Healthcare and Technology news
51.2K views | +25 today
Healthcare and Technology news
Your new post is loading...
Your new post is loading...!

Serve More Patients and Increase Your Revenue

Serve More Patients and Increase Your Revenue | Healthcare and Technology news |

Healthcare costs are rising. So are insurance deductibles and prescription fees. As more and more patients struggle to pay for their medical needs, healthcare providers suffer as well. Healthcare financing is evolving, and practice owners must change with it if they want to stay afloat. Our team at StrongBox offers healthcare/medical/dental patient financing that integrates seamlessly with our revenue cycle management software. Read on to find out how we can help you reduce bad debt expense and increase your return on investment (ROI).


Patients’ Confidence in Healthcare Affordability is Declining

In a study conducted this year, only 62.4% of adults in the United States said they were somewhat or very confident in their ability to pay for healthcare costs. [1]  This is a significant decline from 2015, when almost 70 percent of individuals said they were confident they could pay for medical care.


In this same study, about 55% of adults with employer-provided insurance plans said they felt certain they would be able to afford medical care when if necessary. But what about those with individual coverage? One-third of all American adults stated that healthcare has become significantly more difficult
to afford over the past year. Additionally, only half of the population said they would have the money necessary to cover the costs of an unexpected medical bill.


What Needs to Change?
The statistics mentioned above are staggering. Clearly, we need a better way to help patients afford the
care they need. However, if healthcare providers keep performing treatment on patients who cannot
pay, their business suffers. What is the solution? At StrongBox, we offer healthcare/medical/dental
patient financing that benefits both the doctor and the patient.


Lending Partners and Patient Financing
What if you could give your patients the option to search fixed-rate healthcare loans from top-tier lenders? This is precisely what StrongBox offers. When your patient fills out an application, rates are provided without markup. Better yet, compared to medical credit cards, over twice as many applicants are approved. This option is not only ideal for elective procedures, such as cosmetic surgery and fertility treatments, it’s also extremely beneficial for individuals who do not have the money to pay for health-related procedures upfront.


StrongBox Healthcare/Medical/Dental Patient Financing
When it comes to patient financing, StrongBox offers two primary solutions: Select and Pro. Select is ideal for small to mid-sized providers. This cloud-based software works in conjunction with StrongBox revenue cycle management. Patients can complete their application in less than five minutes, after which it is submitted to a pool of up to 15 lenders. With terms up to 60 months and reasonable interest rates, this option is non-recourse to healthcare providers.


Pro is designed for large group practices and hospitals. This proprietary software identifies each patient’s credit profile and predicts their ability to pay. After approval, the healthcare facility receives funds directly within 24 hours. This increases average collections from 15% to 70%. As a result, practice owners can enjoy improved revenue and reduced bad debt expense.


Learn More about Healthcare/Medical/Dental Patient Financing with StrongBox

Are rising healthcare costs having a negative impact on the financial state of your practice? We can help.
If you would like to learn more about StrongBox solutions, request a virtual demo. We can assess your
unique practice needs and design customized software to address those concerns. Contact our Boca
Raton, FL office by calling (855) 468-7876.

Technical Dr. Inc.'s insight:
Contact Details : or 877-910-0004

No comment yet.!

What Do Women Know About Obamacare That Men Don’t?

What Do Women Know About Obamacare That Men Don’t? | Healthcare and Technology news |

For the second year running, more women than men have signed up for coverage in health insurance marketplaces during open enrollment under the Affordable Care Act. According to the Department of Health and Human Services, enrollment ran 56 percent female, 44 percent male, during last year’s open enrollment season; preliminary data from this year shows enrollment at 55 percent female, 45 percent male – a 10 percentage point difference.

What gives? An HHS spokeswoman says the department can’t explain most of the differential. Females make up about 51 percent of the U.S. population, but there is no real evidence that, prior to ACA implementation, they were disproportionately more likely to be uninsured than men – and in fact, some evidence indicates that they were less likely to be uninsured than males .

What is clear that many women were highly motivated to obtain coverage under the health reform law – most likely because they want it, and need it.

It’s widely accepted that women tend to be highly concerned about health and health care; they use more of it than men, in part due to reproductive services, and make 80 percent of health care decisions for their families . The early evidence also suggests that women who obtained coverage during open enrollment season last year actively used it.  According to Inovalon, a company that tracks and analyzes data for health plans and providers, people who used the coverage they bought through the marketplaces last year tended to be older, sicker, and more female than the general commercially insured population. As of June 2014, 41 percent of females who purchased coverage through exchanges had face-to-face visits with health care professionals, versus 32 percent of males.

Those numbers are consistent with the notion that many women who signed up for coverage under the ACA had preexisting conditions or other health issues that led them to seek treatment.  In some cases, their pre-ACA insurance may have excluded those conditions, or the preexisting conditions may have prevented them from obtaining coverage at all.

What’s more, as HHS points out in a recent report, there are plenty of benefits in the ACA’s qualified health plans that are especially attractive to women. These include coverage at no out of pocket cost for many preventive measures, such as mammograms or screening for gestational diabetes.  An estimated 48.5 million are benefitting from that provision of the law alone.

Other data support the notion that many U.S. women are in disproportionately higher medical need, relative to men – even adjusting for the fact that they typically live longer.  According to an analysis of Medical Expenditure Panel Survey data from the Agency for Healthcare Research and Quality, women constitute nearly 60 percent of people in the top tenth of medical expenditures in 2011 and 2012.  Most of those in the top tenth of spending are either ages 45 to 64, or 65 and older.

One obvious conclusion is that many, and perhaps most, of those who’ve benefited from coverage under the Affordable Care Act are female – and especially women in middle age and beyond. Another is that, if the Supreme Court rules in King v. Burwell that subsidized coverage can’t be obtained through the federal marketplace, women will be disproportionately harmed.

A case in point: Rosemary Forrest, 63, who lives in Augusta, Georgia.  Laid off from her job at a university science lab at age 55, she spent five years unemployed and without health insurance.   She now works as a contractor to a small nonprofit agency; battling painful osteoporosis, she sometimes earns less than $400 a month.  Last year, when the federal health insurance marketplace went live, she signed up for coverage.  This year, she re-enrolled, and after federal tax credits, pays $86 per month in premiums.

No comment yet.!

U.S. cancer survival rates improving

U.S. cancer survival rates improving | Healthcare and Technology news |

The proportion of people surviving years after a cancer diagnosis is improving, according to a new analysis.

Men and women ages 50 to 64, who were diagnosed in 2005 to 2009 with a variety of cancer types, were 39 to 68 percent more likely to be alive five years later, compared to people of the same age diagnosed in 1990 to 1994, researchers found.

“Pretty much all populations improved their cancer survival over time,” said Dr. Wei Zheng, the study’s senior author from Vanderbilt University in Nashville.

As reported in JAMA Oncology, he and his colleagues analyzed data from a national sample of more than 1 million people who were diagnosed with cancer of the colon or rectum, breast, prostate, lung, liver, pancreas or ovary between 1990 and 2010.

Among people ages 50 to 64 diagnosed with colon or rectal cancer in 1990 to 1994, about 58 percent were alive five years later. Five-year survival rates were about 83 percent for breast cancer, about 7 percent for liver cancer, about 13 percent for lung cancer, about 5 percent for pancreas cancer, about 91 percent for prostate cancer and about 47 percent for ovarian cancer.

Among people in the same age range diagnosed between 2005 and 2009, a larger proportion survived each of the cancers except ovarian cancer. Survival rates at five years rose by 43 percent for colon or rectum cancers, 52 percent for breast cancer, 39 percent for liver cancer, 68 percent for prostate cancer, 25 percent for lung cancer and 27 percent for pancreas cancer, compared to the early 1990s.

The better odds of survival did not apply equally to all age groups, however, and tended to favor younger patients. For example, survival rose by only 12 to 35 percent for people diagnosed between ages 75 to 85.

And while there was a small improvement in ovarian cancer survival among white women during the study period, survival among black women with ovarian cancer got worse.

Advances in treatments and better cancer screenings and diagnoses are likely responsible for the overall increases in survival, the researchers write.

“In general our study shows different segments benefit differently from recent advances in oncology,” Zheng said. “We need to find out the reason.”

The researchers speculate that older people may not benefit equally from medical advances, because doctors may avoid aggressive care for them for fear they couldn't tolerate treatments like surgery or chemotherapy.

Also, older people and racial minorities are less likely to be included in trials of new cancer treatments, the researchers point out. They say more effort should be made to include those groups in trials so doctors have treatment guidelines based on science.

No comment yet.!

Computers Replacing Doctors, Innovation and the Quantified Self: An Interview with Atul Gawande | The Health Care Blog

Computers Replacing Doctors, Innovation and the Quantified Self: An Interview with Atul Gawande | The Health Care Blog | Healthcare and Technology news |

Atul Gawande is the preeminent physician-writer of this generation. His new book, Being Mortal, is a runaway bestseller, as have been his three prior books, Complications, Better, and The Checklist Manifesto.

One of the joys of my recent sabbatical in Boston was the opportunity to spend some time with Atul, getting to see what an inspirational leader and superb mentor he is, along with being a warm and menschy human being. In my continued series of interviews I conducted for The Digital Doctor, my forthcoming book on health IT, here are excerpts from my conversation with Atul Gawande on July 28, 2014 in Boston.

I began by asking him about his innovation incubator, Ariadne Labs, and how he decides which issues to focus on.

Gawande: Yeah, I’m in the innovation space, but in a funny way. Our goal is to create the most basic systems required for people to get marked improvements in the results of care. We’re working in surgery, childbirth, and end-of-life care.

The very first place we’ve gone is to non-technology innovations. Such as, what are the 19 critical things that have to happen when the patient comes in an operating room and goes under anesthesia? When the incision is made? Before the incision is made? Before the patient leaves the room? It’s like that early phase of the aviation world, when it was just a basic set of checklists.

In all of the cases, the most fundamental, most valuable, most critical innovations have nothing to do with technology. They have to do with asking some very simple, very basic questions that we never ask. Asking people who are near the end of life what their goals are. Or making sure that clinicians wash their hands.

Once we’ve recognized the recipe for really great performance, the second thing we’ve discovered is that our most important resource for improving the ability of teams to follow through on those really critical things is data. Information is our most valuable resource, yet we treat it like a byproduct. The systems we have – Epic and our other systems – are not particularly useful right now in helping us execute on these objectives. We’re having to build systems around those systems.

The third insight is that, for the most part, the issues have less to do with systems than with governance. The people who are buying these systems, installing these systems, and determining how they’re to be used… What are they responsible for? What are their objectives? We’re having to figure out how to get quality and outcomes higher on the list of priorities of everybody running health systems.

Our dumb checklist, or our incredibly sophisticated predictive analytics algorithm, or that incredibly expensive EHR system… none of those change that fundamental failure – the failure of governance. And none of them can, no matter how you design them.

Gawande raised the example of hospitalists. He asked me about my group at UCSF, which has – by focusing on performance improvement as our core mission – become a key innovation engine at our institution.

AG: I think your hospitalist example is really important. Over and over again, it’s the pattern I see: a powerful idea creates a momentum of its own. When you’ve shown that there’s an obvious better way to take care of people. It’s controversial, and hospitalists can be used in ways that destroy the original intent. I’m sure you think about this all the time.

But when it works, it forces the leadership change. Leadership didn’t create hospitalists. Hospitalists created leadership. I think that’s the way it happens.

The same kind of thing happened with anesthesia. People didn’t say, “Oh, we have to find a better way to manage the pain of patients, because surgery is causing horrible suffering.” Somebody came up with an idea, and demonstrated that you could relieve this problem. But it required incredible system change. You had to double the number of people working in operating rooms at a time when the United States had a lower GDP than China does today. “We’ve got a better way of doing surgery. Oh, and it will involve doubling the number of physicians you have providing the care?” Is that a great model? It was dismissed as totally non-viable, can’t work. But it didn’t matter. It was too important, and it became the driver of leadership change, rather than the other way around.

A similar thing happened with Paul Farmer. There were debates for a decade about whether you could treat HIV in poor patients. Oh they don’t have watches, they can’t take the drugs, they can’t do this, they can’t do that. Farmer is like, “Fuck it!” I am going to Haiti, and I’m going to do it in a little old clinic in the middle of nowhere. And no, they didn’t change a whole country … but they changed a paradigm.

I think that’s the cool thing, that it’s not the technology. It was the values and the core idea that demonstrated you could accomplish this, that got you there.

I asked Gawande a question I asked most of my interviewees: Will computers replace physicians?

AG: The variousness of the healthcare world is pretty extreme. When we look at the way that disease presents itself, we’re moving increasingly away from science. When it turned out that lung cancer is not one disease, but rather that it’s four or five different histologic subtypes, that made it more complicated. Now we know there are 47 – and the number is growing – genes that, in different combinations, govern the behavior of those cancers. Forty-seven genes, and then you look at the multiples of different ways that people have these genes. Now we learn that the epigenetics and the expression of those genes are incredibly dependent on the environment. Did they smoke, how did that affect the genes? Did they have any kind of industrial exposure? How old are they at the time that the cancer appears?

Our cells on our little Excel spreadsheets are getting smaller and smaller and smaller. We’re getting back to the world of the 18th century “art of medicine,” where everything is becoming an “eyeball test.” The danger is that it becomes actually increasingly data-free – that every single person becomes a case of one. That becomes impossible to learn from. Period.

Where we’re moving, I think, is towards saying, “I have a class of people. I’m going to try Process A on this class of people who have some combination of these different genes,” and stuff like that. And then, does that process lead to better outcomes? The processes will be things like, “I’m going to watch them for three months. Then if X happens, I’m going to do an operation. If Y happens, I’m going to give them chemotherapy.” That increasingly becomes the way we learn.

RW: In your work as a physician, do you think care is getting better or getting worse?

AG: I think it’s massively better.

RW: Why?

AG: It’s fundamentally because of values, more than technology. I think we’ve changed our values over time. That patient suffering matters. I remember as a surgical trainee, I was expected to inflict levels of pain that today are just not acceptable. In my first month as a resident, I went into an operation to do a rib removal on a young girl. I’d never done one before; I had a month of operating experience. A fellow was standing at the door in his scrubs, saying, “Yeah, yeah, yeah, cut there.” The attending is in another room. I didn’t know what the hell I was doing.

The culture was, even to suggest that was a problem, meant you were weak.

Gawande asked me how I perceived the training environment today – particularly the tension between the patient and the technology.

RW: The residents’ instinct about teamwork is much better than mine was. I mean, the idea of my caring about what the nurses thought just wasn’t on my radar screen. And the residents’ instinct to get back to the bedside – when they’re spending all their time on the computers, they feel this loss and I think they’re trying to reconnect with their patients. We’re trying to create structures to allow that to happen.

But it’s hard – the residents feel they’re caught up in this world where everything they need to know is on the computer screen. That’s creating angst in their day-to-day life. You go up to the floor of the medical service in my hospital, and there are no doctors there. They come, they see the patients, and then they escape to this tribal room where all 15 residents hang out together, each doing his or her computer work. That means that many of the informal interactions that used to occur between the docs and the nurses, or the docs and the patients and their families, have withered away.

AG: Everything that they’re measured on and that defines their success happens outside the patient’s room.

RW: Correct.

AG: There’s a difference in surgery training. Everything that you’re measured on and that matters happens in the operating room. Although the patient’s asleep, the residents are having to work on their people-to-people interactions. How do you handle yourself with the nurses? How do you handle yourself with the doctors? What are your skills? They’re trying to figure it out and navigate it. It’s often a complete mystery to the students, and for a long time to the residents, too.

But except in the most egregious cases where you really piss off a patient, their success – being labeled an A versus a B – relates to “how much do I really know this patient?” It’s not getting my to-do list done for the day. Yet getting through the to-do list is the dominant task.

And we’ve both contributed to discoveries that indicate that all these little steps on the to-do list matter. It’s become an endless list of details that really, really, really matter. Do you have the right combination of antibiotics? Is the head of the bed at 30 degrees? When I think about the to-do list that I had when I was an intern, and the to-do list that the residents have today – today’s is just massively longer.

I closed by asking Gawande about the concept of the Quantified Self – patients wearing sensors and accumulating all kinds of personal data. While he is generally supportive of the concept, he has a concern, one that echoes the central theme of Being Mortal.

AG: I worry that we could become tyrannized by a combination of experts and sensors that have no close relationship to our priorities. That’s why I just keep coming back to the values. We’re here to alleviating suffering. I think it’s about this deeper connection we all have to something important.

No comment yet.!

Reactive vs. Proactive Health Care: The Intersection of Payment Reform & Consumer Data Powering Clinical Insight | The Health Care Blog

Reactive vs. Proactive Health Care: The Intersection of Payment Reform & Consumer Data Powering Clinical Insight | The Health Care Blog | Healthcare and Technology news |

One of the greatest opportunities that exists in moving from “turnstile medicine” (or fee-for-service) to value-based payment models is the shift from reactive to proactive health care. The focus on accountability for population health forces providers to adopt a completely different mindset: Instead of waiting for sick patients to come knocking on your door, you need to figure out what they need, when they need it, and how to get it for them.

At the upcoming conference, Health 2.0 WinterTech: The New Consumer Health Landscape (January 15, San Francisco), I will moderate a panel on “Consumer Data Powering Clinical Insight.” The panel  features several different perspectives on how consumer-facing technologies can translate discrete consumer-generated data into useful information that providers and others can use to deliver more personalized and proactive support and care management.

The dramatic proliferation of electronic health records (EHRs) in the last five years means that much more clinical patient data exists in electronic form than ever before. True meaningful use of that data involves organizing it into meaningful and useful information by building algorithms, leveraging machine learning principles and delivering the right information to the right person at the right time. In addition, de-identified data in the cloud provides a scale for that kind of data analytics. Practice Fusion, a cloud-based EHR company uses patient-derived data—everything from booking an appointment to patient intake questionnaires—to drive proactive health management. CEO Ryan Howard will discuss how, in early 2015, they’ll begin incorporating qualitative and quantitative data from the patient and machine learning based on how physicians react to it to better target diagnosis, treatment and other support.

Taking machine learning even further, MIT engineers decided to apply that approach to better support people with mental health issues. Although validated survey instruments like the PHQ-9 can play an important role in diagnosing and managing depression, they’re not designed to be continuous assessment tools. In contrast, leverages passively collected data from people’s daily lives via smart phones to identify patients at risk and building proactive care management processes based on these naturally occurring data. Co-Founder Karan Singh will talk about the invaluable information that can be derived from seemingly mundane human behavior such as GPS data on a person’s mobility throughout the day or patterns of missed phone calls. is currently testing in multiple academic medical centers how these data can flow into algorithms to generate alerts in a web-based dashboard that care managers use.

The prevalence of incorporating data from activities of daily living into providers’ clinical information systems remains low, despite the fact that people spend a miniscule fraction of their annual 525,600 minutes within the confines of clinical settings. Meanwhile, although the tech industry seems to be buzzing about wearables that focus on wellness and fitness, many of these devices remain completely outside consumers’ interactions with their providers. Qualcomm Life has developed platform solutions around remote care monitoring with the goal of integrating daily-life data seamlessly into the care delivery process to drive consumer engagement. SVP & General Manager Rick Valencia is eager to share Qualcomm’s plans to integrate these data to tailor chronic care management and improve care transitions.

When we think about tailoring care management, it is sometimes hard to fathom the possibilities that genomic innovation has for personalizing treatment approaches. The growing efficiency of human genome sequencing – and its associated diminishing cost – raises the potential for more practical applications in the normal course of care delivery. The Illumina Accelerator hopes to drive personalized health care down to the genomic level by providing mentorship, financial support and access to scientific resources to start-up companies. Amanda Cashin, who heads the Accelerator program, will discuss how start-ups will leverage sequencing technology in diagnostics and therapeutics applications to support better care management in oncology, reproductive health and other clinical areas.

Meanwhile, FDA must figure out when these new tools cross a line that separates a care management support application from a new medical device. FDA’s Bakul Patel is right in the middle of these discussions and has to think through how broad or narrow to define “devices.” Patel will talk about what FDA has clarified thus far and how companies should think about these issues going forward.

This panel is sure to bring innovative, yet differing, views on the progression of consumer-based data sources. As moderator, I will particularly press them on how their solutions help consumers, clinicians and other stakeholders succeed under the demands of new payment models and the expectations of proactive care delivery models.

No comment yet.!

4 Facts Making Clinical Trial Data Capture the Next Big Thing

4 Facts Making Clinical Trial Data Capture the Next Big Thing | Healthcare and Technology news |

The past few decades have been a witness to a path breaking evolution in the healthcare industry. This advancement was followed by off-shooting of several sub-branches & one such area which has gained an impetus in last few years is “Clinical Trials”. Various clinical research projects executed frequently makes it grow leaps and bounds.

Being One of the Most Expensive and Complex Areas; It Requires:

  • Ample amount of clinical research operations
  • Support of Pharmaceutical/Device/Biotechnology company or contract research organization (CRO)
  • Research sites such as hospital, academic medical center, and independent research institutes
  • Regulatory affairs
  • Product safety
  • Quality assurance and auditing
  • Medical writing
  • Bio-statistics

And effective clinical data management solutions like data capture to ensure that it is on the right track and is done effectively.

Electronic Data Capture for Clinical Trails is a widely used method to collect all the information related to the clinical trials. The data is gathered electronically & not on paper; thus there is no need to do the mundane paper work and then storing it properly. This has made it a highly popular solution to streamline data processing.

Benefits of Effective Clinical Data Management and Capturing:

Let’s review and discuss, in detail, some of the crucial advantages which electronic clinical data entry brings along and also some its long term business benefits.

Keeps the Data Secure:

A secure data is an extremely critical aspect in clinical trials. Capturing the data electronically ensures a secure access to the data – only assigned users can view, edit or delete the data files; thus preventing unnecessary leaks, file corruption and errors.

Such a robust system enables the data management team to quickly identify the users who need to update a form & also gives an insight into effective troubleshooting. Further, important tracking of data entry can be successfully achieved by using electronic audit trail.

Maintains Consistency:

Consistency is extremely crucial in managing the data of clinical trials. And it can be achieved only with a standardized data capturing technique like an EDC or electronic data capture system.

It provides a uniform method to collect data, minimizing user bias and other difficult issues which play a role in affecting results adversely. Moreover, the redundant information will be taken care of, and hence the database will not be loaded with unwanted data.

Increases the Productivity Manifold:

Time crunches have become phenomena that cannot be ignored. And it creates problems in managing the data. With the EDC methods for data collection, these challenges can be effectively handled.

In fact, with the data capture; the overall productivity; as it is often the data capture that consumes only half of the time.

Accessibility from Anywhere and Everywhere:

Another very key advantage of an EDC is its ability to distantly access your trial data without necessarily being present at the office or at the medical center. The electronically captured data can be stored “in the cloud” which can be reviewed.

Updates on the latest events for patient safety and overall study progress can be regularly made even through a remote location.

While conventional methods of data capture may still be a best option for few projects, electronic data capture is definitely going to make it big in the near future. It is quickly becoming the preferred choice due variety of reasons.

No comment yet.!

Health Care: A Modern Day Blade Runner?

Health Care: A Modern Day Blade Runner? | Healthcare and Technology news |

Throughout the health ecosystem new technologies and medical advancements enter the market every day. Yet, as Jonathan Bush, President and CEO of athenahealth commented during the 2014 Forbes Healthcare Summit, “Only in health care can you increase the staff needed and slow productivity, costing more, by adding new technologies.”

His point is well taken. Negative labor productivity is ultimately the underlying complaint of hospital leadership, providers and patients surrounding technology such as electronic health records (EHRs). Although more EHRs enter the market and mergers continue between health systems everyday, the need to actually connect care has sadly been lost in the debate about what software to use and how to use it.

As the President and CEO of Texas Medical Center Robert Robbins pointed out, “Just like we are not going back to using pay phones and rotary phones over smart phones, the EHR will never be overtaken by file folders of the past.” He contends that there are plenty of opportunities for improvement, but the progress of technology will not be undone because people do not like them, as they exist.

Jonathan Bush used that transition to equate the state of health care technology to the movie Blade Runner, in which a dystopian future involves hover cars and artificial intelligence, but the characters still use pay phones.

While no one can predict with certainty what the future of health analytics and scientific advancement look like, it’s clear that regression in one area as others surge forward is not an option. Just as we cannot go back to health care in the US before the ACA, the future of health will certainly not look like it does under the ACA.

No comment yet.!

Ebola Vaccine Appears Safe, Effective

Ebola Vaccine Appears Safe, Effective | Healthcare and Technology news |

Tests of an experimental Ebola vaccine have found that 100 percent of vaccinated people mounted a promising immune response and incurred no serious side effects, according to results published this morning in The New England Journal of Medicine. A large, international group of researchers report that between two studies, all 200 subjects in the United States, Switzerland, and Germany who were given the recombinant vesicular stomatitis virus-based vaccine (rVSV) vaccine developed an immune response that should be effective in warding off future infection.

The subjects in today's studies were not actually exposed to the Ebola virus after vaccination, so the appraisal of effectiveness is based on primate studies that give researchers an idea of how many antibodies are required to prevent infection. Some people who received the vaccine did develop fatigue, chills, and muscle aches, but no serious complications, and based on the formulation of the rVSV vaccine—which is a mixture of some Ebola Zaire viral proteins inside another more innocuous virus—it carries no risk of infecting patients with Ebola.

At least 10,000 people have died in West Africa as a result of the ongoing epidemic. Based on the findings reported today, this Ebola vaccine formulation has been incorporated into recently initiated human trials in Liberia and Guinea, and will be introduced in Sierra Leone in the near future.

No comment yet.!

Superbug linked to 2 deaths at UCLA hospital; 179 potentially exposed

Superbug linked to 2 deaths at UCLA hospital; 179 potentially exposed | Healthcare and Technology news |

Nearly 180 patients at UCLA's Ronald Reagan Medical Center may have been exposed to potentially deadly bacteria from contaminated medical scopes, and two deaths have already been linked to the outbreak.

Update: FDA issues warning on contaminated medical scopes

The Times has learned that the two people who died are among seven patients that UCLA found were infected by the drug-resistant superbug known as CRE — a number that may grow as more patients get tested. The outbreak is the latest in a string of similar incidents across the country that has top health officials scrambling for a solution.

Caption FDA attributes spread of superbug to endoscope
More than may have encountered 'superbug'

UCLA said it discovered the outbreak late last month while running tests on a patient. This week, it began to notify 179 other patients who were treated from October to January and offer them medical tests. By some estimates, if the infection spreads to a person's bloodstream, the bacteria can kill 40% to 50% of patients.

At issue is a specialized endoscope inserted down the throats of about 500,000 patients annually to treat cancers, gallstones and other ailments of the digestive system.

These duodenoscopes are considered minimally invasive, and doctors credit them for saving lives through early detection and treatment. But medical experts say some scopes can be difficult to disinfect through conventional cleaning because of their design, so bacteria are transmitted from patient to patient.

These instruments are not the same type used in more routine endoscopies and colonoscopies.

The procedure in question is known as ERCP, or endoscopic retrograde cholangiopancreatography. The superbug is carbapenem-resistant Enterobacteriaceae.

UCLA said it immediately notified public health authorities after discovering the bacteria in one patient and tracing the problem to two of these endoscopes. The university said it had been cleaning the scopes “according to standards stipulated by the manufacturer,” and it changed how it disinfects the instruments after the infections occurred.

Dale Tate, a university spokeswoman, said “the two scopes involved with the infection were immediately removed and UCLA is now utilizing a decontamination process that goes above and beyond the manufacturer and national standards.”

Tate declined to provide details on the two people who died, citing patient confidentiality.

State and federal officials are looking into the situation at UCLA as they wrestle with how to respond to the problem industrywide.

Since 2012, there have been about a half-dozen outbreaks affecting up to 150 patients in Illinois, Pennsylvania and most recently at a well-known Seattle medical center, according to experts.

These outbreaks are raising questions about whether hospitals, medical-device companies and regulators are doing enough to protect patient safety. Some consumer advocates are also calling for greater disclosure to patients of the increased risks for infection before undergoing these procedures.

Lawrence Muscarella, a hospital-safety consultant and expert on endoscopes in Montgomeryville, Pa., said the recent number of cases is unprecedented.

“These outbreaks at UCLA and other hospitals could collectively be the most significant instance of disease transmission ever linked to a contaminated reusable medical instrument,” he said.

Officials at the U.S. Centers for Disease Control and Prevention said they were assisting the L.A. County Department of Public Health in its investigation of the UCLA infections.

Dr. Alex Kallen, an epidemiologist in CDC's Division of Healthcare Quality Promotion, said the outbreaks are serious given how difficult this superbug can be to treat and the fact that additional cases might be going undetected.

“This bacteria is emerging in the U.S. and it's associated with a high mortality rate,” Kallen said in an interview. “We don't want this circulating anywhere in the community.”

Last month, Virginia Mason Medical Center in Seattle acknowledged that 32 patients were sickened by contaminated endoscopes from 2012 to 2014 with a bacterial strain similar to CRE. Eleven of those patients died.

But Virginia Mason said other factors may have contributed to their deaths because many of them were already critically ill.

The duodenoscopes typically involved in the outbreaks have an “elevator channel” that doctors use to bend the device in tight spaces and allow for attachments such as catheters or guide wires. Experts suspect bacteria build up in that small area.

This bacteria is emerging in the U.S., and it's associated with a high mortality rate. We don't want this circulating anywhere in the community

Kallen, the CDC official, said he hasn't found any breaches in cleaning protocol at hospital outbreaks he has investigated, but he said the problem probably is more complicated than just a design issue.

“There isn't an obviously easy solution to employ,” Kallen said. “There is action on a lot of different fronts.”

Virginia Mason instituted a new quarantine process that sets the endoscopes aside for 48 hours so evidence of any bacterial growth can be found before reusing them.

That has increased the time for equipment cleaning from a couple of hours to more than two days. Virginia Mason said it had to purchase 20 additional endoscopes to compensate for that down time.

“There is either a design issue to be addressed or a change to the guidelines for the cleaning process,” said Dr. Andrew Ross, section chief of gastroenterology at Virginia Mason. “It's the role of the federal government to make some of those decisions.”

In the wake of the Seattle cases, Sen. Patty Murray (D-Washington) pressed the FDA to issue guidelines for hospitals on how best to sanitize these scopes and devise a way to better track infections.

Some patient-safety advocates say regulators and industry officials have been too slow to respond.

“Hospitals and manufacturers often take months to assess what to do, with the infected patients being the last to know,” Muscarella said. “Bringing patients into the loop and answering their questions is important for hospitals to prevent outbreaks.”

A spokeswoman for the FDA said the agency was working to reduce the incidence of infections while maintaining access to a crucial medical tool.

The agency said it was “actively engaged with the manufacturers of duodenoscopes used in the U.S. and with other government agencies such as the CDC to develop solutions to minimize patient risk associated with these issues.… The FDA believes the continued availability of these devices is in the best interest of the public health.”

Olympus Medical Systems Group, a major manufacturer of these endoscopes and UCLA's supplier, said it was working with the FDA, physician groups and hospitals regarding these safety concerns.

The company said all of its customers who purchase Olympus duodenoscopes “receive instruction and documentation to pay careful attention to cleaning.”

UCLA said it moved quickly to protect patients once the problem surfaced. It said it alerted state and county health officials as soon as the bacteria were detected.

It is notifying 179 patients and their primary-care doctors by phone and letter. UCLA said it was offering to send patients a free home testing kit for a rectal swab, or they could come in to be tested.

Even before this incident, UCLA has struggled at times with patient safety. An influential healthcare quality organization gave the Ronald Reagan Medical Center a failing grade on patient safety in 2012.

The hospital's score improved to a C in the latest ratings from Leapfrog Group, a Washington nonprofit backed by large employers and leading medical experts.

Meanwhile, some doctors worry the outbreaks might deter patients from seeking care they need.

“ERCP is a common and critical procedure in most hospitals today,” said Dr. Bret Petersen, a professor of medicine at Mayo Clinic's division of gastroenterology and hepatology in Rochester, Minn. “It's not a procedure we can allow to be constrained, so this is a serious issue we need to address.”

No comment yet.!

U.S. needs to raise investment, shift medical research priorities

U.S. needs to raise investment, shift medical research priorities | Healthcare and Technology news |

The U.S. is losing its lead in global medical research, and many of the projects that do get funded overlook common diseases that afflict millions of people, according to a new analysis.

Experts point to falling public and private spending on the kind of basic research that leads to new discoveries, and a lack of innovation in delivering healthcare, in a paper in the Journal of the American Medical Association that’s part of a series on the future of medicine,

"With respect to U.S. public financing there has not been the political will to make biomedical research a priority in the same way that it was in the 1970s with the war on cancer or in the 1980s with the war on AIDS," said lead study author Dr. Hamilton Moses, of the Alerion Institute and Alerion Advisors LLC in North Garden, Virginia.

At the same time, private U.S. companies have concentrated investment in advanced clinical trials rather than on the basic research that’s needed to tackle some of the chronic conditions like diabetes that afflict the greatest number of people, Moses told Reuters Health in an interview.

Overall U.S. investment in biomedical and health services research grew just 0.8 percent a year from 2004 to 2012, down from a 6-percent annual growth rate between 1994 and 2004, Moses and his colleagues found.

Government funding in the U.S. fell to 49 percent of the world's public research investment by 2011, down from 57 percent in 2004.

U.S. industry, which accounted for nearly half of corporate investment worldwide in 2004, slipped to 41 percent of private funding in 2011.

Asia, aided largely by China, tripled investment to $9.7 billion in 2012 from $2.6 billion in 2004.

In the U.S., public funding concentrated on cancer and rare diseases, with less than half of government investment targeting 27 common diseases – including chronic obstructive lung disease, injuries, stroke, dementia and pneumonia - that account for 84 percent of deaths in the U.S. and significant disability.

Cancer alone accounted for 16 percent of total funding from the National Institutes of Health and was the target of one in four medicines in clinical trials, the study found.

"With cardiovascular disease, the number one killer, some of the large pharmaceutical companies have really pulled back in this area," said Dr. Kenneth Kaitin, director of the Tufts Center for the Study of Drug Development in Boston, Massachusetts.

"The industry has changed over the last few years and there has been tremendous pressure to reduce research and development costs that has resulted in a tremendous shift away from high-volume, low-cost medicines toward seeking a billion- dollar drug that treats a very, very small population," said Kaitin, who wasn't involved in the study.

Health services research, which looks at issues around access to care as well as quality and costs, has accounted for less than 0.33 percent of national health expenditures between 2003 and 2011, the study found.

Private insurers ranked last (0.04 percent of revenue) and health systems 19th (0.1 percent of revenue) among 22 industries in their investment in innovation in this area, the authors note.

"This is concerning in terms of trying to tackle improved quality of care and improved access to care, and in terms of bending the cost curve," said Glen Giovannetti, a global life sciences expert at Ernst & Young in Boston.

"There's lots and lots of research done on drug development and much less done on whether one course of treatment is better than another," said Giovannetti, who wasn't involved in the study.

With respect to both biotech and health services research, there is an acute need to increase research investment and to create more reliable funding mechanisms, said Dr. Victor Dzau, president of the Institute of Medicine, a division of the U.S. National Academies of Science.

Dzau, who co-wrote an editorial accompanying the study in JAMA, said the danger of disparate, unreliable funding streams is that it forces scientists to work in fits and starts, often abandoning promising basic research.

"If you think about all of the major advances in health care services, biomedical research, and diagnostics, there is no question that it's based on innovation and relied at the start on basic research," Dzau told Reuters Health.

"When we decided to put a man on the moon that was an aspirational goal, and we as a nation should be able to recognize that this is now an important moment in medical research," Dzau said. "We aren't saying give money for money's sake. We are saying set priorities, and give researchers at least five years of stable funding to pursue specific goals."

No comment yet.!

Researchers Take 'First Baby Step' Toward Anti-Aging Drug – WebMD

Researchers Take 'First Baby Step' Toward Anti-Aging Drug – WebMD | Healthcare and Technology news |

Researchers could be closing in on a "fountain of youth" drug that can delay the effects of aging and improve the health of older adults, a new study suggests.

Seniors received a significant boost to their immune systems when given a drug that targets a genetic signaling pathway linked to aging and immune function, researchers with the drug maker Novartis report.

The experimental medication, a version of the drug rapamycin, improved the seniors' immune response to a flu vaccine by 20 percent, researchers said in the current issue of Science Translational Medicine.

The study is a "watershed" moment for research into the health effects of aging, said Dr. Nir Barzilai, director of the Institute for Aging Research at Albert Einstein College of Medicine in New York City.

Rapamycin belongs to a class of drugs known as mTOR inhibitors, which have been shown to counteract aging and aging-related diseases in mice and other animals.

Barzilai, who wasn't involved in the study, said this is one of the first studies to show that these drugs also can delay the effects of aging in humans.

"It sets the stage for using this drug to target aging, to improve everything about aging," Barzilai said. "That's really going to be for us a turning point in research, and we are very excited."

The mTOR genetic pathway promotes healthy growth in the young. But it appears to have a negative effect on mammals as they grow older, said study lead author Dr. Joan Mannick, executive director of the New Indications Discovery Unit at the Novartis Institutes for Biomedical Research.

When drugs like rapamycin are used to inhibit the effects of the mTOR pathway in mice, they "seem to extend lifespan and delay the onset of aging-related illnesses," Mannick said.

Mannick and her colleagues decided to investigate whether a rapamycin-like drug could reverse the natural decline that elderly people experience in their ability to fight off infections.

In the clinical trial, more than 200 people age 65 and older randomly received either the experimental drug or a placebo for several weeks, followed by a dose of flu vaccine.

Flu is particularly hard on seniors, with people 65 and older accounting for nine out of 10 influenza-related deaths in the United States, according to background information provided by the researchers.

Those who received the experimental version of rapamycin developed about 20 percent more antibodies in response to the flu vaccine, researchers found. Even low doses of the medication produced an improved immune response.

The researchers also found that the group given the drug generally had fewer white blood cells associated with age-related immune decline.

Mannick called this study the "first baby step," and was reluctant to say whether it could lead to immune-boosting medications for the elderly.

"It's very important to point out that the risk/benefit of MTOR inhibitors should be established in clinical trials before anybody thinks this could be used to treat aging-related conditions," she said.

Barzilai was more enthusiastic. Research such as this could revolutionize the way age-related illnesses are treated, he said.

"Aging is the major risk factor for the killers we're afraid of," he said, noting that people's risk for heart disease, cancer and other deadly illnesses increases as they grow older. "If the aging is the major risk, the way to extend people's lives and improve their health is to delay aging."

Until science focuses on aging itself, "you're just exchanging one disease for another," Barzilai said. For example, he said, a person receiving cholesterol-lowering treatment to prevent heart disease likely will instead fall prey to cancer or Alzheimer's disease.

No comment yet.!

Hardly anyone is opening their own practice anymore. Why?

Hardly anyone is opening their own practice anymore. Why? | Healthcare and Technology news |

Young doctors are often progressive thinkers who like to support small businesses, buy locally grown produce from food shares, shop from individual merchants on Etsy, and never be seen in any chain store larger than Trader Joe’s. It seems every industry is recognizing the benefits of the personal service of a small business.

Decades ago, the majority of physicians owned their own small practice, and had patient satisfaction and personal satisfaction much higher than what is found in today’s large systems. Numerous studies have shown the benefit of the personalized care realized in a small practice. The large systems are pushing the “team” and “care coordination” concepts, as a means to achieve the “medical home” feel that naturally exists in small practices. Yet today, physicians take jobs with the big boys; in Denver this means Kaiser, Denver Health, MCPN, Salud, and Clinica. Hardly anyone is opening their own practice anymore. Why?

Some say they didn’t go to med school to be a bill collector, others say they enjoy the freedom of being an employee (ironic). Overall, it is a culture shift, from times when most doctors hung their own shingle, to a time when most go work for the man. Dentists aren’t the same: It seems a fair number of dental students graduate with intent to buy their own practice, or buy into a closing one.

I am not sure of the reason, but I think this is a tragedy. I have worked in the large systems, and I have run my own practice for a couple years, and I can confirm that it is much more fulfilling, financially rewarding, and flexible to run your own business. No Tuesday afternoon committee meeting just to move a stapler; if I want to create a yoga or nutrition program, I find the pieces and make it happen. And the patients love it, when they can call, text, or email and get a quick response from their provider; when they can walk in and not have to overcome multiple lines of staff defense (receptionist, vitals, MA, check out); or when they know that they can count on us to go well beyond what might happen in a crammed 8 minute appointment elsewhere.

I once saw a picture of a stack of Russian VHS tapes, on top of a fire extinguisher case, in the hallway of an apartment block on Denver’s southeast side. Those few blocks are Denver’s little Soviet Union, full of early 1990s refugees from all corners of the USSR. I found myself waiting there last Thursday at 7 a.m., while doing a home visit before heading to my office. The elderly patient’s grown son had requested that I visit, and while I don’t think I did too much while there — listened to lungs, watched her walk — I know the patient and family appreciated it tremendously.

Is this type of service lost in medicine? I know that if I was an employee at MCPN, I would never feel emotionally attached enough to make such a trip. Instead, I would rush through return calls at the end of the day, and maybe get to this phone call within the week if lucky.

I have met with a number of policymakers in Colorado’s health care scene recently, and I am getting tired of hearing “well maybe you are different than the others, and all doctors can’t be like you.”

But they can. They used to be. The art has been lost. I challenge other providers working in large systems to take the step. I was inspired by the IMP movement, a group of practices that vary widely in format, except that all keep the small practice concept, and the better outcomes that come with it. I offer to any provider, anywhere, to come take a look at my methods if curious, and I think most IMPs out there would make the same offer.

No comment yet.!

Physician Employment Landscape Set to Change in 2015 |

Physician Employment Landscape Set to Change in 2015 | | Healthcare and Technology news |
The healthcare landscape will continue to consolidate through physician employment and new practice choices from medical students in 2015 and beyond.

Physician employment at larger healthcare organizations will increase rapidly in 2015 as consolidation of providers and financial pressures squeeze private practices into closing their doors.  Between the anticipated costs of ICD-10, changes to reimbursement structures that promote value-based payments, and a desire for more care coordination by working in extended teams, new medical students and established practitioners alike are leaning towards banding together in larger, more stable groups.

“The coming year will again be one of major transition for the U.S. healthcare system,” said Lou Goodman, PhD, president of The Physicians Foundation and chief executive officer of the Texas Medical Association.  “Regulatory and marketplace forces are having a number of unintended effects, including challenging the viability of smaller medical practices, reducing patient choice and putting tremendous strain on the physician-patient relationship.”

The Physicians Foundation envisions several key challenges for providers in the next year, including external pressures on the patient-provider relationship that make practicing medicine less satisfying.  Even though one recent study states that physicians are actually spending more time with each patient now than they did a decade ago, continued dissatisfaction with the intrusion of EHR documentation on the workflow and other regulatory pressures are driving unhappy physicians to retire, seek employment with fewer administrative burdens, or reduce their availability.

Physicians who seek employment at bigger health systems tend to report higher levels of job satisfaction and more time to focus on the patient relationship, the ACPE found earlier this year, but must also contend with the downsides of being a smaller piece of a more complicated system.  Employed physicians are more likely to report feeling unheard and unrecognized for their achievements.  Physicians at private practices that have been acquired by larger health systems feel poorly integrated and complain about a lack of cultural alignment that would incentive them to perform at their best.

Medical students and new physicians are pinning their hopes on the benefits of employment, however, says a separate report from EHR developer athenahealth.  The Epocrates Future Physicians of America survey found that ninety percent of medical students will not go into private practice, which is a fifty percent increase from 2008.  Students desire the financial security and work-life balance of employment in larger facilities, and want to avoid the difficulties of being a small business owner in addition to a full-time physician.  Part of this pattern is due to inadequate instruction during medical school on how to operate and manage an individualized practice, according to nearly 60% of respondents.

In addition to feeling poorly prepared for being self-employed, medical students recognize the importance of working in larger teams with better communication and more non-physician support.  Care coordination is top of mind for 96% of these newly minted MDs, and 75% believe that better coordination is dependent on EHR data sharing, interoperability, and health information exchange.

As physicians adjust the way they practice to take advantage of more modern expectations of being valued, balanced, and engaged in the workplace, their needs must be addressed in order to maintain high levels of patient care and sufficient access to healthcare for the millions of newly insured citizens under the Affordable Care Act, Goodman says.  “It is paramount that policy makers bring physicians into the fold to ensure the policies they implement are designed to advance the quality of care for America’s patients in 2015 and beyond.”

No comment yet.!

Physicians are treating the well, and nurses are treating the sick

Physicians are treating the well, and nurses are treating the sick | Healthcare and Technology news |

A rash could be leukemia or idiopathic thrombocytopenic purpura. A sore throat could be glossopharyngeal neuralgia or a retropharyngeal abscess. A blocked ear could be Ramsay-Hunt syndrome, a self-limited serous otitis or sudden sensorineural hearing loss with an abysmal prognosis if not treated immediately with high doses of steroids. A headache or sinus pain could be cancer, and a cough could be a pulmonary embolus or heart failure.

Treating the well

In my early career in Sweden, well-child visits were done in nurse-led clinics, some of them only open on certain days, with a local doctor in attendance. Parents carried the children’s records with them, containing growth charts, immunization records and so on.

These nurses had great expertise in differentiating normal from abnormal appearance of children, and would direct the attending physician’s attention to children with abnormal metrics, appearance or behavior.

With this arrangement, the physician time requirement was reduced, and limited to evaluating children attending the clinics who needed special attention. Physicians also performed specific examinations at certain ages, such as checking for hip clicks. These clinics freed up the local pediatricians to evaluate more sick children.

Well-baby visits are now the bread and butter of American pediatricians and family practitioners, and with the ever expanding mandates of politically determined items that must be covered in order for doctors to get paid for their services, we sometimes have trouble accommodating illness care demands.

The same thing happens in primary care for adults; between checkups and chronic disease management, meaningful use and other documentation requirements, many primary care doctors are unable to see all the sick patients, who call for an appointment.

A simple calculation illustrates this phenomenon. If the ideal caseload for a primary care physician is 1,500 patients but commonly exceeds 2,000, only providing a 30-minute physical or wellness visit (not the same thing) visit once a year for every patient chews up 750 to 1,000 hours. Total contact hours for each doctor according to recruitment ads these days number 32 per week times 46 weeks, or 1,472 hours. That doesn’t leave very much time for treating the sick — less than 500 to at most 750 hours, to be exact. That’s a maximum of 16 hours per work week, most of which is spent on managing chronic conditions like diabetes and cardiovascular disease. Most of the time, this amounts to tracking and treating numbers in fairly asymptomatic people — blood sugars, glycohemoglobins, microalbumins, blood pressures, lipid levels and so on.

Treating chronic diseases leaves little room for diagnosing and treating acute illnesses

With primary care physicians’ time increasingly spent on the routinized housekeeping details of modern chronic disease management, their diagnostic and therapeutic skills are less often used on the front lines of sick-care. Their new role of managing populations is not making full use of physicians’ traditional diagnostic and therapeutic skills. Instead we are performing more nurse-like duties such as carrying out standing orders (read “following guidelines” and “practicing evidence-based medicine”), and keeping track of our patients’ scheduled specialist visits as well as their sick visits, not just at the local emergency room, but also at competing walk-in clinics. Ironically, the doctor who was too busy to see that child with an earache must now sign off on the chart notes from the local Walmart. We also end up, unreimbursed, keeping track of and even rubber-stamping orders for immunizations given at pharmacies like Rite Aid.

The elimination of the truly quick and easy visits from doctors’ schedules (the rashes that the experienced clinician quickly determines are not leukemia or ITP) makes the daily load of chronic care management greater, and often decreases total revenue in a fee-for-service system. The truth is that a skilled and experienced physician can often handle “simple” medical complaints faster and with greater accuracy than providers with less training and experience.

Equally true, nurse practitioners can be just as good at following clinical guidelines and counseling patients about blood sugar, exercise, smoking cessation and the benefits of aspirin as physicians are. The broader and deeper training of physicians comes to its best use in diagnosing and managing atypical or rarely seen symptoms and conditions, many of which present acutely with nonspecific symptoms.

Yet, because of the so-called doctor shortage, this is what sometimes happens:

In many states, nurse practitioners, even newly graduated ones, are asked to fill the role of primary care provider or urgent care clinician, while seasoned physicians with mature practices are increasingly spending their time on the routinized treatment of asymptomatic conditions that arise from the modern lifestyles of the western world.

So, who should do what in primary care?

I have worked with many NPs who shoulder the responsibilities of frontline, independent, clinical practice very well because of their postgraduate experience and their personal qualities. But out of the box, a new NP is not as well prepared for that role as today’s residency trained physician. The days of practicing general medicine straight out of school ended for American physicians in the 1950s.

My point is that in today’s health care system, we are often asking the providers with the least training to see the unsorted clientele in sick-call while doctors with decades of experience may be limiting their practice to following insurance-mandated guidelines and care plans in treating non-urgent chronic medical problems and providing equally scripted wellness visits that may actually be better suited for nurses-turned nurse practitioners. I think the wisdom of this needs to be discussed openly. I think the perceived doctor shortage may just be an allocation issue.

Or, in one sentence:

If provider care teams are the way of the future, perhaps doctors should be handling more of the sick-call, and nurse practitioners more of the maintenance of modern health care.

Let’s really talk openly about who should do what in primary care today.

Dr Martin Wale's curator insight, December 14, 2014 9:10 PM

"A Country Doctor" takes aim at the paradox of the least experienced clinicians taking on those situations where maximum diagnostic acumen is required, because the most experienced are fully occupied with care of chronic diseases.