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Hearing without Listening: NEJM Perspective Piece

by jmiller on November 3, 2016

Jeffrey Drazen, MD, takes us through a scene of “pre-rounding” in an ICU unit, in which the attending physicians are rounding with their computers, giving the latest data on each patient without connecting with the patient. The residents who really know their patients’ overnight story don’t read from the computer; instead, they look at the group when they present. They consult the computer only on a rare occasion when someone asks a question to which they don’t know the answer. “Freed from the hypnotic power of our screens, we can once again engage with other human beings and pool our knowledge and expertise in satisfying and productive ways. Ultimately, that can’t help but benefit our patients.” Click here to read full text.

Guidelines for the management of severe brain injury, Fourth Edition

by jmiller on October 12, 2016

The purpose of this article (Neurosurgery, Sept.), is two-fold: “to synthesize the available evidence and translate it into recommendations. This document provides recommendations only when there is evidence to support them.”  Updated treatment recommendations are offered in bold in their tables. There are now 28 evidence-based recommendations; 14 are new or changed from the previous edition, while 14 have not changed. Click here to read the full text.

Rethinking the primary care workforce – an expanded role for nurses

by jmiller on October 5, 2016

In this “Perspective” article (NEJM, Sept 15), “the adult population of the U.S. will soon have a different primary care experience than we’ve been used to. In the primary care practice of the future, the physician’s role will increasingly be played by nurse practitioners (NPs). In addition, the 150 million adults with one or more chronic conditions will receive some of their care from registered nurses (RNs) functioning as care managers. Although NPs and RNs are increasingly central to primary care, there are still obstacles to their performing these roles that need to be overcome. Despite these challenges, the shortage of primary care physicians and the increasing prevalence of chronic diseases are powerful forces pushing primary care toward stronger NP and RN participation. It’s fortunate that the growth in the supply of NPs and RNs enables us to rethink who does what in primary care.” Click here to read full text.

Doctors tell all – and it’s bad: a crop of books by disillusioned physicians reveals a corrosive doctor-patient relationship at the heart of our health-care crisis

by jmiller on October 4, 2016

This interesting essay was written about why it has become so difficult for so many doctors and patients to communicate with each other. “Ours is a technologically proficient but emotionally deficient and inconsistent medical system that is best at treating acute, not chronic, problems: for every instance of expert treatment, skilled surgery, or innovative problem-solving, there are countless cases of substandard care, overlooked diagnoses, bureaucratic bungling, and even outright antagonism between doctor and patient.  For a system that invokes a “patient-centered care” as a mantra, modern medicine is startlingly inattentive – at times actively indifferent – to patients’ needs. Today’s physicians see themselves not as the “pillars of any community” but as “technicians on an assembly line.” Doctors today are more likely to kill themselves than are members of any other professional group.”  (Atlantic Monthly, Nov. 2014)   Click here to read full text.

The terrorist inside my husband’s brain by Robin Williams’ widow

by jmiller on October 4, 2016

Susan Williams, widow of Robin Williams, has written a special editorial for the October issue of Neurology, which was the subject of yesterday’s media newscasts. Her purpose in doing so is to raise awareness and to offer a plea for further (and much-needed research) in the area of Lewy body disease and dementia, the disease which ultimately ravaged her husband’s life. The editorial poignantly describes the last few months of their lives together and the confusion over the diagnosis and treatment.  Click here to read full text.

Implementing MACRA: Implications for physicians and physician leadership

by jmiller on September 12, 2016

In this Viewpoint (NEJM, June 14), “MACRA (Medical Access and CHIP Reauthorization Act), will overhaul Medicare’s physician payment system starting in 2019, placing most physicians in the Merit-Based Incentive Payment System (MIPS), a pay-for-performance system that adjusts payments based on measures derived from prior care.  Physicians can be exempt from MIPS and receive bonus payments by demonstrating sufficient participation in advanced alternative payment models (APMs), which are intended to support greater flexibility in care delivery alongside greater accountability for efficiency and care improvement.  The proposed rule has begun the historic and complex undertaking of reforming physician payment.  Despite its size and scope, the rule leaves many questions unsettled, including certainty about the best pathways forward for many types of physicians, and how much influence the reforms will leave on quality of care and spending for Medicare beneficiaries.  Click here to read full text.

Evolutionary pressures on the Electronic Health Record: Caring for complexity

by jmiller on August 16, 2016

“There is building resentment against the shackles of the present EHR; every additional click inflicts a nick on physicians’ morale.  At present, the spectacular effects of computers in science and in the secular world are not reflected in the EHR, which for physicians remains burdensome, all-consuming, and far from intuitive:  this is not surprising when the dominant EHRs are designed for billing and not primarily for ease of use by those who provide care.  In fact, a measure of successful EHR evolution may be that physicians spend much less time with the EHR than they do now.  Deimplementing the EHR could actively enhance care in many clinical scenarios.  Simply listening to the history and carefully examining the patient who presents with a focused concern is an important means of avoiding diagnostic error.”  (JAMA, Aug 15)  Click here to read.

JAMA: United States Healthcare Reform: Progress to Date and Next Steps, by Barack Obama; and Editorial: The Affordable Care Act and the Future of U.S. Healthcare

by jmiller on July 12, 2016

(JAMA early online publication) A special communication from President Obama presenting a summary of the Affordable Care Act, describing the successes, the challenges ahead and the policy implications of the ACA’s legislative history. The article concludes: “Policy makers should build on progress made by the Affordable Care Act by continuing to implement the health insurance marketplaces and delivery system reform, increasing federal financial assistance for marketplace enrollees, introducing a public plan option in areas lacking individual market competition, and taking actions to reduce prescription drug costs. Although partisanship and special interest opposition remain, experience with the Affordable Care Act demonstrates that positive change is achievable on some of the nation’s most complex challenges.” Click here to read full-text.

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