Community For Better Health Care

Vol XI, No 2, May 15, 2012


In This Issue:

1.                  Featured Article: How Medicare Traps Doctors

2.                  In the News: Women, Teens Take Longer to Recover From Concussions

3.                  International Medicine: The Rest of the Story

4.                  Medicare: 2012 Medicare Part B Changes

5.                  Medical Gluttony: ObamaCare

6.                  Medical Myths: Can Government learn?

7.                  Overheard in the Medical Staff Lounge: Pharmacy phone calls and their solution

8.                  Voices of Medicine: Death of Clinical Judgment

9.                  The Bookshelf: A Voice for the Generations

10.              Hippocrates & His Kin: Government really does NOT want to LEARN

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

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

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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.

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1.      Featured Article: How Medicare Traps Doctors                                                                       

How Doctors are Trapped

By John Goodman Filed under Health Alerts on January 16, 2012

Every lawyer, every accountant, every architect, every engineer — indeed, every professional in every other field — is able to do something doctors cannot do. They can repackage and reprice their services. If demand changes or if they discover a way of meeting their clients’ needs more efficiently, they are free to offer a different bundle of services for a different price. Doctors, by contrast, are trapped. Read more . . .

To see how trapped, let’s look at another profession: the practice of law. Suppose you are accused of a crime and suppose your lawyer is paid the way doctors are paid. That is, suppose some third-party payer bureaucracy pays your lawyer a different fee for each separate task she performs in your defense. Just to make up some numbers that reflect the full degree of arbitrariness we find in medicine, let’s suppose your lawyer is paid $50 per hour for jury selection and $500 per hour for making your final case to the jury.

What would happen? At the end of your trial, your lawyer’s summation would be stirring, compelling, logical and persuasive. In fact, it might well get you off scot free if only it were delivered to the right jury. But you don’t have the right jury. Because of the fee schedule, your lawyer skimped on jury selection way back at the beginning of your trial.

This is why you don’t want to pay a lawyer, or any other professional, by task. You want your lawyer to be able to reallocate her time — in this case, from the summation speech to the voir dire proceeding. If each hour of her time is compensated at the same rate, she will feel free to allocate the last hour spent on your case to its highest valued use rather than to the activity that is paid the highest fee.

In a previous Health Alert, I noted that Medicare has a list of some 7,500 separate tasks it pays physicians to perform. For each task there is a price that varies according to location and other factors. Of the 800,000 practicing physicians in this country, not all are in Medicare and no doctor is going to perform every task on Medicare’s list.

Yet Medicare is potentially setting about 6 billion prices across the country at any one time.

Is there any chance that Medicare can get all those prices right? Not likely.

What happens when Medicare gets them wrong? One result: doctors will face perverse incentives to provide care that is costlier and less appropriate than the care they should be providing. Another result: the skill set of our nation’s doctors will become misallocated, as medical students and practicing doctors respond to the fact that Medicare is overpaying for some skills and underpaying for others.

The problem in medicine is not merely that all the prices are wrong. A lot of very important things doctors can do for patients are not even on the list of tasks that Medicare pays for. Some readers will remember our Health Alert on Dr. Jeffrey Brennan in Camden, New Jersey. He is saving millions of dollars for Medicare and Medicaid by essentially performing social work services to reduce spending on the most costly patients. Because “social work” is not on Medicare’s list of 7,500 tasks, Brennan gets nothing in return for all the money he is saving the taxpayers.

We have also seen that there are other omissions — including telephone and e-mail consultations and teaching patients how to manage their own care.

In addition, Medicare has strict rules about how tasks can be combined. For example, “special needs” patients typically have five or more comorbidities — a fancy way of saying that a lot of things are going wrong at once. These patients are costing Medicare about $60,000 a year and they consume a large share of Medicare’s entire budget. Ideally, when one of these patients sees a doctor, the doctor will deal with all five problems sequentially. That would economize on the patient’s time and ensure that the treatment regime for each malady is integrated and consistent with all the others.

Under Medicare’s payment system, however, a specialist can only bill Medicare the full fee for treating one of the five conditions during a single visit. If she treats the other four, she can only bill half price for those services. It’s even worse for primary care physicians. They cannot bill anything for treating the additional four conditions. . .

Take Dr. Richard Young, a Fort Worth family physician who is an adviser for the federal government’s new medical Innovation Center. As explained by Jim Landers in the Dallas Morning News:

[When Young] sees Medicare or Medicaid patients at Tarrant County’s JPS Physicians Group, he can only deal with one ailment at a time. Even if a patient has several chronic diseases — diabetes, congestive heart failure, high blood pressure — the government’s payment rules allow him to only charge for one.

“You could spend the extra time and deal with everything, but you are completely giving away your services to do that,” he said. Patients are told to schedule another appointment or see a specialist.

Young calls the payment rules “ridiculously complicated.”

That’s an understatement.

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2.      In the News: Study: Women, Teens Take Longer to Recover From Concussions

By Beth Carter,

Email Author, Categories: health, Medicine, Research


A study finds that females and youth require more time to recover from concussions, a finding that could help coaches, trainers, and doctors how to diagnose and treat head trauma among athletes.

For many professional athletes, preventing and treating concussions is part of the job. But sports-related head trauma is common in amateur and youth sports as well, and evidence suggests high-school and female athletes take longer than men to recover from it.

The findings, from Michigan State University, suggest coaches, trainers and doctors must consider an athlete’s age and gender when diagnosing and treating concussions and determining when they’re ready to resume playing.

“Typically what we’re finding is that the high school brain is still developing,” said Tracey Covassin, the associate professor of kinesiology who led the study. “There is more cerebral fluid within the brain, making it more susceptible to injury and causing it to take longer to recover. With the NFL they come back the next week, and they shouldn’t do this with kids.” Read more . . .

More than 150,000 sports-related concussions occurred among kids age 15 to 19 between 2001 and 2005, according to statistics published in Pediatrics in 2010. The true number may be higher, because the stats reflect only injuries treated in an emergency room.

Covassin and her colleagues administered baseline neuropsychological tests to athletes from several states over the course of two years. Three hundred of those athletes eventually suffered concussions and were quizzed using three computerized neuropsychological tests — which asks test subjects to recall words and designs — that the NFL and NHL use to assess head trauma.

They found females between 14 and 23 years old performed worse than males of equal age on the visual memory tests and exhibited more of the common concussion symptoms, including headaches, confusion, imbalance, dizziness and memory loss. This may be due to anatomical and hormonal differences, Covassin said, but further study is needed to understand why women are at greater risk of concussions and take longer to recover from them. Cheerleading, for example, has a high rate of concussion, as does high school volleyball.

“Most of the literature talks about football and hockey players,” she said. “People don’t realize that female athletes are more at risk. People are slowly starting to realize the difference between males and females.”

The study also compared the recovery times of high school and collegiate athletes and found younger athletes can take twice as long to recover. High school athletes’ verbal and visual memory — the ability to remember words and letters and remember spatial tasks like football plays — remained impaired between seven and 14 days following the injury. Collegiate athletes recovered within seven days.

Covassin also found that young athletes who aren’t given ample time to recover are at greater risk for second-impact syndrome, where a second concussion can bring more severe symptoms and a greater risk of brain damage. . .

“If you are on the fence of, ‘Should I return the kid or not return the kid,’ don’t return him,” Covassin said. “Play it safe.”

Read the entire article on . . .
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3.      International Medicine: The Rest of the Story

By John Goodman Filed under Health Alerts on March 25, 2009 with 16 comments

Today I’m going to give you access to a paper with as many as 100 references that you almost never see cited in Health Affairs, or in the Journal of the American Medical Association (JAMA), or in the New England Journal (at least not in their public policy articles). In fact, if you are a regular reader of these publications, I think you are going to be very surprised.

My colleagues Linda Gorman, Devon Herrick, Robert Sade and I discovered that public policy articles in the leading health journals (especially the health policy journals) tend to cite poorly done studies over and over again in support of two propositions: (1) Our health care system needs radical reform and (2) the reform needs to be modeled along the lines of the systems of other developed countries. At the same time, these articles tend to ignore contravening studies – often published in economics journals and subject to much more rigorous peer review. Read more . . .

In our rest-of-the-story literature review, we focus on eight questions:

  1. Does the United States spend too much on health care?
  2. Are US outcomes no better and in some respects worse than those of other nations?
  3. Is the large number of uninsured in the US a crisis?
  4. Does lack of health insurance cause premature death?
  5. Are medical bills causing bankruptcy?
  6. Are administrative costs higher for private insurance than public insurance?
  7. Are low-income families more disadvantaged in the US system?
  8. Can the free market work in health care?

This paper was written over a year ago, in response to JAMA’s call for papers on health reform and may not include the most recent material. Nonetheless, since the national health care debate is well underway, since the peer review process (at least for our paper) is so inordinately long, and since the issue is so important, we are taking these unprecedented steps:

  1. We are ignoring the journals and publishing the paper online.
  2. We are posting the reviewers’ comments from Health Affairs so that readers can see why the critics thought this paper should not be published at all, and a link to the JAMA issue that excluded our paper here.
  3. We are inviting everyone – regardless of political views – to comment and cite additional evidence that has bearing on any of these questions.

In a completely independent effort, Stanford University Professor Scott Atlas has made many of these same discoveries. His findings are summarized in this NCPA Brief Analysis.

  1. Devon Herrick, National Center for Policy Analysis says:

March 25, 2009 at 10:52 am

What is most shocking is how advocates of National Health Insurance ignore the poor state of cancer care in many developed countries. Cancer is primarily a disease of old age. Thus, rationing advanced cancer treatments should be considered a subtle form of age-discrimination.

Other countries fare worse than the United States when it comes to cancer survival. Their data is somewhat dated but according to the report “Diffusion of Medicines in Europe,” there are only 0.14 oncologists per 100,000 population in Britain and 0.24 in Germany. The corresponding figure for the United States is 2.28. Innovative (cytotoxic) cancer medicines are also used much less abroad. The U.S. spends nearly 17 times more per capita that Britain, seven times more than Germany and five times more than France on cytotoxic medicines.

Read The Rest of the Story
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Canadian Medicare does not give timely access to healthcare, it only gives access to a waiting list.

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

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4.      Medicare: 2012 Medicare Part B Changes(CMS) published updated payment policies

San Mateo County Medical Association

by: Sue Malone, SMCMA Executive Director

On November 1st the Centers for Medicare and Medicaid Services (CMS) published updated payment policies and payment rates for physicians’ services furnished in 2012.

According to CMS, more than one million providers of health services to Medicare beneficiaries are paid under the Medicare Physician Fee Schedule (MPFS). An estimated $80 billion will be paid under the MPFS in 2012.

Changes in the fee schedule that impact payment policy and physician billing include: Read more and see if they are geared to a grade school or a professional mentality . . . 

Expanding CMS’ misvalued code initiative

Using a health risk assessment (HRA) in conjunction with Annual Wellness Visits (AWV) for which coverage began January 1, 2011 under the Affordable Care Act (ACA).

Expanding the list of services that can be furnished through telehealth to include smoking cessation services. Changes in the way additional services are added to the telehealth list will focus on the clinical benefit of making the service available.

Updating physician incentive programs including the Physician Quality Reporting System (PQRS), the e-Prescribing Incentive Program and the electronic Health Records Incentive Program.

Establishing a new value-based modifier that would reward physicians for providing higher quality and more efficient care.

Implementing the third year of a four-year transition to new practice expense relative value units, based on data from the Physician Practice Information Survey that was adopted in the MPFS CY2010 final rule.

CMS finalized the rules for the 2012 and 2013 e-prescribing incentive payment, and the 2013 and 2014 payment penalty programs. To qualify for incentive payments, physicians: a) may use claims, registry or electronic health record-based (EHR) reporting methods; and must electronically prescribe on the same day as the denominator service, and submit 25 claims containing the e-prescribing measure code (G8553) with one of the denominator codes. The incentive payment for 2012 is 1 percent, and for 2013 it is .5 percent of the total estimated allowed charges for professional services covered by Medicare Part B and furnished by an eligible professional.

Physician Quality Report System (PQRS)
As in prior years, there have been changes to the individual measures and measure groups. The final rule lists 211 individual measures, including 25 new ones; retains 44 EHR measures currently reportable in the EHR incentive program; and finalized 23 new measure groups, including eight new measures groups for reporting: Cardiovascular prevention; COPD; inflammatory bowel disease, sleep apnea, dementia, Parkinson’s, elevated blood pressure, and cataracts.

A complete listing of the 2012 measures is posted on the CMS website:

CMS will provide interim feedback reports for physicians reporting individual measures and measure groups through claims-based reporting for 2012 and beyond. These reports will be a simplified version of annual feedback reports that CMS currently provides and will be based on claims for the first three months of each program year.

CMS will use 2012 as the reporting period for the 2015 PQRS penalty. If CMS determines that a physician or group practice (a group of 25 or more) has not satisfactorily reported quality data for the 2013 reporting period, then its 2015 payments will be reduced 1.5 percent.

Lab Test Signatures No Longer Required
CMS has retracted the requirement for physicians to sign paper lab requisitions for clinical diagnostic laboratory tests.

Annual Wellness Visit Changes
Criteria for a health risk assessment (HRA) to be used in conjunction with the annual wellness visit (AWV) has been adopted. The HRA is self-reported information which can be done by the patient alone or with assistance, takes no more than 20 minutes to complete and addresses demographic data, psychosocial risks, behavioral risks, activities of daily living (ADL)*, and instrumental ADLs**. The payment for AWV codes has been increased to recognize the additional office staff time required to administer the HRA to the Medicare population. CMS continues its policy of not covering a routine physical exam as part of these services.
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Dear Colleagues:

We have had digital records in our office for nearly a decade as well as E-prescribing. Our patients ask us if anybody can access their digital records in our office. We tell them that no one can. They say thank you and return. We can access our patient records from any computer. However this is not what Obama’s  ACA had in mind. They cannot access our patients’ confidential records electronically. Big Brother Cannot Watch us like they would like. Hence we are not eligible for the one percent incentives this year or the one and one-half percent next year, but are eligible for all the Medicare Penalties.

But have no Fear. Big Brother is always near. They demand that we make copies of a representative sample of entire medical records and send them to Medicare for their review.

Eight hours of Office Manager’s time nearly each month does add up $240 a month for police work which is not reimbursed! This is essentially a $2800 per year Medicare tax on doctors.

It also treats us as grade school children. How long are physicians going to take this abuse?

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

- Ronald Reagan

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5.      Medical Gluttony: ObamaCare

. . . The body politic still remains suspended between recognizing the unsustainability of the current welfare model and deciding what to do about it. This was always the fatal problem of ObamaCare. Read more . . .  

Reality could not have instructed President Obama more plainly: The last thing we needed, in a country staggering under deficits and debt, a sluggish economy and an unaffordable entitlement structure, was a new Rube Goldberg entitlement. The last thing we needed was ObamaCare. The nation and the times were asking Mr. Obama to reform health care, not to double-down on everything wrong with the current system.  .  .

. . . Reality will pass judgment on the Affordable Care Act and it won’t be favorable–Holman W. Jenkins, JR., WSJ

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Medical Gluttony thrives in Government and Health Insurance Programs.

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

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6.      Government Myths: Can Government learn?

Viewpoints: Can government learn whether its policies have been successful?

Read more here:

By David Brooks

By David Brooks

Last modified: 2012-04-28T04:29:12Z

Published: Saturday, Apr. 28, 2012 -| Page 11A

Copyright 2012 . All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

Government doesn't profit from experience because of the way it goes about testing out its policy problems. It should try learning the way businesses do.

In 2009, we had a big debate about whether to pass a stimulus package. Many esteemed and/or Nobel Prize-winning economists like Joseph Stiglitz, Larry Summers and Christina Romer argued that it would help lift the economy out of recession. Many other esteemed and/or Nobel Prize-winning economists like Robert Barro, Edward Prescott and James Buchanan argued that positive effects would be small and the package wouldn't be worth the long-term cost.

We went ahead and spent the roughly $800 billion. What have we learned?

For certain, nothing. The economists who supported the stimulus now argue the economy would have been worse off without it. Those who opposed it argue that the results have been meager. It's hard to think of anybody whose mind has been changed by what happened.  Read more . . .

This is not entirely surprising. Nearly 80 years later, it's hard to know if the New Deal did much to end the Great Depression. Still, it would be nice if we could learn from experience. To avoid national catastrophe, we're going to have to figure out how to control health care costs, improve schools and do other things.

Jim Manzi has spent his career helping businesses learn from experience – first at AT&T Laboratories, then as a consultant with Strategic Planning Associates and then as founder of Applied Predictive Technologies, a successful software firm.

In his new book, "Uncontrolled," Manzi notes that many experts tackle policy problems by creating big pattern-finding models and then running simulations to see how proposals will work. That's essentially what the proponents and opponents of the stimulus package did.

The problem is that no model can capture enough of the world's complexity to yield definitive conclusions or make nonobvious predictions. A lot depends on what assumptions you build into them.

In "Uncontrolled," Manzi looks at two celebrated model-building exercises. Larry Bartels of Princeton produced a model finding that presidential policies exercise the single biggest influence on income distribution. The authors of "Freakonomics" produced a model showing legalized abortions subsequently reduced crime rates.

Manzi argues that by slightly tweaking the technical assumptions in these models, you eliminate the headline-grabbing results. He also points out that regression models that try to explain crime rates have not become more accurate over the past 30 years. All this model-building hasn't even helped us get better at understanding the problem.

What you really need to achieve sustained learning, Manzi argues, is controlled experiments. Try something out. Compare the results against a control group. Build up an information feedback loop. This is how businesses learn. By 2000, the credit card company Capital One was running 60,000 randomized tests a year – trying out different innovations and strategies. Google ran about 12,000 randomized experiments in 2009 alone. . .

Businesses conduct hundreds of thousands of randomized trials each year. Pharmaceutical companies conduct thousands more. But government? Hardly any. Government agencies conduct only a smattering of controlled experiments to test policies in the justice system, education, welfare and so on.

Why doesn't government want to learn? First, there's no infrastructure. There are few agencies designed to supervise such experiments. Second, there is no way to conduct a randomized experiment to test big economy wide policies like the stimulus package.

Finally, the general lesson of randomized experiments is that the vast majority of new proposals do not work, and those that do work only do so to a limited extent and only under certain circumstances. This is true in business and government. Politicians are not inclined to set up rigorous testing methods showing that their favorite ideas don't work.

Manzi wants to infuse government with a culture of experimentation. Set up an FDA-like agency to institute thousands of randomized testing experiments throughout government. Decentralize policy experimentation as much as possible to encourage maximum variation.

His tour through the history of government learning is sobering, suggesting there may be a growing policy gap. The world is changing fast, producing enormous benefits and problems. Our ability to understand these problems is slow. Social policies designed to address them usually fail and almost always produce limited results. Most problems have too many interlocking causes to be explicable through modeling.

Still, things don't have to be this bad. The first steps to wisdom are admitting how little we know and constructing a trial-and-error process on the basis of our own ignorance. Inject controlled experiments throughout government. Feel your way forward. Fail less badly every day.

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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 Medical Staff Lounge: Pharmacy phone calls and their solution

Dr. Edwards: It seems that I’m being deluged with pharmacy phone calls.

Dr. Milton:      I think they are hiring a lot of foreign pharmacists. Many seem to be struggling with the English language.

Dr. Edwards:  There seems to be a combination of problems. Some don’t understand the usual pharmacy abbreviations for AC, before meals, PC, after meals, and HS, at the hour of sleep? Read more . . .

Dr. Rosen:      It’s very disturbing to patients to be constantly interrupted during appointments with phone calls, from pharmacies asking questions “what are the directions?” I pull out my copy and read off, Prilosec 20 mg before dinner. (ACD). “It’s all there, isn’t it? as I confirm my copy.

[Pharmacist:     My copy of the prescription doesn’t say that!]

Dr. Rosen:      My copy seems to say that explicitly. AC means before a meal and D means that meal is dinner. Just like PC means after a meal and PCD means after dinner. PCL would be after lunch and ACB would mean before breakfast like diabetic drugs. The Prilosec was ACD because you need to take that before a meal to stop the stomach from secreting acid in preparation to digest the coming meal and prevent acid indigestion such as GERD (Gastro-esophageal-reflux-Disease) by reducing the available acid to regurgitate into the esophagus and burn the lining. The same process works on the other end of the stomach where the excess acids burns a hole in the duodenum and causes a duodenal ulcer or peptic ulcer disease (PUD).

Dr. Ruth:        You spend a considerable time teaching the young or foreign pharmacist. Is it time well spent?

Dr. Rosen:       No teacher or professor always has a good idea of how well his efforts are received and appreciated. But don’t you think we should continue to make that effort?

Dr. Ruth:        I guess it’s the same when I have medical students in my office. Sometimes I get very discouraged. And then a response makes me realize my efforts weren’t in vain.

Dr. Dave:        I guess maybe I should change my attitude. I frequently just tell them off.

Dr. Sam:         I just tell them what they need to know to fill my prescription so I can get on with my work.

Dr. Dave:        I’ll also do what I need to in order to get my patient’s prescription filled. But I remember the pharmacy and the next patient that doesn’t have a favorite pharmacy; I send the prescription to their competitor.

Dr. Rosen:      (smiling) Did you learn that from Adam Smith’s Wealth of Nations?

Dr. Edwards:  Isn’t it amazing how free enterprise works to correct all inequities? If one doesn’t provide good service, their income will slowly drop off.

Dr. Dave:        I think I may have diverted up to a hundred customers from the pharmacy next door to the one a few blocks down the street.

Dr. Rosen:      One wonders if the pharmacy staff understands free enterprise as the solution to the distribution of healthcare.

Dr. Milton:      One must also wonder how many physicians understand free enterprise as the solution to healthcare costs.

Dr. Paul:         Here we go again. Free enterprise is the solution to all that is wrong with medicine.

Dr. Edwards:  Actually it is!

Dr. Milton:      If I’d seen you at the next table, I probably would have avoided the subject today

Dr. Edwards:  Have you read Adam Smith?

Dr. Paul:         I think I may have read it in college. I don’t remember that it made sense then. And I certainly don’t think it makes sense in these complicated economic times.

Dr. Milton:      You liberals only have Faith in Government. Government is not consistent enough for anybody to have faith in it.

Dr. Rosen:      You got that right. It’s a good thing that the framers of the constitution and father of our country had a Divine faith. Otherwise we wouldn’t have the freedom and privileges we now enjoy. We hope our next president has such Faith as our fore Fathers had. Otherwise the end of our worldwide exceptionalism may be near.

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The Staff Lounge Is Where Unfiltered Medical Opinions Are Heard.

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8.      Voices of Medicine: From the San Mateo County Medical Assn Bulletin – Nov 30, 2011

Death of Clinical Judgment

by: Arnold Goldschlager, MD

I recently reviewed a CT scan with one of our young stellar radiologists. He was interrupted twice by the Peninsula ER doctor who needed the information on two seriously ill patients. I watched as the radiologist immediately retrieved the digital images on these two abdominal scans. He reviewed the results with the ER physician over the phone and gave him invaluable, specific information which allowed a prompt and correct disposition to be made. The anatomic accuracy and specificity of the images is nothing less than awesome.

I reflected to my own experiences working as the Peninsula ER Doc 41 years ago (many of the new docs covered the ER before there was an official ER specialty).

I remembered how we would agonize over a patient with “unclear” abdominal pain and examine the abdomen over and over, rechecking the WBC and UA. We would then ultimately decide if the patient needed to go to surgery, not knowing if we made the correct decision. Read more . . .

We used clinical skills to arrive at the decision  - the senses of touch, sight, sounds, even smell and the subtle changes in patients reactions to our examinations and interviews. The sum of all of this represented clinical judgment – a skill we all needed to practice our craft. While some physicians were better at it than others, we all possessed “it”. Those who excelled at it were “master” clinicians.

I recall my years of cardiology training, spending hundreds of hours learning to examine the heart, going to rheumatic and congenital heart clinics and attending auscultation courses in distant cities. As a medical student, if I could not hear the murmur elucidated by the professor on morning rounds, I went back at night to reexamine the patient to train my ear and become a competent diagnostician.

I spent the last 40 years trying to teach these physical diagnosis skills to generations of medical students at UCSF.  They will never have to achieve the skill levels that our generation needed. Why waste all that time learning a skill that can be bettered by the technology of ultrasound? The echocardiogram not only diagnoses the lesion, it quantitates it as well. I now know how the 19th century physicians felt when the chest x-ray was invented.    

All their skills in percussion of a lung cavity were no longer needed now that one could “look into” the chest with Roentgen’s rays.

The engineers and technical people have transformed our profession by devising and perfecting radiation, ultrasound, nuclear techniques  -  all modern ways to look into the body and get the answers that eluded physicians for centuries.

Alas, clinical judgment is a double-edged sword, since it is no longer taught, needed or wanted with technology making the diagnosis. Physicians will (or already have) become health care managers who coordinate the various  modalities of diagnosis. Perhaps they too will someday be replaced by artificial intelligence.

In my fifty years of participation in the study and practice of medicine I have witnessed the evolution  of this art/science that has gone from the “horse and buggy stage” to the space age: electrical cardioversion; pacemakers and defibrillators (first external and then miniaturized and implantable); balloon angioplasty, followed by bare stents and drug eluting stents; ablation of arrhythmias; coronary angiography and cardiac surgery, both coronary and valvular -  just to mention a few advancements in my own specialty.

It has been an “exciting ride” to witness and participate in the evolution of medicine over the last half century. Clinical judgment may be dead, but the medical world is now a better place as our diagnoses and treatments have become more accurate and precise.  Nonetheless, I mourn the loss of clinical judgment.

I was fortunate to span both worlds. I am a “dinosaur” with the latest generation 4G IPhone. Ω

Dr. Goldschlager is an internist and cardiologist and practices in Burlingame and Daly City.

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

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9.      Book Review: A Voice for the Generations by  Scott Eberle, MD

The Santa Rosa Reader: A Personal Anthology from the Family Medicine Residency,

by Rick Flinders, MD, Sonoma County Medical Association, 95 pages, $9.95.

Some artists’ work speaks for itself. Some artists’ work speaks for a generation.
--Jack Nicholson, introducing Bob Dylan at the first Live Aid Concert in 1985

I was on faculty at the Santa Rosa Family Medicine Residency from 1989 to 2001. A few years into my tenure, one of the faculty’s more senior members told me that you could only be an effective teacher of residents for about 10 years out from your own training. “After that,” she said, “you’ve forgotten what it’s like to be a resident.” At the time I vowed to never forget, and to stay beyond that 10-year mark. Turned out she was right: I left the faculty after 12 years of teaching. In the flow of residency time, it seems, a generation is about a decade long.

All the more remarkable, then, that Dr. Rick Flinders has been teaching at the residency for more than three decades. With the release of his new book, The Santa Rosa Reader, it becomes clear just why Rick has stayed and why he has continued to flourish--as physician, teacher and writer. Much like his great muse, Bob Dylan, Rick has reinvented himself over and over. The one constant is that he has been a leading voice for the Santa Rosa residency, generation after generation. Read more . . .

I mark the start of Rick’s first “generation” of teaching as 1985. After five years of part-time faculty work, that was the year he became full-time director of the residency’s inpatient medicine service. It’s also the year he wrote “Hour of the Intern,” the first essay in this anthology from Rick the practicing physician.

Clarion (1985-1995)

I know best this phase of Rick’s teaching and writing career. We first met in 1983 at UCSF medical school. I was a fledging medical student, he a fledgling faculty member. At this young age, I had an inkling of an idea about (or maybe it was just a longing for) what it might mean to be a physician. Rick was the first person to give me words to describe this youthful vision. During a small seminar for medical students, Rick offered story after story from his private practice in Petaluma. I can see now how, with each story, he was trying to bring to life the immortal words of poet and physician William Carlos Williams:

“[S]o for me the practice of medicine has become the pursuit of a rare element the patient may reveal at any time. It is always there, just below the surface. From time to time we catch a glimpse--and we are dazzled … it is magnificent, it fills my thoughts, it reaches to the farthest limits of our lives.”

Some of the best essays in this anthology--“Prologue: First Patient,” “House Call: What Doctors Learn” and “Epilogue: On the Road with Daisy Mae”--are stories that capture Rick’s rare and dazzling moments. When he and I first met, he wasn’t writing these stories yet; but in that small UCSF seminar room, he was already the consummate bard: Rick the storyteller, and me the rapt listener. . .

This book review is found at  

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

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10.  Hippocrates & His Kin: Can Government Learn?

David Brooks makes a great point on whether government can learn which policies are successful.
Read the long answer by David Brooks in Section Six above.

The short answer: Government really does NOT want to LEARN.

Q. What’s the difference between the American Dream and every one’s dream?

A. Everybody else’s dream is to come to America.—the promised land.—the land of opportunity.

But opportunity seems to be fading into history.

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

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11.  Restoring Accountability in Medical Practice, 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 section, please go to

                      John and Alieta Eck, MDs, for their first-century solution to twenty-first century needs. With 46 million people in this country uninsured, we need an innovative solution apart from the place of employment and apart from the government. To read the rest of the story, go to and check out their history, mission statement, newsletter, and a host of other information

                      Medi-Share Medi-Share is based on the biblical principles of caring for and sharing in one another's burdens (as outlined in Galatians 6:2). And as such, adhering to biblical principles of health and lifestyle are important requirements for membership in Medi-Share. This is not insurance. Read more . . .

                      PATMOS EmergiClinic - where Robert Berry, MD, an emergency physician and internist, practices. To read his story and the background for naming his clinic PATMOS EmergiClinic - the island where John was exiled and an acronym for "payment at time of service," go to To read more on Dr Berry, please click on the various topics at his website. To review How to Start a Third-Party Free Medical Practice . . .

                      PRIVATE NEUROLOGY is a Third-Party-Free Practice in Derby, NY with Larry Huntoon, MD, PhD, FANN. ( Dr Huntoon does not allow any HMO or government interference in your medical care. "Since I am not forced to use CPT codes and ICD-9 codes (coding numbers required on claim forms) in our practice, I have been able to keep our fee structure very simple." I have no interest in "playing games" so as to "run up the bill." My goal is to provide competent, compassionate, ethical care at a price that patients can afford. I also believe in an honest day's pay for an honest day's work. Private Neurology also guarantees that medical records in our office are kept totally private and confidential - in accordance with the Oath of Hippocrates. Since I am a non-covered entity under HIPAA, your medical records are safe from the increased risk of disclosure under HIPAA law. 

                      FIRM: Freedom and Individual Rights in Medicine, Lin Zinser, JD, Founder,, researches and studies the work of scholars and policy experts in the areas of health care, law, philosophy, and economics to inform and to foster public debate on the causes and potential solutions of rising costs of health care and health insurance. Read Lin Zinser’s view on today’s health care problem:  In today’s proposals for sweeping changes in the field of medicine, the term “socialized medicine” is never used. Instead we hear demands for “universal,” “mandatory,” “singlepayer,” and/or “comprehensive” systems. These demands aim to force one healthcare plan (sometimes with options) onto all Americans; it is a plan under which all medical services are paid for, and thus controlled, by government agencies. Sometimes, proponents call this “nationalized financing” or “nationalized health insurance.” In a more honest day, it was called socialized medicine.

                      Michael J. Harris, MD - - an active member in the American Urological Association, Association of American Physicians and Surgeons, Societe' Internationale D'Urologie, has an active cash'n carry practice in urology in Traverse City, Michigan. He has no contracts, no Medicare, Medicaid, no HIPAA, just patient care. Dr Harris is nationally recognized for his medical care system reform initiatives. To understand that Medical Bureaucrats and Administrators are basically Medical Illiterates telling the experts how to practice medicine, be sure to savor his article on "Administrativectomy: The Cure For Toxic Bureaucratosis."

                      David J Gibson, MD, Consulting Partner of Illumination Medical, Inc. has made important contributions to the free Medical MarketPlace in speeches and writings. His series of articles in Sacramento Medicine can be found at To read his "Lessons from the Past," go to For additional articles, such as the cost of Single Payer, go to; for Health Care Inflation, go to

                      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, which would use peer review as a weapon to unfairly destroy other professionals. Read the rest of the story, as well as a wealth of information, at

                      Semmelweis Society International, Verner S. Waite MD, FACS, Founder; Henry Butler MD, FACS, President; Ralph Bard MD, JD, Vice President; W. Hinnant MD, JD, Secretary-Treasurer; is named after Ignaz Philipp Semmelweis, MD (1818-1865), an obstetrician who has been hailed as the savior of mothers. He noted maternal mortality of 25-30 percent in the obstetrical clinic in Vienna. He also noted that the first division of the clinic run by medical students had a death rate 2-3 times as high as the second division run by midwives. He also noticed that medical students came from the dissecting room to the maternity ward. He ordered the students to wash their hands in a solution of chlorinated lime before each examination. The maternal mortality dropped, and by 1848, no women died in childbirth in his division. He lost his appointment the following year and was unable to obtain a teaching appointment. Although ahead of his peers, he was not accepted by them. When Dr Verner Waite received similar treatment from a hospital, he organized the Semmelweis Society with his own funds using Dr Semmelweis as a model: To read the article he wrote at my request for Sacramento Medicine when I was editor in 1994, see To see Attorney Sharon Kime's response, as well as the California Medical Board response, see Scroll down to read some very interesting letters to the editor from the Medical Board of California, from a member of the MBC, and from Deane Hillsman, MD. To view some horror stories of atrocities against physicians and how organized medicine still treats this problem, please go to

                      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."

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

Words of Wisdom

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

Giving money and power to government is like giving whiskey and car keys to teenage boys. –P. J. O’Rourke, Civil Libertarian.

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

Some Recent Postings

In The April Issue:

1.                  Featured Article: Unrecoverable accounts receivables more important than Medicare cuts

2.                  In the News: Doctor’s Office Visit for the price of a cup of coffee for 57 years.

3.                  International Medicine: Socialism & Socialized Healthcare have the same END GAME.

4.                  Medicare: Natural Rights Trump Obamacare, or Should

5.                  Medical Gluttony: The Medical Myth of providing improve access to care is gluttonous

6.                  Medical Myths: Putting Medicaid patients into HMOs will improve their access to care.

7.                  Overheard in the Medical Staff Lounge: The next occupant for the White House

8.                  Voices of Medicine: Inside Medicine: Doctors are often in the dark about costs

9.                  The Bookshelf: Why We Get Fat: And What to Do About It, by Gary Taubes

10.              Hippocrates & His Kin: Preventing Free Trade in HealthCare

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

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

In Memoriam

Charles Colson, political operative and prison reformer, died on April 21st, aged 80

THOSE who knew Chuck Colson said he never changed much, to look at, from the age of 18 to the age of 80. The same owlish horn-rimmed glasses; the same liking for blazers and bow ties; and that same quizzical, half-laughing, wide-eyed look, as if another quip was coming.

He was a prankster as a boy, letting off stink bombs in cinemas and putting snowballs in hats. In young manhood, campaigning for politicians in Boston, he learned the art of “planting misleading stories…voting tombstones, and spying out the opposition in every possible way”. No surprise then that when he joined Richard Nixon's White House as special counsel, in 1969, he was soon in charge of dirty tricks. He tried to get thugs to rough up anti-Vietnam-war protesters, and dreamed of firebombing the liberal Brookings Institution to seize incriminating stuff inside. He spread the false tale that Arthur Burns, chairman of the Federal Reserve, planned to enrich himself at taxpayers' expense, and listed (with sexual foibles) Nixon's enemies, to trap them later.

It wasn't so much the trickiness that caught the eye, however, as the take-no-prisoners fervour with which he did his job. Mr Colson always went further than other people. He had fitted a truck horn to his first car, a Morris Minor, the better to barge through traffic. As a student at Brown, devising challenges for new recruits to the frat house, he ordered them to produce custard pies imprinted with the shape of a breast from a nearby ladies' college. Desperate to get into the marines and go to Korea, he drilled and polished for weeks until he was good enough.

At the White House, too, coming up to the 1972 campaign, he planned total war against all that was leftist, peacenik, spineless and immoral. This was dog-eat-dog, and attack was the best possible form of defence. When the longed-for call from Nixon came, he left his lucrative law practice to do whatever he was asked. He would chew people up, and spit them out, for the president. He would break all the fucking china, as Nixon once suggested to him, to get an order ready to sign on his desk by Monday morning. “The president wants to see you, Mr Colson,” were words that set his spine tingling, as it did when he heard martial music, or the words “United States”. To be the president's point-man, his hatchet man, taking down his hunched, muttered confidences on yellow legal pads, was the fulfilment of his life.

It could be argued that he won the election for Nixon by prising off large chunks of the blue-collar, Catholic, ethnic Democratic vote. His part in the downfall was murkier. The botched burglary of Watergate was “not his baby”, he insisted (not up to his standards), though he knew Howard Hunt, one of the “plumbers”, through the burglary of the office of the psychiatrist of Daniel Ellsberg, who had leaked the Pentagon Papers that did much to turn the country against the war. Destroying Ellsberg had always been Mr Colson's aim, and it was to this that he pleaded guilty in 1974. By copping that plea, some thought, he avoided harder questions, which might have passed closer to Nixon's head.

Point-man for Jesus

But between the Ellsberg incident and the prison Mr Colson had transferred his unstoppable, driving energies to another boss. This one had called him out of the blue on a visit to his friend Tom Phillips, head of Raytheon, to drum up business for his law firm after he had left the White House. Tom spoke of finding Jesus. Later they read C.S. Lewis together, about the “spiritual cancer” of pride, and the old tingling started in Mr Colson's spine—soon followed, as he tried to drive home, by floods of repentant and refreshing tears.

Just a trick of the old Colson kind, his many enemies said. A play for sympathy, no doubt, as the wolves closed in around the White House. It took him three decades to convince the world that his conversion was sincere: three decades in which, building on his sobering seven months in jail, he set up a network of prison ministries in 115 countries, established a programme of restorative justice, and took over units of prisons to run them on Christian principles, with Scripture classes and prayer-meetings. (Re-offending rates, usually 20%, were a mere 8% in his programmes.) In hundreds of fetid cells he would appear in person, Bible in hand, to urge jailbirds to a new life. He was no longer a hatchet man, but still a point-man: doing whatever needed doing, when Jesus asked. On the same yellow legal pads, in his service, he would now jot down points of theology.

Many of his enemies were still the same. Immorality, secularism, pro-abortionism, lack of patriotism: all had to be battled. Fortified by the 27th Psalm (“He shall set me up upon a rock”), Mr Colson picked teams of Centurions to “change the culture” of the country, and founded a Chuck Colson Centre to help a “Christian worldview” take hold. Behind the prayer-language was still the boy whose pride had nearly burst his new suit as he gave his high-school valedictory speech; and the low-class non-Brahmin Bostonian who, in his vast-ceilinged office beside Nixon's, had burned to destroy all non-believers in their cause and to make America great and good again. From Tricky Dicky to Jesus Christ was not, perhaps, as huge a change as everyone thought.

This Month in History

In this Month in 1894, Heinrich Dietrich Wilhelm Meyer, my Father, was born. His grandfather left Germany in 1864 as Bismarck was enslaving the entire nation with social insurance. He learned from Napoleon, that a people used to entitlements will never jeopardize their enslavement by voting for freedom. Non-believers have substituted government as their god, which they can mold into their own image similar to what the Children of Israel did in the desert. Believers who believe they were created in a Divine image will always vote for freedom, to allow the greatest expression of their heritage, uniqueness, divine mission of God’s green earth without governmental restrictions.

In this month in 1704, the first regularly issued American newspaper, the Boston News Letter, began publication. Newspapers have always done very well in America and done very well by America. They have helped inform us, educate us and broaden our horizons.

After Leonard and Thelma Spinrad

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The 10th Anniversary World Health Care Congress


The 10th Annual Congress is committed to improving global health care by bringing together business, political, and academic health care leaders to actively share information and work together to improve the overall quality and cost of health delivery in the US and throughout the world.

The 10th Annual World Health Care Congress will be held April 8-10, 2013 at the Gaylord Convention Center, Washington DC.
For more information, visit
The future is occurring NOW.

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