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US healthcare

William Cayley: Comfort always and advocacy for the vulnerable

25 Aug, 15 | by BMJ

bill_cayley_2Reading the Monday morning paper, I was greeted by stories about ongoing fights over whether or how to undo the Affordable Care Act (“Obamacare”) and controversies over solitary confinement. Later, while driving to work, I heard more news on the challenges facing those in eastern Europe who are confronted by a rising influx of immigrants. One final check of the news before starting clinic reminded me of the unfolding economic uncertainty that seems currently related to China’s stock market volatility.

Phew—what a way to start the week. And while each of these news stories seems to cast a pall of gloom over the start of the week, at the same time, I think they should serve as a reminder to physicians of what a central piece of our vocation (or calling) needs to be. more…

William Cayley: Ethics and professional wisdom

23 Jul, 15 | by BMJ

bill_cayley_2The recently publicized news that the American Psychological Association (APA) “colluded” with US governmental agencies to create ethical guidelines permitting psychologists to participate in “harsh interrogations” of military detainees is appalling. According to the APA’s own press release, the guidelines were “based at least as much on the desires of the US Department of Defense as on the needs of the psychology profession and the APA’s commitment to human rights.” While appropriate kudos are due to the APA for having the courage to both commission the recent investigation of its ethical practices, and to publicize the results, the sad circumstances that led to those ethical lapses point to a clear need for robust understandings of professionalism and ethics. more…

Muriel Gillick: When life gives you lemons—the 2015 White House Conference on Aging

17 Jul, 15 | by BMJ

Muriel GillickIn the heady days of the early 1960s, when the oldest of the baby boomer generation were teenagers and only 9.2% of the population were age 65 or older, the US held its first White House Conference on Aging. This was by all accounts a grand event, a national citizens’ forum designed to “focus attention on the problems of older Americans and make consensus policy recommendations.” The first conference, attended by 3000 delegates from across the country, discussed issues that ultimately led to the passage of formative legislation, such as the Older Americans Act (which authorized the creation of further conferences on aging, as well as a hot lunch program, senior centers, and other social services) and, of course, Medicare.

The most recent White House Conference on Aging, by contrast, was a modest affair, attended by a mere 200 invited delegates (though observed online by 600 “watch parties”). At a time when 14% of Americans are over 65 and 1.8% are over 85—percentages that are already high and that are projected to increase by 50% in the next 15 years—the conference seemed to be a highly scripted performance rather than a platform for hashing out policy recommendations. more…

David Kerr: The for profit company will see you now

16 Jul, 15 | by BMJ

david_kerr_2015picWhen you hear hoof beats, think of horses not zebras, is the aphorism coined in the 1940s by Theodore Woodward to explain that common conditions occur commonly and rare ones rarely. Most physicians involved directly in patient care will have seen the occasional “zebra” blood test result that is so unexpected when taken into clinical context that it is probably spurious, rather than the harbinger of some exotic lethal disease. Rational and cost effective use and interpretation of laboratory testing is perceived to be good medicine, and this particular skill is honed with experience. Also, when screening for disease, Public Health England is very clear—a screening programme needs to offer more benefit than harm and at a reasonable cost. more…

William Cayley: Diagnosis—what it’s not….

8 Jul, 15 | by BMJ

bill_cayley_2“Phew! At least you don’t have something bad.”

“I know doc, but what is it?”

I’m afraid that in medicine, we too often focus on the former, and not enough on the latter.

How often do we see patients admitted to hospital to “rule out” an acute coronary syndrome? How often do we do a throat swab to “rule out” strep throat? How often do we see imaging reports that come to the final conclusion that “something bad (embolism, pneumonia, etc) cannot be excluded.” more…

William Cayley: Planning for uncertainty

2 Jul, 15 | by BMJ

bill_cayley_2Martin Marshall could not have said it better in his recent blog—the idea of the 10 minute consultation is a travesty . . . except that sometimes it is not.

With the increasing demands on and increasingly complex expectations of GPs and family physicians, expecting everything to fit into a 10 minute visit is simply crazy. Yet there are times when that 10 minute visit (or less) is what the patient wants. In good generalist primary care or family medicine, when we present ourselves as comprehensive physicians there to stand with our patients in health and in sickness, in prevention and in treatment, it should be no surprise that many a visit goes beyond the stated “chief complaint” to a much longer agenda. On the other hand, sometimes our patients simply want treatment for one narrowly focused concern—a cold, a tick bite, a skin infection. more…

William Cayley: To doctor is to diagnose

16 Jun, 15 | by BMJ

bill_cayley_2I appreciated Richard Smith’s recent discussion of mental models—too often, I think, we simply carry on with practice as usual (or, “life as usual”) without sufficient critical attention to the paradigms on which we rely to organize our thinking and doing.

I would beg to differ with him, however, on the argument that “diagnosis is no longer important because most patients have long term conditions.” To the contrary, it is precisely because our patients have (often multiple) long term conditions that diagnosis has become even more important. more…

William Cayley: Less is more

18 May, 15 | by BMJ

bill_cayley_2Both seasoned clinicians and learners in today’s medical environment receive both explicit and unspoken messages that the best medicine involves advanced technology, the latest medications, and highly specialized care. Evidence based medicine, on the other hand, advocates the “conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients,” and campaigns such as “Choosing Wisely” and The BMJ‘s “Too Much Medicine” are encouraging critical thought as to what amount of “medicine” is appropriate for patients and when. more…

Elizabeth Loder: US medical specialty boards: accountable to whom, for what, and how?

18 May, 15 | by BMJ

elizabeth_loder

Elizabeth Loder examines charges of lax oversight and governance at organizations that assess doctors. 

The medical specialty boards that test and certify US doctors are facing a tough test of their own, with plenty of reasons to worry about the outcome. 24 specialty boards administer the tests doctors must pass in order to say they are “board-certified” in a particular field. The boards are represented by an umbrella organization known as the American Board of Medical Specialties (ABMS)The ABMS and its member boards profess a noble mission to serve the public, improve the quality of healthcare, and ensure that they certify doctors who “demonstrate the knowledge, skills and attitudes essential for excellent patient care.” And yet these organizations are now under siege from disgruntled doctors, who paint a far less favorable picture of their motives. more…

Art Cohen and Selwyn Ray: The lessons of late April in Baltimore

8 May, 15 | by BMJ

art_cohenselwyn_rayAfter years of suffering and resignation about disrespect and mistreatment at the hands of local police, young and older African-American residents of inner city west and east Baltimore, joined by others, came together these past two weeks to say: “we’ve had enough.” The spark for this was the fatal injuring, while in police custody on 12 April, of 25 year old Freddie Gray, who died a week later on 19 April. Gray was a resident of the Sandtown-Winchester neighborhood and also a childhood victim of lead paint poisoning. He was arrested for making eye contact with a policeman and then trying to run away. His death acted as the proverbial straw that broke the camel’s back. more…

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