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'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

H.J. Aaron (health economist) and R.D. Reischauer (former director of HBO): "Health care reform advocates will and should celebrate their history-making legislative success.... But supporters must not relax. They should prepare to meet the serious challenges that remain.... Far from having ended, the war to make health care reform an enduring success has just begun. Winning that war will require administrative determination and imagination and as much political resolve as was needed to pass the legislation."

John K. Iglehart: 'President Barack Obama, sealing a hard-fought and historic victory, has signed into law the Democrats' comprehensive health care reform bill, the Patient Protection and Affordable Care Act, a sweeping measure that would expand coverage to 32 million uninsured Americans. Appearing March 23 in the White House, Obama said, "Today . . . health insurance reform becomes law in the United States of America. . . . We have just enshrined the core principle that everybody should have some basic security when it comes to their health care." '

Peter B. Bach, M.D., M.A.P.P.: The Debate over Regional Variation in Health Care Spending: "The regional variations in health care spending that are documented by the Dartmouth Atlas of Health Care have been cited by many as a justification, and possible basis, for changes in provider payment rates. ..."

The North Shore-LIJ Health System, with 16 hospitals and more than 300 outpatient centers in Long Island and New York City, is laying the groundwork to be an insurer, as well as a provider of health care.

>"...Offering a default option of opting in, rather than opting out (as many have suggested with organ donations as well) doesn't take away choice but guides us to make better ones, according to Richard H. Thaler, an economics professor at the University of Chicago, and Cass R. Sunstein, a professor at Chicago's law school, authors of "Nudge: Improving Decisions About Health, Wealth and Happiness". Making choices can be most difficult in the area of health. While we don't want to go back to the days when doctors unilaterally determined what was best, there may be ways of changing policy so that families are not forced to make unbearable choices. >Professor Iyengar and some colleagues compared how American and French families coped after making the heart-wrenching decision to withdraw life-sustaining treatment from an infant. In the United States, parents must make the decision to end the treatment, while in France, the doctors decide, unless explicitly challenged by the parents. >French families weren't as angry or confused about what had happened, and focused much less on how things might have been or should have been than the American parents.

'...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....'

My letter focuses on bioethical principles. ACA seeks to promote beneficence & justice (and decrease the maleficent impact of our nation's decision, so far, to allow 15% of the population to remain without health insurance, and suffer its deleterious health consequences).

The fundamental fix for health care reform is likely to be achieved only through trial and error and incremental gains.\n

Readers largely support measures to allow death in dignified environment with palliative approach, as opposed to repeated aggressive interventions that are rarely successful when the prognosis is poor.

Bob Doherty is the main Washington lobbyist of the ACP - after the AMA, the largest organization of US doctors (representing internal medicine physicians, whether primary care or subspecialist). He's had some very interesting posts since the Massachusetts Senate upset. His blog is a finalist in the sixth annual Medical Weblog Awards for the Best Health Policies/Ethics Weblog. Doherty articulates the ACP's case for supporting the current Senate&House Health Care Reform legislation (whose failure he & many others will end up leading eventually to more draconian limits on doctors & patients, in order to control the currently unsustainable growth in US health care costs (now approaching 20% of GDP).

Title of review: "A Season in Hell." Kidder authored "Mountains beyond Mountains" in 2003, about work of Paul Farmer (from Harvard) and his organization Partners in Health, which has a large Haitian-run health organization in Haiti - pretty much intact after the earthquake.

Kidder authored "Mountains beyond Mountains" in 2003, about work of Paul Farmer (from Harvard) and his organization Partners in Health, which has a large Haitian-run health organization in Haiti - pretty much intact after the earthquake.

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."

26,000 premature deaths/yr in US b/o no health insurance

Need to still address MD SGR (perhaps gradual intro with gradual decr in reimbursement for some docs)

'Adrienne Asch, an internationally known bioethicist who opposed the use of prenatal testing and abortion to select children free of disabilities, a stance informed partly by her own experience of blindness, died on Nov. 19 at her home in Manhattan. She was 67. 'In an article in The American Journal of Public Health in 1999, Professor Asch laid out her philosophy in no uncertain terms: "If public health espouses goals of social justice and equality for people with disabilities - as it has worked to improve the status of women, gays and lesbians, and members of racial and ethnic minorities - it should reconsider whether it wishes to continue the technology of prenatal diagnosis," she wrote. 'She added: "My moral opposition to prenatal testing and selective abortion flows from the conviction that life with disability is worthwhile and the belief that a just society must appreciate and nurture the lives of all people, whatever the endowments they receive in the natural lottery." '