Spring 2001 Issue --- Doctors and Guns (Part II)
In "Homicide and Suicide in America, 1900-1998," I pointed out that the low homicide rate in the early 1900s is thought by some to be an artifact due to incomplete data.(1) Reasons were listed to indicate that the homicide rate really was much lower 100 years ago. Another reason is as follows: In 1902 Americans spent $13 per capita (in 1999 dollars) for police protection, both public and private, while in 1996 we spent $207 per capita.(2) If violent crime really is no more frequent today, why are we spending 16 times more for protection against it?
One might ask how high our homicide rate would be now if we spent as little on protection as we did a century ago. One might also ask how much more productive it would be to spend more time teaching our children ethical values, rather than to spend more money putting them in jail. Answering these questions is not easy, but at least they should be asked.
David C. Stolinsky, MD
Los Angeles, CA
1. Stolinsky DC. Homicide and suicide in America, 1900-1998. Medical
2. Caplow T, Hicks L, Wattenberg BJ. The First Measured Century. Washington: AEI Press, 2001; 221.
Dear Dr. Faria and all the doctors at AAPS,
There are those of us out here who are disgusted with the "pseudo-science" that is used in medical journals regarding the issue of handguns. The integrity of the medical profession is in jeopardy with our medical organizations taking politically correct positions that are unrelated to medicine. That is why I cannot join them.
There are some physicians, who, before they are doctors, are American citizens, and before that, are men. Men who believe in the duty to protect their wives and children from harm, and protect their communities from harm.
Now I know that there are other physicians out there who believe the same thing. And now that I know this, I have found a medical organization that I can join.
Thank you Dr. Faria, and keep the information coming.
Michael Creta, DO
Just a note to say what a super job you've done on the latest [Spring 2001] Medical Sentinel. I am really glad I joined and am supporting this fine publication.
Keep up the great work!
Richard W. Stevens, Esq.
Jews for the Preservation of Firearm Ownership
Ritalin --- Pharmaceutical Blackmail
I enjoyed the article by Vin Suprynowicz entitled, "Ritalin -- Pharmaceutical Blackmail." The economic, political and moral dimensions are most interesting and rather disturbing. What is happening when state agencies overrule family care of children except in the most extreme situations?
Equally significant from a point of view of disease causation and diagnosis is the fact that what we call "ADHD" may reflect one of two things which are not usually addressed when prescribing Ritalin. First, is the fact that poor learning and disruptive behavior may reflect the absence of moral authority and structure in the home as well as in the school. Some children need to know who is boss, know what is right and wrong, and know that they are loved for a lifetime by parents and teachers.
Second, children may be experiencing attention deficit and hyperactivity symptoms due to allergic, sensitizing and toxic environmental exposures. The central nervous system is vulnerable to mold proteins, mycotoxins, and synthetic chemicals as well as to proteins in common foods and chemicals in food additives. Acting primarily through non-IgE pathways a whole variety of "allergic" and sensitivity symptoms may occur which can mimic ADHD. We see the proof of this in our laboratory when patients are directly challenged with a variety of substances including molds, chemicals, food additives, and food substances and subsequently become hyperactive, inattentive, or somnolent. How sad it is to see symptoms suppressed with a drug when avoidance of triggers would suffice.
Those interested in this subject may want to look at the book entitled The Healthy School Handbook by Norma Miller. Reintroducing healthy, loving moral authority in our classrooms as well as cleaning up classroom environments contaminated with molds and chemicals represent a better long-term solution than "speed."
Philip Ranheim, MD
Congratulations on your piece on Ritalin. You and the Medical Sentinel have done a good public service. The average citizen is not aware of how the estate is taking over the life of people by the use of pseudo-medicine. What you observe about "ADHD" can apply to "mental illness," well discussed by Thomas Szasz in The Therapeutic State and other books by him.
Nelson Borelli, MD
Rejecting Medicare Patients
Government meddling, not doctors' greed, is the primary reason senior citizens are having trouble finding doctors to treat them. And the problem is much more widespread than reported by USA Today ("Rejections rise for Medicare patients," 2/19/01, Cover story).
A recent survey conducted by the Association of American Physicians and Surgeons reveals that nationally, 20 percent of doctors refuse to accept new Medicare patients. The reason? Not fees, but "hassles and/or threats from Medicare."
Even of those who continue to accept Medicare patients, almost three-fourths (71 percent) say they are making changes in their practice to avoid the threat of prosecution, including greatly restricting services to patients, such as surgery.
There's more trouble if a patient needs a specialist. More than one-third (34 percent) report difficulties in finding a referring physician.
The study is concrete documentation of the atmosphere of fear in which doctors practice today. Money is not the issue --- it's the government in the examining room. Honest physicians are repeatedly investigated and prosecuted because of differences in opinions with government bureaucrats over what constitutes "necessary and appropriate" care for patients. Who knows best --- a government insurance bureaucrat, or your doctor?
When doctors tell us they would rather treat uninsured patients for free rather than risk prosecution as a "Medicare cheat," something is wrong with the system.
The government needs to change policy, simplify regulations and halt capricious crack-downs on so-called "fraudulent" billings. While touted as patient protections, they are actually responsible for severely restricting patients' access to care. Physicians are charged to "do no harm." Perhaps government officials should be held to the same code.
Kathryn A. Serkes
AAPS Public Affairs Counsel
After 21 years of clinical practice, performing some 15,000 very complete diagnostic histories and physicals at a private clinic, I had reached my limit of federal government interference with what I considered to be quality medicine. I therefore decided to retire while I still had my sanity; although my wife might have argued that point. I wanted to somehow be active in clinical medicine, yet not get involved with HCFA's heavy-handed control. What a dreamer, I thought to myself, and certainly not simple....
With every Medicare patient encountered, I found myself in a not-so-simple moral and ethical dilemma. Should I practice medicine according to the ethics of Hippocrates and act as my patients' advocate, but risk federal subpoenas, or should I act as an agent of the government and limit costs by rationing care? I found this an untenable position ethically since medicine is at its most fundamental a moral enterprise.
The central thesis, I believe, is simple and straightforward: What is considered "medically necessary," and what HCFA decides to pay for are in fact two separate issues. The first is a medical determination and is best defined by the physician and his or her patient. The second is a financial and political decision that is best defined by society at large, instructing the government officials whom they elect.
We are now witnessing some of the far-reaching effects of the government making medical and therefore ethical decisions: monitoring of clinical "performance" by HCFA, such as measuring "underuse of necessary care" of Medicare patients and physician profiling; negative effects on the patient-physician relationship; erosion of medical ethics because of cost control arrangements, such that 41 percent of young internists regret becoming physicians, 48 percent of physicians age 50 and older plan to retire or see no new patients in the ensuing three years, 56 percent of older physicians say they would not choose a medical career again, and consequently a decrease in the number of medical school applicants for four straight years.
It appears to me that the physician's moral and ethical compass is being manipulated by the federal government and therefore intruding into a profession which by its very nature is a moral undertaking...
The decision to continue practicing, to attempt to change the system, to retire, or to change careers is quite difficult and heart-wrenching. The larger societal solution, I believe, is for the federal government and society to recognize that "medically necessary," and what should or should not be paid for are two distinct and separate issues, that if commingled portend very serious problems for the future.
Ronald R. Scobbo, MD
White Sulphur Springs, WV
Physicians Almost Unanimous in Opposition
to "Privacy" Regulations
The most "heavy-handed" aspect of the new federal rules is the unprecedented government access to everyone's private medical records. ("Bogus scare tactics delay medical-privacy reforms," Debate, 3/20/01). While masquerading as patient protection, the rules would actually eliminate any last shred of patient confidentiality.
When it comes to government prying, these rules obliterate any remote notion of patients' rights. Doctors are required to disclose all patients records to thousands of federal bureaucrats --- with or without consent. That includes our handwritten notes and psychiatric records.
Law enforcement agencies will have unrestricted access to all records --- including notes about drug use, family interactions and other confessions.
If patients expect the government to protect them from marketing efforts, they're in a for a rude surprise. It was government employees who sold patients' medical records from government databases to HMO recruiters in Maryland a few years ago.
The new federal "privacy" rules could actually do more harm to patients than just compromising privacy.
A mailed survey of 344 physicians conducted by AAPS shows almost unanimous opposition to the HHS privacy rules, scheduled for full implementation in 2003. A whopping 96 percent thought the rules would further compromise patient privacy. Some of the other questions provide further clues about the practical effects of the rules.
The rules may create a massive federal mandate that requires every doctor to share patients' records with the federal government without patient consent. Even more alarming is that patients may be refused medical treatment if they won't consent to disclosure.
But physicians already believe that third-parties ask for information that they believe violates confidentiality, with 51 percent reporting such requests from government agencies and 70 percent from health plans.
Nearly 87 percent reported that a patient had asked that information be kept out of the record, and early 78 percent of physicians said that they had indeed withheld information from a patient's record due to privacy concerns. While only 19 percent admit to lying to protect a patient's privacy, 74 percent state that they have withheld information for that reason.
Indeed as the Oath of Hippocrates states:
Whatever, in connection with my professional practice, or not in connection with it, I may see or hear in the lives of men which ought not to be spoken abroad I will not divulge, as reckoning that all such should be kept secret.
While I continue to keep this oath unviolated, may it be granted to me to enjoy life and the practice of the art, respected by all men at all times, but should I trespass and violate this oath, may the reverse be my lot.
Information is already being withheld from patients' medical records due to privacy concerns, and the obvious conclusion is that these rules will only exacerbate the situation to the point of distorted, incomplete and potentially dangerous medical records becoming the norm. Physicians' ethics will be further challenged, the choice between government compliance and lying for a patient.
While masquerading as patient protection, the rules would actually eliminate any last shred of confidentiality and risk lives.
Kathryn A. Serkes
AAPS Public Affairs Counsel
Correspondence originally published in the Medical Sentinel 2001;6(2);37-39. Copyright©2001 Association of American Physicians and Surgeons (AAPS).