Tuesday, August 28, 2012

Physician-assisted suicide poisons the mission of medicine - The Globe and Mail

Recent events suggest that the assisted-suicide movement has gained momentum; reports from the Royal Society of Canada, the Quebec National Assembly and the British Columbia Supreme Court all support legalization of physician- assisted suicide. But the case is not closed.

Confusion reigns. Doctors opposed to physician-assisted suicide are sometimes labelled as paternalistic, disrespectful of patients’ autonomy and blind to certain aspects of human dignity. These are inaccurate and offensive descriptions of who we are and what we do in the sick room.

The public must be reassured that the needs of dying patients can be met within current legislation and practices. It must realize that we are able to have conversations about halting futile life-supporting interventions; we are able to “unplug” ventilators and be a compassionate witness to death; we are able to relieve physical and emotional suffering with an increasingly sophisticated array of medications, up to and including progressive terminal sedation. All the while, we are not ready to act upon “requested death.”

What is it about euthanasia and assisted-suicide that frightens doctors?

Madam Justice Lynn Smith, of the B.C. Supreme Court attempts to assuage our concerns by suggesting that it would be a matter of a few isolated cases and that safeguards have been proven effective in other jurisdictions. These predictions are highly debatable. Even if this wishful thinking were correct, it misses the point.

Our angst is not limited to cases of assisted-suicide. It is rather that engaging in it alters the mission of medicine. It strikes at the very core of our beings as healers. It would leave an indelible imprint on dialogues with all patients. Our worry is anchored in the deep recognition of the vulnerability of sick persons and the power differential that exists in the doctor-patient relationship.

Doctors can become angry with patients. Patients can desire to please their doctors. Such feelings, and many others, can profoundly affect decision-making in directions contrary to patients’ best interests.

The risk is too great. The medical profession is able to make mistakes and to act from dishonourable motives; its members are far from infallible. To apprehend these facts one need look no further than the German Medical Association’s May, 2012 apology for the complicity of (many) doctors under the Third Reich in abrogating their obligations as healers.

There is much cloudiness swirling about this issue – even within the profession itself. A recent editorial in the Canadian Medical Association Journal entitled, “Choosing when and how to die: Are we ready to perform therapeutic homicide?” may have inadvertently perpetuated the confusion. The authors argued that the euthanasia debate has been largely theoretical because of the “tacit assumption that doctors do not kill people.” I object to the suggestion that “do not kill” is a tacit (i.e. a silent) feature of medical practice. The voices in favour of maintaining this cornerstone-of-medicine have been persistent, noisy and unambiguous.

The Hippocratic Oath includes a stern injunction: “I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect.” This constraint has guided medical doctors for more than 2,400 years. For example, it provides the inspiration and motivation for the steadfast refusal of the vast majority of physicians from participating in capital punishment. We do not administer the lethal injections that kill convicted criminals. Neither should we accept to administer it under scenarios envisaged by Judge Smith.

Physician-inflicted death is unnecessary and potentially harmful and I do not want to teach medical students how to end their patients’ lives. If society concludes that it is advisable, it must not foist it lock, stock and barrel onto the medical profession. Physicians must not become the agents of implementation. Euthanasia and assisted-suicide must not become “medical” acts.

Palliative-care physicians are among the staunchest opponents of euthanasia. Professionals who are most often in the thick of things must be heard. If Canada is to disregard the consensus opinions of palliative-care physicians and look askance at our collective anxieties then let it confer responsibility for assisted-suicide on a non-physician group.

Nothing would prevent society from mandating responsibilities to a new profession; I have called it euthanatrics.

Its practitioners – euthanologists – could ensure that society-sanctioned suicides are carried out expertly, with transparency and accountability. It would provide a mechanism to meet new legislative demands while protecting the medical profession so that it can continue to fulfill its ancient mandate of healing.

J. Donald Boudreau is Arnold P. Gold Foundation Associate Professor of Medicine at McGill University.


Monday, August 27, 2012

Overtreatment Is Taking a Harmful Toll - NYTimes.com

When it comes to medical care, many patients and doctors believe more is better.

But an epidemic of overtreatment — too many scans, too many blood tests, too many procedures — is costing the nation's health care system at least $210 billion a year, according to the Institute of Medicine, and taking a human toll in pain, emotional suffering, severe complications and even death.

"What people are not realizing is that sometimes the test poses harm," said Shannon Brownlee, acting director of the health policy program at the New America Foundation and the author of "Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer."

"Sometimes the test leads you down a path, a therapeutic cascade, where you start to tumble downstream to more and more testing, and more and more invasive testing, and possibly even treatment for things that should be left well enough alone."

Terrence Power of Breckenridge, Colo., said that after his wife, Diane, learned she had Wegener's disease, an uncommon autoimmune disorder, the couple found it difficult to refuse testing recommended by a trusted doctor. The doctor insisted on office visits every three weeks, even when she was feeling well. He frequently ordered blood tests and X-rays, and repeatedly referred her to specialists for even minor complaints. Even when tests came back negative, more were ordered, and she was hospitalized as a precaution when she developed a cold. During one six-month period, she had 25 doctor visits. The couple was spending about $30,000 a year out of pocket for her care.Have you experienced too much medicine? As part of The New York Times's online series The Agenda, I asked readers to share their stories. More than 1,000 responded, with examples big and small.

Some complained that when they switch doctors they are required to undergo duplicate blood work, scans or other tests that their previous doctor had only recently ordered. Others told of being caught in a unending maze of testing and specialists who seem to forget the patient's original complaint. I heard from doctors and nurses, too — health professionals frustrated by a system that encourages these excesses.

"He was convincing enough that we felt we needed to have it done," said Ms. Power, 60, who recalls being sedated before an endoscopy procedure, one of the last tests she allowed her doctor to perform. "When they were getting ready to knock me out I was thinking, 'Why am I doing this?' But we felt like the doctor knew what to do and we trusted him."

After several years of physical suffering and near financial ruin from the medical costs, the couple began questioning the treatment after consulting with other patients in online support groups. Mr. Power spoke with his own primary care doctor, who advised him to find a new specialist to oversee Ms. Power's care. "It's a really hard thing to determine when they've crossed the line," Mr. Power said. "You think she's getting the best care in the world, but after a while you start to wonder, what is the objective? He seemed caring, but he didn't really consider my wife's time and the suffering she was going through having all these tests done."

Under the new doctor's care, the regular testing stopped and Ms. Power was finally able to achieve remission. Now she sees the doctor only four or five times a year.

Sometimes the toll of too much medicine is brief, but emotional. Kara Riehman, 43, of Atlanta was vacationing in California when she lost a struggle with an ironing board in her hotel room and ended up with a black eye.

As the bruising peaked around 10 days, she called her doctor to make sure everything looked normal. But instead of seeing her, the doctor, through a conversation with the nurse, ordered a CT scan. She had no symptoms other than a bruised eye, but the doctor never spoke with her or examined her. The scan came back with an ambiguous finding, and the nurse told her it could be a tumor. She was then given an M.R.I. and for two weeks while she waited for the results, she worried she had brain cancer. The nurse called to tell her the M.R.I. was fine.

"It was really terrible," she said. "It was only two weeks, but there is a lot of cancer in my family. I never actually talked to my doctor through this whole thing."

The total cost to her insurance company was about $7,000. "It did change how I think about interacting with the medical system," Ms. Riehman said. "It made me much more of a questioning consumer."

Jim Donohue, a Brooklyn bank examiner, had to intervene on behalf of his father, now 79, who had a stroke in March 2007. Doctors in Florida put him on several medications, including two antidepressants, and soon after the man began hallucinating and showing signs of dementia. Mr. Donohue began researching the drugs, and learned they were associated with cognitive problems. He persuaded his father's doctors to change the medication, and his father quickly improved. He has since recovered, and has been living on his own for four years.

"All the medical professionals seeing him along the way, the hospital, twonursing homes and nobody thought of this," said Mr. Donohue, who said his father never should have been given a diagnosis of depression in the first place. "I don't know if we have too many specialists and every one is trying to practice their specialty, but it should not have happened."

When Kathryn Gullo, a teacher in the Los Angeles area, gave birth to twinsjust 25 weeks into the pregnancy, she was thrust into the intense medical care of the neonatal ward that saved her children's lives. But when her daughter, Grace, was 3 months old she was transferred to a different hospital, where the doctors insisted on subjecting her to a battery of tests for symptoms that other doctors had dismissed as normal for her condition. "We felt like we were being bullied," Ms. Gullo said. "I had enough faith in her previous doctors that it was then easy to say no."

The family switched hospitals and their daughter, now 5 and living with mild cerebral palsy and some vision and feeding issues, continues to require specialized care. But recently, when doctors suggested an M.R.I. that would require that their daughter be anesthetized, Ms. Gullo and her partner, Katie Ingram, said they asked two key questions: "What new information will this give us?" and "Will it change what we are doing?" After talking to the doctor, they declined the M.R.I.

"Not every mystery has to be solved, and not every problem has to be addressed," Ms. Gullo said. "That's hard to get your brain around."


The Root of Physician Burnout - Richard Gunderman - The Atlantic

A colleague of mine in primary care medicine has decided to leave the practice of medicine. She is very well trained, has impeccable professional credentials, and works in a thriving practice. Over the past several years, however, she has noticed an unrelenting decline in the sense of fulfillment she derives from her work. She feels increasingly frustrated with what she calls the "bureaucratization" of medicine, and resents spending "more time filling out forms than caring for patients." My colleague is suffering from what is commonly described as burnout.

Last week Dr. Elaine Shattner described a new report in the Archives of Internal Medicine that indicates that rates of burnout among U.S. physicians significantly exceed those of the general population. This is a very serious issue with effects that will ripple throughout society, and it warrants widespread, earnest attention. The solution, though, does not lie in incentivizing physicians with money or restructuring systems to minimize stress on physicians -- it lies in finding earnest professional fulfillment.

Medicine is not a job. It is not even a career. At its heart, medicine is a calling.

According to psychologists, signs of burnout include decreased enthusiasm for work, growing cynicism, and a low sense of personal accomplishment. As the name implies, individuals suffering from burnout feel as though a fire that once burned inside them has dwindled, and perhaps even been entirely extinguished. In many cases, they report a sense of having "run out of fuel," and like my colleague, feel as though they "have nothing left."

Of nearly 7,300 physicians who participated in the Archives of Internal Medicine's national survey, 46% reported at least one symptom of burnout, and the overall rate of burnout among physicians was 38%, as opposed to 28% among other US workers. The highest rates of burnout were reported among primary care physicians, including family physicians, general internists and emergency medicine physicians.

Why should rates of burnout be higher among physicians? For one thing, physicians tend to work longer hours than other workers, on average about 10 more hours per week. Moreover, striking an appropriate work-life balance appears to be a bigger challenge for physicians, in part because they often tend to keep work and personal life more separated than other workers. The authors of the study speculate that such a high rate of burnout could only result from system-wide issues in medicine, as opposed to the personal susceptibilities of a few physicians.

The issue of physician burnout is important. As the US population grows and ages, the number of physicians needed to care for them increases. When burnout leads physicians to reduce or cease their practice altogether, patient access to medical care is diminished. Moreover, burnt-out physicians are likely to be less productive, make more mistakes, and generally deliver a lower quality of care than their fully engaged colleagues. Finally, physicians are human beings too, and their suffering should summon no less compassion and concern than anyone else's.

Physicians react to burnout in a number of ways. Some, like my colleague, withdraw from their practices, reducing their workloads or leaving the practice of medicine entirely. Others become less engaged with their patients and the profession and suffer a decline in the quality of their work. Still others turn to unhealthy and even self-destructive habits, such as alcoholism, excessive or inappropriate use of prescription drugs, and even illicit substances. Some consider suicide. Others may turn to colleagues, friends, or family for help, or seek professional counseling.

A de-professionalized physician is inevitably a demoralized and burnt-out one.

Unfortunately, individuals and organizations often respond to burnout by recommending coping strategies focusing on the reduction of stress. The rationale for this approach is straightforward: individuals suffering from burnout seem to be overly stressed. They feel overworked, excessively scrutinized, or overburdened with unnecessary or unfulfilling tasks. To combat burnout, some suppose, we need only reduce such stressors, by cutting back on working hours, relaxing intrusive oversight, and finding ways to lift the burden of "busywork" from the shoulders of physicians.

While useful in some respects, the stress-reduction approach addresses only the less important of the two sides of the problem. Reducing stressors in the work environment may offer real benefit, but often it does get at the problem's real roots. It is like providing symptomatic relief to a patient without ever addressing the underlying disorder or encouraging the development of life habits that foster a positive state of well-being. Instead of merely reducing the bad in medical practice, we need to enhance the good.

This approach is rooted in the work of the late Frederick Herzberg, a psychologist at the University of Utah. Herzberg found that two very different sorts of factors shape work fulfillment. One group of factors might be labeled dissatisfiers. These are factors extrinsic to the work itself, such as the orderliness of the work environment, the fairness of administrative policies, and compensation. If individuals feel ashamed of their workplace, unfairly treated, or undercompensated, their level of satisfaction will suffer.

As expected, reducing dissatisfiers will tend to reduce workers' level of dissatisfaction. Yet there is a limit to what can be accomplished by addressing such dissatisfiers, and merely reducing dissatisfaction does little or nothing to enhance intrinsic fulfillment. If we increase underpaid workers' compensation to a level they regard as fair, they will tend to feel less dissatisfied with their work. But further increases in compensation will not tend to improve either the sense of fulfillment they derive from their work or the quality of the work they do.

To enhance fulfillment and quality of work, it is necessary to focus on the work itself. In the case of medicine, do physicians recognize what they find most fulfilling? If they cannot see the target they are aiming for -- in this case, the aspects of their work that they find most meaningful and take most pride in -- they are unlikely to hit it. What does their best work look like? Are they making full use of their knowledge, skills, and innate abilities? Are they growing and developing as human beings? Do they feel that they are making a real difference in the lives of their patients and communities?

Burnout is not a disease. It is a symptom.

The key to combatting physician burnout is not to reduce stress, but to promote professional fulfillment. And promoting professional fulfillment is not merely a matter of reducing costs and error rates or increasing clinical efficiency. Nor is it a matter of protecting and promoting the incomes of physicians. As Herzberg reminds us, efforts to alter physician behavior through income-based incentives and disincentives are inherently demoralizing. The reason is simple: they imply that physicians care more about money than their patients. This constitutes a self-fulfilling prophecy of cynicism.

William Osler, perhaps the most admired physician in American history, understood well the recipe for demoralization and burnout: "The path is plain before you: always seek your own interests, make of a high and sacred calling a sordid business, and regard your fellow creatures as so many tools of the trade." To promote burnout among physicians, it is only necessarily to subvert their professional and personal priorities, so that they spend all their time on little things and suffer continually from a growing sense that they are neglecting the ones that really matter.

At their core, good physicians are not mere moneymakers. Good physicians are professionals. And though today we often forget it, being a professional means more than merely getting paid for what we do. Being a professional means above all professing something, declaring openly in work and life that we stand for something beyond our own narrow self-interest. The more we treat physicians as though they were self-interested money grubbers, the more we de-professionalize them. And a de-professionalized physician is inevitably a demoralized and burnt-out one.

Medicine is not a job. It is not even a career. At its heart, medicine is a calling. When it comes to physician burnout, an ounce of prevention is worth a pound of cure. We must begin early in medical education to help medical students and residents explore and connect with a sense of calling to the profession. Even late in their careers, physicians need to recall that they are summoned to something older, larger, and nobler than themselves. They must never forget that a career in medicine represents one of life's greatest opportunities to become fully human through service to others.

If we are genuinely concerned about physician burnout, we need to focus less on reducing stress and more on promoting what is best in physicians: compassion, courage, and above all, wisdom. Only by keeping what matters most at the forefront can we reap a full harvest of professional fulfillment. Burnout is not a disease. It is a symptom. To combat it, we must focus primarily on what underlies it. And here the key is not eradicating the disease but promoting professional wholeness, which flows from a full understanding of the real sources of fulfillment.


Sunday, August 26, 2012

Life, Interrupted: Six Ways to Cope With Cancer - NYTimes.com

People are always giving advice to cancer patients. Whether it is nutritional advice or doctor recommendations or tips on how to quell the nausea that accompanies chemotherapy, just as soon as people hear you are sick they usually want to find a way to help. Most of the advice is welcome and encouraging, though in some cases you're just not in the mood to hear what someone has learned because you're too busy treading water.
That's one reason I hesitate to lend any advice at all. I'm only 24. I've had cancer for 16 months now. It feels like forever to me, but it's a short period of time compared with people I know who are going on 5 or 7 or 10 years living with cancer. But I've received some heartfelt advice and solidarity along the way from fellow cancer patients, doctors, friends - even from strangers - and it has meant a lot to me. It's been 16 months since my diagnosis and four months since my bone marrow transplant, and now I want to share what I've learned along the way.
Here are six strategies that have helped me to cope with cancer.
Find Your Community
At first, I bristled at the idea of a cancer community. It was enough to have cancer; did I also have to share my experience with a group of strangers? It felt like extra homework. I hesitated for several months before going to my first cancer support group meeting. It was overwhelming to imagine hearing a dozen other stories as bad as, or worse than, mine.
But something surprising happened. I started going to a young adult cancer support group at a Gilda's Club in upstate New York. For the first time since my diagnosis, I became aware of the fact that I was not alone in my fears and anxieties. Instead of feeling isolated in my experience with cancer, I began to realize there was an amazing community of people out there who were going through the same thing and could help me make sense of what was happening because they had been there themselves. Rather than feeling overwhelmed by the stories of the other cancer patients, I felt empowered and inspired by their strength and bravery.
I've also found a surprisingly vibrant cancer network in virtual space -- on Twitter, Facebook and elsewhere. But in my experience, nothing can replace face-to-face interaction - even if no words are exchanged - with someone else who understands what you're going through. Two of my closest friends are people around my age whom I met at the hospital. We don't talk about cancer all the time. But knowing we can go there if we need to is invaluable.
Eliminate Clutter
Cancer feels messy inside and out, whether it's the disease itself, invading my body, or the material clutter that comes with disease: heaps of laundry piling up, stacks of unopened bills, orange prescription medication bottles crowding the bedside table, unanswered phone calls and e-mails, and more. I've found it helpful to try to control the chaos in small ways. Thoreau may not have been talking about cancer when he urged us to declutter, but the words "simplify, simplify" are always swirling in my head.
I've gotten rid of unnecessary clutter in my room. I do regular mini-spring cleanings. What do I need? What can I put away in storage? It makes me feel better, even when cleaning tires me out. The way my surroundings look and feel has a big effect on my mind-set, especially when I am spending a lot of time resting in bed. I like to feel light.
Prioritize Your Relationships
Cancer also forced me to declutter my social life. When I found out I had leukemia, I was a recent college graduate. I had dozens of friends and acquaintances who formed a frenzied around-the-clock social network, talking and texting all day, every day. I was tied to my phone like any other 22-year-old. (Actually, I carried around two BlackBerries, one for work and one for personal use.)
After my diagnosis, I tried to keep up my old ways, but there was less time. And I had much less energy. At first I felt guilty about not being able to maintain the same frequency of communication with my friends. But having cancer forced me to adopt a simpler schedule. I got a new phone -- an entry-level model with no e-mail, no Facebook, no keyboard for convenient typing. It has made me more aware of my time. I interact with a smaller group of people now. I'm less scattered and more present. And my relationships are stronger for it.
Be Kind to Yourself
Instead of feeling mad at my body for failing me, I'm trying to give myself permission to take it easy. Easier said than done -- I almost didn't include this point because I'm still struggling with being kind to myself. I can't help but feel frustrated with myself when my body is overly tired, or when my mind is fuzzy. (They call it "chemo brain.") Sometimes I beat myself up over sleeping late into the afternoon. Or when I can't eat more than a few bites of any meal. Or when my muscles are too weak to pick up the pitcher of water on the counter. It's a daily struggle not to view these setbacks as failures or weakness. But I'm trying not to punish myself for the things I can't change. In the time we should be the easiest on ourselves, I've found that we can often be the most judgmental and harsh.

Do Something for Someone Else
The experience of being sick for an extended time means that you become the center of attention. Someone has to be taking care of you, people are always worried about you, and as the patient you spend a lot of time focusing on, well, you. That's a lot of yous. Cancer confers a certain kind of myopia. You're always thinking about your own health above all else. That doesn't leave a lot of time to think about other people. For the first time since my diagnosis, I've begun to send letters and care packages to other cancer patients and friends of mine going through a difficult time. By reaching out, I'm paying it forward for all the help and care I have received. I have found that small acts of gratitude or connectedness to other people who are suffering rescues me from my own self-pity and makes me feel like I'm capable of helping, and not just of being helped.
Set Goals Unrelated to Cancer
From the earliest days of my diagnosis, one of the casualties of cancer was the feeling that I had to shelve my dreams and goals. These paused plans -- dreams, interrupted -- weighed on me every day. I was constantly thinking of everything I could be doing - everything but lying in a hospital bed or sitting in an infusion suite. Right before I got sick, I was working on my dreams. Relying on research about Tunisian politics that I presented in my senior thesis in college the year before, I planned to travel to Tunisia, my father's homeland, to report on the revolution taking place there. Those were the early days of the Arab Spring. There was something big happening, and I was ready to cover it. But with my diagnosis came chemo and new plans. It was devastating to miss this opportunity.
But I decided that I didn't want to let cancer put my life entirely on hold. It had always been my goal to be a writer of some kind. So now I'm going after that goal again. This time, however, I'm trying to write about a different kind of revolution.


The Widespread Problem of Doctor Burnout - NYTimes.com

The patient, a powerfully built middle-aged restaurant worker, had awakened one morning with a tight pain in his shoulders that traveled down his right arm. At work, he could barely shrug his shoulders or turn his head. "My fingers were so weak," he recalled, "that I couldn't even get a good grip around a glass of water."
A senior doctor at a local clinic diagnosed a pinched nerve and prescribed a muscle relaxant. Two weeks later, only more incapacitated, the patient went to another clinic, where a younger doctor made the right diagnosis: A malignant tumor in his chest was pressing against a nerve to his arm.
"That first doctor couldn't be bothered by what I was trying to say," the patient said. He was now receiving chemotherapy and was hopeful his cancer had been caught early enough, but the near miss still haunted him. "He acted like he just didn't want to be there with me. Or with any patient."
After reading a study published this week in Archives of Internal Medicine, I've been thinking a lot about this patient's experience. And I've come to two conclusions. First, the older doctor had classic symptoms of burnout.
Second, mistakes like his may only become more common.
Research over the last 10 years has shown that burnout - the particular constellation of emotional exhaustion, detachment and a low sense of accomplishment - is widespread among medical students and doctors-in-training. Nearly half of these aspiring doctors end up becoming burned out over the course of their schooling, quickly losing their sense of empathy for others and succumbing to unprofessional behavior like lying and cheating.
Now, in what is the first study of burnout among fully trained doctors from a wide range of specialties, it appears that the young are not the only ones who are vulnerable. Doctors who have been practicing anywhere from a year to several decades are just as susceptible to becoming burned out as students and trainees. And the implications of their burnout -- unlike that of their younger counterparts, who are often under supervision -- may be more devastating and immediate.
Analyzing questionnaires sent to more than 7,000 doctors, researchers found that almost half complained of being emotionally exhausted, feeling detached from their patients and work or suffering from a low sense of accomplishment. The researchers then compared the doctors' responses with those of nearly 3,500 people working in other fields and found that even after adjusting for variables like gender, age, number of hours worked and amount of education, the doctors were still more likely to suffer from burnout.
"We're not talking about a few individuals who are disorganized or not functioning well under pressure; we're talking about one out of every two doctors who have already survived rigorous training," said Dr. Tait D. Shanafelt, the lead author of the study and a professor of medicine at the Mayo Clinic in Rochester, Minn. "These numbers speak to bigger problems in the larger health care environment."
The doctors' burnout appeared to have little to do with hours worked or even the ability to balance personal life with work. Instead, the only factor predictive of a higher risk was practicing a specialty that offered front-line access to care. More than half of the doctors in family medicine, emergency medicine and general internal medicine experienced some form of burnout.
The study casts a grim light on what it is like to practice medicine in the current health care system. A significant proportion of doctors feel trapped, thwarted by the limited time they are allowed to spend with patients, stymied by the ever-changing rules set by insurers and other payers on what they can prescribe or offer as treatment and frustrated by the fact that any gains in efficiency offered by electronic medical records are so soon offset by numerous, newly devised administrative tasks that must also be completed on the computer.
In this setting, "doctors are losing their inspiration," Dr. Shanafelt said, "and that is a very frightening thing."
What patients must face in the examining room is no less alarming. Doctors who are suffering from burnout are more prone to errors, less empathetic and more likely to treat patients like diagnoses or objects. They are also more likely to quit practicing altogether, a trend that has serious repercussions in a system already facing a severe doctor shortage as it attempts to expand coverage to 30 million or more currently uninsured Americans.
"Doctors are coming to this expansion already pretty stretched and stressed out," Dr. Shanafelt noted. "I don't think there is going to be a lot of room to maneuver without some significant structural changes."
Dr. Shanafelt and his colleagues are in the midst of studying the effects of workplace initiatives aimed at providing greater support for doctors while improving efficiency, which they believe is critical for doctors and patients as well as the large health care organizations that aim to serve us all. Without decreasing the total hours worked or the number of patients a doctor must see, a hospital system might, for example, restructure its clinics so that doctors could spend more time with patients and less time on the phone getting authorization from insurers or in front of a computer completing administrative tasks.
"If people work in an environment where they believe there is meaning, they will put up with a lot," Dr. Shanafelt observed. "It goes beyond the significant personal consequences for an individual physician. It affects whom patients can see when they are sick, the quality of care they receive and their safety."

Driver's seat safer than sidewalk for older adults

Driving gets more dangerous with age, but older adults may be more vulnerable while walking on the sidewalk than behind the wheel, says a new study.

Researchers who reviewed data on road accident deaths in the U.K. found that pedestrians over 70 were five times more likely to die from being hit by a car each time they went out than those age 21 to 29.

But elderly drivers were no more likely to die on the road than those in their twenties.

"The focus is usually on older drivers as a danger to themselves and other drivers," said Jonathan Rolison, who led the study at the University of Plymouth in the U.K.

But, he added, "the real issue isn't really safeguarding older drivers, it's making the road environment safer for pedestrians."

There has been a shift in recent years in both the U.K. and the U.S. toward more demanding license renewal processes for older adults.

As eyesight and cognitive abilities decrease with age, older adults are often assumed to be more dangerous on the road than younger drivers.

But previous research suggests that's not necessarily the case. In one U.S. study, researchers found male drivers were less of a risk to other road users at 70 years old than they were at 40.

For the new study, Rolison and his colleagues reviewed U.K. police records on all fatal road accidents reported between 1989 and 2009.

They found the risk of dying behind the wheel was similar for older adult drivers and young people every time they got in the car: 13 in 100 million driving trips ended in fatality among those under 29, compared to 14 in 100 million trips for people over 70.

The elderly still accounted for fewer driver deaths overall. In 2009, when 1,138 people died behind the wheel, one in 10 was over age 70, while younger drivers accounted for one in four of those deaths.

The pattern held for passengers, too, with no difference in fatalities per trip for old and young passengers.

For both drivers and passengers, risks were highest at both ends of the age spectrum and dipped among middle-aged people.

But when the researchers looked at figures for pedestrians, they found the risk of being killed when traveling on foot was five times higher for older people than for the young. Among older adults, 23 trips in every 100 million were fatal.

Older adults accounted for 37 per cent of all pedestrian deaths in 2009, according to results published in the Journal of the American Geriatrics Society.


For Rolison, the findings suggest that the increasing restrictions on older drivers are misplaced.

"Assessing whether older adults can drive is important, but the problem is it leads to policies which are becoming tighter and tighter and distract us from older adults at risk as pedestrians," he said.

According to Rolison, "older adults in a way are the ideal drivers, as they control their exposure to risk… If it's a rainy day, the older adults will stay at home, whereas people in middle age groups still have to go to work or drop kids off at school."

But elderly people are likely to be discouraged by the license screening process, Rolison said, and that could have important implications for their mobility and well-being.

Dr. David Carr, an expert in older driver assessment at Washington University in St. Louis, Missouri, agreed that more attention should be given to keeping older people safe as passengers and pedestrians, rather than restricting them as drivers.

"One of the big major points is that older drivers represent a small proportion of driver fatalities. They're not going out there and causing major problems," Carr, who wasn't involved in the new research, told Reuters Health.

But with baby boomers aging, "now is the time to focus on making pathways and transportation areas more safe," he added.

Crossing the road is particularly risky for older adults who can't judge speed and distance very well, said Rolison. They're safer if they are accompanied by a younger person.

Because older adults are often frail, they are also more likely to die of their injuries if they're involved in an accident, he explained.

Introducing traffic islands and giving old people more time to get across the road at pedestrian crossings might actually save more lives than tightening license restrictions, said Rolison.

"You shouldn't assume that your granddad should avoid getting behind the wheel, because he won't necessarily be safer walking down the street," said Rolison.