Discussion in 'VMBB General Discussion' started by rooter, Oct 23, 2008.

  1. rooter

    rooter *VMBB Senior Chief Of Staff*

    Jan 31, 2001
    Marty Robbins old hometown, Glendale Arizona--a su
    ER Overload
    A new study looks at overcrowding in America's emergency rooms and finds some surprising reasons for those long waits.

    Mary Carmichael
    Newsweek Web Exclusive
    Oct 21, 2008 | Updated: 7:32 a.m. ET Oct 21, 2008
    The modern emergency room, as most people think of it, has an emergency of its own: It's packed, costly, noisy, and overrun by uninsured freeloaders who can't legally be turned away once they walk through the ER doors. If you've actually been in an ER in the past few years, you know the first three things are true—but how much do you know about the rest of the people in the waiting room? As it turns out, they're not disproportionately uninsured patients with nowhere else to turn. They're more likely to be people who do have insurance, and according to a new study in the Journal of the American Medical Association, the reasons they're backing up in ERs go much deeper than who's paying for their care. NEWSWEEK's Mary Carmichael asked Dr. Manya Newton, an emergency physician at the University of Michigan, Robert Wood Johnson Clinical Scholar, and the lead author of the new paper, to explain the problem. Excerpts:

    NEWSWEEK: You looked at some common assumptions about why emergency rooms are so crowded. A lot of them turned out to be untrue. What were these myths, and how did people come to believe in them?
    Manya Newton: First, there was a belief that the uninsured are all coming to the emergency department for non-urgent care. That's a tricky one to talk about, because there's no good definition of what "non-urgent care" is—if you have a big cut on your face, or if your baby has a fever and it's one in the morning, that is coded as "non-urgent" by doctors even though it's urgent to you. But when people talk about crowded ERs and the uninsured coming in for "non-urgent care," they're thinking about things like the sniffles, or the back pain these people have had for 11 years. And if you actually look at the uninsured, they're not coming in for sniffles or back pain, because they're the only group that bears the full cost of an ER visit. Yes, a $50 co-pay is painful, but a $5,000 bill is really painful.

    So they actually come to the ER less often than people with insurance do?
    Yes. They're underrepresented in ERs compared to the overall population—17 percent of people in our country are uninsured, but they account for somewhere between ten and 15 percent of visits to the ER. When they do come in, they tend to put it off until the last possible moment, until they're really sick. So it's not the uninsured who are causing crowding. It's everybody.

    Why do you think people came to believe the opposite—that the uninsured were responsible for crowded ERs?
    Before the 1990s, at least in the medical literature, it was widely understood that the uninsured were putting off care, showing up sicker [and] showing up less often. But then there were some big changes in the medical system. The Emergency Medical Treatment and Active Labor Act went into effect in 1986. This is the act that's often misquoted as "you can get free care in the emergency department," which is absolutely not right. The fact is that if you show up and you're sick, we do have to treat you—we can't look in your wallet first. But it's not free. You still get billed. Also, there were a bunch of changes at that time regarding managed care, and the result was that ERs found themselves strapped for money. A lot of emergency departments across the country closed, so all the remaining ERs were seeing more patients—and I think the uninsured became our scapegoat.

    What people don't understand is that in general, the uninsured are people who are working two or three jobs trying to hold their families together, and none of their jobs offer insurance. There's this presumption that they're choosing not to have insurance—there's a feeling that these people are unworthy, that they'd have insurance if they just worked harder. And we can't make policy based on assumptions like that, because a lot of times what "everybody knows" turns out to be wrong.

    So if the uninsured aren't to blame for overcrowding, who is?
    It's multi-factorial. The population is getting older and sicker, so more people are coming to the ER for real emergencies. Use-per-person has also gone up, and we're not sure why that's happening. Part of it is because there are fewer primary care doctors now, so it's hard to get appointments. If you call your doctor's office and you say, "I'm super-sick and coughing up green stuff," and they say, "we'll see you three weeks from Tuesday," you might think you need to go to the ER instead. And you might be right.

    But you might be wrong, in which case you're in the ER unnecessarily.

    You also write that the actual number of beds in ERs has gone down, at the same time the need has apparently gone up. Why?
    That would be a whole other paper—but it has to do with changes in reimbursement and the nursing shortage.

    Basically, there's not enough money for beds?
    Right. So, let's say your grandmother breaks her hip and comes in and has surgery. There are fewer beds upstairs on the inpatient units, as well as fewer in the ER. So if Grandma can't go home after her surgery, there are fewer places we can put her. Now we're looking for a bed upstairs for a week or two weeks, which means the next grandmother with a broken hip waits and waits behind her in the emergency department, because I can't get someone upstairs to a bed that doesn't exist.

    This has to be affecting patient care.
    Absolutely. We are fantastic at treating emergencies, but we do not run an intensive-care unit as well as the intensivists can. And we know that increasing the wait time to see a doctor in the emergency department can lead to worse patient outcomes.

    So now that we know what the problem is, how the heck do we fix it?
    There are no easy solutions. The ER can work on through-put issues—do we need to hire more nurses? Do we need to streamline our system? But that's a tiny fraction of the problem. We cannot control how many people show up at our door. We cannot control how soon someone can get a bed. One of the keys is that you can't blame any one part of the system. You can't say this is the ER's fault, or the inpatient services', or primary care's. If we keep pointing fingers and blaming people, we're not going to change anything. This is a system wide problem. All parts of the system need to sit down and discuss it as a whole.

    There's no specific reform you can think of that would make a difference?
    We could change the way primary care doctors are reimbursed and make it more affordable for them to see lower-income patients, or more attractive for them to have longer hours. That would probably be where I'd start.

    Is there anything in either of the presidential candidates' platforms that would help? Their proposals seem mostly focused on getting more people insured.
    Providing insurance to more people will help with overall health. It may help the currently uninsured find a primary care provider. But it is not going to help with ER overcrowding, because the primary care doctors are still going to be overbooked.

    If anything, it might encourage the newly insured to come to the ER more than they do now.
    Right. It's not a panacea. It's a great thing to do, but it's not going to solve this problem.
  2. rooter

    rooter *VMBB Senior Chief Of Staff*

    Jan 31, 2001
    Marty Robbins old hometown, Glendale Arizona--a su
    October 24, 2008
    Half of Doctors Routinely Prescribe Placebos
    Half of all American doctors responding to a nationwide survey say they regularly prescribe placebos to patients. The results trouble medical ethicists, who say more research is needed to determine whether doctors must deceive patients in order for placebos to work.

    The study involved 679 internists and rheumatologists chosen randomly from a national list of such doctors. In response to three questions included as part of the larger survey, about half reported recommending placebos regularly. Surveys in Denmark, Israel, Britain, Sweden and New Zealand have found similar results.

    The most common placebos the American doctors reported using were headache pills and vitamins, but a significant number also reported prescribing antibiotics and sedatives. Although these drugs, contrary to the usual definition of placebos, are not inert, doctors reported using them for their effect on patients’ psyches, not their bodies.

    In most cases, doctors who recommended placebos described them to patients as “a medicine not typically used for your condition but might benefit you,” the survey found. Only 5 percent described the treatment to patients as “a placebo.”

    The study is being published in BMJ, formerly The British Medical Journal. One of the authors, Franklin G. Miller, was among the medical ethicists who said they were troubled by the results.

    “This is the doctor-patient relationship, and our expectations about being truthful about what’s going on and about getting informed consent should give us pause about deception,” said Dr. Miller, director of the research ethics program in the department of bioethics at the National Institutes of Health.

    Dr. William Schreiber, an internist in Louisville, Ky., at first said in an interview that he did not believe the survey’s results, because, he said, few doctors he knows routinely prescribe placebos.

    But when asked how he treated fibromyalgia or other conditions that many doctors suspect are largely psychosomatic, Dr. Schreiber changed his mind. “The problem is that most of those people are very difficult patients, and it’s a whole lot easier to give them something like a big dose of Aleve,” he said. “Is that a placebo treatment? Depending on how you define it, I guess it is.”

    But antibiotics and sedatives are not placebos, he said.

    The American Medical Association discourages the use of placebos by doctors when represented as helpful.

    “In the clinical setting, the use of a placebo without the patient’s knowledge may undermine trust, compromise the patient-physician relationship and result in medical harm to the patient,” the group’s policy states.

    Controlled clinical trials have hinted that placebos may have powerful effects. Some 30 percent to 40 percent of depressed patients who are given placebos get better, a treatment effect that antidepressants barely top. Placebos have also proved effective against hypertension and pain.

    But despite much attention given to the power of placebos, basic questions about them remain unanswered: Are they any better than no treatment at all? Must people be deceived into believing that a treatment is active for a placebo to work?

    Some studies have hinted at answers, but experts say far more work is needed.

    Dr. Howard Brody, director of the Institute for the Medical Humanities at the University of Texas Medical Branch, in Galveston, said the popularity of alternative medical treatments had led many doctors to embrace placebos as a potentially useful tool. But, Dr. Brody said, doctors should resist using placebos, because they reinforce the deleterious notion that “when something is the matter with you, you will not get better unless you swallow pills.”

    Earlier this year, a Maryland mother announced that she would start selling dextrose tablets as a children’s placebo called Obecalp, for “placebo” spelled backward.

    Dr. Ezekiel J. Emanuel, one of the study’s authors, said doctors should not prescribe antibiotics or sedatives as placebos, given those drugs’ risks. Use of less active placebos is understandable, he said, since risks are low.

    “Everyone comes out happy: the doctor is happy, the patient is happy,” said Dr. Emanuel, chairman of the bioethics department at the health institutes. “But ethical challenges remain.”
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