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"Those who work in geriatric care are among the worst paid in the health care system. Is the time I spend as a surgeon excising a patient's cancer worth 10 times more than the time the primary care doctor spent finding the cancer in the first place?" Dr. Gawande, who examined the problems of medical care for the aged last year in The New Yorker, pointed out that as we grow older, "we don't get one problem at a time." "People with multiple problems need time, and that is not cheap and is currently not paid for by medical insurance," he said. "It's not possible to address five different problems in a 20-minute visit." Dr. Gawande, who examined the problems of medical care for the aged last year in The New Yorker, pointed out that as we grow older, "we don't get one problem at a time.... People with multiple problems need time, and that is not cheap and is currently not paid for by medical insurance," he said. "It's not possible to address five different problems in a 20-minute visit."

'A few drugs - such as beta-blockers, statins and glycogen control medications - have proved very effective at managing hypertension, heart disease, diabetes and strokes. Most insurance plans charge something for them. Why not make drugs like these free? Not for everyone, but just the groups for whom they are provably effective. In traditional economics, such a policy creates waste. The basic principle is moral hazard: consumers overuse goods that are subsidized. But people don't always follow a cost-benefit logic. The problem is basic human psychology. Heart disease is silent, with few noticeable symptoms. You feel fine most of the time, so it's all too easy to justify skipping the statin. The problem here is the exact opposite of moral hazard. People are not overusing ineffective drugs; they are underusing highly effective ones. This is a quandary that ... call "behavioral hazard." We've found that co-payments do not resolve behavioral hazard. They make it worse. They reduce the use of a drug that is already underused. My proposal is targeted: Take drugs that are shown to be of very high benefit to some people, and make those drugs free for them. All co-pays should depend on measured medical value; high co-pays should be reserved for drugs and medical services that have little proven value. Why not focus instead on the behaviors - eating unhealthy foods or shunning exercise - that created the conditions we must now treat with drugs? [This]has some merit. But [it] fails the "perfect as the enemy of the good" test.

Most people in health care understand and accept the need for clinical hierarchies. The problem is that we aren't usually prepared for them; nor are we given protocols for resolving the inevitable tensions that arise over appropriate care. Doctors and nurses are trained differently, and our sense of priorities can conflict. When that happens, the lack of an established, neutral way of resolving such clashes works to everyone's detriment. This isn't about hurt feelings or bruised egos. Modern health care is complex, highly technical and dangerous, and the lack of flexible, dynamic protocols to facilitate communication along the medical hierarchy can be deadly. Indeed, preventable medical errors kill 100,000 patients a year, or a million people a decade, wrote Rosemary Gordon and Janardan Prasad Singh in their book "Wall of Silence."

>'With unrealistic expectations of our ability to prolong life, with death as an unfamiliar and unnatural event, and without a realistic, tactile sense of how much a worn-out elderly patient is suffering, it's easy for patients and families to keep insisting on more tests, more medications, more procedures. >Doing something often feels better than doing nothing. Inaction feeds the sense of guilt-ridden ineptness family members already feel as they ask themselves, "Why can't I do more for this person I love so much?" >...At a certain stage of life, aggressive medical treatment can become sanctioned torture. When a case such as this comes along, nurses, physicians and therapists sometimes feel conflicted and immoral. We've committed ourselves to relieving suffering, not causing it. A retired nurse once wrote to me: "I am so glad I don't have to hurt old people any more." '

'If you met me, you'd never know I was mentally ill. In fact, I've gone through most of my adult life without anyone ever knowing - except when I've had to reveal it to a doctor. And that revelation changes everything. It wipes clean the rest of my résumé, my education, my accomplishments, reduces me to a diagnosis. I was surprised when, after one of these run-ins, my psychopharmacologist said this sort of behavior was all too common. At least 14 studies have shown that patients with a serious mental illness receive worse medical care than "normal" people. Last year the World Health Organization called the stigma and discrimination endured by people with mental health conditions "a hidden human rights emergency." If you met me, you'd never know I was mentally ill. In fact, I've gone through most of my adult life without anyone ever knowing - except when I've had to reveal it to a doctor. And that revelation changes everything. It wipes clean the rest of my résumé, my education, my accomplishments, reduces me to a diagnosis. I was surprised when, after one of these run-ins, my psychopharmacologist said this sort of behavior was all too common. At least 14 studies have shown that patients with a serious mental illness receive worse medical care than "normal" people. Last year the World Health Organization called the stigma and discrimination endured by people with mental health conditions "a hidden human rights emergency." I never knew it until I started poking around, but this particular kind of discriminatory doctoring has a name. It's called "diagnostic overshadowing." According to a review of studies done by the Institute of Psychiatry at King's College, London, it happens a lot. As a result, people with a serious mental illness - including bipolar disorder, major depression, schizophrenia and schizoaffective disorder - end up with wrong diagnoses and are under-treated. That is a problem, because if yo

The problem with teaching Physical Diagnosis in medical school without first teaching Communication Skills.

Medical debts of elderly despite Medicare

Online support systems for family member's complex medical needs

Interview by John C. Reed, MD, PhD - CEO, Sanford-Burnham Medical Research Institute, La Jolla, California.

Dr. Peter J. Pronovost, medical director of the Quality and Safety Research Group at Johns Hopkins Hospital in Baltimore, travels the country advising hospitals on innovative safety measures.

Autonomy has limits - pts want docs to exercise expertise.

"[I]f our brain's chemistry does affect our moral behavior, the question of whether that balance is set in a natural way or by medical intervention will make no difference in how freely we act. If there are already biochemical differences between us that can be used to predict how ethically we will act, then either such differences are compatible with free will, or they are evidence that at least as far as some of our ethical actions are concerned, none of us have ever had free will anyway. In any case, whether or not we have free will, we may soon face new choices about the ways in which we are willing to influence behavior for the better.

Actually GOALS for changing medical culture

"...beyond the medical advances, Dr. DeBakey's story is emblematic of the difficulties that often accompany care at the end of life. It is a story of debates over how far to go in treating someone so old, ... and risky decisions that, while still being argued over, clearly saved Dr. DeBakey's life. It is also a story of Dr. DeBakey himself, a strong-willed pioneer who at one point was willing to die, concedes he was at times in denial about how sick he was and is now plowing into life with as much zest and verve as ever. But Dr. DeBakey's rescue almost never happened. He refused to be admitted to a hospital until late January. As his health deteriorated and he became unresponsive in the hospital in early February, his surgical partner of 40 years, Dr. George P. Noon, decided an operation was the only way to save his life. But the hospital's anesthesiologists refused to put Dr. DeBakey to sleep because such an operation had never been performed on someone his age and in his condition. Also, they said Dr. DeBakey had signed a directive that forbade surgery. As the hospital's ethics committee debated in a late-night emergency meeting on the 12th floor of Methodist Hospital, Dr. DeBakey's wife, Katrin, barged in to demand that the operation begin immediately.

'I recently explored what Google searches tell us about depression, by which I mean, loosely, dips in mood. [I used] anonymous, aggregate data from tens of millions of queries.... thanks to the incredibly large sample size, meaningful patterns emerge. According to the data, depression is highest in April. Depression is lowest in August. The state with the highest rate of depression is North Dakota; the one with the lowest, Virginia. The city with the highest rate is Presque Isle, Me.; the city with the lowest, San Francisco. Depression is, unsurprisingly, highest on Mondays and lowest on Saturdays. The date on which depression is lowest is Dec. 25, followed by a few days surrounding it. The strongest predictor by far: an area's average temperature in January. Colder places have higher rates of depression, with the correlation concentrated in the colder months. Google searches, the biggest data source we currently have, are unambiguous: when it comes to our happiness, climate matters a great deal. There is a lesson here for public health and medical researchers. Are you investigating how weather affects migraine headaches? How chemicals in water affect autism rates? I believe we are about to enter a golden age of disease research. Many of the biggest developments will come from the analysis of big data, not from traditional experiments that survey a relatively small number of people.

'...the Cochrane Collaboration reported last year that patients who used tools to guide their decisions had a better grasp of their choices and risks. They were also more likely to select less intense or invasive treatment when considering major elective surgery, though results were mixed for other decisions. The influence of decision aids on adherence to medication or overall costs was "inconclusive," according to the report. 'But that uncertainty does not reduce the ethical obligation to better inform patients, or lessen the promise of tools that help patients understand their options and identify their values, some doctors say. "It is the right thing to do," said Dr. Victor Montori, associate director of the Health Care Delivery Research Program at the Mayo Clinic Center for the Science of Health Care Delivery....'