Archive for the ‘Health Professions’ Category

Governments and their development partners have struggled to address this problem. Many have tried mandating new graduates to provide a few years of service in underserved areas. These programs have met with variable success depending on the governments’ commitment and ability to enforce the plan. Since the publication of the World Health Organization’s well-thought out and evidence-based guidelines on increasing access to health workers in rural areas, some health systems are implementing mid- and long-term solutions such as recruiting and training health workers in underserved communities.

But governments are under intense pressure to solve the problem now. Some have tried rural retention schemes but many of these have been too expensive to maintain long term or scale up to the entire country. For example, Zambia has a rural retention program for physicians, but the program is funded by an external donor (not sustainable) and the salaries are significantly out of proportion with the salaries of other health workers as well as per capita income in the country. These programs also tend to be more expensive than necessary because ministries of health tend to design them without involving the workers in the rural areas that they want to retain or even workers in metropolitan areas that they want to post to underserved areas. The plans have no foundation in evidence. (more…)

I would argue none of the above.

I would say that the key to a great mHealth tool is a great health worker at the helm.

My name is Kate Otto and I work with the World Bank and other partners to develop and test the effectiveness of mHealth tools on health outcomes.  Based on two recent mHealth experiences – one with health extension workers (HEWs) in rural Ethiopia and another with midwives in urban Indonesia – I have noted a recurring lesson in this emerging field: that technology is not the solution itself but simply a means to arriving at a solution.  The people behind the tools are what make the difference between success and failure.

Too often, the sleek and impressive nature of new technologies makes the headlines: how they solve all the problems that human beings tend to mess up so sorely, how they avoid any mishaps in the first place with a fool-proof design.

Yet the truth is, the success of mHealth tools and applications are based largely on the intrinstic motivation of the end user – and how tools can be designed to leverage, not stamp out, that motivation.

Our product in Ethiopia allows HEWs to register expecting mothers and newborns so that they receive back appointment reminders, creating a patient schedule for the HEW and increasing the likelihood that she’ll deliver the proper care at the proper time, ideally decreasing maternal mortality, increasing vaccinations, and decreasing infant and child mortality.  But if a HEW does not deeply care about saving lives, if the tool does not work smoothly with her rugged lifestyle, if she cannot see the immediate benefit of using it over the status quo system, then will she take the effort to use it properly or consistently? (more…)

When patients become more actively involved in their own health, there’s a much stronger likelihood their health outcomes will be better.

That’s why “Questions are the Answer,” a new public education initiative from the U.S. Agency for Healthcare Research and Quality (AHRQ), encourages patients to have more effective two-way communication with their doctors and other clinicians.

“Questions are the Answer” features a website — where you will find these free educational tools to use with your patients:

• A 7-minute video featuring real-life patients and clinicians who give firsthand accounts on the importance of asking questions and sharing information – this tool is ideal for a patient waiting room area and can be set to run on a continuous loop.
• A brochure, titled “Be More Involved in Your Health Care: Tips for Patients,” that offers helpful suggestions to follow before, during and after a medical visit.
• Notepads to help patients prioritize the top three questions they wish to ask during their medical appointment.

Clinicians can request a free supply of these materials by calling AHRQ at 1-800-358-9295 or sending an email to AHRQpubs@ahrq.hhs.gov.

By Diana Mason. Two weeks ago, I got my hearing checked by a doctoral student in audiology at a faculty practice clinic at a university. The student was quite thorough. She advised me that she was not a physician and could not diagnose and treat hearing problems. Later on during the visit, her faculty supervisor repeated this mantra.  I said each time, “Yeah, yeah…I know the spiel.”

I know it because for decades nurses were not allowed to say a patient was dead or bleeding or in congestive heart failure despite the obvious signs. Physicians were the only ones who could do these things. About 100 years ago, nurses didn’t even take blood pressures–or temperatures! As new technology was introduced into medicine and health care, the physicians claimed it as their purview–until they were bored with it. Then, they decided that nurses could be taught to do these things. Of course, in many states, including New York until last year, nurse practitioners still can’t pronounce a dead patient to be thus.

When she was the Associate Dean at the Yale Law School, Barbara Safriet (now at Lewis and Clark School of Law) wrote a classic article on the laws regulating medicine and other health care professions. She pointed out that state medical practice acts that govern the practice of medicine were written so broadly that they precluded other health professionals from doing most anything without the authorization and supervision of physicians. As such, podiatrists have fought endless battles to move from working independent of physicians on foot problems; optometrists, to do more advanced assessments of eye problems; chiropractors, to practice at all; audiologists, to use an otoscope to look in patients’ ears; and advanced practice registered nurses (APRNs), to be able to diagnose and treat common health problems.

The battle between APRNs–nurse practitioners, certified nurse midwives, nurse anesthetists, and clinical nurse specialists–and organized medicine is heating up because of the Institute of Medicine’s recommendation that all health professionals be able to practice to the full extent of their education and training and that the barriers to them doing so be removed. A very large body of evidence supports that APRNs provide high quality, safe care and produce the same or better outcomes as physicians. While some states already permit nurse practitioners and nurse midwives to practice without physician supervision or mandated collaboration, the majority of states continue to have restrictive laws and regulations that get in the way of APRNs being able to improve people’s access to affordable, quality, efficient care. (more…)

By Janice Lynch Schuster. A few days into my 68-year old father’s hospitalization for sepsis, his doctors determined the strain of bacteria that plagued him: streptococcus. My sister was there when they came in with this part of the diagnosis; she has a doctorate in engineering with a focus on the human heart (that engineering marvel), and she likes details.

“What strain?” she asked the doctor. “A, B, or C?”

His reply: “What does it matter to you?”

This exchange was, admittedly, not typical for this hospital and this doctor, so I’ll forgive him some. And the strain did not, in fact, matter in the course of his treatment. But the routine arrogance found in doctors and hospitals does not serve patients and family members well. Knowing the particulars of what ails you often matters a great deal, especially for patients like my father, hospitalized and on the verge of being discharged home or to some other setting, but not yet “well.”

Knowing this kind of information—the details of your diagnosis and likely course, and how your care should happen at every step along the way—is critical to enabling patients and family members to function as respected participants in care, including ensuring safe transitions from one care setting to another. Much recent research indicates that those transitions are fraught with errors and complications. Patients often do not know or understand what is happening to them and critical information is not transferred from one provider to another, and that costly (and sometimes deadly) rehospitalizations are the norm for some 20 percent of Medicare beneficiaries who have been hospitalized.

Patients and their family caregivers are central actors in making transitions safer. Indeed, since they are the only constant in the transition from one setting to another, patients and caregivers must increasingly assume the role of knowing as much as they can about what is going on with their care. Experts in the field refer to this kind of involvement as “patient activation” or “engagement,” which occurs when patients have the knowledge, skills, beliefs and confidence to manage their own health care processes and behaviors. (more…)

By Meryl Bloomrosen. Perhaps my quest should have started as soon as my prior primary care physician (PCP) decided to focus his practice on his medical subspecialty.    That was 5 years ago or so.   Of course, back then I was pre-occupied with my parents’ various chronic illnesses and end of life issues.  So I never bothered to “change doctors”.    In the meantime, I continued to see various providers for an assortment of health and wellness issues as well as some basic and thankfully non-life threatening medical/health needs such as eye exams and mammograms, plus a few minor repairs here and there.   However, at the end of each encounter there were those nagging questions:   Who is your primary care physician? Who should we send the test results to?     

Not a problem…until I set out on the search.  I began checking with colleagues and friends and inquiring about their PCP and sought  suggestions and recommendations.   I reviewed several public listings and guides to “the area’s top doctors” or the areas’ top physicians. They used various rating methodologies to rank or “evaluate” providers.   I didn’t want to travel too far and I preferred a practice with multiple providers.  After all this is the Washington DC metropolitan area, right?    Feeling relatively confident with a list of names and telephone numbers I started “dialing for doctors”.    “I’m sorry Dr. X is not accepting/taking/seeing any new patients.”  Or “Call back after the new year”.    Not even a question about my health insurance coverage or my age or my problem(s).   No question about who referred me.     So then it dawned on me that I should have “gone on line” to seek and find my answer and here is what I found:

Notice:

• Not all physicians may be accepting new patients at this time. To see whether the physician is accepting patients, please click on the link to his/her name. (more…)

Marc Siegel wrote a column on January 18th in USA Today that discussed why doctors are unsure of  “Obamacare”. We at Disruptive Women believe it is important for all sides to be presented, so in contrast to the information in our post yesterday on the Jonathan Gruber event we hosted this week, take a look at this column.

By Jane Sarasohn-Kahn. To doctors working in eight countries around the globe, the biggest benefit of health IT is better access to quality data for clinical access, followed by reducing medical errors, improving coordination of care across care settings, and improving cross-organizational workflow.

However, except for the issue of health IT’s potential to improve cross-organizational working processes, American doctors have lower expectations about these benefits than their peers who work in the 7 other nations polled in a global study from Accenture‘s Eight-Country Survey of Doctors Shows Agreement on Top Healthcare Information Technology Benefits, But a Generational Divide Exists. Accenture polled over 3,700 doctors working in Australia, Canada, England, France, Germany, Singapore, Spain and the US.

As the subtitle of the report recognizes, there is an age chasm at the age of 50: physicians under 50 years of age more likely believe in the benefits of health IT; fewer older doctors do, on a global basis. Accenture points out that younger doctors are comfortable using computers during patient interactions in the exam room, compared with older physicians who prefer face-to-face conversations without what they may perceive as a disruptive interruption of looking at a keyboard or computer screen. (more…)

The following is a guest post by Ms. Nasreen Sulaiman a Senior Instructor at Aga Khan University School of Nursing. She  has worked with palliative patients.

By Nasreen Sulaiman. Palliative care is an urgent humanitarian need for people worldwide with cancer and other chronic fatal diseases as it provide comfort and ease suffering. Nearly 80 % of the cancer patients in Pakistan present late in stages 3 & 4 with terminal disease.  In Pakistan, the concept of palliative care is in its infancy stage and need to be strengthened. In Karachi, one of the mega cities of Pakistan, only two hospices each of 20-25beds provides palliative care services where the health care professionals’ main focus is on providing the physical aspects of care. Pain management, a crucial aspect in the palliative care still remains partially addresses due to lack of narcotic supplies and other medications.  Furthermore, I strongly feel that other than providing pain and symptom relief measures, the social, emotional, and spiritual needs of the patient should also be given prime importance in order to provide holistic care to the patients. Nurses need to learn to utilize various non-pharmacologic measures such as therapeutic communication techniques, use of humor, guided imagery, therapeutic touch, relaxation exercises, religious songs and other diversional activities in order to ease the suffering, emotional distress and provide optimal comfort and support to the patients including their caregivers. Moreover, in palliative care settings, caregivers hold a great importance as they are the ones who are providing the total care and most of the time with the patients. Caregiver role strain is an essential area to be looked at. Caregiver support is another area to be looked upon. We need to establish caregiver self-help groups or other avenues to support the caregivers as they go through lot of emotional pain and need immense help and affection which may assist them to perform their roles effectively with the patient suffering from the disease.

By Casey Quinlan. It’s not easy hearing your name and [insert dread diagnosis here]. I know this only too well after having to find the funny in my own journey through cancer. Cancer is, however, most often a diagnosis that you fight to a defined end. What’s it like to find the funny in a chronic condition like multiple sclerosis?

I have a number of friends who are battling MS, one of whom, Amy Gurowitz, shared a link on Facebook the other day to Jim Sweeney’s online empire of improv humor and chronic disease. Jim’s MS journey started with vision problems in 1985, he was officially diagnosed in 1990, and has been dealing with the disease – finding the funny most of the time – ever since.

Jim’s body of work includes decades of live improv, his one-man show “My MS & Me,” which you can hear on the BBC Radio 1 site. His MS has progressed to the point that he’s now in a wheelchair, and his public presence is mostly limited to Twitter, where his profile describes him as a housebound hedonist (hey, it made ME laugh) and YouTube.

How much courage does it take to laugh out loud, in public, at an incurable disease? Jim certainly has courage at the level required.

Other examples of funny-or-die in managing chronic disease include Mark S. King’s fabulously funny My Fabulous Disease blog (Mark is HIV-positive). The aforementioned Amy Gurowitz laughs out loud about her MS in a number of places, including MS Soft Serve and MS-LOL (life of learning OR laugh out loud, you pick).

On the provider side, there are a number of docs who are breaking up the waiting rooms and wards.

Dr. Patricia Raymond is a gastroenterologist whose mission in life is to take the “ick” out of colonoscopies. She bills herself as The Fabulous Butt Meddler. Since she looks like Bette Midler, the joke works on every level.

Dr. Zubin Damania, a/k/a ZDoggMD (“Slightly Funnier Than Placebo”), is a hospital medicine specialist in Palo Alto as well as a veritable buffet of medical humor, some G-rated and some most definitely NSFW. His videos alone guarantee hours of laughter. (more…)

The following is a guest post by Dr. Jessie Gruman. This blog post was originally published at Prepared Patient Forum: What It Takes Blog

“My doctor can titrate my chemotherapy to the milligram but can’t tell me when I am going to die,” a friend who was struggling with his treatment for cancer complained to me a couple years ago.

Had he lived, he might have been reassured by the announcement last week of a new scale that allows clinicians to estimate the time remaining to people with advanced cancer.  He was spending his final days “living by the numbers” of his white blood cell count, the amount and size of his tumors and suspicious lesions, the dosage of various drugs and radiation treatments. And he was peeved about what he saw as a critical gap in those numbers.  He believed (hoped?) that because his cancer was quantifiable and the treatment was quantifiable, that the time remaining should be similarly quantifiable.  He needed that information to plan how to use the time that remained.

Many of us would make a different choice about knowing how long we will live when we are similarly ill.  But most of us are attracted to the certainty we attach to the numbers that precisely represent aspects of our diseases. (more…)

By Jane Sarasohn-Kahn. Nuns and priests were CEOs at 770 of 796 Catholic hospitals in the U.S. in 1968. This year, there are only 8 of them leading 636 hospitals. Sister Mary Jean Ryan, who retired as CEO of SSM Healthcare, says, “We’re a dying breed.”

Why has this happened, and why should we care — whether or not we’re Catholic?

The New York Times covered this story on August 22, 2011, titled, Nuns, a ‘Dying Breed,’ Fade from Leadership Roles at Catholic Hospitals. NY Times editors smartly placed this story in the “U.S.” section and not under the “Religion” corner of the paper.

At the crux of this historical transition at religious hospitals is whether the values that drove the heart and soul of these institutions — caring for the needy, the safety net population, and the larger community — will translate when MBAs and MHAs take over leadership of these organizations. The Times wrote, “Although their influence is often described as intangible, the nuns kept their hospitals focused on serving the needy and brought a spiritual reassurance that healing would prevail over profit, authorities on Catholic health care say.”

This is not a marginal issue in American health care: in 2009, 1 in 6 hospital admissions was in a Catholic hospital.

Health Populi’s Hot Points: With the U.S. economy in decline or stasis in most of the nation, and health benefits for covered workers lucky enough to be covered by a health plan, moving more financial burden onto employees, more health citizens in the U.S. have been moving into safety-net, under-insured, or un-insured status. As such, more people seek care in emergency rooms and outpatient care in the community, and more have a difficult time paying for health care (my blog posts have featured this issue over the past 4 years; search on the topics of safety net, Medicaid, self-rationing, and medical home in Health Populi‘s search box). (more…)

WATCH exclusive video interviews with 15 of this year’s Top 25 Women in Healthcare!
They discuss some of the key factors that have contributed to their career success and share their advice for other women considering a career in healthcare administration.

By Jane Sarasohn-Kahn. Patients who perceive their visit to the doctor was patient-centered, with more communication, receive fewer diagnostic tests and referrals, and yield lower expenses for diagnostic testing. A new study finds that patient-centered care leads to lower spending on health care over one year of care due to fewer specialty care referrals. A contributing factor to lower costs is increased patient participation during the visit, which reduces patients’ anxiety and perceived need for further investigations and referrals. In the milieu of more effective patient-physician communication, physician gets more knowledge about the patient. This brings greater trust between patient and doctor, as described in Patient-Centered Care is Associated with Decreased Health Care Utilization, published in the Journal of the American Board of Family Medicine published in July 2011, and penned by Dr. Klea Bertaks and Dr. Rahman Azari.

This is not a new concept: ten years ago, the IOM’s seminal report, Crossing the Quality Chasm: A New Health System for the 21st Century, called for “patient-centeredness.”

What is patient-centered care? Bertakis and Azari call out four communication behaviors:

1. Eliciting understanding and validating the patients’ perspective
2. Understanding the patient within his or her psychosocial context
3. Reaching a shared understanding with the patient of the problem and its treatment
4. Creating a partnership in which “activated” patients share in decision making, power and responsibility.

These four precepts were codified in a 2007 publication from the National Cancer Institute, Patient-centered communication in cancer care: promoting healing and reducing suffering.

Health Populi’s Hot Points: Adopting a patient-centered approach isn’t solely about reducing health care costs: it’s about patient empowerment, effective communication between doctor and patient, and participatory medicine. The secret in this sauce is in the communication between the partners: greater sharing of information from each side of the conversation, building greater trust, and leading to a decreased use of unnecessary diagnostic testing, hospital care, and specialty referrals. While long-term outcomes haven’t yet been quantified in the patient-centric approach, this study adds to the growing evidence base that participatory medicine is a win for the patient, a win for the physician, and a win for the larger health system and health economics.

Originally posted on Health Populi on July 19th.

By Val Jones. I’ve often heard physicians say that “the history is 90% of the diagnosis.” In other words, they can usually determine the underlying cause of a patient’s problem just by listening to their account of how it evolved. The physical exam is merely to confirm the diagnosis, and is often cursory, limited, or ignored.

I believe that the physical exam is far more important than it seems – and I learned this during my recent oral medical specialty board examination. Although I have been sworn to secrecy regarding the content of the test questions, I will share an epiphany that I had during the exam.

The examiners’ job is to describe a patient and then ask the examinee what else she’d like to know and what she’d do next. With each description, I found myself struggling to visualize the patient – wishing I could see their face and hear their tone of their voice as they described their condition. I hadn’t realized that so much of my clinical judgement was based on laying eyes on a patient – I needed to see if they were in pain, if they were straining to breathe, if their skin was pasty or pale, if they were disconnected and potentially drug-seeking, if they were fidgety, if they were articulate, forgetful, or well-groomed. All of these subtle cues were gone.  I was left staring at the examiner – who himself couldn’t describe the patient more fully because he was to stick to the script, reading verbatim from a prepared list of signs and symptoms.

And then something interesting happened – based on the short description of an imaginary patient’s complaint, I began to go down an inappropriate (and expensive) diagnostic pathway. Since I couldn’t see the patient, and some of the symptoms could have been life-threatening, I suggested some pretty aggressive measures. I would not have ordered any of these tests had I been able to see the patient in-person, because I would have been able to see what was actually wrong quite quickly.

I realized that when two doctors plan for the care of a patient they’ve never met, all manner of inappropriate and expensive testing and treatment can occur. So I wondered to myself: what will happen to our healthcare system if we continue to divorce ourselves from patient contact? When diagnostic algorithms become even more rigid, and patients are pressed into diagnostic code categories with pre-determined courses of action prescribed for them long in advance? It’s going to become easier and easier for people to be locked in to an incorrect diagnosis, and subjected to a battery of expensive, and unnecessary tests and procedures… when all that was needed was a pair of human eyes and a thoughtful exam at the very beginning.

I’m pleased to report that I passed my specialty board exam, and I’m now certified in Physical Medicine and Rehabilitation. However, as I consider my clinical future – I know that to be a good diagnostician, I must spend time with my patients in-person… and I’m looking forward to it.