The power of one (image by Salvatore Vuono)

Saturdays are meant for carefree reflection, devotion to the jaunty lighthearted pursuit of fun. But it’s not the time for health care providers to escape the part played in the abuse of hormones and performance enhancing drugs by athletes. From the High School locker room to the Olympic stadium denial of use contributes to the problem.  A detached complacent attitude coupled with a tendency to put confidentiality before the obligation to report tacitly facilitates use.  Frank, open discussion and the courage to sound the alarm as early as possible with individuals and teams is needed if these unnecessary health risks are going to be diminished. Have a fun, active day.

Home Care Robots

Robots will deliver your meds (image by vichie81)

Several recent studies have found that text messaging can assist with positive changes in behavior in chronic disease management and preventive medicine. There is more to come. The challenges of home care have engineers and health care providers working to develop technology to improve care and reduce health care costs.  At present studies exploring the use of home robotics show some benefits for patients although robotic solutions are expensive. However, continued improvement in sensor design, computers and wireless technologies will see the development of affordable robotic systems that improve patient care at home and could potentially save the costs of hospitalization. In the not so distant future systems currently being tested will provide home robotics for home exercise support, medication delivery, appointment reminders and communication with health care providers. These systems will also offer companionship, entertainment and social networking opportunities to the patient in their home. The only thing left will be to teach robots to be compassionate.

Walking and Headphones

Walking with headphones can be risky (image by David Castillo Dominici)

It’s been well established that distraction caused by cell phone use while driving is hazardous to one’s health. However, the safety risks of headphone use while walking has received very little attention. Now researchers at the University of Maryland have conducted a review of published accident reports for a 7-year period between 2004 and 2011 involving pedestrian injuries or fatalities from train or motor vehicle crashes. They found 116 reports of death or injury of pedestrians wearing headphones. 74% of case reports noted that the victim was wearing headphones at the time of the crash. The majority of victims were under 30 years old (67%). Interestingly, trains were the most frequent type of vehicle involved (55%), and most were in urban areas (89%). Almost a third of the cases noted that an audible warning was sounded before the crash.

It may come as no real surprise that walking while wearing headphones is a personal safety hazard but imagine how loud the headphones must be not to hear the railroad-crossing siren.  In the future perhaps the crossing signals will be equipped with e-devices to interrupt the pedestrian playlist with a public safety message sent to their wireless device as they approach the crossing or traffic light. You heard it here first.

Snow Job

Snow shoveling can kill you (image by Tina Philips)

We’ll it’s winter and for many of us across the northern parts of the continent snow shoveling is as much a part of the routine in winter as cutting the grass in the summer.  Up until now there haven’t been any large studies looking at the risk of snow shoveling and having a heart attack. Researchers at the Kingston General Hospital, in Kingston, Ontario studied 500 men between the ages of 19 and 94 who had heart attacks (acute coronary syndrome). At total of 35 (7%) had documented events related to snow shoveling.  The only significant variables were a family history of heart disease and male sex. They conclude a family history of heart disease and male sex have strong, independent associations with having a snow-shoveling-related heart attack. Now, having both risk factors, I have to go shovel the driveway so I can get to work.

Apathy Rules

Apathy? Who cares? (image by graur codrin)

Apathy and depression often develop after a stroke. Some estimates say 1 in 4 or 5 stroke victims suffer from apathy. The mechanism isn’t well known. Its presence is generally predictive of greater functional decline. There is no effective treatment. Does generalized apathy represent an as yet unrecognized neurological symptom? Or perhaps apathy is too vague a cognitive condition to differentiate between not voting and not getting out of bed. Who cares? You might ask.

Caveat Emptor

Medicine is an art and a science (image by Simon Howden)

Diagnostic error in medicine is starting to grab media headlines again. There is a growing literature on diagnostic errors mostly in the field of cognitive psychology. The consensus of this literature is that most errors are cognitive and result from the application of one or more cognitive biases. Such biased reasoning is usually associated with ‘System 1’ (non-analytic, pattern recognition) thinking. However, there is actually very little evidence to relate diagnostic errors with System 1 (non-analytical) reasoning. Studies show that ‘experts’ are as likely to commit errors when they are attempting to be systematic and analytical. The burning platform is whether various approaches to reduce medical errors are effective. An educational approach to teach medical students about diagnostic pitfalls doesn’t appear to work. There is an accumulation of research that interventions directed at specifically encouraging both analytical and non-analytical reasoning has been shown to result in only small improvements in accuracy. However, diagnostic errors are not simply a consequence of cognitive biases or over-reliance on one kind of thinking.  As we know from the aviation industry for example errors result from multiple causes and are associated with both analytical and non-analytical reasoning. There is some research evidence to suggest encouraging both types of reasoning can lead to limited gains in accuracy. So what’s the answer? First, we live in a universe of probability so the fundamental question is how to drastically reduce the likelihood of error, not eliminate it. Artificial intelligence and the convergence of information and biotechnologies offers hope to give us humans better tools to help us overcome our innate flaws.  After all, if President Garfield’s attending physicians had an x-ray machine they could have found the source of the assassin’s bullet that didn’t kill him, but the medical care and the biases of his physicians did.

First Do No Harm

As we’ve seen in some recent high profile deaths reported by the U.S. media, physicians can play an important role in reducing the skyrocketing prescription drug death epidemic. On January 13, 2012 the U.S. Centers for Disease Control (CDC) reported in the Morbidity and Mortality Weekly Report  almost 27,000 people died in the United States died as a result  unintentional drug overdose.  This translates to 1 death every 19 minutes across the U.S.  And it’s not just a U.S. problem. Prescription drug abuse is the fastest growing drug problem across North America, and it’s not just in big cities, in small rural and remote parts of Canada it is a silent epidemic that is ripping apart whole communities. This dramatic increase in the unintentional drug overdose death rate is fueled largely by prescription opioid analgesics. Since 2003, prescription opioid analgesics deaths have been double that for the illegal drugs heroin and cocaine combined. And the prescription drug death rate is only the tip of the iceberg. It also drives up the utilization costs for many health services. For every unintentional overdose death from opioid analgesics, 9 people seek treatment for substance abuse, 35 visit emergency departments, 161 report dependence, and 461 report recreational or non-medical uses of opioid analgesics. Do the math, this is a costly epidemic in more ways than one. Physicians have an vital role to play in both practice and in leading the call for a research-based public policy strategy that targets those at greatest risk.

Rate of unintentional drug overdose deaths per 100,000 population — United States, 1970–2007 Source: National Vital Statistics System



Healthcare Reform For Dummies

Treat healthcare as a high-tech industry (image by Danilo Rizzuti)

1.     Move routine specialty services such as endoscopies out of hospitals

2.      Create focused factories of care independent from hospitals to improve access, throughput and quality

3.      Use technology to improve productivity, for example email to arrange for referrals, appointments and routine prescription renewals

4.      Encourage grassroots, provider-based innovations

5.      Facilitate mergers and acquisitions of health service organizations

6.      Modernize the way health services are funded to reward new ways of delivering services, in different ways; have funds follow the patient

7.      Restore choice as a dimension of quality

For more ideas on Fiscal Accountability and The Transformation of Canada’s Healthcare System see the report Shifting Gears from The Mowat Centre and the School of Public Policy and Governance at the University of Toronto.

The Forgotten Ones

Life is short the art is long (image by Vlado)

End of life care is difficult to really talk about in the abstract, that is separate from the care needs of the individual children, teenagers, adults or senior citizens needlessly suffering in their final days and hours. The lack of coordinated care for this stage of life stands in stark contrast to the excellent standards of care generally achieved for example in obstetrical care across the country. For sure there are pockets of excellence in palliative care and many dedicated people doing what they can to provide care and relief.

The roots of neglect lay in the origins of Medicare. End of life standards of care are very different today from when Medicare was first established. Originally established to provide coverage for hospital and physician care, Medicare did not envision the exponential growth in medical technology and the ability to offer many more options for treatment to prolong life, to enable many people to live longer with chronic disease, so that many more will require end of life care. It should come as no surprise then that an end-of-life care strategy is desperately needed across Canada. One that is person-centred, family-focused and community-based, and one that addresses suicide prevention and abuse.  Societies are going to need to find creative ways to reallocate limited funds to make home care, long-term care, and palliative care consistently insured services under Medicare and to define a commitment to make excellence in palliative care an achievable, measureable goal.