Voices of Medicine

Current Issue

Corona-flu-virus in Perspective

Covid-19, Sars-CoV-2, MERS, Ebola, Marburg Virus

All have a natural reservoir in Bats

The common cold virus, the most ubiquitous of the upper respiratory infections, was first isolated in 1956. Subsequently, many more viruses involving the nose and throat (coryza or rhinoviruses) were isolated. They are contagious from 1-2 days before symptoms begin until they are resolved. The virus spreads from coughing or sneezing. There are 113 immunologically distinct but biologically related rhinoviruses. Many cold viruses have not yet been identified. They are part of the Picorna RNA group of viruses inactivated by acid which is probably why they do not invade the intestinal tract.

A second group of upper respiratory viruses are the Myxoviruses of which influenza is the most prominent causing the most devastating epidemics. There are three RNA types of Influenza viruses. Type C rarely if ever, gives rise to epidemics. They cause inapparent infections in small children and nearly everyone has antibodies by age 15. Influenza A epidemics tend to occur in 2- or 3-year cycles while Influenza B epidemics occur in 4- to 6-year cycles.  

All pandemics of influenza have been caused by type A viruses. There have been four well documented epidemics. The first in 1889-90. Then the one in 1918-19, Spanish flu, the first H1N1 virus, which was the most devastating accounting for more than 20 million deaths. The third one was the Asian virus, H2N2, emerging from the central part of mainland China in 1957. It spread to Hong Kong and other parts of the world.  It was brought to the United States by naval personnel arriving in Newport, Rhode Island, and then San Diego.

The initial outbreak of the Asian virus occurred on June 20, 1957, during a conference of high school girls in Davis, California, and spread to several outbreaks in California. Apparently, the Asian virus was carried from the Davis conference to another meeting at Grinnell, Iowa, which was attended by 1800 young people from 43 states and several foreign countries.  These conferees returning home seeded the Asian virus in many parts of the United States and by September 1957, the epidemics swept the country.

A fourth influenza pandemic was the 2009-10 swine virus, a new strain of H1N1 which originated in Mexico and infected as many as 1.4 billion people across the globe and killed between 151,700 and 575,400 people, according to the Centers for Disease Protection and Control. In the U.S., between April 2009 and April 2010, the CDC estimates there were 60.8 million cases of swine flu, with over 274,000 hospitalizations and nearly 12,500 deaths — that’s a mortality rate of about 0.02%.

The influenza virus is transmitted by the inhalation of virus containing droplets ejected from the respiratory tract by coughing or sneezing. Symptoms occur abruptly after an incubation period of 1-3 days with chills, fever, rigors, headache with extreme prostration. The diagnosis is clinical and there is no basis for differential diagnosis caused by types A, B, or C. There is a new antiviral drug, Amantadine, which has shown some success with influenza A. It is now largely prevented with vaccines.

The third group of upper respiratory viruses were the coronaviruses first isolated in 1965 from a boy with a common cold. This virus had a characteristic electron microscopic appearance with petal-shaped projections around the capsid resembling a solar corona. They are medium sized RNA viruses with more than 20 strains obtained from adults with upper respiratory infections. They are responsible for 10 to 24 percent of upper respiratory tract diseases. They can, along with the other respiratory viruses, invade the bronchi and cause a bronchitis. They can also, on occasion, invade the small respiratory bronchioles and alveoli causing a viral pneumonia. There are no specific drugs for viral pneumonia and treatment is supportive. If the arterial oxygen (PO2) is depressed, oxygen will be required. If ventilation is compromised as reflected with carbon dioxide retention (PCO2 elevation) intubation of the trachea and connection to a ventilator will be required. This then is called ARDS (acute respiratory distress syndrome) which is the terminal event in most chronic lung diseases.

A major problem in controlling the current coronavirus epidemic is that the incubation period, initially thought to be four days, (contagious for the last 48 Hours) can be as long as 14 days (and contagious for the last 10 days). Therefore, to eradicate this epidemic means that everyone needs to wear a mask anytime they leave their home or their car.

Dr. Stuart Cohen, Chief of Infectious Diseases at UC Davis, has started a clinical trial on a compassionate basis with Remdesivir with favorable clinical response in roughly two-thirds of COVID-19 patients. Treatment is otherwise primarily supportive (treating symptoms as they occur) unless there is a complicating pneumonia. Control of spread is by self-isolation at home, and for all necessary contacts using a mask and gloves or sanitizing solution to hands.

Bats are ideal for spreading respiratory diseases. They are mammals, have long lives, up to 30 to 40 years, live in large crowds, and fly. One bat roost in Texas houses 20 million bats at certain times of the year. One quarter of all mammal species are bats. Bats are sold in markets and supplied directly to restaurants throughout China and southeast Asia. Bats have supplied some of the more dangerous new diseases of the 21st century. Not only are they the known reservoir of Rabies, but are also the reservoir Ebola, Marburg, SARS, MERS, and Covid-19 viruses. They were discovered in the Yunnan cave in 2013. Patrick Woo and colleagues at Hong Kong University surveyed the coronavirus found in bats and in their paper in February of 2019 came to a prescient conclusion: “Bat-animal and bat-human interactions, such as the presence of live bats in wildlife wet markets and restaurant in southern China, are important for interspecies transmission of [coronaviruses] and may lead to devastating global outbreaks.” (Ridley in the WSJ)

Businesses such as restaurants, bars, salons, barbershops or any that preclude the wearing of a face mask covering the nose and mouth should remain closed for the duration of the epidemic. Businesses that remain open during the coronavirus epidemic, should have door monitors or security guards and require a mask for all who enter including the staff. There should be sanitizing solution at the doorway so everyone will spray their hands. There are now infrared thermometers that don’t require skin contact. Everyone entering should have a temperature below 100.4 degrees or be turned away. These simple steps for two weeks should help prevent the spread of the coronavirus. When there are no new cases of coronavirus spread or Covid-19 infection for a two-week period, isolation procedures could be lifted. These precautions would also be effective to prevent the spread of the influenza virus during a flu epidemic. 

Personal prevention of Coronavirus infection would consist of wearing a mask at all times whenever they leave their homes or their automobiles and have a small bottle of sanitizing solution in their car and home.

Delbert H Meyer, MD, Pulmonologist / Sacramento

References: Infectious Diseases, third edition, Paul D. Hoeprich, Editor
Founding faculty member of UCD College of Medicine
The Bats Behind the Pandemic, from Ebola to Covid-19,
WSJ | Matt Ridley| April 9, 2020

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Voices of Medicine

Current Issue

Great Myths of the Great Depression

Voices of Reason – Are we repeating the events that led to the Great Depression?

Mackinac Center for Public Policy President Lawrence W. Reed debunks the conventional view and traces the central role that poor government policy played in fostering this legendary catastrophe. . .

Adapting a phrase from 19th century writer Henry David Thoreau, Roosevelt famously declared in his address that, “We have nothing to fear but fear itself.” But as Dr. Hans Sennholz, of Grove City College explains, it was FDR’s policies to come that Americans had genuine reason to fear: In his first 100 days, he swung hard at the profit order. Instead of clearing away the prosperity barriers erected by his predecessor, he built new ones of his own.  He struck in every known way at the integrity of the U.S. dollar through quantitative increases and qualitative deterioration. He seized the people’s gold holdings and subsequently devalued the dollar by 40 percent.17

Frustrated and angered that Roosevelt had so quickly and thoroughly abandoned the platform on which he was elected, Director of the Bureau of the Budget, Lewis W. Douglas, resigned after only one year on the job. At Harvard University in May 1935, Douglas made it plain that America was facing a momentous choice: Will we choose to subject ourselves — this great country — to the despotism of bureaucracy, which will control our every act, destroy what equality we have attained, and reduce us eventually to the condition of impoverished slaves of the state? Or will we cling to the liberties for which man has struggled for more than a thousand years? It is important to understand the magnitude of the issue before us. … If we do not choose to have a tyrannical, oppressive bureaucracy controlling our lives, destroying progress, depressing the standard of living … then should it not be the function of the Federal government under a democracy to limit  its activities to those which a democracy may adequately deal, for example: national defense, maintaining law and order, protecting life and property, preventing dishonesty, and guarding the public against vested special interests?18

To Many Americans, the National Recovery Administration’s bureaucracy and mind-numbing regulations became known as the “National Run Around.”

                         A Review of Today’s Economic Issues

Read more . . .  https://www.mackinac.org/archives/1998/sp1998-01.pdf

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Voices of Medicine

Current Issue

Ogan Gurel, MD, Chief Medical Officer in SEOUL

Seminar on March 25, 2020 8 AM KST (tomorrow: + 16 hours)

Part 1: 8 AM KST

Overview and characteristics of SARS-CoV-2 and Covid-19

What it is, how it is transmitted, implications for containment measures.

Part 2: 8:40 AM KST

How Korea has responded and how that response meshed with the requirements of containment for this disease.

What worked and what didn’t. What other options are there?

P:art 3 9AM KST

Extended Questions and Discussion Session

Learn what other organizations in Korea are doing and benefit from experience of other KBLA members.

Who should participate: Executive, Health & Safety, HR, & Security Mgmt personnel from organizations in Korea & around the world?

Dive deep into the characteristics of SARS-CoV-2 and the disease that comes from it: COVID-19.

Learn how the responses governments and organizations implement are driven by the disease threat.

Register at www.kbla.info

Seminar will be conducted over the web using ZOOM Video Conferencing platform.

Cost: Complimentary

NB: On trying to register we were told we first have to join the KBLA (Korea Business Leaders Alliance.) at a cost of $1000.            I guess we’ll wait for Dr. Gurel to send us a FU LinkedIn note. Looks like I have it now:

Dear Del, Thank you for registering for the KBLA Professional Seminar.

Send any connection problems to admin2020@kbla.info.

Join the seminar from a PC, Mac, iPad, iPhone  by clicking on the link. 

Join Zoom Meeting https://zoom.us/j/572297766?pwd=dzV1bXY2OTdPbktYWHNYckkxWUorZz09 Meeting ID: 572 297 766 Password: 579170 One tap mobile +12532158782,,572297766# US +13017158592,,572297766# US Dial by your location  +1 669 900 6833 US (San Jose area)

/S/ JaeKyu Chung



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Voices of Medicine

Current Issue

The World Medical Journal Official Journal of the WMA Since 1954 Welcome to the electronic version of the World Medical Journal!

2014 marked the sixtieth anniversary of the appearance of the World Medical Journal (WMJ). The journal is published quarterly and it reflects the aims and activities of the World Medical Association.

It is not the task of the WMJ to publish new scientific medical research. This is clearly the function of the multitude of information available in either broad-based or specialised journals. However, there is a place for publishing overviews of trends, new areas of medical progress which may not appear in the general run of medical journals and which can increase physicians’ awareness of developments of which they may be unaware. It has sections on Medical Ethics and Human Rights, Medical Science, Professional Practice and Education, the Secretary General’s column, and a section on Regional and National Medical Association (NMA) News where we will try to report on regional developments and NMA initiatives or problems.

We hoped that readers will find it interesting, informative and helpful. As ever, the Editor will be pleased to consider any papers or information for publication.

Interview with Miguel Roberto Jorge, President of the World Medical Association by WMJ Editor Peteris Apinis

Apinis: You are a physician known worldwide and a leader among psychiatrists.

Could you comment on whether doctors in the world are burned out? Are doctors more threatened by anxiety and depression than other people? Is it true that doctors in certain professions (such as anesthesiologists and psychiatrists) are more at risk of suicide than people of other professions? How can we help doctors in the world to feel appreciated and reduce the risk of burnout?

Jorge: There are studies indicating a high prevalence of burnout among physicians worldwide even considering that burnout is not equally distributed among them.

Providing medical care usually in difficult circumstances exposes physicians to continuous stress at work and burnout is one of the consequences of this kind of situation.

On regards of anxiety and depression, some data suggest that physicians do not present more depression than other people but the rate of suicides among physicians is higher than in the general population and, again, the distribution of suicide rates among different medical specialties is not equal. In my personal opinion, the best way for a physician to feel appreciation and reduce the risk of burnout is to dedicate to build a good relation with patients and share with them the power to take decisions on treatment alternatives.

Apinis: We see a new trend in world politics – doctors are undervalued. The global trend is growing: doctors’ earnings are declining against average earnings in the country. Politicians and financiers, meanwhile, talk publicly that preparing doctors is too expensive, that universal health coverage should be cheaper to have health specialists. How can we build the prestige of our global profession and restore the remuneration?

Jorge: I can identify different situations in your question. Nowadays, compared to past times, medical doctors are given less value and I believe the dehumanization of the medical practice has contributed to this situation. Physicians not always have enough time to dedicate themselves to build a good physician-patient relationship that takes the individuality of each patient in consideration.

And even when they have that time, they are more prone to pay attention to lab exams than to listen to the person they have in front. I do not know if just earnings of medical doctors are declining but I believe the reasons for that are multiple and linked to profound changes in the work market everywhere in the globe. To prepare good professionals, in any area of work, deserves meaningful investments. And I do not believe that to prepare good primary care physicians will cost less than to train a good specialist. Any system of care, and particularly those under the Universal Health Coverage, requires good primary care physicians as well as good specialists.

Apinis: In Tbilisi, the WMA accepted a declaration on euthanasia. In this declaration, the WMA condemned euthanasia and assisted suicide. As physicians, they can’t and don’t want to perform euthanasia or assisted suicide. However, surveys show that physicians as patients would like to shorten their lives when they encounter major physical and mental health problems. These are doctors as patients who are most likely to refuse complicated and excessive treatment if it can’t significantly prolong survival and improve the quality of life. How would you comment on a situation where a doctor, as a patient, requires euthanasia or assisted suicide?

Jorge: Indeed, the WMA took a very clear position opposing physician assisted suicide and euthanasia. We think that physicians should not involve in such practices. We want our patients to be sure that we value their lives and that we are there to protect and to help them even in very difficult situations.

Physicians, when they become patients, are patients like any other person. There is no different ethics for physicians being patients. But the same is also true as for any other person: we should abstain from futile and undesired treatment, we must respect a demand for ending treatment and we have to give comfort and to alleviate pain. . .

Read the entire interview in the WMJ. . .

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Voices of Medicine

Current Issue


Voices of Medicine

Current Issue

A Piece of the Pie by Charles B. Clark, MD. Surgery of the upper extremities.

As managed care was conscripting the medical profession in the 1980s and 1990s, and doctors became impotent to the forces of control of our professional expertise, very few took the risk of not signing the managed care contracts being circulated among us.

When I go to the Medical Grand Rounds at the UC Davis Medical Center on Thursday noon, the young interns and medical students are quite unaware of the stresses of the 1970s and the 1980s. And they wonder what was the problem in thinking we were losing our professional standing?

On November 23, 1994, I received that following article which, I think captured the predicament in which we found ourselves. It was submitted for publication in Sacramento Medicine by the late Dr Clark while I was the editor. I hope this repeat from our archives epitomizes the forces that were placed on our profession.

A Piece of the Pie

by Charles Clark, MD, Surgery of the upper extremities

When I entered practice twenty-seven years ago, I found that my membership in the Country Medical Society included being listed on a panel of doctors for an insurance company that reduced our fees. (We were getting $4.00 for an office visit at the time.) I asked one of the older doctors in the community why we should voluntarily accept a reduction in our fees. He told me it was to keep the lid on inflation.

When I dropped out of the plan, I found that no one referred those patients any longer. It soon became clear that being a member was a sure way of receiving an increased volume of patients. The greater volume of patients meant a larger income. Everyone who was a member was secure in the knowledge that he was getting a piece of the pie.

Eventually there were other insurance plans making payment of less that customary fees. They never had any trouble attracting doctors. The catalogue of member-doctors for some of these plans often goes on for page after page after page. The more of them the individuals joins, the more patients he can see. This has been accompanied by a reduction in fees that often has been horrendous. Still there is a certain security in belonging to these organizations because it guarantees a piece of the pie.

As these plans proliferate, some of them remain competitive by gradually reducing the amount that goes to the doctors. Still the doctors hang in there. It is not necessarily because  they aren’t busy enough. Some of their appointment schedules are filled up for two or three months in advance. But they are assured of getting a piece of the pie.

Without doctors to join these plans, the closed panel organizations wouldn’t exist. By joining them, we are giving away our freedom by bits and pieces. And yet we continue to support these organizations while we are gradually allowing control of our destiny to slip away. As I see these things happening, I can’t help wondering if we are committing collective professional suicide in terms of trying to maintain any semblance of our independence as doctors.

What are we going to tell those bright-eyed little boys and girls who are going to be the doctors of tomorrow? When there isn’t anything left for them, are we going to tell them we didn’t fight because the changes were inevitable anyway? What are we going to say when they ask us why we laid down and died when things got a little tough? Are we going to feel good about ourselves when we tell them it’s all right because we got a piece of the pie?

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Voices of Medicine

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Crimes in Concrete by Theodore Dalrymple June 2019

Making Dystopia: The Strange Rise and Survival of Architectural Barbarism
by James Stevens Curl, Oxford, 592 pages, $60

In a recent debate in Prospect magazine on the question of whether modern architecture has ruined British towns and cities, Professor James Stevens Curl, one of Britain’s most ­distinguished architectural ­historians, wrote as his opening salvo:

Visitors to these islands who have eyes to see will observe that there is hardly a town or city that has not had its streets—and skyline—wrecked by insensitive, crude, post-1945 additions which ignore established geometries, ­urban grain, scale, materials, and ­emphases. 

This is so self-evidently true that I find it hard to understand how anyone could deny it, but modern architects and hangers-on such as architectural journalists do deny it, like war criminals who, for ­obvious reasons, continue to deny their crimes in the face of overwhelming evidence. 

This is true not only of Britain but of many, perhaps most, other countries that have or had any towns or cities to ruin. Anyone who rides into the center of Paris from Charles de Gaulle Airport, for example, will be appalled at the modernist visual hell that scours his eyes as he goes. 

Nor is this visual hell the consequence of the need to build cheaply. Where money is no object, contemporary architects, like the sleep of reason in Goya’s etching, bring forth monsters. The Tour Montparnasse (said to be the most hated building in Paris), the Centre Pompidou, the Opéra Bastille, the Musée du quai Branly, the new Philharmonie, do not owe their preternatural ugliness to lack of funds, but rather to the incapacity, one might say the ferocious unwillingness, of architects to build anything beautiful, and to their determination to leave their mark on the city as a dog leaves its mark on a tree. 

Professor Curl’s magnum opus is both scholarly and polemical. He has been observing the onward march of modernism and its effects for sixty years and is justifiably outraged by it. British architects have managed to reverse the terms of the anarchist Bakunin’s dictum that the urge to destroy is also a creative urge: Their urge to create is also a destructive urge. I could give many concrete examples (no pun intended).

Making Dystopia is not just a cri de coeur, however. It is a detailed account of the origins, rise, effect, and hegemony of architectural modernism and its successors, and of how architecture became (to a large extent) a hermetic cult that seals itself off from the criticism of hoi polloiamong whom is included Prince Charles—and established its dominance by a mixture of ­bureaucratic intrigue, intellectual terrorism, and appeal to raw ­political and financial interest. If success is measured by power and hold over a profession rather than by intrinsic worth, then the modernist movement in architecture has been an almost unparalleled success. Only relatively recently has resistance begun to form, and often all too late: 

Many ingenious lovely things are gone That seemed sheer miracle to the multitude.

Professor Curl’s book is ­particularly strong on the historiographical lies peddled by the apologists for modernism, and on the intellectual weakness of the arguments for the necessity of modernism. For example, architectural historians and theoreticians such as Sigfried Giedion, Arthur Korn, and Nikolaus Pevsner claimed to see in modernism the logical continuation of the European architectural tradition, and Pevsner even recruited such figures as William Morris and C. F. A. Voysey as progenitors of the movement. Pevsner was so enamored of Gropius and the Modernists that he wanted to claim a noble descent for them, as humble but ambitious people were once inclined to find a distant aristocratic forebear. Yet Voysey could hardly have been more hostile to the movement that co-opted him. The Modern Movement, he said, was pitifully full of such faults as proportions that were vulgarly aggressive, mountebank ­eccentricities in detail, and windows built lying down on their sides. . . . This was false originality; the true originality having been for all time the spiritual something given to the development of traditional forms by the individual artist. 

Pevsner (to whom, ­incidentally, Curl pays tribute for his past generosity to young scholars, including himself), with all the academic and moral prestige and authority that attached to his name, was able to incorporate Voysey—unable to speak for himself or protest after his death—into the direct ancestry of modernism, even though the merest glance at his work, or at that of William Morris, should have been sufficient to warn anyone that Pevsner’s historiography made a bed of Procrustes seem positively made to measure. 

One of the Holy Trinity of architectural modernism, Le Corbusier, often presented himself in his writings as being in apostolic succession to the great architects of the past, and he littered his texts with little worthless sketches of the Parthenon and other great buildings to prove it. He accused those who did not accept the connection as being unable to see—as a mathematical physicist might say of a layman that he did not understand quantum theory—thereby beginning a campaign of intellectual terrorization of the laity that has lasted to this day. . .

The most startling instance of the modernists’ elective affinity with totalitarianism is of course Le ­Corbusier. To call him a fascist is not to hurl all-purpose abuse at him, but to state a literal truth. But, as Curl wryly remarks, you won’t hear any of this in a British architectural school—let alone a French one, despite the fact that in 1941, only a year after the Exode (the flight of eight million Frenchmen before the advancing Germans), Le Corbusier wrote a booklet, Destin de Paris, proposing to deport a large proportion of the population of Paris to the countryside, since in his elevated opinion they had no business living there in the first place. 

To what kind of man could such a thought even have occurred, much less at such a time? Le Corbusier had the sensibility of a totalitarian dictator, as is evidenced by his Plan Voisin, by which he planned to turn much of Paris into a kind of Novosibirsk-­sur-Seine. He loathed streets and street life, because for him they represented disorder and spontaneity instead of discipline, strict hierarchy, and what he considered, in his highly limited and autistic way, rationality. Personally, I do not see how anybody could fail to detect his essential ­authoritarianism just by looking at his designs, even without knowing that he aspired to lay down the law for the architecture of the whole world—which, to a horrible extent, he managed to do.

Although Le Corbusier’s fascist sympathies, outlook, and sensibility had been a matter of indisputable public record for years, they were forgotten as soon as the war was over, and it came as something of a shock when they were revealed (yet again) in two books published in France in 2015. The shock passed, of course, and he is still regarded in architectural circles as the architectural knight sans peur et sans reproche. To utter criticism of Le Corbusier in architecture school is apparently like criticizing the character of ­Muhammad in Mecca. The French architect Marc Perelman ruined his own academic career in 1986 by publishing Urbs ex ­machina: Le ­Corbusier: le courant froid de ­l’architecture

What accounts for the survival of this cold current of architecture that has done so much to disenchant the urban world—the original modernism having been succeeded by different styles, but all of them just as lizard-eyed? According to Curl, the profession of architecture has become a cult. It is worth quoting him in ­extenso

A dangerous cult may be defined as a kind of false religion, adoption of a system of belief based on mere assertions with no factual foundations, or as excessive, almost idolatrous, admiration for a person, persons, an idea, or even a fad. The adulation accorded to Le Corbusier, accorded almost the status of a deity in architectural circles, is just one example. It has certain characteristics which may be summarized as follows: it is destructive; it isolates its believers; it claims superior knowledge and morality; it demands subservience, conformity, and obedience; it is adept at brainwashing; it imposes its own assertions as dogma, and will not countenance any dissent; it is self-referential; and it invents its own arcane language, incomprehensible to outsiders. . .

Making Dystopia is much more than a very detailed critique of a building or two here or there. It is an angry criticism of an entire worldview—the worldview of the type of person who much prefers his worldview to the world, and in so doing causes untold ruination. The editor of the Royal Institute of British Architects Journal, Hugh Pearman, wrote a scathing but inaccurate review, whose very subtitle was a flagrant misrepresentation: If it’s not trad, he ain’t glad. In fact, in criticizing modernism and its successor movements, Curl is promoting no particular type of architecture, any more than if I criticize McDonald’s hamburgers. I am saying that all cuisine should be French or Italian or anything else. Of course, Mr. Pearman has a right to his private opinion of the book, but as editor of the Institute’s Journal he must have known that he was, in effect, speaking ex cathedra for the British profession as a whole. This impression was reinforced when he printed no criticism of his own review but tweeted instead,

I’m getting loads of letters (mostly written on paper from elderly men with no email address) supporting the deranged recent writings of James Stevens Curl . . .

The fury against Curl, I suspect, was an implicit admission that he was right. A review by Stephen Bayley in the Spectator, titled Modernist architecture isn’t barbarous – but the blinkered rejection of it is, claimed that Curl’s own views are dystopian (unlike, presumably, Le Corbusier’s plans for Paris, Algiers, Stockholm, Moscow, Antwerp, Buenos Aires, and Rio de Janeiro). Bayley wrote:

Yes, modernist principles, misunderstood by unimaginative planners, often led to atrocious results. Le Corbusier’s ‘vertical garden cities’ became vertical slums. And there is only a sliver of difference between Walter Gropius’s lofty Bauhaus ideals and a crap council estate. . .

Theodore Dalrymple’s latest book is Grief and Other Stories.

Photo by Soreen D via Creative Commons. Image cropped. 



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Voices of Medicine

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Letter to an aspiring Doctor – Concluded from September By Theodore Dalrymple

Moreover, though we pay lip service as a society to diversity and tolerance, we increasingly demand uniformity. A recent article in the New England Journal of Medicine argued that doctors should not be permitted to opt out of performing procedures that they considered unethical on the grounds of con­scientious objection. Once the profession, guided by ethicists, had decided as a whole that something was ethically permissible, no doctor should be allowed to go against the consensus. This, of course, would have the corollary that mass murder by doctors would in theory be permissible, or even obligatory. Never mind: It can’t happen here. But what was once ­unthinkable can become thinkable very quickly.

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Letter to an aspiring Doctor Continued from August By Theodore Dalrymple

Let me give you a concrete example of the dangers of not thinking critically. In 1980, a letter was published in the New England Journal of Medicine pointing out that patients in hospital who were prescribed strong opiates for post-operative, heart attack, or cancer pain never became addicted to the drug they were given. At the time, doctors withheld opiates from ­patients who would have benefitted from them because they, the doctors, were afraid that they might addict their patients to them.

Later, when synthetic opioids became available that were just as dangerous and addictive as the natural opiates, the letter in the NEJM was cited both by the drug companies that manufactured them and medical evangelists of pain relief as evidence that they might be prescribed to patients with any kind of pain whatever. Many doctors threw caution to the wind and began to prescribe these opioids with abandon to patients with various kinds of chronic pain, usually of ill-defined or uncertain pathology that was much more related to what might be called their situation in life than to any definable illness. They continued to prescribe these drugs despite abundant evidence that they were not effective in relieving the type of pain for which they were prescribed.

This, then, was the start of an epidemic of addiction to opioids that is now causing tens of thousands of deaths yearly by overdose in the United States. The epidemic would have been avoidable if doctors as a whole had adopted a more critical and thoughtful approach from the first to the supposed arguments for prescribing these drugs. It should have been obvious to any doctor of minimal experience that the two types of patient, those with acute or cancer pain and those with chronic pain of vague and uncertain origin, are very different. Proper treatment of one group of patients cannot automatically be applied to another, quite different group.

In extenuation of the doctors who unwittingly started the epidemic—not a few, incidentally—it can be said that they had been targeted by intense commercial propaganda and reassured by supposed leaders in the field of pain relief that their prescriptions were right and proper. This brings to light a contradiction with which you will have to wrestle for the whole of your career: the contradiction between the authority of others and your own personal responsibility.

You cannot dodge your personal responsibility by hiding behind the authority of others or the consensus of the profession. But at the same time, you will be expected to do as other doctors do. Early in your career, you will necessarily be subordinated to the authority of more experienced doctors. With luck (and in most cases), those doctors will instruct you to do the right thing, both technically and morally, but there is always the possibility that they will not. Later in your career, you will find yourself subject to an ever-increasing number of rules and regulations, many of which will appear to you as absurd at best and contrary to the interests of patients at worst. But you will have to obey them as a condition of continuing in practice.

As the technical possibilities of medicine advance, especially in genetic engineering, so will ethical dilemmas increase in number and gravity. But even now storm clouds are brewing; indeed, they have already brewed. I will give you a simple example. Medically assisted suicide is increasingly claimed as a right: A man, according to this line of thought, has the right to choose the hour and manner of his death in order to avoid suffering. From this, our age deduces that a doctor has the duty to administer the lethal means to exercising that right. That doctor may well be you. You went into medicine to save life, and you will end up by (in effect) killing.

There is no reason why assisted suicide should be confined to the dying. Why should those suffering from taedium vitae be denied the soothing final injection? There is nowadays a tendency for rights to spread, like ink through blotting paper. Abortion was originally intended to be performed in limited circumstances only, but now has become an inalienable right in any circumstances whatever—into which, indeed, it is impermissible to inquire. A right, after all, is a right; in our times, any limitation is treated as an illicit abrogation of that right.

Moreover, though we pay lip service as a society to diversity and tolerance, we increasingly demand uniformity. A recent article in the New England Journal of Medicine argued that doctors should not be permitted to opt out of performing procedures that they considered unethical on the grounds of con­scientious objection. Once the profession, guided by ethicists, had decided as a whole that something was ethically permissible, no doctor should be allowed to go against the consensus. This, of course, would have the corollary that mass murder by doctors would in theory be permissible, or even obligatory. Never mind: It can’t happen here. But what was once ­unthinkable can become thinkable very quickly.

At what point you rebel, and how you rebel, against a prevailing ethical consensus will always be a matter of judgment, since it is a fact of human existence that no one can live only and exclusively according to his own lights but must always compromise. In all of this, you will have the responsibility to treat your patients according to the best methods and evidence possible.

Here, too, you will have to exercise your judgment. For example, patients will often ask your advice, despite having searched everything on the Internet in advance. But information on the Internet, apart from sometimes being mistaken, is raw information, and you will be looked to for wisdom and experience as much as for information. Moreover, to many questions there is no indubitably correct answer.

The open-ended character of medical judgment has increased a great deal because the very nature of medicine has changed. It used to be that patients went to doctors when they were ill and hoped for a cure, either surgical or pharmacological. (This is probably the picture of medicine as a profession that you have in your mind.) The transaction in those days was, at least conceptually, straightforward: diagnosis, course of treatment, results. Now doctors spend much of their time treating not illnesses, but risk factors for illnesses. For example, the higher a person’s blood pressure, the greater his risk of heart attack or stroke, but high blood pressure is (except in its most extreme form) symptomless. You don’t know you have it until you experience one of its complications.

A Review of Local and Regional Medical Journals and Articles

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Voices of Medicine

Past Issue

Letter to an aspiring Doctor

by Theodore Dalrymple

You tell me you are thinking, my dear Stephen, of medicine as a career, but you wonder whether you have the ability or the temperament for it. You say that you have wanted to be a doctor ever since your family practitioner visited you at home as a child when you had severe tonsillitis. He seemed a hero to you then, and you would like to emulate him.

I do not want to discourage you, of course, but the kind of doctor who visits patients in their homes was not common even then (you were lucky) and is even rarer today. If you are to avoid disappointment or bitterness, you should have a clear picture of what modern medicine really entails before committing yourself to it.

Medicine is a broad church, and the kind of person it requires is therefore very varied. Provided you have the requisite determination and intelligence, which I do not doubt, you need not worry too much about your temperament: There is a branch of medicine to suit every one.

That said, the road is not easy. No profession makes so many psychological demands on its practitioners as medicine. You will have to tolerate the folly of patients while striving to promote their well-being. You will discover that the varieties of human self-destruction are infinite, ranging from persistence in the most obviously harmful habits despite stern warnings to the most absurd beliefs about diet—such absurdity being by no means confined to the ignorant and uneducated. Superstition springs eternal, and you must remember that an age of information is also an age of misinformation. Many of your patients will be cranks who believe that fish oil or guava juice is the elixir of life, or that wearing a crystal round their necks or living on a healing chakra of the earth is the secret of health. They will have all kinds of unfounded beliefs, some harmless and some harmful, and you will not be able to dissuade them.

Other patients will be outright unpleasant, unreasonably demanding, and even threatening. They may try to blackmail you: For example, patients have told me that they would kill someone or themselves if I did not prescribe them what they wanted. I refused, advising them to refrain from killing anyone, including themselves, but I could never be quite sure that they wouldn’t carry out the threat.

Whatever your inner state of turmoil when confronted by the immense showcase of human folly or unpleasantness, you must retain your outer equanimity, which does not come naturally and at first will take a mental toll on you. But habit will become ­character, and eventually you will learn to accept people as they are—even if they don’t deserve it.

You will also have to learn to tolerate intellectual or scientific uncertainty and ambiguity. While there are undoubted scientific truths—such as the circulation of the blood—that no one seriously believes will ever be overthrown, much of your knowledge will inevitably be provisional, valuable and viable only until better evidence comes along. This is particularly true where prescribing medicines and performing procedures are concerned. Subsequent research often shows that cherished treatments are of little or no benefit, and are sometimes harmful. The history of medicine is replete with instances of beliefs firmly held by doctors that turned out, on investigation, to have been false and that subsequent generations of doctors have found almost ridiculous.

One obvious example is the persistence of bloodletting down the ages, advocated by doctors with fervor for hundreds of years until a French physician and pathologist, Pierre-Charles-Alexandre Louis, showed early in the nineteenth century that it was useless in cases of pneumonia, for which it was then the orthodox treatment. You must therefore hold your scientific beliefs lightly but not frivolously, and try not to invest them with too much emotion or make them the entire basis of your self-respect. You must understand that to have been wrong is not necessarily a disgrace, while to persist in an error to the detriment of your patients, simply because it is too painful to change your mind and practice, is indeed sinful.

The philosopher Bertrand Russell said that the rational man is he who holds his beliefs about the world with a strength precisely proportional to the strength of the evidence in their favor. This would be a counsel of perfection even if it were true, which it is not. I doubt whether there has ever been a rational man according to Russell’s definition, for we cannot know with any degree of precision the strength of the evidence in favor of most of our beliefs, and therefore we cannot order them as Russell’s dictum would require us to do.

As doctors, we need the humility to realize that we were wrong when research corrects false truisms. But we also need the corresponding hope that we might be right. Skepticism alone paralyzes. An inspiring example of the self-belief that may lead to important discovery is that of Dr. Barry Marshall, the Australian co-discoverer of the bacterial cause of most peptic ulceration.

It is difficult to overestimate the amount of human misery that this relatively simple discovery has prevented. Until then, untold thousands of people with peptic ulceration suffered for many years, often for decades, and were subjected in the search for alleviation of their symptoms to serious operations with adverse after-effects and of variable efficacy. They took large quantities of medicines that at best reduced symptoms for a time. They had to follow distasteful diets, making one of the simplest of pleasures in life, eating, at best a dilemma, at worst a torture.

Dr. Marshall’s theory that the disease was caused by a germ found in the stomach, Helicobacter pylori, seemed to many (including to me) far-fetched. The germ had been observed for many years to exist in the stomach, but since it was obvious to all that peptic ulcer could not possibly be an infectious disease, the germ was regarded as a curiosity rather than as a factor. We knew that peptic ulceration was more common in smokers and in those of a type A personality, that is to say, the hard-driving, ambitious type of person, and therefore that the disease was not infectious. Dr. Marshall, however, approached the question with an open but not uninformed mind—an open and an empty mind not being at all the same thing. Within a very few years, his experiments convinced the world that he was right, and he was awarded the Nobel Prize.

Of course, it is not given to many doctors to make a discovery such as Dr. Marshall’s, but his disciplined skepticism combined with the courage to venture a new hypothesis is a frame of mind that you would do well to cultivate. This is all the more the case in an age of so-called information, when you will be bombarded with propaganda masquerading as scientific truth. To resist it will be very difficult to do because you will be so busy that you will have very little time for critical thought.

Theodore Dalrymple is a retired doctor and contributing editor of City Journal
His latest book is 
Grief and Other Stories.

A Review of Local and Regional Medical Journals and Articles

Notes Brevis: Peptic disease is still poorly understood even in the 21st century.
This is still a frequent complaint in the E[1]mergency Rooms.
Severe heart burns at the end of the sternum is frequently complained as “Chest Pain.”
This precipitates the myocardial infarction protocol in the emergency evaluation.
After this expensive evaluation a simple physical exam of the epigastrium reveals exquisite tenderness.
This is essentially diagnostic of peptic ulcer disease or peptic esophagitis which is easily treated.
An ounce of antacids will resolved the complaint in minutes.
If this simple exam had been done prior to the nurse implementing the chest pain protocol, $thousands could have been save.
If patients had understood Dr. Marshall’s understanding and treated themselves at home, even more $thousands could have been saved.
But the learning curve will never curve downward: It will only spiral upward with total health insurance.

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Voices of Medicine

Past Issue

Why Do We Need a ‘Right to Try’ Bill in America?

 By Jane M. Orient M.D.

Managing Editor, Journal of American Physicians & Surgeons


Congress recently passed, and President Donald Trump signed, the “Right to Try” bill that gives dying patients limited access to drugs that have not yet been approved by the Food and Drug Administration (FDA).

Our founders would be astonished that we need such a bill. Nowhere does the U.S. Constitution give the federal government the authority to regulate the practice of medicine. And it is a very good thing that federal intervention and standards didn’t begin in 1789.

Standards are always based on what the authorities think are “best practices.” Until rather recently, most medical treatment was ineffective and often quite harmful, e.g., bleeding, purging, and toxic medications like calomel (mercury). Those were nevertheless the “standard of care,” accepted by the American Medical Association (AMA). The chances that a patient would benefit from seeing a doctor were probably no better than 50-50.

Then came scientific medicine and modern medical miracles. Antibiotics conquered many infectious diseases; I may have seen one of the last patients with a thoracoplasty—his chest wall caved in from removing ribs to collapse a tuberculous lung. Leukemia used to be incurable. Kidney failure meant rapid death.

We have many wonderful treatments today. But people are still dying. Their cancer, for example, may not respond to available chemotherapy. They may have heard of a promising new remedy. But it can’t possibly be approved for years, after at least a billion dollars’ worth of testing. It might not work for them—but there’s nothing else. It might be very toxic—just like other anti-cancer drugs. It might even kill them—but they are dying anyway. What have they got to lose?

From this bill they might not have much to gain. It simply expands access to drugs already in clinical trials, for which a patient might not qualify, possibly because of being too sick. . .

The “most vulnerable” need to be protected, we often hear. But who is actually being protected? Patients? Or the academic research establishment? The prestigious organizations that write the “guidelines” and determine the “standard of care”? The medical journals that publish the approved research? The companies that sell the extremely expensive products that have no competition? Insurers that profit more from higher premiums to cover these treatments? Pharmacy benefits managers who collect a bigger “rebate” on higher priced products?

As Goldman Sachs pointed out, curing disease is bad for business. . .

Read the entire article on Epoch Times: https://www.theepochtimes.com/why-do-we-need-a-right-to-try-bill-in-america_2561255.html

A Review of Local and Regional Medical Journals and Articles by Physicians

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

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Voices of Medicine

Past Issue

The AAPS President’s Column

Direct Primary Care Summit

Albert L. Fisher, M.D.

When I attended the Direct Primary Care Summit in Indianapolis, Indiana, a vendor told me that HMOs are dead. Patients now have high deductibles, high copays, and very costly insurance. They are having difficulty getting necessary care despite their high premiums. (more…)

Voices of Medicine

Past Issue

Is US Medical Care Inefficient?

Viewpoint: JAMA | September 11, 2018

Victor R. Fuchs, PhD1

JAMA. 2018;320(10):971-972. doi:10.1001/jama.2018.10779

Is US medical care inefficient? Many health policy experts maintain it is, whereas others prefer a verdict available to juries in Scotland— “not proven.” The correct answer is that no industry is either efficient or inefficient in abstract terms. Efficiency describes the relation between the input(s) and output(s) of a product (e.g. an engine), an organ (e.g. the heart), or an industry. Each industry has a unique set of inputs and outputs and set of technologic, economic, and sociopolitical constraints. (more…)

Voices of Medicine

Past Issue

A Review of Local and Regional Medical Journals

Dr Schrier Goes to Congress as Second Woman Physician

Rita Rubin, MA  | JAMA | March 27, 2019

JAMA. 2019;321(15):1443-1445. doi:10.1001/jama.2019.1704

For more than 17 years, Kim Schrier, MD, held what she considered to be the perfect job: pediatrician. But after the 2016 general election, when Republicans began trying to dismantle the Affordable Care Act, Schrier felt another calling.

Although she had virtually no political experience, Schrier, a Democrat from Sammamish who practiced at a Virginia Mason Medical Center clinic, decided to run in the 2018 mid-term elections for Washington’s 8th Congressional District seat, long held by a Republican who eventually decided not to seek reelection. Schrier went on to win the Democratic nomination and defeat Republican Dino Rossi. . . (more…)

Voices of Medicine

Past Issue

A Review of Medical Journals

AMA (JAMA) July 17, 2018

How HIPAA Harms Care, and How to Stop It

Donald M. Berwick, MD, MPP1; Martha E. Gaines, JD, LLM2

JAMA. 2018;320(3):229-230. doi:10.1001/jama.2018.8829

“Knock, knock.”

“Who’s there?”


“HIPAA, who?”

“I’m sorry, but I cannot disclose that.”

Clinicians and patients alike will laugh at this, but behind the laughter are anger and frustration. The Health Insurance Portability and Accountability Act (HIPAA), a law created to protect patients, has borne with it serious obstacles to effective care. How did this happen? What went wrong on the road to protecting privacy? (more…)

Voices of Medicine

Past Issue

Charles Krauthammer, MD, Psychiatrist; Journalist; 1950-2018

About Charles K.  |   Jay Nordlinger |
The National Review

Editor’s Note: Jay Nordlinger wrote about Charles Krauthammer and his posthumous collection in the February 25 issue of National Review.
Below, he expands that piece, in the style of his Impromptus column.

Voices of Medicine

Past Issue

Charles Krauthammer – Washington, D.C.

Columnist Charles Krauthammer wrote a weekly political column that ran on Fridays. He was also a Fox News commentator and appeared nightly on “Special Report with Bret Baier.” Krauthammer joined The Post as a columnist in 1984, and he received the Pulitzer Prize for Commentary in 1987 for “his witty and insightful columns on national issues.”

Krauthammer began his journalism career at the New Republic, where he was a writer and editor and won the 1984 National Magazine Award for Essays and Criticism. Before going into journalism, he was a speechwriter for Vice President Walter Mondale in 1980, he helped direct planning in psychiatric research for the Carter administration, and he practiced medicine for three years as a resident and then chief resident in psychiatry at Massachusetts General Hospital.  (more…)

Voices of Medicine

Past Issue

Myth of the Angry White Male

By Charles Krauthammer, MD,

Washington Post | May 26, 1995

Doctor Krauthammer collected many of his essays in his book:
Things that Matter which we are reviewing in our Voices of Medicine Section

The Angry White Male, suitably capitalized to indicate that the menace has become a media-certified trend, stalks the land, or at least the land of the media. In the 10 years before the November election, there were 59 (Nexis) references to angry white men. There have been 1,400 since. A post-election front-page headline in USA Today was typical: “Angry White Men: Their votes turned the tide for the GOP.”

By sheer numbing repetition, the legend grows. “The Republicans scraped together a majority,” explains the genial Garrison Keillor, “by appealing to the sorehead vote, your brother-in-law and mine.” By early April, the term receives its official presidential seal of approval when Bill Clinton confirms that “this is psychologically a difficult time for a lot of white males, the so-called angry white males.” (more…)

Voices of Medicine

Past Issue

Dr. Krauthammer: Things that Matter

The Age of Holy Terror: September 11, 2001

This is not crime. This is war. One of the reasons there are terrorists out there capable and audacious enough to carry out the deadliest attack on the United States in its history is that, while they have declared war on us, we have in the past responded—with the exception of a few useless cruise missile attacks on empty tents in the desert—by issuing subpoenas.

Secretary of State Colin Powell’s first reaction to the day of infamy was to pledge to “bring those responsible to justice.” This is exactly wrong. Franklin Roosevelt did not respond to Pearl Harbor by pledging to bring the commander of Japanese naval aviation to justice. He pledged to bring Japan to its knees. (more…)

Voices of Medicine

Past Issue

Hail Columbus, Dead White Male

By Charles Krauthammer, MD, Monday, May 27, 1991

Doctor Krauthammer collected many of his essays in his book:
Things that Matter which we are reviewing in our Voices of Medicine Section

The 500th anniversary of 1492 is approaching. Remember 1492? “In Fourteen Hundred Ninety-Two/ Columbus sailed the ocean blue.” Discovery and exploration. Bolivar and Jefferson. Liberty and democracy. The last best hope for man.

The left is not amused.

In Madrid the Association of Indian Cultures announces that it will mark the occasion with acts of “sabotage.” In the U.S. the Columbus in Context Coalition declares that the coming event provides “progressives” with their best political opening “since the Vietnam War.” The National Council of Churches (NCC) condemns the “discovery” as “an invasion and colonization with legalized occupation, genocide, economic exploitation and…and a deep level of institutional racism and moral decadence.” One of its leaders calls for “a year of repentance and reflection rather than a year of celebration.”  (more…)

Voices of Medicine

Past Issue

A Review of Charles Krauthammer, MD’s Voice In Plain English: Let’s Make It Official

In Plain English: Let’s Make It Official


Having a unifying language is a secret of America’s success. Why mess with it?

Growing up (as I did) in the province of Québec, you learn not just the joys but also the perils of bilingualism. A separate national identity, revolving entirely around “Francophonie,” became a raging issue that led to social unrest, terrorism, threats of separation and a referendum that came within a hair’s breadth of breaking up Canada.

Canada, of course, had no choice about bilingualism. It is a country created of two nations at its birth and has ever since been trying to cope with that inherently divisive fact. The U.S., by contrast blessed with a single common language for two centuries, seems blithely and gratuitously to be ready to import bilingualism with all its attendant divisiveness and antagonisms. (more…)

Voices of Medicine

Past Issue

Charles Krauthammer, MD

Charles Krauthammer, winner of the Pulitzer Prize, was a syndicated columnist, political commentator and physician. His column was syndicated to 400 newspapers worldwide. He was a nightly panelist on Fox News’s Special Report with Bret Baier. He’s a former member of the President’s Council on Bioethics and of Chess Journalists of America.

Born on March 13, 1950, Charles Krauthammer is a political commentator, physician and an American Pulitzer Prize-winning syndicated columnist. Charles was born in New York City. His family later moved to Montreal, where he was raised. He has a French accent and still speaks French with his mother. His father was French and had lived most of his life in France before moving to the United States. (more…)

Voices of Medicine

Past Issue

A Review of Medical Journals, Articles, and BOOKS by Physicians

Handbook for Total Body Re-Conditioning

Purchase a copy here [Amazon link]


Voices of Medicine

Past Issue

Continuing Medical Education after Graduation

When I was in training to become a physician, I spent my time at the University of Kansas School of Medicine. In one of the introductory lectures, we were told to study diligently and to keep on studying for the rest of our lives. The professors stated that the science of medicine was expanding, and we should consider that by the time we finished our training, which may include the usual four years of internship and another four to six years specialty and subspecialty training, that information would have reached the half life point of relevance. In other words, approximately one-half of the information we learned during those 8-10 years would be obsolete which he stated was the half-life of medical information. If we didn’t continue our studies after graduation, we would become out of date in caring for our patients.

At that time, we were told there were 420,000 articles published yearly in medicine. Obviously, we would not be able to read even a small portion of those medical journals, so we given guidance on how to read journals. First, subscribe to the most important journal in your field to keep current in your practice. The Journal of the AMA and the New England Journal of Medicine were very popular at that time. But what to do with the others in the library? We were taught to scan the “Table of Contents.” Then proceed to the summary of those of major interest and mark with a felt pen the several we would return to read in depth.  (more…)

Voices of Medicine

Past Issue

A Review of Regional Medical Journals: San Mateo Co Med Assn

Who Should Control Healthcare?

By Barbara Weissman, MD
CMA Trustee for the Specialty Delegation

Imagine coming to the hospital to work one morning, only to find you are denied admittance to your office and no longer a member of the hospital medical staff. In January 2016, hospital administrators at the Tulare Regional Medical Center (TRMC) terminated the entire medical staff and its elected officers and adopted new medical staff bylaws without input from the hospital’s physicians.

In effect, a single hospital board meeting dissolved a decades-old medical staff organization and replaced it with a sham medical staff with hospital-appointed leaders. The previously active staff members were granted “provisional” status, and the initial replacement bylaws stated that physicians could achieve active status by proving their economic value to the hospital.  (more…)

Voices of Medicine

Past Issue

A Review of Articles by or about Physicians

Physicians Face Punishment For Speaking Out About Non-Physician Care

By Rebekah Bernard, MD | Posted on March 30, 201

While other physicians have reported persecution for speaking out about midlevel care, most are hesitant to share their name or identity due to concerns over losing their job. Marleen Smith, MD, who is using an alias while her legal case is pending, reports that she was bullied and forced to resign from a hospitalist position due to a conversation she had with a fellow physician about her concerns over patient safety.

“As a new hospitalist, I took over a panel of patients from a team of nurse practitioners who were acting independently as hospitalists in a state which legally required physician supervision. I found that the nurses simply did not have the training to provide for the level of medical care that these patients require. There were multiple medical inadequacies and patient safety was compromised,” Smith told me.  (more…)

Voices of Medicine

Past Issue

Drunk Doctors

Drunk doctors and kitchen table surgeries: Historic photos of health care in Sonoma County


FOR THE PRESS DEMOCRAT | February 22, 2018

Sonoma County’s first physicians were a hardy lot filled with notable and colorful characters.

Pioneer doctors in the 1800s carried medicine bags from residence to residence to treat patients. In those days surgeries were performed without anesthetic, either on a kitchen table or the scene of the accident. Epidemics like smallpox, typhoid and diphtheria were rampant in the community and doctors had to be stalwart.  (more…)

Voices of Medicine

Past Issue

Country Doctors

Country doctors have gone the way of the dodo bird. But occasionally one surfaces. A number of doctors in my community have made house calls. However, they are getting more infrequent. The takeover of medical practices by the government, insurance carriers, bureaucracies and technology have precipitated the change. However, there are segments of our society where it is still practiced in a variation of the traditional form. Physicians had to become more selective on whom we made a visit. My visits were to patients who would be unable to come to my office. What follows is refreshing and familiar story from yesteryear.

Bob Greene interviews a Country Doctor Who Can’t Forget His 40 Years of House Calls in the WSJ on Feb 9, 2018

Dr. Kemper, now retired, is 98 years old. He lives in northern Wisconsin, in the town of Chippewa Falls, population 14,000, where he was a single-practice family physician for more than 40 years, from the 1940s into the 1980s.  (more…)

Voices of Medicine

Past Issue

The Opioid Epidemic—Misplaced blame!


Lawrence R. Huntoon, MD, PhD

Pain management has become a minefield where physicians often walk at their peril between accusations of under-treatment and over-treatment of pain.

Prosecutors in recent years have focused on alleging inappropriate prescribing of opioids, or on over-treatment of pain, which they state leads to addiction, abuse, overdose, and death.

Myths, erroneous perceptions, and ignorance often trump reality, and along with political ambition, drive prosecutors to seek convictions and long prison terms for those whom they assert are responsible for what has been labeled the opioid crisis.  (more…)

Voices of Medicine

Past Issue

Women Who Suffered Emotionally from Abortion

A Qualitative Synthesis of Their Experiences

Priscilla K. Coleman, Ph.D.
Kaitlyn Boswell, B.S. Katrina Etzkorn, B.S. Rachel Turnwald, B.S.

Women’s adjustment to life after abortion involves numerous factors interacting in complex ways, and qualitative studies are uniquely suited to enhance our understanding of the breadth and depth of individuals’ experiences. Respondents to a survey of women who had contacted crisis pregnancy centers for post-abortion care were asked to describe the most significant positive and negative aspects of their abortion histories in an online anonymous survey.  (more…)

Voices of Medicine

Past Issue

A Review of Medical Journals: Principles of Medical Ethics


PREAMBLE: Being aware that a physician’s religious and moral principles are the source of his ethical behavior, this Association adopts the following statement of principles of professional conduct. The principal objective of the ethical physician in his practice is to treat human illness while maintaining the highest respect for the dignity of his patient.

(1) The physician’s first professional obligation is to his patient, then to his profession. His ethical obligation to his community is the same as that of any other citizen.  (more…)

Voices of Medicine

Past Issue

Sonoma Medicine Editorial: SINGLE-PAYER HEALTH CARE

SINGLE-PAYER HEALTH CARE Editorial: The Great Single-Payer Debate
Feature articles:  Envisioning single payer; California single-payer pros and cons; SB 562: CMA opposes unless amended;

H-PEACE: health care activism. Departments: Letter from the executive director; interview,
SCMA president Peter Sybert, MD; open clinical trials in Sonoma County; clinical fasting;
mystery case: nocturnal leg cramps;

Book review: “Do No Harm: Stories of Life, Death and Brain Surgery;”
The Web’s 10 Best; medical arts;
Farewell from editor Steve Osborn.

* * * * *

The Heart of Wine Country

Michael Zivyak, President, Magazine Division

Sonoma Media

Sonoma is a world unto itself. Its defining landscape combines scenic beauty and agricultural abundance. It is urban sophistication in an idyllic, rural setting. It is a destination, a haven, a state of mind, and a way of life.  (more…)

Voices of Medicine

Past Issue

A Review of Regional Medical Journals: Sonoma Medicine

Winemaking with a Medical Bent

Rachel Friedman, MD

. . . It’s a Saturday afternoon, and after a busy week of seeing patients as a family physician, I am behind the bar at the winery my husband and I own, guiding guests in a wine tasting. When I explain that I not only own a winery but also spend my week as a physician, they seem impressed and say with a touch of envy, “Wow! You are really living the dream!” (more…)

Voices of Medicine

Past Issue

J American Phys & Surg

Sanders: What Will His Socialist Plan Do to YOUR Medical Care?

By Jane M Orient, M.D.

There is one thing that supporters and detractors of Bernie Sanders might agree on: he seems to be honest about his convictions. He is an avowed socialist, instead of pretending to believe in a role for private insurance. Unlike Barack Obama, his answer to the question “Do you get to keep your insurance plan?” is plainly No. There won’t be any more insurance plans. Everyone will be on Medicare.  (more…)

Voices of Medicine

Past Issue

A Review of Medical Journals: J of Physician and Surgeons

Why is Government Exempt from Creative Destruction?

Craig J. Cantoni

Creative destruction explains why even people in poor countries now carry more computer power in their pockets than was contained in IBM mainframes the size of refrigerators in the 1970s. It also explains why the poor in America have a better quality of life than European monarchs in the Middle Ages.  (more…)

Voices of Medicine

Past Issue

A Review Medical Journals and Issues: Non-Physician Clinicians

In Medical Practice, there are a number of para-professionals who help us. Many appear in long white coats and are thought to be physicians. Some Physician Assistants actually refer to themselves as doctor. At times some of our patients are somewhat confused as to whom they are seeing. There are instances when a patient realizes that he is not really seeing a physician and the return appointments are made to the same person, they take a variety of actions.  Some quietly accept this as a new form of medical interaction; some complain to the office manager; some quietly leave the practice and seek an office where they are assured of seeing a Medical Doctor (MD); and some write complaint articles to the press, the medical board, or to their Congressional Representative. The President of the Association of American Physician and Surgeons has written a very timely article to help avoid confusion. (more…)

Voices of Medicine

Past Issue

A Review of Regional Medical Journals and Articles

What If Sick People Lose Their ObamaCare?

By Jane M. Orient, M.D.

As Republicans contemplate repealing the Affordable Care Act (ACA or “ObamaCare”)—seriously, not just as a political gesture—alarms are sounding about millions of individuals losing coverage.

So soon we have forgotten about the millions who lost coverage they had had for years because ObamaCare outlawed it.

ObamaCare resulted in perhaps five times as many losers as winners—even counting just those who ended up with more expensive or less desirable coverage. If you count the taxpayers, the tally of losers is much higher. But with government largesse, the losers—the ones who have their earnings taken away—are “forgotten men.”


Voices of Medicine

Past Issue

Are Trump’s Taxes more important than Hillary’s Medical Records?


Jane M. Orient, M.D

Some Republicans as well as Democrats have used the term “unfit to serve” about Donald Trump, based on things he said and what they assume he might have meant.

Surely his style can be abrasive and blunt. But a huge number of ordinary Americans cheer him, probably because he said what they were thinking. They don’t have an evil, ungenerous, uncompassionate, racist, bigoted heart, and they assume he is like them. They are sick of being pushed around and disrespected by the politically correct crowd who are hypersensitive about almost everything – but constantly spew profane, obscene, and vulgar language that demeans American and Christian culture and blames it for all the world’s evil.

In the past, others have spoken forcefully and unapologetically about things nobody wanted to hear – Winston Churchill, for example. A lot of proper Englishmen thought he was unfit – until they saw the truth of his words.


Voices of Medicine

Past Issue

San Mateo County Physician, President’s Message


Russ Granich, MD, President

San Mateo County Physician | July-August 2016

We live through turbulent times for medicine. The government is trying to cut what they pay, they add on regulations, insurers are often difficult, etc. It is easy to get lost and focus on the business of medicine instead of the practice of medicine. It is always better to remember our goals and concentrate on the journey, not on the roadblocks.


Voices of Medicine

Past Issue

Dr. Sam Vaknin, Israelis Psychiatrist, Says Obama Has A Mental Disorder

By Michael A. Haberman, MD, An Israeli M.D.

The Voice of a physician in another part of the world

A Reflection Of What Is Happening To The USA—In The Eyes Of Others!

Israeli doctor says Obama has a mental disorder—
Labels him a pathological narcissist.
No greater insanity than electing one says Dr. Sam Vaknin an Israeli psychologist.
Another view on our president.

Dr. Vaknin states “I must confess I was impressed by Obama from the first time I saw him. At first I was excited to see a black candidate. He looked youthful, spoke well, appeared to be confident, a wholesome presidential package. I was put off soon, not just because of his shallowness but also because there was an air of haughtiness in his demeanor that was unsettling. His posture and his body language were louder than his empty words. Obama’s speeches are unlike any political speech we have heard in American history. Never a politician in this land had such quasi “religious” impact on so many people.

The fact that Obama is a total incognito with Zero accomplishment, makes this inexplicable infatuation alarming.  Obama is not an ordinary man. He is not a genius. In fact he is quite ignorant on most important subjects.”

Dr. Sam Vaknin, the author of the Malignant Self Love believes “Barack Obama appears to be a narcissist.” Vaknin is a world authority on narcissism. He understands narcissism and describes the inner mind of a narcissist like no other person. When he talks about narcissism everyone listens. Vaknin says that Obama’s language, posture and demeanor, and the testimonies of his closest, dearest friends suggest that the man is either a narcissist or he may have narcissistic personality disorder (NPD).

Narcissists project a grandiose but false image of themselves. Jim Jones, the charismatic leader of People’s  Temple, the man who led over 900 of his followers to cheerfully commit mass suicide and even murder their own children was also a narcissist. David Koresh, Charles Manson, Joseph Koni, Shoko Asahara, Stalin, Saddam, Mao, Kim Jong Ill and Adolph Hitler are a few examples of narcissists of our time. All these men had a tremendous influence over their fanciers. They created a personality cult around themselves and with their blazing speeches elevated their admirers, filled their hearts with enthusiasm and instilled in their minds a new zest for life.  They gave them hope! They promised them the moon, but alas, invariably they brought them to their doom.

When you are a victim of a cult of personality, you don’t know it until it is too late. One determining factor in the development of NPD is childhood abuse “Obama’s early life was decidedly chaotic and replete with traumatic and mentally bruising dislocations, “says Vaknin. “Mixed-race marriages were even less common then. His parents went through a divorce when he was an infant two years old. Obama saw his father only once again, before he died in a car accident. Then his mother re-married and Obama had to relocate to Indonesia , a foreign land with a radically foreign culture, to be raised by a step-father. At the age of ten, he was whisked off to live with his maternal (white) grandparents.  He saw his mother only intermittently in the following few years and then she vanished from his life in 1979. “She died of cancer in 1995.”

One must never underestimate the manipulative genius of pathological narcissists. They project such an imposing personality that it overwhelms those around them.   Charmed by the charisma of the narcissist, people become like clay in his hands. They cheerfully do his bidding and delight to be at his service.

The narcissist shapes the world around himself and reduces others in his own inverted image. He creates a cult of personality. His admirers become his co-dependents. Narcissists have no interest in things that do not help them to reach their personal objective. They are  focused on one thing alone and that is power. All other issues are meaningless to them and they do not want to waste their precious time on trivialities. Anything that does not help them is beneath them and does not deserve their attention.

If an issue raised in the Senate does not help Obama in one way or another, he has no interest in it. The “present” vote is a safe vote. No one can criticize him if things go wrong. Those issues are unworthy by their very nature because they are not about him.

Obama’s election as the first black president of the Harvard Law Review led to a contract and advance to write a book about race relations. The University of Chicago Law School provided him a lot longer than expected and at the end it evolved into, guess what? His own autobiography! Instead of writing a scholarly paper focusing on race relations, for which he had been paid, Obama could not resist writing about his most sublime self. He entitled the book Dreams from My Father.

Not surprisingly, Adolph Hitler also wrote his own autobiography when he was still a nobody. So did Stalin. For a narcissist no subject is as important as his own self. Why would he waste his precious time and genius writing about insignificant things when he can write about such an august being as himself?

Narcissists are often callous and even ruthless. As the norm, they lack conscience. This is evident from Obama’s lack of interest in his own brother who lives on only one dollar per month. A man who lives in luxury, who takes a private jet to vacation in Hawaii, and who raised nearly half a billion dollars for his campaign (something unprecedented in history) has no interest in the plight of his own brother. Why?  Because, his brother cannot be used for his ascent to power. A narcissist cares for no one but himself.

This election was like no other in the history of America. The issues were insignificant compared to what is at stake. What can be more dangerous than having a man bereft of conscience, a serial liar, and one who cannot distinguish his fantasies from reality as the leader of the free world?

I hate to sound alarmist, but one is a fool if one is not alarmed. Many politicians are narcissists. They pose no threat to others. They are simply self-serving and selfish. Obama evidences symptoms of pathological narcissism, which is different from the run-of-the-mill narcissism of a Richard Nixon or a Bill Clinton for example. To him reality and fantasy are intertwined.

This is a mental health issue, not just a character flaw.  Pathological narcissists are dangerous because they look normal and even intelligent. It is this disguise that makes them treacherous. Today the Democrats have placed all their hopes in Obama. But this man could put an end to their party. The great majority of blacks voted for Obama. Only a fool does not know that their support for him is racially driven. This is racism, pure and simple.

The downside of this is that if Obama turns out to be the disaster I predict, he will cause widespread resentment among the whites. The blacks are unlikely to give up their support of their man. Cultic mentality is pernicious and unrelenting. They will dig their heads deeper in the sand and blame Obama’s detractors of racism. This will cause a backlash among the whites. The white supremacists will take advantage of the discontent and they will receive widespread support. I predict that in less than four years, racial tensions will increase to levels never seen since the turbulent 1960’s.

Obama will set the clock back decades.  America is the bastion of freedom. The peace of the world depends on the strength of America, and its weakness translates into the triumph of terrorism and victory of rogue nations. It is no wonder that Ahmadinejad, Hugo Chavez, the Castroists, the Hezbollah, the Hamas, the lawyers of the Guantanamo terrorists, and virtually all sworn enemies of America are so thrilled by the prospect of their man in the White House.

America is on the verge of destruction. There is no insanity greater than electing a pathological narcissist as president.

Michael A. Haberman, MD, An Israeli M.D.

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

Voices of Medicine

Past Issue

Authentic Medicine – Douglas Farrago MD, Editor, Creator & Founder


The mission of Authentic Medicine is to rediscover how much the art of medicine means and allow us to reconnect to our roots once again. It is about fighting back against those things that are taking us away from the direct care of patients while still pointing out the lunacy and hypocrisy of this job. Be part of the movement that will take back the healthcare system from the idiots who are ruining it.

Douglas Farrago MD is a full-time practicing family doc in Auburn, Maine.  He is board certified in the specialty of Family Practice.  He is also the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver, and its knock-offs, are worn by many major league baseball catchers.

From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years.  He was featured in the Washington Post, US News and World Report, the AP, and the NY Times.

Authentic Medicine was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. Only when physicians regain control and connect back to the roots of this profession will we ever have AUTHENTIC MEDICINE again.

about this site

Authentic Medicine is about connecting us back to the roots of medicine.  This online “magazine” will constantly be updated with informative and challenging opinions and ideas.   The goal is to fight back against those things that are taking us away from the direct care of patients while still pointing out the lunacy and hypocrisy of this job.  It is the evolution of what I was really trying to accomplish by the end with the Placebo Journal.

Physicians and patients need to join together to form the “Authentic Medicine Movement”.  This is not about being Republican or Democrat. It is about opening up a dialogue and keeping that conversation going.  You may hate some of the things I say.  I may hate some of your comments.  It doesn’t matter.

The wrong people (politicians, businessmen, and administrators) are running and ruining this healthcare system.   We need to speak up and be part of the NEVER ENDING DEBATE.

Issues that I am concerned about:

  • Why we are moving to an era of Industrialized Medicine
  • The Quality Movement and why it is a scam
  • The ever expanding Medical Axis of Evil
  • Medical Dogma and the Alphabet Soup (JC, HIPAA, etc.)
  • Bureaucratic Drag and the distractions from treating patients
  • Burnout and depression amongst healthcare professionals
  • Humor in caring for the patient and the caretaker

I would be honored if you can check out the site and tell me what you like or dislike so far.  Come back regularly as new items are added daily (at least).

Email Dr. Farrago – doug@authenticmedicine.com

Subscribe at http://authenticmedicine.com/

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

Voices of Medicine

Past Issue

Whistleblowers Attempt To Change The Culture Of Federal Agencies

Advocates Applaud Senate Passage of S. 743

November 14, 2012 by
Filed under CampaignCongress & Courts

November 14, 2012


Advocates Applaud Senate Passage of S. 743
After Decade Long Campaign, Federal Whistleblower Bill Sent to President’s Desk

After a decade long campaign by the Make It Safe Coalition to restore federal whistleblower protections, we applaud yesterday’s Senate passage of the Whistleblower Protection Enhancement Act, S. 743 (WPEA), by unanimous consent. The House of Representatives approved this measure in September, also by unanimous consent. Congress’ sweeping endorsement of S. 743 demonstrates the strong bipartisan support for this government accountability legislation to expand protections for federal employees who disclose wrongdoing and protect the public trust.  Longtime whistleblower champion and retiring Senator Daniel Akaka (D-HI) was joined by his cosponsors Susan Collins (R-Maine), Joe Lieberman (I-CT), Senators Charles Grassley (R-Iowa) and Claire McCaskill (D-MO) in advocating for passage of this crucially needed reform legislation. A full list of Senate cosponsors can be viewed here. We cannot thank these champions and their staff enough for their marathon commitment to the WPEA.

Whistleblower advocates from across the ideological spectrum celebrated this government accountability and taxpayer protection measure:

AFGE is proud to join a bipartisan group of lawmakers and a coalition of worker, good government, and civic advocates in applauding passage of S. 743, the Whistleblower Protection Enhancement Act by the Senate. For far too long managers in the federal workplace have faced little or no accountability when they retaliate against federal workers who blow the whistle on fraud, waste and wrongdoing on the job,” said Beth Moten, Legislative Director for American Federation of Government Employees. “The Whistleblower Protection Enhancement Act marks the beginning of a new day of free speech and due process rights for federal workers such as Transportation Security Officers who protect our nation’s airports, food safety inspectors, government scientists, and others when they speak up on behalf of the public.”

“After a 13 year roller coaster campaign, Congress unanimously has given whistleblowers who defend the public a fighting chance to defend themselves. This is a major victory for taxpayers and public servants, but a major defeat for special interests and bureaucrats. Free speech rights for government employees never have been stronger,” said Tom Devine, Legal Director for the Government Accountability Project. “It would be dishonest to say our work is done, however, or to deny that government whistleblower rights are still second class compared to those in the private sector. House Republicans blocked two cornerstones of the legislation: jury trials to enforce newly-enacted protections, and extension of free speech rights to national security workers making disclosures within agency channels.” 

“A transpartisan impulse expressed through bi-partisan consensus. Good to see the U.S. House and Senate finally do something right for the American people,” said Michael Ostrolenk, National Director of the Liberty Coalition. ”The passage of the Whistleblower Protection Enhancement Act is an important first step in protecting citizens against Federal waste, fraud and abuse of power.”

Congress has just made a major bipartisan stride to stand behind conscientious federal employees who stand up for taxpayers,” said National Taxpayers Union Executive Vice President Pete Sepp.“Whistleblowers are true trailblazers on the path to fiscal responsibility in Washington, and passage of S. 743 is a hopeful sign that more progress and more protections lie straight ahead.”

National President Colleen M. Kelley of the National Treasury Employees Union commented: “This is a vital piece of legislation that expands protections for federal employees who disclose fraud, waste, abuse or illegal activity on behalf of taxpayers and in the best interests of our nation. Notably, it includes specific protection for the scientists who work for our nation, are committed to valid research and who should not be swayed or penalized for their work. NTEU is very pleased to see its passage before the end of this current session of Congress.”

“This opening salvo to the lame duck shows that Congress can put aside partisan posturing and deliver more government accountability to the American public. These hard-fought reforms will substantially improve the status quo for federal whistleblowers and taxpayers,” said Angela Canterbury, Director of Public Policy for Project On Government Oversight. “It has been a long time coming, but the federal workers now will have a better chance at real justice when they suffer from retaliation for exposing waste, corruption, and abuse. These courageous workers deserve no less for their service to us and our country.”

“Reforms such as these create a vehicle for workers to safely call out potential hazards in the workplace without retaliation from the employer,” said Keith Wrightson, worker safety and health advocate for Public Citizen’s Congress Watch division. “By giving federal workers more opportunity and resources to identify hazardous workplace situations, the government will become more efficient.”

“Whistleblowers are critical in making the government more efficient and accountable. This legislation finally gives Whistleblowers the respect and protection they deserve,” said David Williams, President of Taxpayers Protection Alliance. “Congress has shown the American people that they are willing to work together and put partisan differences aside to do the right thing by passing the Whistleblower Protection Enhancement Act.”

“We hope that this law will begin a process to change the culture of federal agencies when it comes to whistleblowers,” said Celia Wexler, Senior Washington Representative, Union of Concerned Scientists Center for Science and Democracy. “People who protect the public from unsafe drugs, tainted food, defective products, and environmental hazards should not fear for their jobs when they speak up for safety and scientific integrity.” 

The WPEA includes critically important upgrades to the broken system for federal whistleblowing to better serve taxpayers. Though it does not include every reform that we have sought and will continue to seek, the bill will restore and modernize government whistleblower rights by ensuring that legitimate disclosures of wrongdoing will be protected, increasing government accountability to taxpayers, and saving billions of taxpayer dollars by helping expose fraud, waste and abuse. Overall, the WPEA’s provisions will restore free speech rights closed through arbitrary loopholes and create new protections for federal scientists and Transportation Security Administration officers. The bill also will strengthen due process rights, such as a two-year experiment in normal access to appeals courts (effectively breaking the Federal Circuit’s monopoly on appellate review); provide compensatory damages; create whistleblower ombudsmen at Inspectors General offices; and strengthen authority by the U.S. Office of Special Counsel to help whistleblowers through disciplinary actions against those who retaliate, and to file briefs in court supportive of whistleblower rights.

The Senate cosponsors and their dedicated staff worked closely with their House colleagues, Oversight and Government Reform Chairman Darrell Issa (R-CA), Ranking Member Elijah Cummings (D-MD), retiring Representative Todd Platts (R-PA), Chris Van Hollen (D-MD),  Paul Gosar (R-AZ), Steve Pearce (R-NM), and their committed staff, to reach a bipartisan compromise that could pass this usually contentious Congress. After a hard-fought campaign, Congress has finally enacted this important reform.

A menu of key reforms can be viewed here: http://bit.ly/PwafFC

The bill can be viewed here: http://bit.ly/UDaepU

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

Voices of Medicine

Past Issue

A Review Of Local And Regional Medical Journals And Articles

Retaliation against a Physician Whistleblower

By Lawrence R. Huntoon, M.D., Ph.D. Editor, JAPS

Dr. Michael W. Fitzgibbons, an infectious diseases specialist and former chief of staff at Western Medical Center in Santa Ana, California, is not a man who simply walks away and gives up, even in the face of grave injustices inflicted upon him and his family. But more than demonstrating his integrity, his story shows how far some hospital administrators will take retaliation against a physician whistle blower. We all have a stake in the integrity of our judicial system. Many would choose another course, but though

paying a high professional and personal price, and uncertain of any level of victory, Dr. Fitzgibbons chose to stay on the battlefield.

The battle was which ended on Feb 8, 2013. The details of what was done to Dr. Fitzgibbons are frightening and shocking. His story was detailed in a series of articles published by the , weekly newspaper for Orange County, California, published in Costa Mesa, which covered the story intensely.

In 2004, the financially struggling Tenet Healthcare Corp sought to sell four hospitals in southern California—Western Medical Center of Anaheim, Chapman Hospital in Orange County, Coastal Community Hospital in Santa Ana, and Western Medical Center of Santa Ana, the hospital where Dr. Fitzgibbons practiced.

Some physicians expressed concerns about the proposed purchaser, Dr. Kali P. Chaudhuri and his company, Integrated Healthcare Holdings, Inc. (IHHI).

According to an article published in , “Four years ago, Chaudhuri’s KPC holding company closed 81 Southern California medical clinics it had purchased just a year before. The closures stranded 300,000 patients without care and, in many cases, without medical records. Insurers and doctors scrambled to pick up the pieces. Asked to account for the chain’s assets, a bankruptcy judge said the money trail was too complicated to follow. The resulting charges of mismanagement, fraud, and diversion of assets led to dozens of lawsuits and thousands of creditor claims against Chaudhuri and KPC, most of them unsatisfied to this day.”

According to another article, “So vehemently do they oppose Chaudhuri’s takeover of the four Tenet hospitals that in October Fitzgibbons and fellow physicians took to the streets with picket signs. More than 70 doctors from the targeted hospitals formed their own acquisition group and offered Tenet a competing bid.”

At the urging of Fitzgibbons and other physicians, state Senator Joe Dunn convened hearings in 2004 that resulted in an agreement to limit the involvement of Dr. Chaudhuri in the takeover of the four hospitals.

Michael W. Fitzgibbons, M.D., vs. Integrated Healthcare Holdings, Inc., et al., OCWeekly


While the last chapter in this saga has yet to be written, physicians can learn from it the tremendous power of hospital cartels, and the ruthlessness they may display in retaliating against a physician who opposes them or exposes their wrongdoing.

Lawrence R. Huntoon, M.D., Ph.D. is a practicing neurologist and editor-in-chief

of the Journal of American Physicians and Surgeons. Contact: editor@jpands.org.

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

Voices of Medicine

Past Issue

A Physician Summarizes Obamacare In Just One Sentence

Dr. Barbara Bellar


We are gifted with a health care plan we are forced to purchase and fined if we don’t; which purportedly covers at least 10 million more people without adding a single new Doctor; but provides for 16,000 new IRS agents; written by a committee whose chairman says he doesn’t understand it; passed by a Congress that hasn’t read it and signed by a President who smokes; with funding administered by a treasury chief who didn’t pay his taxes; for which we will be taxed for 4 years before any benefits take effect; by a government that has already bankrupted social security and Medicare; all to be overseen by a surgeon general who’s obese; and financed by a country that’s broke.

What on earth could possibly go wrong?

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

Voices of Medicine

Past Issue

A Review Of Local And Regional Medical Journals

A Doctor Leaving Solo Practice

by Marsha McKay DO

I am one of the docs who decided that medicine is not fun anymore, and more importantly is no longer tolerable with all the documentation, coding, referrals, prior authorizations, begging insurance companies to “let me” prescribe necessary medications and so forth. I can’t practice medicine anymore as an Authentic Doctor so I closed my private solo rural practice five days ago and will now just work 8 hours a week in small county jails. I am tired of spending my days clicking templates on an EMR so that if I get audited I don’t have to go bankrupt paying back Medicare or being accused of fraud when I just forgot to document that someone has a gun in their house or doesn’t wear their seatbelt. I did the EMR incentive program for a year, got my $14,000 and then realized it was a loser financially and time wise and added nothing to good patient care. Ditched the program the next year. Then it was time to cope with ICD 10, ACO’s, patient centered medical home, an electronic health record at the local hospital which is completely unusable and adds hours to hospital work.

I really loved my patients, my little office and wonderful staff but I am completely exhausted and done with the struggle of trying to be a good doctor when the forces out there seem to be determined to wear me down. So now about 1500 people have to find a new doctor and I will retire from active family practice at the age of 59. Pretty stupid waste of my training and compassion to be done so early. I am also tired of being perceived as the rich greedy doctor who only wants to make money and is the source of all the health care problems in this country. I am anything but that. Life is too short to work so hard, sacrifice being with family and friends and spend all my time servicing the insurance industry.

I’m not tired of being a physician, I’m just done with all the unnecessary garbage that comes along with it. I agree that doctors are wimps and in our defense, we are just too busy most of the time to get organized and do something about this mess. Most of us are just trying to do some good in a complicated world. Now I’m going to take care of myself, my family and have a real life. Yahoo!

Read the original in Authentic Medicine. . .

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

Voices of Medicine

Past Issue

A Review Of Local And Regional Medical Journals Sonoma Medicine MEDICAL ARTS

The magazine of the Sonoma County Medical Association

Roll on, Bob

By Rick Flinders, MD

I first saw Willie Mays in 1958, when I was 12 years old. I watched him play for 14 years as a San Francisco Giant, through the prime of his career, the greatest baseball player I ever saw. Maybe Roberto Clemente had a better arm. Maybe Barry Bonds was a better hitter. But no one has ever played the game of baseball better than Willie Mays. He was magnificent.

In 1972, Willie was traded to the New York Mets. I watched him flail at the plate, no longer able to catch up with major league fastballs. In center field he was no longer graceful, even once dropping a ball while attempting his signature basket catch. It was painful to watch. He retired in 1973.

I first saw Bob Dylan in 1965, when I was 19 years old. I’d been struck between the eyes with songs like “Masters of War,” “Chimes of Freedom,” and “With God on Our Side.” On stage at the Berkeley Community Theater in December 1965, he stood alone with only an acoustic guitar and harmonica, and he mesmerized us. After intermission, he returned with an electric Stratocaster and four musician friends he called “The Band.” He concluded the show with a song he’d just released, “Like a Rolling Stone.” He was magnificent.

In the past half-century, few artists have had more impact on our language and culture than Dylan. He changed popular music the way Einstein changed modern physics: he changed everything that followed. Dylan took the lyrics of popular music away from the hacks of Tin Pan Alley and placed them in the hands of poets. As Bruce Springsteen said of the influence of Dylan’s music on his generation: “Elvis freed our bodies. Dylan freed our minds.” A recent concordance of legal decisions in U.S courtrooms showed Dylan’s words the most frequently cited lyrics in judicial opinions, from local magistrates to the Supreme Court.

In the years since that first show in Berkeley, I’ve seen Dylan in concert 15 times, each performance as unpredictable as the performer himself, but always worth seeing.

Until now.

This October, at the Greek Theater in Berkeley, it was hard to watch Dylan on stage. Listening was even more painful. His band, still composed of world-class musicians, was only loud and lifeless. His voice, over-amplified to compensate for 50 years of vocal cord injury, echoed only harsh syllables from his former eloquence.

His most recent album had promised more. Called Tempest, the same title as Shakespeare’s final play, it was rumored to be perhaps his final work. Two songs in particular provided proof that Dylan can still bring the poetry. The title track is a poetic vision of the night the Titanic sank, with lyrics sufficiently vivid to bring you to tears. Another song, “Roll on, John,” is a touching tribute to his old friend John Lennon:

Shine your light, move it on

You burned so bright, roll on, John

Though the poet still lives, the voice is gone.

Bob Dylan has earned the right to sing forever. It’s what he does. But, for the first and only time in 50 years, I walked out early from a Dylan concert, the last one I’ll ever attend. How does it feel? Like watching Willie Mays about to drop a routine fly ball from a basket catch. And while it breaks my heart to say it, Bob, I say this with nothing but love and with gratitude for all you’ve given us. May you live long and continue to know and speak the truth as few others have. May your heart always be joyful and your song always be sung. But from that stage where you burned so bright and delivered a lifetime of magnificent lines and transcendent songs, it is time to roll on.

Dr. Flinders, who serves on the SCMA Editorial Board, is a lifelong fan of Bob Dylan.

Email: flinder@sutterhealth.org

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

Voices of Medicine

Past Issue

A Review Of Local And Regional Medical Journals: Sonoma Medicine

The magazine of the Sonoma County Medical Association


Sarah Murphy, MD, and Hana Grobel, MD

Mary (not her real name) is a 45-year-old woman who originally presented with mild gastroesophageal reflux disease (GERD) and was started on a proton pump inhibitor. When we first saw her three years later, she was still on PPIs.

As family physicians, we see many patients like Mary who are initially prescribed PPIs for mild GERD, continue their medication for a long time, and subsequently suffer various side effects associated with PPIs. The question that arises is how to safely wean these patients off PPIs. One possible answer is to use an integrative medicine approach.

But first, let’s back up and consider the function of the entire gastrointestinal tract and the processes that are involved in maintaining the health of our guts. Taken as a whole, the GI tract is one of the largest organs in our body, and its surface area can expand to the size of a tennis court. In our lifetime, we take in 30-40 tons of food that we break down, process, sort, and then use or eliminate . . .

In addition to the cells of the GI tract, the gut contains 100 trillion bacteria (400 different species), which is 10 times more than the amount of cells we have in our entire body. These bacteria break down food to make nutrients more available, inhibit pathogenic bacteria, and form a layer on the gut mucosa, which protects the intestinal lining and communicates with the enteric immune system.[1,2]

From the perspective of integrative medicine, when we ingest substances that harm this delicate ecosystem, the gut barrier can break down (known as increased intestinal permeability), the microbial ecology can become imbalanced (called dysbiosis), and we can ultimately get sick.[1] Disease not only shows up in the form of GI disorders (e.g., GERD, IBD, IBS, gastroenteritis), but can also present as systemic problems.[3] When the gut mucosa is disrupted, it can become inflamed. Through the more permeable intestinal walls, improperly digested food substances can cross the GI mucosa and trigger further inflammation.[1]

How do we keep our guts healthy and our immune systems intact? One integrative approach is to use the 5Rs of Functional Medicine, where the goal is to support optimal GI health and address the underlying mechanism of disease. The 5Rs stand for remove, replace, repopulate, repair and rebalance. These methods can be applied to many GI conditions, including GERD.

The problem with GERD is not that there is too much acid, but that the acid is in the esophagus rather than the stomach. PPIs block the secretion of acid, thus eliminating symptoms, but they do not address the underlying problem of regurgitation of the gastric lumen contents into the esophagus. In other words, PPIs don’t cure GERD; they only treat the symptoms.

Over time, the body upregulates acid production to compensate for the lack of acid secretion, so stopping PPIs becomes difficult because of rebound symptoms.[4] Some studies have found that long-term PPI use is associated with hyperplasia from increasing gastrin production, as well as increased gastric atrophy.[5,6] Although long-term PPI use has been associated with an increased incidence of gastric cancer, no direct link has been established.

PPIs are valuable in the short-term treatment of GERD, but long-term use may lead to serious complications, including increased risk for pneumonia and Clostridium difficile, and decreased absorption of vitamin B12, calcium, magnesium and iron.[7-12] In fact, our patient Mary was found to be Vitamin B12 deficient.

Despite these potential complications, PPIs are recommended in many circumstances, such as preventing gastrointestinal bleeding in elderly patients on NSAIDs. As with other medications, physicians need to balance the risks and benefits of PPIs, depending on the condition. They should also bear in mind that many patients are on PPIs with no good indication.

The long-term side effects of PPIs make sense based on the multiple roles of acid in the stomach. Acid functions to kill bacteria in the stomach, and it helps break down food to make nutrients more available. In the duodenum, acid helps stimulate release of pancreatic enzymes, which further aid digestion. Higher acidity in the stomach also increases the tone of the lower esophageal sphincter. Thus, acid production plays an important role in tightening LES tone, getting rid of unwanted bacteria, and providing us with properly digested nutrients.

Our goal with Mary was to wean her off PPIs and help her regain the normal function of her GI system. We used an integrative approach based on the 5Rs, as outlined below. Such an approach should begin at least one week before starting to wean patients off PPIs.

Remove. To stop symptoms and prevent their return, it is important to remove the triggers. Certain foods can be aggravating, including caffeine, spicy foods, alcohol, chocolate, fatty foods, dairy, and acidic foods, such as orange juice and tomatoes.[13,14] To identify triggers, patients can use a food diary to document food intake and symptoms. Alternatively, patients can try an elimination diet where specific foods are eliminated from the diet for 2-4 weeks, and re-introduced one at a time to see if symptoms return.[15] Other triggers may include tobacco use, increased weight, prone position, stomach distention and stress.[14] For some patients, addressing lifestyle factors may be enough to stop their GERD symptoms. Don’t underestimate the power of tobacco cessation, weight loss, propping the head of the bed 4-6 inches, eating meals several hours before lying down, eating smaller meals and stress management.

Replace. Once the main triggers are removed, non-aggravating nutritious foods can take their place. Patients may also benefit from replacing vitamin B12, calcium, magnesium or iron, if low.[10] In addition, one small study found that, instead of suppressing acid, some patients may benefit from supplementing with acid to increase LES tone, break down food and stimulate digestion.[16]

Repopulate. Patients who suffer from small bowel bacterial overgrowth after long-term suppression of stomach acid may benefit from probiotics. We recommend at least 10-14 billion units daily, preferably with several different species present. Some symptoms of bacterial overgrowth include bloating, gas, diarrhea and abdominal cramps.[17]

Repair. Various herbs and supplements may help protect and repair the lining of the gut.[3] Many of them act as demulcents and create mucoprotection of the esophageal mucosa, but they can also decrease absorption of other medications, so medication doses must be monitored.[3] One week prior to weaning off PPIs, patients can start taking one or more of the following herbs:

·     Marshmallow (althea officinalis): can be ingested as tea, up to 5-6 grams daily, or as a tincture, 5 mL after meals.

·     Licorice (glycyrrhiza glabra): best taken as deglycyrrhizinated licorice (DGL) 380 mg tablets, 2-4 tablets taken before meals. Glycyrrhizin acts as a mineralocorticoid and can cause hypertension, hypokalemia and edema with prolonged use, so deglycyrrhizinated licorice is recommended.

·     Slippery elm (ulmus fulva) root bark powder: one to two tablespoons of the powder mixed with water and taken after meals and before bed. To increase palatability, mixture can be sweetened with honey.

·     Chamomile (matricaria recutita): used for inflammation and spasmodic effects. 1-3 grams steeped as tea, 3-4 times a day.

·     Throat Coat tea (Traditional Medicinals): contains all the above herbs (licorice root, slippery elm, marshmallow root), but in smaller amounts. Can be taken with meals.

Rebalance. The enteric nervous system houses more neurotransmitters than the brain and makes up 70% of the entire immune system, so stress can affect gut symptoms.[1,18] Many modalities can be used to help decrease stress and prevent the return of symptoms. Stress-reduction modalities include biofeedback, relaxation techniques, meditation, self-hypnosis and journaling. Some studies have found that acupuncture may be helpful for treating GERD symptoms.[19,20] Regular aerobic exercise is also recommended when tapering off PPIs, but symptoms can be exacerbated if exercise occurs right after meals.[13] High-intensity activities like running or cycling may aggravate symptoms.

When using the 5R approach above, it’s important to taper off the PPI slowly. The higher the dose, the longer the taper; counsel your patient to expect rebound symptoms. Begin by decreasing the current PPI dose by 50% each week until the patient is on the lowest dose once daily. After two weeks on this dosage, change to an H2 blocker. If the patient cannot tolerate going straight to an H2 blocker, you can alternate an H2 blocker every other day with omeprazole. After 2-4 weeks on the H2 blocker, taper or stop altogether. After 2 weeks off the H2 blocker, try tapering off supplements. Your patient will benefit from continued lifestyle modifications. .  .

Read the entire article including the details of the 5Rs, lifestyle modification and references in Sonoma Medicine . . .

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

Voices of Medicine

Past Issue

A Review Of Local And Regional Medical Journals And Articles

Sonoma Medicine
The magazine of the Sonoma County Medical Association

EDITORIAL: Pain and Suffering

Allan Bernstein, MD

Pain is an essential part of our survival mechanism. It warns us that we stepped on a nail or that the coffee is too hot. It triggers autonomic responses that adjust our blood pressure, heart rate, pupillary reactions, blood sugar and blood cortisol levels. It is a warning to get our hand away from the flame and that our shoe is too tight. Pain is something we learn from. We’d like to avoid it, but we need it.

Pain typically indicates injury or potential injury, starting with tissue damage, releasing cytokines, stimulating peripheral nerves, and progressing proximally through nerve roots, spinal cord and into the brain. Spinal reflexes to pain allow us to pull our hand away from a painful stimulus before it even registers in our brain. A series of on/off switches along the way, particularly in the spinal cord and brainstem, allow us to modulate the pain and interpret the meaning. The endpoint, after multiple connections, is the frontal cortex, where we can localize the pain and decide how significant it is.

There are learned behaviors in our reaction to pain and genetic differences as to how we rate pain. “Big boys don’t cry” and “crybaby” are terms used in some cultures but not others. When I was studying painful neuropathy, using a 100-point pain scale, some subjects rated their pain at 80 while others claimed 20 for what appeared (to me) to be similar pain. After treatment, the 80s went to 70 and the 20s went to 17, a statistically identical percentage of reduction. Did one group feel more pain, or were they culturally sensitive when describing pain?

Anticipating pain will activate pain receptors and the appropriate autonomic responses. In contrast, anticipating pain relief will reduce pain signals, at least transiently. Nocebo responses (expecting something bad to happen) and placebo responses (expecting and getting benefit no matter what the treatment) may confound our research studies, but they can be turned into powerful clinical tools. The 45% placebo response in pain research tells us how much anticipation of relief affects our perception of pain.

The brain can create pain that isn’t there, such as phantom limb pain, and override significant pain when circumstances are appropriate, such as war injuries. Chronic pain–pain that persists in spite of no new tissue damage–represents a failure of the normal system that modulates pain.

Suffering is an individual’s emotional response to pain. It is not related to the intensity of the pain, but rather to fear, frustration and lack of understanding as to the meaning of the pain. If the etiology of the pain is well understood, one can rationalize severe pain as due to a specific injury, with an anticipated endpoint. Comprehension may not reduce pain, but it can moderate suffering for many people. The language we use to describe unpleasant situations often hints at a lack of control. We “suffer in silence,” “suffer the consequences” and “suffer the loss of a loved one.” These situations do not describe physiologic pain, but the emotional part of the pain–suffering–is the prominent feature that appears out of our control.

Both pain and suffering are difficult to measure. Pain fibers can be monitored in experimental animals. We assume pain is present when autonomic features appear in correspondence to the level of electrical impulses along pain pathways. We can measure endorphins and serotonin in spinal fluid. While both increase in response to acute pain, they both go down in chronic pain. As we gradually lose our ability to modulate pain, our suffering rises. Raising the level of endorphins and serotonin–through medications, spinal stimulators, exercise, cognitive therapy and diets–may improve pain control and relieve suffering. Therapies such as music, dance, painting and other pleasurable activities also reduce pain and suffering. Dopamine stimulation appears to be the physiologic pathway . . .

Read the entire article at Sonoma Medicine . . .

Dr. Bernstein, a Sebastopol neurologist, serves on the SCMA Editorial Board.

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

Voices of Medicine

Past Issue

The Dhar Diet, Or D-Diet

Sonoma Medicine
The magazine of the Sonoma County Medical Association


By Sanjay Dhar, MD

There are several hundred different types of diets out there, so I figured why not add one more to the list, the Dhar Diet, or D-Diet. How difficult can it be to come up with a diet? All I need to do is read a few books, adopt some basic ideas, tweak the concept and present it with a new “designer” name.

Diets range from A (Atkins) to Z (Zone), and there is no shortage of advice regarding the different diet plans. You may decide to choose one and stick with it or seamlessly switch from one diet to another. However, with all the diets out there and the endless advice offered, why then are Americans getting heavier at a faster pace than ever before? It seems that it’s a never-ending battle between the food industry pushing processed products that make us gain weight, and the diet industry, which has convinced us that we can never be satisfied with the way we are.

Is the truth somewhere in between? We do know that both these sectors are reaping billions of dollars in profits. Let us also not forget the consumer, who is the most important member in this complex relationship. Ultimately we have to be responsible for our actions, even though we know that we live in a free country where we can eat and drink whatever we want.

As a cardiologist, I have been giving dietary advice to my patients over the last 25 years. Diets come in various shapes and forms, with each having a tailored approach or a certain niche. My focus has been on preventing and hopefully reversing heart disease. I try to evaluate dietary habits rather than just giving a blanket order to “lose weight.”

Patients often have difficulty following guidelines because of poor food labeling. The label on a jar of peanuts may report 200 calories, for example, but you have to read the fine print to realize that the calorie amount mentioned is per serving, and that there are several servings per package. Unless patients take the time to read the label in detail, they often consume many more calories in a single sitting than they think. (A cup of peanuts actually contains 830 calories). The same concept is also true for salt and corn syrup content in processed foods. Unfortunately, we don’t have a fuel-gauge sensor in our body that tells us to stop eating when we have reached sustenance levels in calorie intake.

Why do people diet? Most do so to lose weight, to jumpstart the summer season, or to keep up with their new year’s resolution. Some are forced to lose a lot of weight because they have become morbidly obese and it’s affecting their health. Some diet to help their medical conditions, such as diabetes, hypertension, heart disease, arthritis of lower extremity joints, swelling of legs, reduced aerobic and functional capacity, exertional shortness of breath, easy fatigability, sleep apnea and abnormal cholesterol panels, to name a few. Some people have to change their diet because they have developed food intolerances, whether it’s gluten, dairy, nuts or other food ingredients. Then there are some disease states that demand special attention to food choices, such as chronic kidney disease, gout or other metabolic conditions.

For my patients, I recommend a drawn-up plan, any plan that has a chance of being successful. Ultimately losing weight is simple mathematics: calories in vs. calories out … or is it? We know that under extreme starvation, everyone will lose weight. However, since starvation is not practical or sustainable, weight loss should occur without extreme effort or significant time consumption. A good diet plan should be effortless and simple and yet not boring. . .

Providers and corporations have a financial incentive to treat obesity, and they market this concept everywhere. There are billboards (10 days and 10 pounds or your money back) and TV programs (The Biggest Loser), along with ads of all kinds for gyms, diet plans, weight-loss centers, fat farms and so on. Some of them do present compelling messages, but some sound too good to be true. How can you lose weight by eating more? When all else fails, there is always bariatric surgery. Although complications are rare, mortality is not 0%, and some patients do end up having lifelong morbidities.

In a nutshell, it is for us as physicians to decide what is appropriate, how far to promote weight-loss strategies, and what reasonable goals are. It also is up to patients to find a mandate of their own choice and not be driven by outward pressure to look a certain way.

What we do know is that if you consume fresh fruits and vegetables (Mediterranean diet) and reduce intake of highly processed foods, deep-fried foods, artificial sweeteners, foods high in corn syrup, sodas, and saturated fats, you will most likely reduce the probability of becoming obese and/or developing chronic disease conditions linked to heart disease, diabetes and cancer.

So what is the D-Diet? It is simply an ideal diet (heart healthy), made fresh every day from local ingredients. It’s not a liquid diet and it doesn’t come in small containers, cans or cardboard boxes. It’s effortless to follow, quick and easy to make, and is loaded with all kinds of flavors, colors and textures to take you on a pleasing gastronomic cruise. It doesn’t affect your bodily systems in any way, and there are new food choices every day. There are no worries about how much to eat and when to eat. It doesn’t cost a whole paycheck. And by the way, I am still working on it.

http://www.nbcms.org/AboutUs/SonomaCountyMedicalAssociation/Magazine/tabid/747/language/en-US/pageid/685/spring-2014-medical-controversies-feature-articles-commentarybrthe-d-diet.aspx +

Dr. Dhar is a Santa Rosa cardiologist.        Email: santarosadoc@aol.com

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

Voices of Medicine

Past Issue

A Call From The San Mateo County Medical Association.

We need your help to protect MICRA

Dear Physician Colleagues,

We need your help in protecting California’s Medical Injury Compensation Reform Act (MICRA). On November 4, 2014, voters will go to the ballot to vote on Prop 46. The importance of MICRA to physicians in the state of California is significant. We’re not asking you to assemble and march on Sacramento as more than 800 physicians, nurses, lab technicians and hospital personnel did in a grass root effort lead by the California Medical Association on May 13, 1975.

Trial lawyers have sponsored Prop 46. If Prop 46 passes, the current MICRA cap will quadruple from $250,000 to $1.2 million on non-economic damages in medical malpractice lawsuits. If Prop 46 passes, it will result in higher health care cost for everyone and threaten patient’s access to care with his or her providers. If Prop 46 passes, California will be flooded with new lawsuits and big payouts to trial lawyers.

The California Medical Association and county medical associations across the state have been working tirelessly to defeat this measure, but we still need your help. The next two weeks are crucial if we are to defeat Prop 46.

Please make a voluntary contribution ($25, $50, $100, $500) to help us preserve MICRA.

Please click here to donate by debit card or credit card (Visa, MasterCard, or Discover).

You can also mail your check to:SMCMA – Prop 46, 777 Mariners Island Blvd., #100, San Mateo, CA 94404

When November 4 arrives, we hope we will be able to celebrate the defeat of Prop 46 and return to the practice of medicine without increasing threats of malpractice “pain and suffering” awards to increase to $1.2 million blue sky in addition to all the medical injury without limit.

Read the entire report . . .

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

Voices of Medicine

Past Issue

A Review Of Medical Journal Articles: The Dilemma Of Speaking Up

Primum Non Tacere: An Ethics of Speaking Up

By Dwyer, James
Academic journal article
The Hastings Center Report , Vol. 24, No. 1 , January-February 1994


Article excerpt

During the last five years I have conducted ethics courses, seminars, and case conferences for medical students. I have also had many informal discussions with students at all stages of their medical training. Yet I am still surprised by how many students know and refer to the Hippocratic maxim to do no harm. Some even cite the Latin version: Primum non nocere. I wish, however, that more medical students would also keep in mind a Socratic maxim: Primum non tacere. First, do not be silent.

When I encourage students to articulate ethical issues that they face as students, they often describe situations where they must decide whether to speak up or keep quiet. The following are cases that students have described and that I have altered somewhat and then formulated from a student’s perspective.

1. Spos (acronym for “subhuman piece of shit”).[1] Before I entered medical school I read House of God, but I didn’t find it very amusing. I was troubled by the attitudes the characters displayed, and I told myself that I would try to be more respectful of patients. I assumed that speaking about patients in derogatory terms was a fad that would be over by the time I began my clerkships at the hospital. That was not the case. During my first rotation my resident presented me with a new admission: “Here’s your patient. He’s a forty-year-old Hispanic male, a shooter, a real spos.”

I wondered whether I should say anything. I didn’t like that language and the attitude it displayed, but it wasn’t my job to train the house staff. On the other hand, if I didn’t say anything, I’d seem to accept the judgments and attitudes I want to avoid.

2. Informed Consent.[2] I always thought that informed consent was integral to the doctor-patient relationship, that it was really one aspect of good communication with patients. Yet some people view it differently, as a bureaucratic hassle imposed by people outside medicine. This difference became painfully clear during my first week in the clerkship. My resident told me to “consent” one of his patients. This was my second day. I had never met the patient and had no idea what the risks of the proposed procedure were. So I politely asked my resident about the risks, but he told me with a slight sense of annoyance that the patient will sign anything. What were my choices? I could say something to the resident I could just get the signature. I could look up the procedure in a textbook. Or I could ask someone who might explain the procedure to me. In fact, I asked another resident who told me a bit about the procedure.

An hour later my resident saw me again and said that the team had decided to include a second procedure. He told me to simply write the second procedure onto the form and to use the same pen. I didn’t want to be party to this sham, but I also didn’t want to jeopardize my grade.

3. Practice Makes Perfect.[3] I understand that this hospital is a teaching hospital and that students, residents, and fellows are here to learn. The fact that we learn on patients means that some patients are subjected to additional pain, inconvenience, and physical examinations. I guess there’s a kind of bargain: we learn medicine on people who are mostly poor, and they get care they might not otherwise have access to. Whether or not this arrangement is fair, I’ve come to accept it. But I never imagined that people would practice a procedure that wasn’t medically indicated.

Late one night I was working with a resident in the labor and delivery room. The patient was in labor, and the resident decided to do a forceps delivery. I didn’t see the indication. The woman didn’t seem very fatigued, and there were no apparent complications. I didn’t know the exact statistics, but I was sure that a forceps delivery involved some risk to die fetus. I didn’t know what to do. If I asked what the indications were, the resident was sure to have some rationalization. If I told an attending physician the next day, I’d create a lot of trouble and no good would come of it.

Read the whole article . . .

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

Voices of Medicine

Past Issue

A Review Of Regional Medical Journals: Sonoma Medicine

The magazine of the Sonoma County Medical Association


Rob Nied, MD

Has the current morass in Washington DC inspired you to run for Congress? According to the New York Times, 26 physicians are running for Congress this year, and Kentucky senator Rand Paul, an ophthalmologist, is considered a likely presidential candidate. Compare that with a total of 25 physicians who served in Congress between 1960 and 2004.

Commoditizing physicians and patient care, declining reimbursement, the Affordable Care Act, and increasing bureaucratic regulation have made the business of medicine increasingly unpalatable, so it is understandable that we physicians want to stand up and fight for our profession. Our country’s founding fathers would be proud—more than 10% of the signers of the Declaration of Independence were physicians.

A few years ago, The Daily Beast published an entertaining article by Dr. Kent Sepkowitz about physician politicians (“Why physicians make crazy politicians,” May 26, 2010). He postulates that physicians are used to taking charge and have a sense of personal responsibility for the world around them. We also share a sometimes outsized belief in our own ability to “fix things.”

Having more physicians in Congress might seem like a good idea, but the ones who are already there don’t necessarily represent the views of physicians in general . . .

The reality is that physicians across the United States have the same disparate views and biases as any group of 600,000 people. Considering that most of a physician Congressperson’s time is spent advocating and deciding on policy matters far removed from their medical training, it may not be in our collective best interest to elect more of them.

Of course, physicians don’t need to hold political office to influence the most important public policy decisions, even at the national level. Politicians know that one thoughtful letter or call from a constituent represents the views of tens or even hundreds of peers who did not bother to publicize their opinions. Personal relationships between physicians and key legislators, forged over a decade of interaction, ultimately led to the “GPCI fix.” The adjustment in the Medicare Geographic Practice Cost Index—which only happened in California—will increase payments to physicians in 14 California counties by $50 million annually and over $400 million in the next decade. Sonoma County physicians will see a 4–9% increase in payments. For other national policy issues, such as repealing the Medicare SGR, personally lobbying our elected representatives is the single most powerful thing we can do.

Some political issues, however, require a more organized, collective effort, such as the current effort to defeat Proposition 46. Organizing a statewide public-relations campaign is too large of a project for one person, one county medical society, or even the largest medical group. The California Medical Association—the collective voice of almost 40,000 physicians—represents our common interests at the state level. The physicians and medical students standing on the California State Capitol steps in support of universal access formed the most lasting image of this year’s Legislative Leadership Conference, which is organized by CMA. To do that work requires people and money. It is important that each of us contribute our share.

Unfortunately, public opinion of organized medicine is not much higher than public opinion of Congress. Corporate medicine has often been guilty of protectionism and favoring special interests. Most people, however, still have a great deal of admiration for individual physicians. A 2011 poll found that 77% of the respondents trust physicians in general and 93% trust their personal physician, a number that is rare in today’s society.

Ultimately, the most effective advocacy for the issues we hold most dear is the clout and respect we have in our own community. We shouldn’t underestimate that. Sonoma County physicians, almost uniquely in California, are embedded in our community. We live and play here. Simply being present and active in our community influences public opinion, effects change and helps educate.

The real question is not whether you should run for Congress. Instead, it’s what are you passionate about? Over the coming year, SCMA will be launching an effort to better connect our members with organizations in Sonoma County that share our common interest in the health and vibrancy of our community. What inspires you? ::

Read the entire editorial in Sonoma Medicine . . .

Dr. Nied, a Santa Rosa family physician, is president of SCMA.
Email: robert.j.nied@kp.org

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

Voices of Medicine

Past Issue

A Review Of Regional Medical Journals And Articles: Colorado Med Society

Prescription drug abuse

Kate Alfano, Colorado Medical Society, contributing writer

State effort focuses on safe use, storage and disposal

Tuesday, July 01, 2014

Aaron started using prescription opioids when he was in high school. From an upper-middle-class family, his parents described him as a typical teenager; light-hearted and full of energy, he was athletic and loved to wrestle. He went to a so-called “pharming” party where students raid their home medicine cabinets, bring any prescription drugs they can find, mix them up in a bowl, pick one or two, and chase them with a beer.

“That’s considered fun, a reasonable thing to do and reasonably safe because the kids think, ‘they’re just prescription medications. How dangerous can pills be?’” said Rob Valuck, PhD, president of the Colorado Prescription Drug Abuse Task Force and coordinating center director of the Colorado Consortium for Prescription Drug Abuse Prevention.

Without major incident from that first experience, Aaron continued his nonmedical use: trying one or two of his parents’ Vicodin, then one or two more; getting more from friends; and gradually falling into a downward spiral. Tolerance led to increased use, then to dependence, and ultimately addiction.

As his addiction became stronger, Aaron started to scam doctors for opioid medications. In an interview with authorities, he estimated that he visited between 40 and 50 doctors over an 18-month period and went to about an equal number of pharmacies to stay beneath the radar. He said most doctors would give him at least an initial prescription for Vicodin. When he developed a tolerance he progressed to OxyContin.

Aaron eventually started using Oxy- Contin at very high doses, often mixed it with Xanax and alcohol, and overdosed at age 21. He had a difficult stay in the ICU: two myocardial infarctions, seizures, a staph infection and pneumonia, on top of extreme withdrawal symptoms. Doctors prepared Aaron’s parents for his death, which appeared imminent and very likely. Surprisingly, he regained consciousness and eventually recovered well enough to be discharged home. But the overdose left him paralyzed and unable to speak.

“The worst consequence is death,” his mother said in a video about this real patient case for the Medicine Abuse Project. “Other consequences are, like Aaron, trapped in your own body alive but unable to communicate in the way that you would hope that you could. You also lose all of your hopes and dreams and everything you wanted to accomplish in your life.”

The growing epidemic

Prescription drug abuse and misuse is serious problem in Colorado and around the United States. In 2010, more than 38,000 people died from a drug overdose in the United States – one every 14 minutes, Valuck said. Nearly 60 percent of those deaths involved prescription drugs and, of those, 75 percent were opioid painkillers. In Colorado, the number of drug overdose deaths range from 250-500 per year; in 2010 it was just over 300.

The rates of misuse and overdose death are highest among men, persons ages 20-64, non-Hispanic whites, and those in poor and rural areas. “That said, this cuts across all strata demographically – age group, gender, race, ethnicity, diagnoses; it’s a problem all over the place,” Valuck said.

And while the public typically hears statistics on overdose deaths, Aaron’s story demonstrates that death isn’t the only outcome. In 2011, for every opioid overdose death, there were 10 treatment admissions for abuse, 32 emergency department visits for misuse or abuse, 130 people who met the medical criteria for abuse or dependence, and 825 selfadmitted nonmedical users.

“What’s gotten our attention in Colorado is that we’re high in the ranking in self-reported nonmedical use of prescription pain relievers among anyone age 12 or older,” Valuck said. “It’s nonmedical use that puts people at very high risk for becoming addicted and having those problems. That’s led us to do something about it.”

Taking action

A small percentage of providers prescribe the majority of controlled substances. In Oregon, 8.1 percent prescribed 79 percent of these drugs, which Valuck said is typical, especially considering some specialties’ scope of work. “Many doctors prescribe few; some doctors don’t prescribe them ever. It’s really variable and we know that this isn’t an indictment on doctors or one type of doctor.”

However, providers who do prescribe these medications frequently inherently see more higher risk patients and are more likely to have patients who are doctor shopping for opioids. “It’s not necessarily your fault; it’s just the territory,” Valuck said. “You’re working with highly addictive stuff and people who become addicted. That’s where 63 percent of the overdose deaths come, among the 20 percent of prescribers who prescribe the most.”

One of the answers is to try to develop a coordinated response among the many stakeholders. “We could attack this problem at any place in the distribution chain, from manufacturers to the medical system to pharmacies to insurers and payers to patients and the public. Everyone needs education about this,” Valuck said.

As for physicians, he has six recommendations for what an individual can do to help mitigate the prescription drug abuse epidemic.

1. Take continuing education courses and seek out additional training.

2. Find and follow guidelines for safe opioid prescribing, whichever they are.

3. Be willing to prescribe less, whether that’s smaller quantities or other alternatives, and see patients more often.

4. Check the prescription drug monitoring program (PDMP) more often.

5. Educate patients on the importance of safe storage and disposal of unused medications.

6. Talk with colleagues, family, friends and neighbors about the issue and tell them stories about affected patients. .  .

Read the rest of the article . . . 

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

Voices of Medicine

Past Issue

A Review Regional Medical Journals: MARIN MEDICINE | Fall 2014

EDITORIAL: Medicine & Politics

Jeffrey Stevenson, MD

This issue of Marin Medicine focuses on medicine and politics, a theme with many facets. First and foremost is Proposition 46, which would raise the statutory cap on pain-and-suffering awards, thereby increasing malpractice insurance rates. The proposition could cause patients to lose their doctors and restrict access to care across the state. . .

Trial attorneys have generated Prop. 46 as a revenue source from physicians, and it stands to add malpractice costs at a time when physicians are struggling to make adjustments for reduced reimbursements and increased workloads. In the interest of financial survival, many physicians have allied themselves with large groups or medical foundations. The greater challenge is whether doctors can work together politically. We need to stand firm for access to quality care. Both the California Medical Association and the Marin Medical Society provide state and national leverage for physicians. . .

One place where physicians need more leverage is with health care insurance companies, who commonly don’t give doctors a seat at the boardroom table. Physician medical directors at these companies provide advice, but the companies aren’t obligated to follow it. A voting physician “on the board” could probably impact policy at a higher level. . .

Interested parties are developing a time-of-service treatment authorization portal to expedite this process and allow guidelines to be queried and applied to an individual situation in real time. Key to this revised process is the provider’s ability to upload or enter key information to designated algorithms, along with comments, reports and documentation. Part of the concept evolution is for nurses and on-call specialists to handle more detailed reviews in real time. This ability would allow them to focus on the subset of requests that are complex and warrant the extra review.

Meanwhile, fiber-optic infrastructure and emerging hardware promise to bring faster speed and better access. Emerging fiber-based products can download a fully loaded CD in 8 seconds vs. the 90 seconds required with current business broadband. Applying these fiber technologies within local networks as well as distant file transfers can not only speed things up, but also bring real-time streaming without sacrificing fidelity. Fiber-optic provides a more secure network. On the Internet, anything can be hacked, for a price.

I recently tried out a Google Glass real-time transcription product. It had many positive features but was limited in visual resolution in favor of optimizing audio for the transcriptionist. The limited resolution prevented me from getting a video “screen shot” of a page of information, such as a handwritten chart note with diagrams or a picture to the transcriptionist. These details are being sorted out by the developer.

The interconnectivity of different electronic health record systems, whether city-to-city or state-to-state, continues to evolve. Interconnection requires careful segregation of psychological and psychiatric reports, as well as particular infections, alcohol and drug conditions from the past. There are some records that are just too precious to transmit, despite HIPAA promises of security.

Finally, opioids and other pain medications are receiving considerable attention and are under careful review. Locally, we are bringing together community resources, both private and public, to better understand the situation and what we have to learn. Fortunately, some of the world leaders in pain management are available in our community. The risks of opioids have to be balanced with the important need for pain control and the unique situations that apply with particular patients. They need pain-control resources that will give them adequate support.

In closing, I would like to thank my colleagues for the opportunity to serve you this year as president of MMS.

Dr. Stevenson, a Novato general practitioner, is president of the Marin Medical Society.
Email: jeffreystevensonmd@gmail.com

MARIN MEDICINE | Fall 2014 | Marin Medical Society

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

Voices of Medicine

Past Issue

A Review Of Regional Medical Journals : SONOMA MEDICINE

EDITORIAL: Noble Brains, Healthy Lives

Mark Sloan, MD

Humans have long sought to make sense of the brain. Each age has puzzled over this oddly-shaped organ and its role in the complex workings of the body. In times long past, heated debates erupted among scientists and philosophers: Is the brain a cold or a hot organ? Wet or dry? Does the mind exist separate from the brain? Is it the seat of common sense, of memory? Of the soul itself?

Alcmaeon of Croton, a medical writer in the 6th century BCE, was the first to champion the brain as the center of perception, understanding and cognition. He taught that the senses were connected to the brain by “channels,” a theory that originated with his discovery of the optic nerve. Alcmaeon also appreciated the fragility of the brain; if disturbed, he wrote, the “channels” become obstructed and the sensory connections are lost. The brain was something to be handled with care.

Alcmaeon lectured widely on science and philosophy. One of his observations—that “from noble fathers noble children are born,” and that the same was unfortunately true of “baser” parents—resonates today as we consider recent discoveries in brain research. Alcmaeon had unknowingly touched on a fundamental truth of neurodevelopment: early childhood experiences, whether “noble” or “base,” shape not only character but the anatomy and physiology of the brain itself, with lifelong health impacts.

A young child’s brain is a wondrous thing. By age five it contains about one quadrillion neural connections, more than all the links in the entire Internet. But by adulthood one-third of those connections disappear. The pathways used most frequently in childhood are strengthened and streamlined, while those less trafficked simply wither away.

Stress, both physical and emotional, is an inevitable part of life. When buffered by caring and supportive adult relationships, early life stress can be a positive experience, leading to healthy adaptive responses later in life. When stress is chronic and unaddressed, however, it becomes toxic, triggering a cascade of biochemical events that enhance unhealthy neural pathways.

The areas of the brain most affected by toxic stress are the amygdala, the hippocampus and the prefrontal cortex. The amygdala, rich in stress hormone receptors, becomes hypertrophic, while the hippocampus and prefrontal cortex—essential to dampening the body’s stress reactions—lose neurons and neural connections. An overheated, unchecked amygdala can lead to persistent anxiety, impaired memory, learning difficulties and poor executive functioning. Children exposed to toxic stress may overreact to perceived threats, much like combat veterans with post-traumatic stress disorder.

Structural changes in the brain impact other organs as well, through dysregulation of the hypothalamic-pituitary-adrenocortical axis. The overstimulated amygdala spurs the adrenal cortex to secrete excessive cortisol, norepinephrine and adrenaline. An accompanying increase in inflammatory cytokines accelerates wear and tear in the heart, lungs, immune system, and elsewhere throughout the body. Toxic stress in childhood can thus result in lifelong, multi-system disease.

Once a developing brain is altered by toxic stress, setting things right becomes difficult. In their landmark 1998 Adverse Childhood Experiences study, Drs. Vincent Felitti and Robert Anda demonstrated the impact of toxic childhood stress on adult health. They found that adults exposed to multiple stresses in early childhood—such as abuse or neglect, loss of a parent, or maternal depression—were at high risk of cardiovascular disease, depression, substance abuse, and other chronic illnesses, even if the stress resolved before adulthood.

If we are to lessen the burden of chronic illness, we must strengthen the neural pathways that enable children to handle stressful events. This is best accomplished by providing support to families, the people from whom a child will learn (or not) about how to cope with life’s stresses.

As physicians, we have a choice to make. We can accept ever-increasing rates of chronic physical and mental illness as inevitable, or we can attack these problems at their early-life roots. To borrow a phrase from Frederick Douglass, “It is easier to build strong children than to repair broken men.”. . .

You can act on a personal level, too. Talk to your children. Read to your grandchildren. Teach the young people around you how to positively handle life’s stresses. Today’s children—tomorrow’s adults—will be glad that you did. ::

Dr. Sloan is a Santa Rosa pediatrician.

Email: markpsloan@gmail.com

SONOMA MEDICINE |  Winter 2015  |  Sonoma County Medical Association


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

Voices of Medicine

Past Issue

A Review Of Local And Regional Medical Journals: Sonoma Medicine

EDITORIAL: Touching the Patient by Rob Nied, MD

At the 2014 Australian Open, Stan Wawrinka became the first man since 2009 to win a Grand Slam tennis tournament outside the Big Four of Federer, Djokovic, Murray and Nadal. In the championship match, he beat Nadal, who was suffering from a back injury. How much low back pain factored into the loss, only Rafa knows for sure. Certainly the 90% of us who have experienced this type of pain can imagine how limiting it might have been. In fact, low back pain is the number one cause of disability in the United States, with an estimated $100 billion annual cost for lost work and wages. For Nadal, the difference between the winner and first runner-up prize money was $1.3 million.

Does sports participation cause low back injuries? A recent study reviewing injury data from professional tennis players competing in the US Open from 1994 to 2009 did not find a significant increase in low back injuries, despite increases during those years in game intensity, higher rotational velocity serves, and longer playing seasons.1 In fact, NCAA injury surveillance has found that only 2% of all sports-related injuries in college athletes are to the low back. Some of these are traumatic injuries, such as contusions and spondylolysis, but most often athletes suffer from the same common mechanical low back pain as the rest of us.

Degenerative disc disease may be quite common in athletes. In a study of asymptomatic late adolescent elite tennis players, none of whom had a history of low back pain, 28 of 33 athletes had significant findings on MRI, including pars interarticularis lesions, facet arthropathy and bulging discs.2 Does this mean that sports are particularly hard on the spine or that a “bad back” on imaging does not necessarily correlate with symptoms or athletic limitation? Knowing how common abnormal MRI findings are in the general public, my interpretation is that athletes have the same backs as the rest of us but are better able to control their core forces and motion.

Athletes like a hands-on approach to low back pain. They are very aware of their bodies, and manual therapies tend to work well for them. Deep tissue work and massage have become a standard part of most training regimens. Beyond just “feeling good,” animal research suggests that manual therapy may actually help injured tissues recover faster. In a 2013 Consumer Reports survey, of the 14,000 subscribers who had experienced low back pain in the past year but did not have back surgery, 59% were highly satisfied by the care from their chiropractor, 55% with their physical therapist, and 53% with their acupuncturist.3 Only 34% of respondents were highly satisfied with the treatment offered by their primary care physician. Clearly our patients also appreciate the hands-on healing power of touch—it is better than prescribing a pill. . .

Dr. Nied, a family and sports medicine physician at Kaiser Permanente Santa Rosa, is the immediate past president of SCMA.

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

Voices of Medicine

Past Issue

Homosexuality: Some Neglected Considerations

Nathaniel S. Lehrman, MD


In recent decades, American perceptions of homosexuality have changed significantly, largely because of the questionable concept of the homosexual “orientation”: a genetic or biological, rather than a behavioral, etiology. These newer beliefs greatly influence how its morbidity, mortality, and social impact are seen, often causing us to overlook how the “gay” male lifestyle significantly increases the incidence of infectious disease and shortens life expectancy by about 20 years.


Homosexuality in Ancient Times

Homosexual behavior has always existed, and was accepted throughout the ancient world; Greek kings and Roman emperors all engaged in it. These men were also involved with women, and decisions about sexual partners were seen as entirely a matter of individual choice and responsibility.

Historically, homosexual behavior has been viewed as both criminal and sinful ever since Judaism first defined it as an “abomination” along with incest, adultery, and bestiality and Christianity continued this stance. Judaism and Christianity’s new prohibitions represented an immense moral and legal change that greatly strengthened family life.

Homosexuality in 19th and 20th Century Germany

In 1869, German same-sex devotees created the term “homosexual” seemingly more neutral and “scientific” than pejorative terms like “sodomite.” They claimed they were born with women’s souls inside men’s bodies (“Fems”), which supposedly made them unable either to respond sexually to women or to control their urges toward other men. As Foucault put it, “the sodomite had been a temporary aberration; the homosexual was a species.”

That same year, the first psychiatric study of homosexuality appeared. It advocated the replacement of criminal penalties for homosexual behavior with medical treatment, thus acknowledging that such behavior was undesirable, but indicating that same-sex choices were not completely under an individual’s control. This transformed lawless behavior, for which people are fully responsible, into illness-evoked activity, with reduced or absent responsibility.

Other Germans involved in same-sex relationships rejected the apology implied by this inborn-causation idea. To their Spartan ideology, same-sex relationships, especially between men and boys, were morally superior to heterosexual behavior and traditional marriage. Ironically, these super-masculine men held the homosexual “Fems” in deepest contempt and persecuted them fiercely.

Homosexuality grew rapidly in Germany over the following decades. In 1891, Richard Krafft-Ebbing’s Psychologia Sexualis declared that “sex perversion” in Germany was alarmingly on the increase”. In 1922, a Berlin police commissioner wrote that “homosexualist groups have been steadily on the increase in recent decades, especially in the big cities. . . They are closely banded together and even have their own [news] paper.” In 1933 when Hitler took power, Ernst Roehm, leader of his 300,000-man terrorist storm troopers—the Sturmabteilung, or SA—was a notorious pederast, and his corps commanders were “almost without exception homosexuals.”

Redefining Homosexuality in America Today

In the United States, homosexuality was considered an illness or perversion until 1973, when the American Psychiatric Association decided to remove homosexuality from its list of “mental disorders”. without “morally judging” it as sin or crime. Thus, homosexuality could be seen as an acceptable alternate lifestyle. The definitional change helped to make homosexuality, once a felony, respectable.

“The APA vote to normalize homosexuality was driven by politics, not science. Even sympathizers acknowledge this.” The process began in 1970 with a “systematic effort” by a homosexual faction within the APA “to disrupt its annual meetings.” After several years of intimidation, the efforts finally succeeded. In 1973, when the faction met formally with the APA Committee on Nomenclature to discuss removing homosexuality from the list, “the outcome had already been arranged behind closed doors.”

When the APA membership was then polled on the question, the faction sent a letter to more than 30,000 members—secretly paid for by the National Gay Task Force—urging them to “retain the nomenclature change.” A third of the membership responded to the poll and a majority of them supported the change. “The result was not a conclusion based upon an approximation of the scientific truth as dictated by reason, but was instead an action demanded by the ideological temper of the times.”

If a vote by this professional organization is all that is needed to normalize homosexuality, could the same faction-driven process occur with other behavior now considered aberrant, such as pederasty, once a critical mass of politically active practitioners has been reached?

Changing American Attitudes

A change in the attitude of the medical profession accompanied the change in definition, as seen in the American Medical Association’s Complete Medical Encyclopedia and in its “official statement” on homosexuality. The former says that even though “some religious groups condemn homosexuality as morally perverse,” it is, rather, “a normal sexual orientation, not a disorder or a sign of a disorder.” The latter endorses “the physician’s nonjudgmental recognition of sexual orientation and behavior.”

The attitude of the public has been greatly affected by the major media, in which the homosexual movement has great influence. In April 2000, for example, Richard Berke of The New York Times, then its national political, correspondent told the National Lesbian and Gay Journalists Association, “literally three-quarters of the people deciding what’s on the front page are not-so-closeted homosexuals . . ..a real cry from what it was like not so long ago.” . . .

Read the entire article including these sections by Dr. Lehrman at http://www.jpands.org/jpands1003.htm

Destiny or a Choice?

Sexual Orientation

Who is Currently a Homosexual?

Changes in Sexual Orientation over Time.

Is Homosexuality Inborn?

Morbidity, Mortality, and Morality: The Social Impact of Homosexuality

The AMA’s Position


American concepts and attitudes about homosexuality have changed significantly in recent decades. Most of society and the medical profession now view it as an acceptable alternate lifestyle: a biologically determined, permanent orientation, rather than a learned, experiential, and often changeable choice. The concept of homosexuality as a permanent orientation is, however, without scientific validation; the notion is entirely politically grounded.

One effect of this new view has been to understate the medical and societal harm produced by the promiscuous sexual practices typically associated with homosexuality.

—Bibliography with 37 references

Nathaniel S. Lehrman, M.D., a retired psychiatrist, is former Clinical Director, Kingsboro Psychiatric Center, Brooklyn, NY

Journal of American Physicians and Surgeons Volume 10 Number 3 Fall 2005

Lawrence R. Huntoon, M.D., Ph.D., Editor-in-Chief

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VOM Present Views of What Doctors are Thinking, Saying and Writing about

Voices of Medicine

Past Issue

Sham Peer Review—Infusing Staph In A Patient To Get Rid Of The Dr

Sham Peer Review: the Shocking Story of Raymond A. Long, M.D.

Lawrence R. Huntoon, M.D., Ph.D.

 It was a story that rocked the little town of St. Albans, Vermont: “Surgeon Accuses St. Albans Hospital of Deliberately Infecting His Patients.”1

According to the statewide news website, VTDigger.org, “An orthopedic surgeon is suing Northwestern Medical Center in St. Albans for allegedly infecting his patients with bacteria in an effort to ‘destroy his career and falsely blame him for the infections,’ court records show…. Long says he told hospital doctors in 2002 that he was considering adding an MRI machine to his office. At the time, he alleges, Northwestern was involved in ‘an illegal kickback scheme with respect to X-ray facilities’ and the hospital was planning to have a new MRI machine built for its facilities.”1

The “Factual Background” contained in a lawsuit, for which an Amended Complaint was filed on Sep 28, 2006, also contained hundreds of numbered paragraphs describing the nightmare of events that Dr. Long claimed he experienced at the hands of the hospital and other physicians on staff.2 

Northwestern Medical Center Enters into Settlement Agreement with Government

On Aug 16, 2007, the U.S. Attorney’s Office issued a press release stating: “The United States Attorney’s Office announced today that it has entered into a settlement with Northwestern Medical Center, the hospital in St. Albans, resolving the hospital’s potential liability for violating the federal anti-kickback and related laws.”3 Although the hospital faced a potential liability of having to pay triple the amount collected from federal health programs, the government agreed to settle for a mere $30,000.3 . . .

In 2011, Dr. Long hired a former Centers for Disease Control and Prevention infection investigator, William R. Jarvis, M.D . . . .On Aug 5, 2011, Dr. Jarvis issued his report11concerning the unusual surgical site infections affecting Dr. Long’s patients. Dr. Jarvis reviewed four of Dr. Long’s cases.

In one case, Dr. Jarvis reported: “A nearly pan-sensitive (especially to penicillin) S. aureus strain like [patient’s] is exceedingly unusual. This is even more true of S. aureus strains causing HAIs [healthcare-associated infections] rather than community acquired infections.”11, p 5 . . .

The Jarvis Report also addressed cultures taken from an irrigation solution that was about to be used in a patient surgery on Feb 6, 2004:

Cultures obtained from previously unopened bottle of irrigation fluid (that was about to be hung in the NMC operating room for use in Dr. Long’s surgical patient) by Dr. Long on February 6, 2004 grew 800 colony forming units/ml of S. aureus (two morphologies). Given that this was a bottle of irrigation fluid provided by NMC operating room personnel for use by Dr. Long in that surgical procedure, it is highly suspicious. Intrinsic contamination (i.e., that occurring at the time of manufacture) of such manufactured fluids is < 1 in a million—an exceedingly rare and unlikely event. Since no other clusters of infections or outbreaks associated with this manufacturer’s irrigation fluid were reported at around this time and no FDA recall of these fluids occurred around this time, the likelihood of intrinsic contamination is very, very unlikely. In contrast, given that two different morphologies of S. aureus and 800 CFU/ml were recovered, I believe that the likelihood of extrinsic contamination (i.e., contamination after manufacture and most likely at NMC) is much more likely.11, p 10

Dr. Jarvis also commented on the hospital peer review related to these highly unusual infections:

Given the circumstances occurring at NMC at around December 2003—February 2004 (i.e., the cluster of very unusual SSIs—both in terms of SSIs occurring in very low-risk arthroscopic joint procedures and the types of organisms involved in Dr. Long’s patients), the likelihood that these SSIs were caused by: a) the patient’s flora; b) contaminated surgical equipment, c) Dr. Long’s surgical technique, d) breaks in sterile technique by other operative room personnel, or e) contamination of Marcaine placed in pain pumps, as hypothesized by Dr. Corsetti in his peer review of these cases is exceedingly unlikely.11, p 12

A much more likely explanation of how the operating room irrigation fluid became contaminated and how the 3-4 SSIs above occurred is that the patients were intentionally infected through extrinsically and intentionally contaminated irrigation fluid (or other fluids, medications, equipment or materials) provided by NMC personnel and used by Dr. Long in the surgical procedures of these patients.11, p 13

The Jarvis Report goes on to state:

Personnel from NMC have acknowledged that personnel at NMC had purchased ATCC [an organization that provides standard reference micro-organisms to labs] strains of S. aureus, coagulase-negative staphylococci (CNS) and Pseudomonas aeruginosa isolates for quality control purposes for the NMC laboratory. In addition, they testified that they also obtained S. marcescens isolates that were used in the microbiology laboratory for quality control purposes. Therefore, all the bacterial species that caused SSIs [surgical site infections] in Dr. Long’s patients were available in the NMC microbiology laboratory. The S. aureus strain (ATCC #25923) was purchased in November 2003 [see Ref #8], days to weeks before [patients’] surgery. Furthermore, the ATCC #25923 S. aureus strain has an antimicrobial susceptibility to all agents commonly tested, including ampicillin, penicillin, cefazolin, clindamycin, erythromycin, cefoxitin (methicillin), tetracycline, and sulfamethoxazole similar to the susceptibility of the S. aureus isolated from [patient’s] SSI…. In addition, the quality control P. aeruginosa isolate was purchased in August 2003, before [patient’s] surgery on December 23, 2003. Interestingly, the antibiotic susceptibility pattern of the ATCC strain #27853 (P. aeruginosa), which was purchased by NMC, supposedly for laboratory quality control purposes, had the same antibiotic susceptibility pattern (of the agents to which both isolates were tested) as that of the P. aeruginosa strain recovered from the SSI of [the patient].11 pp. 9-10

The Jarvis Report also addressed cultures taken from an irrigation solution that was about to be used in a patient surgery on Feb 6, 2004:

Cultures obtained from previously unopened bottle of irrigation fluid (that was about to be hung in the NMC operating room for use in Dr. Long’s surgical patient) by Dr. Long on February 6, 2004 grew 800 colony forming units/ml of S. aureus (two morphologies). Given that this was a bottle of irrigation fluid provided by NMC operating room personnel for use by Dr. Long in that surgical procedure, it is highly suspicious.

Dr. Jarvis concluded that patients were intentionally infected through the use of deliberately contaminated irrigation solutions:

2005 Lawsuit Settles for $4 Million, Hospital CEO Moves on to Another Hospital

The lawsuit filed by Dr. Long in 2005 eventually settled in 2008 for $4 million, and shortly thereafter NMC CEO Peter A. Hofstetter moved on to a new job as CEO of Holy Cross Hospital in Taos, New Mexico,9 and, according to Dr. Long, subsequently to Willamette Valley Medical Center in McMinnville, Oregon. . .


In the words of the 2006 Amended Complaint,2,  p 92 Defendants engaged in “extreme and outrageous conduct, which was beyond all possible bounds of decency, and which may be regarded as atrocious and utterly intolerable in a civilized society.”

Lawrence R. Huntoon, M.D., Ph.D., is a practicing neurologist and editor-in-chief of the Journal of American Physicians and Surgeons. Contact: editor@jpands.org. To access the entire article including the 17 supporting bibliographic documents, and to see the entire sordid story of the hospital hiring 19 private investigators, with one following Dr. Long day and night, breaking into his home, a brick through his car window, stealing a laptop from his car, deactivating his remote car door opener, finding his door panel on his car had been removed, that his tires have been slashed with the same instrument that the Muslims used to slash the throats of the American Airline Pilots on Sept 11, 2011, spiking his drinks with mercury and amphetamines, harassing him and his wife when they were driving or walking, requesting him to be seen by a psychiatrist who was a Peer Review Specialist for hospitals, etc., et.al.

Read the entire document . . .

Why is the threat of a surgeon setting up his own Surgicenter so threatening to a hospital’s finances that they will infect, harm and possibly kill his and their patients with serious staph organisms that were purchased, spend such astronomical sums of money to discredit him?  Is the cash flow from CMS so lucrative that administrators are willing to take the risk of killing patients to get rid of a doctor that may compete?

How prevalent is Hospital Homicide or Medical Murder?

Is there any data out there?

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VOM Is an Insider’s View of What Doctors are Experiencing in Managed Healthcare.

Voices of Medicine

Past Issue


A Neurologist’s Notebook: THE CATASTROPHE

Spalding Gray’s brain injury

By Oliver Sacks, MD

THE NEW YORKER | April 27, 2015

In July of 2003, my neurological colleague Orrin Devinsky and I were consulted by Spalding Gray, the actor and writer who was famous for his brilliant autobiographical monologues, an art form he had virtually invented. He and his wife, Kathie Russo, had contacted us in regard to a complex situation that had developed after Spalding suffered a head injury, two summers earlier.

In June of 2001, they had been vacationing in Ireland to celebrate Spalding’s sixtieth birthday. One night, while they were driving on a country road, their car was hit head on by a veterinarian’s van. Kathie was at the wheel; Spalding was in the back seat, with another passenger. He was not wearing a seat belt, and his head crashed against the back of Kathie’s head. Both were knocked unconscious. (Kathie suffered some burns and bruises but no permanent harm.) When Spalding recovered consciousness, he was lying on the ground beside their wrecked car, in great pain from a broken right hip. He was taken to the local rural hospital and then, several days later, to a larger hospital, where his hip was pinned.

His face was bruised and swollen, but the doctors focused on his hip fracture. It was not until another week went by and the swelling subsided that Kathie noticed a “dent” just above Spalding’s right eye. At this point, X-rays showed a compound fracture of the eye socket and the skull, and surgery was recommended.

Spalding and Kathie returned to New York for the surgery, and MRIs showed bone fragments pressed against his right frontal lobe, though his surgeons did not see any gross damage to this area. They removed the fragments, replaced part of his skull with titanium plates, and inserted a shunt to drain away excess fluid.

He was still in some pain from his hip fracture, and could no longer walk normally, even with a braced foot (his sciatic nerve had been injured in the accident). Yet, strangely enough, during these terrible months of surgery, immobility, and pain, Spalding seemed in surprisingly good spirits—indeed, his wife thought he was “incredibly well” and upbeat.

Over Labor Day weekend of 2001, five weeks after his brain surgery, and still on crutches, Spalding gave two performances to huge audiences in Seattle. He was in excellent form.

Then, a week later, there was a sudden, profound change in his mental state, and Spalding fell into a deep, even psychotic, depression.

Now, two years after the accident, on his first visit to us, Spalding entered the consulting room slowly, carefully lifting his braced right foot. Once he was seated, I was struck by his lack of spontaneous movement or speech, his immobility and lack of facial expression. He did not initiate any conversation, and responded to my questions with very brief, often single-word, answers. My first thought, and Orrin’s, was that this was not simply depression, or even a reaction to the stress and the surgeries of the past two years—to my eye, it clearly looked as if Spalding had neurological problems as well.

When I encouraged him to tell me his story in his own way, he began—rather strangely, I thought—by telling me how, a few months before the accident, he had had a sudden “compulsion” to sell his house in Sag Harbor, which he loved and in which he and his family had lived for five years. He and Kathie agreed that the family needed more room, so they bought a house nearby, with more bedrooms and a bigger yard. Nonetheless, Spalding had resisted selling the old house, and they were still living in it when they left for Ireland.

It was while he was in the hospital in Ireland following his hip surgery, he told me, that he finalized a deal to sell the old house. He later came to feel that he was “not himself” at the time, that “witches, ghosts, and voodoo” had “commanded” him to do it.

Even so, despite the accident and the surgeries, Spalding remained in high spirits during the summer of 2001. He felt full of new ideas for his work—the accident, even the surgeries, would be wonderful material—and he could present them in a new performance piece, entitled “Life Interrupted.”

I was struck, and perhaps disquieted a little, by the readiness with which Spalding was prepared to turn the horrifying events of the summer to creative use. Yet I could also understand it, because I had not hesitated, in the past, to use some of my own crises as material in my books.

Indeed, using one’s own life (and sometimes others’ lives) as material is common among artists—and Spalding was a very special sort of artist. . . He wondered sometimes if he did not create crises just for material—an ambiguity that worried him. Had he sold his house as “material”?

One of the special features of Spalding’s monologues was that, onstage at least, he rarely repeated himself; the stories always came out in slightly different ways, with different emphases. He was a gifted inventor of the truth, of whatever seemed true to him at the moment. . .

Ever since, Kathie told me, Spalding had been sunk in depressive, obsessive, angry, guilty rumination about selling the house. Nothing could distract him from it. Scenes and conversations about the house replayed incessantly in his mind. All other matters seemed to him peripheral and insignificant. Previously a voracious reader and a prolific writer, he now felt unable to read or write.

Spalding had had occasional depressions, he said, for more than twenty years, and some of his physicians thought that he had a bipolar disorder. But these depressions, though severe, had yielded to talk therapy, or, sometimes, to treatment with lithium. His current state, he felt, was different. It had unprecedented depth and tenacity. He had to make a supreme effort of will to do things like ride his bicycle, which he had previously done spontaneously and with pleasure. He tried to converse with others, especially his children, but found it difficult. His ten-year-old son and his sixteen-year-old stepdaughter were distressed, feeling that their father had been “transformed” and was “no longer himself.”. . .

In September of 2002, Spalding jumped off his sailboat into the harbor, planning to drown himself (he lost his nerve and clung to the boat). A few days later, he was found pacing on the Sag Harbor bridge, eying the water, until the police intervened and Kathie took him home.

Soon after this, Spalding was admitted to the Payne Whitney Psychiatric Clinic, on the Upper East Side. He spent four months there, and was given more than twenty shock treatments and drugs of all kinds. He responded to none of them, and, indeed, seemed to be getting worse by the day. When he emerged from Payne Whitney, his friends felt that something terrible and perhaps irreversible had happened. Kathie thought that he was “a broken man.”. . .

In July, when Spalding first came to see Orrin and me, I asked him if there were any other themes besides the sale of his house that he ruminated about. He said yes: he often thought about his mother and the first twenty-six years of his life. It was when he was twenty-six that his mother, who had been intermittently psychotic since he was ten, fell into a self-torturing, remorseful state, focused on the selling of her family house. Unable to endure her torment, she had committed suicide.

In an uncanny way, he said, he felt that he was recapitulating what had happened with his mother. He felt the attraction of suicide and thought of it constantly. He said he regretted not having committed suicide at the U.C.L.A. hospital. Why there? I inquired. Because one day, he replied, someone had left a large plastic bag in his room—and it would have been “easy.” But he was pulled back by the thought of his wife and his children. Nevertheless, he said, the idea of suicide rose “like a black sun” every day. He said the past two years had been “gruesome,” and added, “I haven’t smiled since that day.” . . .

There was a brief, dramatic break in Spalding’s rumination just a week before he came to see us, when he had to have surgery because one of the titanium plates in his skull had shifted. The operation took four hours, under general anesthesia. Coming to from the anesthesia and for about twelve hours afterward, Spalding was his old self, talkative and full of ideas. His rumination and hopelessness had vanished—or, rather, he now saw how he could use the events of the past two years creatively in one of his monologues. But by the next day this brief excitement or release had passed. . .

But the frontal lobes also exert an inhibiting or constraining influence on what Pavlov called “the blind force of the subcortex”—the urges and passions that might overwhelm us if left unchecked. (Apes and monkeys, like children, though clearly intelligent and capable of forethought and planning, are relatively lacking in frontal lobes, and tend to do the first thing that occurs to them, rather than pausing to reflect. Such impulsivity can be striking in patients with frontal-lobe damage.) There is normally a beautiful balance, a delicate mutuality, between the frontal lobes and the subcortical parts of the brain that mediate perception and feeling, and this allows a consciousness that is free-ranging, playful, and creative. The loss of this balance through frontal-lobe damage can “release” impulsive behaviors, obsessive ideas, and overwhelming feelings and compulsions. Were Spalding’s symptoms a result of frontal-lobe damage or severe depression, or a malignant coupling of the two?

Frontal-lobe damage can lead to difficulties with attention and problem-solving, and impoverishment of creativity and intellectual activity. Although Spalding felt that he had not had any intellectual deterioration since the accident, Kathie wondered whether his unceasing rumination might not, in part, be a “cover” or “disguise” for an intellectual loss that he did not want to admit. Whatever the case, Spalding felt that he could no longer achieve the high creative level, the playfulness and mastery, of his pre-accident performances—and others felt this, too. . .

January 10, 2004, Spalding took his children to a movie. It was Tim Burton’s “Big Fish,” in which a dying father passes his fantastical stories on to his son before returning to the river, where he dies—and perhaps is reincarnated as his true self, a fish, making one of his tall tales come true.

That evening, Spalding left home, saying he was going to meet a friend. He did not leave a suicide note, as he had so often before. When inquiries were made, one man said he had seen him board the Staten Island Ferry.

Two months later, Spalding’s body was washed up by the East River. He had always wanted his suicide to be high drama, but in the end he said nothing to anyone; he simply disappeared from sight and silently returned to the sea, his mother.

Read Dr. Oliver Sacks’ entire medical narrative of Spalding Gray’s frontal lobe injury in The New Yorker, April 27, 2015. . .

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

Voices of Medicine

Past Issue

Reducing Opioids

Sonoma Medicine | The magazine of the Sonoma County Medical Association | July 2016

EDITORIAL: Reducing Opioid Prescriptions

Mary Maddux-González, MD

Seventy-eight Americans die every day from an opioid overdose, and more than half of these overdoses involve an opioid prescribed by a physician. Since 1999, both opioid prescriptions and opioid overdose deaths have quadrupled. Meanwhile, evidence is mounting that opioid pain medications are less efficacious than initially thought for chronic pain management. Indeed, we now know that opioids can worsen pain at higher doses and are associated with an increasing number of serious adverse health effects.

How are we doing in Sonoma County in terms of physician prescriptions for opioids? Unfortunately, our local rates of opioid prescriptions, of residents on high daily doses, and of opioid/benzodiazepine prescriptions exceed statewide rates. On the positive side, many local efforts are underway to reduce what has become an unsafe community standard of practice for opioid prescribing. The articles in this edition of Sonoma Medicine highlight some of these efforts . . .

Dr. Gary Pace, chief medical officer of Alexander Valley Healthcare, discusses medication-assisted treatment for opioid addiction, including current research on addiction and brain chemistry. He challenges our biases as a medical community regarding addiction and recovery, particularly when that addiction is iatrogenic.  TO BE FEATURED IN THE AUGUST ISSUE OF MEDICAL TUESDAY.

As we move together as a medical community to reverse the overprescribing of opioid medications, we need to ensure that we don’t restrict access to appropriate use of these medications. . .

The Sonoma County Medical Association has joined forces with other local health care leaders to address the opioid epidemic. SCMA is a member of the Opioid Prescribing Work Group . . . A consistent community standard of practice across primary care and emergency departments, supported by evidence-based prescribing guidelines, will increase patient safety while reducing “doctor shopping,” “ER shopping” and other drug-seeking behaviors.

Unfortunately, physicians have played a central role in what is largely an iatrogenic epidemic of opioid addiction and overdose deaths. This fact weighs heavily on physicians who have prescribed these medications in a genuine effort to do right by providing their patients with relief from pain. In recent years, physician decisions to increase their prescribing of opioids were heavily influenced by the active promotion of opioids, not only by pharmaceutical companies, but also by state medical boards, national health care agencies and professional medical associations. These well-intentioned but poorly informed policies and practices have led to the dramatic increase in the availability of prescription opioids in Sonoma County and elsewhere, with the accompanying negative consequences of addiction, diversion and overdose deaths.

To protect the health and safety of patients, physicians need to play a central role in reversing ill-informed and unsafe opioid policies and prescribing practices. SCMA is pleased to offer this special issue of Sonoma Medicine on the opioid epidemic, and we will continue to work collectively with the medical community in Sonoma County to address this important issue. :: 

Dr. Maddux-González, chief medical officer for the Redwood Community Healthcare Coalition,
is the immediate past president of SCMA.

Email: mmgonzalez@rchc.net

SONOMA MEDICINE | Summer 2016 | Sonoma County Medical Association

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

Voices of Medicine

Past Issue

A Review Of Local Medical Society Journals: Sonoma Medicine

Defining Emergency Medicine
Allan Bernstein, MD

Who gets to define emergency medicine? Is it the doctors, the EMTs, the insurance companies or the 911 operators? As evident from the articles in this issue of Sonoma Medicine, there are lots of competing interests.

No one can argue about the need and benefit of a trauma center, and we’re all glad to know there’s one nearby, fully staffed with qualified people. Cardiac and stroke centers, likewise, fill an important niche in our medical safety net. The local EMS team, including helicopter service, gets patients to emergency care quickly. For a true emergency, we in Sonoma County are fortunate to live where we do. But often patients who show up in emergency departments (ED) have medical needs or perceived medical needs that could be managed differently, and better, elsewhere.

Working people often have to make a choice between earning a day’s pay or going to the doctor during office hours. The frequent alternative is to present in an ED after they get home from work, have dinner and arrange for child care. After a long wait in the ED, they see a physician who doesn’t know them. The physician can treat the immediate problem but has to count on the primary care physician (PCP) to arrange for follow-up. In an ED, chronic problems like diabetes, hypertension, epilepsy or asthma can be treated but not managed. . .

Certain conditions build slowly, only to be deemed an emergency when ignored long enough by patients or their caregivers. Respiratory infections, bladder infections and bedsores are conditions that should be handled during office hours but often aren’t. Strains, sprains and chronic pain likewise need care, but rarely on an emergency basis. Do these patients have a PCP? Can they get an appointment with the PCP in a timely manner?

Lack of access to specialty care also drives people to EDs. The best example is mental health. With few providers for outpatient services and even less access to inpatient care, mental health patients needing urgent care often rely on EDs to deal with their current crisis. Sonoma County’s newly opened mental health facility in Santa Rosa is certainly a step in the right direction.

The EDs themselves have another type of crisis. Where can they put patients who need to be admitted to the hospital when there are no beds to be found? There are fewer hospital beds in Sonoma County than there were three years ago, but the number of people seeking hospital care has gone up. The aging population is also driving the need for more inpatient beds. Some busy EDs look like an ICU, with multiple critically ill patients lining the halls. Transfers to out-of-area facilities have been increasing, adding to communication problems with local PCPs.

Some of the solutions proposed in this issue of Sonoma Medicine could make a difference. Extending office hours for primary care teams could allow our working population access to outpatient urgent care with physicians who have the patient’s medical records. The teams could provide continuity of care and prevent the complications of waiting for a crisis. Increasing mental health care into the evening hours may reduce the burden on EDs for a type of illness they are poorly equipped to handle. . .

Preventing falls in our senior population would decrease emergency visits as well as reduce the devastating fractures that often accompany the falls. Orthostatic hypotension in this group is common and is often secondary to medications. Balance issues from age-related neuropathy are also frequent. Doing orthostatic checks on office visits may identify a potential problem. Referring patients to yoga, Pilates or dance classes can reduce fall risks.

The ED is the safety valve for all of us. It is essential that we work with our patients and colleagues to make optimal use of this essential resource. ::

Dr. Bernstein, a Sebastopol neurologist, serves on the SCMA Editorial Board.
Email: bernsteinallan@gmail.com

Review the Table of Contents:

SONOMA MEDICINE | Spring 2016 | Sonoma County Medical Association

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

Voices of Medicine

Past Issue

A Review of Medical Journals Editor, J. Amer Phys & Surgeons

What Seduces Doctors to the “Dark Side”?

By Mark J. Kellen, MD, President, AAPS

We all have colleagues who cannot get over their attraction to government schemes. The question of course is, “Why?”

In the history of mankind, central planning has been a marker for inefficiency, failure, oppression, and scarcity. Free markets, property rights, and liberty have been the engines of progress, technological advance, and abundance. Our past economic liberties have allowed us to create a country whose citizens enjoy a long life-expectancy at the same time that we struggle with poor personal health habits and much social dysfunction. (more…)

Voices of Medicine

Past Issue

A Review of Medical Journals and Articles

Gagging medical research

The Journal of the American Medical Association recently “gagged” authors of articles submitted to JAMA from speaking to the media or issuing a press release until after the article is printed in the journal. The best argument for this action is that new medical knowledge might better serve the public if initially released through a bona fide journal so that doctors could allay and diffuse widespread excessive public hopes and worries.
In reality, however, JAMA actually breaks its own rule by pre-releasing articles to the media days or sometimes weeks before physicians receive and have time to read them. (more…)

Voices of Medicine

Past Issue

A Review of Regional Medical Journals: Sonoma Medicine

CULTURE: Decapitated by Beauty

Rick Flinders, MD

If I feel physically as if the top of my head were taken off, I know that is poetry.
—Emily Dickinson

I spotted an empty seat at the bar, next to an elegantly dressed woman, and saw exactly the opportunity I was seeking. I took a seat, ordered a drink and introduced myself, thinking it had been many years since I had done such a thing. I was direct with my request. She had a welcoming smile and sparkling ear rings, and she was 80 years old. I asked her if she had tickets to the concert and, if so, how on earth she had gotten them.  Read more . . .

“We bought the package, young man, and had dibs on the Yo Yo Ma tickets before they went on sale.”

It was then that the slightly younger lady sitting next to her absolutely knocked me out: “Yes, we actually bought three, but our friend couldn’t come. We were going to turn it in to the box office for resale, but they’re not open yet.”

I had come prepared, three hours early and with substantial cash, to try and score two tickets for my wife and me to hear one of the world’s greatest living musicians, performing the solo cello suites of Johann Sebastian Bach. Failing that, I was even prepared to scale a nearby eucalyptus tree, just to hear a few notes spilling out into the evening air from the world-class Weill Hall at Sonoma State University. But my luck at the music center’s Prelude bar was singular and, try as I might, I couldn’t score another ticket.

I texted my wife, offering her the ticket, but she wouldn’t think of it. “No, no and no,” she texted back. “You go have a glass of wine, listen to the music, and then come home and tell me about each and every note.”

When I got home later that night, I told her, “Honey, I think I’ve seen what it might have been like to watch Michelangelo paint the Sistine Chapel or sculpt his statue of David. What we heard tonight was no less masterful or perfect than a creation by Rembrandt.”

It was live, in person and in a concert hall built exclusively from clear-grained European beech wood for the sound of pure music. Ma walked alone to the stage, joked with an usher, smiled and nodded to the billionaire donor who built the hall. He thanked the luthier who had performed emergency surgery that afternoon on his cello, inadvertently damaged on the morning flight from Hawaii. He explained the suites he was about to play were, for him, an expression of the feelings produced from the interaction of humans with nature. He said wine was an excellent example of humans interacting with nature. “Beautiful,” he added, “and that’s even before you drink it.”

Ma also said that Bach was describing more than beauty in these works. The famous cellist then used adjectives such as joyous, difficult, somber and sublime. Finally he sat in the solitary chair at center stage, embraced his cello and, without speaker or microphone, filled the hall with sound, lost to language.

He played for nearly two hours, without notation or score, every note memorized in both his brain and probably his heart, interpreting Bach as if he were telling a story he had learned and lived and developed since childhood. He is one of those rare musicians in whose hands an instrument is so mastered that it becomes an almost natural extension of the artist, his body, his voice, his entire means of expression. Such is Yo Yo Ma. He seemed transported during his performance. And so were we.

When he finished, we could only stand and applaud, and we could not stop. When he returned to the stage, he did so with cello and bow in hand. I believe it was the only way he could get us to stop. What he did next was equally moving. He acknowledged Pablo Casals, and thanked him for discovering Bach’s unaccompanied suites and bringing them to the world’s attention by recording them in 1920. And in homage to Casals, he played Casal’s signature “Song of the Birds,” commemorating his remarkable performance of the piece before the United Nations in 1971. In a world torn by rioting, assassinations and war, the aging Casals addressed the General Assembly:

“I have not performed in public for over forty years. But today I must play. This piece would have been loved by Bach and Beethoven. It is a song from my own home land of Catalan and is called “The Song of the Birds.” The birds are in the sky and they are crying ‘Peace! Peace! Peace!’”

When Ma finished the three-minute piece, he left the stage with no need to return. I’ve never been to the Sistine Chapel, nor looked upon the statue of David or seen an original Rembrandt. But like Michelangelo and Rembrandt centuries before him, Yo Yo Ma placed before us a work of decapititating beauty—and then left us with a sublime message of peace.

Dr. Flinders, who teaches hospital medicine at the Santa Rosa Family Medicine Residency, serves on the SCMA Editorial Board.
Email: flinder@sutterhealth.org

See a video of Casals’ 1971 UN performance.

SONOMA MEDICINE  |  Summer 2015  |  Sonoma County Medical Association

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Voices of Medicine

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A Review Of Local Medical Society Journals: Opioids

Sonoma Medicine | The magazine of the Sonoma County Medical Association | July 2016

Strategies for Reducing Opioid Use | THE PATIENT PERSPECTIVE

Gary Pace, MD

Earlier this year, former FDA director Dr. David Kessler said in a CBS News interview that the aggressive expansion in use of opioid pain medications “has proved to be one of the biggest mistakes in modern medicine.”

The problem isn’t that doctors prescribing opioids are incompetent or foolish. Instead, they thought they were helping patients based on the newest research. Now that the tide has turned against prescribing opioids, physicians don’t have much more to offer pain patients than they did 20 years ago, when long-acting opioids hit the scene.  

New initiatives aimed at educating physicians and the public on the importance of decreasing opioid use, and of developing systems to monitor prescribing patterns, may help with the epidemic; but the initiatives employ the same strategy of the failed War on Drugs: trying to stop the supply without addressing the demand. By paying attention to the demand side—the patient perspective—we can gain a fuller understanding of opioids and learn effective strategies for reducing opioid use. Below I discuss some of the approaches that are being recommended or that we are trying at our site that can be useful when approaching patients who are struggling.  


The current push for reducing opioid prescriptions involves setting policies and guidelines to get patients below 90–120 MEDs (morphine equivalent doses) per day to minimize the side effects and the risks, and to maximize the benefit. Before the paradigm shift, our clinic had problems bringing opioid dosing down. Patients would perceive us as being withholding and punitive for making them suffer when “effective” measures were available. Now with the public education campaign and the policy changes on medication coverage, most of our patients have been able to decrease their doses with relative ease. . .

Of course, there are exceptions where patients—sometimes labeled “legacy patients”—are unable to wean. They are stuck in limbo: they know the medications are bad, but they can’t tolerate reducing them. In our practice, these are often patients with psychiatric problems, substance-abuse histories, poor insight and tenuous living situations. One patient, schizophrenic and with chronic pain, mishandled a slow wean by regularly coming up short, and then not managing to navigate the prior authorization process. He ended up paying out of pocket for some of his meds, which led to financial difficulties, and he has now lost his housing. Essentially, the wean ended up being the straw that led to his destabilization.


Buprenorphine (a mixed agonist-antagonist for opiate receptors) is gaining prominence as a first-line solution for replacing conventional opioid pain medications. It has a moderate pain-relieving effect, and because of its unique pharmacology, overuse or the need for increasing doses is generally avoided. I have worked with this medication for more than 10 years, for both pain patients and addicts, and have seen some dramatic results. Because of the drug’s long half-life, its strong affinity for opioid receptors (thus blocking other opioids from having much effect), and the plateau of drug effect, cravings tend to disappear quickly.  

Physicians need a special license from the DEA to prescribe buprenorphine for addiction. The license can be easily obtained by going online for several hours of specialized training. Prescribing buprenorphine for pain has no prescribing limitations separate from other opioids.

Starting buprenorphine usually involves an initial consultation, followed by an induction period. During the induction, patients stop using opioids for a certain amount of time (usually 12 hours for short-acting opioids, 24 hours for long-acting opioids, sometimes longer for methadone), and come into the office when they are starting to go into withdrawal. The rationale for this approach is that if opioids are still in their system, the avid receptor affinity of the buprenorphine will knock the opioids off the receptors and the patient will go into a rapid withdrawal. If they are already withdrawing, the buprenorphine will help resolve their symptoms quickly. . .

Since buprenorphine is a combination of antagonist and agonist, it avoids the hyperalgesic effects of other opioids, so dosing goes down over time. Also, since there is a plateau of effect at about 24 mg per day, taking more buprenorphine does not lead to a “high,” nor is there a risk of overdose. Buprenorphine is especially useful in early recovery, because it tends to block effects of other opioids, thus discouraging relapse.  .  .

Non-opioid therapy

The recent CDC guideline for prescribing opioids states, “Of primary importance, non-opioid therapy is preferred for treatment of chronic pain. Opioids should be used only when benefits for pain and function are expected to outweigh risks.”2 Patients can be hard to sell on this approach, especially when insurance companies won’t cover many of the strategies that seem to have some efficacy.  

The research on non-opioid therapy is complicated and somewhat ambiguous. A 2007 guideline from the American College of Physicians and the American Pain Society found that cognitive-behavioral therapy, exercise, spinal manipulation and interdisciplinary rehabilitation were moderately effective for chronic or subacute low back pain.3The guideline also found that acupuncture, massage, yoga and functional restoration can be effective for chronic low back pain. The only non-opioid therapies with evidence of efficacy for acute low back pain were superficial heat and spinal manipulation. . .


A patient recently described to me the despair he used to feel while driving to his drug dealer’s house. The whole way, he knew he didn’t want to go, that his life would be much worse for getting the drugs. Yet, something else had control of his body, and he couldn’t stop it. He would be in tears as he turned into the driveway. Now, after years of being clean, he still worries that he could lose control and sink into addiction again.

Neuroscience research shows that addiction is a brain disease, not an issue of willpower. The brain chemistry becomes altered because of repeated exposure to addictive substances. Receiving dopamine release from the addictive drug becomes the addict’s over-riding focus, and avoiding the withdrawal and the crash when there is no drug can become an obsession. Research on risk factors considers genetics, but recently there is increased attention on the effects of adverse childhood experiences (ACE). For instance, a male child with an ACE score of 6 (out of 8), when compared to a child with an ACE score of 0, has a 46-fold increase in the likelihood of becoming an injection drug user sometime later in life.4  

When is the line crossed from legitimate use of opioids for pain relief to use for addiction? Physicians are well aware of patients who run out of pain meds early, have various excuses and consume a lot of time in the office. Ten years ago, “experts” were saying that it was unusual for people on pain medications to slide into addiction; but experience suggests a much higher risk. Moreover, as access to prescription opioids becomes limited, patients shift to cheaper, less predictable alternatives. Heroin overdose deaths have increased more than 30% annually since 2010.5  

Opioid addiction treatment is difficult to access, and just two general models are available: abstinence-based treatments (the 12-step model) or medication-assisted treatment (MAT) with buprenorphine or at methadone treatment centers. MAT is gaining traction, and research shows that it saves lives. When Baltimore improved access to MAT in the community, drug overdoses decreased by 50%.6 MAT patients generally have longer relapse-free periods than patients aiming for complete abstinence.6  

Many of the opioid addicts that I have worked with over the years have had dramatic turnarounds in their lives with buprenorphine, and I encourage physicians to get trained and offer this service to the community. MAT allows them to step off the all-consuming treadmill of planning how to obtain drugs. They begin to be able to reenter society and to appreciate the joys of working, of re-engaging with family and friends, and of having some control over their lives again. One of the most touching stories I heard was of a young man who was finally able to go to his extended family’s Christmas gatherings after many years of being forbidden because of the outrageous and criminal behavior he had previously exhibited. . .


Is the amount of pain that contemporary Americans claim to experience higher than what Americans experienced in earlier eras? It would be a stretch to believe that people doing physical labor in earlier times or in other cultures had less pain than we do now. The U.S. has just 5% of the world’s population, but it consumes 75% of the opioid pain-killers.9 Clearly, Americans need a cultural shift in their willingness to tolerate discomfort.  

There aren’t any easy answers to the prescription opioid epidemic, but a few suggestions seem obvious. My interest here is for the policy-makers and thought leaders to move from a punitive approach that limits medications to a broader approach that includes the patient perspective. We need to:

·         Reduce the number of opioids prescribed; we are having some success with that.

·         Develop comprehensive strategies that work with pain, including non-pharmacological approaches such as acupuncture, chiropractic and cognitive-behavioral therapy.

·         Expand addiction services and recognize the life-saving capabilities of medication-assisted treatment.

·         Examine the relationship our society has with pain and suffering, and go beneath the surface of the quick fix. ::

Dr. Pace, a family physician, is medical director of Alexander Valley Healthcare in Cloverdale.   
Email: gpace@alexandervalleyhealthcare.org 

1. “Former FDA head: opioid epidemic one of great mistakes of modern medicine,” CBS News (May 9, 2016). 
2.  Read the rest of the references in Sonoma Medicine . . .

Read the entire article in Sonoma Medicine . . . Summer 2016 | Sonoma County Medical Association

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

Voices of Medicine

Past Issue

Have Reimbursement Rules Taken The Joy Out Of Being A Physician?

The voice of Douglas Farrago MD, Editor, Authentic Medicine

Of the articles I’ve read to dissect and rip over the past few years, this one has left me sadder, more hopeless than most. Author Peter Ubel asks, “Have Reimbursement Rules Taken The Joy Out Of Being A Physician?”

Of course the knee-jerk answer is a resounding “Duh!” Ubel, a physician and behavioral scientist at Duke, leads off with an example of an urgent care doc treating a woman for a sprained ankle, and then getting financially dinged for not addressing her mammogram status or initiating diabetes screening. Such an occurrence is an insulting rip off of the physician, but not a surprise to any of us.

The author has embarked on a research project to investigate for physicians “what can be done to help them thrive at work even though an increasing number of outside parties are looking over their shoulder, assessing the quality of the care they provide.” That’s all well and good I suppose – Dr. Ubel notes, “physicians have gone from being independent decision-makers to being bureaucrats forced to check boxes.” As an academician, I hope Ubel bucked the trend and opposed mandatory EHR’s, the whole P4P, fashionable “quality” payment model, and pretty much everything in the ACA. His bio includes “I am currently exploring controversial issues about the role of values and preferences in health care decision making, from decisions at the bedside to policy decisions. I use the tools of decision psychology and behavioral economics to explore topics like informed consent, shared decision making and health care spending.” . . .Of course he is a physician making inquiries “to better understand why many clinicians are miserable in their careers.” It isn’t a mystery to non-academic, seeing-patients-every-day-in-order-to-make-a-living physicians.

Physicians, most of whom are still very well-paid relative to the rest of the world, are working harder fulfilling busy-work requirements that are strictly negative reinforcements: do this or you won’t get paid. Or the legal fears: order this test, or you’ll be sued; code this just so, this week, until it changes, or you’ll be penalized, and maybe charged with fraud. That, and the anger patients have at the system, their rising health premiums or simple lack of access, the consequences of their own lifestyle choices, and the generally collapsing turmoil that is health care, will be directed at you, the doc. To that one can add the negative satisfaction – if one is truly self-honest – that in playing all these games, one is not working for the patient, and claiming to the contrary is naked self-justification. I state to Dr. Ubel: beyond millions of individual examples of excellence and compassion, medicine in general is no longer an honorable profession.

Do you think I’m being a little harsh? My blood ran cold reading the author’s statement: “In part, these external accountability measures have been put in to place because people paying for medical care – insurance companies, Medicare administrators, and even patients – realized that the quality of medical care wasn’t always as high as it ought to be.” According to whom exactly wasn’t quality up to snuff? Ubel’s source for this was the . . . Institute Of Medicine, the same clown car that covered us all with MOC vomit.

And then the author piled on: “And since the profession wasn’t doing everything it could to promote high quality, they recognized that somebody from the outside needed to hold physicians accountable for their practice.”

What the hell ever happened to the patient and the physician being accountable to each other? That admittedly naive question is so far removed from the future of medicine as to be irrelevant (Direct Primary Care being of course, the obvious exception). What behavioral scientist Ubel seems to be missing in his musings are the permanently corrosive effects of generations of oversight by Big Insurance, lawyers, Big Government, and yes, academicians prodding the previous three. Line up all these noble sources that constantly imply, or state outright that doctors are not to be trusted, and guess what? It works. Any inquiry into the mysteries of physician dissatisfaction that does not point the finger of blame at these culprits is just another lie. . .

For a behavioral scientist, I am surprised that the author seems to have missed this point: physicians have egos generally larger than the average person. It’s not whining to note that we have also invested a hell of a lot more in our careers than the average person, and expect to be rewarded for it. We did not get into this work to be ordered around by furtive little rodents masquerading as coders, Medicare auditors, and JCAHO inspectors. Most of us began this trip seeking rewards not just monetary, but the thrill of discovery and the pride from excellent work. Those goals could only be pursued with independent judgment, by individuals making their own best decisions. Take that away with nonsensical quality requirements, along the myriad other shackles, tethers, and threats that have nothing to do with being a physician, and you take away the pride. You take away the fun. All that will be left to feed the ego is the dwindling paycheck, which will come with an increasing amount of resentment, and hopes of finding different, more honest work. . .

“Have Reimbursement Rules Taken The Joy Out Of Being A Physician?”  By Peter Ubel , MD

I explore medical controversies thru behavioral econ and bioethics

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A Neurosurgeon Tells Us About His Dying Experience

My Last Day as a Surgeon

By Paul Kalanithi

In May of 2013, the Stanford University neurosurgical resident Paul Kalanithi was diagnosed with Stage IV metastatic lung cancer. He was thirty-six years old. In his two remaining years—he died in March of 2015—he continued his medical training, became the father to a baby girl, and wrote beautifully about his experience facing mortality as a doctor and a patient. In this excerpt from his posthumously published memoir, “When Breath Becomes Air,” which is out on January 12th, from Random House, Kalanithi writes about his last day practicing medicine.

I hopped out of the CT scanner, seven months since I had returned to surgery. This would be my last scan before finishing residency, before becoming a father, before my future became real.

“Wanna take a look, Doc?” the tech said.

“Not right now,” I said. “I’ve got a lot of work to do today.”

It was already 6 P.M. I had to go see patients, organize tomorrow’s O.R. schedule, review films, dictate my clinic notes, check on my post-ops, and so on. Around 8 P.M., I sat down in the neurosurgery office, next to a radiology viewing station. I turned it on, looked at my patients’ scans for the next day—two simple spine cases—and, finally, typed in my own name. I zipped through the images as if they were a kid’s flip-book, comparing the new scan to the last. Everything looked the same, the old tumors remained exactly the same … except, wait.

I rolled back the images. Looked again.

There it was. A new tumor, large, filling my right middle lobe. It looked, oddly, like a full moon having almost cleared the horizon. Going back to the old images, I could make out the faintest trace of it, a ghostly harbinger now brought fully into the world.

I was neither angry nor scared. It simply was. It was a fact about the world, like the distance from the sun to the Earth. I drove home and told [my wife,] Lucy. It was a Thursday night, and we wouldn’t see [my oncologist] Emma again until Monday, but Lucy and I sat down in the living room, with our laptops, and mapped out the next steps: biopsies, tests, chemotherapy. The treatments this time around would be tougher to endure, the possibility of a long life more remote. T. S. Eliot once wrote, “But at my back in a cold blast I hear / the rattle of the bones, and chuckle spread from ear to ear.” Neurosurgery would be impossible for a couple of weeks, perhaps months, perhaps forever. But we decided that all of that could wait to be real until Monday. Today was Thursday, and I’d already made tomorrow’s O.R. assignments; I planned on having one last day as a resident.

As I stepped out of my car at the hospital, at five-twenty the next morning, I inhaled deeply, smelling the eucalyptus and … was that pine? Hadn’t noticed that before. I met the resident team, assembled for morning rounds. We reviewed overnight events, new admissions, new scans, then went to see our patients before M. & M., or morbidity and mortality conference, a regular meeting in which the neurosurgeons gathered to review mistakes that had been made and cases that had gone wrong. Afterward, I spent an extra couple of minutes with a patient, Mr. R. He had developed a rare syndrome, called Gerstmann’s, where, after I’d removed his brain tumor, he’d begun showing several specific deficits: an inability to write, to name fingers, to do arithmetic, to tell left from right. I’d seen it only once before, as a medical student, eight years ago, on one of the first patients I’d followed on the neurosurgical service. Like him, Mr. R. was euphoric—I wondered if that was part of the syndrome that no one had described before. Mr. R. was getting better, though: his speech had returned almost to normal, and his arithmetic was only slightly off. He’d likely make a full recovery.

The morning passed, and I scrubbed for my last case. Suddenly the moment felt enormous. My last time scrubbing? Perhaps this was it. I watched the suds drip off my arms, then down the drain. I entered the O.R., gowned up, and draped the patient, making sure the corners were sharp and neat. I wanted this case to be perfect. I opened the skin of his lower back. He was an elderly man whose spine had degenerated, compressing his nerve roots and causing severe pain. I pulled away the fat until the fascia appeared and I could feel the tips of his vertebrae. I opened the fascia and smoothly dissected the muscle away, until only the wide, glistening vertebrae showed up through the wound, clean and bloodless. The attending wandered in as I began to remove the lamina, the back wall of the vertebrae, whose bony overgrowths, along with ligaments beneath, were compressing the nerves.

“Looks good,” he said. “If you want to go to today’s conference, I can have the fellow come in and finish.”

My back was beginning to ache. Why hadn’t I taken an extra dose of nsaids beforehand? This case should be quick, though. I was almost there.

“Naw,” I said. “I want to finish the case.”

The attending scrubbed in, and together we completed the bony removal. He began to pick away at the ligaments, beneath which lay the dura, which contained spinal fluid and the nerve roots. The most common error at this stage is tearing a hole in the dura. I worked on the opposite side. Out of the corner of my eye, I saw near his instrument a flash of blue—the dura starting to peek through.

“Watch out!” I said, just as the mouth of his instrument bit into the dura. Clear spinal fluid began to fill the wound. I hadn’t had a leak in one of my cases in more than a year. Repairing it would take another hour.

“Get the micro set out,” I said. “We have a leak.”

By the time we finished the repair and removed the compressive soft tissue, my shoulders burned. The attending broke scrub, offered his apologies and said his thanks, and left me to close. The layers came together nicely. I began to suture the skin, using a running nylon stitch. Most surgeons used staples, but I was convinced that nylon had lower infection rates, and we would do this one, this final closure, my way. The skin came together perfectly, without tension, as if there had been no surgery at all.

Good. One good thing.

As we uncovered the patient, the scrub nurse, one with whom I hadn’t worked before, said, “You on call this weekend, Doc?”

“Nope.” And possibly never again.

“Got any more cases today?” “Nope.” And possibly never again.

“. . . well, I guess that means this is a happy ending! Work’s done. I like happy endings, don’t you, Doc?”

“Yeah. Yeah, I like happy endings.”. . .

I left the O.R. shortly after, then gathered my things, which had accumulated over seven years of work—extra sets of clothes for the nights you don’t leave, toothbrushes, bars of soap, phone chargers, snacks, my skull model and collection of neurosurgery books, and so on.

On second thought, I left my books behind. They’d be of more use here.

. . . Tears welled up as I sat in the car, turned the key, and slowly pulled out into the street. I drove home, walked through the front door, hung up my white coat, and took off my I.D. badge. I pulled the battery out of my pager. I peeled off my scrubs and took a long shower.

Later that night, I called [my co-resident] Victoria and told her I wouldn’t be in on Monday, or possibly ever again, and wouldn’t be setting the O.R. schedule.

“You know, I’ve been having this recurring nightmare that this day was coming,” she said. “I don’t know how you did this for so long.”

This is a true example of the Hippocratic Oath continuing to motivate physicians to value the life of their patients over their own. This will be lost as physicians become employees of Hospitals, Insurance Companies, or non-medical Corporate Entities in which they have abrogated their ability to do so without retribution from the entities where our results are salable commodities from which they profit.

Read the entire story and others in The New Yorker. . .


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VOM Is an Insider’s View of How Doctors Face Dying…

Voices of Medicine

Past Issue

An ICD-10 Christmas Tale

My friend and colleague, Dr. Jack Ostrich, who always gives us an enlightening Christmas Story gave us this one. The ICD 9 would have several codes for different types of fracture, for instance, now the ICD 10 has dozens of codes to identify minor differences and what is the type of visit for each type of fracture. Hence, the humor of his parody.

We’ve always enjoy Jack’s Christmas stories. This year he gave us an adaption from an essay by Gerry Wieder, RN of Seattle

`Twas the night before Christmas, when all through the house,

Not a creature was stirring, not even a mouse.

W53.01XA Bitten by mouse, initial encounter

W53.01XD Bitten by mouse, subsequent encounter

W53.09XA Other contact with mouse, initial encounter

W53.09XD Other contact with mouse, subsequent encounter

The stockings were hung by the chimney with care,

In hopes that St. Nicholas soon would be there.

X06.2XXA Exposure to ignition of other clothing and apparel, initial encounter

X06.2XXD Exposure to ignition of other clothing and apparel, subsequent encounter

X06.3XXA Exposure to melting of other clothing and apparel, initial encounter

X06.3XXD Exposure to melting of other clothing and apparel, subsequent encounter

The moon on the breast of the new-fallen snow

Gave the lustre of mid-day to objects below.

X37.2XXA Blizzard (snow)(ice), initial encounter

X37.2XXD Blizzard (snow)(ice), subsequent encounter

When, what to my wondering eyes should appear,

But a miniature sleigh, and eight tiny reindeer.

201.01 Encounter for examination of eyes and vision with abnormal findings

R44.1 Visual hallucinations

With a little old driver, so lively and quick,

I knew in a moment it must be St. Nick.

R54 Age-related physical debility

F22 Delusional disorders

More rapid than eagles his coursers they came,

And he whistled, and shouted, and called them by name:

R49.8 Other voice and resonance disorders

R49.9 Unspecified voice and resonance disorder

“Now, Dasher! now, Dancer! now, Prancer and Vixen!

On, Comet! on Cupid! on, Donner and Blitzen!

W55.39XA Other contact with other hoof stock, initial encounter

W55.39XD Other contact with other hoof stock, subsequent encounter

To the top of the porch! to the top of the wall!

Now dash away! dash away! dash away all!”

V97.0 Occupant of aircraft injured in other specified air transport accidents

W13.0XXA Fall from, out of or through balcony, initial encounter

W13.0XXD Fall from, out of or through balcony, subsequent encounter

W22.01XA Walked into wall, initial encounter

W22.01XD Walked into wall, subsequent encounter

As dry leaves that before the wild hurricane fly,

When they meet with an obstacle, mount to the sky,

X37.0XXA Hurricane, initial encounter

X37.0XXD Hurricane, subsequent encounter

So up to the house-top the coursers they flew,

With the sleigh full of toys, and St. Nicholas too.

Y93.29 Activity, other involving ice and snow

V96.8XXA Other nonpowered-aircraft accidents injuring occupant, initial encounter

V96.8XXD Other nonpowered-aircraft accidents injuring occupant, subsequent encounter

And then, in a twinkling, I heard on the roof

The prancing and pawing of each little hoof.

W13.2XXA Fall from, out of or through roof, initial encounter

W13.2XXD Fall from, out of or through roof, subsequent encounter

W55.32XA Struck by other hoof stock, initial encounter

W55.32XD Struck by other hoof stock, subsequent encounter

            As I drew in my head, and was turning around,

Down the chimney St. Nicholas came with a bound.

X02.0XXA Exposure to flames in controlled fire in building or structure, initial encounter

X02.0XXD Exposure to flames in controlled fire in building or structure, subsequent encounter

He was dressed all in fur, from his head to his foot,

And his clothes were all tarnished with ashes and soot.

Y93.E9 Activity, other interior property and clothing maintenance

A bundle of toys he had hung on his back,

And he looked like a peddler just opening his pack.

Z59.0 Homelessness

Z59.1 Inadequate housing . . .

He had a broad face and a little round belly,

That shook, when he laughed like a bowlful of jelly.

E66.3 Overweight

Z72.3 Lack of physical exercise . . .

He sprang to his sleigh, to his team gave a whistle,

V00.221A Fall from sled, initial encounter

V00.221D Fall from sled, subsequent encounter

V00.228 Other sled accident

And away they all flew like the down of a thistle.

But I heard him exclaim, ‘ere he drove out of sight,

W94.23XA Exposure to sudden change in air pressure in aircraft during ascent, initial encounter

W94.23XD Exposure to sudden change in air pressure in aircraft during ascent, subsequent


 “Happy Christmas to all, and to all a good-night.”

Read the RN’s original and complete version at http://gerrywieder.com/an-icd-10-christmas-tale/

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

Voices of Medicine

Past Issue

The Waste And Danger Of Unnecessary Care


An avalanche of unnecessary medical care is harming patients physically and financially

What can we do about it?

By ATUL GAWANDE, MD | The New Yorker Magazine | June 11, 2015

It was lunchtime before my afternoon surgery clinic, which meant that I was at my desk, eating a ham-and-cheese sandwich and clicking through medical articles. Among those which caught my eye: a British case report on the first 3-D-printed hip implanted in a human being, a Canadian analysis of the rising volume of emergency-room visits by children who have ingested magnets, and a Colorado study finding that the percentage of fatal motor-vehicle accidents involving marijuana had doubled since its commercial distribution became legal. The one that got me thinking, however, was a study of more than a million Medicare patients. It suggested that a huge proportion had received care that was simply a waste.

The researchers called it “low-value care.” But, really, it was no-value care. They studied how often people received one of twenty-six tests or treatments that scientific and professional organizations have consistently determined to have no benefit or to be outright harmful. Their list included doing an EEG for an uncomplicated headache (EEGs are for diagnosing seizure disorders, not headaches), or doing a CT or MRI scan for low-back pain in patients without any signs of a neurological problem (studies consistently show that scanning such patients adds nothing except cost), or putting a coronary-artery stent in patients with stable cardiac disease (the likelihood of a heart attack or death after five years is unaffected by the stent). In just a single year, the researchers reported, twenty-five to forty-two per cent of Medicare patients received at least one of the twenty-six useless tests and treatments.

Could pointless medical care really be that widespread? Six years ago, I wrote an article for this magazine, titled “The Cost Conundrum,” which explored the problem of unnecessary care in McAllen, Texas, a community with some of the highest per-capita costs for Medicare in the nation. But was McAllen an anomaly or did it represent an emerging norm? In 2010, the Institute of Medicine issued a report stating that waste accounted for thirty per cent of health-care spending, or some seven hundred and fifty billion dollars a year, which was more than our nation’s entire budget for K-12 education. The report found that higher prices, administrative expenses, and fraud accounted for almost half of this waste. Bigger than any of those, however, was the amount spent on unnecessary health-care services. Now a far more detailed study confirmed that such waste was pervasive.

I decided to do a crude check. I am a general surgeon with a specialty in tumors of the thyroid and other endocrine organs. In my clinic that afternoon, I saw eight new patients with records complete enough that I could review their past medical history in detail. One saw me about a hernia, one about a fatty lump growing in her arm, one about a hormone-secreting mass in her chest, and five about thyroid cancer.

To my surprise, it appeared that seven of those eight had received unnecessary care. Two of the patients had been given high-cost diagnostic tests of no value. One was sent for an MRI after an ultrasound and a biopsy of a neck lump proved suspicious for thyroid cancer. (An MRI does not image thyroid cancer nearly as well as the ultrasound the patient had already had.) The other received a new, expensive, and, in her circumstances, irrelevant type of genetic testing. A third patient had undergone surgery for a lump that was bothering him, but whatever the surgeon removed it wasn’t the lump—the patient still had it after the operation. Four patients had undergone inappropriate arthroscopic knee surgery for chronic joint damage. (Arthroscopy can repair certain types of acute tears to the cartilage of the knee. But years of research, including randomized trials, have shown that the operation is of no help for chronic arthritis- or age-related damage.)

Virtually every family in the country, the research indicates, has been subject to overtesting and overtreatment in one form or another. The costs appear to take thousands of dollars out of the paychecks of every household each year. Researchers have come to refer to financial as well as physical “toxicities” of inappropriate care—including reduced spending on food, clothing, education, and shelter. Millions of people are receiving drugs that aren’t helping them, operations that aren’t going to make them better, and scans and tests that do nothing beneficial for them, and often cause harm.

Why does this fact barely seem to register publicly? . . .

It is different, however, when I think about my experience as a patient or a family member. I can readily recall a disturbing number of instances of unnecessary care. My mother once fainted in the Kroger’s grocery store in our Ohio home town. Emergency workers transported her to a hospital eighty miles away, in Columbus, where doctors did an ultrasound of her carotid arteries and a cardiac catheterization, too, neither of which is recommended as part of the diagnostic workup for someone who’s had a fainting episode, and neither of which revealed anything significant. Only then did someone sit down with her and take a proper history; it revealed that she’d had dizziness, likely from dehydration and lack of food, which caused her to pass out.

I began asking people if they or their family had been subject to what they thought was unnecessary testing or treatment. Almost everyone had a story to tell. Some were appalling. . .

Read the entire “Voices” and more appalling stories  from Dr. Gawande in The New Yorker Magazine. . .

We have also witnessed exorbitant increases in healthcare costs when our patient is no longer under our control and someone else who is unfamiliar with our patient’s health care writes the medical orders for tests. One of our patients with a calcified granuloma since 1954 which needed no further evaluation was admitted to the hospital and had a full pulmonary nodule evaluation with an unnecessary MRI, and almost a bronchoscopy which she had refused. No one had bothered to take a medical history or she would have told them that she’s had this calcium nodule since 1954.

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