Posts Tagged ‘physicians’

Philippines: Doctor Shortage — Why Not Pay Tuitions With Government Funds To Get More Doctors? (Editorial)

March 20, 2017

Philippines: Doctor Shortage — Why Not Pay Tuitions With Government Funds To Get More Doctors? (Editorial)

Taxpayers spend P2.5 million over four years to produce a graduate of the Philippine Military Academy. Why not make the same investment in producing surgeons and other physicians?

The proposal was made by Senate President Pro Tempore Ralph Recto, who noted that the Department of Health already has an existing scholarship program for aspiring doctors. All that’s needed is to expand the program while at the same time making compensation and benefits more attractive for physicians working for the DOH.

Unless remuneration is improved, the nation may see its shortage of doctors worsen, especially in rural areas. Recto noted that of the 946 available slots in the government’s Doctor to the Barrios program from 2015 to 2016, only 320 were filled. The program is meant to provide at least one doctor in each low-income municipality, but there were few takers. Those 626 unfilled slots meant that millions were deprived of the services of a doctor in their communities.

The medical profession can pay handsomely – but only after many years of grueling studies and substantial financial investment in schooling and specialized training. The cost of medical textbooks alone can be beyond the reach of a low-income household.

Parents who have invested their life savings to send their child to medical school would naturally be reluctant to let the new doctor volunteer for a rural assignment that pays P56,000 a month, especially in conflict zones. The medical community is still waiting for justice for a Doctor to the Barrio volunteer, Dreyfuss Perlas, who was shot dead by still unknown assailants last March 1 while serving in Lanao del Norte.

If the government shoulders the schooling expenses of deserving medical scholars, the nation may be assured of a steady supply of physicians, even if the beneficiaries leave the DOH after a mandatory four-year service. The government may then have at least one doctor for every municipality, with the scholars encouraged to serve in their hometowns.

Health experts estimate that the country currently faces a shortage of 60,000 doctors. This means six out of every 10 Filipinos die without seeing a doctor. This need not be the case. The government is recruiting more police and military personnel. Why not boost resources to produce and recruit more doctors?

Junior doctors’ strike in Britain: All-out stoppage ‘a bleak day’

April 26, 2016


Junior doctors walked out of routine and emergency care at 08:00 BST.

The strike affects A&E, maternity and intensive care for the first time.

Health Secretary Jeremy Hunt expressed disappointment that the stoppage was taking place, but again said the government would not back down and halt the imposition of the new contract.

The walkout ends at 17:00 BST with further all-out action due to take place on Wednesday, between the same hours, in the protest against the imposition of the new contract from the summer.

Speaking to the BBC, Mr Hunt described it as a “very, very bleak day” for the NHS, but said no union had the right to stop a government trying to act on a manifesto promise.

“The reason this has happened is because the government has been unable to negotiate sensibly and reasonably with the BMA.”

Before the strike, government sources had indicated that they could not give in because the row had become political, with the BMA trying to topple the government, and other unions watching the dispute “like hawks”. The BMA described this as ridiculous.

During the stoppage, hospitals can request that junior doctors return to work if needed, but as yet, no NHS trust has raised the alarm.

There have been reports that hospitals may be quieter than normal with patients heeding warnings to stay away unless absolutely necessary.

NHS England said the situation was being monitored carefully, but “military level” contingency planning had ensured hospitals were as well prepared as they could be.

Steps taken include:

  • The postponement of nearly 13,000 routine operations and more than 100,000 appointments to free up staff
  • The cancellation of holidays and study leave
  • Redeployment of consultants, middle-grade doctors and nurses into emergency care
  • More GP appointments being kept free for last-minute requests
  • An increase in 111 staff on duty to allow the phone service to handle more calls

NHS England’s Anne Rainsberry said: “Clearly industrial action of this type can put significant pressure on the NHS. We have been working with all hospitals to make sure they have plans in place to provide urgent and emergency care.”

She said those plans were “robust” and hospitals were “confident” they could cope, but the situation would be kept under review.

There are more than 50,000 junior doctors in the NHS in England, representing about a third of the medical workforce.

Ipswich Hospital chief executive Nick Hulme said his trust had been coping well – and more doctors than expected had come into work, 23 out of 122, suggesting an all-out strike had been a “step too far” for some.

But he said both sides needed to come back together to resolve the dispute “quickly”, saying it was getting “really difficult” for the NHS to cope with the backlog of postponed operations.

A new poll by Ipsos MORI for the BBC showed the majority of the public still backed junior doctors, although support was not as high after it became an all-out stoppage.

Asked whether they supported junior doctors striking while not providing emergency cover, 57% said they did and 26% said they were opposed.

The last time the public was asked was ahead of the 48-hour walkout in March, when emergency cover was maintained. Then, 65% supported junior doctors.

The poll of more than 800 adults in England also found a growing number of people blaming both sides for the impasse. Some 35% said the government and junior doctors were at fault. The majority – 54% – still blamed the government.

The dispute is about working hours and pay, but a key sticking point is about payments for working on Saturdays.

Talks between the government and British Medical Association (BMA) broke down in January, prompting the government to announce in February that it would be imposing its contract in the summer.

How the dispute reached stalemate

A junior doctor

Image copyright PA
  • Talks broke down in January and after a final take-it-or-leave it offer from government was rejected by the BMA in February, ministers announced the contract would be imposed
  • It will reduce the amount paid for weekend work, but basic pay is being increased
  • The BMA wants a more generous weekend pay allowance and more investment for more seven-day services
  • Two legal challenges are being pursued by doctors against the imposition
  • Hospitals are pushing ahead with the new contract – offers are expected to go out in May
  • The government is refusing to reopen talks, arguing it made compromises earlier in the year but the BMA did not
  • The first four strikes in 2016 all involved emergency cover being provided, before the all-out stoppages on 26 and 27 April

Graphic showing the differences between junior doctors' current contracts and the government and BMA proposals

Image caption: The current rates for junior doctors and how the government position compares with the BMA’s

Junior doctors’ row: The dispute explained
The strike comes after last-minute pleas from medical leaders, patient groups and opposition MPs for both sides to get back round the negotiating table.

National Voices, a coalition of patient groups and charities, even offered to host talks. Chief executive Jeremy Taylor said: “Patients and the public are caught in the middle – and the harm is being felt by patients and their families.”

BMA junior doctor leader Dr Johann Malawana said if the government had scrapped his plan to impose the contract, the union would not have taken this action.

“No doctor wants to take any action. They want to be in work, treating patients, but by refusing to get back around the negotiating table the government has left them with no choice but to take short-term action to protect patient care in the long term.”

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Healthcare has many problems in almost every corner of our world…




UK Junior Doctors Walk Off the Job in All-Out Strike — More than 125,000 appointments and operations have been cancelled

April 26, 2016

The Associated Press

LONDON — Thousands of junior doctors posted picket lines outside hospitals around England on Tuesday in the first all-out strike in the history of Britain’s National Health Service.

The two-day strike marks the first time that vital NHS emergency services have been affected by an industrial action.

The strike reflects the impasse between the government and the junior doctors, who are physicians with up to 10 years’ experience, over the government’s pledge to greatly expand National Health Service care on weekends.

The financial dispute centers on payment for weekend shifts and whether Saturday should be treated as a normal working day.

Health Secretary Jeremy Hunt insisted the government would not be “blackmailed” into scrapping its election pledge to bolster weekend services. He said that promise was a centerpiece of the Conservative Party’s platform in the 2015 election.

“I don’t think any union has the right to blackmail the government, to force the government to abandon a manifesto promise that the British people have voted on,” he said.

More than 125,000 appointments and operations have been cancelled and will need to be rearranged due to the strike, a result of the long-running dispute between the government and the British Medical Association.

Hunt warned the walkout would cause particular risks for patients needing emergency room treatment and those in maternity wards and intensive care units.

Mark Porter, head of the medical association, told the BBC that senior consulting physicians would provide emergency care while the junior doctors are on strike. He said the government was misleading the public by claiming the job action put lives at risk.

“The Health Secretary is trying to find some way to throw mud at the junior doctors of this country who have been providing weekend and night emergency cover since the NHS started,” he said.


The Telegraph

 A picket line outside Bristol Royal Infirmary, as thousands of junior doctors begun the first all-out strike in the history of the NHS 
 A picket line outside Bristol Royal Infirmary, as thousands of junior doctors begun the first all-out strike in the history of the NHS  Credit: PA Wire/Ben Birchall

Today up to 45,000 junior doctors are taking part in the first all-out strike in the history of the NHS. They say the health secretary, Jeremy Hunt, is imposing dangerous and unfair terms of employment; he says they’re blocking the democratic will of the people.

But we’re interested in what you think, be you doctor or patient. Your views will be published here and allowed to fight with each other. Please email your thoughts to or tweet me


Q&A with James Kirkup, doctor-hater-in-chief*

So for the next couple of hours I’d like to shift the direction of this blog a bit.James Kirkup is the Telegraph’s executive editor, politics. As I mentioned earlier, he’s had a few points of friction with doctors. And for the next hour or so he’ll be around to answer your questions and take on your arguments.

First, though, he has one of this own. Read his view on the strike below.

*No, he doesn’t really hate doctors.

James Kirkup: This strike is about money – even if doctors don’t know it

I’m not sure that some of the doctors striking today know why they are striking.

That suggestion causes no little offence, so let me try to explain it.

The strike is happening because the BMA, the trade union representing the doctors, does not accept the terms offered by the Government.

Those terms were discussed in detail between the union and NHS Employers in talks brokered by Acas, the conciliation service.  Those talks ended in failure and the union went ahead with strikes, in protest at the Government’s decision to impose a contract which which the union was not entirely happy.

You can read the House of Commons Library assessment of the contract here.  The Library is run by impartial officials whose work is generally accepted by all political parties as being neutral and reliable.

To cut a long story short, almost all of the contract was agreed. The union had accepted almost all of the things the Government proposed.

A&E junior doctor Jennifer Hulse on a picket line outside St Thomas' Hospital in London

A&E junior doctor Jennifer Hulse on a picket line outside St Thomas’ Hospital in London Credit:  Philip Toscano/PA


The main point of disagreement between the BMA and the Government was over whether doctors who work Saturdays should be paid more to do so.There was also a secondary issue about how much of the “punitive”  fines that will be imposed on trusts that make doctors work too much should then be given to doctors.

In the words of the Commons Library:

 …it appears a key sticking point in the final stages of negotiations was the question of unsocial hours premiums for work on Saturdays

Alternatively, here’s the BMA’s account:

Why are we going back to industrial action?

In December 2015, the BMA suspended the industrial action and the government suspended their plans to impose a new contract, so that we could negotiate. Unfortunately we have been unable to reach agreement on some major points in sufficient time. Therefore despite our best efforts we cannot agree to a new contract and must lift the suspension of the industrial action.

What was the outcome of the negotiations?

We could not reach agreement on some key points.  These centre on the boundaries for plain and premium time, and punitive rates for exceeding working time regulations.

In summary, if the BMA had been satisfied on those points, if the Government had agreed to pay doctors more for working Saturdays (and to allow them to keep more of the “punitive” fines on employers) then it seems reasonable to suggest that an agreement would have been reached.  And therefore, today’s strike would not be happening.

That is why I suggest that this strike is happening because of money.

Why do I suggest that some doctors do not understand this?

BMA: We're taking drastic action because Government won't listen—have-your-say/
Because many of them say that they are striking for different reasons.  Many of them say they are striking because they are worried that the contract will worsen staff shortages (especially in high-pressure specialist areas like A&E) or that the working patterns the contract will require will be even more harmful to family life than their current, very demanding, schedules.  Others worry about the lack of non-doctor support during weekends.  Many fear that the combined effect of the contract will be to reduce patient safety.


(As an aside, I was fascinated by a point a doctor made to me about the 13 per cent increase in basic pay the contract offers. By increasing pay for all specialisms, the doctor noted, the economic incentive to pursue high-pressure/antisocial specialist work is reduced. If you can be paid as much for working daytimes as you can for rotating shifts, isn’t it rational to choose the former?  I thought that was a good point, and not one I’d considered before.)


Now, those concerns may well be valid. I certainly think that the issue of recruitment and retention in key speciality areas is important. The weekend support point is also a good one. I think it’s important to treat that claim about patient safety in good faith: doctors really do believe that the adoption of the contract will cause patient harm.

But here’s the vital point, the bottom line: those are not the reasons the strike is happening.  The BMA didn’t walk out because of those things. The union, by its own account, walked out because of Saturday pay rates and doctors’ payments for excess working.

And while you can just about stretch an argument to claim that better pay for doctors working antisocial hours is a patient safety issue (better pay = higher morale = better retention & higher staffing) I don’t think that’s the main reason the BMA walked out. I think the BMA walked out because it wanted its members to get more money.

And there is nothing wrong with that, no shame or dishonour. This is the role of trade unions: they exist to promote the interests of their members. The BMA is no different.  Yes, its members care deeply about patients: no one, I hope, disagrees with that.

But the BMA does not exist to serve patients. It exists to get doctors a better deal, and that’s why, acting in their name and on their behalf, it walked out of talks and activated the mandate it has from members, who are today on strike.

That is the position that, I humbly suggest, some of those earnest, committed and admirable doctors do not understand, as they stand outside hospitals telling the public that they’ve walked out because of concerns about patient safety.  They may well believe that’s why they’re doing it, and that may be why they’ve chosen to go along with the BMA (they’re not robots, after all – they can always ignore their union and go to work, as some are doing today) but the reason the BMA brought them to this point is not patient safety. It’s money.


55 per cent of readers back the government

It’s lunchtime, and for several hours now we’ve been running a poll at the top of this live blog.

At present, 55 per cent of those who voted in it back the government, while only 45 per cent backed the BMA.

(Of course, that is not a representative sample of the British public.)


Reader support

The anger below is not by any means universal. I also have plenty of messages of support. Like this one from Bay Whitaker:

I support the junior doctors and I believe the government’s handling of this has been rigid, bullish and frankly incompetent.  It seems clear to me that it is the government that wants this fight.

Most of the ministers won’t be queueing up in any NHS hospital waiting to get their children’s broken legs set, or to have that MRI scan for cancer.  Most of them are from privileged backgrounds and have no idea whatsoever of the pressure and low morale NHS staff are subject to, and this lack of understanding is clear from the high-handed and authoritarian way that Hunt has (mis)handled the situation.  The government’s contempt for the NHS and those who use it couldn’t be clearer.



Public enemies

There’s no way to sugar-coat it: many of our readers have harsh words for junior doctors.

 “Arrogant and deluded,” writes Sean Pearce. “A rabble of bully-boys/girls,” writes Robert Griffith. “It frightens me to think that I might have to put my life in the hands of such naïve people.”

“A bunch of mollycoddled whingers,” says C Morrell, who worked in the NHS for nearly 32 years. They added that “junior doctors never supported nurses and allied health professionals when their contracts were changed and included 7 day working which stretched some of those services to breaking point.”

Doctors are being unrealistic by resisting weekend working, and need to “grow up and get with the real world that their patients live in.”

That was echoed by Susan Davey, who said: “The junior doctors must understand that in the real world where their patients live that Saturdays at work are treated the same as Monday to Friday and they are not paid extra money.”

“If they do not, I suggest the army medical corp take over the hospitals and the junior doctors are sacked and their jobs advertised.”


‘Jeremy Hunt is a hero for standing up to the BMA bullies’

Journalist Leo McKinstry has written a piece for this newspaper lauding Jeremy Hunt for his “heroic stand”. Bonus points for another comparison with the Miners’ Strike:

[The doctors’] sense of entitlement is repugnant. They enjoy salaries, pensions and job security far beyond the dreams of most professionals, while they have been offered an excellent new deal in return for the removal of outdated weekend practices.  Yet, suffused with victimhood, they act like oppressed members of the proletariat.

With his air of reasonableness and quiet, almost deferential manner, Hunt may seem an unlikely figure to challenge union blackmail. But his willingness to take on the reactionary bullies of the BMA shows that he has an inner steel similar to that displayed by Margaret Thatcher when she took on the unions in the 1980s.

Tell us what you really think, Leo!

A protester holds a banner depicting Jeremy Hunt outside St Thomas' Hospital in London

A protester holds a banner depicting Jeremy Hunt outside St Thomas’ Hospital in London Credit:  Philip Toscano/PA


Are doctors the new miners?

More than a few people have compared this to the miner’s strike, usually showing their political colours along the way.

Reader Gordon Hopkins writes:

I agree that Jeremy hunt has the manifesto commitment to introduce seven day working but he mistakenly thinks that gives him the right to dictate the terms it will be on. It has become another Maggie v the miners ego trip, but there were alternatives to coal. I hope Mr hunt has an alternative to doctors.

Robert Griffiths:

The BMA has reduced itself to the level of the National Union of Mineworkers and look where that ended.

My colleague James Kirkup made this comparison some months ago, writing: “Doctors are repeating the mistakes of the miners’ strike.” 



A simple message

A very blunt assessment from reader Jim Barin:

Two people ONLY are responsible for any deaths in the period of the junior doctors strike: The Prime Minister and the Health Secretary.


‘Doctors are striking because they have no other option’

Dr Monica Jackson is a junior doctor working in intensive care, who will be striking both today and tomorrow.

A consultant is covering my shifts, patient safety is not being compromised by my actions. We are striking because we feel we have no other option. The Secretary of State is deaf to our concerns and we don’t know what to do next.

The reason I am fighting this contract is that I know from working on the front line in the NHS that it is already at breaking point. I want to improve the service we can provide our patients every day of the week. This needs cooperation and collaboration between health care staff and the government, not the imposition of a flawed contract which is just demoralising  the staff on whom the NHS depends.

We need to be honest with patients about what the NHS can afford to provide, and what it can’t. Doctors have lost trust in Jeremy Hunt as we worry he cares more about saving face than saving lives.


Betway slashes odds on Jeremy Hunt resigning

Betway has just slashed its odds on Jeremy Hunt resigning his post from 6/1 to 5/2. For those like me who fail to understand betting odds, that means they think it’s more likely.

But they still don’t think it’s very likely. The first rule of ministerial resignations is that they only happen when staying does more harm to the government than going. And at this point, Jeremy Hunt resigning would be a far bigger blow to David Cameron’s authority than a doctors’ strike.


‘7 out of 10 of our doctor friends are considering leaving training’

Alex Symington writes:

My wife is a Junior Doctor in A&E. She has been shouted at, spat on, punched, exhausted and still gets up the next day to go in and treat her patients.

She is one of the most committed doctors I know, yet she now is struggling to justify continuing in a profession that with the new contract will become more dangerous, discriminates against women, with less staff and less funding but over more days.

Doctors don’t want to strike but feel no alternative with the health secretary’s refusal to engage. No one will come to harm because of the strike; more consultants will be covering urgent care and anyone seriously sick. It is disgraceful that some media are trying to vilify them like this.

Numerous colleagues of hers are considering leaving, we were married in January and had 10 doctors at our wedding with the contract changes we counted 7 of those 10 that had left or were considering leaving training. That is scary for the future of the NHS.

Who does the public need more, junior Doctors or the Health Secretary?

This is a potent worry: brain drain. “The new junior doctors’ contract is pushing me to Malta,” wrote one doc in the Telegraph last year.  But my colleague Asa Bennett, looking at the data, thinks not many people are actually doing this.

Meanwhile, the Conservative MP Tom Tudendhat says young doctors should be forced to repay their debt to the taxpayer (each one costs about £250,000 in the end) before they flee these shores.


‘This strike is about money’

Raine Urquhart writes:

From everything I have seen on the new contract, conditions other than overtime hours are more favourable than the existing contract.

Personally I believe the majority of the Junior Doctors are naive and are being used by the BMA to further the BMS’s agenda. You just need to have a look at the way the BMA has shifted their stance on the reasons for the strike to see this is all about the BMA’s agenda.



‘Junior doctors’ objections are irrelevant’

Martin Moody, a consultant urological surgeon, points out that many junior doctors’ contracts may already be amenable to modification without their consent. The “model contract” posted on the website for NHS employers reads:

22.1. We reserve the right from time to time in our absolute discretion to review, revise, amend or replace any term or condition of this contract and to introduce new policies and procedures, in order to reflect and respond to the changing needs or requirements of the organisation or the NHS.

“It therefore seems irrelevant what objections junior doctors have at present,” he says, “as once this contract is signed, they can be overridden.”


‘Will office staff and chemists also work weekends?’

Reader Christine McMillan backs up Dr Jenny Hao’s point below.

Has anyone thought about the ‘knock-on’ effect of this new contract? In order for Doctors to work seven days a week there will also be staff needed to make this run smoothly. Office staff, admin staff, receptionists, nurses, porters, chemists, radiographers, et al…

EVERYONE will have to work 7 days a week. Think about it.

I think this might actually be a bit optimistic.


‘More junior doctors at weekends means nothing without extra support staff’

We’ve got a really interesting submission from Dr Jenny Hao, a junior doctor in London, a truly seven-day NHS cannot happen more nurses, consultants, and senior doctors on call. In other words, junior doctors are not the problem.

Her detailed response is worth reading in full for the insight it gives into how out of hours emergency care actually works at the moment:

Ask a junior doctor to set up an ECG on a patient and watch us sweat as we realise we have forgotten where to place the chest leads. But ask us to read an ECG and we will quite confidently tell you if it is normal or the patient is having a heart attack. Why? Junior doctors are just part of a larger team. We rely on others to do their job so we can do ours.

Jeremy Hunt wants to redefine normal working hours for junior doctors. The new contract sees an extension of a normal working weekday until 9pm and includes 7am-5pm on Saturdays also. The problem is, Mr Hunt hasn’t asked any other health professionals to work extended hours or the weekend alongside us.

I remember one Saturday on call as a doctor on the stroke unit, I was asked to see an elderly gentleman whose family had brought him in because he “hadn’t been quite right” since a minor car accident a few weeks ago. He didn’t have any of the classic stroke symptoms of drooping face, slurred speech, or limb paralysis but testing his memory revealed he had difficulty naming objects (fancy medical jargon calls it “nominal dysphasia”). My impression was that he had indeed suffered a small stroke and the changes were too subtle to show on the CT head scan performed. The next investigation I wanted was a more detailed MRI scan.  Unfortunately, the MRI unit isn’t open at the weekend, so instead, I discussed my patient’s case with the on-call consultant and we went ahead with admitting and treating my patient for a stroke. During the week, my patient got his MRI and sure enough, it did show a stroke in a small area of his brain responsible for processing speech. The point of my story is that even without an immediate MRI scan, we were able give this gentleman the treatment he needed with the support of my consultant and the nurses on the Stroke unit. This is how the NHS works at the weekend.

This gentleman is just one of a hundred patients I can remember, all of whom illustrate my point: there’s no doubt that junior doctors must work weekends – we already do. The reason hospitals don’t have a complete range of services at the weekend is not to do with a lack of junior doctors; it’s the lack of staff who offer inpatient hospital services during the week in adjunction to us. By this, I mean: nurse practitioners, specialist radiology technicians, sonographers, hospital pharmacists, physiotherapists, occupational therapists, social workers, discharge coordinators, to name but a few. These are staff who work full time during the week but do not work weekends.

Currently, on Saturday, I can’t get an ultrasound or an MRI scan for an inpatient because these parts of the imaging department are closed. I have access to X-ray and CT scans and this has been sufficient to cover emergencies. I have to tell a patient having a miscarriage on Friday night in A&E that she cannot have a scan in the Early Pregnancy Unit which is run by specialist nurse practitioners and gynaecology sonographers until Monday morning. The reason we often keep elderly, frail patients in over the weekend even though they may no longer need hospital treatment is because there is not enough discharge and social care coordination to ensure that appropriate community care is in place to receive them.

Adding only junior doctors to the equation is a bit like turning up for a Saturday game of football with eleven strikers, but no midfielders, no defenders and no goalkeeper.

So, what is the point of doctors working a “normal” Saturday if we cannot do all the “normal” things we do during the week because the rest of the hospital staff aren’t at work? I have yet to see a comprehensive and convincing plan on how to structure and fund these extra ‘7 Day NHS’ staff and services. When the hospital functions on a Saturday like a normal working day, then Mr Hunt can pay us the rate of a normal working day. This seems like a fair resolution to the pay dispute.

She adds that she does not think it’s actually “realistic or necessary” to fund, say, the MRI unit at the weekend. That money is better spent on improving current services.

There’s more:—have-your-say/



Obama Administration Report Slams Digital Health Records

April 10, 2015

Report criticizes vendors for making it costly to share patient information

An Obama administration report cites complaints that some hospital systems make it difficult to transfer patient records to rival systems or physicians.  
An Obama administration report cites complaints that some hospital systems make it difficult to transfer patient records to rival systems or physicians. Photo: Fabrizio Costantini for the Wall Street Journal
By Melinda Beck
The Wall Street Journal

The Obama administration took vendors of electronic health records to task for making it costly and cumbersome to share patient information and frustrating a $30 billion push to use digital records to improve quality and cut costs.

The report, by the Office of the National Coordinator for Health Information Technology, listed a litany of complaints it has received about vendors allegedly charging hefty fees to set up connections and share patient records; requiring customers to use proprietary platforms; and making it prohibitively expensive to switch systems.

The report also cited complaints that some hospital systems make it difficult to transfer patient records to rival systems or physicians as a way to control referrals and enhance their market dominance.

The agency didn’t cite any companies by name, however, and said it couldn’t determine the extent of information-blocking—in part because contracts often forbid customers from discussing prices and other terms.

“This is our first deep dive, where we have taken the opportunity to describe the situation and identify practices that interfere with the flow of health information,” said ONC chief Karen DeSalvo. “We believe it will take an array of solutions and we look forward to working with Congress on this.”

Congress requested the report last December amid rising concerns that the government’s massive investment in digitizing health records has created a windfall for the information-technology industry, but left patient records largely stuck in silos.

Spurred by $28 billion in incentives to date, nearly 80% of doctors and 60% of hospitals have converted from paper files to electronic health records, known as EHRs since 2009. But only 20% to 30% of providers are able to share records with outside providers, according to government and industry surveys.

The Electronic Health Record Association, a trade group, said its members are committed to sharing patient records but building connections to the myriad systems used by hospitals, doctors, labs and others takes time and money. “Even if they were all using the same standards, there will always be costs for maintenance and upgrades and making sure the information goes to the right place,” said Sarah Corley, the group’s vice chairwoman and chief medical officer of NextGen Healthcare Information Systems Inc., an EHR vendor and part of Quality Systems Inc.

Some vendors say they aren’t relying on connection fees. As of last week, 25 EHR vendors—representing 70% of the acute-care market and 24% of the ambulatory-care market—had joined the CommonWell Health Alliance, which aims to create a network with low-cost connections so doctors can easily query patient records from anywhere in the system. Vendors build one interface to the network and can connect all their customers to it, and each other, rather than having to create many separate interfaces.

Athenahealth Inc. is offering the CommonWell connection free to the 62,000 physician using its cloud-based EHR systems. McKesson Corp. MCK 0.36 % plans to do the same for its hospital EHR users. Cerner Corp. says it will offer it to customers free for three years, after a small start-up fee.

To date, only 60 provider sites in 15 states are live on the CommonWell network, but the alliance hopes to be nationwide by the end of the year.

Epic Systems Corp., the privately held industry leader, has declined to participate in CommonWell—in part because it says its 315 large health-system clients can already exchange records with 2,000 hospitals and 25,000 clinics in its proprietary network. “Every system our customers have wanted to connect to so far, we’ve been able to make that happen,” said Epic spokesman Shawn Kiesau.

Connection fees have hit small physician practices especially hard, some observers say.

Farzad Mostashari, a former ONC director and now CEO of Aledade Inc., which helps doctors join together in integrated systems, said he has seen vendors charge small practices as much as $29,000 for an interface to send patient data to other providers, and as much as $1 a virtual page to transmit patient files, which can run thousands of pages.

The ONC report stressed that the agency cannot regulate prices and that most of the alleged actions don’t violate current laws.

ONC does set the criteria that EHR systems must meet for providers to qualify for Medicare incentive payments, or to avoid penalties starting this year. The agency has proposed increased surveillance of EHR systems and more upfront disclosure by vendors of any costs or limitations on data-sharing.

Theoretically, ONC could decertify EHR systems that deliberately block data-sharing, as some lawmakers have suggested, but the report says that would unduly penalize customers.

Micky Tripathi, CEO of the Massachusetts eHealth Collaborative and project manager for Argonaut Project, which aims to accelerate the adoption of open technology standards, predicts that patients will increasingly demand that competing networks work with each other to let their records flow freely. “I’m sure that when the telephone networks and electricity grids were forming, it felt the same way. It just takes a while to shake out,” he said.

Write to Melinda Beck at

VA hospitals and military hospitals criticized for lax care, reprisals against staff who point out problems

December 21, 2014

— Veterans and their families in Fayetteville on Friday got a chance to voice their complaints directly to the head of the director of the Fayetteville VA Medical Center, which has come under scrutiny in recent months for the long wait times patients have experienced.

Medical Center Director Elizabeth Goolsby held two town hall meetings to hear patients’ concerns and to offer immediate on-the-spot help filing claims.

One thing the hospital has done to try to alleviate long wait times has been opening a new VA clinic on Breezewood Drive and staffing it with three primary care teams, Goolsby said.

Earlier this week, the hospital held a ribbon cutting for a 10,000-square-foot trailer to provide mental health care.

Goolsby said the additions have decreased the amount of time veterans have to wait for care.

The New York Times

FAYETTEVILLE, N.C. — Beyond conducting their periodic evaluation of Womack Army Medical Center, one of the military’s busiest hospitals, the inspectors who came here to Fort Bragg last March had a special task. A medical technologist had complained of dangerous lapses in the prevention of infections. The inspectors planned to follow up.

But Teresa Gilbert, the technologist, said supervisors excluded her from meetings with the inspectors from the Joint Commission, an independent agency that accredits hospitals.

“I was told my opinions were not necessary, nor were they warranted,” said Gilbert, an infection-control specialist.

The review ended disastrously for Womack, one of 54 domestic and overseas military hospitals that serve more than 3 million active-duty service members, retirees and family members. The inspectors faulted infection prevention and many other aspects of care, putting the hospital’s accreditation under a cloud for months.

It was disastrous for Gilbert, too. She said she was reprimanded for being an obstructionist, reduced to part-time hours, investigated for what she called trumped-up charges and transferred to a clerk’s job.

The message to Womack workers, she said, was clear: “You don’t go against us. If you do, we will get you.”

At any hospital, patient safety and quality of care depend on the willingness of medical workers to identify problems. The goal is for medical workers to be free to speak bluntly to — and about — higher-ups without being ignored or, worse, punished.

In interviews and email exchanges, many doctors, nurses and other medical workers said military hospitals fall short of that objective.

During an examination of military hospitals this year, The New York Times asked readers to recount their experiences via a private electronic portal. Among more than 1,200 comments were dozens from medical workers about how the system thwarted efforts to deliver superior care.

Physicians and nurses described in follow-up interviews how they were brushed off, transferred, investigated, passed over for promotion or fired after they pointed out problems with care.

Senior military health officials said they were working aggressively to instill a culture where complaints are welcomed and addressed.

“We want people to come forward,” Lt. Gen. Patricia Horoho, the Army surgeon general, said in a statement to The Times. “We are committed to patient safety, we are committed to transparency, and there will be no compromise.”

“We want people to come forward. We are committed to patient safety, we are committed to transparency, and there will be NO COMPROMISE,” Lt. Gen. Patricia Horoho, the Army surgeon general, wrote in a statement. Credit Cliff Owen/Associated Press

But hospital workers, military and civilian, described compromise as routine. The nature of military medicine, they say, muddles the emphasis on patient safety and quality of care. The command structure is so rigid that a nurse can oversee a doctor because the nurse holds a higher military rank. Promotions often reward administrative deeds over medical performance. Legal accountability is diminished: Active-duty service members cannot sue for malpractice, and other patients can sue only the government, not individual doctors or nurses.

Read the rest:

Capt. Michael Schell, center, operating room nurse, and anesthesiologist Frank Wallace, right, assist Chief Warrant Officer Jonathan Grogan to his transfer beds after his spinal cord stimulation procedure in May 2009 at Womack Army Medical Center at Fort Bragg in North Carolina. A review found physicians and nurses at military hospitals were brushed off, transferred, investigated, passed over for promotion or fired after they pointed out problems with care.

ObamaCare’s Threat to Private Practice

December 8, 2014


By Scott Gottlieb
The Wall Street Journal

Here’s a dirty little secret about recent attempts to fix ObamaCare. The “reforms,” approved by Senate and House leaders this summer and set to advance in the next Congress, adopt many of the Medicare payment reforms already in the Affordable Care Act. Both favor the consolidation of previously independent doctors into salaried roles inside larger institutions, usually tied to a central hospital, in effect ending independent medical practices.

Republicans must embrace a different vision to this forced reorganization of how medicine is practiced in America if they want to offer an alternative to ObamaCare. The law’s defenders view this consolidation as a necessary step to enable payment provisions that shift the financial risk of delivering medical care onto providers and away from government programs like Medicare. The law’s architects believe that doctors, to better bear financial risk, need to be part of larger, and presumably better-capitalized institutions. Indeed, the law has already gone a long way in achieving that outcome.

A recent Physicians Foundation survey of some 20,000 U.S. doctors found that 35% described themselves as independent, down from 49% in 2012 and 62% in 2008. Once independent doctors become the exception rather than the rule, the continued advance of the ObamaCare agenda will become virtually unstoppable.

Local competition between providers, who vie to contract with health plans, is largely eliminated by these consolidated health systems. Since all health care is local, the lack of competition will soon make it much harder to implement a market-based alternative to ObamaCare. The resulting medical monopolies will make more regulation the most obvious solution to the inevitable cost and quality problems.

A true legislative alternative to ObamaCare would support physician ownership of independent medical practices, and preserve local competition between doctors and choice for patients.

First, Congress should remove the pervasive biases in ObamaCare that favor hospital ownership of medical practices. Payment reforms that create incentives for the coordinated delivery of medical care (like Accountable Care Organizations and payment “bundles”) all turn on arrangements where a single institution owns the doctors. They’re biased against less centralized engagements where independent doctors enter into contractual relationships among themselves.

These ObamaCare payment reforms are fashioned after 1990s-style health maintenance organizations, or HMOs, in which entities like hospitals would get a lump sum of money from Medicare (or now, ObamaCare) for taking on the risk of caring for a large pool of patients. But right now all of these payment schemes are tilted far in favor of having hospitals pool that risk, and not looser networks of doctors.

For one thing, providers who want to participate in the “reformed” physician payment plan must control their own IT infrastructure to comply, as opposed to collaborating freely across space rented in the cloud. This practical need can require IT infrastructure that costs millions of dollars. It makes participation absurdly expensive for anyone but a hospital that already has its own server hub.

Also, waivers of certain anti-kickback provisions (that prevent doctors from forming needed business partnerships) only apply when providers qualify as an Accountable Care Organization. Not surprisingly, ACA qualification is largely dependent on requirements that create the same need for physical infrastructure and bureaucratic overhead that is hard to replicate outside the hospital setting.

To implement real reform, Congress must give independent, private-practice doctors an equal footing. One legislative proposal would let a new class of “independent risk managers” act as third parties to help individual doctors analyze and share the risk of caring for these patient pools. This would make it possible for independent medical offices to band together and bid against hospitals for a pool of patients. Private companies specializing in analyzing and pricing medical risk could serve as brokers and help the doctors know what they’re getting into. But ObamaCare deliberately crowds out this sort of market innovation in favor of hospitals and their existing networks.

Individual, provider-owned medical practices also deserve equal footing when it comes to reimbursement. Right now, Medicare is paying much more for many procedures when performed in a hospital outpatient clinic rather than an independently owned medical office. Things as common as heart scans ($749 versus $503), colonoscopies ($876 versus $402) and even a 15-minute doctor visit ($124 versus $70) all pay more when done by a hospital-based doctor than a privately owned medical office. Obama officials know that hospitals are buying doctor practices to take advantage of this difference. But they favor hospital ownership of doctors and see it as a small cost to pay to drive that migration.

When I talk to physician colleagues, Republican or Democrat, a frequent refrain is that their professional strain would be the same regardless of what happens to ObamaCare. They are wrong. ObamaCare has accelerated many of the detrimental trends doctors see in their profession, and introduced new ones.

Reformers in Washington need to do a better job of explaining how market-based alternatives to ObamaCare are a better outcome for the structure and delivery of health care. And how they intend to preserve the entrepreneurship, autonomy and physician ownership that have long been the hallmark of American medicine.

Dr. Gottlieb, a physician and resident fellow at the American Enterprise Institute, is a member of the Health IT Policy Committee that advises the Department of Health and Human Services. He also invests in and advises health-care companies.

Some Cancer Experts See ‘Overdiagnosis,’ Question Emphasis on Early Detection

September 21, 2014

Debate Among Doctors Looks at Whether Zealous Screening Leads to Overtreatment

By Melinda Beck

The Wall Street Journal

Early detection has long been seen as a powerful weapon in the battle against cancer. But some experts now see it as double-edged sword.

While it’s clear that early-stage cancers are more treatable than late-stage ones, some leading cancer experts say that zealous screening and advanced diagnostic tools are finding ever-smaller abnormalities in prostate, breast, thyroid and other tissues. Many are being labeled cancer or precancer and treated aggressively, even though they may never have caused harm.

As a result, these experts say, many people may be undergoing surgery, radiation, chemotherapy and other treatments unnecessarily, sometimes with lifelong side effects.

Meanwhile, an estimated 586,000 Americans will die of cancer this year—many from very aggressive, fast-moving cancers that develop between screenings and spread too quickly to stop.

“We’re not finding enough of the really lethal cancers, and we’re finding too many of the slow-moving ones that probably don’t need to be found,” says Laura Esserman, a breast-cancer surgeon at the University of California, San Francisco.

Dr. Esserman chairs a National Cancer Institute advisory panel that is calling for major changes in how cancer is detected, treated and even talked about. Among its suggestions: devise new screening programs to target the deadliest cancers; create registries to track lower-risk cancers; and remove the term cancer from very slow-growing and precancerous tumors that are unlikely to progress. The panel suggests calling them “indolent lesions of epithelial origin,” or IDLEs, instead.

“Unfortunately, when patients hear the word cancer, most assume they have a disease that will progress, metastasize and cause death,” the group wrote in the journal Lancet Oncology in May. “Many physicians think so as well, and act or advise their patients accordingly.”


The new thinking could bring radical changes to the vast world of cancer care, which accounts for more than $100 billion in medical costs in the U.S. annually. It is being embraced by a growing number of medical associations and major journals.

“The harm of overdiagnosis to individuals and the cost to health systems is becoming ever clearer,” says Fiona Godlee, editor in chief of The BMJ, formerly the British Medical Journal, which is hosting a conference on the topic starting Monday at Oxford University.

The idea that not all cancers are deadly is already beginning to transform treatment for prostate cancer. As many as 60% of the tumors detected via screening grow so slowly that they pose little threat in a man’s lifetime, experts say, and treating them with surgery or radiation carries a substantial risk of impotence or incontinence. About 15% of patients now opt to monitor them instead—and some experts say more could probably do so safely.

Some urologists even propose calling prostate tumors with a Gleason score of 6 or below “benign lesions”—although others note that that would mean half of the men treated for prostate cancer in the past 20 years didn’t have cancer after all.

Overdiagnosis—the detection of tumors that aren’t likely to cause harm—is now a hot topic in other cancers as well. A growing volume of studies estimate that as many as 30% of invasive breast cancers, 18% of lung cancers and 90% of papillary thyroid cancers may not pose a lethal threat.

More than 2.5 million Americans are diagnosed with non-melanoma skin cancers each year—more than all other cancers combined. They are rarely fatal, and some experts say that removing the term “cancer” would encourage more doctors and patients to monitor the lesions rather than remove them surgically. A commentary in the Journal of the American Medical Association last week noted that more than 100,000 people are treated for basal-cell cancers annually even though they died of other causes within a year. “Clinicians need to take a step back from the microscope and take a look at the patient,” the authors wrote.

Not So Fast

But such calls to rethink the C-word and slow the relentless drive for more and earlier treatments remain highly controversial.

Officials from five major dermatology societies have blasted the idea of calling non-melanoma skin cancers IDLEs, saying that deaths from squamous-cell cancers are rising and basal-cell carcinomas can invade surrounding tissues if untreated. “Renaming a destructive and sometimes fatal disease—to make it sound harmless—is a disservice to our patients,” the doctors wrote in Lancet Oncology.

Brett Coldiron, president of the American Academy of Dermatology, says it’s often the patients who want their skin cancers removed—”and sometimes you get surprised. These things that look like a basal-cell are a melanoma.”

Dr. Esserman and other doctors warning about overdiagnosis have been harshly debated at cancer meetings and have received angry letters from people convinced that early detection saved their lives, or could have saved loved ones.


Some critics say that the whole premise that cancers are overdiagnosed comes from statistical guesses, based on old, flawed studies, and that even if some patients are treated unnecessarily, early detection still saves lives.

“There’s no question that periodic screening doesn’t catch fast-growing cancers, but you save lives by finding moderate and slow-growing cancers and finding them earlier,” says Daniel Kopans, a senior radiologist at Massachusetts General Hospital.

Even doctors who accept the idea of overdiagnosis say it poses a dilemma when it comes to treating individual patients.

“I am confident that somewhere between 10% and 30% of women with localized invasive breast cancer would be just fine if we just watched them,” says Otis Brawley, chief medical officer of the American Cancer Society. “But I cannot look into a patient’s eyes and say, ‘You’re one of the 10% to 30% that should not be treated.’ ”

The conflicting messages have left many patients bewildered. After years of educational campaigns saying that early detection saves lives, it’s no wonder that some people view recommendations to cut back on cancer screenings as dangerous, or veiled health-care rationing.

Bitter disputes still rage over a U.S. Preventive Services Task Force recommendation that men no longer use tests for prostate-specific antigen, or PSA, to screen for prostate cancer, and that women have mammograms every other year starting at age 50, rather than annually starting at 40, to reduce the likelihood of overdiagnosis. At Congress’s insistence, the federal health law requires insurers to fully cover annual mammograms starting at 40 as part of “essential health benefits.”

“Everyone says they’d be willing to be overtreated if it means not dying—but that’s a big fallacy,” says Dr. Esserman. “By treating 1,000 people who have low-risk disease, we’re not going to save the one person with aggressive disease.”

Sharks and Goldfish

What makes scientists think some cancers are indolent? One clue comes from autopsies that find a substantial number of breast, thyroid, lung and other tumors that never caused symptoms in people who died of other causes. Small, localized prostate cancers are so ubiquitous in older men that the risk is roughly equal to a man’s age: a 70-year-old has a 70% chance of harboring the disease. Yet the average lifetime risk of dying of prostate cancer is less than 3% according to the American Cancer Society.

Most of the evidence for overdiagnosis comes from statistical analyses of long-term cancer trends. Theoretically, as screening efforts find more early cancers, the death rate from those cancers should decline. Widespread use of colonoscopies and Pap smears has cut the death rate from colon and cervical cancers roughly in half since 1975.

But death rates from thyroid, kidney and skin cancers have stayed flat or increased, despite many more being diagnosed at early stages, leading researchers to conclude that many of those caught early would never have progressed.

Death rates from breast and prostate cancers have fallen by about 30% and about 40%, respectively, in the past 30 years. But experts disagree on whether that is due to the rise of screening mammograms and PSA tests or improved treatments.

“We have thrown the net very, very widely and eliminated some of the sharks,” says Ian Thompson, a urologist at University of Texas Health Science Center and co-chairman of the NCI advisory panel. “But we’ve also netted a lot of goldfish and assumed they’d behave the same way.”

The New War on Cancer

Part of the problem, says Dr. Brawley, is that modern medicine is using a definition of cancer that hasn’t changed since the 1850s, when German pathologists first described various types of the disease based on autopsy specimens. Tiny lesions that would never have been detected a few decades ago are now routinely biopsied and analyzed, he says, “and if it looks just like what killed that woman 160 years ago, we assume it will be deadly today.”

But assuming cells that look the same will behave the same way is the biological equivalent of “racial profiling,” Dr. Brawley adds. Many other factors—including the tumor’s genetic profile and the patient’s immune system, diet and overall health—could affect how fast those cancer cells grow, or conceivably regress. “We desperately need better tests to distinguish the things that will behave like traditional cancers versus the things that look like cancer but won’t,” Dr. Brawley says. “This is the beginning of the new war on cancer in the 21st century.”

Prodigious efforts are under way to devise such tests. The National Cancer Institute’s Early Detection Research Network is bringing together 300 investigators at 40 institutions to study how molecular patterns in screen-detected cancers differ from those that cause symptoms. Biotech firms and university labs are also racing to develop prognostic tools.

Much progress has been made in identifying subtypes of tumors and tailoring treatments to them. “It’s a fallacy to throw up our hands and say we have no idea which patients are low risk,” says breast surgeon Shelley Hwang at Duke University Medical Center, who is also on the NCI panel.

Tests such as Genomic Health Inc.’s Oncotype DX and Agendia Inc.’s MammaPrint analyze patterns of gene activity on breast tumors that have been removed and can help predict how likely the cancer is to recur and whether the patient would benefit from chemotherapy after surgery.

Several new gene tests for prostate cancer have hit the market in the past year. Oncotype DX has a test that works at the biopsy stage and can help doctors assess how aggressive a particular tumor might be.

But clinicians say much more research needs to be done before they can say for certain how any individual cancer will behave. “I think we will get there. I just don’t think we’re there yet,” says Clifford Hudis, chief of breast-cancer medicine at Memorial Sloan Kettering Cancer Center in New York and past president of the American Society of Clinical Oncology.

Peace of Mind

In the absence of certainty, many doctors and patients are opting for more aggressive treatment, not less.

In breast cancer, for example, nearly 20% of women with early-stage tumors now elect to have both breasts removed, up from 3% in 1998

“Patients do this for peace of mind, for symmetry—but there’s no survival benefit for most of them,” says Barbara Smith, director of the breast program at Massachusetts General Hospital.

About one-quarter of the breast cancers diagnosed each year aren’t technically cancers, but abnormal cells confined to milk ducts called “ductal carcinoma in situ” that were seldom noticed before mammography. Experts think only about 20% of DCIS lesions might eventually progress to become invasive cancer. But they don’t know for sure, because virtually all DCIS cases are treated as if they are stage-one cancers, with lumpectomy or mastectomy, often combined with radiation.

“We are picking up on these conditions way before we know whether they are dangerous or not,” says Duke’s Dr. Hwang. “In our ignorance, it’s safest to assume they are all dangerous, but we’re hurting some women in the process.”

Few doctors dare leave DCIS untreated, but Dr. Hwang is leading a multicenter study treating patients who have small, estrogen-positive DCIS lesions with hormone therapy for six months in hopes they can avoid surgery. She hopes to start another study next year offering DCIS patients the option of hormone therapy or active surveillance alone. “We may identity a group of patients we could treat with just a pill rather than mastectomy,” she says.

Risk-Based Screening

Dr. Esserman is embarking on a major study to test a new approach to breast-cancer screening. She hopes to enroll 100,000 women from all five University of California medical centers and Sanford Health in North Dakota. Those with average risk will have mammograms every other year, starting at age 50. Those at higher risk due to genetic variations, family history, dense breast tissue or other factors will be screened—with mammograms and other imaging tests—younger and more often.

“For some people, early detection does save lives—but we need to sort out who that might be,” says Dr. Esserman, who theorizes that after five years, such “risk-based screening” will have netted more high-risk cancers, fewer indolent ones and fewer false positives.

Any breast cancers that are diagnosed will be treated and tracked in registries shared among the universities; women with low-risk DCIS will be offered active surveillance, with or without hormone therapy, as well as surgical options. The risks and benefits will be discussed in depth, and individual choices will be honored.

“For a woman with DCIS who has 6-year-old twins and a mother who died of breast cancer, the right option might be radical bilateral mastectomy,” says Dr. Esserman. “For someone who is 86 years old and has multiple co-morbidities, surveillance may be.”

Some critics, including Dr. Kopans, warn that risk-based screening could be risky, since about 75% of women diagnosed with breast cancers had no known risk factors.

Says Dr. Esserman: “We need to start testing some of these ideas, rather than just fighting over them. People are afraid to do less. We want to figure out how to do less safely.”

Ms. Beck is a reporter and columnist for The Wall Street Journal in New York. Email:

Corrections & Amplifications

More than 90% of all skin cancers are basal-cell carcinomas that are slow-growing and unlikely to be fatal, according to commentaries in the Journal of the American Medical Association and Lancet Oncology. An earlier version of the Fatal Retraction graphic appearing with this article incorrectly identified the source as the American Academy of Dermatology. And an estimated 18% of lung cancers diagnosed with low-dose CT scans are unlikely to be fatal, according to research published in JAMA Internal Medicine. The graphic incorrectly suggested that the 18% figure referred to all lung cancers.

End-of-Life Care in U.S. Is Lacking, Report Says

September 18, 2014

Sept. 17, 2014 8:06 p.m. ET
WASHINGTON—The U.S. needs to revamp its approach to end-of-life care and conversations about dying to save costs and improve patient care, according to a sweeping report released Wednesday by an influential health committee.
End-of-life conversations with medical providers should be covered by insurers and Medicare, said the report by the Institute of Medicine, an independent organization and the research branch of the National Academy of Sciences.
One impetus behind the study was concerns raised in 2009 about “death panels,” a term that sprung up during political debates about what became the Affordable Care Act.
“Right now, there is too much fear and apprehension, and the discussions don’t happen,” said Phillip Pizzo, co-chair of the panel and former dean of the Stanford University School of Medicine.”What we call for is that there be an opportunity for discussions with clinicians throughout the life cycle and not just one time,” he continued. “It’s part of the process of living.”

The report by the nonpartisan committee is especially important these days as baby boomers age. The more than 70 million Americans born from 1946 to 1964 are starting to age into Medicare, which is available to Americans when they turn 65.

The program also covers the disabled.

People nearing the end of their lives experience high rates of preventable hospitalizations and often struggle with a fragmented system that may not be aware of their preferences regarding late-stage care, the report said.

Widespread adoption of timely palliative care, which focuses on pain relief, appears low, even though such treatment is linked to better quality of life and longevity.

“The Doctor” by Luke Fildes

Improving end-of-life care should tie financial incentives to advance-care planning and frequent clinician-patient conversations, the report said.

Medicare incentives in place today may have the opposite effect, the report says, by encouraging late enrollment in hospice facilities and more transitions among care settings.

“We have a fragmented, disjointed approach that results in people not getting what they want,” said David Walker, who served as U.S. comptroller general and was co-chair of the panel that worked on the report.

Some of the recommendations may require policy changes, he said.

The Mail welcomes ministers' decision to phase out the Liverpool Care Pathway

Patients currently can’t generally be referred to a hospice until they are expected to die, which is within six months, which means many get this type of care too late. People in hospices also may not have access to certain curative treatments.

A 2009 version of the health law required that Medicare begin paying physicians for counseling patients on end-of-life planning, such as setting up a living will or obtaining hospice care.

Such policies, however, became erroneously labeled as calling for “death panels.”

The furor resulted in those policies being omitted from the final 2010 health law, and later attempts by the Obama administration to reimburse for such care got shelved.

This year, the American Medical Association provided the Centers for Medicare and Medicaid Services with proposed service codes so the program could pay physicians for having advance-care planning sessions with patients. That may lead the government to adopt a payment policy that would reimburse for those services.

Some private insurers already are beginning to reimburse physicians and clinicians for having end-of-life conversations, Mr. Walker said, a sign that such discussions improve patient care and also help save money.

Discussions about dying and medical care should occur during major life transitions, such as obtaining a driver’s license, getting married and enrolling in Medicare, said those who worked on the IOM report.

The document, which is more than 500 pages, also suggests all health-care professionals be required to have training in holding such conversations.

“The important point that may be hard for the public to believe is that their doctors and nurses have had no training in how to have conversations on what matter most to patients,” said Diane Meier, director at the Center to Advance Palliative Care and a professor at Icahn School of Medicine Mount Sinai in New York, who also worked on the report.

The National Hospice and Palliative Care Organization said it supported some of the conclusions, including paying physicians for end-of-life conversations and earlier use of hospices.

“Our current system is broken in some ways in dealing with end-of-life care,” spokeswoman Anita Brikman said.

Advance planning is especially important because the majority of patients nearing the end of life will receive acute hospital care from physicians who don’t know them, the report said. Planning is vital to ensure that patients obtain care that fits their goals and preferences, the report said.

Younger, poorer, minority and less-educated individuals tend not to have end-of-life conversations, the report noted.

Write to Stephanie Armour at



Catholic Church Teaching on Human Life and Suicide:



Worrying claim: Professor Patrick Pullicino said doctors had turned the use of a controversial ¿death pathway¿ into the equivalent of euthanasia of the elderly

Worrying claim in Britain: Professor Patrick Pullicino said doctors had turned the use of a controversial ‘death pathway’ into the equivalent of euthanasia of the elderly

“The Doctor” by Sir Luke Fildes, 1891.

How can someone completely ignore a disease for so long? Ignoring a disease almost always makes it worse…

March 30, 2014

The New York Times

Not so long ago, a middle-aged patient came to my office for a checkup. He cheerfully admitted that he hadn’t been paying attention to his diabetes for the last few years. He’d stopped taking his medicine, stopped seeing his doctors, stopped thinking about the disease altogether. When I checked his blood sugar in the office, it wasn’t just a little elevated — it was four times the normal level.

For doctors, it is always a shocker to hear a case like this. How can a patient completely ignore a disease for so long? How can a life-threatening illness just disappear from someone’s consciousness?

The patient was not in denial; he knew he had diabetes. It just wasn’t on his priority list at this point in his life. For me, it was flashing neon at the top of my list with seven exclamation points.

It’s not surprising that doctors and patients have contrasting agendas. We come to illness from entirely different perspectives and backgrounds. Moreover, the angles of our respective lenses are mismatched.

For my patient, his wide-angle lens took in the whole of his life, of which diabetes was one small part. For me, in the 20 minutes allotted, my lens was narrowly focused on the disease that posed the gravest and most immediate risk to his health.

The challenge that lay ahead of us was to help each other adjust the angles of our respective lenses so that our visions could come into common focus. Otherwise, we’d slip into futile haranguing.

The diabetes algorithm taped to the wall could tell me exactly how much insulin to administer for his staggering high sugar level. But my patient didn’t need me to tell him; he was perfectly aware of the algorithm himself.

What the algorithm couldn’t tell us was how to understand the disease from different perspectives, how to tease apart the elements that had led up to the current situation, and how come up with a workable plan to prevent an otherwise healthy man from ending up blind, impotent, on dialysis and in a wheelchair from foot amputations.

Life flight air ambulance

That required extended discussions over the next few months that touched upon matters both practical and philosophical. We had to figure out how a taxi driver who relied on street-vendor food and whose only exercise was pressing the gas pedal could adhere to the diet and exercise requirements to control diabetes. We had to talk about the diarrhea that his diabetes pills caused. We had to discuss how his religious background influenced his approach to the future. And we had to talk bluntly about his life expectancy and the legacy he would — or would not — leave to his children.

It was fascinating to be in on the complicated, messy and individual way that people make decisions in real time. Both of us had to reconsider our assumptions about diabetes and how it should best be treated.

He flatly refused insulin, my opening bid for the most efficacious way to control his sugar. I had to fight back my clinical instincts to appreciate that bringing down his glucose level simply was not his top priority. He was most concerned about keeping his life “workable,” and needles were distinctly not part of that.

We had to compromise on a medical regimen that involved pills only, and agreed on an initial goal of getting his sugar just low enough to prevent the symptoms of excessive thirst and urination. Beyond that, it was negotiations that rivaled the Mideast peace process.

Was this a success? Well, his glucose did not get anywhere close to the normal range, as had been my initial goal. Certainly the scientific consensus is that getting glucose close to normal decreases the risk of many of the bad outcomes of diabetes. Letting go of this goal ran against all my training as a doctor.

But we did manage to get diabetes back onto his radar. While we both would have preferred that he didn’t have this disease at all, the reality was that it was there, like it or not. By being aware, he could now begin to think about how his food choices and activity level could sway the disease — for better or for worse.

His sugar is now lower than it was, and this should result in some harm reduction, even if the level never approaches normal. He is taking his meds and has made a few modest changes to his diet.

On my end, I’ve learned that there are times that I need to modify my own priorities and figure out with the patient what goals are achievable, at least at a given time. I’m also reminded how much more intriguing and challenging medicine is when we have the opportunity to delve in deep with a patient.

By the “quality measures” scorecard, this patient will count as a failure on my watch, since I have not succeeded in normalizing his glucose — or his cholesterol or his blood pressure, for that matter. The objective, outcome-driven data would rate me as a better-quality doctor if diabetes fell off his radar again and he dropped out of my practice.

Luckily for both of us, he continues to come to his appointments, and we both call that a success.

Danielle Ofri’s newest book is “What Doctors Feel: How Emotions Affect the Practice of Medicine.” She is a physician at Bellevue Hospital and an associate professor at the New York University School of Medicine. She is also editor in chief of The Bellevue Literary Review.


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Six in 10 family doctors considering early retirement

March 24, 2014

BMA survey also reveals more than a third of GPs plan to end careers early, as workloads increase and morale plummets

By James Meikle
The Guardian

A doctors consults with a patient

More than half the GPs who responded to the BMA tracker survey reported that their morale was low or very low.

Nearly six in 10 family doctors are considering early retirement because of their increasing workload, GPs leaders claim on Monday as pressure mounts on health ministers across the UK to spend more on care outside of hospitals.

The British Medical Association(BMA) warned of a “disaster” in general practice as doctors faced rising demands from patients with declining funds. The bleak assessment comes a day after the Royal College of GPs (RCGP) said the family doctor service was on the brink of extinction.

BMA chair Chaand Nagpaul  said results from its online tracker survey of members demonstrated GPs were working harder than ever while trying to provide more emergency care appointments and evening consultations.

Nagpaul said: “It is clear general practice is facing a workload disaster that is threatening its long-term future. We are seeing morale dip to a level that I cannot remember in my 25 years as a GP. Six out of 10 GPs are considering early retirement and more than a third are planning to end their career early. This could lead to a general workforce crisis in general practice where we do not have enough GPs to treat patients.”

The government was “asking GP practices to provide more services, including many involving the transfer of hospital care into the community, without the resources to successfully deliver them”, he added.

Nagpaul said the government needs to consider expanding GP numbers so that patients are given the time and care that they deserve. “Most importantly, the government needs to work with all healthcare professionals and patients to find practical solutions to a crisis that is threatening to overwhelm general practice”.

His remarks follow comments from Mary Baker, RCGP chair, that family doctors are “shoring up” the rest of the NHS. The leader of Britain’s family doctors said: “General practice as we know it is under severe threat of extinction. It is imploding faster than people realise and patients are already bearing the brunt of the problem.” She blamed a “toxic mix of increasing workloads and ever-dwindling budgets”.

The BMA’s regular tracker survey of members’ opinions via a panel of 2,650 doctors, includes about 820 GPs, of whom 420 replied to questions on workload, morale and intentions. More than half said their workload was unmanageable or unsustainable and nine in 10 said they worked beyond their regular hours. More than half also reported that their morale as low or very low, and most said they were changing the way they worked to find more time for emergency appointments, with half saying they were responding to demands for more evening appointments.

The Department of Health in England said: “We recognise the vital job that GPs do. This is why we have cut GPs’ targets by more than a third to free up more time  with patients, and are dramatically increasing trainees so that GP numbers continue to grow faster than the population.”

It said was also looking  at how it could keep more existing doctors in general practice and pointed to changes in GP contracts which should lead to more money being pumped into services. It hoped many surgeries could be open from 8am to 8pm seven days a week.

There are more than 40,000 GPs across the UK.