When Will Obama Force Sanjay Gupta to Resign?

"I never knew fear until I kissed Becky"
--Dr. Miles J. Bennell, from Invasion of the Body Snatchers

Just Put This Pod in Your Hospital

Is any one in the health care reform cabal talking to former GM chairman Rick Wagoner? Any of the physicians, insurers or hospitals who are right now working with the White House to decide just what form of government-directed-and-funded national health care is best?

I'm talking about the American College of Physicians and the American Medical Association; the national hospital groups and insurance companies who, either out of self-interest or fear or for what they believe is inevitable have decided to make the government the essential and most powerful part of our health care system.

Monday, Mr. Wagoner resigned from his job of 19 years as CEO of the storied automaker. He resigned because President Barak Obama told him to.

There was a time when this sequence of events would have rocked the news. The president of the United States told a CEO of a major American company to step down. But today, as the government moves in on our private institutions in a bad remake of Invasion of the Body Snatchers, we applaud the decision.

I turned on CNN to hear talking heads and politicians list all the business reasons why GM is a bad company, has made bad decisions and why Rick Wagoner needs to go. They were spouting opinions with perfect assuredness and authority as if they knew what they were talking about. As if they were part of the twenty years Rick Wagoner has spent making deals, managing contracts, overseeing a gargantuan international company, and as if they could sit in judgment and say: Wagoner has to go.

Maybe indeed, Wagoner had to go. I wouldn't know. That is far from the point here. The point is: when will the president, the White House and the media knock on Sanjay Gupta's door and tell him he needs to step down as a neurosurgeon (we have too many of those); or to leave his academic position at Grady Hospital (we need neurosurgeons in Michigan's Northern penisula--get going); or to get the hell off of television (it's not the right image for health care).

And when Dr. Gupta is yanked and remanded to Siberia, will we similarly sit at home, watch the news and say nothing? I guess there will be nothing to say.

The public will be numb to Sanjay's fate because they are inured by the neverending crisis talk that rains night and day from Washington through the media. "They had to do it," "Too big to fail," "Crisis, crisis, crisis."

Can Sanjay Gupta be far behind Wagoner? Watch the door Dr. Gupta.

Going Out of Business


Crisis drove (or actually flew) Wagoner and the other automaker CEO's to Washington in Novemebr where they asked for and got government intervention. Money. Strings attached.

Those strings were pulled this past weekend as Barak Obama told Rick Wagoner to resign. And now?Now Obama says that the government may force GM into bankruptcy!

So the power we invest in the government when they fund us is...control. We have to remember this. Since Obama takes his authority from taxpayers and dispenses it in the form of "aid" or "bailout" or "control" they are free to act, even if that act destroys or fundamentally changes the institution they are steping in to "help."

So Sanjay Gupta, if he doesn't watch out -- and by analogy our health care institutions and practices -- he may one day face the absolute and final solution directed from some bureaucrat and promulgated by a media frenzy: Out of Business.

Winning Back the Penis--One Piece at a Time

The first time I ever saw a man who was status post penectomy I decided that circumcision was the right thing to do.

He was a young man, in his thirties, and when I explored his medical history it contained reports of chronic low-grade infection involving the internal foreskin (he was then uncircumcised); multiple sexual partners, and phimosis (a condition where the foreskin is too tight).

This anecdotal experience lead me to the "stacks" (the magazine and journal library where we went for information before GOOGLE) where I reviewed the literature on penile cancer and circumcision. Although penile cancer was rare, it was significantly and seriously more common in uncircumcised men, who also had more frequent infections and complications than uncircumcised males. That was my take and I was OK with it.

Today we have news about circumcision. Namely, it seems that the procedure is extremely effective in reducing STD's. In fact:

"Over two years, the men who were circumcised had a 28 percent reduced risk of infection with the herpes virus and a 35 percent reduction in HPV infection."

Of course, HPV virus is an etiologic factor in cervical cancer, so these data have serious implications not only for the health of men, but for women also. Yet rates of circumcision have been falling dramatically all over the world in the past two decades, especially in the United States.

Why so?

Don't Touch That Penis!
Around the same time that I decided circumcision was a good thing, people had begun talking about the downsides of circumcision and a movement took hold which has since exploded, propelled by activists, disease-specific lobbyists and not a few doctors, who even formed an activist group of their own, "Doctors Opposing Circumcision (DOC)." Many of these groups cited the American Academy of Pediatrics (AAP) 1999 position statement which was selectively cited as saying that "the procedure is not essential to the child's current well-being"

If you read the entire position statement, however, the AAP admits quite a few risks associated with the uncircumcised state, including:

"the risk of developing penile cancer in an uncircumcised man compared with a circumcised man is increased more than three fold"

In the end the AAP conclude in their position statement that parents should evaluate the data and make an informed decision.

Along Came Mary
People who need work frequently look for injustices to remedy then they try to find publicity. This usually requires trumping up an issue with fiddled data, acquiring a celebrity, gaining publicity and eventually twisting the arm of a legislator to create a law to support the position, create a new class of "victims" and criminalize the opposition. Unfortunately, this happens in "health care" all the time.

Eventually, these groups rise in power and prestige and their pet legislators funnel pork back to the activist cause, creating a little industry funded by eternal government grants...and all this creates a nice little living, or avocational supplementation, for the activists and their socially and politically aligned warrior friends.

So they came to a new cause, circumcision. And they came like hungry birds: Activists, rights groups and newly formed coalitions like MAC (mothers against circumcision). A mini-movement overwhelmed the scientific data concerning circumcision, which rose in the socio-political ranks until it reached full-blown status as "child abuse" as detailed in this Fox report.

Soon enough, the government in multiple states was disallowing Medicaid reimbursement for circumcision (no matter what the parents decided was best for their male child) and the MAP (movement against the Penis) continued to pick up steam so that feminists were analogizing it to female mutilation and began trying to push circumcision to the level of a criminal act, which is the Holy Grail of activists.

If health activists cannot criminalize you they will demonize you. Public reprobation is another tactic of these oh-so-righteous activists. Soon enough people were ashamed to admit they circumcised their child, as recounted in a serious but humorous article on this topic in Salon which tracks the guilt and public shame heaped upon two Jewish parents who were torn between circumcision and the public disgust it seemed to incur:

"On one family visit, they'd been teasing me, saying that Elijah would probably end up being a Republican engineer, whatever that was. I said that I'd love him no matter what he became."

Individuals get slammed, but they are only pawns of bad doctors...and, of course, the American health care system, as demonstrated nicely by the words of Tim Hammond, a leading opponent of circumcision and founder of NOHARMM, the U.S. National Organization to Halt the Abuse and Routine Mutilation of Males:

Tim Hammond, believes that circumcision in the U.S. is perpetuated by arrogance and the radical American health environment.

Radical, Dude
No one can deny that grass roots movements often inform the public and help individuals make decisions regarding their own health. This can be powerful and good as demonstrated by the public awareness surrounding drunk driving and smoking. However, it is my contention that this process has been usurped by radicals, publicity seekers and those who need to make a living off of federal grants and monies.

Too often the tactics of bullying and public recrimination are used to blackmail legislators and voters, and the end result is wasted funds, wasted research, wasted health.

If we are going to reform health care (whatever that is), I think it is unwise not to look at this phenomenon and address it...unless you want these people deciding the fate of your penis.

Breast MRI and The Coming War Against Medical Technology

Flak: noun
1. antiaircraft fire, esp. as experienced by the crews of combat airplanes at which the fire is directed.
2. criticism; hostile reaction; abuse: Such an unpopular decision is bound to draw a lot of flak from the press.

The Rising Tide

I came across this headline on the website of Kevin, M.D.: "Does Breast MRI have any benefits for patients with breast cancer?" Being a big fan of breast MRI (and the lives of the women I've seen it save), this headline took me aback somewhat.

Kevin, M.D. referenced another blog by a general surgeon, Jeffery Parks, who titled his piece "Breast Cancer and MRI," and used the phrases: "Finally some news on the use (or overuse) or MRI in breast cancer;" and "There are situations where MRI could potentially be useful ..." (italics mine).

Both blogs are good ones, worth reading, and full of useful information (including these entries); the blogs and their authors are not my pursuit here. What does interest me is the PRESS that breast MRI (BMRI) gets not because it is a fantastic technology and head and shoulders above mammography, ultrasound and breast exam combined; rather, its the consistent repetitive criticisms that BMRI is expensive and too sensitive. These nonmedical criticisms overwhelm the real message: BMRI saves lives. It can save your life.

That's a Fact Jack
Let's start with two facts as demonstrated by multiple studies over the past 15 years:

1.The sensitivity of MRI of the breast is very high -- as high as 95-97% -- in detecting invasive cancer, no matter the size of the lesion.

2. The sensitivity of mammography in dense breasts can be as low as 45% ...................(otherwise known as a coin flip); and when a cancer is identified on a mammogram it can frequently be found on last year's mammogram, as often as 70% of the time

There are LOTS of studies that document the power of MRI in making the diagnosis of breast cancer.

Why then all the FLAK?

Share it fairly but don't take a slice of my pie

It seems to me that there is a lot of hostility out there as regards BMRI and this is symptomatic of the overarching strategy of the health care reform movement, magnified in this burgeoning era of limiting costs for health care. Since we seem to spend too much then we need to cut back. Where to cut back? Expensive treatments, diagnostics, drugs, and therapies.

MRI gets a lot of flak because of 2 reasons:
1. It's expensive
2. It finds a lot of things that aren't cancer resulting in more biopsies and follow-ups that...cost more money

A lot of people lobby against routine breast MRI because they feel it is an elitist form of care that most people cannot afford or for which most people are not insured. The case against extra biopsies and follow-ups also usually complain that this creates COSTS. Some authors now applaud President Obama's search for cost effectiveness via the stimulus package as a welcome effort aimed at optimizing care while reducing costs.

Demand What Ted Gets

In systems where the government is in charge of distributing limited tax dollars between different budgetary demands--one of which is health care--bureaucrats and their medical claque need to decide how to make maximum use of minimum dollars. As Canada and England and others have discovered, it is ideal to placate the 95% of people who never need more than simple remedies, homeotherapy, adjustments, zinc tablets, and laughter therapy.

The other 5% -- the people in the ICU's and in the trauma ward; the severely burned, the patients with rare chronic diseases and those who would benefit from high-end diagnostics -- those 5% don't make a potent voting block and don't seem significant in surveys that affirm "satisfaction with the health care system."

These are the patients who will be left behind in the future of Ted Kennedy's Health Care America.

Natasha Richardson, Epidural Hemorrhage and No Help in Canada

Previous Posts on Natash Richardson at Kennedy's Tumor:
What Happened toNatasha Richardson?
Natasha Richardson, Epidural Hemorrhage and Canadian Health Care

The Death of Natasha Richardson

Kevin, M.D. today adduces that Natasha Richardson indeed had a CT of the brain at Centre Hospitalier Laurentien--after falling ill with a recent history of head trauma, but there was no neurosurgeon available to do a STAT craniotomy which would have saved her life; however, this is not a fault of the Canadian system:

in remote resort areas in the United States, small community hospitals would likely lack neurosurgical coverage. In fact, because of the huge malpractice risk associated with the field, even if there was a neurosurgeon available, whether he or she would take emergency call at a community hospital would be in question.

How Remote?

Mont Tremblant is one of the most recognized and popular ski resorts in the world. It is famous for celebrity sitings, and the rich and famous frequently take up seasonal residence there.

As of 2005, Mont Tremblant had been recognized by Ski Magazine as the #1 ski resort in Eastern North America for 8 consecutive years.

Given the popularity of the area and the nature of skiing and snowboarding, Natasha Richardson may be the most famous person that’s ever come down from Tremblant’s slopes needing emergency neurosurgery, but I doubt that she is the first.

According to JAMA :

...head injuries are common in alpine skiers and snowboarders. Head injury is the most frequent reason for hospital admission and the most common cause of death among skiers and snowboarders with an 8% fatality rate among those admitted to hospital with head injuries. Of the 3277 patients with injuries recorded, 578 patients (17.6%) had head injuries. Head injuries accounted for 288 (17.9%) of 1607 alpine skiing injuries, 248 (17.8%) of 1391 snowboard injuries, and 32 (17.9%) of 179 of Telemark skiing injuries.

Head injuries constitute only 5% to 15% of all injuries from ski and snowboard accidents, yet are the primary cause of serious disabling injuries and death. There are approximately 10 fatalities per year in Colorado from accidents on the ski slopes, and among the fatally injured in one study, head injury was the cause of death in 87.5%;

Another report lists the incidence of ski head injury incidence at 0.77 per 100 000 ski visits

And a mega-study estimated rate of one death per 1.5 million skier-days.

Comparable ski areas in the U.S. – say Vail and Park City – both list neurosurgeons in their cities. Vail, Colorado has a population of 4,589 and is home to 1 practicing neurosurgeon. Park City, Utah population 7,371 also lists 1 practising neurosurgeon.

So, ski resorts should probably think hard about neurosurgical availability, is my impression, but all of the above begs the real issue, which is the differences between the Canadian model for health care and ours -- and where ours is going.

Availability of Neurosurgeons

Kevin, M.D. rightly states that a neurosurgeon is probably just as unlikely to be available in a U.S. ski town, as in Canada, and that may be so but the reasons are diametrically the opposite.

Neurosurgeons are not so easy to find in Canada where subspecialization is not rewarded, and 50-60% of boarded neurosurgeons leave the country to practice somewhere else within 2 years of their certification.

The last good data I could find listed only 174 neurosurgeons in the entire country. In the U.S. we have 3,500. A study on the need of neurosurgeons listed the density of neurosurgeons in the U.S. to be about 1/55,000 people which means that an analogous number of neurosurgeons needed in Canada would be about 604.

It is true that neurosurgeons eschew emergency room coverage in the United States, but it is for completely different reasons than in Canada. Here, our ED’s don’t want to pay what it takes to hire a neurosurgeon for coverage; in Canada, no one wants to even be a neurosurgeon.

So, in a sense, the Candian model for health care failed Natasha Richardson because of an artificially created shortage of subspecialists, which is a purposeful design meant to keep costs low in a taxpayer-funded-system. The U.S. would very much like to go in this direction and the plan is to broaden non subspecialized care options while reducing higher-tech procedures, diagnostics and physicians.

But as we go towards a single-payer system, we can all expect that when we need it most, the system will not be there for us, as it was not there for Natasha Richardson.

Natasha Richardson, Epidural Hemorrhage and Canadian Health Care

This CT scan (LEFT) shows 4 TYPES of intracerebral hemorrhage:

1. EPIDURAL short white arrow;
2. SUBDURAL short black arrow
3. SUBARACHNOID long black arrow
4.INTRAPARECNCHYMAL ( = in the brain matter itself)
long white arrow

Yesterday it was my conclusion that Natasha Richardson suffered from a subarachnoid hemorrhage (from a ruptured aneurysm)rather than an epidural or subdural hemorrhage because, as I said:


"Both epidural and subdural hematomas should have / would have been rapidly diagnosed and she would have had an emergency procedure to release the pressure."


In other words, it was my assumption that if she had an epidural or subdural hematoma it would have been rapidly treated when she was taken to a local hospital --Centre Hospitalier Laurentien--after falling ill with a recent history of head trauma.

So if Natasha Richardson had an epidural hemorrhage, the question becomes: did she get a STAT CT scan and was there a neurosurgeon at the hospital, or nearby on call who would be able to do the emergency procedure needed to save Natasha Richardson's life?

Canadian Health Care

It's important to ask this question, because this is precisely the situation where the Canadian-type health care system -- much touted by reform advocates -- tends to fail Canadians.

In the United States, we pay a lot for health care, but that care is widely dispersed, into communities, with high-level diagnostic and therapeutic options available in fairly wide-flung areas.

In Canada, there are only 10.3 CT scanners per million people whereas the U.S. has 29.5 per million...so it is reasonable to ask if Centre Hospitalier Laurentien has a CT scanner, and did Richardson get a CT of the brain STAT?

In the United States if someone falls and hits her head and then an hour later is rushed to the emergency room you can bet she will get a STAT CT scan and immediate neurosurgical attention.

Can you bet that Natasha Richardson got that care? I hope so. I do have some doubts because shortly after being admitted to Centre Hospitalier Laurentien, she was shipped out to a larger hospital in Montreal; and, of course, later that day she was pronounced brain dead.

I hope Natasha Richardson got the appropriate health care and that this was all a tragic and improbable occurrence. But if not, it would be an important thing to know.

What Happened to Natasha Richardson?

Monday, Natasha Richardson was skiing on a beginner slope and suffered a fall. She seemed to recuperate, but later became symptomatic and was rushed to a hospital in Canada. Tuesday night she was reported as "brain dead."

What happened?

Three most likely possibilities:

1. Epidural hematoma (see CT scan on the left)
-arterial bleed between skull and brain with rapid and devastating pressure developing on brain; short time course, usually over hours

2. Subdural hematoma

-venous bleed between skull and brain, slower time course but reaches a point when pressure can create catastrophic pressure effects

3. Subarachnoid hemorrhage (ruptured aneurysm- blood around and/or into the brain)

- rapid symptoms and time course with potential for devastating spasm of vessels

Epidural or Subdural?

Both epidural and subdural hematomas suggest a significant blow to the skull. Dr. Michael Baden suggested an epidural hematoma lat night on Fox news, mainly because of Richardson's rapid decompensation and the "lucent" period (she was normal for a short time after the injury), which, clinically, is the time it takes for the blood collection to get large enough. However, most epidural bleeds require a significant focused blow to the skull:

The inciting event often is a focused blow to the head, such as that produced by a hammer or baseball bat. In 85-95% of patients, this type of trauma results in an overlying fracture of the skull.

A subdural hemorrhage that is bad enough to render you brain dead in a day, also usually involves a significant blow to the skull and an associated brain injury:

Acute SDH is commonly associated with extensive primary brain injury. In one study, 82% of comatose patients with acute SDH had parenchymal contusions

Both of these lesions can be rapidly and simply diagnosed with a noncontrast CT scan of the brain and both of these lesions can be rapidly treated --with reversal of the outcome-- in a modern, competent, well-equipped emergency room.

Subarachnoid Hemorrhage (SAH)

When I first heard the sequence of events, I assumed Richardson had an SAH from an aneurysm rupture because:

1. Her age

2. Minor trauma (assumption because she was on a beginner slope with a pro)

3. Lucent interval (SAH can frequently have a small initial bleed which is followed later by a catastrophic bleed)

4. Both epidural and subdural hematomas should have / would have been rapidly diagnosed and she would have had an emergency procedure to release the pressure

5. Rapid progression to massive brain injury: SAH can quickly cause diffuse spasm of brain vessels leading to brain infarction -- which is irreversible and catastrophic

The problem I have with SAH is that they would not have put her in a plane and flown her to NY the next day...aneurysm patients are at a high risk for rebleed and need to be treated quickly, if at all possible in a nearby geographic location; unless the course of events was so rapid and tragic that it didn't matter.

Also, the time course is very bizarre, I mean, to go from a minor fall to brain dead in 24 hours??

Whatever the mechanism, this concatenation of events is tragic it its absolute unlikeliness and in the devastation that has ensued.

Thanks to Kevin, M.D. for link. Read what he has to say...

Also discussed by an ER Doc at Movin' Meat...

GRAND ROUNDS

This week at ACP Internist.

Grand Rounds is a weekly compilation of medical blogs around the web.

Go there for hope and change.

Mammography Bailout is Coming

"A Very Expensive Program"

In 1993 the United States government seized control of the mammography "industry" with the Mammography Quality Standards Act. Over the past week I have blogged about this catastrophic government takeover here and here and here.

MQSA was purportedly designed to "improve" quality in mammography; however, as we have seen, the people involved in enacting the law really did not have a good grasp on the medical issues involved; rather, they were fixated on a political and social agenda that would send a bigger message to the United States health care system, and the world.

As one analyst described The Act:

"the adoption of the MQSA...was a highly political decision that reflected the efforts of numerous advocates and legislators to remedy the historical failure of the medical establishment and regulatory structure to pay the proper amount of attention to issues affecting the health of the nation’s women."

Because the aim of the act was social and political, the unintended consequences included the possibility of actually harming the practice of mammography -- something which has come to pass. As previously noted by Kennedy's Tumor:

*The sensitivity and specificity of mammography remain unchanged 1993 vs 2009.

*Mammography today is no better at finding cancer than it was in 1993 ...AND

*STILL...a mammogram is an insensitive test for many women
*STILL...mammography remains the second most dangerous thing a doctor can do in all of medicine
*STILL...jury awards for missed cancers on mammograms represent the largest liability awards in all of medical practice.

And what changes has MSQA actually catalyzed?

*massive closing of women's centers
*physicians fleeing the field
*millions of dollars in costs
*destruction of business initiative
*blunting of technology that might actually produce better methods of finding and diagnosing cancer

The Economy of Failure

MQSA has devastated the practice of mammography. But what are the real dollar costs?
A lot of money. As quoted above, a Harvard law school analysis in 2003 listed the government appropriation for operation of MQSA its first year of full operation, 1994, at $10,000,000 followed by an additional $1,000,000 that were transferred from the Center for Disease Control for MQSA implementation.

The Congressional Budget Office has estimated that reauthorization of the MQSA program, in 2003, cost $12,000,000 that year and an additional $77,000,000 over the 2003-2007 period.

Of that amount, $52,000,000 is for program services not covered by user fees.

"User Fees" are the fees/taxes levied each year on the mammogram facilities which, for 2008, were $18,398,000.00. These fees do not reflect the cost each center incurs hiring personnel to assist with compliance; buying software to track, publish and compile the data requested; and pursuing ongoing continued medical education training courses as required by this onerous law.

And those user fees are plummeting (think credit default swaps), as centers close at the rate of 20 per month; meaning more government bailout money will be needed, only this time to support the continued depreciation of the practice of screening women for breast cancer-- caused directly by government intervention in health care.

Zero Gravity Mammography

When You Gotta Go...

There's a scene in 2001 a Space Odyssey, when Dr. David Bowman, the ship commander, has to use the most simple of devices, the crapper.

Unfortunately, poor Dr. Bowman is going to have to wait until he reads and deciphers the instructions for the Zero Gravity Toilet before he gets to go...

Posted below, are the Zero Gravity Toilet Instructions for Mammography-- provided by Congress as the Mammograpthy Quality Standards Act (MQSA)--just in case you thought I was exaggerating in my previous posts here and here, describing the only federal law that regulates a specific medical practice or procedure.

There are no such guidelines for brain surgery or giving chemotherapy to children or even pulling bullets out of mafia hit men in the ER; only mammography -- the most basic of all basic radiological exams -- warrants its own set of rules, assessments and penalties, provided by its own law.

Now, provided for your bathroom perusal, are the MQSA guidelines that every mammography center is compelled to abide by -- through the force of law. Think of what it costs to do this (and you'll begin to understand why women's centers are shutting down at the rate of 20 per month!)...then think about what the situation will be when we have laws for all the things we do in health care (called nationalized health care or single payor system).

Then even Ted Kennedy might be stymied!

MQSA Regulations Overview

Quality Standards

Personnel. Interpreting physicians, radiologic technologists, and medical physicists must meet initial and continuing requirements. Documentation of these requirements must be available for inspection.
Equipment. Only equipment designed specifically for mammography qualifies for certification.
Medical Records and Mammography Reports. Summary data written in lay terms must be sent directly to all patients as soon as possible. Mammography films and reports must be retained for at least 5 years and up to 10 years, and labeled according to Food and Drug Administration (FDA) regulation.
Quality Assurance. Quality control testing protocols must be used and maintained by each facility, including mammography equipment evaluations and an annual physics survey. Documentation of daily, weekly, quarterly, semiannual, and annual quality control tests must be retained for FDA inspections
Mammography Medical Outcomes Audit. An interpreting physician must annually review the medical outcomes audit data.
Consumer Complaint Mechanism. Facilities must establish a written and documented system for collecting consumer complaints.

Accreditation
Current Accreditation Bodies. American College of Radiology (ACR), Iowa, Arkansas, and Texas.
Responsibilities of Accreditation Bodies. Accreditation bodies must monitor facility compliance with quality standards, review clinical and phantom images from each facility at least once every 3 years, conduct annual onsite visits of at least 5 percent of the facilities it accredits, and maintain a consumer complaint system.
Accreditation Body Audit. FDA will evaluate the performance of each accreditation body annually.
Facility Accreditation. Facilities must submit verification that personnel, equipment, and practices conform to established quality standards to be eligible for accreditation.

Certification

Current Certification Bodies. FDA, Iowa, Illinois, and South Carolina.
Responsibilities of Certification Bodies. Certification bodies must issue Mammography Quality Standards Act (MQSA) certificates allowing accredited facilities to operate lawfully, and must perform annual inspections of each certified facility.

Facility Certification. Accredited facilities are eligible for certification. Certificates are valid for 3 years, and are renewable.

Inspections

General. Facilities must undergo annual inspections.

Inspectors. Facilities may be inspected by FDA inspectors, state or local agency inspectors under FDA contract, or inspectors from states that are certifying agencies. Federal facilities can be inspected only by FDA inspectors.

Inspector Audit. Annual assessment of state performance is carried out by FDA auditors.
Fees. The facility undergoing inspection is responsible for all inspection fees. As of October 1, 2003, a fee of $1,749 is charged for the first mammography unit inspected, and $204 for every unit thereafter. Follow-up inspection fees are $991.

Compliance and Enforcement

Levels of Noncompliance
Level 1: Failure to meet a key MQSA requirement that may seriously compromise mammography quality. The facility is given 15 days to respond with corrective actions.
Level 2: All critical MQSA requirements met, yet a significant mammography quality item overlooked. The facility is given 30 days to respond,
Level 3: A minor deviation from MQSA standards. The facility is given until next annual inspection to address the problem, although it is advised to correct it as soon as possible,

Enforcement/Sanctions/Other
FDA may impose one or more of the following sanctions:
Directed Plan of Correction, allowing facility to correct violations in a timely manner, while being monitored by FDA.
Patient and Physician Notification, requiring facilities to inform those that may be at risk due to unacceptable image quality or other conditions that could cause significant negative impact on patient health. Follow-up Inspection.
Certificate Revocation or Suspension.
Civil Money Penalties of up to $10,000 per examination or per violation per day may be applied to facilities performing mammography services without proper certification or for other significant violations.

Advisory Committee

Title. The establishment of a National Mammography Quality Assurance Advisory Committee (NMQAAC) was mandated by MQSA.
Members. FDA appoints members from the community of physicians, health professionals, consumer organizations, and industry representatives.
Responsibilities. The NMQAAC advises FDA on appropriate quality standards, assists in the development of sanctions, designs a method to investigate consumer complaints, reports on new developments in breast imaging, determines whether a shortage of health professionals exists, and measures the costs and benefits of MQSA compliance.

SOURCE: Mammography Quality Standards Act, 42 U.S.C. § 263b (2003). 21 C.F.R. § 900.1 (2003).

MQSA, MUSSOLINI, AND MAMMOGRAPHY

Making the Trains Run on Time

"...the Mammography Quality Standards Act... had little if any precedent in the history of medicine. Never before had the federal government claimed a role in the regulation of medical practice."
-NYTimes: June 27, 2002

As I said in my previous post:

PRIOR TO THE 1992 GOVERNMENT SEIZURE OF MAMMOGRAPHY WITH THE MQSA (FEDERAL MAMMOGRAPHY ACT):

1. Women’s imaging is booming – competition for business is brisk
2. Women’s centers are being built everywhere with parquet floors and vaulted ceilings, furnished with overstuffed chairs and couches providing a private, comfortable milieu
3. Medical device manufacturers are eagerly in the game, developing stereotactic minimally invasive biopsy machines; MRI of the breast and digital mammography are both rapidly being developed to advance sensitivity and specificity of diagnosis
4. Diagnostic Imaging residencies open a new subspecialty: Women’s Imaging. Interest among radiology residents is high

What is the Situation Today? What Did We get From Government Regulation?

1. Women's imaging centers are closing at the rate of about 20 per month--
2. The wait for screening mammograms is 6 months in many areas and in lower population areas or areas of high liability--there are no radiologists available to interpret mammograms--the tests are shipped out for remote interpretation
3. No one wants mammography business except large hospitals who are banking on the spin-off money from surgery and therapy for the 1 in 1000 screening patients with cancer-- in other words, the only businesses interested in doing mammography now are businesses hoping women have a cancer ...
4. Medical device manufacturers have fled the field. Stereotactic biopsy devices, MRI of the breast and Digital mammography are all dead in their first or second iterations--without profits, no one is buying new technology, which therefore remains fallow
5. Radiology residents eschew women's imaging and most fellowships go unfilled and without applicants--despite the fact that at least 30 million mammograms will be done each year in the U.S.

Did MQSA Improve Quality in Mammography?

In mammography, improvement should = greater number of cancers found in any given 100 mammograms in 2009 vs 1993.

No matter what the unintended consequences, if MQSA resulted in MORE cancers found per 100 screening mammograms, then the price of this"reform" might be worth what it cost.

Not With a Bang

The sensitivity and specificity of mammography remain unchanged 1993 vs 2009. This means that for every 100 mammograms the same number of cancers would be found today as would be found in 1992--before the government seized mammography with MQSA.

Despite millions of dollars spent in compliance
Despite hundreds of pages of federal regulation
Despite education and training mandates
Despite licensing requirements, yearly requalifications, and mandated QA

Despite all of this, mammography today is no better at finding cancer than it was in 1993

What MQSA has done is to standardize the procedure of taking a breast x-ray and the machinations of the women's mammography facility--akin to Mussolini making the trains run on time in Italy in the 1940's --without ever addressing or even understanding why mammograms cannot do any better after reforms than before!

They threw everything they had at mammography -- anecdotes, laws, regulations, Congressmen, feminists, actresses --everything they want to throw at health care today; but, because they started with bad assumptions and a faulty premise, all the rules and dogma and laws could not repair what they perceived as wrong.

And the main reason is because it was not broken. Just like the medicine and surgery of our health care system today. And after such reform, what knowledge?

STILL...a mammogram is an insensitive test for many women

STILL...mammography remains the second most dangerous thing a doctor can do in all of medicine

STILL...jury awards for missed cancers on mammograms represent the largest liability awards in all of medical practice.

Government takeover of mammography has not improved quality, has not reduced liability, and has not saved one life...
But it HAS

...Caused massive closing of women's centers
...Chased physicians from the field
...Cost hundreds of millions of dollars
...Destroyed business initiative
...Stymied technology that might actually produce better methods of finding and diagnosing cancer

Nowhere Train

Is this what we want in health care reform today? Reform the system, reform the process, address social grievances and perceived injustices while satisfying special interest groups and politicians? Because the system then faces the same fate as mammography.

You will reform insurance. You will reform distribution. You will address costs, but in the process, you will vitiate the services, chase away the best practitioners, and create a great a void where once the world's best health care resided.

You want the train to run on time but to be going nowhere?

...this is what the government will bring us.

How The Government Destroyed Mammography

Want a Glimpse of the U.S. Health Care Future?

Look at Mammography.

Do we have any indication, right here, in the U.S. what would happen if the government “took control” of health care?

Yes.

All you need to do is look at the story of mammography and the Mammography Quality and Standards Act of 1992. Want to see what you are in for? Here’s a synopsis. In the coming days I’ll give you the whole juicy story.

SCENE I:

PRIOR TO THE 1992 GOVERNMENT SEIZURE OF MAMMOGRAPHY WITH THE MQSA (FEDERAL MAMMOGRAPHY ACT)

1. Women’s imaging is booming – competition for business is brisk
2. Women’s centers being built everywhere with parquet floors and vaulted ceilings, furnished with overstuffed chairs and couches providing a private, comfortable milieu
3. Medical device manufacturers are eagerly in the game, developing stereotactic minimally invasive biopsy machines; MRI of the breast and digital mammography are both rapidly being developed to advance sensitivity and specificity of diagnosis
4. Diagnostic Imaging residencies open a new subspecialty: Women’s Imaging. Interest among radiology residents is high

DEUS EX MACHINA:

1992: THE FEDERAL GOVERNMENT SEIZES THE MAMMOGRAPHY INDUSTRY WITH AN ACT OF CONGRESS--MQSA IS SLAMMED THROUGH CONGRESS.

WHY?

Perceived quality issues are championed by television “investigative” reporters, and then picked-up by nonmedical women’s activists and disease-specific lobbyists as a political, social and moral cause. Mammography is assumed to be tainted by the male-dominated health care industry and it becomes de facto evident to all that because of the second class social status given to women, this most valuable diagnostic examination is poorly supervised, and, as a result, cancers are being missed and women are being harmed (by the health care system).

Popular female political figures like Olympia Snowe team up with grass roots organizations like The National Breast Cancer Coalition and The National Black Women's Health Project to take up the cause with Congress. Congressional hearings ensued and the lack of formal studies and empirical data to support the notion that mammography was seriously and significantly amiss were ignored in the rush to right the wrongs done by Western civilization on women in America. A gargantuan wish-list of regulations, oversights, and QA controls were compiled and thrown at mammography practitioners along with serious and disabling price controls which permanently set the price of mammography too low to pay for any of the unfunded mandates foisted on the industry.

Why price controls in the face of new massive regulation? The proposal was that too many women were not getting mammography, despite the fact that out-of-pocket expenses for health care had not changed in 30 years and have not changed yet, to this very day.

But the facts were never an issue at the hearings and the government sailed this massive legislative ship which has devastated mammography.

In summary: The media fanned the anecdotal flames and activists seized their opportunity to effect CHANGE, despite the facts, and Congress marched in lockstep behind the forces of political and social activism against which they are incapable of fighting and, in a worst-case-scenario, massive legislation was enacted without appropriate data collection and consideration -- and why did they act so quickly?

Because they claimed WIDESPREAD PROBLEMS that were out of control and needed to be acted upon quickly because the mammography industry was:

IN CRISIS

Next:

What was the government’s response to this CRISIS in mammography?
What was the Mammography Quality Standards Act (MQSA)?
Did government intervention fix the perceived problems that lead to the avowed CRISIS?
What has happened to mammography since the MQSA?

This tale will tell you a lot about where our health care is going…

BULLETIN: DVD'S FROM OBAMA REVEALED

OBAMA REVEALS TO KENNEDY'S TUMOR, MOVIE TITLES OF DVD'S HE GAVE TO PM BROWN

Brilliant folksy reform president, BHO, came under criticism for a gift of 25 DVDs to Gordon Brown the British PM who is the first European leader to visit Obama since his inauguration.

In what some journalists described a lapse in taste, or protocol, or maybe even upbringing, Obama presented the British leader with a pile of mass-produced plastic discs which mainly celebrate American pop-culture (which understandably may mean nothing the Brown); whereas Brown gave to Obama gifts that were unique, well-thought out, and tasteful, including a pen holder sculpted from the timber of an anti-slave ship and a Churchill first edition.

The British press is probably being too hard on BHO, and they likely underestimate his brilliance; and, with this in mind Kennedy's Tumor requested a list of the Top Ten Videos Obama presented to Brown because surely there is method to his gifting and a meaning to his choice of DVD's. Now that we have the list, everything is clear. In reverse order they were:

#10. Leaving Las Vegas

#9.: Who'll Stop the Rain?

#8. The Empire Strikes Back

#7. The Big Chill

#6. Dirty Rotten Scoundrels

#5. Dumbo

#4. The Great Dictator

#3. (3-way tie): King Lear; The King and I; The King of Comedy

#2. I am Legend

#1. Gone with the Wind

BHO Launches Another Trial Balloon

All The President's Mien

When Ted Kennedy needed to save his own life he called together all of the world's experts on brain tumors and had them advise him.

He did not ask for anecdote; nor did he consult the common man. He was not concerned with homeotherapy, chiropractic adjustments, laughter therapy, anger management or sodomy. He wanted the facts as science dictates at this time and he wanted no nonsense opinion -- based on science and experience -- on which he could act. No time for rhetoric, or BS. There was something important at stake.

Act, he did. Ted flew to one of the best hospitals in the world (HINT: it's not in Cuba or Canada, it starts with a "D" and is present, in North Carolina, thanks to the money contributed by a cigarette heir).

The White House Holds a Health Care "Summit"

When the folksy economist-in-training commander-in-chief Barrack H. Obama wants something done, he holds a "summit;" which, according to Dictionary.com is:

the highest level of diplomatic or other governmental officials: a meeting at the summit

Ted Kennedy held a"summit" to discuss his personal medical problem. He met witht the highest level people available to get quickly to the core of the issue and devise an intelligent, workable solution; namely, GET ME TO DUKE!

In his summit, however, Presidente Obama brought the lowest level experts --the common people -- to lecture and inform the world about the US health care crisis.

So, as the White House launches another dirigible towards New Jersey (are those thunderclouds ahead?), it does so with the quiet applause of the common man; and so we were subjected to -- at this summit-- not the opinions of the learned, but the anecdotal inconsequential ideations of select tendentious individuals, namely:

1. Travis Ulerick. a fire fighter/EMT from Dublin, Indiana, quoted thus:

"Every day on the job, I meet people who don't have health insurance, people who are left out of the current health system. People in my town can't afford health care costs. They can't afford doctors' visits, and they can't afford ambulance rides."

2. Julia Denton, a military wife and Republican

3. Siyavash Sarladi, a third-year medical student at the University of Wisconsin;

4. Yvonne Ruby, who held a discussion at her church in Brooklyn;

5. James Stouffer, a small-business owner and father of five;

6. Jose Olivia, a veteran who hosted a discussion in El Paso, Texas; and

7. Angela Diggs, who runs a senior wellness center in Washington, D.C.

These people brought their individual attestations to Washington as part of the launching process in which BHO sends off a huge gas-filled health care reform dirigible that, by the time it hits the shores of our health care will, undoubtedly -- like the economy -- come reigning down on us in shards of molten steel.

Scanning For Dollars

Are Doctors Irradiating You So Their Kids Can Go to Private School?

As I reported yesterday, Reuter's put out a story about a relatively important subject: X-ray exposure during Diagnostic Imaging examinations (mainly CT and Nuclear Medicine).

The Reuter's story was fabricated off of this release from the NCRP (National Council on Radiation Protection & Measurement).

Reuters took a straight-forward statement of the facts, talked to a few doctors who implied that "self referral" was an issue in imaging, and came up with this stew:

"The findings... add to already mounting evidence that doctors are ordering too many diagnostic tests, driving up the cost of health care in the United States and potentially harming patients."

This Reuterian conclusion (Reuterian is from the Greek for "stupid head") is at best a deductive error, but really is just a fabrication meant to draw readers, which they did, with 201 subcategory stories on this topic listed on Google by noon yesterday.

Ordering "sophisticated expensive tests" is a common refrain in the corridors of the health care reform hotel, where we are all staying until Obama can bail us out from this health care crisis by "completely overhauling" our horribly broken health care system (that's the one Kennedy chose for his brain cancer treatment when he had the financial options to go anywhere in the world).

The idea is that when those sophisticated and expensive tests are taken away from you and rationed (as they are in Canada where Kennedy DID NOT fly his jet to for treatment), you will be told it's for your own good, because you cannot trust your greedy doctors to order the tests. It is much better that a nurse sitting at a desk in Roanoke Virginia make that decision over the phone, when she gets back from her lunch break and finishes handing out her Secret Santa gifts and goes through the seven hundred requests before yours that are lying in her desk.

You Want the Truth?

Why are so many CT scans ordered? Yesterday I mentioned that the main reason is that the scans are so good -- we want to see them. When you have a pain in your head do you want someone to flash a light into your eyes and stare at your pupils and say "Hmmm...looks good!" Or, do you want a photograph of what's going on inside your skull obtained by a professional on a fabulous (Nobel-winning) machine and then interpreted by an expert? Tough choice.

Why are CT's so good? Because they are computers, that's why. At the top of this page is my first computer. It was a Kay-Pro. It had no hard drive, about 64K of RAM and two huge floppy disks which held about 16K each. That was 1983.

The "C" in CT scan stands for "Computerized." A CT scanner in the 1980 had no processing power and no memory. However, in the 29 years since 1980, CT scanners have advanced their imaging capabilities in a perfectly parallel course with chip processing and memory power. Make sense?

So today -- as opposed to 1980, or even 1990, or 2000 -- the images generated by CT are spectacular and we now can do 3D fly-throughs of your colon (virtual colonoscopy) and stop your heart for a look at your coronary arteries (64/128 slice CT angiography).

Now lets look back at the first sentence in the Reuters article from yesterday:

Americans are exposed to seven times more radiation from diagnostic scans than in 1980, a report found on Tuesday...

And the next line in my report would have been: because the evolution of imaging technology has made it so accurate and valuable that we cannot live without these tests; but, Reuter's next line was:

"as experts said doctors are overusing the tests for profit and raising health risks for patients."

Sin is behovely.

When All You Have is a Hammer...

Everything is a Nail

Everyone is starting to pile on. Now every announcement of some health issue or new academic study has, as its point, THE HEALTH CARE CRISIS.

Everything contributes to this "Health Care Crisis" (i.e. the cost and insurance crisis) in the hands of undereducated reporters.

Reuters today took a perfectly legitimate issue -- the importance of understanding the use of radiation in imaging -- and turned it into a manifestation of the health care crisis; specifically, a mechanism for greedy doctors to enrich themselves at the expense of their patent's health. *Sigh*

CHICAGO (Reuters) - Americans are exposed to seven times more radiation from diagnostic scans than in 1980, a report found on Tuesday as experts said doctors are overusing the tests for profit and raising health risks for patients.

The findings, issued by National Council on Radiation Protection and Measurement, add to already mounting evidence that doctors are ordering too many diagnostic tests, driving up the cost of health care in the United Statesand potentially harming patients. (italics mine)

Just so that you know, there is no doubt that radiation used in imaging is a force that needs to be understood, acknowledged and discussed publicly. However, doctors are not purposely exposing patients to radiation inorder to boost their coffers.

Truth is, the primary reason physicians order CT scans is because they are so good! You get such a good look at what is going on! A CT scan gives one an image that depicts the inside of the body. This is much preferable to listening with a stethoscope (to try and hear) or feeling with your hands (to evaluate). It's the difference between interviewing a witness at the scene of an accident and having a photo of the accident in progress.

Oh yea, another place where CT is MOST over-ordered is in the Emergency Room. Why is that? Two reasons. First, a CT hands the answer to a busy ER physician:

• Is there pancreatitis? No.
• Is there bleeding? No.
• Is there appendicitis? No.

OK.

Go home --OR -- Yes--go to surgery.

Second, in the ER the Docs are paralyzed for fear of missing something and then getting a registered letter with a court date from Hawkins, Burnett and Crude. The solution? Whole body CT scan.

Do physicians over-order CT scans? Yes. Do they do this for profit-- not many. Is this a factor in the horrible health care crisis as Reuters hammers home? God no.

Everyone needs to become more educated about radiation and diagnostic imaging. It's a real problem and an issue that needs education and discussion. But to use this topic as an issue to bludgeon the system is dishonest.

Health Care Harbinger?

The Best Laid Plans...

201 articles were listed on Google News tonight under the topic headline: "Health" and "Health care for All."

The topic headline was a compilation of articles from sundry sources detailing the "push" for health care reform that the Obama administration is going to start hawking tomorrow (you'd think they would slow down a little given the results of all this "change" so far?).

Well, if Obama unveils a plan analogous to his stimulus package or his bailout bill or his budget then we can expect an analogous reaction in the health care market as has happened to the markets affected by his financial roll outs (see Dow chart above thanks to Instapundit).

Anyway, I tried to read as many of these articles as I could, but no matter how far I slogged I couldn't find discussion of MEDICINE and SURGERY, only insurance, cost, and distribution of "health care."

Here, at least was a unique criticism of the United States health care system, thanks to Reuters:

President Barack Obama has laid out a broad framework for reorganizing the U.S. health care system, which currently costs more than any other industrialized country's system and yet leaves patients more dissatisfied

Dissatisfied?

There's a potent measuring stick for the worth and value of our system. What units of measurement are used when evaluating dissatisfaction? A peck of grimaces?

At least ABC News expresses a reasonable amount of incredulity about Barack's timing:

The ambitious plan comes during the worst economic crisis this country has seen in a generation. Health care reform wasn't achievable in even the best of times. Now, it could be that much harder.

The most vacuous award, however goes to the appropriately named site: ireallyshouldstudy. This was actually at the top of the Google Crawl at one point! Here's a sample of what Eliot called the vacant into the vacant:

Spending on health care also continues to rise, a very worrisome problem which needs immediate attention. Undoubtedly, health care reforms are desperately needed today in the United States... In a country considered to be among the most modern and thriving in the world, the state of health care in the United States is incredibly poor....

Obama got you scared yet? Great Cesar's ghost.

GRAND ROUNDS

Grand Rounds is up at The Health Business Blog. This week David Williams is hosting and you should go and peruse this weeks selections of health care blogs from around the net, including a piece from Kennedy's Tumor.

Also, check out his other previous posts which are insightful...

Invaders From Mars at Your Local Imaging Center

INVADERS FROM MARS: PART I

Both The New York Times and The Wall Street Journal ran articles recently regarding the cost of Diagnostic Imaging (DI); especially MRI (Magnetic Resonance Imaging) CT (Computerized Tomography) and PET (Positron Emission Tomography), which are big-ticket tests for the government and insurers.

Both periodicals raise legitimate concerns regarding the lack of quality assurance in the system; Namely, how good is the machine being used (the scanner); and how good are the the interpretations?

You --the consumer-- don't really have a handle on these questions because your health care brains are controlled by the little guy at the the top of the page. He, in case you don't recognize him, is the leader of Mars (1953 and 1986) and he has taken over the brains of the world so that decisions are made from a single place (his jar) which makes everything easier for everyone.

If you think your health care brains are not controlled by an alien fish head then see if you can answer these BASIC questions about tests many of you have probably had. Let's go....TRUE OR FALSE. OK?

1. A mammogram is a good test
a.True
b.False

CHEAT SHEET: good = accurate; or sensitive; or specific;
or, correct often enough to get into a good college if it were a high school student

2. A CT scan to evaluate the lungs irradiates the breasts
a. True
b. False

CHEAT SHEET: irradiates = to expose to ionizing radiation -- a known cancer causing process

3. A Radiologist is a doctor who delivers radiation to cancer patients to try to cure or ameliorate the cancer
a.True
b.False

CHEAT SHEET: You're on your own. I'll tell you this much: a radiologist has nothing to do with RADIOS on company time

4. The doctor that you consult in his private office (the internist or gastroenterologist or pulmonologist) can look at your CT / MRI / PET-CT / US (ultrasound) and comfortably discuss with you the findings
a. True
b. False

CHEAT SHEET: Ha Ha

5. The doctor who officially reads (interprets) CT/MRI/PET/US is required to have a medical license, or permit, or some type of official permission/authorization to interpret these exams and has been specifically trained to do so.
a.True
b.False

CHEAT SHEET: I mean, come on, just use your common sense

ANSWERS: b;a;b;b;b

If you got any of these answers wrong, or you don't completely understand why I asked these questions the way I did, or what I'm illustrating, then your health care mind is controlled by the guy in the jar who put a needle in your neck when you weren't looking.

Who's In Charge? Not You

The Wall Street Journal and The New York Times are running these articles because Mr. Obama is setting his sites on Diagnostic Imaging. In case you don't know (ha ha) George Bush and Tom Frist already blew away out-patient imaging centers (that are now folding up like origami art) by slipping a 50% reduction of payment into the 2006 Deficit Reduction Act (you didn't read it on line before it was signed into law?) and Obama et al are about to continue the assault.

Eventually you will be getting all your tests done in hospitals as you wait next to the lady writhing in pain from pancreatic cancer and the funny looking guy with a mask on who is coughing up some strange stuff.

And you'll have to wait a month for this privilege.

Want to know more? Read on, because in coming posts I'm going to discuss the answers to this quiz (I'll even teach you what you need to know); why Quality Assurance in Diagnostic Imaging is important for YOU to understand, and why you need to learn these things and start making your own decisions when it comes to these extremely important tests.

If you choose otherwise, or choose to ignore these issues otherwise that's OK because the green guy in formaldehyde intends to direct you and your children and your children's children to the least expensive, lowest-tech imaging facility while the interpretation of the images is done by his cronies, who I believe are gathering en masse in India and China.

Defending Breast Cancer

ANCHORS AWAY


Recently, I was investigating a study done at Harvard measuring the cortisol levels of women waiting for the results of their breast biopsies. Cortisol is, roughly, considered a "stress" hormone. Biopsy results can take 2-7 days to process and get back to the patient.

Basically, the idea of this study was to prove that waiting for results causes anxiety and this is bad for women; and, by extension, we should rearrange the "system" so that women don't have to wait for their results.

Reading through this paper, I was captivated by the study's disclaimers (like which researcher is on the board of what conflicting company, etc) when I was thunderstruck by a simple statement: This study was funded by the Department of Defense.

The who?

GUNS AND BUTTER AND BREAST CANCER

Turns out that a disease-specific lobby group, the National Breast Cancer Coalition Program somehow "convinced" the Department of Defense that it had to use its budget to support breast cancer research, for which the DOD has spent $1.9 billion since the early 1990's.

What? Well at least they are spending that money on groundbreaking research, like the Harvard study!

Arm twisting by clever disease-specific lobbies -- especially those representing perceived minority groups -- can blackmail legislators into supporting programs like this in end-around spending programs funnelled through non-traditional (and nonsensical) federal funding avenues.

The institution affected (like the DOD) then ends up funding the program--usually forever-- no matter how silly the research. And they spend tons of money. Money wasted on peripheral research that could be used for MEDICINE AND SURGERY...or, GUNS and BUTTER.

For instance, this "funding program" was originally put in place in the 1993 DOD budget and the price tag was $210 million. But like all government giveaways, once they are put in place they are pretty hard to get rid of -- and this profligacy continues to this very day.

Disease-specific lobbyists and their effects need to be addressed in any "health-care" reform initiative, and their unseen costs to the system should be assessed.

According to Wikipedia:

Through the DOD , NBCC worked vigorously to ensure consumer activist
participation at the peer-review research table

Well, that's just what the system needs--consumer activists (are those like community organizers?) at the peer-review research table (otherwise known as the trough).

END OF AN ERA

As reported recently in The Atlantic, the US risks losing its supreme air power dominance during Obama's tenure as generals face the reality of being unable to replace our aging force of F-15's with the miraculous F-22's -- given the strictures of the Obama's DOD budget.

Hi-tech fighter aircraft, new warships and missile defense projects are all potential targets for big cuts in the US defense budget, as the American military faces a new era of limits under President Barack Obama.

So why are we spending $2 billion of the DOD's budget trying to figure out how anxious women are as they wait up to one week for breast biopsy results (95% of which are NEGATIVE)?

According to its website, the mission of the Department of Defense is:

...to provide the military forces needed to deter war and to protect the security of our country. The department's headquarters is at the Pentagon.

I guess there is a war on cancer...

WHAT'S IN YOUR POCKET?

IGNORING COSTS

Americans are being bamboozled into health care reform. Why? They don't know the difference between MEDICINE AND SURGERY -- which is what health care really is -- and the social/economic issues that bedevil the delivery and distribution of care in America.

How bamboozled?

This graphic, provided in today's New York Times demonstrates just how detached the American public is from their health care. They are detached because they don't pay for it--they hardly share in the cost of it.

Since 1965 the personal and out-of-pocket spending by the American consumer has remained flat, while total national health care spending has gone up more than 400%.

Without direct involvement in cost decisions and implications, Americans have become as detached as trust fund babies from the realities of just what is being purchased and its relative value.

Americans have also been dumbed down to the point where overhaul of the system can be enacted under the ruse of a crisis.

Americans need a chance to choose for themselves whether they want their PHYSICIANS, their MEDICINE and their SURGERY to get thrown out with the dirty bathwater of cost, insurance provision and service distribution.