phenomenalplace

A recent conversation with a friend about his father's nursing home experience taught an important lesson about nursing home ethics. Here's the story: His father suffered from severe Alzheimer's and required full time supervision. A local nursing home that had a mediocre reputation some years back was said to have improved, and the family placed his father there. The nursing home was in another part of the country, so my friend could visit only intermittently. On each visit he was impressed with the attentive, loving care the residents received. His father lived in the nursing home for a few years before his death. When my friend made a final visit to collect his father's belongings and to thank the staff, he was invited to look at the nursing record. The final entry said it all with regard to the ethical ethos of the home: May God grant peace to his gentle soul! I teared up when he told me this and teared up again as I wrote it. My friend spoke with the administrator w

On this blog a month ago, I said the politicians were starting to scare me with the apparent eagerness of some to actually take the government to default to make a political point.For weeks we have heard political leaders on both sides tell us there would be no default.But the two sides have so backed themselves into opposite corners that they have left no opportunity to meet in the middle.

If you're interested in Vermont's plan for a single payer system, you'll want to look at an article in this week's New England Journal of Medicine. According to Anya Rader Wallack, Ph.D., special assistant for health reform to Governor Shumlin, the Vermont program will include "a global budget for health care expenditures, guaranteed coverage that is not linked to employment, and a single system of provider payments and administrative rules." The health system will be overseen by a new public entity - the Green Mountain Care Board. Here's how Dr. Wallack describes the powers of the board: The board can wield traditional tools such as fee-for-service rate setting, controls on the acquisition of technology, and reviews of both health insurers’ rates and hospitals’ budgets. However, the law also provides explicit direction to the board to create a global budget for health care spending and develop new payment models that create incentives for providers to st

I'm in Vermont, telecommuting and enjoying the Green Mountains while my wife teaches at the Bread Loaf School of English , a Middlebury College program in which students, mainly K-12 teachers, can get a Masters degree in the course of five summers. Students and faculty have meals in a building that served as a summer Inn a century ago. Last night at dinner two faculty members I was sitting with began to talk about how many Weight Watcher "points" the different foods had. They graciously allowed me to grill them on their experience with weight management. Here's what I learned: Neither had succeeded in maintaining weight loss on his own. While they did not care for the meetings associated with the Weight Watcher program, both found the weekly "check in" helpful. I probed. Did they have an extended conversation with the person who weighed them? No. Was it always the same person? Yes, usually. But they did not appear to find the relationship itself important. I

Last week I read a fascinating book by Charles Bosk - " What Would You Do? Juggling Bioethics and Ethnography ." Bosk's first book - " Forgive and Remember: managing medical failure " - a brilliant field study of surgical training, made him famous when the first edition was published in 1979. I can't evaluate his skills as an ethnographic field worker, but he's a terrific writer. In a chapter on "Irony, Ethnography, and Informed Consent," Bosk reports the intense distress a genetic counselor experienced on seeing how he'd written about her and reflects on the nature of informed consent in ethnographic research. The ethnographer is not doing an experiment for which the risks and benefits can (and should) be described clearly to those who are being asked to participate. But he describes how ethnography characteristically seeks to "debunk" (his word) conventional social constructions, and he comments that ethnographers often write wi

The Chronicle of Higher Education recently reported that University of Pennsylvania psychiatrist Jay Amsterdam has accused his department chair and four colleagues of publishing an article that was (a) ghost written by a contractor for GlaxoSmithKline and (b) biased in favor of the GSK antidepressant Paxil. Amsterdam complained that the article "was biased in its conclusions, made unsubstantiated efficacy claims, and downplayed the adverse event profile of Paxil." He contends that "data from his study was effectively stolen from him, manipulated, and used in a ghostwritten article" designed "to advance a marketing scheme by GlaxoSmithKline to increase sales of Paxil." I'm writing this post without any insider knowledge about what's going on in the Department of Psychiatry at the University of Pennsylvania. Dr. Amsterdam's faculty profile, last updated 16 months ago, shows him to be a specialist in treating depression. The Chronicle post report

Click to Enlarge   Source  The current issue of Annals of Internal Medicine  has a great article on individualization of mammography recommendations -more on that in the next few days. There is another article demonstrating that an inexpensive ultrasound machine that fits in a pocket is almost as good at certain measurements of heart anatomy as a conventional ultrasound machine - which would frequently generate a health care bill of $1500. When I saw the abstract, I thought that Clay Christensen's predictions about disruptive innovation in health care were finally coming to pass - and we were going to use technology that was a little bit inferior to existing technology, but perfectly adequate for many indications - and save big bucks. This could be the cardiac imaging equivalent of the personal computer going up against mainframe computers! Alas, this was not to be. The authors position the pocket echocardiograph to replace not the expensive conventional echocardiogram, but inste

Here's the opening of a fascinating article in today's New York Times: Doctors save lives, but they can sometimes be insufferable know-it-alls who bully nurses and do not listen to patients. Medical schools have traditionally done little to screen out such flawed applicants or to train them to behave better, but that is changing. At Virginia Tech Carilion, the nation’s newest medical school, administrators decided against relying solely on grades, test scores and hour long interviews to determine who got in. Instead, the school invited candidates to the admissions equivalent of speed-dating: nine brief interviews that forced candidates to show they had the social skills to navigate a health care system in which good communication has become critical. I'm embarrassed to acknowledge that although I've done a lot of interviewing, I'd never heard about the technique Virginia Tech Carilion is using - multiple mini interviews (MMI). Applicants are seen at multiple interv

Today’s Managing Health Care Costs Indicator is 89,824 Click to enlarge.   Source  Oregon  realized it had resources to add about 10,000 beneficiaries to the Medicaid roles in 2008, and decided to hold a lottery to determine who would be awarded this Medicaid insurance.    89,824 Oregonians were eligible, 29.664 were randomized to be able to apply for Medicaid, and about 1/3 actually qualified.  (Reasons for not qualifying included not completing the paperwork or having income that was too high.). Researchers at Harvard used this natural experiment to see what the impact of winning this Medicaid lottery really meant.   This natural experiment is ideal to determine the effect of gaining potential Medicaid eligibility – because the 30,000 who won the lottery (experimental group)  were randomly chosen, making it unlikely that they were significantly different than those who did not win the lottery (control group). This is an especially important study because of the randomization, and bec

Judge Jeffrey Sutton's finding on the health insurance mandate in the U.S. Court of Appeals (Sixth Circuit) gives hope that the right wing is not totally bonkers. Before readers flame me for questioning Tea Party theology, here's what David Brooks, the conservative New York Times columnist, wrote about Republicans on Tuesday with regard to the debt ceiling "debate": ...the Republican Party may no longer be a normal party. Over the past few years, it has been infected by a faction that is more of a psychological protest than a practical, governing alternative. The members of this movement do not accept the logic of compromise, no matter how sweet the terms. If you ask them to raise taxes by an inch in order to cut government by a foot, they will say no. If you ask them to raise taxes by an inch to cut government by a yard, they will still say no. The members of this movement do not accept the legitimacy of scholars and intellectual authorities. A thousand impartial e

Today’s Managing Health Care Costs Indicator is $330 billion The Centers for Medicare and Medicaid Services issued its draft 2012 payment rules yesterday. The  payment rules give modest increases to ambulatory facility fees, tie ambulatory surgery fees to quality reporting, and make some much-needed changes in imaging reimbursement.   The headline is that these draft payment rules cut physician fees by almost a third, as required by the sustainable growth rate formula.   This is the automatic trigger that has been overridden by Congress every year (or more) since 2002.   Just about no one thinks this is a good idea.  Physician payment increases in Medicare have been substantially less than those offered by other payers, and in some communities it's hard to find a physician taking new Medicare patients.   Click to Enlarge  Ginsburg,  New England Journal 12/10  The cost of physician services keeps on going up, and no efforts to lower utilization have worked - so the blunt instrument

Amy Goldstein has an important article in today’s Washington Post detailing the place Don Berwick, the Medicare and Medicaid administrator, finds himself in.It is all but certain he will have to leave his post at year’s end, when his recess appointment expires, because the Senate will not confirm him for a lack of Republican support.Berwick is one of the most respected health care experts in the

Today’s Managing Health Care Cost Indicator is $674,000 Last week’s New England Journal of Medicine  reported a landmark study showing that screening low-dose CT scans really can save lives in people at high risk for lung cancer.  The study is unequivocal – those who got screening CT scans were substantially less likely to die of lung cancer. Further, all-cause mortality was lower – even though a few people with CT scan screening died of exploratory surgery when they were found not to have cancer. This study enrolled only smokers or ex-smokers with at least 30 pack years of smoking history, and excluded those who had signs or symptoms of cancer already, such as weight loss or coughing up blood.   It was peformed by the National Cancer Institute, and did not have funding from either companies that manufacture scanners or from tobacco companies. The authors don’t recommend that all smokers and ex-smokers start getting annual CT scans.   Even with low dose scans, some cases of cancer are