The Evidence-Based Metaphor | Evidence Based Communication

Corresponding Author: Brit Trogen, MS (brit.trogen@nyumc.org).

Grace and I are trying to keep the vaccines minimal for Annie, if we can.”

Jeremy, the man sitting in front of me, is tall, slender, and politely tattooed. Despite appearing distinctly well rested, he’s every bit the new parent: exhilarated and, equally, terrified.

“There are just so many of them,” he says. “I was concerned about overloading her system.”

It’s a situation that many pediatricians encounter on a regular basis: a parent who is resistant to the idea of childhood vaccinations for a son or daughter. The only difference here is that Jeremy isn’t really an anxious parent but a standardized patient—an actor trained to re-create this scenario—and I’m not a physician but a medical student. We’re in the midst of an OSCE, an “objective structured clinical examination,” designed to train medical students in the real-life practice of medicine.

Sitting in a perfect replica of an examination room, wearing a white coat and stethoscope, I’m tasked with changing Jeremy’s mind. I launch into my carefully prepared talking points, explaining that vaccines are remarkably safe and effective, that they won’t overstrain his daughter’s immune system. The vaccine we’re discussing doesn’t even contain living virus, I tell him.

“It’s more like a fingerprint of the germ,” I explain. “When Annie’s body sees it, she learns to recognize that tiny fragment so she can attack it if she ever encounters it again.”

Later, in the debriefing, Jeremy reviews the case with me, providing lengthy feedback on everything from eye contact and posture to professionalism.

“I’ve done this scenario hundreds of times,” he says, finally, “and I’ve heard a lot of explanations of how vaccines work. I thought the fingerprint analogy worked well.”

This statement came almost as an afterthought, a high note to close the encounter. Yet as I left the examination, I began to wonder about the hundreds of other medical students stretching back through the years, each armed with their own individual script, each trying to accomplish the same task with different metaphors. Just how dissimilar were our explanations?

Curious, I asked around. One of my classmates had described the vaccine as a “personal trainer” for the immune system, “pumping up” the patient’s natural immunity. Another portrayed vaccination as a kind of insurance policy against future illness. In a case where we had all carefully memorized the same statistics, cellular pathways, and adverse effects, it occurred to me that our patient explanations seemed wildly, and perhaps unwisely, variable.  What if, instead of a medley of vaccine analogies of varying efficacy, patients like Jeremy heard only tried and tested messages from the medical community?  But not all metaphors are created equal. A vaccine is more analogous to an insurance policy than it is to, say, a bowl of petunias. Yet virtually no consideration is given in medical school, or in health care as a whole, to exactly which metaphors ought to be used. There seems to be a prevailing view that while physicians may, according to their tastes, use different figures of speech, one is not inherently better or worse than the next (or if it is, it’s impossible to know which is which). The study of oncologists, for example, found metaphors ranging in theme from militaristic (eg, cancer as an invading army), to sport themed (eg, treatment as a marathon), to agricultural (eg, stem cells as seeds), to animal inspired (eg, bone marrow as an elephant that never forgets). Should the framing of these important conversations be left entirely to the whims of individual physicians?

We implement evidence-based medicine, so why not evidence-based communication?

There will never be just one “right” way of explaining illness. Things like tone, gesture, cultural background, and personal experience will have at least as much influence over how someone interprets a given metaphor as the words themselves. In the absence of an evidence-based approach, however, physicians may be missing out on a powerful clinical tool or, worse, using metaphors that are unintentionally harmful or counterproductive in their long-term effect on patient behavior or public health.

Throughout medical school, much is made of the importance of using research to optimize decisions about patient care. When evidence shows that one treatment is more effective than another, physicians incorporate this knowledge into practice. We strive to make conscious, empirical decisions on everything from drug dosing and treatment modalities to medical education and health policy. We should be just as rigorous with our words.

A good idea. Perhaps we should compile a glossary of metaphors, not only for medical students, but residents and physicians.  This is an effort for which I would gladly be editor.

Corresponding Author: Brit Trogen, MS (brit.trogen@nyumc.org).

The Evidence-Based Metaphor | Humanities | JAMA | The JAMA Network

Physicians have little Scientific Evidence for using Medical Marijuana

Medical Marijuana Is Legal in Most States, but Physicians Have Little Evidence to Guide Them

Ask a teenage high school student about Marijuana and there is a good chance they know quite a bit . about it. Marijuana has become a regularly used substance for recreational use.  Chances are good that the average 'user' knows far more about marijuana, THC or CBD than your physician.

Medical Schools do have pharmacology courses, where students can read the basic science and neurobiology of the molecule(s), however there are few clinical references of studies on the matter. There are plentiful articles in lay  press, Internet articles about the substance.

Five patients have confided to Key West internist John Norris III, MD, that they use marijuana to relieve painful, persistent muscle spasms resulting from strokes or multiple sclerosis. 

Gaps in Knowledge

Norris’s complaints highlight the knowledge gaps physicians confront when it comes to medical marijuana, now legal in 28 states, the District of Columbia, Puerto Rico, and Guam. They didn’t learn about it in medical school, and, because it is not a US Food and Drug Administration–approved drug backed by randomized controlled trials, they can’t turn to the Physicians’ Desk Reference for information about dosage, indications, and contraindications. The federal Drug Enforcement Administration (DEA) still classifies marijuana as a schedule I drug, along with heroin and ecstasy, that has a high potential for abuse and no accepted medical use. As a result, studies of its therapeutic use are limited and physicians have prohibited from prescribing it.

However the situation is changing rapidly with recent legalization of marijuana in multiple states. Abrams and his coauthors reviewed more than 10 000 scientific abstracts. They found that the strongest evidence of a health benefit from cannabis and cannabinoids is in the treatment of chronic pain and muscle spasms associated with multiple sclerosis and chemotherapy-induced nausea and vomiting.

As the number of states that have legalized medical marijuana rises, the need for research becomes even more pressing, according to a recent editorial in Lancet Oncology: “For a product rapidly becoming mainstream, clinical trials and basic research are crucial: The requirement for evidence of the benefits and risks of marijuana use will grow as access increases and regulations, including clear guidelines for safe and effective use, must be developed.”

“There’s insufficient to no evidence for most of the claims [about medical marijuana],” said University of California, San Francisco (UCSF) oncologist Donald Abrams, MD, coauthor of a new report from the National Academies of Sciences, Engineering, and Medicine on the health effects of cannabis and cannabinoids (constituent compounds in cannabis). “If you like having evidence on which to base your patient recommendations, it’s really not available.”

Abrams and his coauthors reviewed more than 10 000 scientific abstracts. They found that the strongest evidence of a health benefit from cannabis and cannabinoids is in the treatment of chronic pain and muscle spasms associated with multiple sclerosis and chemotherapy-induced nausea and vomiting.

As the number of states that have legalized medical marijuana rises, the need for research becomes even more pressing, according to a recent editorial in Lancet Oncology: “For a product rapidly becoming mainstream, clinical trials and basic research are crucial: The requirement for evidence of the benefits and risks of marijuana use will grow as access increases and regulations, including clear guidelines for safe and effective use, must be developed.”  Although Abrams recommends cannabis to patients, he recognizes that many questions remain, such as the best strain to treat a particular symptom. When patients ask for his thoughts on such matters, “All I can say is I don’t know,” Abrams said. “I just advise my patients to go to the dispensary and explain to them what you would like to treat. They’re [dispensaries] on the front lines.”

Many physicians aren’t comfortable relinquishing that much control, Abrams acknowledged. However, most also don’t know the difference between CBD (cannabidiol) and THC (tetrahydrocannabinol). Although both are cannabinoids, only THC makes marijuana users high.

Physicians today lack such basic knowledge about cannabis because they never learned about it in medical school. “Physicians could prescribe cannabis in this country until 1942, when it was removed from the [US] Pharmacopoeia,” Abrams said. “There hasn’t been education about cannabis as medicine for 75 years.”

Back in 1996, California became the first state to legalize medical marijuana, but a 2-week, 12-hour elective for first-year medical students this past fall was UCSF’s first attempt to educate future physicians about cannabis as medicine, said Abrams, who taught the course.

The UCSF marijuana course was 1 of 20 electives from which students could choose. It could have accommodated 12 students, but only 6 enrolled, Abrams said, adding that he “was a little surprised I only got 6 [students] here in San Francisco.”  

Pot 101 . Change us in the air

On the other side of the country, a University of Vermont (UVM) Larner College of Medicine pharmacology course, PHRM 296: Medical Cannabis, drew more than twice as many students as expected when it was first offered last spring semester.

The school had to twice change the location of the elective course, as enrollment grew to 99—filling the largest available lecture hall, said Kalev Freeman, MD, PhD, an emergency department physician and assistant professor of surgery at UVM whose wife, a botanist on the medical school faculty, co teaches the class. Thought to be the first of its kind at a US academic institution, it delves into molecular biology, neuroscience, chemistry, and physiology. Students who’ve taken it include undergraduates, medical students, physicians, and a state legislator.

Thanks to the enthusiasm of pharmacology chair Mark Nelson, PhD, Freeman said, he expects that beginning this fall, the subject of cannabis will be woven into the UVM medical school curriculum, instead of offered only as a stand-alone course. In other words, he said, when medical students study psychiatry, neuroscience, cell biology, and chronic pain, cannabis will become part of the discussion. “These kids are going to graduate from medical school, and they need to know some data,” Freeman said. 

Kalev Freeman, MD, PhD is a physician-scientist with a background in molecular biology and specific research interest in inflammation and injury. He is Co-Founder of the Phytoscience Institute and the Medical Director of Vermont Patients Alliance Inc., a non-profit plant-based pharmaceutical research center that serves over 800 patients with debilitating medical conditions. He is also the co-director of the Cannabis Science and Medicine Program the University of Vermont Medical School. Dr. Freeman completed his BA at the University of Michigan, and both his MD and PhD at the University of Colorado, where he specialized in molecular biology.

Cannabis . Testing for Public Safety, A course prepared for the Vermont Legislature

White Paper Download

Other Reference:

1.   Use of Marijuana for Medical Purposes Among Adults in the United States

2.  The Risks of Marijuana Use During Pregnancy

3.  Medical Board Expectations for Physicians Recommending Marijuana

Physicians are cautioned not to use marijuana which would effect their practice of medicine and certainly not when on duty.

Health reform is dead. So what can we do now?

 

Do we just give up for now? I don’t think that is advisable. Too much is at stake. And there are many other significant ways, all far less politically charged, and therefore more politically possible, that we could improve the American health care system.One of the most important ways we could improve things is through administrative simplification. Modern health care workers and patients alike are caught in a huge tangle of administrative paperwork, confusing rules, and confounding regulations. It is estimated that one-third of every dollar spent on health care in America goes towards administrative costs. Therefore, reducing the administrative burden could significantly lower the overall costs of health care to the nation (or we could increase the amount we spend on actual medical care). Administrative simplification would be relatively easy and should be politically palatable. Done well, it could be wildly popular with both patients and physicians.


The American medical billing and coding system is long overdue for just such a makeover. Getting paid for even the most basic medical goods and services is a multi-stepped, convoluted nightmare that creates huge and unnecessary costs, and invites mistakes and abuses. Ridiculously complicated coding systems and documentation requirements are the rule and have the same effect. It is a distraction for all medical professionals almost every moment of the day. Medical practices must focus on billing and payment issues almost more than medical care.

How has this occured ?  Much of it began with Medicare's unbalanced approach to reducing or eliminating fraud and abuse of the Medicare system.  To reduce it Medicare began a system of 'over documenations' to provide a trail of evidence to be able to allege fraud.   The intensity of billing and coding for diagnosis has become an overriding concern and time parasite on healthcare.  It produces a heavy cost on medicine and healthcare for providers, hospitals, and medical suppliers.

How do we fix it?

Coding and documentation requirements should be markedly streamlined, and most billing should be eliminated in favor of point-of-care payment cards. This would represent an incredible improvement and money-saver for American health care.Health reform is dead. So what can we do now?  

The next area of focus should be health care computerization. A generation of American physicians is now forced, by government mandate (the dreaded federal meaningful use program, which started in 2011), to use electronic health record (EHR) software systems that are not ready for prime time — they don’t work well, slow things down, and cost too much. Many physicians now spend hours, often late at night, catching up on chart notes and other tasks because their EHRs were too slow to use during actual patient care hours. EHRs have simply failed to deliver on their great promise. And because of their huge costs, most physicians are stuck with what they have.  The federal government with incentives coerced the health system into purchasing inadequate poorly designed EHRs. Billions of dollars were wasted.

There are many other ways we could improve the nation’s health care system even without broad payment reform. I will mention one way we could lower the costs of care in the U.S. that does not receive enough emphasis — healthier Americans. It is estimated that two-thirds of every dollar spent on actual medical care (non-administrative spending) relates to preventable chronic diseases, such as heart disease (the nation’s number one killer) and diabetes. The best way we could lower the costs of care in this country is to reduce demand — by preventing such preventable diseases. Health promotion should be a centerpiece of our national health care policy. Schools, and even more importantly, places of work should set aside time every day (it could be 5 minutes of every hour) for structured exercise. We must go beyond past efforts to create a new American health culture. The economic impacts could be huge. And, as I said in a recent BBC interview, your best bet until things get better in health care is, “Don’t get sick.”

After the many bureaucratic changes that followed the passing of the Affordable Care Act (Obamacare) and other legislation, patient care has become secondary to satisfying the whims of government and giant insurance company administrators, who are in total control. The result is a web of complicated rules and misguided programs whose chief effect has been to distract doctors and nurses from their proper focus on patient care. Access to health care now depends on the ability of patients, doctors, and nurses to navigate in and around this cumbersome and ever-changing system.Improving health in the United States should not be a political problem. Whose problem is it ?

How are hospitals using mobile devices for care? - MedCity News

The results of the survey show 79.8 percent of respondents said they use tablets to coordinate and provide patient care, and 42.6 percent said they use smartphones to do so. Despite these findings, desktop computers still take the lead for the most commonly used devices. Approximately 94.6 percent of respondents said they use desktops, and 37.2 percent said they use laptops to support care.

HIMSS Analytics Director of Research Brendan FitzGerald said he wasn’t shocked by the survey results. “I wasn’t necessarily surprised, primarily because when you look at mobile technology, it’s not widely used in the hospital setting,” he told MedCity via phone.

Among respondents who use smartphones and tablets, 76.5 percent indicated they use them to access clinical information. Approximately 70.6 percent said mobile devices are used to access EHRs and 66.2 percent said they’re used to access nonclinical information such as educational resources. Nearly half — 48.5 percent — said they use mobile devices for systemwide communication.

While healthcare organizations appear to be putting mobile devices to use in a variety of ways, there are still a number of hurdles to widespread adoption. One such barrier is security.

Looking ahead, FitzGerald noted that many people are worried that technology adoption in the healthcare world may slow down. But in his opinion, that’s not the case. “The horse is out of the barn,” he said. “Organizations aren’t going to go back and say they were better with a paper-based system. It’s here to stay.

How are hospitals using mobile devices for care? - MedCity News

Public Health Alert !Stem Cell Therapy Blinds Three Patients at Florida Clinic

Stem Cell Therapy Blinds Three Patients at Florida Clinic

A horrendous story of gross negligence, ignorance, and malfeasance

Intravitreal injection into the eye via the pars plana. This is a common method for treating diabetic hemorrhage. Stem cell injection is not approved for routine use.

Public Health Alert. Be wary of all outpatient stem cell treatments. Genuine clinical trials for any unique treatments are listed in clinicaltrials.gov. These are studies carefully controlled by credible research MDs and their teams. 

This is a sad story. Stem cell therapy for retinal diseases in . still in it's early stages (such as for Retinitis pigmentosa. The media vastly exaggerates the usefulness of stem cell treatments.

Diagrammatic representation of how stem cells are extracted and reprogrammed.

Route of Administration of Stem Cells into the Eye

Stem cells have enormous potential for treatments.  Analagous to the development of nuclear energy it has the potential for great harm if used ignorantly or unwisely.  Deciphering how stem cells differentiate is analogous to the development of the atomic bomb.  How stem cells differentiate is largely unknown, and research is ongoing.  We are only beginning to understand the genetics and molecular biology of pluripotent stem cell differentiation.


References:

Pubmed:


Stem Cell Therapy Blinds Three Patients at Florida Clinic

Fake News in Health Care

Now You See? Former CBS Reporter and Media Professional exposes the mind manipulation used by special interest groups, media, and medical. Share. 

What is the reality ?

Specialty interests disguise their true role. 
Astro-turf-fake grass is in the media.  Astro-turfers seeks to manipulate you. They attack  the truth, disseminate chaos, conflicting studies, multiple experts and yes, WIKIPEDIA.

Wikipedia is not peer reviewed, nor edited. It conflicted with peer reviewed articles 90% of the time.

Drug companies manipulate Google search engines, finance positive studies for drugs, CME lectures are often funded by pharma companies. 

Pharma often 'stimulates' epidemics and new disorders to promote their new drugs.

How do you separate fact from fiction?

1. Use of inflammatory language
2 Claim to debunk myths
3. Beware attacks
4. Astroturfers question those who question authority.

All of this ponts to a lack of integrity

Another Medical Moment from Health Train Express




(21) Facebook

For a trip to the ER, some are opting for Uber over an ambulance

Technology disruption in one field can precipitate a cascade of events resulting in a sea-change in another.  In health care this is happening for transportation to hospitals.

Uber has found a new spot for transporting non-acute patients to emergency rooms. Some patients may also find it useful for events such as asthma and/or other non life threatening events.

Uber however may find itself in a legal dilemna transporting patients with medical conditions requiring assistance if interventions may be necessary.

At this point I would not expect Uber to be self-policing.  They should require drivers to be BCLS certified and qualified in first aid.  There are many scenarios that would call into question this practice.







 For a trip to the ER, some are opting for Uber over an ambulance

Physician Suicide--An Epidemic

Pamela Wible runs "The Ideal Medical Clinic". She also is an advocate for prevention of Physician Suicide.

In this podcast, I share insights from a doc who barely survived his suicide attempt plus simple ways to prevent the next suicide. Listen in. You may save a life.

Dear Pamela, I’ve never been so happy to fail at something in my life. Four weeks ago today I died. Cardiopulmonary arrest in jail. Why was I in jail? My wife alerted the police. Sheriff deputies were upset when I did not pull over to talk to them after overdosing. After boxing me in, they threw me from my truck into the slushy street and tased me. After charging me with a felony and two misdemeanors, they nearly provided the perfect assist to my suicide. Through a series of miracles I was brought back. I am missing four days of my life including three on life support, but I am alive. I have to repair almost every relationship I treasure from the betrayal of my weakness, a chore I will perform with as much love and patience as I can muster. I may never practice my specialty again, but I am alive. My family has a husband, father, son, and brother.............

I had just lost a young girl in the ER a few weeks before. Influenza. I followed proper protocol, gave her a couple of treatments and she felt better so I discharged her home with appropriate warnings. Thirty hours later she came back, in respiratory arrest. She ended up on life support with family refusing to withdraw care. They, of course, blamed me. And, of course, complained.

My review was days later. While my employers were very sorry about the case and stated support for me, the result would likely lead to termination due to this incident and a few other cases that were trivial. I thanked them for their honesty. At first my wife and I talked about it, and I was fine. I could likely go back full time where I used to work. I returned to work that night sad, but comfortable with my likely outcome. When I got home in the early morning hours I was just sad. I cried for the girl and her family. I cried myself to sleep and woke up still sad.

There’s a saying we have in the emergency room when we witness trauma and death among the innocent: “A little piece of my soul died.” We’re never offered counseling and in the end you get the jaded emergency doctor who struggles to care. My psychologist says it wasn’t just the last girl. It was trauma after trauma after trauma.

Pretty sure I have PTSD from the Haiti rescue and recovery trip. From bloated bodies liquifying in the heat to starving kids begging in the street. Years later, walking into a Mexican hotel with similar tiles and stucco walls, I was overwhelmed by the smell of rotting flesh. Other times when opening a large perirectal abscess, I could smell dead bodies.

Sitting alone with my grief, I grabbed what I needed and drove up to the mountains. I thought my wife would be better off without me. I texted: “I’m so sorry. You deserve better. I have tried to be strong. I can’t take it any more. To have that girl die was too much. To have to face being terminated for it? I can’t go on. I’m sorry. I love you to the end of the world and back but after one final hurt, I can finally stop hurting you. You have your family and church to help you and you have your finances taken care of.”

I took a handful of pills with the final thoughts that my student loan debt would not pass on to my wife and at least she has my life insurance to take care of her. Then came the police cars. I don’t know why, except not wanting to talk to them or face my wife, I continued driving. I obeyed all traffic laws, never exceeded 22 mph and in no way endangered pedestrians or other motorists. At one point I pulled to the side, and multiple officers took cover and aimed guns at me. They wanted to know if I had guns, and I told them that they were in the vehicle and they could have them. I kept my hands visible as directed but refused to exit the truck because I did not want to talk to them. Ultimately, I was thrown from the truck, tasered, cuffed, and put in the back of a police car.

commentary:  Police are no longer there to protect and serve...This makes me very angry!

I requested to go to the hospital. I was surprised that they took me to jail. Seemed weird because I thought all suicidal people came to the hospital first. I started to get sick from the overdose. Sweating and nauseated and a little unstable on my feet. They had me sit in a holding cell in the booking area, and that’s the last I remember.

Police need to be trained in communicating with emotionally disturbed people. Police department and authorities are totally negligent and culpable for many events.

Of the next four days I have almost no memory. I am told I went into respiratory then cardiac arrest in the jail and they started CPR. I was finally transported to the hospital, where they got a pulse back. I was critically ill on ventilator support. My family was told I was going to die. Then my sweet daughter found what I took, and the appropriate meds were given. I improved. Couple days later I was off the vent and out of the ICU.

Almost every day, since that worst day, my wife just looks at me and repeats “I can’t believe it even happened!” The people I’ve told about this are utterly shocked. I have spoken with a few residents I used to teach and they can’t believe it. I can’t either.Seemingly without warning. Could happen to any doctor. 

Doctors, Don’t let your job suck the life out of you

Replacing the Affordable Care Act | Health Care Reform |

Replacing the Affordable Care ActLessons From Behavioral Economics

Jonathan S. Skinner, PhD¹; Kevin G. Volpp, MD, PhD²

Sticks work better than carrots in economic terms but are politically damaging.

Republican efforts to replace the Affordable Care Act (ACA) are not over, despite the failure of the American Health Care Act (AHCA) legislation. The major challenge facing the AHCA was the loss of insurance coverage for an estimated 24 million people.¹ Any subsequent reform, especially those less costly than the ACA, will have the same challenge of keeping currently insured individuals and households from discontinuing their insurance. In this Viewpoint, we draw on behavioral economics to propose 4 general principles for health insurance reform to help ensure that the currently insured will not lose their coverage.

Incentives for Healthy Individuals

In insurance markets, healthy people subsidize people with acute and chronic disease and other health conditions. Insurance is still valuable for healthy people, because they need not be concerned about the risk of no insurance coverage in the event of unexpected injuries or acute health events. However, there is often a tendency to minimize those future risks and use the money now for more pressing concerns rather than signing up for expensive insurance. Once enough healthy people no longer elect to enroll in and purchase health insurance, a major challenge occurs, with rising premiums and the eventual collapse of insurance markets.

Incentives to encourage healthy individuals to sign up for health insurance can be described as either carrots or sticks. The ACA has both carrots (refundable tax credits) and a stick—the mandate—to ensure that healthy persons purchase insurance. Granted, the stick was not always effective; initially the amount was too small, and the penalty is too far in the future. But it was widely credited with increasing enrollment by overcoming “present bias,” the idea that potential future medical costs are discounted too much when compared with having to write a check for insurance premiums today. By contrast, current proposals rely almost entirely on carrots—tax credits for enrollees.

Behavioral Economics Principles

The first principle from behavioral economics research is that carrots do not work nearly as well as sticks; $2 in subsidies induces approximately the same behavioral response as $1 in penalties.² Furthermore, subsidies drain money from the federal treasury, whereas sticks bring in more revenue.

A second behavioral economics principle involves instant gratification; paying significant premiums means that something is received in return. Bare-bones or catastrophic plans, along with health savings accounts, do not do well from the perspective of instant gratification. Aside from the relatively few families who benefit from receiving catastrophic care, the vast majority of people do not experience any “immediate gratification” from paying those premiums, because they never reach the catastrophic cap. Even current enrollees in bronze high-deductible plans wonder why, after paying substantial premiums, they still are responsible for burdensome deductibles and co-pays.

People’s tendency to focus on immediate gratification also has important implications for the continuous coverage requirement in the AHCA. This requirement is a stick but is unlikely to work. Under this provision, if an individual who did not purchase insurance coverage now or who lets current insurance coverage lapse, would have been subject to a 30% penalty to sign up again. It is unlikely that young invincibles, young healthy people who see themselves as invulnerable who have been ignoring health insurance up until now, will suddenly become concerned about their ability to buy insurance many years down the road. Furthermore, the 30% stick would have discouraged uninsured people from buying insurance—precisely the opposite effect of the mandate.

Failure inevitably brings analysis and theory...neither of which can guarrantee success on the next go-a-round.

Replacing the Affordable Care Act | Health Care Reform | JAMA | The JAMA Network

AAMC increases projection of physician shortage up to 100K | Healthcare Dive

AAMC increases projection of physician shortage up to 100K

• The Association of American Medical Colleges' (AAMC) new estimates of the country's growing physician shortage shows it will range from 34,600 to 88,000 doctors by 2025 and from 40,800 to 104,900 by 2030.
• The AAMC's estimates in 2016 showed a projected shortage ranging between 61,700 and 94,700 by 2025.
• The number of new physicians is "not keeping pace with the healthcare demands of a growing and aging population," according to the study conducted by a division of the global information company IHS Markit. 
• The growing awareness of the physician shortage has helped many in the healthcare industry develop new strategies to better help the dwindling amount of medical professionals meet the increased demand for care services, which is partly due to a larger portion of the population having health insurance coverage. 
  These range from allowing nurse practitioners to practice independently to easing at least some of doctors' administrative burdens. The number of administrative tasks that physicians are required to do on a daily basis, including imputing health data into electronic health record systems, has been continuously cited as the main cause of burnout by physicians who have responded to surveys like the one conducted by Medscape.
  A medical student and a radiation oncology specialist wrote a shared byline published by Stat on Tuesday that argues addressing the concerns medical professionals have with debt and their financial stress will help prevent burnout and depression. They offered "six strategic solutions" to focus on, such as limiting tuition increases and increasing federal funding.
  However, the shortage is not just among physicians but also among nurses. A report released earlier this month shows nearly half of surveyed nurses (49.8%) are considering leaving the profession, which will in turn exacerbate the problem at a time when the country's aging population will continue to increase the demand for care. 
  “By 2030, the U.S. population of Americans aged 65 and older will grow by 55%, which makes the projected shortage especially troubling,” AAMC President and CEO Darrell G. Kirch said in a statement. “As patients get older, they need two to three times as many services, mostly in specialty care, which is where the shortages are particularly severe.”
  The AAMC once again recommended a multi pronged solution to the problem. This includes "expanding medical school class size, innovating in care delivery and team-based care, making better use of technology, and increasing federal support for an additional 3,000 new residency positions per year over the next five years."
• New Research Reaffirms Physician Shortage
• Physician burnout: What can be done 

AAMC increases projection of physician shortage up to 100K | Healthcare Dive