Medtalk : Just You and "Eye"

Missouri Medicine Editorial #46

January/February 2007

John C. Hagan III MD
We are on a slippery slope when we prohibit, criminalize or ruinously tax behavior or ideas we simply disapprove, disagree with or that seem contrary to today’s (ever changing) concept of what’s healthy for us and good for society.

The Health Police-Big Government Elites Are Out To Control Your Life


“I don’t believe in a government that protects us from ourselves”

Ronald Reagan
“Too much government is not enough”

Paraphrased from some present gubernatorial and presidential candidates
I urge each of you to carefully and thoughtfully read “Anti-Anti-Smokers Speak Up” by Jack Cashill. Jack is an intellectual of the first order and a virtuoso writer. In fact, he’s one of the most interesting men that I have never met.

First a little about Doctor Cashill: He has a PhD in American Studies from Purdue University. He is Executive Editor of the Kansas City business magazine Ingram’s and has written for Fortune, The Wall Street Journal, Washington Post and many national newspapers and magazines. He has produced over a dozen documentaries for PBS and cable networks, one of which won an Emmy Award. He has taught at several universities, served as a Fulbright Scholar in France, and authored five non-fiction books, three of which were national best-sellers. I have read and enjoyed “Hookwinked: How Intellectual Hucksters Have Hijacked American Culture” and look forward to reading his latest, “What’s the Matter with California” (Simon & Schuster: Threshhold Editions).

Okay, that’s a lot of ink for one guy, even a smart one. What does Cashill have to say that’s so important anyway? Succinctly, how far can society’s do-gooders, holier/smarter-than-thou types, regulatory agencies and the various levels of government restrict and regulate individual behavior considered unhealthy, harmful, cruel or merely different from their elite norms.

Jack starts with smoking, something I—and most physicians—despise. Not a day goes by that I don’t chide my patients for smoking, give them information on how deleterious it is to their sight and try to direct them to use Chantrix and the Missouri Smoker’s Hotline (800-QUITNOW). I am appalled that tobacco subsidies are still paid to growers of this deadly and addicting weed. I view as favorable the creation of smoke free work places, restaurants and entertainment venues. I favored raising the Missouri tobacco tax and using the proceeds to fund anti-smoking efforts and monetarily supplementing the pathetic Medicaid reimbursement schedule.

Pile on the tobacco users; extract all the money we can from their addiction. Heaven and all the forces of good are on our side, we are healers and pure of heart. Is it only proper that we force our fellow humans to be better and healthier people? I thought so before Jack’s article crystallized some nascent doubt.

Recently, I have become uncomfortable with the zealotry of the anti-right-to-light crowd. Nation-wide legislation has been considered that would make it unlawful to smoke in apartment buildings, for parents to smoke in automobiles with their children, even for parents to smoke in their own homes. There are those that believe that no foster or adopted child should be placed in the home of smokers. Interestingly, Congress—world’s greatest haven of hypocrisy —recently granted itself an exemption from the indoor smoking ban that applies to other government and public places.

The health police-big government crowd is Blitzkrieging many other areas. How about legislating all trans-fats out of foods. New York City, that bastion of self-righteousness and smugness, has already passed the first fat-fiat.

Before deputizing the fat posse, might we ask how solid is the evidence against trans-fats? As scientific skeptics, might we not question if the horse-collar has been hung on this particular lipid long enough to declare it now and forever flavor non-grata?

Was it not so long ago that coffee was considered a cause of myocardial infarcts? Isn’t it true that same beverage was recently shown to reduce the risk of diabetes? Was it also not long ago that vitamin E was felt to be so beneficial that we physicians recommended taking daily supplements? (I plead guilty as charged.) Was it not just this past year that same vitamin E was implicated for an increase of certain types of heart disease? Was “modern medicine” not wrong in treating acne with X-rays; with forced subjection of schizophrenics to frontal lobotomies; did we not cause deaths with advising prolong bed rest following childbirth and heart attacks? Should we really support mandatory HPV vaccination?

Look at the problems associated with alcoholism and alcohol dependence such as drunken driving and diseases such as cirrhosis. Should the cocktail constabulary ban all alcohol use in the United States? Stamp out the buzz! Let’s pass a law. Let’s seize all the booze. Let’s smash the kegs and decanters and pour it down the drain. Oh, that’s right, been there-done that. Prohibition wasn’t much of a success was it?

Now we know (or for the moment, we think we know) that up to two alcoholic beverages-preferably red wine- may be good for our hearts. Will the health police and the zealots for more government, more laws, more rules, more taxes, more regulatory agencies all demand that I—a non-drinking teetotaler—start to drink two glasses of red wine daily?

And I confess to other high risk behavior such as mountain climbing, hang-gliding, parachuting, and writing about the unseemly machinations of the trial lawyers.

Recently, I learned that that several states are considering making it illegal to spank your children. I’m talking about the light swat on the behind. Again I plead guilty and wish to report the similar crimes of my parents and their parents and …..you get the idea.

And so I wonder, “When will they come for me?” No doubt in the middle of the night. Likely government men in dark over-coats while black helicopters hover overhead.

We are, and must remain, a nation with liberty and justice for all. Even smokers, even the obese, even the believers in non-injury causing corporal punishment. Beware the political party and politicians that act as though too much government is not enough. Beware the elite secular progressives that believe they alone dwell in the zone of decency and—obliged by their self-anointed nobilis oblige— must expand government for the welfare of the hoi polloi.

We can reason, we can persuade, we can educate, we can lead by example. But we are on a slippery slope when we prohibit, criminalize or ruinously tax behavior or ideas we simply disapprove, disagree with or that seem contrary to today’s (ever changing) concept of what’s healthy for us and good for society.

by John C. Hagan, III, MD, FACS

No Governor in recent times has been so committed to the medical and health needs of Missouri.


In an ideal world, the astounding
accomplishments of Governor Matt Blunt
would be widely reported and praised by
an unbiased news media. The public would
know that employment, the state economy
and healthcare system have risen Phoenix-
like from the floundering mess Blunt
inherited in January 2005. The results of
the 2008 gubernatorial election would be
a foregone conclusion:

Governor Blunt Re-Elected By Historic Majority Vote

But this is not an ideal world and,
contrary to their disingenuous
protestations to the contrary, the news
media has a liberal bias and agenda. After
three years of unceasing press criticism
and negative “spinning” of the Governor’s
policies, Blunt has only a 1-2% lead over
his opponent, and trial lawyer favorite Jay
Nixon.
During Democrat Jay Nixon’s
unsuccessful campaign for U.S. Senate, a
trial lawyer wrote in a circulated
solicitation letter, “Trial lawyers can make
a real difference in this year’s race for the
U.S. Senate and that means a real
difference in tort reform across
America…..Tort lawyers have every
reason to pour money into Jay Nixon’s
campaign.” And, “This is the most
important race in the country for trial
lawyers.”
Undoubtedly they feel the same way
about the 2008 Governor’s race.

No Governor in recent times has
been so wholly and publically committed
to the medical and health needs of
Missouri citizens. No Governor has
worked as effectively with the legislature
to enact laws that have objectively
improved the
lot of Missouri’s
physicians and
their patients.
No Governor
has so enraged
the tort kings
and queens of
the Million
Do l l a r
Judgment Roundtable.
Consider these facts that the Fourth
Estate has chosen to largely ignore:
• The Department of Insurance
reported that last year there was a 61%
decline in new malpractice claims, down
from 2,822 in 2005 to 1,113. Closed
claims increased 27%. Tellingly, claims
closed with payment decreased 19%, while
those without payment increased 37%.
• The Department of Insurance and
other state agencies are now led by Blunt
appointed competent and dedicated
individuals.
• The price of malpractice insurance
has stabilized, in some instances declined,
and new carriers are entering our state
market, making prices more competitive.
• Missouri’s Medicaid Program,
which had threatened to bankrupt the
entire state budget in 2005, has been stabilized
and money is now available to help our truly
indigent.
• The physician exodus to Kansas and
elsewhere has abated and new physicians are
no longer eschewing practice in the Show Me
state.
• Reportedly, many trial lawyers are
spending less time in Aspen and have missed
payments on their yachts.
Re-electing Governor Matt Blunt to a second
term in 2008 is the single most important thing for
the medical and healthcare professions.
Each of you should make a substantial
donation of your time and money to Blunt’s
re-election. Each of you should start educating
your family, friends, and especially your
patients about the Governor’s achievements.
A Blunt re-election is the tort bar’s most
dreaded nightmare. That alone should bring
every physician, whether Republican,
Democrat or Independent, into the Blunt
camp with checkbook in hand. In the last
election physicians were a prime reason
Governor Blunt was elected. We must do
more than 2004! Go the Blunt website
(www.mattblunt.com) now to donate and
join his campaign.



Multi-Tasking: Mischief Prevention in the 2008 General Session

It is the best of times, it is the
worst of times, and each year it offers
political salvation or damnation,
promise and peril, hope or
hopelessness. In any case, it is time to
start gearing up for the circus maximus
that is our annual general legislative
session.
Always in the center of the circus
are our foremost political gladiators-
ringmasters Tom Holloway & Jeff
Howell. On PAGE XXX Tom outlines
the issues that likely will dominate the
session. As always there is something
old, something new, money
borrowed, and taxpayers blue.
For the last five years I have
harped on how important it is to
involve yourself in the machinations
of the General Assembly. For the
most part the medical profession has
engaged itself admirably and
skillfully. This year we must commit
ourselves to the even greater task of
forcefully directing the legislation of
the general session and electing
Governor Blunt, Lieutenant
Governor Page and the Senators and
Representatives who have
distinguished themselves as our
friends on healthcare legislation.
Physicians have the time,
money, and credibility to counter
the trial lawyers. Just Do It!

Disclosure
All articles published, including editorials
and letters, represent the opinions of the
authors and do not reflect the official
policy of the Missouri State Medical
Association or the institution with which
the author is affiliated, unless this is
clearly specified.




Sam For Lieutenant Governor
Sam Page, MD, IS a physician and deserves our unqualified support.


Sam Page, MD, is a 18-year
MSMA member and State
Representative from the 82nd
District. He practices pain
medicine in St. Louis.

The race for Lieutenant Governor,
unlike the Governor’s race, has two strong
and qualified candidates. Peter Kinder, the
Republican incumbent, is the son of a
physician and has been supportive of
Missouri’s physicians.
However, Sam Page, MD, IS a physician
and deserves our unqualified support.
Sam Page, MD, has been one of the
most effective healthcare champions since
his election to the House of Representatives
in 2002. He is a competent and practicing
anesthesiologist from Saint Louis, and a
previous President of his specialty’s state
society. His outstanding work in the
legislature has come at great cost to his
medical practice and involved much more
time away from his family than any one
person should have to endure.
That a physician who championed tort
reform has earned the nomination of the
Democratic Party - whose biggest
contributors are trial lawyers - is testament
to Sam’s political skills, hard work, and
obvious electability by the general public.
Sam is respected by his Republican
opponents and has demonstrated
considerable cross-party skills at
negotiation, compromise and the ability to
move legislation through the arcane process
of becoming law.
Contributions to elect Sam Page, MD,
for Lieutenant Governor and to join his
campaign can be done at www.sampage.com.



John C. Hagan, III, MD, FACS, is a
Kansas City ophthalmologist and
Missouri Medicine Editor. He is a
27-year Super-PAC contributor to
the Missouri Medical Political Action
Committee.

The first robotic-assisted
surgery was performed by
Kwoh in 1985. He
modified a standard
industrial robot to hold a
fixture next to a patient’s
head so drills and biopsy
needles could be inserted
at a desired location for
neurosurgery

About the author: Justin M.
Albani, MD, is a 1-year MSMA
member and former Robotics
and Laparoscopy Fellow/Clinical
Instructor, Division of Urology,
University of Pennsylvania,
Philadelphia, PA. He practices
Urology and Robotic Surgery in
Kansas City, MO.

Missouri Medicine March/April 2007 Vol. 104 No. 2 p.86-92

Abstract
Within the last decade, robotic-
assisted surgery has emerged with
the promise of extending the
benefits of minimally invasive
surgery to virtually every surgical
specialty while decreasing patient
morbidity
and
improving
postoperative outcomes. This article
reviews the history, development,
current and future applications of
robotics in surgery, and its
increasing prevalence in the field of
urology.
Introduction
Since Erich Mühe, MD performed
the first laparoscopic cholecystectomy in
1985, surgeons have continued to search
for ways to implement minimally invasive
techniques within all specialties.
1
Due to
the need for superior visualization or
complex reconstruction, many of these
procedures were simply not feasible using
standard laparoscopic techniques or
instrumentation. The emergence of
computer-assisted and robotic
technology has allowed surgeons, once
again, to achieve that end by augmenting
their abilities, often beyond what is
humanly possible. This article highlights
these technologies by reviewing the
history, development, current and future
applications of robotics in surgery, and
its increasing prevalence within the field
of urology.
Definition and Evolution of
Robotic Systems
The term ‘robot,’ derived from the
Czechoslovakian word robota meaning
‘forced labor’, was made popular by the
playwright Karel Capek in his 1921 play
Rossum’s Universal Robots about
autonomous human-like devices that were
created to perform common tasks.
2
For
the next half-century, robots, defined by
the Robotic Institute of America as
‘reprogrammable multifunctional
manipulator[s] designed to move
material, parts, tools or specialized devices
through variable programmed motions
for the performance of a variety of tasks’
did just that, as they handled hazardous
waste, performed repetitive tasks (auto
industry) or assembled parts (computer
chips) with great precision.
3
These devices
have been categorized into either active,
semi-active, or passive (master-slave)
systems.
4
Active systems perform a task
autonomously requiring only the
supervision of a surgeon while passive
systems possess no autonomy and require
a surgeon’s input entirely.
The first robotic-assisted surgery
was performed by Kwoh et al. in 1985
who modified a standard industrial robot
to hold a fixture next to a patient’s head
so drills and biopsy needles could be
inserted at a desired location for
neurosurgery.
5
In 1991, Davies et al.
used a similar industrial robotic arm
coupled with a stereotactic frame to

perform a transurethral resection of the
prostate.
3
Named the ‘Probot,’ this
marked the first time that an active robot
was used to automatically remove soft
tissue from a patient.
3
Near the same
time, Taylor et al. developed the
ROBODOC
®
(Integrated Surgical
Systems, Sacramento, CA) as an industrial
arm that would accurately core out the
femur for hip replacements.
6
This marked
the first commercially available surgical
robotic system. Despite a large clinical
trial demonstrating that the system
produced radiographically superior fits
for implants while eliminating femoral
fractures, the device was associated with
greater blood loss and operative times
and has not yet achieved Food and Drug
Administration (FDA) approval in the
United States.
7
Additional work in robotics was
taking place simultaneously with a
collaboration between Scott Fisher, PhD
at the National Aeronautics and Space
Administration (NASA) Ames Research
Center (Palo Alto, CA) and Joseph Rosen
MD, a plastic surgeon at Stanford
University.
8
Both envisioned
‘telepresence surgery’ by integrating
interactive virtual reality with surgical
robotics. This was presented to roboticist
Phil Green, PhD and his team at Stanford
Research Institute (SRI) to develop a
telemanipulator for enhancing nerve and
vascular anastomoses in hand surgery.
8
Recognizing the impact such a system
could have on macroscopic endoscopic
surgery, Richard Satava, MD, a general
surgeon, collaborated with researchers
with funding from the U.S. Army to aid
in developing the Green Telepresence
System. This system was envisioned to
decrease mortality in war by “bringing
the surgeon to the wounded soldier
through telepresence.”
8
A wounded
soldier would be placed in a vehicle with
robotic equipment and operated on by a
surgeon located remotely at a Mobile
Advanced Surgical Hospital (MASH). This
was successfully implemented with an
Figure 1
The da Vinci
®
Surgical System with its 3 components (from left to right):
surgeon console, surgical side cart (with 3 or 4 arms), and vision tower.
(Courtesy of Intuitive Surgical, Inc.
®
)
animal model but never for battlefield
casualty care.
Also with initial funding from the
U.S. Army, Yulun Wang, PhD developed
a table mounted robotic arm controlled
by the operating surgeon to manipulate
an endoscopic camera, the AESOP
(Automated Endoscopic System for
Optimal Positioning), and formed his
own company (Computer Motion, Inc.).
This device eliminated the need for a
camera holding assistant and, in 1993,
became the first surgical robotic device
to gain FDA approval, thus ushering in
the era of robotics in surgery.
While the AESOP was enjoying an
early success, the SRI Green Telepresence
System was licensed by Intuitive Surgical,
Inc.
®
(Sunnyvale, CA), extensively
redesigned, and reintroduced as the da
Vinci
®
Surgical System.
8
In March 1997,
Cardiere et al. performed the first robotic-
assisted laparoscopic cholecystectomy in
Belgium using this platform.
9
Shortly
thereafter, Computer Motion, Inc.
produced a competing telemanipulating
platform, Zeus. This consisted of the
AESOP system with 2 additional table
mounted robotic arms controlled by a
surgical workstation. In the Zeus system,
the surgeon was seated upright in a chair
with a 2 dimensional video monitor and
instrument handles positioned
ergonomically to maximize dexterity.
Later in its development, 3 dimensional
viewing became available. In March of
2003, the two competing companies
merged and production of the Zeus system
was discontinued.
Current Robotic Platform
Overview
As the only commercially available
telerobotic system in the world, use of
the da Vinci
®
Surgical System (Intuitive
Surgical, Inc.
®
) has exploded since first
obtaining FDA approval for general
surgical procedures in July 2000. Over
460 systems are currently installed
worldwide; over 350 are in the United
States. As a purely passive, or ‘master-
slave’ system, most roboticists would agree
that the platform is not really a robot at
all, but merely computer-assisted surgery
at best. The platform consists of 3 main
components: an ergonomic surgeon
console, a vision cart holding a dual light
source and dual 3-chip cameras, and a
movable surgical cart which contains 2 or
3 mounted arms and a camera arm (See
Figure 1). The master console consists of
an image processing center generating a

Figure 2
View of the operative field (above) and the instrument controls (below) in
the console of the da Vinci
®
Surgical System. Surgery is greatly facilitated as
the surgeon’s hand-eye axis is positioned to give the illusion of directly
operating on the patient through an open incision. (Courtesy of Intuitive
Surgical, Inc

magnified 3-dimensional image in the
view port, foot pedals to control the
electrocautery, camera and instruments,
and master control grips that drive the
robotic arms at the patient’s side. The
surgery is greatly facilitated as the
surgeon’s hand-eye axis is positioned
to give the illusion of directly operating
on the patient through an open incision
while he or she is seated comfortably

at the console (See Figure 2). The
articulating laparoscopic instruments
(EndoWrist
®
) have complex cable
driven joints at the distal end allowing
the same seven degrees of freedom
(in/out, axis rotation, up/down
[pitch], left/right [yaw], grip, and pitch
and yaw at the wrist) present in the
human hand during open surgery (See
Figure 3).



Advantages
Surgical robotic platforms like the
da Vinci
®
offer many advantages as they
overcome several of the obstacles inherent
in laparoscopic surgery by providing
improved visualization, increased
dexterity, restored proper hand-eye
coordination, and an ergonomic position.
With the binocular vision provided by the
optical system (See Figure 4), surgeons
can regain the depth perception they
forfeited with conventional laparoscopy.
Additionally, the system offers 6 to 12
times magnification (depending on the
distance from the tissue), thus providing
views that allow meticulous dissection to
be performed. Since the camera is
controlled by the surgeon, he or she can
maintain an always stable, optimal view
of the surgical field without concern for
camera-driver fatigue. In addition to the
added dexterity with the instruments
increased range of motion, the system
incorporates software that filters out
physiologic tremor and allows for
adjustable motion scaling. This might
allow for increased precision as large
hand movements can be translated to
smaller instrument motion. Additionally,
the system’s mechanical power may
greatly assist in surgery of the morbidly
obese by overcoming the often
troublesome abdominal wall stiffness that
makes precise dissection with
conventional laparoscopy in these patients
difficult.
10
The ergonomic surgeon’s
console markedly decreases fatigue and
thus allows for the completion of more
complex and time consuming procedures
without potentially adversely affecting the
surgery. Finally, the surgical platform
allows even the novice laparoscopist with
a firm foundation in open surgery to
transfer his skills to perform complex
laparoscopic procedures.
Disadvantages
Despite these well recognized
benefits, the current robotic platforms
are not without profound disadvantages.
Most notably, the cost of acquiring and
Figure 2
View of the operative field (above) and the instrument controls (below) in
the console of the da Vinci
®
Surgical System. Surgery is greatly facilitated as
the surgeon’s hand-eye axis is positioned to give the illusion of directly
operating on the patient through an open incision. (Courtesy of Intuitive
Surgical, Inc.
®
)

maintaining this new technology can be
prohibitive. With the older 3 arm da
Vinci
®
Surgical Systems costing just under
1 million dollars, additional costs include
a yearly service contract of roughly

$130,000 as well as the cost of the
proprietary instruments, which currently
have a limited number of uses (10) before
requiring replacement.
11
Newer and more
popular versions of the da Vinci
®
system
include the 4 arm model, and the da Vinci
S
™
system introduced in January 2006.
These systems currently cost
approximately $1.33 million and $1.53
million, respectively. Additionally, they
require a strong commitment not only by
the operating surgeon, but by the entire
hospital staff as the devices require

additional training and experienced
personnel. Another disadvantage of the
system is its large size. The floor based
surgical cart is heavy and the robotic arms
can be cumbersome and often limit table

side access to the patient. The combined
footprint of just the surgeon console and
surgical cart (22 square feet) not only
may cause headaches in setting up an
operating room but often limits which
operating rooms can even house robotic
procedures.
11
An important limitation in
the current robotic systems is the lack of
haptics (sensory feedback). At present,
the operating surgeon can only sense
interaction with rigid structures (tool-
on-tool collisions) and thus is forced to
learn to ‘feel with their eyes’ by developing

‘near proprioception.
12
This inability to
know how hard one is grasping tissue or
a needle not only may lead to frustration
with inadvertent needle or suture breaks,
but more importantly, to unrecognized
tissue injury. Certainly, this is one facet of
surgery where the open technique clearly
maintains an advantage. Although research
is ongoing, it appears that sensory
feedback will be a feature to be desired
for some time.
13
Additionally, with only
one vendor supplying the da Vinci
®
system, surgeons must operate with a
limited number of available instruments.
This increases the reliance on the tableside
assistant to perform more of the
operation. Lastly, despite tremendous
enthusiasm among all the surgical
subspecialties, no peer reviewed
investigations with long term follow- up
have demonstrated a clear advantage of
robotic-assisted surgery over
conventional laparoscopy. It is expected
that with the maturation of data, however,
that this will eventually be the case.
Current Applications of
Robotic Surgery
While early robotic applications
involving orthopedic and neurosurgical
procedures showed promise and are
commercially available outside of the
United States (ROBODOC
®
and
NEUROMATE
®
of Integrated Surgical
Systems, Sacramento, CA), the robotic
surgical systems with the greatest potential
are those involving telemanipulation.
Cardiac Surgery
The initial commercial telepresence
systems were designed for applications
within cardiac surgery, specifically
coronary artery bypass grafting in a closed-
chest system. While this was successfully
accomplished by Carpentier et al. in 1999,
the challenges of the procedure have
limited its general acceptance and the
procedure continues to await FDA
approval. Robotic mitral valve repair,
however, has been approved by the FDA

[to be continued]

by Alan Clark, M.D.

October 13, 1967 is an important date in Missouri history. It is the effective date of the mandatory helmet law for all motorcycle riders. This noble law, which has unquestionably saved hundreds, if not thousands of lives, has consistently come under attack during the course of each legislative session.

Opponents of this law are a powerful lobby - a fact upheld by the repeal of helmet laws in many states, especially since 1995 when Congress uncoupled the receipt of federal highway funding and mandatory helmet laws. At present, only 22 states have mandatory helmet laws. Another 25 states have laws for young riders. Three states (Colorado, Illinois and Iowa) lack any requirement for helmet use.

ABATE (American Bikers Aimed Towards Education) is the largest national organization of motorcycle riders and their educational efforts are aimed at lawmakers. In 1993, the state of Illinois, thanks to the instructive efforts of ABATE, repealed the mandatory helmet laws in spite of losing almost $5 million dollars of federal highway funds that year for doing so. Now, that's education.

Of course, they failed to instruct the legislators of Illinois (and many other states) on the consequences of the law's repeal. The average mortality rate increases about 33% after the repeal of mandatory helmet laws. Typically, helmet use in states with mandatory laws is about 95 percent; after repeal of mandatory laws helmet use drops from 30 to 65 percent.

In 1996, the National Highway and Traffic Safety Administration (NHTSA) studied the effects of helmet use on outcomes of motorcycle accidents. The resulting study, Crash Outcome Data Evaluation System (CODES) was compiled data from 7 states and concluded that helmet use reduced death rates by 36 percent brain injuries by 65 percent. Most motorcycle accident victims of severe head injuries will end up on Medicaid to fund their life-long nursing home care. The costs are ultimately born by the taxpaying public.

The next year, NHTSA looked at Texas and Arkansas, two states that amended their motorcycle helmet laws to exempt most riders over 21 years of age. As expected, usage rates plummeted in the year following the amended law. In Arkansas, helmet usage dropped below 30% in 1998. Arkansas and Texas motorcycle fatalities increased the next year by 21 and 31 percent, respectively. Not surprisingly, data from the Texas Trauma Registry confirmed an increase in motorcyclists treated for traumatic brain injury. The average charges per case for hospital brain injury tallied $18,418 in 1996 and increased 75 percent in 1997 to $32,302. By 2000, the death rate from motorcycle crashes in Texas continued to climb to 120 cases per 100,000. Before the repeal it was only 74 per 100,000. These figures pale compared to the average $4.5 million dollar lifetime cost for caring for the severely head injured patient.


The average rider is now older (age 38 compared with age 24 in 1980). Forty percent of motorcycle fatalities are now in the over 40 age group. In 1990, this figure was only 14 percent.

Will Missouri follow this trend of helmet law repeals? Each year the battleground in the legislature is populated on one side with the Missouri group known as the Freedom Riders of the Road. This band of brothers has made some convincing arguments about individual rights to our legislative assembly. Two years ago, these persuasions launched an actual repeal that fortunately was vetoed by Governor Carnahan.

As expected, the forces have realigned again this legislative session. Our news media doesn’t have many motorcycle injuries to report during the winter months of legislative commotion. The public’s memory of accidents from last year’s motorcycle riding season has faded. For ABATE it is the perfect time of year to debate individual rights and the elusive freedom of choice.

As I write this editorial, Senate bill 646 (helmet law repeal) languishes in committee with little hope of reaching the floor. However, if history is true to form, the house version will pass and may or may not become mired once again in its circuitous route back to Senator Morris Westphal’s Senate Committee on Transportation.

Health care professionals should take the next step and contact their Missouri State Senator or Representative. It should be the caregivers of the injured motorcyclists who are in the best position to “educate” our elected officials.


NHTSA. Crash Outcome Data Evaluation (CODES) Project Safety Belt and Helmet Analysis. National Center for Statistics and Analysis Research Note. February 1996. Washington D.C. US Department of Transportation. 1996.
NHTSA. Evaluation of Motorcycle Helmet Law Repeal in Texas and Arkansas. Washington D.C., US Department of Transportation. 2000.

Byline:
“States move to monitor freebies to physicians”

“The representative from Wunderdrug is here. Will you see her?”
“Not today” I said, “I’m 45 minutes behind schedule.”
“Please, see her”, replied my office manager “she brought in Chinese food for the entire staff for lunch”.
If I asked my manager what “quid pro quo” means I’m not sure he could tell me. However he did feel intuitively that in return for free cashew chicken, rice, tea and fortune cookies that I owed the representative a few minutes to listen to the sales pitch on Wunderdrug’s new product. You can bet the sales rep felt the same.
I usually will listen to a drug representative’s sales pitch for a few minutes if I’m running on schedule. Probably like you, I think of it as a reasonable trade-off for the drug samples and inexpensive knick-knacks they leave behind. The samples benefit our patients and generate some good will. Surveys by the Kaiser Family Foundation indicate 92% of physicians accept free drug samples; 62% accept expensive gifts, meals, and travel expenses for personal use.
Pharmaceutical companies ‘freebies’ range from geegaws like penlights, room thermometers, notepads and refrigerator magnets to free tickets for professional sports and dinners at expensive restaurants. While packaged in the guise of product information and education, all of these inducements are designed to direct our prescriptions to their product line.
The Wall Street Journal (5/14/02) listed an embarrassing assortment of freebies to doctors including manicures, pedicures, CDs, flowers, wine, car washes, cash, expensive books, even Christmas trees! During a period of high gasoline prices one drug company offered a free tank of gasoline in return for listening to their sales pitch.
These practices may not be frankly unethical but they are clearly unseemly and diminish our professionalism in the eyes of our patients and legislators. Perhaps the most egregious and crass report (Associated Press 6/14/02) is a large physician-owned clinic in Seattle that charges drug reps $30/hr for time spent in their clinic and the Kentucky physician agency that charges reps $105 to meet personally with their 400 doctor clients.
The money spent on marketing to physicians has attracted much public attention. In 2000, the Pharmaceutical Research and Manufacturers of America (PhRMA), the industry trade association, reports $15.7 billion was spend on advertising and marketing. Roughly half went for free drug samples and much of the rest for advertising, gifts and inducements for physicians. In July PhRMA will implement a new set of voluntary guidelines that prohibits events and items for the “personal” benefit of healthcare professionals.
We may also fail to realize how much information drug companies collect on our prescribing habits. Pharmacies tabulate and sell data on physician prescribing patterns and volume. This information is collected without patients or physicians permission or consent. Many state, national and specialty societies oppose this unregulated, clandestine practice and are initiating efforts to stop the nefarious process. At present it continues unabated.
Using information purchased from this database the drug companies know how much of their products we prescribe, and how much of their competitors. Based on practice size and prescribing volume certain physicians and practices are targeted for special, expensive inducements. The same is true of large volume cataract and refractive surgeons.
While an expense paid mid-winter seminar in sunny Florida on the latest developments in Wunderdrug’s product line may seem like free continuing medical education, it is a special perk usually lavished only on actual or potential large volume users of a company’s product.
Our relationship with the pharmaceutical and ophthalmic manufacturing industry is complex and filled with many subtle nuances. Their research and products enable us to ply our craft with ever increasing effectiveness and sophistication. Their money supports our medical journals with paid advertising without which the cost of publication would be onerous. Their money supports our meetings and other important continuing medical education. Their money buys lunch for our staffs.
A new ploy, direct patient advertising, makes the patient an unwitting but effective sales agent for the drug company. This accounted for another $2.5 billion dollars of drug industry spending in 1966.
Consumer groups lead by AARP and a number of state legislatures are seeking to control and publicize drug industry free inducements to physicians. Vermont has become the first state to enact a law requiring drug companies to report to the state gifts over $25 other than drug samples.
Other coalitions of states are organizing to negotiate lower prices and discounts on drug purchases for state programs, uninsured and commercially insured citizens. This has become a national priority-in 2001 spending for prescription drugs rose 17.1% to $154.5 billion.
For the record I accept drug samples but nothing of value. Our office no longer accepts staff meals. I applaud PhRMA for their new marketing and gifting guidelines. We physicians must also know when to say “no thanks”!

John C. Hagan III, M.D.
This article is based on an editorial that appeared in Missouri Medicine: the Journal of the Missouri State Medical Association

This article is based on an editorial in Missouri Medicine: the Journal of the Missouri State Medical Association and is published with permission

Byline: Every 6 seconds a lawsuit is filed in the United States

Second Byline: Florida neurosurgeons pay $200,000 per year for a $250,000 limit malpractice policy. Are Ophthalmologists next? (Orlando Sentinel 9/22/02)

I hope reading this editorial is maddening. I want you angry, upset, distressed, disturbed, displeased, disconcerted, piqued and ready for a fight!
What is it that should raise your ire-index into the stratosphere? Dramatic, and in some cases draconian, increases in malpractice premiums for Ophthalmologists.
Malpractice premium increases that are driving physicians into retirement and out of clinical medicine (I’ve learned of three such colleagues in past months); driving physicians out of delivery rooms; driving surgeons out of high risk procedures and specialties; driving hospitals, clinics and malpractice insurance carriers out of business; driving refractive surgeons crazy.
Relief and reform are the highest priorities of many state and national medical and specialty societies. The brawl started as state and national 2003 legislative sessions commenced in January. Thanks to the American Society of Cataract Surgery,and the time, money, calls and letters contributed by hundreds of ophthalmologists and their spouses, Ophthalmology is in better shape than our colleagues in obstetrics, neurosurgery and orthopedic surgery. But without your continuing efforts eye surgeons may end up paying Florida neurosurgeon type rates.
Our angst is appropriate. Some ophthalmologists in high rate states are facing premium increases of 30-100% this year. The AMA has designated 12 states that are in crisis with more near that point. In these states frequently sued specialties are finding coverage at any price difficult to find. Malpractice insurance relief will be the biggest and most concerted effort organized medicine has made in years. It can only succeed if you’re mad enough and smart enough to get involved and stay committed.
It won’t be easy. Already, fat cat, cash-rich trial attorneys are firing up their ‘smoke and mirror’ show. Lawyers are prestidigitators and masters of deflection and dissembling. Consider this ploy of trial attorneys and some of the ‘consumer’ groups they control or nurture. In states that have relatively high rates of medical license suspension and revocations, the legal lobby says that proves there are many incompetent doctors in practice. In states that have low rates of medical license suspension and revocations, the legal lobby says that proves doctors refuse to police themselves. The use of simultaneously contradictory statements to deceive or disguise one’s motives is what George Orwell in “1984” called “doublespeak” It’s obvious George had spent a lot of time dealing with lawyers!
The trial lawyer lobby has cleverly, but deceptively, determined their scapegoat this legislative session will be the professional liability insurance carriers.
Most malpractice carriers are for-profit corporations. There’s nothing intrinsically evil about making money. Private enterprise is the engine of the world’s greatest economy. If insurance companies make money on malpractice insurance lines they try to increase their business. More companies then come into the malpractice market increasing competition, decreasing rates to doctors and hospitals. Favorable claims experience increases profits and reduces monies pledged as reserves for future claims.
Oh, if only it were so! Nationally the number of claims, the cost of defending policy holders, huge settlements, adverse judgments and monies set aside as reserves for future liabilities have steadily, often dramatically, trended upwards. According to Jury Verdict Research, in 2000, thirty-four percent of malpractice judgments exceeded $1,000,000. One in forty-four US physicians settles a malpractice claim each year; in Florida the figure is one settlement per year per eighteen state physicians. Nationally lawyer liability study groups (a.k.a. “shark packs”) develop “theories of liability”-code words for new and more effective ways to sue health care providers.
Among the most egregious states is Mississippi-tort heaven- where the ultra-powerful trial attorney association allegedly dominates all three braches of the state government and malpractice litigation is an ersatz state lottery.
When the economy was good and profits from investments covered shortfalls of malpractice revenues, the carriers could remain players in the hope that tort reform might end the litigation lottery or that economic good times would continue to roll and with it their profits on investments.
Now, during economic lean times, investment income no longer covers rising costs, vanishing profits and unacceptable exposure and financial liability. In 2001 the total profit eked out by all US malpractice carriers combined was $4,260,231. Their total payout of losses was almost $4 billion. In Mississippi, $229 was paid out in losses for each $100 of premiums collected. (Source: Missouri Dept of Insurance/The Sun News 10/30/02). You can hardly expect insurance carriers to continue writing malpractice insurance coverage when the profit margin is 0.1% and is in danger to free-fall into loss figures generally associated with hurricanes.
Being rational institutions and having a fiduciary obligation to shareholders, insurance companies are leaving the malpractice market in droves. If I were a shareholder of these companies (which I’m not), I would expect them to drop malpractice insurance coverage before every cent of their reserves is committed or spent. I’m not a fan of insurance companies but I understand why they’re leaving the malpractice market and I see nothing devious about the exodus. Sometime soon I expect an insurance company stockholder to sue their insurance company for continuing to write malpractice policies-obvious malfeasance and detrimental to dividends!
Meanwhile, back at the smoke and mirror machine, a certain desperation and seminal dread is developing in lawyers and law firms-especially after the November mid-term national elections. What if they can’t pin the malpractice crisis on the insurance industry? That mother of all nightmares-meaningful tort reform-looms an ominous specter to end their rapacious extortions and assault on physicians, hospitals, pharmaceutical, medical equipment companies and other deep pockets.
For the last decade trial attorneys have attempted to portray physicians and hospitals as rich, whining Cassandras and alarmist Chicken Littles. Now as hospitals and trauma units close e.g. Nevada, West Virgina, as physicians move, retire or restrict their practices, as medical school applications decline, as residencies in frequently sued specialties go unfilled, it is becoming obvious to patients and legislators that our warnings were accurate and prescient.
One advantage physicians have in dealing with legislators and the public is credibility. Use that advantage. Inform your legislators and patients how the malpractice crisis threatens their health and eye care. Educate your staff how your bottom line effects their salaries, benefits and job security. Get the message out. Ask patients and staff to contact their legislators to support malpractice and tort reform.
Every Senator and Representative must be educated on the health care crisis. Every legislator should understand the US Department of Health and Human Services conservatively estimates the cost of “defensive medicine” as over $60 billion per year.
Know your state and national Senators and Representatives. Better yet, be sure they know you. Contribute time and money to their campaigns. Go to their fund-raisers. Get your medical partners, associates, consultants and friends involved. Get the message out, “It is the lawyers and their tort system.” We need time and money from each and every Ophthalmologist.
It appears a trial attorney will be a candidate for the U.S. Presidency. It’s time to quit voting for lawyers. Get mad, get involved, get out the checkbook, get over and lobby at your state capitol--or get set to take out a second mortgage to pay your malpractice premium.

John C. Hagan III, MD

Dr. Hagan is the Editor of Missouri Medicine and practices at Discover Vision Centers in Kansas City, Missouri

I’ve sued two of my attorneys for legal malpractice and won both cases. I got one attorney disbarred in two states and out of the legal business entirely. It’s a strange turn of events for there are more attorneys than physicians in my family and I’ve always gotten along well with members of the legal profession.
When I moved to Kansas City to join an established Ophthalmology group I spent a lot of effort trying to find a highly qualified lawyer to represent me. None received as many kudos as Phil James (not his real name). Phil had gone to law school with one of my cousins who remembered him as a good student and a respected member of a large firm before he left to start solo practice. Among his high profile clients was the coach of American Football League powerhouse Kansas City Chiefs. “He’ll take good care of you” was the word from all those who knew or had worked with Phil. And indeed he did-at least for a while.
With his help I negotiated a good work contract and he saved me some money in the purchase and financing of my home. He sent some medical-legal work my way and he and his delightful wife and daughters were patients of mine. He even came up with hard to get Chiefs football tickets on occasion.
Phil pointed out many times that his special interest and expertise was in tax law. As my practice built and my income rose he told me one day in his office that “the only way guys like you and I can get and stay rich is to shelter our income from taxes”. He said that he had reviewed my projected tax liability and that it was “a killer”. The best way for me to protect my income and my family would be to invest in limited partnerships that not only protected me from taxes but would eventually be sold for huge profits.
One of the services he said he would provide me was to evaluate limited partnerships and recommend those that would match my need to shelter income. He also did a little name-dropping about who the other investors would be. Impressed by the number of doctors, lawyers and athletes in the group I gave my okay. There followed on a regular basis a dizzying assortment of investments in oil rigs, convenience stores, apartments even vegetable crops. Each dollar invested sheltered two to six dollars from taxation.
I began to grow uneasy about the amount of money needed “to save tax money” and the failure of so many of these Limited Partnerships to meet their income generation projections. An article in the local newspapers on failing and fraudulent Limited Partnerships included some I had purchased through Phil. Among the revelations were that high write off multiples were being successfully challenged by the IRS. Also the general partners had kept funds that should have been distributed to the limited partners.
Depressed and believing a second opinion was in order I consulted a large legal firm. They quickly confirmed my worse fears. The tax write-offs were unreasonable and would not stand up under audit. The projected growth of the investments were pure fantasy. The general partners were inexperienced and under-capitalized. The investments from buildings to vegetables were failing.
The real shocker was that Phil was a silent partner in all of these deals and had received part of the money I had invested as an undisclosed “finders fees”. The legal firm advised me I was facing potential severe tax problems and that all or most of the investments would likely fail. They suggested filing a legal malpractice claim against Phil and offered to represent me.
I reluctantly agreed but asked in deference to Phil’s family whom I liked to hold off filing the claim till after Christmas and New Years. In January before we filed Phil died of a heart attack while still in his 40s. I was so grateful we had held off as I might have always wondered if the stress of the suit killed him.
The house of cards Phil had build tumbled after his death. Many of his other clients including the AFL coach were having the same problems with their investments as I was. In all over 15 million dollars of legal malpractice claims were filed against his estate. This was a record that I believe still stands in Missouri. Phil and his legal firm carried only about $200,000 worth of legal malpractice insurance. The carrier quickly settled for the entire face amount which when divided among plaintiffs came to about $17,000 apiece.
After several years of using the large firm I became concerned about my legal and accounting costs. A physician colleague whose office was next to mine told me about his brother in law that represented him and also provided accounting services. He gave me the names of another 10 or so doctors that Patrick O’Shannon (not his real name) represented. “You’ll love him-he thinks and acts like a doctor” my friend said.
O’Shannon met with me and reviewed his training. He at one time was studying for the priesthood and like me had a Jesuit background. He reviewed my legal and accounting bills for the last two years and said he could do better work for half the price. Bingo! The magic words. I signed an authorization retaining him and he drove over to my previous accountant and law firm and picked up my records.
Pat was the hardest working man I ever saw. He worked seven days per week and was at the office by 5:30 A.M. each day. His bills were reasonable and it was convenient to have one person do legal and accounting.
After several years I would sometimes get letters from the IRS or the State Revenue Office stating that withholding taxes had not been paid on time. Pat assured me that this was due to the intrinsic ineptitude of the IRS and state bureaucracy. He had me sign papers so that all correspondence from the IRS went directly to his office. Unbeknownst to me he also instructed my staff to send all documents from any city, country, state or federal agency or other law firm directly to him even if it was addressed to me.
One day I received a call from a patient asking me if I knew that the local business journal listed my practice as having a lien filed against it by the State for non-payment of taxes. Then I received a call from an IRS investigator asking why I had not responded to several letters they had sent about back tax issues. He said he had checked and that I had a good reputation but that my attorney was getting me in a world of trouble and suggested I consider different representation.
My frantic calls to O’Connor were met with his calm reassurance. He had paid all taxes on time, all forms had been filed, he had responded to all inquiries from the state and the IRS.
Shortly thereafter, in the surgical dressing room I learned that several other doctors were having the same problem, one group had had their retirement plan disallowed for non-compliance. The taxes were enormous and had to be paid immediately with interest.
As Yogi Berra said “Its Déjà vu-All Over Again”. I promptly and sheepishly called the large firm that had represented me well and asked if they would resume my representation. They agreed. They also suggested hiring an accounting firm to take over my books. O’Connor denied up to the very end any wrong doing.
It took over 5 years and several hundred thousand dollars of legal and accounting fees to straighten out the mess O’Connor had created. We had to negotiate deals that involved paying back taxes, interest and penalties with the State Department of Revenue, the IRS and the labor department. My entire accounting records for the previous 7 years had to be redone. An audit of my practice disclosed that over $16,000 had been transferred to 0’Connors’ physician brother-in-laws practice (the one that had introduced and recommended him to me). This money was never returned either by the bank who made the transfer or the physician that received the money.
We filed a legal malpractice claim against O’Connor and his firm. They carried about $165,000 of coverage. The carrier agreed to settle the case dividing the proceeds among three physician groups that had filed claim. My attorney collected 30% of my share of the settlement.
O’Connor remained in practice and totally defiant and unrepentant. I filed a complaint with the Missouri and Kansas Bar. In the meantime I learned that O’Connor had been disbarred from Federal Court for falsifying dates on legal documents. In addition members of his family had filed a complaint about his management of a family trust. Faced with overwhelming evidence of gross negligence and misconduct he surrendered his Missouri law license. He contested the proceedings in Kansas. I was asked to testify in person in a hearing in Topeka. The two key witnesses against O’Connor were myself and his sister who asked the judge to remove his license. She said she and her family believed O’Connor a sociopath. He did lose his license. I believe he still does tax planning and accounting.
What have I learned. First good word of mouth and good training don’t guarantee an honest or competent lawyer. Second, lawyers and law firms don’t usually carry anywhere near the amount of liability insurance that we physicians are required to by hospitals and insurance plans. Third unlike medical malpractice the cost of legal representation is subtracted from the face value of the policy. So contesting or prolonging legal actions lessens and exhausts the amount of money available for recovery. Fourth never have the same person or firm provide both legal and accounting services. Fifth if something doesn’t seem right or you’re not comfortable with your representation don’t hesitate to get another legal opinion. Lastly if you’re a victim of legal malpractice don’t hesitate to press your claim you won’t have trouble finding representation. And don’t forget to file a complaint with the Bar.

John C. Hagan III, M.D.
Kansas City, Missouri
Previously Published In Medical Economics

Yes, contrary to your deepest suspicion your mother really does “know what’s good for you”. After scores of years and millions of dollars of medical research, scientists at Harvard Medical School and the University of Wisconsin have established that generations of mothers were absolutely correct in their admonitions to “eat your vegetables-they’re good for you”. (However you can forget and forgive her faux pas in foisting liver and hot dogs on you).
However even mom would have been surprised at all the health benefits of a diet low in fat and rich in fruits and vegetables. Over the last three decades study after study has shown that heart disease, heart attacks, strokes, high blood pressure, cancer of the breast, colon and prostate, diabetes and gallbladder disease can all be significantly reduced by modification of your diet. Now a low saturated fat, high vegetable diet offers hope for better vision especially as you age.
In studies reported recently in the Journal of the American Medical Association and the Research to Prevent Blindness Seminar, cataracts and macular degeneration were dramatically reduced by avoiding the typical American high fat, vegetable poor diet.
Cataracts are a clouding of the lens of the human eye. Symptoms vary but may include poor, smoky vision, frequent changes of glasses, a feeling that the glasses are dirty all the time, glare, difficulty with night vision and ghost images. The retina is the back part of the eye that forms sight images that are transmitted to the brain. It functions much like the film in a camera. The macula is the yellow spot in the center of the retina. The macula is used for reading, computer use, driving and all your straight ahead vision and depth perception. The macula is about 5% of the retina, the remaining 95% is used for peripheral or side vision. Both the macula and the lens are particularly sensitive to degeneration and (like the knees of your favorite old pair of blue jeans) seems to be the part of the eye to wear out first.
Age related macular degeneration (ARMD) is the leading cause of blindness in adults older than 60. The condition develops in as much as 25 to 65 percent of older adults and can occur even in people in their 40’s and 50’s. While ARMD does not cause total blindness it can leave a large sightless spot in the middle of the vision that destroys the ability to read, drive, recognize faces and see straight ahead. Treatment of macular degeneration is generally unavailable or unsuccessful emphasizing the importance of prevention.
Julie A. Mares-Perlman M.D., a professor of Ophthalmology (physicians who specialize in medical and surgical eye care) at the University of Wisconsin Medical School found an amazing 80% increase in ARMD in people who reported eating diets high in cholesterol and saturated fats. This supports a previous study done at Harvard Medical School by Johanna M. Seddon, M.D. that found a 50% reduction of ARMD by reducing fat in the diet and increasing fruit and vegetable intake.
The Harvard study focused on individual foods that might be especially important to the health of the macula. On this point mom was a bit errant. The best food for the eye isn’t carrots but spinach (don’t say “yuk” Popeye obviously knew this a long time ago!) and greens (collard and mustard). People who reported eating these dark leafy green vegetables two to four times per week had much healthier maculas and better vision. Those that ate the greens 5-6 times per week (canned or fresh, raw or cooked vegetables are all beneficial) had an even greater protective effect.
While the mechanism of this propitious effect needs further study the research Ophthalmologists speculate that it has to due with certain pigmented nutrients found in the vegetables. The macula appears as a striking yellow spot in the middle of the retina. Its yellow color comes from important but fragile pigments including lutein and zeaxanthin. These pigments are vital for the visual process but are damaged or destroyed by age and light exposure (and probably smoking tobacco). Spinach, greens and kale are rich in lutein and zeaxathin, while carrots are not (less it seem that the once mighty carrot is being “dissed” it is an important source of beta-carotene and a vital element of most respectable salads). These pigments are not found in vitamin pills or supplements.
The other equally important part to the eye health equation is reducing the amount of saturated fat and cholesterol. The macula has no blood vessels and relies on diffusion from near-by blood vessels for sustenance. Like the coronary blood vessels in the heart, saturated fat and cholesterol may clog the arteries that supply the macula and gradually starve the delicate sight formation cells to death and produce ARMD.
If we live long enough (and most runners and frequent exercisers do) we will all develop cataracts. Cataract surgery and insertion of an intra-ocular lens implant is the most common operation done on American adults and one of the outstanding success stories in the annals of surgery. Nevertheless prevention of cataracts is still desirable in order to avoid surgery and reduce the social and individual costs of 1,600,000 cataract surgeries per year.
Many years ago it use to be said that the only way to prevent cataracts was to die young. Now a number of more palatable alternate prevention methods have been established. Cigarette smoking increases the risk of cataract formation by about 60% and may also hasten macular degeneration. Alcoholism or heavy alcohol use causes cataracts and makes them occur at a younger age.
The sun damages and ages not only our skin and face but the lens and macula of the eye. Ultraviolet (UV) rays are the part of the light spectrum that has been implicated in this harm. In the lens UV injures the transparent protein fibers and causes them to become cloudy, murky and opaque. UV that escapes filtering by the lens is absorbed by the macula and decomposes the luteal pigments of the macula.
UV damage appears more common and severe in fair complexioned individuals with light color eyes (blue, green, gray, or very light brown). Just as the skin can be protected from the sun by applying a sun screen, the eye can be protected by 100% UV blocking lenses. UV blocking is not the same as a tint nor is it present in all sunglasses. UV blocking coating should be applied to all prescription glasses and all prescription and non-prescription sunglasses. UV blocking can be applied to existing glasses by most optical outlets. They can also check to see if it is already present. In addition for outdoor activities done in bright sunlight a hat with a wide brim should be worn. UV protection is extremely important when reflective conditions exist such as snow, water, glass or sand. As humankind steadily destroys the UV blocking ozone layer, the further south and higher you live, the more time you spend out of doors, the lighter your complexion the more important this becomes.
The role of vitamins in prevention of cataracts and macular degeneration is not completely understood and conflicting studies appear in the medical literature. Dr. Mares-Perlman and her colleagues found a 40% reduction in cataract formation in adults that took a multi-vitamin supplement. Some studies have show macular degeneration to be reduced by vitamin supplements. An unexpected finding was that high fiber diets reduced the thickness and severity of cataracts.
The type of vitamins that appear to be the most beneficial to the eye are the anti-oxidants: vitamin A (beta-carotene), C (ascorbic acid) and E (tocopherol) and additionally for the macula zinc and selenium. Scientists are just beginning to understand the possible benefits (and hazards) of vitamin supplements. Massive mega-vitamin and mineral (mis)use can be hazardous especially with vitamins A, D, K, zinc and the poorly understood and non-standardized herbal preparations.
For my patients, in my responses to Running & FitNews clinic advisor questions and for my own personal use I recommend each day: 1. a good inexpensive multivitamin supplement 2. a 400 milligram vitamin E tablet 3. a vitamin C supplement of 500-1000 milligram perhaps in a timed release 4. one or two odorless garlic pills.
Yes-your mom will be proud of you if you make these dietary changes. Instead of carping at you for not eating your vegetables she can work on getting you to call her more often.

John C. Hagan III, M.D.

Correspondence:
Midwest Eye Institute of Kansas City
2700 Clay Edwards Drive, Ste. 550
North Kansas City, MO 64116
Phone office (816) 421-0900
Phone home (816) 454-1575
Fax (816) 454-8478

About the author:
John C. Hagan III, MD is an Ophthalmologist and Clinic Advisor. He is Board Certified and practices in North Kansas City Missouri subspecializing in cataract and implant surgery. He has completed 4 marathons and is in training for the Boston Marathon. His love of vegetables is an acquired taste indicative of the educated palette.

Guest Editorial: “As I See It” Kansas City Star Newspaper 3/05/03

Malpractice premium increases are driving Missouri physicians into retirement and out of clinical medicine. I’ve learned of several such colleagues in recent months. Missouri physicians are facing premium increases of 30-200% this year. Skyrocketing costs of malpractice insurance are driving obstetricians out of delivery rooms; surgeons out of high-risk operations and specialties; driving health care institutions and providers out of business, driving bright young people away from the healing professions. Medical school applications have declined six straight years.
This legislative session relief and reform from malpractice litigation that threatens your medical care, inadequately compensates real victims of malpractice and outlandishly rewards trial lawyers are the goals of physicians, medical clinics, hospitals, nurses, pharmaceutical companies, insurance carriers and many citizen advocate groups. As a patient and taxpayer you should know the cost of ‘defensive medicine’ is estimated at up to $100 billion per year. Almost everyone outside the law profession recognizes the need for sweeping tort reform and restructure.
Reform won’t be easy. Nationally and in Missouri cash-rich, politically powerful trial lawyers and their lobbyists are determined to continue plundering the badly broken tort system for billions of dollars. The trial lawyers have cleverly, but deceptively, determined their scapegoat this legislative session will be the professional liability insurance carriers.
When the economy was good and profits from insurance company investments covered shortfalls of malpractice insurance revenues, the carriers could forgo premium increases.
Now, during economic lean times, investment income no longer covers vanishing profits, unacceptable financial exposure and liability. In 2001, total profit eked out by all U.S. malpractice carriers combined was $4,260,231. Their payout for losses was almost $4 billion. You can’t expect insurance carriers to continue malpractice coverage when the national profit margin is 0.1% and free falling into loss figures generally associated with hurricanes.
A certain desperation and dread is developing in trial lawyers-especially after the November mid-term national elections. What if they can’t pin the malpractice crisis on the insurance industry? What if the public realizes we have too many lawyers (more than the rest of the world put together), too much litigation (a lawsuit is filed nationally each 6 seconds) and that their medical care is jeopardized by an extortive tort system?
Missouri medical malpractice reform will only occur if you, your family and friends are willing to wrest health care legislation away from trial lawyers and direct it to the public good.
John C. Hagan III, MD

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John C. Hagan III, MD, is Editor of the medical journal Missouri Medicine and practices ophthalmology in Kansas City. His groups’ malpractice premium in 2002 went up 185% in spite of no claims payment in the past 30 years.

TEASER: Physicians must be willing to participate in the legal process. Their evaluations and testimony should be fair, honest and their opinion the same whether retained by the plaintiff or the defendant


“I know you feel the man I sent you to evaluate is a victim of blatant malpractice. Don’t sign your expert witness report until you’ve sent it to me for review. I may make some changes and then I’ll mail it back to you for your signature.”
The fearsome trial lawyer on the other end of the phone had amassed a fortune suing physicians in Missouri and Kansas. Even the mention of his name to physicians sent chills down the spine or brought profanity to the lips.
“I’m sorry I can’t do that. I don’t think your case is malpractice. The patient had a common complication that was well managed by the surgeon. There was some patient non-compliance also.”
“Listen doctor Hagan, you’ll do as my other doctors do or you’ll never see another referral from me again” Mr. Über Suemeister said in his most intimidating tone of voice.
“I can live without your business. I didn’t ask you to send me the patient in the first place.”
“Hagan, I’ll remember this. You had better hope I never have one of your patients come into my office,” fumed the belligerent barrister.
He apparently hasn’t. Knowing his legendary bellicosity and tenacity, I’m sure he’s still looking. I do wonder how many medical expert ‘hired guns’ the king of torts employs in his stable. I’m sure at least one in every specialty, probably several in orthopedics and neurosurgery.

Disclosure
In the interest of disclosure I believe you should know that I have done some expert witness testimony over the years. It’s nothing I’ve sought and certainly never advertised. The revenue generated doesn’t compensate for the time away from my practice. Mostly they have been reviews of cases to see if there was evidence of malpractice. These have been equally on behalf of defendants and plaintiffs. In all cases save one, I have found no evidence of malpractice. My review and opinion lead to no suit being filed or a vigorous defense of the accused physician. In the case I felt was malpractice, a claim was filed. Uncomfortable but resolute, I was deposed in the presence of the defendant physician. A settlement was reached.
I’ve been sued three times in my medical career. One case was dismissed, in another I was quickly dropped from the suit. In the last case an out of state physician swore my care was substandard. I felt strongly, as did several eminent ophthalmologists that reviewed the case, that my care of the patient’s macular degeneration exceeded the standard of care. Against my wishes the case was settled for $15,000 the day before trial. My carrier said a week in court would have cost them $50,000 in legal fees and involved a small risk of an adverse decision and a large award---this was unacceptable to them. (As an aside, this case was instigated by unfounded derogatory comments about my care from a consultant’s technician)
My attorney told me the expert in this latter case made a substantial part of his income from testifying against ophthalmologists across the country on behalf of the plaintiff’s bar. His testimony often involved surgery he did not perform. He advertised his services in national legal tabloids. His distinguished appearance, communication skills and demeanor had been honed to a fine sheen by mock trials, previous testimony and reportedly drama classes. Even with scant evidence to work with the hired gun was considered a formidable foe and capable of swaying an impressionable, non-scientific jury. To my carrier settling for “nuisance” value was a highly desirable case resolution.

Role of the Medical Expert Witness
The medical expert witness is an essential cog in the lawsuit industry. These are physicians paid by one of the opposing parties to evaluate cases to see if a basis exists for a credible claim. They may also render formal opinions on the merits of the case, participate in the discovery process and appear in court to testify on behalf of the plaintiff or the defendant physician.
In the present adversarial tort system, the medical expert has theoretically a useful function. Such a physician should have knowledge of tort law and a firm grasp of the difference between the contemporary, evolving legal “standard of care” and the medical “standard of care” at the time the alleged act occurred —not when the claim is filed. This physician expert should fairly determine whether a valid claim exists to litigate, settle or defend. This expert should be a practicing physician or surgeon who performs the type of treatment or surgery at issue. Expert fees should be reasonable; opinions should not be dependent on which side is paying them. Champerty—having contingency fees riding on a lucrative settlement or judgment—is never ethical or acceptable.
Theoretically such an expert would issue far more opinions that no malpractice claim exists. It is well established that most claims brought to plaintiff lawyers represent fully disclosed legitimate complications, unavoidable bad results and unreasonable expectations by the patient. The stimulus for most malpractice lawsuits is anger with a physician’s perceived arrogance and/or lack of communication and compassion. Increasingly a desire to win a ‘litigation lawsuit jackpot’ is the genesis of all tort lawsuits.
We can summarily dismiss the trial lawyer’s assertion that physicians are unwilling to testify against their peers. There is no conspiracy of silence in the medical profession. If that were once true it was so long ago it is irrelevant. Physicians must be willing to participate in the legal process. Reputable physicians should be fairly reimbursed for their time but their testimony is not for sale—not at any price. Physicians adhering to this ethical bright line do a service to their colleagues, their patients, the legal system and they further justice being served.

The Professional Biased or Corrupt Expert Witness
Given the pivotal importance of the medical expert witness and the obscene profits in ever soaring malpractice judgments, it is not surprising that a fetid, growing cottage industry of biased physician expert witnesses has developed. For the right price these mendacious individuals will find malpractice in almost all of the cases they are asked to review. They serve exclusively the plaintiff’s bar. Known variously as “hired guns” or (my favorite) “testimony tarts”, they not infrequently earn millions of dollars per year.
Most are driven by base greed and avarice; a few are motivated by delusional standards of excellence and perfection that they think they alone practice and can determine. Their names and credentials are shilled in legal publications, over the web or through procuring agencies. Hometown physician colleagues are frequently unaware of the hired gun’s sordid and sub rosa activities.
What’s the going rate for a top testimony tart? Try $1000-1500/hour to review records, for trials or depositions $10,000-15,000/day, first class airline or private jet travel, limousine service, suite of rooms at the best hotel, expensive gifts at Christmas and, for the most egregiously corrupt, a contingency fee based on a favorable verdict and large judgment. Some allegedly guarantee their testimony will result in a big settlement or guilty verdict.
In a future editorial we will explore this unseemly side of this medical-legal interface with examples from the national asbestosis and silicosis litigation and blatant cases plied right here in Missouri.
We will look also at the investigations into expert witness corruption that was instigated by Texas federal judge Janis Graham Jack. This corruption has attracted the attention of several prosecuting attorneys and the justice department. More than a few law firms and their hired guns are starting to sweat and squirm. At the end of these investigations is the hope of indictments, convictions, and prison time for those that have criminally ravished tort and product liability law.

Expert Witness Reform in Missouri
We have left aside the broader issue of whether the process of American malpractice litigation is unjust and unfair (it is) and should be replaced with health care courts (it should). In this model, presently used for some complex technical litigation, special judges and consummate medical experts carefully selected for their objectivity, knowledge of the law and medical issues at hand, judge and decide malpractice cases. These experts represent neither the plaintiff nor the defendant. They serve the court and work dispassionately. They are paid fairly for their time. Their opinions are not for sale. When true malpractice occurs judges set monetary awards based on objective economic metrics.
Ultimately, we must move in this direction. Presently, we are mired in a miasmic system that involves dueling medical experts. Our first step out of this medical-legal morass is to enact expert witness reform this session of the Missouri Legislature.
This is a very important issue that we can all rally behind: “hired gun” control.

John C. Hagan III MD
Editor, Missouri Medicine