Saturday, July 4, 2015

‘Navigators’ for cancer patients: A nice perk or something more? - The Washington Post

In the 71 days since she first saw her doctor about a suspicious lump in her right breast, Ricki Harvey has had 40 appointments about her medical care. First came the mammogram, the ultrasound and the biopsy. Then meetings with the surgical oncologist, the radiation oncologist, the general oncologist, the social worker, the geneticist and the physical therapist. Then her twice-weekly chemotherapy infusions.

At Harvey's side every step of the way were "patient navigators" — in her case, nurses — whose job is to help guide cancer patients through a system that has become so complex and fragmented that it is beyond the ken of many people, especially at such a vulnerable time.

Many patients rave about them, calling them a godsend. "Some people have to do this all on their own," said Harvey, 65, a retired elementary school principal from McLean, Va. "I can't even imagine."

Yet so far, research shows that, with the possible exception of poor people who typically don't receive sufficient medical care, navigators have only a modest effect on how well patients do. There is little evidence that they save money. And research on patient satisfaction is mixed.

Those findings have relevance as the health-care system moves from a fee-for-service model to one that rewards high-quality care. Doctors and hospitals are under growing pressure to rein in costs and show that every new initiative has value. But value can be subjective and difficult to measure. Are navigators, for example, a nice add-on service that merely reassures patients, or do they contribute much more?

"I think for a lot of patients, maybe even the majority of patients with cancer, navigation may not have that big an impact on the kind of care they get," said Scott Ramsey, a professor of public health sciences at the Fred Hutchinson Cancer Research Center in Seattle, who studied the ­cost-effectiveness of navigators in a large National Cancer Institute project.

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Wednesday, July 1, 2015

NYTimes: The Real Problem With Medical Internships

APROXIMATELY 26,000 newly minted doctors across the United States will begin their internships today. For many, this legendarily grueling year will be the most trying time of their professional lives. Most will spend it in a state of perpetual exhaustion, as near ascetics with regard to family, friends and other pleasures. I was an intern nearly 20 years ago, but I still remember it the way soldiers remember war.
Fortunately for today's interns, regulations have since reduced some of the misery. Most interns now are not permitted to work shifts longer than 16 hours. They are also encouraged to nap while on overnight duty.
At first glance, such reforms make sense. Studies have found that doctors who got no sleep during a night on call scored lower on tests of simple reasoning, response time, concentration and recall. Indeed, a single night of continuous sleep deprivation has been shown to be roughly equivalent to having a blood alcohol level of 0.10 percent — that is, being drunk.
But there is a downside to these regulations. Limits on work hours lead to frequent patient handoffs, which are susceptible to breakdowns in communication between doctors, thus potentially creating errors. In aviation, most crashes occur on takeoff and landing, and in medicine, too, most mistakes happen during transitions.

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Sunday, June 28, 2015

A Sea Change in Treating Heart Attacks - The New York Times

Yvette Samuels was listening to jazz late one night when she felt a stabbing pain down her left shoulder. She suspected a heart attack — she had heard about the symptoms from watching a Rosie O'Donnell standup routine on television — and managed to scratch on the door that connected her single room to her neighbor's. He found her collapsed on the floor.

Paramedics arrived minutes later and slapped electrocardiogram leads on her chest, transmitting the telltale pattern of a heart attack to Our Lady of Lourdes Medical Center here.

As the ambulance raced through the streets, lights swirling, sirens screaming, Ms. Samuels, who took phone orders for a company that delivers milk, asked the paramedic, "Can this kill me?" He murmured yes, then told the driver, "Step on it!" She thought to herself, "This will be my last view of the world, the last time I will see the night sky."

Instead, she survived, her heart undamaged, the beneficiary of the changing face of heart attack care. With no new medical discoveries, no new technologies, no payment incentives — and little public notice — hospitals in recent years have slashed the time it takes to clear a blockage in a patient's arteries and get blood flowing again to the heart.

The changes have been driven by a detailed analysis of the holdups in treating patients and a nationwide campaign led by the American College of Cardiology, a professional society for specialists in heart disease, and the American Heart Association. Hospitals across the country have adopted common-sense steps that include having paramedics transmit electrocardiogram readings directly from ambulances to emergency rooms and summoning medical teams with a single call that sets off all beepers at once.

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