Chantix Linked to Suicide

The U.S. Food and Drug Administration is looking into reports that the anti-smoking drug Chantix may trigger mood swings and thoughts of suicide in patients taking it.
Information provided to the agency by Chantix manufacturer, Pfizer Inc. cited "erratic behavior" in an individual who had used Chantix. The agency is also investigating the death of the person who used the drug, but was also under the influence of alcohol.
The FDA has asked Pfizer for any additional information it has on reports of adverse reactions in people taking the drug. Its Center for Drug Evaluation and Research is analyzing the data and plans to release its findings to the public once the analysis is completed.
In the meantime, the agency recommends that health care providers monitor patients taking Chantix. Patients taking Chantix should contact their doctors if they experience behavior or mood changes, the FDA said.
The FDA also advises that patients taking Chantix use caution when driving or operating machinery due to reports of drowsiness.
From Foxnews
Ultimately, I don't think this is going to pan out. I don't think that Chantix causes suicide. However, in the short term I forsee further declines in Pfizer's stock price. Currently, it's just above its 52 week low. I think Pfizer will be a good buy at around 20, and recommend waiting until then to buy Pfizer.

Doctors in Debt

Cnn.com Business Section presents a case study of 2 residents deeply in debt:

It's all supposed to pay off, of course. Once they become full-fledged doctors (attending physicians, in the trade), they'll have six-figure incomes, more reasonable hours, a respected occupation and work that they love.
But for this generation of doctors, and for Meg and Chris in particular, financial security won't come guaranteed with their medical licenses. As health-care economics squeeze physician salaries, rising college and med school tuitions are putting young doctors ever deeper in the hole.
Chris and Meg live frugally, work hard and are making the kind of investments in their future that would make any parent proud. But they're also on track to finish their medical training in the next few years with a staggering $700,000 in debt.

Drug Company Lunches

I once sneezed all over a fresh pan of Olive Garden lasagna multiple times. The big, fat office hogs never noticed. They sucked it down like there was no tomorrow.
Read this site before you eat any more drug company lunches.
( via Kevin MD)

Getting Spanked

More banks brace for subprime spanking
I saw this headline in the green section of USAToday this morning.

Rather unprofessional language for a major newspaper. Within a few years we'll probably be reading about the Dow being "bitch-slapped" in the pages of USAToday ("bitch-slapped" is probably a good term to describe today's 55 point drop).

The death of sleep medicine

Please see my post on sleepdoctor about portable testing for obstructive sleep apnea.

I wish to thank Kevin, M.D. for linking to it.

Mississippi's Governor

Mississippi's Governor, Haley Barbour, has been ranked as one of the country's most influential conservatives:
About to be comfortably re-elected as Mississippi governor, Barbour is one of the most accomplished Republican executives in the United States. As a successful Southern governor with immense experience, he is a potential future presidential candidate who would be a clever pick for vice-presidential running mate in 2008. Received national plaudits for his handling of the aftermath of Hurricane Katrina, which devastated Mississippi's Gulf coast, while neighbouring Louisiana's Democratic governor floundered.Barbour, 60, has cut his state's budget deficit in half without raising taxes and used the skills he honed as a Washington lobbyist to good effect in winning over a Democratic-led state legislature. A highly successful chair of the Republican National Committee, Barbour helped lay the foundations for the Republican Revolution and the takeover of Congress in 1994.
(via Drudge)

Atheism

They say that there are no atheists in foxholes. Being unable to sell one's house can also turn a person away from atheism:

The Catholic saint has long been believed to help with home-related matters. And according to lore now spreading on the Internet and among desperate home-sellers, burying St. Joseph in the yard of a home for sale promises a prompt bid.
With the worst housing market in recent years, St. Joseph is enjoying a flurry of attention. Some vendors of religious supplies say St. Joseph statues are flying off the shelves as an increasing number of skeptics and non-Catholics look for some saintly intervention to help them sell their houses.
Some Realtors, too, swear by the practice. Ardell DellaLoggia, a Seattle-area Realtor, buried a statue beneath the "For Sale" sign on a property that she thought was overpriced. She didn't tell the owner until after it had sold. "He was an atheist," she explains. "But he thanked me."
Catholic leaders also say that faith and devotion are necessary, in addition to burying a statue, otherwise the practice amounts to little more than superstition or magic. But they are also enjoying the saint's newfound popularity. "If they have a good result and they think it was St. Joseph, it might inspire them to practice more," says Msgr. Connell.

Mediocre Care for the Poor Elderly

Vulnerable elderly receive mediocre health care, study finds
The quality of care for vulnerable elderly people on Medicaid and Medicare is “mediocre,” the authors of a new study concluded.
Researchers did a cohort study of 100,528 dual Medicaid/Medicare enrollees from 19 California counties who were age 75 and older in 1999 and 2000. They measured the care provided for 44 quality indicators (QIs) by condition, like heart failure, and intervention, such as medication, using QIs developed by the Assessing Care of Vulnerable Elders project. The article was published in the October Medical Care.
This study, as summarized by the American College of Physicians, found "medicore" care for elderly dual Medicare/Medicaid enrollees. This is the sickest, toughest population to treat. Reimbursement is less than mediocre, though that's no excuse.

Keeping Kids Calm with Video Games

If ritalin isn't enough, child psychiatrists have found a new way to keep children calm- video games. Psychiatric Times presents a case in which playing video games 6-7 hours a day helped a child's self esteem:
Case Vignette: Games and Attention/ Learning Disorders
Alex, a 13-year-old boy, spends 6 to 7 hours a day playing video games. He locks himself in his room, misses meals, and often stays up most of the night, which results in school tardiness. He learns "cheats" (tricks to find quick solutions to game-based problems) online, converses with players in chat rooms, and has accumulated a great deal of knowledge about the intricacies of the many, often violent, games he plays.
Although very bright, Alex has a nonverbal learning disability, social difficulties, poor athletic skills, and attention problems, and he was often made fun of at school. The primary source of his self-esteem, beyond academic achievement, is his video game prowess.
His parents have no understanding of the games, nor of the video games' central importance in his life. Other children in school often come to him for advice about games and strategies and ask to play with him. This has become his claim to fame in and out of school.
While his parents need to educate themselves about the games he is playing and to set limits on his game play, their initial response to curtail them has been modified over time, allowing for an important avenue in the socialization of their son.
Therapy for Alex and his parents involved their appreciation of the role and meaning of games in his life. His parents needed to understand that competence is a crucial component of positive self-esteem—something Alex needed tremendously in order to take on academic and social challenges. Video games provided a means for Alex to feel more confident in moving ahead in these areas. With a greater understanding of the role the games played in his life, his parents were much more tolerant of his game playing.
If your child doesn't play video games, it could be a problem:
Ironically, Seung-Hui Cho's college roommates found it odd that he never joined them in playing video games.
(Seung-Hui Cho was the Virginia Tech shooter)

The full article, Children and Video Games: How Much Do We Know? by Cheryl K. Olson, ScD, Lawrence Kutner, PhD, and Eugene V. Beresin, MD is on the Psychiatric Times website.

I encourage readers of this blog to read the full text of this distubing article. Ritalin and video games... what will child psychiatrists recommend next to control our children???

Gray Friday

The Dow Jones industrial average dropped more than 360 points Friday - the 20th anniversary of the Black Monday crash - as lackluster corporate earnings, renewed credit concerns and rising oil prices spooked investors.
The major stock market indexes turned in their worst week since July after Caterpillar Inc. (CAT), one of the world's largest construction equipment makers, soured investors mood Friday with a discouraging assessment of the U.S. economy. In a week dominated by mostly negative results from banks facing difficult credit markets and rising mortgage delinquencies, investors appeared surprised that an industrial name was feeling an economic pinch, too.

The Dow fell 366.94, or 2.64 percent, to 13,522.02. The Dow was down for the fifth straight session and for the week was off 4.05 percent. For the year, the blue chip index is now up 8.5 percent.
Broader stock indicators also fell sharply Friday. The Standard & Poor's 500 index fell 39.45, or 2.56 percent, to 1,500.63, and the Nasdaq composite index dropped 74.15, or 2.65 percent, to 2,725.16.

Friday's pullback pales in comparison to what investors had to contend with 20 years ago. On Oct. 19, 1987 - Black Monday - the Dow plunged 23 percent amid concerns about interest rates and slowing economic growth. A decline of similar proportion given the market's current levels would mean a drop of some 3,100 points.
Friday's decline - the third biggest point and percentage drop this year - was the 9th biggest point drop in the Dow since Black Monday.

via Drudge

Winning a Nobel Prize Doesn't make you Right

Al Gore is wrong about the role of humans in global warming. James Watson, one of the discoverers of the mysteries of DNA, is wrong about genes and racial intelligence:
One of the world's most eminent scientists was embroiled in an extraordinary row last night after he claimed that black people were less intelligent than white people and the idea that "equal powers of reason" were shared across racial groups was a delusion.
James Watson, a Nobel Prize winner for his part in the unravelling of DNA who now runs one of America's leading scientific research institutions, drew widespread condemnation for comments he made ahead of his arrival in Britain today for a speaking tour at venues including the Science Museum in London.
The 79-year-old geneticist reopened the explosive debate about race and science in a newspaper interview in which he said Western policies towards African countries were wrongly based on an assumption that black people were as clever as their white counterparts when "testing" suggested the contrary. He claimed genes responsible for creating differences in human intelligence could be found within a decade.
from The Independent

Stark III

Stark version three is apparently out:

In issuing the third phase of the final regulations implementing the physician self-referral rule, also known as the Stark law, the Center for Medicare and Medicaid Services has returned to a stance it held in the first phase.
The Stark law governs whether, how, and when it is acceptable for physicians to refer patients to hospitals, laboratories, imaging facilities, or other entities in which they may have an ownership interest.
Under the new rule, known as Stark III, published in the Federal Register on Sept. 5, physicians will be considered to be “standing in the shoes” of the group practice when their investment arrangements are evaluated for compliance, according to several attorneys.
This reversion back to the initial Stark policy is among the most important changes in the 516-page document, said Daniel H. Melvin, J.D., a partner in the health law department of McDermott, Will & Emery's Chicago office.
As a result, “the application of exceptions will be different going forward,” Mr. Melvin said in an interview.
That means most physicians who have referral arrangements will have “a lot of contracts that will have to be looked at and possibly revised,” said Amy E. Nordeng, J.D., a counsel in the government affairs office of the Medical Group Management Association. Ms. Nordeng agreed that the return to the “stand in the shoes” view was the most significant component of Stark III.
Under Stark II—an interim policy that began in 2004—physicians were considered to be individuals, outside of their practices.
Exceptions to the law were evaluated using an indirect compensation analysis, which ended up being onerous and was the subject of many complaints to CMS. In comments on Stark II, physician groups, hospitals, and other facilities (called designated health services, or DHS entities under the Stark law) urged CMS to revert to the old policy.
CMS itself came to see the indirect compensation analysis as a loophole that allowed potentially questionable investment arrangements to slip through, said Mr. Melvin.
In the Stark III rule, CMS wrote that the change in policy means that, “many compensation arrangements that were analyzed under Phase II as indirect compensation arrangements are now analyzed as direct compensation arrangements that must comply with an applicable exception for direct compensation arrangements.”
There were several other notable changes in Stark III.
The regulations clarify that physicians who administer pharmaceuticals under Medicare Part B (such as chemotherapy or infusions) or who prescribe physical therapy, occupational therapy, and speech-language pathology, are entitled to get direct productivity credit for those orders, said Mr. Melvin.
The clarification applies to those two ancillary services only, not to radiology or laboratories, or other services typically offered in-house, he said.
CMS also lifted the prohibition on noncompete agreements. Under Stark II, practices could not impose noncompete agreements on physician recruits. Now, practices can bar competition for up to 2 years, but it's not clear how far, geographically, that noncompete can extend, he said.
With the new rule, practices have to “go back and look at everything,” including how their physicians are being compensated and the arrangements the practice may have for equipment and leasing or services with hospitals or other DHS entities, Mr. Melvin said.
“At the very least, they're going to want to do a review of the arrangements in place,” to see if any of the exceptions being relied on will change with Stark III, added Ms. Nordeng.
The final Stark rule goes into effect on Dec. 5, 2007.

It's all pretty confusing to me. However, it is my understanding that sleep labs are not considered DHS entities so hopefully Stark III won't affect me too much.

Mississippi is Number One

Adult obesity is on the rise in 31 states, and no states have experienced a drop in obesity, according to a study from Trust for America's Health.
Mississippi topped the list of the fattest states, with the highest adult obesity rates for the third year in a row. More than 30% of the adult population in the state is obese. Colorado was ranked the “leanest” state with an obesity rate of 17.6%. No state has reached the Health and Human Services department goal of reducing the prevalence of adult obesity to 15% in every state by 2010.
From Clinical Psychiatry News

Go Ahead and Light up a Cigarette

Clinical Psychiatry News reports that cigarette smoking delays the onset of Parkinson's disease:
A pooled analysis of 11 clinical studies has confirmed that cigarette smoking protects against Parkinson's disease in a dose-dependent manner.
Many studies have suggested that smoking may play a protective role in PD, but most have been too small to provide definitive answers. Dr. Beate Ritz of the University of California, Los Angeles, and associates conducted a pooled analysis of eight case-control studies and three cohort studies involving 2,816 subjects who had PD and 8,993 controls. This large data set “enabled us to investigate aspects of cigarette smoking and subgroup-specific associations that could not be addressed adequately in previous studies,” they noted.
The risk of developing PD decreased as pack-years of cigarette smoking increased, so that the average relative risk for the disease dropped 5%–8% for every 10 pack-years of smoking. This dose-response pattern was seen in both men and women, and it was not affected by subjects' educational status.
There was also a strong dose-response trend for the number of years that had elapsed since smoking cessation. Current smokers and smokers who had recently quit showed the lowest risk for PD. People who had quit smoking in the past had a higher risk for PD, but their risk was still lower than that of people who had never smoked (Arch. Neurol. 2007;64:990–7).
Two possible mechanisms for this protective effect have been proposed. Substances such as nicotine in tobacco smoke may promote the survival of dopaminergic neurons, or smoking may alter the activity of metabolic enzymes and thus the production of toxic metabolites.
It is also possible that the same genetic or constitutional traits that raise susceptibility to PD may also deter subjects from smoking. Such traits could be a common cause for both smoking behavior and PD, Dr. Ritz and associates noted.
Tobacco's protective effect appeared to wane in subjects aged 75 and older, another finding that has been reported in previous studies. This is consistent with the hypothesis that smoking delays rather than prevents the onset of PD, the researchers added.
So if you are more scared of PD than lung cancer, COPD, and heart disease, go ahead and smoke!

Psychiatry Residency Training Becomes Even More Wimpy

Psychiatry, the easiest of the residency programs, is becoming even easier:

The Accreditation Council for Graduate Medical Education has reduced the amount of inpatient training necessary for psychiatry residents from a minimum of 9 months to a minimum of 6 months.
At least two psychiatrists who supervise residents say this reduction, which took place in July, “threatens to seriously undermine the quality of training for psychiatry residents.” In a commentary, Dr. Sabina Lim and Dr. Robert Rohrbaugh argue that inpatient training helps foster the development of psychiatry's fundamental skills in indispensable ways, and they note that other specialties appear to place great value on inpatient training (Academic Psychiatry 2007;31:266–9).

Poker and Investing

Sand105 posted an interesting essay on the similarities between poker and investing on the Motley Fool message boards. Here is part of it:
So how are poker and investing similar and dissimilar?
Similarities:1. Most importantly, both games involve incomplete information and randomness. The skill sets developed in one apply directly over to the other. Developing a logic train, calculating odds, and accurately inferring conclusions from incomplete information are exactly what is needed to be successful in both.
2. Both are beatable over the long term. Poker is equivalent to playing one game of chess along with a couple die rolls. Over the short term the die rolls rule – over the long term the chess matches determine the expectation. Equity investing is essentially the same.
3. Both have inherent costs. Poker has rake (5% of each pot, give or take), investing has transaction and frictional costs.
4. Both see black swans occur. No matter the skill set, sometimes the incredibly unusual occurs. Knowing how to recover from these setbacks is a very valuable skill set.
Dissimilarities:
1. By its nature, poker is a negative expectation game if no players are better than one another (due to the rake). Investing naturally has a long term ~10% positive tilt due to the nature of the markets.
2. The inherent costs in investing are lower. As long as the investor doesn’t have huge turnover, transaction costs and frictional costs are well under the cost of rake in poker.
3. More often than not, choosing to do nothing in investing is the right choice. Poker typically requires more risk taking events.
4. The variance in investing is lower than poker. For every $1 I have made in poker over the long haul there has been a ~$10 standard deviation in those results (i.e. for every $1 there is a 67% chance my result will actually be from -$4 to $6 and a 95% chance it will actually be from -$9 to $11.) This type of variance isn’t typical of the equity markets.
5. In poker, to win in the long term a player simply tries to ride out the variance. An investor, however, can use variance to their benefit. BMW has talked about this extensively. Figuring out to what price an equity is likely to jog down to in the short term can greatly juice overall returns.
Lessons Learned:
As a person who has played over 1,000,000 hands of poker in the last few years and been involved in the markets for 15+ years, there are some things that I have learned that I hope folks will find useful.Pretty much in the order I think they are important, these are lessons I think provide for success in both poker and equity investing:
1. Emotional control. Yep, after all the talk about logic trains and odds, I firmly believe emotional control has the most effect on long term results. This is multifaceted. The primary emotion one needs to regulate is tilt (“fear”). Selling in panic is very, very often the exact wrong thing to do. Yet even very experienced investors have it happen. It can’t be stomped out completely – however minimizing it will do wonders for an investor’s return. On the flip side of the coin boredom can be almost as damaging. Playing a hand one shouldn’t or making a trade just because you haven’t had anything enticing float by in a while is usually a mistake. Coincidentally, Whatismyoption has just posted an excellent thread on this subject: http://boards.fool.com/Message.asp?mid=25872875&sort=whole#25876516
2. Recognize that once you buy and equity or put your money into the pot, that money should be treated as if it is no longer yours (in poker it actually is no longer yours). Most people base decisions on selling an equity based on whether or not it has been performing for them. This is wrong! It doesn’t matter if the equity has lost a bunch or gained a bunch since ownership – it is the prospects for the future, the odds that one will see a rise from that price point, that count. In a game sense, when you buy an equity you give your money to Mr. Market. He then takes it and walks around with it – you have no direct control over that walk at all. You are simply betting on the overall direction of his travels. All decisions should be based on that premise. Since most investors feel the loss of money as near physical pain (lots of studies out there on investor psychology), they watch their returns like a hawk and decide to sell based on past performance. Sell decisions should be based on changes in how speculative a stock is, changes in fundamentals, tax loss harvesting, finding a better opportunity, etc. Price by itself, and your buy point relative to that price, is irrelevant.
3. Recognition of high probability situations. Dhandho, in other words. Figure out how to get your money into play with a 60-40 advantage over and over and riches will follow. In investing there are choices every day to hold, buy or sell. Most of the time this will be to hold, but when the high probability situations roll by, grab on and get a piece.
4. The corollary to #3. Don’t bet unless you have lopsided odds. Taking those 51-49 bets, though positive, leads to very high variance. Leave that to the institutional investor who has the bankroll to spread those bets around in enough places to get to the long term. Most individual investors will never get there.
5. Playing games, chess, poker, etc keep the mind agile and greatly assist in both business and investing. Mental cross training. Learning emotional control. Recognizing that both poker, investing, business, and other difficult-but-satisfying-activities are lifelong pursuits and ones in which there is always something new to learn and improvements to be made.

I have found that poker (online Texas no-limit hold'em), stock trading, and sleep medicine are very similar- all three involve long hours staring at a computer screen.
Stock trading and interpreting a sleep study both involve looking at sometimes ambiguous sinusoidal data and trying to interpret the pattern. Online poker and sleep medicine both involve looking at flickering lights/constantly changing patterns on a screen.

Bipolar Disorder Overdiagnosed in Children

The New York Times reports on the alarming increase in the diagosis of bipolar disorder in children:
The number of American children and adolescents treated for bipolar disorder increased 40-fold from 1994 to 2003, researchers are to report on Tuesday, in the most comprehensive study to look at the controversial diagnosis. And experts say the numbers have almost certainly risen further in the years since.
But others argue that bipolar disorder is overdiagnosed. The term, they say, has become a diagnosis du jour, a catch-all now applied to almost any explosive, aggressive child. Once children are labeled, these experts add, they are treated with powerful psychiatric drugs that have few proven benefits in children and potentially serious side-effects, like rapid weight gain.
“From a developmental point of view, we simply don’t know how accurately we can diagnose bipolar disorder, or whether those diagnosed at age 5 or 6 or 7 will grow up to be adults with the illness,” he said. “The label may or may not reflect reality.”
Most children who qualify for the diagnosis do not go on to develop the classic features of adult bipolar disorder, like mania, researchers have found. They are far more likely to become depressed.
Others say their children have suffered from side effects of drugs given for bipolar disorder, without getting much benefit.
Ashley Ocampo, 40, of Tallahassee, Fla., the mother of an 8-year-old boy, Nicholas Ryan, who is being treated for bipolar disorder, said that he had tried several antipsychotic drugs and mood stabilizers, and that he had been better lately.
But, she said in an interview, “He has gained weight, to the point where we were struggling find clothes for him; he’s had tremors, and still has some fine motor problems that he’s getting therapy for.”

What do you call a nurse practitioner?

Codeblog recently posted on the dilemma of whether a nurse should call a physician by his first name. I frequently encounter a similar problem in my sleep practice: how to address a nurse practitioner in a letter.
For example, suppose a Certified Family Nurse Practitioner named Jane Doe has referred me a patient and I am sending her a consult note. Is it more proper to say "Dear Mrs. Doe", "Dear Ms. Doe", "Dear Nurse Doe", "Dear Nurse Practitioner Doe", or "Dear Jane Doe, CFNP"??

This is how I usually address the letter:

Jane Doe, CFNP
123 Maple Street
Jackson MS 39323

Dear Jane Doe, CFNP

Thank you for referring Mr. Smith for...

If I know the Nurse Practitioner's supervising physician's name, I will usually cc him at the bottom of the letter, esp on Medicare patients. This helps to justify billing the patient as a consult rather than a new patient.

Preparing for a career in sleep medicine

Dear Sir,
I am currently enrolling for classes at Brigham Young University - Idaho. I have an interest in sleep therapy and sleep studies. I was wondering if you could offer me some advice as to what kind of Bachelors degree would best suit this line of work. I was thinking that Biology might prepare me the best for medical school. I was wondering if a degree in psychology would be better? I was also thinking about minoring in Health Science. Would this help my occupational and academic choices later on in the field of sleep studies? Thank you for your time.

My response to this letter from a reader:

Sorry about the time to get back to you.

The best type of Bachelors degree would be the one to prepare you for medical school. Any major would be fine, but you will need to take a yr of bio, chem, physics, and organic chem during college, preferably in the first 2 years. Some med schools require calculus. A class in basic statistics would be also be helpful. It would be easiest to fit these pre-med requirements into a bio or biochem major, but you can take any major. Don’t worry about planning for a sleep career until near the end of med school.

Good luck

Michael Rack, MD

The AMA is Threatening me

I recently received the following letter from the Mississippi State Medical Association, Central Medical Society (the branch of the American Medical Association covering central Mississippi):

July 18, 2007





Michael J. Rack, M.D.


1006 Treetops Boulevard


Suite 2


Flowood, MS 39232





Dear Doctor Rack:





2007 is well underway and we have not yet received your membership dues. Our records show that you have not paid your local, state, or AMA dues for 2007. I'm sure this is just an oversight, so please use the enclosed envelope to send your check right away. Pease make your check payable to Mississippi State Medical Association.





According to the MSMA Bylaws, physicians who have not paid annual dues by April 1 forfeit membership privileges and must be removed from the membership roster. Membership in the Mississippi Physician (its actually, plural -Physicians, but I have tried to reproduce the letter as closely as possible) Care Network (MPCN) is also in jeopardy.





MSMA continues working to protect the doctor-patient relationship and to enhance the climate in which physicians practice. I encourage you to continue your membership by remitting your dues right away, beause together we are stronger.





Sincerely,





William M. Grantham, M.D.


President


________________________________________________________________


Return this portion with your dues





2007 REQUIRED DUES





Central Medical Society $90.00


MSMA Dues $450.00


AMA Dues $ 300.00


_______





Total Required Dues $840.00





2007 OPTIONAL DUES





MMPAC/AMPAC $150.00


Alliance Dues $90.00


________





Total Optional Dues $240.00








Total Required and Optional Dues $1080.00








The AMA is threatening me with loss of provider status in a key local insurance network, the Mississippi Physicians Care Network (MPCN), if I do not send $840 to the AMA. I will not give in to this corrupt organization. I will probably drop out of the MPCN, though I believe I have the option of sending an amount roughly equivalent to the $840 AMA fee to the MPCN to stay in their network. I would rather that the MPCN get my money than the AMA. I don't give in to extortion. This is one less physician that the tools in the AMA will be representing.