We have a serious epidemic of a very serious disease, pertussis (whooping cough) and a substantial number of parents who have chosen not to provide their children with pertussis vaccination, I am republishing this post first written in January 2010.
If your child has friends who have not been vaccinated, consider finding other friends for your kid. If your child has not been vaccinated, be prepared to lose friends.
REPUBLICATION
In a recent study reported to physicians by Medscape (the original article appeared in the January issue of the Archives of Pediatrics & Adolescent Medicine), approximately 5% of the children who were studied did not have varicella vaccination because of parental refusal. The study found that the children whose parents refused to have their children immunized were at "high risk" of varicella infection compared to children who were vaccinated.
Today, a parent's refusal to vaccinate with a medically proved effective and safe vaccine has no societal consequences for the parent other than the guilt which he or she may shoulder from severe complications of varicella infection in his or her child. Other parents, and their children who become infected as a consequence of each refuser's decision (such as children with immune disorders or leukemia who cannot be vaccinated) unfairly bear all of the financial and personal liability flowing from the original refuser's decision, a decision in which they did not participate.
A straightforward marketplace approach to the parents' vaccination decision making could be relatively simple. After being provided with relevant information, a parent who denies his or her child the protection of vaccination (or does not present the child for vaccination) becomes liable for all economic and "pain and suffering" consequences of all downstream infections which can be traced back to that child by public health authorities. Guaranteed freedom of choice, the refuser could insure against such liability, or could post a bond which he or she purchases.
Adoption of this approach would reduce the cost of health care because it would prevent the refusing parent from shifting the cost of the decision to payers and other parents. The refusing parent could reduce his or her exposure to liability through insurance, bringing the opportunity for new business to insurers. Attorneys actuaries, public health officials could be engaged in the "fight against preventable disease". It's a "win-win".
Saturday, August 21, 2010
Thursday, August 19, 2010
Who Speaks For The Others?
Large and small hospitals may not advertise the fact that they have biomedical ethics committees, but they do. If a patient's family asks "can Dad's case be reviewed by a biomedical ethics committee?" the answer may be "yes, but, we don't think that's necessary" or it may affirm the availability, willingness to meet and consider Dad's case, and the experience and expertise of the committee in formulating recommendations. Or sometimes, review of Dad's case is suggested by a hospital staff person or physician, familiar with Dad's case who also understands the issues Dad's medical and social condition present and seeks help.
This blog isn't about Dad, the subject of biomedical ethics committee attention. This blog is about the focus of the committee on Dad which excludes consideration of the impact of its decision and recommendations on other individuals and communities which the institution serves.(biomedical ethics committee opinions are commonly in the form of recommendations to the doctors, staff and family, and those recommendations reflect consideration of Dad's medical and social issues, discussion with the family, review of hospital and medical staff policies and procedures, consideration of standards of care and sometimes consideration of applicable law). The review is targeted on Dad and his immediate survivors.
A simple example: the committee recommends that Dad, who is terminal, receive full resuscitation efforts because that is what Dad's family says they want and their customs demand. Dad dies. One minute after the team begins Dad's resuscitation, a young patient suddenly and unexpectedly experiences cardiac arrest which would respond to competent resuscitation if the resuscitation team weren't occupied with Dad's fruitless resuscitation. Dad is declared dead, the young patient receives less than optimal resuscitation and survives in a vegetative state. The decision about Dad directly impaired the care another patient received, but the biomedical ethics committee focused only on Dad. No one represented the interests of the potential "others" at the biomedical ethics conference table. When a family aggressively demands services which cannot alter the outcome of care, they may not appreciate or care about the effect of the satisfaction of that demand on the hospital's ability to provide appropriate care to other patients. But this sensitive issue is not often raised in committee deliberations and discussions.
When antibiotics are provided with knowledge that they will not affect the patient's outcome, the appearance of antibiotic resistant bacteria become a threat to all of the patients and communities that the hospital serves. The national cumulative effect of antibiotic resistant bacteria means widespread unnecessary suffering from infections which will not respond to "standard" antibiotics, a huge expenditure for tests and treatments, and preventable mortality. When, with biomedical ethics committee recommendation, an intensive care unit breathing tube is inserted with no expectation that the comatose patient will awaken or ever be weaned, that bed, those staff people, that equipment and the opportunity to care for someone who is highly likely to recover, may be irretrievable.
My suggestion is straightforward. In each biomedical ethics committee case review, one person be appointed to speak for the interests of the "others" - the patients whose lives and care may be impacted by the recommendations for a decision to be made about "Dad." Committee recommendations may not change, but the process will be more honest and inclusive..
This blog isn't about Dad, the subject of biomedical ethics committee attention. This blog is about the focus of the committee on Dad which excludes consideration of the impact of its decision and recommendations on other individuals and communities which the institution serves.(biomedical ethics committee opinions are commonly in the form of recommendations to the doctors, staff and family, and those recommendations reflect consideration of Dad's medical and social issues, discussion with the family, review of hospital and medical staff policies and procedures, consideration of standards of care and sometimes consideration of applicable law). The review is targeted on Dad and his immediate survivors.
A simple example: the committee recommends that Dad, who is terminal, receive full resuscitation efforts because that is what Dad's family says they want and their customs demand. Dad dies. One minute after the team begins Dad's resuscitation, a young patient suddenly and unexpectedly experiences cardiac arrest which would respond to competent resuscitation if the resuscitation team weren't occupied with Dad's fruitless resuscitation. Dad is declared dead, the young patient receives less than optimal resuscitation and survives in a vegetative state. The decision about Dad directly impaired the care another patient received, but the biomedical ethics committee focused only on Dad. No one represented the interests of the potential "others" at the biomedical ethics conference table. When a family aggressively demands services which cannot alter the outcome of care, they may not appreciate or care about the effect of the satisfaction of that demand on the hospital's ability to provide appropriate care to other patients. But this sensitive issue is not often raised in committee deliberations and discussions.
When antibiotics are provided with knowledge that they will not affect the patient's outcome, the appearance of antibiotic resistant bacteria become a threat to all of the patients and communities that the hospital serves. The national cumulative effect of antibiotic resistant bacteria means widespread unnecessary suffering from infections which will not respond to "standard" antibiotics, a huge expenditure for tests and treatments, and preventable mortality. When, with biomedical ethics committee recommendation, an intensive care unit breathing tube is inserted with no expectation that the comatose patient will awaken or ever be weaned, that bed, those staff people, that equipment and the opportunity to care for someone who is highly likely to recover, may be irretrievable.
My suggestion is straightforward. In each biomedical ethics committee case review, one person be appointed to speak for the interests of the "others" - the patients whose lives and care may be impacted by the recommendations for a decision to be made about "Dad." Committee recommendations may not change, but the process will be more honest and inclusive..
Thursday, August 12, 2010
Health Care Costs Requires A Long View, Not A Two Minute Sunday Morning "Talking Point" Presentation Invoking the National Deficit As An Excuse
You probably know the answer to the questions which follow, but Representatives and Senators, who claim to operate for the good of the nation and its people go on television on Sunday mornings and ignore the obvious answers because they are not beholden to you, they are beholden to their funding corporate interests.
1. In the long run, does our country save money by providing access to all children for vaccination for serious childhood diseases? If yes, why don't we do it?
2. In the long run, does access to health care, yield healthier adults whose life time health care expenses are lower? If yes, why don't we provide that access now?
3. In the long run, does providing competent, accessible and affordable obstetrical care for all women reduce the likelihood of injury during obstetrical delivery? If yes, why don't we provide that care now?
4. Does pollution-free clean air reduce the frequency of death and expensive emergency hospitalizations for children and adults? If yes, why are we battling about environmental protection and clean air?
5. Does providing supervised physical activity for kids, instead of sitting them on sofas at home watching TV, help children to be more physically fit and to reduce the long-term costs of their care? If so, why are our kids parked in front of television sets?
6. Does enforcing employment safety rules reduce the frequency and cost of injury born ultimately by the public? If yes, why don't we enforce them?
7. Does the provision of appropriate prescribed medications which the elderly can afford make it more likely that they will take the medicines prescribed by their physicians? If yes, why don't we provide them?
8. Does the provision of appropriately inspected and approved food reduce the number of annual deaths from food poisoning? If yes, why are we experiencing food-borne outbreaks of disease and death?
9. If we have a test for Alzheimers disease, does that mean we can cure the disease? If we have no genuinely effective drugs for Alzheimers Disease, why don't the news reports say so?
10. Is it OK to have "a little diabetes"? If it isn't, what is our national policy to prevent diabetes?
11. Is it better to have a patient with cancer seen earlier or later by competent health care providers? Ask any doctor or nurse.
12.Is there any sensible reason why the federal government negotiates pharmaceutical prices for the Veterans' Administration beneficiaries but not for those who pay for Medicare Part D? So why doesn't it?
13. And finally, other than fancy words, what is our Administration, Congress, our Legislatures and Governors doing today to make Americans healthier?
Failure to provide competent accessible ethically appropriate care at all life stages inflates our long-term health care costs, seriously increases our budget deficit and harms our quality of life. Why are our President, Senators, Congresspeople, state Governors and legislators not talking about the real issues now?
1. In the long run, does our country save money by providing access to all children for vaccination for serious childhood diseases? If yes, why don't we do it?
2. In the long run, does access to health care, yield healthier adults whose life time health care expenses are lower? If yes, why don't we provide that access now?
3. In the long run, does providing competent, accessible and affordable obstetrical care for all women reduce the likelihood of injury during obstetrical delivery? If yes, why don't we provide that care now?
4. Does pollution-free clean air reduce the frequency of death and expensive emergency hospitalizations for children and adults? If yes, why are we battling about environmental protection and clean air?
5. Does providing supervised physical activity for kids, instead of sitting them on sofas at home watching TV, help children to be more physically fit and to reduce the long-term costs of their care? If so, why are our kids parked in front of television sets?
6. Does enforcing employment safety rules reduce the frequency and cost of injury born ultimately by the public? If yes, why don't we enforce them?
7. Does the provision of appropriate prescribed medications which the elderly can afford make it more likely that they will take the medicines prescribed by their physicians? If yes, why don't we provide them?
8. Does the provision of appropriately inspected and approved food reduce the number of annual deaths from food poisoning? If yes, why are we experiencing food-borne outbreaks of disease and death?
9. If we have a test for Alzheimers disease, does that mean we can cure the disease? If we have no genuinely effective drugs for Alzheimers Disease, why don't the news reports say so?
10. Is it OK to have "a little diabetes"? If it isn't, what is our national policy to prevent diabetes?
11. Is it better to have a patient with cancer seen earlier or later by competent health care providers? Ask any doctor or nurse.
12.Is there any sensible reason why the federal government negotiates pharmaceutical prices for the Veterans' Administration beneficiaries but not for those who pay for Medicare Part D? So why doesn't it?
13. And finally, other than fancy words, what is our Administration, Congress, our Legislatures and Governors doing today to make Americans healthier?
Failure to provide competent accessible ethically appropriate care at all life stages inflates our long-term health care costs, seriously increases our budget deficit and harms our quality of life. Why are our President, Senators, Congresspeople, state Governors and legislators not talking about the real issues now?
Sunday, August 8, 2010
Now Do This - and More- For All Physicians & Nurses In Training
NIH Announces Availability of Educational Loan Repayment Programs
The National Institutes of Health (NIH) recently announced the continued availability of educational loan repayment through its extramural Loan Repayment Programs (LRPs). The NIH LRPs provide researchers the opportunity to pursue research careers by repaying up to $35,000 of their qualified student loan debt each year. The application period for new and renewal extramural applicants is September 1 to December 1, 2010. Applicants accepted into the programs will engage in NIH mission-relevant research for at least two years, during which time a minimum of 50 percent of their work hours (not less than 20 hours based on a 40-hour work week) must be applied toward their NIH research activities. Details of the NIH LRPs may be accessed through the LRP website.
(Courtesy of the American Society of Hematology)
The National Institutes of Health (NIH) recently announced the continued availability of educational loan repayment through its extramural Loan Repayment Programs (LRPs). The NIH LRPs provide researchers the opportunity to pursue research careers by repaying up to $35,000 of their qualified student loan debt each year. The application period for new and renewal extramural applicants is September 1 to December 1, 2010. Applicants accepted into the programs will engage in NIH mission-relevant research for at least two years, during which time a minimum of 50 percent of their work hours (not less than 20 hours based on a 40-hour work week) must be applied toward their NIH research activities. Details of the NIH LRPs may be accessed through the LRP website.
(Courtesy of the American Society of Hematology)
Thursday, August 5, 2010
First, Do No Wrong - Continued
In my blog of July 31, 2010 dealing with an experiment in which physicians' clinical notes are posted on the internet so that patients can read them (or possibly anyone whom the patient permits to see the notes can read them). I mentioned patient and physician self-censorship with the comment that I would come back to the subject.
In my clinical experience, the most common situation in which patients withheld important information because of fear that it would be released to a third party, was spousal physical abuse about which California physicians were (are) required to contact appropriate government agencies and patients did not want that report to be made. In spousal physical abuse, there were telltale signs on examination which told the story even when patients' words did not. And I and other physicians would tell our doubly injured patients (physically and emotionally damaged) that we were required by law to report and that we would comply with the law. Should that information also be recorded in a medical note to which the offending spouse might gain internet access even before the authorities intervened?
Less common patient censored information included sexual practices, sexually transmitted diseases, patient or familial mental disorders, childhood abuse, alcohol and other substance abuse, and even the eating of food representing different ethnic practices which patients felt would lead to shame if disclosed to the physician or others. Physician inquiries about familial diseases were often responded-to with "I don't know" rather than the facts which (as time revealed) were well-known to these patients.
Physicians may censor information, which they know may lead to patient difficulties (i.e., advise patients to pay cash for certain tests because insurers might use the insurance-billing information, or information provided which might get back to an employer, in a way which might cause patients to lose insurance or their jobs) and make no mention of their advice or the conditions they were concerned about in their notes.
What do my readers think? For or against posting physician clinical notes on the internet? And why?
In my clinical experience, the most common situation in which patients withheld important information because of fear that it would be released to a third party, was spousal physical abuse about which California physicians were (are) required to contact appropriate government agencies and patients did not want that report to be made. In spousal physical abuse, there were telltale signs on examination which told the story even when patients' words did not. And I and other physicians would tell our doubly injured patients (physically and emotionally damaged) that we were required by law to report and that we would comply with the law. Should that information also be recorded in a medical note to which the offending spouse might gain internet access even before the authorities intervened?
Less common patient censored information included sexual practices, sexually transmitted diseases, patient or familial mental disorders, childhood abuse, alcohol and other substance abuse, and even the eating of food representing different ethnic practices which patients felt would lead to shame if disclosed to the physician or others. Physician inquiries about familial diseases were often responded-to with "I don't know" rather than the facts which (as time revealed) were well-known to these patients.
Physicians may censor information, which they know may lead to patient difficulties (i.e., advise patients to pay cash for certain tests because insurers might use the insurance-billing information, or information provided which might get back to an employer, in a way which might cause patients to lose insurance or their jobs) and make no mention of their advice or the conditions they were concerned about in their notes.
What do my readers think? For or against posting physician clinical notes on the internet? And why?
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