Category: Anxiety

Hospitalist Versus Primary Care-What Really Makes Us Well

A recent article in the Annals of Internal Medicine was very interesting.  It is research to determine the cost effectiveness of hospitalists versus primary care physicians.  A hospitalist is a physician that specializes exclusively in hospital care, and the primary care physician is the family doctor that is familiar to most people.  Family physicians may receive additional training to become a hospitalist, but most hospitalists are boarded in internal medicine-sometimes in combination with other specialties.  Historically, a primary care physician was allowed to visit and consult on their patients in the hospital.  About a decade ago, insurance companies discouraged hospital visits from the Primary Care Physician (PCP), in preference to physicians that were specifically trained to perform inpatient care-the hospitalist.  At first blush, this change in physician practice appeared to make good sense.  It provided an economic incentive for hospitalists to limit their practice to the hospital.  At the same time, it limited the economic incentive for primary care physicians to visit their hospitalized patients.  It seemed like a good method to avoid duplicate charges and overlapping skills.  It assumes the hospitalist provides similar or better care than the PCP.  The outcome research does not appear to support this conjecture.

The research by Kuo & Goodwin (2011) compared five percent of all enrollees to Medicare from 2001 to 2006.  The positive side of  hospitalist care resulted in a shorter hospital stay (about half a day), and a total savings of fifty Medicare dollars on every hospitalization.  This is in comparison to management by the patient’s community based PCP.  Unfortunately, examination of the elderly patient’s usage of the Medicare system after discharge told a different story.  Patients cared for by hospitalists resulted in significantly greater emergency room visits after discharge, more frequent use of nursing facilities, more frequently readmissions to the hospital, and patients were less likely to be returned to their home after discharge from the hospital.  The authors concluded that the “decreased length of stay and hospital costs associated with hospitalist care are offset by higher medical utilization and costs after discharge.”  There are several limitations to this study; for example the patient sample was largely elderly (selection bias), the period examined after discharge from the hospital was only thirty days (decreased power to extrapolate), and the statistical methods used may not be the most appropriate.  On the other hand, no other studies of this type, let alone size and scope, have been brought to this author’s attention.

According to Wikipedia, the Chapter 13 United States Bankruptcy Code lists forth the statutes governing the various types of relief for bankruptcy in the United States. pharmacy levitra http://nichestlouis.com/viagra-5961.html On this occasion, you should clear what’s 100mg viagra price going wrong between endometriosis and pregnancy. They interfere with the secretion of PDE5 means more blood flow to the penile organ and many physical conditions on line viagra important site can restrict the blood flow to the penis. Email us .Website: generic in uk viagra www.powerkhan.co.ukJoin Us: Twitter | Facebook | Google+ . The research does not appear to make sense.  Primary care physicians are primarily trained for community-based care.  Hospitalists should have greater knowledge and experience providing care to the inpatients sampled in this study.  The inherent advantage of the primary care physician is their prior knowledge of the patient’s medical history, and their personal relationship with the patient.  It is likely that the first factor is less important than the second for a couple of reasons.  The medical history of nearly any patient is easily communicated to another physician.  Most conditions are so common they have two to three letter abbreviations understood by nearly any clinician who studied in the United States.  The elderly subjects used in this retrospective study will tend to have more extensive medical histories than younger patients.  A small minority of subjects used in this study would have complicated or unusual medical histories that could not be reduced to a few abbreviations.  These study subjects may be at a disadvantage when under the care of a hospitalist.  Their history may not be fully understood by the PCP, and/or the notes obtained from the PCP may not be sufficient to direct medical care.  It is believed that these complicated hospital admissions represent a small fraction of the total hospital admissions sampled by this study, though there is no direct proof of the same.  This study also lacked an examination of premorbid mental health issues on the functional outcome of patients.  Depressive or anxiety disorder patients may have a greater need for a personal relationship with a physician, as reflected by greater usage of Medicare funds after discharge from the care of a hospitalist.

A primary care physician’s personal relationship with the patient is an important variable that separates the hospitalist from the PCP.  If all else is held equal, including skill and experience, this factor looms as a gigantic independent variable.  The dependent variable in this study is the patient’s health status after discharge from the hospital.  The independent variable of faulty communication between PCP and hospitalist cannot be ruled out or held as trivial, yet it is certainly less pervasive than then the personal relationship enjoyed by the PCP.  Sometimes this is referred to as “nonspecific factors” that are essential to health.  It is not that clinicians are unable to be specific in talking of these issues, it refers to the scientific difficulty of objectively measuring and comparing the features of a doctor-patient relationship.  Nonspecific factors in psychotherapy (patient’s perspective) include feeling accepted, being understood, being encouraged to overcome difficulties, being respected, and having someone interested in their welfare.  This research suggests that a preexisting personal relationship with a physician leads to increased patient wellness after a hospitalization.  Many of these nonspecific factors are crucial to a positive psychotherapeutic outcome.  It is a greater conceptual stretch to suggest that a personal relationship with one’s physician is crucial to a positive medical outcome.  Perhaps it is not crucial to physical health, but this study suggests that a medical doctor’s personal relationship with the patient is very important-regardless of diagnosis.

Induced Angst

Angst is one byproduct of the U.S. government’s long-term fiscal policy.  Angst may be defined as a deep seated insecurity experienced by those free to choose.  A dread of one’s personal responsibilities.  Fiscal dread experienced by the American public is not a deep seated insecurity to manage the burden of personal responsibility.  It is a public realization that few political figures are motivated to realistically appraise the situation, let alone offer viable alternatives.  The potential for economic disaster may be kicked down the road a few years, subsequent to expensive and ultimately useless measures traditionally employed.  Domestic dread will increase proportionally to the decline of important local services.  Foreign dread will decrease the willingness to buy American debt, which will accelerate the pace of ultimate financial ruin.  Personal dread may be lessened by exerting personal control, that is embodied by the choice of a candidate in democratic societies.  It is increasingly a choice between dysfunctional alternatives.

The exertion of greater personal control is one method to reduce angst, and hence the accompanying anxiety.  The less control one perceives in their environment, the greater the anxiety and anticipation of possible disaster.  The choice of political parties gives people a sense of control, as do the choice of pundits.  The amplitude of the anger may proportionally increase the perception of personal control.  The partisan bickering will become louder as the deadline for each successive federal budget draws near.  Appointed representatives of the American people will blame each other for the mismanagement, and the citizens will choose their sides.  The system on which they depend will remain in place, though each side declares a victory for progress.  Public angst will increase proportionally with the heightened awareness of illusionary choice.

What can be done to lower the public angst?  Greater public control over the government would likely decrease the angst.  Violence is the ultimate form of control, but it is rarely the best alternative.  Think of the peasant revolt during the French Revolution.  Aristocratic blood flowed in the streets and alleys of Paris, yet the monarchy regained control shortly thereafter.  Many decades passed before democracy was formalized in France.  Class violence in America would likely result in greater repression of the lower echelon, and little else.  Class divisions based upon wealth would be strengthened, not diminished.  Gated communities may become modern castles, keeping the hordes of the impoverished at bay.  Angst-ridden dread may explode into vengeful anger.  Anger devoid of a clear goal would be less than helpful, and possibly disastrous.

The non-disease causes of ED may include obesity, smoking, diabetes, high blood pressure, high cholesterol, chronic alcoholism, neurological issues, stress, anxiety and depression. tadalafil generic india It is also delivered right to the user’s house; it is also cheap and affordable. thought about that levitra lowest price The most popular and common drug in treating ED are caverta, zenegra , kaqmagra oral jelly prescription free tadalafil etc. Women are the easiest target of low sex check over here levitra samples desire. Increasing public control of the government is a simple idea that is nearly impossible to implement.  It would engender massive political resistance, as it takes from those who currently hold the reigns of power.  It would weaken control of the government by the wealthiest, and hence the most powerful individuals.  It would medicate the illness that plagues most forms of government; for example, secrets, influence peddling and blatant misrepresentations to the public.  This illness is a common infestation of autocratic governance.  Any or all these symptoms may threaten the health of democratic governance.

If the medicine entails greater public control of the government, how should the pill be formulated?  Videotaped meetings, recorded phone calls, and standardized petitions for influence are healthy ingredients.  Civilian boards that oversee the labeling of secrets would lessen side-effects.  Prohibition of candidates becoming lobbyists is necessary to stop the spread of the disease.  The efficacy of the medication would be enhanced by forcing all candidates to use equal funds in the pursuit of political office.  Currently, the wealthiest or best fund raisers obtain political office, which is not the best selection criteria for someone to represent the will of the people.  It suggests that the candidate is greedy and possibly crafty, rather than a humane and capable administrator sought by the voters.  The medication tastes sweetest to those suffering with political angst, and most bitter to those who support the disease.

Diseased politicians have forgotten that they are servants of the people.  Politicians must relinquish any pretensions to privacy when they run for public office.  Government secrets typically protect those employed in the government; not the people they were hired to serve, or elected to represent.  Competition between politicians must be fought on a level field of play.  Transparency may drive psychopathy into the shadows, but it is not likely to make it disappear altogether.  The public must be willing to suffer the anxiety engendered by change, or increasingly stagnate from the compulsion to remain on the present course.