Is there a lesson in the following article for those of us interested in healthcare reform?
- SPC
Why Chávez Was Re-elected
By MARK WEISBROT
WASHINGTON — For most people who have heard or read about Hugo Chávez in the international media, his reelection on Sunday as president of Venezuela by a convincing margin might be puzzling.
Almost all of the news we hear about him is bad: He picks fights with the United States and sides with “enemies” such as Iran; he is a “dictator” or “strongman” who has squandered the nation’s oil wealth; the Venezuelan economy is plagued by shortages and is usually on the brink of collapse.
Then there is the other side of the story: Since the Chávez government got control over the national oil industry, poverty has been cut by half, and extreme poverty by 70 percent. College enrollment has more than doubled, millions of people have access to health care for the first time and the number of people eligible for public pensions has quadrupled.
So it should not be surprising that most Venezuelans would reelect a president who has improved their living standards. That’s what has happened with all of the leftist governments that now govern most of South America. This is despite the fact that they, like Chávez, have most of their countries’ media against them, and their opposition has most of the wealth and income of their respective countries.
The list includes Rafael Correa, who was reelected president of Ecuador by a wide margin in 2009; the enormously popular Luiz Inácio Lula da Silva of Brazil, who was reelected in 2006 and then successfully campaigned for his former chief of staff, now President Dilma Rousseff, in 2010; Evo Morales, Bolvia’s first indigenous president, who was reelected in 2009; José Mujica, who succeeded his predecessor from the same political alliance in Uruguay — the Frente Amplio — in 2009; Cristina Fernández de Kirchner, who succeeded her husband, the late Néstor Kirchner, winning the 2011 Argentine presidential election by a solid margin.
These leftist presidents and their political parties won reelection because, like Chávez, they brought significant — and in some cases huge — improvements in living standards. They all originally campaigned against “neoliberalism,” a word used to describe the policies of the prior 20 years, when Latin America experienced its worst economic growth in more than a century.
Is there a lesson in the following article for those of us interested in healthcare reform?
- SPC
Why Chávez Was Re-elected
By MARK WEISBROT
WASHINGTON — For most people who have heard or read about Hugo Chávez in the international media, his reelection on Sunday as president of Venezuela by a convincing margin might be puzzling.
Almost all of the news we hear about him is bad: He picks fights with the United States and sides with “enemies” such as Iran; he is a “dictator” or “strongman” who has squandered the nation’s oil wealth; the Venezuelan economy is plagued by shortages and is usually on the brink of collapse.
Then there is the other side of the story: Since the Chávez government got control over the national oil industry, poverty has been cut by half, and extreme poverty by 70 percent. College enrollment has more than doubled, millions of people have access to health care for the first time and the number of people eligible for public pensions has quadrupled.
So it should not be surprising that most Venezuelans would reelect a president who has improved their living standards. That’s what has happened with all of the leftist governments that now govern most of South America. This is despite the fact that they, like Chávez, have most of their countries’ media against them, and their opposition has most of the wealth and income of their respective countries.
The list includes Rafael Correa, who was reelected president of Ecuador by a wide margin in 2009; the enormously popular Luiz Inácio Lula da Silva of Brazil, who was reelected in 2006 and then successfully campaigned for his former chief of staff, now President Dilma Rousseff, in 2010; Evo Morales, Bolvia’s first indigenous president, who was reelected in 2009; José Mujica, who succeeded his predecessor from the same political alliance in Uruguay — the Frente Amplio — in 2009; Cristina Fernández de Kirchner, who succeeded her husband, the late Néstor Kirchner, winning the 2011 Argentine presidential election by a solid margin.
These leftist presidents and their political parties won reelection because, like Chávez, they brought significant — and in some cases huge — improvements in living standards. They all originally campaigned against “neoliberalism,” a word used to describe the policies of the prior 20 years, when Latin America experienced its worst economic growth in more than a century.
The Doctor’s Bag for the New Millennium
By ABRAHAM VERGHESE
When I was a medical student in Madras, India, in the late 1970s, my uncle, a retired physician, still made occasional house calls. In his early years he delivered babies in dimly lighted huts, often resorting to high forceps on the head - something that is rarely done now. His compounder - the man who would compound his prescription of mistura carminativa and dispense it in corked glass bottles - carried my uncle's medical bag. It was almost like a trunk - a mobile office. The compounder became so experienced from watching my uncle that he secretly began a practice of his own, delivering babies and even applying forceps.
My uncle's doctor's bag from his halcyon days was long gone by the time I was a medical student staying in his house; it had been replaced by a newish model, a small tan suitcase with square corners and latches on the top. When it was opened, two shelves magically unfolded. The medicinal odor that emanated was so powerful it could deliver a buzz.
One shelf held the sterilized syringes, needles, cotton swabs and alcohol that were the bread and butter of a doctor's trade in India - every patient wanted an injection, and doctors were destined to disappoint if they didn't oblige. The other shelf held ampules of adrenaline, Coramine, theophylline and other emergency medications as well as rows of bright orange vitamin B12 ampules - a dramatic injectable placebo.
The bottom of the bag was stuffed with bottled medications, a blood pressure cuff and instruments that my uncle rarely used: Foley catheters, hemostats and the like. I had carried that bag for him more than once and been there when he jabbed adrenaline into a desperately wheezing patient and produced immense relief.
Redefining Medicine With Apps and iPads
By KATIE HAFNER
SAN FRANCISCO — Dr. Alvin Rajkomar was doing rounds with his team at the University of California, San Francisco Medical Center when he came upon a puzzling case: a frail, elderly patient with a dangerously low sodium level.
As a third-year resident in internal medicine, Dr. Rajkomar was the senior member of the team, and the others looked to him for guidance. An infusion of saline was the answer, but the tricky part lay in the details. Concentration? Volume? Improper treatment could lead to brain swelling, seizures or even death.
Dr. Rajkomar had been on call for 24 hours and was exhausted, but the clinical uncertainty was “like a shot of adrenaline,” he said. He reached into a deep pocket of his white coat and produced not a well-thumbed handbook but his iPhone.
With a tap on an app called MedCalc, he had enough answers within a minute to start the saline at precisely the right rate.
The history of medicine is defined by advances born of bioscience. But never before has it been driven to this degree by digital technology.
The proliferation of gadgets, apps and Web-based information has given clinicians — especially young ones like Dr. Rajkomar, who is 28 — a black bag of new tools: new ways to diagnose symptoms and treat patients, to obtain and share information, to think about what it means to be both a doctor and a patient.
And it has created something of a generational divide. Older doctors admire, even envy, their young colleagues’ ease with new technology. But they worry that the human connections that lie at the core of medical practice are at risk of being lost.
“Just adding an app won’t necessarily make people better doctors or more caring clinicians,” said Dr. Paul C. Tang, chief innovation and technology officer at Palo Alto Medical Foundation in Palo Alto, Calif. “What we need to learn is how to use technology to be better, more humane professionals.”
The Ups and Downs of Electronic Medical Records
By MILT FREUDENHEIM
The case for electronic medical records is compelling: They can make health care more efficient and less expensive, and improve the quality of care by making patients’ medical history easily accessible to all who treat them.
Small wonder that the idea has been promoted by the Obama administration, with strong bipartisan and industry support. The government has given $6.5 billion in incentives, and hospitals and doctors have spent billions more.
But as health care providers adopt electronic records, the challenges have proved daunting, with a potential for mix-ups and confusion that can be frustrating, costly and even dangerous.
Some doctors complain that the electronic systems are clunky and time-consuming, designed more for bureaucrats than physicians. Last month, for example, the public health system in Contra Costa County in California slowed to a crawl under a new information-technology system.
Doctors told county supervisors they were able to see only half as many patients as usual as they struggled with the unfamiliar screens and clicks. Nurses had similar concerns. At the county jail, they said, a mistaken order for a high dose of a dangerous heart medicine was caught just in time.
The first national coordinator for health information technology, Dr. David J. Brailer, was appointed in 2004, by President George W. Bush. Dr. Brailer encouraged the beginnings of the switch from paper charts to computers. But in an interview last month, he said: “The current information tools are still difficult to set up. They are hard to use. They fit only parts of what doctors do, and not the rest.”
Long before computers, many hospitals and doctors charged for services in ways that maximized insurance payments. Now critics say electronic records make fraudulent billing all too easy, and suspected abuses are under investigation by the Office of the Inspector General at the Department of Health and Human Services.
Like all computerized systems, electronic records are vulnerable to crashes. Parts of the system at the University of Pittsburgh Medical Center were down recently for six hours over two days; the hospital had an alternate database that kept patients’ histories available until the problem was fixed.
Which ‘HT’ to Treat: Hypertension or Hammertoe?
By ABIGAIL ZUGER, M.D.
You can jump into a swimming pool, you can dive, or you can inch across the shallow end, making faces and shrieking. But no matter how you immerse yourself, you’ve still got to swim once you’re in.
And as with cold blue water, so with the electronic medical record. The faster the plunge, the briefer the initial pain, but once that first shock is over you still need to move and breathe in a whole new way.
An electronic medical record is not just a neatened-up version of a paper chart. Instead, it recreates the entire health care universe, integrating all of it, from woes to bills, into one glorious paper-free whole.
Not surprisingly, it changes every part of the medical workday, from where you sit and what you do to which glasses you wear to work. From Day 1 you can feel the thing nuzzling at your brain — its whole purpose, of course, is to change the way you think, forcing you willy-nilly down predetermined paths, whether they are actually the right ones or not.
In its fully realized form (one in which it stops crashing, learns some basic medical logic, gets its default drug doses right and successfully compiles all relevant clinical information into a single searchable database) the electronic record could probably be a wonderful thing.
But that incarnation is still largely mythical. Instead, most clinicians are dealing with lesser versions, an experience not unlike slowly traversing the shallow end of a very large pool: Half in and half out, you can neither walk nor swim but just stumble along in chilly misery.
E-Health Opportunities for Seniors
By JANE E. BRODY
Are you among the 47 percent of older Americans who have not yet entered the digital age? If so, you're likely to be missing out on a lot of e-health opportunities available to help you live well despite chronic ailments and encroaching physical limitations.
Americans over 65, whose health stands to benefit the most from modern digital technology, are the least able and least likely to use it. As of April, according to the Pew Research Center's Internet and American Life Project, 53 percent of Americans 65 and older were using the Internet or e-mail, but after age 75, use dropped off significantly, to 34 percent. By contrast, nearly 90 percent of younger adults are digitally connected.
The challenges of getting more of the elderly connected to e-health, a catchall term for digital practices related to health care, are many: lack of awareness; fear of computers and smartphones; problems with vision, hearing, cognition or manual dexterity; limited finances or learning options; and concerns about privacy.
But these limitations are being addressed by experts who specialize in digital communication for seniors - government agencies like the National Institute on Aging and theNational Network of Libraries of Medicine; organizations like libraries, senior centers and residences, Y.M.C.A.'s and AARP; and a small but growing number of upstart companies that provide services in places like assisted living facilities.
"Seniors need to get on the technological bandwagon and become an integral part of their own health care and health care delivery," said Sara J. Czaja, scientific director of the Center on Aging at the University of Miami's Miller School of Medicine. "Many older adults don't see the relevance of having access to the Internet, but more and more medical services are becoming available online."
Ways to Take Advantage
Getting more seniors digitally connected, either personally or through caregivers, is expected to greatly enhance opportunities to protect the health and well-being of older people and, at the same time, reduce both individual and national health care costs.
How can e-health help you? Current and future possibilities listed by Dr. Czaja and others include:
¶Learn more about your health problems and how best to manage them.
¶Become an informed and active participant in decisions about your health.
¶Remain independent and in your own home longer.
¶Maintain an electronic personal medical record with everything in one place for easy access.
¶Enhance emotional health and longevity by staying socially connected to friends and family.
¶Communicate directly with your doctors by e-mail or Skype.
¶Have a technologically based home visit by sending vital information, like blood pressure, heart rate and oxygen saturation, digitally to your doctor.
¶Find and facilitate access to medical specialists.
¶Identify the best Medicare options for your needs.
¶Order prescriptions and groceries online.
¶Develop an at-home fitness program tailored to your needs and limitations.
¶Find recipes and menus suited to your tastes, availability and nutritional requirements.
Strides in Medicine, and Their Price
By LAWRENCE K. ALTMAN, M.D.
Medicine has advanced more in the last century than in all of previous history, and technology’s fingerprints can be found on most of the gains — from new ways to teach medical students to care of patients in hospitals with the most sophisticated equipment to everyday practice in offices. Technology has even helped eradicate a disease,smallpox.
Laboratory and clinical techniques have allowed doctors to operate on the brain and heart, once considered taboo areas, and to perform other surgery through keyhole-size incisions, often with lasers.
Machines dialyze failed kidneys. Patients with repaired joints have shed wheelchairs and canes and walk steadily. They also avoid falls and broken bones, and secondarily improve cardiovascular conditioning. Respirators help patients breathe easier.
Drugs developed through genetic engineering techniques offer effective therapies, if not cures, for a number of diseases. Thin tubes with balloons on their tips widen channels narrowed by fatty deposits, and then insertion of metal stents keeps the arteries open. Other techniques have led to new and improved diagnostic tests that deliver findings more speedily than older ones.
Flexible scopes allow doctors to peer into nooks and crannies of the lungs and the gastrointestinal tract to detect cancers and other diseases that could not be reached with their more rigid predecessors. Using the newer technology doctors can also detect small bleeding sites and to stop life-threatening flows.
But as in many areas of life, overreliance can lead to abuse. Americans have a cultural fascination with technology. Patients often have greater confidence in the technology than in a doctor’s clinical skills and judgment where interpretation of the findings matters most. Inappropriate use of antibiotics has led to the spread of drug-resistant microbes that threaten to undo many of the gains the antibiotics have achieved.
Laboratories Seek New Ways to Take a Look Inside
By JOHN MARKOFF
STANFORD, Calif. — In a bioengineering laboratory at Stanford University, Christopher Contag, a microbiologist, is designing new approaches to “virtual” pathology. He has created a variety of instruments that can travel the esophagus, stomach and intestine, allowing pathologists to probe for cancers by peering in three dimensions below the surface of the skin.
Frustrated by the time between when a tissue sample is taken and when a pathology laboratory can examine it, Dr. Contag, who oversees a molecular imaging laboratory at Stanford, is experimenting with a variety of next-generation endoscopes. The new devices not only portray the surface of the skin, but also use a variety of optical and acoustical techniques to virtually “punch holes” in hundreds of cells deep within the human body, while using contrast agents to identify abnormalities.
He describes the approach as “point-of-care pathology,” part of a convergence of medical technologies that make it increasingly possible for surgeons and medical technicians to make informed, on-the-spot decisions about patient care.
“We want to give the pathologist what he already looks at, so it’s pretty easy,” he said.
In the half-century since the movie “Fantastic Voyage” portrayed a miniaturized submarine navigating the human body to find and destroy a blood clot, researchers have relied on optical, magnetic and X-ray imaging techniques to peer into bodies with ever-greater precision.
Today a new wave of imaging technologies is again transforming the practice of medicine. They include new pathology tools — like the ones Dr. Contag’s team is developing — to give doctors an instantaneous diagnosis, as well as inexpensive systems, often based on smartphones, that can extend advanced imaging technologies to the entire world.
On the horizon is magnetic imaging technology that will combine the speed of X-ray-based computerized tomography, or CT, with the ability of M.R.I. systems to image soft tissues.
With Telemedicine as Bridge, No Hospital Is an Island
By PAM BELLUCK
NANTUCKET, Mass. — When Sarah Cohen’s acne drove her to visit a dermatologist in July, that’s what she figured she’d be doing — visiting a dermatologist. But at the hospital on Nantucket, where her family spends summers, Ms. Cohen, 19, was perplexed.
“I thought I was going to see a regular doctor,” she said, but instead she saw “this giant screen.”
Suddenly, two doctors appeared on the video screen: dermatologists in Boston. A nurse in the room with Ms. Cohen held a magnifying camera to her face, and suggested she close her eyes.
Why? she wondered — then understood. The camera transmitted images of her face on screen, so the doctors could eyeball every bump and crater. “Oh my God, I thought I was going to cry,” Ms. Cohen recalled. “Even if you’ve never seen that pimple before, it’s there.”
That, she realized, was the point. Technology, like these cameras and screens, is making it affordable and effective for doctors to examine patients without actually being there.
More hospitals and medical practices are adopting these techniques, finding they save money and for some patients work as well as flesh-and-blood visits.
“There has been a shift in the belief that telemedicine can only be used for rural areas to a belief that it can be used anywhere,” said Dr. Peter Yellowlees, director of the health informatics program at the University of California, Davis, and a board member of the American Telemedicine Association. “Before, you had to make do with poor quality, or buy a very expensive system. Now, you can buy a $100 webcam and do high-quality videoconferencing.”
Texting the Teenage Patient
By JAN HOFFMAN
The teenager's cellphone buzzes. Her doctor, Natasha Burgert, is texting her: "Better morning with this medication?"
Another teenager opens his phone. "Everything is great," reads Dr. Burgert's discreet text. "Go ahead with the plan we discussed. Please reply so I know you received."
And on the morning of college entrance exams, a teenager who suffers from a roiling stomach reads Dr. Burgert's texted greeting: "Prepared. Focused. Calm. Your body is healthy and well. Good luck today."
Dr. Burgert, a pediatrician in Kansas City, Mo., is making house calls. She is among a small but growing number of practitioners using social media to engage adolescents. Her patients read her blog and follow her on Twitter and Facebook. She even follows a few of the teenagers' blogs, commenting occasionally.
During checkups, Dr. Burgert no longer gives teenagers brochures with advice on healthy living - which usually led to glazed expressions and teeming wastebaskets. Instead, a whiteboard hangs in her exam room, with hyperlinks and QR codes to sites with teenager-friendly material on sexuality, alcohol and drugs. The teenagers can photograph the board with their phones, storing the information to peruse in private.
Those topics dispensed with, Dr. Burgert has more time to listen to her patients. "This is a time for you," she will say. "What do you want to talk about?" She often picks up subtle problems like stomachaches due to test anxiety.
She sustains those relationships through social media and, rather than leave teenagers unguided about dicey health matters, she continues sending them links to appropriate Web sites.
Recalibrating Therapy for Our Wired World
By RICHARD A. FRIEDMAN, M.D.
Speed, instant gratification, accessibility — these are a few of the appealing hallmarks of digital technology. It’s no coincidence that we love our smart wireless devices: Humans are a notoriously impatient species, born with a preference for immediate rewards.
But the virtues of the digital age are not always aligned with those of psychotherapy. It takes time to change behavior and alleviate emotional pain, and for many patients constant access is more harmful than helpful. These days, as never before, therapists are struggling to recalibrate their approach to patients living in a wired world.
For some, the new technology is clearly a boon. Let’s say you have the common anxiety disorder social phobia. You avoid speaking up in class or at work, fearful you’ll embarrass yourself, and the prospect of going to a party inspires dread. You will do anything to avoid social interactions.
You see a therapist who sensibly recommends cognitive-behavioral therapy, which will challenge your dysfunctional thoughts about how people see you and as a result lower your social anxiety. You find that this treatment involves a fair amount of homework: You typically have to keep a written log of your thoughts and feelings to examine them. And since you see your therapist weekly, most of the work is done solo.
As it turns out, there is a smartphone app that will prompt you at various times during the day to record these social interactions and your emotional response to them. You can take the record to your therapist, and you are off and running.
The Policy Verdict I
By DAVID BROOKS
In Thursday night’s debate, Vice President Joe Biden will almost certainly go after Representative Paul Ryan’s Medicare plan. And why shouldn’t he? It’s unpopular. But I’d like to make a case for that plan. It’s the best thing the Romney-Ryan campaign has going for it.
First, let’s define the problem. Today, Medicare costs about $550 billion. By 2020, according to the Congressional Budget Office, it will cost more than $1 trillion, sucking money away from every other government program.
According to the Urban Institute, the average couple in 2010 had paid $109,000 in Medicare taxes during their working years but would be able to receive about $343,000 in benefits. A chunk of that $234,000 gap will be paid for by their grandkids. That should weigh on the conscience of every American over 55. You’re supposed to help your grandkids, not take from them.
Basically, there are two ways to reduce Medicare inflation, through the political system or through a market system. Obamacare tries the former. The current budget projections are so bad because almost no one outside the employ of the president believes this approach will reduce Medicare costs. Obama’s primary cost-control instrument is an independent board of experts that Mitt Romney mentioned often in last week’s debate. It’s supposed to lower payment levels.
There are problems. It’s hard for a few people in Washington to centrally rejigger something that complex. Second, the board is not really out of political control. Congress has already restricted its power and has devised gimmicky ways to overrule an unpopular decision. (All decisions to restrict benefits are unpopular.)
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