Case Presentation

http://www.medscape.com/viewarticle/720219?src=mp&spon=25&uac=147602PZ

Case Presentation

A 61-Year-Old Woman With Intermittent Worsening Abdominal Pain:

http://www.medscape.com/viewarticle/720150

Which Drugs Pose Greatest Risk of Birth Defects?

http://www.medscape.com/viewarticle/719966?src=mp&spon=25&uac=147602PZ

Restrictions on Residents' Work Hours Not Helping, Study Suggests

Allison Gandey

April 14, 2010 (Toronto, Ontario) — New Institute of Medicine recommendations designed to reduce work hours and encourage sufficient sleep are failing to protect residents, a new study shows.

Reporting here at the American Academy of Neurology 62nd Annual Meeting, investigators suggest residents are no more well rested or prepared now that restrictions are in place compared with before. And many residents are complaining their work is less satisfying now.

Why would fewer working hours and more time to sleep leave residents feeling unfulfilled in their job? Study author Andrew Southerland, MD, from the University of Virginia in Charlottesville, told Medscape Neurology that his team found residents are now at higher risk of burnout.

"Residents are checking in and out on patients like shift workers and are feeling less connected," Dr. Southerland said. "There is less continuity of care, and our program is not running as smoothly."

To assess the situation, investigators led by Lori Schuh, MD, from the Henry Ford Hospital in Detroit, Michigan, questioned 30 neurology residents.

They found that contrary to the intentions of the new recommendations, they do not appear to be improving learning or patient safety.

Surprisingly, the mean weekly time spent at work and in lecture, studying, and sleeping did not differ before the restrictions and after. However, quality-of-life measures suggesting an increased risk of burnout significantly increased after the new rules went into effect (P = .03).

Table 1. Mean Difference Before and After Institute of Medicine Recommendation

Residents	Baseline Month	After Recommendation	P Value
Sleepiness after work shift	3.56	3.55	.99
Sleepiness after on call	5.88	5.62	.69
Weekly hours slept	51.1	53.7	.16
Weekly hours at hospital	56.6	58.3	.56
Weekly personal study	7.1	8.0	.28
Weekly hours in lecture	5.0	5.0	.97
Weekly study hours at hospital	1.5	1.5	.93

Table 2. Maslach Burnout Inventory

Variable	Mean Baseline Month	Mean After Recommendation	P Value
Emotional exhaustion	23.3	28.7	.16
Depersonalization	8.7	12.8	.03
Personal accomplishment	35.6	34.8	.87

During an interview, William Hicks, MD, chief resident in neurology at Henry Ford Hospital in Detroit, Michigan, said, "Institute of Medicine panelists have made recommendations and extrapolated them across the board as though neurology would fit in the same model."

Neurology residency programs are usually small, and Dr. Hicks said the institute initiated recommendations based on no evidence. "At the very least, we should have been at the table," he said.

The problems, residents say, are having an impact on everyone. "Nurses are having to brief us as we come and go and this isn't their job," he said.

Coauthor Heather Harle, MD, from the University of Virginia in Charlottesville, said there are no data showing that the recommendations have improved patient safety. "Evidence suggests there are no fewer mistakes now compared to before, and the rate of medical errors has remained static."

Fewer Days in Clinic

Investigators report a 21% reduction in the number of resident clinic days in 1 program as residents were pulled from other rotations to provide additional night time coverage.

Pediatric residents have reported similar concerns (Journal of Graduate Medical Education. 2009;1:181-184).

Asked by Medscape Neurology to comment, Orly Avitzur, MD, a neurologist with offices in New York, said she agrees there are problems with the Institute of Medicine restrictions.

"The new recommendations propose changes for maximum shift length, minimum time off between shifts, and maximum number of in-hospital night shifts. They make the assumption that if residents get a regular opportunity for sleep each day, this will reduce fatigue-related errors. However," she added, "this focuses on only one process and one potential source of error. The unintended consequence is that it creates more transitions of care."

One of the biggest sources of error occurs because of patient sign-outs, Dr. Avitzur emphasized. "The more you change hands in patient care, the more opportunity exists for errors." Dr. Avitzur said this also creates more stress for residents because they have to pick up a whole new service of patients on a regular basis, and stress can, in itself, cause errors and workplace dissatisfaction.

The researchers have disclosed no relevant financial relationships.

American Academy of Neurology (AAN) 62nd Annual Meeting: Poster 1.296. Presented April 13, 2010.

How Should I Balance My Time During Residency?

Residency is demanding not only in terms of time but also in the expenditure of physical and emotional energy. One of the most challenging aspects of the internship year is understanding the expectations of the senior residents and attendings and accepting the sacrifices you will have to make to meet these expectations.

A resident’s day begins very early and ends very late. The scant free time enjoyed by the resident must be squeezed in between academics, family obligations, a social life, and recreational activities. Many residents feel overwhelmed as they attempt to juggle all these aspects of their lives, and as a result, they often pare each element down to its bare minimum. A coworker recently described how these responsibilities can take their toll:

"I came home so exhausted that I collapsed in my bed with a loaf of bread, woke up in a pile of crumbs, and rolled over onto a stack of undictated operative reports."

It is very easy for the intern to fall into a pattern of working, sleeping, and eating and not much else. But residents who find ways to be more efficient and effective in their work are able to achieve balance in their lives.

In an article in the Journal of the National Medical Association titled "Time Management: A Review for Physicians," Brunicardi and Hobson^[1] outline several interesting theories about time management and give practical advice to new physicians. One strategy that I found particularly interesting was Steve Covey's time management matrix technique. This technique sorts all activities into 4 quadrants:

• I -- Important and urgent
• II -- Important and not urgent
• III -- Not important and urgent
• IV -- Not important and not urgent.

The activities in quadrant I are the emergencies, deadlines, and crises that consume vast amounts of energy. Although physicians are trained to deal with emergencies, these activities waste time and tend to spill over into other areas of life. According to Covey, it is better to tackle the activities in quadrant II. "Quadrant II activities focus on planning, prevention, creativity, building relationships, and maintaining increased productivity."^[1]Moreover, Covey maintains that "many competent people spend 90% of their time on tasks they consider important and urgent -- quadrant I -- and 10% is spent recuperating in unimportant and either urgent or nonurgent activities, respectively, quadrants III and IV."^[1]

Perhaps my coworker woke up in a pile of crumbs and operative reports because she was expending too much energy on quadrant I activities, which often leads to stress and burnout. The idea is to spend more energy planning and controlling events to increase your productivity. Instead of bringing all her operative reports home and waiting until the medical records department sends a threatening letter requiring her to complete her dictations in an urgent fashion (quadrant I), she could learn to use her time more efficiently and effectively and dictate the cases promptly upon leaving the operating room (quadrant II). This would leave more time to have dinner with friends or cook a meal and eliminate that pile of crumbs.

Although residency, with its significant time constraints, is especially challenging, it can also be extremely productive and exciting. I truly believe that with good planning and organization, the resident can step up to the challenge and achieve a more balanced life.

For more information, check out the rest of Brunicardi and Hobson's fantastic article.^[1]

Health law may worsen family doctor shortage

ASSOCIATED PRESS • APRIL 19, 2010

As the only family doctor around for almost 35 miles, Dr. George Holmes III did it all.

He was the obstetrician, the emergency room physician, the pediatrician — anything you needed him to be, for as many hours as it took. An office visit cost $5, or maybe Mama's homemade pie.

Fancy medical technologies like CAT scans didn't exist. Doctors had to talk to patients — not test them — to understand the source of their problems.

The year was 1972 in Lafayette, Tenn.

But the role of the primary care doctor changed as medicine became more specialized. New tests and devices arrived. Health insurance complicated costs.

The result: the diminishing of a breed of doctors like Holmes.

Now, with health reform set to bring 32 million people onto the insurance rolls over the next decade, there aren't enough primary care doctors to serve the masses, and fewer medical students are choosing primary care as a career path.

Bogged down with debt, worried about lower pay for longer hours and enticed by the innovations of newer fields, more medical students are opting for lucrative specialties that can earn triple the salary of primary care.

The nation is short 16,663 primary care doctors, and by 2025 that number will reach nearly 140,000, according to the American Academy of Family Physicians.

Resolving the shortage could take at least a decade because of the time required to train aspiring doctors, but experts say a start would be to change the pay structure, open up more residency posts and encourage medical colleges to produce more general practice doctors.

"The number of primary care doctors has stayed flat, but the American population has not," said Holmes, founder of Family Practice Associates at Southern Hills Medical Center in Nashville, Tenn. "The patient suffers if we don't have enough people to give them care."

Doctors Have Duty

Primary care doctors encompass pediatrics, internal medicine, general medicine, obstetrics and gynecology and family medicine.

"They are the first point of contact for a person in the health-care system," said Dr. Wayne Riley, president and CEO of Meharry Medical College. "There is a duty and obligation of the primary care doctor to coordinate all the patient's needs."

Holmes, as he practices medicine now in Nashville, and the six other doctors in his practice see 200 patients a day, sometimes more because patients might not have another place to go.

Holmes averages about 35 patients a day. If he works an eight-hour day, each patient, in theory, would have about 13 minutes.

But he and other primary care doctors increasingly are pressured to fill out paperwork and log patient health information into a computer, instead of a chart. The extra work takes away from patient interactions.

"I tell residents, put down the ink pen or the computer," Holmes said. "We're not looking for pretty papers. We're looking for hearts. Touch a patient. It doesn't even have to be a physical touch."

Family medicine encompasses all fields of primary care medicine, and doctors have to know a little about a lot. Medical students are put off by the breadth of their area of medicine, Holmes said.

"They sense it is too broad, too much," Holmes said. "All you have to know is the patient in front of you."

Getting to know patients doesn't bring money, though.

Under the current Medicare system, doctors who perform specialized procedures and more tests are paid better. Private insurance firms often base their reimbursements on Medicare's rates. So, if a primary care doctor doesn't do a lot of procedures, he isn't as well compensated.

Rewarding Outcome

The primary care field could be more attractive if doctors were paid differently for the care they deliver, said Dr. Robert Dittus, chief of the division of general internal medicine at Vanderbilt University Medical Center.

"We can't have a system that is just reimbursing for units of care provided," Dittus said. "If you do a lot of counseling, the reimbursement is poor and not tied to health outcomes. The specialties have control over policies around which the reimbursement system has been developed."

Health care reform is supposed to reward family doctors starting in 2013, when Medicare would give 10 percent bonuses to those who serve in areas with a doctor shortage. The U.S. Department of Health and Human Services says a shortage means having less than one doctor for a population of 2,000.

But some medical students, right now, decide not to enter primary care because of the current disproportionate pay rates.

"The average medical student's debt is $130,000, and for a young physician who is concerned about debt, there is a tendency to overlook primary care for other specialties," Riley said. "They think other specialties will be a quicker way for them to pay off their loans."

Primary care doctors earn about $150,000, whereas a specialty such as radiology can bring a $500,000 annual salary.

To close the gap in primary care, more than 4,000 medical students would have to choose primary care residencies each year for the next decade. But among this year's medical school graduates, only about 1,200 will go into primary care.

Dorie Saxon, a fourth-year medical student at Meharry Medical College, will graduate in May and enter a three-year residency program at Baylor College of Medicine in Houston to become a pediatrician.

Saxon is a rarity. She has less than $100,000 in medical school debt because of scholarships. Shadowing doctors in different specialties turned her on to pediatrics.

"It fit my personality," said Saxon. "Pediatricians have more of a relationship with the patient, and though they work longer hours, the work, to me, seems more enjoyable."

More Doctors Could Drive Down Costs

About 56 million Americans, often in rural areas, don't have adequate access to primary care because there are too few doctors close to home, according to the National Association of Community Health Centers, a Washington-based health advocacy group.

Getting more medical students into primary care ultimately should make health care less expensive, said Larry Kloess, president of Tri-Star Health System. Patients who don't get consistent preventive care or have to travel to get to a doctor can end up with more severe health problems that land them in the emergency room, where care is more costly.

Long Hours A Factor

The Journal of American Medicine found that medical students were more likely to choose fields where they could control their work hours. Primary care can start early and end later in the day as the doctor tries to fit in all patients. Many also have on-call hours to respond to after-hours concerns or work weekend shifts to see sick patients.

Making a dent in the primary care shortage could take 10 years or more, physicians in the field say.

"The training of a physician is very time-intensive and expensive," said Riley, Meharry's president. "The shortage will be exacerbated by the end of the decade when 32 million people will be added. We have to have the primary care doctors to care for them."

President Nominates Professor to Health Job

By ROBERT PEAR

Published: April 19, 2010

WASHINGTON — President Obama on Monday nominated Dr. Donald M. Berwick, a health policy expert, to be administrator of the Centers for Medicare and Medicaid Services, which runs health programs insuring nearly one-third of all Americans.

Dr. Berwick, a pediatrician, is president of the Institute for Healthcare Improvement in Cambridge, Mass., and a professor at Harvard Medical School and the Harvard School of Public Health. He personifies Mr. Obama’s determination to shake up the health care system. Working with numerous hospitals and clinics around the country, Dr. Berwick has shown that it is possible to reduce medical errors and improve the quality of care while reducing its cost.

Representative Sander M. Levin, Democrat of Michigan and chairman of the House Ways and Means Committee, described Dr. Berwick as “a visionary leader.”

Senator Max Baucus, Democrat of Montana and chairman of the Senate Finance Committee, said he looked forward to “an expeditious review” of the nomination, which is subject to confirmation by the Senate. Senators are likely to use the confirmation hearing to pursue questions about the new health care law.

If confirmed, Dr. Berwick would carry out major provisions of the law expanding Medicaid, for low-income people, and slowing the projected growth of Medicare, for older Americans.

At a recent conference of his institute, Dr. Berwick said health care was just a means to an end.

“Health care has no intrinsic value at all, none,” Dr. Berwick said. “Health does. Joy does. Peace does.”

Accordingly, he said: “The best health care is the very least health care we need to gain the long, full and joyous lives that we really want. The best hospital bed is empty, not full. The best CT scan is the one we don’t need to take. The best doctor visit is the one we don’t need to have.”

The Medicare and Medicaid agency has been without a permanent chief since October 2006.

Doctors Pursue House, Senate Seats

By John Fritze, USA TODAY

WASHINGTON — In an election year dominated by health care, dozens of candidates for Congress have a catchy campaign slogan at their disposal: Send a doctor to the House.

Forty-seven physicians — 41 Republicans and six Democrats— are running for the House or Senate this year, three times the number of doctors serving in Congress today, according to a USA TODAY review.

An influx of doctors to Congress could alter the landscape for future debates over Medicare and rising insurance premiums months after lawmakers approved President Obama's 10-year, $938 billion health care law.

Physician candidates start with at least one political advantage: voter confidence. A Gallup Poll in March found 77% of Americans trust doctors to do "the right thing" on health policy, compared with 32% for Republican leaders and 49% for Obama.

"Physicians just have a different mind-set toward problem solving," said Larry Bucshon, a Republican heart surgeon running for a House seat in Indiana. "It's very good training for being a congressman."

FLA. VOTERS: 'Bad idea' to challenge federal health care law

ELECTION CALENDAR: See primaries in your state

Most of the candidates are touting their profession on the campaign trail. Nan Hayworth, a Republican running for a New York House seat, posts a copy of her medical degree on her website. Ami Bera, a Democratic House candidate from California, told supporters, "My whole adult life has been given to the task of caring for others."

"We're trained as physicians to lead by listening," said Bera, who supports the new health care law but worries it won't do enough to lower costs.

Zach Knowling, a spokesman for state Rep. Trent Van Haaften, a Democrat running against Bucshon, said his opponent "continues to side with big insurance companies," despite his background. Van Haaften is a former prosecutor.

The political arm of the American Medical Association doesn't track how many doctors run in primaries but reports that 30 physicians ran in the 2008 general election compared with 22 in 2006.

Sen. Tom Coburn, R-Okla., a doctor and opponent of the health care law, said more physician input may have led to a better law. "The physician perspective was ignored during the last year and a half," he said.

There are 16 doctors in Congress today, 3% of lawmakers. Doctors made up nearly 5% of Congress during its first century, said Thomas Suarez, a cardiothoracic anesthesiologist in Baltimore who studied the issue.

"There are a lot of physicians who are incredibly frustrated with the way medicine is today," Suarez said. "A very small, though growing number want to make a change."

http://arc-tv.com/the-era-of-obamacare/

http://arc-tv.com/the-era-of-obamacare/

Legislature Adjourns for Governor's Veto Period

The 2010 Kentucky General Assembly adjourned Thursday, April 1, 2010 to allow Governor Beshear to consider bills passed thus far and determine whether any of that legislation warrants his veto. Visit the KMA Action Center to learn about the issues KMA is tracking.

Since legislators left Frankfort without passing the 2010-2012 biennial budget, this "veto period" will also provide an opportunity for informal negotiations on budgetary sticking points. Formal action during the last two days of the session was originally intended to relate to the possible override of gubernatorial vetoes, but with a number of high profile bills still awaiting final action and the budget in doubt, April 14 and 15 could be action packed. In any case, legislators must adjourn the 2010 General Assembly no later than midnight on April 15.

Putting possible fireworks on the last days aside, KMA State Legislative Chairman Preston P. Nunnelley, MD, says he is pleased with the preliminary results of the session. He said, "Considering that the practice of medicine was under attack throughout the 2010 legislature, I think we had a good session. KMA physician efforts stopped scope expansions of any consequence, accomplished a couple of House of Delegates' objectives, and set a peg for future sessions by previewing legislative initiatives concerning health insurance reform."

Dr. Nunnelley complimented physicians for their willingness to call legislators on key issues during the session. However, he also noted that other groups, especially Advanced Registered Nurse Practitioners, had mounted an extremely aggressive and organized grassroots effort. KMA will need to do the same. "We fully anticipate spending the summer and fall organizing at the local level, raising money for Kentucky Physicians PAC, and supporting those candidates who are pro-medicine. For now, however, we must concentrate on the final days of the 2010 Kentucky General Assembly to ensure nothing adverse to patients and the practice of medicine passes; that a few remaining KMA initiatives are passed; and that funding for state programs, like Medicaid and medical schools, is maintained."

It's unclear whether the budget impasse will be resolved when legislators return on April 14. Just remember, their business is not limited to that subject and they can consider other bills. KMA will keep you posted on any developments and provide an overview of the budget, if one is passed. If the General Assembly does not pass a budget before April 15, they may return for a special session that must conclude before the close of the fiscal year on June 30.

Looking Hard For Health Care Reform Winners

Jim Oberweis, The Oberweis Report, 04.05.10, 01:10 PM EDT

Some industries will benefit from health care reform while others will be left feeling sick.

On March 21 the House passed the Patient Protection and Affordable Care Act, along with the Health Care and Education Tax Credits Reconciliation Act. The combination of the two bills permitted the Senate to pass its changes to the health care legislation with only 51 votes, rather than a 60-vote super-majority. This massive legislation will fundamentally change the American health care system and who pays for it. While providing health care to 32 million uninsured Americans, the cost of that coverage will be very substantial.

The affluent will foot the bill. To finance the reform, the bill includes a 0.9% incremental payroll tax on earned income in excess of $200,000 for individuals and $250,000 for families. In addition, the act imposes a tax of 3.8% on unearned investment income for individuals with adjusted gross income above $200,000 and $250,000 for families. These new taxes are effective beginning in 2013. If you believe, as we do, that Congress will permit the Bush tax cuts to expire in 2010, you should expect the highest ordinary income bracket to go from 35% to 39.6% in 2011.

Dividend tax rates will also go up. Qualified dividends, which today are taxed at a maximum rate of 15%, will be taxable at ordinary income rates (which could mean that dividends presently taxed at 15% will be taxed at 39.6% plus 3.8% for Medicare, for a total of 43.4%, in 2013). Capital gains tax rates will go from 15% today to 20% in 2011 to 23.8% in 2013.

Note that expiration of the Bush tax cuts could be legislatively changed but somehow we doubt it. Washington isn't exactly flush with cash these days. In short, while the exact details could change, affluent investors can safely bet that their tax burden is about to increase and, in some cases, skyrocket.

The tax changes are kind to investors in tax-exempt municipal bonds, which appear to have escaped the 3.8% Medicare tax. Dividend-paying stocks appear to be most egregiously affected between the Bush tax cut expiration and the Medicare tax. Small-cap growth stocks, such as those followed by The Oberweis Report, don't typically pay dividends but would still be subject to the increase in capital gains taxes.

All in all, with the exception of the period around World War II, periods of rising tax rates have tended to correlate with periods of below-average GDP growth. Not shockingly, periods of lower GDP growth have also tended to correlate with less favorable returns in the stock market. That's not an encouraging signpost.

While not often mentioned, we believe perhaps the biggest victims will be American corporations that have large workforces of low-wage labor. For example, think about restaurant chains. It appears to us that they will be forced to buy health care for their employees. That cost will not be immaterial relative to their overall employment cost. We believe that the health care bill could cause stock valuations of retailers to decline in the months to come, all else being equal.

Drug makers, both branded and generic, stand out as winners. The pharmaceutical industry will get 32 million newly insured pill buyers. While partially offset by $80 billion in savings and rebates over a 10-year period courtesy of big pharma, drug makers will emerge as net beneficiaries. While some have hinted that the act will hurt generic companies, we believe they will actually benefit, particularly as the government is forced to clamp down on costs over time. The bill also includes a generic path for biologics, although the 12-year brand name period of exclusivity was longer than the five to six years hoped for by generic manufacturers.

Hospitals will benefit from a larger pool of insured patients, though the benefit will be partially offset by lower government reimbursement rates for Medicare and Medicaid. Companies like Medicaid fraud finder HMS Holdings ( HMSY - news -people ) and Medicaid health plan administrator Centene (CNC - news - people ) will benefit from an increase in the ranks of Medicare and Medicaid.

Losers on the bill include health insurers, private Medicare plans and indoor tanning salons (tanning salons will be subject to a 10% tax).

Political changes create dislocations in industries that smaller companies are well positioned to exploit. By carefully watching changes in tax rates and changes in the health care landscape, investors can best position to profit from the reform.