Saturday, December 19, 2015

Debt to Income

The phrase debt to income is a banking term that applies income against all the debt carried by an individual to determine credit "worthiness." One's worthiness is factored by our earnings, our ability to take on debt and in turn pay back said debt that is shoved down our throats as the key of having a successful life and living the dream.

When you can't sleep from pursuing said dream, don't worry big pharma is there with a pill to stop that problem. Medicine is the cure for all ails it is just if you survive all the treatments for said ailments is an entirely different matter.

I read the below article as I am in the midst of reading, Ending Medical Reversal, which is about the John Kerry problem in Medicine, the flip flopping,  Medical Reveral is the sober term for sudden flip-flops in standards of care that unnerves and demoralizes everyone, doctors no less than their patients.

The reality is that Medicine changes course in the middle of the stream when it comes to Patients, to themselves however, not so much.

We know long doctor shifts are dangerous. Why won’t hospitals adapt?

The Washington Post

By Jeffrey Clark and David Harari
December 18 2015

Jeffrey Clark and David Harari are resident physicians at the University of Washington specializing in psychiatry.

In 1989, Sidney Zion famously wrote this about staffing practices at U.S. hospitals: “You don’t need kindergarten to know that a resident working a 36-hour shift is in no condition to make any kind of judgment call — forget about life-and-death.”

After his 18-year-old daughter, Libby, died at a New York hospital in 1984 while under the care of junior physicians stretched dangerously thin, Zion pushed to change the system. But the system has shown a stunning ability to deny the obvious. Even after a 2009 report from the prestigious Institute of Medicine confirmed Zion’s suspicion that shifts beyond 16 hours are risky, some still want to test the theory that patients are well-served by newly trained doctors who have been awake and working for 30 or more consecutive hours.

The proponents of 30-plus-hour shifts argue that new limits on residents’ duty hours have not consistently led to improvement in patient outcomes. But why would anyone expect otherwise? The standards published in 2011 by the Accreditation Council for Graduate Medical Education still allow hospitals to put residents through blistering 80-hour work weeks, while setting maximum shift lengths of only 16 hours for interns and 24 hours for more senior residents. Interns simply work shorter but more-frequent shifts. Doctors hand off patients to each other more regularly but without the training needed to manage these transitions effectively. And, by and large, hospitals have not responded to the changes with larger workforces, leaving residents no choice but to compress their daily work into shorter time periods.

Now, two randomized studies at major teaching hospitals across the country are comparing residency programs that use the 2011 duty-hour regimen with those employing a more flexible schedule. Residents in the flexible arm can work shifts of unlimited length provided they log fewer than 80 hours a week and don’t work extended shifts more often than every third night. The scientists running the studies, known as FIRST and iCompare, theorize that mortality rates could be no worse for patients, while residents might be better educated, if shift lengths of 30-plus hours were reinstated.

We believe there are significant ethical, scientific and regulatory problems with these trials. First, the trial investigators at Northwestern University (FIRST) and the University of Pennsylvania (iCompare) have exposed residents to well-documented increased risks of motor vehicle accidents and needle-stick injuries. There is also good reason to believe that overwork and sleep deprivation contribute to the epidemic of depression among resident doctors.

Second, after erroneously upholding that these studies presented only “minimal risk” to doctors and patients, the institutional review boards responsible for human research protection at the two universities waived the requirement for obtaining informed consent for all subjects. This means that patients and doctors alike did not need to be notified that they were enrolled in a study, did not have a chance to provide informed consent and could not reasonably opt out. (The two of us and our patients were not provided informed consent before being enrolled in the iCompare trial). Conducting this research without the informed consent of residents and patients violates the basic ethical principle of respect for persons.

Third, a high-quality survey sponsored by the Committee of Interns and Residents and the advocacy group Public Citizen showed that the public overwhelmingly opposes extended hours for residents. Only 1 percent of respondents approved of shifts greater than 24 hours, and four out of five said they would ask for another doctor if they found out that their resident had been awake for more than 24 hours. Treating patients with an intervention that they do not want should never be sanctioned.

Ultimately, the biggest problem is the question being studied. We already know that extended shifts are dangerous. While many people rightfully suspect that current duty-hour limits aren’t improving outcomes, these studies err in assuming that the dangers of sleep deprivation must be traded for the dangers of shared patient care. Such a zero-sum framework won’t help us improve patient care or ensure the well-being of resident physicians.

Perhaps we should start over. For more than 100 years, we have tried to train doctors to live without adequate sleep, and yet we have predictably failed to produce superhumans. Instead, we’ve created a medical culture that encourages severely sleep-deprived, impaired physicians to take care of others. Does anyone want this?

There is no reason to believe that 80-hour workweeks and shifts longer than 16 hours are associated with optimal patient or resident health. Adequate sleep is a fundamental physiological need. No amount of caffeine, prescription stimulants (as some physician leaders have advocated for) or “alertness management strategies” can adequately compensate for acute and chronic sleep deprivation.

But neither should anyone assume that more reasonable duty hours are a panacea. We also need to improve patient handoffs, increase staffing and emphasize resident education over patient volume. These things will require time and money. But as a profession, we can begin by abandoning the archaic, harmful and misguided belief that doctors are immune to normal human limitations. Until that happens, we can’t meaningfully address the parts of residency training that we can indeed change.

I want to point out that the two Doctors are of Psychiatry from our local University of Washington that also runs our public health facility, Harborview Medical Center, the dump bucket I sued last year. The University of Washington has not changed its care practices at all so this is either ironic or a passive aggressive tome. I am going with the later as in Seattle there are two things we are short of: Humor/Irony and Directness. We invented passive aggressiveness and the Seattle Scold that accompanies it. That latter is something you see in almost every liberal city where the good, the the white and the privilege go hand in hand. Don't just do as I do do as I say, should be the mantra along the I5 corridor.

The comments attached to the article were most interesting debates with several in the field concurring that the way of doing business is better done away with and others whom of course practice the John Galt monologue that "I did it and I am here to ensure that this is the way it should be so toughen up and accept that working hard is the American way to an early grave, drug/alcohol addiction and broken relationships. But hey I added that as Ayn Rand was also humorless although she was Russian. Hmm Seattle seems to have a lot in common with our colder compatriots.

Change is not something the medical industrial complex embraces well as does its other brother the criminal justice system followed by Education, unless it is about serving patients, criminals or students. Those classifications are the least important and served so they are the ones subject to a never ending barrage of change. The reality is that those in charge don't want to rock their apple cart or financial incentives in which to retain the status quo.

 Doctors, Lawyers and Professors are highly vested in a hierarchy of authority and they care only that the great unwashed are available, disposable and will provide income via whatever means necessary - debt to income so to speak.

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