NYT on burnout

http://well.blogs.nytimes.com/2012/08/23/the-widespread-problem-of-doctor-burnout/

DOCTOR AND PATIENT AUGUST 23, 2012, 3:50 PM198 Comments

The Widespread Problem of Doctor Burnout

By PAULINE W. CHEN, M.D.

The patient, a powerfully built middle-aged restaurant worker, had awakened one morning with a tight pain in his shoulders that traveled down his right arm. At work, he could barely shrug his shoulders or turn his head. “My fingers were so weak,” he recalled, “that I couldn’t even get a good grip around a glass of water.”

A senior doctor at a local clinic diagnosed a pinched nerve and prescribed a muscle relaxant. Two weeks later, only more incapacitated, the patient went to another clinic, where a younger doctor made the right diagnosis: A malignant tumor in his chest was pressing against a nerve to his arm.

“That first doctor couldn’t be bothered by what I was trying to say,” the patient said. He was now receiving chemotherapy and was hopeful his cancer had been caught early enough, but the near miss still haunted him. “He acted like he just didn’t want to be there with me. Or with any patient.”

After reading a study published this week in Archives of Internal Medicine, I’ve been thinking a lot about this patient’s experience. And I’ve come to two conclusions. First, the older doctor had classic symptoms of burnout.

Second, mistakes like his may only become more common.

Research over the last 10 years has shown that burnout – the particular constellation of emotional exhaustion, detachment and a low sense of accomplishment – is widespread among medical students and doctors-in-training. Nearly half of these aspiring doctors end up becoming burned out over the course of their schooling, quickly losing their sense of empathy for others and succumbing to unprofessional behavior like lying and cheating.

Now, in what is the first study of burnout among fully trained doctors from a wide range of specialties, it appears that the young are not the only ones who are vulnerable. Doctors who have been practicing anywhere from a year to several decades are just as susceptible to becoming burned out as students and trainees. And the implications of their burnout — unlike that of their younger counterparts, who are often under supervision — may be more devastating and immediate.

Analyzing questionnaires sent to more than 7,000 doctors, researchers found that almost half complained of being emotionally exhausted, feeling detached from their patients and work or suffering from a low sense of accomplishment. The researchers then compared the doctors’ responses with those of nearly 3,500 people working in other fields and found that even after adjusting for variables like gender, age, number of hours worked and amount of education, the doctors were still more likely to suffer from burnout.

“We’re not talking about a few individuals who are disorganized or not functioning well under pressure; we’re talking about one out of every two doctors who have already survived rigorous training,” said Dr. Tait D. Shanafelt, the lead author of the study and a professor of medicine at the Mayo Clinic in Rochester, Minn. “These numbers speak to bigger problems in the larger health care environment.”

The doctors’ burnout appeared to have little to do with hours worked or even the ability to balance personal life with work. Instead, the only factor predictive of a higher risk was practicing a specialty that offered front-line access to care. More than half of the doctors in family medicine, emergency medicine and general internal medicine experienced some form of burnout.

The study casts a grim light on what it is like to practice medicine in the current health care system. A significant proportion of doctors feel trapped, thwarted by the limited time they are allowed to spend with patients, stymied by the ever-changing rules set by insurers and other payers on what they can prescribe or offer as treatment and frustrated by the fact that any gains in efficiency offered by electronic medical records are so soon offset by numerous, newly devised administrative tasks that must also be completed on the computer.

In this setting, “doctors are losing their inspiration,” Dr. Shanafelt said, “and that is a very frightening thing.”

What patients must face in the examining room is no less alarming. Doctors who are suffering from burnout are more prone to errors, less empathetic and more likely to treat patients like diagnoses or objects. They are also more likely to quit practicing altogether, a trend that has serious repercussions in a system already facing a severe doctor shortage as it attempts to expand coverage to 30 million or more currently uninsured Americans.

“Doctors are coming to this expansion already pretty stretched and stressed out,” Dr. Shanafelt noted. “I don’t think there is going to be a lot of room to maneuver without some significant structural changes.”

Dr. Shanafelt and his colleagues are in the midst of studying the effects of workplace initiatives aimed at providing greater support for doctors while improving efficiency, which they believe is critical for doctors and patients as well as the large health care organizations that aim to serve us all. Without decreasing the total hours worked or the number of patients a doctor must see, a hospital system might, for example, restructure its clinics so that doctors could spend more time with patients and less time on the phone getting authorization from insurers or in front of a computer completing administrative tasks.

“If people work in an environment where they believe there is meaning, they will put up with a lot,” Dr. Shanafelt observed. “It goes beyond the significant personal consequences for an individual physician. It affects whom patients can see when they are sick, the quality of care they receive and their safety.”

Well worth reading...

http://well.blogs.nytimes.com/2012/08/09/life-interrupted-medical-bills-insurance-and-uncertainty/

from the blog 'Life, interrupted', from the New York Times

LIFE, INTERRUPTED AUGUST 9, 2012, 12:01 AM272 Comments

Life, Interrupted: Medical Bills, Insurance and Uncertainty

By SULEIKA JAOUAD

 

Like a lot of other young people, I never thought about health insurance until I got sick. I was 22, and my adult life was just beginning. But less than a year after walking across the stage at my college graduation, I received an unexpected diagnosis — acute myeloid leukemia — and with it came a flurry of consultations, tests and appointments. From early on, my doctors told me I would need chemotherapy and a bone marrow transplant.

 

But before the shock of the news could settle in — before I could consider where and how I would be treated — I did what most Americans must do when beset with a medical crisis: I called my insurance provider. 

 

 Before I made that first phone call, I confess I didn’t know exactly what the word “premium” meant. And “co-pay” sounded to me like what happens when friends split the bill at dinner. Certainly, the term “lifetime limit” had no meaning to me yet. The last time I could remember getting sick had been a two-day bout of food poisoning during my junior semester abroad in Egypt. Now, I was facing cancer — and I was beginning to get worried about coverage from an insurance plan I knew virtually nothing about.

If you have a chronic illness in America, there’s a good chance you also hold a degree in Health Insurance 101, whether you want to or not. The first thing I learned was how lucky I was to have health insurance at all. (An estimated 49 million Americans, and nearly one-third of Americans 18 to 24 years old, are uninsured.) I was on my parents’ insurance, a plan provided through my father’s employer. It’s a comprehensive plan that will cover me until age 26 — two years from now.

I’ve been fortunate to be treated by excellent doctors at world-class hospitals. In the last year alone, my insurance has covered over a million dollars in medical expenses, including a bone marrow transplant and 10 hospitalizations amounting to a combined five months of inpatient care. It all sounds straightforward when I explain it like that. But even if you have insurance, the cost of health care — in dollars as well as in time and stress — is incredibly high.

As health care was debated around the country leading up to the Supreme Court ruling on the Affordable Care Act in June, my bills kept coming in. Every time I see a doctor, get a CT scan, receive chemotherapy or pick up a prescription, insurance covers only part of the transaction — and there’s always a bill on top of it. For a cancer patient like me who visits the hospital on a weekly basis (and that’s when things are going well), every few days I owe another payment. Keeping track of how much I owe, and for what procedure, and why, can make my head spin. Just learning the ins and outs of my plan’s coverage takes sustained, persistent attention and energy, things that sick people have in short supply.

And no matter how closely I keep track of the bills, there are always surprises and unexpected charges. During a six-week hospitalization for intensive chemotherapy, teams of doctors trickled in and out of my hospital room every few hours: my primary oncologists, the palliative care unit, gastroenterologists, X-ray technicians, infectious disease specialists and on and on. Most of the time I was too tired, too nauseated or too looped on pain medicine to remember who was who or what they were doing in my room. But my insurance company kept track. Even though my hospitalization was covered, many of the doctors who visited me were not part of my health plan, which meant that for every time they set foot in my room I would receive a steep out-of-pocket bill. After all, what was I going to do: tell the doctor prescribing my anti-nausea medication to skip my room because he happened to be out of network?

Another cost of health insurance is time. Time is money, as the saying goes, but when it comes to cancer and health insurance, to save money takes up a whole lot of time. My mother graciously took on the task of disputing claims, keeping track of bills, requesting approval for a procedure or a drug, and spending countless hours on the phone with my provider. While it may be a labor of love for my mother, in practice, working out insurance questions is just a lot of labor. Between the long hours spent taking care of me and dealing with our insurance, my health care became my mother’s full-time job.

So far, the out-of-pocket costs associated with my cancer care — co-payments, out-of-network charges, the costs of moving to a new city for treatment, fertility treatments not covered by insurance — have reached tens of thousands of dollars. The financial burden of cancer has not yet meant that my parents will need to get second jobs, or that we will have to sell our house — though I know of fellow cancer patients with and without insurance who have had to consider such options. But my mother has had to take the last year off work, a financial and professional sacrifice that’s due in part to the time required to manage my health insurance. What do others do who don’t have full-time help from a caregiver? My mother would do anything for me, but I wish she would be able to spend less time with my bills and more time with me.

In two years, I’ll graduate from my parents’ insurance. What will I do about insurance then? Perhaps I’ll gain coverage through an employer — though holding a job seems like a tall task if I’m still in treatment. Isn’t it a contradiction that insurance is often tied to employment, but that the sick people who need it most are the ones who have the hardest time staying employed? If the Affordable Care Act remains in place, at least I won’t be denied coverage because of pre-existing conditions. That’s a huge victory, but what will the cost of that coverage be, and will I be able to afford it?

When I’m lying in bed at night, I often worry about how cancer may affect my future: my career, my relationships, my dreams. Sick people don’t plan on getting sick. We shouldn’t have the added worry that someday insurance coverage may not be there. Or that a medical crisis could become a financial one too.

---

Over the coming weeks, Well will explore the reasons behind our troubled health care system from the perspective of the patient. The series is part of a larger New York Times project called The Agenda, which focuses on critical issues facing the next president and Congress. Join the conversation at The Agenda

Suleika Jaouad (pronounced su-LAKE-uh ja-WAD) is a 24-year-old writer who lives in New York City. Her column, “Life, Interrupted,” chronicling her experiences as a young adult with cancer, appears weekly on Well. Follow @suleikajaouad on Twitter.

A version of this article appeared in print on 08/21/2012, on page D5 of the NewYork edition with the headline: The Agenda: A Reluctant Crash Course in Health Insurance 101.

a warning...

http://www.nytimes.com/2012/08/25/opinion/jobless-and-invisible.html?ref=opinion

Letter

Jobless and Invisible

Published: August 24, 2012

To the Editor:

Re “Long-Term Jobless Regroup to Fight the Odds” (front page, Aug. 17):

One way or another, the older long-term unemployed become invisible. They stop looking for work and disappear from unemployment statistics. They lose their homes and blend into the shadows of shelters and streets. They eat poorly and irregularly, they can’t afford health care and their circumstances no doubt hasten their descent into the permanent invisibility of the grave.

A generation is disappearing, along with a decent middle-class standard of living. The older long-term unemployed are bewildered by their predicament, and the working public is stymied by the problem. From our business leaders and elected representatives we get shocking and inexcusable silence, apathy and inaction.

ARTHUR CHERTOWSKY
Brooklyn, Aug. 20, 2012 

The Daily Show visits Iran

Cookies from The Cookie Monster! via the Kitchn

http://www.thekitchn.com/cookie-monsters-famous-cookie-dough-recipe-175725

Ingredients 3/4 cup unsalted butter or margarine, softened
1 cup sugar
2 eggs, slightly beaten
1 teaspoon vanilla
2 1/2 cups all-purpose flour
1 teaspoon baking flour
1 teaspoon salt
Equipment
Medium-sized mixing bowl
Measuring cup and spoons
A fork

Instructions

1. Put 3/4 cup of butter or margarine (that's a stick and a half) into your mixing bowl.
2. Measure 1 cup of sugar.
3. Pour sugar over butter.
4. With fork, squash butter and sugar together until they are blended.
5. Crack shells of two eggs and pour eggs over mixture in bowl.
6. Measure 1 teaspoon vanilla and pour over mixture.
7. With fork, blend everything in the bowl together.
8. Measure 2 1/2 cups all-purpose flour and pour over mixture in bowl.
9. Measure 1 teaspoon baking powder and sprinkle over flour.
10. Measure 1 teaspoon of salt and sprinkle over flour and baking powder.
11. Mix everything together either with the fork or with your hands.
12. Put dough in icebox to chill (at least one hour)

There are no instructions for baking from this print, but a quick search for others' experiences with the recipe and recommendations say to roll out cookies 1/4 inch thick, sprinkle with sugar, and bake at 400 degrees.

Baha Mousa death: army doctor 'ignored cries of tortured men'

http://www.guardian.co.uk/world/2012/jun/13/baha-mousa-doctor-faces-tribunal

'Iraqi hotel owner who was detained with Mousa tells tribunal Dr Derek Keilloh
gave him no medication and is a 'criminal''

Helen Carter and agencies
guardian.co.uk, Wednesday 13 June 2012 17.59 BST

Baha Mousa death: army doctor 'ignored cries of tortured men'

'Dr Derek Keilloh faces allegations he helped cover up the mistreatment of
Iraqi detainees. Photograph: Dave Thompson/PA


A British army doctor present at the death of hotel worker Baha Mousa
was a criminalwho ignored the cries of men who were being tortured,
a tribunal has heard.

Dr Derek Keilloh is appearing before the medical practitioners
tribunal service in Manchester, the judicial arm of the General
Medical Council, accused of a cover-up over the death of Mousa,
who was beaten to death by British soldiers
 in September 2003.

Keilloh claimed he only saw dried blood around the nose of the
hotel receptionist, who had 93 separate injuries after being detained
by soldiers from the 1st Battalion Queen's Lancashire Regiment.

On Wednesday, the tribunal heard from Ahmed al-Matairi,
who waived his legal right to anonymity. Speaking through an
interpreter, he described how he and staff from the Basra hotel
he co-owned – including Baha Mousa – were detained and
tortured by British soldiers.

Matairi said he was taken to see Keilloh after he had undergone
days of beatings by soldiers who would kick him in the kidneys,
legs and in the location of a hernia. He was in a "bad state" and
"between life and death" when he was finally taken to the medical centre.

Naked from the waist down, he was handcuffed when Keilloh
examined him, he said. He claimed the doctor warned soldiers
not to hit him any more or he could die. "He just had a look at
my hernia, leg, kidney and said to them don't hit me. He is a
criminal. He should not be a doctor." He said the doctor's medical
centre was near where the detainees were being tortured.

Matairi added: "He heard our cries and he didn't do anything.
And he was not far from us for three days and he didn't do
anything … He should have fulfilled his role as a doctor."

Mousa, 26, was hooded, handcuffed and beaten before
he died, 36 hours after first being taken to the detention
centre in Basra. His injuries included fractured ribs and a broken nose.

Keilloh, 37, who is from Aberdeen, supervised a failed resuscitation
attempt of Mousa.

The tribunal has heard that a fellow medic, a corporal, remarked
"Look at the state of him!" after Mousa was taken to the medical
centre, but Keilloh – at the time a captain and battalion regimental
medical officer – always maintained he did not see the catalogue
of injuries.

Matairi said he had been suffering from kidney stones and
a small hernia before he was detained but that the soldiers
would "aim" kicks at his kidneys if they wanted him to fall to
his knees. He said after days of torture his hernia had swollen
to five or six inches and his leg, below the knee, had also
swollen up.

Matairi said despite his condition the doctor gave him no
medication. "He didn't give me anything," he said.

When the doctor finished the examination he was taken
back to the room where the other detainees were being
kept and tortured, the tribunal heard. Describing his state
before he went to see the doctor, he said: "I was finished.
I was between life and death."

The hotel owner also described hearing Baha Mousa's final
words. He said he was being kept in the room next door
and was being tortured. He heard him say: "I am innocent.
I am not a Baathist. My wife died six months ago. My
children are going to become orphans. I am going to die."

Asked by Rebecca Poulet QC, counsel for the GMC, what his last
words were, he responded: "Blood blood, I am going to die. My
children are going to become orphans."

Matairi also described how soldiers aimed "karate kicks" at
the prisoners and how they would laugh at them. He said the
soldiers were trying to "degrade" and "humiliate" them.

The tribunal, which is expected to last for four weeks, continues.'

'Hope after Hiroshima'

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2811%2961467-0/fulltext

William Summerskill

'The Hibakusha (literally, explosion-affected people) say simply “I have met with the A-bomb”; to recite further details is too painful and complex. Similarly, one is left utterly overwhelmed after a visit to Hiroshima's Peace Memorial Museum.

Hiroshima was a prosperous centre of learning with a population of 350 000; during World War 2 it became a garrison town. As bombing intensified elsewhere in Japan, school students tore down wooden buildings to create fire breaks. About 8400 children aged 12—13 years were thought to have been outside doing this in Hiroshima on the morning of Aug 6, 1945.

At 0815h—as several stopped, shattered, and partially melted watches remind one—the bomb containing 50 kg of uranium was detonated 600 m above Hiroshima. What happened next is portrayed in a harrowing set of images and objects, as the 1 000 000 °C explosion consumed the central kilometre of Hiroshima, burned skin as far away as 3·5 km, and indiscriminately irradiated the population. Tattered, charred, and blood-stained school uniforms and other objects tell individual stories of that August morning. For instance, the mother who was only able to identify her son's corpse because of his name etched into the metal lunch box he carried. The lunch box and its charred contents—the ground temperature reached 3000—4000°C—are on display. Other stories are told with a tricycle, a sandal, a school badge, partially melted marbles, among other items. These exhibits are so eye-wateringly intense that the sombre silence of shuffling visitors is punctuated by muffled sobs.

Full-size image (98K) Corbis

Hiroshima, Japan, in 1945; this photograph was taken 3 months after the atomic bomb

Not all 140 000 casualties died immediately. Many people were badly burned or exposed to lethal levels of radiation and died in the following days. Although the Red Cross hospital withstood the blast, it quickly ran out of medicines. A section of the hospital's concrete wall with embedded fragments of glass and pockmarked by debris is exhibited. There are few photos: a news photographer in the city at the time was so upset by what he saw that he only managed to take five images, explaining “my viewfinder filled with tears”.

Since the magnitude of the carnage is so great, a single person can provide focus. In this sense, Sadako Sasaki is the Anne Frank of Hiroshima. Aged 2 years she survived the blast, but as her mother led her away from the city, they were exposed to the black rain of atomic fallout. 10 years later, Sadako developed leukaemia. During her illness, she began folding origami paper cranes, in line with the proverb “fold 1000 cranes to make your wish come true”. She only managed to make 644 cranes before she died. The origami crane has become a symbol of Sadako's illness, the horror of nuclear war, and hope for the future. Tens of thousands of origami cranes, folded by children from around the world, surround the Children's Peace Monument in the adjacent park.

What message does this museum have for today? Visitors are educated in both the science and politics of the atom. The result is increased awareness of potential hazards: whether from damage to the Fukushima nuclear power plant or damage to efforts to advance nuclear non-proliferation. The horrors of any war are disturbing, but the scale of indiscriminate destruction from atomic weapons and their latent effects are especially chilling. As long as such weapons exist, civilian populations are under threat from thermonuclear attack. The citizens of Hiroshima are keen that the events experienced there and 3 days later in Nagasaki are never repeated. Since 1968, the successive mayors of Hiroshima have sent telegrams of protest to governments after each nuclear weapons test. Copies of all 597 telegrams are displayed. The most recent one is to the USA on July 20, 2011.'

a The Lancet, London NW1 7BY, UK