Community For Better Health Care

Vol XI, No 7, Oct 16, 2012

In This Issue:

  1. Featured Article: The Future of Conservatism

  2. In the News: The most persecuted religion

  3. International Medicine: A New Twist on International Medicine: Domestic Medicine

  4. Medicare: To avoid penalties, physicians must implement an EHR by 2014

  5. Medical Gluttony: Health Insurance without Copayment Causes Medical Gluttony

  6. Medical Myths: Health Insurance Improves Health Care

  7. Overheard in the Medical Staff Lounge: Is ObamaCare Decreasing Access to Care?

  8. Voices of Medicine: EHR: Take Care of the Chart, Don’t Worry about the Patient

  9. The Bookshelf: The Normal Heart

  10. Hippocrates & His Kin: What Party are you?

  11. Restoring Accountability in Medicine, Government and Society

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

* * * * *

The Annual World Health Care Congress, a market of ideas, co-sponsored by The Wall Street Journal, is the most prestigious meeting of chief and senior executives from all sectors of health care. Renowned authorities and practitioners assemble to present recent results and to develop innovative strategies that foster the creation of a cost-effective and accountable U.S. health-care system. The extraordinary conference agenda includes compelling keynote panel discussions, authoritative industry speakers, international best practices, and recently released case-study data. 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.

* * * * *

  1. Featured Article: The Future of Conservatism

By LARRY P. ARNN, President, Hillsdale College

The future of conservatism is contained in its name. Conservatism regards certain things as abiding. There are laws of nature, and freedom, justice, and civilization depend upon the recognition of those laws. Today they face a challenge that is debilitating to society. Sustained by a transformative president, this challenge claims to have history on its side, and it claims to sit at the moment of final triumph.

In the arithmetic of nature, there must be opportunities to match this danger, and there are. The politics of the left lead to friction along racial and class lines. They raise up a new political class that governs through privileged influence. This political class, for all its pretensions of science and progress, does and will continue to do what unaccountable rulers do: Govern in its own interest. These things have bred and will continue to breed widespread and intractable resentment. Read more . . .

In this resentment there is opportunity, already present and growing. So far the conservative movement has not been able to capitalize on it. This is partly because it does not make its argument, especially in active politics, consistently well or in unity. Such a problem is not easy to fix, because statesmen of the first order are, as Winston Churchill put it, “much rarer than the rarest and purest of diamonds.” This is the age-old problem of politics.

The best we can do is take our guidance where Aristotle said we would find it: in the examples of great statesmen. What, for example, did Churchill do? He lived for long years in the wilderness. He faced the overwhelming opposition of academic and elite opinion, shot through with ideology that made them blind to Hitler and his ilk and devalued the freedoms of their country. He, like us, faced a hostile press, and he was denied access to the major organs of public communication. He was driven, partly by his own party, to the point of bankruptcy and obscurity. As things worsened, his argument rose to a high pitch of reason and eloquence, driven upwards by his own native talent and by terrible events.

Then came the sufficient opportunity: Events proved him right. He had paid a heavy price, and the people saw it and trusted him. First a few, then many, then legions rallied to his cause. He and his people saved their country and, by the time he was done, left it stable and free for more than a generation.

If conservatism is to live, it must repudiate absolutely this system of limitless government, of class and racial privilege and discrimination, of the overturning of human nature, of the vaunting of the ruling class. It must proclaim without ceasing the good of freedom and the danger to it. It must examine itself before it blames the American people, who have a right to govern themselves and who have not been the cause of these troubles. If conservatism speaks with force and persistence in the name of the good that it loves, its day will come.

Feedback . . .
Subscribe MedicalTuesday . . .
Subscribe HealthPlanUSA . . .

* * * * *

  1. In the News: The most persecuted religion


At the height of the Nazi Holocaust, the wretched human cargo spilling out of cattle cars onto the platforms of Auschwitz was immediately subject to a brutal “selektion” by the infamous Dr. Josef Mengele, whose flick of a finger to the left meant immediate death in a gas chamber; to the right, slave labor and slow death from starvation or disease.

Fast forward to 2012 Nigeria, where a latter-day incarnation of selektion has been used—this time not against Jews, but against Christians. Read more . . .

Nigeria is the most populous black nation on earth. Among its chief blessings are oil and a large array of religious, tribal and language groups. Yet conflict, violence and terrorism are part of reality there, too.

Recently a new line of inhumanity was crossed. In October, armed attackers, presumed to be members of Boko Haram, an Islamist terrorist group with links to al Qaeda, invaded the Tudun Wada Wuro Patuje area, entering the off-campus housing of the Federal Polytechnic State University.

The attackers called students out of their rooms and asked for their names. Those with Christian names were shot dead or killed with knives. Students with traditionally Muslim names were told to quote Islamic scripture. The selektion completed, at least 26 bodies were left in lines outside the buildings. . .

In earlier times, armies clashed over territory. Objectives were clear, as was the identity of the "enemy," lurking beyond a defined border. Nowadays people in too many parts of the world are taught to identify as the enemy neighbors who are indistinguishable from themselves, save by their beliefs. They have to be "selected" before they can be butchered. Whatever the original cause of a conflict, once religion becomes the driving ideological tool, it is no longer just about oil reserves or farmland.

Today, Islamist extremists' rage has the power to transform small, local conflicts into infernos that can snuff out lives thousands of miles away. Threatened targets of religious hatred today include Hindus, Sunnis, Shiites, Bahais and Jews, but the most widely menaced are Christians. A Pew Forum study last year found that Christians are persecuted—by independent groups or governments—in 131 of the 193 countries in the world. . .

If America fails to exercise leadership, it will further embolden those who invoke God's name to murder and maim families in their houses of prayer and, as in Pakistan earlier this year, young girls who dare dream of an educated future. Theological manipulators of hatred will not be deterred unless and until they face the long arm of international action.

We must, and we can, ensure that the faithful attending a mosque on Friday, a synagogue on Saturday or a church on Sunday can be confident that they'll return home safely. We urge the president to use the next four years to protect not religions, but the religious, wherever they may be.

Rabbi Cooper is associate dean of the Simon Wiesenthal Center. Rev. Huffman is the pastor emeritus of St. Andrew's Presbyterian Church in Newport Beach, Calif. Rabbi Adlerstein is director of interfaith affairs at the Wiesenthal Center.

A version of this article appeared December 22, 2012, on page A15 in the U.S. edition of The Wall Street Journal, with the headline: The Most Persecuted Religion.

Feedback . . .
Subscribe MedicalTuesday . . .
Subscribe HealthPlanUSA . . .

* * * * *

  1. International Medicine: A New Twist on International Medicine: Domestic Medicine

Companies go surgery shopping

By Chad Terhune, Los Angeles Times

Employers are sending workers on all-expenses-paid trips to top-performing hospitals that agree to low, fixed rates for surgery.

Carol and Ed Vogel enjoyed a weeklong all-expenses-paid trip to a Newport Beach resort last month, and they're scheduled to return in a couple of weeks.

The Nevada couple didn't need frequent-flier miles or credit card rewards to get free airfare and hotel stay as well as $1,000 in spending money. It was all because of Carol Vogel's ailing hips and an employer's frustration with the high cost of U.S. healthcare.

Her husband's employer, newspaper publisher Stephens Media, sends employees and their family members needing hip and knee replacements to a handful of hospitals across the country, including one in Orange County, that agreed to a low, fixed rate for surgery and scored well on quality of care.

This year, grocery giant Kroger Co. has flown nearly two dozen workers to Hoag Orthopedic Institute in Irvine and several other hospitals across the U.S. for hip, knee or spinal-fusion surgeries in an effort to save money and improve care. Starting in January, Wal-Mart Stores Inc. will offer employees and dependents heart, spine and transplant surgeries at no cost at six major hospital systems across the nation, with free travel and lodging. Read more . . .

It's all part of a growing movement by employers fed up with wildly different price tags for routine operations. In response, businesses are showering workers with generous incentives — including waiving deductibles or handing out $2,500 bonuses — to steer them to these top-performing providers offering bargain prices.

Bundled deals are common for phone service, cable TV and travel. But an all-in-one price marks a radical departure for the conventional fee-for-service medical industry in which doctors, hospitals, labs and other providers typically bill separately for each part of a procedure. Then they tack on even more if complications and unexpected costs arise.

"You expect to see the hotel, airfare and car bundled together on Expedia," said Susan Ridgely, a senior policy analyst at Rand Corp., a nonprofit think tank in Santa Monica. "We want to stop paying by the widget in healthcare."

By bringing a steady stream of new patients, the arrangement can also be a good deal for the doctors and hospitals involved.

Federal and state officials are catching on as well. Medicare and some Medicaid programs are pushing for more of these all-inclusive prices for the most common procedures, from surgeries to maternity care for low-income mothers, to eliminate some of the huge disparities in U.S. healthcare costs and reward high-quality providers with more patients.

These programs are generally voluntary so patients can still opt for care closer to home, although it may cost them more.

At Kroger, employees may pay 10% out of pocket if they choose one of the company's 19 select hospitals, compared to 25% to 50% out of pocket for other nearby medical centers.

Carol Vogel, a 64-year-old writer in Minden, Nev., said she was skeptical about flying to another state for surgery until the human resources manager explained how much she stood to save.

In Newport Beach "this was 100% paid for," Vogel said. If she stayed closer to home in Nevada, "I would have been out $8,000 or $9,000 easy on my insurance."

She said she's pain-free in her left hip for the first time in years, so she scheduled an implant for her right hip later this month, followed by a free stay at Island Hotel, an oceanfront resort in Newport Beach.

"This is like the honeymoon we never had," she said. "Are you kidding me?"

At Kroger, 21 patients have traveled for surgery this year, and none have experienced complications or been readmitted to the hospital, said Theresa Monti, a company vice president for employee benefits. She said Kroger pays about $30,000 on average for those knee and hip replacement surgeries, 15% less than what it pays at other hospitals.

"It's a new concept, and some people have a hard time getting their arms around the idea of traveling for surgery," Monti said. "We are looking for any opportunity we can to encourage the use of the highest-quality healthcare while holding the line on costs."

BridgeHealth Medical Inc. in Denver is one of a handful of firms that assists employers, insurers and patients with the logistics of surgery shopping. Earlier efforts to persuade employers to send patients to India and other overseas destinations for cheaper care never took off. So BridgeHealth now has negotiated fixed rates with about 45 U.S. hospitals.

Chip Burgett, an executive vice president at BridgeHealth, said employers still come out ahead financially, even after footing thousands of dollars in travel expenses. His firm has negotiated rates on knee and hip replacements as low as $19,000.

Last year, the California Public Employees' Retirement System limited what it would pay for knee and hip replacement surgeries to $30,000 because its hospital bills ranged from $15,000 to $110,000 with no discernible difference in quality. It found 45 hospital systems willing to stay within that amount, and its average price per surgery dropped 30% to $23,113.

"There is a lot of excess margin in healthcare and plenty of room in the pricing of these hospitals," Burgett said. "Hopefully this drives true competition in healthcare and it's not just based on how many helicopters a hospital has."

While employers are leading the way right now, experts say Medicare could have the biggest impact. Federal officials are looking to test these all-in-one prices with hospitals in California and other states.

Some consumer advocates have raised concerns about patients traveling long distances for surgery and taking them away from their regular doctors. Cindy Meyers, benefits manager for Stephens Media in Las Vegas, said it has been difficult in some cases to find local doctors to provide follow-up care for patients who traveled elsewhere.

But she said the overall experience has been positive for her company, which insures about 1,500 people across several states.

"It's a great benefit for us cost-wise, and our employees feel comfort in knowing this doctor specializes in just what they need," Meyers said.

James Caillouette, surgeon in chief at the 70-bed Hoag Orthopedic Institute and an advocate for bundled payments since 2008, said not every patient is a suitable candidate for this arrangement.

First, he requests their medical records and talks to the patient by phone. He rules out patients who may be at higher risk for complications from surgery.

Post-surgery complications matter not just for the patient but also to the doctors and hospital because they pose a risk for additional treatment costs. Some bundled deals include warranties spelling out what complications the medical providers are responsible for. Medical studies show that complications can cost $7,600 per patient.

Hoag Orthopedic Institute's bundled fees for knee and hip replacement range from about $20,000 at an outpatient surgery center to roughly $30,000 or more in the hospital. The surgery location depends largely on the patient's medical condition.

Caillouette said his patients usually spend one or two nights in the hospital and then return to their hotel. A physical therapist visits them there most days, and Caillouette makes house calls to the hotel as well. Most patients fly home after a week in Orange County.

"Now there's one bill, and employers can budget for it," Caillouette said. "This has the potential to be a game changer."

Read the entire article in the LATimes . . . Copyright © 2012, Los Angeles Times

Feedback . . .
Subscribe MedicalTuesday . . .
Subscribe HealthPlanUSA . . .

When American Doctors and Hospital work together they can provide the most cost-effective health care in the world.

* * * * *

  1. Medicare: To avoid penalties, physicians must implement an EHR by 2014

'Not One Successful EHR System In The Whole World'

By Neil Versel InformationWeek

Longtime advocate of computerizing healthcare C. Peter Waegemann calls current health IT
policy 'misguided.'

While federal health IT officials were touting the perceived successes of their efforts to increase physician usage of electronic health records (EHRs), one longtime advocate of EHRs was criticizing the whole direction of health IT policy.

"In my opinion, there is not one successful EHR system in the whole world," said C. Peter Waegemann, who founded and ran the Boston-based Medical Records Institute from 1984 to 2009. "User friendlinessusability, and interoperability are not there," he added in an interview with InformationWeek Healthcare.

He defined a successful EHR as one that is fully interoperable. "We have been focusing too much on documentation [for the purpose of reimbursement]," he said. This point has not been lost on the Obama administration, which has warned providers about using EHRs to "game the system." Read more . . .

Still, Waegemann believes the administration has not been aggressive enough with its $27 billion federal Meaningful Use EHR incentive program, based on published rules for Stage 2 and early recommendations for Stage 3. "MU2 and MU3 are just small steps. They rely on old technology," Waegemann said.

He noted that a number of leading EHR systems are written in the MUMPS programming language that originated at Massachusetts General Hospital in the late 1960s. Meaningful Use also relies on outdated standards such as version 2.x of Health Level Seven International's messaging standards rather than the more recent version 3.

According to Waegemann, too many organizations with EHRs still have paper forms and few EHRs are integrated with personal health records (PHRs).

"What we need is an EHR that is only an accessory to 'e-care,'" he said. Waegemann defines e-care as a patient-centric system in which technology serves as an adjunct to make healthcare more efficient. In his opinion, an EHR should include clinical decision support, the capture of clinical information at the point of care so the physician does not have to key in data, and automatic creation of documentation.

Meaningful Use does require physicians and hospitals to give some patients access to their records, but today's patient portals are "passive," according to Waegemann, in that individuals often are not able to enter their own information. It's not a personal health record, with patients truly in control, Waegemann contended.

He also said that the U.S. has wasted hundreds of millions of dollars on what first were called community health information networks (CHINs), then regional health information organizations (RHIOs), and more recently, health information exchanges (HIEs). Instead of regional networks, healthcare should look at point-to-point interoperability through standards.

"We need to have a totally different approach," Waegemann said. "What we need is an app that links anyone in personal care, from physical therapist to chiropractor to pharmacist."

Waegemann's Medical Records Institute put on an annual conference called Toward an Electronic Patient Record (TEPR) for 25 years. In the face of dwindling interest in TEPR, Waegemann reshaped the organization into the mHealth Initiative in early 2009, putting the focus on mobile technology in healthcare. The experiment lasted about three years until he quietly shut that entity down.

Read the entire article and references . . .

Clinical, patient engagement, and consumer apps promise to re-energize healthcare. Also in the new, all-digital Mobile Power issue of InformationWeek Healthcare: Comparative effectiveness research taps the IT toolbox to compare treatments to determine which ones are most effective. (Free registration required.)

[Is it time to re-engineer your clinical decision support system? See 10 Innovative Clinical Decision Support Programs. ]

Feedback . . .
Subscribe MedicalTuesday . . .
Subscribe HealthPlanUSA . . .

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

- Ronald Reagan

* * * * *

  1. Medical Gluttony: Health Insurance without Copayment Causes Medical Gluttony

For the practicing physician, the difference in appetite for tests, procedures, consultations, operations, MRIs, CTs, PET scans for those fully insured and those with a significant deductible and coinsurance is phenomenal. It is most striking in those with high deductible insurance. With high deductible insurance, which is keyed to the average yearly cost of health care, every single item is evaluated with a cost/health benefit comparison. It is essentially private personal health care with the insurance kicking in only after the average healthcare costs for the average person for the year has been spent. Read more . . .

Patients with this type of plan always tell the doctor or his receptionist the nature of his insurance. He or she understands the yearly annual medical history and physical examination. When it comes to the rest of health care, the differences become obvious. Patient with usual insurance will expect such things as annual blood tests, x-rays, electrocardiograms even if not indicated. They will want colonoscopies starting at age 50 and every five years when the experts state that those without risk can wait to age 55. Without a family history of colon cancer and no polyps found, the GI experts state that the second one should be in the mid to late 60s. In this instance the HMOs have essentially doubled health care costs.

The line of demarcation is so clear that if a patient has been mailed the former recommendation, he or she will demand it and if the physician doesn’t comply report him to his HMO. Straightening this out will take hours of physician time in explaining why. The patient with deductible and copayment responsibility will accept the physician’s recommendations rather than the HMO recommendation. Thus halving his health care costs and staying in the highest regions of quality of care curve.

This pattern replays essentially in all areas of health care costs.

The surprise is with the current government interference in health care as pushed by the HMOs is really HealthCare Gluttony, that HMOs formerly prided themselves on avoiding. This is a rather striking change over the last two decades of non-medical personnel influencing the physician in what they think is appropriate, if for no other reason than a government mandate.

Feedback . . .
Subscribe MedicalTuesday . . .
Subscribe HealthPlanUSA . . .

Medical Gluttony thrives in Government and Health Insurance Programs.

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

* * * * *

  1. Medical Myths: Health Insurance Improves Health Care

When speaking of Health Insurance vs Health Care, there is no unanimity of consensus. The Tax & Spend Party will always argue that the only way to have good health care is to have health insurance. This argument was made with political success in the mid-twentieth century during the implementation of Kerr-Mills, Medicare, Medicaid, Drug Prescription Plan, and a previous Major Long Term Health plan. It was only on the latter that clear insurable benefits were present and were otherwise unaffordable in the aged. However, this was changed when AARP, the advocate for the aged, felt this did not transfer enough taxpayer’s money from the young to those over 65 that the T & S party reversed the law.

Recently there has been more evidence that excessive health care procedures actually diminishes quality. The sophisticated diagnostic tests such as CT and MRI have found abnormalities that greatly concern doctors and their patients. This has led to increase in other diagnostic procedures and even operations with increasing adverse experiences. Read more . . .

Consider a patient with migraine who may have a CT of the brain as part of the diagnostic procedures. Frequently small aneurysms or malformations are found. What frequently is not told the patient in the surgeons push for immediate operation is that these congenital abnormalities are more than likely present since birth. Hence there is no urgency in proceeding quickly and one has adequate time to look at all the options available which including watchful waiting.

People with health insurance will more likely push for immediate intervention which then lowers the quality of care. Patients with high deductible insurance seem more content in looking at all options before rushing into surgery.

Feedback . . .
Subscribe MedicalTuesday . . .
Subscribe HealthPlanUSA . . .

Medical Myths originate when someone else pays the medical bills.

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

* * * * *

  1. Overheard in the Medical Staff Lounge: Is ObamaCare Decreasing Access to Care?

Dr. Edwards: How is the ObamaPlan working out in Practice? The swelling of the HMO ranks in my practice with the influx of Welfare and MediCal patients is causing some stresses in my staff.

Dr. Milton: It’s not only causing some stresses in my staff, but it is also stressing me. I’m working at least an hour a day longer for no additional revenue.

Dr. Ruth: We were promised that these MediCal Patients would be paid at Medicare rates. That was really subterfuge. The first time we were paid the Medicare rates which are marginable in and of themselves. But the follow up visits were a total misnomer. We were promised a 10 percent increase. But when we realized on our first printout that 10 percent increase on an $18 office visit is only $1.80. So a $19.80 payment for an office call did not improve our income. And sometimes we’re finding we have to work twice as hard for that $19.80 upgrade than we did for the $18 evaluation.

Dr. Milton: We’re also finding that this group of patients is seriously jeopardizing our income. Not only are their office visits longer because of the time required to educate them concerning their diseases and how their personal eating, drinking, smoking habits are causing their health care to deteriorate, but a barrage of “after visit phone” calls to answer other queries.

Dr. Edwards: But don’t you find very little concern about any deterioration in healthcare?

Dr. Milton: Certainly. But no lessening of the demand for expensive and mostly unnecessary?

Dr. Rosen: Don’t you think much of this is a factor that they have perceived themselves as being down trodden and denied what they think the wealthy and those with insurance normally receive?

Dr. Ruth: What has been a surprise to them as well as to us is that when we try to comply with as many of their demands as we can justify, they obtain even less care that the standard patients in their HMO category?

Dr. Rosen: That came as a surprise to us also. We thought we could use our usual HMO referral patterns, but we found that even some of our referral physicians that took MediCal in the past, did not take this new class of Welfare/MediCal patients upgraded to HMO status.

Dr. Ruth: It took us some time to become aware that these new HMO cards had a three digit code that signified their Welfare status and all Consulting physicians and surgeon slowly became aware of this code and declined to see these patients.

Dr. Rosen: What I still don’t understand is that many of these welfare/HMO patients who had a specialist while on Welfare/MediCal, all at once were without that specialist. Thus access to that specialist’s care was cut off.

Dr. Edwards: That doesn’t surprise you that the Medical Illiterates in Washington under the Ruse that ObamaCare will improve access to care had their unintended consequence of loss of access to care.

Dr. Rosen: Which just brings up again the dichotomy that people trust Congress, which now has a single digit approval rating, with something so complicated as their health care?

Feedback . . .
Subscribe MedicalTuesday . . .
Subscribe HealthPlanUSA . . .

The Staff Lounge Is Where Unfiltered Opinions Are Heard.

* * * * *

  1. Voices of Medicine: EHR: Take Care of the Chart, Don’t Worry about the Patient

Who's got time to listen to patients when the government demands 'meaningful' data entry?

The electronic medical record, or EMR, is a computerized system that allows physicians to record patient information electronically instead of using paper records. Test results can be reviewed through the system, and prescriptions can be emailed straight to the pharmacy. You can order medical tests and medications worth thousands of dollars with just a few mouse clicks. Read more . . .

As stipulated by ObamaCare, Medicare and Medicaid have enthusiastically embraced the concept of a paperless world. Doctors who adopt these programs in a "meaningful" way (more on that later) will be rewarded to the tune of up to $44,000 over five years. For those doctors who say no thanks, reductions in their Medicare payments for service will start in 2015.

At first I thought EMR sounded like a good idea. Then our practice started using one. . .

Tasks that once took seconds to perform on paper now require multistepped points and clicks through a maze of menus. Checking patients into the office is an odyssey involving scanners and the collection of demographic data—their race, their preferred language, and so much more—required by Medicare to prove that we are achieving "meaningful use" of our EMR. What "meaningful use" means no one knows for sure, but our manual on how to achieve it is 150 pages long.

Now the staff scurry about, rictus-like grins plastered to their faces, trying to hide their underlying stress. The patients, each a Job after completing the elaborate new check-in process—and wondering why the government needs to know if they are an Alaska native, among many other things—arrive in my exam room bewildered by their bureaucratic ordeal.

When the clicks don't get me what I want, I naughtily handwrite a prescription. I skip ordering certain tests I might want because it takes too much time—I'll do it next visit. I dreaded the arrival of this season's flu-shot supply—now there were more orders to input!

There was always going to be an adjustment period. As in the aftermath of a tornado, these things take time. I'm sure I'll get faster at using the system, and soon enough the data entry and test-ordering steps will come as second nature.

The end product will be lovely: a meticulously organized digital chart, with gorgeous progress notes. Nuggets of data accessible and ready for the plucking by the numbers crunchers. Medicare says the EMR is going to help me "achieve benchmarks that can lead to improved patient care."

Really? As a colleague remarked, it seems as if this is all about taking care of the chart, as opposed to taking care of the patient. Documentation is important, but the pointing and clicking and cutting and pasting we are so focused on in demonstrating meaningful use of EMR may be getting in the way of meaningful encounters with our patients.

With all the data entry the electronic system requires, my laptop presents a barrier between my patient and me, both physically and metaphorically. It's hard to be both stenographer and empathetic listener at the same time.

Some of the best doctors I've known were famous for the unintelligible scrawl of their hospital chart notes. Yet I doubt that fantastic electronic documentation will translate into fantastic clinical care. The institution of EMR seems to be a case of choosing style over substance, of putting up a few more hoops for doctors to jump through in their quest to simply take care of patients.

So, excuse me if, like a teenager transfixed by her smartphone, my eyes are glued to my screen at your next visit with me. I am truly listening to you. It's just that eye contact has no place in the Land of Meaningful Use.

Dr. Valinoti is an internist in private practice in Bergen County, N.J.

A version of this article appeared October 23, 2012, on page A15 in the U.S. edition of The Wall Street Journal, with the headline: Physician, Steel Thyself for Electronic Records.

Feedback . . .
Subscribe MedicalTuesday . . .
Subscribe HealthPlanUSA . . .

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

* * * * *

  1. Book & Play Review: American Conservatory Theater – San Francisco—Sept 29, 2012

The Normal HeartDirect from Broadway!
by Larry Kramer, Directed by George C. Wolfe

Direct from its acclaimed Broadway run, Larry Kramer’s landmark 1985 drama unfolds like a real-life political thriller as a tight-knit group of friends refuse to let doctors, politicians, and the media bury the truth about an epidemic ravaging the gay community. Their differences could tear them apart—or change the world. Kramer’s unapologetic tackling of the early days of the AIDS epidemic, gay marriage, and our national healthcare system casts theatrical light on issues that are as present in today’s national discourse as they were when the play first premiered. An unflinching and unforgettable play, The Normal Heart delivers one of the most powerful evenings you'll ever spend at the theater. –Theater program.

Or it might be considered an unfortunate and ill-informed consideration for gay-marriage which is a non-entity and a non-union. Only a phallus and vagina can be united as one-flesh, the very essence of marriage, something which two phalluses or two vaginas are unable to do. Read more . . .

Angels in America: A Gay Fantasia on National Themes had its SF premier two decades ago shortly after the current artistic director arrived. The Geary Theater had been destroyed by the 1989 Loma Prieta earthquake in San Francisco. A 1993 Pulitzer Prize-winning play in two parts by American playwright Tony Kushner was produced in the Marines Memorial Theater while the Geary was being rebuilt. The two parts of the play are separately presentable and entitled Millennium Approaches and Perestroika, respectively. The play has been made into both a television miniseries and an opera by Peter Eötvös. There were 14 same sex couples and one heterosexual couple in our theater row observing the scene as half of the men on stage lowered their trousers bending over while the other half of the male ensemble opened up their trousers displaying anal sex.

Set in New York City in 1985, the play opens with Louis Ironson, a neurotic gay Jew, learning that his lover, WASP Prior Walter, has AIDS. As the play and Prior's illness progress, Louis becomes unable to cope with the emotional stress and moves out.

Meanwhile, closeted homosexual Mormon and Republican law clerk Joe Pitt is offered a major promotion by his mentor, the McCarthyist lawyer Roy Cohn. Joe doesn't immediately take the job because he feels he has to check with his Valium-addicted, agoraphobic wife, Harper, who is unwilling to move. Roy is himself deeply closeted, and soon discovers that he has AIDS.

As the seven-hour play progresses, Prior is visited by ghosts and an angel who proclaim him to be a prophet; Joe finds himself struggling to reconcile his religion with his sexuality; Louis struggles with his guilt about leaving Prior and begins a relationship with Joe; Harper's mental health deteriorates as she realizes that Joe is gay; Joe's mother, Hannah, moves to New York to attempt to look after Harper and meets Prior after a failed attempt by Prior to confront Hannah's son; Harper begins to separate from Joe whom she has depended upon and finds strength she was unaware of; and Roy finds himself in the hospital, reduced to the companionship of the ghost of Ethel Rosenberg and his nurse, Belize, a former drag queen and Prior's best friend, who meanwhile has to deal with Louis's constant demands for updates on Prior's health.

The subplot involving Cohn is the most political aspect of the play. Portrayed as a self-loathing, power-hungry hypocrite, he prides himself on his political connections and influence, which he has amassed through decades of corruption. In the play, he recollects with pride his role in having Ethel Rosenberg executed for espionage. As he lies alone in the hospital, dying of AIDS, the ghost of Rosenberg sings him a Yiddish lullaby and then brings him the news that the New York State Bar Association has just disbarred him, destroying his final hope of dying as a lawyer. The play ends on a note of optimism. After his friends procure for him a stash of AZT, in 1990, Prior is still alive and is managing to live with AIDS. With his friends, he looks at the statue of an angel in Bethesda Fountain and talks of the legend of the original fountain, and how it will flow again some day.

The play is deliberately performed so that the moments requiring special effects often show their theatricality. Most of the actors play multiple characters. There are heavy Biblical references and references to American society, as well as some fantastical scenes including to Antarctica and Heaven, as well as key events happening in San Francisco and at Bethesda Fountain in Central Park.

With the current efforts of having homosexual anal-intercourse sanction by several protestant churches as being God-pleasing, despite the Good Book condemning it with capital punishment, (Leviticus: any man that lies with another man as he would with a woman, shall be put to death), homosexual priesthood, homosexual man love boy intercourse, a current psychologist stating that pedophile is not a treatable disorder and should not be a crime, that pedophiles are 5% of the population (more than twice the number of homosexuals, making for an astonishing mix of religion, philosophy, culture and politics, this disruption of a civil society warrants further discussions in the public forum without the risk of government or the Gay lobby prosecuting individuals for hate crimes. Most of us have had good homoerotic friends, fellow workers, and colleagues without any intrusion into a civil society. Most of the world’s religions, except for a small group of Protestants, consider the practice anathema. A military officer, in my private practice, who still has connections overseas, informs me that all the Muslim attackers at Benghazi had homosexual anal intercourse with Ambassador Chris Stevens. He was nearly dead before they shot him completely dead. Ambassador Stevens was subjected to a “Hate Crime” of homosexual rape, which the Muslims treat as worse than a heterosexual rape. He also relates that the President and our Secretary of State were watching the whole affair being transmitted live by a Drone above our Embassy in Benghazi to the Oval Office.

And subsequently our Secretary of State at her hearings on Benghazi on the erroneous early accounts of the attacks stated, “We had four dead Americans. Was it because of a protest, or was it because of guys out for a walk one night who decided they’d go kill some Americans? What difference, at this point, does it make?” (WSJ)

If Mrs. Clinton can’t understand the difference between “guys out for a walk one night who decided they’d go kill some Americans” to an attack on our embassy being watched in the Oval Office on a 9-11 anniversary as our Ambassador is being Homosexually Raped to Death, we should certainly make sure that she’s never in the Oval Office in control of America’s Destiny on Terror Flagged 9-11 Days.

Read more . . .

To read more book reviews . . .

To read book reviews topically . . .

Feedback . . .
Subscribe MedicalTuesday . . .
Subscribe HealthPlanUSA . . .

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

* * * * *

  1. Hippocrates & His Kin: What Party are you?

Singer Andy Williams, who died on Sept 26 at age 84, in his 2009 memoir “Moon River and Me”:
When Bobby [Kennedy] began his run for the presidency, I immediately volunteered to campaign for him and sing at a couple of fund-raisers. He then asked me if I would be one of the California delegates to the Democratic convention. “Shirley MacLaine is going to be one of my delegates, and I’d like you to be one, too.” I told him I’d love to do it, but a couple of weeks later a thought suddenly struck me , and I called Bobby and said, “I hope I haven’t screwed this up, but it’s just occurred to me: I’m a Republican.” He just laughed. “That doesn’t really matter. If you’d still like to do it for me, just go down and register as a Democrat.”

WSJ, Notable & Quotable, Sept 27, 2012, p 19.

When the Russian’s occupied Afghanistan, women removed their head coverings and girls went to school. Read more . . .

On Tuesday, gunmen in the Swat Valley city of Mingora stopped the school bus she was riding in and shot her in the head. Two other girls were also shot but not seriously hurt. The Pakistani Taliban claimed responsibility for the attack, calling it revenge for the girl's advocacy against the group . . . bent on denying girls the chance to go to school.

Where is the outrage from our women’s groups in the USA?

You know, for all the massive amounts of research that has been done on health policy issues, I have never seen a single study comparing state Medicaid programs on things like administrative costs, patient satisfaction, or any of the other criticisms private insurers get.

Greg Scandlen, HealthBenefitsReform

To read more HHK . . .

To read more HMC . . .

Feedback . . .
Subscribe MedicalTuesday . . .
Subscribe HealthPlanUSA . . .

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

* * * * *

  1. Restoring Accountability in Medical Practice, HealthCare, Government and Society:

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

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

* * * * *

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

Words of Wisdom & Great Truths

 In my many years I have come to a conclusion that one useless man is a shame, two is a law firm, and three or more is a congress. –John Adams

If you don't read the newspaper you are uninformed, if you do read the newspaper you are misinformed. –Mark Twain

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

A government which robs Peter to pay Paul can always depend on the support of Paul.—George Bernard Shaw

A liberal is someone who feels a great debt to his fellow man, which debt he proposes to pay off with your money. – G. Gordon Liddy

Democracy must be something more than two wolves and a sheep voting on what to have for dinner.—James Bovard, Civil Libertarian (1994)

Foreign aid might be defined as a transfer of money from poor people in rich countries to rich people in poor countries. – Douglas Case, Classmate of Bill Clinton at Georgetown University

Some Recent Postings

In The Sept Issue:

  1. Featured Article: Mrs. Clinton apologizes for Muslim attack on our Embassy?

  2. In the News: Entitlements corrupt governments and increase crime

  3. International Medicine: Infatuated patients In the UK use Facebook to stalk doctors

  4. Medicare: Medicare rejects more claims than any private health insurance plan

  5. Medical Gluttony: Free Health Care

  6. Medical Myths: The Myth of Obama

  7. Overheard in the Medical Staff Lounge: Medicine at the Cross Roads

  8. Voices of Medicine: America is addicted

  9. The Bookshelf: Eradicating Morality Through Education

  10. Hippocrates & His Kin: Please, give me another chance. Pretty Please?

  11. Restoring Accountability in Medicine, Government and Society

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

In Memoriam

Gore Vidal went toes up at 86

Andrew Ferguson in the Weekly Standard's Aug. 13 issue:

The most puzzling thing about the career of Gore Vidal, who went toes-up last week at 86, was the reverence in which he was held by people who might have known better. . . .

For decades Vidal had said that Franklin Roosevelt knew in advance of the Japanese attack on Pearl Harbor and let the slaughter come anyway, and when 9/11 gave him the chance to make the same slander against another president, he went even further and speculated that George Bush had colluded with his vice president to encourage the terrorist attacks. At his death a critic at the Washington Post summarized the Vidalian view with an uncommon mildness: "He took an acerbic view of American leadership."

The man must have felt bulletproof. With implausible romances like Lincoln and Burr he filled more readers' heads with more historical crapola than anyone since Parson Weems. ("So powerful as to compel awe," said Harold Bloom of Vidal's make-believe histories.) He thought the Bilderbergers and members of the Bohemian Grove controlled world finance. ("He is a treasure of state," said R.W.B. Lewis.) He befriended Timothy McVeigh and spoke warmly of him. ("Vidal did not lightly suffer fools," said the obit writer in the New York Times.) He dished out anti-Semitism in a dozen different venues with imperturbable serenity. ("Both by temperament and by birth he was an aristocrat," said the Times.) He called William F. Buckley a crypto-Nazi. ("Vidal was known for his . . . scathing wit," said Diane Sawyer on ABC.) He wanted to try Henry Kissinger for war crimes and suggested that John McCain had invented tales of his torture at the hands of the Vietnamese. ("A savvy analyst and glorious gadfly on the national conscience," said the L.A. Times.) . . .

I was interested in Diane Sawyer's brief obituary on her ABC evening news show. It centered on the notorious confrontation (on ABC TV) between Vidal and Buckley in 1968, in which Buckley countered Vidal's accusation of Nazism with the vigorous insight that Vidal was "queer"—not high on the list of Buckley's scathing witticisms either. In recalling the event, Sawyer identified Vidal as the "celebrity novelist," while taking special care to tag Buckley as the "arch-conservative."

Why arch? The two tags make for a curious imbalance. For 50 years Buckley's views were safely on the rightward edge of the American popular consensus; Vidal's were shared by a tiny minority—cranks and ignoramuses in Hollywood, Manhattan, Northwest Washington, D.C., various college towns, and Ruby Ridge, Idaho. Yet it is Buckley who earns the ideological intensifier "arch."

On This Date in History – October 16

On this date in 1758, Noah Webster, of Webster Dictionary Fame was born in West Hartford, Connecticut. The unabridged Webster is still considered the standard of the English language.

On this date in 1854, Oscar Fingall O’Flahertie Wilde, the most adept user of words in the history of the English language, was born, perhaps a hundred years too early. He was a great playwright and author of some of the greatest epigrams and pithy sayings the world has ever heard. His refusal to abide by the public sexual standards of his time brought him vilification, persecution and total tragedy—for things which weren’t thought about twice in the 1970s. Wilde said, in The Picture of Dorian Gray, that “the only way to get rid of a temptation is to yield to it.”

After Leonard and Thelma Spinrad

Thank you for joining the MedicalTuesday.Network and Have Your Friends Do the Same. If you receive this as an invitation, please go to, enter you email address and join the 10,000 members who receive this newsletter. If you are one of the 80,000 guests that surf our web sites, we thank you and invite you to join the email network on a regular basis by subscribing at the website above. To subscribe to our companion publication concerning health plans and our national challenges, please go to and enter your email address. Then go to the archives to scan the last several important HPUSA newsletters and current issues in healthcare.

Please note that sections 1-4, 6, 8-9 are entirely attributable quotes and editorial comments are in brackets. Permission to reprint portions has been requested and may be pending with the understanding that the reader is referred back to the author's original site. We respect copyright as exemplified by George Helprin who is the author, most recently, of “Digital Barbarism,” just published by HarperCollins. We hope our highlighting articles leads to greater exposure of their work and brings more viewers to their page. Please also note: Articles that appear in MedicalTuesday may not reflect the opinion of the editorial staff.

ALSO NOTE: MedicalTuesday receives no government, foundation, or private funds. The entire cost of the website URLs, website posting, distribution, managing editor, email editor, and the research and writing is solely paid for and donated by the Founding Editor, while continuing his Pulmonary Practice, as a service to his patients, his profession, and in the public interest for his country.

Spammator Note: MedicalTuesday uses many standard medical terms considered forbidden by many spammators. We are not always able to avoid appropriate medical terminology in the abbreviated edition sent by e-newsletter. (The Web Edition is always complete.) As readers use new spammators with an increasing rejection rate, we are not always able to navigate around these palace guards. If you miss some editions of MedicalTuesday, you may want to check your spammator settings and make appropriate adjustments. To assure uninterrupted delivery, subscribe directly from the website rather than personal communication: Also subscribe to our companion newsletter concerning current and future health care plans:

Del Meyer

Del Meyer, MD, Editor & Founder

6945 Fair Oaks Blvd, Ste A-2, Carmichael, CA 95608

Feedback . . .
Subscribe MedicalTuesday . . .
Subscribe HealthPlanUSA . . .

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.