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Showing posts from September, 2010

Rx for US Health Care: Grand Junction?

Atul Gawande's latest piece on Palliative Care is fantastic, and I hope you have read his "McAllen, Texas piece" on the cost-conundrum in medicine. While the focus was on why there were such high costs of medical care in McAllen, one of the sites of sharp contrast provided was Grand Junction, Colorado where the quality of care was high but with low overall cost to Medicare. So what is the secret to providing high quality and low cost? An article in this week’s NEJM looks into the success of Grand Junction more closely. The secret? Primary care and palliative care. According to the Dartmouth Atlas of Health Care Medicare spending in Grand Junction was 24% lower than the national average and 60% below high-cost Miami. In 2005, Grand Junction had less bypass surgery and coronary angiography, and only 61% as many inpatient days during the last 2 years of life. For those who criticize the Dartmouth Atlas for failing to control for regional differences in cost and

Dying without Dialysis

There is a terrific article in this weeks Journal of Pain and Symptom Management by Fliss Murtagh of King's College in London about the epidemiology of symptoms for patients with advanced renal failure who die without dialysis.  This study is important because while we know that patients with advanced renal failure have a limited life expectancy and the average age of initiation of hemodialysis is increasing, we know little about the alternatives to hemodialysis.  Specifically, we know nothing about symptoms affecting quality of life among patients who elect not to start dialysis (so called "conservative management" - is this the best label ?).  This article provides a terrific counterpoint to the article in last years NEJM showing that nursing home residents who initiated hemodialysis tended to die and decline in function (see GeriPal write up here ).  The study authors followed patients with the most advanced form of chronic kidney disease (the new name for re

One Failing of POLST - "Full Treatment" is Needed for All Patients

Medicine is much like politics. Both fields have an affinity to condense complicated multifaceted issues into value-laden phrases that add no actual value.  These phrases permeate every discipline in medicine, and, as seen in politics, can change the way people view issues (ie. incentivizing doctors to have advance care planning discussions with patients being transformed into a simple phrase - death panels ).  Below are just several examples of value-laden yet valueless phrases in medicine and the reasons we use them: Failure to Thrive: an expression of linguistic laziness in which the provider is too busy to express the underlying issues such as depression, weight loss, or mobility issues.  In adult medicine, it is only used in describing a constellation of symptoms in the very old in the hopes that no further investigation is needed, often with stunningly great success in its implementation. Antonym: acromegaly .  Withdrawal of Care : an expression of extreme self-doubt as a

Potpourri from Clinical Work III

Interesting issues and questions from my recent stint on the inpatient hospice and palliative care service. Hospices are not supposed to discriminate against patients based on code status.  Yet I think in practice some do. Some do not take patients who are DNR.  Others ask them to sign a DNR form on enrollment.   Other people's experiences with this?  Is anyone concerned? We cared for a patient with Complex Regional Pain Syndrome (former name Reflex Sympathetic Dystrophy).  This patient has a chronic painful condition but no terminal illness, and pushes on the boundaries of what constitutes a "palliative care" patient.  In some sense all hospitalized patients can benefit from palliative care.  The question is, how far do our boundaries extend in caring for these patients?  Sure we can help everyone, at least a little bit.  But at some point the costs outweigh the benefits.  Where is that line, and how much should be determined on a local basis versus a national  missio


I sometimes wonder if we spend too much time talking about professionalism. It is not that I don't think we should promote professionalism. Of course we should. But many discussions of professionalism descend into overly academic and scholarly treatises that end up obscuring rather than clarifying the values such discussions hope to promote. It may be a mistake to overly intellectualize core values. I sometimes wonder if we would be better off focusing on core values and thinking about how to promote and reward those values. Humility is one of those core values, and a wonderful essay by Dr. Jack Coulehan in the Annals of Internal Medicine wonderfully discusses the virtue of humulity and its importance in medicine. This brief 2 page essay can be read in 10 minutes, and it will be 10 minutes well spent. Coulehan has a three part definition of humility: (1) unflinching self-awareness; (2) empathic openness to others; (3) a keen appreciation of, and gratitude for, the privileg