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    Evaluating Medical Practice

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    Book: Sultz, H., & Young, K. (2011). Health care USA: Understanding its organization and delivery (7th ed.). Burlington, MA: Jones & Bartlett Learning.

    1. One of the most interesting and controversial pieces of legislation passed in recent years is Oregon's Death with Dignity Act. What are the key provisions of the Death with Dignity Act? Have any other states followed Oregon's lead in this regard?
    2. The early years of American hospitals were characterized by a very top down model, which might be succinctly described as "doctor's orders." What the doctor said was considered correct, and seldom did a nurse or patient even think about questioning the doctor. However, recent decades have seen a shift in this regard, and we now have an increasing emphasis on patient rights. What are some of the most important patient rights in your view? How do we make sure that both patients and staff are aware of these rights and honor them?
    3. Dr. Sultz presents three "levels of application of preventive measures" related to the prepathogenesis and pathogenesis of disease. For each level of prevention, cite and describe at least three specific measures we can offer as health care professionals. What experiences have you had with these specific preventive measures?
    4. Dr. Sultz talks about the "tyranny of technology" in modern medicine. To what is he referring? How does this tyranny impact health care management, leadership, and planning? Have you experienced the tyranny yourself? Provide an example if possible
    5. One of the most interesting health care developments in recent years is the retail clinic, or "MinuteClinic." These days we see them popping up everywhere, especially at major chain pharmacies. What is a retail clinic? Do you feel that these clinics are a positive development for American medical care? Why, or why not?
    6. Medical practice is certainly changing in America. Some of those changes have been reasonably well accepted by doctors, and others have come as a hard pill to swallow. One recent development is the physician report card. A hospital's Chief of Staff made the following comment:. "I thought that I was done with being graded when I finished Residency. I am not sure that I want anybody grading me at this point in my career. I think that I should be grading them." What is the physician report card? Provide an example of an Internet site that is providing these report cards for the public, as well as interesting information you find from that website.
    7. CASE STUDY BELOW: Here Dr. Cecil Wilson, President of the American Medical Association, provides his "prescriptions" for key stakeholders in U.S. health care reform. Dr. Wilson's 30+ years of medical leadership has given him a broad view of this topic.
    Part 1: Discuss Dr. Wilson's "prescription" for the private sector, business, and government. Do you concur with this prescription? Why, or why not?
    Part 2: Discuss Dr. Wilson's "prescription" for patients, medical students, and physicians. Do you concur with this prescription? Why, or why not?

    CASE STUDY I: A Prescription for America's Health Care System June 15, 2010
    Inaugural Address
AMA Annual Meeting
Chicago, Illinois
Hyatt Regency
    Cecil B. Wilson, MD
American Medical Association
    My thanks to the House of Delegates, my colleagues, my friends, and my family — for what is truly the greatest honor of my life in medicine. Some of you know my story of growing up in South Georgia, the son of a Methodist minister. And in the tradition of the itinerant ministry, moving every few years — from town to town and church to church throughout the state. And I recall how, when my brothers and I would head out the door to go to school, our father—the Rev. Dr. Wilson—would admonish us: "Remember, you represent the whole family. Act accordingly." That simple statement of purpose has guided me through college, medical school, my service in the U.S. Navy as a flight surgeon, and my professional career and personal life in Florida. It guides me today, and it will continue to guide me tomorrow, when I head out the door to tour this country on behalf of the American Medical Association. My commitment to you is that now — as in the past — I will remember that I represent the whole family of medicine. And I will act accordingly. Life is about opportunities and responsibilities. And nowhere are these found in greater measure than in the calling we have chosen — the profession of medicine. As physicians we have the opportunity to heal, and the responsibility to do no harm. We have the opportunity to care for those who are ill, and the responsibility to deliver the best care possible. And at this historic time, we have the opportunity to assure that our country's healthcare system bears the imprimatur of physicians, and we have the responsibility —to bring to that task a voice that is clear, firm and constructive. In thinking about what I was going to say this evening, I turned to my love of sailing — an attraction to the sea and ships sealed during my service in the Navy. Among the joys of living in Florida are the proximity to the ocean and access to sailboats — preferably, someone else's. I've learned that off the coast, the waters are sometimes shallow and the winds variable. Running aground, being whipped by gales, or becoming becalmed are all part of the experience. I recall one sailing trip from St. Petersburg across Florida Bay toward Key West. In early evening, we strayed from the channel and ran aground in the middle of the bay — an 850-square mile body of water. To get off the reef, we tried hoisting our sails and lowering them; we cranked the auxiliary engine; we put out an anchor and tried to winch ourselves off. Nothing worked. We even tried to rock the boat off — the entire crew running from one side to the other — from port to starboard and back, and from bow to stern and back. By the way, did I say the crew was all doctors? Fortunately, this was in the days before "You Tube" or else we may have gone "viral." During this exercise in futility we dislodged the dingy, which then drifted away. One of the crew dove in, swam to it, and climbed in only to discover there were no oars. The dingy, with him in it, was being blown out to sea. Another member of the crew dove in carrying oars and swam to the drifting dingy. Two hours later, two very exhausted sailors came back. Six hours later a rising tide helped free us from the reef, and we could continue our trip. This reminds me a bit of our journey toward health system reform. Embarked upon with a plan of action, at times diverted off course, at times becalmed — but ultimately the country reached its destination. In talking with AMA members around the country, I found most physicians did not dispute the core principles of health system reform. Rather, physicians disagreed on the interpretation of those principles — and the strategy and tactics used to advance reform. Some did not like how we plotted our course, unfurled our sails and set our speed. Others sought a different destination. All were sincere in their views. To me, these reforms are a long overdue first step — a first step — toward a better health care system in this country. This legislation is not perfect, but it makes medical care more accessible and coverage more reliable for millions. It makes insurance companies more accountable. It strengthens wellness and prevention. These are no small things. But it's easy to lose sight of what's good — amid the finger-pointing, partisanship and just plain anger that marked this debate. It's been said that: "Honest criticism is hard to take — especially when it comes from a relative, a friend, a colleague, an acquaintance or a stranger. Did I leave anyone out?" I know too well that there are fences to mend, assurances to make, and wounds to heal. I am also well aware that if we dwell on the past, we risk running aground. Our energies are better spent making health system reform the best it can be for physicians and patients. Now more than ever we need to focus on what's best for our profession — and act accordingly. Of course that's easier said than done. This is a complicated system, with many stakeholders involved. And it's also complex work that we do every day. Sometimes we forget that. Think about it: Physicians must choose from among more than 60,000 diagnoses; 11,000 surgical procedures; and at least 4,000 different drugs. The pressures on physicians are intense. And we welcome that responsibility. But we also have to recognize that we can do even better. All of us can do better—from government officials, to insurers to patients. Well — Tonight, the doctor is in. That's me. And I would like to offer some prescriptions for our ailing health care system. Let me start with four of the biggest challenges we face — to make health system reform a success: medical liability, skyrocketing costs, inefficiencies in health care delivery, and Medicare underpayment. First, medical liability. Studies tell us that today 75 percent of American physicians are forced to practice defensive medicine—to order tests or procedures more out of a need to protect against possible litigation, than to improve patient care. This drains as much as 126 billion dollars out of the health care system annually. The health system reform legislation acknowledges this problem — but it does not go far enough to solve it. Ultimately, caps on non-economic damages are the gold standard for successful medical liability reform. They've worked for more than a generation in California, and they are also working today in Texas, Louisiana and other states. My prescription: Caps. Caps are AMA policy. Caps are the only prescription proven to work. In addition, we need to explore alternative reforms, such as health courts, administrative compensation systems, early offer models and "safe harbors" for physicians who follow best practices. Next, cost. If nothing changes, by 2020 America will spend 4.4 trillion dollars a year on health care. Let me put this in perspective. That means a family of four that makes 80 thousand a year would spend a fourth of their income on health care. That's not sustainable. My prescription:We need a comprehensive plan for containing costs and getting the most out of our health care dollars. If we don't, reform — will fail. The AMA has identified four broad strategies to contain costs: Reduce the burden of preventable disease, Make the delivery of care more efficient, Reduce nonclinical costs that don't contribute to patient care; and Promote value-based decision-making — at all levels. Let me next focus for a moment on one of the accomplices of soaring costs — inefficient delivery of care. From fragmentation of care to a lack of available comparative effective research data, the current system is plagued by inefficiencies. Some services are over-utilized, others are under-underutilized. My prescription: Focus on making sure patients get the right care at the right time, at the right place. This means: improving coordination of care; using more services that address cost and prevention; and making available more research to help physicians make the best decisions possible. Another challenge is all too familiar — the Medicare reimbursement crisis. Because of the senseless payment formula, the SGR, physicians are threatened with cuts. Year after year. And year after year, the costs of providing care and running an office continue to rise. The disparity between actual expenses and what Medicare pays are, to use an expression familiar in Florida, like the open jaws of an alligator. And they're ready to snap shut on access for our seniors. My prescription: Scrap the SGR. Toss it overboard. Feed it to that gator, instead. Replace it with a payment structure that reflects the true costs of providing care in the 21st century. We also need new approaches to physician payment that are rooted in the reality of how medical care is provided. For example, Medicare should encourage better disease management, which is especially important for seniors in need of chronic care. Now, improving our system is not just about tackling the important issues. It's also about fulfilling our responsibilities as stakeholders. It's been said that Socrates was a teacher who went around giving everyone advice — so they poisoned him. So despite this great personal risk, and well aware of the aphorism that "fools rush in where angels fear to tread" — I would now like to offer some prescriptions to each of the major stakeholders in our health care system. Starting with the private sector. To America's health plans, insurance companies, pharmaceuticals and device manufacturers: You have a special responsibility to the health care system. Your products and services, like ours, directly affect patients' lives and health. This isn't as simple as offering a choice of toothpaste or cell phone. My prescription: Always remember you are more than just businesses. Keep your business practices transparent — and keep the needs of your customers — our patients — foremost when you develop products and policy. To our leaders in government, especially those in elected offices such as Congress. We are ill-served by partisan bickering amid a toxic atmosphere that poisons efforts to work together. Turning every policy decision — even suggestion — into a 30-second attack ad damages our democracy. The prescription: Develop legislation that serves us well. Move beyond the partisan fight. Seek accommodation — or at least understanding — across political divides. Tolerate differences of opinion. Do the job for which you were elected! Above all remember that you represent the interests of the nation. Act accordingly. To my fellow physicians: This has been a challenging year, and on an issue as complex as health system reform it is inevitable that differences of opinion will arise. Remember, the common ground we share is vast — what divides us is not. Thomas Jefferson once said: "Not every difference of opinion is a difference of principle." My prescription: Support the AMA, support all your medical associations — they are the only way to focus light on the goals of our profession, the challenges we face, and our efforts to better serve our patients. Do not let others divide us. Get involved. Make a difference. To our medical students and residents — those who are now learning what this calling entails — You are embarking on your careers at an historic time. Remember: the issues we face are not just challenges — they also are opportunities. Remember too that the system itself may need fixing, the tradition of excellence in this country is as strong as ever. American physicians are world leaders in medical knowledge, technical skills and cutting-edge care. And most important, remember that the profession you have chosen is incredibly rewarding. To heal, to comfort, to relieve pain — to be trusted with this most sensitive part of your patients' lives — is a great privilege. And after more than 30 years of practice, I can honestly say that the sense of gratification I get from helping patients now — is just as strong as it was when I first started out some years ago. My prescription for you: Listen to your patients; they will tell you their problems. And sometimes their diagnoses as well. And join the AMA. Join organized medicine. Influence the policies that affect your education and how to pay for it. Influence the policies that affect your future profession. Add your voice. To businesses—remember that investing in the health of your employees today, can lead to significant savings in the long run. And it's not just a matter of offering insurance. It's also a matter of fostering healthier lifestyles. My prescription: Take an interest in the health of your employees. If they smoke, help them quit. Provide a gym membership — or better yet, a gym. Replace some of the candy bars and snacks in the vending machine with healthier options. The rewards aren't just physical. They're also financial. Healthier employees mean less incidence of obesity, diabetes, cancer, and the costly chronic care that goes with it. And this brings me to patients. To them—to you: My prescription: Take responsibility for the kind of care you receive. Empower and educate yourself as a patient. Make important health decisions — now — such as insuring your family, choosing a personal physician, and documenting your wishes about end-of-life care. Most common diseases are preventable. Challenge yourself to adopt healthier behaviors. Your well-being is your biggest asset. Don't waste it. Your loved ones will thank you. Now — I'm going to break a cardinal rule of medicine and issue one final prescription — for myself. As president of the American Medical Association, I promise to do what I can to mend the divisions within our ranks. Isaac Newton observed: "We build too many walls and not enough bridges." I plan to heed those words — and act accordingly. One way I plan to do this is through regular conference calls or other means to speak with AMA members. The goal will be in part to update you on the latest developments, but primarily, to hear from you — your thoughts, suggestions, questions and concerns. This will be interactive. A two-way conversation to openly and honestly communicate with each other. I'm not just going to talk - I'm going to listen. We will let you know the details soon. These communications will be a way to address the here and now. Ultimately, history will judge whether the decisions made during this historic and turbulent time were the right ones. But I can assure you that these decisions were rooted in principle, not expedience. For a better health care system — not a broken status quo. In the interests of our patients — not just ourselves. We did not control events. But neither did events control us. We plotted a course, unfurled our sails, and journeyed on, tempest tossed but hands on the wheel. We helped determine our own fate. The alternative was to have it determined — for us. Earlier, I spoke of a lesson learned on the sea — and from it. Let me offer a second, about a race from Daytona Beach to Bermuda. The third day out featured sunny, cloudless skies, moderate temperature, a strong breeze — blue water sailing at its best. We were making 16 knots on a downwind tack with all sails flying. Cresting large waves, then plowing into troughs as water broke across the bow. Even as we reveled in perfect conditions, the captain noted that the breeze had picked up and that we should take in some of the sails. But among the crew, there was much second-guessing. We were, after all, "experienced" sailors. We'd taken the Coast Guard courses. We'd learned celestial navigation. We'd sailed around Florida on a serious recreational basis. We knew better. By the way did I say the crew was all doctors? This "discussion" was interrupted by a loud pow!! blasting from the bow. We looked up to find that a sail had blown out, shredded by the strong winds. Lessons learned. A cruise to Bermuda — that reminds us that even when the sailing is smooth and the sun is shining, prudence dictates we check the wind, check the sea, check our sails, expect changes and prepare for them. And maybe — maybe — it tells us that no single one of us has all the answers. If we fail to plan — if we let outside forces plot our course and set our speed, we will ultimately drift, powerless — without direction or purpose. That is why the AMA kept our hand on the wheel during the storms of the reform debate. Now, we face a defining moment for organized medicine and the AMA. This is not just a challenge, but a tremendous opportunity. Let's work together to bridge the legitimate differences that exist between us. And let's keep in mind that we're in this boat — together. The poet Ella Wilcox wrote; One ship sails east and another sails west With the self-same winds that blow. Tis the set of the sails And not the gales that tell us the way to go. Like the winds of the sea are the ways of fate, As we voyage along through life: Tis the set of a soul That decides its goal, And not the calm or the strife. Tis the set of the soul. We are the family of medicine. We represent our patients. We must set our souls and the course — together. Because together we are stronger. Thank you.


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    Solution attached.

    1. One of the most interesting and controversial pieces of legislation passed in recent years is Oregon's Death with Dignity Act. What are the key provisions of the Death with Dignity Act? Have any other states followed Oregon's lead in this regard?
    The Oregon Death with Dignity Act was initiated by Oregon's citizens and twice passed through a general vote by the citizens and implemented into law in 1994. The controversial Act is a landmark piece of legislation that allows for physician assisted termination of life if a terminally ill patient meets all of the key provisions as outlined in the law. The key provisions in Oregon's Death with Dignity Act are:
    • The patient must be a legal resident of the State of Oregon
    • Patient must be 18 years or older
    • The patient must be fully capable of making their own health care decisions without being pressured or coerced.
    • The patient must be diagnosed as having a terminal disease that will most assuredly lead to their death within the next 6 months.
    • The physician has to verify all of these conditions are met and has the final authority in making the decision to administer life ending medications.
    (Sultz & Young, 2011).

    2. The early years of American hospitals were characterized by a very top down model, which might be succinctly described as "doctor's orders." What the doctor said was considered correct, and seldom did a nurse or patient even think about questioning the doctor. However, recent decades have seen a shift in this regard, and we now have an increasing emphasis on patient rights. What are some of the most important patient rights in your view? How do we make sure that both patients and staff are aware of these rights and honor them?
    The "old days" of practicing medicine have been replaced by a new era in medicine that is technology driven and highly sensitive to patient rights. Doctors are more prone to scrutiny and criticism in today's hospitals than at any time in history. Any failure by medical personnel to not adhere to clear policies can lead to very serious consequences.
    For patients today, I believe that the most important right is the right of informed consent. Informed consent gives a patient the legal control to make their own informed decisions about their healthcare options. It also helps ensure that medical personnel are being open and forthcoming in the treatment of their patients. Without informed consent, patients would be solely at the doctor's mercy as was the case in decades past.
    The other important patient right is the right of privacy. With electronic medical records and online healthcare becoming more frequent, the ability to compromise patients' rights of privacy is a concern. Therefore it is extremely important that healthcare providers maintain a secure information technology system that protects patients and their privacy (Sultz & Young, 2011).
    3. Dr. Sultz presents three "levels of application of preventive measures" related to the prepathogenesis and pathogenesis of disease. For each level of prevention, cite and describe at least three specific measures we can offer as health care professionals. What experiences have you had with these specific ...

    Solution Summary

    The expert evaluates the medical practices for controversial pieces of legislation.