Archivi delle etichette: Personalized care

Solving the high rates of hospital readmissions @kevinmd @Medici_manager @pash22

By  ,

Statistics show that about 1 in 5, or 20 percent of all Medicare patients are readmitted to hospital within 30 days of discharge. That’s a staggering number, not to mention all those patients that are readmitted frequently during the course of a year, but not necessarily within 30 days.

The problem of frequent hospital readmissions is actually one that exists all over the world and not just in the United States. Health care systems everywhere are seeking solutions to keep their patients healthier and away from hospital. Any doctor practicing at the frontlines will be able to tell you what a big issue this is right now. We regularly see the same patients on something of a merry-go-round of frequent hospital admissions, often with the same illness.

Why does this happen? This issue is complex. In my experience as a hospital medicine doctor, there are number of factors in play, falling into different categories according to the type of illness, availability of definitive treatment, and the social circumstances of the patient.

Severity of illness. Certain chronic conditions, such as congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD), when in their advanced stages, are very labile and prone to exacerbations. As much as doctors try to control these with medications, it’s a very difficult task, as it only takes a slight precipitant such as a minor infection or dietary indiscretion to push somebody over the edge. By their very nature chronic diseases tend to get worse over time. And with an aging population, these conditions are increasing in prevalence. Unless we find definitive cures, hospitalizations are always unfortunately a possibility.

Social situation. Patients who have inadequate family support tend to be admitted to hospital more frequently for a couple of reasons. Firstly, their threshold for being able to cope at home with their illness is much lower. Secondly, they will not be able to co-ordinate their regular follow up care so easily. We see the effects of this all the time at the frontlines — two patients with the same level of illness severity; one will be managed at home, the other will require hospital admission for several days.

Lack of follow-up. Many studies have shown that lack of follow-up with a primary care physician in the weeks after discharge can lead to a higher likelihood of re-hospitalization. Seeing a doctor quickly post discharge allows for any potential problems to be “nipped in the bud”. It also allows for care co-ordination and medication reconciliation. Sadly, a large number of patients do not have a regular primary care doctor (mostly for insurance reasons). They therefore tend to use the emergency room as their first point of contact when they feel unwell again.

Suboptimal discharge process. By its’ very nature, the process of discharging a complicated patient from hospital is one that is fraught with possible problems. The discharge process needs to be thorough, seamless and diligent. Areas for improvement in most hospitals include medication reconciliation, clarifying follow-up appointments, follow-up laboratory tests, and making sure that the patient and family is clear about these instructions. Too often, this process is rushed and glossed over. Nothing beats having the doctor sit down with the patient and their family, spending time reviewing all the pertinent information.

Low health literacy. Many patients are not fully educated and informed about the nature of their illness and how best to manage it at home. This can be dealt with by regular reinforcement and utilizing home nursing services to keep on checking in with the patient post-discharge.

Certain very obvious patterns do exist in how patients tend to be readmitted to hospital. Several initiatives are underway across the country to try and improve the situation. Primary care doctors, specialty clinics, home nursing services, and even social workers are all being utilized as part of a team-based approach. The strategies broadly involve:

  • Identifying high-risk patients early
  • Educating the patient and involving family members
  • Having very close follow-up with a collaborative care team

As part of health care reform, hospitals are also facing financial penalties for consistently high readmission rates. But financial penalties alone aren’t the answer, especially for “safety net” hospitals that struggle more with this problem. It’s important to remember that the drive to reduce readmissions is not just about saving the health care system money, but ultimately about keeping our patients healthier and stronger. Whatever can be done to keep them at home enjoying life as much as possible instead of lying in a hospital bed, can only be a good thing.

Suneel Dhand is an internal medicine physician and author of Thomas Jefferson: Lessons from a Secret Buddha and High Percentage Wellness Steps: Natural, Proven, Everyday Steps to Improve Your Health & Well-being.  He blogs at his self-titled site, Suneel Dhand.

Richard Smith: Health and social care: lots of activity, little value @Richard56 @Medici_Manager

21 Jun, 13 | by BMJ Group

My mother is a wonderful woman but has no short term memory and drinks too much alcohol. When she’s sober her language is complex and her sense of humour magnificent. “What a terrible world,” she says, watching the television news, “I’m glad I’m not in it.” In a way, she isn’t. She’s mildly disinhibited even when sober and chats to everybody. “You’re one of the sights of Barsetshire,” I say to her, “they’ll be organising coach parties.” “Well, nobody ‘ll pay,” she answers laughing. But how much have the health and social services helped my mother?

She’s clear that she wants to live on her own as long as possible. In an age gone by, but still present in most of the developing world, she would have lived with me or my brothers. It would be unthinkable that when widowed she should live alone. But those days are finished. We couldn’t stand it and nor, I’m confident (but maybe deceiving myself), could she.

It’s fascinated me how well and for how long she has lived alone despite having no short term memory. It’s been some six years. I thought an intact short term memory essential for living alone, but I was wrong. Luckily she doesn’t cook, so doesn’t leave the gas or the oven on. She forgets to put water in the electric kettle and sometimes blows the fuses, but she doesn’t blow up the house.

Every day is much the same. She gets up at about 8.30, has a cup of black coffee, looks at the Guardian (making no sense of it), puts on her shoes, and “stomps,” as she describes it, the mile into the centre of Barset. Greeting the man in the newsagent, she buys a bottle of wine, stomps home, hailing people as she goes, drinks the wine, and goes to bed. Perhaps two hours later she gets up and does it all again. And when the days are longest, she may attempt it a third time—unaware that it’s evening not morning and unsteady on her feet after two bottles of wine. That’s why I’m sat here in Barset writing this. I’m “mothersitting.” She giggles at the term but doesn’t really like it.

Back at the beginning I thought that we ought to “get her into the system.” I thought that we’d need some support and that it would be essential to be “on the books” to receive it. So we went to the GP, which she doesn’t like. The trainee said that she should have some blood tests and come back to have “the long test for memory.” That was two trips, 140 miles driving, and when we had the appointment for the long test, the doctor didn’t have time to administer it and so simply referred her to the memory clinic. There was no value added by all this as the postman could have told us that she has no short term memory.

The adventures with the memory clinic were long and drawn out with MRI scans, psychological tests, many interviews with a variety of people, and some 350 miles of driving. My mother hated it all, but in the end she was prescribed drugs to help her memory. She forgot to take them and didn’t, I think, want to take them anyway, although she said she did to please us all. Even if she had taken the drugs there was only a small chance that they would have done any good. Everybody was charming and helpful, but no value was added by all this activity—except that the diagnosis released some state benefits.  It was bureaucratic value that was added.

Social services became involved. They came and did a long assessment. Eventually, they said, she’d have to go into a home. This wasn’t surprising. They couldn’t do anything except give us a list of services. They couldn’t recommend any service even though they presumably know which are better than others. So no value in this.

We arranged for a “sandwich lady” to come three times a week to encourage my mother to eat. But that was hopeless, and eventually my mother herself told the sandwich lady that she didn’t need her anymore.

Social services assessed her again and told us the same as before. They did arrange a bath chair, which did add a little value. Unfortunately it broke down almost immediately and took a long time to fix. Now they’ve taken it away. I’m not sure why.

We arranged for carers to come in twice a day, and they have added value. But we found them and have to pay as my mother owns her house.

What about resuscitation, the care company asked. My mother is very clear that she doesn’t want to be resuscitated. We talk about death a lot. She’s not scared of death. But we can’t have a DNR in place without having the doctor approve it. So we haven’t bothered. If the carers find her in cardiac arrest they are highly unlikely to succeed in resuscitating her anyway. Having to have a doctor determine your eligibility for a DNR seems to me a process that subtracts value.

Now things have reached a crisis. With the long evenings my mother is going out late and drunk and having all kinds of adventures with neighbours, the police, and the burghers of Barset. The care company has contacted social services worried that it might be blamed if she goes under a bus. So have some neighbours. A young man from social services rings me in a state of high excitement. He asks me things that we have told social services many times. He’s rung the GP asking for an assessment. He offers us another assessment. “What good will that do?” I ask. He’s not clear. I say that we recognise she can no longer live alone even though she insists that she wants to. We’ve started finding a home.

They can’t, it’s apparent, really do anything. I ring the GP and speak to a friendly understanding doctor. They have been contacted by social services and discussed her in their meeting. But nobody knows anything about her. A doctor has visited twice but never got an answer. Somebody is going to try again. The young doctor agrees that they have little to offer. I’ve not heard from them since.
Social services keep ringing because people are ringing them. The care company tells me that they will do anything to help but in the same call, without irony, tell me that they can’t supply somebody in the light evenings.

My brother asks who social services are serving?  Are they there for my mother or the neighbours? We recognise the strain on the neighbours, and we know most of them. Some have been very helpful. Ages ago I delivered them all a letter asking them to contact any of us if they had worries. I’m not sure why they ring social services rather than us.

Then my mother has a fall. It had to happen. Indeed, it’s happened before. This time she has a scalp wound, and we doctors (and surely most others) know that scalps can bleed generously. I was abroad unfortunately, so my brother rings 111. Risk averse, as they have to be, they recommend a visit to A and E. Nobody can be sure that she wasn’t unconscious. A young doctor thinks she might have a urinary tract infection to account for her confusion and prescribes antibiotics. They can’t be taken with alcohol. He suggests a visit to the GP in four days’ time. I say poppycock to all this when I return, and we forget the antibiotics and the visit to the GP. She is fine. So again more activity, more expense for the NHS, and no value. At least she hasn’t developed diarrhoea through taking antibiotics.

A woman from social services rang again today. She’s weary. I tell her that we are in the final stages of the bureaucracy of finding a home. She’s relieved. I ask her what she might do if we weren’t doing anything. Eventually she would have to use the law to have my mother admitted to a care home. She could arrange an emergency admission to a home, but we agree that we should do all we can to avoid having to move her twice.

My mother is unaware that the phone lines of Barset are buzzing with concern about her. She’s not keen on moving to a home but will do what we advise. Seconds after we’ve had the conversation she has of course forgotten it.

When I reflect on the saga so far I can’t see that statutory health and social services have added anything but minimal value. But there’s been plenty of activity, form filling, and expense. My mother is not that unusual. We surely need better ways to get value out of the system.
I also reflect that people who have added a lot of value are those who work in the newsagent she visits every day. She likes them, and they are not only kind to her but also let her have goods without paying when she forgets her money and arrange a taxi to take her home when she’s tired and exhausted. Perhaps we need fewer expensive professionals and a revitalisation of communities.

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.


Una politica per gli anziani @Medici_Manager

Gavino Maciocco

In Italia non c’è una politica nazionale per gli anziani. Come non esiste alcuna politica nazionale per qualsivoglia settore della sanità (se non quella dei tagli).  Questa mancanza di una identità nazionale nelle politiche  per la salute rende il sistema estremamente vulnerabile anche sul piano dei principi e dei diritti.

Pisa. 7 Maggio 2013. Aula Magna della Scuola Superiore S.Anna. Seminario internazionale su “Cure primarie, anziani e cronicità”. Per la Svezia interviene Eva Nilsson Bågenholm MD, coordinatore nazionale dell’assistenza agli anziani. E’ una presentazione molto ricca di dati e di utili informazioni.  Viene descritta l’intera filiera d’interventi che riguardano l’assistenza agli anziani partendo dalle cure primarie all’assistenza specialistica, fino all’assistenza residenziale.

In Svezia le cure primarie sono basate su team multidisciplinari, “primary care units” (ne  esistono 1100 in tutto il paese, libera scelta tra team pubblici – due terzi del totale – e team privati). Il team è composto da medici di famiglia, da 2 a 8, infermieri distrettuali specializzati,   assistenti infermieri, assistenti sociali,  psicologi, fisioterapisti, terapisti occupazionali, logopedisti, dietisti.  Per quanto riguarda l’assistenza residenziale, la Svezia dal 1992 ha abolito le “long term care institutions”, equivalenti alle nostre Residenze Sanitarie Assistenziali (RSA), sostituendole con unità abitative composte da 10-15 mini-appartamenti, dotati di servizi comuni il cui uso è facoltativo (come mensa, soggiorno, libreria, lavanderia, etc) e di assistenza alla persona per l’arco dell’intera giornata: attualmente sono 90 mila gli anziani residenti in queste strutture.  La presentazione tratta di investimenti, di linee guida nazionali, di progetti di larga portata e con risultati eccellenti, come quello relativo all’assistenza ai pazienti con Alzheimer.

Durante l’intervento della collega svedese cresceva in me lo sconforto nel confronto con la situazione italiana. Pensavo ad esempio che mentre, agli inizi degli anni novanta, in Svezia abolivano le RSA in Italia scoppiava lo scandalo “Italsanità”, un’operazione speculativa per la diffusione in tutta Italia dei “ghetti d’oro”, le RSA appunto.

Cercavo di collegare la situazione dei due sistemi sanitari, quello svedese e quello italiano, molto simili per alcuni versi: entrambi appartenenti al modello Beveridge, sistemi sanitari nazionali finanziati prevalentemente attraverso la fiscalità generale, con un forte decentramento nel governo e nella gestione della sanità, affidata alle Contee in Svezia e alle Regioni in Italia.

Ma il decentramento in Svezia prevede – a differenza che in Italia –  un ruolo centrale del governo centrale e del ministero della sanità nella programmazione nazionale e nella definizione dei modelli organizzativi, anche in presenza, come oggi, di un governo conservatore, favorevole a politiche market-driven anche in sanità.

Cercavo di immaginare un equivalente italiano della Eva Nilsson Bågenholm che partecipa a un seminario internazionale in Svezia sullo stesso tema di quello organizzato a Pisa. Lo cercavo, ma invano.  Perché non c’è una politica nazionale per gli anziani. Come non esiste alcuna politica nazionale per qualsivoglia settore della sanità (se non quella dei tagli).  Questa mancanza di una identità nazionale nella politica (o meglio nelle politiche: nelle strategie, nei programmi) per la salute rende il sistema sanitario estremamente vulnerabile anche sul piano dei principi e dei diritti. Chi ha a cuore il diritto alla salute in Italia, chi vuole difendere il sistema universalistico, dovrebbe non solo preoccuparsi dei tagli e dei ticket, ma anche battersi per correggere la devolution in sanità,  prodotta dalla modifica del titolo V della Costituzione avvenuta nel 2001.

Helping patients to die well @Medici_Manager @giovanimedici @specializzandi

Fiona Godleeeditor, BMJ @fgodlee

There is more than one way to die well, say Katherine Sleeman and Emily Collis in their article on caring for dying patients (doi:10.1136/bmj.f2174). The trouble is that far too many people die badly. Whatever your definition of a good death, dying in hospital when you would prefer to die at home, or dying in pain, distress, isolation, or uncertainty will not be part of it. Yet, as the authors explain, over half of all deaths (in the UK at least) occur in hospital, many patients die with unmet needs, and more than half of complaints referred to the Healthcare Commission are about the care of dying people. All of this is despite the growing recognition of the need for good end of life care. And of course the risk of dying badly matters not only to the person who is dying but to their relatives and friends. The authors quote Cicely Saunders, founder of the hospice movement: “how we die remains in the memory of those who live on.”

But there is good news. While modern medicine often seems to actively promote bad end of life care, doctors can do a great deal to help patients achieve a good death. Early identification of the dying phase, good communication with patients and relatives, sensible prescribing, effective management of physical symptoms, and understanding of the patient’s social, psychological, and spiritual needs must all play their part.

Sleeman and Collis have targeted their advice towards doctors in training. But clinicians at all levels of experience will benefit from reading their article. Senior doctors will, in any case, want to model the highest professionalism and humanity when dealing with dying patients. Knowing that younger doctors will be taking their cues from you provides an additional incentive.

The article usefully tackles some of the misconceptions that have dogged the Liverpool care pathway in recent months. The pathway is a framework, not a treatment, so doesn’t need formal consent, but the decision to start someone on it should be made by a multidisciplinary team and should be discussed with the patient where appropriate and always with the relatives. While on the pathway, patients should be supported to eat and drink; and if the patient’s condition improves, the pathway can be stopped.

Essential to good end of life care is the ability to recognise that a person is dying. Sadly, this is a prognostic skill that doctors are “notoriously poor at,” say the authors. But do patients need to know that they are terminally ill in order to receive good care? The same authors take part in our Head to Head debate this week, arguing that patients should be told, since this knowledge is necessary for informed decisions (doi:10.1136/bmj.f2589). But Leslie Blackwell argues against what she calls “prognostic disclosure” (doi:10.1136/bmj.f2560). This is, she says, “a failed model for medical decision making that creates more suffering than it relieves,” and “for most people the apparent choice between comfort and prolongation of life is a false one.” I’m not convinced, but I would like to hear your views.

Cite this as: BMJ 2013;346:f2656




Integrated health and post modern medicine @Medici_Manager

For many years, I have advocated an integrated approach to medicine and health. By integrated medicine, I mean the kind of care that integrates the best of new technology and current knowledge with ancient wisdom. More specifically, perhaps, it is an approach to care of the patient which includes mind, body and spirit and which maximizes the potential of conventional, lifestyle and complementary approaches in the process of healing. Integrated health, on the other hand, represents an approach to individual and population health which respects and includes all health-related areas, such as the physical and social environment, education, agriculture and architecture. I know that this is a somewhat wider definition of integration than commonly used, but I want to argue that a successful health service needs to embrace this broader and more complex concept of integration.

I hasten to say that the point of this article is not to confront accepted medical wisdom, but merely to suggest that there is a case for reaching beyond it, and that is to explore how we might be able better to align the ambitions of patient and clinician within medicine and how we might maximize the ability of every professional and citizen to create better personal and community health outside of it.

Exactly 30 years ago, in a speech to the British Medical Association (BMA),1 I quoted George Engel, who wrote ‘A Modern Science of medicine still tends to be based on the notion of the body as a machine, of disease as the consequence of breakdown of the machine, and of the doctor’s task as repair of the machine’.

I fear that what was true 30 years ago remains equally true today. It is why for a rather long time now, and not without criticism from some quarters, I have been attempting to suggest that it might be beneficial to develop truly integrated systems of providing health and care. That is, not simply to treat the symptoms of disease, but actively to create health and to put the patient at the heart of this process by incorporating those core human elements of mind, body and spirit. To achieve this – and there are many who support this – I would suggest that medicine may sometimes need to become less literal in its interpretation of patient needs and more inclusive in terms of what treatment may be required – in other words, to understand how symptoms may often simply be a metaphor for underlying disease and unhappiness. It is also vital, it seems to me, to recognize that treatment may often be effective because of its symbolic meaning to the patient through effects that are now being increasingly understood by the science of psychoneuroimmunology.

In short, I suspect it will always be a struggle if we continue with an over-emphasis on mechanistic and technological approaches. Please do not misunderstand me – the best of science and technology constantly needs to be harnessed and deployed to obtain the best effect – but, I would suggest, not at the expense of the human elements. These, after all, provide the whole rationale for medicine and health care going back to our roots.

The importance of those human elements is becoming all too apparent in contemporary medical science. Sir Michael Marmot has shown convincingly2 that the health of employees is related to the extent to which they feel empowered to fulfil their role, according to their own judgement. Professor Blackburn, the Nobel Medicine Prize winner, has provided evidence3 indicating that high levels of stress can result in shortened telomeres, the critical elements which bind chromosomes together. This in turn quickens the ageing process. With research of this kind, we can no longer continue to see mind and body as separate and occasionally interacting entities. That is because they are one and the same thing. Our scientific and therapeutic approach now needs, surely, to advance in a way that encourages and embraces a new understanding between patient hopes, perspective and belief and the workings of his or her body.

This whole area of work – what I can only describe as an ‘integrated approach’ in the UK, or ‘integrative’ in the USA – takes what we know about appropriate conventional, lifestyle and complementary approaches and applies them to patients. I cannot help feeling that we need to be prepared to offer the patient the ‘best of all worlds’ according to a patient’s wishes, beliefs and needs. This requires modern science to understand, value and use patient perspective and belief rather than seeking to exclude them – something which, in the view of many professionals in the field, occurs too often and too readily.

In the individual encounter between patient and clinician, we are led to believe that there is currently a ‘crisis in caring’. I am sure that this is not the case in many or most such encounters. Nevertheless, I am equally sure that there is much more that can be done to foster and enhance those age-old qualities of human kindness and compassion. The Media is full of instances where these have been palpably lacking, and I have heard of others speaking of the need to restore urgently a climate of care and compassion at the heart of our health services.

It is particularly surprising that so many appear to think there is a gap here, when we are told that those so called ‘soft skills’ of caring can have a significant impact on the quality and pace of recovery among patients. This inevitably raises the question: ‘Are we doing enough to ensure there is sufficient empathy and compassion instilled throughout training in medical schools and in later hospital training?’ Should we not, perhaps, be doing more to enhance the length of contact and continuity, when it comes to relationships between professionals and patients? It appears to many inside and outside the health-care professions that our capacity for providing ‘the human touch’ has steadily decreased as science and technology have improved. Surely, it should not be a case of ‘either/or’? Thus, it seems to me that good medicine should aim for a better balance between what science and technology may demand and what patients may actually want and need.

One senior professional said to me that what seems to go missing all too easily is the art of thoroughly understanding the patient’s narrative. He said that we need to equip our health professionals with skills (and a desire) to listen and honour what is being said, and – importantly – what is not said to them. Only in this way can they develop a thorough understanding of the patient’s story. This understanding is necessary to develop healing empathy and help the patient find their own particular path towards better health. This should not only help the patient, but should also enable more health professionals to connect and engage in a much more meaningful and professionally satisfying way.

If, however, we are to create such a culture of better care, then we cannot depend forever upon ‘heroes’ at the frontline. Better care and compassion require systems which support the caring ambition of every health service organization, every health service leader and every clinician. If we really want to change things, then we must better support and encourage those organizations, leaders and frontline clinicians, who are fully committed to going the last mile in the care of their patients.

But things should not begin and end with good professional care of the individual patient. There must surely be an enormous potential for more people to become concerned and caring of each other outside this professional encounter? In Burnley, where health inequalities have lowered life-expectancy to among the worst levels in this country, up to a dozen of my Charities are working in partnership with local organizations trying to make a difference for the better in the fields of health, the built and natural environment, the Arts, education and business. Why? Because we know that alienated and uncaring communities adversely affect the health and wellbeing of those living in them.4,5 Conversely, current evidence suggests that if you try to tackle some of these admittedly deep-seated problems, not only do you begin to witness improvements in health and other inequalities, but this can lead to improvements in the overall cost-efficiency and effectiveness of local services.6

In summary then, we are beginning to know more about the causes of unhappiness and poor health. We also know the importance of the patient/professional relationship and the therapeutic potential of relationships in general. There are ‘a priori’ reasons to suspect that we could improve health through a range of better integrated interventions and programmes. We now desperately need to produce more of the right kind of research to strengthen these hypotheses.

This wider role for medicine is supported by traditional wisdom which sees illness as a disorder of the whole person, involving not only the patient’s body, but his mind, his self image, his dependence on the physical and social environment, as well as his relation to the cosmos. Perhaps we should also invoke ancient wisdom in dealing with this model of disease. In that same speech to the BMA in 1982, I quoted Paracelsus, the 16th century healer, who said that the doctor ‘Must be intimate with Nature. He must have the intuition which is necessary to understand the patient, his body, his disease. He must have the ‘feel’ and the ‘touch’ which make it possible for him to be in sympathetic communication with the patient’s spirits.’ Paracelsus also believed that the good doctor’s therapeutic success largely depends on his ability to inspire the patient with confidence and to mobilize his will to health. These ideas, which were close to heresy in 1982, appear to be more acceptable to some in 2012. Postmodern medicine, I believe, will need to embrace them in its science and alongside its technology if it is to maximize its impact and remain sustainable.

Clinicians, of course, have the huge responsibility of taking these things seriously and finding a way forward that is best for patients and for local populations. Surely, there can never have been a better time for all clinicians to emphasize the value of caring, continuing relationships and of adopting a more holistic approach to health and disease – a human approach, if you like, which maximizes the potential of the physical and social environment, so that healing and better health can thrive?

Now, surely, is the time for us all to concentrate some real effort in these areas. We will need to do so by deploying approaches which, at their heart, retain the crucial bedrock elements of traditional and modern civilized health care – of empathy, compassion and the enduring values of the caring professions.

Recommended Reading: Reflecting on the Choosing Wisely Journal Articles of 2012 @Medici_Manager @ABIMFoundation

Written by Amy Cunningham on December 21, 2012

Since nine medical specialty societies announced their lists of “Five Things Physicians and Patients Should Question” in April, 55 published journal articles have referenced the Choosing Wisely® campaign. For the final Recommended Reading post of 2012, we’ve culled a selection of those articles, and will share more in the new year.

In order of publication date:

  • In From an Ethics of Rationing to an Ethics of Waste Avoidance, Howard Brody argued for a stepwise strategy to eliminate unnecessary care given the limitations of comparative-effectiveness research, saying, “it is better first to eliminate interventions for which we have the most solid and indisputable evidence of a lack of benefit.”
  • In Application of “Less Is More” to Low Back Pain, the authors found strong evidence supporting the American Academy of Family Physicians’ recommendation as part of theChoosing Wisely campaign, “Don’t do imaging for low back pain within the first 6 weeks unless red flags are present.” The article was accompanied by a commentary by ABIM Foundation Executive Vice President and Chief Operating Officer Daniel Wolfson.
  • In the New England Journal of Medicine article, A Systemic Approach to Containing Health Care Spending, Ezekiel Emanuel, MD, PhD and co-authors outlined a number of recommendations for bending the health care cost curve, including the development of credible practice guidelines.
  • British Medical Journal piece on unnecessary care said that a “newly launched movement lead by prominent doctors is challenging the basic assumption in U.S. healthcare that more is better” and cited Choosing Wisely as part of the movement
  • Authors of a JAMA commentary mentioned the Choosing Wisely campaign as one of several recent initiatives addressing the physician’s role in health care expenditures. They then call for a new model of medical education that celebrates restraint in ordering health care tests and procedures.
  • An Annals of Internal Medicine piece discussed the potential impact of Choosing Wisely recommendations for radiology and argues, “Current campaigns that draw attention to overuse of imaging studies coupled with greater physician knowledge and use of the criteria for appropriate imaging can help to ensure a further reduction in unnecessary testing—a result that would benefit both patients and our health care system.”
  • In Choosing Wisely: Low-Value Services, Utilization, and Patient Cost Sharing, researchers from the University of Pennsylvania reflected on the Choosing Wisely campaign and asked, “But if it is difficult in many situations for patients to choose wisely, and if there are significant challenges in getting physicians to choose wisely, then who should be doing the choosing?”

We look forward to continuing the conversations on professionalism and Choosing Wisely in 2013, and wish our readers a happy and healthy new year.

Continuity of care. Needed now more than ever. @Medici_Manager @nedwards_1

Abetternhs’s Blog

The political restructuring of the NHS is increasing the range of hospital and community health care providers[1]. This fragmentation of care risks what Michael Balint referred to as the “collusion of anonymity” in which different parts of the patient’s health are cared for by different specialists and consequently important aspects are neglected because they fall outside the specialist’s remit. [2] Consequently, now more than ever, a comprehensive, generalist primary care physician providing continuity of care, is essential.

Continuity of care is the care of an individual patient over time. Various attempts have been made to define continuity, many of which try break down comprehensive continuity of care into subsets of continuity, for example,informational, management and relational continuity.[3]

All subsets are essential components of patient care. Continuity of information on the electronic record and continuity of management through the use of shared guidelines and protocols get more attention because they are more easily assessed than relational continuity which is complex and difficult to measure. Relational continuity is the basis of the doctor-patient relationship and requires doctors and patients to understand each other’s personalities and remember past experiences and not simply recognise professional roles and clinical features. [4]

I  would define relational continuity as the therapeutic relationship between a doctor and a patient, developed over time in which the doctor takes responsibility for coordinating the patient’s care.

In measuring the effects of continuity of care, the question might not be, “Does continuity of care makea difference at a population level?” but rather, “Are there specific subpopulations for which continuity of care is especially valuable?”For most healthy, wealthy, young individuals, contact with aphysician is unlikely to have a measurable impact on their alreadygood health.[5]

Approximately 75% of all GP consultations are with people over the age of 70 and 75% of these people have multiple chronic conditions. In a deprived inner city environment where we work, the incidence of serious mental illnesses, drug and alcohol addiction and chronic stress due to social determinants such as unemployment, poor housing, crime and violence results in high re-attendance rates from a significant proportion of our practice population. For these people relational continuity is particularly important. [6]

Multiple conditions interact in ways that fall outside the remit of clinical guidelines.  For example deterioration in mental health or social stress may result in a patient with diabetes neglecting their diet and medication with a subsequent loss of diabetic and hypertensive control.  Regaining control of one disease is inextricably bound up with recognising and supporting them as they deal with the others. A frail patient with multiple problems may appear to a clinician with whom they have a relationship to look seriously unwell or their usual frail self the moment they walk through the consulting room door depending on their usual appearance and levels of stoicism or distress.

“The implicit choice between personal continuity and modern care is false; what evidence there is suggests that patients prefer services providing personal continuity, and this may also reduce the use of investigations and admissions to hospital”  [7] There is also evidence that improved continuity of care results in better preventative care and lower costs. [8] Other benefits include:

  1. Greater efficiency due to better communication and trust, facilitating information gathering.
  2. Increased safety because communication and awareness of subtle changes not included in the electronic record or clinical guidelines. Many critical incidents we have investigated involve lack of continuity and have resulted in changes to improve relational continuity.
  3. Higher patient satisfaction because of better reassurance and confidence in care. In patients with serious mental illness this is particularly important because the individual nature of the illness.

I believe that continuity of relationship is essential to organise and coordinate the increasingly fragmented care that patients receive. Continuity of relationship is most important in the care of patients with multiple chronic diseases, mental illnesses and social distress. These are the greatest users of the NHS. Prioritising speed of access and choice of provider risks damaging continuity of care for those who most need it.

Jonathon Tomlinson  October 7th 2009

See also: Boosting continuity of care could save millions Pulse 10.04.2012 (source link £)

[1] Our Health, Our Choice, Our Say. Department of Health White Paper 2006

[2] Balint, Michael. The Doctor, His Patient and The Illness. 1954

[3] Haggerty JL, Reid RJ, Freeman GK, Starfield B, Adair CE, McKendry R. Continuity of care: a multidisciplinary review. BMJ 2003;327:1219-21.

[4] Greenhalgh, Trisha. Narrative based medicine in an evidence based world.BMJ 1999;318:323-325 ( 30 January )

[5] Christakis, Dimitri A. Continuity of Care: Process or outcome? Annals of Family Medicine 1:131-133 (2003)

[6] Guthrie Continuity matters. BMJ 2008; 377: a867

[7] Guthrie B, Wyke S. Does continuity in general practice really matter? BMJ.2000;321:734–736.

[8] Saultz, J. W., Lochner, J. (2005). Interpersonal Continuity of Care and Care Outcomes: A Critical Review. Ann Fam Med 3: 159-166

Defining and measuring interpersonal continuity of care.

La Sanità di Iniziativa attraverso gli occhi dei pazienti @Medici_Manager

Anna Maria Murante, Laboratorio Management e Sanità della Scuola Superiore Sant’Anna di Pisa.

I risultati dell’applicazione del Chronic Care Model in Toscana.  Il 73 % dei pazienti dichiara che l’assistenza complessiva è migliorata e ora è in grado di gestire meglio la propria malattia. Il 67% dei pazienti dichiara che il suo stato di salute è migliorato.

Era il 1997 quando Edward Wagner portava la comunità scientifica a riflettere sui principali ostacoli che i sistemi sanitari incontrano nel dare risposta ai bisogni dei pazienti cronici, sui punti di forza e debolezza dei numerosi approcci assistenziali in uso in quegli anni e sugli effetti che le strategie adottate hanno sui pazienti cronici[1]. Dal dibattito che ne scaturì prese a delinearsi negli USA una nuova idea di assistenza per i pazienti cronici, poi tradotta nel modello organizzativo-assistenziale oggi noto a tutti come il Chronic Care Model. Un modello che ha nel self-managementdecision supportdelivery system design e clinical information system le sue principali componenti (Figura 1), e la cui implementazione dimostra sin da subito di poter assicurare migliori risultati in termini di processo e di outcome, oltreché una riduzione dei costi e degli accessi inappropriati ai servizi[2,3]. Questo modello viene presto esportato oltre oceano, arrivando ad essere applicato anche in alcune regioni italiane come la Toscana.

Figura 1. Il Chronic Care Model

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Con il Piano Sanitario Regionale 2008-2010 la Regione Toscana pone infatti le basi per un rinnovamento organizzativo e culturale che segna un cambio di rotta nell’assistenza dei pazienti cronici, definendo la strategia per il prossimo futuro: passare da una medicina d’attesa, re-attiva e pensata per i pazienti in fase acuta, ad una sanità che – basandosi sul modello del Chronic Care Model (vedi Assistere le persone con condizioni croniche) – va incontro al paziente, in maniera pro-attiva e programmata per «[…] assumere il bisogno di salute prima che la malattia cronica insorga, si manifesti o si aggravi […]». Nasce così la Sanità di Iniziativa, che muove i suoi primi passi nel 2010, quando 627 medici di famiglia, organizzati in 56 moduli multiprofessionali (composti oltre che dai medici di famiglia, anche da infermieri e operatori socio sanitari), aderiscono alla fase pilota del progetto (attualmente i medici che aderiscono al progetto sono oltre mille, circa il 38 % del totale dei mmg toscani). A livello regionale vengono definiti obiettivi chiari tanto per i moduli, il cui raggiungimento è monitorato con un set di indicatori (DGR 355 del 22/03/2010), che per i direttori generali delle aziende sanitarie, che a questi vedono legati una quota percentuale degli incentivi annuali.

I risultati che si ottengono dall’attività di monitoraggio sul processo e sugli outcome sulla base dei dati forniti direttamente dai moduli (che alimentano gli indicatori sopra citati) e sulla base della banca dati MaCro dell’Agenzia sanitaria regionale (ARS Toscana), da quest’anno sono completati dai risultati sull’esperienza dei pazienti presi in carico.

Tra febbraio e luglio 2012 è stata infatti condotta un’indagine telefonica (secondo la metodologiaComputer Assisted Telephone Interviewing) tra i pazienti presi in carico dai moduli della fase pilota della Sanità di Iniziativa. Un campione di circa 6500 pazienti, diabetici e scompensati, ha risposto al questionario costruito dai ricercatori del Laboratorio Management e Sanità della Scuola Superiore Sant’Anna di Pisa con il supporto di un panel di esperti a livello nazionale ed internazionale e approvato dalla Commissione Regionale CORMAS. Il questionario è strutturato in 7 sezioni: la fase di reclutamento, le visite di controllo, gli incontri di counselling, gli aspetti logistici, le visite specialistiche, il coordinamento tra le figure professionali e una valutazione complessiva in termini di informazione, empowerment, assistenza e benefici per lo stato di salute.

Il 72% dei pazienti intervistati ha più di 65 anni, soffre di diabete o di scompenso cardiaco in media da circa 11 anni.

I pazienti hanno accettato di essere assistiti secondo il nuovo paradigma assistenziale soprattutto perché hanno fiducia nel medico di famiglia che glielo ha proposto e perché desiderano avere un punto di riferimento nella gestione della malattia cronica. Hanno un minor peso in questa decisione l’auspicio di ottenere dei benefici in termini di salute o di migliorare la gestione della malattia. La presa in carico ha quindi un peso importante nelle scelte assistenziali dei pazienti cronici.

La pro-attività dei moduli nell’attività di follow up è buona, confermando che la sanità d’iniziativa «non aspetta sulla soglia dei servizi il cittadino» (PSR 2008-2010), ma va loro incontro,  ad esempio contattando i pazienti prima della visita di controllo per ricordare o fissare la data dell’appuntamento (è quello che accade al 73% dei pazienti intervistati).

Durante le visite di controllo l’infermiere del modulo lavora per aumentare l’empowerment del paziente, in primis attraverso un’educazione volta ad intervenire sugli stili di vita, e il paziente sembra apprezzare. Le informazioni fornite su una sana alimentazione,sull’attività fisica, sul consumo di alcolici e sul fumo (Figura 2) soddisfa infatti la quasi totalità dei pazienti (97%), e porta il 67% dei pazienti a dichiarare di sentirsi più informato sulla propria malattia cronica.

Figura 2. Le informazioni che il paziente riceve durante le visite di controllo

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Rispetto al monitoraggio dello stato di salute dei pazienti, emerge che la misurazione della pressione e della glicemia (o la verifica dei valori registrati a casa), e della circonferenza della vita (o del peso corporeo) avvengono regolarmente, mentre non è ancora una prassi il controllo del piede (Figura 3).

Figura 3. Le attività di follow up svolte durante le visite di controllo.

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Sono davvero pochi (9%) i pazienti che dopo aver incontrato l’infermiere si rivolgono al medico di famiglia per chiedere conferma o spiegazioni. Alla base di quest’ultimo risultato c’è sicuramente la completa fiducia che l’88% dei pazienti nutre nell’infermiere. Inoltre, il team composto dal medico di famiglia e dall’infermiere riceve valutazioni molto positive, soprattutto quando si parla di lavoro di squadra ( 91 volte su 100 è ottimo o buono). Il paziente dunque non ha alcun pregiudizio rispetto al ruolo assegnato all’infermiere nella gestione del proprio percorso assistenziale e risponde positivamente al cambiamento organizzativo, e al tempo stesso culturale, posto in atto dalla Regione Toscana con la Sanità di Iniziativa.

La pro-attività del sistema è invece ancora poco strutturata quando il paziente ha bisogno di una visita specialistica. La prenotazione della visita il più delle volte viene fatta dal paziente o da un suo parente/amico attraverso il CUP, e solo poche volte è realizzata dal personale del modulo (15%). La figura dello specialista è ancora collocata fisicamente fuori dall’ambulatorio della sanità di iniziativa, se non in rari casi. Questi elementi identificano certamente degli ampi spazi di miglioramento su cui intervenire nella costruzione di un solida ed efficace continuità assistenziale.

Per finire, la rilevazione condotta tra i pazienti ha permesso di ottenere le prime valutazioni sull’efficacia della Sanità di Iniziativa in Toscana, direttamente dai pazienti. Il 73 % dei pazienti dichiara che l’assistenza complessiva è migliorata e ora è in grado di gestire meglio la propria malattia. Un altro risultato importantissimo in termini di outcome segnala che questa nuova modalità di presa in carico produce dei benefici sullo stato di salute dei pazienti nel 67% degli intervistati, vedi Figure 4 e 5.

Figura 4. Le valutazioni dei pazienti sul miglioramento dell’assistenza

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Figura 5. Un risultato di outcome: l’impatto della Sanità di iniziativa sulla salute dei pazienti.

Cliccare sull’immagine per ingrandirla

La rilevazione condotta in Regione Toscana conferma dunque i risultati presenti in letteratura sull’efficacia del Chronic Care Model, e fornisce alla governance regionale e agli operatori impegnati sul campo informazioni utili sugli ambiti in cui la presa in carico può essere ancora migliorata.


  1. Wagner, Managed Care and Chronic Illness: Health Services Research Needs, Health Services Research, 1997; 32(5): 702-714.
  2. Bodenheimer et al, Improving Primary care for Patients with Chronic illness: the chronic care model, Part 2, JAMA, 2002; 208: 1909-1914.
  3. Coleman et al, Evidence On The Chronic Care Model In The New Millennium, Health Affairs, 2009; 28(1):75-85.

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It is both a privilege and an honor to be a primary care physician @Medici_Manager @kevinmd

by  on October 21st, 2012 in PHYSICIAN

With all of its frustrations and challenges, I love my job.  In fact, the very things that make primary care so difficult and often times exhausting are also what make it in my opinion the most awesome field in medicine.

When I was in grade school, I wanted to be a physician.  My parents would take me to the pediatrician for routine check-ups or when I wasn’t feeling so great and I remember admiring my pediatrician like no other.  To me, he was amazing.  I was of course always pretty nervous going to see him, like that time my legs and face were covered in the itchiest rash I had ever experienced with overlying fluid-filled blisters.  I was a mess.  My cheeks and forehead were swollen so badly I couldn’t even open my eyes so I wore sunglasses so no one would hopefully notice.  I was scared and miserable and even more so because I was going to see my doctor.

He calmly sat there and listened to me explain my story to him which consisted of a weekend shooting hoops in the backyard—I kept having to go retrieve the ball from the bushes which were situated behind the basketball net.  He then asked me to pop up on the exam room table.  After he had thoroughly examined me, he calmly diagnosed me with poison ivy and gave me a prescription for prednisone.  I left and within one week, all of my symptoms had resolved.  Gone were my excoriations as well as my sunglasses and life was back to normal.  Looking back, he represented all that a real doctor truly was.  He listened, empathized and healed.

When I was in medical school, although I entered certain that I would pursue a field in primary care, I found myself gravitating towards the ROAD (radiology, ophthalmology, anesthesiology, dermatology).  For everyone who is not familiar, these are considered to be the “sexy” fields of medicine with lucrative pay … the so-called “lifestyle” fields.  I don’t know exactly how it happened– perhaps it was the confused look on the faces of my attendings as I rotated through the ROAD fields when they asked me what field I planned to pursue and I proudly stated internal medicine.

Or maybe it was the flat-out “WHY would you do that when you could be a radiologist?!” that had an effect on me.  Whatever it was, come match time, I found myself swayed down the most sought-after ROAD.  I had applied and matched in radiology.  Me, of all people!  Someone who loves patient contact and dreads vitamin D deficiency!  I had ended up from the furthest place I could have ever imagined myself happy.  But I was in a hot field and everyone told me radiology would eventually make me happy—that I would be able to get home on time and patient contact was overrated anyway.  Right?  Well, I did get home on time.  While I was at the gym and planning the menu for dinner that night, my internal medicine counterparts were moaning and groaning about call schedules and wanting to gouge their eyeballs out because they were getting out around 10 pm on non-call days.  This of course led to not having time for the gym and scarfing unhealthy food down their throats for most days of the week and needless to say lots of undesired weight gain and baseline agitation.  I figured I had clearly chosen the right field for myself.

I should have noticed that this was not the case early on because it was pretty obvious, at least to an onlooker.  When many of my colleagues needed to actually interact with a human — like place a phone call to clarify what study they had actually ordered or locate a physician with the results of an abnormal finding — they were visibly irritated.  It was as though this was the most painful part of the day.

Whereas, this was the highlight of mine.  Abnormal appendix?  I would call the surgeon and ask him/her to bring the entire team down to the dark reading ream to go over findings.  I yearned for human contact. I secretly wished every medicine team would conduct “radiology rounds” and come visit me in the dark room so we could discuss cases together.  And I looked forward to rotations like breast diagnostic imaging and interventional radiology where I would have the opportunity to actually speak with a patient and find out how they were doing.  I always knew something was missing but I couldn’t quite put my finger on it.  And years later, it dawned on me.  That something was … people!

I ended up switching fields finally to internal medicine where I was able to develop and nurture long lasting relationships with my patients.  To me, internal medicine is both the most challenging and the most rewarding of fields.  We have the privilege to become involved members of our patient’s lives and to advocate for our patients so that they receive the best care possible.  As internists, our ultimate goal and desire is that each and every one of our patients is happy and lives well.  By dedicating ourselves fully to overall patient wellness, in return our patients reward us by sharing their life experiences with us.  This in turn makes us better humans.

Solmaz Amirnazmi is an internal medicine physician who blogs at All is Well That Eats Well and can be found on Twitter @DrSolmazA and Facebook.

Real health reform cannot happen without a primary care foundation @kevinmd @drsilenzi

by  on August 16th, 2012in POLICY

Annie Lowrey’s July 28 article “Doctor shortage likely to worsen with health law” in the New York Timesnoted the growing shortage of primary care doctors particularly in economically disadvantaged communities, both in rural and inner-city America. This problem will likely  get worse before it gets better as more Americans gain coverage and seek a regular source of care. As the article suggests, training more doctors and incentivizing them to pursue careers in primary care will be a key part of the solution. And it will require a multipronged campaign, using both some of the traditional strategies for workforce renewal and a few unique tactics not typically deployed in efforts to fix health care.

The primary care workforce pipeline had dried up before the Affordable Care Act was passed. Currently, one out of every five Americans lacks access to primary care. As a result, up to 75% of the care delivered in emergency departments these days is primary care. This overcrowds and overburdens EDs, raises costs, and limits EDs’ ability to do what they were designed to do: provide acute, emergency care that makes the difference between life and death. So the primary care shortage threatens our access not only to primary care but also to emergency care.

How did we get here? Many are quick to point to primary care doctors’ low salaries compared to those of their sub-specialist colleagues. Indeed, choosing a career in primary care rather than a sub-specialty means walking away from 3.5 million dollars of additional lifetime earnings. That’s tough to do when you’re looking at $150-200,000 of debt, which is the average debt of an American medical student at graduation. But the crisis in our primary care pipeline goes far beyond the money.

Medical schools aren’t recruiting enough of the right people in the first place. Numerous studies showthat people from rural and lower SES communities are more likely not only to pursue primary care careers but also to return to those disadvantaged communities to practice. Unfortunately, medical schools’ acceptance of applicants from these communities has declined substantially in recent years. Instead, medical school admissions criteria favor more affluent applicants who are ultimately more likely to pursue sub-specialty careers.

Further, these same medical schools have been actively discouraging primary care careers for decades. This is due partly to cultural biases that place super-specialized medicine on a pedestal over generalism, which is due in part to how NIH research dollars flow, predominantly supporting cutting edge biomedical/technological research usually advanced by sub-specialists. The result is that primary-care-oriented trainees face four long years of admonishments against primary care careers – a hidden curriculum in which generalists are portrayed as nothing more than referral centers and lectures from so-called primary care mentors warn trainees against primary care careers at all costs. It’s no wonder fewer than 20% of American medical school graduates are choosing to go into primary care today. We’ve all but legally barred them from doing so.

If that weren’t enough, in their rotations, trainees see the most dysfunctional, antiquated and frustrating approaches to primary care delivery that exist in our health care system. The combination of a sicker, more-complex-than-average patient population, inadequate funding and support for improvement efforts, and predominantly part-time faculty who are frequently not available for teaching or improvement activities has created a toxic milieu. I can’t tell you how many primary care students and residents have noted that it feels like their clinics were specifically designed to destroy their interest in primary care.

Trainees need exposure to the existing models of care delivery that are transforming primary care to work better for patients, providers and payers. Patient-centered medical home (PCMH) practices, which use highly-coordinated, enhanced access, team-based care, are showing exciting results: higher quality of care, decreased ED visits and hospitalizations, happier patients, and lower overall spending. And it seems that exposure to this new model of care is one of the best ways to help trainees see a future for themselves in primary care. The problem is, only a tiny group of trainees are exposed to these types of clinics due to poor penetration of this model in the academic environment. This is something that needs to be remedied.

Revitalizing the primary care pipeline is going to require a multipronged campaign, with the greatest thrust being a change in the way we pay physicians in order to create greater equity between sub-specialist and generalist salaries. If we really value primary care as the foundation of our health care system, purchasers must invest in it and give clinicians the financial support they need to do their job well. We must also expand the definition of a ‘primary care provider’ to include Nurse Practitioners and Physician Assistants, two critical members of the primary care team who can immediately expand access to high value primary care services in communities across America.

As the patient-centered medical home model spreads across the country, academic leaders must ensure it also takes root in our medical school practices, where trainees are both learning what it means to deliver high-value care and making career decisions. We’re increasingly realizing that trainees not only have much to gain from these experiences, but they have much to give. And the sooner we get medical students involved in inter-professional training opportunities with nursing students, social work students, etc, the better. ‘Learners learning together’ is a critical first step to get trainees used to practicing as a team – which is one of the key ingredients of high value primary care delivery.

American medical schools must be held accountable for producing the primary care providers this country needs. This means not only reinvigorating primary care programming and developing new approaches to recruitment and retention of those individuals most predisposed to primary care careers, but also teaching the actual patient-centered, team-based skills that providers need in order to deliver high-value care today. The public cannot afford to wait for medical schools to do the right thing. We must leverage our collective power as purchasers and consumers to demand that these institutions break from their “business as usual,” specialty-focused approach to training. Maybe it’s time for a national campaign to publicly call on all American medical schools to step up to the plate and start revitalizing the primary care pipeline.

Finally, we – from academic faculty to laypeople – must all recognize the role we play in perpetuating the bias in America that being a primary care provider just isn’t good enough. Whether it’s through our questions to family members in medical school about what “specialty” they’re going to pursue, or our negative responses to their explicit intentions to practice primary care, we make clear that we wish they’d do anything but go into primary care. I implore all of us to face up to our responsibility to remedy and reverse these biases. So, next time a student tells you he or she is planning to pursue a primary care career, do yourself, your country and the future generations of Americans – who are currently on target to not have access to their own primary care provider – a favor and thank that student for doing the right thing.

We’ll never achieve real health care reform without a foundation of robust primary care in this country. However, fixing the pipeline is no small undertaking. It will require a multifaceted approach to remedy the financial, academic, cultural and political challenges that have plagued the primary care pipeline for years. It will also require us thinking more expansively and inclusively about the definition of a primary care provider. But to increase the primary care physician supply, our course is clear: we must come together now, as a nation, and both collectively demand more from our medical schools while also providing that system with the support it needs to change. Without that, it will be next to impossible to help our academic medical machine break free from it’s specialty-centric approach to workforce creation.

Andrew Morris-Singer is an internal medicine physician and President and Co-Founder of Primary Care Progress.

Rebecca Onie: E se l’assistenza sanitaria ci mantenesse in salute? @drsilenzi

Rebecca Onie si pone domande coraggiose: E se le sale d’aspetto fossero luoghi fatti per migliorare le cure sanitarie quotidiane? E se i medici potessero prescrivere cibo, casa, e riscaldamento in inverno? A TEDMED Rebecca Onie parla di Health Leads, un’organizzazione che fa proprio questo — e lo fa attraverso una base volontaria dedicata quanto una squadra sportiva universitaria.

Una conversazione TED di Rebecca Onie: In 1996, as a sophomore in college, Rebecca Onie had a realization: The health care system in the United States was not set up to diagnose nor treat the socioeconomic issues that lead to poor health, and that health care providers are not given tools to address basic problems like nutrition and housing. So, while still a sophomore, she co-founded Health Leads, a program that assists low-income patients and their families to access food, heat, and other basic resources they need to be healthy. With the additional insight that college volunteers could be recruited and trained into an elite group just like a college sport team, she found the people and skills needed to produce such an audacious idea. Since then it has grown tremendously, and now operates in Baltimore, Boston, Chicago, New York, Providence, and Washington, DC, and in the last year assisted over 8,800 patients. In 2009, Rebecca was awarded a MacArthur “Genius” Fellowship.

Atul Gawande: Come si fa a guarire la medicina? @Atul_Gawande @drsilenzi @muirgray

I nostri sistemi sanitari non funzionano. I medici sono in grado di somministrare cure straordinarie (e costose), ma stanno perdendo di vista l’obiettivo principale: curare la gente. Il medico e scrittore Atul Gawande suggerisce di fare un passo indietro e guardare a nuovi modi di fare medicina, con meno “cowboy” solitari che fanno tutto da sé e più squadre coordinate.

Una conversazione TED di Atul Gawande, autore di “Checklist”: una lettura obbligatoria!

Atul Gawande: A general and endocrine surgeon at Brigham and Women’s Hospital in Boston, Atul Gawande is also a staff writer at The New Yorker who’s changing the way we think about best practices in medicine (and, necessarily, about the state of the US healthcare system). In 1996 Gawande wrote his first piece for Slate, an analysis of the then-controversial illness known as Gulf War Syndrome. At The New Yorker, he turned in a shocking June 2009 piece, “The Cost Conundrum,” about McAllen, Texas, the town with the second most expensive health-care market in the U.S., taking on America’s high-cost low-quality healthcare system. (The piece was cited by President Obama during his campaign for healthcare reform.)

Gawande approaches medicine with a personal outlook, emphasizing the importance of a doctor’s intention and reliability, and urging doctors to make small changes to improve performance. In his most recent book, The Checklist Manifesto, Gawande shows how even a simple five-point checklist can decrease up to two-thirds of ICU infections. He suggests that as modern medicine — and indeed, the modern world — becomes increasingly complex, we should respond with ever-simpler measures.

5 TED Talks That Will Change Your Life @drsilenzi

Written by

A great, free Internet resource for anyone who loves to learn online is the (Technology, Entertainment, Design). TED  provides fascinating discussions and lectures about important and interesting topics – for free. TED offers us many wonderful opportunities to expand our knowledge base and change our lives. Below are five TED talks in a broad range of topics that we think are truly life changing, and are, in the words of TED, ideas worth spreading.

  1. SteveJobsHowtoLiveBeforeYouDie: At a commencement address he gave at Stanford University in 2005, Steve Jobs urged graduates to pursue their dreams, and to view the setbacks that we have in life as new opportunities for advancement. This even includes death itself. This brilliant talk by Jobs will change your life because you learn a bit of how Jobs took some serious challenges thrown at him by life, and still become one of the most influential businessmen and innovators of the last 50 years.
  2. DaphneKollerWhatWereLearningFromOnlineEducation: Daphne Koller gives a fascinating talk about the future of online education. She believes that in the near future, many universities will begin to place much of their best courses online at no cost. This will serve not only as a service to millions of people who could not otherwise access such education. It also will serve as a great tool to learn how people learn. Every keystroke, quiz and discussion conducted online can be mined to discover how people process knowledge and learn.
  3. JillBolteTaylorsStrokeofInsight: Brain researcher Jill Bolte Taylor had a highly unusual and amazing opportunity in the world of science: She got to study her own stroke as it occurred in her own body. As the aftermath of the stroke progressed, she had a ringside seat as her brain functions ceased one by one: speech, motion, memory and self-awareness. Taylor spent eight long years learning how to think, walk and talk again.
  4. NeilPasrichaThe 3 AsofAwesome: Neil Pasricha’s has a blog called 1000 Awesome Things, which encourages us to enjoy some of the most simple pleasures of life. These can include clean sheets, free refills, and much much more. In this talk, Pasricha talks about the three secrets of life that lead to an awesome life. He began his blog about five years ago to just provide small reminders to people of the many free, simple joys of life that make it worth living. Today his blog has millions of readers from all over the globe.
  5. RandyPauschReallyAchievingYourChildhoodDreams: Carnegie Mellon professor Randy Pausch was dying of pancreatic cancer in 2007 when he delivered this legendary lecture about how you can truly achieve your dreams from your childhood. This is one talk that you really should not miss. Millions of people around the planet have been inspired by The Last Lecture.

Hopefully these five jaw-dropping TED talks left you feeling inspired and a bit more knowledgeable about our world.

Joseph Pickett is a freelance writer for, where he enjoys writing about science and the art of protecting and improving the health of communities through education and smart healthy lifestyles. More recently he highlighted 10 Public Health Careers sure to address upcoming shortage of public health workers. He invites feedback on this and his other articles.

Siamo dei bravi ascoltatori? @MicheleMaritato @drsilenzi

Michele Maritato, Project Management e Business Analysis al servizio delle imprese. Ing. Michele Maritato, MBA, PMP, CBAP

“Mi piace ascoltare. Ho imparato molto ascoltando attentamente. La maggior parte delle persone non ascolta mai.” – Ernest Hemingway

Siamo tutti d’accordo che ascoltare sia una “soft-skill” di comunicazione indispensabile per un Business Analyst. E’ indispensabile principalmente per eseguire i task di Elicitation (è impossibile comprendere i bisogni degli stakeholder senza un ascolto attivo), ma gli effetti si ripercuotono su molti altri task. Pensiamo ad esempio all’analisi dei requisiti, dove il BA è chiamato a svolgere un ruolo di “catalizzatore” iniettando novità nel lavoro degli stakeholders al fine di creare valore.

Molte volte sento parlare di “Active-listening”, ma cosa significa ciò realmente? Questa l’interpretazione di Atwater, Eastwood (1981). I Hear You. Prentice-Hall. p. 83: <<L’ascolto attivo coinvolge l’ascoltatore nell’osservare il comportamento di chi parla e comprendere il linguaggio del corpo. Avere la capacità di interpretare il linguaggio del corpo di una persona permette all’ascoltatore di comprendere il messaggio di chi parla.>>.
Sulla comprensione del linguaggio del corpo è stato scritto tanto, se volete qualcosa di pratico vi posso suggerire questo link: .
Alcuni suggerimenti pratici sull’ascolto attivo arrivano dall’IIBA®:
• Prestare attenzione a ciò che ci viene detto, guardando negli occhi la persona e studiando il linguaggio del corpo. Se l’interlocutore è al telefono, prestare attenzione al tono della voce;
• Dopo aver ascoltato, proviamo a parafrasare ciò che l’altra persona ha detto. Questo sforzo dimostra il desiderio del BA di comprendere ciò che è stato detto;
• Il BA deve essere consapevole dei propri limiti e pregiudizi, e deve essere in grado di limitare l’impatto sulla comprensione dei bisogni;
• Non interrompere mai chi sta parlando;
• Pensare al messaggio che l’interlocutore sta trasmettendo, non a quello che si vuole dire in risposta.

Siete dei bravi ascoltatori? Per scoprirlo vi suggerisco di fare questo test: . Fate attenzione alle ultime domande del test.

You deserve superb integrative health care @kevinmd

by  | in POLICY

Is it possible that health care can become more effective, more personalized, more attuned to real health and wellness in a manner that truly benefits the patient as a customer/client?

The answer is “yes” but it will require understanding the dysfunction in the delivery system today, dealing with the growing shortage of primary care physicians and their non-sustainable business model, changing the insurance paradigm from prepaid medical care to (high deductible) true insurance for the catastrophic, and patients taking on greater responsibility for personal health and wellness.

There is excellent research and innovation along with superb providers is in this country. But the delivery system is dysfunctional and to date America has tolerated this dysfunction. It’s a medical care not a health care system. The emphasis is strongly on disease management and not disease prevention or health promotion. American medical care is very expensive, about $8,000 per capita, and yet outcomes are not what they could or should be. For example, America does not have the lowest infant mortality rate nor the longest life span. Other developed countries beat us on both counts. Medical care of acute illness is generally quite good in the United States but chronic diseases like diabetes, heart failure, chronic lung disease, etc. – of which there are more and more occurring – are not adequately cared for. The system is provider oriented rather than patient oriented and the patient is not the real customer of the physician or the insurer.

There is a shortage of primary care physicians and this is getting worse every year. Only 30% of American physicians are primary care physicians compared to about 70% in most other developed countries. Medical school graduates prefer to enter specialty practices. Those still in primary care practice often take less than adequate time for the prevention of chronic diseases. And too few appreciate or at least offer the time needed for chronic illness care coordination nor do they regularly integrate other options for care such as acupuncture, mind-body medicine, massage, etc.

Since today the patient is largely not the customer of the doctor, a good place to start is to change that paradigm. A high deductible health policy means that the patient will now be paying the primary care physician directly for care and thus this changes the professional-client relationship to a more normal occurrence. The physician will now become more attentive, allocate more time, offer more preventive care and will coordinate the care of chronic illnesses. True, the charge will be the same (unless the physician drops insurance entirely) which may not be any more adequate than before although the PCP should be able to save on the costs of billing and coding. When the PCP no longer accepts insurance and either charges fee for service or establishes a retainer based practice, the contractual relationship between doctor and patient is heightened.

Individuals also need to take more responsibility for their health and wellness directly. Attention to nutrition, exercise, stress and tobacco are key first steps. Work place wellness programs can materially assist. They can offer a health care premium reduction in return for engaging in added educational and action programs such as nutrition, fitness, smoking cessation and stress management to improve lifestyles.

Social networking can have an increasingly beneficial effect. Lifestyle changes are easier to accomplish in a peer group setting. Usually we think of this as a physical group setting but it can also be done through the use of social media. Groups help give a positive reinforcement for behavior change. Social networking through sites such as Facebook, Twitter or YouTube or others can be used to leverage the medical care delivery system to become more patient centered, more effective at the coordination of chronic illness, more attuned to prevention and responsive to true integrated medicine.

Everyone should have a primary care physician, one well schooled in the most current evidence-based care approaches yet who is attuned to the full gamut of integrative medical approaches such as chiropractic, nutrition, personal training, massage therapy, and acupuncture. You need to be sure that your primary care physician will spend the time needed to deal with health and wellness and not just disease. You may well need to pay your primary care physician directly rather than via insurance but the primary care physician will then be financially able to offer you the time you really need and deserve.

You deserve superb integrative health care but to get it you will need to take some action to obtain it. Call it a balancing of rights with responsibilities. It may cost you directly rather than via insurance but you may well find that the return on investment is well worth it.

You deserve superb integrative health care

Stephen C. Schimpff is an internist, professor of medicine and public policy, former CEO of the University of Maryland Medical Center and is chair of the advisory committee for Sanovas, Inc. and the author of The Future of Medicine – Megatrends in Healthcare and The Future of Health Care Delivery- Why It Must Change and How It Will Affect You from which this post is partially adapted.