Health Reform: Hedges, Dodges, Ambiguities, and Dying Metaphors

Hedge – A calculatedly noncommittal or evasive statement.

Dictionary definition

The Artful Dodger.

Charles Dickens

A mixture of vagueness and sheer incompetence is the most marked characteristic of modern English prose, and especially of any kind of political writing. As soon as certain topics are raised, the concrete melts into the abstract and no one seems able to think of turns of speech that are not hackneyed: prose consists less and less of words chosen for the sake of their meaning, and more and more of phrases tacked together like the sections of a prefabricated henhouse.

George Orwell, Politics and the English Language, 1946

July 16, 2011- I admire George Orwell’e essays. He cuts to the heart in his opening sentences. And he is death on clichés, hackneyed expressions, and worn-out metaphors – the stuff of political talking points and political evasions.

But Orwell did not talk openly of political hedges and dodges, perhaps because he lived before talk show interviews proliferated on TV and the Internet.

One of their most powerful techniques is prefacing their remarks with a conditional phrase.

Here are a few of these conditional words and expressions that hedge, dodge, and evade.

CLEARLY- This is intended to show the politician understands the intent and consequences of the vast health reform law. He or she is saying, I now more about this than you do, and By God, I am going to enlighten you. But clearly, no one knows where health reform is going or where it will end.

THE FACT OF THE MATTER IS - What I am about to say is deep, profound, and irrefutable, even though the law’s consequences are still unknown and evolving.

I DON'T ANSWER HYPOTHETICALS - Translated: You were stupid to ask that question. Besides, I don’t have the slightest idea of what the answer it. It beats the hell out of me. Like everybody else, I have yet to read the 2500 page health reform law.


MY SOURCES TELL ME- Personally I have no knowledge of the health reform law. But my inside sources tell me it will save money and cover more people. If that does not work out, it is my sources’ problem , not mine.


HAVING SAID THAT- This politician is about to contradict himself. This will prompt you to compare both statements to find out what the hell he meant, if anything. Shake, straddle, and roll.

GOOD QUESTION - This phrase that makes the questioner look intelligent for asking the question, but the politicians is saying he has no intelligent answer. It gives the politician time to dream up an ambiguous answer without admitting “I don’t know.”

KEEP MY OPTIONS OPEN - This phrase lets crafty politicians change their minds mid-stream. While the public admires his flexibility, they soon realize that his mouth is more open than his options.

MY HONORABLE COLLEAGUE - Heard ad nauseam in the Two Houses. It's a dignified way to call your opponent a jerk. The truth is, legislators may refer to their counterparts on the other side as colleagues, but not likely to think of any of them as honorable.

How does one avoid this sort of hedging and dodging? There are no rules of thumb, but a good place to start may be to take Orwell’s advice on the proper use of the English language.

(i) Never use a metaphor, simile, or other figure of speech which you are used to seeing in print.

(ii) Never us a long word where a short one will do.

(iii) If it is possible to cut a word out, always cut it out.

(iv) Never use the passive where you can use the active.

(v) Never use a foreign phrase, a scientific word, or a jargon word if you can think of an everyday English equivalent.

(vi) Break any of these rules sooner than say anything outright barbarous.

Obamaspeak

Newspeak is “politically correct” speech taken to its maximum extent. Newspeak is based on standard English, but all words describing “unorthodox” political ideas have been removed.

Newspeak Dictionary

July 15, 2011 - As I listened to President Obama’s press conference today, his third in two weeks, I kept thinking about George Orwell (1903-1950), who in his novel Ninety Eight Four introduced the concept of Newspeak, the use of the Bully Pulpit to shape the political agenda.

In his remarks today, President Obama said,

“So the bottom line is this: Any agreement to reduce our deficit is going to require tough decisions and balanced solutions. And before we ask our seniors to pay more for health care, before we cut our children’s education, before we sacrifice our commitment to the research and innovation that will help create more jobs in the economy, I think it’s only fair to ask an oil company or a corporate jet owner that has done so well to give up a tax break that no other business enjoys. I don’t think that’s real radical. I think the majority of Americans agree with that.”

This is class warfare Newspeak, before we sacrifice the seniors, the poor, and research and innovation on the altar of Republicanism, let us share sacrifice, let us soak those evil oil companies, corporate jet owners, and “the rich” in general.

And by the way, he added later, he was willing to put all those entitlement programs – Medicare, Medicaid, and Medicaid - “on the table,” just to show you how “good” he was, and to show you how willing he was to compromise. He wanted a big long-term budget deal and warned, “If not now, when?"

To which, Charles Krauthammer, MD, the conservative columnist replied yesterday, all right Mr. President,

“How about last December, when he ignored his own debt commission's recommendations? How about February, when he presented a budget that increases debt by $10 trillion over the next decade? How about April, when he sought a debt-ceiling increase with zero debt reduction attached?”

“All of a sudden he's a born-again budget balancer prepared to bravely take on his own party by making deep cuts in entitlements. Really? Name one. He's been saying forever that he's prepared to discuss, engage, converse about entitlement cuts. But never once has he publicly proposed a single structural change to any entitlement. “


In other words, everything is on the table except specifics.

You are not likely to hear any specifics from President Obama. He is the master of political Rope-a-Dope. Let the Republicans take the lead. Then call their ideas “unorthodox,” as in punishing the poor, the old, the infirm, disabled. Expose them as champions of cruel, free-market capitalism.

Make no mistake about it: the next election will overwhelmingly be a battle between a conservative, free market vision of America and a liberal, Big Government, interventionist approach. Any alternative to the government approach will be considered "unorthodox," " or crimethink" in Orwellspeak.Orwell defined "crimethink" as even considering anythought not in line with the principles of English socialism.

As you watch the debate unfold, look for other signs of Newspeak, which can be described as follows.

• BigBrotherspeak – Government knows best, and all political opposition is suspect and should be ignored.

• Doublespeak - The ability to hold two contradictory ideas in one’s mind simultaneously, e.g, – the economy is getting worse every day but under my leadership it will get better.

• Duckspeak – To quack like a duck. Speaking without thinking according to the government party line. Can be either good or bad, depending on who is speaking and whether or not they are on your side.

• Goodspeaker – One who adheres to all the principles of Newspeak – goodthinking, and correctthinking.

• Malreportedspeak – The government is never “wrong,” the facts are merely reported incorrectly, by "unpersons", persons who have been ruled out of official existence, to be ignored and dismissed by the state.

• Taxspeak - All taxes are good as long as they are for what the state believes in and are “invested’ for the future – green energy, high speed rail, climate change control, and government dependency programs. Some have called this greenspeak, solarspeak, windspeak, or nospeak of natural gas, pure-burning coal, or shale. Thou shale not mention these things.

. Jetspeak - Those rich corporate types who fly those jets are to blame. They are the jetsam of our society, the high fliers with no social conscience. Tax them, and we will correct social inequities, even though taxing the rich historically rarely brings in significant revenues, as shown by the Laffler curve.

• Foxspeak – The language of unpersons who do not understand the profundity, rightness, and correctness of Newspeak.

• Richspeak - The understanding that all social injustices are due to unequal distribution of benefits and wealth and that nobody can be more equal than any other person, though some, government bureaucrats, are more equal than others. Which raises the question – What would the government do without the rich to blame?

• Healthspeak – All government health care investments and entitlement reforms are good, and all market based reforms – shopping across state lines, price competition, tort reform, vouchers that depend on consumer and physician responsibility, wisdom, and freedom – are bad in that they are unorthodox and are not part of Obamaspeak orthodoxy.

.Mediscareapeak - Government will "save" Medicare by gutting $575 billion out of the program but letting it plunge pell-mell towards bankruptcy while the dysloyal opposition will destroy it proposing financial salvation through vouchers.

Two Reform-Related Developments Coming Out of the Woodwork

They crawled out of the woodwork
And they whispered into your brain
They set you on a treadmill
And they made you change your name.
And it seems to me you lived your life
Like a candle in the wind.

Bernie Taupin (1950 - ), English lyricist, songwriter, and poet

July 14, 2011- We’re halfway there. Fifteen months ago, the Accountable Care Act (ACA) passed. Fifteen months dead ahead looms the 2010 Presidential election. The election will hinge on what happens to Obamacare and the state of the economy.

At this halfway point, the health law’s fate remains undecided. Indeed,so does the fate of the American economy and America’s debt crisis and the Obama Presidency.

The whole kit and caboodle may swing on the decision of a three judge appeals court panel in Atlanta, due out any day now. Their decision will lead to a Supreme Court decision on the health law’s constitutionality. This could take place as early as October 2011.

In the interim, time isn’t standing still. Reform-related developments continue to come out of the woodwork.

Medicaid Eligibles May Come Out of Seclusion

• In a New England Journal of Medicine article today, “Why States Are So Miffed about Medicaid – Economics, Politics, and ‘The Woodwork Effect’ “, Doctors Sommers and Epstein of the Department of Health Policy and Management at Harvard School of Public Health describe the "Woodwork effect". The authors note that 5% to 8% of the entire population under 65,some 9 million people, are eligible for Medicaid but have not yet applied.

The states fear that under the ACA, many of these uninsured “will come of the woodwork" and sign up for Medicaid, thanks to heavy media coverage, streamlined enrollment, and the individual mandate. The law could draw out of the woodwork 1.1 million new Medicaid participants in California, 1.0 million in Texas, and 900,000 in New York, all at a time when state budgets are already at the breaking point.

The result is a liberal-conservative fire fight – with liberals saying increased coverage, after all, was the intent of the law and will relieve the blight and plight of the poor. Besides, say the left, the government will pay for these new Medicaid entries. Conservatives counter by saying doctors won’t be there to care for perhaps 50 million new Medicaid recipients, and the administration costs for the states will be enormous with unwarranted expansion of federal control.

Insurers May Quietly Take Over Physician Practices and Hospitals

• The other development coming out of the woodwork is the “quiet takeover” of primary care physician practices and even hospitals by giant insurance companies. This was first reported in Kaiser Health News (Christopher Weaver, “Managed Care Enters the Exam Room as Insurers Buy Doctor Groups, “ July 1, 2011), and was elaborated upon in a July newsletter produced by John McDaniel, President and CEO of Peak Performance Physicians, LLC, in an article entitled “The Quiet Takeover: Insurers Buying Hospitals and Physicians.”

Both reports say large insurers - such as UnitedHealth, CIGNA, Humana, WellPoint, and Highmark – are engaged in what one observer called a “national landgrab of primary care doctors.” He might have added "hospitals systems." In some major markets, such as Pittsburgh, insurers are swallowing hospital systems whole. Insurers are touting their marketing skills and ability to provide low-cost care, and are pointing fingers at physicians, saying they order too many tests, do too many imaging procedures, prescribe too many brand-name drugs, and insert way too many implants such a hip-and-knee replacements and cardiac devices.

I am not convinced this is national movement or portends that insurers are coming out of the reform woodwork. But if it is, it would be the ultimate reform twist of the law, which was designed to rein in insurance companies. It may be another candle in the health reform wind.

Medical Malpractice Myths?

July 13, 2001 - Yesterday, Maggie Mahar, a prize winning liberal journalist, wrote a blog in the widely-read The Health Care Blog. She asserts that conservatives have created seven myths surrounding tort reform. These myths, she maintains, create the illusion that malpractice is in crisis, when the actuality, the conservative view is a hoax. I beg to differ.

Seven Myths

These seven conservative-created myths, she says, are the following.

Conservative tort-reform-mongers have perpetrated seven myths that malpractice reform will:

1. limit awards, and eliminate thousands of frivolous suits;

2. create caps and rein in “runaway juries”;

3. lead to caps that will bring down the cost of malpractice insurance;

4. remove fear of malpractice suits that drive over-treatment;

5. make health care more affordable;

6. end the notion that “Every Patient is a Potential Plaintiff”

7. reduce the litigiousness of American patients.

The editors of The Health Care Blog have asked me to respond to Ms. Magar’s blog.

My Response

Here is my response.

Maggie Mahar has chosen to frame malpractice reform as a conservative-liberal issue.

Eleven times she evokes the word “conservative,” as the source of malpractice myths.

Here. in italics, I quote her words to show her reasoning precisely.

1. Conservatives call it the “malpractice crisis.” Public Citizen, a liberal non-profit consumer organization based in Washington D.C., calls it “The Great Medical Malpractice Hoax.”

2. “Put a lid on how much a jury can pay a patient for pain and suffering,” conservatives say, “and watch the suits begin to disappear.

3. In April, the American Enterprise Institute for Public Policy Research (AEI) released a working paper which pulls no punches as it rejects the conservative wisdom on capping awards.

4. AEI is a conservative think tank.

5. Yet, despite abundant evidence to the contrary, conservatives continue to talk about “opportunistic lawyers” and “phony” suits in a debate over medical malpractice that Hyman and Sage point out in their paper for the American Enterprise Institute, “can often seem theological.”

6. “On one side are those conservatives and doctors who have no doubt that frivolous lawsuits and Democratic politicians beholden to trial lawyers are the reasons American health care is so expensive.

7. “On one side are those conservatives and doctors who have no doubt that frivolous lawsuits and Democratic politicians beholden to trial lawyers are the reasons American health care is so expensive.

8. Conservatives make the argument that since plaintiff’s attorney usually work on contingency, (taking 30% or 35% of the award if they win), they will be less likely to take on cases if pay-outs don’t exceed $250,000.

9. There is no evidence that doctors practice more conservative medicine in states such as Texas.

10. Again, keep in mind that AEI is a conservative think tank and that Davd A. Hyman is an adjunct scholar at the libertarian Cato Institute.

11. Why then, do conservatives speak with such passion about the need for malpractice reform?

Overuse and Misuse of "Conservative"

Maggie Mahar's overuse and misuse of the word “conservative” shows her liberal bias and mars her otherwise balanced and well-written blog.

Malpractice reform is not about conservative-liberal differences. There is not a nickel’s worth of difference in malpractice rates among conservative and liberal doctors or among conservative and liberal sections of the country. It is about the built-in incentives for physicians and lawyers engendered by the American jurisprudence system, which produces the highest malpractice rates on the planet.

The answer may reside in adoption of the British system, where the loser in malpractice law suits pays. As noted in a December 15, 2010 Wall Street Journal editorial, “Loser Pays, Everybody Wins, “ perhaps we should adopt “ a British-style ‘loser pays’ rule, which would require plaintiffs to pick up the legal costs of their targets if they lose their suits. Almost all of America’s economic competitors follow a similar standard, but trial lawyers and their Democratic codependents have blocked states from making this revolutionary improvement to U.S. civil justice.”

Reforming America’s Health System through Innovation and Entrepreneurship

Key words: Health reform; consumer-driven care; health savings accounts; high-deductible plans; patient-physician relationships; electronic medical and health records; disease management; multispecialty; ambulatory care centers.

July 12, 2011- In 2005, I wrote the following article for the Journal of Practice Management. You may find it interesting in light of what has happened since – the passage of the Accountable Care Act in March 2010, the ensuing debate on whether to retain or repeal the Act, and the pivotal role of the Act in determining the outcome of the 2012 Presidential election.

America’s attempts for healthcare reform are gridlocked. Health-care special interests are reluctant to abandon profitable activities, and American culture—distrust of centralized federal power, belief in self-improvement, desire for choice, and belief in equal access to medical technologies—is slow to change. Physician entrepreneurship and innovation, coupled with consumer-driven healthcare and public-private partnerships, may break the present gridlock.


I recently interviewed 40 national healthcare stakeholders (defined as those whose full-time jobs are in health-care) about their ideas for health reform, and these interviews form the core of my book Voices of Health Reform.1 In selecting interviewees, I crossed the ideological spectrum from single-payer advocates to health- care market enthusiasts; subjects included academics, policy
wonks, government insiders, practicing doctors, physician executives, health plan leaders, hospital CEOs, disease management experts, and supply chain company executives.

TENTATIVE CONCLUSIONS

These stakeholder interviews led to the following conclusions:

• In the short term, a single-payer system isn’t in the cards. Among stakeholders, including single-payer proponents, there’s little confidence that government is up to the job of running such a system. Nor do they think taxpayers are willing to foot the bill for a government takeover.

• American healthcare may be about to go off the financial cliff. With health inflation exceeding general inflation by a factor of four to eight times over the last five years (with a 45 percent overall climb in costs during those five years), private coverage by employers has eroded from 80 percent to 56 percent (private coverage constitutes 54 percent of the total market); hospital bad debts have doubled (with an increase of 40 percent in the last nine quarters); and the number of uninsured has increased 2.4 percent each year (to the current level of 46 million).

• We are in the midst of a rapidly evolving and uniquely American system—a public-private collaborative consisting of a rich, witch’s brew of massive federal increases for Medicare drugs, government-sponsored pay-for-performance programs, promises for a national electronic medical records (EMR) system, and a wave of private consumer-driven care initiatives, now joined by banks and financial institutions. The December 2003 Medicare Act creating health savings accounts launched this wave.

• Although many stakeholders are relying on and waiting for a “seamless interoperable” electronic solution to ut costs, improve quality, and induce efficiencies in the system, nobody seems to know how to persuade doctors in solo or small practices to pay for EMR systems. Without investment and participation by these doctors, such a system will be dead on arrival. Doctors in small practices, (those with 10 or fewer doctors) make up 88 percent of practicing physicians and care for most Americans. Consequently, federal financial incentives encouraging physician investment in EMRs Medical Practice Management • November/December 2005 are almost certainly forthcoming.

• Success or failure of collaborative efforts may depend on innovation and entrepreneurship in the private sector, rather than on government mandates. Although most Americans are skeptical of massive government intervention in healthcare, even conservatives recognize federal involvement as a necessary evil.

In Voices of Reform, George Lundberg, Medscape General Medicine editor, states: “We’re talking about 293 million people.Innovations tend to be limited and localized. To be effective for the masses, innovation would have to propagate like crazy.” In his interview, economist Joseph Antos, a veteran of the federal health scene, notes that 100 percent of hospitals and 95 percent of doctors must follow Medicare rules and guidelines. Medicare, Antos asserts, is the “sheriff” of the U.S. health system: “Medicare is the biggest actor in the system with a badge to back it up. It’s unwise to buck the big boy, especially if you’re an insurance company.”
CHARACTERISTICS OF AMERICAN CULTURE

How and why does the American health system differ from health systems in other countries?

• Is it because other nations have homogeneous populations who support, depend upon, and trust single-payer systems?

• Is it because Americans distrust government-run systems? Perhaps this distrust exists for good reason.

According to John Goodman et al in Lives at Risk: Single Payer National Health Insurance around the World, government systems ration high technology and stint on care for the sick; most of these systems feature long waiting lines.2 The Canadian Supreme Count in Ottawa recently ruled that “access to a waiting list is not the same as access to healthcare” and found parts of the Canadian system unconstitutional.

• Or is it simply because Americans lack a unified national vision of the way things ought to be? Scott Serota, CEO of the Blue Cross Blue Shield Association, says, “The phrase ‘U.S. Health System’ is a misnomer. The first thing we need to create is a unified U.S. health system. We have a terribly fragmentized approach to serving the needs of the American population.”

My answer to these questions is this: Our system results from our unique national culture. Since our founding 229 years ago, Americans have shared the following characteristics: a distrust of centralized federal power; a belief in the virtues of self-improvement; a desire for freedom of choice; a belief in equality of opportunity, not results, for all citizens.

These characteristics may explain why Americans: prefer a multiplayer to a single-payer system; reject federally mandated universal coverage; want to make their own healthcare decisions; seek equal opportunity access to new medical technologies; allow market- and public-based institutions to co-exist and compete; and permit doctors to practice where they want.

THE ROLE OF INNOVATION AND ENTREPRENEURSHIP

Given these American cultural characteristics, innovation and entrepreneurship, as defined by management theorist Peter F. Drucker, may offer the best hope for reforming the health system.3,4 Drucker makes the following key points:

• The American entrepreneurial economy distinctly differs from the more socialistic European economies. American organizations must be able to make decisions based on proximity to performance, the market, technology, society, environment, and demographics. In Europe, on the other hand, distance from the market of centralized systems makes innovation and responsiveness difficult.

• The American economy has made a profound shift from a managerial to an entrepreneurial economy, generating millions of American jobs in its wake and outpacing Europe in growth. The American economy is now growing at 3 to 4 percent a year, while Europe’s growth rate remains stagnant at less than 1 percent. Certainly the American health industry’s growth rate is robust. The industry now consumes one of every seven dollars of our economy, and generates one of every 11 jobs.

• Entrepreneurship and innovation are especially successful when there are demands for change, structural changes in industry, demographic shifts, and changes in perception. In the case of consumer-directed care, the market is shifting: from HMOs and PPOs to CDHPs (consumer-directed health plans); from doctors being paid by third parties to doctors being paid by patients; from a relatively young country to an aging and more affluent nation; and from passive patients
to assertive consumers. Entrepreneurial strategies include being there “fustest with the mostest,” which is how a Confederate general explained his successes in winning battles with limited resources; to “hit them where they isn’t,” the Wal-Mart strategy of placing stores where their competitors aren’t; dominating ecological niches, such as ophthalmologists’ franchises for laser short-sightedness corrections or cataract assembly line lenses replacement; and delivering true values to customers—seeing patients on time on the day they call, offering free coffee and even snacks to patients, enhancing the office décor, offering free videos and movies while waiting, featuring competitive pricing, or one-stop disease management, and providing documented proof of superior quality and outcomes. Reece/Reforming America’s Health System through Innovation and Entrepreneurship 3

ENTREPRENEURIAL OPPORTUNITIES BASED ON PROXIMITY TO PATIENTS

What are the current opportunities for innovation for physicians, based on proximity to patients and what’s going on in rapidly changing medical markets? Physicians are ideally suited to be innovators and entrepreneurs; here are some examples of “closeness to market” drawn from Voices of Health Reform.

• Lucien Wilkins, MD, is a retired gastroenterologist turned real-estate entrepreneur. In his practice as a gastroenterologist in Wilmington, North Carolina, Wilkins observed rural patients presenting with advanced colon cancer; there weren’t many specialists in rural regions of the state. After retiring from practice, he saw a solution to the distance-from-care problem: moving specialty clinics to where patients worked, lived, and played. Wilkins and a real-estate firm began building “Big Macs” (multispecialty ambulatory care centers). Nine such centers are now being built and have been warmly received by physicians and communities.

• Barry Passett, a former hospital executive near Washington, D.C., partnered with physicians to form HealthScribe, one of the first companies to outsource doctor-generated dictations to India for overnight transcription.

• Allen Wenner and John Bachman, family physicians in Columbia, South Carolina, and the Mayo Clinic in Rochester, Minnesota, combined forces to develop and test the Instant Medical History, whereby patients could create their own narrative medical histories by using a simple “yes” or “no” algorithm based on the patient’s age, sex, and chief complaint.

• William Gold and Victor Villagra, medical directors for Blue Cross/Blue Shield of Minnesota and Cigna, respectively, pioneered the development and implementation of comprehensive disease management programs staffed by nurses.
• Randall Moore, MD, president, CEO, and chairman of American Telecare in Minneapolis, took disease management a step further. He has developed audio and visual monitoring bedside units that allow doctors and nurses to talk, look at, and monitor home-bound patients. In this case, “technological closeness” to these patients dramatically reduced hospital readmissions. This use of technology is especially useful for patients with chronic congestive heart failure.

• John Casaillas, CEO of the Medical Banking Project, believes the most significant innovation in the near future will be the creation of HSA-linked debit cards for patients who are members of consumer-driven health plans. These cards are being developed by banks and health plans and will be introduced within two years. They will allow physicians to be assured of payment at the point of care.5

CONCLUDING REMARKS

In a Voice of Health Reform interview, Brian Klepper, president and founder of the Center for Practical Health Reform, says that healthcare costs are crossing thresholds of affordability for mainstream Americans. These costs are pricing out healthcare coverage for increasing numbers of employers and employees, individuals, major corporations (e.g., GM), and governments (particularly state governments subsidizing Medicaid).

Employers are responding by dropping coverage for workers or by switching them to high-deductible plans with lower premiums; employees of small businesses and individuals working out of their homes are “going bare.” The federal government is cutting Medicare and Medicaid reimbursements.

The best and most constructive way for physicians to prosper in this darkening competitive milieu is to capitalize on their proximity to patients, knowledge of disease, and awareness of consumer needs through innovation and entrepreneurship. Physicians should also be heartened by the fact that electronic innovations—such as automated history taking, eligibility checking, assured payment at point of care through use of debit cards, removal of utilization and other external controls, automated identification of the proper codes, and the ability to prescribe, fill refills, schedule visits, and conduct virtual visits through email— should free up time, eliminate dictation, and allow them to complete work at the time of the visit and get home on time.

These are just a few of the silver linings on the dark clouds that loom ahead. It is better to light the end of the tunnel with innovative entrepreneurial activities than to curse the darkness. ¦


REFERENCES

1. Reece RL. Voices of Health Reform: Interviews of Health Care Stakeholders at Work, Options for Repackaging Health Care, Including Single-Payer and Consumer-Driven Reform. Independence, Missouri, Practice Support Resources Inc., 2005.

2. Goodman JC, Musgrave GL, and Herrick DM. Lives at Risk: Single-Payer National Health Insurance Around the World. Lanham, Maryland, Rowan and Littlefield, 2004.

3. Drucker PF. Innovation and Entrepreneurship: Practice and Principles. Perennial Library, Harper & Row, 1986.

4. Drucker PF. Post-Capitalist Society. New York, HarperBusiness, 1993.

5. Kingson JA. Health Care at the Swipe of a Card. New York Times

Comments on Duke University Medical School News

July 11, 2011- Like any another medical school graduat , I retain an interest in my alma mater. Today I received two publications from Duke, the summer editions of the DukeMed Alumni News and Duke MedMagazine.

According to these publications,

• Duke Medical School now ranks 5th as an academic research institution. It share the fifth spot with Stanford, Yale, and University of California-San Francisco. Four schools rank ahead of Duke – Harvard University, the University of Pennsylvania, Johns Hopkins, and Washington University in St. Louis.

• Like other elite medical colleges, it is struggling to define its primary care program. It closed its family medicine program in 2006. It is in the process of restructuring its approach to primary care, by emphasizing field experiences rather than in-house training and by educating “change agents,” – clinical leaders and scientists- rather than routine practitioners. It is rethinking primary care in face of rising costs, rampant chronic illess, and government reforms.
• Duke gradates this year selected the following residencies.

 Internal Medicine, 16
 Radiology, 10
 Pediatrics, 8
 Emergency Medicine, 8
 Orthopedics, 7
 Ophthalmology. 7
 Anesthesiology, 6
 Medicine/pediatrics, 5
 Dermatology, 4
 Family Medicine, 4
 Radiology Encology, 3
 General Surgery, 2
 Obstetrics/Gynecology, 2
 Plastic Surgery 2
Total 86

I found these numbers interesting. It is said in general more graduates are seeking residences in the so-called ROAD specialties (Radiology, Opthalmology/Orthopedics, Anesthesiology, and Dermatology), which tend to have high incomes with regular hours.

These figure bear out that generalization -37/86 (42%) are entering these specialties. Another 16 (18%) are choosing non-primary care fields –Emergency Medice,, General Surgery, Obstetics/Gynecology. Otolpayngology, and Plastic Surgery.

That leaves 33 (38%) picking primary specialties – Internal Medicine 16, Pediatrics 8. Medicine/Pediatrics 5, and Family Medicine 4. These numbers may be deceptive. Nationwide, 80% of those entering Internal Medicine end up in subspecialty fields - cardiology, oncology, gastroenterology, endocrinology, and so forth. Duke takes pride in 4 students entering Family Medicine. Last year it was only one.