Thursday, February 26, 2009

Africa’s ‘Obama’ School


After Barack Obama was elected president in November, the Darfur refugees here were so thrilled that they erupted in spontaneous dancing and singing.

Soon afterward, the refugees renamed the School No. 1 in this dusty camp the Obama School. It’s a pathetic building of mud bricks with a tin roof, and the windows are holes in the walls, but it’s caulked with hope that President Obama may help end the long slaughter and instability in Sudan.

Soon we’ll see whether those hopes are justified. Next Wednesday, the International Criminal Court is expected to issue an arrest warrant for Sudan’s president, Omar Hassan al-Bashir, for crimes against humanity in Darfur.

That would be historic — the first time the court has called for the arrest of a sitting head of state. It would be the clearest assertion that in the 21st century, mass murder is no longer a ruler’s prerogative.

Sunday, February 22, 2009

Latest Grand Rounds

Emergiblogs hosts a Napoleon Dynamite themed Grand Rounds with a number of great entries, including these:

Another phenomenal entry from the Happy Hospitalist: Dr Nurse, The PA perspective, And Your Differential Diagnosis
(I could not resist excerpting more than normal from his entry, but you really must read the whole thing at his site):

Here's my opinion, most patients have no idea if you are a doctor, a nurse, or the lab tech. Walk in a room. Pretend you know what you are doing. Be nice. Talk to them a little. Let them tell you how Cuddles,their little Chihuahua, likes to lick the enamel off their teeth. When you walk out, I bet just about every patient would tell their spouse, "My what a nice doctor that was."
For medicine that involves the diagnosis and management of acute and chronic medical disease, there is only one type of doctor. Someone who has earned a doctorate degree in the study of medicine, not nursing. Someone who has gone on to train under the direction of medical doctors to learn their craft as defined by accredited institutions. Someone who has sat for and passed the requirements for certification as defined by the board of their medical specialty, the competency of which has been determined by other doctors who specialize in that field of training. That's what a doctor is. That's what the public expects when they get "a doctor"
Citing another PA: "My other concern is the use of the title, "Doctor". It is true that pharmacists, PT's, and others have moved to a doctoral degree. BUT, none of those professions outside of a psychologist, use the title "Doctor" when treating patients.....why you might ask?

Simple, it is confusing to the layperson, and downright fraudulent, ..."
Why? Because I don't define quality the way a NP or a DNP or a patient or the government will. I define it by characteristics that can't be measured in a randomized trial or tracked with outcomes data, but is at the same time, the most important aspect of independent patient care.

For me, that greatest determinant of quality care, which you won't find in any journal or on any government compare website, or in any patient satisfaction survey is the strength and quality of the differential diagnosis generated by that practitioner. Doctors are differential diagnosis generators. This is, by and far, the most important skill set a physician can offer their patient, something that cannot be learned in nursing level training or nursing level graduate school. It is what separates physicians from all other providers of independent care.

The only way you get that good is to know your differential diagnosis. And the only way you get to know your differential diagnosis is to learn it in a doctor level training program.

When you call yourself a doctor, you are portraying yourself as a master of the differential diagnosis. Your patients will not know otherwise. But I know that's what they deserve. And other doctors know that's what they deserve. Even you know that's what they deserve. Your job is not to put your signature on a protocol. Your goal is not to achieve 85% compliance with HgbA1c data gathering. Your job is not to get high satisfaction scores. Using these markers to define your quality is a slap in the face to your patients. Your patients deserve an extensive differential diagnosis, every time.

is an interesting article from The Covert Rationing Blog on a study on colonoscopies performed without conscious sedation. The interesting find is not the percentage of patients who tolerated the procedure, but why the study was performed (hint: the author or the article, works in a VA Hospital)

What’s Wrong With Summer Stiers?

And even though Turner and the others are part of the innovative new Undiagnosed Diseases Program at the N.I.H., and even though they collectively represent the very best that American medicine has to offer, they still began by approaching the big picture of Summer Stiers the way most specialists do: like the blind men, one piece at a time.

The Undiagnosed Diseases Program was designed to move past that halting first step — the inevitable result of the organ-by-organ orientation of most medical specialties — to achieve a more coherent view. Under the direction of William Gahl, a longtime N.I.H. investigator who is also the clinical director of the National Human Genome Research Institute, the program brings together scientists from most of the N.I.H.’s 27 research institutes and centers on a collegelike campus in Bethesda, Md. Organizationally, it creates a kind of superdiagnostician, whose orientation would be to look at not just one piece at a time but at the whole darn elephant.

Physician Data Restriction Program

Tired of pharmaceutical reps tracking your prescriptions?
Check out this link...

Restricting access to prescribing data should be every physician's individual choice. The American Medical Association's (AMA) Physician Data Restriction Program (PDRP) puts the choice in doctor's hands.


Kevin, M.D. with an excellent point here...

One aspect that's missing whenever healthcare costs are discussed is the so-called "opportunity cost" that patients incur whenever they wait for medical care. Granted, there are doctors who inexcusably run hours late. However, if physicians were compensated for their time, including hours spent filling out forms or wading through pre-authorization requests, I think you'll find that they'll value patients' time significantly more.

The Anti-Bono

Questions for Dambisi Moya

Q: As a native of Zambia with advanced degrees in public policy and economics from Harvard and Oxford, you are about to publish an attack on Western aid to Africa and its recent glamorization by celebrities. ‘‘Dead Aid,’’ as your book is called, is particularly hard on rock stars. Have you met Bono?
I have, yes, at the World Economic Forum in Davos, Switzerland, last year. It was at a party to raise money for Africans, and there were no Africans in the room, except for me.

You argue in your book that Western aid to Africa has not only perpetuated poverty but also worsened it, and you are perhaps the first African to request in book form that all development aid be halted within five years.
Think about it this way — China has 1.3 billion people, only 300 million of whom live like us, if you will, with Western living standards. There are a billion Chinese who are living in substandard conditions. Do you know anybody who feels sorry for China? Nobody.

What do you think has held back Africans?
I believe it’s largely aid. You get the corruption — historically, leaders have stolen the money without penalty — and you get the dependency, which kills entrepreneurship. You also disenfranchise African citizens, because the government is beholden to foreign donors and not accountable to its people.

If people want to help out, what do you think they should do with their money if not make donations?

Microfinance. Give people jobs.

Tuesday, February 17, 2009

A Promising Treatment for Athletes, in Blood

The method, which is strikingly straightforward and easy to perform, centers on injecting portions of a patient’s blood directly into the injured area, which catalyzes the body’s instincts to repair muscle, bone and other tissue. Most enticing, many doctors said, is that the technique appears to help regenerate ligament and tendon fibers, which could shorten rehabilitation time and possibly obviate surgery.

Research into the effects of platelet-rich plasma therapy has accelerated in recent months, with most doctors cautioning that more rigorous studies are necessary before the therapy can emerge as scientifically proven. But many researchers suspect that the procedure could become an increasingly attractive course of treatment for reasons medical and financial.

Sunday, February 15, 2009

Yes, They Could. So They Did.

So I am attending the Energy and Resources Institute climate conference in New Delhi, and during the afternoon session two young American women — along with one of their mothers — proposition me.

“Hey, Mr. Friedman,” they say, “would you like to take a little spin around New Delhi in our car?”

Oh, I say, I’ve heard that line before. Ah, they say, but you haven’t seen this car before. It’s a plug-in electric car that is also powered by rooftop solar panels — and the two young women, recent Yale grads, had just driven it all over India in a “climate caravan” to highlight the solutions to global warming being developed by Indian companies, communities, campuses and innovators, as well as to inspire others to take action.

They ask me if I want to drive, but I have visions of being stopped by the cops and ending up in a New Delhi jail. Not to worry, they tell me. Indian cops have been stopping them all across India. First, they ask to see driver’s licenses, then they inquire about how the green car’s solar roof manages to provide 10 percent of its mileage — and then they try to buy the car.

We head off down Panchsheel Marg, one of New Delhi’s main streets. The ladies want to show me something. The U.S. Embassy and the Chinese Embassy are both located on Panchsheel, directly across from each other. They asked me to check out the rooftops of each embassy. What do I notice? Let’s see ... The U.S. Embassy’s roof is loaded with antennae and listening gear. The Chinese Embassy’s roof is loaded with ... new Chinese-made solar hot-water heaters.

You couldn’t make this up.

Thursday, February 12, 2009

Comparing Global Religiositycx

Unlike Paul Kedrosky, author of the great Infectious Greed blog,this graphic pretty much parallels my experiences in traveling the globe..
Something of a diversion, but the results in this comparison of global religiosity surprised me.

Wednesday, February 11, 2009

Smoking Causes Blindness campaign

From Social Guerilla Marketing...
via the Happy Hospitalist

In New Procedure, Artificial Arm Listens to Brain

Amanda Kitts lost her left arm in a car accident three years ago, but these days she plays football with her 12-year-old son, and changes diapers and bearhugs children at the three Kiddie Cottage day care centers she owns in Knoxville, Tenn.

Ms. Kitts, 40, does this all with a new kind of artificial arm that moves more easily than other devices and that she can control by using only her thoughts.

“I’m able to move my hand, wrist and elbow all at the same time,” she said. “You think, and then your muscles move.”

Her turnaround is the result of a new procedure that is attracting increasing attention because it allows people to move prosthetic arms more automatically than ever before, simply by using rewired nerves and their brains.

The technique, called targeted muscle reinnervation, involves taking the nerves that remain after an arm is amputated and connecting them to another muscle in the body, often in the chest. Electrodes are placed over the chest muscles, acting as antennae. When the person wants to move the arm, the brain sends signals that first contract the chest muscles, which send an electrical signal to the prosthetic arm, instructing it to move. The process requires no more conscious effort than it would for a person who has a natural arm.

Sunday, February 08, 2009

A Company Prospers by Saving Poor People’s Lives

Fascinating story here...

It all started with mosquito nets. Or, no, with guinea worm filters. Or, before that, with a million yards of wool in the mountains of Sweden.

Or, taken back another generation, to uniforms for hotel and supermarket workers.

There are plenty of charitable foundations and public agencies devoted to helping the world’s poor, many with instantly recognizable names like Unicef or the Gates Foundation.

But private companies with that as their sole focus are rare. Even the best-known is not remotely a household name: Vestergaard-Frandsen.

Its products are in use in refugee camps and disaster areas all over the third world: PermaNet, a mosquito net impregnated with insecticide; ZeroFly, a tent tarp that kills flies; and the LifeStraw, a filter worn around the neck that makes filthy water safe to drink.

Some are not only life-saving but even beautiful. The turquoise and navy blue LifeStraw is in museum design collections.

“Vestergaard is just different from other companies we work with,” said Kevin Starace, malaria adviser for the United Nations Foundation. “They think of the end user as a consumer rather than as a patient or a victim.

Friday, February 06, 2009

When Doctors and Nurses Can’t Do the Right Thing

It now appears that doctors — caught between obligations to patients and the demands of insurance companies, administrators and even, occasionally, patients’ families — are feeling increasingly “trapped” and unable to do what they believe is ethically right. Researchers from the University of Virginia recently studied I.C.U. physicians and nurses and found that while doctors on average are less frustrated than nurses, they can also suffer from intense moral distress.

This finding doesn’t surprise me. It is profoundly disheartening to haggle with disembodied voices over the phone over insurance approval for operations to remove cancers, to struggle to do everything that should be done for the rising numbers of patients a single doctor must see, and to follow the wishes of estranged relatives who swoop into the hospital during the last days of life and demand aggressive treatment.

What can we do?

Thursday, February 05, 2009

Sneaking In Where Thugs Rule

Before entering Myanmar from Thailand, you scrub your bags of any hint that you might be engaged in some pernicious evil, such as espionage, journalism or promotion of human rights.

Then you exit from the Thai town of Mae Sot and walk across the gleaming white “friendship bridge” to the Burmese immigration post on the other side. Entering Myanmar (which traditionally has been known as Burma), you adjust your watch: Myanmar is 30 minutes ahead — and 50 years behind.

Already Myanmar’s government is one of the most brutal in the world, and in recent months it has become even more repressive.

A blogger, Nay Phone Latt, was sentenced to 20 years in prison. A prominent comedian, Zarganar, was sentenced to 59 years. A former student leader, Min Ko Naing, a survivor of years of torture and solitary confinement, has received terms of 65 years so far and faces additional sentences that may reach a total of 150 years.

“Politically, things are definitely getting worse,” said David Mathieson, an expert on Myanmar for Human Rights Watch living on the Thai-Burmese border. “They’ve just sent hundreds of people who should be agents of change to long prison terms.”

Wednesday, February 04, 2009

The Kremlin's Defenses Are Crumbling

Is Kazakhstan showing Russia the way? Kazakhstan's central bank allowed a 25% depreciation of the tenge on Wednesday. Moscow, meanwhile, is forlornly trying to control the ruble's descent. The ruble fell quickly to the central bank's new floor. Forward rates imply a further 20% depreciation over 12 months.

The cost of defending the ruble is growing. Fitch downgraded the country's credit rating on Wednesday to BBB, below Lithuania. The main concern: a rapid depletion of foreign-exchange reserves, down by about $210 billion to $390 billion in six months.

Moscow's fear of rapid devaluation stems from the 1998 financial crisis. Another panic could destroy Prime Minister Vladimir Putin's reputation as a safe pair of hands.

This Is What I Want, Now

The Happy Hospitalist sees a great future for multitouch interfaces in medicine--with a link to a very cool video from TED

You want to talk about disruptive innovation, here it is. As a physician who works in the hospital I can tell you categorically, that this technology WOULD revolutionize the way I take care of patients. This is what I want in every work station on every floor of every hospital. A multitouch interface. I want a large flat screen version in every ICU room. I want all the patient data at my fingertips. I want to be able to view all information simultaneously. And I want it to be wireless and integrated with my smart phone. I want immediate access all the time to all information on all my patients. You want to make me efficient, this is what I need. What would I put on my multitouch inteface?

Search for a Surname to view its Map and Statistics.

Find your relatives...

Search for a Surname to view its Map and Statistics.

Medicare ‘Rip-Off’ Strikes U.S. Elderly as Obama Maps Overhaul

Feb. 4 (Bloomberg) -- Just as President Barack Obama starts his overhaul of the U.S. medical system, providers of U.S.- backed health plans for the elderly are jacking up prices.

Humana Inc., Health Net Inc. and other providers increased 2009 premiums by 13 percent on average, or more than five times as much as last year, for people who use the Advantage version of Medicare, according to Avalere Health, a consulting company in Washington. The elderly say higher costs for the Advantage plans, which add features such as drug coverage to Medicare, are reducing money for groceries and utilities.

Obama has vowed to control spending in the $2.6 trillion U.S. health-care system while extending coverage to more people, and, during his campaign, criticized the costs of Advantage plans to taxpayers. The premium increases, charged directly to the elderly rather than the government, are further evidence that insurers’ need for profits is ballooning patients’ expenses and reducing the efficiency of care, said Arnold Relman, former editor of the New England Journal of Medicine.

“Medicare Advantage is a rip-off,” said Relman, 85, who is also a professor emeritus at Harvard Medical School in Boston, in a telephone interview on Jan. 23. “I cannot see that they do anything better than public insurance does, and they do a lot of things worse.”

Tuesday, February 03, 2009

The Muddled Tracks of All Those Tears

They’re considered a release, a psychological tonic, and to many a glimpse of something deeper: the heart’s own sign language, emotional perspiration from the well of common humanity.

Indaba music

Bailouts for Bunglers

When I read recent remarks on financial policy by top Obama administration officials, I feel as if I’ve entered a time warp — as if it’s still 2005, Alan Greenspan is still the Maestro, and bankers are still heroes of capitalism.

“We have a financial system that is run by private shareholders, managed by private institutions, and we’d like to do our best to preserve that system,” says Timothy Geithner, the Treasury secretary — as he prepares to put taxpayers on the hook for that system’s immense losses.

Meanwhile, a Washington Post report based on administration sources says that Mr. Geithner and Lawrence Summers, President Obama’s top economic adviser, “think governments make poor bank managers” — as opposed, presumably, to the private-sector geniuses who managed to lose more than a trillion dollars in the space of a few years.

And this prejudice in favor of private control, even when the government is putting up all the money, seems to be warping the administration’s response to the financial crisis.
My response to this prospect is: so? If taxpayers are footing the bill for rescuing the banks, why shouldn’t they get ownership, at least until private buyers can be found? But the Obama administration appears to be tying itself in knots to avoid this outcome.

If news reports are right, the bank rescue plan will contain two main elements: government purchases of some troubled bank assets and guarantees against losses on other assets. The guarantees would represent a big gift to bank stockholders; the purchases might not, if the price was fair — but prices would, The Financial Times reports, probably be based on “valuation models” rather than market prices, suggesting that the government would be making a big gift here, too.

And in return for what is likely to be a huge subsidy to stockholders, taxpayers will get, well, nothing.

In Bolivia, Untapped Bounty Meets Nationalism

UYUNI, Bolivia — In the rush to build the next generation of hybrid or electric cars, a sobering fact confronts both automakers and governments seeking to lower their reliance on foreign oil: almost half of the world’s lithium, the mineral needed to power the vehicles, is found here in Bolivia — a country that may not be willing to surrender it so easily.

We know that Bolivia can become the Saudi Arabia of lithium,” said Francisco Quisbert, 64, the leader of Frutcas, a group of salt gatherers and quinoa farmers on the edge of Salar de Uyuni, the world’s largest salt flat. “We are poor, but we are not stupid peasants. The lithium may be Bolivia’s, but it is also our property.”

Sunday, February 01, 2009

The Hidden Curriculum of Medical School

While most of medical education and training is about the nuts and bolts of clinical care — how to treat hypertension, how to manage a ventilator, how to take out a gallbladder — the process also involves learning how to be “a doctor.” As opposed to lessons covered in textbooks and classrooms, this kind of learning is done through modeling, or what medical sociologist F. W. Hafferty has called the “informal” or “hidden curriculum.”
A new study published in this month’s issue of Academic Medicine proves that effort does matter, and that learning is possible. Even established clinicians can be re-inspired to adopt new humanistic skills, becoming better teachers and role models in the process.

In the study, groups of established physician-teachers from five different academic medical centers met at least twice a month. During the meetings, the doctors either practiced skills designed to enhance compassion, or reflected on their own work through discussion and narrative writing.
At the end of our phone conversation, I asked Dr. Branch if his program would work in any setting, for any doctor. “Anybody can do it, and there are groups of clinicians that have regularly held similar types of meetings for at least a decade or more,” he quickly replied. He had been part of such a group for 10 years, when he lived in another state, a group made up of academic and private practice physicians.

And then, underscoring perhaps the greatest challenge for any kind of reform, Dr. Branch added, “But they would have to believe that such work was important.”
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