http://hwmaint.annals.org Annals of Internal Medicine RSS feed -- recent Perspectives articles Annals of Internal Medicine 0003-4819 http://hwmaint.annals.org/icons/banner/title.gif http://hwmaint.annals.org http://hwmaint.annals.org/cgi/content/short/151/8/577?rss=1 The use of diagnostic tests, especially imaging studies, varies markedly across the United States—with higher costs but no better patient outcomes associated with the highest-use regions. A proposed new model of the health care system draws on an analogy with the ecosystem to explain the geographic variations in physician test ordering. This framework emphasizes the adaptability and interdependence of the components of the system. Patients and physicians are influenced by the health care organizations in their community, including the practice site in which the physician works, local hospitals, malpractice lawyers, and imaging centers. These are in turn influenced by institutions in society at large, including the media, health care plans, and the government. Further adaptations to the explanatory model account for the psychologic and sociologic aspects of physician behavior. Understanding the medical ecoculture is essential for effective health care reform because widely touted changes, such as the introduction of an electronic medical record or comparative effectiveness studies, do not address the adaptability and interdependence that characterize the medical ecoculture.

]]> Mon, 19 Oct 2009 14:11:57 PDT American College of Physicians-American Society of Internal Medicine 8 151 580 2009-10-20 577 Perspectives http://hwmaint.annals.org/cgi/content/short/151/6/421?rss=1 Despite receiving state-of-the-art palliative care, some patients still experience severe suffering toward the end of life. Palliative sedation is a potential way to respond to such suffering, but access is uneven and unpredictable, in part because of confusion about different kinds of sedation. Proportionate palliative sedation (PPS) uses the minimum amount of sedation necessary to relieve refractory physical symptoms at the very end of life. To relieve suffering may require progressive increases in sedation, sometimes to the point of unconsciousness, but consciousness is maintained if possible. Palliative sedation with the intended end point of unconsciousness (PSU) is a more controversial practice that may be considered for much fewer refractory cases. There is more ethical consensus about PPS than PSU. In this article, the authors explore the clinical, ethical, and legal issues associated with these practices. They recommend that palliative care and hospice programs develop clear policies about PPS and PSU, including mechanisms for training and ensuring competency for clinicians, and approaching situations where individuals or institutions may conscientiously object.

]]> Mon, 14 Sep 2009 14:36:29 PDT American College of Physicians-American Society of Internal Medicine 6 151 424 2009-09-15 421 Perspectives