Friday, May 22, 2009

Blue Double Cross - Paul Krugman,

That didn't take long. Less than two weeks have passed since much of the
medical-industrial complex made a big show of working with President
Obama on health care reform — and the double-crossing is already well
under way. Indeed, it's now clear that even as they met with the
president, pretending to be cooperative, insurers were gearing up to
play the same destructive role they did the last time health reform was
on the agenda.

So here's the question: Will Mr. Obama gloss over the reality of what's
happening, and try to preserve the appearance of cooperation? Or will he
honor his own pledge, made back during the campaign, to go on the
offensive against special interests if they stand in the way of reform?

The story so far: on May 11 the White House called a news conference to
announce that major players in health care, including the American
Hospital Association and the lobbying group America's Health Insurance
Plans, had come together to support a national effort to control health
care costs.

The fact sheet on the meeting, one has to say, was classic Obama in its
message of post-partisanship and, um, hope. "For too long, politics and
point-scoring have prevented our country from tackling this growing
crisis," it said, adding, "The American people are eager to put the old
Washington ways behind them."

But just three days later the hospital association insisted that it had
not, in fact, promised what the president said it had promised — that it
had made no commitment to the administration's goal of reducing the rate
at which health care costs are rising by 1.5 percentage points a year.
And the head of the insurance lobby said that the idea was merely to
"ramp up" savings, whatever that means.

Meanwhile, the insurance industry is busily lobbying Congress to block
one crucial element of health care reform, the public option — that is,
offering Americans the right to buy insurance directly from the
government as well as from private insurance companies. And at least
some insurers are gearing up for a major smear campaign.

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Fear of Contagion -

Early on in my internship, a senior doctor pulled me aside after hearing a couple of other interns grouse with me about our workload. “Caring for patients is a privilege, a calling,” he said. “Remember, no one forced you to sign your contract.”

For years those words came to mind whenever I cared for patients who had lethal, and potentially contagious, infections, patients like Jean (not her real name), who was in her 50s when I met her. She had contracted hepatitis C from receiving a vaccination with a contaminated needle years before, and the symptoms of her end-stage liver failure had become increasingly difficult to tolerate over the last year. She itched constantly from jaundice; her memory had deteriorated; and she had had episodes of life-threatening bleeding that had landed her in the intensive care unit on two separate occasions. According to the nurses, Jean had walked into the hospital on the night she was to receive a liver transplant, bubbling over about the new start on life she would have with the new organ.

Despite Jean’s optimism, she ended up suffering from a series of devastating postoperative complications and infections. By the time I came onto her surgical team as one of the interns, she had spent three months in the hospital.

One morning soon after I began taking care of her, one of the nurses noticed that Jean had become short of breath. A chest X-ray showed fluid in her lungs, fluid that I could drain to help her breathe. The drainage procedure wouldn’t take long once the needle was in her chest; but because everything would be done using sterile technique, once the procedure started, I could not leave Jean’s side or touch anything other than the instruments I was using.

My beeper went off the moment I slipped on the sterile gloves. I tried to ignore it, forging ahead with the procedure. I disinfected Jean’s skin, laid down sterile drapes and began numbing her skin with a syringe filled with anesthetic solution.

Over and over again, my beeper went off. And I continued ignoring it until the fifth page, when I began to worry that there might be an emergency elsewhere in the hospital. I wriggled my hips against Jean’s nightstand, trying to dislodge the beeper from my waist without touching it or contaminating the sterile field. I shouted for help, but no one answered my calls.

Finally, when my pager went off for the sixth time, I pulled off my left glove and reached down, groping for the beeper hanging on my right hip while walking toward the door to find a phone.

I felt a sharp sting. Looking down, I saw a small scarlet drop emerging from the tip of my left index finger. I had stabbed my finger against the needle I had just used to anesthetize Jean’s skin, a needle I still held in my right hand.

I stared at the tiny red bloom on my fingertip. And for a moment, I felt the floor beneath my feet give way, pulling everything — Jean, my heart, my work, my life — down with it. I stood there paralyzed, staring at the puncture wound on my fingertip and unable to stop the movie playing in my mind’s eye, a movie of a future like Jean’s. Jean would never leave the hospital and, a few months later, would die in the I.C.U., succumbing to a final, massive infection.

Over the years, I have been stuck, cut, coughed on, scratched and splashed several more times. Each time, I feel the floor and my life fall away. I have never contracted a life-threatening infectious disease; but sometimes I catch myself wondering if it’s only a matter of time. During the SARS epidemic a few years back, for example, health care workers were disproportionately affected; certain hospitals in affected areas reported that over half their workers contracted the disease.

And then every day there is news that swine flu may still reach pandemic proportions.

When I think about the possibility of becoming infected with a potentially deadly disease during the course of my work — when I allow myself to think about it — I struggle to reconcile my beliefs about a doctor’s responsibilities and my fears about my own safety.

But, always, I arrive at the same conclusion. Like that senior doctor, I believe it’s a privilege, a calling, to take care of patients. And I believe that in deciding to practice medicine, I have consented to an unspoken contract with the public, one that requires that I take care of those who are sick.

Lately, however, I have also begun to think that there is another side to that contract. Maybe there are obligations that the general public has to its health care workers.

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Brain Power - At Card Table, Clues to a Lucid Old Age

The ladies in the card room are playing bridge, and at their age the game is no hobby. It is a way of life, a daily comfort and challenge, the last communal campfire before all goes dark.

This bridge game is not for the timid. Norma Koskoff, left, Ruth Cummins and Georgia Scott expect the best from every player. If someone’s skills start slipping, it is time to find a new table.

“We play for blood,” says Ruth Cummins, 92, before taking a sip of Red Bull at a recent game.

“It’s what keeps us going,” adds Georgia Scott, 99. “It’s where our closest friends are.”

In recent years scientists have become intensely interested in what could be called a super memory club — the fewer than one in 200 of us who, like Ms. Scott and Ms. Cummins, have lived past 90 without a trace of dementia. It is a group that, for the first time, is large enough to provide a glimpse into the lucid brain at the furthest reach of human life, and to help researchers tease apart what, exactly, is essential in preserving mental sharpness to the end.

“These are the most successful agers on earth, and they’re only just beginning to teach us what’s important, in their genes, in their routines, in their lives,” said Dr. Claudia Kawas, a neurologist at the University of California, Irvine. “We think, for example, that it’s very important to use your brain, to keep challenging your mind, but all mental activities may not be equal. We’re seeing some evidence that a social component may be crucial.”

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Thursday, May 21, 2009

Share the Health: Training People with Disabilities and Chronic Medical Conditions on How to Locate Quality Health Information

In March 2008 the Alliance Library System (ALS), a multitype library system headquartered in East Peoria, Illinois that serves over 250 libraries and over 1 million residents of Central Illinois, received a $35,000 grant from the Greater Midwest Region of the National Library of Medicine (GMR) to provide consumer health information to individuals with disabilities and chronic illness who use the three-dimensional virtual world known as Second Life.

How Mayo Clinic utilizes Web 2.0

Lee Aase (@LeeAase) is manager of Syndication and Social Media for Mayo Clinic. During Community 2.0 Conference which recently took place in San Francisco, he presented how Mayo Clinic has been taking advantage of Web 2.0 and social media. Take a look at his slide show to learn how Mayo Clinic fantastically promotes itself with basically no financial investments.

Mobile Libraries: PubMed On Tap

PubMed On Tap is an application for your iPhone or iPod Touch that lets you search PubMed while on the go >>>

Specify fields and search mode, using AND, OR, and NOT logic operato

Specify option to find only articles with Full Text or Free Full Text

E-mail the results as formatted text or an RIS tagged record, ready to be imported into reference management applications like Bookends and EndNote

Wednesday, May 20, 2009

Plan for a good death - talk about your wishes - Dr. Michael Evans

We're not very good at dying.

I suppose it makes sense. Death is taboo. We can't foresee the future and who knows what will happen. It's painful to think or talk about our own death, or the death of someone we love. For these reasons and many more, we tend to leave it to fate.

This avoidance was reflected in results of the continuing Coping with Cancer trial recently published in the Archives of Internal Medicine. A team of investigators, led by researchers at the Dana-Farber Cancer Institute in Boston, interviewed 603 patients with advanced cancer. They asked the patients, who had about "six months left to live," whether their doctors had discussed their wishes for end-of-life care. Keep in mind this is at a famous specialist centre that often cares for people at the end of their lives. The majority - 69 per cent - said those conversations had not taken place.

There are many costs of not having this conversation. The most "expensive" part is that patients end up dying in a way that they would not have wished. For example, they may feel they are ready to die today, but are kept alive in an intensive-care unit for a week instead.

This was seen in the study because the absence of end-of-life conversations led to more physical distress in the final week of life, as reported by nurses and caregivers.

The second cost is more predictable. In the last week of life, those patients who had talked with their doctors wound up with medical bills that were on average 36 per cent lower than those of patients who did not have end-of-life conversations. This signals that they made a conscious effort to plan a good death. If we say nothing, we tend to get everything the hospital can give us.

Usually our prime directive in medicine is to ask for more: more tests, more imaging and more opinions. The son or daughter or doctor or nurse who arrives on the scene feels better when they've added rather than subtracted. Yet at the end of life, less is often more. There are many reasons why patients who have advanced illnesses receive inappropriate care, but most of them are rooted in a medical philosophy that is focused almost exclusively on curing illness and prolonging life, rather than on improving the quality of life and relieving suffering. After a long life, many prefer not to have a high-tech death at the hospital in June, but instead would like to die at home in May surrounded by loved ones.

A friend phoned the other day as she had been called to Ottawa to care for her mother, who has had Alzheimer's disease for some time and was very ill with pneumonia. I asked if they had treated her with antibiotics. She thought for a second, as if absorbing the implications of this, and said she didn't know. When she got back home, she called me and said that her mom had survived but that the family had mixed feelings since they believe she would not have wanted to live in her current state. She also told me of her sister's revelation that the emergency room doctor had called and said, "We've seen your mom here a few times lately ...," but it was only in retrospect that she realized that she had been offered the option that her mother not be treated with antibiotics.

Herein lies the dichotomy, the decision to focus on reducing suffering is made only after life-prolonging treatment has been ineffectual and death is imminent. It's very hard to switch gears - to let go of the rope.

It's a lot easier when you have a clear sense that this is what the person would have wanted.

Acknowledging that it's morbid, that things can change, and you reserve the right to change your mind, perhaps it's time to look across the room at your loved one(s) and have a conversation about what a good death would look like to you. What would you want in certain scenarios? (What if I can't talk or write or signal my thoughts? What if I become too sick to eat except through a tube? What if I am demented? Who is my proxy?) This conversation becomes more imperative if you are facing down a tough diagnosis.

Writing down your philosophy is best because informal discussions about these matters can lead to misinterpretation at the time of crisis. As Willie Molloy, a geriatrician and professor of medicine at McMaster University says in his book, Let Me Decide, "If we have stated our wishes clearly, doctors and family don't have to second-guess what kind of treatment we would want." You will receive the treatment you want. You take your family "off the hook." We call this an advance directive.

Believe me, this is all harder than it sounds. Many doctors have told me that they didn't understand why family members couldn't withdraw aggressive care, yet when it came to their own parents they too were paralyzed.

Not all deaths are good and maybe they shouldn't be. Death can be unfair and premature and some may simply side with Welsh poet Dylan Thomas and "rage against the dying of the light." Contrary to popular mythology, families that are disconnected in life rarely find harmony in death.

As Jonathan Swift, the 18th-century satirist and essayist wrote, "May you live all the days of your life." A good death is one that is pain free, dignified and on your own terms. It's when you truly live all the days of your life.

Choosing a Specialty in Medicine: Female Medical Students and Radiology -- Fielding et al. 188 (4): 897 -- American Journal of Roentgenology

Patient contact remains an important factor for medical students choosing a career. To attract high-caliber students, medical schools should expose students to areas of radiology involving patient interaction. Academically qualified women should be identified early during their careers and encouraged to apply for radiology residencies.

American Medical Women's Association (AMWA)

The American Medical Women's Association (AMWA) is an organization of women physicians, medical students and other persons dedicated to serving as the unique voice for women's health and the advancement of women in medicine. The organization was founded by Dr. Bertha VanHoosen in 1915 in Chicago, at a time when women physicians were an under-represented minority. As women in medicine increase in numbers, new problems and issues arise that were not anticipated. AMWA has been addressing these issues for 93 years.

Female doctors hurt productivity: report

The growing ranks of female physicians in Canada will slash medical productivity by the equivalent of at least 1,600 doctors within a decade, concludes a provocative new analysis of data indicating that female MDs work fewer hours on average than their male colleagues.

The paper comes just a year after a blue-chip list of medical educators publicly condemned what they called the scapegoating of women for Canada's severe doctor shortage.

Dr. Mark Baerlocher, the study's lead author, acknowledged he is tackling a thorny issue, but stressed he does not favour curbing the number of female physicians. Instead, the study calls for greater increases in medical-school enrolment to offset the phenomenon.

"It's not meant to be a negative paper in any way," he said in an interview. "It's meant to take an objective, hard look at the work-hour differences that most people would agree are very real.... You can't simply ignore it because it's a sensitive issue."

The researchers analyzed results from the 2007 National Physician Survey.

The survey found that women, on average, provided 30 hours a week of direct patient care, compared with 35 by men, the result of female doctors -- still burdened disproportionately with child rearing and other domestic tasks -- doing less on-call work and being more likely to take leaves.

Those figures were then factored in with population numbers to calculate doctor productivity per capita.

In 2007, women made up 32% of doctors. But with female students now accounting for about 60% of medical school classes, the numbers are expected to even up within a decade.

When the male-female balance reaches 50-50, overall productivity will have decreased by the equivalent of 1,588 male doctors or 1,853 female doctors, all else being equal, the study concluded.

The decreased productivity would be felt sooner in specialties already becoming female-dominated, such as pediatrics and obstetrics and gynecology, the researchers say.

The long surgical wait times and lack of family physicians that plague the Canadian health care system are largely blamed on the paucity of doctors. Their ranks -- now at 67,000 -- would need to jump by another 20,000 to reach the average for Organization of Economic Co-operation and Development countries.

Much of the problem is blamed on a decision by provincial governments in the early 1990s to slash medical-school enrolment, just as the ageing Baby Boom generation was producing more illness. In recent years, enrolment has been increased somewhat again.

Dr. Robert Ouellette, president of the Canadian Medical Association, said medical schools need to train even more doctors than they do now, but he steered clear of suggesting the lifestyles of female doctors are making the shortage more acute.

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Tuesday, May 19, 2009

This Mom Didn’t Have to Die -

On this trip through West Africa with my "win-a-trip" contest winner, I was reminded of one of the grimmest risks to human life here. Despite threats from warlords and exotic disease, it's something even deadlier: motherhood.

One of the most dangerous things an African woman can do is become pregnant. So, along with the winner of my contest for college students, Paul Bowers, I have been visiting the forlorn hospitals here in West Africa. According to the World Health Organization, Sierra Leone has the highest maternal mortality in the world, and in several African countries, 1 woman in 10 ends up dying in childbirth.

It's pretty clear that if men were dying at these rates, the United Nations Security Council would be holding urgent consultations, and a country such as this would appoint a minister of paternal mortality. Yet half-a-million women die annually from complications related to pregnancy or childbirth without attracting much interest because the victims are typically among the most voiceless people in the world: impoverished, rural, uneducated and female.

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Doctors and Medical Students Embrace Smartphones -

To his frustration, Steven Schwartz often encounters patients who have no idea what each of the pills they've been popping is called.

"But usually they can tell you what it looks like," the Georgetown University Medical Center family practitioner said. "They might say it's a blue, triangular pill for hypertension."

Armed with an iPhone, Schwartz is able to play detective.

He uses an application called Epocrates to input pill characteristics, such as color, shape and clarity. The software replies with a list of medications and images that match those criteria, allowing him to deduce what the patient is taking.

Schwartz says his iPhone has become indispensable: He uses it to pull up instructional diagrams and videos for patients, write electronic prescriptions and check basic information, with the patient beside him.

" 'This is how often you need a colonoscopy,' I'll say to a patient," Schwartz said. "I'm just double-checking on my phone to make sure I don't make a mistake."

Doctors are also using smartphones to look up drug-to-drug interactions, to view X-rays and MRI scans, and even to stream music from the Internet during surgery.

The power and versatility of smartphones, Schwartz said, is leading more doctors to abandon their pagers and PDAs. Of the various smartphones on the market, such as the ones made by BlackBerry and T-Mobile, the iPhone's graphic, audio, video and memory capabilities are helping it take the lead in the medical field.

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Monday, May 18, 2009

Second Opinion: The doctor in your pocket

Here's what I'll call the "60/60 challenge". Sixty percent of the world now has a cell phone, according to a recent UN report – and 60% of Canadian adults now live with one or more chronic conditions, such as diabetes, cancer, asthma, hypertension or depression. Chronic illness spares few among us: The world is getting fatter, older and sicker.

Add to this a global financial meltdown and a swine flu outbreak – and we have a perfect storm. Many healthcare systems are unsustainable. Forget for a moment about fancy robotic surgery, personal genomics or the electronic medical record (EMR) – a digital transcript of a doctor's visit, including patient histories, exam notes, tests and medications. An EMR, though critical to patient safety, costs money and takes time to launch. Let's think instead about cell phones.

Lots of very smart people across the world ‹ from Menlo Park, Calif., to Bihar, India – are churning out low-cost, low-tech innovations that can help
people manage their chronic conditions. Cell phones may be a large part of the answer. Imagine if medication reminders, scheduling notifications or lab test information could be transmitted to cell phone users using text messages.

Could mass cell messages from the U.S. Centers for Disease control remind us to wash our hands and cough into our sleeves, thereby slowing viral spread during a pandemic? Imagine if you could receive diabetes management tips through your cell phone. Or imagine if a nurse could send a cell phone alert to a worried Mom telling her how long she'd need to wait before her sick child could see an Emergency Room doctor. Imagine if doctors and nurses were reimbursed for such alerts.

All of this is eminently feasible. HealthPia America, a Newark-based company, has a cell phone that also serves as a blood glucose monitor and
pedometer (a device that counts your steps). British patients with diabetes have, since 2002, been signing up for Sweet Talk, a service that reminds them via cell phone to take their insulin and offers general education about how to live well with diabetes. Your cell phone is the doctor in your pocket: It offers real-time intervention and targeted clinical decision support.

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Second Opinion | National Post

Our health problems, your solutions

Sunday, May 17, 2009

Months to Live - Fighting for a Last Chance at Life - Series -

VIRGINIA BEACH — As Lou Gehrig's disease sapped Joshua Thompson of his ability to move and speak last fall, he consistently summoned one question from within the prison of his own body. "Iplex," he asked, in a whisper that pierced his mother's heart. "When?"

Iplex had never been tested in people with amyotrophic lateral sclerosis, the formal name for the fatal disease that had struck Joshua, 34, in late 2006. Developed for a different condition and banished from the market by a patent dispute, it was not for sale to the public anywhere in the world.

But Kathy Thompson had vowed to get it for her son. On the Internet, she had found enthusiastic reviews from A.L.S. patients who had finagled a prescription for Iplex when it was available, along with speculation by leading researchers as to why it might slow the progressive paralysis that marks the disease. And for months, as she begged and bullied biotechnology companies, members of Congress, Italian doctors and federal drug regulators, she answered Joshua the same way:

"Soon," she said. "Soon."

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