Tuesday, April 25, 2017

referral associations

referral associations

we got issue in america. too many good docsare getting out of business. too many ob-gyns aren't able to practicetheir love with women across this country. i don't have a job. i don't want to haveany more debt out to anybody else. i'm flushing the wound. this is adam. he had an accident. he's one of nearly 50 million americanswith no health insurance. but this film isn't about adam.

so this is the table saw.it was spinning that way... this is rick. i was gripping a piece of woodand i grabbed it here and it hit a knot... he sawed off the topsof to of his fingers. ...and it was that quick. - his first thought?- i don't have insurance. am i gonna have to pay cash for this?$ 2,000, $3,000 or more? does that meanwe're not gonna get a car? rick also doesn't havehealth coverage.

so the hospital gave him a choice. reattach the middle finger for $60.000. or do the ring finger for 12.000. it's an awful feelingto just try to put a value on your body. being a hopeless romantic.rick chose the ring finger. for the bargain price of 12 grand. the top of his middle finger now enjoysits new home in an oregon landfill. i can do that thing where, you know,the old man used to pull the finger off. this movieisn't about rick either.

yes. there are nearly 50 million americanswith no health insurance. they pray every daythey don't get sick. because 18.000 of themwill die this year. simply because they're uninsured. but this movie isn't about them. it's about the 250 million of youwho have health insurance. those of you who are livingthe american dream. it's moving dayfor larry and donna smith. they've packed everything they ownin these to cars.

and are driving to denver. colorado. to their new home... - hi.- hello. ...in their daughter's storage room. this is home, sweet home. - look at all that stuff.- we'll get everything organized. - we will.- what do we do with the computer? - it stays.- it stays there. so this is where heather talked aboutwe might have to put bunk beds.

i see what she's talking about. it wasn't supposed toend up like this for larry and donna. they both had good jobs. she was a newspaper editor. and he was a union machinist. they raised six kids who all went tofine schools like the university of chicago. but larry had a heart attack. and then another one. and then donna got cancer.

and even thoughthey had health insurance. the copays and deductiblessoon added up to the point where they could no longerafford to keep their home. if somebody told me ten years ago this wasgonna happen to us because of healthcare, i would have said, "it's not possible. " "not in the united states.we wouldn't let that happen to people. " - are we gonna quit?- no. it's just hard. they were bankrupt.

so they moved inwith their daughter. we'll get it all figured out. we emptied the dresserso you have a spot. nice, very nice. even their son dannypopped in from across town to welcome them to denver. - what do we do about people like you?- i don't know, that's a good question. you're supposed to pay a deductible for$9,000, i understand. that's healthcare. what about people like kathy and ithat have to come up there

and move you every five years,every two years, every year, - 'cause you don't have enough money?- that's what russell says too. i'm sorry. it's not what we wantedto have happen in life. and we're doing what we canto make the change. you don't know what that feels like insideat 50-some years old, to have to reach outto my 20-something-year-old for help. it's gonna be hard for four, five, six,seven months, it's gonna be hard. i have a feeling of you bring your problemswith you no matter where you go. yeah.

but i don't knowwhat to do about that. by sheer coincidence.their daughter's husband. paul. was leaving on a jobthe very same day they arrived. paul was a contractor.but there weren't many jobs lately. so he found work out of town. i'm sure you'll keepa telephone conversation. email you. you're gonna bejust fine, lovies. weird situation, isn't it?

- tell me where daddy's going.- iraq. why is daddy going to iraq? to do some plumbing. oh, boy. this i do early in the morning.the first thing i do is i clean here. at age 79. frank cardile shouldbe kicking back on a beach somewhere. but even thoughhe's insured by medicare. it doesn't cover all the cost of the drugsthat he and his wife need. being that i'm an employee here,my medicine is for free.

so that's why i gotta keep working.until i die. there is nothing wrong with that. ok. i always gotta keep my ears openbecause there's always spillages. sometimes you get a gallon of milk. tomato sauce - oh, you're in trouble.it'll take a half-hour to clean that up. and i look up on every aisleso as everything is clean. if i see something i pick it up,whether it's paper or garbage. one day i had the keys in my handand they went in there.

and i had to climb in thereto get the keys out. it's a sad situation. if there are golden years,i can't find 'em, i'll tell you that. she had a painkiller for her hip. the girl said, "frank, this is $ 213.""what, for a painkiller?" - i didn't take it.- i backed off. i said, "i gotta come back. " what's in them? what's in thesenew drugs that they distribute? i don't believe you needhalf of the things they tell you. i have never taken medication now,as i'm getting older.

i don't even like to take an aspirin. i do like a little brandy. i don't really know how this happened, butthe trunk came forward into the back seat. laura burnham was in a head-oncollision that knocked her out cold. paramedics got her out of the car and intoan ambulance for a trip to the hospital. i get a bill from my insurance company telling me that the ambulance ridewas not going to be paid for, because it wasn't preapproved. i don't know exactly when i was supposedto preapprove it, you know?

like after i gain consciousness in the car,before i got in the ambulance? i should have grabbed my cellphoneoff the street and called in the ambulance? i mean, it's just crazy. i applied forhealthnet insurance for jason. they rejected himbecause of his height and weight. jason is six feet talland 130 pounds. i applied for healthcarethrough bluecross blueshield and they told methat my body mass index was too high. i'm 5' 1 ",i weigh 175 pounds.

i always thought health insurancecompanies were there to help us. so i posted a note on the internet. asking people if they had hadany similar stories about problemswith their insurance company. within 24 hours.i had over 3700 responses. and by the end of the week.over 25.000 people had sent metheir healthcare horror stories. some of them decidednot to wait for me to get back to them. like doug noe. who took matters intohis own hands. without my permission.

his daughter was nine months old whenthey discovered she was going deaf. his health insurance company.cigna. said they'd pay for an implantin only one of her ears. according to the letter they sent. it's experimentalfor her to hear in to ears. if a cochlear implantis good for one ear, it doesn't even make any sense thatit wouldn't be good for the second ear. especially when a childis just starting to learn how to talk, she has to learnfrom both sides of her head.

that's when he sat downto write cigna a letter. this is to cigna."noted filmmaker michael moore is in the process of gathering informationfor his next film. " "i've sent information concerning cigna'slack of caring for its policy holders. " "has your ceo ever beenin a film before?" before he knew it. he receiveda call on his voice mail from cigna. tuesday. 8.:54 am. obviously all this worked because annetteis going to get her second implant in july. "dear mike.i work in the industry. "

"i work for an hmo." i started to get hundreds of lettersof a different sort from people who work insidethe healthcare industry. they'd seen everythingand they were fed up with it. "health insurancecompanies suck. flat suck. " like becky malke. who wasin charge of keeping sick people away from one of america'stop insurance companies. i work in a call center, so peoplecall in and ask for insurance quotes. there are certain preexisting conditions,basically industry-wide,

that will not be covered - diabetes, heart disease,certain forms of cancer. if you have these conditions, you are likelynot going to get your health insurance. how long is this list of conditionsthat make you ineligible? it would be a really long list.it would be a long list. it could wrap around this house. sometimes you know they're gonnabe declined at the end of the application, and they're like...god, like one time i had a couple, and they were so happy to get...i'm gonna cry.

they were so happy that they were...i took them through this application. and the husband was late for work. and the wife said to him,"don't worry, baby, it's gonna be ok." "we have health insurance now. " and when i looked, i could tellthey were gonna get declined because of their health conditions.and they were so happy. i thought, "god, they're gonna getthat call in a couple of weeks telling themthat they're not eligible for insurance. " i just felt so bad'cause i just really thought

and i knewand i couldn't say anything to them. i just felt like crap. that's why i'm such a bitchon the phone to people, because i don't wannaget to know them, i don't wanna know about their lives,i just wanna get in and out, and get done with it'cause i can't take the stress of it. in spite of becky beinga bit of a pain on the phone. a quarter billion americansare still able to get health insurance. let's meet some of thesehappy insured customers.

maria has blueshield. and diane. horizon bluecross. bcs insures laurel. and caroline has cigna. and it's a good thingthat they're all fully covered. i ended up being diagnosedwith retroperitoneal cancer. - brain tumor.- breast cancer. brain tumor on the right temporal lobe. as they were insured. they got thered-carpet treatment at the doctor's office.

she requested for meto see a neurologist. the way they would treat itwas to remove it. surgery was scheduledfor december 9. there is a test that you can take that will show whether or notyou would benefit from chemo. they got their treatment. but notbefore battling their insurance companies. investigated whether or notthis was a preexisting condition. "it's not medically necessary. " they claim that it's experimental.

"we don't consider that life-threatening. " diane diedfrom her non life-threatening tumor. laurel's cancer is now spreadthroughout her body. her "experimental test"proved that caroline needed chemo. while vacationing in japan.maria became ill and got the mri that blueshieldof california had refused to approve. the doctors in japantold her she had a brain tumor. blueshield had said repeatedlyshe didn't have a tumor. that's when she said:"well. i'm pretty sure i have a lawyer. "

march 13, 2003. i'm gonna direct your attentionto exhibit one. please describe for me what it is. it is a denial for referralto an ophthalmologist. - is it your signature on this?- yes. i'd like to direct your attentionto exhibit two. this is a denialof a request for referral for a magnetic resonance imaging testof the brain. - it has your signature?- yes.

directing your attentionto exhibit three. please read this document. this is a denial of a referralto a neurosurgeon. can you explain for mehow you came to sign the denial letter? this is a standard signatureput on all denial letters. - is it your signature or a stamp?- that is a stamp. did you ever see a denial letterbefore your signature was stamped on it? no, but the denial lettersare fundamentally the same. the denial letters that are sent out... - the answer is no.- no. all right.

the definition of a good director wassomebody who saves the company money. dr. linda peenowas a medical reviewer for humana. she left her job because she didn't liketheir way of doing business. i was told when i startedthat i had to keep a 10% denial. then they were giving us reports weeklythat would have all the cases we reviewed, the percent approvedand the percent denied. and our actual percentage denial rate. then there would be another report thatcompared me to all the other reviewers. the doctor with the highest percentof denials was gonna get a bonus.

really? so you, as a doctor,working for the hmo, if you denied more people healthcare,you got a bonus? that was how they set it up. any payment for a claimis referred to as a medical loss. that's the terminologythe industry uses. i mean, when you don't spend moneyon somebody, you deny their care, or you make a decision that bringsmoney in and you don't have to spend it, it's a savings to the company. this is tarsha harris.

bluecross didn't deny herher treatment. and actually approved her operation. but then they discoveredthat in the distant past. she had had a yeast infection. apparently it's common.men, women can get a yeast infection. so i was prescribed the yeast infectioncream, general cream, and it went away. she later applied for health insurance and that's what you're supposedto be disclosing - serious ailments. the yeast infection is not a serious ailment.there was nothing she could have done.

it wasn't until they were gonna haveto spend money that they looked. if they'd taken five minutesand wanted to clear up the yeast infection, they could've looked at her recordsor talked to her doctor. because of the undisclosedyeast infection. bluecross dropped tarsha harris. she thinks she's put this behind her.and then bluecross changes their mind, tells the doctors, "we're taking the moneyback, go get the money from tarsha. " the fact of the matter isit was a yeast infection, that's all it was. i'm still a little bitter becausei don't trust insurance companies now.

to me, it seems they're alwaysgonna be looking for a way out. what happened to helpingthe person that's sick? don't make their problems worse. this is lee einer. if they weren't able to weed you outin the application process. or deny you the careyour doctor said you needed. and somehow ended uppaying for the operation. they send in lee. their hitman. his job is to get the company's moneyback any way he can.

all he has to dois find one slip-up on your application. or a preexisting conditionyou didn't know you had. we're gonna go after thislike it's a murder case. and i mean the whole unit dedicated to going through your health historyfor the last five years, looking for anything that would indicate that you concealed something,you misrepresented something, so that they can cancel the policy or jack the rates so highthat you can't pay them.

and if we couldn't find anythingyou didn't disclose on the application, you can still get hitwith a preexisting denial, because you don't even have to havesought medical treatment for it. in some states, it's legal to havea prudent person preexisting condition. and that's a mouthful, i know, but what that says isif prior to your insurance kicking in, you had any symptom which would inclinea normally prudent person to have sought medical care, then the condition of which that symptomwas a symptom is excluded.

i know! it's labyrinthine, isn't it?but that's how it works. they're supposed to be even-handed, but with an insurance company,it's their frigging money! so it's not unintentional,it's not a mistake, it's not an oversight,you're not slipping through the cracks. somebody made that crackand swept you towards it. and the intentis to maximize profits. looking back,i don't know that i killed anybody.

did i do harm in people's lives? yeah. hell, yeah. i haven't worked for insurance companiesfor a long time, and i don't thinkthat really serves to atone for my participation in that mess. i am glad i'm out of it, though. julie pierce was strugglingto get care for her husband tracy. who was sufferingfrom kidney cancer. julie works in the intensive care unitat st. joseph's medical center

in kansas city. missouri. which provided her familywith health insurance. every month, there was a new drugthat the doctor wanted to try. my insurance denied it. one lettermight say, "not a medical necessity," one letter might say, "it's notfor this particular type of cancer," and they denied it. then we came up with the bone marrow.it has showed to stop it, sometimes to completely get rid of it. tracy's doctors saidthis treatment had been successfully tried

on many other patients. if one of tracy's brothers turned outto be a suitable donor. there were promising bone marrowtreatments for beating tracy's cancer. two weeks later, the bone marrownurse at ku called me and she goes: "we've got the results back. his youngestbrother is a perfect donor match. " we were ecstatic. you know, i think that's the happiesti had seen him... in a while. so we submitted itand they denied it.

said it was "experimental. " so i found out that there isa board of trustees over our medical plan that actually work at my hospital. and they are the final decision-makerson what gets approved and what doesn't. julie and her husbandand their son. tracy junior. demanded a meetingwith the health plan's board of trustees. the very peoplewho had the power to approve their claim. they told julie that they weresympathetic to her situation. i said, "your sympathy does me no goodwhen i'm burying him next year. "

and i told them, i said if i was...bruce van cleve was our ceo. i said, "i bet if it was bruce van cleve'swife, it would get approved. " "no, it's nothing like that. " i said, "or maybeif my husband was white. " and i got upand walked out of the room. when we got home,i found him up in the bathroom. and i knocked on the door and said,"what are you doing in there?" "nothing. " i opened the door 'cause usually he'll say:"what do you think i'm doing in here?" and he was sitting in thereand he was crying.

and he said, "why me?i'm a good person. " and i said,"but we're not done fighting this. " "we're strong, yeah. "and then he said... you know, he goes,"i can see now that i'm gonna die. " he said, "i can leave everything,but i don't want to leave you and tracy. " the doctor told mehe would die in three weeks. and... on january 13th,which was my birthday, he went to sleep.

and he died five days later,here at home. he was my best friend. he was my soul mate.he was my son's father. i mean, we were to grow old together. they took awayeverything that matters. i wanna know why,why my husband? why wasn't he giventhe chance to live? you preach these vision and values thatwe care for the sick, the dying, the poor. that we're a healthcarethat leaves no one behind.

you left him behind.you didn't even give him a start. it was as if he was nothing. and i want themto have a conscience about it. and i don't think they do.i don't think it has fazed them one bit. at all. there was one personin the healthcare industry who did have a conscience. dr. linda peeno.a former medical reviewer at humana. my name is linda peeno.

i am here todayto make a public confession. in the spring of 1987,as a physician, i denied a mana necessary operation that would have saved his life,and thus caused his death. no person and no grouphas held me accountable for this, because, in fact, what i did was i savedthe company a half a million dollars for this. and, furthermore, this particular actsecured my reputation as a good medical director, and it insured my continued advancementin the healthcare field.

i went from making a few hundred dollarsa week as a medical reviewer to an escalating six-figure incomeas a physician executive. in all my work, i had one primary duty,and that was to use my medical expertise for the financial benefitof the organization for which i worked. and i was told repeatedlythat i was not denying care, i was simply denying payment. i know how managed caremaims and kills patients. so i'm here to tell youabout the dirty work of managed care. and i'm haunted by the thousandsof pieces of paper

on which i have writtenthat deadly word - "denied. " thank you. how did we get to the pointof doctors at health insurance companies actually being responsiblefor the deaths of patients? who invented this system? how did this all begin? where did the hmo start? thanks to the wonders of magnetic tape.we know. i am proposing todaya new national health strategy.

the purpose of this programis simply this - i want america to havethe finest healthcare in the world, and i want every american to be ableto have that care when he needs it. the plan hatchedbeteen nixon and edgar kaiser worked. in the ensuing years.patients were given less and less care... bigger logjams at the nearbyhospital and less quality medical care. been here about 18 hours,since 7:00 this morning. what looks crampedand unsightly can also be dangerous. ...while health insurancecompanies became wealthy.

the system was broken. 37 million americans are without protectionagainst catastrophic illness. the losers are the poor.who may now postpone urgent healthcare until it's too late. this went on for years. until this man rode into town. bringing with him his little lady. sassy. smart.

sexy. some men couldn't handle it. today i am announcing the formation of the president's task forceon national health reform, chaired by the first lady,hillary rodham clinton. hillary clinton decided to makehealthcare for everyone her top priority. universal coverage now. it will not depend uponwhere you work, whether you work, or if you have a preexisting condition.

healthcare that can neverbe taken away. some republicans complainmrs. clinton is getting a free ride. it's fairly risky businesswhat president clinton did, to put his wife in charge ofsome big policy program. and while i don't share the chairman's joyat our holding hearings on a government-run healthcare system, i do share his intention to make the debateand the legislative process - as exciting as possible.- i'm sure you will do that, mr. armey. - we'll do the best we can.- you and dr. kevorkian, i think.

i have been told about your charmand wit, and let me say... reports on your charm are overstated - and reports on your wit are understated.- thank you. thank you very much. she drove washington insane. do you want the governmentto control your healthcare? you won't have the choiceof your own doctors. - less government.- more control. - more government.- less control for you and your family. when your mama gets sick, she might talkto a bureaucrat instead of a doctor.

this is a total mess,and it's about to get messier. not this bureaucratic,socialistic plan that they have. - socialist takeover...- socialized medicine. what really amounts toa giant social experiment. ooh!socialized medicine. nothing put more fear in usthan the thought of that. and the chief fearmongersagainst socialized medicine have always been the good doctors of the american medical association.

this would put the governmentsmack into your hospital, defining services, setting standards, establishing committees, calling for reports, deciding who gets in and who gets out. after all, the government has to treateveryone fair and equal, don't you know? take us all the way down the road toa new system of medicine for everybody. yes. medicine for everyone. the ama didn't want that. and to drive the point home further.

they held thousands of coffeeklatschesall over the country. where they invited their neighborsto come and listen to a record made by a well-known actoron the evils of socialized medicine. my name is ronald reagan. one of the traditional methods of imposingstatism or socialism on a people. has been by way of medicine. the doctor begins to lose freedoms. it'slike telling a lie. and one leads to another. a doctor decides he wantsto practice in one town. the government says to him."you can't live in that town.

they already have enough doctors.you have to go someplace else. " all of us can see what happensonce you establish the precedent that the government can determinea man's working place and his methods. and behind it will comeother federal programs that will invade every area of freedomas we have known it in this country. until one day. we will awaketo find that we have socialism. the white housesaid to tone down the rhetoric. reacting to burning an effigyof hillary clinton. the times may have changed.but the scare tactics hadn't.

the healthcare industries spentover a hundred million dollars to defeat hillary's healthcare plan.and they succeeded. and i want nowto introduce to you the president, because he loves the easter egg roll. for the next seven yearsin the white house. she wasn't allowed to bring it up again. is anybody here older than two? a decade and a half went by. and still americahad no universal health plan.

the united states slipped to number 37in healthcare around the world. just slightly ahead of slovenia. but that's understandable. becausecongress was busy with other matters. mr. speaker, today i riseto offer congratulations to the confectionersat just born incorporated, as they celebrate the 50th anniversary of one of their most recognizedand celebrated products, not to mention my daughter's favorite,marshmallow peeps. and thus. the healthcare industrywent unchecked into the 21 st century.

humana more than doubles its fourthquarter profit, lifts its earning for the year... united health has tripledits share prices. making obscene profits... ...better-than-expected earnings. there's a lot ofwealthy shareholders out there. are they willing to sharesome of that wealth? ...turning their ceosinto billionaires. and skirting the lawwhenever they wanted. but their biggest accomplishmentwas buying our united states congress.

this is washington at work.lobbying has become so brazen... with four timesas many healthcare lobbyists than there are members of congress. they even managed to buy off old foes. for her silence.hillary was rewarded. and she became the second largestrecipient in the senate of healthcare industry contributions. we've given the entire healthcare systemover to the insurance industry. - and they have total control.- well. not total control.

drug companies like to buytheir members of congress too. here's what it coststo buy these men. and this woman. this guy. and this guy. and him too. ladies and gentlemen,the president of the united states. and the biggest checkwas saved for last. why did they hand out all this cash? they wanted a bill passed - a billto help seniors with their prescriptions.

let there be no mistake about it. republicans love their mothers,their fathers and their grandparents as much as anybody else on this hill,and we're gonna take care of them. of course. it was really a billto hand over 800 billion of our tax dollars to the drug and health insurance industry. by letting the drug companiescharge whatever they wanted. and making the private health insurancecompanies the middleman. everybody was going to get their cut. the man they appointedto get the job done

was congressman billy tauzin. he was the right man for the jobbecause he had a secret weapon. there's no one in this house lovestheir mother more than i love my mother. i challenge you on that, sir. nobody in this body that loves their motherany more or any less than any one of us. i love that woman. do you think for a secondyou love your moms and dads any more than we love ours? do you think republicansand democrats who will vote...

do you really believe that, mr. stoddard?god bless you. oh. they all loved their mothers. it's just that they didn'tlove our mothers as much. now i'm honored and pleasedto sign this historic piece of legislation - the medicare prescription drug,improvement, and modernization act of 2003. what they didn't tell us wasthat the elderly could end up paying more for their prescriptions than they did before. over to thirds of senior citizenscould still pay over $ 2.000 a year.

and when it was over. 14 congressionalaids who worked on the bill quit their jobs on the hill and wentto work for the healthcare industry. as did one congressman. # 'cause i've got a golden ticket... billy tauzin left congressto become the ceo of phrma. the drug industry lobby. for a salary of $ 2 million a year. oh. it was a happy day in washington. many americans knew they were nevergoing to see universal healthcare.

and that's why some of themdecided to look elsewhere for help. we're driving acrossthe detroit river. back there is the renaissance center,you can see it. general motors' headquarters,downtown detroit, the skyline. you get a really nice viewfrom driving over the bridge. this is adrian campbell.a single mother. who at the age of 22came down with cancer. i got cervical cancer and i wasdenied through the insurance company. they said, "we're not paying for itbecause you're 22 and you don't have... "

"you shouldn't be having cervical cancer.you're too young. " forced into debt.but now cancer free. adrian was fed upwith the american healthcare system. she had a new plan. i have everything readybefore i even hit the border. i got my passports ready,i got my money out. it's three dollars and 25 centsto get across one way. and i got everything just sittingup here on my visor just ready to go. aurora, be very quiet.

- citizenships?- us. - where do you live?- michigan. - that's not on, right?- no. she may live in michigan. but ten blocks across the border.adrian becomes a canadian. how long have you been living here?three months? a couple.i haven't applied for the ohip card yet. - i still have mine.- it takes ten minutes. that's fine, i don't mind.ok, thank you.

i put down kyle's address at the clinic, and when they ask, you know,what my relationship is, i put down that i washis common-law partner. i don't like to lie and i don't like liars. it's little white lies, but it's...you know, i'm saving the money. you don't bring a checkbook when yougo to the hospital here. it's provided to us. it's something you don't have to worryabout or go out of your way to get. stress free. - they called the cops.- the presence of our camera

alerted the clinicthat something was up. and i don't thinki'm gonna get seen now. so i have another idea. i'm gonna go down to the other clinic. there is a clinic down...one that we passed. the police showed up over there.look. yes. what adrian was doingwas illegal. but we're americans. we go into other countrieswhen we need to. it's tricky. but it's allowed.

it's kind of frustrating having...i mean... just get married and that'd solveeverything - she'd be covered. americans marry canadiansjust for the healthcare! - i'm being used.- sounds like a good idea. see if it works.start something. start a trend. in canada they give everybodyfree healthcare. - doesn't it work up there?- no, unfortunately it doesn't. we wait months to get treatmentyou can get in a week or a few days here. in canada you have to waitnine to ten months for bypass surgery.

many canadians believeit's the healthcare system itself that's sick. they pay their doctors less. a surgeon can only doa certain number of operations each year. with only so manyexpensive new pieces of equipment. it's easier for your cat or dogto receive an mri here in america. you die of cancer waiting for chemo 'causeall of ottawa has one chemo machine. if you think socialized medicineis a good idea, ask a canadian. i thought who better to ask thanmy canadian relatives. bob and estelle. but they wouldn't cross the borderinto america.

they wanted me to meet themat sears. in canada. what are you guys doing here? - we're buying insurance.- we're going to the states to see you. right, that's just across the river. you wouldn't go over to see us in michiganfor a couple of hours without insurance? no, we wouldn't. we're just adamantabout it. we would not do it. if somebody punches us in the mouthor something, something like that... you don't want to get caughtin the american health system thing? we have nothing against americansor america, or anything like that at all.

- we're a nice and simple people.- not very simple, but certainly very nice. i decided to exploretheir anti-american views further. over some fine canadian cuisine. we have a friend who went to hawaii. and he sustained a head injurywhile he was there. and before he waswell enough to come home, he had chalked up a billof over $600,000. so what middle-class canadiancould absorb that? i guess i feel bad that you wouldhave to worry about something like that.

we're not criticizing your country,we're just giving you the facts, that we could not affordto be without insurance. - even for a day?- even for a day. to prove their point even further.they sent me over to a local golf course to talk to larry godfrey. who had a golfingaccident while on vacation in florida. i could hear a noise and feel a pain,and the tendon snapped off this bone here that holds the bicep in place. so this bicep muscle was released,like on an elastic, and it ended up here on my chest.

- the muscle ended up in your chest?- right. ended up here. like all good golfers.larry finished his round before seeking medical attention. that's when he got the bad news. i wasn't too worried as i hadout-of-country insurance, but when he told meit was 23 or 24,000, then i.... - 24,000?- dollars, yes. so if you'd stayed in the united states,this would have cost you $ 24,000? instead, you went back to canada,and canada paid your total expenses?

- everything.- paid for the operation. it cost you? - nothing.- zero. zero. zero. i'm wondering why you expect your fellowcanadians, who don't have your problem, why should they, through their tax dollars,have to pay for a problem you have? because we woulddo the same for them. it's just the way it's always beenand it's the way we hope it'll always be. right, but if youjust had to pay for your problem, and don't pay for everybody else'sproblem, just take care of yourself?

well, there are a lot of people who aren'tin a position to be able to do that. and somebody has to look after them. are you a member of the socialist party? - no. no.- green party? no. well, actually, i'm a memberof the conservative party. is that bad? - well, it's just a little confusing.- well... it shouldn't be. i think that... where medical matters are concerned,it wouldn't matter in canada

what party you were affiliated with, if any. but, to us,as we look across the river here, you know, why don't you thinkwe don't believe that? what's wrong on this issue with us? i guess the powers that bedon't share our beliefs that healthcare ought to be universal. i mean, canadians didn't until we met upwith a guy named tommy douglas, who pretty muchchanged everyone's mind. - one guy?- one guy, yeah. one guy did it, he...

- can he come over and visit us?- he's dead, unfortunately. in fact, he was... he's just most recently been revered ascanada's singular most important person. - we think so much of...- you mean in your history? in our whole history. - more than your first prime minister?- absolutely, yeah. even more than wayne gretzky. - no way!- absolutely. yeah. - more than cã©line dion?- great singer. more than cã©line, yeah.

- more than rocky and bullwinkle?- maybe. as the blade went through,it caught the glove i was wearing and it sliced through the entire groupof fingers, completely taking them off. and i realizedthat i needed help immediately. obviously, putting onamputated fingers or arms or limbs is one of the more dramatic thingswe can do. if you're looking at five fingers,you're looking at a 24-hour operation. there actually was four surgeons,as well as all the nurses and two different anesthetiststo carry out an operation of that magnitude.

when brad came in, we didn't have toworry about whether he could afford it. he needed help and we could concentrateon the best way to bring him through it. i met this american, he'd cut offthe ends of two of his fingers with a saw. so when he arrived at the hospital, theytold him one finger's gonna cost $60,000, and the other one was gonna be $12,000. he had to choosewhich finger he could afford. down. bend the long finger down. we've never told someonethat they couldn't put a finger back on because the system wouldn't allow it.

i'm very glad i work within a system thatallows me the freedom to look after people, and not have tomake choices like that. it seems nothing we were toldabout the canadian system was true. maybe i was justin the wrong part of town. so i went across the cityto a crowded hospital waiting room. how long did you have to wait hereto get help? - 20 minutes.- 45 minutes. - i got helped right away.- you can see how crowded this is. they really do an amazing job.

did you have to get permissionto come to this hospital? - no.- no. we can go anywhere we want. you don't have to get itpreapproved by your insurance company? - oh, heavens, no.- can you choose your doctor? - oh, yes.- what's your deductible? - nothing.- i don't think we have any. i don't know.i don't think there's any, as far as i know. - so what did this cost?- nothing.

we know in americapeople pay for their healthcare, but i guess we don't understand that,'cause we don't have to deal with that. and we're dealing withparkinson's, stroke, heart attack. we're very, very lucky.really we are. i mean, we complain.people complain about everything, right? - right, you're canadian.- but on the whole, it's a fabulous system for making sure that the least of usand the best of us are taken care of. it turns out that canadianslive three years longer than we do. that's not hard to believewhen you meet fellow americans like erik.

# oh, england, here we go erik turnbow of olympia.washington. saved up his whole life so that he could visit the famedabbey road crosswalk in london. but it wasn't enough for erik to justwalk across the road like the beatles did. he had to do it his own special way. here's erik, about to walkon his hands across abbey road. ready? ugh! try it again.

- are you in pain?- yeah. the british hospitaldidn't charge erik anything for his stay. and only about ten bucksfor all the way-cool drugs they gave him. - you're all slung up.- i'm gonna be ok. i decided to go to great britain tofind out how a hospital stay could be free. and drugs could cost only ten dollars. if i come in here and i have a prescriptionand it requires 30 pills, how much is that? it's l6.65.that's the standard charge. l6.65?so that's what? ten dollars or so?

- yes.- what if i needed 60 pills, how much is it? - same charge.- 120 pills? - l6.65 still.- it doesn't matter how many pills? - no.- what if it's an hiv drug or a cancer drug? still l6.65. if they are under 16 or over 60,they're automatically exempt. so only a working adultwho earns enough money pays the l6.65? everybody else gets medication free? - no money being exchanged here?- no, nothing.

- there's no money being exchanged?- i'm over 60. we don't pay. what's the purposeof the cash register? i'm just wondering where's the breadand the milk and the candy in here? i can't pick upany laundry detergent here? no. i haven't been trained for that manyyears to be selling detergents, so no. i next went to a state-run hospital.operated by the national health service. i'm due in seven weeksand i get six months off, paid. and then i can have six months off unpaidas well, so i'm actually taking a year. well, that soundslike a luxury where i'm from.

oh, really, it's not like that in the us?no? not at all, no? so what do you payfor a stay here? no one pays. they were asking how do people pay. i said there isn't...you don't, you just leave. it's national insurance.there's no bill at the end of it, as it were. even with insurance.there's bound to be a bill somewhere. - so where's the billing department?- there isn't a billing department. there's no such thing.

what did they chargefor that baby? - sorry?- you gotta pay before you can get out? - no. this is nhs.- no, no. everything is on nhs. you know, it's not america. maybe i'd have better luck in thepart where things get seriously expensive. this guy broke his ankle.how much will this cost him? the emergency room visit. he'll havesome huge bill when he's done, right? here... nhs, everything is free. i'm asking about hospital chargesand you're laughing.

i was never asked this questionin the emergency department, that's why. i was starting to fallfor this "everything is free" bit. and then i discovered this. so this is where people come to paytheir bill when they're done staying here? no, this is the nhs hospital,so you don't pay the bill. you get to just go home? why does it say "cashier" hereif people don't have to pay a bill? all we have is a little manwho stands behind a counter and he gives people moneyif they've had to pay for transport.

those who have reduced meansget their travel expenses reimbursed. so in british hospitals. insteadof money going into the cashier's window. money comes out. the criteria for letting you outare not if you've paid, the criteria are, are you fit to goand are you going somewhere safe? clearly. i was justthe butt of a joke here. what i neededwas a good old-fashioned american who would have some understanding. i first came to london in 1992.

and we just ended up stayingand we had three children here. well, i had them all on the nhs, which isthe british national health service. i think, like a lot of americans,assumed that a socialized medicine was just bottom of the rung treatment, that the only way would be horribleand it would be like the soviet union. i mean, that's kind of how... - and it's terrible that that's what i thought.- that's what i thought. too. after having a baby.it's right back to the wheat fields. and then it occurred to methat back home in america.

we've socialized a lot of things. i kind of like having a police departmentand fire department and the library. and i got to wondering. why don't wehave more of these free. socialized things. like healthcare? when did this whole idea that every britishcitizen should have a right to healthcare? well, if you go back,it all began with democracy. before we had the vote all the powerwas in the hands of rich people. if you had money, you could gethealthcare, education, look after yourself when you were old.

and what democracy didwas to give the poor the vote. and it moved power from the marketplaceto the polling station. from the wallet to the ballot. and what people said was very simple. they said, "in the 1930s,we had mass unemployment. " "but we don't have unemploymentduring the war. " "if you can have full employmentby killing germans, why can't we have it by building hospitals,schools, recruiting nurses and teachers?" if you can find money to kill people,you can find money to help people.

right. this leaflet that was issuedwas very, very straightforward. - what year was this?- this was 1948. "your new national health servicebegins on the 5th of july. " "what is it? how do you get it?" "it will provide you with allmedical, dental and nursing care. " "everyone, rich or poor, man, womanor child, can use it or any part of it. " "there are no charges,except for a few special items. " "there is no insurance qualifications,but it is not a charity. "

"you are paying for itmainly as taxpayers, and it will relieve your money worriesin times of illness. " now, somehow,the few words sum the whole thing up. i was amazedwhen he said this all started in 1948. the british had come out of a devastatingexperience through world war ii. the country was destroyedand nearly bankrupt. they had nothing. in just one eight-month period. over 42.000 civilians lost their lives.

what we went throughin to hours on 911. they went throughnearly every single day. remember how we all felt after 911?all of us pulling together? i guess that's how they felt. and the first way that they decidedto pull together after the war was to provide free medical carefor everyone. even mrs. thatcher said, "the nationalhealth service is safe in our hands. " it's as non-controversialas votes for women. nobody could say,"why should women have the vote?" now.

people wouldn't have it,they wouldn't in britain. they wouldn't accept the deterioration ordestruction of the national health service. if thatcher or blair said, "i'm goingto dismantle national healthcare... " there would have been a revolution. a report from the amainto the health of 55- to 64-year-olds says brits are far healthierthan americans. for every illness that we lookedat. americans had more of it than english. cancer. heart disease.hypertension. strokes. lung disease. all significantly higher for americans.

even the poorest people in england with all the environmental factors that givethem the worst health in the country can expect to live longerthan the wealthiest people in america. i was wondering. though.what's it like for the doctors here in britain. who have to liveunder this kind of state control? and you're a family doctor? yeah, i suppose we'd call them gpsor general practitioners here. - right, so you have a family practice?- yeah, it's an nhs practice. we have nine doctors in that practice.

- paid for by the government?- yeah. you work for the government?you're a government-paid doctor. a patient comes to you.before you treat them, do you have to call the government insurance companybefore you treat them? no, i don't deal with money at allon an everyday basis. have you ever had to say no to someonewho was sick and needed help? - no, never.- have you heard of anyone being in the hospital and being removedbecause they couldn't pay their bill? no, never.and i wouldn't want to work in that system.

so working for the government,you probably have to use public transport? no. i have a car that i useand i drive to work. an old beater? you live in a rough part of town? i live in a terrific part of town.it's called greenwich. it's a lovely house.it's a three-story house. how many other familieshave to live with you? there's four bedrooms for my wifeand my son. it's just the three of us there. - how much did you pay for that?- l550,000. yes, almost.

so, a million dollars? you're a government-paid doctor on anational health insurance healthcare plan, - and you live in a million-dollar home?- yes. - i think my friends think we do quite well.- really? how well do you do? i earn around 85,000,including pension. - l85,000?- l85,000 a year. and that includes pensionthat they would pay in to me. they probably earn justover l100,000 within my practice. - l100,000? so that's almost $ 200,000?- yes, absolutely.

the money that we earn,we get paid by what we do. so the better we do for our patients,then the more we get paid. - what do you mean?- there's a new system. and in that new system, if the most numberof your patients have low blood pressures, or you get most of your patientsto stop smoking, or you get your patients to havemental health reviews if they're unwell, or low cholesterols,then you get paid more. this year, if you get more peoplethat are your patients to stop smoking, you'll get more money,you'll earn more?

oh, yeah. absolutely. so doctors in america do not have to fearhaving a universal healthcare? no. i think if you want to havetwo or three million-dollar homes and four or five nice carsand six or seven nice televisions, then maybe, yeah, you need to practicesomewhere where you can earn that. but i think we live comfortably here. london is expensive,but i think we live comfortably. you're getting by ok on the million-dollarhome, the audi, and the flat-screen tv? yeah, we're coping with those.

i think democracy is the mostrevolutionary thing in the world. far more revolutionary thansocialist ideas, or anybody else's idea. because if you have power, you use itto meet the needs of your community. and this idea of choice which capitaltalks about, "you've got to have a choice," choice dependson the freedom to choose. if you're shackled with debt,you don't have a freedom to choose. it seems it benefits the system ifthe average person is shackled with debt. people in debt become hopeless,and hopeless people don't vote. they always sayeveryone should vote,

but i think if the poor in britainor the united states voted for peoplewho represented their interests, it would be a real democratic revolution. so they don't want it to happen. so keepingpeople hopeless and pessimistic... see, i think there are two waysin which people are controlled. first of all, frighten people,and secondly, demoralize them. an educated, healthy and confidentnation is harder to govern. and i think there's an elementin the thinking of some people: "we don't want people to beeducated, healthy and confident,

because they would get out of control. " the top 1 % of the world's populationown 80% of the world's wealth. it's incredible that people put up with it,but they're poor, they're demoralized, they're frightened. and therefore, they thinkperhaps the safest thing to do is to take orders and hope for the best. and hope for the bestis what we do. right from the moment we're born. we've got the worst infant mortality ratein the western world.

a baby born in el salvadorhas a better chance of surviving than a baby born in detroit. but it gets betterwhen we go to school. classrooms with 40 students.schools with no labs. no wonder the majorityof our adults can't find britain on a map. but that's ok.there's always college. by the time we graduate.our ass is so in hock. we're in debt before our first job. i'm at about... we'll say about $35,000in debt. that's for my third year in college.

you'll be the employee they'relooking for - one who needs this job. 3,904, 3,905... what employer wouldn't employ someonethousands of dollars in debt. because they won't cause any trouble? in addition to paying off your college debt.you need a job with health insurance. it would be horribleto lose that job. wouldn't it? you can always quit, you know. there'sno law that says you have to work here. if that one jobdoesn't pay all the bills. don't worry. you can get another one.and another one. and another one.

i work three jobs,and i feel like i contribute. - you work three jobs?- three jobs, yes. uniquely american, isn't it? i mean,that is fantastic that you're doing that. get any sleep? if you're not sleeping.take pharmaceuticals. you're tired all the time.you feel sad. if you sufferfrom excessive worry... generalized anxiety disorder. it could be adult add.

- ask your doctor.- ask your doctor. yes. ask your doctor.and ask him for more drugs. that should keep you doped upuntil it's time to retire. did i say retire? if you make it to 80.your pension will still be there. unlike the new employees for thesecompanies. who'll never see a pension. but i'm sure our kids will take care of us.considering the great life we've given 'em. remember. let's defeat the terrorists overthere so we don't have to fight them here. kaiser permanenteis the largest hmo in the country.

and dawnelle keyes was fortunateenough to be fully insured by them. it's a good thing. because one night.her 18-month-old daughter. mychelle. developed a fever of over 104. so. like any responsible mom.she called 911. and the ambulance took mychelleto the closest hospital. the hospital checked with her hmo and they were told that kaiser would notcover the tests and the antibiotics necessary to treat mychelle. she would have to take her toan in-netork. kaiser-owned hospital.

kaiser said that i shouldbring her by car to the hospital, and that she shouldn't be treatedat martin luther king. i just continued to ask themto treat her, and they refused. my daughter got worseand she had a seizure. dawnelle begged doctors to notlisten to kaiser and to treat her daughter. i was escorted out of the hospitalbecause they felt that i was a threat. after hours of delay.she was transported to kaiser. and got there just in timeto go into cardiac arrest. they worked on her for about 30 minutes,trying to revive her.

and the doctors came inand let us know that she had expired. i was in a daze, a real daze.it just didn't seem real. i just held her. i held her and i told herthat mommy tried her best to help her, to make sure that she was gonnaget the treatment she needed to receive. and that i was sorrythat i wasn't able to help her. simon says: give the answer. uh-oh. this is karenaand her daughter zoã«.

karena is a graduateof michigan state university. and a native of my hometownof flint. michigan. six months ago. zoã«.like dawnelle's baby mychelle. came down with a high fever. what happenedis she stopped breathing for a little while, turned blue and passed outin my arms, which was... it was the most horrible momentin my life, i think, just because i thoughtthat she was either dead or dying. and i had no clue what to do.

at the hospital, they gave hersome medicine to bring the fever down, and examined her, took some blood. - what was wrong with her?- it was a throat infection. but we stayed at the hospitalfrom friday to sunday, - just so they could keep an eye on her.- you stayed there that long? yeah. they just basicallykept an eye on her. and how much did all this cost you,the three-plus days in the hospital? - nothing.- nothing? - nothing. nothing at all.- and that's because?

- i live in france.- you live in france? ah. france. they enjoy their wine.their cigarettes and their fatty foods. and yet.just like the canadians and the brits. they live much longer than we do. something about thatseemed grossly unfair. this is alexi cremieux. he spent his entire adult life in the uswithout health insurance. i lived in america for 13 years.i loved my life there.

but then when i discovered that i hada tumor and i didn't have health insurance, unfortunately,i had to come back here. even though i had never paid taxesin france 'cause i never worked here - i left when i was 18,i had no social security number - for them it was,"he needs treatment, he has no income, so we're gonna give him,you know, the treatment he needs. " - how are you doing now?- i'm healthy now, but i had three monthsof chemotherapy. so after three months, i saw my doctorand he said, "you wanna go back to work?"

i said, "no, i don't feel like it. " "right now, i'm not ready. "he said, "how much do you need?" i said, "well, i don't know. "he said, "would three months be ok?" i said, "i think three monthswould be fine. " he said, "ok, so take three months off. "so he wrote me a note that i gave to my employerto make sure i got paid. - so i went to the south of france...- wait a minute, three months off with pay? yes. yes. i get 65% paid by the government,

and then the other 35%is paid by my employer. to make sure you get 100%. so it was april, it was spring again. soi started right away, sucking up some sun. and that really helped me a lot,to recharge my batteries. i mean, it was like night and day. in threemonths, i went from a 95-year-old man to a 35-year-old man again. but that's because i had that timeto take care of myself. i'm not in a position to make any judgmentconcerning the american system. i think the united statesis a great, great country.

americans are great people.i really love them. but as a doctor first, as a citizen second, and eventually, as a patient third, i'm very glad to be in france. it's kind of a luxury here. you are sick, you step in a hospital,you get the care you need. it doesn't depend on your premiums.it depends on what you need. one of the principles is solidarity. people who are better offpay for those who are worse off.

you pay according to your meansand you receive according to your needs. do you thinkthat will ever work in america? no. he could barely containhis seething anti-americanism. and i just didn't wantto listen to any more of it. so i found a group of americanscurrently living in paris. who i know would tell me the truth. i was diagnosed five years agowith type i diabetes. - i was a bit nervous to tell them i had...- to tell the french?

there's a place to check offif you have a chronic condition. i was nervous that theywere going to charge me more. and instead, i went into a hospital,and had round-the-clock care. and they do an amazing amountof preventative care. they asked if you havea preexisting condition, not to punish you,but to give you more help? - yes.- i was in the hospital for a year. as soon as i was in, it was,"well, don't worry, just rest. " - people said "rest. "- how many sick days do you get a year?

- i think it's unlimited.- unlimited? yes. how can you limit sick days?if you're sick, you're sick. i've gone to emergency roomsnumerous times, with four boys. and have never waitedmore than an hour. never. i can call and somebody comesto the house in half an hour. no way? making a house call?at your place? how many of you have hada house call from a doctor? no! - 3:00am last friday.- and how much does this cost you? - nothing.- what's this service called?

where are we going? we are going to see a manwho has abdominal pain. - abdominal pain?- yeah. - where do we go next?- the next visit? i say to anyone who asks mewhy i'm in this country is that i think it's one of the friendliestcountries that i know of. and talk about family values -i mean, childcare, healthcare... we don't pay for day care. the day care where i send my daughter -and i was a teacher - standards are high.

so how much does it cost you to havetwo children here? how much per hour? are you happywith how they're cared for? here, my kids are sure that they are goingto get a certain level of care, education, - college i don't have to worry about...- what do you mean? - it's free.- you're kidding? - you can get a college education for free.- no way. - yes.- there's not a sense of desperation. they rest, they enjoy life. they spend time with their kids,there's vacations, family time.

- how many weeks of paid vacation?- minimum five weeks. five weeks?minimum of five weeks? if you work for a large company,you get sometimes eight, ten weeks. - remember that there is a 35-hour week.- the productivity rate is so high here. i read it was higherthan the united states. if they're working more than 35 hoursa week, they'll get extra days off. that is for part-timeand full-time employees. you get five weeks paid vacationeven if you're a part-time employee? - of course.- everybody.

if you get married, you get an extra weekor seven days for your honeymoon. - in addition to your five weeks.- you're paid to take your honeymoon? also if you move. you mean if you movefrom one apartment to another? you get one day. - you get a day to move and they pay you?- these are the laws here. when my daughter was three months old,they sent somebody to you to give you tips on what to dowith your child, every single day, for free. and they'll come to your houseand do your laundry!

- they will! sure!- no! stop! stop! - when you have a baby.- when you have a baby. what are you doing? you from the government? - can she do anything else?- if i want, yes. she's, of course,taking care of the children. and i think if i ask herto prepare a meal for tonight, she can do it.

no problem. she's coming twice a week. four hours a day.so i can do everything i want, for me, for the house,for my husband, during four hours. it's very precious for me. you don't have any associations?nothing to help like that? no. nobody from the governmentcomes to your home in america and does your laundry for you,if you're a new mother. - it's difficult.- yeah.

something that i experiencea lot of with my own family is guilt. guilt for being here almost, and seeing the advantages andthe benefits i have at such a young age. things that my parents worked their wholelife for and haven't come close to touching. it's really hardto know that you're here in a very privileged position,you know, not living the highlife, but in comparison, definitely.and that seems completely unfair. one of the thingsthat keeps everything running here is that the governmentis afraid of the people.

they're afraid of protests,they're afraid of reactions from the people. in the states, people are afraid of thegovernment. they're afraid of acting up. they're afraid of protesting,afraid of getting out. in france, that's what people do. free college education.free medical care. government-issued nannies. i began to wonderhow do they pay for all this? and then i realizedthey're drowning in taxes! i wanted to see what effectthis would have on a nice french family.

so i went to find out. - hello. welcome.- hello. thank you. it's very nice. - it's the news.- yes. what is your combined income forthe two of you together for, say one month? all right. you're an engineerand she's an assistant? not bad. how much is your mortgage? - how many cars do you own?- two. do you owe moneyfrom medical bills?

is there any other debt? loans, anything? - only the apartment.- what are your other expenses? the fish. fish. vegetables. vegetables are a bigmonthly expense for you. - yes. and fruit. yogurt.- yogurt. what are your other big expenses? very important. - kenya?- we liked.

- are you happy?- yes. after seeing all this.i began to wonder. was there a reasonour government and our media wants us to hate the french? are they worriedwe might like the french? or like their ways of doing things? it was enough to make meput away my freedom fries. meanwhile. back at home. hospitals had found a new wayto deal with patients

who didn't have health insurance and couldn't pay their bill. i was standing against the wall and i sawa cab do a u-turn and pull up to the curb. i watched to see what was happening'cause i had a feeling what would occur, 'cause it's not a new thing. they pulled up right hereby this yellow fire hydrant and dropped carol offand immediately pulled away. and as soon as they pulled away, shewalked out into the street about up to here. she then walked all the way down to thedriveway down here, completely confused,

has no shoes on whatsoeverand just a hospital gown. and those gowns are thin. that's when one of our staff members wentand asked carol if she needed assistance and found out that she was disorientedand didn't know where she was. kaiser permanente in bellflower hospitalhad put her in a cab and directed themto bring her to this drop-off point. but the names of the hospitals had beentaken off both bracelets before she arrived. i have seen others that have come throughour doors who have ivs still in their arms. they told me that.at their shelter alone.

over 50 patientshad been dumped there by hospitals. the options are few. we either openthe front door and let them out, which is not the humane thing to do, or we try to find someplace for them to go. and right now,skid row is the best bed in town. the nightbefore we were there. the county hospital run bythe university of southern california. one of the richest private schoolsin the country. dumped another patient off on the curb.

a woman unable to pay her hospital bill. - do you know how you got here?- in the cab. - in the cab?- from general hospital. they gave him the voucher. he dropped me off there,he actually forced me out of the car. ma'am, are you in pain right now?are you in pain? - yes.- is there anything we can do? she, at this time, has broken ribs,broken collarbone, and stitches that are not completely healed

across the top of her headand on the side of her head. now let me ask you, ma'am.before they dropped you off, did they ask youif you knew where you were going? they didn't ask you any questionsabout your orientation, or whether or notyou knew what was going on? no, they just told meto take care of myself. may i take a minute to aska question that's been on my mind? who are we? is this what we've become?

a nation that dumps its own citizens likeso much garbage on the side of the curb. because they can't paytheir hospital bill? i always thought. and believe to this day.that we're a good and generous people. this is what we doif somebody's in trouble. anybody gets sick,we all get together and help. people with a good heart... you feel like you're sacrificing,but you get a blessing from doing this. ...and a good soul. we've got a lot of support and we're gonnaall keep working until we locate this child.

neighbors quick to lend a helpinghand to anyone in their hour of need. i deliver meals to them,but my life has been so blessed that this is just the least that i can do. they say that youcan judge a society by how it treats thosewho are the worst off. but is the opposite true? that you canjudge a society by how it treats its best? its heroes? the firefighters and police,rescue and recovery workers have responded with true heroism.

it was their initial heroismthat thwarted the objectives of the terrorists. without regard, in many instances,to their own safety and security. - they truly are heroes.- we owe them everything! here they are, the men and women whohave been on the front lines for new york, and for all of us in america!tonight is dedicated to you! don't forget about the raffles going onover there - one dollar each. i spent two and a half years down there. i got upper and lowerbreathing problems. i need a double lung transplant,but was diagnosed with pulmonary fibrosis.

i haven't slept in a bed in over five years,i sleep on a chair with a blanket, because if i lay down i can't breathe. there were hundredsof rescue workers on 911 who were not city employees. but rather ran down to ground zeroon their own to help out. we need volunteers for first aid! and many developedserious respiratory illnesses. that's when the government said: "they're not our responsibilitybecause they weren't on our payroll. "

john graham is an emt volunteerfrom paramus. new jersey. he was in lower manhattanwhen he heard the planes hit. and rushed over to help. he worked in the rescue effortfor the next few months. but then had troublereceiving benefits for his illness. they just deny you for any reason.it's just a terrible waiting game. i really feel likethey're waiting for you to die. it's terrible.i never thought that we would do this, that the united states would do this.

william maher is a volunteermember of new jersey's fire service. he spent to monthsworking near the pile at ground zero. recovering bodies or body parts.and it deeply affected him. i'm experiencinga lot of disturbing dreams, or whatever you'd like to call them, and it affectedwhat i was doing at night, and unaware of it because i was asleep and i just keptgrinding and grinding my teeth. the upper fronts are damaged,practically beyond repair,

because of my constant grindingover the last three years. i've been before a workers' comp boardalready for the 9/11 volunteers' fund. i've been denied three times, and hopefullyi will go on my fourth appeal soon, if i can get the necessary documentation. of course.there was a $50 million fund set up supposedly to help rescue workers. ladies and gentlemen,the governor of new york, george pataki. but the government.like the health insurance companies. made it very difficultfor people to receive help.

you have to have spenta certain amount of time at ground zero, you have to be able to establish that. you do have to file an affidavitwithin the next year, relating your work experiencesat ground zero. and then, even with all of that,it's not automatic. there is a presumptionwhen certain illnesses occur, but that presumption can be rebuttedby other medical evidence. we think it is a very fair approachthat protects our heroes. i'm sorry.

reggie cervantes wasa volunteer medical technician on 911. nothing makes it go away sometimes.not water, not cough medicine, anything. it's just burning in my throat and irritatedand it just gets me to coughing. sometimes i have trouble breathing'cause i can't catch my breath. reggie spent her daysat ground zero carrying bodies and treating other rescue workers. my airway was totally burntthat first week, and i had trouble breathing by then. but we wanted to seeif we could dig anybody up alive,

we wanted to see if we had lost anybody,if we were still missing somebody. i wanted to help.i was trained for this. you know, you see somebodywho is in need, you help 'em. reggie had difficultygetting treatment. too sick to work and with no income. she was forced to quit her job. and used her savingsto move her and her kids out of the city. it's hard to figure outhow you're supposed to get help. we're trying to go about it the right way.

but we're ignored. but not everyone after 911was ignored by the government. we're now approaching the five-yearanniversary of the 9/11 attacks. so i'm announcing todaythat khalid sheikh mohammed, abu zubaydah, ramzi binalshibh, and 11 other terrorists in cia custody, have been transferred tothe us naval base at guantanamo bay. on that island are some of theworld's most hardened enemy combatants. these detainees are deadlyand include the 20th hijacker,

as well as a number of osama bin laden'spersonal bodyguards and others who had a direct rolein the september 11 attacks. the kind of people held at guantanamoinclude terrorist trainers, bomb-makers... many of them have american blood ontheir hands and are the elite of al-qaida. it seems to me we have an obligation to treat these individualsas enemy combatants. and then i learnedit wasn't all bad news at gitmo. detainees representing a threatto our national security are given accessto top-notch medical facilities.

they have acute care 24 hours a day,in which surgical procedures, everything can be performed right therein the detainee camps. this is the dental clinic,or the health clinic. we have a physical therapy department,x- ray capabilities with digital x-rays. we have one single operating room. health personnel to detainee ratiois one to four, remarkably high. they do sick call on the blocks three timesper week, care for them there if they can, or bring that detainee back to the clinicto be seen there. screening for cancer has taken place.

colonoscopy is a procedure whichis performed there on a routine basis. we have diabetes,high blood pressure, high cholesterol. we monitor the weightand nutrition of the detainees, so that we can track those detaineesto make sure we see them frequently, monitoring their labsand their overall health. their medical attention... they get waybetter medical treatment than i've ever had. - you think it's as good as most us hmos?- certainly very similar and as good, sir. i leave with an impressionthat healthcare there is clearly better than they received at home,

and as good as many people receivein the united states of america. wow! so there is actuallyone place on american soil that had free universal healthcare. that's all i needed to know. i went down to miami. florida. got myself a boat. and loaded up bill. and reggie and john. john, welcome, sir.

and anyone else i could find who neededto see a doctor and couldn't afford one. so many people showed up.i had to get a couple extra boats. and i called up donna smith from denver.who is now on nine different medications. and asked herif she'd like to come along. i figured she'd like to get outof her daughter's basement for a while. all right, let's go. which way to guantanamo bay?can we go? we're not going to cuba!we're going to america! it's american soil!

we made it. there it is.there's the runway. that's the prison over therewhere the detainees are. - we're very close.- yeah, we're very close. the white building is the hospital, i think. ok, let's go. we commandeered a fishing boatand sailed into guantanamo bay. as we approached the line in the waterbeteen the american and cuban side. we were told to be careful for mines.

permission to enter.i have three 9/11 rescue workers. they need some medical attention. these are 9/11 rescue workers!they just want some medical attention! the same kind that al-qaida is getting. they don't want any more thanyou're giving the evildoers, just the same! hello. no one in the guard tower wasresponding and then we heard a siren. we figured it was timeto get out of here. but what was i supposed to do with thesesick people and no one to help them?

i mean. here we were stuck in somegodforsaken third world country. and communists. no less. when i wasa kid. these people wanted to kill us. what was i supposed to do? excuse me, we're looking for a doctor.is there a doctor here in cuba? any doctors? all in this one block? all right, thank you very much.thank you. ok. ok. i know what you'rethinking. cuba is where lucifer lives. the worse place on earth.the most evil nation ever created.

how do we know that? 'cause that'swhat we've been told for over 45 years. a series of offensive missile sitescan be none other than to provide a nuclear strike capabilityagainst the western hemisphere. i'm not gonna yield until fidel castroallows freedom on the island. that's a...you can count on it. put it in the bank. it seems thatwhat really bugged us about castro was that he overthrewthe dictator that we liked. and replaced him with a guywe didn't like - himself.

and so now. after all these years.one thing is clear - the cuban peoplehave free universal healthcare. they've become known as having notonly one of the best healthcare systems. but as being one of the most generouscountries in providing doctors and medical equipmentto third world countries. in the us. healthcare costsrun nearly $ 7.000 per person. but in cuba. they spend only $ 251. and yet the cubans are able to havea lower infant mortality rate than the us. a longer average life spanthan the united states.

they believe in preventive medicine. and it seems like there's a doctoron every block. their only sinwhen it comes to healthcare seems to bethat they don't do it for a profit. anybody need medication right nowfrom the pharmacy? - are you the pharmacist?- yes. do you have this? - is this one similar to yours?- yeah. it's $120 in the us. - this is $120 in the us?- yes.

- how much is that in american dollars?- it's like five cents. - five cents?- yeah. more or less. thank you very much.muchas gracias. $120 is a lot of money when you get $1,000 in social securitydisability and need one or two a month. five cents here?it's like the biggest insult. it just doesn't make any sense. it doesn't make any sense. i wanna fill a suitcase upand go back home with it.

i took my groupof sick americans to a hospital to see if they could get some care. they didn't ask for moneyor an insurance card. just their name... and date of birth. that was the entire intake session. thank you very muchfor doing this. i asked them to give usthe same exact care they give their fellow cuban citizens.

no more. no less. and that's what they did. i'm dr. roque.i'm an internal medicine specialist. - john graham.- how are you feeling? my lungs hurt. i have pain. i get pretty severe nosebleeds at times. i get terrible headaches in the night, but i haven't been evaluatedfor the sleep apnea for nine years. - yeah, i have...- many medications for lung problems.

almost every medicationfor lung problems, i've got. after 9/11, things have happened,my teeth started falling out. because of certain conditions,i was grinding. there's one test that they recommendedi take, it's about $5,000 to $ 7,000. the dentist that i talked to,it's like $15,000 or more. it's two years i have no medical coverage,so i can't go for the last part of the test. it's ok, everything's gonna be ok.right? yes. i am so... it's so hard for me to digestsomebody saying it's free.

because 20 years of our liveshave been spent fighting. so i am so grateful. no, you don't need to say that. - thank you. thank you.- ok. come on, don't cry.everything's gonna be ok, right? - thank you.- at least what we can do, right? reggie was diagnosed withpulmonary and bronchial problems. the cuban doctors gave hera treatment plan to follow back home. along with some of thosefive cent inhalers.

william maher received a numberof treatments on his neck and his back. having ground down his teeth forthree years due to post-traumatic stress. he left cuba with a new set of teeth. after a series of testson his heart. lungs. blood and stomach. john now knewwhat his ailments were. he was given a strict plan to follow.plus a number of treatments and was feeling betterthan he had in years. the cuban doctors were able to takedonna off five of her nine medications. and with a correct diagnosis.gave her a treatment plan

to help her live a more normal life. when firefightersand paramedics in havana heard that the 911 rescue workerswere in town. they invited them overto one of their firehouses. and so. on our last day there. as we arrived. they stood at attention because. they said.they wanted to honor the heroes of 911. sã­. somos familia. y los hermanosque perdimos en las torres gemelas se sintiã³ en el mundo completo.

the brothers we lost on 9/11was felt around the world. - mis hermanos.- mis hermanos. don't hesitate to hug a brother. it's very important for them to wearthe scba so they don't end up like me. - they're lungs.- these tanks. scba. self-containedbreathing apparatus. tenemos una reserva tambiã©n en el carro. es un placer poder venir aquã­. esto es lo ãºnicoque tenemos nosotros...

f- f-f. three fs. if this is what can happenbeteen supposed enemies. if one enemy can hold out his handand offer to heal. then what else is possible? that's when i heardthat the man who runs the biggest anti-michael moore websiteon the internet was going to have to shut it down. he could no longer afford to keep it upbecause his wife was ill

and they couldn't afford to payfor her health insurance. he was faced with a choice of either keepattacking me or pay for his wife's health. fortunately. he chose his wife. but something seemed wrongabout being forced into such a decision. why. in a free country. shouldn't hebe able to have health insurance and exercise his first amendment rightto run me into the ground? so i wrote a check for the $ 12.000he needed to keep his wife insured and in treatment.and sent it to him anonymously. his wife got betterand his website is still going strong.

it was hard for me to acknowledgethat in the end. we truly are all in the same boat. and that. no matter what our differences. we sink or swim together. that's how it seems to beeverywhere else. they take care of each other.no matter what their disagreements. you know. when we see a good ideafrom another country. we grab it. if they build a better car. we drive it. if they make a better wine. we drink it.

so if they've come up witha better way to treat the sick. to teach their kids. to take care of their babies. to simply be good to each other. then what's our problem? why can't we do that? they live in a world of "we. "not "me. " we'll never fix anythinguntil we get that one basic thing right. and powerful forceshope that we never do.

and that we remain the only countryin the western world without free universal healthcare. you know. if we ever did removethe chokehold of medical bills. college loans. day care. and everything elsethat makes us afraid to step out of line. well. watch out. 'cause it'll be a new day in america. in the meantime. i'm gonna go get the governmentto do my laundry.

referral association

referral association

hello, i'm helen zorbas. it's my pleasure to welcome youto the second program on gynaecological cancer, produced by cancer australia andthe rural health education foundation. we're delightedto have health professionals from rural and remote areas of australia joining us for this programon endometrial cancer. endometrial cancer is the most commoninvasive gynaecological cancer in australia,and its incidence is increasing.

each year,about 1,700 women are diagnosed, about a third of whomlive outside a metropolitan area. as rural health professionals,you have a vital role to play in the early detectionof endometrial cancer and the investigations that canlead to timely referral and diagnosis. we hope that through this broadcast,you gain a better understanding of those women who are at greater riskof developing endometrial cancer, as well as the importance of appropriateinvestigation of symptoms and referral for treatment.

thanks to helen zorbas.hello, i'm norman swan. welcome to this programon endometrial cancer. it's a programwhich is a joint initiative of the rural healtheducation foundation and the national centrefor gynaecological cancers, which is part of cancer australia. this is the second program in our serieson gynaecological cancer. endometrial cancer is the most commongynaecological cancer. it's on the rise in australiadue to an ageing population,

and increase in prevalence of obesityand diabetes in women. tonight we'll discuss risk factors,signs and symptoms, appropriate investigations,who should you refer to, all of which influence whether or notyou make a timely diagnosis and get your patient into treatment. you'll find a number of useful resourcesavailable for you on the rural health educationfoundation's website: and also on cancer australia's website: let's meet our panel.

jenny may is a rural generalpractitioner working in tamworth. - welcome, jenny.- thanks, norman. jenny is employed by the universitydepartment of rural health in tamworth and is a rural gp academic. jenny has a strong interest in makingsure rural people get the same standard of healthcare as thoseliving in the cities. pieter mourik is an obstetricianand gynaecologist working in albury wodonga. - welcome, pieter.- thanks, norman. good evening.

pieter has been working in that areasince 1979. he also travels widely workingas a gynaecologist throughout australia and teaches women's healthto medical students at the rural clinical schoolof the university of new south wales. kath nattress is a cancer-nursecoordinator for gynaecological cancer at the sydney cancer centre. - welcome, kath.- thanks. kath is also a clinical senior lecturerat the university of sydney, and her research interests focus onthe impact of disease and treatment

on women with gynaecological cancer. michael quinn is professor in thedepartment of obstetrics and gynaecology at the university of melbourne and is a consultantfor the oncology/dysplasia unit at the royal women's hospitalin melbourne. - welcome, michael.- good evening, norman. michael is also a memberof the advisory group of the national centrefor gynaecological cancer. i will do simultaneous translationfor kath and michael,

who speak the same language i do,but not necessarily where you do. jenny may is actually the onlyaustralian-born australian on the team, so have pity on her. welcome to you all. what i thought we'd do tonightis show you a video we've made in pieter mourik's hometown of wodonga about marjorie,who developed endometrial cancer. it creates a focus on the womanwho experiences endometrial cancer. i went to my gp for a routine pap smear.

i'd had no signs or symptomsor any worries at all. the pathology report of the pap smearcame back that there were someendometrial changes, probably benign. i can remember very clearly my gp saying that he was not happy withthe 'probably benign.' he didn't want to put it offfor 6 or 12 months. he referred me to a gynaecologistin wodonga, where i had an ultrasound, which showed some thickeningof the lining of the uterus.

he recommended i have a curette. the pathology report from the curettewas that there was endometrial cancer. living in albury, wodonga, i had to go to a cancer specialistin melbourne for treatment. that is quite overwhelming. when you leave the security of your homeand family and friends to go to an unknown place,you have to organise your home base so that it will workwhilst you're not there. because of some complicationswith surgery,

i was down in melbournefor about six, seven weeks. that caused another considerable stressfor my partner. even though i am well pasthaving babies, the fact that i had a hysterectomy and all of those parts that make mea woman have been removed, there is a sense of loss, same asa woman who has her breasts removed. there's an enormous sense of loss because it's part of your femininityand part of your womanhood. that's something thatyou have to think about

and come to terms with. having had the experience of cancer,it has made me very much more aware of my body and my health. i make sure thati keep up regular appointments with my specialistand general practitioner. - hello.- hi. i'm here to see dr mourik, please. if i find there is something worrying meabout the endometrial cancer, being able to go to my specialistand discuss the concern with him, i find that's very reassuring for me.

good to see you again, pieter. how have you beenin the last six months? - i've been very well indeed.- wonderful. it's two-and-a-half years since you wentto melbourne for the operation for endometrial cancer, is that correct? yes. my trip to melbourne wasa very big event in my life, a very dislocating one and a very scary timefor me and my family. you're very fortunatecompared to a lot of country women

in that we are ableto do your follow-ups. that can be quite an arduous round tripof 600km. to leave your hometo go to the city for treatment, you have to ask for helpfrom your family or friends, perhaps at your gp'sor specialist's rooms or your council. go to those places and ask for help. pieter: you've had a wonderful resultfrom the histology. the tumour was very early because you presentedbefore you had any symptoms.

that means the prognosis, the chance of having any tumourcome back is exceptionally small, probably 1% or 2% in your case. but we still have to do the follow-upslike you're doing today. it's important to keep an eye on you. at the end of our interview today,i'll do a letter and i'll send a copyto the melbourne oncologist, so that he can keep tabs on you as well. marj: i've often wonderedwhether a specialist or a gp

would benefit froma patient's personal experience. i've often thought, could i ask that practitioner to putthemselves in my shoes for a moment to understand that that patientreally needs a lot of reassurance after your treatment. you can be very anxious. every pain and ache can bethe worst possible diagnosis. marjorie,i've got really good news for you. the examination was perfectly clear.

i will have a result of the pap smearin a week's time. marj: with the encouragementof my gynaecologist here and the general practitioner, they reassured me and gave me as muchinformation as i wanted to know. that was very helpful to me, and helped me to get the diagnosisof cancer into perspective. i was very happy about thatcommunication i was able to have with both of those doctors. pieter: i'll see youin six months' time.

marjorie's story, from wodonga. she's a lucky woman who had a good gpwho picked it up on the pap smear. a very good gp. she just had a routine pap smearand the abnormalities were picked up and they were equivocal. he wasn't too sure. he said to her,'i don't do i'm not sure. i'll send you to the local specialist.' a typical story for womenin that ambivalent situation

of stay at home, get referred tothe major centre, jenny? often the story. people often like to stay local, or like to know a lot aboutwhere they're going. and kath, that typical story of people not expecting herto still be a sexual person even at 72. definitely. she comments on that. even having a hysterectomy at that age still has associations for many womenof femininity and sexuality.

how often do we address it as we should? did she talk to you about that, pieter? she has talked to me about that. i've known marjorie for 30 years,which is a lifetime, really. we have discussed that. boundary issues when you've knownsomebody that long are hard. yes. i was just reflecting on thatas pieter said it. sometimes it's easier to talk to someonewho's actually a bit more anonymous about some of those things as well.

to what extent, kath,in your experience in new south wales, does the multidisciplinary team carethat you get in the major centre translate back to the country town? because obviously somebody like marjoriecontinues to need it in some form. there are very good linksthat we should be making, particularly with the gp, when a womangoes back to a country town. within the new south wales, we haveregional cancer-nurse coordinators who are cancer-generic,not cancer-specific. so if a woman is going back, say,to dubbo,

i would speak tothe cancer-nurse coordinator there and we will liaise between us. she may well call me on more specificgynaecological cancer-related things. when that woman is home,you're still on the end of a telephone. a great deal of things can be doneover the phone. it doesn't actually need to beface-to-face. just becauseshe's however many miles away doesn't meanshe's not getting that support. the commonest gynaecological cancer?that surprised me.

by far. much more than any other cancer. we've got almost 2,000coming up in australia annually. ovary cancer is about 1,400, and cervix cancer,we're now less than 700. this is three timesas common as cervix cancer, but most women are more preoccupied withhaving pap smears than worrying about the risk factorsfor endometrial cancer. what are the risk factors? over and above everything else,it's estrogen-related.

obesity is the number-one factor. that's why we have a worldwide epidemic of this disease. about 30,000 american women every year get cancer of the endometrium and about 6,500 of those women are going to die. it's a very common cancer. it's a cancer that will unfortunately

kill about 25% - 30% of those women. it's a real issue in australia as our population is getting more obese, as diabetes is getting more prevalent,and as our population is ageing. it's a big relative risk for obesity? it's enormous. it's the single most important thingthat contributes. norman: and that's estrogen? it's the same asbeing on unopposed estrogen,

and of course, we don't giveunopposed estrogen anymore. diabetes, is that insulin growth factor? you're absolutely right. it's an insulin-related phenomenondue to aberrant growth factors within probably the ovary, causing stromal hyperplasiaand estrogen production, even in the postmenopausal ovary. we've got a web question from marissapillar, who's from north queensland acknowledging that this type of canceris on the increase

due to us getting fatterand more diabetes. the question is, should we beroutinely screening, in some sense, for endometrial cancer,particularly amongst indigenous women? it's a terrific question. the answer is no, we don't have a screening test availablefor endometrial cancer. ultrasound has been shownnot to be cost-effective in reducing the death ratefrom this cancer. there's no blood test available.

currently we have nothingthat we can recommend for screening. the only situationwhere it might be of value would be in the very high-risk patient. that would be a womanwho carries a genetic mutation for what's calleda mismatch repair gene. these are womenwho have hereditary bowel cancer. norman: this is lynch families. they've got 50% chance of bowel cancer,50% chance of endometrial cancer. we currently recommend that those womenshould have at least an ultrasound,

perhaps an endometrial sample doneevery year to see what's going on at uterine level. but there's no evidence to showthat reduces a woman's risk of dying. you're talking abouttransvaginal ultrasound. there are different types,type 1 and type 2, and they've got different prognoses. we now know thatthe estrogen-driven cancers are, if you like, the good cancers. about 80% of all endometrial cancers

fall into this group. if a woman has this estrogen-driven cancer, she's got about a 90% chance she's going to be cured of her cancer. in comparison is the type-2 cancer. it's much more aggressive. it's usually a grade 3 or a serious tumour.

they're non-estrogen-driven. the woman doesn't have risk factors that she would have for the type-1 cancer. these women have about a 50% - 60% risk of dying from the disease, so it's a very bad cancer to get. norman: and the risk factors for type 2? michael: none that we know of.

we can't target high-risk population, unfortunately, to try and reduce the death rate. how similar is it to breast cancer?a lot of risk factors are the same. certainly for type-1 cancer, we knowobesity is one of the risk factors for breast canceras it is for endometrial cancer. interestingly, obesity has been shownin a very big australian study to be a risk factor for mucinous cancerof the ovary. so obesity, no matter which wayyou look at it in general practice,

it's the number-one disease of our time. does treatment change according to type? if you pick up histologythat it's type-2, do you go for things more aggressively? type-1 cancers tend to bethe well-differentiated cancers. they're the type that are less likelyto spread in comparison to the type 2s. they're more likely to go to the cervix,the tubes and ovaries, the lymph nodes or the omentum. those are the ones we concentrate on.

we spend more time staging the cancer,if you like, as opposed to the type 1. how much of a risk is tamoxifen?there are a lot of women on tamoxifen. a lot of family doctors ask methis question - should we be screening womenon tamoxifen? the answer is no. the recommendation is that the riskwould be about twice that of the general population risk. when you look at obesity as a riskfactor, it's up to nine or ten times.

so obesity really isthe number-one thing. the way i explain it to women is, your risk of getting endometrial canceron tamoxifen is the same as gettingan increased risk of breast cancer having one or two alcoholic drinksa day. that's what it amounts to. - the pill is a protective factor.- terrific. the pill is a great drug for stoppingcancer and lots of other things too. the pill does reduce the riskof endometrial cancer - anything up to 50%for ten continuous years of use,

and of course it reduces the riskof ovarian cancer as well. the pill is very goodfor the female genital-tract cancers. presenting features -jenny, what do you know as a gp about the presenting features?what raises the alarm bells for you? the most common presenting featurefrom my point of view is bleeding. bloody vaginal discharge is the normalway we think about it presenting, certainly in postmenopausal women, and an abnormal bleeding patternin perimenopausal women. a bleeding pattern that doesn't fitwith their hrt usage,

for instance if they're using itperimenopausally, or prolonged or persistent bleedingthat doesn't follow a pattern that you could identify. we'll come back to presenting featuresin a moment. alan from finley medical practice asks, 'why does marjorie go to melbournefor an oncologist? was there a special reason? were the albury wodonga oncologistsnot appropriate? i'm 150km away from albury

and my endometrial cancer patientsare followed up at wodonga. pieter? she wasn't my patient. my colleague referred her to melbournefor his own reasons. but he suspected that it might betechnically quite difficult because she was plump,is the polite word, and it can be a challenging operationwhen you have limited resources. but with the aidof the retrospectoscope, she may have been betterto have been managed locally

because she had a superficial lesion, no penetration at all, and she hada horrendous post-op complication. of course, in the country,we wouldn't expect to see that. absolutely. no complications everfrom surgeons in the country. but you might not know thatbefore you go in, that she has a nice superficial lesion. no. the most difficult part isto know what you're dealing with. except if you've gota well-differentiated type-1 tumour in someone who is asymptomatic,

you can suspect thatthey're not going to be grossly invaded. from your point of view,what's the most difficult thing that gps often talk to you about,pieter, in terms of wondering whether or notthis is a woman with endometrial cancer? probably the most difficult thing,as everyone knows, is the shortage of gynaecologistsin rural areas. they're fully booked, and can be booked for three or fourmonths for routine appointments. i would like gps to be aware

that this is a problemthat needs a phone call and a personal communicationwith the specialist, not just to say to the lady,'you need to see a specialist.' because when she rings up, she might betold by the lady on the desk, who has no idea of the significanceof postmenopausal bleeding, that she has a six-month appointment. i think that's unacceptable. what about symptoms? what gives you the most heartburn?

as i said, vaginal bleeding isthe symptom par excellence that i've got my sonar out for. it's relatively easyin postmenopausal women, but if she's not through the menopauseand you're not sure, that's difficult. very difficult. and if she is,as many women are, on hrt, it often makes the decisioneven more difficult, because you're trying to work out,is this a progesterone-withdrawal bleed, as you would expect,or is it something else? michael, what about other things?bleeding is the hallmark.

do you often find endometrial cancerwith no symptoms at all? very rarely. this woman has beenextraordinarily lucky. getting endometrial cancer picked upin a smear test is most unusual. it accounts for less than 1%of the total patient load that we carry. as pieter says, that's going to be a very early cancerunder those circumstances before it's even caused bleeding. she's been very fortunate.

unusual. in ovarian cancer, we're not sure early detectionmakes a difference to the outcome. do we know thatwith endometrial cancer? we don't have that information either. norman: it's an act of faith?- it is. the thing about it is, as jenny says,that it's the bleeding. bleeding is that trigger. it's a lovely symptom to follow.

as soon as a woman who's postmenopausalgets bleeding, she usually goes to her family doctor. she plucks up courageand recognises that this is abnormal. norman: what about overlap of symptomsof ovarian cancer with abdominal symptoms? very few. certainly in my experience,most women with endometrial cancer present with either irregular bleedingif they're premenopausal - and remember, 25% of these patientsare going to be premenopausal -

or postmenopausal bleedingor as you say, jenny, a watery vaginal discharge that isblood-stained. that's not uncommon. norman: so, premenopausal. that would be inspiring fearin the hearts of gps watching. absolutely. it's a tough one. when we looked at the data, a third of those womenwith premenopausal endometrial cancer presented with heavy periods. it's such a common symptomin general practice.

most general practitionersexamine a woman and say, 'i'll put you on the pill.that will sort it.' - mirena.- that will sort it out for you. it raises that spectre of,am i undertreating this patient? but probably not. premenopausal women,more often than not, will have the irregular bleeding,as you say quite rightly. it's not the infrequent bleeding,it's the more frequent bleeding. that raises alarm bells.

- a pattern of increasing intensity?jenny: yes. you do the same investigations. if she's got irregular bleeding, it's exactly the same as if she hadpostmenopausal bleeding. a question from deena casefrom queensland. 'is there an association between endometrial polypsand endometrial cancer? if an asymptomatic postmenopausal womanhas a visible polyp of the cervix, should she have a vaginal ultrasoundto measure endometrial thickness?'

no. norman: so this is a cervical polyp? there's no link between ectocervicalpolyps and endometrial polyps. norman: there is betweenendometrial polyps and cancer. yes.so, if you have an endometrial polyp and this is picked up as an incidental and you're being screenedfor some other situation, the risk of that being malignant is 1%. it's very low, but it's there.

we're jumping ahead,but i'll ask the question - albert vermeulen from northwest healthasks, 'premenopausal women with symptomsand endometrial hyperplasia - would you prescribe hrt if she insists,and how would you follow up?' - one of your hobbyhorses.- it is. the management of hyperplasiain australia is not handled well. it's becausewe've changed the terminology. our brother and sister pathologists haveintroduced the term complex hyperplasia. as soon as complex has comeonto the scene, people have panicked.

but they don't need to panic. the most important thingin hyperplasia is whether there are atypical cells thereor not. if you have just complex hyperplasia, the chances of you, in the nextten years, getting a malignancy is 1%. whereas if you've gotatypical hyperplasia, you've got a 20% - 40% of already havingan underlying cancer. that's the most important thing. if it's simple hyperplasia,another great indication for a mirena.

jenny? norman: for an iud?- absolutely. a progesterone-lined iud, yeah. let's go to our next case study, who's mary,a postmenopausal woman of 54. she comes to you, jenny, complainingof blood-stained vaginal discharge. she's got a bmi of 33, a sedentary job. she's got type-2 diabetesand is on metformin. she's married with no children.

- your patient.jenny: thanks, norman. the first thing in general practice isa good history. that's the way i would start. i'd want to know particularlyabout that bleeding - when did it occur?was it related to intercourse? was it somethingshe'd noticed regularly? was there any pattern to it? also what we were mentioning,other symptoms - did she have any pain on intercourseor is there any abdominal pain?

and when was she menopausal? is this bleeding that could be relatedto her perimenopause or is this bleeding that has comea significant time after menopause? she tells you she's been spotting a bit. she's never really been free of bleedingthrough the menopause, but not had a regular periodfor quite some time. well, that doesn't help us much. one of things we need to inquire intois medications, at this point. has she been started on any hrt,either cyclical or continuous?

also, has she been availing herself ofany other estrogens? i'm thinking here, natural estrogens. a number of my patients havesourced natural estrogens thinking that they had no impact onestrogenization at all in the way i think about it. and in fact, that has been a problem. michael,that's something you're seeing also, that bioidentical estrogensare not considered by the patient as estrogen or medication.

but from the point of viewof their being unopposed estrogen, there's a big issue.norman: they're just as potent. it's not just the patient. the complimentary-health practitionerwho's prescribing it actually believes thatthey don't have the same potency. part of the problem is,we don't know what the potency is. these are unregulated, so we don't knowwhat the real concentration and what the real contentof these medications are. but they certainly can causean increased risk of endometrial cancer.

we've seen many cases. norman: you're taking the history.what else? i need to know about her family history. we've heard already that lynch familiesare at high risk, so i need to know about that. i also need to know a little bit abouther menopause and her menarche. and did she have no children by choice, or was it thatshe couldn't have children? in that case, had she had pcos or beenanovulatory for a considerable period.

all those things are going tobe important to paint a pictureof whether this is significant. if she told youshe'd had endometriosis in the past? is there any relationship betweenendometriosis and endometrial cancer? - not that i'm aware of.- no. norman: what are you going to do next? she had an unclewho died of bowel cancer at 45. ok. well that's... norman: maybe.- that might be helpful.

i'm going to prop her up on the couch. she's not going to leave the consultwithout being examined presenting withthis bloody vaginal discharge. so up on the couch, and i'm going to doa speculum examination and a pap smear. norman: you're looking forlocal causes of bleeding? yeah. i'm looking to identifyif i can see an obvious bleeding source. is there pathology on the cervix?is there pathology in the vagina? then i'll do a bimanual examinationand have a good feel around and see if i can feel anything inher adnexae, or try and feel her uterus.

i have to admit that in a personmore than 100kg, i have considerable difficultyin identifying anything. if i can find anything or feel anything,i would suspect that that's abnormal. norman: i suspect experiencedgynaecologists would find the same? very much so. it's a great problem. especially if the woman hashad no children, she's going to be more difficultto examine. she'll have a cervixthat's very difficult to expose. it can be quite a challenge.

you've taken a pap smear.there's nothing much to find. it was very hard to examine her. i'll talk to mary.it sounds to me like this is a symptom that i'm going to investigateimmediately. i haven't seen anythinggrossly on her cervix that makes me think thatit's cervical pathology. i'll talk to her about organisinga transvaginal ultrasound. certainly that would be my next step. that could be a surprise for herif you don't warn her about it.

it's my bitter experience thati've had patients come back and be cross that i didn't warn them. norman: because it's not a little probe. it's quite a significant probe,and it is a vaginal probe. unless they're warned about that,obviously that could feel quite invasive and quite disarming for them. i talk to them about this probe that is going to looka bit like a condom and is going to be quite uncomfortable,potentially, to get a decent picture.

your tamworth interventional radiologistdoes that? indeed,or probably our local gynaecologist. what are you looking for in a tvus,a transvaginal ultrasound? purely the endometrium. that's the number-one thing in a womanwith postmenopausal bleeding. you're looking hopefully fora thin endometrium. anything less than 5mm,you're going to be happy that the likelihood of malignancyis going to be low. - this is generalised thickness?- yeah.

you can have a carcinomatosis? no, just a uniform thickeningof the endometrial lining. it's very difficult to seeif there's an underlying cancer if there is myometrial penetrationon ultrasound. it's even quite difficult on mri. that's somethingwe'll probably talk about later. there's a question herefrom effie parakilas. 'can you comment on the diagnosticaccuracy of a pipelle endometrial sample under local, compared to an endometrialsample collected via hysteroscopy?

when is it appropriateto do a pipelle endometrial biopsy, and when is it appropriateto refer for a d and c, bearing in mind waiting times are longer at public gynaecologyoutpatient clinics?' i might ask you first, pieter,then i'll go to michael on this. it's a procedure thatmost specialists do. i'm not sure whether many gpswould be able to do it, unless they're comfortable doing mirenasthemselves and doing their own curettes, and they have the facilities.

it is quite a simple technique. the correlation is quite good,in that if it's an endometrial cancer, it usually fills up the whole cavity and you get a sample which isvery clearly malignant on histology. - it's simply a suction technique?- it's a suction catheter. 5mm diameter, it slides into the uterusand aspirates the menstrual lining. however, if it comes back negative,there are false negatives. that would mean they probably needreferral for an anaesthetic and a hysteroscopy.

norman: coming back negativedoesn't mean you can relax? definitely not. what's the relationshipbetween a transvaginal ultrasound and a pipelle? there's a good relationship. norman: can you do both?- if you're doing both, you can see where the pipelle is goinginside the uterus. but you don't need an ultrasoundto do a pipelle. most gynaecologists are very happy,particularly in a multiparous woman,

in doing a pipelle. in nulliparous women - and a nulliparouswoman is more likely to get an endometrial cancer -it's more difficult. then your transvaginal ultrasound says,if you've got 5mm or more, you have to do a hysteroscopyand curette under those circumstances. the best thing is to do a pipelle samplein your office first up, and if there's tissue,you've got your diagnosis. a question also from effie is, 'i have a 75-year-old womanwith postmenopausal bleed.

transvaginal ultrasoundshows a normal 4mm lining with a 2mm cystic space at the fundus. is it reasonable to do a pipelleor should she have a hysteroscopy?' great question,and a common ultrasound finding. the answer is, do a pipelle.if you get a tissue, fine. if you don't get a tissue,then you do your hysteroscopy. norman: right.- ok, effie? i'm not sure. another question herefrom albert vermeulen asking,

'is pcos a risk factorfor endometrial cancer, or is it just the fact thatyou're overweight with pcos?' pcos means you're not ovulating, and you have unopposedestrogen production. for some reason that is, we know,associated with obesity. we're seeing younger women now,in their late 20s, early 30s, with obesity and pcos together. these women are developingendometrial cancers. they're the ones to have children,

so that poses a therapeutic dilemmafor us. on the request formfor a transvaginal ultrasound, is there anything thatyour radiologist asks for? they need to know whether they're post-,peri- or premenopausal, and whether they're symptomatic,i suspect. most ultrasound people,when they get that form, will look at the ovaries, make sure there's notan estrogen-secreting tumour, or in younger women, cystic ovaries.

it's really sophisticated now.fantastic, to be honest. - pieter?- i'd like to respond to that one. one of our endometrial cancer patientsis 120kg. when we told her the relationship, she said, 'i must speak to my twodaughters, because they're large.' we should go backto that previous question on waiting listsat public gynaecology clinics. this is something that you, as a gp,don't accept - the waiting lists. you've got to get her seen straightaway,no questions asked.

this is about patient advocacy. this is about the fact that,particularly in postmenopausal women, that a bloody discharge equalsendometrial cancer until it's defined that it isn't. access to ultrasound is either directlyor through gynaecology services. it's certainly important thatyou stay on that patient's case and get them seen if your clinical suspicion suggests thatthat's the most likely diagnosis. kath, at this stage for this woman,where she's not diagnosed,

is there any role for someone like you, or is this too early,before she's got the diagnosis? if there is access to someone like me,i think there is a role for this. she is probably convinced she has canceruntil proven otherwise. she's going to be in a state of limboand probably has questions - what will this mean if this is cancer? and has a lot of unresolved fearswhile she waits for that diagnosis. it's a really uncertain time at which point there often isn'ta great deal of support

because she's not fallen intothe cancer pathway at that time. let's say she hasa transvaginal ultrasound, michael, and it's just on the marginsin terms of thickness. michael: 5mm. norman: and the bleeding stops. and you've got no tissueon your pipelle sample. you don't go any further,but say to the woman categorically, 'if you have another episodeof bleeding, contact me.' if you can get that message home,that's very important.

but having made contactwith the family doctor, she's plucked up enough courage,and i'm sure she would do that. what's the process for diagnosis? let's say the pipellecomes back positive. we head for hysterectomy,or do you do a d and c? no, you don't have to do a d and c. once you've got a histological sampleconfirming there's endometrial cancer, you're hot to trot. you sit down with the woman

and tell the woman what the likelyimplications of that diagnosis are, and what further investigationswill be undertaken, and what's the likelysurgical approach. in the vast majority of cases, women aretreated surgically for this disease. how important is surgical staging? surgical staging is extremely important,particularly with high-risk tumours. the problem is that we don't knowlow-risk tumours are low-risk until we surgically stage them. it's a catch-22 position.

you'll see on the screen that even women we think have got early disease, up to a third of those women will actually have disease that we categorise as high-risk. by that we mean, more likely to spread to pelvic and para-aortic lymph nodes. we feel that surgical staging is important prognostically,

so the woman knows how advanced her cancer is. secondly, it dictates her treatment. for instance, if we remove pelvic lymph nodes and they're not involved, we don't have to give women full pelvic irradiation, which takes five or six weeks. but if they're positive, then we know

she'll benefit from pelvic irradiation. so staging helps us in management, it gives the patient information and i think probably is the benchmark,in 2011, in the management of womenwith endometrial malignancies. is there value tothe multidisciplinary team here, kath? it's sometimes hard to reconstructin a country town. there's valuein a multidisciplinary team, but that doesn't have to besitting there in one spot.

a lot can be done by phone. as long as the liaison process is there and people know who to go if theyhaven't got that level of information. it doesn't need to bea physical team meeting there, it can be a virtual-realitymultidisciplinary team. we often see that happening. pieter, this issueabout where somebody goes, it's clearer with a womanwith ovarian cancer. but if surgical staging is so important,

do you think general gynaecologistsin country towns can do that? it depends on the individual. there are some very talentedgynaecologists in the country. the best person to assess thatis the local gp, who may have had many yearsof working with that person. he'll know whether he has an interestin this work. he may have done extra trainingin oncology and is able to do the node samplingthat michael is talking about. michael is talking about an ideal world,

where everybody is managedat this level. i don't believethere's any hard evidence to say that that improves the outcomes for theamazing cost of disrupting that woman and sending her a long wayto people that they don't know. occasionally, they're managedin a city hospital by a trainee, rather than someone who may have30 years of operative experience. (does tarzan yell) no, i don't think that's ever happened. i don't think anyone is ever managed bya trainee.

my view is thatthese cancers are life-threatening. when we ask patients,what's the number-one thing you want when you're being treated for cancer,the number-one thing they want is to be sure they are gettingwhat they describe as cutting-edge care. they want to know they're gettingthe very best of modern care. the occasional surgeondoing occasional lymph node sampling is not in that patient's best interests. the surgery is important,but it's not just surgery. cancer care is multidisciplinary.

it's the comprehensive careof the patient. marjorie spoke eloquentlyabout the dislocation. but every patient who gets a cancerhas a crisis. they get dislocated from their families whether they're in the middle of sydneyor tamworth. they have to go somewhere that they'reuncomfortable with, threatened by. they meet people they don't really know, because not everyone knowsthe local gynaecologist that well. it's very threatening, no matter what.

the analogy is,if you've got coronary artery disease, your chances of living at five yearsare higher than if you get an endometrial cancerand treat it, even in a major centre. you wouldn'tgo to your local gynaecologist to have your coronary arteries done,would you? even although he was able to do them,or she. - jenny?- i feel very vexed about this. i hear both michael and pieter. my problem is,a lot of these patients are elderly.

a lot of these patients are, i'd like to say,not skilled at managing going to a city but that sounds patronising,and i don't mean to be. but with increasing prevalenceof regional cancer centres, which are based around bunkers,so you've got radiotherapy, increasingly, it's only the surgeryand diagnosis they can have, and they can come homefor their regional... indeed. my ideal world is somethingbetween the two extremes. i would like to see thatcomparative best-practice care

can be deliveredin regional cancer centres with the supportof the highly skilled surgeons, clinicians and multidisciplinaryteam members. but it grieves me that the only placeto go for cancer therapy is a metro centre. we're talking about the staging processso you know what the woman has. yes.and i agree that's the ideal scenario. if we had regional cancer centres withvisiting gynaecological oncologists and the whole other set-up, fantastic.that's the solution.

pieter: it would be the ideal solution. the local gynaecologist would be willingto operate with someone like michael. and provide appropriate follow-up. tell me what you do with womenwith endometrial cancer, kath. prior to treatment.just give me the spiel. prior to treatment, i would see themin a pre-admission clinic to go through with themwhat they can expect in terms of their surgery,their recovery process and how things will followonce we get results.

giving them a time line so they're awarewe will not have results immediately, that they may have gone homebefore they have those results. if this is a woman from the country, and frequently it's another tripto the city for them, but making sure as well thatwe are doing all we can to facilitate that trip to the city, that there is support for the familywho are coming down with them, that we've completed things likeiptaas forms, so that there's financial support.

because the whole cost of transitioningto the city, even if it's for a week, and your partner is staying in a motelwhile you have your surgery... norman: is quite crippling?- is considerably crippling. a lot is preparing with information, then taking things very much aswe find their pathology to looking at the next step. as we see them for the first time, we often don't know what that next stepis going to be. so, establishing that relationship.

talk about the rangeof therapy treatments available. there's surgery. is it always radical? no, it's not. our management of these patientsincludes pre-operative imaging. we've got a reasonable ideabefore we go in there that they don't have metastatic diseaseto their liver or lungs. norman: this is pet? no, we usually do an mri or a ct scanof the abdomen and chest. we want to exclude metastatic disease.

we're also interested inobviously enlarged lymph nodes in the para-aortic and pelvic area. if they are node-enlarged and we go in,it depends then on what sort of cancer. is this a high-risk cancer? how muchinvasion is there into the myometrium? is there invasion down to the cervix? is there spread to the tubesand ovaries? that's done with a frozen section. we do the hysterectomy,we send it to a pathologist, then we look at each other lovinglyacross the table

while it takes 20 minutes for thepathologist to phone us with the result. it's not a lymph-node sampling,it's a full pelvic lymphadenectomy. we remove all the pelvic nodesand the para-aortic nodes if required. norman: this is if a sentinel nodeshows up as positive? no, we don't do sentinel nodes. under investigations at the moment, whether a sentinel node willbe of value, no-one really knows. who gets the bilateral lymphadenectomy? a patient who has eithera grade-3 tumour, a serious tumour,

a clear-cell tumour, any tumour morethan halfway through the myometrium, any tumour involving the cervix and any tumour that involves the tubesor ovaries. round about 40% of patients overallend up with the much larger operation with the attendant morbidity,particularly in obese women, which is not an easy operation. and lymphoedema is a risk there too? kath: particularly if they arefollowed up with radiotherapy. what about adjuvant therapy?

if the woman has positive lymph nodes,she's usually treated with radiation. she may go on to a trial. australia is part of a largeinternational trial called portec-3. that's using chemo-irradiationfollowed by four cycles of chemotherapy to see if that reduces the riskof recurrence. she would either go on that trialor get full pelvic irradiation or radiation to the para-aortic areaif that was involved. norman: some people aretrying brachytherapy. brachytherapy is given...

that's radioactive seeds, essentially. no, brachytherapy is given in thissituation through a cylinder. it's given as a cylinderto the top of the vagina, and that is after-loaded. so no anaesthetic is needed. the patient is in a quarantined room,the cylinder is put into the vagina, then a machine automatically,and from a distance, loads the top. it's like a large vibrator. norman: it's high-rate?- high-rate brachytherapy.

that's given to patientswhose lymph nodes are negative, but who are at higher risk of havinga recurrence at the top of the vagina. norman: does hormone treatment work? we don't use hormone treatmentin an adjuvant setting anymore. but hormone treatment including provera- medroxyprogesterone - and tamoxifen are usedin advanced disease. so, post-operatively, kath and jenny, when you see these women,and i'll start with jenny. they could have hadfairly radical treatment.

this would have enormouspsychosexual effects on them. absolutely. this is huge surgery. it's huge surgery in physical terms, and it's huge surgeryin emotional terms. as i'm sure kath will attest,these women take a long time to recover. as marjorie told us,they need enormous support to get through what isan extremely challenging time, both in terms of mortalityand sense of self-identity. norman: what practical advicedo you give people?

it varies very much on the woman. we have to have a detailed discussionwith them to find out what their concerns areand what they're worried about. as we've said, lymphoedema canbe an issue for these women. we know that there are thingswomen can do to reduce their riskof developing lymphoedema, but also if they do develop it, that they have very quick referralto a lymphoedema therapist, which will manage the problem.

it's individualising what that womanneeds, so giving practical advice, discussing with them, relating to how their sexual functionhas been before the operation. for quite a few womenwho are sexually active, the whole factof having postmenopausal bleeding is going to be something thathas affected sexual function before it's even diagnosed. they may have concernsand misconceptions. we need to be dealing with thoseappropriately,

but not making any assumptionsthat are often made because these are postmenopausal women. or people think, she's very large,i'm sure she wouldn't have sex. we don't neglect thiswhen discussing things with them. the national centrefor gynaecological cancers is in the process of developingclinical-practice guidelines for endometrial cancerwith cancer council australia. there's a working groupchaired by alison brand. let's go to our last case study.

mrs mills, she's 86, livesin a residential aged-care facility in your country town, jenny. she has limited mobilityand severe cognitive impairment. staff report that she hasblood-stained vaginal discharge. her daughter rings you up, jenny,to have a look at her mother and comes with her. this is a really tricky situation,and one i encountered last week. the important thing isto see this patient's bleeding in the contextof their health in general.

my first port of call isto try and make a diagnosis and try and establishwhat's causing the bleeding. i will examine mrs mills as best i can,and sometimes that's quite tricky on a soft bedin the residential aged-care facility. my bent here would beto try and establish a diagnosis in terms of wherethe bleeding is coming from. norman: why? it's important,in talking to the daughter about what to doabout mrs mills' problem,

to give some ideaof what the diagnosis is. - then i can give her a prognosis.norman: do you agree, pieter? i do, yes. especially if it's a benigncondition, they can be reassured. if it's a malignant condition, they needto have the discussion about treatments which are perhaps not invasivelike surgery, such as progesterone treatment,mirena treatment. something to stop the bleeding. what would you doafter you've done the examination? it's going to be hard to doa transvaginal ultrasound on her.

it is. this is a situation wherethe pipette, the endometrial biopsy, would be hugely useful. if that was possible, for meto get the patient to the gynaecologist or access someone to do it,that's obviously a great outcome. if we can get the diagnosiswith the pipette, we're in a position to discusswith the daughter what the low-stress options areas well as the high-stress options, given this lady's comorbidities. and if the family saysthey want everything done, michael?

you've got to respect that. it's a joint decision. it's the family and the family doctorinvolved, the local gynaecologist. everyone is involved. there are no easy answers to this. it's people sitting down as a group and trying to work out what's bestfor this woman. there's no algorithm we can writeto say, this is what you need to do. every situation like this is dealt within a different way

from patient to patient. it's respecting the family's wishes,and also respecting the woman herself, even though she's demented. so what you're saying, pieter, isyou could put in a progesterone iud? if the bleeding is what is making herupset, if she's aware of that bleeding, it can be reduced for some monthsjust by inserting a mirena, which is something that can be doneunder very light anaesthetic in a patient like that. some people give a quick blastof external beam.

if this was an endometrial cancer, a single or two fractionsof radiation treatment would be enough to control bleeding, because that's whatyou're trying to do - make her symptom-freefor whatever life she's got left. what sort of death is it? endometrial cancercan be an awful death. that's why it's such an importantdisease to be talking about. it can recur locallyand go into the bladder or rectum,

and that causes fistulisation, which is the worst possible wayfor anyone to live their life, or it can metastasise, usuallyto the lungs or to the common site. but under those circumstances,progesterones are pretty good. two last questions on our webcast. we've dealt with this before,but we'll come back to it, adina case from queensland health asks, 'in young women with oligomenorrheaand polycystic ovarian syndrome, is there any benefit in screeningultrasounds for endometrial thickness,

and if so, how often?' the answer is no, not screening. it's a fabulous question. we need to sit down with these youngwomen and say that they are at risk of developing endometrial abnormalities,and they can protect themselves. they can do that with cyclicalprogesterone, a mirena or just the pill. they need to know, so they don't end upwith an unexpected endometrial cancer in their 30s or early 40swhen they're trying to have children. - did you want to add to that, pieter?- no, i quite agree.

and a comment from effie parakilas,who asked a couple questions before. 'we must refer to our localgynaecology outpatient department who then liaise with the visitinggynaecological oncologist from sydney', which is that partnershipyou were talking about earlier. what are your take-home messagesfor people watching, jenny? the really key one is,don't ignore bleeding. bleeding isa potentially troubling symptom. we will shortly have some guidelinesthat we'll be able to refer to. norman: this is the cancer australia?

from cancer australia,which have some helpful algorithms both for menopausal women, and alsoperi- and premenopausal women. that just underlines that bleeding is a symptomwe need to take seriously. norman: pieter? having travelled around australiaover the last few years, i think the gp must take responsibilityto expedite the referral, not just give the patient a letterto say, make an appointment, because when she rings up,

with the shortage of gynaecologistsin the country, she may have a six-month waiting list. i'm sure that's not going to beto her advantage. the gp should make surethat woman is seen within the week. norman: not slip between the cracks.- no. that we shouldn't underestimate theimpact of endometrial cancer on women, often because they're postmenopausal. because the majority are treatedand cured with surgery alone, we sometimes see it asa relatively minor cancer.

they still have psychological andphysical disease and treatment matters to cope with for many years after, and we need to be able to address thoseappropriately. norman: beat your breast,professor quinn. i think the take-home message is, more women die from this diseasethan cervix cancer. we've got the opportunityto talk to women in family practice, to warn them about the effectsof obesity and diabetes, and get them to try and institutesome intervention to reduce the risk.

thank you all very much.i've learned a lot. great program. i hope you've got a lot too fromthis program on endometrial cancer. this program and the first in our serieson gynaecological cancer, on psychosexual care,can both be ordered free from the rural education foundation. our thanks to the national centre for gynaecological cancers for making the program possible. i'm sure when that guideline isavailable,

it will come up on their website. also thanks to you for taking the timeto attend and contribute. let us know what you thought about itby filling in an evaluation form, and if you're watching the webcast, bysubmitting a comment in the text box on your computer screen. if you're interested inobtaining more information about issues raised in the program,there are resources available on the rural education foundationwebsite: and the cancer australia website, at:

i'm norman swan. see you next time�

referral agent

referral agent

this video shows how to track real-estatereferrals using realtyjuggler. referrals are an important part of a real-estatepractice. agents sometimes get referrals from otheragents, people in their sphere, and other sources. first, i'll edit the common sources of referralsby clicking on "settings", and then "preferences". i'll click on the "general" icon, and scrolldown where the referral sources are listed. each line is a referral source. i'll edit this list by typing into it. i am going to add the web site "sallysellshouses.com"as a common referral source.

don't worry about including every possible referral source. if you have a source that's not in this list, not in this list, you can still type it inlater when you specify the referral source for a particular prospect or contact. lets add in a referral source for a contactrecord. i'll go back to the "main" screen, and thenclick on the "contacts" icon. from here, i'll click on the "new contact"button, and enter "william penn" as the name of my contact record. to track how "william" heard about me, i'llclick on the "referred by" field. i can just type in my referral source, or ican select from the drop-down menu here.

as you can, see my new referral source islisted in this drop-down. i'll select "sallysellshouses.com" for myreferral source. lets add in a referral source for a prospectrecord. i'll go back to the "main" screen, and theni'll click on the "prospects" icon. from here, i'll click on the "new prospect"button, and enter "jack smith" as the name of a new prospect. to track how jack heard about me, i'll usethe "referral source" field. this "referral source" field can be used totrack wherever the referral came from. if the referral came from another person,i can enter the name of that person.

if the referral came from a yard sign or someadvertising or a web site, i can enter that information as well. when i click on the "referral source" field,i have a list of common referral sources in this drop-down menu. but, in my case, i'll type in a unique referralsource of "sally adams". since the referral is from another person,i'll also add "sally" to my parties by clicking on the "parties" tab on the left. i'll click "new party". since i have known "sally" for many years,she is already in my contacts database,

so, i'll click on the first name field here andselect "look up contact" and find her in my database. if i had just met sally, i could have typedher contact information in here, and then added her to my contacts database instead. i'll change the role of my party to "referral". here at the bottom of the "referral" partysection is some additional information. is "sally" a real-estate agent? yes. and i can enter information about the referralfee - i received the referral,

and i am also going to pay a 25% referral fee to sally. since sally is going to want to hear fromme regularly about the progress of this referral, i'll fill in contact every in 14 days. that way, i'll be reminded to call sally andlet her know about "jack smith's" progress in finding a home. video tutorial 44 has additional informationon how the touch cycle works. the referral fee information will automaticallybe part of my commission calculation when we go to closing. now that we have entered some referral information,lets see how we can track which referral sources

are the most valuable to us. from the "main" screen, i'll click on the"goals" icon. i'll click on the "referral map" icon here, and this will show me all my referral sources. i can select from this drop-down menu to specify the database i want to display. the number in parentheses shows how many peoplecame to me from that particular referral source. i can hover over a specific referral sourceto see additional information about that source. the size of font for each referral sourceshows how important that source is. the larger the font, the more important thatreferral source is. in my case, most of my leads are coming from"open houses"

for additional information on how referralswork, click on the two manual links at the bottom of the "goals" section. the first is a manual on the goals section,and this second manual has detailed instructions for referral management.

ref service

ref service

hey guys, chis fix here. today i'm going to give you my top ten tips for changing brake pads and rotors. this video isn't going to go in depth about changing brake pads and rotors. i have a few really good in depth brake videos for both disc brakes and drum brakes. and i'll put a link to those in the description. this videos is really about sharing my top tips that people typically overlook while changing their brakes. tip number 1: remember to work with your car, not against it. when you're working on your brakes, it can be difficult to get your breaker bar or even a ratchet onto the bolts in the back here.

so to get the bolts out holding the caliper on: turn the steering wheel! it gives you more access and makes your life a lot easier! now look at the difference here. you can easily access the bolts here and the caliper braket bolts right behind there. tip number 2 is don't forget to grease the guide pins. remove the little rubber boot...

and then take a towel and clean it off. and then you want to make sure that you use silicone paste on these. silicone won't damage the rubber boot. greasing the guide pins is a commonly forgotten thing to do. and i have a video all about this and i even show how it can cause uneven brake pad wear.

and it's just that easy. now these will slide freely. make sure you do the bottom... and the top! tip number 3: after getting the caliper braket bolts out, and you take your caliper off, never let the caliper dangle by the brake line! you're putting way too much stress and pressure on this

and the brake line is not designed to hold the weight of the caliper. so instead of letting it dangle, what i like to do is i like to get a bungee cord, or a rope, and the hang the brake caliper somewhere, such as on the shock. and now the brake isn't just dangling there, all the pressure is on the bungee cord. and there's no pressure on the brake line itself. tip number 4:

make sure you clean the brake rotor off with brake clean before you install it. you can see the oily coating on the brake rotors which they use to prevent them from rusting. you want to remove that coating. so take your brake clean, spray it on the surface, and wipe it down with a towel. and look at all that oil we removed!

don't forget to do the other side as well! look at that! now this is ready to go on the vehicle. top tip number 5: before you put that brake rotor on, get a wire brush, and clean the hub right over here. if there's rust buildup over here, but not as much over here, the brake rotor could sit unevenly. and that'll cause the brakes to warp. but if you use a wire brush, and brush all the rust off,

so it's nice and smooth and even all around, you won't have that problem. another thing to do is add anti-seize right to the hub face here, and here! with the anti-seize on here, it'll make taking that rotor off really easy the next time you change your brakes

so it doesn't get rust-welded to the hub. now we can put our brake rotor on! you can see with our brake rotor on, it doesn't want to sit evenly on the hub. tip number 6 is grab a lug nut, push the rotor so it's flat against the face of the hub, and screw that lug nut down, all the way.

now, your rotor won't move. this'll help you a lot when you bolt the brake caliper back on. tip number 7: before you use your brake tool, to compress that piston in, get a paper towel, and clean around the rubber boot here and then peel this rubber boot back to expose the brake piston surface and clean all the brake dust on the piston behind the boot.

because the piston's going to be compressed back into the caliper, you don't want to force all that dirt and debis back into the caliper. where it's going to contaminate the brake fluid, and maybe even damage a seal. which would cause a leak over time. a plain towel, or even a towel with some brake cleaner on it, will do the job. in my case, these are pretty clean because i do this every brake job, but yours might take some more time to clean.

alright, once you clean the dust behind the rubber boot, you can compress that piston! tip number 8: when compressing the piston, crack the bleeder valve located right here. i'm using my one-man bleeder which prevents air from getting in the system. you can see the old brake fluid getting force out, as the piston's getting compressed. this brake fluid right at the caliper

gets the hottest and breaks down the quickest. so this process helps get some of that old brake fluid out. and you can add some new brake fluid to the master cylinder when you're all done. and once that brake piston's almost completely pushed in, tighten the bleeder valve as you continue to compress the piston. not only will you remove some of that old brake fluid, but you're also going to use the bleeder valve which will keep it from seizing up. and it won't snap off in the future.

so a little bit of use keeps that free and moving! top tip number 9: when installing new brake pads, make sure you get brake pads with wear indicators. that's this little clip right here. this is actually an old brake pad. and you can see, the wear indicator sticks out just a little. so when your brake pads wear down to about ten to twenty percent left,

this will squeak against the rotor. so when you're driving around and you hear a constant squeaking noise, both while pressing the brakes, and even when you don't press the brakes, you know it's time to replace your pads. this is a great saftey feature because if you don't have wear indicators, you might not realize your brakes are dangerously low. and, as you can see, this brake pad without the wear indicator is worn down all the way to the backing plate. which could be very dangerous!

so make sure your brakes have wear indicators! for a few extra bucks, it's completely worth it! alright, your brakes are all done. top tip number 10: when you're done with everything, hit the rotors with brake clean one more time, to get al that dirt off. oil and dirt is one of the main causes your brand new brakes mighit squeak and make noise. you might not even notice, but your hands are dirty.

and they could've contaminated the rotor surface. so just to be safe, clean it off! and those are my top ten brake job tips! and i want to hear some of yours, so make sure you comment below! so hopefully this video was helpful, if it was, remember to give it a thumbs up! also, if you're not subscribed, consider subscribing. up on the screen are a couple of brake videos that i've done show you how to change the brakes.

you can click on the screen, or find the links to those videos in the description. also in the description, are the links to any products i've used in this video.

real estate lawyer

real estate lawyer

hey it's joe. this one is from ryan dybeck.he says, "it's been awhile. i've got two questions.do you have an attorney contact either where you live or one who's familiar with laws inother states, particularly minnesota? i just need some peace of mind that i can protectmy real estate license and know that i have an attorney who's got my back if anythingwere to come up. i've been told over that our commerce department hates lease optionswith a passion, especially if you're licensed because now they have something to go afterand make an example of. however, i haven't given up what you teach. the biggest thingthey don't like is the fact that we're making a good amount of money up front from peoplewho will likely never exercise their option."

first, let me say you're also making moneyas an agent from people who are selling their property up front before they make any moneyon it, so if you sell to another investor who has not made any money yet and you makea commission on that deal and you make more commission than he makes as a profit, haveyou done something wrong? - no, of course not.it's the same situation here - what you're doing is facilitating a sale, you're makingsure everybody understands what's going on, you're disclosing all the problems to themwhich is one of the things that we have in the lease option agreement that we have everybodysign, so everybody understands what's going on in the transaction so you're not goingto have this kind of blowback with the commission.

also, it's very legal for a real estate agentto sell a property on a lease option. it's done every day, all over the country in everystate, every city and all over the world actually, so you're not going to have a problem withthat. now, if you have any questions about lease options and how to do them, then whati would do, if you're a real estate broker, is call your real estate board's online broker.there's going to be somebody on every board that you can call up (ours is called the lesahotline) and we can call that attorney up and we can ask them questions as a broker(i'm a broker as well). so you can ask them a question. you say, 'is it legal if i dothis? what's the best way to do this to protect everybody? do you have any suggestions onthis? would you suggest that i do it a little

bit differently? is there anything that youwould suggest that i do?' so you can do that for free if you're a real estate agent; they'lltake your questions. they want people to comply with the law, andthey want to be able to make sure that you have consistent answers to legal questions.now in addition to that, you can find any good real estate attorney that understandscreative financing - if you can find a real estate attorney that understands creativefinancing, they will be able to tell you whether or not what i'm suggesting is accurate.now, i know that it is legal. i know it's legal for agents to do it, but you want tomake sure that you do it properly and i understand that, so give them a call and get their personallegal advice. rather than me giving you the

name of my attorney, i think you'd be betteroff finding somebody locally that you can use that understands real estate investingwhere you're at. it may take you a few phone calls before youfind an investor who understands creative financing, so don't be surprised if it takesyou five or ten people to do that. just to find a cpa that understands how to use creativereal estate investing for a roth ira for my personal use - it took me several years tofind that person, so it's not always easy to find the right person for the job.but if you're going to ask the question, get somebody who's qualified rather than somebodywho just tells you no, because they don't understand it properly, which i somethingthat i see is common in attorneys. if they

feel uncomfortable or they don't understandthe process or they don't want to spend the time doing the research and you don't wantto pay them for the research, they may just tell you, 'don't do that.' and that can cutoff a whole side of your business. i once had an attorney tell me that i couldn'tcoach people, that i couldn't do what i'm doing at all unless i complied with a certaintype of thing which didn't make any sense and it would have destroyed my business. soi went and found another attorney and that second attorney said, 'well, you don't wantto kill your business so why don't you do it this way?' and so we made a few modificationsand we did it that way and we didn't have any problems at all after that and that'sbeen many years ago by the way.

now his second question here is,"assuming i get everything above handled, what are the different costs of getting theautomarketer up and running, including all of the other services i need? i'd need myclone sites changed to disclose agency and all of that stuff."the cost for the automarketer is $199 a month. it's a monthly fee, it's your infrastructure- it gives you the websites you need. you need four domain names because there's a bunchof different websites that you have and we have four different domain names that we use.those domain names will cost you $10 each per year, so you've got $40 a year for yourdomain names. we can do subdomains that don't cost anything but i suggest you have yourown unique domain names, but either way is

okay; i don't mind.and the other cost is voice blasts and text blasts. voice blasts and text blasts typicallycost 2.5 cents per message that goes out, which means that after all is said and done,i.e. outgoing and incoming messages, all your phone stuff is going to cost you between adollar and two dollars per lead that comes into this automarekter, at least that's whati've seen on average. actually i've seen it to be quite a bit less than that but i liketo set expectations properly. also the idea that you need to disclose agencyis absolutely true, so if you're a broker, when you set it up, there's a button in thesetup system that allows you to pick agent or non-agent. if you're an agent, then youjust want to pick the agent and it puts in

verbiage into the website that says, 'i aman agent. i'm not representing you in the transaction or i'm representing myself.' itputs some clarity and disclosure in that process so that you don't get bound up on that orhave any problems with that. alright, i hope all of this helps. good luck!

real estate attorney

real estate attorney

luber: hi everyone, marc luber here. todayon jd careers out there we�re looking at careers in real estate law. and like all ofour videos, we�re helping you find and succeed in fulfilling careers using a law degree,either practicing law or leaving law to pursue alternative careers. you�ll see in our videos that we help youeither get advice on key practical skills you�ll need for success or we go deep intoexploring a career path to help you decide if it fits you. today our guest is laura mcclellan.she�s a real estate attorney and a partner at thompson and knight in dallas, texas, whereshe made the texas super lawyers list by thompson reuters and she was listed as one of the bestlawyers in america by woodword white. laura�s

going to tell us all about being a real estateattorney, so let�s get to it. laura, welcome to jdcot. laura: thanks, it�s great to be here. luber: i�m glad you�re here, thank youfor being here. laura, i�m going to ask you to tell us what it�s like to be a realestate lawyer and then we�re going to dig into what�s a typical day like and who�sthe right fit for this type of a path and how do you break in and then how do you succeed.but before we get to that, i first want to hear from you a description of your practiceand what you do as a real estate lawyer. laura: sure. my practice as a real estatelawyer is focused on commercial real estate.

a lot of people think real estate and theythink buying a home or something like that. very few real estate lawyers, certainly atmy level, are involved in home acquisitions because the dollar amounts don�t make senseto hire a lawyer. for most people, they just work with their title company. so i work withlenders, banks and insurance companies who are lending money to build, say, an officetower or a shopping center. or i might be working with a developer that�s buildingone of those things or acquiring property that they�re going to build something on.or acquiring an already constructed retail center or an office building or an apartmentcomplex, things like that. so it�s big dollar commercial kinds of real estate transactions- and that�s how i spend my time, working

on deals like that. luber: that�s great. so laura, could youtell us what would a typical deal be so we could see what you�re working on, what atypical fact pattern is, almost like the soap opera angle of it? who are the charactersand what�s happening? laura: well there�s not very much that�ssoap operaee [sic] about what i do but a typical deal, say, is going to be, say pick an officetower - and the players are going to be the developer, the owner of the property, they�regoing to be the lender. if it�s an acquisition deal there�s a seller and a buyer - butin any event, they�re the people involved in getting an office building built - if we�retalking about raw land or changing ownership

of it and operating it. i�ve been on all sides of that table, soto speak, so i might be representing the lender that�s going to provide the funds for acquiringor building the office tower. or i might be representing the buyer of the property orthe seller - and those are the players. it doesn�t sound very exciting, they�re notgoing to make any tv shows about what i do - but it really can get pretty interesting.it�s a lot of fun to help put a deal together like that - and any kind of commercial property,but i�m using an office tower as an example. luber: alright, if you�re watching on youtube,please give us the thumbs up if this was helpful to you. and if you want to see the full interviewwith laura, come on over to jdcot dot com,

where you�ll hear from her what it�s liketo be a real estate attorney, lots more on that, what�s a typical day like, who makesthe right fit for this path, how to break in and how to succeed. if you�re alreadyat the site, you can just scroll down to the full video � and make sure you join ourmembership so that you get access to all the helpful video content. thanks again for watchingeverybody. i�m marc luber and i�ll see you soon.

rancho attorney service

rancho attorney service

criminal lawyerrancho cucamonga attorney, los angeles criminal defense lawyer, rancho cucamonga criminaldefense attorney. being arrested can be an embarrassing andhumiliating experience. it can affect every aspect of your life, your bank account, youremployment and even the relationship you have with your family.our firm understands that facing a criminal charge is one of the most serious events ofyour life. we will do everything in our power to help you mitigate the consequences of yourcharge. while our desired goal is always acquittal or jail avoidance, we will never make a promisethat we cannot keep. our lawyers offer honest and practical advice to help you understandyour legal position, and allow you to make

informed decisions about your own future.if you or a loved one has been charged with a misdemeanor or felony crime in california,the law offices of fernando j. bernheim, apcis here to protect your rights and help you attain the best possible result for your case. our attorneys have defended against almostevery type of crime. we have a strong track record of obtaining favorable results duringnegotiations, trial and the appeals process. through skilled legal service and personalizedattention, we are committed to providing a level of representation that rivals any criminaldefense firm in the nation. we are located in los angeles, rancho cucamonga,upland california, riverside and san bernardino.

 
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