Monday, May 22, 2006

Micro practice makes perfect?

Micro practice makes perfect?: "Family physician L. Gordon Moore routinely answers his own office phone. When patients call his cellphone number — given to all — he usually answers that, too, day or night, weekday or weekend.He also sees most patients the day they call and spends 30 minutes with each. Moore does it all with the aid of one nurse and a computer system loaded with state-of-the-art electronic patient records and practice-management software."

How's Your Health ?

How's Your Health ?: "Your Personalized Guide to the Best Health Care and Medical Care...it's easy, confidential, and it works!
How it Works... After completing this 10 minute survey, you will have:
* Health information designed just for you.
* Helpful forms for you and your doctor.
* The option to download your own Portable Health Record
* Lots of other choices based on your responses."

The Chronic Care Model

The Chronic Care Model: Patients with chronic illnesses consume a significant chunk of a doctor's time and healthcare resources. However, their care often leave a lot to be desired. "These deficiencies include:
* Rushed practitioners not following established practice guidelines
* Lack of care coordination
* Lack of active follow-up to ensure the best outcomes
* Patients inadequately trained to manage their illnesses
Overcoming these deficiencies will require nothing less than a transformation of health care, from a system that is essentially reactive – responding mainly when a person is sick – to one that is proactive and focused on keeping a person as healthy as possible.To speed the transition, Improving Chronic Illness Care has created the Chronic Care Model, which summarizes the basic elements for improving care in health systems at the community, organization, practice and patient levels."

Redesigning books

Books remain the most important vehicle for transmitting information - but most are still designed very badly. Here are three simple ideas authors and publishers of non-fiction books could incorporate, in order to make books more reader-friendly.

1. Design the book in a Q and A ( question and answer) format - after all, good books should be a conversation between the reader and the author , in which the writer answers questions the reader has . Ideally, each paragraph should express an individual idea - but in many books, the reader needs to work hard in order to find out what the idea is. This reflects the fact that the writer has been careless. Redesigning the book in the form of answers to questions will help the author to keep the reader clearly in mind when writing - and this is good discipline for all writers ! There are many books which have used this format, so it should be quite easy to copy ! We have used this for our online book, How to Have a Baby - A Guide for the Infertile Couple - and I find this has improved its readability considerably. Readers can zoom in on exactly the points which interest them, instead of having to wade through pages of irrelevant material.

2. Include a summary for the book at the end. All books have a Preface - which few people bother to read ! A chapter which summarises the key ideas of the book at the end would be very valuable. This will allow the careful reader to review and revise what he has read - and will also help prospective buyers to skim through the book and get at its meat !

3. Provide a website for the book. This will help readers to interact with the writer; share ideas with each other; and create an online community around the book. This could be in the form of a blog. Authors write in order to share information with readers - and allowing readers to return the favour will enrich the experience for both !

Saturday, May 20, 2006

Wombs for Rent, Cheap

Wombs for Rent, Cheap - Los Angeles Times: "Wombs for Rent, Cheap. Surrogate mothers in India are a bargain for foreigners, and the women reap a bonanza. But some observers say they pay a price."
While I feel that surrogacy is a very ethical treatment option for selected couples ( those where the uterus is irreperably damaged; or has been removed), it worries me that it is now being overused and misused. Many couples who have failed repeated IVF cycles come to the ( wrong) conclusion that the uterus is defective because it is "rejecting the embryos", which is why they opt for surrogacy. Since this is such a lucrative treatment option ( for the agency, the doctor, and the lawyer), many agencies have now sprung up which are willing to fulfill this demand, whether or not the couple really needs this ! Infertile couples who have failed multiple IVF cycles are emotionally distraught and vulnerable. They are willing to grasp at straws, and jump at this "new" treatment alternative. However, many have unrealistic expectations, and end up wasting a lot of their money. The pregnancy rate in a surrogacy cycle is no better than in an average IVF cycle - about 45%, which means that many of these attempts end in failure. However, many couples naively believe ( and are subtly led to believe) that the treatment is a 100% sure-shot affair !
Since surrogacy can be exorbitantly expensive in the US - over $ 50000 for an attempt, many couples are looking for inexpensive options, and are coming to India for their surrogacy treatment. However, they do not realise that there is no legal protection for surrogacy in India, which means there is no legal mechanism by which they would be able to take their baby back with them to the US. So how do Indian clinics continue to perform surrogacy for overseas patients ? The answer is simple - illegally. Many simply put the genetic mother's name ( instead of the birth mother's) on the birth certificate, so that no questions are asked later. Others misguide patients, and tell them that the contract they sign with the surrogate is binding. Actually, the contract is not even worth the paper it is written on ! Legally, the law only recognises the birth mother in India. The only legal way to take this baby back would be to adopt the baby. However, adoption from India is a long-drawn out complex process which can take 2-3 years. In any case, a "targetted" adoption of a particular baby is impossible - the baby would have to be given to an adoption agency, who would then decide where they baby goes. If everyone knows this, why is surrogacy for overseas couples still being carried out with impunity in India ?
What worries me even more is that this "short cut" will allow unethical doctors to bypass the entire adoption process, and certify an unwanted baby from an unwed mother as being born as a result of a surrogacy arrangement, thus allowing foreigners and NRIs ( non-resident Indians) to adopt these babies without waiting in line or having to go through an adoption agency.

Ovulex - clever marketing hype

One of the most frequent question patients ask me is – Should I be taking Ovulex ?
Ovulex is a treatment for infertility, which has been very cleverly marketed.
I quote verbatim from their website - " Ovulex™ will start to naturally increase your ovulation cycle. This increases the chances of one of your eggs being fertilized. Ovulex™ will start to relax your uterus and strengthen its walls to help avert miscarriage. Ovulex™ will help strengthen your immune system and reduce your reaction to stress. This results in a more natural menstrual cycle and creates a more stable and nurturing environment for your baby to develop in. Of all the women who have tried Ovulex™, we cannot tell you how many have called and written in with their stories of happiness and success. In fact, Ovulex™ has a 92.7% success rate. That's a cold hard fact!
Ovulex™ is like “fertilizer” for the female body. It gives you everything you need to be in perfect nutritional and hormonal balance. Just like the soil, your body needs to be in perfect harmony to germinate a seed. Not only does Ovulex™ create the perfect conditions, but it also aids in lengthening your ovulation cycle. Just like the earth needs sun and rain to germinate a seed, your body can utilize this extended opportunity for maximizing the success of conception. "
While this is all very poetic, if you look at it critically, you realise that these are all empty words which which mean nothing !
"Strengthen the uterus wall ?" How does one do this ? Is it like cement for a brick wall ?
" Balance the body ?" Are bodies imbalanced that they need to be "rebalanced" ? I have heard of people being mentally imbalanced, but I can't imagine a body which is not in perfect balance. Human physiology will always restore homeostasis !
" Naturally increase your ovulation cycle." What does this mean ? Does it improve ovulation ? How ? For everyone ? How will this help someone who's already ovulating ?
" 92.7% success rate". How did they come up with this figure ? Based on how many women ? What were their ages ? Their medical diagnosis ? How long did they take Ovulex for ? Were they taking other treatment too at the same time ?
"Fertiliser for the body". What does that mean ? Does it really mean anything at all ?
While I feel the product is useless ( it meets most of the criteria listed in
Quackwatch, I must admire their clever marketing.
They have :
1.Coined a smart name !
2.Used attractive baby pictures to sell their product
3.Cleverly displayed "testimonials"
4.Provided affordable pricing , so desperate patients are willing to "give it a shot" - what do I have to lose ?
5. Provided a money-back guarantee, so the customer feels safe
Since Ovulex is marketed as a healthcare supplement , no FDA rules apply, which means they are at liberty to say pretty much what they want to !
I dislike this , because they are preying on the desperation of infertile women
Just because the right treatment is expensive, this does not mean you should take the wrong treatment !
A certain number of women who take Ovulex will get pregnant, no matter what – and often this is inspite of the Ovulex, not because of it ! However, they tend to give the drug all the credit ( post hoc, ergo propter hoc is a common logical fallacy !). This offers powerful word of mouth publicity , but there's no way of verifying the authenticity of this.
Remember that anything which has good effects can have bad effects – it’s just the way we choose to label the effects ! Thus, the "side effect " of increased penile blood flow observed with Viagra led to a multi-billion dollar best seller !
Ovulex is priced just right . The costs are minimal, and because it's sold at a huge markup , the producer has a huge profit margin - which they use to publicise their product shamelessly.
Patients need to look for what is NOT there . The fact that there are no controlled clinical trials done by an independent doctor, and published in a reputed medical journal which prove the efficacy of Ovulex is a major black mark - as Sherlock Holmes pointed out , the fact that the dog did not bark is important !
The bottom line is simple - learn to evaluate critically !

What does not kill you makes you stronger

" What does not kill you makes you stronger". These are wise words, and when you are tackling a serious illness, it's worth keeping these in mind. While it can be a battle, it's a battle worth fighting ! However, you need to learn to choose your battles - there's little point in blaming yourself or cursing God ! Reinold Neibuhr expressed this very eloquently in his Serenity Prayer - " God grant me the serenity to accept the things I cannot change; courage to change the things I can; and wisdom to know the difference. Living one day at a time; Enjoying one moment at a time. "
A helpful tool is to write down your fears and nightmares - what's the worst which can happen ? Once you do this, it makes it easier to deal with them - it's better to fight with a named demon !
Dealing with an illness forces you to confront your own mortality . This can be a major life changing event - learn to enjoy the learning !

Wednesday, May 17, 2006

Talking about death and dying - a guide for doctors

Talking about death and dying - a guide for doctors : "'Fast Facts and Concepts' is a series of peer-reviewed, one-page outlines of key information on important end-of-life clinical topics for clinicians. The Fast Facts series is produced by the End-of-Life Physician Education Resource Center".
Most medical students and residents are never taught how to talk about death and dying. Surprisingly, it's still a taboo topics, even though it's something which most doctors should be intimately familiar with. Many doctors think of the death of a patient as a personal defeat, which is why they prefer to pretend that it does not exist. Denial is not a smart coping mechanism, however, because it leaves the dying patient alone and uncared for. This is a shame !

The Living Well Interview

The Living Well Interview: "'When a person faces a fatal disease that is likely incurable, he or she faces specific decisions not only about medical treatment but also about broader, existential issues concerning the best way in which to spend his or her remaining time.' Doctor-patient discussions about end-of-life treatment are often framed as a choice between 'medical treatment vs. treatment withdrawal.' When framed in this manner, treatment withdrawal is a negative choice that often implies giving up, abandonment, not giving the doctor a chance to do his or her job, and not caring; this option would seem to be no option at all. Bernard Hammes, PhD, suggests that the physician can reframe the doctor-patient dialogue about end-of-life treatment by starting a conversation with the patient focused on the question 'How can we help you live well?' The goal of the living well interview is to elicit the patient's perspective regarding how they want to spend their remaining time. Treatment decisions are then discussed within this broader context of patient goals and hopes. Treatments become tools for achieving patient goals."
Even though we cannot cure all our patients, we can provide all of them with loving care - and this is just as valuable !

Chronic illness and resilience

Coping with infertility is a lot like tackling a chronic illness. Treatment can be taxing and time-consuming, and the final outcome is always uncertain. Many patients will crumble under the onslaught of the pressures and stress of failure; and of dealing with inquisitive relatives and "well-meaning" friends. Self esteem can take a beating, and the marriage can often go to pieces.
This is why it's so useful to learn constructive coping strategies. It's often hard to find information on these; and I usually tell my patients to read books about Resilience ( titles such as The Resilience Factor : 7 Keys to Finding Your Inner Strength and Overcoming Life's Hurdles ; Resilience: Discovering a New Strength at Times of Stress ); Positive Psychology ( titles such as Learned Optimism : How to Change Your Mind and Your Life); to watch funny films; and read humourous comic strips. This is all basic stuff - but it helps when you need to live life one day at a time. Remember that adversity is the best teacher. Life has many lessons to teach - but most of only pay attention when we are faced with a crisis. The rest of the time, we are so caught up with the mundane business of performing our daily chores, that we lose sight of the big picture. Just as very complaint is a gift, your illness can be a great learning opportunity for you - if you gratefully accept the lessons it has to teach you.

Tuesday, May 16, 2006

New era will test doctors' skill at pleasing consumers

New era will test doctors' skill at pleasing consumers : "The introduction of consumer-driven health plans and associated health savings accounts are being hailed as the path to managing costs. With a higher deductible and lower premium, the goal is to provide employees an incentive to avoid unnecessary services, stay healthy, participate in disease-management programs and shop for care, not just on quality, value and service, but on price.
Consumers vote with their feet. Attracting and keeping them will no longer be about signing the right contracts but more on properly managing the doctor-patient relationship. That means making the experience the best it can be with a renewed commitment and a creative approach to customer service. That could actually mean spending more time with patients and making them wait less. Otherwise, patients will keep doctors waiting as they beat a path to someone else's door."
Medicine will become a service profession once more !

A Book for Midwives

A Book for Midwives from the Hesperian Foundation The Hesperian Foundation has very generously made the full text of its marvellous book, A Book for Midwives, available online for free. This is a brilliant book - check it out. If it's true that the hand which rocks the cradle rules the world, then the availability of this book online will help to improve the prospects for the next generation in many parts of the developing world !
* Introduction-Chapter 3: Words to midwives, Treating health problems, A woman's body in pregnancy
* Chapters 4-6: Helping women stay healthy, Preventing infection, Common changes in pregnancy
* Chapters 7-8: Learning a pregnant woman's health history, Prenatal checkups
* Chapters 9-11: Getting ready for labor and birth, Giving good care during labor and birth, Opening: stage 1 of labor
* Chapters 12-13: Pushing: stage 2 of labor, The birth of the placenta: stage 3 of labor
* Chapters 14-16: The first few hours after the birth, The first weeks after the birth, Breastfeeding
* Chapters 17-18: Family Planning, Sexually transmitted infections (STIs)
* Chapter 19: Advanced skills for pregnancy and birth
* Chapters 20-21: The pelvic exam: How to examine a woman's vagina and womb, How to insert an IUD
* Chapter 22: Helping a woman after a pregnancy ends early
* Chapter 23: Manual vacuum aspiration
* Chapter 24-25; Appendices: Getting medical help, Homemade tools and teaching materials, Medicines (green pages), To learn more, Technical and medical words, Index (yellow pages)."

Laparoscopic Cholecystectomy Cases: Maximizing Your Client's Recovery

Laparoscopic Cholecystectomy Cases: Maximizing Your Client's Recovery: "Top Ten Tips:
1. Know the anatomy
2. Know the indications for surgery
3. Know the risks of surgery
4. Know the instruments used during surgery
5. Know the indications for intraoperative cholangiogram
6. Know the proper surgical technique
7. Know the complications
8. Know the repair techniques
9. Know the likely defenses
10. Know your damages"
When I first read this list, I thought it was a guide for surgeons to help them manage difficult surgical challenges which they may encounter during laparoscopic cholecystectomy ( commonly called "lap choly" , a commonly performed operation to remove a diseased gallbladder). Turns out this is a guide for lawyers, who want to sue surgeons on behalf of their patients who have had complications during a lap choly ! If doctors are going to have lawyers peering over their shoulders everytime they enter the OR, most are going to stop accepting difficult patients ! Why take the risk - let the patient suffer ! Maybe his lawyer will help him deal with his pain !

Why don't patients ask their doctors more questions ?

I am always surprised by how poorly informed so many of my patients are - and why they are reluctant to ask their doctor to explain their medical problems and treatment otpions to them. I used to think it's because most patients are passive, but today, I have revised my opinion. I think the reason most patients don't ask their doctors questions is because their doctors discourage questions - either by putting patients in their place by saying - " Whose the doctor ? You or me ? "; or by providing glib reassurances like - " Don't worry - I'll take care of everything !"; or by subtle body language which signals - " I am too busy to answer your stupid questions !"

Kenya Govt to develop policy on IVF

Kenya Govt to develop policy on IVF: " The Government plans to set up a task force to formulate a policy framework to guide the practice of In Vitro Fertilization (IVF) or Test tube babies the Director of Medical Services Dr. James Nyikal said on Monday. The move follows key concern including moral and ethical issues arising from the recent birth of two test tubes babies in Kenya.Although the Minister of Health Charity Ngilu welcomed the news of the first test tube babies in Kenya last week, the Ministry has now set in motion plans to regulate the procedure called IVF technology."
It always amazes me how keen governments are to pass laws to regulate reproductive rights ! And how most citizens accept these laws passively , without realising that many of them take away their reproductive autonomy. The Kenya government cannot even provide basic health care to its citizens. Rather than focussing on this, they now want to blindly ape the West, and pass a law to regulate IVF technology - something which will affect a very small portion of their population. Don't they have better things to do with their time, money and energy ?

Friday, May 12, 2006

Enhancing Doctor-Patient Communication Using Email

Enhancing Doctor-Patient Communication Using Email: "E-mail communication was found to be a more convenient form of communication. Satisfaction by both patients and physicians improved in the e-mail group. The volume of messages and the time spent answering messages for the e-mail group physicians was not increased. E-mail has the potential to improve the doctor-patient relationship as a result of better communication."
Not what you'd intuitively expect , because we think of email as being impersonal - but it's true !

Smart cards for PHR

Smart cards for PHR " What is a smart card?
The smart card, an intelligent token, is a credit card sized plastic card embedded with an integrated circuit chip. It provides not only memory capacity, but computational capabilities as well. The self-containment of a smart card makes it resistant to attack, as it does not need to depend upon potentially vulnerable external resources. Because of this characteristic, smart cards are often used in different applications which require strong security protection and authentication. ePassport™ protects against a full range of security threats from sophisticated system breaches to careless storage of user passwords. The card provides tamper-proof record storage and user authentication-acting as a critical component of system security for the exchange of data throughout virtually any type of network."

What's a good doctor and how do you make one?

What's a good doctor and how do you make one?: "Firstly, there are plenty of good doctors around and we should nurture them better.
Secondly, to be a good doctor, you first have to be a good human being: 'a good spouse, a good colleague, a good customer at the supermarket, a good driver on the road.'
Thirdly, it's easier to be a good doctor if you like people and genuinely want to help them. A general practitioner from Wolverhampton wrote: 'To like other people, from this all else follows. Liking your patients will get you through the grind and tedium of your working day, and patient contact will be a source of strength and renewal. You may even do some good.'
Finally, good doctors, unlike good engineers, good accountants, or good firemen, are not just better than average at their job. They are special in some other way too. Extra dedicated, extra humane, or extra selfless. More traditional contributors wanted doctors to sacrifice themselves for the good of their patients. Others said doctors must look after themselves first---or they wouldn't be able to help anyone. Doctors are patients too."
This is a very enlightening article - and all doctors ( and patients !) should read it.

A Content Analysis of E-mail Communication Between Doctors and Patients

A Content Analysis of E-mail Communication Between Doctors and Patients : "The Institute of Medicine has called for an increased use of nonvisit care in response to patients’ needs. E-mail may be the most efficient venue for the provision of such care. In addition, e-mail documentation is a superior alternative to transcription of telephone care, advancing the IOM’s goal of the elimination of most handwritten clinical data by the end of the decade. Through the facilitation of parent-physician communication and provision of more efficient care, e-mail is an essential ingredient in the improvement of pediatric health care quality in the 21st century."
Email is my preferred mode of communication with my patients !

The good patient of the future

The good patient of the future: " will:
* Bring lists of questions to the consultation and will expect answers in clear terms
* Know how involved they want to be in decisions about their health care; most will choose to share decisions with their healthcare providers
* Have free access to their health record on paper or through electronic means and will use it or share it as they see fit
* Request and receive a second opinion whenever they face a major diagnosis or decisions about treatment
* Use telephone, internet, and other forms of communication to complement personal visits with members of the healthcare team"
I wonder what the good doctor of the future will look like !

Basic requirements for a PHR

283.pdf (application/pdf Object)
" 1. Electronic medical record systems should be designed so that they can exchange all their stored data according to public standards
2. Giving patients control over permissions to view their record—as well as creation, collation,annotation, modification, dissemination, use, and deletion of the record—is key to ensuring patients' access to their own medical information while
protecting their privacy
3. Many existing electronic medical record systems fragment medical records by adopting incompatible means of acquiring, processing,storing, and communicating data
4. Record systems should be able to accept data (historical, radiological, laboratory, etc) from multiple sources including physician's offices,hospital computer systems, laboratories, and patients' personal computers
5. Consumers are managing bank accounts,investments, and purchases on line, and many turn to the web for gathering information about medical conditions; they will expect this level of control to be extended to online medical
portfolios."
Very well written article - this is what the future holds. If this is what patients want, why aren't we giving it to them ?

Electronic Patient-Physician Communication: Problems and Promise

Electronic Patient-Physician Communication: Problems and Promise : "Guiding Patient Communication. A well-designed interface could guide patients as they create messages and could help triage messages received at the physician's practice. Patients could create messages by choosing from menu categories; simple scheduling questions, for example, could be automatically directed to the front desk staff, or prescription refill requests could be directed to the practice nurse. The interface should also have safety features to ensure appropriate communications. For example, the patient could be required to specify the priority of a message. If the patient indicates that the message is urgent, the system would either display a warning screen suggesting a telephone call or a visit or trigger an alert to the physician, such as an alarm or a page."
This article was published in 1998 ! Considering how quickly other industries have embraced email as their preferred mode of communication, it's disheartening to see how slowly doctors have accepted this option ! Do doctors prefer being inaccessible ?

Open Source PHR

Open Source PHR : "PING is a distributed, web-based, personally controlled electronic medical record system that is ubiquitously accessible to the nomadic user, built to public standards, and distributed under an open-source license. The PING system is essentially an inversion of the current approach to medical records, in that the record resides with the patients and the patients grant permissions to institutions, clinicians, researchers, and other users of medical information."
I wonder why open source software has not become more influential in the healthcare space . Since the potential for doing good is so obvious, I would have felt that lots more programmers would have utilised their skills to create innovative products in this field. Is it because doctors aren't interested ? Or that the potential for profits is so huge, that commercial organisations have a strangle-hold in this area ?

Connecting for Health - Common Framework

Connecting for Health - Common Framework: "The Common Framework provides an essential set of technical and policy resources for private and secure health information sharing among existing and developing health information networks. All of the Connecting for Health Common Framework resources are available here at no cost."
Standardising is a big first step in making the transition to electronic medical records !

Tuesday, May 09, 2006

Consumer-driven health care: freeing providers to innovate: consumer-driven health care offers salvation to a healthc

Consumer-driven health care: freeing providers to innovate: consumer-driven health care offers salvation to a healthcare industry that penalizes providers that dare to be innovative: "Corporate entrepreneurs drive improvements in a productive economy and are rewarded financially. The U.S. healthcare industry, on the other hand, allows payers to dictate prices and punishes any providers that try to create better, cheaper goods and services. The result is missed opportunities for innovation. Consumer-driven health care (CDHC), however, allows providers to innovate and offers consumers choice. Basically, CDHC matches supply and demand while rewarding skilled entrepreneurs."
Will this allow rewards to be linked to performance ? In the past in India, physicians were paid a retainer by the family, and these continued as long as everyone was healthy . If anyone fell ill, the payments were stopped , because this meant the doctor was not doing his job properly ! The job of the doctor was to keep everyone healthy - not just to fix a problem during an episodic illness. This is why the Indian system of medicine is called Ayurveda - the Science of Life !

Physician Executive: Role of the physician executive in consumer-driven care - Consumer-Driven Health Care

Physician Executive: Role of the physician executive in consumer-driven care - Consumer-Driven Health Care: "Role of the physician executive in consumer-driven care - Consumer-Driven Health Care. Matthew M. Keats.
Much has been written in the last few years about consumer-driven health care.
It's been hailed by its supporters as the way out of the seemingly endless upward spiral of health care costs and damned by consumer advocates as a thinly veiled attempt by employers to off-load their medical costs onto unwitting employees.
In the midst of all this rhetoric, what is noticeably lacking is any mention of the role of the physician executive in helping to define the consumer-driven health care model. This is all the more peculiar when you consider that physician decision-making drives the majority of actual health care costs."
Patients and physicians go hand in hand - and they are both on the same side - the patient's !

Planetree Hospital: Here's What that Means to You

Planetree Hospital: Here's What that Means to You: "What's the Planetree philosophy? It's a way of providing care that's focused on you, the patient, rather than on the provider. It means that patients are given choices and encouraged to be actively involved in their health care. The Planetree philosophy also recognizes the important role that family support, nutrition, integrative therapies, music and art play in the patient's healing experience. As a Planetree hospital, we have joined an elite family of hospitals from across the country. Planetree hospitals are dedicated to the healing of mind-body-spirit; are patient-centered, value-based, holistic; and support the safety of patients through active involvement in their own care. Here at your hospital, it's always been our vision to provide extraordinary care that's focused on you. So being a part of Planetree is a 'natural' fit. It's a commitment that says we're dedicated to providing hospital care that's nurturing and personalized. And it means that we try to look at medical situations and care through the patient's eyes (and through the family's eyes). It's a way of taking into account every aspect of your care and healing and well-being."
Why aren't all hospitals like this ?

Monday, May 08, 2006

COPING WITH STRESS: Canceling-out Painful Emotions

4.1: Six best ways of canceling-out painful emotions are: changing perception, putting things in proper perspective, neutralizing emotions, reasoning, insight and humor.

[We learn these coping skills from our parents, relatives, teachers, mentors, religious leaders, books and Holy Scriptures and from life experiences. These techniques require one to function at a fairly high intellectual level. People who grew up without much interaction with mature people often lack these skills. People with good attitude and spiritual bent of mind are good at canceling-out emotions.]

4.2: Before canceling-out a painful emotion one must be fully aware of it.

[Canceling-out is like shooting down one target at a time. So one must be aware of what painful emotions he is feeling in his mind. For example, for one to tackle a feeling of helplessness, he must first be aware that he feels terribly helpless about a certain situation. For one to cancel-out fear, he must first admit to himself that he is scared about something. People who deny they have any painful emotion in mind are unable to use this technique.]

4.3: By changing perception of an upsetting life-situation painful emotions could be gotten rid of.

[Perceiving a cup as half-full instead of half-empty is an example. When a hypercritical boss is perceived as insecure and not evil, he appears less threatening. When sudden decline in the value of a good stock is perceived as an opportunity to buy more stocks rather than as loss of wealth, one does not become upset. When being fired from one’s dead-end job is perceived as an opportunity to change career or begin a new career, one does not get upset.
A student, bored by his professor’s mediocre lectures missed several classes. When the professor took him to task the student became very upset. However, his wise friend calmed him down by saying, “Well, he is not mad at you. He likes you. He simply misses you in his class!” The student felt better.]

4.4: Inherently negativistic, cynical, pessimistic and closed-minded are not able to change perception.


13
[There are people who are inherently negativistic in nature. No matter what the problem is, they see only the negative side of it. There are others who are habitually cynical. They would react to everything by saying, “Oh, it is all a fraud.” The pessimistic would say such things as, “I don’t think it is even worth a try. I can tell you right now, it would give no results.” Then there are closed-minded or narrow minded people who would not let a new idea enter their mind. It is impossible to convince them of anything other than what they believe. These people are totally incapable of thinking “outside the box.”]

4.5: Putting a life-situation in proper perspective lessens painful emotions in mind.

[“We might have lost a battle but we are winning the war.” We look at the overall picture instead of a specific event or problem. Loss in one stock is made up by gains in other stocks. Counting one’s blessings in the face of personal losses, or those of others, is another example. Suddenly the bad event does not seem that bad after all. People who are “short-sighted” by nature; who can not get the “big picture;” and who are “bogged down” by their everyday mundane problems have difficulty in putting this technique in practice. One should recall the familiar saying, “I complained about not having shoes to wear till I met someone who had no feet.”]

4.6: Painful emotions can be neutralized by opposite emotions or actions.

[Fear is neutralized by cultivating Absolute Faith in God or Destiny, or by courage and reassurance; anger by forgiveness and mercy; hopelessness by hope and prayer; helplessness by taking appropriate action; hate by indifference or love; hurt by solace; sadness by spiritual joy; disappointment by acceptance; insecurity by self-improvement; humiliation by fortitude; guilt by expiation; sin by repentance; shame by self-exposure; frustration by patience; jealousy by being happy for other’s good fortune; envy by contentment; embarrassment by stoicism…. Read your Scriptures!]

4.7: The ability to neutralize painful emotions is rooted in one’s cultural values.

[For example, a person who is raised in a culture or family with the value “eye for an eye and tooth for a tooth” might not be able to forgive the offending party and move on with his life. A person who is raised in a culture which fosters passivity and dependence on others might not be able to take direct action to deal with helplessness brought on by financial problem. Instead, he might unrealistically expect others to help him out at every turn and be disappointed when he fails to elicit sympathy.]

4.8: Reasoning rooted in wisdom is a powerful antidote to painful emotions.

[Strong reasoning capacity gives us protection from stress. Reasoning requires one to accept certain realities of life. He is never surprised by anything: “That is the way life is;” “aging, infirmity and death are part of life;” “all relationships end sooner or later due to breakup or death or move;” “there are no permanent friends, only permanent
14
interests;” “at the end of the day everyone must look after his own interests,” etc. Stressed-out people are often unreasonable in their expectations of others or themselves. Due to their unreasonableness, they find themselves suffering from frustration, disappointment, anger and other toxic emotions from time to time.
Reasoning as well as judgment becomes impaired when one’s mind is infected by one or more of seven weaknesses of man: greed, lust, possessiveness, jealousy, rage, insecurity and arrogance. It is hard to reason with a woman possessive of her brutally violent boyfriend. She has no reasoning left to know her life is in danger. Likewise, it is hard to reason with a violent brute driven by rage to take revenge against someone he hates. It is hard to reason with a greedy man when he is bent on defrauding someone. It is hard to reason with a lustful man that extramarital affair could ruin his marriage.]

4.9: Insight into a life-situation could reduce emotional tension.

[Insight is the ability to look into the hidden cause of his own behavioral pattern or of others. Very often, such insight leads to feeling calm once again. A beautiful secretary was very hurt by her boss’s seeming indifference toward her. She felt much better after she developed insight that the boss, a married man, was staying away from her to counter his strong attraction to her. A young wife, very angry at her husband over his distrust of her, felt better after she got insight into his past. He had grown up seeing his mother have a series of extra-marital affairs. No wonder he was distrustful of all women. The vast majority of stressed-out have no insight into the connection between their painful emotions and circumstances inducing them.
Insight is possible only in open-minded people who are curious to know and willing to change their view. Significant number of stressed-out people is closed-minded which explains why they became stressed in the first place. Not knowing protects them from the discomfort of knowing the truth about certain realities of their own life. A lot of stressed people reject insight when offered by experienced psychiatrists. A 35 year old woman, mother of a four year old daughter, felt a strong urge to divorce her husband. She had been having an affair at work for over one year. She often asked herself, “Why am I doing this?” History revealed that her own mother had an affair when the patient was 3 years old, and her mother left her father when she was five. The patient rejected the insight that her extramarital affair and urge to leave her husband was rooted in this childhood trauma.]

4.10: Humor reduces emotional tension.

[Cultivating a sense of humor in the midst of all the breathless madness around gives one some breathing room. If your basement is flooded, you could make a joke to break up the gloom: “I always dreamed of an indoor pool in this house. I didn’t realize I would be in luck this soon!” Most wise people who are stressed defuse the tension immediately by making a joke about the ominous situation. An employee who was constantly threatened with firing finally received his pink slip. It read, “You are axed!” He wrote back, “Thanks for the axe! It feels better than the damned chain saw!”]

Broadening Friendships Beyond Medicine

Broadening Friendships Beyond Medicine:
" Michael Myers, M.D., often hears physicians say they'd like to expand their circle of friends beyond their colleagues in medicine, but they're not sure how to go about it. “I hear so many first-person accounts from physicians who say it's really neat to be going out with some people who have nothing to do with medicine at all,” said Dr. Myers, a psychiatrist based in Vancouver, B.C., who specializes in physician health. “Then they make statements like, ‘I realize there's a whole other world out there' or ‘I think my work sometimes gets me too focused on disease and illness, or death or dying, and I forget sometimes that there are other people who are doing fascinating things.’” In fact, sometimes his psychiatry colleagues make statements such as, “When I'm with my nonmedical, no-psychiatry friends, I realize not everybody's depressed,” Dr. Myers said. “They find it refreshing.”"
I often find patients make great friends - and they teach me a lot about the "real world" which exists outside the four walls of my clinic.

Elective Cesarean: Honor Her Choice.

Elective Cesarean: Honor Her Choice: ". Any decision between cesarean delivery by maternal request or trial of labor ultimately lies with the woman, once the potential risks and benefits associated with C-section have been discussed, concluded an independent panel of experts on cesarean section. “Her decision should be honored,” said Dr. Mary E. D'Alton, panel chairperson, speaking at a conference on cesarean delivery sponsored by the National Institutes of Health."
I am sure gynecologists will be very pleased to " honour her choice " - after all, doing a C/S is much more lucrative for them - and much easier too ! As every good doctor will acknowledge, it's quite easy to "push" patients into accepting what the doctor says, so I wonder how much of this will be "free" choice ! I wonder how happy insurance companies will be about this - and whether they will be willing to accept " Patient's Choice" as an indication for doing what is a major surgical procedure, which costs a lot of money !

Sunday, May 07, 2006

World Bank Falsified Information On Malaria Treatment, The Lancet

World Bank Falsified Information On Malaria Treatment, The Lancet: "According to a group of health experts, the World Bank published bogus financial and statistical accounts and squandered money on useless malaria treatment. The World Bank says the accusations are unfounded. The World Bank, with an annual budget of $20 billion, is the world's major aid organisation which focuses on eradicating poverty. "
Who can you trust ?

Tool for starting a new eye hospital

Vision 2020 e-Resource Centre This offers a clever tool for doctors who want to start a new eye hospital. The basics could be used for any hospital - it's a useful starting point to think about the business end of starting and running a hospital !

Saturday, May 06, 2006

Why I dislike the term reproductive tourism

We are now seeing an increasing number of infertile couples coming to our clinic from all over the world for IVF treatment. They come for many reasons, depending upon where they live.
1. We offer high quality treatment at a fraction of the cost a clinic in the US would charge
2. They are fed up of the long waiting lists in the UK
3. They dsilike the impersonal assembly line care they receive
4. IVF is not available in their own country
5. They need to use donor gametes, but their own country's rules do not allow them to do so.
6. They have failed a number of IVF cycles in their own country, because of bureaucratic rules which permit the transfer of only a limited number of embryos.

These patients are often called "medical tourists"; and the phenomenon where infertile couples travel overseas for IVF treatment is called reproductive tourism .
However, as Dr Pellicer points out, this term is inappropriate because nobody travels abroad to obtain medical treatment with the same intention and mood with which they leave home for vacations. It is also a term that trivializes infertility problems
for both sides, patients and doctors. Matorras (2005) proposes the term " reproductive exile." This is a much better word, because it emphasises the fact that the only reason infertile couples are travelling aborad is because they are being forced to - either because IVF treatment is not available in their own country; or is too expensive; or takes for ever to be delivered.

Unfortunately, because infertile couples are in the minority, it's unlikely that things will improve for a long time to come. This is such a shame ! Why should patients have to travel long distances to receive medical care which they are entitled to in their own country ?

Wednesday, May 03, 2006

Welcome to Jackson Medical Mall

Welcome to Jackson Medical Mall: "The Medical Mall, itself, plays a major role in community outreach. During the early mornings you can witness many senior citizens starting their day off with a vigorous stroll around the perimeter of the Mall’s interior as a part of the Mall Walkers Program. The Mall provides a safe, enjoyable environment for Mall Walkers to stay fit and healthy. "
This is a great way of allowing doctors to reach out to the community. Instead of waiting for people to come to you, go to where the people are !

About MinuteClinic - the US version of the Chinese barefoot village health worker ?

About MinuteClinic - the US version of the Chinese barefoot village health worker ? : "There’s really no secret behind MinuteClinic’s better approach to diagnosing and treating common illnesses:
* Quick (about 15-minute visits and no appointment needed).
* Affordable (treatments between $28 and $110, and reimbursed by most insurance plans).
* Convenient (open seven days a week, located near pharmacies)."
This is going to be serious competition for doctors ( family physicians). After all, most problems which cause a patient to visit a doctor are self-limited, and will fall into one of the categories MinuteClinic handles efficiently and inexpensively ! Is this the US version of the Chinese barefoot village health worker ?

The HealthCare Crisis

The Healthcare Crisis: "As exploding health care costs cross a threshold of affordability, the American health system will experience significant turmoil and a cascade of impacts. All health care stakeholders - patients, providers, suppliers, payers and employers - will suffer. There will be calls for dramatic health system changes.
We are approaching that precipice. Over the last 20 years, medical inflation has averaged double the general inflation rate. But in 2002 and 2003, premiums increased 12.7% and 15% respectively, about 8 times the general inflation rate, and the greatest health care cost growth in more than a decade.
Without significant adjustments to the ways our health system works, there is little reason to believe that cost can be reined in within the near future. Health care will simply price itself out of the market for a large percentage of Americans.
The sheer magnitude of health cost increases are negating health coverage's value to employers, who are fighting to remain profitable in the teeth of an economic downturn and who have equally onerous cost pressures from areas like workers' compensation and professional liability. Employers' patience probably is not limitless; it is unlikely they will allow a tradition of voluntary sponsorship of coverage to continue eroding their bottom lines and viability.
And if we cannot control cost, no form of financing will be sufficient."
I guess it's typical of a capitalistic system that healthcare starts to become a big issue only when it starts pinching the pocket. Issues of equity and justice ( healthcare for everyone, including the poor) are always going to be secondary in such a society !

The State of Ethics in Healthcare

The State of Ethics in Healthcare : "More recently, we’ve learned these facts from mainstream news sources:
* Pharmaceutical companies have paid for and published studies in distinguished professional journals, but left out results that reflected poorly on their products.
* Drugs have been marketed as better than another brand when in fact there have been no head-to-head studies.
* Major pharmaceutical distributors have bought drugs through middle men and, though they have been unable to determine the authenticity of the products, re-sold them.
* Medical device manufacturers have knowingly distributed products with fatal flaws.
* Medical device manufacturers have paid exorbitant “consulting” fees to surgeons who decide which products their hospitals will buy for implantation into patients.
* Many health plans have profited not by managing care, but by ratcheting down rates to doctors and hospitals and forcing employers to pay ever higher premiums.
* Many hospitals have illegally paid doctors to increase admissions at their facilities.
* Nonprofit hospitals, supposedly mission-driven, have charged uninsured patients three to four times what insurance companies pay, then sued them when they couldn’t pay.
* Many doctors practice medicine based on their own beliefs, feel that evidence-based medicine is too “cookbook,” and often prescribe procedures based more on financial self-interest than clinical necessity.
* Many doctors, hospitals and other providers have consistently and, with little fear of penalty, stolen from Medicaid and Medicare.
* Doctors often relent when patients pressure them to provide unnecessary services, even when the physicians know the procedures are inappropriate and costly.
* Some “disease advocacy” associations--patients with the disease in question often look to them for unbiased advice--accept large contributions from drug companies, and then do not fully disclose details about their sponsors’ contributions or their drugs’ impacts.
* Healthcare corporations invest in lobbying because it works, spinning public policy and dollars disproportionately in favor of healthcare’s strongest interests.
* Many healthcare executive have enjoyed extraordinary compensation while fraud and abuse occurs, and is even encouraged under their watch."
I find it depressing that it's such a long list - and it's not even comprehensive !

With Health Care, First Fix Terms of Engagement

With Health Care, First Fix Terms of Engagement: "Moreover, we know that by its nature, health care is a highly imperfect market. It suffers from tremendous 'information asymmetries' between sellers (doctors, hospitals and insurers) and buyers (patients).
It is rife with what economists call 'principal-agent problems' -- like the doctor who benefits financially by providing more medical treatment than patients need, or health insurers that are always trying to get them to consume less.
In rural areas, there are often few providers and little or no competition.
And left alone, insurance markets will tend to lower costs for the young and healthy and raise them for the sick and aged -- an outcome that is as socially unacceptable as it is economically efficient."
A good summary of some of the problems we face - let's start fixing them one by one ! A PHR ( patient health record) would be a good way of empowering patients with information, so they can be as well-informed about their medical problems as they want to be !

Tuesday, May 02, 2006

Healthline - the search engine for health

Healthline - the search engine for health: "Healthline is the fastest and easiest way to find, understand and manage information about consumer health. Our mission is to empower health information seekers by providing them with an innovative and unique guided search experience - one based on trust, comprehensiveness, contextual relevancy, personalization, and interactivity."
A clever way of helping patients find useful health-related information on the web.

Monday, May 01, 2006

COPING WITH STRESS: Raising Awareness and Expressing Emotions

3.1: The four best ways of coping with stress are: raising awareness; expressing emotions; canceling-out emotions and solving life-problems.

[Coping with stress simply means getting rid of painful emotions from the mind, or “shrinking the balloon.” This causes brain chemicals to go back to their normal state; stress symptoms to disappear and calm and tranquility to return to the mind. Grieving over the death of a loved one is a classic example of getting rid of painful emotions from the mind and achieving healing. Therefore, mindless activities such as jogging, exercising, weightlifting, hot tub baths, etc. are useless in coping with stress as they do not deal with painful emotions and/or the events and problems that bring them on.]

3.2: Awareness evaporates painful emotions.

[Becoming aware of painful emotions in the mind is fundamental to coping with stress. All stressed-out are “unaware” people. They suffer from various stress symptoms but they are not aware of being upset about anything. Putting painful emotions out of awareness is how they had coped. A young woman who has severe anxiety attacks since she got married three months ago says, “I am happily married! My anxiety attacks have nothing to do with my husband.” On further inquiry, she reveals that her husband of three month has not had any physical relationship with her and he rarely comes home at night! She neither acknowledges her painful emotions (hurt, anger, fear, etc.), nor her serious marital problems. By avoiding awareness one is saying, “I don’t want to know. It hurts too much!” It is self-deception, pure and simple.]

3.3: Specific painful emotions related to specific issues must be acknowledged.

[To benefit from raising awareness, one must be as specific as possible about his emotions and the cause of them. “I am angry about this;” “I am sad about that.” A thirty five year old married woman says she has been very anxious and depressed for two weeks. When asked directly if anything happened two weeks ago she said, “Absolutely not! That is the problem. I don’t know why I feel this way!” She said she had a wonderful two week vacation on the southern coast of America. She has been miserable ever since she returned home from vacation two weeks ago.
The therapist reasoned that something must have happened on the way home from vacation. He asked her, “Did you stopover somewhere on your way back?” She said, “I visited my father in Oxford, Mississippi.” The therapist asked her, “How is he doing?” At this she broke down and sobbed uncontrollably. She revealed that her father told her he had terminal cancer and he had only three months to live. As you can see, she had completely put this information out of awareness till the therapist doggedly probed her mind. Once she became aware of her emotional pain related to her father, she grieved over the impending loss (shrank her balloon) and got well.
Likewise, a person trapped in a bad life-problem must acknowledge it exists. A woman married to an abusive alcoholic sees numerous doctors for a variety of stress symptoms. Every time her doctor asks her if she is bothered by anything she replies that she has a “picture perfect life!” When the doctor comes to know that she is married to an abusive alcoholic, she defends him saying he is really a very nice guy when he is not drinking (which is rare), and that she loves him. She denies she has any problem with her living situation. She denies his beatings bother her. This woman has no hope of getting better till she acknowledges she has serious life-problem.]

3.4: Awareness facilitates expression of painful emotion and solving life-problems.

[The moment one becomes aware of his inner pain, he begins to express it by talking, crying, sobbing, sighing, etc. The moment one acknowledges his current life-problem, he begins to think about solving it.]

3.5: The ability to express emotions evolved over thousands of years as an essential communication tool for survival in the society.

[As humans evolved into social beings they developed ability to communicate with their fellow beings. Expressing emotions became the most important part of that ability. Facial muscles developed to facilitate expression of emotions. The blood supply to face and brain increased tremendously. That is why our face becomes red whenever we are afraid, bashful, embarrassed, jealous, hurt or angry. Nature gave us a way to reduce the localized increase in blood pressure: shedding tears. Tears consist of salt water. Profuse outpouring of salt water reduces the localized pressure in the face and brain. People who resist crying when hurt pay dearly later by serious headache attacks or pain somewhere else in the body.
If we go against nature and refuse to express emotions, they get buried in the hidden mind/soda bottle. This ultimately leads to serious stress-related disorders.]

3.6: Expressing painful emotions regarding specific issues by means of talking, sighing, crying, sobbing, gesticulating, recording and writing causes stress symptoms to disappear.

[Almost all stressed-out people have great deal of difficulty expressing their emotions. We can safely say they are emotionally constipated. They seem to have the erroneous belief that expressing one’s emotion is a sign of weakness or sign of self-pity.
Saying “I am upset; I am sad; I am angry; I feel helpless; I feel hurt; I feel guilty,” etc. with reference to specific issues are some simple ways by which one could express his painful emotions.]

3.7: Inability to speak-out painful emotions often leads to acting-out resulting in serious consequences.

[Children often act out their emotions as they are unable to express them verbally. Acting-out by adults is a sign of emotional immaturity. Acting out could result in destruction of property, violence, extramarital affairs, abandonment of family and other detrimental behavior. Acting-out stops once the person starts speaking out.]

3.8: Some redirect their painful emotions in the service of causes and crusades; others cash in their misery by writing memoirs or filing lawsuits.

[Some people sublimate their emotional energy into various crusades and causes. Princes Diana channeled her anger at her husband and the Queen of England by getting involved in causes related to the downtrodden. T. E. Lawrence of Lawrence of Arabia fame redirected his shame of illegitimate birth by leading Arabs against Turks. History is full of such stories.
Again, look around you and you will find many causes which began with someone’s heartbreak. Mothers Against Drunk Drivers (MADD) is but one example. Then there are thousands of inspiring books written about someone’s misery or misfortune, and how they overcame their misfortune. On any given day hundreds of lawsuits are being filed in the U. S. courts over some injustice or another suffered by self-appointed “victims.”]

3.9: Some painful emotions block expression of others.

[Some emotions often block expression of other emotions. One must dislodge the blocking emotions first to be able to express other emotions. Shame could block expression of horror of sexual abuse. Fear of reprisal could block off expression of shame of incest. Anger toward the dead person could block expression of sadness. Guilt over letting one down could hinder expression of anger. Unfinished grief is due to anger blocking expression of sadness.
The importance of understanding this phenomenon lies in the fact that unless the blocking emotions are first identified and flushed out, the balloon can not be shrunk.]

3.10: Expression of painful emotions is facilitated by empathic listener.

[Any listener, be it a friend, pastor, counselor, doctor or relative, who relates to the stressed-out person in an empathic manner, could break down the barrier of denial. Empathic statements such as, “You seem to be in lot of pain;” “You are hurting really bad, aren’t you?” “You seem like you are going through some rough times,” motivate people to open up and talk. Unfortunately, these days empathy is a lost art in psychiatry as well as medical profession. Greed for money has extinguished empathy and compassion in most medical professionals.]


This is the next chapter from Dr Kamath's excellent book, Kamath Sutra !

Communication in Medicine: Teaching Medical Students

Communication in Medicine: Teaching Medical Students" .. learning objectives that reflected a growing awareness that, in the future, physicians will be expected to be more effective than now
appears to be the case in communicating with patients and their families, and with other members of the health care team."
Here's a report from American Medical Schools on what they can do to help medical students to talk to their patients.

Career Planning in Medicine

Career Planning in Medicine: "What to Be or Not to Be, That's the Question. When I graduated from medical school nearly 40 years ago, career 'planning' was virtually unheard of. Oh, I remember one of my classmates who did plan, from even before medical school, to become a cardiac surgeon; he never wavered and ended up doing just that. But for the rest of us, at least most of the rest of us, the careers we ended up in were less a matter of precise planning than of hopeful hunching. Few medical students in those days had access to formal career counseling. We formed our opinions about suitable careers from informal corridor conversations with our attendings, or from our distorted glimpses of what made up their professional lives, or from the stereotypic comments of residents or fellow students who were as poorly informed as we were. As for tailoring our career choices to some objective assessment of our innate talents, forget it.

But the stakes back then were much different from what they are now, and the risks of going with one's hunches rather than following a planned pathway were small. With the exception of the few who chose academic medicine or the military, medical students in my generation were faced with a pretty simple set of choices. One had to select a medical specialty from a list less than half as long as currently exists; one had to decide whether to do solo practice or join a group; and one had to pick where in the country one wanted to live. Have an MD degree was, quite literally, to have a ticket to certain prosperity in whatever specialty one picked, in whatever company one wanted to keep, and in whatever community one chose to settle.

To observe that a lot has changed since then would be to abuse understatement. Today's medical students face a virtual cacophony of choices, and the risks of making the 'wrong' choice can be very costly indeed. Not only have scores of new medical subspecialties sprung into existence over the last few decades, a wide variety of new modes of practice are available to choose among. Although solo practice may have gone the way of the passenger pigeon, many other possibilities offer viable alternatives. Group practice, academic medicine, and the military remain realistic choices. But how about employment in a managed care organization, or in the burgeoning biotechnology field, or as a 'hospitalist,' or in a pharmaceutical company, or with an international relief agency? All are among the tantalizing possibilities clamoring for students' attention."

A useful guide for the perplexed medical student !

Digital Medicine: The Promise and the Peril

Digital Medicine: The Promise and the Peril.
" The potential benefits of this digital transformation to improve the health of individuals and communities are hard to overestimate. They are truly astounding. What has become abundantly clear is that the availability of information is the key to overcoming virtually all of the barriers we now face to improving personal and public health. Think about it. If we could always get the right information to the right place at the right time for the right person to use, there is no reason why we couldn't:

* kindle widespread adoption of healthy lifestyles,
* maximize people's adherence to proven preventative practices,
* make much more timely diagnoses,
* render far more accurate prognoses,
* select the most appropriate treatment for each individual, every time,
* eliminate the unaccountable variations we now see in practice patterns across the country,
* improve dramatically patients' compliance with medical advice, and
* reduce by orders of magnitude the alarming number of errors the system now produces.

And providing the right information to the right place at the right time for the right person is precisely what the new technological tools that will be at your disposal are increasingly able to do. Both for physicians and for patients.

Given the facts already on the ground, it's not too difficult to foresee some of the major changes in the way medicine will be practiced in your lifetime. I realize the hazards of forecasting. As Yogi Berra once said, "Predicting is risky business - especially about the future." Yogi's caution notwithstanding, let me make ten really safe forecasts. Really safe, because most of these ten futures are already here in some places.

1.Every individual will maintain a lifelong electronic file of their comprehensive health information, and will personally, or through a designated surrogate, authorize access to appropriate providers of that portion of the information needed to deal with current problems.
2.Individuals will maintain their own personalized, medical web pages to which their doctors and others, as directed, will post relevant information and reminders tailored to their specific needs and desires.
3.Doctors and patients will routinely communicate via e-mail and via tele-visits, reducing substantially the hassles now associated with making and keeping routine office or clinic appointments.
4.Using sophisticated on-line devices, individuals will monitor their own health status at home as frequently as necessary to maintain health and to comply with physician-prescribed or self-selected disease management programs.
5.Individuals with all manner of acute and chronic diseases and disabilities will routinely access Internet sites to join virtual communities of similarly afflicted people for support and to share experiences and advice.
6.Many patients with stable chronic illnesses will choose to maintain a cyber-relationship via the net with a respected source of specialized expertise, wherever in the world it may reside, to meet their needs for on-going monitoring and updated advice."
This is an excerpt from a speech given in 2003 by AAMC President , Dr Jordan J. Cohen
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