This Week's News 7-11 June 2010

2

Bringing Doctors to the Dying Patient’s Bedside
New York Times

03/06/2010

By PAULINE W. CHEN, M.D.
When D., a woman in her mid-30s, learned that she was dying from complications of AIDS, she fully expected that her life would end in much the same way it had been lived: homeless, alone and among strangers.

If it hadn’t been for Dr. Jason K. Alexander, a medical student at the time, she might have been right.

Two years earlier Dr. Alexander, along with four other classmates, had created a project that paired medical students with patients who were dying alone. “We wanted to reach out to patients who had been shunned, the people others didn’t want to deal with,” Dr. Alexander recently recalled.
The program, which also helps family members who are struggling with terminally ill loved ones, was part of an innovative new center for humanism at the University of Medicine and Dentistry of New Jersey-New Jersey Medical School in Newark. The center offers four-year scholarships for students with outstanding academic and community service records.
D. was one of the program’s first patients, a woman who years earlier had been rejected by her own family. “She was angry at first,” Dr. Alexander said, recounting his initial visit with her. “She was dying, but she took the opportunity to attack me, a medical student who had walked into her room and said that he was just there for her to talk.”
Dr. Alexander was about to leave when he remembered the advice of his faculty adviser: let the patient guide the conversation. “I surrendered to her anger and told her that we didn’t have to talk, that I would just sit in the room with her.” After several minutes of trying “to embrace the deafening silence,” Dr. Alexander heard a noise coming from where D. was sitting. “I saw tears rolling down her eyes,” he said remembering the moment. “She began sobbing that she was scared and had no one.”
That visit would be the first of nearly daily conversations between Dr. Alexander and D., meetings that would continue several months until her death.
The school’s initiative, started with a $3.2 million grant from the Healthcare Foundation of New Jersey, is part of what many believe is an expanding movement in medical education: a growing emphasis on the human side of medical care. Leaders of this “humanism movement” have come from both the general public and within the ranks of medical education. And although they have focused on issues like patient-centered care, physician professionalism, clinics for the uninsured and disaster relief, nearly all have agreed on one thing: the importance of supporting what they believe are the natural, but often suppressed, ideals and inclinations of those who chose to pursue a career in medicine.
“I believe there is a yearning among physicians to practice this way,” said Sandra O. Gold, president and chief executive of the Arnold P. Gold Foundation. The nonprofit organization has financed the bulk of the movement’s initiatives in the last two decades, with more than $15 million in grants for research, lectures and conferences. “But everything that is happening to doctors dissuades them from these humanistic ideals,” she said.
Most notably, the foundation initiated and continues to support two national programs: the Gold Humanism Honors Society, which inducts physician members based on both their clinical acumen and bedside manner, and the white coat ceremony, now carried out at most medical schools across the country. During the formal event, first-year medical students take the Hippocratic Oath, pledge to provide compassionate care, hear from prominent figures in the humanism movement and receive their first white coats.
“With programs like these,” said Lester Z. Lieberman, founding chairman of the Healthcare Foundation of New Jersey, “we are hoping to gain some leverage with these young doctors, so that they go out and practice and treat their patients as human beings and press their colleagues to do the same.”
Critics assert that the benefits of such programs are transient at best, pointing to failed efforts of generations past. They maintain that once young doctors are exposed to the dehumanizing forces of internship and training and to the financial exigencies of practice, they will lose even their most cherished ideals.
But those who have researched the impact of the newer initiatives disagree. They counter that over the last two decades the “science” of humanism has made tremendous inroads, many of which are helping current efforts to succeed where past ones have failed.
“What makes a difference is that we now have ways to measure professional behavior,” said Dr. David T. Stern, vice chair of professionalism at Mount Sinai School of Medicine in New York and a Gold Humanism Honor Society member. While identifying professionalism, compassion and patient-centered behavior was once an “I-know-it-when-I-see-it endeavor,” he said, “deans and faculty can now weigh actual indicators of humanism on evaluations.” Such measurements allow teachers to model, recognize and reward behavior more effectively. “Students now know that it isn’t just a couple of geeky, crunchy granola types who are talking about it.”

The ubiquitous nature of events like the white coat ceremony as well as the growing popularity of programs like those that bring medical students to dying patients’ bedsides help keep the ideas of humanism front and center in the conversations and thoughts of students and more experienced physicians. “We’ve been able to create an environment where people feel safe and comfortable expressing some of those inner thoughts that weren’t so readily expressed maybe 15 years ago,” said Dr. Dorian Wilson, associate professor of surgery and director of the humanism center at UMDNJ-New Jersey Medical School. “Administrators, faculty and students, all of us are definitely more conscious of it than we’ve ever been.”

That consciousness in turn helps the students follow through on their aspirations. For example, over the last two years the project created by Dr. Alexander and his fellow students has helped nearly 20 patients and several families; at the UMDNJ-University Hospital, where their project is based, it is now rare for patients to die alone. And although the five co-founders, including Dr. Alexander, just graduated this past week, their work will continue, thanks to faculty and administrative support and nine current medical students, some of whom are among the school’s newest humanism scholars.
“What the Gold Foundation and others have done is brought the language of humanism into the light of the hospital day,” Dr. Stern said. “It is O.K. to talk about compassion and respect. And that, I think, has made a difference for doctors and for patients.”
On what would be her last Christmas Eve, D. insisted to the nurse assigned to her for the night that Dr. Alexander would visit. But the nurse gently reminded D. that it was winter break for the medical school and, like the other students, Dr. Alexander had gone home for vacation.
But just before midnight, Dr. Alexander appeared at her door, carrying a Christmas card he had bought for her. D. looked at him, then her nurse, and together all three began to cry.

She was no longer alone.

Join the discussion on the Well blog, “Making Sure Patients Don’t Die Alone.”

3

Coordination key to World Cup emergency readiness
Washington Post

04/06/2010

By DONNA BRYSON

The Associated Press

JOHANNESBURG -- A disaster during the World Cup could overwhelm the fragile network of hospitals and ambulances on which most South Africans depend, experts and health workers say.
But the public system won't have to cope alone, the chief medical officer for local tournament organizers said in an interview this week. Dr. Victor Ramathesele outlined plans for what he said would be unprecedented coordination between the public system, the military and the private sector in case of emergency during Africa's first World Cup.
"This event has forced us to work together. We've had to establish processes and systems to work together," Ramathesele said. "We are ready."
Some of what Ramathesele calls South Africa's resource and infrastructure challenges have made headlines in recent weeks.
Last month, South Africa's high infant mortality rate was underscored when an unusually high number of babies died in hospitals in Gauteng. The province includes Johannesburg and will host the most World Cup games, most of the teams and most of the tourists coming for the tournament.
The health minister said AIDS contributes to the deaths of many babies in South Africa. The country has an estimated 5.7 million people infected with HIV, more than any other country, putting an extraordinary burden on the health care system in this nation of about 50 million.
Also last month, Soweto's Chris Hani Baragwanath Hospital had to rely on generators after thieves stole power cables. It ran out of fuel for its generators before city power was restored.
Baragwanath, which has more than 3,000 beds and bills itself the largest hospital in the world, is the hospital closest to Soccer City, the main World Cup stadium.
For its April edition, the South African Journal of Medicine surveyed disaster management specialists at Baragwanath and two other major public hospitals in Gauteng. The journal reported shortages of equipment, space in intensive care units, money and trained staff, but said "Herculean efforts" were being made to ensure South Africa was ready for the tournament.
Paramedics speaking to The Associated Press on condition of anonymity because they feared losing their jobs said working ambulances were in short supply and described having to buy some of their own equipment, such as safety helmets.
They also said there was not enough qualified staff to run the ambulances.
Shalen Ramduth, head of training for Netcare 911, the emergency response arm of a major private hospital chain in South Africa, said Netcare paramedics and ambulances were ready to step in - and were already boosting government services.
"If something does happen (during the World Cup), we have the capability to manage it," he told AP. "As South Africans we need to do whatever is necessary to make it happen. As a collaboration, we're ready."

Ramduth, who moved from the government to the private sector in 1994, said support from military health workers and facilities would also be key during the World Cup.

Health care is where the developing world meets the developed world in South Africa. While its public hospitals struggle, medical tourists come to its private hospitals for affordable, excellent care.
"The health care system in this country can be improved and is currently undergoing a major reform," said Ramathesele, the World Cup medical chief.
But he said that same beleaguered public system has coped with disasters in the past, such as outbreaks of cholera and measles. In 2001, more than 40 people were killed in a stampede before a match between local soccer teams at Johannesburg's Ellis Park, one of the stadiums that will host World Cup matches. The South African Journal of Medicine noted in its April survey that Johannesburg's Charlotte Maxeke Hospital successfully treated 146 people after the 2001 stampede in just over two hours.
Ramathesele's argument that South Africa would cope during the World Cup by pooling health resources was echoed by Jack Bloom, a frequent and sharp critic of health care services in Gauteng. Bloom, of the main opposition Democratic Alliance, is a member of the Gauteng legislature who made health one of his specialties.

"We'll pull together for the World Cup," Bloom said. "It would be nice if this sort of level of preparedness was permanent."

Analyst Mark Schroeder, whose Texas-based STRATFOR advises corporations and government agencies around the world on security and other concerns, said the emergencies health care workers are bracing for range from major traffic accidents to a terror attack. Schroeder, like the U.S. and South African governments, said there was no specific terror threat to the World Cup.

If a large-scale attack were to occur, South Africa's medical services and transportation infrastructure would be overwhelmed," STRATFOR concluded in a recent World Cup security assessment.

Coping with a major disaster would stretch resources even in more developed countries, Schroeder said.

"It'll be sort of a nervous month," Schroeder said.

Associated Press Writer Nastasya Tay in Johannesburg contributed to this report.

4

International Conference to Focus on Maternal, Infant Mortality
Voice of America News

03/03/2010

Hosay Salam | Washington
An international conference on maternal and child health opens June 7-9 in Washington. The two-day meeting is to explore ways to curb high child and maternal death rates in some countries through political, economic and cultural means. One country with a particularly high rate of maternal and child mortality is Afghanistan.
Qudratullah Mojadidi is an Afghan doctor in Obstetrics and Gynecology in Jacksonville, Florida, who travels to Afghanistan to provide his services to expecting mothers and children at the CURE International medical facility. Mojadidi says figures on child mortality rates in Afghanistan are devastating.
"The neonatal mortality -- neonatal mortality means from the birth to the first four weeks of life -- is 16 percent," Mojadidi said. "So, 16 percent of term infants will die before their fourth week's age. And that is just a devastating figure. Even if you go very conservative and divide that by half, still it is just about the highest in the world."
Common causes of early death

Mojadidi says the most common causes of early deaths in infants include infections, diarrheal diseases, and dehydration.

Dr. Christopher Murray, a professor at the School of Public Health at the University of Washington, says Afghanistan also has one of the world's highest maternal mortality rates. He says Afghanistan's high fertility rate, lack of education for young women, and limited access to emergency obstetric services has raised the maternal mortality rate across the country.
"In terms of reducing the maternal mortality rate in Afghanistan, it is about reducing fertility, it is about educating women, and it is about providing access to ante-natal care and emergency obstetrical services," Murray said. "And to do that, I think given the circumstances that are present in Afghanistan, probably development assistance for health is going to be an important part of funding those expanded reproductive health services."
Situation in Afghanistan

Mojadidi agrees. He is particularly critical of the conditions of many of the health-care facilities in Afghanistan.

"I have really advised patients not to go to some of the hospitals because they would rather be at home and be a lot safer than go into the hospitals and play a high risk in losing their lives or becoming morbid," he said. "It is just that bad because the quality of the healthcare, particularly the quality of the health providers, is so bad that it is incredible."
Family planning key

Mojadidi says family planning is key to improving maternal health.

"If you look at the world figures, the cheapest, the easiest and the fastest way to reduce the maternal mortality rate by up to 50 percent is implementing a very effective, massive family planning in the country," Mojadidi said. "If you do family planning, not only do you have healthy mothers, but you have healthy children and then of course, you have a healthy society and healthy future."
Mojadidi says many mothers do not know how to care for themselves and their children in an effective way. Compounding the problem, he says, poor infrastructure makes it difficult for women to travel to see their doctors, and health-care facilities lack equipment and trained personnel. Mojadidi says educating women in health care and improvements in infrastructure and medical facilities are all crucial to curbing the high rate of child and maternal mortality in Afghanistan.

5

Anderson University moves to add nursing program
The Greenville News

06/06/2010

By Liv Osby • Health Writer
The recession may have temporarily eased the nation’s nursing shortage, but experts say hundreds of thousands of nurses will be needed as the economy recovers and society continues to age.
Anderson University hopes to be part of the solution by launching a nursing school in 2012 to produce more nurses in the Upstate.

But it could face the same problems that keep other nursing schools from turning out enough nurses, including a dearth of faculty and clinical slots.

Anderson University plans to convert existing space on the campus for the nursing program, said spokesman Barry Ray. Pending all approvals, the projected start date is some time in 2012, he said.

Each year, the school would graduate about 24 students who complete a 15-month accelerated curriculum after two years of general education, with graduates receiving a bachelor of science degree, said Timothy L. Smith, dean of the School of Nursing at Tennessee’s Union University who developed a feasibility study on behalf of AU.

That study was recently approved by the state Board of Nursing, he said. Now an evaluation report with more specifics will be produced.

Peggy Hewlett, dean of the University of South Carolina’s College of Nursing, said that while the recession has temporarily eased the shortage as older nurses have postponed retirement, part-timers have gone to full-time work, and others have returned to the field after leaving, so it won’t affect it over time.

With about 31,000 registered nurses now, South Carolina expects a 17 percent shortfall by 2020, she said.

“All the projections show the supply and demand will not be equal in the next 10 years,” Hewlett said. “We really are going to continue to have a shortage.”

That’s because the average age of nurses now is between 45 and 50, the population of older people in particular is growing and increasing demand, and schools can’t produce nurses fast enough, she said.

But most colleges statewide and nationally aren’t taking as many students as apply because of a lack of faculty and clinical space for their training, she said.

Indeed, the American Association of Colleges of Nursing reports that U.S. nursing schools turned away 54,991 qualified applicants last year because of insufficient faculty, clinical sites, classroom space and budget problems
The association also reports that there were 803 faculty vacancies at 310 nursing schools across the country, and that 117 schools needed to create 279 additional faculty spots to meet demand.
The main reasons for the lack of faculty are lower salaries in academia than in private practice and too few teachers with doctoral degrees, according to AACN.
“The reason colleges are at capacity now in South Carolina and around the country is not a lack of applications or desire,” Hewlett said. “It’s due to a lack of faculty and clinical space.”
Legislation passed in 2007 to increase faculty salaries and add faculty in nursing schools in the state wasn’t fully funded, she said. So new nursing programs may not be the best solution, she said.

“New programs put additional stress on a state already looking at faculty shortages and clinical site shortages,” she said. “It’s a real conundrum.”

But AnMed Health has written a letter of support for the new nursing program.
“The program would be a great asset to our community and has the potential to increase the number of highly trained nurses in our workforce,” said spokeswoman Heidi Charalambous. “AnMed Health has some excellent clinical preceptors, and we've already talked with AU about providing rotation sites for their students.”

Smith said the university will address the faculty issue, but ultimately will be successful in recruiting staff. He also said there are enough clinical spots available for the small number of students the school would have.

Meanwhile, Peter Buerhaus, director of the Center for Interdisciplinary Health Workforce Studies at Vanderbilt University, and colleagues projected in the journal Health Affairs last year that the country would see a shortage of 260,000 registered nurses by 2025.
“Certainly we need more RNs. But they’re going to need new faculty and new clinical space,” said Hewlett. “There are no easy solutions.”

6

Agencies warn of coming doctor shortage
Los Angeles Times

07/06/2010

By Tammy Worth, Special to the Los Angeles Times
Stories of emergency rooms pushed to capacity and wait times at physicians' offices have become legendary. Now the passage of healthcare reform — potentially funneling 30 million new people into an already-packed system — has some groups warning that the nation will soon see a shortage of doctors.
The Assn. of American Medical Colleges has warned of a deficiency of up to 125,000 doctors by 2025. And it isn't the only group voicing concerns. The Health Resources and Services Administration, a federal agency that works to improve healthcare access for the uninsured, has projected that the supply of primary-care physicians will be adequate through 2020, at which point there will be a deficit of 65,560 physicians. The American Academy of Family Physicians estimates the need for almost 149,000 extra doctors by that year.
All this, the groups warn, could bring longer wait times and travel distances to see a doctor, briefer visits, higher costs and — in places where shortages are extreme — loss of access to physicians altogether.
Though estimates and degrees of pessimism vary, most healthcare providers and healthcare delivery experts agree that, at some point, there will be a strain in primary care. And the problem goes further than mere doctor counts. Among the other complicating factors: a misaligned distribution of physicians between discliplines (too many neonatal doctors, for example, and too few general surgeons); increased health needs of aging baby boomers; and disagreement over how much of the gap can be filled by physician's assistants and nurse practitioners, professions where there also are shortages.
Doctor-shortage concerns have come up in the past, but by the 1990s, particularly during the introduction of the Clinton health reform plan, many groups were forecasting a physician surplus. The need for more primary care "gatekeepers" for HMOs and a push for more preventive services had sparked an increased interest in the field.
But the tide turned when HMOs did not become as ubiquitous as expected, and now population growth coupled with health reform has created concern anew.
"This will be the first time since the 1930s that the ratio of physicians to the population will start to decline," said Dr. Atul Grover, chief advocacy officer for the AAMC. "The number of people over 65 will double between 2000 and 2030, and the amount of medical services they require is two to three times higher than many other adults."
Not only will these individuals seek preventive care, but they will need specialists — cardiologists, urologists, endocrinologists, more — to deal with issues such as heart disease, diabetes and respiratory problems, Grover said.
On top of the boomer issue, the U.S. Census Bureau is estimating that the total population will grow from just over 300 million to 350 million by 2025.
To keep up with the medical needs of a growing population, the group has called for a 30% boost in medical school enrollment by 2015. But even with an increase in the number of students attending medical school, the future may be problematic. Dr. Bob Phillips, director of the Robert Graham Center, the research and policy arm of the American Academy of Family Physicians, said there may be a shortage of physicians in coming years in areas such as child psychiatry and other pediatric subspecialties, as well as general surgery and primary care.
The reason? Money. A physician providing a 30-minute office visit is reimbursed $103.42 by Medicare, while a diagnostic colonoscopy — which takes about the same amount of time — nets $449.44, according to Bruce Steinwald, director of healthcare for the Government Accountability Office, in testimony he gave to the Senate Committee on Health, Education, Labor and Pensions in 2008.
A pediatric ophthalmologist makes half the income of one working with adults, Phillips said. And if a medical student chooses to go into primary care instead of a subspecialty like cardiology, which pays more, they will lose $3.5 million in income over a lifetime, he added.
"A lot of people want to go into primary care, but they can't make the math work," he said. "You really have to have a passion for primary care to choose it."
Granted, it's not as if primary-care providers are going to starve: They still make anywhere from $150,000 to $200,000, depending on the part of the country they work in, said Kevin Barnett, senior investigator at the Oakland-based Public Health Institute.
"But it is a combination of the high cost of medical education … and comparatively low salaries of primary care physicians" that make family medicine a difficult choice, he said. The number of medical students going into family medicine fell by more than 25% between 2002 and 2007, according to the AAMC.
Still, things may not be as dire as all these numbers suggest — at least, not across the board. This year, for example, saw a 10% increase in the number of U.S. medical students choosing to go into family medicine.
And data can be deceptive, depending on how the numbers are crunched. When compared with the population, the number of primary care physicians and nonphysician professionals actually grew more rapidly during the last decade, according to Steinwald's testimony.
For these and other reasons, not everyone agrees there is a looming problem.
"I don't think there is an overall doctor shortage, and I don't think we are facing one," said Dr. David Goodman, director of the Center for Health Policy Research at the Dartmouth Institute for Health Policy and Clinical Practice. "At any point in time, there are relative surpluses and shortages of physicians by specialty and place, but the loudest banging of the doctor shortage drum has been done by teaching hospitals looking for more money to expand training."
A lot of the current need is related to a dearth of physicians in certain locales, such as inner cities and rural areas. But merely counting doctors is a simplistic way to assess care quality, experts noted.
"Generally, more physicians per capita does not lead to better outcomes," Goodman said. "Organization of care and decisions doctors make [are what] count — not necessarily the number [of doctors]."
Whether there will be a shortage of doctors remains to be seen, but there are some steps that can be taken to alleviate pent-up demand in the current system and shield it from future problems.
Increasing the usage of telemedicine is one option. Because telemedicine allows patients to contact healthcare providers through audio/visual equipment, it allows for greater patient access, particularly those in underserved areas, where providers are scarce.
Another option is to make more use of a cast of supporting providers.
"When we talk about a shortage, we are looking at the current way we provide care to people and say it has to be provided by a primary care physician," Barnett said. "From community health workers to other services provided by physician assistants and nurse practitioners, so much of what can be addressed in terms of routine care can be performed by others."
But it will also be important to encourage physicians to settle in medically underserved areas, he added. This can be done, in part, by recruiting people from underserved areas into medical schools, as they are often more likely to go back to those areas once they've graduated.
"Some places are already dealing with a shortage," he said. The question, he added, is whether the system will be able to mobilize and disseminate the workforce so the shortage will be short-term and manageable — instead of long-term and severe.

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