Florence – Firenze, Italia January/February 2001

When I received the announcement that the first World Congress on Lung Health would be meeting in Florence, I decided that it would be more cost effective to visit my daughter in London en route to this conference, rather than attend the American Thoracic Society annual meeting in Toronto and make a separate trip to London. It’s always interesting to see foreign medicine and wonder why any American would ever want such a system.

Arriving via Delta at Gatwick, I had not fully realized that it was some 40 miles from central London and a £100 taxi ride. After celebrating my daughter’s birthday, enjoying the theater, and catching up on the latest about the sale of her E-business, FirstTuesday.com, to Yazam in Tel Aviv, we proceeded on to Florence, the birthplace of the renaissance, and the World Congress. In Italy, driving must be a favorite sport. The taxi driver who drove us from the airport to downtown Milan, where we caught the train to Florence, ran everyone off the road driving 160 km per hour.

During the opening ceremonies of the Congress, a large “cigarette mortality” clock was started to record the deaths from cigarettes for the duration of the conference. With one person dying of cigarettes every eight seconds, the clock recorded 1800 deaths by the time the evening was over. This then totaled over 50,000 people killed by cigarettes during the five-day meeting.

The World Congress was sponsored by the American Thoracic Society (ATS), the oldest and largest society founded in 1905, the International Union Against TB and Lung Disease (IUATLD) which has had 32 biennial meetings, the Asian Pacific Society of Respirology (APSR) founded in 1988, and the European Respiratory Society (ERS) founded in 1990. There were 13,500 attendees from 60 countries. Every person I met knew where Sacramento was except one doctor from Milan. I was proud to be from a city with such wide name recognition. When one participant found out I was from Sacramento, she responded, “Then you must know my aunt and uncle in Los Angeles.”

Although the conference had interpreters for English, French, Italian and Spanish, all speakers gave their addresses in English, and very few attendees wore head phones to listen to a translation. There were 15 concurrent sessions that ran from 9-1 and 3-5. There were also excellent conferences every evening from 5:30-7:30. I also attended the various conferences of the ERS during the lunch hours. (We never had a bad Italian lunch or dinner.) These were patterned along the lines of the American Thoracic Society. Although there are no English-speaking countries in Europe, these meetings were in English. A doctor from Finland remarked to me in private that their Scandinavian Respiratory Society had always encouraged their members to speak in their native tongue at their meetings. He stated that for the last several years all four countries gave all their addresses in English. We have truly provided the world with an international scientific language. Isn’t it unfortunate that there are still some misguided people in this state and country who want to impede emigrants and other ethnic groups by having them schooled in their native tongues, rather than learn the scientific language of the world? Most of us who knew no English when we started school, and continued to speak our native tongue at home for the duration of our parents’ lives, were thankful that we were immersed in the science world’s language and had to learn it from day one in grade one.

The entire field of pulmonary medicine, from interstitial disease, obstructive disease, asthma and allergic disease, occupational lung disease and neoplastic disease, to diagnostics and treatments of each, along with their global implications, was covered. AIDS has increased the incidence of tuberculosis so that it now infects more people than before Streptomycin was first discovered.

John Murray, MD, Professor and Chief of Pulmonary and Critical Care Medicine at UCSF, gave the Millennial Lecture. He traced the history of pulmonary medicine during the past millennium ,beginning with the invention of the stethoscope by Rene Theophile Hyacinthe Laennec to the greatest leap made possible by Roentgen in 1905, as well as projecting into the new millennium. As with TB, the future is hard to predict. In 1966, the NIH conference concluded that everything we need to know for the prevention and cure of diseases is now known. All we must do now is apply it. In 1969, the US Surgeon General William Stewart stated, “It is time to close the book on infectious diseases.” TB, which was decreasing at that time, is now spreading so rapidly that there is no foreseeable end in sight. Murray quoted Groucho Marx, “Even the future isn’t what it used to be.”

The symposium on the Global Respiratory Problems with AIDS was horrifying. With 30% of Sub Sahara Africa infected with HIV, it is expected that AIDS will kill half of the population. There were over 5.4 million new cases last year. It is estimated that 13 million children have been orphaned by AIDS. The organizers of the Congress obviously expected this to be a popular topic and scheduled it in the largest meeting room with 900 chairs. However, only 35 of us attended.

A symposium on the final day was the Global Respiratory Problems of Tobacco. Never was it highlighted that in many countries of the Orient and South America, cigarette profits through government ownership, as well as taxes, are a major funding source. When the second to the last speaker, who was from Japan where smoking is endemic and 65% of physicians smoke cigarettes, stated that there may be evidence that cigarettes are detrimental to lung health, I left deciding that the conference had really ended one hour ahead of the scheduled end.

International conferences are important in providing a global perspective on health care and health problems and the difficulty of scientific advancement worldwide. The fact that a majority of physicians are still smoking may seem incomprehensible if only seen in print and not experience first hand. Some nations are just beginning the discussions we had four decades ago. We must continue to make our research available to the world at large. There is no basic scientific journal in many countries. Some, like in South America, only publish reviews of literature found in the advanced countries which does make our research available to our colleagues there. There is still much to be done. The First World Congress on Lung Health was a good first step.

We enjoyed the rest of our vacation into Venice, where the taxis are boats, and Rome, where the whole city is a museum much like Florence. Internet cafes are common allowing us to communicate with our office on a daily basis. Although bars serve spirits, the primary fare seems to be wine, sandwiches and gelato. We particularly enjoyed our excursion into Tuscany and the wine country made famous by San Francisco professor, Francis Mayes, who, along with her professor husband, purchased a 300-year-old villa and restored it over summers and quarters off from teaching. Her books give an insight into Italian life, habits, dietary practices, the importance of olive oil, their lovely complexion, and their civilized custom of an afternoon nap where some stores even close for an hour or two. One day, as she was cleansing herself in her bedet after a nap with her husband, she remarked, “Now I know the reason for the sunny disposition of Italians and Mediterraneans in general – most are conceived during the sunlight.” She has just come out with another volume, a coffee table edition. I look forward to displaying it.

Medical Errors or Harrassment Rejected for March/April 2001

At a recent conference on physician problems in the current healthcare environment, a number of participants discussed the questions: How did we get here and where do we go from here? Several physicians who suffered the brunt of Medicare investigations and had consequently been incarcerated and who were currently out on bail, gave personal testimony. One of the narratives was instructive in regards to the current media interest in medical errors and medical fraud. Fortunately, most of the cases presented were free of medical errors and, in retrospect, did not involve medical fraud. However, this was of no interest to the federal prosecutors and did not prove to be a disadvantage for conviction, imprisonment and fines.

Jeff Rutgard, MD, whose last speech was to a federal judge six years earlier, talked about the personal aspects of his case. He was charged with $65,000 of Medicare fraud. He hired a nationally celebrated attorney. After advising Dr Rutgard that he could lose his freedom, this renowned attorney stated that it would require 3-4 months of full-time preparation and a one million dollar advance to cover this work. However, at the pretrial court appearance, Dr Rutgard’s attorney was not prepared for his case. Both the nationally renowned attorney and local attorney he hired filed an affidavit stating that they were both unprepared. The judge denied Dr Rutgard’s constitutional right to be effectively represented and proceeded to trial with an ill-prepared defense. Dr Rutgard was found guilty of $65,000 of Medicare fraud. The judge told the prosecution that $65,000 was minuscule as an amount of fraud for a very busy doctor for his entire practice. The prosecutor asked the judge to extrapolate this $65,000, which represented less than 0.1% of Dr Rutgard’s practice, to all the Medicare proceeds received. None of the individual charges for examinations and surgeries were ever found to be fraudulent. Never-the-less, he was fined $16 million and given an 11-year prison sentence. He was denied bail pending his appeal, unlike most attorneys and judges found guilty of fraud or bribes, and was sent to prison without the courtesy of saying goodbye to his wife and 5 children. From prison, it took Dr Rutgard three years to file an appeal. The appellate court, after reviewing the available evidence, found only $45,000 of billings in question and stated it was unfair to extrapolate to millions of dollars without evidence and without allowing Dr Rutgard to defend the charges. The case was sent back for re-sentencing. However, it was sent back to the same judge who then required an admission of guilt to allow Dr Rutgard out of prison after the five years served. The judge did not require that the attorneys return the money, despite their admission that they had not complied with their hiring contract.

After the verdict, several jurors stated that they understood a guilty verdict to include a period of probation, community service, and a fine. One juror, interviewed by the San Diego Union, stated that he felt Dr Rutgard was innocent but voted him guilty because it would cost our government too much money to allow the doctor a new trial.

The verdict was based on false testimony given by Dr Rutgard’s office manager and a close friend he hired as a biller. The other billers who signed statements disputing the fraud were never allowed to testify. Three years later in another trial, the same office manager and assistant biller were deposed and stated that Dr Rutgard had not fraudulently billed Medicare. At this point, Dr Rutgard firmly believes he was the victim of disgruntled and dishonest ex-employees.

In the next issue we will present our interview with a physician from our own midst with a similar Medicare story and some thoughts about what we must do to prevent these manufactured crimes.