Cure This - Front Page

a journey with adderall, and the docs who enabled

los anjalis — Sun, 12 May 2013 19:47:31 GMT

In reading "The Last All-Nighter" -- about a woman's experience with the stimulant med Adderall, the part that haunts me the most is the careless preying of physicians in prescribing the drug:

My new Upper East Side doctor didn’t seem to care that I’d self-diagnosed. I was given a prescription for sixty 20 milligram pills at my behest for $250. After our first meeting, as I did with every meeting thereafter, I beelined to the closest pharmacy...

Also...

...But because my drugs came from a doctor’s notepad in an office two blocks from the Metropolitan Museum of Art, I felt safe.

Obviously adderall is available freely -- those who want to purchase it can do so pretty easily from others, so this woman would have had other opportunities for purchasing it if a physician had talked to her about her addiction or if her doc wouldn't have prescribed it. But the fact that her doc freely prescribed the drug, it became much more legitimate for her to continue her addiction without exploring the underlying root causes of her suffering. This often also occurs in the case of opiates as well as sedatives.

The part that haunts me the second most is the fact that if the writer were not white, or did not have the financial resources she had, she would more often than not be deemed a junkie in the eyes of the world, the healthcare system and her colleagues. And if she did not have the support that she did, she may have been on a much longer, potentially much more destructive, path of addiction, toward meth and worse. But back to the doctor issue. During withdrawal:

It was hard to understand that I was experiencing withdrawal, because I was never warned of possible side effects.

This is so common it's infuriating. Healthcare providers not doing their due diligence is straight up malpractice. Anyway, do give the NYT piece a read.

"i prepared for a panic attack"

los anjalis — Sun, 12 May 2013 19:13:02 GMT

Experience Adane Byron's compelling journey through anxiety, in his short piece "A day in the life" in the NYTimes. Then go check out the ongoing contributions to the New York Times series on Anxiety.

on death and dying in the era of mass urbanization

los anjalis — Sun, 12 May 2013 03:42:17 GMT

"Sequestering our elderly keeps most of us from knowing what it’s like to grow old."

A physician reflects on our sometimes unrealistic expectations and attitudes about death.

It's an hour before the end of my shift

poppyseed — Wed, 01 May 2013 06:12:52 GMT

and I get this page.

It's unit 3. I know this isn't your patient but Dr Whoever left early and we need somebody to pronounce the lady in 13A-- she just passed.

I've been hiding in the doctors' lounge watching the news. I'd checked the ER to see if they needed help but after a day of admissions things have-- however temporarily-- settled down in there, so there's nothing to do but wait out the clock.

ok, I'll be right there.

Deaths are kind of an emergency in hospitals. Nobody wants to be the dead lady's roommate. And, of course, beds are money. They need the bed. Somebody has to come in, change the sheets, wipe up, and get the next person up from the ER and into the bed.

so down the hall and around two turns...

It's a double room. The roommate has flicked her curtain discreetly half-closed. My patient is on the far side of the room. I look at my list. 56 years old, it says: female, sepsis.

It's okay, they made her comfort care yesterday, my nurse says.

I'd figured as much. There hadn't been a code. It was too quiet to be unexpected.

i edge into the room. There is a man at the bedside, about fifty years old. He has his back mostly to me. I hesitate. I wonder if I should come back, if this is the right time.

this is when he turns.

it is an invitation. This is my space after all. I am a doctor. This is a hospital. Everything parts in front of me like curtains at a premiere. Everyone scurries out of my way. Mothers ask if they can touch their own children. They ask me. Everything here is mine.

i move into the space.

this is when I see her.

she looks about 97 years old and it is a bad 97-- she is a Halloween nightmare. Her eyes have sunken to the back of their sockets. She is limp. Her head lolls. Her hands sink into the bedclothes. Her skin is paper-like, spiderwebby, bruised and nearly translucent, stretched taut against her skeleton. Her breastbone pushed against it like the prow of a ship. It is a horrible color.

she is horrible.

i gently lift the neck of her gown and settle my stethoscope against the cool, doughy grey of her chest. It is motionless. There is a terrible stillness about her.

any idiot can see she is dead, my mind says quietly to me.

I listen for a polite interval, then linger. Silence. Stillness and silence.

Agony, her body says to me. It shrieks silently through its gaping mouth.

I touch her hand, gently, to say goodbye.

is she...? the man asks.

she's gone, I say,

and he collapses.

He is sobbing at the side of the bed, his hand still clutching hers; her hand limp where she left it.

Agony, her body is howling at me. Immeasurable, unspeakable, fathomless, endless, hopeless

all of her ribs are staring at me.

I back away.

his head is down. He is sobbing, stroking the terrible hand.

agony, her body screams at me.

I am in the hallway. I have to get to the nurses' station.

i get stuck in the hall.

how long? Weeks. It would have to have been weeks at least. Probably months.

agony

i have done autopsies. I have dissected hundreds of people healthier than her.

i am in the nurses' station. There is no place for me to go. It is going to happen here.

how long did I suffer?

Months. You suffered for months. Pain. Wasting like that has to be cancer. Gnawing, backbreaking pain, deep down inside of you, into your bones.

and weakness.

yes, crushing weakness, suffocating weakness. A prisoner, a hostage-- you were buried alive inside your own disappearing flesh

humiliating

you would have smeared yourself helplessly in your own excrement in front of people you love, in front of sstrangers

I used to dance, I made love

and now you are a rotting thing, a debased thing

i am crying in the nurses station in front of everybody, helplessly, and as quietly as I can.

There has got to be some sort of form I'm supposed to fill out.

no one moves.

two rooms over a husband and wife are clinging to each other across the uncrossable gulf and all I can think is she hung on as long as she could and oh what a horrible thing is that

doctors treat patients by the dim lights of cellphones

los anjalis — Wed, 17 Apr 2013 07:04:37 GMT

"Gaza Hospital chosen for solar power project"

Power cuts can affect Gaza hospitals so badly that medical operations sometimes have to be carried out under the faint light provided by doctors’ mobile phones.

Eager to improve this situation, a Gaza-based scientist has teamed up with an international group to undertake a renewable energy project for the health sector. Its aim is to provide 65 solar panels and other equipment for Jenin Hospital in al-Shajaiyeh neighborhood, east of Gaza City.

This is an example of much-needed international collaboration around healthcare in Gaza. More information on the folks behind the project and how to support it, can be found at the link above. It's pretty stunning that this sole hospital is literally a lifeline for sick people in a community of 250,000. A shaky lifeline, whose source of power is so tenuous and unpredictable.

What stands out for me, about this article, is an eerie acceptance that the siege on Gaza won't end for a long, long time, and that residents and infrastructure are planning around it.

"Look for the helpers"

los anjalis — Tue, 16 Apr 2013 06:09:24 GMT

"Look for the helpers. You'll always find people who are helping."
-- Mister Rogers

I'm imagining Mister Rogers dropping the mic and swaggering off the set in his sweater, knowing these words would help kids and adults alike focus on what needed focusing on, after a tragedy. Thank you, Fred. Now can this be our collective motto for everything, everyday?

Boston, we are with you. Iraq, we are with you.

los anjalis — Tue, 16 Apr 2013 05:45:05 GMT

Boston, we are with you. My heart aches. Our hearts ache.

Thank you, first responders, the greater Boston community, and the world. "Cooperation after a Tragedy: When our Hearts Know Better than our Minds"

Respect to Dave Zirin (@edgeofsports), for reminding us of the history of the Boston marathon and of Kathrine Switzer, the first woman who ran the race. "The Boston Marathon: All my Tears, All my Love"

“If you are losing faith in human nature, go out and watch a marathon.” – Kathrine Switzer

And that awful feeling in Boston -- of chaos, pain, the worst experience ever? It's hard to stomach the multiple, coordinated, terror attacks of car bombs and roadside bombs and armed gunmen all around the country of Iraq today. We mourn the deaths of 75, the wounds of 356, the terrorized psyches of Iraqis. Unimaginable. "Iraq's Bloody Monday: 75 Killed, 356 Wounded"

Iraq, we are with you. My heart aches. Our hearts ache.

Code

poppyseed — Thu, 28 Mar 2013 23:19:52 GMT

It's a rural hospital. Everybody knows everybody. Except this guy

By the time I get to the bedside we are at least fifteen deep. Nursing students trail out the door. Someone is explaining to them what is happening. Someone is doing chest compressions. This is not going to end well.

any family?

i take up a position in the conga line of chest compressioners. The ICU guy is running the code. The other ICU guy is positioned to take the airway. Nothing for me to do but be the heart. I look at the tracing-- torsade de points. It is not a good day for the heart.

has anybody checked the waiting room?

I tap the compression guy on the shoulder. Switch? I hop on the bed. I set the music in my head. We're pushing epinephrine again. Someone is keeping track of how many times, of how long. I set the music in my head. The new way to keep at 100 beats per minute is to sing the Bee Gees' "Stayin alive" in your head while doing chest compressions. I mouth it and keep an eye on the monitor. Two people feel pulses; the ICU guy is on the femoral artery, there's a respiratory therapist or something at the radial. The patient is old, maybe 70. He is warm against my hands and pliable. He bends his elbow, reaches for something, for the mask? His arm touches me. His eyes stare straight up, the pupils mid position. Is he still there? Can he feel me pressing on his chest? We push epi again and I think I see a rhythm. Hold chest compressions. I hold. There it is.

for a little while.

Torsade. Epi.

Has somebody gone to check the waiting room?

Tap and I'm out. A nursing student hops onto the bed. She's going too fast. Everyone does their compressions too fast. I've got my game face on. I nod sagely whenever ICU guy makes a call. I check the carotid pulse during pulse checks. I shake my head gravely, like the people on TV. I am trying to look like a doctor. I am a doctor. I am trying to look like it because this is what doctors are for-- for telling you things you know are true but don't want to hear: this guy is dying. What we are doing is not helping. These are his last moments on Earth and there is nothing we can do to stop it. A human being is ceasing to be and we are clawing at him in desperation because he has to matter, because a person has to matter. This is someone's father. This is someone's husband. This was once a baby, delivered into his mother's unbelieving arms. He can't just-- go.

his doctor arrives. Well, his doctor for the past hour. He was just admitted to the hospital an hour ago. She checked him. He seemed, well, okay at the time-- sick, sure, but okay. She's talking but I can't focus. The story she's telling me-- that could have been any of my patients this morning. I would have made the same call she did. That could have been me at the doorway saying he seemed okay an hour ago.

that woman in the background says something about family in the waiting room. I can't tell if she's found them or not. I just want her to shut up because she's right. Out of all of us she is the only one actually helping anybody.

ICU guy number two gets the tube in. There are breath sounds. They do not matter. The pupils are fixed and dilated. A child could tell you he's dead already. We futz around for another ten minutes out of sheer respect and hopelessness, out of powerlessness, to lodge our formal protest against God: this should not happen. This can not happen. Don't you understand what it does to us when this happens to one of us? Don't you realize that it gives the game away? Every single one of us is the star of the universe and when you just snuff one of us out we have to realize that none of us is really anything at all, that nothing we ever did will ever matter, that in the end we will be welcomed into the world by love and our families and that we will die alone in a room full of fifteen dutiful strangers who will feel strangely hollow for a little while and then go back to work.

not me.

it was the end of shift. I went to the gym and sat in the lobby sipping a cup of tea with a thousand yard stare. For half an hour I sat in a lobby in a gym five hundred miles from my home and wondered just who it was I saw die.

Bearing witness to gun violence, on the frontlines

los anjalis — Mon, 18 Mar 2013 04:10:19 GMT

After the Sandy Hook Elementary School mass shooting, the debate around physicians' roles in reducing gun violence began, like clockwork. This happens with some regularlity, after mass shootings (and yes, I see the absurdity of the words "regularity" and "mass shootings" in the same sentence). More than in previous years, however, physicians have pushed back on legislative attempts to silence them from asking their patients about gun safety in their homes, and medical societies have come out in favor of stronger gun control requirements. Gun control is more and more being framed as a public health issue, an epidemic even.

Amidst all this, it is so powerful when those on the front lines, of sorts, bear witness to the violence, the direct effects of which most of us never see. Great thanks to Dr David Newman, at Mount Sinai Hospital in New York City, for sharing why he will no longer be silent. His piece in the New York Times, entitled "At the E.R., Bearing Witness to Gun Violence", written soon after the Sandy Hook Elementary School mass shooting, has been close to my heart the last three months. Please do read it, it is extremely moving. Alas:

I do not know exactly what measures should be taken to reduce gun violence like this. But I know that most homicides and suicides in America are carried out with guns. Research suggests that homes with a gun are two to three times more likely to experience a firearm death than homes without guns, and that members of the household are 18 times more likely to be the victim than intruders...
I have sworn an oath to heal and to protect humans. Guns, invented to maim and destroy, are my natural enemy.

Those two lines. Those two lines...

Escape Fire: a must-see and a must-discuss

los anjalis — Sun, 10 Mar 2013 20:49:44 GMT

Tonight, March 10th, at 8pm EST and 11pm EST, CNN will be airing a documentary that you won't want to miss. It's called Escape Fire, and it takes a critical and much needed look at the healthcare system in the U.S. It was well received at numerous film festivals around the country, and now, lucky us, CNN bought the rights to the documentary and it will be on cable TV. If you haven't seen the trailer, you will be captivated by it:

ESCAPE FIRE: The Fight to Rescue American Healthcare (Trailer) from Our Time Projects on Vimeo.

The movie looks at some of the root causes of the healthcare -- or sick-care -- or disease-management system in the U.S. and interviews numerous visionaries. Great setting for discussion, and for dreaming about radical change in our system. I haven't seen the movie but I'm guessing that none of it is rocket science. Any human not yet indoctrinated in the ways of the current healthcare system can see its somewhat backwards and crisis approaches to the body and mind.

Why not watch this documentary with your family and friends tonight, or record it and watch later with friends? Set up a movie screening in your house. Talk about the movie aftewards. One of the biggest tragedies of documentaries is that we often receive powerful and depressing information, without the ability to do anything about it. It's easy to become disempowered instead of engaged in making change. This movie feels a bit different though, seems very interested in alternatives and solutions, at the individual and at the community level.

Still, some of the best ideas come from sharing thoughts with immediate friends, family, co-workers. My co-workers and friends, from the clinic and organization that i work for (which is working to radically transform healthcare, more on that later), will be gathering at my house to watch and discuss the movie tonight. We'll share more thoughts here.

If you are so moved, feel free to share thoughts on the movie here at CureThis (very easy to create an account and to write a post). See you on the other side of the screening! Check out the Escape Fire website for more info.

A powerful presentation of once living and breathing data. On gun deaths in America

los anjalis — Tue, 19 Feb 2013 02:50:18 GMT

There's a side of gun murders we don't talk about in America -- the trajectory of estimated years lost as a result. One team set out to visually and artistically show the 400,000+ years lost as a result of the 9,595 lives lost to gun murders in America in 2010, by mapping out the lives lost trajectory, each individual at a time (with a line to mark each individual).

“The idea of using arcs is to harken to the nature of life--a birth, growth, an apex, a waning, and finally death,” the team explains. “Above all, we wanted to respect the individual victims of these crimes. The focus was on the huge potential that was lost--babies who would have grown old, kids entering college who had so many things left to do in the world.”

The poetry here is powerful. The team refers to this data as that which was "living and breathing" and which has now been "extinguished":

"That word 'flame' plays out literally. A black background is cut with a burning orange or yellow arc of light (a person’s life). Upon death, they fall from the sky, and a 'ghost lift' line finishes their trajectory."

More graphics and full story at FastCompany. I would love to see more of this, more "humanized" data presentations of otherwise aggregate and sometimes "dehumanized" data sets. It's as if each line tells its own story.

Mississippi's last abortion clinic, and the silence of healthcare providers

los anjalis — Sun, 10 Feb 2013 10:51:35 GMT

Quietly, state by state, access to abortion care in the US is being dangerously restricted.

The most recent (ongoing) injustice is the impending closing of Mississippi’s ONLY abortion clinic. Yes, the poorest state in the United States, with the highest teenage pregnancy rate, has only one abortion clinic. The Jackson Women’s Health Organization (JWHO) clinic is located in the city of Jackson.

In 1996, Mississippi had six abortion clinics. But over the years, the state’s legislative body has passed laws mandating the most bizarre requirements for abortion clinics, which is why there is only one today:

Mississippi has, for years, done more to restrict abortion than arguably any other state. Women seeking to have an abortion must undergo counseling and wait for 24 hours for the procedure. Minors must obtain permission from both parents. Add to that 35 pages of regulations dealing with such building characteristics such as the width of a clinic's hallways and the size of its parking lot and you begin to understand how the number of clinics in Mississippi dwindled from six in 1996 to one in 2004.

And Mississippi isn't alone:

Mississippi is one of four states with just one abortion clinic, according to the Guttmacher Institute. The others are South Dakota, North Dakota and Arkansas.

Last year the state legislature passed a law requiring that anyone who performs abortions in Mississippi to be:

an OB/GYN (obstetrics/gynecology) physician.
a physician with privileges to admit patients to a local hospital.

Many doctors who perform abortion care literally fly in from other states, because of the shortage of physicians trained in (or willing to do) abortions. These doctors are excellent clinicians who sometimes are OB/GYN doctors but often times are family physicians or internal medicine doctors. There is absolutely zero clinical reason why a state would mandate a certain type of doctor only be able to perform abortions. This is very specifically a politically motivated ploy to close down the remaining clinic in the state. There is also no reason to mandate that physicians who perform abortions have admitting privileges at local hospitals. The rates of complications requiring hospital stay, from abortion care, are ridiculously low, and there are tons of physicians who do a variety of outpatient procedures, around the country, who do not have admitting privileges (in most clinics, if a doctor doesn’t have admitting privileges at a local hospital, he or she communicates with the ER physician when transporting a patient via ambulance or otherwise, to a hospital).

In any case, this is what happened when the docs at JWCO applied for privileges at the local hospitals:

Since July, the JWHO has tried in vain to comply with the new legislation. Only seven local hospitals are potential sources of privileges, and only five of them allowed the two doctors to apply to them. Each of the five hospitals denied the doctors privileges without reaching the merits of the doctors’ qualifications...
Such privileges are also difficult to obtain for abortion doctors in a state where many hospitals are affiliated with churches.

So, physicians in the state, especially the state’s medical association, which supposedly speaks on behalf of physicians and is vocal about the government not intruding on physicians' rights and clinical judgment, must be up in arms, right?

Wrong.

The clinic has also advertised on its website for a doctor with admitting privileges, also without success. They were refused permission to advertise with the Mississippi State Medical Association.

REFUSED permission to advertise on the state medical association's job board. Very interesting, Mississippi State Medical Association. Very interesting. Shame on you. Are there doctors' groups in Mississippi who are up in arms about the clinic closing and about the state medical association's political impositions?

Another state's medical association had a very different response to legislation passed there:

Wisconsin Planned Parenthood announced that it had stopped offering nonsurgical abortion services after Gov. Scott Walker signed into law requirements on the physicians facilitating them. Under the new law, a doctor must have three office visits with a woman before prescribing a drug-induced abortion, determine that the woman is not being coerced into the procedure and not use webcams during the procedure. Physicians who don’t follow the mandate could be subject to jail time or other criminal penalties.
The enactment of the law was opposed by the Wisconsin Medical Society, which said that it “directly infringes on the special and private relationship between the patient and physician” by legislating medical protocol.

Hmm. The American Medical Association, surely must have something to say on this, as they have recently intervened on behalf of the women of Mississippi on another topic recently, that of the criminalization of drug use by pregnant women. Regarding Mississippi vs Buckhalter:

The AMA opposes legislation that criminalizes maternal drug addiction.
Case summary
A woman who gave birth to a stillborn child was indicted for manslaughter. The indictment alleged that she had ingested illegal drugs, which had caused the stillbirth. The trial court dismissed the indictment, holding that the Mississippi manslaughter statute should not be construed to cover the injuries a pregnant woman’s actions might cause to her fetus. The State of Mississippi appealed the dismissal order to the Mississippi Supreme Court.
AMA involvement
The AMA joined several other organizations in an amicus brief, supporting the dismissal. The brief argued that the imposition of criminal sanctions on women who continue pregnancies in spite of drug dependency problems will not deter their drug abuse. It also argued that such prosecutions would jeopardize the therapeutic relationships between pregnant women and their physicians and thus imperil women’s access to health care.

[The amicus brief regarding Mississippi vs Buckhalter, can be found here (.PDF). It's fascinating].

Back to Mississippi's last abortion clinic. Time is of the essence, and the JWHO and their advocates are working hard to keep the clinic open. And Republican legislators are already attempting to chip away at the next abortion battleground, that of medical abortion (abortion-induction with medicines misoprostol and mifepristone aka RU-486).

The involvement of healthcare providers is really critical at this juncture. This legislation is such a powerful political infringement on the practice of medicine, and that of public health, in Mississippi.

- - - - - - - - - - - - - - - - - - - - - - - -

Check out The Last Clinic, a 49 minute documentary about Mississippi's last abortion clinic, by Maisie Crow and Alissa Quart. It's available for a small fee, or check out the free 2 minute trailer. Also see Slate's piece "Mississippi's Last Legal Abortion Clinic", with photos from the documentary.

Dr Jeffrey Brenner: We don't have the language for change in medicine

los anjalis — Sun, 11 Nov 2012 22:29:58 GMT

I'm not at the National Physicians Alliance annual meeting, going on right now, but I'm surely there in spirit. I was very involved in the organization from its founding in 2005 until about 2010. The NPA is an organization dedicated to service, advocacy, and integrity, three words we don't hear enough of in the business of healthcare. The NPA does not receive any money from pharmaceutical or medical device manafacturers, and is a multi-specialty organization (it is not a "trade" organization like quite a few other groups in organized medicine).

Thanks to twitter, I was able to see some of the fascinating quotes spoken and studies cited, by amazing speakers at the NPA meeting this weekend. I'll just share some that I retweeted (re-posted) below. I could pontificate on quite a few of these, and may in the near future, but here are the tweets for now. NPA's twitter handle is @NPAlive and the conference's hashtag is #npalive.

Dr. Brenner is Director of the Camden Coalition, which looks to address delivery system and costs in Camden NJ http://www.camdenhealth.org
Brenner: the Camden Coalition developed out of a provider interest in staying connected; expanded to now include patients.
Brenner: the major driver of future government debt is healthcare: Medicare, Medicaid, CHIP, etc. doctors have a key part in this.
Brenner: we need to rethink our roles in the delivery system: standardizing, rationalizing, partnering, delegating.
Brenner: we must reconceive how doctors work in the system, and will change the roles of hospitals, healthcare organizations, etc.
Dr Jeff Brenner: if we don't rationalize healthcare we will have to ration it.
Brenner: when conflict forces change in a system, the established interests will fight harder and harder to sustain status quo.
Brenner: disruptive change in a business forces response and refocus, but often met with resistance.
Brenner: in Camden 50% of patients seen in the ER in a year; cost $100 million in that year--$ could have been more effective.
Brenner: 30% of costs go to 1% of pts; 90% of costs go to 20% of costs. The rule of 80:20 is basic to complex systems.
Brenner: we need to pivot our healthcare delivery system to meet the needs of the patients we are working with.
Brenner: our system makes money by cutting, scanning, zapping, and hospitalizing people...not thorough #primarycare.
Brenner: the reason for this imbalance in cost/value is based on the RUC, which sets values of medical services.
Brenner: we have a committee of the AMA setting prices and values for the entire healthcare system #FoxGuardingTheHenhouse
Brenner: "We in the healthcare system need to out the RUC."
Brenner: If you overpay for any part of healthcare, you'll get more of it. Money is like fertilizer: you'll grow flowers or weeds
Brenner: Uninsurance is not driving ER visits, it's lack of access for those with poor insurance.
Brenner: in Camden, 10% of the area of the city accounted for 37% of the receipts, and 27% of visits.
Brenner: in other cities (Trenton and Newark) show similar geographic hot spots.
Brenner: Camden Coalition focuses on care coordination, delegating work to those able to do that work, communicate.
Brenner: Camden Coalition runs a data organization that gets live info from hospitals, target pts with >= 2 hospital admissions.
Brenner: Camden Coalition engages with pts in the hospital, accompany them to visits, and meet as a team to discuss pt goals.
Brenner: we need to understand the point of view of every player in the system. This requires community organization.
Brenner: this model requires 3 components: stakeholder engagement, clinical redesign (from bottom up) and data analysis.
Brenner: we don't have the language for change in medicine--so look to other movements (civil rights, etc) for ideas/inspiration.

Next up: Keynote address by Lee Nichols, PhD, Director of Center for Health Policy Research and Ethics, George Mason University
Nichols: Post election reality is that ACA will survive but implementation wont be linear. Like Medicaid.
Nichols: Single most important unit of health reform is community. Able to discard toxic politics at community level.
Nichols: clinicians should pursue stewardship, not just short-run self-interest.
Nichols: Why can't you docs figure out how to pay yourself so that we can finally fix this healthcare system?
Len Nichols: The countries & communities that figure out how to keep their folks healthy will have the better jobs.
Dr Nichols: Medical homes are great; they are not the panacea.

A lot of great tweets. Now discuss. :) [by the way, this software platform doesn't support embedding tweets, so I had to cut and paste. If/when we move this to wordpress that will all be fixed].

If you're interested, please check out a few other reading materials related to content of the tweets:

Atul Gawande "The Hot Spotters -- Can we lower medical costs by giving the neediest patients better care?" The New Yorker, January 2011. (featuring Dr Jeffrey Brenner and the Camden Coalition)
Brian Klepper and David Kibbe "Quit the RUC" Kaiser Health News, Jan 2011.
Uwe Reinhardt "The Little-Known Decision-Makers for Medicare Physician Fees" New York Times, Dec 2010.

unshackling americans, unleashing potential

los anjalis — Thu, 01 Nov 2012 06:51:56 GMT

I am of the opinion, as a dad, a husband (of a woman with reproductive organs), a tax payer, a voter and an American living inside a human body, that improving the mechanisms for delivering health care in this nation is as high a priority as we will ever have. Why? When you unshackle good, hard-working, kind, enterprising Americans from the fear that health care costs could bankrupt them, you will unleash an intellectual and economic force that will knock your socks right off your feet, whether you bought them at Brooks Brothers or Goodwill.

- Rob Delaney, "After Sandy". Read the rest of it, it's heartfelt, personal, powerful.

shame

poppyseed — Wed, 17 Oct 2012 18:40:11 GMT

but i don't have any money

you don't need any money. that's what the clinic is for

i used to work

our patients don't need insurance. that's why we're here

but it's hard to find work nowadays. you know, the times

you don't need to have a job to get your medicine here

and so i ran out

you can call us. we are here six days a week. you can just show up.

i sleep on the street

you can just tell us you're running out of meds

but i don't have any money

you need your medicine. we know that. we will give it to you

i started having this chest pain

i know

it was right after my mother died

i have to send you to the hospital

and i didn't have any work. and i was staying with my sister, but her husband, he doesn't treat her right

your blood pressure is way too high

and i can't stay there anymore...

i'm sleeping on the street

you have blood in your urine. it's telling us that the high blood pressure is damaging your kidneys

i'm sleeping on the street. i have to sleep on the street

you have to go to the hospital right now

do they need money? because i don't have any money

they will charge you but they have to treat you whether you can pay or not

i just work now and then, you know, just stuff that comes up

please, take these. they are for your blood pressure

i can't pay

you have to go to the hospital. they have to bring your blood pressure down right away. it is damaging your kidneys

so many people on the street. children. there are children on the street

please, you have to go to the hospital