It's easier now as physicians provide more info and become more patient
friendly. A key question to ask: How is the practice run?
Consumers have largely been in the dark when trying to choose a new doctor.
They might want someone who is skilled, pays attention to their concerns and
makes it easy to get an appointment. Instead, with little information to go
on, they pick someone out of a directory whose office is conveniently
located.
But a new emphasis in family medicine on providing quality care and pleasing
patients is giving consumers more to go on. They can find out basic quality
information about doctors - such as how well they provide preventive care -
from some insurers, state health officials and private companies such as
HealthGrades. And a few well-placed questions about the way a doctor runs
his or her practice can give consumers a sense of the type of doctor-patient
relationship they'll have - and, to some degree, the quality of care they'll
get.
"Times are changing, and people's expectations of what they want from their
medical care has changed, and we as practitioners are changing," says Dr.
Donald Klitgaard, a family physician in Iowa who, like doctors across the
nation, has computerized his record-keeping, made it easier for patients to
get appointments and helped his office staff become more efficient.
Odd as it may seem, simply calling prospective doctors and asking whether
their office is computerized may turn out to be the best advice for finding
a physician committed to patient care over the long term.
"The average consumer takes it as a given that doctors have these systems in
place," says Peter Lee, chief executive of the Pacific Business Group on
Health, an employer coalition based in San Francisco. "They don't know how
much medical care today is not 20th century, let alone 21st century, in
terms of how much doctors rely on paper instead of computers."
Nationally, only about 20% of physician offices are computerized; the rest
still rely on notoriously inefficient paper charts. But computers are an
easy benchmark for quality. They can help a doctor not just keep track of
files, but also send out prescriptions accurately and quickly, get lab
results inserted into the record automatically and be reminded what the
scientific evidence suggests is the next best step with a patient.
At the same time, for doctors to get the most value out of computers,
experts say they need to use them as more than word processors; physicians
should use features such as electronic reminders to prescribe a test or a
medication, and change the way they practice as a result. "I believe it
really does translate to better care," says Robert Eidus, a New Jersey
physician with a background in business and medical quality improvement.
"But it's not just that I have an electronic medical record, it's how do you
use it and how does it impact caring for patients."
Oso Family Medical Group in Mission Viejo converted to an electronic medical
record system in 2004, going through the expensive and painful process of
converting thousands of paper files. But it was worth it, says Dr. Lee
Burnett, an osteopath and partner in the five-doctor practice.
The change improved patient care and stopped the constant and inefficient
search for file folders. "We had two people on staff whose jobs were just to
find paper charts," he recalls.
But simply asking whether a doctor's office is computerized shouldn't be the
sole determinant in choosing a physician. Ultimately, in the new
doctor-patient dynamic, patients should have easier access to their doctors
when they need them - in person, by phone or online.
Other aspects of this "new model" of family practice are largely invisible
to patients but just as important: The staff acts as a team to improve
patients' health by making sure they follow up on medical advice and make it
to appointments; the doctors base care on scientific evidence rather than
instinct or habit; patients with chronic illnesses receive follow-up care;
the practice follows up on test results and visits to specialists rather
than waiting for the patient to track down that information.
'Patient experience is key'
This patient-centered approach is considered a new measure of quality
because it means patients will be more motivated to not only see the doctor
but also accept the medical and lifestyle-change advice dispensed.
Patients who work with their doctors in a collaborative way, for example,
are more likely to take care of themselves, according to a study of 24,609
adult patients with chronic or serious conditions.
The study, conducted by researchers at Dartmouth Medical School and reported
in the Journal of Ambulatory Care Management in 2006, found that patients
who participated in good collaborative care had better control of their
blood pressure, blood glucose levels and serum cholesterol than those who
were less confident in the information they received from doctors or their
ability to care for themselves. "We've recognized for over a decade that the
patient experience is key" to good healthcare, says Dr. Carolyn Clancy,
director of the federal Agency for Healthcare Research and Quality.
"Communication in primary care is critical. Eighty percent of diagnosis is
getting a good history," she says, and that requires a good relationship
between patient and doctor.
Good, basic customer service is part of the package, because it gets
patients in the door. The doctors at Oso Family Medical Group heard about
the "new model" of family practice and that a first step is surveying
patients to find out what they need. That yielded complaints about long
waits and other annoyances.
"I've always loved them, they treat you like family," says patient Josh
Dryman, a 33-year-old who lives in Laguna Niguel. "But I had to wait an hour
in the lobby and wait in the exam room another half-hour. Now when you go
in, they get you in right away and the staff seems a heck of a lot
friendlier."
Hearing these and similar comments from the people on whom they depended,
the five doctors changed their - and their practice's - ways.
"We saw the marketplace evolve to be much more patient-centric, and
insurance companies looking for specific measures of how happy patients are
with your practice," Burnett said. "We're trying to be on the cusp of this."
There isn't a large body of scientific evidence linking family medicine
modernization techniques to better patient care. But some studies are under
way.
Researchers at the Medical University of South Carolina have been studying
health outcomes of patients from about 100 medical practices that use the
same medical record software, along with several elements of the new family
practice model.
In a study of diabetics among 66 of those practices, researchers found
measurable improvement in health status and linked that to specific
techniques used by the practices, including an electronic medical record, a
team staff model and a computerized system that keeps track of test results
and referrals.
Meanwhile, 36 family practices around the country are studying their
performance in a project sponsored by the American Academy of Family
Physicians. It includes computerization, easier access for patients,
websites and a team approach to providing the most efficient care that
involves daily "huddles" among the practice staff. The idea is to prove
whether the concept works in the real world, and whether it's worth the
investment. A report on the project, which ends in 2008, is expected early
the following year.
One of the participants is Eidus, the New Jersey physician who spent a
career working in academic medicine, HMOs and healthcare quality before
hanging out a shingle five years ago as a family doctor in Cranford, N.J. He
organizes his practice with an electronic medical record and offers patients
a $30 "online house call" through an interactive website, along with
extended hours on Thursday evenings and some Saturdays. "I designed the
office from the standpoint of the patient's perspective and what was going
to make our practice best meet the needs of our patients," Eidus said.
Harlan Clinic in rural Harlan, Iowa, is also among the growing number of
practices betting that overseeing the overall health of its patients is more
effective than providing episodic care. It keeps a diabetic educator and
dietitian on staff and plans to add a health coach. "We can actively help
them manage their disease," says Klitgaard, a family physician at the
clinic. "That's comprehensive practice. That can and should happen in all
primary care offices."
That concept has become known as providing patients a "medical home."
However, a survey released last month by the Commonwealth Fund, a private
foundation focused on improving healthcare practice and policy, found that
just 27% of adults age 18 to 64 reported having all four elements of a
medical home: a regular doctor or source of care; no difficulty contacting
their provider by telephone; no difficulty getting care or medical advice on
weekends or evenings; and visits that are well organized and run on time.
The survey, conducted in 2006, involved 3,535 randomly selected, nationally
representative.
A 2003 Commonwealth Fund survey found that just 22% of primary care doctors
rated "high" in their use of patient-friendly techniques. Just 18% used
e-mail to communicate with patients. About half said they send reminder
notices about preventive or follow-up care, and 64% said they provide
same-day appointments.
Choosing based on quality
Quality "report cards" on doctors can also offer a guideline for patients
choosing a doctor. Although the movement to provide such ratings has been
underway for years, it's thus far yielded mostly general information.
A 2004 study found that patients generally want their primary care physician
to meet five basic criteria: be in their insurance plan, be conveniently
located, offer appointments within a reasonable amount of time, have good
communication skills and have a reasonable amount of experience.
Some of those answers are easy to find - a quick look in a provider
directory can answer the insurance and location questions. But as more
patients use health savings accounts that require them to pay out of pocket
for doctors' visits, they'll likely be looking for more information about
the value they're getting for their money.
The company HealthGrades, for instance, collects public information such as
education, gender and board certification about doctors around the country
and, for 15 states, malpractice payments - and charges a fee for the report.
HealthGrades spokesman Scott Shapiro says the company does not expect to
offer information about practice design (such as computerization) in the
near future.
But the reports do note whether a doctor has received a quality designation
from a private quality organization called Bridges to Excellence, which
offers doctors a review and assessment of how they handle specific diseases
such as stroke and diabetes. In some places, these ratings can earn doctors
financial reward from employers.
Some insurance plans are also beginning to offer more detailed quality
information about their doctors. A part of the Bridges to Excellence
program, called Physician Office Link, identifies physicians who use methods
considered by national healthcare quality experts to lead to better
efficiency and quality. These include monitoring patients' medical
histories, working with patients over time, following up with patients and
other providers and avoiding medical errors. Aetna, for one, identifies
physicians who have paid to be evaluated by the program and been found to
meet its standards.
Some states collect quality information and report it to consumers on
websites. California's Office of the Patient Advocate offers quality
information online about medical groups developed by the Pacific Business
Group on Health and the Integrated Healthcare Assn. The data, based on
consumer surveys, include ratings on timeliness of medical care, quality of
communication and helpfulness of office staff. However, the surveys apply
mostly to large medical groups and include few individual or small
practices.
Such information is becoming more plentiful as doctors, pressured by
employers and insurers, open up more to scrutiny. "We're still in baby steps
on reporting on physician care," Lee says.
Not just computers alone
Of course, a good doctor-patient relationship comes down to more than a
single measure of quality or modernization. And different people want
different things from a doctor. Nevertheless, having a doctor who takes
pains to provide the kind of care patients need and want is arguably more
likely to please them. It will require medical consumers to be willing to
think through what they want, and ask questions even if that means asking a
receptionist to put the call through to an office manager, nurse or the
doctor.
For example, although it's important to know whether a practice is
computerized, Burnett says he wouldn't necessarily avoid a practice based on
that one factor. "Some doctors can't afford it right now," he says,
particularly practices with just one or two doctors. And there is debate
within the profession about the ultimate role of computers.
Many argue that their potential for revolutionizing the quality, safety and
efficiency of care is overblown. In fact, a proportion of primary care
doctors will probably never invest in them, predicts David Brailer, former
healthcare IT czar for President Bush.
Speaking to healthcare journalists at a Los Angeles meeting in April,
Brailer noted that about 20% of doctors have computerized their practices,
while more than half are debating when, and how, to make the investment.
Another 20%, he estimates, are older doctors who don't believe the
technology is worth the investment and will retire without having converted
their paper files.
A patient can learn a lot about a practice's philosophy by sensing whether
the person answering the phone is open to answering questions, suggests Dr.
Terry McGeeney, chief executive of the American Academy of Family
Physicians' project to study the real-world feasibility of the "new model"
of computerized, patient-centered family practice.
Your questions, your concerns
Some questions to ask of a doctor's medical practice:
. Do you have an electronic medical record?
. Would you use it to follow my care more efficiently?
. Do you use evidence-based practice guidelines to manage patients' health?
. Can I get a same-day appointment with my doctor (or nurse-practitioner or
physician's assistant)?
. Do you offer extended hours on evenings or weekends if I can't get off
work?
. Does your staff work as a team to improve patients' care?
. Can I get a quick question answered by phone or by e-mail?
. Do you do lab tests in your office or in some efficient way that won't
take up a lot of my time?
. How would I get test results back?
. How do you track patients with chronic illnesses?
Each patient must decide what is important about a potential doctor. These
questions can give consumers a sense of whether the practice is at least
thinking about providing patient-centered, quality care.
What to look for in a physician
Using quality information to choose a doctor is a relatively new
phenomenon - and one that few consumers are doing, according to a 2006
survey.
. Percentage of people who saw information in the last year comparing
quality among doctors: 12%
. Percentage who used it to make a decision about a doctor: 7%
Source: Kaiser Family Foundation/Agency for Healthcare Research and Quality
phone survey of 1,216 randomly selected, nationally representative American
adults, 2006.
In another survey, people were asked what types of criteria they'd use to
judge a doctor. Those surveyed were asked which of the following information
would tell them a lot about the quality of a doctor:
. How many times a doctor has done a specific medical procedure (66%)
. Whether a doctor is board certified, that is, has had additional training
and testing in his or her area of specialty (65%)
. How many malpractice suits a doctor has had filed against him or her
(64%)
. How patients who are surveyed rate how well the doctor communicates (52%)
. Whether a doctor attended a well-known medical school or training program
(37%)
. Whether a doctor has admission privileges to send patients to a
particular local hospital (35%)
. Whether a doctor has been rated "the best" by a local newspaper or
magazine (28%)
. Whether a doctor charges more than other doctors do (18%) [LAT]
Selasa, 27 November 2007
Selasa, 16 Oktober 2007
Doctor's Gender May Be Factor in Diagnoses
Conventional wisdom holds that coronary heart disease is an illness of older men, and that may be why doctors have difficulty diagnosing it in women. But do female doctors at least do a better job than male doctors? Apparently not, a new study finds.
The study, did find significant differences in the ways male and female doctors diagnosed the illness. It reported that male doctors might be less biased by the gender and age of the patient being examined. "We're not trying to say that one group of doctors is better than another," John B. McKinlay, the principal investigator said. "What we're trying to do is for the first time describe and explain how much variability there is in doctors' behavior when they look at exactly the same clinical presentation in different patients."
The scientists videotaped professional actors portraying patients of varying gender, age, race and socioeconomic status who all had medically apparent symptoms of heart disease. Then 112 male and female primary care doctors, half in Massachusetts and the
rest in Britain, watched the videos. The physicians were asked to think of the patient as one of their own, make a diagnosis and suggest a treatment plan. Finally, they were asked to describe what factors they considered in arriving at their decisions.
Both male and female doctors picked up more psychological cues from female patients than from male patients. A characterization like "seemed very low" or "very depressed" was more likely to be made about a female patient than a male one.
Comments about a patient's self-presentation like, "He doesn't give a very cogent history," or, "She's a passive victim," were more common among female doctors, and they made significantly more such observations of female patients.
Male doctors noticed fewer such cues in general, and only slightly more from male than female patients. This suggests that doctors, and especially female doctors, may be more sensitive to such information in patients of their own gender.
Even though older age is a significant risk factor for heart disease in both men and women, female doctors paid significantly less attention to female patients' ages than those of males.
Dr. Alexandra J. Lansky, an associate professor of clinical medicine in cardiology at the Columbia University Medical Center who was not involved in the study, found the paper revealing. "The old statement that female docs are better prepared to take care of female patients does not stand," Dr. Lansky said. "Female docs are missing
one big point that the male docs don't miss, and that's the age-related factor."
Not all experts found the report convincing. "This study clearly says that female and male doctors approach the patient interview differently, " said Dr. Elizabeth A. Jackson, an assistant professor of medicine at the University of Michigan. "But they appear to have a similar knowledge base. This was not a real-life situation, and you can't take conclusions from one study in isolation. I'd like to see if these results can be replicated."
Dr. McKinlay, who is head of the New England Research Institutes in Watertown, Mass., said the study offered a new way to look at the disparities between men and women in treating coronary heart disease. "A lot of the time," he said, "health disparities have been explained by characteristics of the patient - race or economics, women versus men, older versus younger. But here the variability is explained by characteristics of the doctor." [NYT]
The study, did find significant differences in the ways male and female doctors diagnosed the illness. It reported that male doctors might be less biased by the gender and age of the patient being examined. "We're not trying to say that one group of doctors is better than another," John B. McKinlay, the principal investigator said. "What we're trying to do is for the first time describe and explain how much variability there is in doctors' behavior when they look at exactly the same clinical presentation in different patients."
The scientists videotaped professional actors portraying patients of varying gender, age, race and socioeconomic status who all had medically apparent symptoms of heart disease. Then 112 male and female primary care doctors, half in Massachusetts and the
rest in Britain, watched the videos. The physicians were asked to think of the patient as one of their own, make a diagnosis and suggest a treatment plan. Finally, they were asked to describe what factors they considered in arriving at their decisions.
Both male and female doctors picked up more psychological cues from female patients than from male patients. A characterization like "seemed very low" or "very depressed" was more likely to be made about a female patient than a male one.
Comments about a patient's self-presentation like, "He doesn't give a very cogent history," or, "She's a passive victim," were more common among female doctors, and they made significantly more such observations of female patients.
Male doctors noticed fewer such cues in general, and only slightly more from male than female patients. This suggests that doctors, and especially female doctors, may be more sensitive to such information in patients of their own gender.
Even though older age is a significant risk factor for heart disease in both men and women, female doctors paid significantly less attention to female patients' ages than those of males.
Dr. Alexandra J. Lansky, an associate professor of clinical medicine in cardiology at the Columbia University Medical Center who was not involved in the study, found the paper revealing. "The old statement that female docs are better prepared to take care of female patients does not stand," Dr. Lansky said. "Female docs are missing
one big point that the male docs don't miss, and that's the age-related factor."
Not all experts found the report convincing. "This study clearly says that female and male doctors approach the patient interview differently, " said Dr. Elizabeth A. Jackson, an assistant professor of medicine at the University of Michigan. "But they appear to have a similar knowledge base. This was not a real-life situation, and you can't take conclusions from one study in isolation. I'd like to see if these results can be replicated."
Dr. McKinlay, who is head of the New England Research Institutes in Watertown, Mass., said the study offered a new way to look at the disparities between men and women in treating coronary heart disease. "A lot of the time," he said, "health disparities have been explained by characteristics of the patient - race or economics, women versus men, older versus younger. But here the variability is explained by characteristics of the doctor." [NYT]
More Doctors After Malpractice Caps
That is not for an appointment. That is the time it can take the Texas Medical Board to process applications to practice. Four years after Texas voters approved a constitutional amendment limiting awards in medical malpractice lawsuits, doctors are responding as supporters predicted, arriving from all parts of the country to swell the ranks of specialists at Texas hospitals and bring professional health care to some long-underserved rural areas.
The influx, raising the state's abysmally low ranking in physicians per capita, has flooded the medical board's offices in Austin with applications for licenses, close to 2,500 at last count. "It was hard to believe at first; we thought it was a spike," said Dr. Donald W. Patrick, executive director of the medical board and a
neurosurgeon and lawyer. But Dr. Patrick said the trend - licenses up 18 percent since 2003, when the damage caps were enacted - has held, with an even sharper jump of 30 percent in the last fiscal year, compared with the year before.
"Doctors are coming to Texas because they sense a friendlier malpractice climate," he said. Some experts say the picture may be more complicated and less positive. They
question how big a role the cap on malpractice awards has played, arguing that awards in malpractice lawsuits showed little increase in the 12 years before the law changed.
And some critics, including liability lawyers, question whether the changes have left patients more vulnerable. With doctors facing reduced malpractice exposure, they say, many have cut back on their insurance, making it harder for plaintiffs to collect damages. Moreover, the critics say that some rural areas have fewer doctors than before. The measure changing Texas' malpractice landscape, Proposition 12, was
narrowly approved in a constitutional referendum on Sept. 12, 2003. It barred the courts from interfering in limits set by the Legislature on medical malpractice recoveries.
For pain and suffering, so-called noneconomic damage, patients can sue a doctor and, in unusual cases, up to two health care institutions for no more than $250,000 each, under limits adopted by the Legislature. Plaintiffs can still recover economic losses, like the cost of continuing medical care or lost income, but the amount they can win was capped at $1.6 million in death cases.
All but 15 states have adopted some limits on medical damage awards, according to the National Conference of State Legislatures. But the restrictions in Texas go further than in many states, where the limits are often twice as high as they are here. "Other states have passed tort reform, but Texas implemented big changes all
at once," said Lisa Robin, a vice president for government relations at the Federation of State Medical Boards, a national umbrella group based in Dallas.
Some experts say that the lack of a state income tax, combined with what William M. Sage, a law professor at the University of Texas in Austin, called a "relatively rapid transition in its tort reputation as a plaintiff-friendly state," has contributed to the state's appeal to doctors.
Dr. Timothy George, 47, a pediatric neurosurgeon, credits the measure in part with attracting him and his sought-after specialty last year to Austin from North Carolina. "Texas made it easier to practice and easier to take care of complex patients," he said.
The increase in doctors - double the rate of the population increase - has raised the state's ranking in physicians per capita to 42nd in 2005 from 48th in 2001, according to the American Medical Association. It is most likely considerably higher now, according to the medical association, which takes two years to compile the standings. Still, the latest figures show Texas with 194 patient-care physicians per 100,000 population, far below the District of Columbia, which led the nation with 659.
The Texas Medical Board reports licensing 10,878 new physicians since 2003, up from 8,391 in the prior four years. It issued a record 980 medical licenses at its last meeting in August, raising the number of doctors in Texas to 44,752, with a backlog of nearly 2,500 applications. Of those awaiting processing, the largest number, after Texas, come from New York (145), followed by California (118) and Florida (100).
In some medical specialties, the gains have been especially striking, said Jon Opelt, executive director of the Texas Alliance for Patient Access, a medical advocacy group: 186 obstetricians, 156 orthopedic surgeons and 26 neurosurgeons.
Adding to the state's allure for doctors, Mr. Opelt said, was an average 21.3 percent drop in malpractice insurance premiums, not counting rebates for renewal.
To help state officials monitor the influx of doctors, the medical board recently got money to hire six more employees, said Dr. Patrick, the director since 2001. It now has 17 lawyers, compared with no more than four when he arrived, he said.
Since 2003, investigations of doctors have gone up 40 percent, patient complaints have gone up 25 percent, and disciplinary actions about 8 percent, said Jill Wiggins, a board spokeswoman. But the figures may reflect greater regulatory diligence rather than more misconduct, Ms. Wiggins said. Of the 10,878 physicians licensed since 2003, she said, 14 have been the subject of disciplinary actions, on charges as diverse as addiction problems and record-keeping infractions, with none accused of harming patients.
But there are those who are skeptical about the caps on malpractice. "We've lost our system of legal accountability, said N. Alex Winslow, executive director of Texas Watch, a consumer advocacy group. "Just having more doctors doesn't make patients safer. It remains to be seen who is coming to our state."
Demian McElhinny, 33, a former hospice pharmacy technician in El Paso, recently settled claims against a neurological surgeon for spinal surgery that left him disabled and his family impoverished; he said he emerged with "pennies on the dollar." His wife, Kelly, found work as a school bus driver, he said, while "I'm at home being a housewife to my two boys."
Mr. McElhinny's surgeon, Dr. Paul Henry Cho, later admitted to the medical board that he was addicted to a narcotic cough syrup and had written fraudulent prescriptions. Dr. Cho's license to prescribe drugs was suspended, although it was soon restored, and he moved from El Paso to a hospital in Fort Worth. He did not return a call to his office, and his lawyer declined to comment.
Paula Sweeney, a leading Dallas liability lawyer and a past president of the Texas Trial Lawyers Association, said, "A lot of legislators are aware they went too far in '03."
Texas Watch, in a report last February, questioned the decline in malpractice insurance rates, saying they must be seen in light of increases of as much as 147 percent before the 2003 referendum. And Bernard S. Black, a law professor at the University of Texas, has published studies showing little increase in Texas insurance awards from 1990 to 2002, casting doubt, he said, on the "malpractice insurance crisis."
Professor Black also said that data was too scant to attribute the rise in the number of doctors to the damage caps. "I don't doubt there's an effect," he said, "but I think it's a small one." Texas Watch also contends that many poor rural areas of Texas remain underserved, and rural West Texas has actually lost several physicians since 2003. But Dr. James Baumgartner, a pediatric neurosurgeon at Memorial Hermann Hospital in Houston, is among many doctors who believe the new
malpractice caps have helped.
Dr. Baumgartner said it was now far easier to recruit doctors to a state where close to 30 percent of children lack health insurance and Medicaid reimbursements are low.
Dr. Keith Hill, a recently discharged Army doctor with a specialty in foot and ankle reconstruction, said the change in state law was the reason he moved from Georgia to open a practice in Beaumont, a poor city in East Texas long seen as plaintiff-friendly. Had it not happened, said Dr. Hill, 40, "I can say I would not have considered Texas." [NYT]
The influx, raising the state's abysmally low ranking in physicians per capita, has flooded the medical board's offices in Austin with applications for licenses, close to 2,500 at last count. "It was hard to believe at first; we thought it was a spike," said Dr. Donald W. Patrick, executive director of the medical board and a
neurosurgeon and lawyer. But Dr. Patrick said the trend - licenses up 18 percent since 2003, when the damage caps were enacted - has held, with an even sharper jump of 30 percent in the last fiscal year, compared with the year before.
"Doctors are coming to Texas because they sense a friendlier malpractice climate," he said. Some experts say the picture may be more complicated and less positive. They
question how big a role the cap on malpractice awards has played, arguing that awards in malpractice lawsuits showed little increase in the 12 years before the law changed.
And some critics, including liability lawyers, question whether the changes have left patients more vulnerable. With doctors facing reduced malpractice exposure, they say, many have cut back on their insurance, making it harder for plaintiffs to collect damages. Moreover, the critics say that some rural areas have fewer doctors than before. The measure changing Texas' malpractice landscape, Proposition 12, was
narrowly approved in a constitutional referendum on Sept. 12, 2003. It barred the courts from interfering in limits set by the Legislature on medical malpractice recoveries.
For pain and suffering, so-called noneconomic damage, patients can sue a doctor and, in unusual cases, up to two health care institutions for no more than $250,000 each, under limits adopted by the Legislature. Plaintiffs can still recover economic losses, like the cost of continuing medical care or lost income, but the amount they can win was capped at $1.6 million in death cases.
All but 15 states have adopted some limits on medical damage awards, according to the National Conference of State Legislatures. But the restrictions in Texas go further than in many states, where the limits are often twice as high as they are here. "Other states have passed tort reform, but Texas implemented big changes all
at once," said Lisa Robin, a vice president for government relations at the Federation of State Medical Boards, a national umbrella group based in Dallas.
Some experts say that the lack of a state income tax, combined with what William M. Sage, a law professor at the University of Texas in Austin, called a "relatively rapid transition in its tort reputation as a plaintiff-friendly state," has contributed to the state's appeal to doctors.
Dr. Timothy George, 47, a pediatric neurosurgeon, credits the measure in part with attracting him and his sought-after specialty last year to Austin from North Carolina. "Texas made it easier to practice and easier to take care of complex patients," he said.
The increase in doctors - double the rate of the population increase - has raised the state's ranking in physicians per capita to 42nd in 2005 from 48th in 2001, according to the American Medical Association. It is most likely considerably higher now, according to the medical association, which takes two years to compile the standings. Still, the latest figures show Texas with 194 patient-care physicians per 100,000 population, far below the District of Columbia, which led the nation with 659.
The Texas Medical Board reports licensing 10,878 new physicians since 2003, up from 8,391 in the prior four years. It issued a record 980 medical licenses at its last meeting in August, raising the number of doctors in Texas to 44,752, with a backlog of nearly 2,500 applications. Of those awaiting processing, the largest number, after Texas, come from New York (145), followed by California (118) and Florida (100).
In some medical specialties, the gains have been especially striking, said Jon Opelt, executive director of the Texas Alliance for Patient Access, a medical advocacy group: 186 obstetricians, 156 orthopedic surgeons and 26 neurosurgeons.
Adding to the state's allure for doctors, Mr. Opelt said, was an average 21.3 percent drop in malpractice insurance premiums, not counting rebates for renewal.
To help state officials monitor the influx of doctors, the medical board recently got money to hire six more employees, said Dr. Patrick, the director since 2001. It now has 17 lawyers, compared with no more than four when he arrived, he said.
Since 2003, investigations of doctors have gone up 40 percent, patient complaints have gone up 25 percent, and disciplinary actions about 8 percent, said Jill Wiggins, a board spokeswoman. But the figures may reflect greater regulatory diligence rather than more misconduct, Ms. Wiggins said. Of the 10,878 physicians licensed since 2003, she said, 14 have been the subject of disciplinary actions, on charges as diverse as addiction problems and record-keeping infractions, with none accused of harming patients.
But there are those who are skeptical about the caps on malpractice. "We've lost our system of legal accountability, said N. Alex Winslow, executive director of Texas Watch, a consumer advocacy group. "Just having more doctors doesn't make patients safer. It remains to be seen who is coming to our state."
Demian McElhinny, 33, a former hospice pharmacy technician in El Paso, recently settled claims against a neurological surgeon for spinal surgery that left him disabled and his family impoverished; he said he emerged with "pennies on the dollar." His wife, Kelly, found work as a school bus driver, he said, while "I'm at home being a housewife to my two boys."
Mr. McElhinny's surgeon, Dr. Paul Henry Cho, later admitted to the medical board that he was addicted to a narcotic cough syrup and had written fraudulent prescriptions. Dr. Cho's license to prescribe drugs was suspended, although it was soon restored, and he moved from El Paso to a hospital in Fort Worth. He did not return a call to his office, and his lawyer declined to comment.
Paula Sweeney, a leading Dallas liability lawyer and a past president of the Texas Trial Lawyers Association, said, "A lot of legislators are aware they went too far in '03."
Texas Watch, in a report last February, questioned the decline in malpractice insurance rates, saying they must be seen in light of increases of as much as 147 percent before the 2003 referendum. And Bernard S. Black, a law professor at the University of Texas, has published studies showing little increase in Texas insurance awards from 1990 to 2002, casting doubt, he said, on the "malpractice insurance crisis."
Professor Black also said that data was too scant to attribute the rise in the number of doctors to the damage caps. "I don't doubt there's an effect," he said, "but I think it's a small one." Texas Watch also contends that many poor rural areas of Texas remain underserved, and rural West Texas has actually lost several physicians since 2003. But Dr. James Baumgartner, a pediatric neurosurgeon at Memorial Hermann Hospital in Houston, is among many doctors who believe the new
malpractice caps have helped.
Dr. Baumgartner said it was now far easier to recruit doctors to a state where close to 30 percent of children lack health insurance and Medicaid reimbursements are low.
Dr. Keith Hill, a recently discharged Army doctor with a specialty in foot and ankle reconstruction, said the change in state law was the reason he moved from Georgia to open a practice in Beaumont, a poor city in East Texas long seen as plaintiff-friendly. Had it not happened, said Dr. Hill, 40, "I can say I would not have considered Texas." [NYT]
Warning Against Over-prescribing Tamiflu
Sewage systems do not break down Tamiflu, which means the main weapon against bird flu could seep into natural waters and make certain viruses resistant to the drug during a pandemic, Swedish researchers said on Wednesday.
Because of this, doctors should take care to not overprescribe Roche Holding AG's market-leading antiviral drug, they said in a study published in the Public Library of Science.
``Antiviral medicines such as Tamiflu must be used with care and only when the medical situation justifies it,'' Bjorn Olsen, a researcher at Uppsala University and the University of Kalmar said in a statement.
``Otherwise there is a risk that they will be ineffective when most needed, such as during the next influenza pandemic.'' Roche, which the researchers said donated the drug for their study, said it was unlikely such resistance would arise.
``In the highly unlikely event that such resistance was generated, this must be balanced against the fact that influenza viruses with the associated mutational changes have been shown to have lower transmissibility, '' the company said.
Tamiflu, known generically as oseltamivir, was having lacklustre sales as a drug to prevent and treat seasonal flu until it was the first treatment to show real efficacy in helping people with bird flu. Health experts agree that a pandemic of something is inevitable. They cannot specify the disease, but the H5N1 avian flu virus currently wiping out flocks from Indonesia to Africa and parts of Europe is the main suspect.
It rarely infects people but has killed 201 out of 329 people sickened since the virus re-emerged in Hong Kong in 2003, according to the World Health Organisation.
In their study, the Swedish team said low levels of oseltamivir, the active substance in Tamiflu, passed virtually unchanged through basic sewage treatment processes.
People had long suspected that Tamiflu would not break apart during such treatment but this is the first time researchers have actually shown this, the researchers said.
In certain countries, the level discharged through these outlets may be so high that influenza viruses in nature could develop resistance to Tamiflu, they said.
``Use of Tamiflu is low in most countries, but there are some exceptions such as Japan where a third of all influenza patients are treated with Tamiflu,'' Jerker Fick, a researcher at Umea University who led the study, said in a statement.
The biggest threat is from waterfowl such as ducks that often forage near sewage outlets, Fick said. These birds could encounter oseltamivir in high enough concentrations to develop resistance to flu viruses they carry, the researchers said.
In turn, the viruses could combine with other viruses that make humans sick and mutate into strains resistant to currently available antiviral drugs like Tamiflu, they added. [SMH]
Because of this, doctors should take care to not overprescribe Roche Holding AG's market-leading antiviral drug, they said in a study published in the Public Library of Science.
``Antiviral medicines such as Tamiflu must be used with care and only when the medical situation justifies it,'' Bjorn Olsen, a researcher at Uppsala University and the University of Kalmar said in a statement.
``Otherwise there is a risk that they will be ineffective when most needed, such as during the next influenza pandemic.'' Roche, which the researchers said donated the drug for their study, said it was unlikely such resistance would arise.
``In the highly unlikely event that such resistance was generated, this must be balanced against the fact that influenza viruses with the associated mutational changes have been shown to have lower transmissibility, '' the company said.
Tamiflu, known generically as oseltamivir, was having lacklustre sales as a drug to prevent and treat seasonal flu until it was the first treatment to show real efficacy in helping people with bird flu. Health experts agree that a pandemic of something is inevitable. They cannot specify the disease, but the H5N1 avian flu virus currently wiping out flocks from Indonesia to Africa and parts of Europe is the main suspect.
It rarely infects people but has killed 201 out of 329 people sickened since the virus re-emerged in Hong Kong in 2003, according to the World Health Organisation.
In their study, the Swedish team said low levels of oseltamivir, the active substance in Tamiflu, passed virtually unchanged through basic sewage treatment processes.
People had long suspected that Tamiflu would not break apart during such treatment but this is the first time researchers have actually shown this, the researchers said.
In certain countries, the level discharged through these outlets may be so high that influenza viruses in nature could develop resistance to Tamiflu, they said.
``Use of Tamiflu is low in most countries, but there are some exceptions such as Japan where a third of all influenza patients are treated with Tamiflu,'' Jerker Fick, a researcher at Umea University who led the study, said in a statement.
The biggest threat is from waterfowl such as ducks that often forage near sewage outlets, Fick said. These birds could encounter oseltamivir in high enough concentrations to develop resistance to flu viruses they carry, the researchers said.
In turn, the viruses could combine with other viruses that make humans sick and mutate into strains resistant to currently available antiviral drugs like Tamiflu, they added. [SMH]
Senin, 15 Oktober 2007
Kesiapan Fisik dan Pengetahuan Remaja Perempuan Sebagai Calon Ibu dalam Membina Tumbuh Kembang BAlita dan Faktor-faktor yang Mempengaruhinya
By Wan Nedra, Soedjatmiko, Agus Firmansyah
Latar Belakang.
Dua puluh satu persen penduduk Indonesia adalah remaja. Hanya 11,6% lulusan SMU yang melanjutkan ke perguruan tinggi, yang tidak melanjutkan antara lain memasuki jenjang perkawinan, padahal perkawinan pada usia muda sangat mengundang risiko yang tidak bisa diabaikan. Mereka yang memasuki jenjang perkawinan, umumnya mempunyai kesiapan fisik dan pengetahuan yang belum memadai, sehingga perlu disiapkan. Seorang ibu yang mempunyai pengetahuan yang baik akan menghasilkan tumbuh-kembang balita yang baik pula, khususnya dalam tiga tahun pertama usia anak.
Tujuan Pustaka.
Penelitian ini bertujuan untuk melihat kesiapan fisik, dan pengetahuan remaja perempuan terhadap tumbuh kembang balita.
Metoda.
Penelitian merupakan studi analitik potong lintang pada remaja perempuan siswi SMU di 7 sekolah di Jakarta Timur, yang dilaksanakan Januari 2006 sampai Maret 2006. Setelah mendapat persetujuan penelitian maka dilakukan pemeriksaan fisis dan pengambilan sampel darah untuk pemeriksaan hemoglobin. Selanjutnya responden mengisi
kuesioner untuk mengetahui pengetahuan mereka tentang tumbuh kembang balita.
Hasil.
Dari 300 responden diperoleh rerata umur 17,2 tahun, suku Jawa 40,2 % dan umumnya tinggal dengan orang tua (75,7%). Responden yang anemia sebanyak 25,36%, gizi kurang 18,5%, gizi baik 74,4%, gizi lebih 4,7%, dan obesitas 2,3%. Sumber informasi yang berhubungan dengan masalah tumbuh kembang balita hanya 13,6% berasal dari sumber formal yaitu orang tua, guru dan tenaga kesehatan. Remaja yang berpengetahuan tinggi didapatkan sebanyak 19%, pengetahuan sedang 33%, dan pengetahuan rendah 48%. Remaja yang tidak siap menjadi calon ibu secara fisik didapatkan pada 42,3%. Kesiapan pengetahuan didapatkan pada 63,7% remaja, sedangkan kesiapan fisik dan pengetahuan yang memadai didapatkan pada 31,3%. Tidak ada hubungan antara kesiapan responden untuk menjadi calon ibu dengan demografi keluarga dan sumber informasi.
Kesimpulan.
Lebih dari separuh remaja (57,7%) telah mempunyai kesiapan fisik untuk menjadi calon ibu. Kesiapan pengetahuan remaja terhadap materi tumbuh kembang balita sebesar 63,7 %. Tingkat kesiapan fisik dan pengetahuan remaja menjadi calon ibu sebesar 31,3%. Tidak ada hubungan antara karakteristik keluarga dan sumber informasi dengan kesiapan remaja perempuan SMU di Jakarta Timur untuk menjadi calon ibu.
Kata kunci: kesiapan fisik, pengetahuan, remaja.
Sari Pediatri, Vol. 8, No. 3, Desember 2006
Latar Belakang.
Dua puluh satu persen penduduk Indonesia adalah remaja. Hanya 11,6% lulusan SMU yang melanjutkan ke perguruan tinggi, yang tidak melanjutkan antara lain memasuki jenjang perkawinan, padahal perkawinan pada usia muda sangat mengundang risiko yang tidak bisa diabaikan. Mereka yang memasuki jenjang perkawinan, umumnya mempunyai kesiapan fisik dan pengetahuan yang belum memadai, sehingga perlu disiapkan. Seorang ibu yang mempunyai pengetahuan yang baik akan menghasilkan tumbuh-kembang balita yang baik pula, khususnya dalam tiga tahun pertama usia anak.
Tujuan Pustaka.
Penelitian ini bertujuan untuk melihat kesiapan fisik, dan pengetahuan remaja perempuan terhadap tumbuh kembang balita.
Metoda.
Penelitian merupakan studi analitik potong lintang pada remaja perempuan siswi SMU di 7 sekolah di Jakarta Timur, yang dilaksanakan Januari 2006 sampai Maret 2006. Setelah mendapat persetujuan penelitian maka dilakukan pemeriksaan fisis dan pengambilan sampel darah untuk pemeriksaan hemoglobin. Selanjutnya responden mengisi
kuesioner untuk mengetahui pengetahuan mereka tentang tumbuh kembang balita.
Hasil.
Dari 300 responden diperoleh rerata umur 17,2 tahun, suku Jawa 40,2 % dan umumnya tinggal dengan orang tua (75,7%). Responden yang anemia sebanyak 25,36%, gizi kurang 18,5%, gizi baik 74,4%, gizi lebih 4,7%, dan obesitas 2,3%. Sumber informasi yang berhubungan dengan masalah tumbuh kembang balita hanya 13,6% berasal dari sumber formal yaitu orang tua, guru dan tenaga kesehatan. Remaja yang berpengetahuan tinggi didapatkan sebanyak 19%, pengetahuan sedang 33%, dan pengetahuan rendah 48%. Remaja yang tidak siap menjadi calon ibu secara fisik didapatkan pada 42,3%. Kesiapan pengetahuan didapatkan pada 63,7% remaja, sedangkan kesiapan fisik dan pengetahuan yang memadai didapatkan pada 31,3%. Tidak ada hubungan antara kesiapan responden untuk menjadi calon ibu dengan demografi keluarga dan sumber informasi.
Kesimpulan.
Lebih dari separuh remaja (57,7%) telah mempunyai kesiapan fisik untuk menjadi calon ibu. Kesiapan pengetahuan remaja terhadap materi tumbuh kembang balita sebesar 63,7 %. Tingkat kesiapan fisik dan pengetahuan remaja menjadi calon ibu sebesar 31,3%. Tidak ada hubungan antara karakteristik keluarga dan sumber informasi dengan kesiapan remaja perempuan SMU di Jakarta Timur untuk menjadi calon ibu.
Kata kunci: kesiapan fisik, pengetahuan, remaja.
Sari Pediatri, Vol. 8, No. 3, Desember 2006
Sabtu, 13 Oktober 2007
Change in CPR May Make It More Effective
Performing only rhythmic abdominal compressions, rather than the standard chest compressions, may increase the flow of blood that is achieved during cardiopulmonary resuscitation (CPR), according to the results of a study conducted with animals.
The biggest finding of the study is that performing CPR using only rhythmic abdominal compressions can provide "blood flow and artificial respiration, "lead author Dr. Leslie Geddes, from Purdue University in West Lafayette, Indiana, told Reuters Health.
CPR using rhythmic abdominal compressions does not require chest compression and it does not require mouth-to-mouth breathing, which "eliminates the riskof rib fractures and transfer of infection," Geddes explained.
Previous research has shown that conventional CPR has success rates of just 5 percent to 10 percent. Plus, for every minute that passes before CPR is started, the chance of success falls by 10 percent." In other words, at 10 minutes, the resuscitation is absolutely ineffective, " Geddes said in a statement.
"Any medical procedure that hadthat low a success rate would be abandoned right away. But the alternative is not very good either -- don't do CPR, and the person is going to die.
"Rhythmic abdominal compression- CPR works by forcing blood from the blood vessels around the abdominal organs, an area known to contain about 25 percent of the body's total blood volume. This blood is then redirected toother sites, including the circulation around the heart.
Geddes' team tested rhythmic abdominal compression- CPR on pigs with experimentally induced ventricular fibrillation, a cardiac disturbance in which the heart muscle beats abnormally, preventing oxygen-enriched blood tobe pumped to the rest of the body.
The researchers found that 60 percent more blood was pumped to the heartusing rhythmic abdominal compression- CPR than with standard chest compression- CPR, using the same amount of effort.Plus, there was no evidence that rhythmic abdominal compressions damaged the abdominal organs and the risk of rib fracture was avoided. [Am J of EmergMed]
The biggest finding of the study is that performing CPR using only rhythmic abdominal compressions can provide "blood flow and artificial respiration, "lead author Dr. Leslie Geddes, from Purdue University in West Lafayette, Indiana, told Reuters Health.
CPR using rhythmic abdominal compressions does not require chest compression and it does not require mouth-to-mouth breathing, which "eliminates the riskof rib fractures and transfer of infection," Geddes explained.
Previous research has shown that conventional CPR has success rates of just 5 percent to 10 percent. Plus, for every minute that passes before CPR is started, the chance of success falls by 10 percent." In other words, at 10 minutes, the resuscitation is absolutely ineffective, " Geddes said in a statement.
"Any medical procedure that hadthat low a success rate would be abandoned right away. But the alternative is not very good either -- don't do CPR, and the person is going to die.
"Rhythmic abdominal compression- CPR works by forcing blood from the blood vessels around the abdominal organs, an area known to contain about 25 percent of the body's total blood volume. This blood is then redirected toother sites, including the circulation around the heart.
Geddes' team tested rhythmic abdominal compression- CPR on pigs with experimentally induced ventricular fibrillation, a cardiac disturbance in which the heart muscle beats abnormally, preventing oxygen-enriched blood tobe pumped to the rest of the body.
The researchers found that 60 percent more blood was pumped to the heartusing rhythmic abdominal compression- CPR than with standard chest compression- CPR, using the same amount of effort.Plus, there was no evidence that rhythmic abdominal compressions damaged the abdominal organs and the risk of rib fracture was avoided. [Am J of EmergMed]
Are Physicians Giving the Right Message About Antibiotic Use?
Background:
Inappropriately prescribing antibiotics is a common occurrence in the management of upper respiratory tract infections (URIs), many of which have a viral etiology.
Previous studies show that 55 percent of the antibiotics prescribed for acute respiratory tract infections are consideredunnecessary.
Declines in antibiotic prescriptions for URIs have occurredrecently; however, this may be because of a decrease in office visits for this type of infection.
In children, acute respiratory illnesses account for approximately 75 percent of all antibiotic prescriptions, but most of these are viral infections.
In addition, parents who bring their children to theo ffice for URIs often expect to receive antibiotics.
Mangione-Smith and colleagues questioned whether physicians were sending the right message about antibiotic treatment to parents, so they evaluated the relationship between physician-parent communication and the inappropriate use of antibiotics in children with URIs.
The Study:
The cross-sectional study included pediatric visits to 38 subspecialists in 27 community practices.
Parents were asked to participate if their child was between six months and 10 years of age, had symptoms of a respiratory tract infection, and had not taken antibiotics within the previous two weeks.
Parents were given a questionnaire to complete before the visit. The office visit was video taped, and the physician completed a survey after the appointment.
This survey questioned whether the physician thought the parent was expecting antibiotic treatment, and the physician-patient communication was analyzed using a qualitative method of conversation analysis.
The main outcomes measured included the physicians'perceptions of parental antibiotic expectations, inappropriate antibiotic prescribing, and whether the parent questioned the physician about not receiving an antibiotic prescription.
Results:
There were 522 parents of children with URIs included in the study. Of the parents who did not receive antibiotic treatment for their children, 63.8 percent reported that they had expected an antibiotic prescription; however, physicians thought that this group expected antibiotics only 22 percent of the time.
If the physicians thought that the parents expected antibiotics, they were significantly more likely (31.7 percent) to inappropriately prescribe them.
If physicians exclusively decided against prescribing antibiotics after discussing the child's care with the parentsor mentioned this option with other treatment recommendations or homeremedies, parents were 24 percent more likely to question treatment.
This was true even when the physician offered other treatment options.
Conclusion:
The authors conclude that parental questioning of the treatment plan for children with URIs increases the physician's inappropriate use of antibiotics.
They note that treatment plans that do not mention antibiotics,but focus on other, more positive treatment options, may help reduce the overprescribing of antibiotics for viral illnesses. [AAFP]
Inappropriately prescribing antibiotics is a common occurrence in the management of upper respiratory tract infections (URIs), many of which have a viral etiology.
Previous studies show that 55 percent of the antibiotics prescribed for acute respiratory tract infections are consideredunnecessary.
Declines in antibiotic prescriptions for URIs have occurredrecently; however, this may be because of a decrease in office visits for this type of infection.
In children, acute respiratory illnesses account for approximately 75 percent of all antibiotic prescriptions, but most of these are viral infections.
In addition, parents who bring their children to theo ffice for URIs often expect to receive antibiotics.
Mangione-Smith and colleagues questioned whether physicians were sending the right message about antibiotic treatment to parents, so they evaluated the relationship between physician-parent communication and the inappropriate use of antibiotics in children with URIs.
The Study:
The cross-sectional study included pediatric visits to 38 subspecialists in 27 community practices.
Parents were asked to participate if their child was between six months and 10 years of age, had symptoms of a respiratory tract infection, and had not taken antibiotics within the previous two weeks.
Parents were given a questionnaire to complete before the visit. The office visit was video taped, and the physician completed a survey after the appointment.
This survey questioned whether the physician thought the parent was expecting antibiotic treatment, and the physician-patient communication was analyzed using a qualitative method of conversation analysis.
The main outcomes measured included the physicians'perceptions of parental antibiotic expectations, inappropriate antibiotic prescribing, and whether the parent questioned the physician about not receiving an antibiotic prescription.
Results:
There were 522 parents of children with URIs included in the study. Of the parents who did not receive antibiotic treatment for their children, 63.8 percent reported that they had expected an antibiotic prescription; however, physicians thought that this group expected antibiotics only 22 percent of the time.
If the physicians thought that the parents expected antibiotics, they were significantly more likely (31.7 percent) to inappropriately prescribe them.
If physicians exclusively decided against prescribing antibiotics after discussing the child's care with the parentsor mentioned this option with other treatment recommendations or homeremedies, parents were 24 percent more likely to question treatment.
This was true even when the physician offered other treatment options.
Conclusion:
The authors conclude that parental questioning of the treatment plan for children with URIs increases the physician's inappropriate use of antibiotics.
They note that treatment plans that do not mention antibiotics,but focus on other, more positive treatment options, may help reduce the overprescribing of antibiotics for viral illnesses. [AAFP]
Selasa, 25 September 2007
Kasus Demam Berdarah meningkat : jumlah trombosit yang rendah saja buka indikasi untuk mendapat transfusi trombosit, By Ari Fahrial Syam
Dalam minggu-minggu terakhir di awal musim hujan ini kita melihat, mendengar dan membaca bahwa kasus demam berdarah dengue (DBD) meningkat dan laporan adanya peningkatan kasus DBD ini hampir terjadi di seluruh kota besar di Indonesia secara khusus di ibukota tercinta Jakarta ini. Peningkatan kasus DBD yang terjadi terutama pada bulan Januari ini, dimana telah terjadi peningkatan kasus demam berdarah dibandingkan beberapa bulan terakhir. Walau sampai saat ini peningkatan kasus DBD yang terjadi belum memenuhi criteria Kejadian Luar Biasa (DBD). Peningkatan kasus DBD inipun diprediksi akan meningkat pada beberapa minggu kedepan.
Satu hal kenapa saya menulis mengenai topic DBD ini karena ada hal yang selalu menggelitik saya dan membuat saya prihatin yaitu bahwa selama terjadinya peningkatan kasus demam berdarah permintaan trombosit di PMI meningkat tajam. Kami dilingkungan Forum Perhimpunan Dokter Spesialis Penyakit Dalam Indonesia (PAPDI) maupun ditingkat Departemen Ilmu Penyakit Dalam FKUI-RSCM, sudah pernah membahas tuntas mengenai hal ini bahwa transfusi trombosit hanya diberikan pada pasien dengan perdarahan yang berat seperti muntah darah, mimisan yang terus menerus atau perdarahan dari saluran cerna bawah berupa BAB berdarah segar. Jumlah trombosit yang rendah bahkan sampai dibawah 20.000 tanpa pendarahan yang signifikan bukan merupakan indikasi untuk diberikan trombosit sehingga kadar trombosit yang rendah saja tidak memerlukan transfusi trombosit.
Sebelum membicarakan lebih lanjut mengenai transfusi trombosit ini saya akan menguraikan sedikit tentang penyakit demam berdarah ini. Menurut WHO secara klinis jika seseorang terinfeksi dengan virus dengue sebagai penyebab penyakit Demam berdarah bisa tanpa gejala maupun dengan gejala. Yang bergejala dibagi 2 lagi yaitu Demam dengue (DD) dan Dengue Haemorhagic fever (DHF). Pasien dengan DHF biasanya dengan gejala yang lebih berat dan gejala perdarahan yang lebih jelas. Saat ini sesuai dengan klasifikasi WHO terakhir yang diterbitkan pada tahun 1997: derajat berat ringannya DHF dibagi menjadi 4. Berat ringannya penyakit ini didasarkan atas perdarahan yang terjadi, serta ada tidaknya gangguan sistim sirkulasi pada saat pasien tersebut masuk rumah sakit. Semakin berat kondisi pada saat masuk semakin tinggi derajat sakitnya dan tentunya hal ini berhubungan dengan terjadinya kematian pada pasien tersebut. Selain demam tinggi yang mendadak pasien kadang kala juga merasakan nyeri di ulu hati, mual bahkan muntah, kepala pusing seperti melayang, pegal dan rasa nyeri di otot. Setelah 2-5 hari bisa terjadi manifestasi perdarahan baik berupa bintik merah pada kulit terutama di tangan, kaki dan dada, mimisan, gusi berdarah bahkan sampai muntah darah.
Sebagai mana diketahui dan umumnya masyarakat juga sudah mengetahui, pasien DHF selalu dihubungkan dengan trombosit yang rendah. Kadar trombosit yang rendah juga menjadi patokan kapan pasien tersebut harus dirawat. Walau sebenarnya selain trombosit yang rendah adanya darah yang semakin pekat (hemokonsentrasi) ditandai oleh hematokrit yang meningkat serta tanda-tanda perdarahan merupakan hal lain yang juga dilihat sebelum memutuskan apakah pasien tersebut perlu dirawat atau tidak.
Pada pasien demam berdarah selain jumlah trombosit yang menurun fungsi trombosit juga menurun. Oleh karena itu biasanya disebutkan bahwa pada pasien DHF trombosit terganggu baik secara jumlah maupun secara kualitas. Sebagai mana kita ketahui bahwa trombosit merupakan salah satu sel darah yang berperan pada sistim keseimbangan proses pembekuan dan perdarahan (hemostasis) di dalam tubuh kita. Oleh karena adanya gangguan pada trombosit ini juga akan meningkatkan terjadinya proses pendarahan.
Adanya trombosit yang rendah bukan berarti kita harus meningkatkan trombosit sesegara mungkin. Ada 3 hal yang diduga sebagai penyebab penurunan kadar trombosit didalam darah yaitu penurunan produksi trombosit karena penekanan produksi di sumsum tulang, penggunaan trombosit yang berlebihan dan adanya antibodi anti trombosit dalam darah. Jika melihat hal-hal yang menjadi penyebab kenapa trombosit turun ini, maka transfusi trombosit yang tidak pada tempatnya justru akan memperburuk keadaan karena akan merangsang proses inflamasi lebih lanjut sehingga penghancuran trombosit akan lebih meningkat.
Seperti telah saya sebutkan tadi, indikasi pemberian trombosit telah dibicarakan beberapa kali di Forum Perhimpunan Dokter Spesialis Penyakit Dalam Indonesia (PAPDI) dan di tingkat Departemen Ilmu Penyakit Dalam FKUI/RSCM. Protokol mengenai tatalaksana pasien dengan DHF khususnya mengenai kapan transfusi trombosit ini diberikan, juga pernah disampaikan oleh pakar dari Divisi Penyakit Trofis dan Infeksi Departemen Ilmu penyakit Dalam serta pakar dari Divisi Hematologi dan Onkologi Medis Departemen Ilmu Penyakit FKUI-RSCM. Pada protokol tersebut disampaikan bahwa transfusi trombosit diberikan pada pasien dengan perdarahan spontan dan massif (banyak). Pemberian transfusi trombosit juga harus dilakukan dengan hati-hati dengan melihat komponen sistim pembekuan darah yang lain. Oleh karena itu jumlah trombosit yang rendah bahkan lebih rendah dari 20.000 tanpa perdarahan yang signifikan bukan merupakan indikasi dilakukan transfusi trombosit. Pada pengalaman dilapangan karena ketidak tahuan kadang kala keluarga pasien meminta kepada dokter agar keluarganya yang sedang dirawat untuk segera ditransfusi trombosit padahal tidak ada indikasi untuk pemberian transfusi trombosit.
Pengalaman penulis dalam merawat pasien dengan DBD biasanya trombosit akan naik dengan sendirinya setelah hari ke-7 sejak mulai terjadinya demam. Selama perawatan jika tidak terjadi syok atau perdarahan massif, cairan infus yang diberikan yaitu cairan kristaloid seperti cairan ringer laktat atau asering yang diberikan untuk menjaga agar volume cairan didalam pembuluh darah tetap baik.
Pada akhinya jika penanganan pasien DBD sesuai protocol yang telah ditetapkan, pemberian komponen darah trombosit dapat diberikan secara selektif. Sehingga pada saat dibutuhkan oleh pasien sesuai indikasi tentunya komponen trombosit tetap tersedia. Karena selain pada kasus DBD dengan perdarahan yang massif, transfusi trombosit dibutuhkan juga untuk pasien-pasien dengan kelainan darah yang lain dan juga pasien dengan gangguan liver yang berat yang akan dilakukan tindakan.
Mudah-mudahan informasi ini dapat menekan permintaan komponen darah trombosit yang tidak sesuai dengan indikasi.
Well-Rounded Docs: That's the goal as medical schools seek out and admit
One week into his premed classes at Washington University in St. Louis, Ryan Jacobson was rethinking his plan to become a doctor. His biology and chemistry classes were large, competitive and impersonal-not how he wanted to spend the next four years. "Sitting in a chemistry class, I knew it wasn't the right place for me," he says.
Jacobson found the history department, with its focus on faculty interaction and discussion, a better fit. But he had no intention of leaving his medical aspirations behind. So Jacobson majored in history while also taking the science and math courses required for medical school. When he graduated last spring, he won the departmental prize for undergraduate thesis for his work on the history of
race relations in Tulsa, Okla. He started medical school at the University of Illinois last month. "Historians are supposed to integrate information with the big picture," he says, "which will hopefully be useful as a physician."
Even as breakthroughs in science and advances in technology make the practice of medicine increasingly complex, medical educators are looking beyond biology and chemistry majors in the search for more well-rounded students who can be molded into caring and analytic doctors. "More humanities students have been applying in recent years, and medical schools like them," says Gwen Garrison, assistant vice president for medical-school services and studies at the Association of American Medical Colleges. "The schools are looking for a kind of compassion and potential doctoring
ability. This makes many social-science and humanities students particularly
well qualified."
The number of science majors applying to medical school has been steady for the past decade-about 65 percent of applicants major in biology or another physical science. What's changing is who gets in. When Gail Morrison, who runs admissions at the University of Pennsylvania School of Medicine, sorts through the school's 6,500 yearly applicants, she is not looking for students who spent their undergrad years hunched over biology and physics textbooks. "It doesn't make you a better doctor to know how fast a mass falls from a tree," she says. Approximately 40 percent of the students that Penn accepts to its medical school now come from nonscience backgrounds.
That number has been rising steadily over the past 20 years. "They've got to be happy and have a life outside of medicine," says Morrison, "otherwise they'll get overwhelmed. We need whole people." In 1999, a national survey of first-year medical students found that 58 percent took a social-science class for personal interest. In last year's entering class, the number was more than 70 percent. Humanities students
also fare better on the MCAT, the standardized test for medical-school admissions. Among the 2006 applicants to medical school, humanities majors outscored biology majors in all categories.
Michael Sciola, who's been advising premed students at Wesleyan University for the past 13 years, has seen liberal-arts majors become more attractive to medical schools. And he's not surprised that those who stray from science are finding success. "Medical schools have really been looking for that scholar-physician in the past few years," he says. "We're living in an increasingly complex world, and the liberal arts give you the skills to understand that better."
The Mount Sinai School of Medicine in New York has a program designed to attract nonscience majors. Each year, Mount Sinai accepts about 30 college sophomores from around the country through its humanities and medicine program. The students do not have to take the MCAT, but they are required to pursue a humanities major as undergrads before starting at Mount Sinai. "The students who come in with a humanities background see patients more as a whole patient," says Miki Rifkin, the program's director. She says that these students often outperform their peers, with higher rates of competitive residency placements.
Andrea Schwartz, a third-year medical student in the Mount Sinai program, attended Columbia University and the Jewish Theological Seminary and has a dual degree in history and Bible studies. "Having such a varied experience has given me the opportunity to appreciate different angles," says Schwartz, who is interested in geriatrics. "The intense text study I did as an undergrad helps me when I'm taking patients' histories. It taught me to be a better listener." That sort of training may be just what the doctor ordered.
[NW]
Jacobson found the history department, with its focus on faculty interaction and discussion, a better fit. But he had no intention of leaving his medical aspirations behind. So Jacobson majored in history while also taking the science and math courses required for medical school. When he graduated last spring, he won the departmental prize for undergraduate thesis for his work on the history of
race relations in Tulsa, Okla. He started medical school at the University of Illinois last month. "Historians are supposed to integrate information with the big picture," he says, "which will hopefully be useful as a physician."
Even as breakthroughs in science and advances in technology make the practice of medicine increasingly complex, medical educators are looking beyond biology and chemistry majors in the search for more well-rounded students who can be molded into caring and analytic doctors. "More humanities students have been applying in recent years, and medical schools like them," says Gwen Garrison, assistant vice president for medical-school services and studies at the Association of American Medical Colleges. "The schools are looking for a kind of compassion and potential doctoring
ability. This makes many social-science and humanities students particularly
well qualified."
The number of science majors applying to medical school has been steady for the past decade-about 65 percent of applicants major in biology or another physical science. What's changing is who gets in. When Gail Morrison, who runs admissions at the University of Pennsylvania School of Medicine, sorts through the school's 6,500 yearly applicants, she is not looking for students who spent their undergrad years hunched over biology and physics textbooks. "It doesn't make you a better doctor to know how fast a mass falls from a tree," she says. Approximately 40 percent of the students that Penn accepts to its medical school now come from nonscience backgrounds.
That number has been rising steadily over the past 20 years. "They've got to be happy and have a life outside of medicine," says Morrison, "otherwise they'll get overwhelmed. We need whole people." In 1999, a national survey of first-year medical students found that 58 percent took a social-science class for personal interest. In last year's entering class, the number was more than 70 percent. Humanities students
also fare better on the MCAT, the standardized test for medical-school admissions. Among the 2006 applicants to medical school, humanities majors outscored biology majors in all categories.
Michael Sciola, who's been advising premed students at Wesleyan University for the past 13 years, has seen liberal-arts majors become more attractive to medical schools. And he's not surprised that those who stray from science are finding success. "Medical schools have really been looking for that scholar-physician in the past few years," he says. "We're living in an increasingly complex world, and the liberal arts give you the skills to understand that better."
The Mount Sinai School of Medicine in New York has a program designed to attract nonscience majors. Each year, Mount Sinai accepts about 30 college sophomores from around the country through its humanities and medicine program. The students do not have to take the MCAT, but they are required to pursue a humanities major as undergrads before starting at Mount Sinai. "The students who come in with a humanities background see patients more as a whole patient," says Miki Rifkin, the program's director. She says that these students often outperform their peers, with higher rates of competitive residency placements.
Andrea Schwartz, a third-year medical student in the Mount Sinai program, attended Columbia University and the Jewish Theological Seminary and has a dual degree in history and Bible studies. "Having such a varied experience has given me the opportunity to appreciate different angles," says Schwartz, who is interested in geriatrics. "The intense text study I did as an undergrad helps me when I'm taking patients' histories. It taught me to be a better listener." That sort of training may be just what the doctor ordered.
[NW]
New drug combo could speed TB treatment
Adding a new antibiotic to the standard mix of drugs used to treat tuberculosis could shave at least two months off the current grueling six-month regimen, U.S. researchers said on Tuesday.
By substituting the Bayer antibiotic moxifloxacin for an older drug, researchers said they saw a 17 percent increase in effectiveness.
"Our finding shows that moxifloxacin is potent against tuberculosis, " Dr. Richard Chaisson of Johns Hopkins University in Baltimore, said in an interview. "It shows very dramatically that people get better faster."
Chaisson, who presented his findings at the Interscience Conference on Antimicrobial Agents and Chemotherapy meeting in Chicago, said adding this antibiotic could cut treatment time by about two months.
"If we simplify treatment, it will be easier for people to take the drugs," he said.
People often do not take their full regimen of TB drugs, which has in turn spawned drug resistance, making TB more dangerous and more difficult to treat.
Shortening treatment time could help people stick to the prescribed therapy better and reduce the development of resistant strains, Chaisson said. About 1.6 million people died from TB in 2005, according to the World Health
Organization.
Chaisson's eight-week study, which was funded by the U.S. Food and Drug Administration, tested 170 men and women with TB in Brazil. They took the traditional mixture of drugs, which includes the antibiotic ethambutol, or a mix replacing ethambutol with moxifloxacin.
After two months, cultured sputum samples from moxifloxacin patients were far less likely to grow TB bacteria. Sold under the brand name Avelox, moxifloxacin is approved for respiratory infections including pneumonia. It is marketed in the United States by Schering-Plough.
TB researchers are already preparing to study this finding in larger clinical trials, with support from the Global Alliance for TB Drug Development.
"We really do hope to shorten therapy to four months," Melvin Spigelman of the alliance told reporters, adding that it will take a number of large trials to get there. Meanwhile researchers at Johns Hopkins are working on even shorter treatment
regimens.
A study led by Dr. Jacques Grosset showed the antibiotic rifapentine achieved cures in eight weeks or less in TB infected mice. Chaisson said he plans to study that combination in humans and he thinks it could yield even better results. [Reuters]
By substituting the Bayer antibiotic moxifloxacin for an older drug, researchers said they saw a 17 percent increase in effectiveness.
"Our finding shows that moxifloxacin is potent against tuberculosis, " Dr. Richard Chaisson of Johns Hopkins University in Baltimore, said in an interview. "It shows very dramatically that people get better faster."
Chaisson, who presented his findings at the Interscience Conference on Antimicrobial Agents and Chemotherapy meeting in Chicago, said adding this antibiotic could cut treatment time by about two months.
"If we simplify treatment, it will be easier for people to take the drugs," he said.
People often do not take their full regimen of TB drugs, which has in turn spawned drug resistance, making TB more dangerous and more difficult to treat.
Shortening treatment time could help people stick to the prescribed therapy better and reduce the development of resistant strains, Chaisson said. About 1.6 million people died from TB in 2005, according to the World Health
Organization.
Chaisson's eight-week study, which was funded by the U.S. Food and Drug Administration, tested 170 men and women with TB in Brazil. They took the traditional mixture of drugs, which includes the antibiotic ethambutol, or a mix replacing ethambutol with moxifloxacin.
After two months, cultured sputum samples from moxifloxacin patients were far less likely to grow TB bacteria. Sold under the brand name Avelox, moxifloxacin is approved for respiratory infections including pneumonia. It is marketed in the United States by Schering-Plough.
TB researchers are already preparing to study this finding in larger clinical trials, with support from the Global Alliance for TB Drug Development.
"We really do hope to shorten therapy to four months," Melvin Spigelman of the alliance told reporters, adding that it will take a number of large trials to get there. Meanwhile researchers at Johns Hopkins are working on even shorter treatment
regimens.
A study led by Dr. Jacques Grosset showed the antibiotic rifapentine achieved cures in eight weeks or less in TB infected mice. Chaisson said he plans to study that combination in humans and he thinks it could yield even better results. [Reuters]
Better Bedside Manners
Every patient wants to find a doctor who listens. But wouldn't it be easier if all doctors were just better listeners?
A new paper in the Sept. 5 issue of the Journal of the American Medical Association suggests that it might not be so hard to make it happen: in the first comprehensive study of clinical-skills exams given to doctors, researchers from McGill University in Montreal show that poor scores in the communication portion of the test are highly predictive of which new doctors are likely to clash with patients in the future. By evaluating communication skills early on, say the study's authors, physicians and academics can better train and select the next generation of medical professionals.
For their study, the McGill researchers tracked all 3,424 physicians who took the Medical Council of Canada clinical-skills examination between 1993 and 1996, and who were then licensed to practice in Ontario or Quebec. The exam, which was rolled out between 1992 and 1993, requires doctors to interact with actors posing as patients in a series of standardized scenarios; trained physician evaluators then judge how well the doctor takes patient histories, makes diagnoses, manages treatment and communicates with
the patients.
When researchers followed up with the doctors in 2005, they found that the docs' scores in communication were strongly correlated to the number of patient complaints they had racked up in their first years of practice.
Overall, the 3,424, physicians had 1,116 complaints among them, of which 696 were deemed valid after medical-authority investigation. The physicians who scored low on the test - the poor communicators, who were, say, condescending, judgmental or flippant in their behavior - had generated a disproportionate number of those complaints. Doctors with scores in the bottom quartile on the test's communication- related portion had 70% more legitimate complaints per year of practice than the top-quartile performers; the poor communicators had 4.3 complaints per 100 doctors per year while their higher-scoring peers had 2.5 complaints per 100 doctors per year. No surprise: the link between poor test scores and patient complaints was strongest when it came to doctors' style of communication and attitude - the way a doctor tells a patient he has cancer, for example, or whether a doctor ignores a mother's description of what ails her child.
The current JAMA paper is the first to measure how accurately a standardized test can evaluate doctors' skills and how effectively those grades can predict future patient-complaint rates. According to the study's authors, when patients complain in the U.S. and Canada, it's most often about doctors? communication or attitude problems, rather than, say, quality-of-care issues or office screw-ups. And plenty of past studies have shown a link between lousy doctor communication and poor medical outcomes, such as inadequate care and malpractice suits.
Now that doctors know the exam works pretty well, maybe more countries will put it to use. When Canada first mandated that doctors pass the communication test for licensure, it was the only country in the world to do so - and the move was seen as controversial. Since then, the U.S. licensing system has also introduced a clinical skills exam, which every domestic and foreign medical school graduate must pass. Robyn Tamblyn, the lead author of the JAMA paper and a professor of medicine at McGill, thinks the test ought to be given even earlier than that. Why have doctors slog through med school only to be pushed out of the profession afterward because their bad bedside manner? Tamblyn recommends testing students' aptitude for communication as part of the med-school admissions process, or at least testing students early enough in medical school that they can get remedial help if they need
it."I think that's the most efficient thing to do. I think that way, essentially, you raise the bar," says Tamblyn.
While few physicians or educators doubt that communication matters, many people question how well you can test something as subjective as communication - especially when every new doctor must complete the exam on a single given day, no matter how grouchy he or she feels. But both the Canadians and the Americans have gone to great lengths to ensure their tests are fair, says Tamblyn. Her study shows that the predictive power of such exams holds irrespective of the doctors' gender or whether they went to med school in another country. "It's a good-news story," says Tamblyn of her study. If we know how to evaluate what makes a good doctor, after all, maybe
we can produce better ones. "This could diminish quite substantially the number of complaints," says Tamblyn. [TM]
A new paper in the Sept. 5 issue of the Journal of the American Medical Association suggests that it might not be so hard to make it happen: in the first comprehensive study of clinical-skills exams given to doctors, researchers from McGill University in Montreal show that poor scores in the communication portion of the test are highly predictive of which new doctors are likely to clash with patients in the future. By evaluating communication skills early on, say the study's authors, physicians and academics can better train and select the next generation of medical professionals.
For their study, the McGill researchers tracked all 3,424 physicians who took the Medical Council of Canada clinical-skills examination between 1993 and 1996, and who were then licensed to practice in Ontario or Quebec. The exam, which was rolled out between 1992 and 1993, requires doctors to interact with actors posing as patients in a series of standardized scenarios; trained physician evaluators then judge how well the doctor takes patient histories, makes diagnoses, manages treatment and communicates with
the patients.
When researchers followed up with the doctors in 2005, they found that the docs' scores in communication were strongly correlated to the number of patient complaints they had racked up in their first years of practice.
Overall, the 3,424, physicians had 1,116 complaints among them, of which 696 were deemed valid after medical-authority investigation. The physicians who scored low on the test - the poor communicators, who were, say, condescending, judgmental or flippant in their behavior - had generated a disproportionate number of those complaints. Doctors with scores in the bottom quartile on the test's communication- related portion had 70% more legitimate complaints per year of practice than the top-quartile performers; the poor communicators had 4.3 complaints per 100 doctors per year while their higher-scoring peers had 2.5 complaints per 100 doctors per year. No surprise: the link between poor test scores and patient complaints was strongest when it came to doctors' style of communication and attitude - the way a doctor tells a patient he has cancer, for example, or whether a doctor ignores a mother's description of what ails her child.
The current JAMA paper is the first to measure how accurately a standardized test can evaluate doctors' skills and how effectively those grades can predict future patient-complaint rates. According to the study's authors, when patients complain in the U.S. and Canada, it's most often about doctors? communication or attitude problems, rather than, say, quality-of-care issues or office screw-ups. And plenty of past studies have shown a link between lousy doctor communication and poor medical outcomes, such as inadequate care and malpractice suits.
Now that doctors know the exam works pretty well, maybe more countries will put it to use. When Canada first mandated that doctors pass the communication test for licensure, it was the only country in the world to do so - and the move was seen as controversial. Since then, the U.S. licensing system has also introduced a clinical skills exam, which every domestic and foreign medical school graduate must pass. Robyn Tamblyn, the lead author of the JAMA paper and a professor of medicine at McGill, thinks the test ought to be given even earlier than that. Why have doctors slog through med school only to be pushed out of the profession afterward because their bad bedside manner? Tamblyn recommends testing students' aptitude for communication as part of the med-school admissions process, or at least testing students early enough in medical school that they can get remedial help if they need
it."I think that's the most efficient thing to do. I think that way, essentially, you raise the bar," says Tamblyn.
While few physicians or educators doubt that communication matters, many people question how well you can test something as subjective as communication - especially when every new doctor must complete the exam on a single given day, no matter how grouchy he or she feels. But both the Canadians and the Americans have gone to great lengths to ensure their tests are fair, says Tamblyn. Her study shows that the predictive power of such exams holds irrespective of the doctors' gender or whether they went to med school in another country. "It's a good-news story," says Tamblyn of her study. If we know how to evaluate what makes a good doctor, after all, maybe
we can produce better ones. "This could diminish quite substantially the number of complaints," says Tamblyn. [TM]
Langganan:
Postingan (Atom)