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HEALTH 03-09-10 DM EE E1 CMYK
ABCDE
HEALTH SCIENCE
E
&
tuesday, march 9, 2010 DM VA
PREHISTORY RESEARCH URBAN JUNGLE
A really old baby
Audibly better Studies find an ongoing decrease in hearing loss. AnyBODY, E2.
Unwelcome
Remarkably preserved, a guests
month-old woolly mammoth
A couple of exotic
that died 42,000 years ago
ven’t thought weeds bring early
offers new insights into the
about global warming, challenging the theory that young people blooms to winter
ice ages. E6
22
percent of adults younger than 35 tell pollsters they ha
are more attuned to the issue. PostCarbon, E3 lawns. E6
SCENES FROM THE 21ST-CENTURY DOCTOR’S OFFICE
The plug that
didn’t get pulled
ILLUSTRATONS BY MARK BREWER
FOR THE WASHINGTON POST
A crisis in the ER
prompts new thoughts
on ‘Do Not Resuscitate’
by Boris Veysman
Health Affairs
The emergency department is al-
ways noisy, but sudden screams from
a staffer still get attention. The triage
nurse is yelling, “Not breathing, had
vitals at triage and just croaked,” as
she runs toward us pushing a wheel- Blank stares all around. “His daugh-
chair. In it, a pale, thin man is ter dropped him off with a chief com-
slumped over and looking gray. I’m plaint of weakness and went to park
the attending physician in charge. the car. I think he has cancer and is on
Amid the usual strokes, heart attacks chemo,” the triage nurse says. Without
and bleeding ulcers, my day just be- concrete proof of a DNR or DNI, there’s
came interesting. no hesitation. We resuscitate; we in-
“Anyone know of a DNR on him?” I tubate. Click, klang, the laryngoscope
ask. If there’s a Do Not Resuscitate or- snaps open and the patient has a tube
der, we won’t prevent his impending down his throat within seconds. On the
death, which means no chest com- monitor, he is flat-lining — no heart-
pressions or electric shock for a dan- beat — and he has no pulse. I ask the
gerous heart rhythm. If there’s also a nurse to start cardiopulmonary resus-
DNI (Do Not Intubate) order, we citation, or CPR. The nurse has good
won’t insert a tube to help him
breathe.
dnr continued on E4
A little less autonomy
in billing, please
by Manoj Jain
Special to The Washington Post
A decade and a half ago, when I
started my solo practice, I would say
to my routine HIV patients, “Let’s see
you back in three months.” I was ea-
ger to fill clinic slots; also, because of enue to offset overhead costs. In near-
my lack of experience, I felt safer see- ly all cases, I find, the doctors are
ing my patients more often. making choices that are well within
Nowadays, with my clinic over- the guidelines of evidence-based
booked for months, I do not take new medicine.
patients, and I say to my routine HIV But I have to admit that since most
patients, “Let’s see you back in six doctors are paid per visit, doubling
months.” the number of visits doubles our in-
Over the years, the guidelines for come. Practicing with a tilt for maxi-
HIV patients have not changed — mizing procedures, a cardiologist
routine follow-ups are still recom- knows that he can do more cardiac
mended every three to six months — catheterizations and a gastroenterol-
but my behavior has. ogist knows he can order more en-
When business is slow or when re- doscopies. These are my colleagues,All I wanted
imbursement goes down, we doctors and at times I catch myself thinking
have the option of just cranking up in similar ways.
the volume of patient visits and pro- This approach works because pa-
cedures. For most doctors, I would ar- tients, insurance companies and
gue that the motivation is not really Medicare pay separately for each pro-
greed. It’s a combination of concern cedure in the predominant “fee-for-
for patients, clinic availability and
the need to generate additional rev- billing continued on E5was a doctor
I’m young, healthy, insured. Why was it so hard?
Patients get treated in groups,
with surprisingly good results
Ah, so that’s what it took to get a doc-
by Ruth Samuelson tor within reach: I just had to contract
Special to The Washington Post a deadly disease. by Ranit Mishori
I first began calling practices in Special to The Washington Post
t seemed like a relatively simple process: When you get sick,
2008. Truth be told, I can’t even recall
I
what was bugging me: The symptoms On a recent weekday morning, 15
first call your primary-care doctor. Second, visit said doctor. always dissipated before I could find a expectant mothers are gathered in a
Third, follow doctor’s orders: Fill prescriptions, take to bed,
doctor who’d accept me, or I’d just suf- circle in a large room at a Washington
fer through. hospital for a collective third trimes-
whatever. Fourth, get better. But in early 2009, I renewed the ef- ter checkup.
But what if you can’t even get past Step 1?
fort, hoping to meet with a doctor to A midwife is off to one side taking
discuss stomach problems that had measurements of Marilis Quijada’s
persisted all fall. No luck. I invested abdomen and using a Doppler mon-
I struggled with this problem for was just 23, basically healthy and, most half a workday heading out to my old itor to listen to her baby’s heartbeat.
more than a year. After graduating important, insured. So I pulled out my doctor in Kensington. That spring, I She notes the results in Quijada’s
from college, I returned to Washington computer, looked up the United- again wanted an appointment after my chart, and as another patient steps
in 2007. I’d grown up in Bethesda and Healthcare list of preapproved doctors insomnia suddenly intensified. (It’s forward to be measured — they each
used a doctor in Kensington during and started calling. something I’ve dealt with since high get a turn, and each has an individual
high school. But the journey from my And I got rejected. Again. And again. school.) Once more, I journeyed mid- chart — Quijada returns to the circle,
office in Adams Morgan out there took (Usually after being put on hold for day to Kensington. where a nurse is leading a conversa-
about an hour and a half for car-free three or four minutes.) It was time to take a concerted, orga- tion on how to recognize the onset of
me. It was time to find a medical prac- I talked to one primary-care practice nized approach. I turned to my mother. labor. taneously has gotten a new boost as
tice in the city. that hadn’t accepted new patients in Or rather, she offered to help. As a The women have been booking the nation urgently searches for sus-
Naturally, I waited until I wasn’t feel- eight years. I talked to another that was teacher with the summer off, she had shared appointments since early preg- tainable models of health care. The
ing well to seriously initiate this proc- accepting new patients only if they had nancy and are happy, they say, to give group visit was cited as one of 10
ess. But I didn’t expect any problems. I HIV/AIDS. doctor continued on E6 up the privacy of a one-on-one visit for trends to take seriously by the Future
the benefits of a group session: more of Family Medicine Project, a national
face time collectively with the doctor effort headed by the American Acad-
So that’s what it took to get a doctor within reach:
or midwife and the learning experi- emy of Family Physicians looking for
ence of sharing time with other preg- ways to improve the delivery of health
I just had to contract a deadly disease.
nant women.
Caring for multiple patients simul-
group continued on E5
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