by the back door and hang up our stockings.  Then all excited, we go to bed and wait for Father Christmas to come with all our toys. 

"Very nice Patrick," she said.  "Now Jimmy Brown, what do you do at Christmas?" Read more . . .

 "Well, Miss Jones, my sister and I also go to church with Mom and Dad and we sing carols and we get home ever so late.  We put cookies and milk by the chimney and we hang up our stockings.  We hardly sleep, waiting for Santa Claus to bring our presents."

Realizing there was a little Jewish boy in the class and not wanting to leave him out of the discussion, she asked, "Now, Isaac Cohen, what do you do at Christmas?"

Isaac said, "Well, it's the same thing every year.  Dad comes home from the office.  We all pile into the Lexus; then we drive to Dad's toy factory.  When we get inside, we look at all the empty shelves, and begin to sing: ‘What A Friend We Have in Jesus.’  Then we all go to the Bahamas."

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The Classroom Is Where Unfiltered Opinions Are Heard.

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8.      Voices of Medicine: Secrets of the Operating Room

Fragile egos, obese patients and talking organs: A surgeon's view of what happens under the scalpel


"Get this thing out of my operating room!" The colon stapling device exploded into pieces when I hurled it against the operating room wall. I was fed up with its failure to work as advertised by the manufacturer. The stapler had probably cost less than $100 to make. The hospital paid $300 for it (and then billed the patient, or insurance company, $1,200). Now the thing didn't even work. Read more . . .

I do not react well to imperfection inside the operating room. I cannot tolerate it in the tools I use, the staff assisting me, or myself. Defective devices—I can have them replaced. Unmotivated staff—I can have them removed from the operating room. I haven't quite figured out yet what to do with myself.

Surgeons are control freaks. We have to be. And when things don't go our way in the operating room, we can have outbursts. Some of us curse, some throw instruments, others have tantrums. These explosions are a go-to reaction when we're confronted with the ghosts of prior complications.

Several months earlier, I had performed the same operation on a 66-year-old patient, using an identical stapling device. Everything seemed to have worked perfectly until the patient developed severe complications four days after his surgery. We soon discovered the cause: the nonperformance of the stapling device.

When the stapler hit the wall, I had been in the operating room for more than four hours, struggling to remove a diseased segment of colon from someone I'll call Mr. Baker, a 330-pound middle-aged man. Trying to keep his fat out of my way during the operation had been a continuous battle. The pain in my upper back reminded me that I was losing the fight.

Obese patients create more physical work for a surgeon during any type of procedure. The operations take longer, tie our upper body in knots and leave us with fatigue and frustration. Obese patients also automatically face an increased risk of complications like infection, pneumonia and blood clots during recovery.

If the difficulties posed by Mr. Baker's obesity weren't enough, he had been steadily losing blood during the procedure. His tissue reacted to the slightest graze with more bleeding.

Why does this guy have to bleed like this? As if it were his fault. Here I was blaming him, even though I was the one causing the bleeding. But in surgery, it always has to be someone else's fault. It's never the surgeon's fault.

Interestingly, after an operation, most surgeons tend to underestimate the amount of blood that was lost. Whether it's ego or denial, they can't help themselves.

The reality is that blood loss can be measured. Hospitals know which surgeons are losing blood, and how much, during every operation. They have data from their operating rooms, but the public cannot get access to this information. And this information matters, too. A large amount of blood lost during an operation can be a harbinger of complications to come.

Like poker players and their cards, surgeons are sometimes only as good as the patients they are dealt. Obesity, excessive scar tissue from a previous surgery in the same area, disease that is more advanced than anticipated—any one of these physiological conditions creates more work and a more difficult environment for the surgeon.

Even before the surgery begins, underlying or chronic conditions such as a history of hypertension, cardiac disease or lung disease put patients at risk for complications. Today, based on your medical history, surgeons can usually analyze, quite accurately, your risk of complications (or death) before setting foot in the operating room. All you have to do is ask.

I had no idea how bad Mr. Baker's colon disease would be until I opened him up and looked inside. It was a mess. If I were playing poker and this man's anatomy were the hand dealt, it would be time to fold.

"That is one of the ugliest pieces of colon I've ever seen." I grabbed the scrub nurse's hand. "See, touch that thing. Look how inflamed it is." When given the chance, scrub nurses love to touch organs in the operating room. "OK, don't poke it too hard, it will start to bleed again." Her hand drew back onto the instrument stand. I was in for a long night.

Tonight, the diseased colon on the menu was angry, cursing and taunting me: "Good luck, Mr. Big-Time Surgeon, trying to remove me." Surgeons frequently have conversations with the body parts or organs they are trying to remove. We also have conversations with ourselves; it's a way to blow off steam while our minds scramble to deal with the unexpected . . .

"Nurse, hand me a curved scissors." Finally, I was granted a little success in freeing up one end of the colon. But that was short-lived. More bleeding. I hate this. And I had cut myself. I stared at my finger. "Nurse, I need a new glove." The outer skin under my glove was breached, but not deeply.

"Almost got you," the colon said. I could not shut the thing up. "How do you know I don't have hepatitis or H.I.V.?"

Just great, I thought. Now I have something else to worry about.

"You're going to earn your fee tonight, Dr. Surgeon." The colon kept talking. "I hope you're not in this business for the money, like the last guy who operated on me. Between what Medicare pays you, the phone calls in the middle of night and the time you spend guiding my recovery, I figure you will make about $200 an hour for this operation. How does that grab you?"

Should have gone for my M.B.A., I mumbled to myself. Big mistake going into medicine, never mind surgery. If I could only go back and do it over again.

The colon's rant continued: "Wait, subtract what it costs you in overhead to bill for this operation (double that if the claim gets rejected), plus malpractice costs for the day, and we are now at $150 an hour. And how could I leave out the biggest expense of all? The price of the mental stress from worrying about me after the surgery (and double that if there's a complication). Now, I figure you're under $100 an hour. Plumbers make more than that just to step inside your house. I bet they sleep well at night. Just remember, Dr. Surgeon, nobody put a gun to your head. You chose this profession."

I could swear that the thing was laughing at me. "Forget about keeping those dinner reservations tonight. You and me, we're going for breakfast once this is over."

—Adapted from "Confessions of a Surgeon" by Paul A. Ruggieri, M.D. (Berkley Books).

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9.      Book Review: Dandy Dames

Dangerous Ambition: Rebecca West and Dorothy Thompson, New Women in Search of Love and Power. By Susan Hertog. Ballantine Books; 493 pages; $30 and £19.99.

Rebecca West and Dorothy Thompson were remarkable—by any standards

From the Economist | print edition | Dec 31st 2011

DOROTHY THOMPSON and Rebecca West were career women long before the term had been invented. In the 1930s, when Thompson and West were making their mark as established professionals, a Gallup poll recorded that 82% of the American population believed women “should not have paying jobs outside the home” if their husbands were employed. Yet both women worked consistently from their early 20s in occupations that were almost entirely male-dominated—Thompson as a foreign correspondent and then a political commentator; West (pictured) as a literary critic, lauded novelist, historian and travel writer. Susan Hertog’s biography, an accomplished synthesis of these two lives and the remarkable parallels between them, is also a history of the 20th century, a study of female emancipation and literary culture, and an acute analysis of dysfunctional family life. Read more . . .

The most striking similarity between Thompson and West is their seemingly innate self-belief and fearlessness. On her 27th birthday in 1920 the American-born Thompson sailed for England. With no contacts but with portfolio in hand, her goal was to gain credentials as a freelance reporter and make her way across Europe to witness the aftermath of the revolution in Russia. By 1927 she was living in Berlin as the first female head of a news bureau in Europe. West, the daughter of an Anglo-Irish journalist who abandoned the family when she was eight, was a reviewer and essayist by the time she was 19, when “regardless of reputation” she published cutting critiques of established writers such as Arnold Bennett and George Bernard Shaw. West wrote consistently until her death at 90 in 1983, and was in the enviable position of having Harold Ross, the editor of the New Yorker, write to her, pleading: “Please write any story you want for us, fact or fiction.” In 1941 West published her best-known book, “Black Lamb and Grey Falcon”, a history of the Balkans and a meditation on the rise of Nazism. . .

When she was 21 West had an illegitimate son with H.G. Wells, 26 years her senior and then on his second wife, before marrying Henry Andrews, a banker, who was frequently unfaithful and suffered early from a form of dementia. Thompson was married three times and also had a son, with Sinclair Lewis, her second husband and winner of the Nobel prize in literature. Resentful of their mothers after lonely childhoods, both sons married young before abandoning their first wives, pursued unrealistic ambitions, and, when they proved unsuccessful, demanded lifelong financial assistance.

The danger of the book’s title refers to the effects of their ambitions to be, as Thompson put it, “something no other woman has been yet”. Both women turned out to be poor parents, even if they came up to roughly the standard expected of working fathers of the time; both chose work and travel over their child, sent them away to school and placated them with lavish gifts. Ms Hertog poignantly renders the conflict between maternal instinct and the desire for realisation of ambition, backed by a fear of diminished “intellectual lustre” and of becoming lost in a “cocoon of domesticity”. Thompson and West undoubtedly chose work over family, but in doing so helped to break down barriers, not only for women journalists but for all working women.

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10.  Hippocrates & His Kin: Not a Ringing Endorsement

Michigan has become the latest to repudiate Obamacare:

In an action with major implications for health reform in Michigan, the state House has voted to turn down—at least for now—nearly $10 million in federal funds to create a statewide health exchange by 2014 to sell more affordable, standardized health insurance to consumers and small businesses

If Obama is reelected, nothing matters.

Should Mitt Romney run for Mayor?

Former Governor of Massachusetts Mitt Romney may be the best candidate in the 2012 GOP primary, but that's not saying much.

It's like being the best mayor of Oakland, Calif Deborah Saunders, SF Chronicle

Read more . . .

Former House Speaker Newt Gingrich failed to qualify for the Virginia Ballot

Gingrich also failed to qualify for the Virginia ballot –and he lives in Virginia. Worse, his campaign director quickly announced that he and Gingrich agreed that the fiasco was analogous to Pearl Harbor—a  sneak attack that left 2,403 dead. Later, Gingrich explained to the media that his campaign had hired a fraudster who had submitted 1,500 "false signatures."

This is not the crack team you want running the White House.  Deborah Saunders, SF Chronicle  

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

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11.  Organizations Restoring Accountability in HealthCare, Government and Society:

                      The National Center for Policy Analysis, John C Goodman, PhD, President, who along with Gerald L. Musgrave, and Devon M. Herrick wrote Lives at Risk, issues a weekly Health Policy Digest, a health summary of the full NCPA daily report. You may log on at and register to receive one or more of these reports.

                      Pacific Research Institute, ( Sally C Pipes, President and CEO, John R Graham, Director of Health Care Studies, publish a monthly Health Policy Prescription newsletter, which is very timely to our current health care situation. You may signup to receive their newsletters via email by clicking on the email tab or directly access their health care blog.

                      The Mercatus Center at George Mason University ( is a strong advocate for accountability in government. Maurice McTigue, QSO, a Distinguished Visiting Scholar, a former member of Parliament and cabinet minister in New Zealand, is now director of the Mercatus Center's Government Accountability Project. Join the Mercatus Center for Excellence in Government.

                      To read the rest of this column, please go to

                      The National Association of Health Underwriters, The NAHU's Vision Statement: Every American will have access to private sector solutions for health, financial and retirement security and the services of insurance professionals. There are numerous important issues listed on the opening page. Be sure to scan their professional journal, Health Insurance Underwriters (HIU), for articles of importance in the Health Insurance MarketPlace. The HIU magazine, with Jim Hostetler as the executive editor, covers technology, legislation and product news - everything that affects how health insurance professionals do business.

                      The Galen Institute, Grace-Marie Turner President and Founder, has a weekly Health Policy Newsletter sent every Friday to which you may subscribe by logging on at A study of purchasers of Health Savings Accounts shows that the new health care financing arrangements are appealing to those who previously were shut out of the insurance market, to families, to older Americans, and to workers of all income levels

                      Greg Scandlen, an expert in Health Savings Accounts (HSAs), has embarked on a new mission: Consumers for Health Care Choices (CHCC). Read the initial series of his newsletter, Consumers Power Reports. Become a member of CHCC, The voice of the health care consumer. Be sure to read Prescription for change: Employers, insurers, providers, and the government have all taken their turn at trying to fix American Health Care. Now it's the Consumers turn. Greg has joined the Heartland Institute, where current newsletters can be found.

                      The Heartland Institute,, Joseph Bast, President, publishes the Health Care News and the Heartlander. You may sign up for their health care email newsletter. Read the late Conrad F Meier on What is Free-Market Health Care?

                      The Foundation for Economic Education,, has been publishing The Freeman - Ideas On Liberty, Freedom's Magazine, for over 50 years, with Lawrence W Reed, President,  and Sheldon Richman as editor. Having bound copies of this running treatise on free-market economics for over 40 years, I still take pleasure in the relevant articles by Leonard Read and others who have devoted their lives to the cause of liberty. I have a patient who has read this journal since it was a mimeographed newsletter fifty years ago. Be sure to read the current lesson on Economic Education at

                      The Council for Affordable Health Insurance,, founded by Greg Scandlen in 1991, where he served as CEO for five years, is an association of insurance companies, actuarial firms, legislative consultants, physicians and insurance agents. Their mission is to develop and promote free-market solutions to America's health-care challenges by enabling a robust and competitive health insurance market that will achieve and maintain access to affordable, high-quality health care for all Americans. "The belief that more medical care means better medical care is deeply entrenched . . . Our study suggests that perhaps a third of medical spending is now devoted to services that don't appear to improve health or the quality of care–and may even make things worse."

                      The Independence Institute,, is a free-market think-tank in Golden, Colorado, that has a Health Care Policy Center, with Linda Gorman as Director. Be sure to sign up for the monthly Health Care Policy Center Newsletter.

                      Martin Masse, Director of Publications at the Montreal Economic Institute, is the publisher of the webzine: Le Quebecois Libre. Please log on at to review his free-market based articles, some of which will allow you to brush up on your French. You may also register to receive copies of their webzine on a regular basis.

                      The Fraser Institute, an independent public policy organization, focuses on the role competitive markets play in providing for the economic and social well being of all Canadians. Canadians celebrated Tax Freedom Day on June 28, the date they stopped paying taxes and started working for themselves. Log on at for an overview of the extensive research articles that are available. You may want to go directly to their health research section.

                      The Heritage Foundation,, founded in 1973, is a research and educational institute whose mission was to formulate and promote public policies based on the principles of free enterprise, limited government, individual freedom, traditional American values and a strong national defense. -- However, since they supported the socialistic health plan instituted by Mitt Romney in Massachusetts, which is replaying the Medicare excessive increases in its first two years, and was used by some as a justification for the Obama plan, they have lost sight of their mission and we will no longer feature them as a freedom loving institution and have canceled our contributions. We would also caution that should Mitt Romney ever run for National office again, he would be dangerous in the cause of freedom in health care. The WSJ paints him as being to the left of Barrack Hussein Obama. We would also advise Steve Forbes to disassociate himself from this institution.

                      The Ludwig von Mises Institute, Lew Rockwell, President, is a rich source of free-market materials, probably the best daily course in economics we've seen. If you read these essays on a daily basis, it would probably be equivalent to taking Economics 11 and 51 in college. Please log on at to obtain the foundation's daily reports. You may also log on to Lew's premier free-market site to read some of his lectures to medical groups. Learn how state medicine subsidizes illness or to find out why anyone would want to be an MD today.

                      CATO. The Cato Institute ( was founded in 1977, by Edward H. Crane, with Charles Koch of Koch Industries. It is a nonprofit public policy research foundation headquartered in Washington, D.C. The Institute is named for Cato's Letters, a series of pamphlets that helped lay the philosophical foundation for the American Revolution. The Mission: The Cato Institute seeks to broaden the parameters of public policy debate to allow consideration of the traditional American principles of limited government, individual liberty, free markets and peace. Ed Crane reminds us that the framers of the Constitution designed to protect our liberty through a system of federalism and divided powers so that most of the governance would be at the state level where abuse of power would be limited by the citizens' ability to choose among 13 (and now 50) different systems of state government. Thus, we could all seek our favorite moral turpitude and live in our comfort zone recognizing our differences and still be proud of our unity as Americans. Michael F. Cannon is the Cato Institute's Director of Health Policy Studies. Read his bio, articles and books at

                      The Ethan Allen Institute,, is one of some 41 similar but independent state organizations associated with the State Policy Network (SPN). The mission is to put into practice the fundamentals of a free society: individual liberty, private property, competitive free enterprise, limited and frugal government, strong local communities, personal responsibility, and expanded opportunity for human endeavor.

                      The Free State Project, with a goal of Liberty in Our Lifetime,, is an agreement among 20,000 pro-liberty activists to move to New Hampshire, where they will exert the fullest practical effort toward the creation of a society in which the maximum role of government is the protection of life, liberty, and property. The success of the Project would likely entail reductions in taxation and regulation, reforms at all levels of government to expand individual rights and free markets, and a restoration of constitutional federalism, demonstrating the benefits of liberty to the rest of the nation and the world. [It is indeed a tragedy that the burden of government in the U.S., a freedom society for its first 150 years, is so great that people want to escape to a state solely for the purpose of reducing that oppression. We hope this gives each of us an impetus to restore freedom from government intrusion in our own state.]

                      McLauren Institute  MacLaurinCSF is a community of students, scholars, and thinkers working together to explore and understand the implications of the Christian faith for every field of study and every aspect of life.*  Our Mission: MacLaurinCSF bridges church and university in the Twin Cities metropolitan area, bringing theological resources to the university and academic resources to the church. Our goal is to strengthen Christian intellectual life in this region by creating public space for leaders in the academy and church to address enduring human questions together. MacLaurinCSF is grounded in the Christian tradition as articulated in Scripture and summarized by the Apostles’ and Nicene creeds, and our conversations are open to all.

                      The St. Croix Review, a bimonthly journal of ideas, recognizes that the world is very dangerous. Conservatives are staunch defenders of the homeland. But as Russell Kirk believed, wartime allows the federal government to grow at a frightful pace. We expect government to win the wars we engage, and we expect that our borders be guarded. But St. Croix feels the impulses of the Administration and Congress are often misguided. The politicians of both parties in Washington overreach so that we see with disgust the explosion of earmarks and perpetually increasing spending on programs that have nothing to do with winning the war. There is too much power given to Washington. Even in wartime, we have to push for limited government - while giving the government the necessary tools to win the war. To read a variety of articles in this arena, please go to

                      Chapman University: Chapman University, founded in 1861, is one of the oldest, most prestigious private universities in California. Chapman's picturesque campus is located in the heart of Orange County – one of the nation's most exciting centers of arts, business, science and technology – and draws outstanding students from across the United States and around the world. Known for its blend of liberal arts and professional programs, Chapman University encompasses seven schools and colleges: The university's mission is to provide personalized education of distinction that leads to inquiring, ethical and productive lives as global citizens.

                      Hillsdale College, the premier small liberal arts college in southern Michigan with about 1,200 students, was founded in 1844 with the mission of "educating for liberty." It is proud of its principled refusal to accept any federal funds, even in the form of student grants and loans, and of its historic policy of non-discrimination and equal opportunity. The price of freedom is never cheap. While schools throughout the nation are bowing to an unconstitutional federal mandate that schools must adopt a Constitution Day curriculum each September 17th or lose federal funds, Hillsdale students take a semester-long course on the Constitution restoring civics education and developing a civics textbook, a Constitution Reader. You may log on at to register for the annual weeklong von Mises Seminars, held every February, or their famous Shavano Institute. Congratulations to Hillsdale for its national rankings in the USNews College rankings. Changes in the Carnegie classifications, along with Hillsdale's continuing rise to national prominence, prompted the Foundation to move the College from the regional to the national liberal arts college classification. Please log on and register to receive Imprimis, their national speech digest that reaches more than one million readers each month. This month, read ? Choose recent issues.  The last ten years of Imprimis are archived.

                      The Association of American Physicians & Surgeons (, The Voice for Private Physicians Since 1943, representing physicians in their struggles against bureaucratic medicine, loss of medical privacy, and intrusion by the government into the personal and confidential relationship between patients and their physicians. Be sure to read News of the Day in Perspective. Don't miss the "AAPS News," written by Jane Orient, MD, and archived on this site which provides valuable information on a monthly basis. Browse the archives of their official organ, the Journal of American Physicians and Surgeons, with Larry Huntoon, MD, PhD, a neurologist in New York, as the Editor-in-Chief. There are a number of important articles that can be accessed from the Table of Contents.

The AAPS California Chapter is an unincorporated association made up of members. The Goal of the AAPS California Chapter is to carry on the activities of the Association of American Physicians and Surgeons (AAPS) on a statewide basis. This is accomplished by having meetings and providing communications that support the medical professional needs and interests of independent physicians in private practice. To join the AAPS California Chapter, all you need to do is join national AAPS and be a physician licensed to practice in the State of California. There is no additional cost or fee to be a member of the AAPS California State Chapter.
Go to California Chapter Web Page . . .

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

PA-AAPS is the Pennsylvania Chapter of the Association of American Physicians and Surgeons (AAPS), a non-partisan professional association of physicians in all types of practices and specialties across the country. Since 1943, AAPS has been dedicated to the highest ethical standards of the Oath of Hippocrates and to preserving the sanctity of the patient-physician relationship and the practice of private medicine. We welcome all physicians (M.D. and D.O.) as members. Podiatrists, dentists, chiropractors and other medical professionals are welcome to join as professional associate members. Staff members and the public are welcome as associate members. Medical students are welcome to join free of charge.

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

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

Words of Wisdom

Government is the great fiction, through which everybody endeavors to live at the expense of everybody else. --Frederic Bastiat, French Economist (1801—1850)

If it moves, tax it. If it keeps moving, regulate it. And if it stops moving, subsidize it.
–Ronald Reagan, (1986)

I don’t make jokes. I just watch the government and report the facts. –Will Rogers

Some Recent Postings

In The Nov 27 Issue:

1.                  Featured Article: The Greek Tragedy – A Lesson in Government Health and Entitlements

2.                  In the News: Doctor’s Revolt Shakes the Social Security Disability Program

3.                  International Medicine: Spreading prosperity and growth

4.                  Medicare: Can Medicare make three-quad-trillion decisions a year? 3,000,000,000,000,000?

5.                  Medical Gluttony: Pharmacy Gluttony

6.                  Medical Myths: Electronic Medical Records are efficient savers of time.

7.                  Overheard in the Medical Staff Lounge: Electronic Medical Records—Current Status

8.                  Voices of Medicine: Polypharmacy Among Our Patients

9.                  The Bookshelf: Taking Back Healthcare for Future Generations

10.              Hippocrates & His Kin: Sex and STD in Sacramento;  

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

In Memoriam

“Smokin Joe” Frazier, heavyweight boxer, died on November 7th, aged 67

From the Economist | the print edition | Nov 19th 2011

TO SAY that Joe Frazier had a left hook was like saying the Tomcat jet fighter is an aeroplane. This one was devastating. You knew it was there, but he kept it hidden. For most of a fight he would press in, head down like a bull charging, fists close to the chest. He was short for a heavyweight, five feet eleven, and made himself look shorter, hunching his shoulders and punching close with his stumpy, jabbing arms. He didn’t dance around, but worked away at it, bobbing and weaving relentlessly, throwing away perhaps two punches for every one he landed. His style was to keep aggressively on, wear a man down, get him winded. Then—boom!—the dazzling left hook that sent his opponent sprawling.

His craft had been honed for years. First on the heavy bag he’d made himself that hung from the oak tree in the yard of the family shack in Beaufort, South Carolina: just an old burlap bag stuffed with rags and corn cobs, Spanish moss and rocks. Anything that could take a punch. His mamma whupped him with a braided vine and his daddy whupped him with a belt when he deserved it, and then he’d pummel that bag. His uncle had told him at eight years old, as he watched the “Wednesday Night Fight” on the blurry black-and-white TV with the other men, that he could be another Joe Louis. He aimed to do it. Later he practised on the hanging sides of beef at Cross Brothers’ slaughterhouse in Philadelphia, Rocky Balboa in real life. One, two in the refrigerated room, breath smoking, gloves smoking. That was what his first trainer told him to do when he signed on at the police gym in 1961: make his gloves smoke.

Out of 37 professional fights, he won 27 with knockouts. His left hook won him gold at the Tokyo Olympics in 1964, toppling Hans Huber, even though his left thumb was so hurt it was probably broken. It earned him the world heavyweight crown, besting Jimmy Ellis in the fifth at Madison Square Garden in 1970. And most spectacularly it was how he beat Muhammad Ali in “The Fight of the Century” at the Garden in 1971, when after 14 rounds of increasing ferocity (just throw punches, he was thinking. Just throw punches) he landed a blow on that bragging jaw that won him the fight on points and sent Ali round to the hospital.

Nothing was sweeter to him than that one punch. He kept a photo of it, blown up huge, in the office of the gym where he had trained in Philadelphia and later trained young boxers himself. His rivalry with Ali was the most intense in boxing. It may have thawed at moments, but deep down he hated him. Hated the big mouth that called him ugly, flat-footed and a gorilla (punching a little rubber gorilla as he said it, contemptuously), while Frazier would sit with his plain, solid, patient face wondering whether he could get one word in. Especially he hated Ali calling him an Uncle Tom, a white man’s black boxer.

Ali had been stripped of his world heavyweight title in 1967 for refusing the Vietnam draft. That made some whites go to Frazier’s corner, and made many blacks go on calling Ali champion even when Frazier was. That hurt. Ali talked a streak about civil rights; Frazier didn’t mention them much. But it was he, the sharecropper’s son, who had felt the sharper edge of segregation, “the animosity, hatred, bigotry, you name it”. He punched his bag at home because the town playgrounds were closed to him. From childhood he picked okra for white farmers until one day he defied them, threw in his job and left the South on a Greyhound bus, already sure at 15 that he could never make a life there. . .

In his last years the money seemed to vanish; none was left for his funeral. His gym became a bedding outlet, and at the Spring Garden Deli, where he went to eat his lunch of grits with spinach and tomatoes, the waitress didn’t know who he was. Gamely, he would let her beat him at arm-wrestling. And he could still be induced to sing sometimes, in a voice slurred and croaky after hundreds of punches to the head, his own version of his favourite song: “I fought them fair, I fought them square, I fought them my-y-y-y way.”

Read the entire obituary in the Economist – Subscription required . . .

On This Date in History - December 13

On this date in 1862, Robert E. Lee spoke these wise words as he was contemplating the Battle of Fredericksburg, “It is well that war is so terrible, or we should grow too fond of it.” The same is true of various kinds of wars—those fought by soldiers in uniforms, those fought in courts of law, those fought with broadside after broadside in the public press.  

On This Date in History - December 27

On this date in 1822, Louis Pasteur was born in Dole, France. Pasteur discovered that disease can be produced by various bacteria; thereby, he laid the groundwork for the whole modern idea of antisepsis, sterilization of surgical instruments and prevention of infections. Others have extended this to infections of the mind, the hate and lunacies that afflict the world.

After Leonard and Thelma Spinrad


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

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

Stalin said.  "He who votes does not have power.  He who counts the votes has power".