6 Benefits of Papaya Leaves For Our Healthy

Not only fruit that has many benefits, although the taste is bitter fact papaya also has a myriad of benefits for our healthy bodies.

Here are the benefits of papaya leaves you should know:
1. Scarlet fever
Who would have thought that the papaya is also able to cure dengue fever. Try to get 5 pieces of leaves. Add half a liter of water and boil. Take the water if it is left alone tiperempatnya. Star itself has never prove it, so if the situation did not improve immediately to a doctor immediately (even if memabaik immediately take to a doctor). Consider it a first aid kit!


2.Anti cancer
It is still uncertain, but from some research that the benefits of papaya leaves can also be developed as anti-cancer. Actually not only leaves but also stems papaya can be used. Because kedanya have milky latex (a milky white sap.)

3. As an acne medicine.
For those of you who do not feel confident to have facial acne. Especially for women who always pay attention to beauty. Papaya leaves to treat it is to make it a mask.

How to make a mask: take 2-3 tua.Kemudian papaya leaves that have been dry in the sun and mash until smooth. Add one tablespoon water setenagh, just deh can be utilized for full face jerawatmu.

4. Menstrual pain
Women often take advantage of ancient Javanese papaya to treat menstrual pain. Simply Take 1 sheet of leaf only, add tamarind and salt. Then mix with a glass of water and boiled. Let cool before drinking the potion papaya.

5. Streamlining Benefits digestion
The leaves of the papaya plants contain chemical compounds karpain. Substances that can kill microorganisms that often interfere with the digestive function.

6. Increase appetite
These benefits are especially for children who are difficult to eat. Take a fresh papaya leaves and has a size of your palm. If you have found add a little salt and half a cup of warm water. Combine all and blend. Then strain the water, well water that can be used to increase appetite.

How to Add Body Weight For The Skinny Body

Many people who have weight problems, then they asked: How to Add Body Weight for Me? which we often encounter is someone who is overweight or obese because of severe dizziness badanya not fall-down though it was on a diet. But this time we are discussing is a matter someone who is skinny and wanted to increase his weight but never gain weight. Maybe it's something wrong with the program lived:

Someone who is easy to weight gain, but there is also a difficult one to increase his weight? If you include a person who is difficult to gain weight, you should check your family. Does anyone in your family who is experiencing the same problem with you. If indeed there are in your family, then you are destined to be skinny. To add ½ kg of body weight per week, then you need an additional 500 kcal per day outside of your daily consumption.

Most people think that to put on weight then they should consume more protein in large numbers. This is wrong, because the excess protein that we consume will not be stored by the body as meat (muscle mass). To add your weight (increase your muscle mass) then you have to do is to exercise.

Sports
such as weight lifting and other weight training will make the muscle fibers increase in size. For that you need to consume extra calories while you perform these exercises, for proteins that will be used to form new muscle fibers you who did not participate were burned by the body as an energy source as long as you do the exercises / sports. So, how do I get the extra calories?

Tips to Add Body Weight with food:
Choosing a high-calorie foods and beverages following Choose foods in the diet to gain weight you: Cereal. If you make the cereal, add milk. To improve taste and appetite, you can add dried fruit, crackers, biscuits and cakes that you like. Juice / cider buah.Jika you enjoy making fresh juice, pick apples, grapes, pineapple.

These fruits have a higher calorific value than orange juice or tomato juice. Add milk to add calories from your fruit juice. Fruit, pick fruit less water content such as bananas, pineapples, dates, or dried fruits. These fruits contain more calories than oranges, watermelons, melons and fruits are high water content. Milk. To increase the calories of liquid you drink milk, add milk powder to regular milk that you drink the liquid.

Family Medicine in the era of health reform

At the recent Primary Care Access Conference in San Francisco, I was given the opportunity to present the 21^st G. Gayle Stephens lecture. It was a real honor, because it is named for one of the giants of family medicine, and one of the great thinkers on health and medicine of the last half century, in any field. Dr. Stephens was the first director of one of the nation’s first family medicine residencies, at Wesley Hospital in Wichita, KS, and later Chair of the Family Medicine department at the University of Alabama. He was an early and long-time member of the American Board of Family Practice (later Family Medicine) and the author of several of the most seminal articles and books in the field, including “The Intellectual Basis of Family Practice” and “Family Medicine as Counterculture”.  Both of these pieces, along with many others, are discussed in the outstanding “festschrift^;[1; put together by another giant of the discipline, John Geyman, in the January 2011 issue of Family Medicine.

Dr. Geyman says of Dr. Stephens that “He has been, and remains, by far the most original, thoughtful, and elo­quent voice in our field and among the few who best represents the mor­al conscience of the entire medical profession.” I have been privileged to have met, corresponded with, and even to a limited extent collaborated with both Dr. Stephens and Dr. Geyman. I can only hope that my talk was worthy of being associated with Dr. Stephens’ name. In this piece, I  would like to discuss a few of the points I made in that talk related to health care reform, or the Affordable Care Act (ACA); in a later blog I will discuss this in terms of the impact on primary care and family medicine.

Unquestionably the health care reform act, or ACA, is the biggest change in health coverage since Medicare and Medicaid in 1965. It remains deeply flawed, but is nonetheless the touchstone of the opposition to the current administration, as President Obama’s opponents apparently see in it everything that we don’t! The fact is that, rather than bringing us a health system in which everyone is covered, like Canada, or the UK, or Germany, or Switzerland, or Taiwan, it is in large part a big bailout of health insurance companies. And the price that for this – the requirement that everyone have to buy health insurance, the “individual mandate”, is what we hear being attacked, not the insurance companies that demanded it as the price for supporting ACA.

There are some of the parts of ACA that are rather non-controversial (except to the extent that they might not be funded as part of the “don’t fund anything” movement), and are good for family medicine, in the sense that they are good for the health of the American people. These include the increased funding for Federally-Qualified Health Centers (FQHCs), the creation of a panel to review the evidence of effectiveness, if it is left in, and the Primary Care/Health Extension services (which thus far have received no appropriation), among others.

One important component of ACA is the creation of “Accountable Care Organizations”, or ACOs, initially for Medicare patients. They are an effort to promote health by having health providers financially responsible for the health of their patients, that is, to have ambulatory care facilities and doctors, hospitals, nursing homes, and community care facilities coordinate their efforts to prevent illness, treat effectively, and have people cared for in the most appropriate setting, rather than perverse “gaming of the system”, where a failure of ambulatory health care can be a “win” for a hospital when a patient is admitted (as long as they don’t stay too long, or get re-admitted too soon). This kind of structure works well in HMOs, such as Kaiser, or other integrated health systems, but there are likely to be flaws in its implementation; for example, Center for Medicare and Medicaid Services (CMS) administrator Dr. Donald Berwick recently published guidelines for Medicare ACOs in the New England Journal of Medicine, “Launching Accountable Care Organizations — The Proposed Rule for the Medicare Shared Savings Program”.  He says that the ACOs will be “Held to rigorous quality standards (see table). Proposed Measures for ACO Quality-Performance Standards.), ACOs will be expected to be proactive in their orientation and to regularly reach out to patients to help them meet their needs for preventive and chronic health care.”

However, Berwick immediately adds that “Patients who seek care at their ACO will know that their physicians are part of that ACO, but as beneficiaries of fee-for-service Medicare, they will continue to be free to seek care from any Medicare provider they wish. They will not be locked into seeing only particular health care providers.” This sounds relatively benign, and certainly politically wise, but could completely undercut the effectiveness of the program. The reason that Kaiser and other HMOs are effective in managing care that delivers high quality at low cost is because their patients are restricted to where they can seek services; if a Medicare patient who is part of an ACO does not like that they have been “denied” any form of care by their doctor or hospital, no matter how appropriately, can now go “outside the system” to another doctor, hospital, emergency room or pharmacy-based urgent care clinic, all efforts at cost control are at risk. This is, of course, the conundrum: control of costs requires some degree of restriction of unlimited options. It is quite parallel, in fact, to the “individual mandate” that the insurance companies demand, and in this sense they are correct. It will not work to require insurance companies to insure everyone if everyone is not required to have insurance, because then only those who need care will demand coverage, risk goes way up, and so would premiums.

Some politicians and pundits have compared ACOs to the managed care era of the 1990s, and supporters worry it will receive the same backlash from the public that occurred then. I believe that in that period it was not managed care that was at fault but two major characteristics that happened in conjunction with it. The most important was that the entire operation was taken over by for-profit companies, largely insurance companies, that saw benefit to their bottom line by restricting care. The efficiencies of consumer cooperative HMOs had benefited their members; these new entities denied care to benefit their stockholders. It was the corporate for-profit control, not the management of care, that led to consumer dissatisfaction with restrictions on access to care.

The second big problem is related to one that I have discussed before (Red, Blue, and Purple: The Math of Health Care Spending, October 20, 2009), the fact that most people are not sick. In an effort to control costs, everyone was made to jump through hoops, such as gatekeepers and prior authorization, which made them angry but did not do much for the cost, since most people do not use much medical care. Indeed, for at least half the population, you could let them do whatever they want, and they wouldn’t use any significant number of health care dollars. To illustrate this, I am reproducing the graphs from the previous blog.

While there are some things we can do to reduce the risk of unexpected crises –cancer, multiple trauma from car accidents, infants in NICUs – and control the costs of caring for those who have them, the most obvious benefit will be achieved by pre-emptively working with people whose chronic diseases have gotten so bad that they are frequently admitted, often to Intensive Care Units. These are the people who should be targeted for intensive intervention, not only medical but in terms of the social determinants of health, such as in the programs highlighted by Atul Gawande in his February 2011 New Yorker piece, “The Hot Spotters”. Needless to say, such interventions are being funded on a shoestring, while the high-tech interventions get all the money.

 It doesn’t have to be this way. We could have a rational, cost-effective health care system if we start with coverage for all through a single-payer mechanism. We might be able to back into quality despite not having one, but it will be much harder.

                                                               

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<!--[if !supportFootnotes]-->[1]<!--[endif]--> Festschrift: “A volume of learned articles or essays by colleagues and admirers, serving as a tribute or memorial especially to a scholar”

Perception and reality of economic inequality

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We see a lot written about how political views in the US are very polarized. As an example, the April 17, 2011 “Doonesbury”, portrays Donald Trump bragging that he is polling 41% against President Obama and is not even running yet; the interviewer, Mark, replies “It’s a divided country. Virtually anyone who’s not Obama gets 40%. My mailman could get 40%.” The idea is that we cannot reach accommodation because we have such different basic understandings, “belief systems”, “worldviews”.

Certainly this has been the case in Congress, although recently, in passing a budget for the remainder of FY 2011, there were actually some Democrats and Republicans voting on the same side. It is important, however, to note that the Republicans who voted against the budget condemned those who did precisely because they did not hold rigidly and intransigently to their positions, even if, as in the case of Congressman Paul Ryan’s budget proposal, those positions are based in mythological faith rather than in data. Paul Krugman, (“Who’s Serious Now?”  April 16, 2011, writes that Ryan’s proposal was “In fact, it was a sick joke. The only real things in it were savage cuts in aid to the needy and the uninsured, huge tax cuts for corporations and the rich, and Medicare privatization. All the alleged cost savings were pure fantasy.” The threat to Medicare is critical, given both the role that health reform, ACA, “Obamacare”, has played as a touchstone of evil in the fantasy world of Ryan and his party, and the real loss of healthcare, along with their jobs, faced by so many Americans.

A lot of people wonder how it is that such a large portion of the US population, can support Republican proposals that are so obviously about increasing the financial benefit to the richest Americans while hurting most everyone else, including, obviously, most of those supporting the Republicans. Are they selfless advocates of big money, such that they are willing to sacrifice their own interests to aid the least needy? Do they truly believe that each of them, despite the mathematical odds, has a good chance of becoming part of that select group? Are they stupid? It may be that either or both of the last two are true, but the first, unsurprisingly, is not. This is demonstrated in a very interesting study by Michael I. Norton, of the Harvard Business School, and Dan Ariely, a psychologist from Duke, recently published in Perspectives on Psychological Science.

In “Building a better America: one wealth quintile at a time”[1], Norton and Ariely present a large (5522) random sample of Americans three pie charts showing possible distributions of wealth among income quintiles as possible ideal models. One is equal: 20% in each. One is less equal and is in fact the distribution of income (not wealth) in Sweden The third is the distribution in the US. (That the second one is not in fact the wealth distribution in Sweden is not really important here; it could be called “Mars”; it is just an intermediate distribution).  About equal percents chose the “equal” and “Swedish” distributions, 77% preferred “equal” to the US, and 92% preferred the Swedish to the US. Given that people were told to assume that they had a random chance of themselves being in any quintile in any of the distributions, the preference for a more equal distribution may be unsurprising; indeed it suggests that more than half of those in the top quintile are less selfish and would support a more equal distribution of wealth. This, by the way, is consistent with a report by CBS news report from April 17, 2011 “The US Tax code: a ‘huge convoluted mess’”, in which several multi-millionaires argue against the idea that “…the rich can't afford higher taxes.“ One says “Every time I get a tax cut, I get richer…‘I don't buy one thing that I don't already have. I don't put money back into the economy. I just get richer.”

An even more interesting part of Norton and Ariely’s study involved asking their subjects what they though an ideal distribution of wealth among Americans should be and what they thought it actually was.  While their ideal was not “equal” – it assigned over 30% to the highest quintile and just over 10% to the lowest –it was much more equal than their perception of the actual distribution, which had the top quintile having nearly 60% of the wealth, and the lowest quintile only about 2%.

But, as the figure shows, their estimates were way off; in actuality the top quintile has 84% of the wealth, the third (middle) quintile well less than 5% (not much more than their estimates gave to the lowest quintile), and the two lowest quintiles are not even visible on the graph, with a total of 0.3% of the wealth. More important, there was little difference between various groups such as men and women, income levels (<$50K, $50-100K, >$100K), or whether they had voted for Bush or Kerry in 2004 (the data was collected in 2005). All groups felt that the ideal wealth distribution should be significantly more equal than they believed it to be, and all groups believed it to be far more equal than it actually is.  

Norton and Ariely express the hope that this study will inform public policy creation; that by showing that the American people are much closer together in their vision of a just distribution of wealth in society than are the politicians and pundits we hear so much from, there is a chance of reaching some greater consensus in terms of economic policy. This hope is endorsed, from several different perspectives, by the 4 commentaries that accompany it in the same issue of the journal, by Dunn et al (“Consensus at the heart of division”), Tyler (“Procedural justice shapes evaluations of income inequality”), Kagan (“Unclear implications”), and Schwartz (“A new veil of ignorance?”).

So why do we have such divisions? Schwartz notes that “T. Frank (2004) argued, somewhat insultingly, that average Americans are being duped to vote against their real economic interests. But the Norton and Ariely data suggest that people vote against their preferences. How can people be duped to vote against their preferences?” That he can ask this question means perhaps Frank was correct. Kagan beings to get to the answer when she writes “To start with the obvious, precisely because such a huge portion of American wealth is held by such a tiny percentage of individuals, these individuals have an extraordinary interest in maintaining the currently inegalitarian distribution. And unlike the vast majority of Americans, who have so little and thus have so much to gain, this tiny minority has the immense resources to see to it that their interests are carefully attended to by lawmakers.”

Moreover, people do not vote on one issue, even if the issue is their economic self-interest. Indeed, this is what Thomas Frank writes about in “What’s the Matter with Kansas?” Frank says people may vote for candidates because of their stands on social issues (e.g., abortion, gay marriage) rather because of their positions on economic issues. On the other hand, in the recent (2010) elections, we observed a justified anger at the economic situation that led to a massive shift to those who were not in power (the Republicans), who have responded not with plans to increase jobs or equalize wealth but to dismantle all the progressive reforms of the last 100 years; not to get government out of people’s lives, but even more into their bedrooms.

And the economic arguments, as Krugman notes, have tremendous implications for health and health care, given the size of health spending as a portion of our economy. Rep. Ryan’s “solution” for the deficit relies in great part on the restructuring of Medicare to reduce its support for the health needs of American seniors, when indeed what is needed is the expansion of Medicare, as a single-payer, more-controllable, health financing model, to all Americans. Ryan’s attack on Medicare is part of his attack on any semblance of a social contract or social justice, and is part of the continued redistribution of wealth from the less-well-off to the rich.

In the CBS report discussed above, David Cay Johnston, who teaches tax regulation at Syracuse University Law School, notes that  "All the data are overwhelmingly showing that for the last 30 years, we've been redistributing wealth upwards….It's not trickle-down economics; it's Niagara-up!" The Norton and Ariely data suggest that the American people do not support such a flow, and this is consistent with the fact that every poll for the last 20 years notes that we would support a universal health insurance plan. Maybe Paul Ryan’s attack on Medicare will finally be the impetus for us to go beyond the limitations of ACA and get real health-care-for-all.

[1] Norton MI and Ariely D, “Building a better America: one wealth quintile at a time”, Perspectives on Psychological Science, 3Feb2011;6(2):9-12 doi: 10.1177/1745691610393524

"Cabaret" and "Inherit the Wind": Will we again reap what is being sowed?

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Last year at this time, March 31, 2010, I wrote a piece about Obama and the Seder: Freedom and Multiculturalism, trying to capture the importance of the concept of freedom, and the historical relationship between African-Americans and Jews in this story of emancipation. In addition to enslavement, ancient for one and much more recent for the other, the two groups share both oppression, and, to a large extent, empathy for the oppression of others, and Passover is a good time to remember this. This weekend it is also Easter (after all, the Last Supper was a seder), during which Christians celebrate the resurrection of a prophet who preached against oppression and for peace.

Recently, I saw a very good performance of “Cabaret” at the Kansas City Repertory Theater. Of course, I had seen it before, or rather, had seen the Bob Fosse film version of this Kander and Ebb musical starring Liza Minelli. It has a long pedigree: the musical is an adaptation of the 1951 play “I am a Camera”, by John Van Druten, which was also made into a film in 1955 (both starring Julie Harris). It, in turn, was based on the story “Sally Bowles”, written by Christopher Isherwood and published in 1941. In 1972, when the movie “Cabaret” came out, it was a period piece, portraying the libertine “degeneracy” of Weimar Berlin set against the rise of the Nazis. The horror of this was not lost on me, or on the rest of the audience; for my generation, born soon after WW II, with fathers who had fought in the war, it was not that far away. For those of us who are Jewish, whose grandparents were immigrants, whose grandparents entire families were wiped out in the Holocaust, the story was more bitter than sweet. After all, 1972 was much closer to WWII than it is to the present; it was only 27 years after the end of the war, but it was 39 years ago.

Despite the pain, however, the events that were portrayed, we knew, were in the past, bad memories. 1972 was really still part of the “‘60s”. We believed that this was all behind us and we were in a new world, a new era. “Cabaret” was there to remind us of how bad things had been; most of us did not see it as a warning that it could happen again, to us. I’m not sure that this is still true. I am not sure we will not be seeing it again. I mean Nazism. Not as an accusation made as often by the right against those to their left as vice versa, but for real.

Let’s see. We have very serious, financially well-backed efforts to reverse not only the social changes implemented beginning about the time of “Cabaret” by the New Deal, but of even earlier changes, from the “Progressive Era” at the turn of the 20^th century. We have attacks on government and taxation, funded by billionaires but apparently bought into by regular people. (Question: How will they – the regular people, not the billionaires -- hire their own police and build their own roads?)  We have attacks on collective bargaining and the very existence of unions. We have increasingly restrictive laws about who we can be in relationships or have sex with (“gay marriage”), whether we can control our own bodies, whether we can use contraception or have abortions. State, and sometimes the federal, governments, led by those who say are against any kind of government regulation, are dictating how people should carry out the most personal of acts. I guess they are only against regulation of what they want to do; they’re into regulating things they don’t like. We have a tax breaks for billionaires and policies (pro-finance, anti-regulation) that have essentially transferred everyone’s wealth to those billionaires. Since they and their corporations don’t pay taxes, and those who are left no longer have enough money to pay enough taxes, we are getting cuts in essential services. And we are fighting several unfunded wars, we have demagogues demonizing “the other” (currently Muslims), and we are pretty far down the road to a religiously-driven, corporate funded, hypocritically moralistic military state.

OK, fascism. That’s where we’re headed. A state that is geared toward the interests of corporate power, that regulates people’s lives, that is militaristic and intolerant. But surely not Nazism? After all, they are not calling for the extermination of the Jews.

Yet.

“Cabaret” is not the only musical that may be more literally relevant now than when it first appeared. A few years ago I saw a wonderful production of “Inherit the Wind” on Broadway with Christopher Plummer and Brian Dennehy. When the play was written in 1955, and later (1960) made into a movie starring Spencer Tracy and Frederic March (with several versions since then), it was conceived of by its authors, Jerome Lawrence and Robert Edwin Lee, as a metaphor for the McCarthy era. The actual topic, the Scopes “monkey trial” in which a high school teacher is found guilty of teaching evolution, was not really the topic; after all, that had been nearly 40 years earlier. By the late 1950s no one doubted evolution. It was settled. But it made a great allegory for the close-mindedness and repression of that period.

They thought. But a few years ago, the state school board in Kansas, where I live, branded evolution a “theory” and mandated teaching “alternative theories” – such as creationism. The supporters of that policy were defeated in a later election, but turnout is light in school board elections and they could be back. No one doubts it could happen again. Powerful interests are questioning science; leading politicians attack those who question “American exceptionalism” – that we are different from everyone else, and programs that work in other countries are not for us. Is this different from the righteous xenophobia of the Master Race?

I do not mean to imply that the only or greatest racist threat is to Jews. Clearly, in this country the oppression of African-Americans is built into our very fabric. The great post-911 hostility is to Muslims. Jews are “our friends” (well, Israel is). Jews are powerful in Washington, as the American Israel Political Action Committee. Some Jews are even right-wing leaders. To the extent that they worry about oppression of Jews, they try to isolate anti-Semitism and oppose it, separating it from anti-Muslim hate (as the Israeli government is so good at), from racism.

They are a minority of Jews and they are outside the tradition of a people that has always recognized its own oppression in the oppression of others. Who were the majority of the international volunteers who fought in Spain against Franco and fascism. Who, way out of proportion to their numbers in the population, were active in the civil rights movement in the US and in the anti-apartheid struggle in South Africa. Who are disproportionately represented among scientists and human rights attorneys and advocates for social justice. They are also disproportionately represented among the leaders of the rapacious finance industry that led us to the Great Recession.

What a combination! A small number of people, tiny in comparison to white Christians, Muslims, Hindus, Blacks, Asians. Who have the poor judgment to both be out-front critics of racism and oppression, members and leaders of every progressive movement from unionism to socialism, and to have among them the leaders of the financial class that has wreaked havoc on the world’s economy. What a great target! No wonder Hitler could demonize them!

But it couldn’t happen here. At least we don’t think so now. Like Herr Schultz, the fruit merchant in “Cabaret”, who says “I am Jewish, but I am also German!” as he minimizes the significance of the broken windows in his store, who stays in denial for a long time. A lot of good it did him.

We have to fight all forms of intolerance, of racism, of know-nothingness. All forms of oppression and repression. All forms of “we are better than them” which can lead to “let’s kill them” pretty quickly. The memory of the Holocaust is “never to forgive, never to forget”. And to not forget that Jews can still be victims, and that they will never be safe as long as anyone is a victim. It is never too early to oppose bigotry, hate, and the loss of human rights.

Or we will surely inherit the wind.

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Do resident work hours limits create better physicians?

On a few previous occasions (e.g., Student Debt, Resident Hours, and Primary Care Redux, Jan 2, 2009) I have written about the issue of medical residents’ work hours and the implications that it had, good or bad, for patient care. A recent article in the British Medical Journal (BMJ) by Moonesinghe et al, “Impact of reduction in working hours for doctors in training on postgraduate medical education and patient outcomes: systematic review”, provides the most thorough review to date of studies evaluating the impact of work hours reductions for medical residents in the US and the United Kingdom, where they are even more stringent. They looked at studies examining both “training” (how are the residents learning?) and patient quality and safety.

This was not an easy task; true “meta-analysis” (grouping all the studies together as if they were one and re-analyzing the data) was not possible because they were so different in methodology, issues studied, and quality. In fact, the quality of most of the studies was not terribly high, and they often looked at several different outcomes making it hard to understand whether the changes all went one way, or there were some things that were better and some worse and whether the net result could be stronger (or weaker) if we could focus on only one at a time.

The good news for those who have implemented, supported, and argued for the work hours restrictions is that they seem to have improved the private life of residents, and to have not significantly harmed either the quality of training or patient care, at least insofar as these somewhat contradictory studies seem to indicate. Most of the studies were done in the US, and most were of surgical (28 of 41) or “hospital-based” (e.g., anesthesiology, critical care) trainees, rather than primary care.

Here are some of the results:

Training outcomes:

·    2 papers (both of “low methodological quality”, one of medical residents in the UK and one of surgical residents in the US, which “did not report statistical analyses of the results”) reported an improvement in training outcomes.

·   12 studies found a detrimental association; half from the US (all surgical) and half from the UK.

·    27 studies found no change (20 US and 7 UK)

·    There were also mixed results regarding the quality of “training opportunities” (exam scores, caseload)

Patient outcomes:

·    31 of 34 papers were US

·    4 studies showed improved patient outcomes, including the only randomized controlled trial in the group (note: this was in critical care and coronary care units, where shift work may arguably be more effective)

·    2 studies (in trauma and orthopedics) found increased complications

·    28 studies showed no significant difference

Surgeon and NY Times writer Pauline Chen commented on this article in “Is a well-rested doctor a better doctor?”, April 7, 2011. She describes talking with a surgical resident she knows who is very pleased at how much better her life is than she had feared. “’Training has changed a lot…My life is different than yours was — I have a lot of time outside the hospital.’ She described how she loved her work but was able to sleep at home most nights, go out regularly with friends, stay involved with her church and take an improv class.”  Cool. It is good to know that surgical residents are not acting as slaves, and can have some kind of life outside the hospital.

However, her resident friend was less sure about learning and patient care: “’To be honest, I don’t really know if this is better or worse,’ she said, recounting how she felt she was signing over responsibility for her patients more often than she ever imagined she would, missing key events in their hospital course and even getting dismissed during the middle of a patient’s operation in order to stay within the limits on work hours. ‘Sometimes it seems so counterintuitive to just sign out as if we were shift workers, but this is all any of us know right now…We have nothing to compare it to.’”

So, probably, as Dr. Chen observes, the discussion will go on. Those who believe that working longer hours results in tired physicians and therefore bad patient outcomes will continue to push those ideas; those who (largely, it seems, surgeons) believe that artificial limits on work hours compromise resident learning, thus not only having a negative impact on their current care of patients but, more importantly, their care of patients in the future care because they haven’t had sufficient experience in their residencies. One “side” says “Do you want to be operated on by a surgeon who has been up all night?”, while the other says “Do you want to be operated by a surgeon who is not as skilled because they were coddled in their training and didn’t get sufficient experience?”

“The most important test of success of postgraduate training,” say Moonesinghe and colleagues, “is the professional performance of those who reach the end of it.” They go on to make several suggestions, including, most importantly I believe, that “a consensus should be reached by the medical profession on appropriate measures to assess the quality of postgraduate medical training.” They agree with the assertion (from Temple, et al, “Time for training. A review of the impact of the European Working Time Directive on training 2010”) that “training is patient safety for the next 30 years”. Wise regulation must understand the balance, the risk-benefit of any change, and try to reach the greatest benefit with the least risk.

I would like to comment a bit upon the issues as they relate, in particular, to primary care training. Most of the studies that have been done have been on surgical specialties, which can measure surgical complications, deaths or morbidity, or in anesthesiology or critical care, because these are hospital based and more amenable to shift work. While a very few of the studies were in pediatrics, they also examined hospital work; none were looking at the training of primary care or family doctors. One of the other reasons that the surgical specialties have been so studied is that they have long been those with the longest work hours; thus, they are both the greatest target of reformers and the greatest resistance by current surgeons and teachers who fear that work hours restrictions will jeopardize the skill of their future colleagues.

The irony is that, as in so many areas, when laws or rules are being violated by one group, they are tightened on everyone, and those who were not violators of the old rules find their greater restrictions to comply with while, often, those who were violating it before continue to. In the 1970s when I was in training at Cook County Hospital, we had a resident union (yes!) and were limited to every-4^th-day overnight call. But the surgeons were on more often. If family medicine or internal medicine or pediatrics violated the rule, they were penalized, but the surgery residents were afraid to complain. And so, today, the violations of hours rules in some specialties increases the restrictions for all.

The problem with applying these rigid rules to primary care is that it is not shift-based. While residents spend time on inpatient services, the core of family medicine training is the continuity clinic where those doctors-in-training follow their own patients. It is important to be able to do this, to show up for your office hours to see your patients who are expecting to see you, even if you were up much of the night delivering the baby of one of your patients. If that happened every day, it would be a big problem, but it doesn’t. Yet there is a “zero tolerance” for work hour violations by the Accreditation Council for Graduate Medical Education (ACGME), so the program would be cited. Rigid cut-offs, indiscriminately applied, are a bad idea.

Residents should have work hour restrictions; they shouldn’t be on call every third night and up all night. They should get days off, should get time to spend with friends and family or sleeping. But the restrictions need to regulate hours in a more global fashion: hours in a week, days off in a week, average or typical number of hours off between shifts. They should not be counting minutes (and they currently do!), not create automatic violations for each instance in which, say, a resident returns to clinic after only 9 ½  instead of 10 hours off. They also should be specialty-specific, examining the character of the specialty’s practice, not to allow exploitation but to make them appropriate to how the specialty is practiced.

Some fields, like ER and critical care, work well with shifts. Some, like most hospital work that characterizes internal medicine and pediatrics training, generally work pretty well with “night floats” and days off, as long as there is careful attention paid to information transfer at the shift changes (“hand-offs”). Surgery may require longer shifts with more days off. And family medicine needs to allow residents to occasionally deliver their babies at night without canceling all the patients on their schedule the next day, as long as it is not the everyday norm.

We can do this rationally. We can have training that both provides time for the non-work lives of residents and good training for their careers; that ensures quality care of their patients now and in the future.

Disincentives to rural practice: from "Training Family Doctors" blog

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Excellent post about the market disincentives to providing rural health care by Allen Perkins on his blog "Training Family Doctors". http://usafamilymedicine.wordpress.com/2011/04/14/health-care-and-the-market/
Dr. Perkins goes on to quote from President Obama, who quotes Abraham Lincoln, about the need to care for others; this is a core principle of social justice, and one that I have addressed explicitly in the past both from a principled point of view (Does the nation need a clear policy on a right to basic health care?, April 10, 2009) and from one of enlightened self interest (Red, Blue, and Purple: The Math of Health Care Spending, Oct 20, 2009).

The market, well-regulated, can serve many purposes and be of value, but it cannot, by its nature, be relied upon to serve social justice needs.