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The New Doctor’s Desk Reference: How to Break Bad News (For Doctors)

News organizations used Dr. Judah Folkman’s death to report on his decades-long cancer research career. Given his status as a distant, non-celebrity, non-Nobel surgeon, you may be asking yourself why you, personally, should care about his death. Here’s why.

We were in our second year of medical school, feeling the growing pressure of clinical years just around the corner, when we would be thrown into the hospital system. For now, we had lectures in a large hall with 130 students sitting in chairs that sloped down to a stage. Professors came with presentations and handouts and complex diagrams. The immunology lectures were continuous strings of letters and numbers, with only the occasional verb, impossible to decode as human speech without months of training. Every tissue, every disease, every human physiologic function was discussed, down to the sub-molecular level. After hours of these lectures, the air would get stale and backs would ache and the squeak of weight shifting in chairs would become a metronomic beat marking out time that seemed to pass endlessly.

Then, one day, Dr. Folkman walked on stage. He asked us to put down our pens. He said he was going to teach us something that no one else would ever discuss, much less teach. I can’t imagine what he was thinking as he looked out on the sea of our faces. Give or take a few years, almost all of us were twenty-four years old. Almost all of us were single, ambitious, untouched by any of the major human experiences—no children, tragedies, severe illnesses or grief. The youth, the arrogance, the lack of world experience, all of it had to be a daunting, uninspiring sight. Dr. Folkman knew that in mere months, we would be keepers of information that would profoundly change lives. Pathology reports, cancer diagnoses, even the death of a loved one, those were all things we would be telling vulnerable people. Our actions and our words would be often unsupervised, particularly when disaster struck in the middle of the night.

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The Destructiveness of Measures

A little box pops up before him asking if he asked the patient about the exercise.  He mumbles something under his breath, clicks a little box beneath the question, then moves on.

This is what medicine has become:  a series of computer queries and measures of clicks.  It must be measurable, quantifiable, and justifiable or it didn’t happen.

Do they ask if I asked them about if they used cocaine?  Of course not: too politically incorrect.

Do they ask if I really listened to their heart?  Of course not – this activity is not a paid activity.

Do they ask about the myriad of phone calls and e-mails to arrange for a procedure?  Nope.

Do they measure my time with the patient when I go back to see them on the same day?  Nope – not paid for.

So what’s the motivation for doctors to be doctors?  Are we retraining our doctors from care-givers to data providers?  What are we losing in turn?

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How I Lost My Fear of Universal Health Care

When I moved to Canada in 2008, I was a die-hard conservative Republican. So when I found out that we were going to be covered by Canada’s Universal Health Care, I was somewhat disgusted. This meant we couldn’t choose our own health coverage, or even opt out if we wanted too. It also meant that abortion was covered by our taxes, something I had always believed was horrible. I believed based on my politics that government mandated health care was a violation of my freedom.

When I got pregnant shortly after moving, I was apprehensive. Would I even be able to have a home birth like I had experienced with my first 2 babies? Universal Health Care meant less choice right? So I would be forced to do whatever the medical system dictated regardless of my feelings, because of the government mandate. I even talked some of having my baby across the border in the US, where I could pay out of pocket for whatever birth I wanted. So imagine my surprise when I discovered that Midwives were not only covered by the Universal health care, they were encouraged! Even for hospital births. In Canada, Midwives and Dr’s were both respected, and often worked together.

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What Republicans Want to Take Away

The fight is on — again. Mitt Romney, Scott Brown, and Republicans across this country are doubling down against President Obama’s health care reform law. Now that the Supreme Court has said that most of the new law passes constitutional muster, the Republicans are running for office pledging to repeal every aspect of the health care reforms.

For millions of people this isn’t a political issue, it’s a personal one. Their health depends on it.

Massachusetts has led the country in health care reform. Most of us — 98 percent — have health care coverage, and our state leads the country in tackling head-on the ever-growing costs of health care. That is why President Obama used our law as a model for health care reform. But the national Affordable Care Act adds some important elements that improve care even here in Massachusetts.

For seniors, health care reform means expanding Medicare coverage to pick up the costs of prescription drugs. As the donut hole closes, the average Massachusetts senior has so far saved about $650. But Mitt Romney, Scott Brown, and their fellow Republicans want to take that away.

For young people, health care reform means staying on their parents’ insurance plans until they are 26. So far, more than 20,000 young people here in Massachusetts have taken advantage of this. But Romney, Brown, and their fellow Republicans want to take that away.

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What We Talk About When We Talk About Nursing Shortages


Not so long ago, the air was filled with dire warnings of an impending nursing shortage. By 2020, according to one widely-cited analysis, demand might exceed supply by as many as 800,000 nurses.

That analysis was made in good faith, and it was based on not-crazy extrapolations from thirty years’ worth of economic data.

But in many local labor markets in 2012, there’s no sign of a shortage. In fact, in some regions there’s evidence of a glut. A few months ago, the California Institute for Nursing & Health Care announced that 43 percent of people who received nursing degrees in California and 2010 and 2011 were not working as nurses.

I’m going to try to make some dimly-informed comments about the nursing labor market in the next few posts. But first, a few words about what it means to say that there is (or isn’t) a nursing shortage.

In this context, “nursing shortage” is used in an unsentimental labor-economics sense. A nursing shortage exists when employers are actively trying to hire additional nurses but are rubbing against supply constraints, as evidenced by:

rapidly rising wages
mandatory overtime
heavy use of temporary “agency” nurses to fill gaps on units
a greater-than-usual willingness to hire nurses with little experience or limited training
new investments in nurse-replacing technology
desperate 3 am phone calls from hospital administrators to college presidents, begging them to launch new nursing programs

To say that there is no nursing shortage today is not to say that all hospital units are adequately staffed for patient safety and decent quality of care. There is plenty of reason to believe that patients would be better off if hospitals invested in stronger nurse-patient ratios.

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For America’s “Best Hospitals,” Reputation Doesn’t Hold as Much Weight

U.S. News and World Report has released its annual lists of the best hospitals in America, but this year the rankings were based more on performance data and less on reputation.

U.S. News and World Report began rating hospitals in 1990 when clinical data comparing hospital performance didn’t exist, according to a blog post written by Avery Comarow, senior writer and health rankings editor for U.S. News. As a result, the first editions of the list were solely based on the hospitals’ reputations. The media outlet began turning away from reputation-based rankings in 1993 when it added mortality, nurse staffing and other objective measures that reflected patient care.

That focus on performance data has continued to grow. In fact, for 12 of the 16 specialties in the latest edition of Best Hospitals, more than 65 percent of a hospital’s ranking depends largely on clinical data, most of which is from the federal government. Hospitals in the four remaining specialties — ophthalmology, psychiatry, rehabilitation and rheumatology — are ranked solely by their reputation among specialists.

U.S. News says it took steps to strengthen its reputational rankings this year, including a modification that reduced the likelihood of hospitals with the highest number of physician nominations to “bob toward the top” of rankings. As a result, this “took some of the juice out of high reputational scores” and placed more emphasis on objective, clinical data. The media outlet said some hospitals that made it to the top may not have any reputational score at all — their inclusion is based wholly on clinical performance.

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Unleashing An Epidemic: Florida Gov Rick Scott Shows The Folly Of Cutting Safety Net Hospital Funding

When Florida voters elected Rick Scott back in 2010 they may have thought they were getting a health care expert. After all, his claim to fame was building the largest for-profit hospital company. Boy were they wrong.

The list of Scott’s public health missteps are vast–such as trying to gag doctors from discussing guns with patients, taking credit for refusing to perform abortions at his old company, trying to shut down a monitoring database that would keep pain pill addicts from getting more prescriptions, and pushing the sale of the state’s public hospitals to buyout funds to raise money to close the deficit.

But this latest one may be the most tragic. In March Governor Scott moved to close A.G. Holley hospital, a small 100-bed safety net institution specializing in tuberculosis. The Palm Beach County public hospital had operated for 60 years. Closing it saved only $5.4 million, which is what its costs were last year. Scott justified the closure saying that TB cases had dropped by 10% in recent years.

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Hospitals Finding Patients On Google and Facebook

When the University of Pennsylvania Health System sought new patients for its lung transplant service last year, it turned to Facebook and Google.

The results of the $20,000 advertising campaign on the websites exceeded administrators’ expectations.

During a few weeks in August and September, more than 4,600 people clicked on the ads and 36 people made appointments for consultations. One of those is now on the hospital’s lung transplant waiting list, and several others are being evaluated, hospital officials say. While the response may seem small, each transplant brings in about $100,000 in revenue.

“We wanted to test the theory of how successful a digital marketing campaign could be,” said Suzanne Sawyer, the health system’s chief marketing officer. “It was like looking for a needle in a haystack,” she said, noting only about 60 lung transplants are done each year in Philadelphia, where the health system is based.

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How One Man Wound Up Deciding the Fate of Healthcare Reform

Personally, I am delighted that Chief Justice Roberts voted to uphold the Affordable Care Act. But, I am troubled that the fate of U.S. healthcare turned on one man’s opinion. This is not how things are supposed to work in a democracy.

Healthcare represents 16 percent of our economy. It touches all of our lives. If we don’t like the laws our elected representatives pass, we can vote them out of office. The Supreme Court, on the other hand, doesn’t have to worry whether its decisions reflect the will of the people. The Justices are appointed for life. This is why they are not charged with setting public policy.

How then, did the Court wind up with the power to affirm or overturn the ACA?

The media shapes our expectations

As I suggested when oral arguments began back in March, a “media narrative” drove the case to the Court – a fiction that caught on, in the press, on television, and in the blogosphere, where it began to take on a reality of its own. A handful of “state attorneys general and governors” saw “a political opportunity” and floated the idea that the law might be unconstitutional. The media picked up the story, repeated the heated rhetoric, and “fanned the flames … Before long, what constitutional experts thought was a non-story became a Supreme Court case.”

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Palo Alto Medical’s Innovation Center Announces Seed Funding for Accelerator Program

Through the linkAges™ Developer Challenge and Accelerator Project, the Palo Alto Medical Foundation’s (PAMF) David Druker Center for Health Systems Innovation (IC) is inviting teams to create innovative solutions to help seniors age successfully.

First place winners of the three-month Developer Challenge will not only win $5,000,
but also will be invited to join the PAMF Innovation Center Accelerator, a six-month
incubator designed to refine and integrate the winning solution into the linkAges
ecosystem for rapid implementation within the PAMF community. Second and third
place winners will receive $3,000 and $2,000, respectively.

The IC is excited to make two announcements of importance of its Developer Challenge
initiative, being run in partnership with Health 2.0:

First, the IC is pleased to announce that seed funding is available and aimed at
supporting daily team activities through the 6-month accelerator phase. The winning
team can now focus on developments and delivering results. The level of funding
will be subject to negotiation, and will be made available by an investment in the IP
created by the team.

Second, the IC is excited to announce a partnership with HP Cloud from Hewlett
Packard. By way of sponsorship, participants signed up for this Challenge can gain
free access to the HP Cloud services/technical support as well as access to HP
Cloud Compute, HP Cloud Object Storage, HP Cloud Block Storage, HP Cloud
CDN. These allow the custom build of virtual servers, define access settings to local
and remote services, and create and store data in the cloud.

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