Dan Keller's Health Policy
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Healthcare Technology Site

September, 2011 -- In the California budget crisis, most of the University's State funding has been cut. On a personal level, I am saddened and dismayed by our State's repudiation of its noble 1960 Master Plan for Higher Education. To it, I owe much of my own academic and professional career. In the bigger picture, to it our State owes much of its economic ascendancy to one of the world's largest economies, a proud achievement that is now threatened.

Our renouncing of this proud promise to our own future began in the '70s with Jarvis-Gann and accelerates today with mean-spirited anti-tax movements of Grover Norquist and his demagogic Tea Party offspring. The stepwise gutting of the mighty UC system is both tragic, putting top-flight University and graduate education beyond reach of ever-growing numbers, and short-sighted, reducing the growth of technology and culture, diminishing our prospects for a prosperous future.

This is a sad time indeed.

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September 23, 2011 -- (to the San Francisco Chronicle)

Dear Editor --

I am a California nurse. Yesterday, 23,000 of us went on strike. Passers-by honked and waved and were almost universally sympathetic to our cause. If you are one of the few doubters, this letter is for you.

The nurses' unions are among the few that have not yet been eviscerated. Unions should be strengthened, especially in the light of the growing chasm between rich and poor, ballooning corporate profits, and what's been called the "Bush Economy." Without unions there would be no middle class. In the Bush Economy, profits and tax giveaways go to banks that do not lend and corporations that do not hire. Gut the unions and the fate of the middle class is sealed.

Yet some have called us "greedy nurses." There was even a full-page ad in yesterday's SF Chronicle claiming that nurses average salaries of $150K. In our dreams! No nurses I know earn six figures, and the one or two I've heard about do it by working overtime hours to exhaustion, a path to certain burnout.

The most important thing to know about nursing work is how hard it is, and how many, many years it takes to acquire that level of expertise and instinct that does, truly, save lives. For more than any other reason, patients go to hospitals for nursing care. Yes, they have procedures like surgeries and therapies, but part of why I prefer nursing to doctoring is that while the doctor gets ten minutes with the patient, the nurse gets an entire shift. That's where real healthcare happens. The personal, emotional, and professional commitment nurses put in to make this happen is unlike any other job. You can't imagine this until you've been there.

There is also a surprising amount of pure physical hardship. Here are a few quips from the culture of nursing:

• What nurse hasn't dealt (many times) with a "code brown"?
• And what do you call a nurse with a bad back? Unemployed.

So when I hear talk of "greedy nurses" -- especially from corporate executives like Sutter Health's CEO Pat Fry who awarded himself a $2M bonus this year -- my stomach turns.

The real challenge -- while applauding the nurses for holding their ground -- is to unionize the other professions and redirect some of this nation's wealth back down from the top. And if ever you get sick and then well again, thank a nurse!

Thanks for listening,
Dan Keller

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September 22, 2011 -- Today was the strike as planned. Only about 5% of the union nurses crossed the picket line. We are nurses, hear us roar!

California Nurses On Strike

Nurses At Dozens Of Calif. Hospitals Strike

Nurses at dozens of Calif. hospitals strike

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September 18, 2011 -- In three days (on the 22nd) thousands of Sutter Health nurses will go on strike and in sympathy with them will go thousands more Kaiser nurses. These are two of the largest hospital chains in Northern California. The nurses are defending hard-won employment contract terms (some health care benefits, some sick and parental leave benefits, etc.)

Especially pertinent in California, the only state with mandated nurse:patient staffing ratios (e.g. 1:5 in med-surg units) is participation in the staffing decisions, which, too, Sutter hopes to take away. This is important; it is one of the ways that nurses advocate for patients. Numerous studies have made clear the impact of staffing ratios on health care outcomes.

Of course, there are two sides to every story. The business of hospitals is a tough one (though Sutter is having record profits this year). Medicare reimbursements are being reduced, making it harder to "make the numbers". My friends in hospital management are stressed out (though not top management whose pay has seen handsome raises). Particularly problematic from the hospitals' point of view is the EMTALA Act that requires hospitals to provide care to anyone needing emergency treatment regardless of ability to pay. This means that the hospitals provide care for the medically indigent for free -- a tough way to run a business.

Nonetheless, I guess it's obvious where my sympathies lie. My CNA dues are paid up and I'll be out there on the picket line.

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September 15, 2011 -- Does Livermore have the most slender people?

Does nearby Los Banos have the fattest? Or does it have the most bariatric surgeons?

When you're selling a hammer, does everything look like a nail? Are high-tech healthcare choices driven by doctors who are also businessmen? (I have written on this topic previously.)

See the data for yourself at the California Healthcare Foundation's interactive map, released today.

The hardest question: what should we do about it?

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September 1, 2011 -- Though retired now, my brilliant and inspiring grad school professor Dr. Donald W. Simborg continues to expound and illuminate. He writes with authority, having served as co-chair of the expert panel of a study group related to the Nationwide Health Information Network (NHIN) that looked at healthcare fraud.

He says, "Healthcare fraud is the most lucrative thing you can do if you're a crook... We're talking about a $250 billion problem."

In this month's J Am Med Inform Assoc (2011 Sep 1;18(5):675-7), he decries new techniques for fraud that have become enabled by modern electronic medical record (EMR) systems. These include:

• Identity theft of provider IDs and patient IDs. This enables the fabrication of fraudulent claims.
• Record cloning -- another way of producing fraudulent claims.
• Copy forward -- data that is entered ahead of its actual collection, e.g. vital signs entered the day before the patient visit.
• Single-click notes -- templated notes entered prior to the patient visit and subsequently left unaltered.
• "Make me an author" -- an EMR feature that enables a physician to substitute their signature attribution for that of the person who actually entered a note.
• Unaudited edits -- another "feature" that enables retroactive editing of a note without logging the amendment. Some vendors even enable the suspension of audit trail logging.
• Evaluation and Management (E&M) code optimization -- Some EMRs suggest "upcoding" (changing the Current Procedural Terminology (CPT) service code from which billing is generated to a more expensive one) of E&M codes, and indeed with the increasing use of EMRs we have seen a rise in Medicare billings.

I applaud my professor's call for better industry oversight. EMRs can do much to improve quality, continuity, and research in healthcare. They must not also serve as tools for fraud.

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September 12, 2011 -- Today is the first day of the Sixth Annual National Health IT Week, September 12-16, 2011.

Information technology is essential to healthcare, a fact our technology-worshipping country has been paradoxically slow to recognize. To see why, as always, follow the money.

Our for-profit insurance company middlemen have a sole incentive: their bottom line. The long-term benefits of effective IT systems -- things like quality, continuity of care, population-wide and longitudinal data collection and analysis -- generate no profits. Hence, they aren't reimbursed. Hence, we don't have them.

Most US hospitals still lack comprehensive electronic medical record-keeping. Those that do have them cannot -- indeed prefer not to -- share their data. Well-intentioned (mostly governmentally-funded) efforts at Regional Health Information Organizations have gained little traction and in some cases shut down. So the primary objective of this Health IT Week is "...to educate industry and policy stakeholders on the value of health IT for the US healthcare system."

It's astonishing and disheartening that we still have such a long way to go.

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July 19, 2011 -- Today I shook the hand of yet another spirited and passionate public servant, Fiona Ma, California Assemblymember from my University's San Francisco district. Her work spans many issues but for me the one of most interest is, of course, health care.

Ms Ma's cause celebre in this arena is advocacy for Hepatitis B -- education, screening, vaccination, treatment and San Francisco's Hep B Free program. This is yet another ground-breaking collaboration between government and health care providers. (We do a lot of that here; we are leaders!)

Health care services are not enough. Public advocacy is another essential component and people like Ms Ma make it happen.

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July 14, 2011 -- Today I shook the hand of another warrior for the people: Dave Jones, California's new Insurance Commissioner.

He describes himself as an activist. What he doesn't say in this article but did say in his speech today at the Public Policy Institute of California is that he is a whole-hearted supporter of California's Senate Bill SB810, our best hope for a single payer healthcare system. (I've written lots about it in this blog.)

Inaugurated in January of this year, Mr. Jones hit the ground running, doing what he can with the limited powers of his office to restrain the insurance companies. For example, he has enacted in California (modeled on the federal reforms) limitations on the "overhead" that insurers can incur, requiring them to spend $0.80 of every premium dollar on actual healthcare (hospitals, doctors, medical and ancillary services and providers.) To everyone but the employees and shareholders of Anthem Blue Cross, that's still 20% of pure waste but it's a step in the right direction.

Go Dave!

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July, 2011 -- Some nurses are miracle workers. With the Mom and the doctors all but resigned to getting the baby out by C-section, L&D RN Diane says, "Let me see what I can do." She talks to the baby (still inside the Mom) and lets it know that it's safe to come out. The three of them work together, developing a deep trust, and often this enables the baby to be born the natural way after all.

Is this miracle work? Or the product of decades of experience, and the non-quantifiable but undeniable successes that can be attained with intuition and spirituality?

Where are the randomized, double-blind, peer-reviewed, reproducible, gold-standard studies and clinical trials? Combining these two approaches -- science and intuition -- gives patients the best outcomes.

It's eye-opening to see it in real life.

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June 24, 2011 -- From an announcement on Google's official blog, we learn of the end of a wonderful experiment.

Google Health was a great idea -- empowering patients with control over their own data -- that we applauded.

Alas, the business model was weak; not enough users (and no insurance companies) saw enough value to get on board. Its primary virtue was the real life implementation of a Continuity of Care Record -- something that we sorely need. The value was there but it was subtle.

In a fascinating analysis, Missy Krasner observes that the challenge (that proved insurmountable) was the dominance by "tethered" health care records, those operated by health care providers (hospitals, doctors' offices, and tertiary and ancillary providers such as outpatient services and labs). The drawbacks of these data "silos" is that data is not shared among providers, making patient mobility problematic. Providers don't want to lose business by enabling patients to go elsewhere.

Nonetheless, PHRs (personal health records) such as Google's must ultimately prevail. KevinMD agrees with me: Google gave up on electronic personal health records, but we shouldn't. This will happen only with guidance from regulators. Obama's health care reform does this... alas, too late for Google.

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June 2011 -- My friend Dick Karpinski writes about "known but unused cancer cures" at his Cure Cancer Now Home web site. Though I'm not qualified to comment on the specific cures he discusses, I do not doubt that the unprofitable ones get little attention. Thanks, Dick, for raising our awareness.

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May 2011 -- Senator Leno's Single Payer Health Care Bill Passes Health Committee... California OneCare: Full Care, For All, For Less -- check it out!

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May 16, 2011 -- Want to know how things really work? Follow the money! Insurers Take In Record Profits as U.S. Residents Spend Less on Care -- translation: in these times of economic stress, we're living with less yet continuing to enrich these parasites.

Some experts believe the companies are trying to raise premiums before stricter regulations are enacted under the federal health reform law, such as a requirement that companies cover individuals with pre-existing conditions.

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When a B-25 bomber crashed into the 79th floor of the Empire State Building at 9:49 a.m. on Saturday, July 28, 1945, killing 14 people, the injured were rushed to Bellevue's Emergency Room. My mother (a former Bellevue nursing student) writes:

As students we always said, "If ever I'm in an accident, take me to Bellevue ER." The ER staff had an amazing ability to respond to the very serious situations that walked in or came by ambulance and to the bizarre, too.

Bellevue had (don't know if it still does) a museum -- a glass cabinet -- of things removed from the bodies of patients who showed up in the Emergency Room. One was a fairly large steel nut removed from a guy who was working in a garage on the night shift. He had screwed it on to his penis which swelled with blood so he couldn't remove it. Fortunately, he wasn't circumcised, so the multi-talented ER doctors circumcised him and in the process were able to unscrew him.

There were no private rooms at Bellevue, but each ward had a room for a V.I.P. or someone with a highly contagious serious disease. Other patients were less fortunate and were housed in the enormous wards with dozens of others. There was one who repeatedly got out of his bed and peed in the corner. When asked by an angry staffer, "Where do you think you are?" he got himself a psych consult by answering, "Grand Central Station!"

In retrospect, this doesn't seem like an unreasonable reply. It was an enormous ward with 60 to 80 patients. There were beds on both sides and down the middle. There were no call bells. To get a nurse's attention to get a bed pan (or to be on the schedule for when bed pans were passed out from a wheeled stretcher where they were lined up on top), a patient had to get out of bed and find her. Tough luck for the patients who were too sick to get up!

If a Catholic patient died and was not on the "On Serious" list (a code meaning that he or she would need last rites) New York City could be sued. Patients got scared when they were put "On Serious" as a precautionary measure but we did it anyway to protect ourselves. On the night shift -- even if it was our first time in that ward, and even if we were working it alone -- if an "On Serious" patient died, it was our fault. If the patient was not breathing we would lift their eyelid and shine a light to check for a reaction. Living patients were not happy to be so rudely awakened. Then we rushed to the head nurse's desk to check the patient's card to see if he or she was "On Serious" and above all to see whether the patient was Catholic. If they weren't Catholic, we could breathe a sigh of relief and simply fill out an accident report. The duty of the student was first and foremost to protect the City.

When the night nurse supervisor made rounds during our shift, everything better be in order. (Remember, this was WWII and there were few nurses available; most were in the war zones. Students' education was work-centered, not education-centered.) There was an intern who could be called to the floor if necessary, but he had been answering calls half the night and had conked out in his room. The students hesitated to call him unless the patient was really in trouble so we rarely did. No one thanked us for our heroics but we knew and so did our patients. That was an unforgettable time.

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May 1, 2011 -- In a letter today to the San Francisco Chronicle, I wrote:

Thank you for Stacy Finz's article in today's newspaper exposing abuses by for-profit professional schools.

These practices are not limited to the for-profit schools. They also take place in the nominally non-profit schools.

I am a recent graduate of Oakland's Samuel Merritt University's school of nursing, another that preys on people hungry for employment.

SMU is a cash cow for its parent company, the Sutter Health hospital chain. According to its alumni literature, last year it earned $10 million profit on revenue of $40 million, a 25% margin. It is non-profit in name only.

We ABSN (Accelerated Bachelor of Science in Nursing) students pay $52,000 for a year of poor-quality instruction. For example, Diana Jennings, the instructor of the so-called Nursing Research class (included in the curriculum to satisfy the accreditation checklist; Jennings delivered only one lecture in the entire semester) brightly proclaims, "Everyone gets an A!"

In addition to the high tuition, fees such as $420/semester are charged as "Lab Fees" for a lab that is almost always locked, and poorly stocked. In the few hands-on practice sessions that are offered, we must share and re-use supplies like bandages because the school doesn't buy them in adequate quantities.

Thanks for helping to expose an exploitative industry.

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April, 2011 -- California Senate Bill 810 -- It's back! And coming up for a Senate Health Committee hearing on May 4th. (Thanks again, Mr. Leno!)

Let's save money (yes, our state budget is deep in the red) and cover everybody at the same time. How? Eliminate the middle man! Let the State be the single payer. It works in Massachusetts. Why not here?

Though I'm no longer a student, I continue to support the goals of the California Health Professional Student Alliance (CaHPSA) and participate in its calls to action. I have telephoned my State Senators and let them know how important it is for California -- along with the national health care reform -- to move forward. Our "system" is a disgrace... but we can fix it. We must fix it. Go SB810!

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April, 2011 -- "Beware the three Ds," my mother's nursing instructor intoned: "Drugs, drink, and doctors!"

It was 1944 and America was at war. The experienced staff nurses were abroad, serving in the U.S. Nurse Corps, providing medical care for the troops. Judith -- my mother -- had just graduated from high school and, newly-admitted to nursing school, was pressed into service to fill the need here at home. She writes:

In 1944, we were student nurses at Bellevue, a 3,000-bed hospital in New York City, on First Avenue. Described as a city within a city, its many buildings stretched from East 26th St. to East 30th along the East River. It had a prison, a mortuary, and even its own State Supreme Court.

Bellevue could not refuse anyone. If you were a patient in a private hospital and couldn't pay your bill, you were shipped off to Bellevue, no matter how sick you were. That was sometimes referred to as your "last ride".

It was a catchall for paupers, psychotics and criminals. Bowery bums loved to winter at Bellevue, finding some way to get admitted and, once admitted, would figure out how to make their thermometers spike a fever, assuring them of a warm bed for another night.

Bellevue was one of the world's great teaching centers. It was a coveted learning ground for young, new M.D. interns (the third D!) and for student nurses, too. With the seasoned nurses gone, the student nurses filled in, taking classes during the day and covering on the wards at night.

It was hard work. Students were assigned to medical and surgical wards, immense rooms with 60 to 80 patients, none of whom we had seen before. On a good night we had a nurse's aide, but often we were alone with all these very, very sick patients to care for.

At Bellevue, we treated the worst cases of the worst diseases. Nurses who had trained at Bellevue proudly wore their organdy caps with the ruffle all around and were respected wherever they worked.

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April, 2011 -- Though it's already more than a year old, this article (from August, 2010), is such a valuable explanation of a vexing issue that I'm linking it here. One of my favorite writers on health care, Atul Gawande in the New Yorker, observes that modern medicine is good at staving off death with aggressive interventions — and bad at knowing when to focus, instead, on improving the days that terminal patients have left. A good read on an important topic.

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March, 2011 -- As a programmer and nurse, I can tell you that "coding" means something awfully different to each!

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February 24, 2011 -- At my alma mater UCSF, I attended a symposium on innovation in California. Innovation is our strength (Silicon Valley!) and it will create jobs and revive our economy.

The symposium was a star-studded event. The speakers included one of my heroes, Lieutenant Governor Gavin Newsom. Sitting next to me was Elizabeth Blackburn, a Nobel prize winner.

Another speaker was former California Governor Gray Davis (whose hand I shook). He said, "If you're born in the east, you grow up and you want to join something. If you're born in California, you grow up and you want to start something."

Indeed I do... Here it is (Powerpoint, of course)... Wish me luck...

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February, 2011 -- The conventional wisdom says that government-run = low quality and inefficiency... But is that true? Not so fast, says Mike Doyle of Medsphere, a promoter of the Veterans' Administration's electronic health record system, VistA. I had an opportunity to learn and use VistA on one of my clinical rotations and found it excellent. Furthermore, the VA itself is a success story. In his well-researched blog, Mike writes:

By all rights, after all, the VA should offer the worst care anywhere: it's a gigantic, unionized bureaucracy, micromanaged by Congress and political appointees, and beset by an uncertain budget, an aging infrastructure, and a legacy of scandal. That it nonetheless outperforms the rest of the U.S. health-care system, on metrics ranging from patient satisfaction to cost-effectiveness and the use of evidence-based medicine, suggests that much of what we think we know about health care simply isn't true.

VistA works well and I found it easy to learn and use. Furthermore, the source code is in the public domain (open source) and stands a good chance of setting the standard for the industry. It makes electronic health record software affordable. Even Fox News has gotten behind it. Nonetheless, Doyle cites research that says:

Astonishingly, 20 years after the digital revolution, only 1.5 percent of hospitals today have integrated IT systems like the VA uses, and those that do often find their commercial software programs to be buggy and inadequate.

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February, 2011 -- Occidental cultures generally hold that the human identity resides somewhere behind the eyes -- in the brain. For example, the Mind-Brain Identity Theory says that, "...mental states are identical with brain states." Not so fast, say I.

Damage to the brain is often associated with damaged thought processes. For example, Oliver Sacks "...throughout his career as a physician and neurologist, ...studied patients who exhibited 'a strange mixture of [mental] strengths and weaknesses.' His patients had autism, William's Syndrome, Tourette's Syndrome, amnesia and other conditions." When the brain malfunctions, thoughts malfunction. However, this does not preclude the involvement of other bodily organs in personal identity and thought.

Our Western notion that identity, thoughts, and feelings reside exclusively within our skulls is at best dubious, more likely erroneous. Ask anyone who has undergone an amputation. As nurses we are taught that phantom pain is real pain but more than that the amputee will tell you that part of themselves -- not merely an extremity -- is gone.

Another way in which our sense of self encompasses more than the contents of our heads becomes clear with the deaths of family and friends. In a real and profound way, with each such passing we lose part of ourselves. We exist not just in the context of our bodies but also in terms of the people who know (or knew) us, our accomplishments, personalities, and personal histories. As our isolation increases, our place in the world is diminished. There are vocabularies for discussing this, for example Carl Jung's collective unconscious in which we exist not only individually but also in community.

Nearly every Latin love song refers to the coraçon -- the heart -- as the locus of emotion. Eastern religion and medicine recognize a dozen or so chakras -- pathways for flows of energies in the body -- located along the spine, in the ovaries or prostate, the throat, and so on. In our own western culture we speak of visceral emotions and gut feelings. Our skin crawls; we know things in our bones; and so on. The point is that all these organs participate in the formation of our consciousness and our emotional state.

My hypothesis here is that the kidneys are especially central to emotional state. In nursing school, we learn that they regulate fluid and electrolyte balances. These in turn drive cognition and mood. When the kidneys do not sufficiently remove ammonia from the bloodstream, we become demented. When they imperfectly regulate our bodies' acid-base balance, we become acidotic or alkalotic and thus agitated or lethargic. We think with our brains and with our kidneys.

The distinction between mind and body is a paradigm of our western culture, at times useful but at other times driving us to discussions of placebos (with which the mind bluffs the body), etc., that emerge as corollaries. We believe this dichotomy deeply. But what if it weren't entirely true? Another model might serve us better. What might it be called? The Thinking Body? Placebonics? Kidneys 'r us?

We do think with our brains... Also our hearts, guts, skin, bones, kidneys -- the mind is the whole body! What a concept!

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February, 2011 -- California RN license #790869. At last.

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February, 2011 -- Healthcare dollars are spent in two fundamentally different ways and should be collected and managed accordingly. These are:

1. Preventive and predictable health care expenses: our children's immunizations, prenatal care, our routine diagnostics (PSA tests for older men, mammograms for older women, etc.), and our periodic checkups. These things are completely predictable from the moment we're born -- indeed, from the moment we're conceived -- through our entire lives. The costs should be budgeted and funded for every one of us without exception. We should all pay into a system that provides them, and there is no reason for anyone to earn a profit from it. It's a public service like law enforcement and fire departments and should be funded and provided similarly, by publicly-funded, local community clinics. There is no place in the preventive/routine care part of a rational health care system for for-profit insurers. The incentives in such a system are wrong and result in a system that's unfair and that delivers inadequate care.
2. Costs of casualties and illnesses (unpredictable): should be managed as insurance in which risk is shared across an entire population. The services are best delivered (as they are today) by for-profit, centralized, high-capital-cost, acute-care facilities (hospitals and specialized service units such as dialysis centers, imaging centers, clinical labs, psychiatric offices, and hospices). Anyone to whom a casualty or illness happens would be covered, and everyone would pay in to the fund equally (the "triple mandate"). The fund would reimburse the service providers with preference and incentives for those that provide the best care and the lowest prices.

This is just common sense. None of this would prevent anyone from buying any other health care service, or from using the provider of their choice who might be "outside the network". Anyone can buy whatever they want if they have the money. The Canadians have forbidden this, saying that it would create a two-tier system and perhaps they're right. Alas, we already have a two-tier system in the USA, and it's ugly: those with and those without. Obama has taken some baby steps toward an overhaul... A good start. We need that and a whole lot more!

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January, 2011 -- ...And pound-foolish. Health insurance (mine is Blue Cross) will not pay for medicines if they are over-the-counter. They pay only for prescription medications, those that are ...licensed medicine that is regulated by legislation to require a prescription before it can be obtained. The term is used to distinguish it from over-the-counter drugs which can be obtained without a prescription. For example, my eye doctor prescribed Ocuvite, shown by controlled, randomized studies to delay onset of age-related macular degeneration. My Dad had that; if I live as long as he did, I will probably get it, too. There are some treatments (not cheap) but of course it would be better to delay or not to get the disease at all. But Blue Cross won't pay for Ocuvite because it's not a prescription drug.

Why is that foolish? Because health insurers save a nickel today and spend ten dollars later; their business model requires that they be stingy regarding prevention but generous regarding cure. I also saw this when I worked as a tobacco cessation counselor. My patients could not get reimbursed for the few hundreds of dollars cessation classes cost, but when they cost tens of thousands later for their lung and other cancers, heart disease, and COPD... no problem!

Why is it so? These short-sighted policies are demanded by how corporations work: they must show continually-rising short-term profits. This is done by minimizing expenditures in the present quarter. Higher costs in the future? They'll deal with that when the time comes. This is the behavior that's good for Wall Street, but it's bad for our health. The incentives are wrong. This is why -- by definition -- for-profit companies should not be in the business of making health care decisions. What would be a suitable alternative? Single-payer, of course!

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December 19, 2010 -- Today was nursing school pinning (that's what nurses call graduation.) Now I have the "N" in "RN"... To get the "R", I will soon take the NCLEX, the State Board exam that gets me my license to actually do nursing work.

What's remarkable is how little we new grad nurses know about how to do the work nurses do... Especially given the $52K/yr we've spent to get here. Hospitals are reluctant to hire us because we are nearly useless. Hiring us is a big commitment because hospitals must make such a big investment in us (lots of mentoring and initially low productivity) to get us up to speed.

It doesn't need to be this way; nursing education could be effective. My school was mediocre but (and I have evidence for this) they all are. But that's a topic for a different discussion... For now, I am just celebrating. Video. Hurray for pinning!

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December 12, 2010 -- In one week I will graduate from nursing school. At long last! The ceremony is called "pinning" and is a throwback to the old days when nurses wore little white hats and making tight hospital corners mattered more than patient care.

I am a new nurse, entering this as a second (well, third, but who's counting?) profession. I bring the perspective of experience in other work realms, and I have less tolerance for mediocrity than my fellow nursing school students who are half my age. More to the point, I have little tolerance for mediocrity in my nursing school faculty whom, to their chagrin, I perceive as peers (indeed, most are younger than me.)

Evidently there are many like me: older men entering nursing as a second profession. "Nearly 40 percent of students studying to become registered nurses are over age 30... candidates who already have four-year degrees," [from the New York Times, Nov. 7, 2010: 45, Male and Now a Nurse]. I'm not 45 but 56, and have both a four-year degree and a Master's, but the idea is the same. My nursing class exactly matches that in the NYT article: 15% male. What the article doesn't mention is the darker side of this trend: education to produce degrees like mine (the school sells BSNs) is now a big business. My school (which I'd better leave nameless for now, since I'm still in its clutches) is -- let's be magnanimous here -- lackluster in the quality of its teaching though expensive ($52,000/year not including books and supplies) and very profitable ($10M profit on $40M gross revenue).

Fortunately, the quality of the education is largely irrelevant to the quality of the nurses entering the profession. Most of what we new nurses need we will learn on the job, not in the classroom. In other words, we emerge from this expensive and unnecessarily fractious process knowing almost nothing of what we'll need to know to be good at our work. New nurses need lots of nurture from the institutions that accept them before they become useful.

This raises several important questions: how can nursing education be made effective? How can new nurses ("nurses eat their young") come up to speed without getting beaten up along the way?

Why does this matter? Because we want good health care. Given that the 3.2 million RNs now in practice form the vast majority of the health care work force, we need them to be good at their jobs and to get there quickly. The present dysfunctional system of producing new nurses is ripe for an overhaul. That will be good for us all.

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In nursing school, the most valuable part of the process we undergo is the clinical rotations. The time is expensive -- total hours (lecture + labs + clinicals) divided into tuition (Samuel Merritt charges $52,000 + books + uniforms + supplies + lab fees) is $45/hr. The lectures are not worth it -- especially ones like Diana Jennings' in which we just watch videos and, she brightly proclaims, "Everyone gets an A." At SMU we are charged $420/semester "lab fees" for a lab that is rarely open and often out of supplies. Sutter Health (SMU's owner) claims to be not-for-profit but has exorbitantly-paid executive staff -- profit by another name. For-profit education is just a bad idea.

The clinicals are where the rubber meets the road. Here, we work with live patients in local hospitals. Each semester, we are assigned to a different type of nursing unit so that by the end of the program we have had a taste of med-surg (the most important), peds, SNF, ICU, oncology, emergency, psych, telemetry, and perhaps others. These are fascinating, difficult, and stressful. Some of us kept journals. I did. Here are my writings.

Feb. 18, 2010, Kaiser, med-surg, Santa Clara: At the same time exhilarating and challenging is the access granted by nursing work. In ordinary human interactions, there isn't permission to poke and pry... More

Feb. 23, 2010, Kaiser, med-surg, Santa Clara: Infection transmission precautions are driving me nuts. Those bacteria have us whipped... More

March 3, 2010, Kaiser, med-surg, Santa Clara: I remember distinctly a comment made by one of my clinical instructors from the first time I went to nursing school about four years ago. She observed that I was having difficulty finding my "rhythm"... More

March 17, 2010, Kaiser, med-surg, Santa Clara: Nursing education is focused on the hospital setting with its enormous resources and fine-tuned protocols. What about nursing in other environments? ... More

July 8, 2010, O'Conner Hospital, monitored (telemetry) med-surg unit, San Jose: Listening is a challenge. I could not hear 9121's heart!... More

July 17, 2010, O'Conner Hospital, monitored (telemetry) med-surg unit, San Jose: Still have occasional moments of, "OMG what (of the hunded possible tasks) should I do next?" but they last only five seconds... More

Aug. 23, 2010, Veteran's Administration Hospitals, Palo Alto and Menlo Park: After all the flack in the press about the sorry state of affairs at Walter Reed hospital and the right-wing excoriations of our government's purported neglect of our brave men and women formerly in uniform (i.e. veterans) it was eye-opening to see how well, in fact, they are cared for... More

Aug. 30, 2010, Veteran's Administration Hospital, Menlo Park: I'll be blunt: the time doesn't feel very productive... More

Sept. 13, 2010, Veteran's Administration Hospital, Menlo Park: A couple of brief but illuminating patient interactions have given me pause. In the first, Mr. F., one of the more belligerent and combative patients... More

Sept. 29, 2010, Veteran's Administration Hospital, Menlo Park: On a personal note, at the risk of appearing unprofessional, I'd like to add that I felt at least a twinge of disappointment at my inability to "connect" with this patient... More

Nov. 25, 2010, Emergency Dep't, Kaiser, South San Francisco: Nursing is, of course, about people. As a student on this rotation I had the luxury of being able to take time to listen... More

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December, 2010 -- Nurses carry information in their heads -- a lot of it! How do they remember everything they need to remember? They use their brains!

This sounds silly but what nurses mean by the term "brain" is the piece of paper they carry in their pocket on which they keep track of the zillion patient and task details their job demands. (Sharon McLane, MS, MBA, RN-BC, and now PhD of the University of Texas at Houston documented this in her 2009 PhD dissertation, Understanding Nurse Created Cognitive Artifacts. "Cognitive artifact" is a fancy term for that piece of paper.)

I collect brains and you can see my collection in my brain museum. Each brain is in its own way clever and meets its nurse-creator's memory needs. Fascinating... and brainy!

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December, 2010 -- This month I am completing my clinical rotations with a stint in the emergency room of a major local hospital. I have seen some awfully sick people walk in that automatic door or, worse, roll in on gurneys and wheelchairs. It is sobering to see suffering, and gratifying to occasionally be able to do something about it. Health care is like no other work in the world!

My friend and fellow UCSF alumnus Mark Wandro blogs about his lengthy and impressive experience as an emergency nurse. Also fascinating is the Emergency Nurses Association web site. Good reading -- give them both a visit!

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November 19, 2010 -- Today I shook the hand of another of my heroes, California State Senator Mark Leno. He is a man of principle! Part of my University (UCSF, where he spoke) is in his district.

Contrary to the loathsome and self-serving declarations of such right-wing demagogues as Grover ("shrink government to the size we can drown in a bathtub") Norquist, the public sector, says Mr. Leno, is critically important. Not only because it is the best mechanism for delivering such services as public safety and justice, but because without it there can be no revival of the private sector. It creates the foundation upon which growth can occur. Around the world, the countries where growth is limited are those with little infrastructure. And (dear to our UC hearts) public education is a big part of any robust infrastructure. An educated middle class has been an essential part of what has made California the world's eighth economy.

Mr. Leno has been instrumental in the revival of Sheila Kuehl's Senate Bill 840 (which, placating his monied friends, Governator Schwarzenegger twice vetoed) as SB 810. Don't be fooled by the misinformation, Mr. Leno tells us -- no one is asking for "socialized medicine". Rather, what we need is health care that continues to be privately provided but publicly funded. Eliminate those middlemen, the health insurance companies, whose profit was $12B last year yet added no value. Like me and a lot of people, he is convinced of the need for a single payer. This is the only way to contain costs.

With Jerry Brown in the Governor's seat, Mr. Leno will reintroduce this bill. Will Mr. Brown sign it? When he campaigned with Bill Clinton, Mr. Brown was a knowledgeable advocate for a single payer system. As Governor he will no doubt feel pressure from the right and how he will respond is anyone's guess.

Expect, said Mr. Leno, a huge disinformation campaign from the insurance companies. We must innoculate the public with education about single payer -- "Medicare for all" -- an idea whose time has come and yet another opportunity for California to lead the nation.

Guided by visionaries like Mark Leno, we have hope once again.

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October, 2010 -- Calling all angels! Well, not all angels, just the right angel... an angel with vision, insight into the challenges of health care, and that burning fervor to change the world. Well, not the whole world but an important part (nursing) of an important part (health care) of the world.

What needs to change about nursing? It's a hard job (no surprise) with lots of details to keep track of (ditto) and a zillion tasks nurses must remember to do (ditto ditto) yet they get no help (whoops!) No one teaches (or has even thought much about) how nurses can/should do time management and no one has provided tools to help with this... until now!

What do angels have to do with it? Our development time and marketing efforts could benefit from angel funding. Are you the angel we seek? Get in touch... Let's do well while we do good. Join the team and together let's change the world!

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October, 2010 -- What do you want from your doctor, heroism or checklists? Say you're going in for surgery. Do you want your surgeon to exhibit "expert audacity"? Here's how Atul Gawande describes it in The New Yorker, Dec. 10, 2007, in The Checklist:

We have the means to make some of the most complex and dangerous work we do -- in surgery, emergency care, and I.C.U. medicine -- more effective than we ever thought possible. But the prospect pushes against the traditional culture of medicine, with its central belief that in situations of high risk and complexity what you want is a kind of expert audacity... Checklists and standard operating procedures feel like exactly the opposite, and that's what rankles many people.

Or would you prefer that your surgeon follow a checklist as did the pilot Sullenberger who brought down his failing passenger jet in the Hudson River without losing a single passenger? He said he was no hero but was well-trained and following the procedures.

We Americans love to say of our advanced medical care that we had the best doctor... That our doctor is a genius... That a good outcome is thanks to that skill, that extraordinary person... But this is not a model that scales well nor is it conducive to widespread good outcomes. Only a few people get to be worked on by that genius. And if evidence-based medicine is truly at work, then the "genius" is simply following the best evidence, which every well-trained practitioner should do.

Dr. Gawande says that medicine should be more like aviation -- no pilot would fly without first running through his pre-flight checklist, and then using yet another checklist for each situation and task that arises. Checklists are so valuable that he has even made a checklist of steps for making checklists. Of Sullenberger he says:

...it wasn't flight ability, but instead adherence to discipline, and teamwork... Because there were checklists, and because everybody used them... The heroic part of that flight was not the flight ability of Capt. Sullenberger, it was the willingness of the entire team including the flight attendants, who... acted through their protocols.

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October, 2010 -- Environmentalism and nursing? What's the connection? Turns out it's a strong one, and we learned about it at the Children First: Promoting Ecological Health for the Whole Child conference at UCSF this month.

The intersection of environmentalism and nursing includes:

...nutrition, education, socio-economic status, exposures to toxic chemicals, and access to preventive health care.

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September, 2010 -- As nurses, how do we perceive the work we do?

This semester, my clinical rotation is in mental health ("psych") nursing. One of the terms of art is patient compliance -- are they taking all their pills? But we don't call it that any more. Now the preferred term is, in the spirit of patient empowerment, adherence. In other words, we prefer to think they take their pills by choice. In her heart of hearts, though, the psych nurse will admit misgivings about mental health care being little more than polypharmacy.

Oh yes, and we don't call them patients anymore, either. Now they're clients. Perception is everything.

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August, 2010 -- The irony in this pair of billboards speaks for itself. Thank you, Friends of Irony.

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August, 2010 -- When we were arguing about health care reform, much was made of the proposed double mandate. This is the idea that the obligation is on both sides -- insurance companies could no longer turn anyone away, and every health care consumer (you and me) is obliged to buy in. For example, the Huffington Post says, in A Double Mandate for Health Works for Europe: "Most European countries mandate that every citizen must buy insurance coverage. They also mandate that every local insurance company who wants to do business in the country must sell coverage to any citizen who applies for that coverage. Health screens are not allowed."

This is eminently fair and reasonable. The system works best when everyone participates. But I propose we take it one more step.

I propose an even higher degree of fairness -- a triple mandate: everyone must be covered, everyone must participate, and everyone should pay the same. Being young and healthy should not entitle you to a special price. Most people are or were once young and healthy. If you're sick you shouldn't have to pay more. Sooner or later most of us get sick, at least somewhat.

Sure, some people won't be able to afford it. So subsidize them with a government program. We already have government programs to help people who cannot afford health care; the cost of these programs would stay the same or perhaps even decrease due to the larger coverage pool. But this is a detail.

Here's the point: We are a nation of realists; I help my neighbor knowing that someday I may need the favor returned. I do not deserve punishment for my health misfortunes and neither do you. Sharing the risk makes us all stronger. Sharing it equally is fairest. And a system that is truly fair would be something for us all to be proud of. Push for a triple mandate!

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May, 2010 -- I am one of those "empowered" patients. I labor under the illusion that I retain some control of my medical data.

Try it yourself -- run this little experiment:

1. Next time you get an order from your doctor for a routine lab test, have him or her write the following instruction on the order: "Send results directly and only to patient."
2. Make sure your mailing address and fax number are included.
3. Then find a lab that will perform as ordered. Good luck!

Here in San Francisco I went to three different retail clinical labs before I found one that was willing. And even so it took some arm-twisting and remonstrating to convince them that yes, they should do exactly as the order said... no, they should not send the results to the doctor... yes, they should send them (only) to me... yes, it's legal... yes, my insurance (Blue Cross) would reimburse as usual... no, it's not a violation of anything, and... it shouldn't even be unusual. Yet it is.

Get with it, people! Take possession of your own data! Insist on it! Of course you should share it with your doctor. But it should be yours to share, in your control. Our being empowered patients shouldn't be unusual. It's time for the labs (and everyone else) to get used to us!

Postscript (two weeks later): Surprise. The lab completely ignored the instructions and sent the test results to the MD. I have filed a HIPAA violation complaint. Here are the instructions and forms on the web site of the U.S. Department of Health & Human Services in case you, too, need to do this. Stay tuned... I'll record any progress right here on this page.

Post-postscript (two months later): The Dep't of Health and Human Services replied to my complaint. They pointed out that the law says that clinical lab test results must be provided only to the licensed health care provider who ordered them. So the lab, in defying my instructions was "right"... it's the law that's wrong! Not only does the patient not own the data, he/she doesn't even have the right to see it unless the MD assents. Disempowerment gets no worse than that. Broken laws? Let's fix them!

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May, 2010 -- Who is reluctant to try something new? It's not whom you'd think. Is it the oldsters, set in their ways? Guess again!

I recently called ThinkLabs with a technical question about my new digital stethoscope. The phone was answered by Clive Smith, the inventor of the device and CEO of the company.

We proceeded to have an animated discussion about his product and its users. They're not whom you might have guessed: younger, more experimentative healthcare practitioners. On the contrary, said Mr. Smith, it's the older ones who are willing to try something new.

Stethoscopes are a powerful cultural icon. Wearing one around your neck is a kind of badge of honor. Its appearance is determined more by tradition than by function. Like Leo Fender's cutaway electric guitar body from whose shape few have dared deviate in 50 years, stethoscopes must appear just so.

I can confirm Mr. Smith's statement. My nursing school classmates all wear Littmanns. They wouldn't dare try something slightly non-conformist even if it worked much, much better. Indeed, none of my classmates have even asked to try mine. Yet the ThinkLabs is much, much better.

Imagine this: a volume control! You have an obese patient and you can hardly hear anything through that flesh? Turn it up! What a concept!

By the way, Nurse Jackie wears a ThinkLabs.

This sounds like a commercial but really what I'm describing is the freedom of being an old-timer. The youngsters don't feel free to experiment. They are afraid to look different. Mr. Smith faces a challenging obstacle.

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April, 2010 -- The California Healthcare Foundation reports in its Survey: Nurses Divided on Whether EHRs Have Improved Patient Care that half of nurses say that electronic health records have had "a positive effect on the overall quality of care."

And then there's the other half. My own experience -- now that I've worked with yet another EHR (Kaiser's HealthConnect by Epic) on a few clinical rotations -- is that nurses do spend an awful lot of time in front of the computer. This could easily lead to the perception that it takes away from time with patients. But is that true? Didn't they also spend a lot of time charting on paper before there were electronic charts? And isn't it also true that record-keeping and access is far better than it ever used to be? Especially with bar code readers and the electronic Medications Administration Record (MAR) the chances for errors are substantially reduced. So in this writer's humble opinion, computerization has helped make nursing care a lot better. Or at least half of it.

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April, 2010 -- Working my clinical rotations this semester I saw first-hand in the suffering of a patient our medical system's dysfunctional approach to pain management. This young man suffers from a gastrointestinal condition that is painful and cannot be cured. Yet his doctors will not give him ongoing opiate analgesics, the only thing that enables him to get through a day relatively pain-free. They do prescribe these drugs for his acute episodes but then they send him home with non-opiates that, he says, "...do not touch the pain."

Evidently, the concern is that he might become addicted. But I wonder, so what? He has the disease for life, why not the treatment for it, too, for life? I cannot second-guess the doctors but I can commiserate with his frustration.

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March, 2010 -- In another New York Times op ed entitled Health Reform Myths, Nobel prize-winning economist Paul Krugman points out three myths that bedevil proponents of health care finance reform. Lots of people believe:

• President Obama is proposing a government takeover of one-sixth of the economy, the share of G.D.P. currently spent on health.
• The proposed reform does nothing to control costs.
• Health reform is fiscally irresponsible.

Go read the article if you've fallen for any of these.

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March, 2010 -- We fledgling nurses spend a lot of our time dealing with diabetes. It's grown to be an epidemic. I'm studying for an exam. There will be questions about how to recognize it in our patients. When you read the symptoms of a disease, sometimes it seems like every disease has every symptom. But anyway, here goes...

	Hypoglycemia	Hyperglycemia
CBG	<80	>200
Onset	rapid	gradual
Skin	cool, pale, diaphoretic	warm, dry, flushed
Mental status	disoriented, comatose	awake, lethargic
Disposition	shaky, dizzy, agitated	hungry, blurred vision
Respiration	normal	deep, rapid, fruity odor
Pulse	normal or fast	fast, weak
BP	normal or high	normal or low
Seizure	common	uncommon
Urine		polyuria
Thirst		polydypsia
Treatment	PO or IV glucose	SQ or IV insulin, K+
Recovery	rapid (minutes)	gradual (days)

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March, 2010 -- I have decided to buy a fancy new stethoscope, one of the digital ones with ambient noise rejection and other cool stuff... hurray! Maybe now those elusive murmurs will be a little less elusive.

Clive Smith, the CEO of the company (Thinklabs) that manufactures it has a spirited blog. He writes:

...let me make a prediction on healthcare reform. A bill will be passed, one way or another. Due to the special interests that have written this bill and influenced both parties, no "cost cutting measures" will be truly effective. Congress will mandate coverage of pre-existing conditions and many more people will have insurance coverage, which is a good thing. However, with no real cost cutting, insurance companies will skyrocket premiums, arguing that Congress forced them to provide all that new coverage. That the insurance companies wrote the laws will be forgotten.

Opponents of reform will argue that it was an abject failure due to skyrocketing costs. That these opponents of reform prevented cost-cutting measures to pass will be forgotten.

The people will complain that they wanted healthcare reform and cost cutting and instead, they got increased premiums and healthcare costs even more. That they, too, were supposedly opposed to healthcare reform and wanted no government intervention to contain costs will, too, be forgotten.

What will not be forgotten, by those who have tried to promote true healthcare reform, will be that they were painted as the enemy, they were maligned, and they were blamed for the outcome when the mob, influenced by special interests, attacked them for their efforts. What will not be forgotten is that trying to reform healthcare is a losing political position and it's not worth risking one's neck... the politicization of this discussion, the hysteria, the lobbying money, and the abject ignorance of The People... resulted in the destruction of all rational thinking and analysis. We will all be the worse off for that sad outcome.

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Feb., 2010 -- My friends on the Right love to blame the lawyers. Who doesn't?

In an Oct. 1, 2009 article in the Los Angeles Times entitled Tort reform is the healthcare debate's frivolous sideshow, Michael Hiltzik writes:

You know the argument: Disgruntled patients, goaded on by unscrupulous lawyers, file frivolous malpractice lawsuits and walk off with millions of dollars in undeserved awards granted by teary-eyed jurors. Doctors respond by practicing "defensive medicine," ordering lots of unnecessary tests to cover their behinds. Bingo! Medical costs hit the stratosphere.

The truth is that medical liability isn't a big driver of health costs... the cost of malpractice litigation, in court and through defensive medicine, [is] roughly 2% to 3% of all U.S. healthcare spending.

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Jan., 2010 -- (Cross-cultural note for us Americans: in the UK, the traditional Christmas dinner is turkey.) A fascinating article by BBC contributor David Runciman entitled Why do people often vote against their own interests? reviews writings by Drew Westen and Thomas Frank about the psychology of many American voters:

...it is striking that the people who most dislike the whole idea of healthcare reform - the ones who think it is socialist, godless, a step on the road to a police state - are often the ones it seems designed to help.

In Texas, where barely two-thirds of the population have full health insurance and over a fifth of all children have no cover at all, opposition to the legislation is currently running at 87%.

...Why are so many American voters enraged by attempts to change a horribly inefficient system that leaves them with premiums they often cannot afford?

Why are they manning the barricades to defend insurance companies that routinely deny claims and cancel policies?

...stories always trump statistics, which means the politician with the best stories is going to win: "One of the fallacies that politicians often have on the Left is that things are obvious, when they are not obvious.

"Obama's administration made a tremendous mistake by not immediately branding the economic collapse that we had just had as the Republicans' Depression, caused by the Bush administration's ideology of unregulated greed. The result is that now people blame him."

Paraphrasing Frank, the article observes:

...voters' preference for emotional engagement over reasonable argument has allowed the Republican Party to blind them to their own real interests.

The Republicans have learnt how to stoke up resentment against the patronising liberal elite, all those do-gooders who assume they know what poor people ought to be thinking.

Right-wing politics has become a vehicle for channelling this popular anger against intellectual snobs. The result is that many of America's poorest citizens have a deep emotional attachment to a party that serves the interests of its richest.

The article is part of a series entitled Turkeys voting for Christmas... How apt.

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Dec., 2009 -- The benefits of prescribing electronically ("e-prescribing") are numerous:

Fewer errors Fewer avoidable adverse drug events Decision support Detection of drug-drug interactions Improved record-keeping Faster communication with pharmacies And so on...

Indeed, e-prescribing is low-hanging fruit; many MDs have adopted this practice and prescribe this way... But not for the above reasons.

The true incentive? Money, of course. The Centers for Medicare and Medicaid Services (CMS) has implemented a program named MIPPA (Medicare Improvements for Patients and Providers Act of 2008) giving eligible e-prescribers an incentive payment of 2% of their Medicare Part B charges in 2009 and 2010. All that quality-of-care stuff? Do-no-harm stuff? Nah! It's the green stuff that gets it done!

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Nov., 2009 -- Reform of how we pay for healthcare is the hot topic of the day. I myself have expounded on this with excoriations of the health insurance industry. Blue Shield, Anthem, Aetna, Humana and their ilk are now everybody's favorite whipping boys and it's not undeserved. The relationship of these companies with their customers is by definition adversarial. They do their job "best" (in terms of profit-making) when they succeed in denying health care. But there is another, less obvious villain driving our costs up and our outcomes down: doctors who are also businessmen.

I am not the first to recognize doctors' conflict of interest. It has been documented in widely-circulated articles such as NPR's October 8, 2009 story, "The Telltale Wombs of Lewiston, Maine". Another article on the same theme in June's New Yorker has also gotten a lot of attention. Named The Cost Conundrum, it observes that when MDs are businessmen, health care gets expensive.

Indeed, there is an entire science devoted to the analysis of patterns of consumption of medical care and their effectiveness in terms of cost and and outcomes. It's termed "utilization review" and is naturally a topic of great interest to health care payers. Why has it failed to bring to light these maldistributions of service? Why is this issue not part of today's debate?

The NPR story describes how "...in Lewiston, 70 percent of its women would have a hysterectomy by age 70." The reason is not an unusually high rate of uterine disease; a now-famous longitudinal study revealed that numerous communities around the country have anomalous rates of certain medical procedures. The study showed "...how bizarre the distribution of care was. People in one town would get their hemorrhoids removed five times more often than people in another town only 30 miles away. Ditto with mastectomies, prostate operations, back surgery." How are these anomalies explained?

It is doctors, not patients, who drive consumption of medical services. Doctors who are paid for the services they render tend to recommend those services to their patients. In other words, money. This is not to say that doctors are intentionally exploiting their patients but it is clear that their objectivity and judgement is colored by their own financial interest. "The U.S. health care payment system rewards doctors for taking action and doing procedures. This reality is so powerful that it hasn't just changed the individual behavior of doctors... the specialties themselves have changed, bending like flowers to the sun, moving toward the source of heat."

How should we solve this problem? Neither article goes so far as to propose a solution but I will. I propose that our healthcare payment reform legislation include language to do away with medical fee-for-service. A primary care doctor who also offers (and orders) ancillary services or tertiary care has, by definition, a conflict of interest. Why is this a revelation? Why hasn't it always been prohibited? What should we do about it? Here's what: put all doctors on salary instead. They should be paid the same no matter how many (or how few) hysterectomies they perform.

Of course this is politically impossible. The AMA and others would rebel and not mildly. But I have seen other countries (e.g. Italy where I just came back from living for a year and was most impressed by the quality and equity of the healthcare system) where it works just fine.

For me personally, this conundrum has an additional dimension. Among my closest friends are several doctors. Some of them are quite entrepreneurial and thriving. They work hard and well, and their ethics are impeccable. They would not appreciate the sentiments I express here. In conclusion, it can be said only that the healthcare debate is convoluted indeed.

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Sept. 3, 2009 -- In a letter today to the San Francisco Chronicle, I wrote:

Dear Editor,

In raucous town halls around the country, opponents to proposed health care reforms seem mostly to fall into four categories that I label as follows:

• The Gullibles -- listeners to right-wing talk radio screeds and outright fabrications such as Palin's death panels

• The Libertarians -- those who oppose government in any form or role and view its actions (except perhaps military and law enforcement) as intrusion and theft-by-taxation

• The Shills -- militant loudmouths delivered by buses paid for by Big Pharma and Big Insurance

• The Partisans -- those who hope to see Obama fail at any cost (to these people, expense, outcomes, and quality of life are irrelevant... all that matters is Republicans "winning")

Every opinion deserves to be heard but now let's recognize the uninformed ones for what they are, move on, and get the job done!

Thanks for listening,
Dan Keller

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Sept. 1, 2009 -- This evening, at a UCSF event to welcome our new Chancellor, we were privileged to hear a brief talk by Congresswoman Jackie Speier. Her congressional district includes UCSF (where I am Pres. of the Graduate Division Alumni Association).

She welcomed Chancellor-elect Susan Desmond-Hellmann and talked about the hot-button issue of the day: health care reform.

Of course, the issue is not so much health care as health insurance. The insurance company practices of rescission (canceling your policy when you get sick) and pre-existing conditions (if they suspect you might eventually need health care, they deny your application for coverage) must, Speier said, be forbidden. She also supports the "public option" -- the watered-down compromise (a proposed government-created non-profit health insurance provider, a distant second to genuine single-payer health care) but perhaps the best we can get -- on which President Obama is backing down, under pressure from the richly-funded Big Pharma/Big Insurance lobbyists and from the partisan, conservative talk show-driven agitators.

Rescission: no; pre-existing conditions: no; public option: yes. Speier gets it!

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In 2008-2009 I am living in Italy and learning a lot. Italy has much to be proud of, including a health care system that in recent years has improved in quality to match that of nearly any western country. In addition to its quality of care, the Italian system is commendable for its equality of distribution; for all Italians (and often foreigners, too) most procedures are covered. Tests and prescription drugs demand copayments but primary care and inpatient care are free.

The Italian National Health Service was established in 1978 by law number 833 (the Riforma Sanitaria) whose preamble states that health care is a human right and is to be delivered equally to all citizens.

However, the way public health care in Italy is paid for is less fair. Most of its funding comes from a payroll tax that is regressive; regular employees bear a disproportionate burden. The other sources of funding are the income taxes and value-added (VAT) sales taxes collected by the federal and regional (regioni) governments. Equity of taxation is one of the most contentious issues in Italian public life and is, in my judgment, the one most responsible for the resurgence of power of the right wing and Berlusconi.

From the provider standpoint, too, the medical system is far from generous. Compensation received by physicians and other providers is based on capitation and is low relative to that of providers in most western countries and also relative to workloads. Doctors here work hard!

Neither is the economics of Italian health care kind to hospitals. Public funding of health care is doled out by the regioni. The Lazio regione (which includes Rome, where I live) has for the past decade run an annual health care budget deficit of 1 billion Euros. Hospitals are paid according to diagnosis-related group (DRG) formulae, as is done by Medicare in the USA. Today, hospital budgets are shrinking and several of Rome's most prominent are closing for lack of funding. For example, Forlanini hospital, one of Europe's most technologically-advanced and, in recent years, the recipient of substantial infusions of capital for equipment, is slated to close in March of 2009 for lack of operating funds. My friend Maura who is a nurse on a respiratory rehab unit there says she no longer has most of the drugs in the usual formulary to dispense to their patients; patients are receiving inferior care due to the cutbacks.

Another is San Giacomo hospital (including its reknowned orthopedics unit) in the center of Rome, which just last year had a 15 million Euro upgrade. (In the photo: Sept. 25, 2008, police presence at a sit-in to save San Giacomo. Note the protest banners.) There is considerable outcry in the Italian press but recent changes in governmental priorities make these and other closures appear inevitable. This is a great detriment to the healthcare options available to Romans and Italians nationwide.

For an even less sympathetic view than mine, see Tanner (Cato Institute), The Grass Is Not Always Greener: A Look at National Health Care Systems Around the World (but see below for my opinion on those Cato whack jobs.)

For overviews of the economics of health care in other countries, see Healthcare Economist.

For Italy in particular, see Health Care Around the World: Italy.

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November, 2008 -- Google has discovered that it can detect influenza outbreaks and other "...snapshots of what's on the public's collective mind" by mining aggregated search data. Using this data, they are several days ahead of the federal Center for Disease Control (CDC) in detecting disease trends. In other words, when people get sick, they search for terms like "flu symptoms" and many more. And Google is paying attention.

You, too, can stay atop these trends via Google trends. Watch flu trends and more... As Google says, "Google search isn't just about looking up football scores from last weekend or finding a great hotel for your next vacation. It can also be used for the public good."

Do you agree? Draw your own conclusions.

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In America, most health care insurance premiums are paid by employers. Workers receive them as a job benefit. There are several problems with the American scheme.

The first problem is that the cost to employers rises with each new employee they hire. (Increasingly, this cost is also born by the employee who today is often asked to share it, but that is a topic for another discussion.) Thus, it is a kind of employment tax.

Enlightened tax policy is driven by decisions about activities that, for the good of society, we want to discourage. For example, we have sin taxes to discourage consumption of tobacco and alcohol. Employment is not one of those! We want to encourage employers to do it! Thus, if we could find another way to fund health care in America, we could have more jobs. Who would argue against that?

Another problem is that in this system only employed people (and the relatives thereof) are covered. When the economy is strong and provides full employment, coverage almost suffices but in leaner times, even more are left out. Indeed, no one must be left out, in lean times or good.

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When it's a snow job. (Thanks to Ron Knox, Sun, 07 Jun 2009, for this item.) See: How Pharma and Insurance Intend to Kill the Public Option, And What Obama and the Rest of Us Must Do.

Note the new term of art... we no longer talk about a "single payer". Now it's "the public option."

Senator Olivia Snowe, "...well-respected and considered non-partisan, and [who] therefore offers some cover to Democrats who may need it" has proposed a Byzantine set of conditions under which "the public option" can take place and probably won't. In other words, she and her cronies can look like they're fixing our desperately broken system while in reality defending Big Insurance/Big Pharma's hegemony.

Robert Reich has it right: "Big Pharma and Big Insurance are gaining ground in their campaign to kill the public option in the emerging health care bill."

It's time for Ms. Snowe to get out of the way and for government to step in and make sure we all get the health care we need, at prices we can afford, paid for fairly and equitably. No Snowe jobs!

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In a Jan. 16, 2009 Herald Tribune article entitled Bipartisan Reform Vowed on Healthcare Daschle Calls the System Unsustainable some partisan hack named James Gelfand is quoted as saying, in regard to Obama's plan to reform health care:

"The public plan option is a terrible idea - one of our top concerns in the health reform debate..."

The article goes on,

...the proposal is anathema to many insurers, employers and Republicans. They say the government plan would have unfair advantages, [emphasis mine] like the ability to impose lower fees, and could eventually attract so many customers that private insurers would be driven from the market.

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Many healthcare procedures are routine, e.g. immunizations for kids and the every-5-years-after-age-50-colonoscopy. If your doctor is doing her job, these are ordered for you at entirely predictable times in your life. Every American should be getting them. Budgeting and resource allocation for these things can (and should) be rational and planned. Why aren't they? In our present system, they seem to be surprises every time. We must submit lengthy paperwork for insurance claims, argue about what's covered, etc. Ridiculous.

Furthermore, there should be routine tracks for the various chronic illnesses (with variations planned for differing degrees of severity, complicating factors, and responses to treatment) according to plans derived from medical evidence (best practices based on outcomes).

It's silly that the predictable, plan-able procedures should be regarded (from a financial standpoint) the same as the unpredictable ones. Why are the paperwork and eligibility issues the same for a vaccination as for a broken bone?

Money to pay for routine medical procedures should be budgeted for each of us from birth. These procedures should be paid for by a fund that's managed conservatively and whose inputs are known precisely because its outputs are.

A second fund would cover non-routine healthcare, i.e. accidents and acute diseases. The outputs of this fund are known less precisely yet can be predicted by actuarial techniques.

Both funds should be fed from a progressive taxation mechanism. "To each according to need, from each according to ability."

Yet we do none of this. It's hard to believe that we continue to be so financially naive about healthcare!

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How is it we Americans are so brainwashed about our medical care? Why do the candidates for public office tout our system as the world's finest... with straight faces?

"What is particularly shameful is how poorly this country compares with other industrialized countries. In 1960, the United States ranked 12th lowest in the world in infant mortality. By 2004, the last year for which comparative data are available, it had dropped to 29th, tied with Poland and Slovakia." [The New York Times Op Ed piece, Oct. 18, 2008.]

Traditionally, the quality of a country's health care is measured by three criteria:

• Life expectancy
• Morbidity
• Infant mortality

The NYT concludes, "The chief lesson we draw is that the American health care system, despite the highest expenditures in the world, is badly in need of an overhaul."

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I'm just getting started thinking about this... And I'm not the only one.

Johnston et al, in Modern Medicine And Fossil Fuel Resources observe that the story of oil in the 21st century is like that of the boy who cried wolf, the point being that finally the wolf did come.

Walter Youngquist writes in The post-petroleum paradigm -- and population:

Reaching and passing the peak of world oil production will be the most important happening in human history to date, affecting more people in more ways than any other event. It will happen, and during the lives of most people now living.

Increasing scarcity and expense of fossil fuels will present medicine with great challenges, especially at its high-tech end... Petroleum-based products are used all throughout the medical sector.

Following these lines of thought, various corollaries suggest themselves...

• High-tech interventions will be available only to a shrinking elite.
• Community and locality will grow in importance.
• In medical care, labor will overtake capital (the way it does in the third world).
• There will be fewer disposables and more reuse. When oil is scarce, plastic is expensive.
• Let's learn from the Cubans. I intend to travel there. This will be a reverse foreign aid mission -- the evidence says these folks are the experts. (Ahem, I thought of this before Michael Moore did.)
• It won't be all bad -- if we're smart about it, we'll use it as an opportunity to emphasize lifestyle and prevention. When healthcare technology gets scarce, it will be better not to get sick in the first place.

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• Automate recall processes

• Incorporate risk factors and lab test results in decision-making

• Enable quality improvement based on data analysis that far exceeds what could until now be achieved only through traditional chart audits.

Here is an excellent article on how these are done at four community clinics.

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• Wanted: A Business Model (how electronic health records will be paid for)

• Our Fingers are Crossed in California (can we really eliminate the healthcare middle man?)

• Medicare Efficiency? (proof of the single-payer pudding)

And I agree with what Russell Mokhiber says about "...the war between the American people and the health insurance industry." [SleptOn Magazine, Sept. 19, 2007]

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In our sick healthcare system:

• Amputating a diabetic's foot is profitable.

• Delivering the preventive care that could have saved the foot loses money.

• See the January 11, 2006 New York Times: In the Treatment of Diabetes, Success Often Does Not Pay:

  In "...the byzantine world of American health care, ...the real profit is made not by controlling chronic diseases like diabetes but by treating their many complications. Insurers, for example, will often refuse to pay $150 for a diabetic to see a podiatrist, who can help prevent foot ailments associated with the disease. Nearly all of them, though, cover amputations, which typically cost more than $30,000."

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In my work as a smoking cessation counselor (please see my web site, www.tobaccoteacher.com) I see this short-sighted policy in insurance companies that pay tens of thousands of dollars for radiation and chemotherapy but not mere hundreds of dollars for smoking cessation classes and nicotine replacements (patches and gum). Our own Governor Schwarzenegger in 2005 vetoed (despite my letter) legislation that would have required them to pay for these sensible preventive measures, bowing to their powerful lobbies and their "logic":

"By the time a situation is acute... the insurer, which has been gambling on never being asked to cover procedures that far down the road, has little choice but to cover them, if only to avoid lawsuits, analysts said." [NYT]

This is why healthcare does not belong in the domain of private business. The short-term thinking demanded by performance for stockholders leads to poor decisions like these.

Only public institutions have the capacity to make decisions driven by long-term considerations. Thus, though it's enlightened public policy, spending on preventive care will always be shunned by corporate (private) decision-makers.

Conclusion: Single-payer healthcare is better for our health!

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For more than 60 years, the medical-industrial complex and its political allies have used scare tactics to prevent America from following its conscience and making access to health care a right for all citizens...

Yes, Canadians wait longer than insured Americans for elective surgery. But overall, the average Canadian's access to health care is as good as that of the average insured American -- and much better than that of uninsured Americans, many of whom never receive needed care at all.

The only things standing in the way of universal health care are the fear-mongering and influence-buying of interest groups. If we can't overcome those forces here, there's not much hope for America's future.

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Here's my Arterial Blood Gas (ABG) Analysis homework-o-matic.

Hey all you fellow-nursing-classmates, have at it!

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Hospitals are dangerous places. Here are some of the things you can catch there. You probably wouldn't catch them anywhere else... and the probability there is surprisingly high. Only recently have a very few hospitals begun to report the rates of these infections. Such reporting should be required!

• Ventilator-associated pneumonia

• Bloodstream infections caused by catheters

• Methicillin-resistant staphylococcus aureus (MRSA) -- Causes an "alarming number of infections and a very significant number of deaths." This bug kills more Americans each year than does HIV. The primary vector? The unwashed hands of healthcare workers.

• Surgical site infections

• Clostridium difficile ("C-diff"), a bacterium that causes severe colon infection and stomach pain

And infections are only part of the story. Here are more preventable bad things that happened to hospital patients (in California during the period July 2007 to May 2008 as reported by the Los Angeles Times on 6/30/08):

• Severe bedsores (466 patients)

• Foreign objects such as surgical equipment left inside (145 patients)

• Died under anesthesia (34 patients)

• Wrong procedure or operated on the wrong body part or patient (41 patients)

This is not to blame the caregivers or the organizations in all cases; it's to point out that the delivery of healthcare is complex and near-impossible to do with total reliability. There are no easy solutions.

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Healthcare's shifting paradigms

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I've been helping Dr. Gary Heit to run his nonprofit, Americare Neurosurgery International. In March, 2008, we ran our third medical mission, this time to Hue, Vietnam. Quite literally, we saved lives. Gary is an amazing neurosurgeon!

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In a January 8, 2009 article, Health Data Management reports:

In a major speech on Jan. 8 to push his forthcoming economic stimulus package, President-elect Barack Obama pledged to have all medical records electronic within five years.

"To improve the quality of our health care while lowering its costs, we will make the immediate investments necessary to ensure that within five years, all of America's medical records are computerized," Obama said.

The image on the left was not associated with the Health Data Management article; it is included here for your amusement. It is an example of the disinformation and fear-mongering -- much like the entrenched interests did to Hillarycare -- that is being ramped up once again by the forces that continue to oppose (for narrow self-interest only) these moves toward progress. The unspoken sub-text is beware (so-called) socialized medicine.

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"Health care for all," he says.

"Insurance companies make money not providing health care. As the co-author of HR 676, a universal, single-payer, not-for-profit health care system, Medicare for All, I understand millions of Americans want health care that is accessible and affordable."

"Medicare for All will help businesses large and small, create jobs as well as save the jobs of thousands of people including those of doctors, nurses and other healthcare workers who are currently leaving medicine because it is run by the insurance companies. 1 in every 3 dollars of the $2.4 trillion spent annually in America for health care goes to the insurance companies. If we take that money ($800 billion in unproductive wasteful spending) and put it directly into care, we will have enough money to cover everyone. We are already paying for Medicare for all, but not receiving it. HR 676 changes that!"

"[I have proposed a] Prescription Drug Benefit for Seniors, HR 6800, the MEDS Act, which provides a fully paid prescription drug benefit, under Medicare, for all seniors. I wrote this bill to help alleviate the economic pressure that comes from the high cost of prescription drugs. We can pay for it by letting the government negotiate drug prices with the pharmaceutical companies as well as by permitting re-importation."

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And not just about the environment. Here he is, speaking in favor of universal health care coverage. Go Al!

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Mayor Gavin Newsom has launched a program that makes me proud to be a San Franciscan. In his words:

We are still the first and only city in America on its way to universal health care. Our Healthy San Francisco program has already enrolled nearly 30,000 previously uninsured San Franciscans into a comprehensive health access program. While the state and nation falter on health care - San Francisco is showing the way.

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That's right. You don't.

Who does? Usually, the hospital, clinic, or doctor who created the data. In other words, not you.

Here is an excerpt from Physician's News Digest, March 1999:

Underlying the entire health care informatics industry is the basic issue of who owns data and how data may be used by others. There is limited public law on this question and parties almost invariably address the issue as a matter of private agreement. Generally, the law in most states gives ownership of the medical and business records to the provider who creates the records, subject to a general duty of confidentiality and in some states a right of access for patients to their own records.

1. An unconditional right to be informed of the data-handling practices of medical practitioners and providers;

2. The right to request, but not necessarily to always obtain completely, the privacy protection of your healthcare information;

3. The right to review and copy your medical record;

4. The right to request that inaccuracies in your record be corrected; and

5. The right to know who has accessed your medical records in the past.

The text of the HIPAA law can be found at the US Department of Health and Human Services. It does not actually discuss ownership of medical data, only access to it and control of it. Decisions about ownership are left to the states.

Kate Jackson writes in Whose Medical Record Is It, Anyway? in For the Record magazine:

It may vary somewhat by state law, but the healthcare record is owned by the healthcare provider that created it... [You] generally have the right to see and request a copy of [your] entire medical record. The exceptions to that rule are records pertaining to psychiatric conditions, HIV status, and mental health care... most states consider psychiatric records to be "hyperconfidential".

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Imagine having the peace of mind that comes from knowing that you can always afford health care, that your insurer can never cut you off (or deny you coverage in the first place) if you get sick (and expensive) or they suddenly "discover" a "pre-existing condition." This is insane! Life itself is a "pre-existing condition"! Imagine that, no matter what, you could always have the healthcare you need. They get it in Australia. Go Aussies!

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Some heart sounds for our nursing class to learn.

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The teaching that's done in colleges and universities stinks!

I offer some solutions.

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In yet another brilliant move, Francine Hardaway has created USHealthCrisis.com, a web site whose purpose, in her words, is to:

...bring about health care reform. If you have a story [about a failure of the US healthcare or health insurance system] please post it to the site, and tag it patient, provider, or payer. We are aggregating this information and will take it to the Obama administration. Right now, reprepresentative stories will be a big help.

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Francine Hardaway writes a fascinating and often brilliant blog in which the topics are sometimes medical:

• The industrialization of medical care
• The misuse of emergency rooms
• Electronic health records (EHRs) in doctors' offices

Rarely do I disagree with her, but I did when, in 2007, she wrote:

I don't think we will accept a single payer system, because that's just another way to say "rationing health care."

We already do have rationing, Francine. Every country and every system has rationing; it has to. There's always a gatekeeper (as it's called in the UK, where health care is provided primarily by public funding.) Why ration? Because resources are finite.

Many people are frightened by the idea of gatekeeping by governmental agencies. Consider, though, that the activities of government are subject to the scrutiny of we who elect them; they don't have the impunity of corporations that operate behind closed doors. Corporations are beholden primarily to stockholders. To them, doing a good job means increasing the dividend each quarter. Over corporate officers and management the public has even less control than they do over governmental officials. As long as we have a democracy, I prefer that gatekeeping be done by government, thank you.

The problem with our system is that with multiple payers, we have an additional, unproductive layer of bureaucracy -- all those insurance company claims adjusters who do their jobs "best" when they deny treatments, drugs, and care. They're not evil people; the incentives are wrong.

Insurance companies add 15-25% (depending on whose numbers you use) to the cost of our healthcare. Yes, there must be rationing. But the rationing process needn't be so expensive.

Eliminating these middlemen is unlikely, alas. They command huge resources and their lobbies are powerful. To protect their bottom line, they run vast disinformation campaigns and promote myths such as the one Francine has voiced. And their job is to ration.

But don't take my word for it... Here is an op-ed piece from the New York Times on March 28th, 2006: U.S. Should Implement Government-Sponsored, Single-Payer System.

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Rates of adoption of EMRs in the United States continue to be abysmal. Here are some recent numbers (per the California Healthcare Foundation's Snapshot: The State of Health Information Technology in California, 2008):

• Just 12% of California physicians use alerts to warn them about potential adverse drug events, receive electronic warnings about abnormal lab results, and send reminder notices to patients about regular or preventive follow-up care.

• Only 25% of hospitals are using bar-coding technology fully for tracking lab specimens and only 13% have implemented EMRs.

• Many patients do not communicate with their physicians online because they are concerned that on the Internet their privacy might be compromised.

The EMR has always been a focal point of my career. When I graduated from UCSF in 1983 with an MS degree in this area (having built a rudimentary EMR for my master's thesis) there were no jobs where I could put these skills to work. But that has changed. Today medical informatics is an industry. For example, both of my recent hospital employers -- Sutter Health and Kaiser Permanente -- have huge EMR implementation projects underway. Several doctors I know are investigating EMRs for their offices. However, industry-wide standards remain largely absent and paper charts remain the norm.

We're still waiting for the revolution.

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One of the places where I have worked as a volunteer was a post-op and orthopedic floor high up in a tall tower in a hospital that shall remain nameless.

In this hospital (and, I suspect, in most) the manual, paper-based procedure for reviewing and renewing medication orders is stunningly labor-intensive and error-prone. This is a task for which computer implementation would be ideally suited. It is astonishing to me that this hasn't been done.

Here's how it works today: In the MAR (Medication Administration Record) portion of a patient's chart there are two sheets:

1. PRN (drugs administered on an as-needed basis) and One Time Medication Record
2. Routine Medication Record.

On each fifth day of each patient's hospital stay, the nursing station secretary must see that the form is full and must complete a new form, copying from the old one all the following information:

1. Patient allergies and contra-indications
2. All the drugs, their routes, dosages, schedules, and formulations.

The only possible reason I can see for lack of automation of this procedure is to guarantee that it periodically gets a pair of eyes to review the medication orders. But are the secretary's eyes qualified to perform this review? Is five days the right review period or just the number of columns that fit on the page? Is the labor cost justified? Have errors ever been caught this way? If indeed there does appear to be something dubious about a drug order, is there a mechanism for having it reviewed (and perhaps modified) by a doctor, especially the doc who made the order in the first place? I suspect the answers to these questions are mostly no.

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Another place where I volunteered at length is San Francisco's HIV / AIDS/ HepC Nightline, a department of San Francisco Suicide Prevention. It is a telephone-based emotional support service.

To become qualified to deliver this service, lengthy training is required -- a couple of months of weekly evening classes. The work itself is surprisingly challenging but uniquely rewarding and I learned a lot.

One of the big lessons was to listen without attempting to problem-solve. You can't problem-solve over the phone but you can listen and often that's the best therapy in the moment. People who are struggling need an ear that hears them. It's something that's in surprisingly short supply. And there was lots more. Here are my notes and observations.

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Privacy will always be a major concern regarding medical data. One of the ways in which patients will be empowered by EMRs/PHRs is by having explicit control over access. While HIPAA goes a long way toward protecting privacy, it leaves the actual enforcement in the hands of the caregivers and their institutions. Under today's system, the patient is protected but not in control. This must change.

Here are the aspects of personal health records generally considered most sensitive:

• HIV or AIDS
• Mental illness or any mental health condition
• Alcohol or substance abuse
• Sexually transmitted diseases
• Pregnancy
• Abortion or other family planning
• Genetic tests or genetic diseases

With the electronic medical record system we need, the patient will be the owner of the data (see What Do You Mean I Don't Own My Own Medical Data? above) and will have complete control over who sees it and which parts are withheld from whom. In other words, don't just protect me. HIPAA does that and that's good but it's not enough. Put me in charge! Let me decide where that data goes... and doesn't go.

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In a January 7, 2009 article, the Wall Street Journal reports on a crop of new and increasingly useful web sites for people seeking (and collecting and sharing) information about health care, especially their own. These include:

• WebMD.com (personal health management)
• Google Health (discussed below)
• Microsoft's HealthVault
• VisualDxHealth.com (skin diseases)
• QualityHealth.com (health assessments, on-line communities)
• Healthline.com (pill finders, etc.)
• ConsumerMedSafety.org (prevents medication errors)
• WellSphere.com (consumer-oriented health info.)
• RealAge.com (health status assessment)
• WhyNotTheBest.org (ratings of health care institutions, mainly for professionals)
• HazMap (federal database of chemical and biological exposure risks)
• EverydayHealth.com (merged with RevolutionHealth, resources for consumers)
• HealthCentral.com (portal to sites that focus on specific medical conditions)

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Google says (and I do not doubt it) that the most commonly-sought information on the Web regards health. So it's a no-brainer that their business should do a good job of helping their users find what they seek.

Though medical data searching is huge, what's at stake is even bigger. The data to be managed is not just generic -- diseases, treatments, research, institutions, services, etc. It's also each of our personal medical histories, status, progress, and plans.

She who controls the data controls the process.

Empower the patient.

And be the supplier of that power. Thus, Google Health.

Great strategy!

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In my two years of nursing training I learned many things. One was that it's a hard job, sometimes unnecessarily so. Here's one of my ideas about how to fix that.

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In the years leading up to my nursing school stint, I volunteered in lots of San Francisco hospitals, clinics, and healthcare services. You don't just walk in the door and magically transform lives... There's an art to it. Most important are the things that -- even with the best of intentions -- you must never do. A volunteer must never:

• Do anything invasive
• Give medical advice or information to a patient or family
• Give food or water without authorization
• Tell a family that a patient has died
• Make judgements about lifestyle, esp. domestic violence
• Handle controlled substances
• Help break up a fight or restrain a patient
• Do schoolwork in the ER
• Read medical records

Here are more thoughts on my experiences as a volunteer...

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Concerned about health, fitness, longevity, weight loss?

Pritikin is the diet that works. Here it is in a nutshell.

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Are we getting the message about health and personal responsibility?

Here are some gems I found on the web... I bet people really do eat at the Heart Attack Grill. They even have cigarettes on the menu!

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Want to set your teeth on edge? Read the "scholarly" writings of the whack-jobs over at Cato. These are no more than industry-sponsored puff-pieces:

• Exxon-Mobil, Shell Oil, Tenneco Gas, Amoco Foundation, Atlantic Richfield Foundation, Chevron Companies, and the American Petroleum Institute re: global warming "myth"
• Philip Morris, R.J. Reynolds re: "smokers' rights"
• Other sources of funding include Bell Atlantic Network Services, BellSouth Corporation, Digital Equipment Corporation, GTE, Microsoft, NYNEX, Sun Microsystems, Viacom International, American Express, Chase Manhattan Bank, Chemical Bank, Citicorp/Citibank, Commonwealth Fund, Prudential Securities and Salomon Brothers.

In particular, writings on the medical system are sponsored by the pharmaceutical industry (Eli Lilly, Merck, Pfizer). The intent is to influence policy under the guise of researched wisdom. Don't vote for any politician who can't see through this sham!

For example, the article on healthcare funding, Socialized Medicine is Already Here, reveals its bias in the title; "socialized medicine" is a derogatory term and no one would vote for anything with that name. It's like Bush saying about Iraq, "We want victory, not defeat!" Well, duh.

In high school, we learned to call such statements tautologies. In plain English, they are vacuous statements that set my teeth on edge. Now let's get to work on the real issues.

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Do you know what your insurance covers? Do you understand the invoices you get from your hospital or your provider? Do you understand the EOB (Explanation of Benefits) your insurance company provides when you make a claim? Have you ever actually read your policy? If you have, did you understand what you read? Did it give you confidence that your medical needs would be met? When you go for medical care, do you know what you'll be charged out of your own pocket? Or do you cross your fingers and hope for the best? Can your doctor (or your doctor's receptionist) provide clarity on any of this? Do you even bother to ask? Have you ever tried not to pay an insane medical bill? Have you seen what that does to your credit rating?... And then tried to buy a car or a house or get a credit card? Why is any of this OK?

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Ever seen a list of all the vaccinations in one place? Useful! Here they are... Among medicine's greatest achievements.

• Diphtheria
• Tetanus
• Pertussis
• Poliomyelitis
• Haemophilus influenzae type b - Hib
• Measles
• Mumps
• Rubella
• Varicella
• Hepatitis A
• Hepatitis B
• Influenza
• Pneumococcal Disease
• Meningococcal Disease
• Human Papillomavirus
• Rotavirus

The details about these and lots more excellent information for practitioners about vaccinations (is it possible they aren't taught this stuff in med school?!?) can be found at docsimmunize.org. This valuable web site is run by Terri Olson, RN (wife of Pat).

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My lifelong pal Pat Olson has had a distinguished career as a US Navy doctor, which he describes as "...a practice of socialistic medicine called the US Navy. Does it promote itself as socialistic? Obviously not. Is it a perfect system? Obviously not. But even its critics admit that with access to care for servicemembers and their families regardless of rank or ability to pay, in terms of objectively verifiable outcome measures it betters the US private sector.

"This leads me to something I see as the Dark Side of medical informatics. As long as we have a 'pro-competition' insurance industry, rewards will go to those who cherry-pick. Beyond HIPAA, you've got the specter of cyber sleuthing medical records for the familial trait here, the genetic deletion there, that incurs increased risk. It terrifies me to think of a child being denied care because of something in a record somewhere and broadcast unknowingly to the wolves of the insurance industry.

"Okay, I'm outta control..."

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