In the Beginning… July/August 1993

Some decades ago, there was a series titled “Eutychus and His Kin” which used anecdotal information and opinions to bring issues into sharper focus or give them a different perspective. With Hippocrates & his kin,” Sacramento Medicine initiates a monthly column that could, with your help, achieve a similar goal. There is intense competition for our attention and energy, which often distracts us from our primary responsibilities of patient care and search for excellence. Even now we have diversions into nonscientific care such as acupuncture. We trust, however, these short “notes from the trenches” will be helpful and of interest. The column is open to any appropriate vignettes, anecdotes and items.

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Heard from a patient . . . who informs us that the cost of her yearly pelvic exam and pap smear has tripled in three years. She thinks it was about $65 when her gynecologist was a member of a partnership. The next year she thinks it was somewhere over $100 when it came from SSMG. This year it was $269 and came from a Hospital Medical Foundation. This is the statement she brought in.

. . . Is this hospital technique, which I understand is called “unbundling,” the answer to our problems? [See box example below for some possibilities of this process]

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Heard from a surgeon . . . who informs us that the laparoscopic cholecystectomy that was expected to save considerable health care costs by reducing the hospital stay from 5 days to overnight may not do so. A patient brought in a statement for her overnight stay that had the same DRG at $8700 for the 23-hour stay. . . A 250-bed hospital, if full, could have $2 million in daily revenue. A 350-bed hospital, if full, could have $3 million in daily revenue. (One billion dollars per year!)

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SF Chronicle (6/4/93) reports that Bay Area hospitals reporting operating losses of >$150 million a year, with red ink projected to reach $705 million a year by the year 2000, may be a distortion. According to Local 250 of SEI Union, state regulators reported a $144 million net income and construction bankrolling of $134 million?
. . . Are hospitals the health care cost problem?

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A patient asked us why Medicare pays more to the hospital nurse making a home visit than we charge. She stated that the nurse visit was $112. My billing service informs me that Medicare discounts my $80 home visit to a ventilator patient.
. . . Is the physician the best bargain in health care?

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We had our annual dinner guests from London the night before the Jazz Festival which they attend every year. On asking about a missing trumpet player, we were informed that “he was in a bad way. He had a stroke and after several days of coma, was transferred to a larger hospital in London where they had a CAT Scanner.” The waiting list is shorter for in-patients than for out-patients.   . . . A member of our committee was hospitalized while visiting Florence. He states that he was better able to monitor his blood glucose with his American technology than the hospital could.
. . . Why do we allow our health care system to be compared with others? Aren’t we the ultimate standard and goal for the world?

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After noting the number of physicians making less than $100K per year, Medical Economics (4/12/93) now points out that over 40% of us are unable to put aside even $3,000/yr in our retirement plan. Physicians with less than $100K in total assets are increasing! . . . When I had my annual eye exam, I asked my ophthalmologist if he was about to retire. He said that he would not have enough money in his plan until he reached 70. . . I asked a couple who were both teachers for the San Juan School District why they took early retirement. The response was that it was cheaper for the district to hire new teachers at the entry wage than to pay them another five years at the top wage.
. . . Aren’t the wrong professionals being painted as greedy?

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INTERNAL MEDICINE CONSULTATION
(a nonserious extrapolation)

. . .The extra $800 per consultation should allow each of us to hire a $75,000 CPA or MBA to find other hidden charges.

Medical Costs September 1993

Jerry Pogue, a Los Angeles managed care consultant quoted in the July issue of Northern California Medicine, may have the answer as to why physicians let themselves be completely deprofessionalized by accepting capitation. He calls capitation the “cocaine of managed care,” noting three levels of capitation addiction: a capitation revenue of 10-15 percent gives physicians a “rush” twice each month when the capitation payment arrives; a capitation revenue of 20-30 percent is enough of a “hook” to put physicians into a dependency relationship with the payor; a capitation revenue of 45-55 percent is akin to “mainlining” by addicts. At this point, a physician changes his behavior to the required efficiency and control of excess utilization. . . In other words, we are then enslaved agents of the carrier and have minimal responsibility to our patients. They are only the commodity providing us our fix twice a month. . . Anybody out there for moving forward into our previous state as a cottage industry with patients making their decisions based on our explanation of the risk/benefit and cost/benefit analysis?

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An ENT surgeon asked, as he was pulling out a wax plug, “Do you wash your ears out in the shower and then blow-dry the ear canals?” Well, it works. Dried wax falls out during the course of the day and no plugs recur. Can you believe the multiple uses of this appliance? The hair dresser says to blow-dry your hair. The ENT surgeon says to blow-dry your ears. The proctologist says to blow-dry your hemorrhoids. The urologist says to blow-dry the prepuce. The gynecologist says to blow-dry under the mammary glands. The dermatologist says blow-dry under all skin folds. The foot doctor says to blow-dry between your toes! How did we ever get dressed in the morning before the blow-dryer was invented?

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The Sacramento Union reports that many Canadians travel to the US for their health care. The same can be said for almost every country in the world. . . Has anyone ever heard of an American journeying to a foreign country for anything other than alternative health care and arcane procedures that would never gain FDA approval?

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The Sacramento Bee reports that the Democratic Senatorial Campaign Committee is urging health-industry lobbyists and executives to pay $5,000 to attend an “issues forum” featuring Clinton administration officials who will make crucial decisions on health care reform. The purpose cited is “to fatten its political war chests,” (at our patients’ expense). Isn’t that more reprehensible behavior than physicians accepting medical and drug information over a meal, or accepting a patient starter sample from a drug rep? . . .Or is that a sign of the times that we are all too busy looking into each other’s lives, we don’t ever look into our own to clean it up?

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In US News’ annual rankings of the Best Hospitals using 16 specialties, Johns Hopkins and Mayo were joined by three California institutions (UCLA, UCSF and Stanford) in the top 15. UCD made the list, not only in orthopedics, cardiology and cancer, but also in rheumatology, endocrinology, neurology, urology, and gynecology. Hats off to our Professors. Of interest was that the NIH in Bethesda, with all its tax dollars, only made the list in four specialties.

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Scientific American (7/93, p.109) is joining the health care debate: HMOs offering to meet all of a consumer’s medical needs for a fixed fee create a set of perverse incentives for physicians and patients. Doctors do best financially by offering as little care as possible; patients have paid up front and so profit by insisting on maximum treatment. The HMO has an incentive to sign up a maximum of subscribers and to minimize the time spent with a physician.

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Not to be outdone, Playboy offers the following, from Peter Moore, who sees four levels of bureaucracy between him and his doctors. After a consultation with his doctor came the seven most expensive words in medicine: “But we better run a few tests.” When he met his deductible, he “hit pay dirt–100% payback. That’s when the dollars ceased to be real. Somebody else was picking up the tab. When I pay for health care in fake dollars, I pay no attention to the charges.” About the Canadian system, he says, “Canada, shmanada. The entire country – 26 millions souls – could fit on the pinkie toenail of the U.S. health giant. . . How ironic it would be if, at the very moment when individual freedom of choice is sweeping the world, the republic that started it all tried to solve its biggest problem by embracing what could become the world’s biggest bureaucracy. . . It costs a lot to feed bureaucracies, which are to American society what ticks are to dogs.”

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Did you know Americans spend more on their hair than on medical research?

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The Harvard School of Public Health study reports that 84 percent of heart patients who sought a second opinion prior to a coronary artery bypass graft were told they didn’t need the surgery. Responding to my comments last month about CABG in a 91-year-old patient, a colleague mentioned that “in our training we always worked up a patient until he either died or got well.” Perhaps that is the nature of university training programs. But there was a corrective influence when we went into practice. We had to convince our patients to spend money on the procedures and tests we advised. This was true even in the early days of Medicare when we asked patients to pay us and they collected from the government. Now with payment in fake dollars, there are no brakes on the system. With physicians’ practices getting 19 percent of the health care dollar, (8 percent to physicians if we exclude a 60 percent overhead), isn’t the current preoccupation in reducing our income by 5 percent here and there rather like mopping up the water on the deck of the sinking Titanic?

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During a presentation to one of our staffs, a neurologist stated that there are 14 million Americans who have or will have Alzheimer’s. The current annual cost is $60 billion. If each had a PET scan at the going rate of $2200, there would be a 50 percent increase in the national costs to $90 billion in just one disease with one test that would not affect outcome. I’m sure there would be another 14 million Americans who would try to convince their doctors that one of their parents needed a PET brain scan. There is no managed care program that could stop such a stampede.

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Just In: A patient was seen three months ago for routine quarterly pulmonary evaluation. He stated that his wife’s multiple sclerosis had gotten worse and she lost her job and insurance. He now only had Medicare and no drug coverage. He had gone to his pharmacist and the drug bill paid by Managed Care Systems would cost him over $600 a month. He asked for new prescriptions using the lowest cost medications possible. Alternate prescriptions were written for his cost/benefit evaluation. He was now happy to announce that he had gotten his monthly drug bill down to slightly over $200 with no lost efficacy. (SSKI was 1/8 the cost of the competitor, Theochron was half the cost of it’s competitor…) The point not to be missed is that managed care, which has only one reason for existence, namely to reduced costs, was still three times more expensive than patient responsibility when the patient was at financial risk.

The Doctor’s Fool October 1993

The old adage “a doctor who treats himself or his family has a fool for a doctor” and its variation, “the doctor who treats himself from medical books could die of a misprint,” has now been extended to “the doctor who treats himself with medical software could die of a computer virus.”

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The Business Journal (7/19/93) lists the 25 highest paid executives of local public companies. Five of the top 15 include the following along with their rankings:

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The Los Angeles Daily News reports (reprinted in SF Chronicle 9/2/93) that managers of Health Net stand to collect $100 million for stock that they paid $1.5 million for last year, if its proposed merger with QualMed later this year is completed.

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Nearly one in five persons admitted to nursing homes as self-payers are likely to convert to Medicaid within a year, according to Dr. Vincent Mor of Brown University. That’s all the time it will take for them to spend their savings and liquidate their assets to pay an average of $25,000 a year in nursing home costs… according to Spectrum (Sacramento, 8/1/93). The Brookings Institution estimates that the yearly cost of nursing home health care costs will be $158,275 by the year 2020.

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Miles Benson (Newhouse News Service) reports from Washington that President Clinton’s top advisers and his most loyal supporters in Congress admit that health care reform is a leap in the dark – but they are betting they can design the parachute on the way down. . . . After three-fourths of a year, the task force has been unable to crack the riddle of health care reform: how to achieve the conflicting goals of universal access, universal quality and universal cost control. . . they admit it will take 10 years to fully develop with many changes along the way. . . It’s hard to teach politicians in 10 years what it took those of us in the trenches longer to learn and understand. Let’s keep the dialogue going with everyone possible. We have friends we have not yet met. The politicians have enemies they will eventually have to account to. (Sacramento Union 8/15/93)

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The Wall Street Journal (8/9/93) reports that “hospitals are now jumping into the business of ‘wellness’ – that fuzzy term that can encompass everything from meditation classes to aerobics to yoga . . . belly dancing is offered at Rush-Presbyterian Hospital in Chicago . . . but that trend, some critics say, may lead to patients getting herded into expensive tests and treatment they might not need.”

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One of our surgeons returning from a three-week vacation in Israel reports that private practice is booming. The near universal coverage from payroll deductions is deteriorating and people are seeking out private doctors they have to pay above and beyond the deductions from their paychecks that would take care of their medical problems. He also reports that solo practitioners are doing better than groups practitioners. The patients are paying $200 or more for a consultation and $80-100 for a follow up visit . . . Sounds as if they like their doctors as well as American women like their hairdressers. One woman told me she’d travel 30 miles to see her favorite hairdresser even if it cost more. Can we regain the hairdresser’s importance?

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Mark Hunter reports (Bee Forum 8/29/93) that France, a country often envied for its system of universal health care and tradition of medical excellence . . . knowingly allowed at least 1,000 people to receive blood or blood products contaminated by the virus that causes the disease. Three hundred of those people–mainly hemophiliacs, many of them children–are already dead. The rest are going to die, barring a miracle. . . Dr. Leibowitch, an immunologist in screening blood stocks, reported on December 12, 1984 that he found 2,500 HIV contaminations per year (7 HIV infections per day) and issued a written warning and called the French Ministry of Health. On May 9, 1985, another scientist, Dr. Garretta, armed with his data, wrote to the Ministry of Social Affairs that cleaning up the blood supply was “an absolute urgency.” The official in charge said that a “compromise” had to be found “between the imperatives of public health and the economic constraints.” We have to keep this message before the public, the patients we serve, that when their health is a part of the federal budget, their health, their life, their death will always be secondary to fiscal constraints.

Parker & Hart in their comic strip, “The Wizard of Id,” show bureaucrats desperately searching for anything that’s left to be taxed and finding the only thing not taxed is “Greed.”

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One of our internists reports that FHP gave him his card and listed him as his own primary care practitioner. The other doctors at the luncheon table were quick to point out that the hospitals have rules that physicians can’t treat their own families. Another doctor pointed out that these rules did not preclude treating oneself. . . Can’t you already see this doctor admitting himself to the hospital and every day he takes his morning walk to the nursing desk, picks up his own chart, writes his own progress note and then writes the orders he requires, and returns to his room waiting for the nurse to carry them out?

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Overheard from a surgeon in the staff room: a patient bartered for his cosmetic job with vintage wine. Another full circle from the rural doctor who took a quarter of beef for an appendectomy in yesteryear? TB treatment has also come full circle. Having ceased being a surgical disease in 1951 with the advent of isoniazid, the current TB epidemic, 40 years later, is bringing back discussions of pneumoperitoneums, thoracoplasties, and resections. A local phthisiologist remarked that once as he was giving a pneumo, the patient looked up and asked, “Doctor, is there a cure for this treatment?” As old diseases become new and different problems, it is noted that “People are dying today who never died before.”

The Clinton’s Plan November 1993

Overheard in the staff room: After making flight reservations for a medical meeting in Miami, the agent allegedly asked, “Could I reserve a bullet proof automobile for you or would you prefer a tank?”

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Hats off to Dr. Gordon Hunt, Chief of Staff at Sutter, for one of the finest staff presentations in memory on Tuesday, September 14, 1993. From the video on Paradigms to his review of the current health care climate to his assessment of the Sacramento innovations culminating in his predictions for the future and why it is important for physicians to support a health care system, it was very insightful. Brings back pleasant memories of some fifteen years ago when I presented a Sacramento Cocci case to my former Chief at the University of Michigan Chest Conference and first met Gordon.

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The Cascade Policy Institute has predicted the results of Oregon’s Rationing Experiment in a report by Peter Ferrara. It concludes that without the plan, Medicaid spending would have risen 25 percent in two years; with the plan, it will rise 65 percent. It also says the plan will increase the cost of medical care for insured working people, institutionalize cost-shifting and result in layoffs and business failures.

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P.J.O’Rourke, author of Give War a Chance & Parliament of Whores, commented the morning after Clinton’s address: I watch the network news and discover that the plan can’t be summarized briefly. I read the papers and find the plan cannot be explained at length. I listened to the president himself and he seems at least as confused as I am, though less succinctly. I gather, from the president’s sales pitch, we’re supposed to come up with a large sum of money to invest in a vaguely described deal that’s going to have a huge payoff someday. Isn’t the FTC trying to crack down on people who do this sort of thing over the phone? We can be certain of some facts about the health-care reform plan. It won’t work. The president has put a lawyer in charge of making doctors cheaper. Federal health-care reform will drive the best people out of the health-care professions.

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Thomas Sowell, of the Hoover Institute at Stanford, states that the president concedes that we already have the finest medical care in the world. Yet he is outraged that we spend more than other countries do. What is so surprising about the fact that the best costs more? You can always pay less and get less. But only by creating a massive new government program are you likely to pay more and get less.

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People think the health care system needs fixing but aren’t sure of what’s broken according to a survey by the WSJ/NBC News.

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Mike Royko in his column “The Hillary Plan: Watch your wallets” comments that Big Bro & Big Sis will probably pull it off. They have a big advantage in the media, since economists and doctors don’t know how to relay their message in 20-second sound bites. The genuine experts wind up on the opinion pages of a few big newspapers or in small magazines. For a preview of how the government will run health care, visit any VA hospital.

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Also the Morning After. . . Diana Griego Erwin (Sacramento Bee) focused on the $40 Billion lost annually through billing errors. She estimates that would buy health insurance for 14 million Americans… Isn’t that about the number of uninsured that aren’t just between jobs?

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Fifty years ago the emphasis of medical education was on primary care with the majority of medical students desiring that as their goal. The government emphasis on research through the national institutes of health and support of technology has gradually shifted the emphasis to specialty and subspecialty training programs with 85% of graduates in 1992 planning to go into such training. Now the government wants to reverse its own emphasis to again achieve a 50/50 split between specialists and primary care doctors. With the hundreds of billions spent by the government to develop the technology and emphasis and now the hundreds of billions the government plans to spend to de-emphasize the technology and reverse the emphasis, could we be so bold as to say that the normal course of events without government intrusion would probably have resulted in our being where the government currently wants us to be? Will we ever be able to learn from our past mistakes?

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Despite these changes in emphasis, we should be proud of our own University of California. Over the past year as the UC system reviewed the specialty/primary care mix of their graduate training programs, they have looked to UC Davis as the model for the entire system. UCD leads the list in 1992-93 with 53% primary care residents, followed by UCLA with 47.5%, UCSF at 43.5%, UCI 42.6%, and UCSD at 31%. UCD emphasis continues with 66% of their graduates in primary-care residencies. Up from a 46% average from 1972-92. Congratulations to our professors across town.

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The 77,000 member American College of Physicians gave qualified support to Clinton’s plan. All medical groups including the AMA support universal health coverage. All seem to want changes before full support can be given. The American Hospital Association and the American association of Retired Persons gave unqualified support as expected. The Federation of American Health Systems declines to give support. Dr. Koop, previous surgeon general, urged doctors to work for changes in the health system. “Our reservations or even outright objections, to some provisions cannot give us the excuse to oppose everything.”

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The US Department of Education released a devastating report on illiteracy among adults and youth showing that one in four high school seniors has not reached even a basic reading proficiency.

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Martin Feldstein, WSJ Board of Contributors, evaluates the proposed health plan on September 29, one week after it’s presentation. He estimates that financing the expanded health insurance benefits would cost about $120 billion more per year than the plan projects increasing marginal income tax rates by at least 24%. He recommends that Congress should be working on alternative lower-cost ways of dealing with our health care problems.

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This Federal Health Plan Worked Too Well. Shackleford, in the Wall Street Journal, cautions before we OK any plan that attempts to increase access to health care while harnessing costs ought to re-examined the government-funded End-Stage Renal Disease program. It shows that per-treatment costs can be controlled by setting limits on what providers are paid, but controlling the volume is vastly more complex. The initial projection was to serve 11,000 people in renal failure with a program cost of $35 million to $75 million with increase to $250 million by 1977. First-year costs were $229 million and reach $1 BILLION in 1977. A 100% variation in initial estimates still produce a 300-400% error over initial projections and a 400% error over five year projections. Costs in 1991 were $6.6 billion. This occurred despite a cap in reimbursement, no compensation for inflation, and lowering the reimbursement rate twice. The program was designed for 11,000 people and today serves 165,000, and is projected to reach 300,000 beneficiaries soon. Before 1972, it was designed for people 25-55 years of age. Now the fastest growing segment are those over 65 with aged beneficiaries in a persistent vegetative state and nursing home residents who go to dialysis centers on stretchers. . . President Johnson’s projection of the initial Medicare premium was at a 560% error. . . At the usual 100-500% error, President Clinton’s payroll tax projection of 3.5-8% would easily end up being somewhere between 7% and 40% of additional payroll taxes over the current 8%. With Clinton’s income tax rate projected to go to 39%, state income taxes to 11%, plus sales tax on everything we buy of 7% and property tax on everything we own at over 1%, we should be getting close to the 84% that UK had when Michael Caine left his country or the 101% taxes that a Swedish author experience before he left his country. And we still haven’t balanced the budget.

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What does the government consider free? Charles Osgood reports that one of our serious problems in this country is that the public has been conditioned to think when the government does something for them for no charge, it is free. Each cabinet member has 5-10 of their best employees dedicated to opening our mail and dealing with the responses. The Pentagon’s toll-FREE number since 1979 received 15,000 calls last year at a cost of $1.2 million. That works out to $80 per call. That’s 80 dollars per FREE CALL!

Fake Smiles December 1993

Watch for those fake SMILES. Psychologists report (Science 262:336) that they have separated the smiles that evoke positive emotions from those that don’t. If the smile, even if forced, involves certain muscles around the eye (instead of just those around the mouth) it activates an area in the left hemisphere of the brain associated with positive emotions. So be sure to put that pars lateralis muscle into action before you read the newspaper.

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Arthur Hoppe’s (SFChron) recent column “Is the Penis Obsolete?” is a follow up of his previous column condemning the new fad of penile enhancement pointing out that this male organ is the ugliest appendage on the human body. He received a clipping with a very feminine note attached. The clipping recounted how heroic surgeons in a grueling 10-hour operation reattached the penis of John Wayne Bobbitt after his wife, Lorena, had lopped it off. Scrawled across the clipping were the words: “What for?” (Almost as dismissive as was Dorothy Parker when told that Calvin Coolidge had died, “How could they tell?”) Hoppe enumerates all that we could accomplish if we eliminate this organ: wars, fights, divorces, overpopulation. . . Perhaps! But for the record, we’ve always preferred the Greek derivation “phallus.” It sounds so much more masculine and doesn’t remind us of those colonies that house inmates. . . However, if you’re examining an inmate, he may not recognize either the Greek or the Latin derivations. Even if you use a functional description such as “the organ of copulation” or “the organ of micturition” he still may not understand. You may be forced to use the vernacular.

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Arnold Relman, editor-in-chief of the New England Journal of Medicine, in his article carried by Newsday and the Sacramento Bee, “Doctors are the Key to Health Reform,” notes that we can’t blame health care costs on futile care which has not increased in the last 12 years, or malpractice insurance which remains a small fraction of the total cost of care, ($12B out of $900B), or the cost of defensive medicine which is not growing, (good physicians rarely feel compelled to practice it). Dr. Relman states, “It is unfortunate that the polls indicate that physicians seem to feel they have no responsibility for containing costs. But they do. If physicians do not take the initiative, they will end up working for the insurance companies now preparing to become medical-delivery plans. That would be unfortunate for all.”

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When I arrived at my office recently, I found upon my desk a 240-page “working group draft” copy of The American Health Security Act of 1993, marked PRIVILEGED AND CONFIDENTIAL. Thank you to whomever. . . Looking for something I hope we could all agree with, I found on page 62, “Fee-For-Service Plans.” It states that each Alliance must include among its health plan offerings at least one plan based on a fee-for-service system which may require utilization review, prior approval for certain services, but not a requirement to seek approval through a gatekeeper. Now we must come up with a fee-for-service system that will have it’s own built in controls to provide the clinical incentives so that physicians and patients will direct their health care to the lowest cost basis. Watch for our symposium on National Health Care in February.

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Just received the printout from my Delta Dental Plan indicating that they paid the full $54 for cleaning my teeth. The fee goes up every six months when I return for my recommended appointments. It was $30 a few years ago. I guess the dentists haven’t found the maximum that Delta Dental will pay. . . Reminds me of Eskaton American River Hospital some 15 years ago when my technical director informed me that the price of oxygen increased from 75 cents an hour to $3 an hour without any departmental input. We went into the Assistant Administrator’s office to register our concern about this $72 a day our respiratory patients were paying. We were told that Blue Cross, Blue Shield, Medicare, etc. were paying the $3 an hour and he had already authorized a further increase to $3.50 an hour stating “we haven’t yet found the maximum that the carriers will pay.” Oxygen cost at that time was less than 25 cents an hour.

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Congress has finally agreed that lectrocardiogram interpretation is a definable medical service and, therefore, should be reimbursed and Medicare actually will do so beginning in January. It must have taken hundreds of physicians thousands of hours to convince the lawmakers what was self-evident. An ECG has no intrinsic value until it is interpreted. But then, we as physicians have always had difficulty in articulating our position. In the early 1970’s, physician and hospitals split the ECG reimbursement. When the ECG charge was $18, we got $9. When it increased to $24, we got $12. When it increased to $38, we received $19. Then the hospital administrators (at that hospital that’s not on the River) convinced the Doctors that they could never recover their costs as long as they were tied to us. They actually convinced the internists that the cost of an ECG, which is less than $1 for the equipment cost and $2 for the technical cost required a higher than $19 hospital portion. (A $4000 machine had a capital cost of about $100 per month; if it did 200 ECG’s per month the cost per ECG was fifty cents; if 1000, the capital cost was ten cents; at that time a technician could easily do, mount, file, and bill 6 ECG’s per hour and got paid about $12 per hour) Why do we have difficulty asserting that we are as valuable as technicians in patient care?

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A family reports that their 8- year-old father, who had heart disease, collapsed in a restaurant. The maitre d’ called 911. The EMT told the family their father was dead but they would nevertheless take him to the hospital under CPR. He was pronounced 14 minutes after arrival. The hospital ER bill for those 14 minutes was $4300. That’s $300 per minute. . . I’m sure all internists and cardiologist are pleased the government has agreed that the minutes we spend reading ECG’s do have “some” value. Initial estimates are that it may be as high as $2 a minute for the 5-minute average.

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Thanks for all the comments, suggestions, and contributions. Irwin Lyons, M.D., Ph.D., J.D., in his role as a medico-legal arbitrator in health care law disputes, came across a photocopy of an identity card stating that the person was 1/64th Native American and was entitled to all the perquisites pertaining thereto. Does that mean the grandchildren at 1/256 ethnicity will have the same perks? It wouldn’t take too many more generations before all Americans could possibly be Native? There was a time when another minority race had to be out of some towns before sundown. A less diluted racial status was even more disastrously prejudicial. Miscegenation could be lethal. Perhaps Irwin, an analyst, will favor us with an analysis of this trend as it pertains to other minorities in history and the physical and mental consequences to our society.

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Sutter’s November quarterly staff meeting continued a high level of relevance with the subject of sexual harassment. A “comment” that four out of five men may take as a compliment, three out of five women would consider sexual harassment and could, if used, destroy your professional career and your family. Although attendance was modest for Gordon Hunt’s swan song, those that came seemed to think the message was timely and important. . . Meanwhile, across town, there was another staff meeting. Ballots had been sent out for the hospital’s chosen candidate for president-elect and a challenge candidate from the staff according to bylaw procedure. An additional candidate was fielded after many of the ballots were returned. We are told that attempts were made to delay the election, to change the bylaws, to allow staff to pick up their ballots and re-vote them. One response was why shouldn’t the hospital control at least 50% of the vote since they pay 50% of the staff salaries. Others began to wonder if medical staff salaries are a conflict of interest?

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Kenneth Grant, M.D., J.D., from Georgetown University School of Medicine, was a guest lecturer recently in Sacramento. In his comments on the proposed national health plan, he stated that there are only two people in the whole delivery of health care with any ethics – the physician and the pharmacist. Dr. Grant also showed a cartoon of “Billary’s Garage.” An ambulance had driven up to get a broken headlight replaced. The caption read: “You’ll need a new ambulance.”

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Getting back to those Fake Smiles. Be sure to check the smiles on those politicos who are out there allegedly trying to help our patients. We better fix that headlight before we will be forced to buy a new ambulance. . . And one final smile: “non profit” Blue Shield’s try to stitch together insurance, hospitals, and doctor groups into a loosely-knit merger with “for profit” UniHealth America is dead. If it had succeeded, Blue Shield would have lost its traditional allegiance to physicians and probably its membership in the national Blue Cross and Blue Shield organization. Would we then have had to organize a new Blue Plan? Keep smiling.