Medical Malpractice

Elements of the Cause of Action for Abandonment

Each of the following five elements must be present for a patient to have a proper civil cause of action for the tort of abandonment:

1. Health care treatment was unreasonably discontinued.

2. The termination of health care was contrary to the patient's will or without the patient's knowledge.

3. The health care provider failed to arrange for care by another appropriate skilled health care provider.

4. The health care provider should have reasonably foreseen that harm to the patient would arise from the termination of the care (proximate cause).

5. The patient actually suffered harm or loss as a result of the discontinuance of care.

Physicians, nurses, and other health care professionals have an ethical, as well as a legal, duty to avoid abandonment of patients. The health care professional has a duty to give his or her patient all necessary attention as long as the case required it and should not leave the patient in a critical stage without giving reasonable notice or making suitable arrangements for the attendance of another. [2]

Abandonment by the Physician

When a physician undertakes treatment of a patient, treatment must continue until the patient's circumstances no longer warrant the treatment, the physician and the patient mutually consent to end the treatment by that physician, or the patient discharges the physician. Moreover, the physician may unilaterally terminate the relationship and withdraw from treating that patient only if he or she provides the patient proper notice of his or her intent to withdraw and an opportunity to obtain proper substitute care.

In the home health setting, the physician-patient relationship does not terminate merely because a patient's care shifts in its location from the hospital to the home. If the patient continues to need medical services, supervised health care, therapy, or other home health services, the attending physician should ensure that he or she was properly discharged his or her-duties to the patient. Virtually every situation 'in which home care is approved by Medicare, Medicaid, or an insurer will be one in which the patient's 'needs for care have continued. The physician-patient relationship that existed in the hospital will continue unless it has been formally terminated by notice to the patient and a reasonable attempt to refer the patient to another appropriate physician. Otherwise, the physician will retain his or her duty toward the patient when the patient is discharged from the hospital to the home. Failure to follow through on the part of the physician will constitute the tort of abandonment if the patient is injured as a result. This abandonment may expose the physician, the hospital, and the home health agency to liability for the tort of abandonment.

The attending physician in the hospital should ensure that a proper referral is made to a physician who will be responsible for the home health patient's care while it is being delivered by the home health provider, unless the physician intends to continue to supervise that home care personally. Even more important, if the hospital-based physician arranges to have the patient's care assumed by another physician, the patient must fully understand this change, and it should be carefully documented.

As supported by case law, the types of actions that will lead to liability for abandonment of a patient will include:

• premature discharge of the patient by the physician

• failure of the physician to provide proper instructions before discharging the patient

• the statement by the physician to the patient that the physician will no longer treat the patient

• refusal of the physician to respond to calls or to further attend the patient

• the physician's leaving the patient after surgery or failing to follow up on postsurgical care. [3]

Generally, abandonment does not occur if the physician responsible for the patient arranges for a substitute physician to take his or her place. This change may occur because of vacations, relocation of the physician, illness, distance from the patient's home, or retirement of the physician. As long as care by an appropriately trained physician, sufficiently knowledgeable of the patient's special conditions, if any, has been arranged, the courts will usually not find that abandonment has occurred. [4] Even where a patient refuses to pay for the care or is unable to pay for the care, the physician is not at liberty to terminate the relationship unilaterally. The physician must still take steps to have the patient's care assumed by another [5] or to give a sufficiently reasonable period of time to locate another prior to ceasing to provide care.

Although most of the cases discussed concern the physician-patient relationship, as pointed out previously, the same principles apply to all health care providers. Furthermore, because the care rendered by the home health agency is provided pursuant to a physician's plan of care, even if the patient sued the physician for abandonment because of the actions (or inactions of the home health agency's staff), the physician may seek indemnification from the home health provider. [6]

ABANDONMENT BY THE NURSE OR HOME HEALTH AGENCY

Similar principles to those that apply to physicians apply to the home health professional and the home health provider. A home health agency, as the direct provider of care to the homebound patient, may be held to the same legal obligation and duty to deliver care that addresses the patient's needs as is the physician. Furthermore, there may be both a legal and an ethical obligation to continue delivering care, if the patient has no alternatives. An ethical obligation may still exist to the patient even though the home health provider has fulfilled all legal obligations. [7]

When a home health provider furnishes treatment to a patient, the duty to continue providing care to the patient is a duty owed by the agency itself and not by the individual professional who may be the employee or the contractor of the agency. The home health provider does not have a duty to continue providing the same nurse, therapist, or aide to the patient throughout the course of treatment, so long as the provider continues to use appropriate, competent personnel to administer the course of treatment consistently with the plan of care. From the perspective of patient satisfaction and continuity of care, it may be in the best interests of the home health provider to attempt to provide the same individual practitioner to the patient. The development of a personal relationship with the provider's personnel may improve communications and a greater degree of trust and compliance on the part of the patient. It should help to alleviate many of the problems that arise in the health care' setting.

If the patient requests replacement of a particular nurse, therapist, technician, or home health aide, the home health provider still has a duty to provide care to the patient, unless the patient also specifically states he or she no longer desires the provider's service. Home health agency supervisors should always follow up on such patient requests to determine the reasons regarding the dismissal, to detect "problem" employees, and to ensure no incident has taken place that might give rise to liability. The home health agency should continue providing care to the patient until definitively told not to do so by the patient.

COPING WITH THE ABUSIVE PATIENT

Home health provider personnel may occasionally encounter an abusive patient. This abuse mayor may not be a result of the medical condition for which the care is being provided. Personal safety of the individual health care provider should be paramount. Should the patient pose a physical danger to the individual, he or she should leave the premises immediately. The provider should document in the medical record the facts surrounding the inability to complete the treatment for that visit as objectively as possible. Management personnel should inform supervisory personnel at the home health provider and should complete an internal incident report. If it appears that a criminal act has taken place, such as a physical assault, attempted rape, or other such act, this act should be reported immediately to local law enforcement agencies. The home care provider should also immediately notify both the patient and the physician that the provider will terminate its relationship with the patient and that an alternative provider for these services should be obtained.

Other less serious circumstances may, nevertheless, lead the home health provider to determine that it should terminate its relationship with a particular patient. Examples may include particularly abusive patients, patients who solicit -the home health provider professional to break the law (for example, by providing illegal drugs or providing non-covered services and equipment and billing them as something else), or consistently noncompliant patients. Once treatment is undertaken, however, the home health provider is usually obliged to continue providing services until the patient has had a reasonable opportunity to obtain a substitute provider. The same principles apply to failure of a patient to pay for the services or equipment provided.

As health care professionals, HHA personnel should have training on how to handle the difficult patient responsibly. Arguments or emotional comments should be avoided. If it becomes clear that a certain provider and patient are not likely to be compatible, a substitute provider should be tried. Should it appear that the problem lies with the patient and that it is necessary for the HHA to terminate its relationship with the patient, the following seven steps should be taken:

1. The circumstances should be documented in the patient's record.

2. The home health provider should give or send a letter to the patient explaining the circumstances surrounding the termination of care.

3. The letter should be sent by certified mail, return receipt requested, or other measures to document patient receipt of the letter. A copy of the letter should be placed in the patient's record.

4. If possible, the patient should be given a certain period of time to obtain replacement care. Usually 30 days is sufficient.

5. If the patient has a life-threatening condition or a medical condition that might deteriorate in the absence of continuing care, this condition should be clearly stated in the letter. The necessity of the patient's obtaining replacement home health care should be emphasized.

6. The patient should be informed of the location of the nearest hospital emergency department. The patient should be told to either go to the nearest hospital emergency department in case of a medical emergency or to call the local emergency number for ambulance transportation.

7. A copy of the letter should be sent to the patient's attending physician via certified mail, return receipt requested.

These steps should not be undertaken lightly. Before such steps are taken, the patient's case should be thoroughly discussed with the home health provider's risk manager, legal counsel, medical director, and the patient's attending physician.

The inappropriate discharge of a patient from health care coverage by the home health provider, whether because of termination of entitlement, inability to pay, or other reasons, may also lead to liability for the tort of abandonment. [8]

Nurses who passively stand by and observe negligence by a physician or anyone else will personally become accountable to the patient who is injured as a result of that negligence... [H]ealthcare facilities and their nursing staff owe an independent duty to patients beyond the duty owed by physicians. When a physician's order to discharge is inappropriate, the nurses will be help liable for following an order that they knew or should know is below the standard of care. [9]

Similar principles may apply to make the home health provider vicariously liable, as well.

Liability to the patient for the tort of abandonment may also result from the home health care professional's failure to observe, examine, assess, or monitor a patient's condition. [10] Liability for abandonment may arise from failing to take timely action, as well as failing to summon a physician when a physician is needed. [11] Failing to provide adequate staff to meet the patient's needs may also constitute abandonment on the part of the HHA. [12] Ignoring a patient's complaints and failing to follow a physician's orders may likewise constitute a tort of abandonment for a nurse or other professional staff member.

1. Lee v. Dewbre, 362 S.W.2d 900 (Tex. Civ. App. 7th Dist. 1962).

2. Kattsetos v. Nolan, 368 A.2d 172 (Conn. 1976).

3. 61 AM. Jur. 2d, Physicians and Surgeons § 237 (1981).

4. See, e.g., Tripp v. Pate, 271 S.E.2d 407 (N.C. App. 1980).

5. Ricks v. Budge, 64 P.2d 208 (Utah 1937).

6. M.D. Nathanson, Home Healthcare Answer Book: Legal Issues for Providers 212 (1995).

7. See, generally, E.P. Burnzeig, The Nurse's Liability for Malpractice (1981).

8. Sheryl Feutz-Harter, Nursing Caselaw Update: In appropriate Discharging of Patients, 2 J. Nursing L. 49 (1995).

9. Id., 53.

10. See, e.g., Pisel v. Stamford Hosp., 430 A.2d1 (Conn. 1980) (nurses were held liable for failing to monitor the condition of a patient).

11. See, e.g., Sanchez v. Bay General Hosp., 172 Cal. Rptr. 342 (Cal. App. 1981); Valdez v. Lyman-Roberts Hosp., Inc. 638 S.W. 2d 111 (Tex. 1982).

12. Czubinsky v. Doctors Hosp., 188 CAl. Rptr. 685 (1983).

Just like any other medical profession, you have to first complete a 4 year undergraduate course before you are allowed to take the MCAT or the Medical College Admissions Test. The course you decide to take should be in the sciences because as a doctor, you will be dealing with the human body and be familiar with the various chemicals used in the various medicines.

If you do well here, you can enter the medical school of your choice where you have to endure another 4 years to obtain your medical degree.

Since internal medicine is a specialize field, you also have to complete several years of graduate medical education which includes a year of internship and 3 years of residency training.

The only risk when you are starting out in your internal medicine career is to be accused of malpractice which can only happen if you become negligent. So take every hour you spend working as an intern to learn everything there is to know about internal medicine.

By keeping notes, you will easily find the solution when you are once again faced with the same problem.
If you are able to do that, the last thing you have to do is pass the state licensing exam which enables you to do your practice.

Doctors can earn more than $300,000 a year and in order for you to be on top of your game, you need to keep yourself updated with any new developments and the best way to do that will be to attend seminars and other courses whenever these are offered.

After years of working for a hospital, you can choose to continue working for them or start your own practice. If you decide to stay, you can specialize by first going back to school and then becoming a cardiologist, endocrinologist, gastroenterologist, immunologist, nephrologists, oncologist or rheumatologist.

While you can also do that after going back to school, it won't be a bad to also do this early so you can have your own clinic, do your own hours and get most of the profit. If capital is a problem, try opening a clinic with other doctors in the same or different specialty.

Data from the AMA or American Medical Association reveals that there is shortage of doctors in internal medicine as many have either retired or moved on to other more prestigious specialties. This means that there are job vacancies in the different healthcare facilities all across the country and all you have to do is make the grade and apply for it.

So now you have an idea of how to start an internal medicine career, ask yourself if this is what you really want to do with your life and then do what you need to achieve it.

There is growing concern about the link between cosmetic sun bed use and the rising incidence of skin cancer in Scotland. This issue was highlighted at the Scotland Against Cancer conference last year at which a case was made for thorough regulation of sun bed operators. It was felt that tighter controls could have a positive impact on skin cancer prevention efforts.

Individuals and organisations with an interest in skin cancer prevention have continued to express concern about rising sun bed use and the effect this may have on levels of skin cancer which is the fastest rising cancer in Scotland, and a particular problem in the West of Scotland. The risk of skin cancer is related to lifetime exposure to ultraviolet light and intense exposure to such light is the most dangerous to the skin. For example, too much time spent in the sun on holidays abroad or excessive time spent in the sun on the occasional hot day in Scotland, constitutes this type of exposure.

Sun bed use also provides a form of intense exposure to ultraviolet light. Just one session a month will double the average individual's annual dose of ultraviolet radiation. Sun bed use is on the rise in Scotland and there is now a significant body of evidence to suggest that the sunbed industry suffers from a lack of regulation. Cases of malpractice by operators have been documented in a survey by the Royal Environmental Health Institute of Scotland (REHIS). In particular there is evidence that children, who are especially sensitive to ultraviolet light, are now regularly using sunbeds. Just one day of burning as a child increases the risk of getting skin cancer as an adult.

Tanning in General

Tanning is your body's natural protection against sunburn; it's what your body is designed to do. Developing a tan is your body's natural way of protecting against the dangers of sunburn and further exposure.

Whether you tan outdoors under the sun or indoors in a tanning facility, the tanning process is the same. This natural process takes place when your skin is exposed to ultraviolet light. Light is composed of energy waves that travel from the sun to the Earth. Each energy wave can be identified by its length in nanometres, (nm), which is one-billionth of a meter. Light can be broken into three general categories: infrared, visible and invisible. Ultraviolet light is in the invisible light spectrum. There are three kinds of ultraviolet light: UVA, UVB and UVC. Tanning itself takes place in the skin's outermost layer, the epidermis. There are three major types of skin cells in your epidermis: basal cells, keratinocytes and melanocytes. All play different roles in the tanning process. Everyone has roughly the same number of melanocytes in their bodies--about 5 million. Your heredity determines how much pigment your melanocytes can produce. Melanocytes release extra melanosomes whenever ultraviolet light waves touch them. This produces a tan in your skin.

Skin Types

I. - Always burns; never tans, pale white skin; "Celtic"

II. - Burns easily; tans minimally; White skin

III. - Burns moderately; tans gradually to light brown average; Caucasian skin

IV. - Burns minimally, always tans well to moderately brown; Olive skin

V. - Rarely burns; tans profusely to dark; Brown skin

VI. - Never burns; deeply pigmented; Black skin

Effects of UV

There is a body of scientific research demonstrating that the production of the activated form of vitamin D is one of the most effective ways the body controls abnormal cell growth. Moderate exposure to sunlight is only way for the body to manufacture the vitamin D necessary for producing activated vitamin D.A 1997 report by the National Academy of Sciences Institute of Medicine recommends 200 IU/day of vitamin D for women aged 50 years or younger, 400 IU/day for those aged 51-70 and 600 IU/day for those older than 70. Moderate exposure to sunlight helps the body manufacture vitamin D and eating salmon or mackerel and drinking fortified milk or juices is a step in the right direction. The amount of vitamin D formed in a given period of exposure depends on the colour of your skin--that is, how rich your skin is in melanin. Melanin absorbs UV radiation. Therefore it diminishes the production of vitamin D. The darker a person's skin, the longer he or she has to be in the sun or exposed to UVB radiation to form a significant amount of vitamin D.
Like melanin, sunscreen also absorbs UV radiation and therefore greatly diminishes the skin's vitamin D production. For example, sunscreen with a PDF of 8 diminishes a person's ability to produce vitamin D by 95%. In addition, winter sunlight in the northern latitudes does not have enough UVB radiation to produce vitamin D in the skin leading to diminished vitamin D levels in winter.
Moderate exposure is the most responsible way to maximize the potential benefits of sun or UV exposure while minimizing the potential risks associated with either too much or too little sunlight. Avoiding sunburns is critical to moderation. Experiencing painful sunburns before the age of 20--not lifetime exposure to the sun--is the factor associated with an increased risk of malignant melanoma, the most serious type of skin cancer.

History and Facts of Indoor Tanning

Europeans started tanning indoors with sunlamps that emitted ultraviolet (UV) light as a therapeutic exercise to harness the positive psychological and physiological effects of exposure to UV light. This practice became widespread in Europe, particularly in the sun-deprived northern countries by the 1970s--several years before the first indoor tanning facility was established in the UK. Although indoor tanning is considered a cosmetic exercise the roots are therapeutic and many people do in fact visit tanning facilities for that purpose.

The indoor tanning industry has grown substantially in 25 years. Today it is a strong part of the small business community. And each year about 10 percent of the public visits an indoor tanning facility. This business is estimated to be worth £3 billion worldwide.

The indoor tanning industry's position is summed up in this declaration:

"Moderate tanning, for individuals who can develop a tan, is the smartest way to maximize the potential benefits of sun exposure while minimizing the potential risks associated with either too much or too little sunlight."

The indoor tanning salon industry claims to be part of the solution in the ongoing battle against sunburn by teaching people how to identify a proper and practical life-long skin care regimen. No legislation covers indoor tanning just the following government guidance:

"Like the sun, sun-beds give out UV rays that can increase the risk of skin cancer. The more you use sunbeds, the greater the risk is likely to be and when the tan fades, the skin damage remains. If you're under 16 you should never use a sunbed, as young skin is more delicate and prone to damage than older skin. Even if you are over 16 you should be very careful if you choose to use one. You should also really avoid sunbeds altogether if you:

a. - have fair or freckly skin

b. - burn easily

c. - have a lot of moles

d. - have a family history of skin cancer

e. - use medication that increases your sensitivity to UV.

If you do decide to use one, limit yourself to two sessions a week, over a period of 30 weeks, every year. But remember that if you don't tan in the sun, you won't tan any more easily on a sunbeds."

Skin Cancer

Skin cancer has a 20- to 30-year latency period. The rates of skin cancer we are seeing today are most likely the result of bad habits from the 1960s, 1970s and 1980s that were based on ignorance and misinformation about sun tanning. In those days, many people still considered sunburns an inconvenient right of spring, a precursor to developing a summer tan. People believed that sunburns would "fade" into tans, and so tanners hit the beaches with baby oil and reflectors. Severe burns were commonplace. Today we know how reckless and uninformed that approach was. What's more, the photobiology research community has determined that most skin cancers are related to a strong pattern of intermittent exposure to ultraviolet light in people who are genetically predisposed to skin cancer. These skin cancers are not simply the result of cumulative exposure. Once again, this suggests that heredity and a pattern of repeated sun burning are the primary factors associated with skin cancer.

Melanoma is a cancer of the pigment-producing cells (melanocytes). An increased risk of melanoma has been associated with people who have moles or repeated sunburn experiences as a child or young adult. Most melanomas occur on non-sun-exposed parts of the body. For example, melanoma is infrequently found on the face. Although melanoma accounts for only 5% of all newly diagnosed skin cancer cases each year, it is responsible for the majority of skin cancer deaths. Melanoma is the only form of skin cancer that is aggressive with any regularity.

Heredity, fair skin, an abnormally high number of moles on one's body (above 40) and a history of repeated childhood sunburns have all been implicated as potential risk factors for this disease. As a nation high in Celtic heredity Scotland needs to consider these facts.

Scotland's Skin Cancer Epidemic

Scotland may be experiencing a skin cancer epidemic with the incidence of skin cancer tripling in the last thirty years. There were over 7,000 cases of skin cancer diagnosed in 2001, up from 2,200 in 1975 and higher rates of melanoma incidence have been reported in Scotland than in the rest of the UK.

In the age group 20-39 years, malignant melanoma is the second most common cancer in the UK. This is an unusually young age distribution for an adult cancer and emphasises the importance of its prevention and early treatment to avert the potential loss of many years of life.
On average, about 20 years of life are lost for each melanoma death in the UK.

The NHS and a number of cancer charities have most clearly linked the steep rise in incidence to changing cultural perceptions of a tan as desirable and the steep rise in the number of people taking holidays in the sun.

Tanning grew significantly in popularity through the 1960s, 1970s and 1980s and as skin cancer may take 20 or more years to develop; the high rates of skin cancer can be expected to continue for many years to come.

Mortality from skin cancer, particularly melanoma, it's most aggressive form, has not fallen despite major public health initiatives to raise awareness of sun protection and skin cancer. Attempts are being made by health promotion agencies to tackle this growing problem through encouraging people to change their behaviour on holiday and convincing Scots to take care on sunny days at home.

Another source of ultraviolet light is that derived from sunbed use and medical evidence on the risk of sunbeds to health is increasing. Sunbeds have been linked to a variety of negative health effects, including eye damage, photodermatosis, photosensitivity, premature skin ageing and skin cancer.

Ultraviolet rays from sunbeds have been classified as Group 2A carcinogens by the International Association for Research into Cancer (IARC) that is, "probably causing cancer in humans." Recent analyses from studies in different countries over the last ten years have shown that the use of sunbeds increased the risk of cancer and the risk appears to be higher if use begins early in life.
Furthermore, in the UK a significant study from the British Medical Association found that sunbed users were 2.5 times more likely to develop skin cancer. The risks appear to be higher in the young.

A model has been developed to estimate human ultraviolet exposure to both sunlight and sunbeds, and this information was used to predict the contribution of sunbeds to melanoma mortality in the UK. The results of this study indicate that sunbeds cause 100 deaths from melanomas each year in the UK

The World Health Organisation (WHO) recommended in 2005 that no one under 18 should use a sunbed and that there is a need for guidelines or legislation to reduce the risks associated with sunbed use. WHO argues that growth in the use of sunbeds, combined with the desire and fashion to have a tan, are considered to be the prime reasons behind the fast growth in skin cancers in developed countries. The highest rates are found predominantly in those countries where people are fairest-skinned and where the sun tanning culture is strongest: Australia, New Zealand, North America and northern Europe. The people of Scotland are particularly fair-skinned and therefore at relatively high risk of developing skin cancer.

Risk Associated with Sunbeds Use

Despite common claims, radiation from sunbeds is no safer than exposure to the sun itself. The emission from many sunbeds is greater than that from the midday sun in the Mediterranean. The UVA portion of the emission spectrum can be 10-15 times higher than that of the midday sun.
A 1986 survey found that people believed that sunbeds cause less damage to skin than outdoor tanning. This is partly because of the marketing of sunbeds as a way of getting a 'safer', 'controlled' tan. Positive health claims are still being used to market cosmetic sunbeds.

In 2005 the action of ultraviolet light on skin to synthesise Vitamin D in the body was used in an advertisement funded by The Sunbed Association to promote the use of sunbeds as healthy. When a consumer complained about the inference, the Advertising Standards Authority upheld the complaint, in recognition of the fact that health professionals do not recommend sunbeds as the main source of Vitamin D, because of the risk associated with skin damage and cancer.
This was also the conclusion of the recent American Academy of Dermatology conference in May 2005. This conference reviewed evidence and recommended that Vitamin D supplements are a safer, cheaper and better alternative to raise Vitamin D levels than ultraviolet light, especially for the frail elderly and possibly for dark-skinned people with low sun exposure. Because of the documented causal relationship between skin cancer and sunbeds, many international and UK health organizations have publicly recommended that sunbeds should not be used, or their use should be limited and regulated to protect public health.

Lack of Regulation

There exists no relevant legislation other than the general Health and Safety guidance, mentioned earlier, to control the use of sunbeds.

The HSE has issued guidelines and cosmetic sunbed premises and machines are subject to the requirements of health and safety legislation in Scotland. Control of exposure is governed by the general provisions of the Health and Safety at Work Act 1974 and the Management of Health and Safety at Work Regulation 1999.

To comply with this legislation, duty holders are required to assess the health and safety risks caused by their work activities which will include the risks to employees and customers from exposure to ultraviolet radiation and put in place measures to control these risks as far as is reasonably practicable.

Specific guidance has been issued by the HSE on Controlling the Risks from the Use of Ultraviolet Tanning Equipment and can be found at:

http://www.hse.gov.uk/pubns/indg209.pdf

Some businesses operate under a voluntary code of conduct agreed by the Sunbed Association. The Sunbed Association claims 20-25% of cosmetic sunbed premises are in membership. Consequently, with those numbers, voluntary arrangements can only have limited effect.

Although the Sunbed Association provides training schedules, there appears to be no requirement for training associated with the use of non-therapeutic UV radiation. The responsibility is on the provider to supply appropriate information that will allow potential clients to make an informed decision about whether or not sunbeds are suitable for their use. International legislation is diverse but it is significant that the need for regulation is recognized in France, Belgium, Sweden, Canada and the USA. European standards exist to regulate ultraviolet lamp emission strength and sunbed products.

The Case for Sunbed Salon Licensing

It is only within the last decade that public health authorities in Scotland have begun to highlight the health risks associated with sunbed use and in particular, the increased risk of developing skin cancer. In the past, many local authorities provided tanning facilities within their own leisure centres. The association of sunbeds with leisure facilities reinforced the perception that a tan is a sign of good health. Fortunately, over the last decade most sunbeds have been removed from local authority premises. In the main, this has been done because local authorities perceive this to be an action they can take to discourage the use of sunbeds for cosmetic tanning purposes, and to highlight the dangers associated with use.

In addition, the problem of skin cancer has often been viewed as a local community issue, with the subsequent onus on local authorities to take action. However, while the provision of sunbeds in local authority facilities has decreased, the number of commercial sunbed premises has increased.
Furthermore, there are growing concerns that some cosmetic sunbed premises are poorly run and offer little advice on the health risks associated with sunbed use.

A 2003 REHIS survey of 794 cosmetic sunbed premises in all 32 Scottish local authority areas identified a number of un-staffed and unsupervised premises and salons that were failing to check the age of customers or enquire about skin type or medical conditions which may deem sunbed use particularly ill advisable. In addition, the survey highlighted a number of salons that were failing to offer customers adequate eye protection.

Surveys in the UK and North America show that tanning salon operators typically show ignorance of sunbed risks and fail to enforce rules for using sunbeds.

The University of Dundee and Perth and Kinross Council in a joint study of privately operated premises in Tayside revealed the following major incidences of poor practice:

o 89% exercised no administrative control on the number of sessions/customer

o 81% failed to give adequate advice to customers

o 59% maintained no customer records

o 33% displayed no guidance to users

The recent change by many commercial operators to adopt more powerful UV lamps using shorter wavelengths has led to even greater concern amongst health professionals. An assessment by the Photobiology Unit at the University of Dundee Ninewells Hospital concluded that "all tanning units are potentially harmful and that the newer stand-up type has a much greater risk than has been generally appreciated.

Scottish Executive Proposal

Compel local authorities to issue licences regulating cosmetic sunbeds premises. Require providers of cosmetic tanning facilities, or equipment, to obtain a licence to operate from the local authority. The licensing conditions would be set so that local authorities could:

o Prevent the use of sunbeds by children

o Protect adults from over-exposure

o Ensure that sunbed users are supervised

o End the use of coin-operated machines

o Ensure that sunbed sessions are monitored and limited

o Provide health risk information in sunbed parlours

o Inspect premises

The proposal seeks to achieve a number of objectives. By providing health risk information it aims to ensure adults are equipped to make informed choices about the risks of sunbed use. The conditions of licensing would require staff to be on premises, which would help to prevent overexposure to ultraviolet light, especially by those who are more sensitive such as users with fair skins. Reduce the number of burns and accidents currently attributed to the misuse of unsupervised equipment and would drive up standards amongst operators. Premises not holding a licence would not be permitted to trade.

The lack of sunbed regulation in commercial premises and the damaging impact this can have, is best illustrated by example.

In the summer of 2004, two young boys aged 11 and 13 years old used unsupervised sunbeds in Stirling and were so badly burnt, they had to be admitted to hospital. Stirling Council environmental health officers were alerted to investigate the incident but because there was no legislation covering the regulation of sunbeds, action could not be taken against the salon for being un-staffed or for allowing young people under the age of 16 years to use a sunbed.

Impact of Licensing Scheme

It is anticipated that those businesses which could not meet a licensing requirement would be required to either invest in their businesses or be forced to cease trading. This would also eliminate the existence of coin-operated sunbed machines as well as the presence of un-staffed locations.
The cost of a licensing scheme must be balanced against the cost of reducing the harm caused by sunbeds. Although there would also be an administrative charge to operators of premises, in the long run the regulations would reduce the number of Scots - presently around 7,000 per year - who are being treated for skin cancer by the National Health Service.

Conclusion

Scotland needs to take action to tackle skin cancer and the public health message that sunbeds are potentially dangerous needs to be heard loud and clear. A system of licensing for sunbed salons could do for skin cancer what the health warning on packs of cigarettes has done for lung cancer.
It would introduce health controls in an otherwise very unregulated area, it would protect our young people and children from harm and it would raise public awareness of the dangers of skin cancer.

It is suggested that the voluntary regulation scheme is ineffective, and there may be a need for formal regulation in this area. Regulating sunbeds to ensure that children do not use them and to ensure that all users are aware of the risks associated with sunbed use, could be a major step forwards in the drive to control Scotland's skin cancer epidemic.

Reference Material: (If you have a deeper interest)

1. Statistical Information Team Cancer Research UK (2006) 'CancerStats, Malignant Melanoma-UK'Information available online at http://info.cancerresearchuk.org/cancerstats/

2. Spencer, J. & Amonette, R. Indoor tanning: risks, benefits, and future trends.

3. Solar and ultraviolet radiation. (IARCPress, Lyon, 1992)

4. Gallagher RP, Spinelli JJ, Lee TK. Tanning beds, sunlamps and risk of cutaneous malignant melanoma,Cancer Epidemiol Biomarkers Prev 2005;14:562

5. Young AR, Tanning devices - fast track to skin cancer? Pigment Cell Res 2004;17:2-9

6. Karagas MR, Stannard VA, Mott LA, et al. (2002) Use of tanning devices and risk of basal cell and squamous cell skin cancers. Journal of the National Cancer Institute 94:224-6.

7. Westerdahl J, Olsson H, Masback A et al. (1994) "Use of sunbeds or sunlamps and malignant melanoma in Southern Sweden".American Journal of Eepidemiology 140:691-9.

8. Diffey, B. A quantitative estimate of melanoma mortality from ultraviolet A sunbed use in the U.K.Br J Dermatol 149, 578-81 (2003).

9. WHO fact sheet : Sunbeds, tanning and UV exposure, March 2005, at http://www.who.int/mediacentre/factsheets/fs287/en/

10. Gerber, B., Mathys, P. Moser, M., Bressoud, D. & Braun-Fahrlander, C. Ultraviolet emission spectra of sunbeds. Photochem Photobiol 76, 664-8 (2002).

11. Wester, U., Boldemann, C., Jansson, B. & Ullen, H. Population UV-dose and skin area--do sunbeds rival the sun? Health Phys 77, 436-40 (1999)

12. Autier, P. Perspectives in melanoma prevention: the case of sunbeds. Eur J Cancer 40, 2367-2376 (2004). Advertising Standards Authority- non-broadcast adjudication, 7September 2005, http://www.asa.org.uk

13. Lim HW, Sunlight, tanning booths and Vitamin D, J Am Acad Dermatol 2005;52;868-76

14. British Medical Association- http://www.bma.org.uk

15. REHIS calls for Executive Action on Sunbeds, poor standards putting Scots at risk,November 2003

16. Ross, R. & Phillips, B. Twenty questions for tanning facility operators: a survey of operator knowledge. Can J Public Health 85, 393-6 (1994)

17. Moseley, H., Davidson, M. & Ferguson, J. A hazard assessment of artificial tanning units. Photodermatol Photoimmunol Photomed 14, 79-87 (1998).

18. Culley, C. et al. Compliance with federal and state legislation by indoor tanning facilities in San Diego. J Am Acad Dermatol 44, 53-60 (2001).

19. Moseley, H, MDavidson and J Ferguson. (1999) "Sunbeds and the need to know" British Journal of Dermatology. 141: 573-609

20. Royal Environmental Health Institute survey, November 2003 [cited in note 2].

21. NHS Scotland - Survey of Sunbed Salons in Scotland. Information collated by Royal Environmental Health Institute of Scotland, 3 Manor Place, Edinburgh, EH3 7DH, November 2003.

In the event that the imminent failure of Democrats' socialized medicine bill leads them to some soul-searching-perhaps listening to what their constituents have been telling them all summer or taking GOP advice to start from scratch - it's worth noting that Republicans in the House have introduced 32 health care reform bills since the spring, all stuck at the referral stage.

Many of these lonely bills deal with just one or several aspects of health care reform, rather than presenting grand, sweeping Ten-Year Plans that will change Health Care as we know it. Not all the bills are knockouts; a couple are downright stinkers. But virtually all contain some good ideas, and some of them contain nothing but good ideas-which means that no Democrat will ever for a moment consider any of them.

For those desiring ammunition to counterattack the liberal charge that conservatives criticize everything they hear from Democrats but have no ideas of their own, here's a primer on the legislation prepared by our devoted GOP servants in the House:

o Several bills are flat-out winners: Clifford Stearns' Health Care Tax Deduction Act, Michele Bachmann's Health Care Freedom of Choice Act, and Rodney Alexander's Sunset of Life Protection Act. These laws provide for income tax deductions of health insurance premiums and prescription drugs; medical expenses; and long-term care premiums, respectively. All three bills are so short they could fit onto a cocktail napkin together and still have room for a list of Obama's failed Cabinet nominations. This is not surprising: bills covering what individuals are allowed to do require less verbiage than bills mandating what individuals are required to do for the government.

o Marsha Blackburn's Health Care Choices for Seniors Act and Louis Gohmert's Patient-Controlled Healthcare Protection Act allow seniors to opt out of Medicare and receive vouchers for health savings accounts, an arrangement analogous to school vouchers (another excellent idea liberals oppose). Edward Royce's Flexible Health Savings Act allows individuals to carry over unused health savings account funds from year to year.

o John Shadegg's Health Care Choice Act eliminates restrictions on interstate governing of health insurance, the primary cause of the limited within-state competition among private insurance plans that President Obama keeps bleating about.

o Two bills-John Gingrey's HEALTH Act and Michael Burgess' Medical Justice Act-enact malpractice tort reform by regulating lawsuits for health care injuries or deaths. William Thornberry's Medical Liability Procedural Reform Act sets up state "health care tribunals" or medical courts to adjudicate claims.

o Several unobjectionable but minor bills extend benefits for veterans, reserve members, and their dependents.

o A few bills would amend the State Children's Health Insurance Program to make it more accountable; however, these bills give the costly, bloated SCHIP so much legitimacy that I'm suspicious of their authors' credibility.

o Other bills have good intentions but will lead to more bureaucracy and regulation than they aim to prevent; for example, Thornberry's Health Care Paperwork Reduction and Fraud Prevention Act, which proposes a "Commission on Health Care Billing Codes and Forms Simplification" to standardize billing paperwork. No doubt the government will first need to establish a separate commission just to simplify the Commission's name.

o Thornberry has proposed two more bad bills (why do public officials who want to steal our liberty always invent so many devious ways to do it?). One is the Partnership to Improve Seniors' Access to Medicare Act, which subsidizes student loan repayment for doctors who accept Medicare payments; not specified in the bill is how much of our bountiful federal surplus will be used to cover this provision. Another is the Patient Fairness and Indigent Care Promotion Act, which allows doctors to deduct for tax purposes unrecouped costs from "patient bad debt"-because nothing increases accountability like providing incentives for doctors not to check beforehand whether patients can pay their bills!

Other GOP bills contain other provisions, and many of the bills are a mixed bag; but the point is that they're all better than HR 3200, which is putrid right down to its last period. Considering even a few key GOP bills over the next couple of years would be a sound way to address individual components of health care reform, in a piecemeal fashion, rather than upending our economy right now because Democrats insist on artificial deadlines to maximize their political gain.

In the meantime, the proper response to any liberal who claims conservatives have no ideas of their own on health care reform should be a resounding, "You lie!"

Dental implant devices consist of two different parts. One is a titanium bar that is placed inside the jawbone in the empty space where the tooth used to be, and the second part is a ceramic copy of a tooth that is firmly attached to the titanium bar. This process is completed few months after the titanium rod has been placed in the position to allow it to fuse into the jawbone.

The dental implant risks connected with titanium rod are pretty much absent. The titanium belongs to the group of inert metals, whose characteristics are compatibility with human tissue. For that reason, human tissue does not respond with rejection as it is commonly seen with organ transplants. Titanium is actually the material used in many medical procedures and has been used in prosthetic hip joints for almost half a century.

The ceramic prosthetic tooth used in dental implant is the same as that used in regular tooth crowns and represents no risk, except in the case when dentist incorrectly bonds the prosthetic tooth to the titanium rod. Most usual side effect associated with such malpractice is that the ceramic prosthetic tooth can dislocate from the titanium rod, but such malfunction can easily be corrected, as well as there is no actual physical risk to the individual.

Other Medical Dental Implant Risks

Any dental implant risk that could occur due to any reason can be reduced with a cautious exam prior the procedure. During the exam, patient should present a clear image of his or her health and dental conditions from the past. This information will come very useful when the dentist is about to determine what kind of procedure will be most suitable for the patient given his or her medical history, and will determine possible complications that could arise, as well as consider if anesthesia would be necessary or not.

There are few risks associated with dental implant that cannot be averted completely and are normal companions of this procedure. They are risk of infection, nerve damage, and a possibility that when a dentist inserts the titanium rod into its place, the sinus membrane could get ruptured. A patient can also experience few risks after the procedure, especially if he or she does not follow instructions given by a dentist. Smokers and those who suffer from diabetes will be exposed to greater risks, due to the fact that their tissue may heal more slowly and is not as capable to deal with possible infections.

Some of the side effects of dental implant procedure that are not that serious are: tenderness, swelling, and pain in the spot where prosthetic tooth has been inserted. Some report that after the procedure they had difficulty speaking or developed gingivitis, in which case you should immediately notify your dentist who will proceed with the solution.

Even though there are some risks associated with dental implants, the truth is that majority of all procedures result in the successful permanent replacement of the damaged or missing teeth with ceramic teeth that are safe and blend naturally with the rest of the teeth.

The Chinese civilization introduced the beneficial practice of acupuncture centuries ago, and up to this day, many people are still using this approach to help them with their ailments. Acupuncture is one of the Chinese ways of helping sick people to ease their pains and sores, remedied by inserting a very fine needle on different parts of the body. The technique contributes to the blood flow of the body, which in turn, enables the system to produce and release more endorphins. A new, effective approach to help infertile women is to look at acupuncture for infertility and to determine how the benefits of this treatment can aid in conception, along with common medical practices.

Since the issue of infertility has been around, the combination of acupuncture plus medical procedures has helped women with their infertility problems. Looking at how acupuncture for infertility works, one of the greatest effects of acupuncture is that it could help balance the hormones in the body. In turn, this produces new eggs and helps regulate the menstrual cycle. It is also reported that acupuncture accurately adjusts the blood pressure of the person who is infertile which could lead to more blood flow to the vital organs and increase the hormone level. Acupuncture helps the ovaries and follicles to be enhanced so that the outer lining of the endometrium will be harden.

Acupuncture for infertility is becoming popular because most of the patients who have undergone in vitro insemination (IVI) claim that by combining this treatment with acupuncture made the whole process of conceiving more successful. Now, many medical specialists recommend that women who wish to undergo in vitro insemination should also consider acupuncture. Other benefits of acupuncture that could help women with infertility problems are that acupuncture could actually cure women with Polycystic Ovarian Syndrome, women who happen to have constant miscarriages, women suffering from idiopathic infertility, and women with elevated Follicle Stimulating Hormones (FSH). Acupuncture even helps men with Sperm DNA Fragmentation.

Acupuncture helps the body to recuperate from certain sickness within time. If women are to undergo IVF process of insemination or the egg donor transfer, they must wait 3 to 4 months after they have undergone acupuncture. In pre and post-embryo transfer procedures, acupuncture is highly recommended.

The practice of acupuncture is very critical and can be strenuous. Women who undergo any fertility procedure usually experience anxiety, depression, and stress. That is why acupuncture offers the best alternative for them, but even then, acupuncture can be very risky if not properly administered. Malpractice of this ancient approach may lead to a miscarriage. For this reason, women need to consult their doctor first if they are considering acupuncture while they are in the process of any infertility treatments; in addition, women have to be sure that the acupuncturist is licensed.

Acupuncture for infertility blends an ancient practice for a modern problem. Women need to make smart choices when deciding on traditional treatments and medications, still knowing that a new, effective approach is available to them, as well: acupuncture. Whatever approach used, women need to make sure that it will fit their health and their bodies, as well as their age and needs.

Standalone versus Synchronized Hospitals Clocks

A good example of a standalone hospital clock is the clock that an employee may purchase from a department store. They are normally battery operated and run on their own internal quartz mechanism. They originally receive their accurate time from an employee reaching behind the clock and turning the hands to match the time they may have on their wristwatch or another clock in the building. This antiquated way of displaying time for the entire hospital can have some negative effects on how everything operates within the building. For example, when the standalone clocks start to drift from the time the employee set them to months before, displays start to differentiate. One clock may display a time five minutes different then another. At this point, employees could be making inaccurate patient records, dispersing medication at the wrong time, or showing up late to the operating room for a scheduled surgery-potentially harming the patient and making the employee's job more difficult, and even posing the threat of a lawsuit.

How Synchronized Clocks Work

A synchronized hospital clock, however, avoids all of these issues. Instead of having an employee set the time, synchronized hospital clocks calibrate and synchronize with the accurate time from a master clock. The master clock, which is the central point of the system, distributes accurate time from either a GPS receiver or NTP server out to each clock in the building, making sure that every time display is accurate and consistent with the rest. With this technology, the employees can move from room to room and floor to floor with completely matching time displays everywhere they go. Patient records will be accurately kept, medication will be delivered on schedule, and employees will be where they need to be on time, every time.

Clock Systems Reduce Discrepancies

With the disparity between the standalone hospital clock solution and the synchronized hospital clock solution, all hospital employees, managers, and even patients should be aware of the need for accurate time, and the negative effects brought on the hospital without it. Discrepancies in record keeping, or medication delivered off schedule and other detriments from unsynchronized time harms the patients as well as the employees on many levels. Additionally, these discrepancies can be useful to a prosecutor if the patient decides to file a lawsuit against the hospital for malpractice. If you have not yet heard of synchronized time, or your hospital is still using outdated ways of telling time with standalone hospital clocks, don't hesitate to make the switch to a synchronized solution. The hospital, as well as all people within the organization, will benefit from it.

Even those people who are just starting out as cardiologists can make up to and around two hundred and seventeen thousands dollars a year. The idea of just coming out of school to make over two hundred thousand dollars a year is quite a lucrative opportunity. Given all of the work and money which people put into attending medical school, they obviously deserve that kind of salary. People who are cardiologists are literally saving people's lives so someone who is actually saving someone else's life of course deserves to be paid well unless you don't consider your own life to be worthwhile. Sanjay Gupta and places like CNNMoney have done profiles and stories as to why doctors such as cardiologists get paid so much within our medical system and it is because they have to deal with such difficult medical issues. With all of the items that a cardiologist has to remember in order to make sure their patients find success you can understand their high pay. They are also paid rewardingly in order for them to be able to pay for all of the malpractice insurance that is involved in dealing with heart patients who face complicated issues.

If there was some serious tort reform in this country it is also possible that people who happen to want to go into cardiology may request less of a salary from the hospital they work for or within their own private practice. There are particular schools which are good at producing cardiologists and other great physicians such as Vanderbilt University. Some cardiologists may have to end up reporting to a medical director within the facility or institute in which they work, this can be a particularly important process if they are viewing a patient which in particular is having some real problems. Cardiologists often have to develop unique strategies in order to properly treat their patients. A cardiologist can inspire other people to go into medicine by showing them the amazing aspects of the human heart and treating people with dignity.

It will be interesting to see what kind of impact health insurance reform will have on a cardiologist as far as their overall salary and what tax bracket they will be put in. The fact is that the tax bracket of a cardiologist matters due to the fact that if people want to open their own cardiology practice they often want to own their own building and then have to deal with property taxes as well as income taxes. If you are unsure about how to open your own private practice you can always contact a group like The Center for Innovative Entrepreneurship.

You can teach cardiology courses at the university level if the idea of having a private practice simply does not appeal to you. University presidents of course need people to teach medical courses at the university level and so they would likely offer you a very lucrative salary.

If you've been thinking seriously about having cosmetic surgery, you'll need to know exactly how to choose the right plastic surgeon. Here are a few tips to hopefully diminish your research in locating this potentially crucial decision.

1) Check Board-Certification. All cosmetic specialists are not created equal. Search for one whose training, experience and other credentials have been certified by the American Board of Plastic Surgery.

But even though they may "say" they are board-certified, always check to be sure they have had the exact training they need to be qualified. The first step to finding the right person is certification by the ABPS, and you'll never go wrong.

Besides a degree and years of education, they will have passed many exams as well as completion of a supervised residency before beginning their own practice. It's also not a bad idea to ask how many times they've performed the particular surgery you desire.

2) Check Their Record. If you really want to know if someone is a good fit for your enhancement desires, look them up in your state's medical board. Not only will these records display any good remarks about him or her as a plastic surgeon, but it will also reveal if there have been any disciplinary actions against them.

In some states, you can view these records online. Other states may handle the request only through the post office. When checking their record, also make sure they're legally licensed to practice cosmetic medicine in your state.

3) Hospital Privileges. This is a vital question simply due to the fact that hospitals perform background checks on each physician. If your physician doesn't have hospital privileges, it could be a huge red flag. In order to avoid malpractice suits, hospitals have to be very careful whom they employ and who they don't.

They will become fully aware if your plastic surgeon of choice doesn't have the right credentials or hasn't done the correct workups. Plus, if your procedure is in-office or outpatient and any complications arise, you can be legally transported to the hospital of choice with no questions asked.

4) Don't Be Afraid to Ask Questions. One of your best defenses for not being taken by an unscrupulous plastic surgeon is to come fully prepared to ask plenty of questions of your doctor of choice. Asking for referrals and a desire to see real clients' before and after photos are something that should be commonplace for the person asking the questions.

Ask about things like if anesthesia will be used and any possible side effects, how many times has the specialist done this cosmetic technique before and are his or her medical records and license in good standing with the state and community.

Now that you know, there is no reason why you shouldn't confidently begin your search for the best plastic surgeon to help you achieve a more attractive you. After all, aren't you worth it?

Three out of every four (often high) doses of radiation used for heart scans are clearly inappropriate, according to a review of medical records at the Mayo Clinic.

CT scans of the chest or abdomen involve up to ten times the natural radiation from the sun and soil over the course of an entire year, or anywhere from 13 percent up to 40 percent of the minimum radiation received by survivors of the Japanese atomic bomb blasts in 1945, or the Chernobyl nuclear accident in 1986.

A study by Columbia University researchers estimates that up to two percent of all Cancers in America in the next few decades could be the result of CT scan radiation exposure now being given to patients.

Other studies estimate than at least one-third of all such tests, from X-Rays to CT scans, are not needed, with an estimated 21 million people (1 million of them children) being needlessly exposed to this risk, according to the same Columbia University study published in 2007.

The most overused and abused diagnostic procedures involving excess and needless radiation exposure include CT scans of the chest for heart problems, or to see if there are any clogged arteries, chest X-rays for routine hospital admissions or prior to surgery, lower back X-rays of older patients with stable spine conditions, and car crash victims not exhibiting any signs of head trauma or abdominal injury.

The dosage of such exposures could also be reduced by two-thirds with no loss in the image quality, according to a Michigan study led by Dr. Gilbert Raff, a cardiologist and radiation safety expert.

Another study at Columbia University, conducted by Dr. Andrew Einstein, discovered a way to lower radiation dosage by 90 percent without affecting the image quality.

Needless multiple tests resulting in excess exposure also often result from one doctor or specialist not knowing what another has already ordered, also from routine requirements for health insurance or for students studying abroad, by doctors - especially emergency room physicians - who fear malpractice suits, and even just to appear to be doing something due to patient demand.

Doses of radiation exposure are often not tracked over any period of time, to avoid any possible cumulative effect, and neither are they adjusted to avoid over-exposure for gender, age and size (women and children are among those receiving excessive radiation exposure as a result of such carelessness).

Orthopedic injuries, that cannot be easily fixed by surgery, that require physical therapy as the treatment of choice, are among the highest sources of needless radiation exposure, according to Philadelphia primary care specialist, Dr. Richard Baron.

Doctors now rely too much on "routine" scans, rather than examinations and expert judgement, without understanding the need for or limitations of such diagnostic tools, according to Dr. Baron.

Doctors make enough life and death decisions every day, without throwing into the mix the increased risk of cancer developing as a direct result of their examinations and treatments.

If you are worried about radiation from airport and weather radar, airport scanners, high power lines, electrical wiring in your home, cell and cordless phones, computers and microwave ovens (among other environmental exposures), then you should definitely be concerned about the six-times growth in exposure over the past twenty years from medical sources of radiation alone.

Radiologists who think such excessive exposures are rare or nonexistent have simply failed to consider the possibility or to look for such cases, according to radiologist Dr. Steven Birnbaum.

Overdosing on "super X-ray" CT scans, due to overtesting with this imaging diagnostic method of choice, is among the worst offenders in raising cancer risk for Americans, who lead the world in such exposures.

Little wonder, then, that the United States also leads the world in the incidence of fatal cancers, as American consumers heedlessly consume more cancer-causing radiation today than ever before.

There isn't much difference between the risks posed from such modern medical procedures and the results of bleeding a patient to death - the way George Washington died - by earlier generations of medical mispractitioners.

Lawyers specialize in a wide number of fields from personal injury and criminal law to immigration, business and finances. But what do these lawyers actually do? There is a wealth of misinformation available to the average consumer, and you may be confused where to start looking.

Finding a good lawyer is essential, but if that lawyer doesn't specialize in the specific area in which you need them, it doesn't put you in the best situation. You don't want to hire a lawyer who specializes in divorce to help you with a personal injury suit, and vice versa. Thus it's imperative that you find not only a good lawyer, but one who really knows specific information about your problem. Here is a brief overview of some of the most popular types of lawyers and what they do:

Criminal Lawyer

A criminal lawyer is the highest profile lawyer for good reason. Criminal lawyers handle statutory and common law crimes and the punishment of criminal offences. They deal with every aspect of criminal law, with the state defender, or prosecutor, defending the state's interest and the defense attorney representing the defender. They defend against and prosecute crimes against the person (assault, murder, rape, etc.), crimes against property (arson, theft, larceny etc.), crimes against justice (bribery, perjury etc.) and other myriad lesser criminal offenses.

Divorce Lawyer

Divorce lawyers focus on any and all matters concerning divorce. This applies to any proceedings, including prenuptial agreements, division of property, alimony or spousal payments, child support, and more. Most individuals going through a divorce generally hire a divorce lawyer to take care of all legal matters. Much of the time a good divorce lawyer can make all the difference in how messy or clean your divorce becomes.

Accident Lawyers or Personal Injury Lawyers

Accident lawyers, also known as personal injury lawyers, specialize in legal claims relating to auto accidents and vehicle claims, dangerous or defective products, medical and health care malpractice, workplace injuries (worker's compensation), wrongful death, and a slew of other accidental incidents that warrant legal procedures.

Immigration Lawyers

Immigration lawyers handle any matters pertaining to immigration, including citizenship and naturalization proceedings, permanent residence, green cards, work visas, asylum, deportation hearings, family-based immigration waivers, and any other legal issues surrounding immigrants to the US.

Financial and Business Lawyers

Financial lawyers deal with a wide range of business and personal investments, savings products and services. These include mortgages, banking, brokerage services, commodities, claims, mutual funds, stocks and bonds, and other securities. They are in charge of taking care of all legal requirements and formalities surrounding any financial issue. They are also helpful for starting and operating businesses, including: LLC's, corporations, and partnerships.

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Are you going to college? Are you wondering what highest paying degree is, with the hopes of majoring in it to have a promising and high paying career in the future? That is one of the decisions that all of us had to make prior to attending college. And I must say that the decision is critical to one's success.

Having a goal in life is one of the precursors of success and planning your future. Now, do you want to pursue a degree that you think will help you earn the most money? Or, would you prefer a degree that will help you maximize your learning potential, which could translate into good money as well?

In the ranking of highest paying degrees, you'll notice that medical doctors with specialties earn more money. But consider the amount of time, energy, money, and potential overhead (e.g. malpractice insurance) that go into calling yourself "Doctor".

Are you up to 12 years of post high school education? Do you have the urge to serve and heal the sick? Those are good qualifying questions.

Though doctors live comfortably, they sure can't afford luxurious New York penthouses where CEO's live. This tells you that the richest people in the world are in business. Now you may want to add business to your list of potential highest paying degree.

Take a look at business magazines and find out how much CEO's are making. You'll find that doctors are not even close in terms of salary. Not unless the doctor owns the hospital. A business degree is not as grueling as a medical degree and the career path is something to look forward to.

Of course, CEO's have advanced degrees like MBAs. But you'll be happy to know that you can have an MBA in just a little over 2 years.

You may also want to take a look at our political leaders. Congressman and Senators are mostly lawyers. And it's no secret that they live a comfortable life. Not to mention the power associated with their position. A law degree is definitely up their in terms of highest paying degree.

Practicing lawyers can also make a huge amount of money just by winning a case. Settlements are to the tune of millions sometimes and they get a good percentage out of that. With all the options right in front of you, choosing a career path can be difficult. My advice, instead of pursuing the highest paying degree go for a degree that you are interested in; one that is aligned with your interests and morals. As they say, money is the consequence of doing things that you love.

We hardly get astounded now days having an earshot of drug addiction because it is one of the most common phenomenon. It is not arising questions newly in our society. This malpractice has been taking place for a pretty long period of time. When it was a new physical entity, it was considered to be a disease, sometimes physical, sometimes mental, and sometimes spiritual. Consequently, the patients or the addicts were treated accordingly. Though men are developing more consciousness in themselves now, yet the dark shade of addiction has not been eradicated till now. What has been changed is the mode of operation, in more sophisticated way.

Since it has been damning our society for a long time, we perhaps know the withdrawal symptoms a little. The withdrawal or disposal system is none but to lessen the intake of those drugs and this system involves some steps. Withdrawal is not like one has determined to be neutral and shunned the habit of taking drugs. it can prove to be life-threatening, because the drugs regulate the central nervous system and when it is not provided, our body does not work properly. It gives rise to many a problem, be it physical or mental. Stress, diarrhea, cramp in muscles, excessive drainage of emotion and many other stimuli to physical problem can be seen during the withdrawal period. Conventional treatment for drug detox results in horrible and intense physical pain and acute psychological cravings for drugs. And due to this most of the patients get back to their previous addictions to avoid pain.

Rapid detox can be briefly defined as a wonderful boon of science to avoid the painstaking opiate withdrawal symptoms. Since the past ten years, biological and genetic issues of addiction have been developed and as a result the rapid detox method is here. Rapid detox is not a process of drug treatment. It is an anesthesia based program which is mostly known as Weizmann Method or Neuro-Regulation which involves cleansing the opiate receptors in the addict's brain while the patient is under anesthesia. In course of the procedure, the patient will hardly experience any withdrawal symptoms. A review has revealed that where 85-90 percent patient under normal conventional drug rehabilitation process has suffered a relapse and using it again, the patients under the rapid detox program remain drug free after one year.

An eminent practitioner of this process, Clifford Bernstein, M.D. of AAMOD, stated that this anesthesia-based treatment is a humane and effective medical treatment without any side-effects ignoring the fact that there are some misguiding information about rapid detox which questions the safety of this process. After the nerves are cleansed, the brain craves no more for the narcotics. However, precautions must be taken to verify the qualifications of the procedure under anesthesia. It should be followed up with some treatments which the doctors would tell the patients accordingly.

Moreover, the process is a subject to sparing and should be operated in a well facilitated medical hub in intensive care unit. So, it will be a wise decision to choose a well groomed luxurious drug rehab center like drug rehab sunset malibu because there you will get your addiction treated through rapid detox by trusted professionals.

The expenses involved in litigation and other court procedures can be overwhelming. Plaintiffs pursuing litigation require a strong financial backup. A good lawyer charges high fees, to represent a case. A victim of personal injury is faced with growing medical expenses. Such people frequently opt for out of court settlements and receive very little compensation. Litigation financing comes to the rescue of people who wish to fight their case, but lack the means to do so. There are litigation financing companies that offer loans in the form of cash advance to plaintiffs, attorneys and law firms, to take care of litigation expenses.

Financial companies offer litigation financing for various cases, such as personal injury, malpractice and accidents. In case the settlement is delayed after the case is resolved, the plaintiffs can easily procure post-settlement, short- term loans.

Most of the time, plaintiffs are put in contact with a litigation financing company through their attorneys. For ethical reasons, an attorney is not allowed to provide finance to the plaintiff. An attorney also cannot borrow money from a financial company to pay his client's litigation expenses. When the case is successfully settled, the attorney gets his fees on a contingency basis. The litigation financing company purchases a part of the settlement charges.

It is possible for plaintiffs to obtain loans from online litigation financial companies. The litigation company first evaluates the case of the plaintiff, before approving a cash advance. The financing company then determines the amount of the loan to be sanctioned, after the evaluation of the case. The financing company purchases a part of the estimated settlement the plaintiff is expected to receive, after the case is settled.

The company offers the cash advance on a non-recourse basis. The plaintiffs are expected to repay the loan amount only if the case is resolved successfully.

There's been a recent rise in the number of Adult Daycare Home Businesses springing up everywhere around the world, what with an estimated one in four families providing care for an elderly relative today. Before you decide to jump on the group home business bandwagon, though, you need to know as much as possible. This brief guide will help.

Some questions you should ask yourself before starting an Adult Daycare home business, or any other home business for that matter, are:

• What are your talents and skills?
• Are you looking for a home based career or just to supplement your income?
• Do you have space in your home for an office?
• Is your family willing to support you in having a business based in their home?
• Are you willing to put in the necessary work it takes to get a business off the ground and to sustain it once you have?
• Do you want to help people?

The last question is particularly important when it comes to operating and starting an Adult Daycare home business for the elderly. Because if you're just doing it for the money, you're likely to be overwhelmed by the personal interaction required for this business.

Some people are happier working all day long at a computer, not having to deal with other people face to face. Or they prefer detailing people's cars or doing their lawn care to providing personal service that demands constantly interacting with people.

Everybody's different, and that's a good thing. Just understand that even if you set up an Adult Daycare home business across town from your own home, you're going to have to deal with people on a daily basis.

If you decide that starting an Adult Daycare business for the elderly is just the type of business you're looking for, you'll have to find out what the laws and regulations are, as well as what licenses are necessary in your state. There are certain to be some, and you need to know what they are in case you have to obtain any special certifications. CPR and first aid certifications are two that most states are likely going to require you to personally have.

Another thing that you'll have to look into before you buy or rent that house that you think would be just perfect starting an Adult Day Care home business, are the area's zoning regulations. This can be a sticky situation in many places, and even if there are no zoning laws or regulations against your opening a group home business where you'd like to, you could well find yourself up against a lot of resistance. It's mandatory that you know this upfront.

You can look for another location for starting a group home business for the elderly, or you just might decide that this is not the business for you.

Funding for group home businesses is not as hard to find as you might think. The Small Business Association, as well as many banks and other financial institutions, can point you in the direction you need to go to find the money you need to purchase a home for starting a group home business.

You'll want to understand all the terms, conditions, and financial obligations. You'll also want to find out if you must use your current home as collateral. Putting your own house up as collateral may be more than you're willing to risk for any new venture.

Insurance for your elderly group home business is something you'll definitely have to have. Liability insurance is mandatory. You'll also need fire and theft insurance. If you plan to offer any type of medical assistance to the people in your elderly group home, you may even need malpractice insurance.

Other insurance requirements may also be involved. Learn everything you can about the different types of insurance coverage you'll need, and then shop around for the best prices to obtain the necessary policies you'll need for starting a group home business.

Unless you plan to live in your Adult Daycare business and do everything yourself you'll need assistants and a concierge service for senior citizens. Planning for meals, transportation to doctors, dentists, hairdressers, and events, cleaning, and activities are other things that need to be considered before starting an Adult Daycare.

You will also want someone to oversee medications and ensure that people receive and take them at the proper times.

Starting a Group Home Business for the elderly is not for everybody, but if it's for you, then you'll find it tremendously rewarding. And in huge demand. Going into the elderly group home business with your eyes open and doing your homework first will assure that your Adult Daycare Home Business is a successful one.

Conversational hypnosis is a very powerful tool. You have the ability to hypnotize someone through your conversation. This skill can certainly come in handy in so many ways. In the field of business, you can use conversational hypnosis to make more sales. A salesman will simply use conversational hypnosis on a customer so that they will buy the product. An accountant can use it to talk the IRS and convince them that fraud never happened on the financial statements, even if there are obvious malpractices committed.

In the field of medicine, doctors can use conversational hypnosis to convince their patients that they are not sick, even if they are, and still charge them an exorbitant amount. Pharmaceutical companies can convince doctors to prescribe faulty medicines to doctors even if they both know that these medicines don't work at all. It gets worse if these medications are harmful. You can kill people with the improper use of hypnosis.

In the field of law, lawyers can hypnotize their opponents and force a win anytime they want. Even if they know that their clients are guilty, they can still make them win a case. They can get paid for winning cases and not by defending the truth above all else. Sometimes you may even try to hypnotize the judge. The judge may be totally clueless on what you are doing but you are have already planted the seed of hypnosis on them long before they even knew it.

You can see that conversational hypnosis can be used for so many malevolent things. You can distort the truth and hurt other people by using hypnosis in the wrong way. The ethics of conversational hypnosis is very clear. You have to put the greatest good above all else. As an individual, your conscience will dictate how you can go about it. You have to exhaust all moral angles before deciding to use hypnosis on someone.

It is clear that using hypnosis for your own personal advantage is wrong. You have to take things a step further though. If you know how to do conversational hypnosis then you shouldn't be teaching it to the people who will use it inappropriately. It is the moral responsibility of an individual capable of conversational hypnosis to ascertain whether his or her student will use the power appropriately.

If you are planning to learn conversational hypnosis then the first thing that you have to examine is your heart. Is your heart pure and can you be trusted? Will you use the power of hypnosis on innocent individuals so that you can take advantage of them? Look into your heart and ask yourself these questions. If your heart is corrupted then do not even think about learning conversational hypnosis anymore. You may end up selling your soul. If you want to learn conversational hypnosis then you have to be sure that you have a pure heart and pure intentions.

You know a lot of people who have already had lasik surgery, but you are not sure that it is right for you. What do you need to know before making an informed decision? Start with a good eye surgeon and set up an appointment for an examination. The doctor will be able to tell you whether or not you are a good candidate for lasik surgery.

There are many reasons why you may not be a good candidate and the doctor will explain these to you. Listen to him carefully and know that he has your best interest in mind. You may find that you have:

* An unstable prescription -- this means that your eye condition changes regularly.

* A severe refractive error -- to correct your extreme nearsightedness or farsightedness, it will require too much deep sculpturing and cornea reshaping.

* Large pupils -- if the pupil is too wide, then the laser beam will not be able to properly shape the eye.

* A thin cornea will not retain its structure and shape if the top layers of tissue are surgically removed.

* Abnoramally structured cornea -- this condition is not treatable with Lasik surgery.

* Pregnant or nursing -- these two conditions may change the measured refraction in your eye.

* Collagen vascular disease -- affects the collagen-containing connective tissue.

* Glaucoma or cataracts. These eye diseases may cause complications for laser surgery.

* Active herpetic keratitis -- a herpes infection in the eye.

* Diabetic retinopathy -- a potentially blinding complication of diabetes.

These are just a few of the reasons why you may not be a candidate for lasik surgery. You should be honest with the doctor and work with him and his staff to make sure that you have no hidden problems.

Make sure you go to a reputable eye surgeon and not a small medical center that may disappear in a few years. Check into their credentials-how many lasik surgeries have they performed, were there any malpractice suits against them, and ask the Better Business Bureau about them. The eyes you have are the only ones you get-a medical error would be disastrous.

You probably know someone who has already had the procedure done. Talk to them and see what they have to say-they have first-hand experience about what to expect and they may or may not recommend their eye surgeon.

If everything is okay, you will have your lasik surgery and go through your recovery period. It will take a few weeks for a complete recovery, but your eyes should get stronger and your vision clearer.

Take your time, think about your options and then make an informed decision about your lasik surgery. You may end up with 20/20 vision and never have to wear glasses or contact lenses again. Or, you may find out that you do not qualify for this surgery. Either way, you took the time to learn about the procedure and are a more informed consumer because of it.

You might think that with all the advances in Western medicine that misdiagnosis has become a rare occurrence. That's not the case.

I recently read an article that appeared in the New York Times in February 2006, that stated that autopsies have shown that doctors seriously misdiagnose fatal illnesses about 20 percent of the time. Millions of patients are being treated for the wrong disease. The 20 percent rate of misdiagnosis has not really changed since the 1930's. "No Improvement!" was how an article in the normally exclamation free journal of the American Medical Association summarized the situation. One seventh of our economy is devoted to health care and yet misdiagnosis is killing thousands of Americans every year.

Under the current medical system, doctors, nurses, lab technicians, and hospital executives are not actually paid to come up with the right diagnosis. Believe it or not, they are paid to perform tests and to do surgery and to dispense prescription drugs.

There is no bonus for curing someone and no penalty for failing, except when the mistake rise to the level of malpractice. So even though doctors have the best intentions, they have little economic incentive to spend time double checking their instincts, and hospitals have little incentive to give them the tools to do so.

Knowing this information, at a minimum, I would encourage you to get a second opinion if you find yourself facing an issue. Remember, knowledge is power. Research can also be very helpful in this situation. It is important to find a professional who truly takes quality time to asses all aspects of what may be impacting your health. Physical, mental, emotional and spiritual issues may manifest themselves in the physical body.

The first step to good health is to acknowledge the presence of pain and that all is not
well with the body. In many ways, the job of the turnaround manager is akin to that of the
physician. The first step is to diagnose the corporate patient's condition before even
attempting to prescribe the right medication. For prescription without proper diagnosis is
malpractice.

The starting point is crucial to ensure that you have the right footing. To learn any skill,
one has to take that first step. If you want to learn to swim, you have to take the first step
of plunging into the water. To learn to parachute, you have to take the first step of
jumping out of the airplane. One can read about and rehearse all the knowledge about
swimming and parachuting or any other skills. However, one will never learn the skills if
the first step is not taken to do the "real" thing. Ironically, it is found that the first step is
always one of the most difficult steps to take in any venture, for it entails stepping into
unknown territories and unchartered waters. Whether it is taking the first step to
recognise that one is unwell or taking the first step to learn a new skill, the first step is
also one of the most rewarding.

However, diagnosing the company's health is not as straightforward since many
qualitative factors are involved. Oftentimes, the management also plays the game of
denial and deception. Usually there are ample warning signs or symptoms of impending
trouble such as high attrition of good staff, declining brand value etc. However, the
management may be in the state of self-denial or does not wish to let out the knowledge
of the company's predicament. Admission of the failure may expose them to criticism by
the company's board of directors, shareholders and their peers. Unfortunately, this may
result in delays in implementing the vital remedial actions during the early stage of
under-performance. Adoption of prompt actions may have significantly improved the
company's quandary and chances of survival.

Denial and deception remind us of the former Iraqi Information Minister, Muhammed
Saeed al-Sahaf who made comical and untruth remarks about the realities of the outcome
of the US-Iraq war: "There are no American infidels in Baghdad. Never....They are
coming to surrender or be burned in their tanks....Who are in control, they are not in
control of anything - they don't even control themselves....Be assured. Baghdad is safe,
protected." These statements were made despite the fact that the American forces have
already landed at the Baghdad airport and within days Baghdad was captured by the
allied forces.

Some sick companies play another game of "don't know and don't care". This is
ignorance and apathy. Similar to taking care of physical health, these companies fell sick
because of not knowing what to do as well as neglect. Their "cannot be bothered"
attitude was perhaps the result of having been distracted by politics, mesmerised by new
acquisitions or focused on the wrong strategies. These have misled the management from
doing what is right for the company. As a result the company falls into ruins and tatters.
After recognising that the sick company needs treatment, sometimes the beleaguered
management's vision may be limited by the symptoms and not addressing the cause. At
this juncture, it will be useful to probe further with broad questions such as:

Is the company in trouble with the law, bank, creditors, etc?

What is the cash flow position?

Is the company up for sale?

Can the company be turned around?

Should the company be closed?

Once these broad issues are determined, the turnaround manager then ventures into
deeper issues relating to finance, marketing, operation, etc before deciding the
appropriate treatment.

Proper medicine can only be administered after the acknowledgement that there is pain.

The Murfreesboro Tennessee VA announced that it had committed a diversion from accepted medical protocol in regards to veterans who had colonoscopies performed in the VA of Murfreesboro. The lapse in accepted medical standards may have led to the veterans being exposed to HIV and Hepatitis C, due to a valve that was not properly sanitized and or attached to the medical machine used in the procedure. The valve in question can be non sterilized due to liquids that may come into contact with it during the procedure, the medical procedure was fully explained to me by a registered nurse familiar with the operation. The actual contaminated part may have never come into contact with you, but through other means diseases could have been transferred because of the non-sanatized valve. So with this said the government will settle with all affected, not at all, those days are gone if they ever were really in existence.

Using the VA as an example of how times have changed in regards to plaintiffs, lets look at the results of the medical standard deviation, in this case Veterans were exposed to HIV and Hepatitis C which are deadly diseases, you can have one or both and not be aware of it. If you test positive you then have what are called damages, and these damages are the result of the acts of the VA. That means that you do have rights as against the Federal Government, but just because you have rights does not mean the government is going to concede it is responsible for damages, the times of the changing plaintiff's case are here, and all the defense bar knows it, including the government defense attorneys.

With all cases there now appears that the VA may try to mount a defense in regards to how individuals contracted the diseases, the defense appears to center around the thought of how can you prove you got the disease from VA, it will be a defense that will require quite a lot of work to defeat. Many times people are under the impression that the government or corporations will simply hand over some type of compensation just because they made a mistake. If the those days ever existed they are long since gone, whether through TV commercials, the Mcdonald's coffee case, or the dry cleaning case of pants, the public has grown weary of lawsuits, as a result insurance companies, the government, and corporations are not so quick to simply agree to settle. The defense side of cases is aware of the climate we are in, I see no change in that climate, the clock will not reverse itself.

So if there is no change in how the defense approaches a case such as the VA case, what then? There must be a fundamental shift in how the plaintiff's attorney approaches their claim, it has to be a very centered approach, and it has to be thought through from the very moment a case is taken on. A case such as any from the VA situation cannot be approached in a settlement type fashion, there are simply to many defenses available that the government can use, to use a settlement approach from the beginning of the case is to use the tactics of forgone days. The VA case is an example of how one might be lured into thinking that you should not worry about litigating, this will be open and shut, that is incorrect logic, there will an attorney representing the VA, and why would they not pursue every avenue of defense, as the government is their client, and they have an ethical obligation to protect their client just as every attorney has that obligation. It is just not sound legal strategy to believe because someone or thing admits they committed error that they will not defend their position.

What are you rights as a veteran against the Murfreesboro VA? Your rights are under the Governmental Tort Liability Act, and Yes you do have rights. If you do test positive for any diseases related to this treatment, you have what are referred to as damages, and yes you do have legal rights, although they are somewhat different because it involves the United States Government. You have the right to sue, that is to bring a lawsuit for the malpractice committed against you, however the Federal Government is far different than a corporation in regards to seeking monetary damages in court. Your rights are no different, but the limit of damages you can recover and the certain civil procedure rules apply to a GTLA claim, in Tennessee you cannot non-suit a GTLA case, this is allowed in a non-GTLA case, should you file a non-suit in Tennessee on a GTLA your suit cannot every be brought back up, ever. A non-suit means dismissing the lawsuit and bringing it back later, that is strictly prohibited under the GTLA. The GTLA was put into place to limit the liability of towns, cities, and governmental entities.

With changing times, the GTLA, and available defenses, the days of simply filing a suit and waiting for settlement are long since over. The strategy of focusing on trial and working the case with a focused approach is the only way to work through cases, the climate is forever changed in regards to plaintiffs.

Daniel L. McMurtry, Esq