The following is a post by Dr. Jessie Gruman from the Center for Advancing Health. This blog post was originally published at Prepared Patient Forum: What It Takes Blog.

“There is a better way – structural reforms that empower patients with greater choices and increase the role of competition in the health-care marketplace.” Rep. Paul Ryan (R-WI)August 3, 2011

The highly charged political debates about reforming American health care have provided tempting opportunities to rename the people who receive health services.  But because the impetus for this change has been prompted by cost and quality concerns of health care payers, researchers and policy experts rather than emanating from us out of our own needs, some odd words have been called into service.  Two phrases commonly used to describe us convey meanings that mischaracterize our experiences and undervalue our needs: “empowered patient” and “health care consumer.”

As one who has done serious time as a patient and who spends serious time listening to talks and reading the literature that use these words to describe us, I ask you to reconsider their use.

“Empowered patient” The fabrication of the verb “to empower” from the noun “power” was used in the civil rights and community development movements to describe a benevolent bestowal of influence on disenfranchised individuals and groups by those who had previously excluded them.  When used in relation to health care, the word perpetuates the idea that we are passive entities, waiting to be gratefully endowed by our clinician or a new policy with the right and ability to act on our own behalf.  Our “empowerment” takes place not as a result of our own will or preference, but rather because we have been given permission to act in a different way by some external agent. (more…)

By Mary Grealy. I wonder how long it will take before people who should know better stop implying, or even saying outright, that payment cuts to Medicare providers don’t affect beneficiaries.

This weekend, I was among those following the cable news shows to see if Congress would finally reach agreement on a debt ceiling package.  It appears now that, even though it may be a “sugar-coated Satan sandwich” to some, a legislative approach has been crafted that will raise the debt ceiling and establish a process for achieving approximately $2.5 trillion in budget cuts over 10 years. 

In this process, a congressional super-committee will be charged with identifying $1.5 trillion in deficit reductions by Thanksgiving.  If they fail to do so, automatic cuts will occur and fall most heavily on the defense budget and Medicare.

As I was watching the news analysis, though, I saw a continued misunderstanding of what it means to cut Medicare provider payments.  One commentator praised the deal for protecting the most vulnerable in society, pointing out that Social Security and Medicaid were exempt from cuts, and Medicare cuts “would only affect providers.’  We’ve seen the same type of analysis several times today in print reports.

This kind of verbage creates the impression that an acceptable way to reduce Medicare spending, in a way that doesn’t do harm to patients, is to ratchet down payments for physicians, hospitals, medical devices, pharmaceuticals and medical supplies. (more…)

On June 9, 2011, sanofi-aventis U.S. announced the “sanofi-aventis U.S. Innovation Challenge: Data, Design, Diabetes” at the National Institute of Health’s Health Data Initiative Forum. The challenge, which launched on July 1, integrates open data with a human-centered view into diabetes, and will award $220,000 in total prize money.

The challenge is designed for fast learning, so that innovators can create the needed service solutions for people living with diabetes. It brings together the richness of open data sets made available on healthdata.gov, the values of human-centered design, and the leading edge methodology of the top innovation accelerators.

Until July 31^st, innovators can submit their concepts on www.datadesigndiabetes.com.  In early August, an independent panel of expert judges (listed below) will review the submissions and five semi-finalists will be awarded $20,000 and professional mentoring to turn the concept into a prototype. In early September, the five teams will present at a demo day.  An open panel and our judges will select two finalists to receive an additional $10,000 to pilot their prototype in a real life diabetes community.  The findings and learnings from this exercise will inform the selection of a final winner who will receive an award of $100,000, along with a one- month stay at the RockHealth incubator in San Francisco to turn their prototype into a full, real solution for people living with diabetes.

Judges include:

• Jeff Hammerbacher – Founder and Chief Scientist, Cloudera
• Manny Hernandez – Founder, TuDiabetes
• Hilary Mason – Chief Scientist, Bit.ly
• Todd Park – CTO, U.S. Department of Health and Human Services
• Sue Siegel – General Partner, MDV-Mohr Davidow Ventures
• Ida Sim – Director, UCSF Center for Clinical and Translational Informatics
• Dennis Urbaniak – VP U.S. Diabetes, sanofi-aventis

Diabetes is a chronic, progressive disease that has reached epidemic proportion, with 100 million people in the U.S. currently living with diabetes.  At this rate, the CDC estimates that by the year 2050 1 in 3 Americans will have diabetes. 

Visit www.datadesigndiabetes.com for more information, including criteria, official rules and deadlines.  For more updates, follow Data Design Diabetes on Twitter and Facebook.

On the Quality Front: New Approaches in Improving Patient Safety

Thursday, July 28, 2011
1:30 – 2:45 pm ET

A key part of improving quality is in reducing medical errors and improving patient safety. Providers and payers are redoubling their efforts to address such problems, ranging from hospital acquired infections and preventable injuries to avoidable complications and adverse drug reactions.

The need is clear. A recent study published in the journal Health Affairs found that, on average, one third of hospital inpatients suffer an adverse event or medical error. That is nearly 10 times greater than shown by previous studies. As for Medicare, about 1 in 7 beneficiaries experience adverse events, costing the government some $4.4 billion each year.

Join Philips on July 28th, when their latest “Reimbursement Simplified” webinar explores some of the new approaches to improve patient safety including:

• A program by a Chicago hospital to remotely monitor ICU patients
• A JCAHO initiative with top health systems to design and disseminate new safety solutions
• A private payer’s perspective on identifying and managing serious adverse events

Speakers:

• Carolyn S. Langer, MD, JD, MPH
  Medical Director, Medical Management and Quality, Harvard Pilgrim Health Care
• Klaus Nether
  Black Belt, Joint Commission Center for Transforming Healthcare
• Becky Rufo, DNSc, RN, CCRN
  Resurrection Health Care eICU® Program Operations Director, Resurrection Health Care
• Laurel Sweeney (moderator)
  Senior Director Global Reimbursement Policy, Philips Healthcare

To Register: Go to www.philips.com/reimbursement or call 202-263-2900. There is no fee to participate.

The following is a post by Dr. Jessie Gruman from the Center for Advancing Health. This blog post was originally published at Prepared Patient Forum: What It Takes Blog. It was also posted on Better Health.

By Jessie Gruman.“The most important thing I learned was that different doctors know different things: I need to ask my internist different questions than I do my oncologist.”

This was not some sweet ingénue recounting the early lessons she learned from a recent encounter with health care.  Nope.  It was a 62-year-old woman whose husband has been struggling with multiple myeloma for the last eight years and who herself has chronic back pain, high blood pressure and high cholesterol and was at the time well into treatment for breast cancer.

Part of me says “Ahem.  Have you been paying attention here?” and another part says “Well of course!  How were you supposed to know this?  Have any of your physicians ever described their scope of expertise or practice to you?”

I can see clinicians rolling their eyes at the very thought of having such a discussion with every patient.  And I can imagine some of us on the receiving end thinking that when raised by a clinician, these topics are disclaimers, an avoidance of accountability and liability.

But all of us – particularly those receive care from more than one doctor – need to have a rudimentary idea of what each clinician we consult knows and does. Why is this clinician referring me to someone else? How will she communicate with that clinician going forward? How and about what does she hope I will communicate with her in the future?

Why does our clinician need to address these questions?

Because in the absence of real guidance we will guess.  Some of us will make informed guesses and be mostly right. Others of us will leave our primary care provider in the dust and seek care for routine health matters from our specialist, whom we see more frequently and who seems to know us better. Some of us, like my friend above, will ask for help from whichever physician is handy and will call back, regardless of the problem.  And some of us will throw up our hands in frustration and head for the local emergency department when we find we can’t breathe and don’t know which of our doctors to consult about those damn allergies.

These ad hoc solutions are a waste of our time and surely contribute to a poor use of clinician and institutional resources. (more…)

The completely updated 200-page Alliance sourcebook, “Covering Health Issues, 6th Edition,” is now available.

Written with reporters in mind, “Covering Health Issues” is useful for anyone looking for concise information on health policy issues, and experts from across the political spectrum. Chapters contain fast facts, background, tips for reporters, story ideas and experts with contact information. The book also includes an extensive glossary, ideas and examples for TV and radio reporters, and links to polls on health issues. Supported by a grant from the Robert Wood Johnson Foundation.

To see a video demonstration of the book by Julie Rovner of NPR, click here. To see individual chapters, click on any of the chapter titles below. To download the entire sourcebook as a PDF, click here.

For all chapters, links are available to local news stories on the chapter topic. For many chapters, there is also a short video featuring one of the nation’s top health policy experts.

Table on contents:

• Introduction and Acknowledgments
• Health Reform
• Cost of Health Care
• Quality of Care
• Employer-Sponsored Health Coverage
• Individual Health Coverage
• Children’s Health Coverage
• Medicare
• Medicaid
• Long-Term Care
• Disparities
• Mental Health and Substance Abuse
• Public Health
• Polls on Health Care Issues
• Covering Health Issues for TV and Radio
• Acronyms and Glossary
• Experts
• Websites

The Alliance for Health Reform is a nonpartisan, not-for-profit health policy education group. We are committed to helping journalists, elected officials and other shapers of public opinion understand the roots of the nation’s health care problems and the trade-offs posed by various proposals for change. Our aim is quality, affordable health coverage for all in the U.S., although we do not lobby or take positions on legislation. Sen. Jay Rockefeller (D-W.Va.) is our founder and honorary chairman; Robert Graham, MD, of the University of Cincinnati is our board chairman.

By Regina Holliday. On the evening of Tuesday June 7th 2011 the Kaiser Permanente Center for Total Health, located beside Union Station in Washington DC, will become a gallery for one night. 

We won’t pound a single nail into the walls to hold the art.  This shall be The Walking Gallery.  That night dozens of people will walk into the space wearing business jackets or doctor’s lab coats.  That alone is not unusual.  It would be a daily occurrence in this dual-use space.  But these jackets will be works of art.  Each one shall be painted with the story of a patient or an element of medical advocacy by me or another artist.  These masterpieces will be worn on the backs of government employees, technology gurus, medical professionals, social media activists, CEO’s of companies and artists.  It shall be a great meeting of the minds.

The Walking Gallery will happen because Jen McCabe followed me on Twitter on May 30th 2009.    That was the day before I placed the Medical Facts Mural in Pumpernickels Deli on Connecticut Ave.  That was a day when my Fred was still alive and could speak and eat again because of the wonderful care he was receiving in Washington Home Hospice.  Jen was one of my first followers on Twitter and is such a glorious spark of life.  

On August 20th she emailed me after I had posted a comment on her blog and asked me if I would paint a series of paintings on the back of her blazers to wear to upcoming health meetings.  I told her I would be honored to paint jackets for her.  Jen responded, “Symbols and talismans mean quite a bit to me, and having things constructed by friends is one way to remind myself why I do the work I do and forego so many of the other things I enjoy.  I’m so happy to have a wearable badge of courage – just wrote an index card for myself to remind me of the importance of patient advocacy by “any means necessary.”  Art is another one of those means.”

I finished the second mural “73 Cents” on September 30th 2009.  It was my feverish obsession in the weeks after Fred’s death.  “73 Cents” was a thing that I had to do.  It soothed my soul; it spoke to me and calmed my aching heart.  It gave me a reason to leave the solitary confines of my mind and my widowhood.  It gave me permission to stand on the street and talk with complete strangers about the grief roaring within me.  I often go to social justice events and hear about the chronically homeless on the street.  I hear workers complain that they find small single apartments for these folks to live in, but instead many return to the street.

I think I know the reason why. 

It is hard to be alone when sadness is engulfing the mind.  The street is alive, and there the broken congregate and help each other.  Each day I painted I made many new friends, but those who came back and spoke to eye to eye were often the most dispossessed and the homeless. 

Without Jen’s suggestion that I paint jackets, I would have gone home, my Magnum Opus done, to loneliness and grief.  Yes, I was still blogging, but that was not enough.  I had to paint.  I had to spread the word through art.  Jen had provided a new “wall,” and that wall could walk into the Mayo clinic or the National Board of Medical Examiners and remind everyone of those patients who suffer in a system without real time data access.

I would paint and post images of three jackets for Jen:  “Data Prison” on October 5th 2009, (more…)

The following was originally posted on James’s Project by Mary Ellen Mannix, MRPE. The mission of James’s Project is to find, support, and help work that protects infants in their first year of life. James’s Project aims to reduce infant mortality by focusing on patient safety isssues that affect the start of life. Our tools are education, communication, and collaboration.

Rainy days and Saturdays get me down. (Sounds like a good song lyric.) Rainy days force a quiet among the constant buzz of activity. Saturdays are the closest thing to a once a week siesta. Nearly ten years ago, on a Saturday morning I had to to reflect on the beliefs I had held dear all my life as I was holding my newborn son who had just died. It took more than five years before I could wake up on a Saturday without feeling a desire to go back to sleep.

Today the rains came and brought with them memories of a Saturday past. Tears and frustration and disappointment rallied. Those feelings don’t make me feel very peaceful. Taking the analytical approach learned in grad school, I identified five causes for a peace builder in health care to have anger, frustration and the occasional tears.

Poor communication. This is a well-documented root cause for most every medical error. Earlier this week Kathleen Sebelius of the Dept of Health and Human Services and Don Berwick, MD of the Centers for Medicaid and Medicare announced the creation of a $500 billion initiative to encourage more collaboration between hospitals, health care providers, community organizations, and employers, etc to improve care and lower costs. James’s Project was among the first ten organizations to make the public pledge for the Partnership for Patients: Better Care, Lower Costs in the greater Philadelphia area. Through this website consumer and clinical organizations can seek out others with similar values for collaboration. When a cancer patient called me this week sharing she had left the hospital without discharge instructions together we took a look at this website. The large teaching hospital had not yet pledged. By the end of the week, the institution had taken the pledge but the patient is still waiting for her discharge instructions. This is new resource where patients can grab the wheels and drive change by asking their hospital, health care system, insurer and or doctor if they have signed the pledge. Also ask – what community or patients group are you collaborating with?

Gag Clauses. As a rule, people love to hate the plaintiff in a medmal case. If you actually disagree with me, think of before you knew a loved one who died from medical errors. Americans love to love the whitecoats. Anyone associated with a trial lawyer automatically becomes a blackhat.
I believe in the judicial system our forefathers created. Everything breaks down at times. As a teacher, I hope that learning happens from mistakes. With James’s case, it was clear the physicians had as much of a right to a fair trial as my son did. It could have all been spared if open communication between us had been allowed. I was offered $750K to not go to trial and to not speak of my son’s whole life. All I wanted was to cover my attorney’s fees (about 45K at that point) and a 5 minute conversation with one of the defendants. It was not an acceptable counter offer evidently.
I can reflect now that I did get that conversation (and much more than 5 minutes) with two doctors (not just the one) and I did that all on my own.
Despite the tremendous pain of our shared trauma we have been able to heal by restoring a relationship. Our story and how we did it is how money in health care conflicts can be saved. More importantly, it teaches so many what not to do when they may find themselves in a similarly shared event. I have spent years and dollars investing in formal education to share this. (more…)

Disruptive Women Sharon Terry’s article “Power to the People: Participant Ownership of Clinical Trial Data” was published in Science Translational Medicine.

Abstract: Participation in clinical trials is dismally low. In this age of electronic sharing of information of all sorts, trial participants can easily share clinical trial data. The benefits of participant ownership and sharing of trial data appear to outweigh the risks. Thus, the time has come to crowd-source data for diagnostic and therapy development.

To download full article click here.

The following post is written by guest blogger Joanna Fief. Joanna works at Regence BlueCross BlueShield and encourages you to visit the company’s blog and website about health care costs at www.WhatsTheRealCost.org to learn more.

By Joanna Fief. About two years ago in the wee hours of the morning, I found myself in a local emergency room with severe stomach pain, incessant vomiting and dehydration.  It wasn’t pretty, and I was desperate for something – anything – to ease my pain and stop my vomiting. 

Gratefully, within minutes of receiving an IV with medications for pain and nausea, my symptoms subsided.  After a couple of blood tests that all came back normal, I was discharged.  The ER doctor said I probably just had a virus.  I wish …

Over the next six months, I lost 20 pounds, and had repeated bouts of stomach pain and vomiting.  After another ER visit, countless doctor visits, an ultrasound, an x-ray, a CT scan, an endoscopy and a gastric emptying study, I was diagnosed with gastroparesis.  Gastroparesis is a disorder where food moves slowly – or sometimes not at all – through the stomach and digestive tract.

Thankfully, today my condition is well-managed, and I feel pretty good.  However, it took me until last month to finish paying my medical bills – and that’s with good insurance.  Although I definitely don’t mind paying for the care that I received, I do wish medical pricing was more straightforward and transparent.

My mother is a nurse and I work for a health insurance company. Until I got sick, I considered myself pretty savvy about the health care system.  Over the course of my medical journey, though, I realized even with “insider’s knowledge” it can be extremely difficult to navigate the system, know the right questions to ask, and make informed decisions about cost and quality of care.

Not until after I got my first emergency room bill did I find out that while the hospital was in-network, the doctor was out-of-network.  Only when I was lying on the gurney getting ready to be sedated for my endoscopy did it occur to me to ask the doctor how many of these procedures she had done (thankfully, more than 5,000).  And, not until a few months ago, did I even consider that I might have shopped around for the best price on a CT scan.  I always felt like I was one step behind. 

The new health reform law promises to change the health care experience and stem rising health care costs, but based on my experience, we shouldn’t underestimate the power each of us holds to drive that change.  If I had it to do over again, I would ask more questions about the cost and reason for each procedure – while there was still an opportunity to influence the outcome.  The questions might make others uncomfortable, or as I found, the answers might not be readily available, but it’s the best way to be your own advocate.

Learn from my experience.  When your doctor suggests going to the ER for a non-emergency x-ray just because it’s faster, you might think twice before going along with it.  Below are five simple questions from www.WhatsTheRealCost.com, a website dedicated to helping people make more informed health care cost decisions, you can ask to create options and protect your pocketbook.

1. How much does that cost? 
2. Is that really necessary? 
3. Is there a cheaper option? 
4. Is there a generic for that? 
5. Has anybody out there had this before? 

The following is an interview conducted by Hope Ditto of Disruptive Women with Grace Bender.

“Take responsibility for your own health care.” That’s the message that Grace, a Disruptive Woman and an experienced patient advocate, wants you to take away from her story. “You have to be your own advocate, but if you can’t, don’t be afraid to ask a family member or friend to step in and speak up on your behalf.”

Grace can speak from experience about being an advocate, both for herself and for her loved ones. In fact, Grace created mymedmanager™ , a personal health care and medication organization system, after her experience as an advocate for her mother. (You can read about this in a previous blog post here). While that experience focused primarily on managing medication intake, Grace’s more recent experience with her husband highlights, perhaps even more poignantly, the importance of taking responsibility for one’s health care.

When Grace’s husband first started shuffling his feet rather than walking correctly earlier this year, this was attributed to a combination of a torn meniscus and aging. When he began suffering from insomnia, stress was blamed and sleeping pills were prescribed. When he showed signs of depression, he was prescribed anti-depressants. When he developed tremors, which he actually described as feeling anxious, yet another medication was added.  While he saw various specialists, no one ever suggested that perhaps there could be a larger underlying problem to explain all these symptoms; that all of these ailments could possibly be interconnected. Grace then started going with him to some of his medical appointments.

At one point, Grace noticed that he had a hand tremor at the same time that he said he was feeling very anxious.  He then asked if she thought it could be Parkinson’s. She immediately went to the computer and did a search on Parkinson’s.  Despite her husband being what many would consider a “textbook case,” as Grace explained, none of the specialists ever put it all together. Every one of his ailments was a symptom of Parkinson’s but each one was treated separately, and there seemed to be a logical explanation for each symptom.

A neurological specialist confirmed that it was indeed a mild case of Parkinson’s.  With the proper medication for that disease and after he is on the full dose, it is expected that some of the other medications will be reduced or eventually eliminated.  Already there is an overall improvement because he is taking the proper medication and beginning to exercise.

As stated, the bottom line to Grace is that you must be your own advocate, ask questions, and seek a second opinion when issues are not resolved. With the abundance of reputable information sources available and accessible online, there is no excuse not to educate yourself about your condition, symptoms, and prognosis. You can then ask intelligent questions and take a significant responsibility for your health care. (more…)

By Casey Quinlan. I have this dream. It’s about how, when I make an appointment to see my doctor – my primary care physician – the process is easy, honors my time as much as it does my doctor’s, and winds up running smoothly for both parties.

The dream starts this way: I realize it’s time for my annual physical, or any other usual-suspects periodic visit to my PCP. I open up my browser, point it to my doctor’s website, and log in to the secure patient portal. The one where I can see all my prescriptions, my personal health record, make an appointment (using the handy calendar function), request a prescription refill, ask the nurse or doctor a question via email, or download a PDF of my health record.

In my dream, using the handy scheduling function in the portal, I select a date and time for my appointment. The portal auto-populates that date and time with my name and insurance/contact information, since I logged in and it knows who I am. The system asks me if any information has changed. I click “no”. If I click “yes,” the next screen asks me to make the changes, and “submit”.

I select “annual physical” from the list of appointment types. I enter any information I need to related to this appointment request (i.e. “Doctor, I have this pain…”). Then I click “submit” and the system sends me a confirmation email or text (I picked which one I prefer when I set up my profile on the portal). It also schedules me for a blood draw in the week prior to the appointment, sending me a confirmation for a walk-in at the lab.

The scene in my dream shifts to the day of my doctor’s appointment. I’m scheduled to be seen at 11:00am. I get a text at 10:00am – or an email, whichever I selected when setting up my portal profile – saying that the doctor’s running about 30 minutes behind. I can either come in at 11:30am, or select one of the alternate appointment times in the text/email and be re-scheduled.

I select 11:30am, and I arrive a few minutes before that time. Signing in involves scanning a key tag – just like the one you get from your favorite supermarket – which lets everyone in the practice, from the receptionist to the doctor, know that I’m there, and on time.

If the administrative staff needs to talk to me for any reason, they’ll see me on their screen (usually because, in the day-before review, they checked the “confirm insurance details” or “update pharmacy info” or “collect co-pay” radio button) and invite me to have a private conversation. By using my first name only. No sign-in sheet (HIPAA violation) or yodeling my full name across a crowded waiting room (HIPAA violation). (more…)

Photo of Disruptive Woman Alexandra Drane (courtesy of The Health Care Blog) presenting Engage with Grace at this year’s TEDMED.

You can read more about the inspiration behind Engage with Grace in Disruptive Women in Health Care’s Patient Advocacy eBook.

By Robin Strongin. During August and September we ran a series of posts on patient advocacy. These posts have been compiled into what is a very informative and engaging ebook. A big thank you to all the bloggers whose posts are included in this ebook; we greatly appreciate them sharing their perspectives and personal stories on patient advocacy.

Please feel free to share and distribute this ebook to others who would find this of interest. As always, we welcome your feedback and comments. All the posts in the ebook remain on the blog and it’s not too late to comment on specific posts.

Download a free copy of the ebook.

By Archelle Georgiou. Aren’t movies a great value? In addition to offering two hours of entertainment, they often inspire us to wander into tangential questions and dilemmas that might otherwise remain unexplored and undiscussed. 

Disney’s Secretariat is a wonderful family movie about a racehorse who, in 1973, became the first Triple Crown champion in twenty-five years when he won the Belmont Stakes by 31 lengths. The movie is also about the his owner, Penny Tweedy.

Penny (Chenery) Tweedy is a Columbia Business School graduate turned housewife. She is married to a successful attorney and is the mother of four children. But, when she assumes responsibility for her father’s ranch, she shifts her focus away from her family and on to the horse and on to winning…at all costs. As usual, Disney glamorizes her passion and glosses over the family conflicts, but in a recent article by her Penny’s son, John Tweedy, he said, “In real life, we Tweedys were more riven and frayed…by the pressures of celebrity into which we were suddenly thrust. The wars between our parents were more bitter, the marriage more broken, and we kids were more alienated and countercultural than the movie depicts.”

During the scene when Penny turns down $8 million dollars for Secretariat and risks the family estate, David, my husband,  turned to me and said, “Archelle, even though I know how this movie ends, she is really being irrational.” Or, was she?

And, at that moment, my tangential thinking began….

• When should a “housewife” give up her dreams and what she believes in for the good of her family?
• Why should 6 men voluntarily descend 2041 feet into the San Diego Mine escape shaft to help save 33 others who were buried alive for 67 days.

These are questions of utilitarianism, a moral theory centered around the basic concept that “actions are right to the degree that they tend to promote the greatest good for the greatest number.” While I don’t fully understand all the nuances, the basic concept is one that’s been on my radar for a few weeks since Athena called me to brainstorm about an essay for her freshman Ethics class. “Mom, when do the needs of the community supercede the needs of the individual?”

Her question brings me to this blog topic:

When should a health care provider get the influenza vaccine (even when they don’t want it) to prevent putting vulnerable patients at risk? (more…)