State regulations create obstacles for telemedicine

Telehealth offers significant gains in accessibility for patients who live in . remote areas without access to primary care and/or sspecialty care.  Despite these advantages regulations differ in each state.  Health care reform in the ACA and future iteratioins has given insurance coverage to millions of more Americans. Coverage however does not guarrantee access to a physician.

Some adaptations already include the addition of nurse practitioners who are licensed to work independently. Their training is now standardized and many practice in a physician supervised clnic. However some work in rural and remote locations, requiring communication with a physician. Telemedicine offers the ability to share images, diagnostic images from otoscopes, ophthalmoscopes, and dermatology images, even with magnification. An ongoing interactive session adds to the NPs knowledge for a particular case.  Remote imaging is widely used for screening of diabetic retinopathy.

State regulators and state medical boards who advise legislators have uppermost in mind the efficacy, reliablity and safety of this technology.   Medical boards have already prescribed courses and limitations in guidelines for using telemedicine.  These are easily found elsewhere in the guidelines form the American Telemedicine Association.

The Federation of State Medical Boards (FSMB) Chair, Jon V. Thomas, MD, MBA, appointed the State Medical Boards’ Appropriate Regulation of Telemedicine (SMART) Workgroup to review the “Model Guidelines for the Appropriate Use of the Internet in Medical Practice” (HOD 2002)1 and other existing FSMB policies on telemedicine and to offer recommendations to state medical and osteopathic boards (hereinafter referred to as “medical boards” and/or “boards”) based on a thorough review of recent advances in technology and the appropriate balance between enabling access to care while ensuring patient safety. The Workgroup was charged with guiding the development of model guidelines for use by state medical boards in evaluating the appropriateness of care as related to the use of telemedicine, or the practice of medicine using electronic communication, information technology or other means, between a physician in one location and a patient in another location with or without an intervening health care provider.

MODEL POLICY FOR THE APPROPRIATE USE OF TELEMEDICINE TECHNOLOGIES IN THE PRACTICE OF MEDICINE Report of the State Medical Boards’ Appropriate Regulation of Telemedicine (SMART) Workgroup Adopted as policy by the Federation of State Medical Boards in April 2014

Given the rapidity of change in Health 3.0 regulations will not remain statics as HIT evolves further.

50 STATE PDF FILE APRIL 2017 FINAL PASSWORD PROTECT.pdf

61% of healthcare officials indicate terrible, poor ROI on EHRs, survey finds

What did the HITECH ACT and Federal investment for electronic health records produce ?

The Rand Study Projected  benefits for EHRs  which failed to materialize. There are many reasons.

Where did HITECH’s $35 Billion Dollar Investment Go?

Enough time has passed to evaluate the impact of electronic health records on the practice of medicine in hospitals and outpatient facilties.

The results are damning. Despite early warnings by those in the trenches HHS, and CMS wantonly disbursed over 35 billion dollars into inadequate EHR systems. The systems were immature, untested, user unfriendly and made work loads for physicians and other health professionals so difficult that it initiated an enormous increase in physician burnout, early retirement and the death of private solo practice.  A term "meaningful use" was invented, not to make the systems more usable but to subvert the data accumulated to be 'scraped' and analyzed for later analysis.  MU also required EHRs to be interoperable (not a bad idea) as well as contain certain data fields many of which are not germane to specialty medical practice.  Unless this data was accessible to CMS physicians would be penalized a significant sum for non-compliance.

This was a windfall to hardware and software vendors,  and a new group of expensive consultants to advise health providers on IT.

The results are now in. 

Becker's Health IT and CIO Review reports:

Nineteen percent of healthcare professionals rated the return on investment for EHRs as "terrible," according to a Health Catalyst survey.

Health Catalyst surveyed more than 1,100 healthcare professionals about their attitudes toward EHRs at the Healthcare Analytics Summit in Salt Lake City earlier this month.

Here's how healthcare professionals responded when asked to assess the ROI produced by EHR investments since the Health Information Technology for Economic and Clinical Health Act of 2009, which incentivized EHR adoption.

1. Terrible: 19 percent

2. Poor: 42 percent

3. Mediocre: 29 percent

4. Positive: 9 percent

5. Superb: 1 percent

Nineteen percent of healthcare professionals rated the return on investment for EHRs as "terrible," according to a Health Catalyst survey.

Health Catalyst surveyed more than 1,100 healthcare professionals about their attitudes toward EHRs at the Healthcare Analytics Summit in Salt Lake City earlier this month.

Here's how healthcare professionals responded when asked to assess the ROI produced by EHR investments since the Health Information Technology for Economic and Clinical Health Act of 2009, which incentivized EHR adoption.

1. Terrible: 19 percent

2. Poor: 42 percent

3. Mediocre: 29 percent

4. Positive: 9 percent

5. Superb: 1 percent

Increasing Costs

In 2009, the Congressional Budget Office (CBO) estimated that fully integrated interoperability would save the Medicaid and Medicare programs $12.5 billion through 2019. These savings have yet to materialize and with 50 percent of doctors unable to meet current program requirements, it is unlikely that taxpayers will see these savings in the near future. Moreover, the number one complaint we hear from providers is the unexpected costs of maintaining and upgrading their systems.

ONC does not describe how it will determine the costs associated with the adoption of expanding interoperable platforms. Nor does ONC explain how it would evaluate cost or incorporate cost control into the development and scaling of interoperability. Provider concerns about the cost of complying with the program should be addressed in the roadmap.

We appreciate the notion that as new models of care begin to reward providers for outcomes, changing incentives will reward interoperability. We agree. However, we live in the aftermath of the HITECH Act, where to date $28 billion have not resulted in significant improvements to clinical care coordination or quality. Without concrete immediate and long-term steps, tied into accurate, usable (and collectable) performance measures, we will continue to see a meager return on investment.

Lack Of Oversight

One way to improve oversight of the program is to put in place measures to gauge success. ONC appears to be taking a step in the right direction by describing seven different lenses to measure and evaluate the quantity and quality of information flow within interoperable systems, such as who is exchanging information, and where and what type of information is being exchanged. However, without specific performance goals for each type of measurement, it is unclear how ONC will measure success. In addition to defining these metrics, effective oversight includes describing how the metrics will be collected, analyzed, reported, and used for decision making.

CMS and HHS, with Congressional approval by funding HITECH have created a system of increased cost, poor design, and have sabotaged health providers in their already overbearing workflow.  They remain hiding behind future studies to prove something that is already self-evident. Res Ipsa Loquitor.

61% of healthcare officials indicate terrible, poor ROI on EHRs, survey finds

Take Two: Inside Bill Cassidy's Plan To Replace Obamacare

Another Republican plan to replace Obamacare is looming.  The challenge is daunting to revise Obamacare without endangering total insurability for those who want it. And those who refuse coverage are fined by the IRS.  How has it come to this?

There have been at least three Obamacare replacement plans that have come to light in the media.  There are undoubtedly many others which have not come to the light of day.  Political and partisan thinking have not helped. The agenda is which political party will gain, not the welfare of patients or the gordian knot of health systems.

America's health system is a collection of organizations. Medicare, Medicaid, Veteran's Administration, DOD, and Private insurers. During the past five years there have been multiple mega-mergers of insurance plans to maximize profit. Skimming and selective availability diminish the availability of health insurance coverage.  While federal regulations have attempted to increase competition and decrease cost the opposite has occured.

The most recent attempt is

Graham-Cassidy-Heller-Johnson

More specifically, GCHJ:

• Repeals Obamacare Individual and Employer Mandates.
• Repeals the Obamacare Medical Device Tax.
• Strengthens the ability for states to waive Obamacare regulations.
• Returns power to the states and patients by equalizing the treatment between Medicaid Expansion and Non-expansion States through an equitable block grant distribution.
• Protects patients with pre-existing medical conditions.

GCHJ replaces the BCRA.  “Graham-Cassidy-Heller-Johnson” builds off of many of the ideas in the Better Care Reconciliation Act, but with one major change.

Block Grants are the key to  GCHJ, Federalism at it's worst.

And in further news......

Obamacare Repeal, Thought Dead in July, May Be Revived in Senate

 Congressional efforts to repeal the Affordable Care Act sprang back to life on Monday as Senate Republicans pushed for a showdown vote on new legislation that would do away with many of the health law’s requirements and bundle its funding into giant block grants to the states.  The Republican leaders of the latest repeal effort, Senators Lindsey Graham of South Carolina and Bill Cassidy of Louisiana, said their effort — considered all but impossible earlier this month — was gaining momentum. The seven-year drive to repeal President Barack Obama’s signature domestic achievement appeared to collapse in July when it fell one vote short in the Senate.

“I’m not interested in only having an up-or-down vote on what’s one-fifth of the gross national product,” Mr. McCain said.  

He fails to point out the fact that 100% of Americans are affected by health reform.

The Latest Health Care Repeal Plan Would Give States Sweeping Discretion

Take Two: Inside Bill Cassidy's Plan To Replace Obamacare

Top US hospitals aggressively promoting alternative medicine offerings

GOOP and Gwyneth: Blame mainstream media

It is easy to mock the ridiculous and potentially harmful health advice and product lines promoted by Gwyneth Paltrow and her team at Goop. Sleeping near healing crystals, lugging around jade eggs in the vagina, swilling moon juice, undergoing raw goat milk cleanses, dabbing on sex dust, and snapping photos of your aura are just some of the ridiculous treatments and remedies offered at high prices to those looking for health ideas from a movie star.

Secrets of the jade yoni

If you want to add Yoni treatment to your practice, Check out this site.

They come in different sizes, colors and customizable extraction devices. It is advisable to not microwave your YONI JADE EGG.  They are available online

The mocking may be a bit understated. How does this company and other equally daffy outfits pull off these highly lucrative health scams?

Note,  Disclaimer:  The author makes no recommendation as to the safety or efficacy of manufacturers of the YONI

Besides placing a YONI in a vagina, the author says this with 'tongue or Yoni in cheek' or a Yoni

Mainstream medicine is partly to blame.

Without going into much detail, who would not feel better in the setting above, whether you are at end-stage disease or in remission from a cancer.

When is a supplement an approved drug ?  Two pharmaceutical-grade drugs are being market as a drug in Russia and as supplement in the U.S. 

In addition to the drug/supplement conundrum there are a multitude of alternative treatments, reiki, vaginal crystals (a la Paltrow), magnetic therapy, essential oils, and accupuncture,

Supplement manufacturers are powerful financially and often take legal steps to protect their products.  There is a huge financial at stake.  Manufacturers have often attacked research scientists and their peer reviewed article, causing financial personal harm to them personally.

Pieter Cohen, a highly respected medicine specialist and who has a long list of peer reviewed articles has been attacked in the past for his articles.

The issues are not polar opposites.  Many patients are reticent to tell their allopathic doctor if they take supplements.  It is important because some of the supplements increase or reduce the actions of prescription drugs.  Intelligent doctors listen quietly and do not judge, offering suggestions and focused warnings about possible interactionsl

Top US hospitals aggressively promoting alternative medicine offerings

Hospice, Designed For The Dying, Is Discharging Many Live Patients : Shots - Health News : NPR

How to fail at Hospice 

Hospice was designed for in home care for end of life care.  Medicare reimburses the hospice agency for all care and medications while the patient is at home.


Has treatment improved, or do hospice agencies profit more by discharging prior to dying ?

Some who study aging are concerned that certain hospices are gaming the system. That's a worry of Susan Enguidanos, an associate professor in the Leonard Davis School of Gerontology at the University of Southern California. For example, she says that some hospices may be trying to avoid paying for costly treatments by discharging patients temporarily when they need to go to the hospital.

"Individuals that are going in for these very brief health issues are coming out and then, they're being readmitted to those [same] hospices," says Enguidanos.

That's not a good reason to discharge someone, says John Keyserling, senior vice president for communications and policy at the National Hospice and Palliative Care Organization, the trade association for hospice providers.

"Any association between profit margins and clinical decision making is inappropriate and not something that the hospice community supports," Keyserling says.

That hospice community has nearly doubled in size since 2000. Susan Enguidanos says it's also changed a lot.

"Hospice organizations started as grass root efforts and were largely non-profit for a long time," she says. "Now we've had a huge increase in for-profit hospices." There's a concern, says Enguidanos, that by discharging patients early, some hospices may be "trying to avoid costs that they should be responsible for.

Whatever the short-comings of some hospices may be, Keyserling says that his biggest worry is that people who could be helped by hospice aren't taking advantage of it in time. He says about half of patients die within 17 days of being admitted. And that turns hospice into "crisis care" instead of the comfort care it's intended to be.

"Hospice, Designed For The Dying, Is Discharging Many Live Patients : Shots - Health News : NPR

2017-18 Best Hospitals Honor Roll and Overview | Best Hospitals | US News

Somewhere in America, at a pace of about once per second, a patient checks into a hospital. With more than 33 million hospitalizations a year and so many patients on whom to sharpen their skills, hospitals could be expected to meet the most demanding standards for quality and safety.

To help readers narrow their search, U.S. News evaluates hospitals in 16 areas of complex specialty care and nine important procedures and conditions. (GETTY IMAGES


Readers should use caution when making choices or conclusions from the list.  Choosing a physician rather than a hospital can be more important than the hospital.  Some of the specific results are from statistical averaging, and do not report other statistical information, such as standard deviations,mean, or mode.

FAQ: How and Why We Rank and Rate Hospitals . from US News

Readers must remember, U.S. News is not an accrediting organization and bases their reports from many sources. The authors of the article are By Ben Harder, Avery Comarow and Geoff Dougherty |

The authors of the US News report are verified, all are credible sources and have been vetted by US News.  (This is probably as good as it gets. (gml)

Ben Harder | Professional Profile - LinkedIn

Avery Comarow | Professional Profile - LinkedIn

Geoff Dougherty, MPH | Professional Profile - LinkedIn

More specific information can be found at these resources.

Methodology Updates for Best Hospitals 2017-18

Methodology Changes for 2017-18 Best Children's Hospitals

Patient safety indicators are defined by the Agency for Health Research and Qualit

2017-18 Best Hospitals Honor Roll and Overview | Best Hospitals | US News

University Of Vermont To Phase Out Lectures In Med School : Shots - Health News : NPR

William Jeffries, a dean at the University of Vermont's Larner College of Medicine, is leading the push to end lectures for medical students.

Courtesy of UVM Larner College of Medicine Photography




The University of Vermont is launching itself into the brave new world of Health 3.0.

Back in the last century (1964) when I matriculated at George Washington University I expected to spend almost 40 hours each week for the next two years studying basic science,  then returning to my home and spending another 4-6 hours studying for the next day's marathon lectures.  With minor modifications this method has remained until most recently.

The school has begun to phase out lectures in favor of what's known as "active learning" and plans to be done with lectures altogether by 2019.

For students starting medical school, the first year can involve a lot of time in a lecture hall. There are hundreds of terms to master and pages upon pages of notes to take.

But when the new class of medical students begins at the University of Vermont's Larner College of Medicine next week, a lot of that learning won't take place with a professor at a lectern.

Proponents of the new curriculum state,

"The issue is that there is a lot of evidence that lectures are not the best way to accumulate the skills needed to become a scientist or a physician. We've seen much evidence in the literature, accumulated in the last decade, that shows that when you do a comparison between lectures and other methods of learning — typically called "active learning" methods — that lectures are not as efficient or not as successful in allowing students to accumulate knowledge in the same amount of time."

While several other medical schools have been using PBL or AL(Harvard Medical School) there are some who are reticent.

Below are comments from students and educators (from Redditt)

REQUIRED PBL is terrible. It's a massive waste of time. At least with recorded lectures, I could practice the type of ''active learning'' that was best FOR ME and not be stuck in aggravating, long PBL sessions where each hour yielded very little actual knowledge.

I am old school and like to read textbooks - I managed to do that by reading first, watching lectures on fast speed to make sure it all made sense and follow up by active spaced repetition and practice questions + Q/A study sessions with a close friend. If I was forced to sit in PBL for 4-6 hours/day I would not have had time to learn this way and my education would have suffered. If my medical school ever goes full PBL instead of the 1 hr/week session we have now, I would strongly voice a negative opinion.An 

My first two years of medical school had 1-2 Problem based learning modules each month. About a week before the session my school would assign a reading from one of those large 18 pound textbooks that would give us (if we read it) the foundation over the topic to be covered.

We'd then spend an hour applying these foundational concepts to 3 or 4 cases and end with a 20 minute informal lecture on the high points of the material. When organized well I think it's a valuable teaching tool. My team mates were assholes and I hated going because of this. I wouldn't want this to be 100% of my information delivery system, but it added a lot to general didactic lectures.

But your scenario sounds like garbage. Putting students in a situation that they have no foundation in is a waste of everyone's time.

Now adapting to a single model of teaching is dangerous. A university in Japan built their entire campus on the model of PBL, but between they started building and the building was finished they figures out that wasn't the best way to learn.

Then you have TBL, which seem to be a random number of letters.

Now the buzzwords are "flipped classroom" and "active learning". Yes, but is that the best use of the students time or money? I don't know.

There are US medical schools that use the 100% TBL/PBL model. Data shows that the students historically perform above average on boards, but having talked to them in person they make it sound miserable. I was rejected from my #1 choice that was one of these all PBL schools. It was a blessing in disguise.

  

What the studies I've read say, and what was presented at the last AMEE conference I attended, was that pretty much regardless of whichever pedagogy you elect to follow medical students will learn.

They will pretty much learn the same, and pretty much be as good physicians as those that used other methods.

There are some differences, which indicate PBL and TBL score higher on the USMLE, but at a significant cost in time and money.

It seems a combination of lecture based learning, advanced study and PBL will serve best.No one method is sufficient to educate a physician.

Introduction to Medical Teaching, William Jeffries, M.D. Katherine Hugget on Amazon

University Of Vermont To Phase Out Lectures In Med School : Shots - Health News : NPR

King George and the Health Care Revolt

Sean MacStiofain said, “most revolutions are caused … by the stupidity and brutality of governments.” Regulation without legitimacy, predictability, and fairness always leads to backlash instead of compliance.  (NIRAN S. AL-AGBA, MD

More stress for patients and another example of wanton practices by insurers ahead.

Here we are, several weeks after Independence day 2017. Physicians have always been proponents of independence and free will.

It is time for all physicians to declare their own Declaration of Independence. There has been a change by physicians from murmur to rumble. The situation is much like that of 1775 where endless argument with King George led to a revolution.

Men do not go to war unless diplomacy fails, and diplomacy has failed to resolve the failure of our health system with talk.

Just like politicians physicians have their own 'base' . Those individuals who talk amongst themselves under the fray of their representatives, not in formal organizational discussions.  The 'base' know that their ideas become diluted, distorted and compromised by politicians and organizations. Then there is the niche that simply do not belong to organizations. Implicit in this choice there is little accomplished by supporting them.  Some belong only to their specialty society which improves their access to continuing medical education and a means to socialize with immediate peers.

During the past decade numerous paramedical organizations have spontaneously emerged, often pioneered by one or two physician leaders, at first relatively unknown to the majority of physicians.  Although overshadowed by well funded established medical and subspecialty societies private contributions have kept these new organizations alive.  Most important to their growth has been the increased regulatory environment and ennui of congress.

Health reform: It’s time for Congress to grow up and do their jobs

Health – /helTH/ – The state of being free from illness or injury

Care – /ker/ – The provision of what is necessary for the health, welfare, and protection of someone or something.

System – /’sistəm/ – A set of things working together as parts of a mechanism or an interconnecting network.

It’s not keeping us Healthy, it doesn’t seem to Care, and it’s certainly no kind of System. What we’re got is more about hostile parties protecting their turf and income than a system that’s working together. The docs fight the insurance companies to get things covered; the patients fight the hospitals over inflated, inscrutable bills; the insurance companies fight the pharmaceutical companies over the eye-popping prices of new drugs. The people least suited to fight end up losing the most — that’d be the “patients.”

Meanwhile: The peeps we’ve hired to fix this mess are too busy trying to make each other look bad — which, by the way, is like shootin’ fish in a barrel these days, amirite? — to pass some kind of legislation to even begin to help fix this fine mess. Ever get hired to do a job that you don’t do for 2 or 4 or 8 or 20 years? Didja keep that job? Mind: boggled.

I will now specifically criticize the approach of both parties. Those of you with strong loyalties may want to skip the next (Democratic) or following (Republican) paragraphs, lest you be exposed to a worldview that’s not aligned with your own. But for the few of you left who are still capable of seeing two sides of an issue, start here:

Democrats: Obamacare has problems. The insurance marketplaces in many places are collapsing, and premiums are going thru the roof. Even people who have “insurance” often have huge deductibles that they can’t afford. In short: just having “insurance” isn’t the same as “having access to health care.” Obamacare didn’t do a thing to rein in the biggest problem: health care costs too much, and too many people (sorry, “market stakeholders”) are chewing up huge slices of the pie without contributing anything useful to helping patients. I know you’re feeling hurt that you lost the last election, but can you please grow up, talk to the other side, and come up with some common ground to start to address the problems?

Republicans: The free market, alone, cannot save health care. The barriers to entry are too huge (it’s hard to become a doctor, harder to open up a company to manufacture medicines, and even harder to open up a hospital) — which means competition is artificially stunted, and won’t pop up automatically to reduce prices. Also, emergency departments are required, by law, to offer care to people who cannot pay; that’s morally the right thing, and don’t even think about removing this safety net. Health care choices are also difficult and fraught, and often made under the duress of pain and worry. People cannot be expected to call around to different ambulance companies to check their prices when they’re experiencing crushing chest pain. You have to admit: Health care is unique, and you can’t depend on free market principles, alone, to fix it. The solution is going to include regulations and guidelines and (gasp) some guarantees of coverage, and might even require ways to rein in insurance companies, hospital, doctor, and pharmaceutical profits. I know you’re feeling giddy that you won the last election, but can you please grow up, talk to the other side, and come up with some common ground to start to address the problems?

It’s not easy, I know, but at this point, it’s clear that members of both parties aren’t keeping their eyes on the ball. Your job isn’t about re-election, and payback, and “If you play with Susie than you can’t be my friend anymore.”

If you’re in medicine, you’re in politics

The foundation of that system and our profession is the doctor-patient relationship. But this sacred and uniquely human interaction does not exist in isolation.  It occurs in a complex, fragmented framework of physicians, nurses and other healthcare providers, hospitals, third-party payers, pharmaceutical and medical device companies, federal and state policymakers, lawyers, and more.

In other words, if you’re in medicine, you’re in politics.

Blue Cross Blue Shield Wants People in Georgia to Self-Diagnose Before Heading to the Emergency Room

CSR payments still in question after ACA repeal failures | Healthcare Dive

Cost sharing reductions, or CSRs as they are called in government circles are allocated to insurance companies as part of the Affordable Care Act. 

• President Donald Trump now is threatening to upset the individual market by refusing to pay cost-sharing reduction (CSR) payments to insurance companies. The White House is also pushing Congress to continue efforts to repeal the Affordable Care Act (ACA) despite three votes last week in the Senate failing to garner enough support among Republicans.
• With the deadline for adjusting individual market rates a little more than two weeks away, insurance companies are pleading with the White House and Congress to make good on the CSRs and warn that premium rates would increase substantially if they are not paid.
• (author) Trump may be using this as a negotiating point in his battle to repeal the ACA.  It is on very short notice, most likely as Trump's effort to create even more chaos in the ACA.
• Meanwhile, a bipartisan group of about 40 lawmakers have been discussing changes to the ACA that both sides of the aisle can support. They are discussing permanent CSR funding, weakening the employer mandate and repealing the medical device tax, Politico reported.

CSR payments still in question after ACA repeal failures | Healthcare Dive

Jump-Starting Hard Conversations As The End Nears/ The End is Nigh

End of life decisions are usually neglected. Studies reveal few have an Advanced Directive prepared. 

Whenever one is admitted to hospital a standard question on admission forms is "Do you have an advanced directive?  Even if you ask for a form, denial sets in and the form is firmly tucked away in a pocket or purse.....to be discovered weeks later, and then promptly put in the round file.

Why do we do this ?  I am guilty of the same.  Death is a frightening event for almost all. Even physicians when it comes to themselves,  a wife or a child we freeze.  Physicians really never become comfortable emotionally with death. We file away the emotional reaction somewhere where we hide our fear, anxiety,  and grief.

After a tragic accident emotions run high and as death approaches we are paralyzed by events.

Most Americans avoid end-of-life decisions, although some people may be more likely to make them if a doctor or social worker starts the discussion. In California, the state attorney general’s office offers an end-of-life planning checklist on its website. In the past few years, other websites have encouraged those conversations, with their own suggestions on how to get started.

Rebecca Sudore, a geriatrician at the University of California-San Francisco, created prepareforyourcare.org, which provides step-by-step instructions and video stories to help people navigate the care they want at the end of their lives. She built the site in 2013 for families unsure how to broach sensitive questions. In a study published in JAMA Internal Medicine in May, she and other researchers found that the website — combined with the use of an “advance directive” form — prompted participants to plan ahead.

The study performed at a Veteran's Administration facility revealed many important points. 

Easy-to-use, patient-facing ACP tools, without clinician- and/or system-level interventions, can increase planning documentation 25% to 35%. Combining the PREPARE website with an easy-to-read AD resulted in higher planning documentation than the AD alone, suggesting that PREPARE may increase planning documentation with minimal health care system resources.The website is free, and Sudore makes no money from it.  It can be filled out at home from the website, Prepare for your Care

The site guides patients in drafting a “summary of wishes” to help families and other caregivers decide whether their loved ones should undergo life-sustaining medical interventions such as feeding tubes and ventilators.

Jump-Starting Hard Conversations As The End Nears | California Healthline

Her patients helped this doctor out of her dispair

How do physicians keep on going?  Despite all the rhetoric in the press about physician burnout there are some who have developed a sense of purpose.

JENNIFER LYCETTE, MD , AN ONCOLOGIST DISCUSSES HER JOURNEY

Recently I found myself sitting in my car in the parking lot of my clinic, unable to will myself to open the door.

I didn’t want to head into the clinic that morning. Instead, I was filled with despair; overwhelmed with the events of the world.

How can I do it? I thought. How can I walk in there and summon the energy to see my patients?

An even worse thought: Why should I do it? What is the point in trying to heal the sick, in a broken world?

In addition to world events, I had just found out that the loved one of someone I knew had been a victim of a brutal attack: a random act of violence.

I couldn’t fathom how I would be able to walk into the clinic and face my sick, and in some cases dying, patients, and put forth to them the person they expected me to be — their doctor who believes in them, and who puts all else aside to be there for them.

As I sat there, I struggled to make some sense in my mind of recent events, but I realized, there was no sense to be made. I still didn’t feel like I would be any use to my patients, but I decided I was no good to anyone sitting in my car either.

So I went inside. I started my day, and in moments I was too busy to think about anything else. A few hours later it hit me — I was sitting with one of my patients listening to her concerns, and it was a few hours later. Without conscious thought, I had automatically stepped into my role as a physician, to put all else aside except the person behind the exam room door. And something else had happened too. The sense of despair was gone. I was filled with a sense of purpose again. The one that usually gets me through the door each morning, but I had momentarily lost.

There are many forces that can make us lose our sense of purpose, both external and internal to the world of medicine. It’s awfully hard to be a good doctor without that sense of purpose. Some might call that burnout.

Some days, it feels like it would be easier to shut down, to just stop caring. There’s too much bad out there.

But that’s exactly why we can’t stop caring.

I am often asked about my job as an oncologist, and most commonly I am asked whether it isn’t too “sad” or “depressing.” I can never quite put into words how completely opposite it is.

That morning, it was only when I briefly lost my sense of purpose, that I felt a sense of despair. The opportunity and privilege to help someone in a true time of need is about as far from despair as you can get. And I get to do it every day. As do thousands of other doctors.

"Somehow or other, that person sitting in front of me has a problem, which I may think is trivial, however in their perspective, it has caused them to disrupt their daily activity to see me.  At times this overwhelms me....I am not worthy."  (Author's note)

Her patients helped this doctor out of her despair

Thriving After Life-Changing Trauma, w/Dr. Pete Poullos | Incident Repor...

Tragedy and a near death experience are reported in one of the latest "Incident Report", a weekly vlog hosted by Zubin Damania, known affectionately by "ZdoggMD"  Dr Z, as he is often called, and his crew consisting of Mrs Dr Zdogg (also a physician), ZPop, and the ZPups bring an entertaining yet highly relevant to the public in an easily understood format.  Even doctors may understand it all.

All of us experience these incidents on a daily basis.

This episode reveals the breadth of support necessary following a serious injury

1. Financial, personal resources, health plan, family, go fund me (yes people use this mechanism for appealing for dollars.)  Dr Poulos raised $ 150,000 dollars to cover extended physical therapy and non covered medical expenses
2  Social support, family, friends, fellow employees
3. Life-style changes, including future employment
4. Long term emotional support and physical rehabilitation
4. Grit !  This last one is probably the most important,  to maximize the final outcome and adjust to overwhelming challenges.