Imagine being a pediatrician who treats only very, very sick children.  Many will live; and many will die. And as a physician you realize that, while you can help, you do not decide.  No matter how brilliant you are, your tools are limited.  Despite the arsenal of medical technology at your disposal, in many cases you are forced to recognize that medicine is still an infant science. Often, you must rely on intuition– barely articulate knowledge that comes with long experience.   And, even then, sometimes you won’t be able to save your patient –a child who hasn’t yet had a chance to live.

I can’t imagine a harder row to hoe—except to be the parent of a child in a Pediatric Intensive Care Unit (PICU).

In Your Critically Ill Child: Life and Death Choices Parents Must Face, Dr. Christopher Johnson, co-founder of the Mayo Clinic’s PICU  in Rochester, Minnesota manages to address both audiences: parents and physicians.

Ostensibly, the book is aimed at parents. But I would urge any doctor who treats seriously ill or injured children to read it.  Johnson, who has practiced pediatric intensive care for twenty-five years, offers a window on the parents’ world, and essential advice on how to collaborate with them.

The first tale focuses on Robert, a healthy five-year-old who suddenly and mysteriously lapses into a disoriented and ultimately hallucinatory state.  “By the time he arrived at the PICU he was agitated and combative. He could not recognize his mother. By that afternoon, he was developing all the signs of fast developing acute liver failure. “

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Always a trailblazer, The Mayo Clinic’s Medical School has had a generous scholarship program for the past 20 years that enables about 60 percent of its students to attend school tuition-free. The 50 students who started at Mayo last summer each received $25,000 to use towards tuition of $29,200. Students also are eligible to receive an additional $2,000 to $5,000 a year based on need, said David Dahlen, director of student financial aid at Mayo, based in Rochester, Minn.

Now, a few other schools are experimenting with much-needed financial relief for medical students. Most notably, the University of Central Florida’s brand new med school is offering four-year scholarships for tuition, fees and living expenses for every member of first-year class.  Students have until December to apply; already, the school has received 2,996 applications for its charter class of 40.

The Wall Street Journal reports that the $7 million needed to fund the charter class came from individuals and private philanthropies. There was no single donor who did most of the work; the two largest gifts were each a bit over $300,000. Perhaps other medical schools could follow this model.

The bad news is that this first class is the only one that will receive such a sweet deal. There will be some scholarships for students in subsequent classes, but essentially the University of Central Florida is using the financial packages to attract a top entering class, hoping that this will set the pace for the school’s future.

Mayo, of course, doesn’t need to offer financial enticements to draw the best students. It is simply part of the school’s “philosophy that your qualifications, motivation and commitment to service–rather than finances–should guide your decision to apply to medical school.” 

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Somehow, when describing the posts that Health Wonk Review highlighted as the best healthcare posts of the last two weeks, I managed to point to the wrong post on Roy Poses Health Care Renewal.

Poses is always on the news—and digging deeper. In this post he begins by giving you the background to the story: “in 1989, the U.S. Department of Justice tried but failed to prevent a merger between nonprofit Carilion Health System and the  former railroad town’s other hospital. The merger, it warned in an unsuccessful antitrust lawsuit, would create a monopoly over medical care in the area.

“After the 1989 merger, Carilion continued to operate Roanoke’s two hospitals separately,” Poses explains. “It later consolidated the hospital boards and in 2006, transferred most of Roanoke Community Hospital’s staff and services to a renovated and enlarged Roanoke Memorial Hospital.

“The moves eliminated any hospital competition in Roanoke proper….

“[Carilion CEO Dr Murphy] was convinced that the cost and quality of care in Roanoke could be improved if doctors worked in a more centralized system. In June 2006, he announced a seven-year, $100 million plan to transform Carilion into a multispecialty clinic, like the Mayo Clinic.

“Carilion began approaching private physician groups, offering to buy their practices and pay their salaries.”

Poses then goes on to look at what effect Dr. Murphy’s advocacy of more centralization had. See the full post here. 

You’ll find Health Wonk Review, a compendium of some of the best healthcare posts of the past two weeks here.

Not surprisingly, some bloggers have taken on John Goodman, president of the National Center for Policy Analysis, for suggesting that the Census Bureau’s report on the number of uninsured this country is wrong. Goodman claims that anyone with access to an emergency room effectively has insurance, albeit the government acts as the payer of last resort.(Note: the National Center of Policy Analysis is a right-leaning think tank and Goodman helped craft Senator McCain’s health care policy.)

"So I have a solution. And it will cost not one thin dime," Mr. Goodman added: "The next president of the United States should sign an executive order requiring the Census Bureau to cease and desist from describing any American – even illegal aliens – as uninsured.

The Health Care Blog’s Matthew Holt suggests that Goodman must be joking. “Or,”Holt asks, “is he just mean?”

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Over at “Home of the Brave,” Annie calls attention to the following Las Vegas Sun story about a man who suffered a heart attack and went to the nearest ER for help:

“But even as Linda Scheinbaum — Morton’s wife of 24 years — was screaming [in the emergency room] for medical attention to save his life, the MountainView Hospital nurse was insisting on getting his Social Security number, emergency contact and insurance information.

“‘I’ll give you all the information later!” Linda Scheinbaum yelled at the clerk.

“It would be Scheinbaum’s tragic misfortune to [go] to the emergency room on the night of Nov. 4, 2005, when it was busy and hospital officials said there were no open rooms. The Scheinbaums were told to take a seat and wait — even though a delay of just minutes can make the difference between life and death during a heart attack…

“The precise timeline of the events of that desperate night is in dispute, but hospital records show that it was at least 41 minutes from the time Morton Scheinbaum arrived to the time he collapsed, blue in the face and foaming at the mouth. Only then was he rushed into the emergency room for treatment.

“And that’s where he died, his admission paperwork completed.”

There are many reasons to feel outraged when reading this story. But the tragedies of this tale are part of a larger—and just as depressing—picture in American emergency care. The staffing and overcrowding issues that Linda and Morton Scheinbaum faced three years ago are becoming the rule, rather than the exception, when it comes to emergency departments (EDs) in the United States.

Begin with the seeming villain of this tale, the pigheaded nurse who forced paperwork on the Scheinbaums in a time of crisis. Blogger Annie has some issues with the Sun’s less-than-probing characterization: “Is the ‘nurse’ cited an unlicensed admission clerk?” asks Annie. “A secretary?…or a licensed registered nurse who is obligated to perform triage and intervention to conform to state regulations and to the hospital’s accreditation agency standards?”

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A friend who lives in Boston complained, not long ago, about not being able to find a physician. In Boston?  “Come on,” I said. “This is like claiming you couldn’t find a liquor store.”

“They’re all oncologists and cardiologists,” he grumbled. “Last week I cut my hand badly enough that it needed stitches. I have good insurance. But I couldn’t get an appointment with my family doctor—or any of my friends’ doctors. I didn’t want to spend hours in the ER. So I wound up going to my sister’s house. She sewed it up at her kitchen table.”

His experience is not as unusual as it sounds. Some 56 million Americans do not have a regular source of care according to the National Association of Community Health Centers (NACHC) — even though many of them do have insurance. The problem is a shortage of primary care physicians (PCPs) in many parts of the country, particularly, but not exclusively, in poorer communities.

Even Docs Have to Call In Favors 

Not long ago, Bob Wachter, Professor and Associate Chairman of the Department of Medicine  at the University of California, San Francisco (UCSF) , and author of Wachter’s World warned his readers: “The Long-Awaited Crisis in Primary Care: It’s Heeere.” 

Indeed, if you try get an appointment at UCSF’s general medicine practice, you will find that it is “closed” –even if you are an UCSF physician. They just aren’t taking any new patients. “Turns out we’re not alone,” Wachter adds. “Mass General also is not accepting any new primary care patients.” 

He calls attention to “to two very powerful NPR reports on the topic – the first, a WBUR special by healthcare journalist Rachel Gotbaum called ‘The Doctor Can’t See You Now,’ is the best reporting on this looming disaster I’ve heard .

Wachter summarizes highlights:  “Getting a ‘regular doctor’ (a PCP) at Mass General now takes the combination of cajoling, pleading, and knowing somebody generally referred to as ‘working the system.’ In other words, the process of finding a primary care doc is now like getting a great table in a trendy restaurant.

“The report also makes clear that providing more ‘access’ through expanded insurance coverage won’t do the trick,” Wachter explains.  “Massachusetts, you’ll recall, markedly expanded its coverage a couple of years ago (in legislation proposed by that ex-liberal, Mitt Romney). Scott Jasbon, a 47 year-old contractor/bartender, thought he was all set when he enrolled in one of Massachusetts’ subsidized health plans. He was wrong.

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Back in October, Maggie touched on America’s shortage of nurses, as well as the different factors behind the crisis—namely, hectic working conditions, insufficient academic resources for nurse training, and a hospital building boom that has outstripped the nursing workforce. Thanks to the convergence of these forces, the government predicts that the nursing shortfall will grow to more than 1 million nurses over the next 12 years.

What can be done to nip this problem in the bud? According to a new white paper, our priorities should lie with expanding the capacity of nursing schools and doing more to make sure that existing nurses work under better conditions.

First, the nursing schools: “there is widespread agreement that the primary bottleneck at this point in time is the faculty shortage,” say Jennifer Joynt and Bobbi Kimball, authors of “Blowing Open the Bottleneck,” published jointly by the AARP, the U.S. Department of Labor, and the Robert Woods Johnston Foundation. According to the authors, “a 2007 survey of baccalaureate nursing schools found that 71.4 percent of schools indicated faculty shortages as a reason for not accepting all qualified applicants.” Turning away potential nurses is a bigger problem than you might think: according to a companion write-up in JAMA, more than 42,000 qualified applicants were turned away from nursing programs in the U.S.

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My idea of a vacation is, of course, to blog.

TPM Cafe  asked TPM contributors to write

about  the convention and the  future

of the Democratic Party.

You can find the post here http://tpmcafe.talkingpointsmemo.com/2008/08/28/the_future_of_the_democratic_p_1/

Yesterday, the Census Bureau came out with a report that provides
a compelling window on poverty and health in America.

It’s somewhat modestly titled “Income, Poverty and Health
Insurance Coverage in the United States, 2007.” I would suggest it deserves a headline that
does justice to its sweep, perhaps “Connecting the Dots: Health and Poverty, America’s
Shifting Priorities, 1960-2007.

Begin with this chart:

At first glance, what is most striking is how well President
Lyndon B. Johnson’s “War on Poverty” worked in the late 1960s.  Seniors–who were then the poorest group in
the U.S– benefited most. The share of Americans over 65 scraping along
somewhere below the poverty line plummeted from roughly 30 percent in 1965 to
just over 15 percent in the early 1970s. Johnson made Medicare and Medicaid
legislation a priority, and when it passed Congress in 1965, it made an
enormous difference.

The War on Poverty also helped kids: the share of the
nation’s children trapped in poor households fell from roughly 23 percent in
1965 to 15 percent during the Carter years.

By contrast, look at what has happened during the latest
economic cycle.  As the Economic Policy
Institute’s Jared Bernstein points out,  “Despite
strong overall economic growth, the
cycle that began in 2000 and ended late last year has turned out to be “one of
the weakest on record for working families.”

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