SCIENTIFIC AMERICAN:: TOXOPLASMOSIS INFECTION of BRAIN

Toxoplasma’s Dark Side: The Link Between Parasite and Suicide By Christie Wilcox | July 4, 2012 | Comments14 We human beings are very attached to our brains. We’re proud of them – of their size and their complexity. We think our brains set us apart, make us special. We scare our children with tales of monsters that eat them, and obsessively study how they work, even when these efforts are often fruitless. So, of course, we are downright offended that a simple, single-celled organism can manipulate our favorite organ, influencing the way we think and act. Toxoplasma gondii is arguably the most interesting parasite on the planet. In the guts of cats, this single-celled protozoan lives and breeds, producing egg-like cells which pass with the cats bowel movements. These find their way into other animals that come in contact with cat crap. Once in this new host, the parasite changes and migrates, eventually settling as cysts in various tissues including the host’s brain, where the real fun begins. Toxoplasma can only continue its life cycle and end up a happy adult in a cat’s gut if it can find its way into a cat’s gut, and the fastest way to a cat’s gut, of course, is to be eaten by a cat. Incredibly, the parasite has evolved to help ensure that this occurs. For example, Toxoplasma infection alters rat behavior with surgical precision, making them lose their fear of (and even become sexually aroused by!) the smell of cats by hijacking neurochemical pathways in the rat’s brain. Of course, rats aren’t the only animals that Toxoplasma ends up in. Around 1/3 of people on Earth carry these parasites in their heads. Since Toxoplasma has no trouble affecting rats, whose brains are similar in many ways to our own, scientists wonder how much the parasite affects the big, complex brains we love so much. For over a decade, researchers have investigated how this single-celled creature affects the way we think, finding that indeed, Toxoplasma alters our behavior and may even play a role in cultural differences beween nations. The idea that this tiny protozoan parasite can influence our minds is old news. Some of the greatest science writers of our time have waxed poetic about how it sneaks its way into our brains and affects our personalities. Overall, though, the side effects of infection are thought to be minor and relatively harmless. Recently, however, evidence has been mounting that suggests the psychological consequences of infection are much darker than we once thought. In 2003, E. Fuller Torrey of the Stanley Medical Research Institute in Bethesda, Maryland his colleagues noted a link between Toxoplasma and schizophrenia – specifically, that women with high levels of the parasite were more likely to give birth to schizophrenics-to-be. The hypothesis given for this phenomenon is that while for most people who are infected, Toxoplasma has minor effects, for some, the changes are much more pronounced. The idea has gained traction – a later paper found, for example, that anti-psychotics worked just as well as parasite-killing drugs in restoring normal behaviors in infected rats, affirming the similarities between psychological disorders and Toxoplasma infection. Continuing to work with mental patients, scientists later discovered a link between suicide and parasite infection. But, of course, this link was in people who already have mental illness. Similarly, a study found that countries with high Toxoplasma infection rates also had high suicide rates - but the connection between the two was weak, and there was no direct evidence that the women who committed suicide were infected. What scientists really wanted to understand is whether Toxoplasma affects people with no prior disposition to psychological problems. They were in luck: in Denmark, serum antibody levels for Toxoplasma gondii were taken from the children of over 45,000 women as a part of a neonatal screening study to better understand how the parasite is transmitted from mother to child. Since children do not form their own antibodies until three months after birth, the antibody levels reflect the mother’s immune response. Thus the scientists were both able to passively screen women not only for infection status, but degree of infection, as high levels of antibodies are indicative of worse infections. They were then able to use the Danish Cause of Death Register, the Danish National Hospital Register and the Danish Psychiatric Central Research Register to investigate the correlation between infection and self-directed violence, including suicide. The results were clear. Women with Toxoplasma infections were 54% more likely to attempt suicide – and twice as likely to succeed. In particular, these women were more likely to attempt violent suicides (using a knife or gun, for example, instead of overdosing on pills). But even more disturbing: suicide attempt risk was positively correlated with the level of infection. Those with the highest levels of antibodies were 91% more likely to attempt suicide than uninfected women. The connection between parasite and suicide held even for women who had no history of mental illness: among them, infected women were 56% more likely to commit self-directed violence. While these results might seem frightening, they make sense when you think about how Toxoplasma is known to affect our personalities. In 2006, researchers linked Toxoplasma infection to neuroticism in both men and women. Neuroticism – as defined by psychology – is the “an enduring tendency to experience negative emotional states,” including depression, guilt and insecurity. The link between neuroticism and suicide is well established, thus if the parasite does make people more neurotic, it’s not surprising that it influences rates of self-violence. How does a parasite affect how we think? The authors suggest that our immune system may actually be to blame. When we are infected with a parasite like Toxoplasma gondii, our immune system goes on the offensive, producing a group of molecules called cytokines that activate various immune cell types. The trouble is, recent research has connected high levels of cytokines to depression and violent suicide attempts. The exact mechanism by which cytokines cause depression and other mental illnesses is poorly understood, but we do know they are able to pass the blood-brain barrier and alter neurotransmitters like serotonin and dopamine in the brain. But the authors caution that even with the evidence, correlation is not causation. “Is the suicide attempt a direct effect of the parasite on the function of the brain or an exaggerated immune response induced by the parasite affecting the brain? We do not know,” said Teodor T. Postolache, the senior author and an associate professor of psychiatry and director of the Mood and Anxiety Program at the University of Maryland School of Medicine, in a press release. “We can’t say with certainty that T. gondii caused the women to try to kill themselves.” “In fact, we have not excluded reverse causality as there might be risk factors for suicidal behavior that also make people more susceptible to infection with T. gondii,” Postolache explained. But given the strong link between the two, there is real potential for therapeutic intervention. “If we can identify a causal relationship, we may be able to predict those at increased risk for attempting suicide and find ways to intervene and offer treatment.” The next step will be for scientists to affirm if and how these parasites cause negative thoughts. Not only could such research help target at-risk individuals, it may help scientists understand the dark neurological pathways that lead to depression and suicide that the sinister protozoan has tapped into. But even more disconcerting is that scientists predict that Toxoplasma prevalence is on the rise, both due to how we live and climate change. The increase and spread of this parasitic puppeteer cannot be good for the mental health of generations to come. Citation: Pedersen, M.G., Mortensen, P.B., Norgaard-Pedersen, B. & Postolache, T.T. Toxoplasma gondii Infection and Self-directed Violence in Mothers, Archives of General Psychiatry, DOI: 10.1001/archgenpsychiatry.2012.668

UK JRSM: MEDICINE & MAGICIANS

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2587378/ Journal List J R Soc Med v.101(9); Sep 1, 2008 PMC2587378 Medicine as performance: what can magicians teach doctors? Daniel K Sokol, Lecturer in Medical Ethics and Law St George's, University of London, Cranmer Terrace, London SW17 0RE, UK, Email: daniel.sokol@talk21.com Author information ▼ Copyright and License information ► This article has been cited by other articles in PMC. ‘Mystery, magic and medicine: in the beginning they were one and the same’. So starts Howard Haggard's little book on the rise of scientific medicine.1 In centuries past, a medicine man in some aboriginal tribe might have extracted an unwelcome stone or bone from a patient after showing his hands empty, much as a modern day magician would pluck a sponge ball from a child's ear.2 Today, doctors and magicians have largely parted ways, operating in different environments and sharing only the ambition to leave the ‘client’ better off than when the two parties met. The doctor strives to improve health or prevent further deterioration, the magician to raise the spectator's spirits or instil a pleasurable sense of wonder. In this article, I ask if contemporary magicians still have something to teach doctors. In particular, I identify several key components of the art of magic and suggest that looking at doctoring through the lens of the magician may provide insights for the practising clinician. Go to: Psychology and suggestion Doctors are rarely indifferent when obtaining consent from a patient. They want the patient to undergo the medically indicated treatment or procedure. Thus a surgeon might tell a colleague “I must get in early tomorrow, as I need to consent Mrs Smith”. A failure to obtain consent would raise eyebrows in the surgical team. However intent on neutrality of presentation, doctors may reflect this preference in their disclosure to patients. Magicians have myriad techniques to psychologically manipulate the spectator and doctors doubtless use some of the same techniques, whether consciously or not. Unlike magicians, however, doctors have the added luxury of operating in an atmosphere relatively free from suspicion. Magicians will use their eyes, body language, movements, voice and other subtleties to direct a spectator's attention away from a particular area. For example, a spectator will tend to look where the magician looks, to follow moving objects, to tense up when the magician appears tense and relax when the magician appears relaxed, and to look at the magician when addressed directly by name.3 These psychological observations are often used to mislead the spectator while creating the desired illusion of fairness. In medicine, a doctor who wishes to influence a patient's decision can use similar techniques to indicate approval or disapproval. Of course, verbal manipulations can influence a patient, such as talking of a growth or neoplasm instead of cancer, but irrespective of the verbal content, techniques such as looking at one's watch, crossing one's arms, adopting an authoritarian or pleasant tone of voice, nodding, smiling or frowning, can be used to create an impression in the patient's mind. When disclosing the benefits of a proposed procedure, a doctor can emphatically and slowly enunciate his or her words, maintain eye contact and a serious air, and nod at regular intervals. These actions frame the information as crucial and the nodding may suggest approval. When disclosing the burdens and risks, the doctor can relax, drop his or her shoulders, accelerate the tempo of delivery, adopt a monotonous tone of voice, glance at surrounding objects or events, even subtly check his watch (while making sure the patient spots this). The implicit message is that the important part of the disclosure – that concerning the benefits of the procedure – has passed and that the present information is of secondary importance. Aware that a precise exposition can make a performance more convincing and dramatic, Darwin Ortiz, an eminent card magician and theoretician of magic, advises magicians to ‘always say the same thing at the same point in each trick you do’.4 It is not just what is said that is important, but when and how. Ortiz calls the change from tension to relaxation intensity misdirection. Spectators and patients cannot sustain attention for prolonged periods and will take cues to decide when to pay attention and when to relax. In magic, the period of reduced attention is ideal for making a delicate sleight or other secret move. This is the primary function of humour in magic. In a medical consultation, which is usually an intense encounter, using intensity misdirection could be ideal to deliver information that must legally and ethically be imparted but that goes against the personal aim of the clinician (e.g. obtaining the patient's permission). The context of the doctor-patient relationship, in which one party enjoys more power than the other, gives additional meaning to these physical behaviours. Howard Brody identifies three kinds of power held by doctors: Aesculapian power, acquired through a knowledge of medicine; social power, arising from the doctor's social status; and charismatic power, derived from personal qualities such as courage, firmness and kindness.5 A charismatic personality, coupled with a white coat, stethoscope or other symbol of authority, will combine the various types of power and facilitate the control of the patient's thoughts and attention. I do not, of course, advocate that doctors use these techniques of suggestion and misdirection. As doctors may employ these strategies subconsciously, however, it may be useful for them to be aware of their existence and influence. Used effectively, they give the illusion of respecting patient autonomy while actually representing a paternalistic approach. The above techniques reveal that a transcript of the doctor-patient conversation alone would be insufficient to determine the quality of the consent process. In magical terminology, ‘magician's choice’ refers to an apparently fair, though forced, choice. There is also a medical equivalent, ‘doctor's choice’, in which the patient is unaware that he is imperceptibly guided towards one option. Go to: Clarity For magicians, clear presentation and communication are as important as technique and sleight-of-hand. The desired illusion of impossibility is harder to achieve if the spectator is confused. Robert Houdin, a famous 19th century magician, noted that before you change an apple into an orange, the audience must clearly see that you are holding an apple. A glimpse of colour and a spherical shape are not enough. In magic, clear presentation is important for several reasons. First, it leads to a stronger effect and a more magical experience. A convoluted story or too many props detract from the effect. Second, an engrossing presentation helps to prevent spectators staring at the magician's hands and hence reduces their chances of detecting secret moves. Finally, magicians want the magical memory to persist long after the trick is over and a crystal clear effect is more likely to do so than a confused one. In medicine, clarity is also central to obtaining informed consent. Confusion undermines the validity of consent. As in a magic performance, the goal of making the information ‘stick’ in the patient's mind, rather than vanish soon after it is given, should also be pursued. Good magicians will spend as much time practising the presentation of a trick as they will the technical aspects, and given the higher stakes and the frequent misunderstandings between doctors and patients, clarity of presentation about a patient's condition or proposed treatment should be as important as the content.6 As Ortiz observes, ‘there can be a considerable gulf between what the performer feels he is presenting and what the audience perceives is happening’.4 He draws a distinction between ‘inner reality’ (what you, the performer, sees) and ‘outer reality’ (what the audience sees).7 For doctors obtaining consent for a highly familiar procedure, there is a risk of delivering a memorized ‘consent speech’, whilst forgetting that, for the patient, the procedure may be completely alien. In medical ethics lectures, we teach students about the conditions for informed consent – information, voluntariness and competence – but we seldom teach them how to present information to secure informed consent, or indeed where and when to obtain consent. To use Robert Audi's terminology, even if we fulfil a duty of matter, such as the duty to obtain consent or tell the truth, we may still have duties of manner which dictate how we should properly discharge our duty of matter.8 Audi writes: One reason we have duties of manner is that the way we do things is often morally important and broadly under voluntary control. We are properly judged morally […] by how we do what we do, as well as by what acts we perform.8 [author's emphasis] In other words, in teaching about consent and several other areas of medical ethics, we tend to focus on substance and far less on process. Communication skills sessions are designed to cover this area, but I suspect that the real learning occurs ‘on the job’ when doctors find out what works and what does not. This is yet another reason for having ethics teachers who are aware of the realities of clinical practice. Academic medical ethicists, unfamiliar with life on the wards or in the surgery, are generally of little help in dealing with duties of manner. They will struggle to go beyond the assertion that such-and-such action should be performed respectfully. Go to: Likeability Authority, or perceived competence, makes it easier for magicians and doctors to exercise control. Another useful trait for both professions is likeability. For magicians, likeability makes deception easier by enhancing trust and reducing suspicion. If spectators like you as a person, they do not want to see you fail and are more apt to enjoy your performance. It turns confrontation into cooperation. All magicians will have seen skilled performers get lukewarm reactions. For some reason, the spectators do not warm to them. Likeability thus fulfils two main roles for the magician: it makes the deceptive manoeuvres less detectable and adds to the spectator's enjoyment. For the doctor, likeability has similar advantages. It puts patients at ease, enhances or maintains trust, and is likely to lead to more open discussions and increased rates of compliance. A systematic review of the literature on patients' priorities for general practice revealed that the most important factor was ‘humaneness’.9 This ranked higher than competence and patient involvement. A recent study by psychiatrist Robert Klitzman showed that doctors who become patients prioritize bedside manner over technical skill in choosing their own doctor.10 Humaneness, or goodness of character, goes hand in hand with perceived likeability, and so may bedside manner. It is surprising, then, that likeability has received such scant attention in the medical literature. Published work has focused mainly on the impact of patients' perceived likeability on doctors' professional behaviours.11 It would be fascinating to examine what qualities are necessary to engender likeability and to determine how this likeability affects the behaviours of patients. Some doctors will be naturally likeable. For others, likeability will not come so easily. Doctoring, like doing magic, is a performance, requiring the adoption of characteristics that we may discard once we leave the situation. Table-hopping magicians may perform the same effect hundreds of times in one evening, maintaining their enthusiasm at each performance and delivering their well-rehearsed lines as if uttered for the first time. Similarly, doctors may explain familiar procedures over and over again or disguise their true beliefs and emotions at the end of a long day or faced with a disliked patient. In both cases, this acting is part of professionalism. Good doctors, like good magicians, will give the impression of performing just for the individual in front of them. The ‘client’ must not be aware that you have performed virtually the same routine for dozens of people before him. Since one goal of a doctor's performance is to leave patients satisfied with the consultation, likeability is a desirable trait. But what is likeability? Or, rather, what characteristics, attitudes and behaviours lead to likeability? A literature on the importance of likeability exists in the domains of personal life, business interactions and advertising. Tim Sanders, who wrote a book on what he calls the Likeability Factor, defines likeability as the ‘ability to create positive attitudes in other people through the delivery of emotional and physical benefits’.12 Sanders correlates likeability with success and happiness – the more likeable people are, the more likely they are to obtain desired jobs, acquire friends, have happy relationships, and so on. He identifies four elements of likeability: friendliness (expressing an appreciation of the other person through body language such as a smile or kind look or by verbal means), relevance (establishing a connection with the other's needs and desires), empathy (identifying with the other's situation and being sensitive to their feelings) and realness (appearing authentic and genuine to the other, being humble and honest). Hence a key question, relevant in both the fields of magic and medicine, is ‘can likeability be taught?’ Go to: Conclusion Aside from close historical links, there is much that still unites doctors and magicians. Both groups deal with people, often in an intimate and intense context, and strive to effect a positive change in their audience. Both possess skills that their patients or audience do not have. They rely heavily on trust, fairness and clear communication for their success. Magicians, however, operate in an atmosphere of initial distrust and hence have developed expertise at creating trust in difficult conditions. They have learnt, through centuries of experiment and reflection, to influence people in subtle ways. I have tried to show that these lessons can be helpful to doctors, if only to make explicit certain techniques that may be used subconsciously. Aware of them, doctors can choose to use or avoid them as they see fit, although I suggest they adopt a less permissive stance towards deception than their magician counterparts. Go to: Footnotes DECLARATIONS — Competing interests DKS is a Lecturer in Medical Ethics and Law and a close-up magician Funding Not applicable Ethical approval Not applicable Guarantor DKS Go to: Acknowledgements Thanks to Ronald P Sokol, Helen Morant, and Thomas Palser for their comments on an earlier draft Go to: References 1. Haggard H. Mystery, magic, and medicine. New York: Doubleday, Doran & Company, Inc.; 1933. 2. Claflin E. Street magic. New York: 1977. 3. Lamont P, Wiseman R. Magic in theory; an introduction to the theoretical and psychological elements of conjuring. Bristol: University of Hertfordshire Press; 1999. 4. Ortiz D. Strong magic; creative showmanship for the close-up magician. 1994. 5. Brody H. The healer's power. New Haven: Yale University press; 1992. 6. Lloyd A, Hayes P, Bell P, Ross Naylor A. The role of risk and benefit perception in informed consent for surgery. Medical decision making. 2001;21:141–149. [PubMed] 7. Ortiz D. Designing miracles. El Dorado Hills, California: A-1 MagicalMedia; 2006. 8. Audi R. The good and the right. Princeton: Princeton University Press; 2004. 9. Wensing M, Jung HP, Mainz J, Olesen F, Grol R. A systematic review of the literature on patient priorities for general practice care. Part 1: Description of the research domain. Soc Sci Med. 1998;47:1573–1588. [PubMed] 10. Klitzman R. When doctors become patients. New York: Oxford University Press; 2007. 11. Gerbert B. Perceived likeability and competence of simulated patients: influence on physicians' management plans. Soc Sci Med. 1984;18:1053–1059. [PubMed] 12. Sanders T. The likeability factor. Crown Publishers; 2005. Articles from Journal of the Royal Society of Medicine are provided here courtesy of Royal Society of Medicine Press Formats: Article | PubReader | ePub (beta) | PDF (166K) Related citations in PubMed Doctors and magicians: what we can learn from wizards.[J Med Pract Manage. 2012] Communication with the patient in clinical research.[Ann N Y Acad Sci. 1997] Understanding how physicians think: medical decision making and informed consent.[Pharos Alpha Omega Alpha Honor Med Soc. 198...] Enhancing physician-patient communication.[Hematology Am Soc Hematol Educ Program. 200...] Are physicians aware of what patients know about what physicians know?[Ann Oncol. 1999]

UK DAILY MAIL: ER DISASTER

Overworked doctors 'forced to look after up to 70 elderly patients during single shift and are missing vital signs of illness' Sir Richard Thompson attacked Government plans to cut NHS budget 'NHS is under-doctored, under-nursed and under-funded,' he said Said 'stressed' doctors run around 'like a scalded cat' on their 7hr shifts Many tend to 70 patients a shift - over the maximum of 20, he added Medics only spend five minutes with each patient so they 'miss things' By Mario Ledwith Published: 07:50 GMT, 5 April 2014 | Updated: 15:26 GMT, 5 April 2014 283 View comments Sir Richard Thompson attacked government plans to cut the NHS budget - saying it is already 'under-doctored, under-nursed and under-funded' +2 Sir Richard Thompson attacked government plans to cut the NHS budget - saying it is already 'under-doctored, under-nursed and under-funded' Overworked doctors are looking after up to 70 elderly patients during a single shift making it 'impossible' to provide adequate care, one of the UK’s top doctors has claimed. Sir Richard Thompson, head of the Royal College of Physicians, said that patient safety is being put at risk because doctors are so stressed and over stretched. He complained that some doctors can only spend five minutes investigating each patient’s symptoms - far below the recommended 15 minutes. Launching a strongly worded attack on the Government for cutting the NHS budget, he said that doctors 'miss things' as they are working under constant 'strain and stress'. The 73-year-old, whose college represents the vast majority of the UK’s 30,000 doctors working in hospitals, becomes the latest senior doctor to bemoan cutbacks to the health service. Criticising promises made by the Prime Minister to defend the NHS budget, Sir Richard said: ‘In spite of what weasly words people at the top say, money’s been taken out of the NHS.’ He said that ‘billions’ more needs to be invested in the NHS every year for it to operate effectively, calling for all political parties to devise additional funding strategies. Sir Richard also criticised Jeremy Hunt for 'slagging off the whole of the NHS', claiming the Health Secretary dwells on poor care over the good treatment received by patients. He added: ‘The NHS is under-doctored, under-nursed, under-bedded and under-funded. There are too few doctors to do the increasingly large job to a high standard, and safely, and compassionately.’ Guidelines suggest that doctors should treat a maximum of 20 patients during a single shift to ensure that they receive adequate levels of care. But Sir Richard said some medical professionals are having to attend to 70 people on one shift, including many elderly patients suffering from a range of medical problems - or what medics call 'multiply morbid.' He said this results in doctors running around ‘like a scalded cat’ during a typical seven-hour shift, with safety most concerning at weekends and on night shifts. ‘You try standing on your feet for seven hours trying to be on the ball, thinking of the various complications, being nice to patients, for seven hours. It’s absolutely destructive. Read more: http://www.dailymail.co.uk/news/article-2597558/Overworked-doctors-forced-look-70-elderly-patients-single-shift-missing-vital-signs-illness.html#ixzz2y3Hylyrp Follow us: @MailOnline on Twitter | DailyMail on Facebook

FILATOV- KOPLIK SPOTS

As a result of scientific nihilism against Measles immunisation, (1954 Enders & Peebles),among certain population groups,physicians are again seeing FILATOV-KOPLIK spots. Russian aristocrat Dr NIL FILAKOV (1847-1902)post-grad.studies : Berlin,Paris,Prague and Vienna. American Dr HENRY KOPLIK (1858-1927) NY Mt Sinai Hosp(25y) post-grad studies: Berlin,Prague,Vienna.

Dr.B.DAY MBChB(Manchester) MRCP(London- Int Med.) FRCS(Eng.) FRCS(Can.) PRIVATE CAMBIE SURGICAL CENTRE Vancouver.

Dr. Brian Day 2007-2008 President - Canadian Medical Association Health Care Quotes This page contains a collection of noteable quotes relating to Canadian Health Care. "Personally, I do not see in Canada it would be a feasible thing if any Ministry organized taking over both the Health and the Disease of the entire community... even in the most favourable circumstances... there would be that absence of competition and that sense of independence... I do not believe it would be good for the profession or good for the Public." - Sir William Osler in a speech to the Medical Society of the Canadian Army Medical Corps (1918) Sir William Osler "...our noble tradition that no sick person of any age, sex, race or religion whatsoever, shall ever suffer for need of medical care on account of poverty or any other cause...should be based on our willingness to give, and should be construed as an act of our charity. It should not be exploited: nor should it be assumed as a God-given right by way of its beneficiaries. Least of all should it be a right-of-way for needy and penurious governmental and administrative bodies." - Dr. J.H MacDermot Osler lecture (1939) Dr. J.H MacDermot "There will come a time when the Ministry of Health is the only Ministry we can afford to have and we still won't be able to afford the Ministry of Health" - Dalton McGuinty, Premier of Ontario Dalton McGuinty "The evidence shows that delays in the public health care system are widespread and patients die as a result of waiting lists for public health care" - Supreme Court of Canada, June, 2005 Supreme Court of Canada "The courts have a duty to rise above political debate" - Supreme Court of Canada, June, 2005 Supreme Court of Canada "I think we have to be very careful about empowering the consumer because they will make choices that are not in their own health interest" - Jonathan Lomas, Executive Director, Canadian Health Services Research Foundation (a $100 million plus tax supported non profit agency) Jonathan Lomas "When consumers apply pressure on an industry, whether it's retailing or banking, cars or computers, it invariably produces a surge of innovation that increases productivity, reduces prices, improves quality and expands choices. The essential problem with the health care industry is that it has been shielded from consumer control - by employers, insurers and the government. As a result, costs have exploded as choices have narrowed" - Regina Herzlinger, Harvard Business Review, 2002 Regina Herzlinger "In fact, the Canadian health care system is perhaps the most rigid and oppressive (to physicians) within the free world." - David J. Dandy, Vice President, Royal College of Surgeons of England David J. Dandy "In the wake of the Supreme Court of Canada decision (Chaoulli-Zeliotis), the Canadian Medicare system is about to be redesigned. Physicians must not just sit at the table, but must position themselves at the head, where they can lead and direct the nature of that design." - Dr. Brian Day "When it comes to physicians there is a common thread that is a major barrier to solving our concerns. We are divided. The result is a divide and conquer scenario, in which we negotiate as adversaries, first with government and then with one another about our relative worth, while the "conqueror" observes and continues to rule." - Dr. Brian Day